The rights of the child in psychotherapy

Special population - child and adolescent psychotherapy

OBJECTIVES

First, to outline the paradigm change of the past 20 years that has transformed the theory and practice of child and adolescent psychodynamic psychotherapy; second, to update aspects of the current Practice Parameters for Psychodynamic Psychotherapy with Children to align with the paradigm change driven by the principles of regulation theory, relational trauma and repair, and the critical need for clinicians' self-care in trauma informed psychotherapy.

CONCLUSION

The emerging neuroscience-driven paradigm of psychotherapy poses challenges for the child and adolescent psychotherapist: to embrace the new conceptual reference points as organising principles leads to an urgent need to rethink traditional diagnostic formulations and time-honoured techniques for intervention. Our child patients and their families are entitled to benefit from the translation of the new research evidence from attachment regulation theory to clinical psychotherapy. Our clinical psychotherapy should sustain the 'best-interest-of-the-child' standards for well-being while also heeding Frances Tustin's warning for therapists to avoid the 'perpetuation of an error' by overlooking recent developments from allied fields in developmental psychology and the neurosciences.

Parental non-compliance--a paediatric dilemma. A medical and psychodynamic perspective

Considerable resources have been directed towards the recognition and management of child physical and sexual abuse and/or neglect. However, the issue of parental non-compliance is less well defined and under recognized. While outwardly seeking advice, non-compliant parents, especially if anxious, are unable or unwilling to comply with the recommendations made. Conflicts of interest between the parent(s)' and the health professionals' perceptions regarding the best interest of the child may arise. Parental non-compliance is centred around the parents' perception of the child's current problems and its relationship to past problems. Such non-compliance may reflect ignorance or misunderstanding of the clinical situation. Ignorance may be readily addressed if the parents are receptive and trusting. However, non-compliance more commonly arises from the parents' inability to cope emotionally with the stresses surrounding the recommended treatment. Parents may be vulnerable to psychological reactions which inhibit rational thinking. Parental anxieties are best understood in terms of psychological constructs, including 'defences' such as 'denial' and 'splitting', 'repetition compulsion' and the need to 'work through' psychological barriers so that the child's best interest is served. Parental non-compliance can serve to protect the parents from overwhelming fears and anxieties, which if addressed may transform parental defensiveness to co-operation. Extreme parental non-compliance may represent a special form of child abuse where, due to parental psychopathology, parents are unable to consider the child's best interest. Clinical vignettes arising from a consultant private and hospital ambulatory setting will focus on management strategies for successful outcomes. Recommendations offered on ways to reduce the risk of parental non-compliance include building trust, eliciting the aid of a parental partner, and organizing a second opinion, thereby improving the chances of a successful outcome.