FAMILY THERAPY IS CHILD THERAPY

During my training as a child psychiatrist, there was a significant focus, that any treatment of children and adolescents needed to be in the context of their family. This was a central and core component of addressing children’s mental health needs. It was impossible to think about a child’s mental health outside of the circumstances and context of the family. The two-year specialty in child and adolescent psychiatry, after completing the general psychiatry training, highlighted child development and family contributions amongst others in understanding the child that was being assessed or treated.

I frequently survey and look at some of the child and adolescent training programs across the country and find that many of them are currently mostly focusing on brain functioning, genetics and pharmacology, in their understanding and approach of helping children with their mental health issue. I certainly agree that these are important aspects of on-going research that need to be studied and learned, and that a child/adolescent specialist should be well versed in evidenced-based approaches to help children overcome complex problems affecting their lives.

Yet, I don’t think we are anywhere near, at least in the next decade of being capable of fixing these complex mental health issues with only medications, genetics or a better understanding of the brain’s pathways. Although these are essential for understanding psychiatric pathology, they currently provide an incomplete guide to understanding and helping children and families presenting at our clinics for guidance in addressing their mental health needs.

Most of the problems we encounter in children and adolescent stem from complex bio- psycho-social/cultural factors, especially in the context of their current stage of development. Let me break this down, bio- psychological concerns in children like temperament (certain traits that we are born with) which then interact with the bonding that occurs with their primary care giver. This attachment is crucial in the toddler and preschool years, since they impact brain development and most skills, including communication and socialization. The primary care giver, frequently the mother, provides a crucial bridge to the family system.

In the context of the family system, children learn the skills that are needed to explore the world outside of the family, especially as they start school. Learning to deal with authority figures, socializing with peers, coping skills, self-esteem, making friendships, limit setting, boundaries etc.

As children move on to middle school, they begin a second separation- individuation phase from their family, this occurs in the early teenage years. Hopefully, they have developed a healthy and secure attachment that they can hold on to and bring forth, skills learned in the family context, especially as they expand their participation in a broader array of classes/ teachers, join competitive sports, begin closer relationships with peers, coaches and other important adults.

The new relationships will be judged and interpreted within the context and measure of their family relationships. Here, I want to highlight the important role that culture has. Many families come from diverse backgrounds and parents should ensure that the child feels comfortable and confidant of their cultural background. It is important for parents and families to foment healthy self-esteem by integrating their cultural background and bringing it forward into new settings and relationships.

As teenagers move on to high school and college, they take their skills, relationships, sense of trust and self-esteem which frequently stem from stable family relationships. As adolescents explore life beyond family ties, they increasingly rely on others for support and connection.

Of course, many issues or disruptions can occur throughout the child’s development, including trauma, losses, separations, family conflicts, divorce, illnesses that may derail normal development.

As a child and adolescent psychiatrist, children present with specific concerns in my practice, including ADHD, depression, anxiety, school, legal, substance use or social media- technology, I believe that besides making an accurate DSM diagnosis and possibly prescribing a medication for mitigation and relief  of symptoms, it is essential that we have a  good understanding of their current stage of development and family functioning  which can provide us with a better and comprehensive approach to their care.

In summary, I don’t think that we can provide adequate psychiatric care for a child/adolescent, unless we understand the Bio-psycho-sociocultural background, and in this case socio-cultural refers to family. Of course, some family relationships have been greatly affected by significant stressors, and we need to start by understanding this and if needed refer to a family therapist to help address the fractured family dynamics that will likely impact the child’s mental health needs. We would encourage training programs that they continue to emphasize and integrate family assessments and therapy for those training to be child and adolescent psychiatrist, if it does not start there , it is unlikely that clinicians will see this approach as valuable.