Psychosocial Interventions in Working with Children and Young People Promoting adjustment to physical health conditions

1. Psychosocial Interventions in Working with Children and Young People Promoting adjustment to physical health conditions 24th November 2010

2. Learning Outcomes - Communication • Understand the role of effective communication in working with children and young people • Identify the conditions, communication skills and styles which • are necessary for effective communication • Be aware of the context and required outcomes when • considering which communication skill and style to use

3. Communication Conditions • Being empathetic – Understanding the issues raised from the child’s perspective and demonstrating this understanding • Adopting a non-judgmental stance – Accepting the child’s opinions and values without evaluating • Being genuine – Being yourself with the child and not playing out a ‘role’ • Being concrete and pragmatic – Clarifying meanings, keeping it simple and being specific • Showing warmth – Being interested in and positive about the child. Showing care towards them. (Rogers, 1965)

4. Communication skills • Asking • Listening • Informing

5. Asking Closed Questions Have you been short of breath? Where do you feel the pain? Have you been sleeping well? Did you take your medication this morning?

6. Asking • Open Questions • What do you think helps you manage your diabetes? • How can I help you? • Can you tell me when the symptoms started? • May I ask you what concerns you most about your condition? • Tell me more about your worries for the future? • Why do you think you feel tired often?

7. Asking Without Questions Observing nonverbal clues Using ‘seem to be statements’ The use of ‘I’ statements Invite a child to answer a question Use minimal responses

8. Which form of Asking is demonstrated by the following? • How have you been getting along? • OK. Tell me more. • Do you still have pain in the morning? • You seem to be annoyed. • I found myself thinking about what I would do if I was in the same situation. • What do you think all these tests are for? • The most sensible way forward is for you to do what we have discussed. Do you agree?

9. Listening Effective and useful communication skill It lies at the heart of our work Listening well is the key to building trust, gaining understanding, and forms the basis of working with children and families Requires more than just hearing the words Needs to be learned and practiced

10. Listening Well There are times when just listening is the most healing and important role the clinician can adopt in particular: At the start of a conversation After breaking bad news/diagnosis Supporting the child/family when upset or distressed In response to open questions

11. Listening Well • Can you identify some good listening skills? • Can you identify some poor listening skills?

12. Poor Listening Pretending to listen Selective listening Spacing out Listening in a self-centred way Word listening

13. Listening Well • Listening can be communicated in the following ways: • Invitation – eye contact, lack of distraction, open question • Silence – active listening • Reflective Listening – simple reflections (repeating or rephrasing), paraphrase, summary

14. Reflective Listening • Phrases to use when you think your perceptions are correct: • I get the impression that... • As I hear it you.... • You mean... • Let me see if I understand.... • So you feel... • What I hear you saying.... • It sounds like you... • You’re wondering if... • You believe...

15. Reflective Listening • Phrases to use when you need clarification or understanding: • Could it be.... • What I guess I’m hearing is... • I’m not sure I’m with you but.... • Let me see if I understand you. You... • I wonder if... • Correct me if I’m wrong but... • Perhaps you’re feeling.... • ....is that what you mean?

16. Activity • Form pairs • Person (1) – Describe a recent achievement which has made you feel proud. (It can be real or make believe). • Person (2) – Listen and while doing so practice the reflective listening skills outlined above (10mins). • Once completed reverse roles. • Discuss how it felt being listened to and using listening skills.

17. Informing • Information is crucial for: • Helping children/families make sense of what is happening • Preparing them for what will happen next • Helping to develop realistic expectations/plans/actions • Allowing them to be actively involved in the management of their care • Allowing them to communicate their needs • Challenging inaccurate beliefs or misconceptions • Developing trust & good relationships with health care staff

18. Informing Principles • Clarity about what information is given and who is giving it • Information needs to be given as honestly as possible • Communication must be given at the child’s level of understanding • Include the child from the start to establish and maintain trust • When children are included appropriately they can form accurate • and hopeful beliefs about their condition and related events. This • forms a basis for adaptive coping strategies • Use different methods of informing, verbal, written, diagrams & play

19. Informing Take care not to overload the child or family Provide information in chunks Try to avoid using jargon and medical terminology Check that the information has been understood regularly Tune in to how receptive the child or family is Do not rush Be guided by the child and family Use informing in combination with asking and listening Use a combination of methods including verbal & written instruction

20. Communication Styles • Directing – ‘informing’ Used when education is required, initially at diagnosis or to update during transitions. • Following – ‘listening’ Used after diagnosis or at the start of a new meeting. Also when upset or distressed. • Guiding – ‘asking’ ‘listening’ & ‘informing’ Used when helping the child or young person work through alternatives.

21. Break • Please resume in 15mins

22. Learning Outcomes: Problem-Solving & Goal Selection • Be familiar with the informal and formal problem-solving approaches in working with children and young people. • Recognise and practice working through the steps involved in problem-solving in relation to clinical practice • Be familiar with goal selection in helping children and young people manage their condition • Practice working through the process of goal selection in relation to clinical practice

23. Problem-Solving • Healthcare staff and parents can help promote adjustment to physical health conditions by working with children to find solutions to their problems. • Once familiar, problem-solving skills can be used more widely in all aspects of their life including interpersonal contact, decision making and perspective taking.

24. Guidelines for Informal Problem Solving • Make a time and place for clear communication • Understand the problem from the child’s point of view. Can you tell me about it?This helps the child to clarify the problem and ensures that there is a shared understanding

25. Guidelines for Informal Problem Solving • Summarise your understanding of the problem and share with • the child or young person. For example, ‘Now I understand • what the problem is. Your friends offer you sweets and you take • them because you do not want to be different to them. You • know this increases your blood sugar which leads to arguments • with your Mum and you feel guilty and ashamed.’A child will be • more motivated to work in collaboration with you if they believe • that you have an understanding of how they feel.

26. Guidelines for Informal Problem Solving • Guide the child to think for them self. Ask questions which encourage them to define the problem, think about what caused it, create their own solutions and express their feelings. • The use of open ended questions will help the child to think it through for themselves. Asking ‘what’ or ‘how’ questions will help engage the child or young person in the process. • For example, ‘What happened?’ ‘How did you feel?’ ‘What do you think your friend knows about your condition?’

27. Guidelines for Informal Problem Solving • Paraphrasing helps to make the child feel valued and listened to. • Discuss one problem at a time • Divide one big problem into a few small problems • Define problems briefly • Explore both positive and negative consequences

28. Guidelines for Informal Problem Solving • Work with the child to anticipate what to do next when something doesn’t work • Be positive, creative and humorous. Use books, games, cartoons and puppets to present hypothetical problems to practice the problem solving steps • Model effective problem solving • Problem solving is a process of learning how to think about and cope with problems and not about getting it right • Celebrate success

29. Problem-Solving • Step1 • Define the problem and the feelings involved • Step2 • Brainstorm Solutions • Step 3 • Explore the pros and cons • Step 4 • Agree an Action Plan. • Step 5 • Implementation • Step 6 • Evaluate the Outcome & Reinforce Efforts

30. Activity • Form pairs • Person (1) takes on the role of the child or young person and person (2) takes on the role of the healthcare worker. • Each person has a copy of the Problem-Solving Handout • Person (1) - from your work practice think about the types of problems with which children present and choose one. • Person (2) – Guide the child or young person through the steps (10mins) • Once completed reverse roles

31. DISCUSS TREATMENT OPTIONS SELECT TREATMENT OPTION SMART goals Confidence rating ACTION PLAN & CONTRACT If / Then Support details SELF MONITORING Diary REVIEW Goal Selection

32. Goal Selection • Discuss treatment options • Select treatment option – following a collaborative discussion • with the child, young person and family a preferred option for • management of the condition is selected • Negotiate schedule and times of treatment – It is helpful to agree the schedule of management around the child’s daily routine to ensure a minimum of lifestyle changes. There may be little option for negotiation on treatment options depending on the condition and this should be discussed openly and an agreed understanding reached with the child and family

33. Goal Selection • Negotiate contracts – It is helpful to agree on a contract with older children and young people on the exact details of the management of the condition. This should be based on details elicited from the child or young person and may be driven by and written up by them. It should be signed by the both parties and reviewed on a regular basis • Self-Monitoring – Using diaries and daily calendars can be a useful means of monitoring management goals and allowing adjustments to be made when necessary. • Review

34. SMART Goals Once the child/ young person has decided upon a health behaviour they want to change, they need to set a goal. Your role is to help the child set a goal that is detailed and likely to be achieved. Goals should beSMART: S pecific M easurable A chievable R elevant T imely

35. HOW DO I FEEL?

36. GOAL SELECTION S pecific M easurable A chievable R elevant T imely

37. 'IF-THEN' PLANS Are there any situations that you can think of that could make it especially difficult for you to perform your goal? (a time, place or a feeling that might make it more difficult) For example, “When I stay over night at my friend’s house I sometimes forget to take my medication the next morning” IF..... THEN..... • Now make some plans for how to make them more • manageable or less likely that they will happen. • Fill in the table below with your difficult situations • and make an IF/THEN plan.

38. My general goal is…………………………………………………………………… • My specific goal is………………………………………………………………….. • Where?............................................................................................................... • When?................................................................................................................ • With Whom?..................................................................................................... • How?.................................................................................................................. • How will I know how I am doing? • )I will keep a diary • 2) I will keep a goal selection chart • 3) I will use a confidence ruler • Tick as appropriate Child/Young Person Contract I will keep to my goals and I will let you know how I am doing. Signature……………………………… Date…………… Healthcare Worker Contract I will see you and discuss your progress at the next meeting. Signature……………………………… Date…………… DATE AND TIME OF NEXT MEETING:

39. GOAL DIARY MY GOAL IS………………………………………………………………………. What made it easy? What made it difficult?

40. Reviewing Goals When reviewing behaviour change with a child/ young person, helpful questions to ask may be: What was tried (and what was the goal)? With what effects (and did the child/young person achieve any success)? What benefits were there? What difficulties were there? How did the child/young person manage any difficulties? Were there any problems filling in the diary? How could these be solved? How confident is the child/young person that they can achieve their goal? Is the child/young person getting enough support? What have you both learnt that could be useful when filling in future diaries? Does the SMART goal need changing?

41. Activity • Form Pairs • In relation to a specific example from work practice, apply the goal selection process • Discuss as you progress and identify strengths and difficulties in the process

42. Lunch • Resume at 1.30pm

43. Learning Outcomes:Reducing Distress • Be familiar with the signs and symptoms of distress in working with children and young people. • Anticipate the situations which may result in distress. • Understand procedural distress and the steps which can be taken to prevent or reduce this. • Be familiar with distraction, visualisation and relaxation techniques.

44. Reducing distress • What are the signs and symptoms of distress? • Two Categories: • Internalizing symptoms including anxiety, low mood, social withdrawal • Externalizing symptoms including hyperactivity, aggression, • Oppositional behaviour

45. Reducing distress • Signs and Symptoms – Include changes in: • Mood: unhappy, moody, reduced interest, reduced motivation, irritable, easily upset, tearful, lonely, feeling hopeless, feeling worthless • Physical Well-Being: changes in sleep pattern - sleeping too little or too much, tiredness and lack of energy, lethargy, changes in appetite, frequent minor health problems such as headaches or stomach aches • Behaviour: tantrums or ‘acting out’, argumentative, becoming withdrawn - avoiding friends, family and regular activities, anxious, restless, fretful, finding it difficult to concentrate; not looking after their personal appearance • Thoughts : guilt, self-criticism, self-blaming, hopelessness

46. Reducing Distress • Where and When are children more likely to be distressed? • At diagnosis • Coping with new or difficult situations in their daily life. • As a result of a change in their condition, treatment or symptoms. • Anticipating procedures that are perceived as painful, frightening, unfamiliar or in which they have little control • At transition.

47. Reducing Distress • Why do children become distressed? • Distress is a normal reaction to experiences that are stressful or upsetting. It has an adaptive function. It communicates that all is not well and that an adaptive response is required. Being alert to situations which may cause distress can help healthcare staff prepare for and reduce distress. When distress occurs, being aware of the signs and symptoms allows healthcare staff to intervene early and help the child or young person develop coping strategies. • When distress persists, is severe or dominates and interferes with daily activity then referral to specialist services is required.

48. Helping the Distressed Child • Assessing the Child/Young Person • Develop a close rapport with the child/young person and family • Communicate with the child/ young person, explore the reasons for the distress (what, where when, why how) • Assess developmental level • Explore contributing factors including previous experiences and current stresses • What coping strategies have the child or family used to date and have they been helpful • Acknowledge distress • Introduce techniques that other children/young people have found helpful • Collaboratively select one, practice and plan review

49. Activity Needle Phobia – Fact or Fiction? Discuss

50. Procedural Distress • What Helps: Preparation • Give appropriate information. Explain what will be done, why it needs to be done, how it will feel, what the child needs to do, how long it will take & what they will feel like afterwards. Ensure that this information is given at the appropriate level and using appropriate materials. Respond to the child’s questions but do not give false reassurances. • Give written information to consolidate information. • Allow the child/young person to have choice when possible. Be creative. • Have a range of skills which facilitate coping (e.g. distraction, visualisation techniques, relaxation practiced prior to the procedure) at hand if necessary. • When possible, parents/carers can be present and with an active role. Prepare and coach parents for taking an active and constructive role.