Arena flexible treatment method

Jan Ivar Ernø

Section of Children’s Mental Health

Oslo University Hospital HF

”Treatment hypothesis”

• Treatment intensity should follow symptom intensity

• Treatment results depend on gained skills• Treatment requires complete alliance

”Treatment hypothesis”

• Crisis give true information about family function• Symptom severity required for motivation• Home situation must be sorted before giving

therapy• Confrontations will threaten the alliance• Functional aggression must have consequences

Historical antecedents

• Two levels of treatment– Out-patient clinic– Hospital admittance – 5 days / week

• Same patient group• Admittance corresponded with level of crisis• Treatment focus on relation with the child• Treatment time 1-3 years• High number of aggressive outbursts• Overall good treatment outcome• Poor long term prognosis

General treatment goals

• Maintain patient integrity• Validating observations• Motivating change• Clearing obstacles (school and care etc)• Creating effective interventions• Evaluating results frequently• Modifying transactions• Generalizing skills and results

Patient distribution

• Emotional disturbances• Mood disorders• Behavioural disorders• Attention deficits and Hyperactivity• Tics / Tourette syndrome• Autism spectrum• Attachment issues / disorders

Systemic approach

• Child’s issues to be understood in its dependent relation to adult caregivers and contexts

• Symptom expression must be understood in correspondence with psychological development

• Troubled families evade functional networks• Troubled families lower their ability to generalize• Troubled families bad transfer of advices to

behaviour

Bronfenbrenner’s ecological model

Arena flexible treatment model

• Hospitalizing - Arena flexible - Ambulatory• On terms with the child and family• Least invasive measures• High observational validity• Treatment results are generalized to natural

context• Realistic treatment goals• Flexibility and structure

Therapeutic indications

• Referred from out-patient clinics• Previous treatment without reaching wanted goals• Referral assumption: Families would benefit from

higher therapeutic intensity (> 2 hrs / w)

• Symptom severity alone are insufficient indicators of treatment level

Patient / parent concent

• Families can be motivated to participate in an intense treatment program with high therapist presence in multiple arenas

• Unhindered work with natural collaborators

• Patient integrity through “control commission”

• Caretaking situation implicates results

Individually adapted school

• School problems for majority of patients• Assisting, adjusting and supervising home school

if possible• Assessing special needs• Temporary schooling in nearby localities• Safe return to home school or special school

Using the bed therapeutically

• Rapid stabilization (destabilization) for the child• Parents present• Indications

– Initial observations and alliance with family Family introduction week

– The need of further clinical observations

– Stabilizing sleep

– Testing pharma treatment

• Training basic skills ADL• Children have their own rooms to withdraw and

regulate

Arenas

Treatment teams

• Full understanding of the family and child requires diverse professional opinions

• Complimenting treatment modalities• Treatment plans are developed, discussed,

executed and evaluated by the team in cooperation with the family

Child therapists Doctor/psychologist Spec. Teacher Child therapist (night)

Treatment plan

Treatment planName: Treatment team:Planen period: Goal:

Goal formulationsChild: Parents: Referral: Others:

 

Date Issue and resource Goal Interventions Method Responsible EvaluationDate/Sign

 

 

 

 

 

 

Main therapeutic methods

• Child therapists working directly with the child and family in several arenas

• Adapted and assisted school

• Traditional family interventions• Psychoeducation• Individual therapeutic sessions

• Supervising external collaborators• Overseeing treatment plans and individual

coordination plans

Selected therapeutic approaches

• Multisystemic perspectives– Children can be understood only when considered in

their common context– Their skills are specific to context, likewise are the

eventual changed skills– Skills are best trained in their natural environment with

motivated trainers

• Individual approaches– Cognitive approaches, Coping cat (Kendall, 2006)– Selected narrative approaches– MIM and Theraplay (Booth & Jarnberg, 2009)

Selected therapeutic approaches

• Family and network approaches– Parental supervision (Marte-Meo)– Circle of security (Cooper, Marvin, Hoffman & Powell,

2013)– Reflective team (Andersen, 1991)– Behaviour modification programs

PMTO and Social skills training

• FOMA– Preventing and handling aggression in children– Revealing and developing adult stress tolerance– Careful physical handling

Historical comparison

• Two levels of treatment– Out-patient clinic– Hospital admittance – 5 days / week

• Same patient group• Admittance corresponded with level of crisis• Treatment focus on relation with child• Treatment time 1-3 years• High number of aggressive outbursts• Overall good treatment outcome• Poor long term prognosis

Historical comparison

• Two levels of treatment – closer relation– Out-patient clinic– Arena flexible interventions - X days / week

• Same patient group• Admittance based on prognostic evaluation• Treatment focus on alliance with family• Treatment time ¼ - 1 year• Low number of aggressive outbursts• Overall good treatment outcome• Promising long term prognosis

Academic collaboration

• Hospital is part of the University of Oslo• Education contracts with UiO and HiOA

– Students Medical training Psychology ½ year full time Child protection Trained nurses – Bsc and Ma

• Lecturing– FOMA 2 day course - HiOA– Flexible arena treatment method 3 day course - HiOA

Reference networks

• Community network – exchanging knowledge– Child welfare institutions

• Academic network – exchanging knowledge• Neuropsychological unit – assessment and

education• User evaluation representatives

Future proposals

• Opportunities– Precise indications for choice of methods– Attachment based interventions– More action less talk– Earlier referrals– Earlier treatment onset

• Possible challenges– Increasing clinical population– Validity of the model

Arena flexible treatment summarized

• Treating the whole family system• Customized interventions• Taking family function into account• Generalizing skills – parental and child’s• Still using the ward and the beds• Lowering the need of coercive care• Shortening treatment time• Reduces relapse

Section of Children’s Mental HealthOslo University Hospital

Jan Ivar Ernø, clinical psychologist

ernj@uus.no