Working with Parents and Caregivers When Children Are Our Primary Clients: Why do it, what does the literature tell us and why is it hard? - Calm Kid Central

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Working with Parents and Caregivers When Children Are Our Primary Clients: Why do it, what does the literature tell us and why is it hard?

As mental health professionals working with children and young people, our primary focus is of course on the mental and emotional well-being of the young humans we have the privilege of supporting.  However, anyone who has worked in child/adolescent mental health for more than 3 minutes knows that working with parents and caregivers of young people is also a critical part of our job.  Yet this parent work has many challenges and difficulties – in fact it is sometimes the hardest aspect of what we do.  It can therefore (understandably) be easy at times to deprioritise or delay this work –especially when parents themselves are finding it difficult to engage with us – and prioritise and focus on providing intervention solely to the child instead.

It’s helpful therefore to occasionally recalibrate our attention towards the significance of parent work.  Hopefully this article can serve as a somewhat motivating summary of the full range of reasons to do this work, the empirical basis for doing it (as well as an acknowledgement of the inherent challenges in it that we need to address and overcome).

Just a note before I start about terminology– we know of course primary caregivers may be biological parents, grandparents, foster parents and others – for the sake of brevity, I’ll refer to the term “parents” in this article as an encompassing term all primary caregivers.

Why work with parents?

Let’s start with considering all the theoretical, practical and ethical reasons we might consider working with parents as child mental health professionals.

Practical Assistance: First the fundamentals – many parents are crucial in the practical logistics of helping their children to attend therapy sessions. They provide or arrange transportation, support referrals when needed and provide the financial support or funding for children to access mental health support.  Working with parents to ensure they are able and committed to being able to do this – and to do so for the length and frequency of treatment required – is critical to avoid children prematurely dropping out of treatment.

Ethical guidelines suggest working with parents is often important
:  Australian Psychological Society Ethical guidelines formally state that when working with children, psychologists are required to “respect the child-parent relationship”.  In addition, ethical guidelines also state the need to obtain informed consent from clients before undertaking psychological treatment with them – and given this is not always possible for younger children we often need to obtain informed consent from their legal guardian/s on their behalf.

Overcoming limited introspective skills: Children and adolescents are often unable to provide us with information we need to provide effective therapy.  This might show itself in a range of ways, for instance, they might not be able to tell us about what might be crucial potential difficulty at the beginning of therapy (for example I can recall many children I’ve worked with who have failed to mention they’ve experienced significant bullying, or don’t sleep before 3am etc) or enough detail about these issues at the beginning of treatment (‘I’m not at school that often’ says one child – ‘you haven’t been there for 3 years’ adds their parent) in ongoing appointments (one child memorably didn’t tell me there had been death in the family since I saw them last). Children often are also unable to tell us about critical contributing factors to their difficulties (aren’t able to provide us with family background information, don’t remember the types of behaviours or thoughts they experience in the midst of emotional dysregulation etc etc) which then makes it harder to identify possible therapeutic components.  I see this as parents being able to (often) provide at least some of the ‘picture on the front of the puzzle box’ rather than us as therapists blindly trying to put together individual pieces.

Supporting therapeutically targeted behavioural change in children:  One of the greatest advantages of working with many children is the existence of parents aka potential ‘live in therapy coaches’.   This matters a great deal – we often know exactly the kinds of skills, behaviours or environmental changes which would be needed to make positive changes to children’s mental health – and sometimes we have live in therapy coaches/aka parents who can effectively ensure these changes/skills can be built or made.  For instance, many parents are able to help a child practice a new skill each day in between therapy sessions, speak to a school to ask for a change in educational circumstances, set up different social experiences for the child on the weekends, prevent the child using an unhelpful coping or avoidance strategy etc etc.  For some kids, not collaborating or engaging with their parents is like trying to help the ill-equipped child dig the foundations for a house with a shovel themselves while ignoring the massive excavator on site ready to do it for them.

Adjusting parenting knowledge and behaviors which might improve child mental health: Certain parenting behaviors, thinking styles and levels of understanding are closely linked in the research literature to better child mental health. For instance, parent warmth, emotion coaching, consistent, autonomy building and reduction of accommodations is highly correlated with children experiencing less anxiety, better emotional regulation, less risky behaviours, better social functioning and so on.  If we can work with parents to change or adjust these parenting behaviours and ways of thinking, improve their understanding and knowledge – this may be one of the most critical ingredients in the plan to improve a child’s well-being.

Targeting parental distress: Parents experience significant distress related to parenting challenges – and particularly so when they have a child with additional challenges. There is a vast literature base documenting the grief, anxiety, loss, frustration/rage, exhaustion and burnout which comes with supporting a child with mental health difficulties. This distress not only affects parents’ own mental health but also is linked in the literature with poorer child functioning and poorer child therapy outcomes. By working collaboratively with parents to reduce or manage their distress, we can often potentially improve both parental mental health and child mental health outcomes.

Empirical Evidence and International Guidelines

All of this sounds good in theory – but is there any empirical evidence for parenting work being effective?  The answer is yes:  a great deal.  Here are some of the key points to know about this research.

  1. Results of randomised controlled trials of particular forms of parent directed treatments.  Various parent directed approaches (ie those which have most of their intervention components directed towards the parent) which have been manualised and implemented with a range of parent groups have been found to very effectively reduce child mental health issues.  For example (and this is not an exhaustive nor detailed list) – parent management training approaches, attachment orientated and relationship/emotion coaching based approaches, parent directed treatments for anxiety, parent directed treatments to increase collaborative problem solving, individual parent CBT, ACT and mindfulness approaches for parent distress – have all been (repeatedly) implemented with (many different types of) parents and found to be linked with significant reductions in their children’s mental health problems (as well as having positive impacts on other outcome measures).
  2. Let’s take one particularly frequently considered – and important – problem:  the treatment of disruptive behaviours in primary aged children. The evidence for parent directed treatments for these problems is of higher quality and quantity than the evidence for child directed treatments for the same issue:  eg a 2017 review of 64 high quality studies classified parent directed interventions as “well-established” treatments compared to individual child directed interventions which the same review classified as only “probably efficacious”
  3. Another way of considering this issue in the literature is to look at studies which directly compare ‘child only therapy’ (in which the child is mostly in the room by themselves) to ‘parent involved child therapy’ (in which the parent is involved in some way – i.e. via practicing with the child, being provided with information, or being present in the therapy room).  These studies usually find the ‘parent involved therapy’ outperforms ‘child only therapy’.  For example, a 2010 meta-analytic review of 48 studies analysing head to head comparisons of child only therapy to parent involved child therapy found the latter type had better outcomes.
  4. Yet another area of empirical study which examines this issue – research which examines the most effective components for child therapy.  This research suggests that ‘involvement of parents’ is one of the most effective components for child therapy.  For example, a 2014 meta-analysis of 76 trials and 2018 review of another group of studies of childhood and adolescent treatment of PTSD, depression and anxiety – found that parental involvement was significantly associated with larger pre- to posttreatment effect sizes as well as pre- to follow-up effect sizes.

Sometimes therapists (and parents) might wonder if this type of evidence for parent involvement is limited to parents with younger children.  However, many studies have found parental involvement obtains better outcomes for teenagers too.  For instance, a 2022 systematic review of psychotherapy for trials for (mostly) adolescents with depression found a significant positive impact of parental involvement compared to the teen only treatment conditions.

Given the evidence above, it is not surprising that many sets of national therapy guidelines recommend parent directed treatments.  For example, the APS evidence based guidelines rates ‘interventions involving families’ as “Level 1” interventions for (both child and adolescent) conduct disorders, eating disorders and ADHD.  NICE guidelines recommend parent/caregiver directed treatment as “first line therapies” for certain disorders – eg disruptive behaviour disorders.  The Australian ADHD Professionals Network guidelines recommend that family/parent training always be offered to children with ADHD.

I hope that this review of the theoretical, practical and ethical reasons and benefits – as well as the empirical evidence for doing this work helps you reorientate again and feel little more energized in working a little more intensively and more frequently with parents.  I know when I reorientate to this theoretical foundation and empirical base, I do have renewed energy and focus for doing this work.

But unfortunately, even with a renewal of focus, it doesn’t take long to feel demoralised at times as we go about the day to day efforts of doing this work.  If you find working with parents to be often one of the trickiest parts of your day, you are not alone.  Let’s talk about this ‘when the rubber hits the road’ effect and what it looks like.

Challenges in working with parents

Below are just some of the difficult issues we have to manage when we do this work. I’ve divided these challenges into a) system/family challenges and b) therapist/therapy challenges.

System/Family Challenges

Both family factors and our health systems as a whole make working with some parents/caregivers difficult.   Consider the following:

Child consent and confidentiality: If a child has the emotional and cognitive capacity to understand the likely consequences of involving (or not) their parents in their therapy, and has decided they do not want us as their therapists to engage with them – then we must respect this decision.  Of course there are complexities and shades of grey (remembering that ethical guidelines tell us that informed consent varies from situation to situation and context to context, and that there are exemptions) – but at the end of the day, there will be situations in which – even when we think it would be helpful and parents are also keen – we can’t do any parenting work due to the child’s desires to have them not involved.

Financial barriers:  Many funding bodies in Australia often do not provide funding or rebates for parent directed therapy work if the child is identified as the client.  This creates financial difficulties for parents when we (and they) think this work is important.  In many situations, parents need to fund this work themselves.  Given that many of the parent directed approaches tested in the literature for are 12 to 24 sessions, this means that conservatively, if a parent is doing this in 1:1 therapy with a psychologist in Australia without their child present in 2024, they might be looking at a cost of $2500-$3500 for a course of an evidence based treatment with a therapist – and this is just not feasible for many parents.  Of course, there are some ways around this cost.  For instance, we might do child and parent work simultaneously while the child is in the room.  This means we need to be introducing parent directed treatment components in a way which ensures both the child AND the parent is benefitting – so that these sessions can have rebates attached to them (because children must be present and the recipient of evidence based treatment directed at them).  Alternatively, we might be able to use other funding models in which parent directed treatment is rebated/supported.  Finally, we might use a ‘parent involved’ treatment model in which the sessions are primarily for children but parent is present, informed and involved as a ‘therapy coach’ – so the funding can be supported.  There are other options too, however many of these still require some level of private funding which presents barriers for many families.

Other practical barriers: Even disregarding the financial challenges above, parents also face other practical challenges related to attending regular therapy sessions, such as child care responsibilities (most parents have multiple children to care for) and work commitments (often the most in need families can’t get time of work without jeopardizing employment).

Parents’ emotional and energy resources:  Parents also often find it difficult to engage in parent directed treatment or be involved in their child’s treatment (either at all, or to the level that we think might be helpful) as a result of their own mental health difficulties or emotional/energy resources – including the parent distress (exhaustion, anxiety, frustration and grief) described earlier.  Many parents are also reluctant to engage due to a fear of feeling ‘blamed’ or judged for their parenting behaviours by therapists.   A couple of studies found that although many parents who engage in a full course of therapy with their child state they feel connected and supported by their child’s therapists, parents who had stopped coming to therapy – or who had children ‘drop out’ – cited a lack of trust/engagement in their child’s therapist as being one of the reasons for the therapy cessation.  When you look at drop out rates, it is likely that – perhaps not the majority – at least some parents do have concerns about being judged or dismissed by us as therapists.

Disengagement or safety concerns for children: Sometimes engaging with their parents triggers children disengagement– many children feel as though therapy is now no longer a ‘safe space’ for them to disclose their true feelings or fears, feel ‘ganged up on’, or anxious about what their parent is going to do or think as a result of us involving or disclosing information to them.  Sometimes these fears are well founded and engaging in therapeutic work with parents does actually triggers unhelpful or unsafe parent behaviours towards their children.  There are many reasons for this – some parents become more distressed or angry by hearing about therapy content for their child and act unhelpfully towards their children in between sessions.

Difficulties with separated or blended families:  Working with separated parents can be additionally challenging on top of all the other issues listed above.  There are potential conflicts regarding consent for treatment, challenges related to navigating parental dynamics, and ensuring confidentiality amidst strained relationships. These differing opinions and unresolved issues between parents may make it difficult to establish and maintain a neutral therapeutic environment and to put in place the therapeutic intervention we think is helpful.

Therapist and Therapy Barriers and Challenges

As well as system and family related challenges to working with parents – there are also a number of challenges related to us as therapists or with therapy itself.

Identifying helpful parent directed treatment components to focus on:  Deciding on exactly what to target in parent directed treatment can be challenging. Therapists are often not comprehensively trained in working with parents during their tertiary training, and are not always knowledgeable about the full range of manualised parent interventions and their components – or how to translate these to be used in community based settings.

Therapist disappointment, concern or frustration with parents: Dealing with what we perceive as ‘unhelpful’ parent behaviours or presentations as a therapist is not easy.  When we perceive as harsh, critical, neglectful, permissive or disengaged parenting behaviours we often experience a strong sense of frustration, disappointment – and worry and sadness for a child.  This is a very common experience for therapists working with families – we all know that feeling of rising tension while we talk and listen to some parents, and unless we know how to manage and address these feelings, they can get in the way of us effectively working with them.

Therapist self doubt and lack of confidence: Many therapists also feel anxious about their own ability to effectively support and interact with parents.  We worry about whether we are effective, whether we are being judged or dismissed by parents.  We often fear that parents will think we are unhelpful, unrealistic or demanding.  For therapists without their own personal parenting experience –  despite the fact there is no evidence to suggest these therapists have any less skill in working with parents than therapists who are parents (and incidentally there are a number of theoretical reasons to suggest there may be some advantages in not being influenced by an experience based on an N of 1) – they may particularly struggle with self-doubt and anxiety about their parenting work.

Unfortunately, some studies suggest that when therapists (whether they have personal parenting experience or not) who have higher levels of doubt about their ability to engage parents, are not may be only less likely to be effective in this work at times, but also have higher levels of therapist burn out themselves.

Limits of “the science”: Notwithstanding the evidence listed in the earlier part of this article which suggests that parent directed treatments do result in reductions in child symptoms and improvement in parent mental health, we also know that not all families experience these benefits.  Even with full participation and high level of therapist skill there will be many parents/children (potentially up to a third) who will not benefit very much from these interventions.  The reality is that we still don’t know enough about exactly who benefits from exactly what any kind of psychological treatment.  We are not setting broken legs – psychological treatment is a field with a lot of limitations and caveats.  This is equally true when we are working with parents.

Facing up to the challenges of this work

When you throw at least 2 or 3 of all the system/parent/therapist/therapy challenges into the mix for every child we work with (and for some children many more than this), it’s not surprising that working with parents can feel very hard at times.

It’s beyond the scope of this article to talk about the practicalities of overcoming these challenges but I hope that the listing of these challenges might helpful in two ways.  First, perhaps reading about these challenges reminds us we are not alone in finding this work tough and also that having poor engagement with some parents, parent drop out etc – is not primarily about therapist lack of skill.   Second, I’m hoping this list of barriers provides a way of us more easily identifying which of the specific challenges is in play at any given moment.  It’s too easy to clump difficulties into a “its all too hard” basket without carefully considering exactly what is preventing parent engagement.  This “all too hard” feeling effectively stops us being able to overcome barriers.  If we can instead be more specific – with ourselves, our supervisors and parents themselves – as to what is getting in the way of effective parent work, we may be able to figure out a place to start in overcoming the specific problems.

I’d like to here state on record my belief that each of these hurdles and challenges can be overcome and surmounted, at least with many of the families we work with.  It’s not easy, and takes a lot of creativity, supervision, persistence and honest, open collaborative conversations – but I am convinced that we can work with many parents effectively and in ways which lead to positive, meaningful and long term change, even in the presence of all of these barriers listed above.

Moving forward

I think working effectively with parents means holding the two concepts I’ve covered in this article in mind simultaneously. In other words, we should remember both that:  a) working with parents is likely to be vital to improving child/youth mental health outcomes for many, and for some, possibly far more important than what we might do with these children themselves and also b) doing this work it is full of real challenges and difficulties which are not insignificant, and need careful addressing.

I have admiration and respect for all of the therapists out there who wade into and swim around in this choppy sea of work with families on a weekly basis.  As always, best wishes with your endeavours to find the energy, humility and compassion needed to persist and work effectively for the good of the children you support.

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