کارهای بالینی با رفتار ضداجتماعی در پسران: مصاحبه ها با تیم های بالینی در روانپزشکی فرزند و نوجوانان سوئدی

Abstract Introduction The aim with this study was to deepen the understanding of contextual aspects in child psychiatric clinical work with boys displaying antisocial behaviour. Method An explorative, qualitative approach, based on team narrations of authentic cases, was used.

Introduction Clinical work with children displaying antisocial behaviour implies diagnosing as well as planning and carrying out treatment interventions. The undertaking of these tasks can be vital for the clinician to provide appropriate support for the child and family (Garb, 1998). Considering that boys with an early start (before ten years) of serious aggressive and antisocial behaviour seem to have an elevated risk for an antisocial lifestyle in adulthood (Moffitt, 1993 and Stattin & Magnusson, 1991) and poorer mental health in general (Loeber & Farrington, 1998 and Loeber & Farrington, 2001), thoughtful and comprehensive clinical decision-making could be of importance to nip disruptive behaviours in the bud. Unfortunately, evaluations of clinical work with children with antisocial behaviour indicate that many of these children do not obtain efficient management (e.g. Barnpsykiatrikommittén, 1998; compare Loeber & Farrington, 2001). Evidence-based practices (here used as a shorthand term for the scientifically evaluated assessments and treatments) could be of importance for helping the clinicians when assessing and treating children with antisocial behaviour. To deal with limitations in clinical work, decision-making and treatment of these children has therefore been supplied with ample prescriptive research-based suggestions. Firstly, recommendations are made of how to conduct assessments. Standardized structured instruments or screening questionnaires evaluated in research are proposed, since these have been shown to result in more reliable and valid diagnoses or estimations of antisocial behaviour (Borum, 2000, Garb, 1998 and Loeber & Farrington, 2001). Secondly, interventions have been acknowledged that can prevent antisocial behaviour from escalating and reduce oppositional and conduct-disordered behaviours (e.g. Chambless & Hollon, 1998 and Fonagy & Kurtz, 2002). Parent management training and problem solving training for children illustrate such empirically supported treatments suggested for use in clinical practices. Thirdly, albeit less thoroughly documented, interprofessional and multi-disciplinary teamwork has been suggested an organizational strategy to improve clinical work for children with severe mental health problems such as conduct disorder (Walker, 2003 and Williams, 2002). However, some children with antisocial behaviour do not improve their behaviour even when empirically supported management is accomplished. Research studies suggest that approximately one-third of families receiving parent management training for having a child with antisocial behaviour do not report any change for the better (Fonagy & Kurtz, 2002). Reduced responsiveness has for instance been found associated to poorer household circumstances, more socially disadvantaged situations (Routh, Hill, Steele, Elliott, & Dewey, 1995), maternal depression (Webster-Stratton, 1996) and higher level of child psychopathology (Ruma, Burke, & Thompson, 1996). Thus, there might be aspects hitherto not covered in empirically supported treatment manuals that could complicate the management. Another problem concerns the fact that when evidence-based practices are employed in a clinical setting, there is no guarantee that the outcomes are similar to those obtained in research (Hoagwood, Burns, Kiser, Ringeisen, & Shoenwald, 2001). Since most procedures have been constructed and evaluated in research situations, there might be other aspects relevant from a clinical point of view that have not been recognized or considered (Elbogen, 2002). Accordingly, there is a risk that even well validated practices will lack ecological validity and clinical usefulness. Given the serious nature of the deviant behaviour, especially with early-onset antisocial behaviour in boys, it is a problem that we do not know enough about how to support these children and their families when they are referred to the clinic. One suggested strategy for understanding aspects that might hamper the implementation of interventions or impede the usefulness of procedures is to collect information about the clinical context of interest (Elbogen, 2002, Mulvey & Lidz, 1995 and Sullivan, 1998). This study was an attempt to generate an understanding of how contextually relevant aspects may relate to clinical work with young boys displaying antisocial behaviour. More specifically, the aim was to understand relevant aspects encountered during work and how these can be related to prescriptive recommendations in evidence-based practices.

3. Results During the analysis, three broad categories emerged (see Table 2). The first of these categories concerned case characteristics related to the boy, and seems to relate to a maturing understanding of the child's difficulties and how these were to be managed. The second describes the importance of collaboration and consent with parents as well as clinicians, whereas the third category illustrates why work with other caregivers sometimes succeeded. Table 2. Categories and themes identified from narrative interviews with clinical teams Categories 1.Descriptions of the child's problems and treatment needs 2. Interdependence of caregivers 3. Ways of solving the challenges Themes a) The boys displayed a plethora of complex problems a) The necessity of collaboration a) Collaboration early in the process b) Different psychological perspectives influence the understanding of the boy's problem b) The lack of consent as a barrier b) Professional consent as a communicative tool c) The link between need and interventions for the boy c) Uncertainty regarding financial accountability and case responsibility c) Clarification of roles and responsibility d) Parental needs d) Reliance on key persons e) Emotions and metaphors related to the boy's behaviour e) Professional networking f) The format, intensity and duration of the treatment Table options We describe the three categories and their related themes separately, even if these were talked about simultaneously. 3.1. Descriptions of the child's problems and treatment needs When trying to understand the antisocial behaviour of the boy, the teams considered not only his difficulties and needs. The whole system around him, including the family and school, was taken into account. Importantly, the boy's problems and the planning for his treatment were not described sequentially. Instead, they were depicted as being intertwined during the process of working with the child and family. 3.1.1. The boys displayed a plethora of complex problems The narrations of the cases revealed differences between the psychiatric diagnoses or problematic behaviour of the children. Three teams described boys with AD/HD, whereof two boys additionally had autistic traits and Tourette's syndrome. One team chose to describe a boy with antisocial behaviour and a possible emanating psychosis. Another team described antisocial behaviour involving hyperactivity problems and personality traits interpreted as psychopathic. The sixth team focused mainly on the aggressive behaviour in school of a boy with AD/HD. The seventh team described a boy with Asperger syndrome and severe aggressive behaviour. Thus, the antisocial behaviour of the boys varied. Despite each case being unique, a common theme appeared to be the multitude of problematic areas for these children. Thus, other disorders or problems that appeared at the same time, for example suicidal thoughts or an antisocial family, added complexity to the overall picture. Example 1 (C) “He had also made some kind of suicidal attempt” (N) “Yes, that's correct, he is …when he is very upset he becomes self-destructive, or at least threatens to be, he has held up a knife against himself at home. And he has said that he wants to take his life and that he doesn't want to live.” 3.1.2. Different psychological perspectives influence the understanding of the boy's problem The team members, as well as the various teams, discussed their understanding of the child's problems and treatment needs by using different theoretical models. The theoretical models and perspectives referred to could be identified as medical, neuropsychological, psychodynamic, family systemic or cognitive-behavioural. All teams mentioned the medical/neuropsychological perspective in their consideration of a DSM-IV diagnosis (American Psychiatric Association, 1994), such as AD/HD, Conduct Disorder or Asperger syndrome. This was done in combination with one or two psychological theories, which appeared to differ between the clinics. In the following example, the team made use of a combined family systemic and neuropsychological perspective. Example 2 (C) “I think there were a lot of complicating circumstances related to both of them, so to speak. The father's difficulties and a very special mother who triggers…well this is unfortunate, it is stored on top of each other, a boy with co-morbidity (authors note: ADHD, oppositional defiant syndrome, autism spectrum disorder)…that is not a very nice combination. And then a parent with this inconsistent way of behaving towards him. It adds up, this, in a sense it is life threatening; if it's been going on for twelve years I can understand that this is the way it looks.” In the next example, the team seemed to make use of a combined psychodynamic and neuropsychological perspective, which can be noticed in the description of DSM-IV diagnoses and attachment style. Example 3 (C) “And I mean, that discussion is imbedded in their evaluation that there are both autistic traits …yes, traits from the autism spectrum, tourette and adhd. So I mean, all of these are combined with the attachment to the mother and relation between husband–wife and the lack of space at home and to some degree the abuse of alcohol.” The different perspectives were also obvious between team members, as illustrated in the following excerpt of psychodynamic and neuropsychological perspectives. Example 4 (C) “But I mean, you made a clear projective dynamic interpretation of his strong anxiety” (P) “Yes, but also … a big part of my evaluation confirmed the neuropsychological difficulties.” Throughout the discussions, the different internal team members did not seem to vary in which main aspects they considered, but rather in how they made sense of these and communicated about them. For instance, when teams discussed problems in the child–parent relationship, these could be interpreted as either attachment problems (psychodynamic) or as inconsistencies in parenting (family systemic/cognitive behavioural). 3.1.3. The link between need and interventions for the boy All teams discussed at least one established treatment method of known value, like medical treatment, cognitive–behavioural therapy or multi-component psycho-educative therapy. Additionally, all teams described less specific treatment efforts, not necessarily related to any special method or established treatment. These could be described as the need to loosen up a tight relationship, establish rules or having a structured environment at home. Example 5 (S) We talked a lot about routines and structures, we draw schemes and discussed them, yes.” Teams with a neuropsychological focus were more elaborate than others when describing the motivation for why specific interventions were needed. Here, certain treatment aspects (e.g. pictogram, speech therapist) were motivated through assessed cognitive deficits. A diagnosis like AD/HD was also rather directly related to structural aspects in the setting (e.g. small class in school) or to medical treatments. 3.1.4. Parental needs Another observation concerned the teams' descriptions of how they considered the ability and personality of the parents. When pertinent, the teams mentioned having recommended and/or conducted medical or psychological interventions for parents, as well. Example 6 (C) “But I actually had to put the father on sick-leave..” (S) “You have been a doctor in this sense, too, for the mother also who had some cough or cold …” 3.1.5. Emotions and metaphors related to the boy's behaviour The teams discussed the alarming feelings that they and other caregivers experienced in relation to the boys' behaviour. Aggressive behaviour was described as creating “panic” and “disruption”. In such errands, those involved expressed the need for something to happen quickly, as seen in following example. Example 7 (P) “Aggressive children who act out arise much more concern among all those involved. Both school, parents, and all this about actions and interventions …well there is more anxiety, one wants things to happen immediately, you know …” (S) “…it creates panic, it creates disruption. And it creates all sorts of things, the tempo is very high.” Several times a parent was perceived as being afraid of his/her son. This affected the possibility to work with established routines and limits in the home, as seen in following excerpt. Example 8 (T) “We had the ambition to work with boundaries and routines and such, because that was what the mother asked for. He did not respect her, everything was supposed to go his way, but as (N) said, we had to drop that rather quickly because the mother was afraid of him. (C) “At the same time she said she had tried everything, so in a way she destroyed the tools you tried to use. Your hands were tied to the back in a way I have never experienced before.” The level of seriousness of the problem was discussed in relation to personal feelings that the team members experienced when working with these children. Emotions such as “fear”, “concern”, or “worry” were those most frequently referred to. Example 9 (fear) (T) “I know that I had a stomach pain, because this was the first time I saw such ‘evil’, well maybe this is wrong, yes evil, I saw evil in the boy that I have never seen in other children. This was really frightening.” The emotions could be related to images of future manifestations of the child's behaviour, i.e. whether the boy would continue behaving in a problematic way or not. Several teams reflected on images or metaphors to communicate concern or discuss predictions of future development. Example 10 (image) (T) “I was so…. this is why I think of him sometimes, because normally I forget children but this one I remember. I keep thinking ‘soon he will be on the first page of (newspaper) next to Ann Nicole'. Like this, ‘she wastes millions, he shoots…'.” Example 11 (metaphor) (C) “It's five to twelve and it's five after twelve already.” These experiences and images of the clinicians seemed to influence the discussions on the format and intensity of the treatment. 3.1.6. The format, intensity and duration of the treatment Team discussions of format, intensity and duration of treatment seemed to be influenced by type of antisocial behaviour as well as its severity in relation to the boy's environment. These topics included discussions about whether or not to recommend individual or group treatment for the child or family. Other available methods were to offer supervision to other organizations, to initiate multi-component treatments, or arrange for outpatient or in-patient facilities. The choice of treatment seemed to be based both on the child's needs and, if needed, on the ambition to protect the environment and the family from the child. Example 12 (C) “Well, I said that too, he must not return home and treat his little sister like that… a way of disclosing that the father could not deal with the situation. His sister was at risk.” The choice of format and intensity was also dependent on the availability of the team members themselves and the resources at the clinic. When referring to the duration of the treatment, three teams reflected on that some children and families probably would be in need of a long contact with the clinic. Example 13 (P) “Well, anyway, at that moment neither S nor myself are involved, but we are in a sense ‘stand-by’. To wait and see (…) He will need help for a very long time, both during his first school years and later during adolescence.” Four teams expressed that the families needed more treatment than what was possible to give, which meant that the interventions suggested or offered never seemed sufficient. Example 14 (S) “And then C says, ‘hey S, so many interventions, and it is never enough?’ It is as if we never did anything. And then you say, we have done this and this, it's very easy to forget how many actions we have taken because it feels as if it is never enough.'” Sometimes the call for more treatment reflected a difficulty to get the child and family to participate in the treatment sessions. Example 15 (C) “He hasn't finished. He has been here on and off, not the way they would like it to be, those who run the group, but he is still on.” (S) “He has been missing an awful lot, more than half of the sessions (…) It's all kind of floating.” 3.2. The interdependence of caregivers The second category that emerged was a combination of different aspects related to the overall case management. The teams emphasized the importance of collaboration and consent with parents as well as professionals. The need for collaboration and consent created interdependence across agencies. Consent, i.e. achieving a common view of the boy's needs and how these should be cared for, was discussed as a precondition to obtain collaboration. Both consent and collaboration were described as difficult to achieve. The following three themes emerged during the discussions of the aspects of collaboration with other caregivers. 3.2.1. The necessity of collaboration Collaboration was referred to as how team members worked together in the team or with other professionals outside their own clinical setting. This was at times discussed as a prerequisite to arrange for family support. This is illustrated in the following example. Example 16 (S) “That an intensive collaboration is attained between school, child and adolescent psychiatry, social welfare, that you can say that you collaborate tight together. I think that is a model to be used for these boys — a close network is needed, where the parents are seen as partners, involved, as tight as possible and all working together.” In addition to emphasizing the need for collaboration, the teams referred to the value of a continuous internal discussion of how to manage a complicated case. Example 17 (S) “In a case like this, a lot of resources are needed, and there are lots of risks so it feels extremely important not to be left on your own, that you can discuss together and that you take different parts.” Collaboration was recognized as important, but it could have negative consequences. Even if the team members had a clear vision of the needs of a certain case, collaboration with others was perceived as time consuming and delaying the planned interventions. Such situations caused frustration in the team. Example 18 (P) “It takes far too long time before he gets the right help (author's note: from social welfare).” (S) “My first thought too. That it is so hard to arrange for his needs that you capture so early. Really tough.” (P) “We thought that we understood the seriousness very early” (C) “One can wonder why the process seems to get stuck in such a horrible way.” 3.2.2. The lack of consent as a barrier One of the main difficulties was the difficulty to establish consent in how to evaluate the case and what kind of treatment was needed. This lack of consent was explained by differences in ideological views, for example in relation to social services, schools, and families. Example 19 (T) “The main problem as I see it is the unwillingness from the school to see that neuropsychological disorders at all exist.// We find ourselves in an ideological conflict, really tough for us to handle because it is not really conscious, not for them nor for us.// And then we represent different cultures. We are a medical speciality and they are in some way an educational agency, we have different ways of thinking and being, we have different customs. We have different managers who don't seem to cooperate either //. It is fantastic that we manage as well as we do sometimes (laughter)!” 3.2.3. Uncertainty regarding financial accountability and case responsibility Another management barrier was related to issues of economic character and case responsibility. An important question was whether or not the child and adolescent psychiatry should pay for treatments, or if the social services or the school authorities should be considered liable. Example 20 (S) “I also believe there are difficulties when collaborating around a boy who is in need both of social welfare and our interventions (author's note:child and adolescent psychiatry). (…) It is also a question of economy, who should pay for the costs, and this becomes an obstacle regarding the treatment he is offered. Those in the system somehow need to find a way to agree.” The uncertainty as to who was ultimately responsible could result in delay and frustration. In the following excerpt, it appeared as if the child and the family were being handled like “hot potatoes” that were shovelled around within or in between agencies. This example also illustrates that organizational strain in one agency may influence the possibility for the other to pursue their work. Example 21 (C) “Yes, and this referral was delayed and discussed on conferences between the two agencies, and it was pushed back and forth, and then the summer came, and then …then one agency which was heavily loaded with difficult cases said ‘we cannot prioritise this’… and then it was shovelled off to another clinic…” 3.3. Ways of solving the challenges Regardless of degree of complexity in each case, the teams still had to find their way forward. The final category was related to an emerging understanding of why the work with other caregivers sometimes succeeded. Five different strategies used were identified from the descriptions. 3.3.1. Collaboration early in the process Some teams pointed out that it could be helpful to engage the family or other agencies in the discussion early on in the management process. This seemed to be a possible strategy to enhance agreement and consent between agencies and with parents, thus increasing later possibilities for collaboration. Example 22 (S) “And if you see it the other way around, that social welfare many times, and I think this is really important, that they get angry because we have found that the boy needs to go to a treatment home. If they instead are involved in the process.“ (C) “Yes, that is right, that you talk about collaboration in advance, so that it (author's note: treatment needs) doesn't become something we say.” (S) “No, the fact that they are with us from the beginning makes it easier both for them and for us.” 3.3.2. Professional consent as a communicative tool Another solution was to strive for a uniform professional communication with the caregiver. Given that the clinicians had achieved the goal of sharing a common view of the case, the communication with the caregiver was facilitated. In the following example, the nurse and medical doctor describe both the mother's statement of understanding the problematic behaviour of her child, and how the team had used reiteration as a successful tool. Example 23 (N) “The mother felt that one of the things she obtained from her stay was that she understood how serious the problem was.” (C) “We kept repeating, we were two medical doctors, one social worker and several treatment personnel and we all said the same thing all the time from different perspectives. So I think we worked collectively with being clear and straight in communicating.” 3.3.3. Clarification of roles and responsibility Clarification of roles and responsibilities was pointed out as decisive for managing the case. Example 24 (S) “It is extremely important to clarify who does what. This is for us in child psychiatry to see to, that and that belong to social services, and that other part to the school. That is, unambiguous roles, and that you know your responsibility.” 3.3.4. Reliance on key persons The localisation of a key person within other organizations with whom the team could cooperate was discussed as an opportunity that might improve collaboration and work with the caregivers. A troublesome fact mentioned by the teams was the high professional turn over. Key persons repeatedly were found to be on sick leave or had changed jobs. Example 25 (C) “But as you say, if the social welfare assistant, if she had stayed at the work and if that evaluative meeting had been undertaken, she hadn't… now they did everything over again, made a new investigation. They had been in this process of deciding where he was to be placed, and now they were investigating again.” (P) “Half a year that passed by…” (C) “… as if her work wasn't done.//” (S) “… yes, but I guess that it is that way, that when important people disappear, our work gets so hard. I think abut a teacher that he liked and trusted// good contacts are very important when it is as troublesome as it was in this case.” 3.3.5. Professional networking Two teams said they had been involved in work projects that included several agencies in the local community. Among these teams, this was discussed as a promising strategy to improve flexibility in organizations and resulting in further contacts with persons of different competences. Example 26 (T) “But the collaboration project has helped in this//” (T) “Yes, that is true” (T) “… to be able to cooperate and see what is needed, these children need that, regardless of who will pay for the costs or which organizational responsibility it is. //” (T) “School, child and adolescent psychiatry, rehabilitation services, social welfare are all involved.//” (C) “In the project team, all of these organizations and different professional roles are represented.”