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Article 74
Culture-Centered Pediatric Counseling Interventions for Young Children
Paper based on a program presented at the 2011 ACES Conference, Nashville, TN, October 27, 2011.
Traditionally, it has been stated that the developmental and preventative assumptions in counseling are defining aspects of the profession and aid in differentiating counseling from other helping professions (Ginter, 1991; Hershenson & Strein, 1991; Kiselica & Look, 1993; Matthews & Skowron, 2004; Myers & Sweeney, 2008). Over the past 30 years, counseling scholars have employed these ideals in research investigations to focus on various client issues, such as eating disorders (Choate & Schwitzer, 2009), suicide (Roswarski & Dunn, 2009), and high risk families (Hogue, Liddle, Becker, & Johnson-Leckrone, 2002). A search for empirical studies in counselor education journals produced by divisions and special interest groups within the American Counseling Association over the past two decades yielded less than ten articles with a focus on direct clinical intervention and prevention with young children (ages 0 to 5 years), especially those from culturally diverse families. Using the pedagogy of counseling as a framework (Nelson & Neufeldt, 1998), the authors articulate an approach to counseling young children they refer to as pediatric counseling. The authors articulate a rationale for the application of core counseling principles to conceptualize, prevent, and intervene when posed with obstacles to young children’s healthy development in the first years of life. Recommendations for counselor training are provided as well as suggestions for future research to advance this body of knowledge.
Review of the Literature
Three main concerns provide the rational for addressing the concerns of young children ages 0 to 5 years. They are young children’s mental health issues, current mental health providers’ responses, and deficits in counselors’ training. Professional counselors working with children often employ adult theories applied in play therapies using toys and expressive mediums (Landreth, 2002). However, such tools are more appropriate for school-age children to express emotions and experiences (Blanco & Ray, 2011). Thus, counselors need to apply an understanding of the intersection of various developmental issues when working with and investigating the needs of young children (Finkelhor, Ormrod, & Turner, 2009).
Young Children’s Mental Health Issues
In discussing young children’s mental health issues, it is important to identify their personal-social interactions, such as developmental delays and environmental influences. Moreover, these interactions can result in mood-related concerns. It should be noted that these three areas must be viewed with a cultural lens as developmental, environmental, and assessment for mood-related disorders should take into account the client’s cultural worldviews.
Developmental delays. Normal child development is often conceptualized using the individual and social relationships between young children and their caregivers as measures of healthy development. Healthy development has been shown to be largely dependent on one’s social environment (Nuru-Jeter, Sarsour, Jutte, & Thomas Boyce, 2010). When young children experience developmental obstacles, such as events that are negative, sudden, and/or out of control (Goodman & West-Olatunji, 2008), they can experience developmental challenges. These experiences are often complex and difficult to assess in those affected (Follette, Palm, & Pearson, 2006), as the effects are often multidimensional and impacting numerous domains of life (Follette & Vijay, 2009).
When children cannot make sense of their sensory information due to chronic stress, they often exhibit acting out behaviors and distress (Johnson, 1997). In the long- term, chronic stress or trauma can confuse understanding and make transitions in peer relationships difficult. Children’s attempts to cope may present as increased aggression, enuresis, sleep disturbances, nightmares, extreme fear of the dark and of enclosed spaces, and intense hypervigilance in anticipation of another traumatic event (Lipovsky, n.d.; Macy, Macy, Gross, & Brighton, 2003). It can lead to trouble regulating anger and the making of connections with others in the second and third years (Gaensbauer & Siegel, 1995). Caregivers of traumatized infants and young children are challenged by the child’s intensified need for security, regressive behavioral and physiological functioning, and increased levels of worry or anxiety.
Environmental influences. Traumatic experiences often result in symptoms that appear at times unrelated to crisis (Johnson, 1997). During extreme stress the result can be faulty memory encoding and retrieval and over- or under-responsiveness to stress. The emotional responses acquired this way become highly resistant to extinction (Suomi & Levine, 1998). Nuru-Jeter et al., (2010) showed that social stressors during early childhood and basal cortisol levels (stress hormones) show a significant inverse relationship, thus the higher the stress the lower the child’s ability to respond to social conditions. Chronic stress can interrupt higher cognitive functions such as planning, working memory, and mental flexibility, interrupting children’s sense of sequence, context, and story (Johanson, 2006; Wilkerson, Johnson, & Johnson, 2008) around an event or experience.
Mood-related concerns. These traumatic experiences can result in an entangled experience of acting out and experiencing distress (Johnson, 1997), especially when the children cannot make sense of the sensory information. In the long-term, trauma confuses an understanding around the origin of the developmental obstacle and makes transitions in peer relationships difficult. A most difficult challenge for caregivers of traumatized infants and young children is that these children have an intensified need for security, tend to have regressive behavioral and physiological functioning, and increased levels of worry or anxiety (Gaensbauer & Siegel, 1995). Children will attempt to cope with these challenges anticipating another traumatic event (Lipovsky, n.d.), leading to disconnection with others, including parents and care givers (Gaensbauer & Siegel, 1995). The resulting isolation has detrimental effects on development, as early experiences are heavily influenced by attachment behaviors (Delius, Bovenschen, & Spangler, 2008).
Chronic stress has been shown to interrupt many developmental functions affecting behavioral control and other important executive functions such as working memory, reasoning, and goal-setting (Nuru-Jeter et al., 2010). The dynamic nature of development (Walker & Archibald, 2006) stagnates in the absence of such interpersonal variables as encouragement, sensitivity, consistency, security, and responsive social- emotional interactions that can be protective of disturbances and traumatic experiences (Andreassen & West, 2007; Lounds, Borkowski, Whitman, Maxwell, & Weed, 2005). This is particularly important around the third year of children’s lives, as this is when they begin to learn the culturally appropriate attachment and self-orientations that will allow them to navigate the many relationships they encounter (Delius et al., 2008; Imamoğlu & Imamoğlu, 2010; Sümer & Kağitçibaşi, 2010).
Given these concerns that are specific to this age group, counselors should have knowledge about how to intervene directly with young children. Unfortunately, service providers currently: (a) lack the ability to detect emotional or psychological problems in young children (Horwitz et al., 2007; Weitzman & Leventhal, 2006) or (b) work exclusively through the parents or caregivers (Sweet & Applebaum, 2004).
Current Service Provider Responses
The point of entry for preschool children to receive mental health services is often pediatric medical or other health care professionals. Doctors often lack training in skillful detection of emotional or psychological troubles that are linked to physical health concerns (Horwitz et al., 2007; Weitzman & Leventhal, 2006). This often results in delays, taking months or years for mental health difficulties to be identified. Further, uninsured children across ethno-cultural backgrounds from impoverished families and culturally and socially relegated children, such as Latinos and African Americans, are excessively identified with mental health concerns. Once young children’s mental health concerns have been identified as a problem or crisis, the focus tends to be on parents and caregiving interventions that are expected to trickle down to the child rather than providing direct services with children (Sweet & Applebaum, 2004). Given this lack of attention to children’s developmental needs when there are emotional and psychological problems presenting, counselors would do well to fill this void. With its focus on developmental needs and prevention (Myers & Sweeney, 2008), the discipline of counseling shows promise as a contributor to serving the mental health needs of young children.
Counselor Training and Young Children
Counseling as a discipline distinguishes itself from other mental health disciplines by asserting its main focus on human development and prevention in the belief that these characteristics would foster expediency in the resolution of client issues (Council for the Accreditation of Counseling and Related Educational Programs [CACREP], 2009). While counselors have distinguished themselves within the mental health professions in various settings and among diverse client populations, little work has been done to investigate counselors’ roles in working with young children from birth to 5 years of age. A search of counselor education journals over the past 20 years for empirical articles with a focus on direct interventions with young children yielded less than ten publications.
Grounded in human development ideals, counselors conceptualize clients’ concerns within the context of their developmental goals and needs (Sue & Sue, 2008). Thus, counselors are acutely aware, for instance, that adolescents might react to trauma in more divergent ways than their early childhood counterparts. Depending on the stage of development, the interventions used will vary.
Additionally, counselors focus on prevention of mental health issues, which suggests the need for early identification of emotional, psychological, physical, and cognitive problems (Mellin & Pertuit, 2009). This is particularly important when working with children who might have compounded stressors due to social factors, such as poverty, that might predispose parents/caregivers to seek mental health services. Moreover, prevention services in the early years are also less costly than remediation in pre-adolescence or adulthood (Karoly et al., 1998).
Cultural competence. Several problems can arise from solely applying theories based on Western beliefs and values, such as cultural encapsulation, equating ethnicity with culture, rigid matching of techniques to stereotype without taking cultural salience of the individual into account, and the complexity and broadness of the definition of culture (Wolfgang, Frazier, West-Olatunji, & Barrett, 2012). Pedersen (2008) raised concerns regarding ethical and moral dilemmas for culturally competent counselors and the need to further develop multicultural competencies within the profession. Nwachuku and Ivey (1991) asserted that culture-centered interventions should reflect culturally specific characteristics as articulated by clients and that they represent rites or behavioral norms within particular cultures. By utilizing (a) their training in meeting developmental needs and prevention practices and (b) further developing proper training for the counseling of young children in a culturally sensitive manner, counselors will be able to address young children’s unique needs and experiences in order to remediate and foster resilience during the early childhood years.
Pediatric Counseling: Working With Young Children
Pediatric counseling is an approach to working with young children, ages 0 to 5 years, that employs the basic assumptions of the discipline of counseling, utilizing an array of theoretical approaches and interventions that incorporate cultural aspects of the child’s family and community, involves more than play therapy, and promotes a sense of professionalism within and outside of the counseling profession. As stated previously, essential to the discipline of counseling is a focus on clients’ developmental needs and prevention. Counseling service delivery with young children would necessitate an understanding of the developmental concerns of children from birth through entry into primary school in order for counselors to assess children’s presentation of symptoms as they do with school-aged children and adults. Additionally, by focusing on young children as a client population, counselors would inherently focus on prevention rather than waiting until children achieve developmental competence to articulate their concerns. Interventions with infants, toddlers, and preschool children can help to deter long-term effects of trauma and other obstacles to children’s growth and development (Johnson, 1997).
While there are varying perspectives on the use of a theory in intervening with clients (Thompson, Rudolph, & Henderson, 2004), pediatric counseling relies on the use of an array of theoretical frameworks to guide assessment and interventions. According to Lazarus (2000), a multimodal approach is needed to effectively work with children. As such, pediatric counseling requires knowledge and use of theoretical assumptions to guide effective service delivery. Pediatric counseling expertise relies on counselors’ familiarity with not only conventional counseling theories, such as Gestalt, person- centered, and cognitive-behavioral, for example, but also culture-centered counseling theories and techniques, such as NTU (Wynn & West-Olatunji, 2009), Ayeli (Garrett, Brubaker, Torres-Rivera, West-Olatunji, & Conwill, 2008), and Cuento (Constantino, Malgady, & Rogler, 1986) therapies.
The basic components of play therapy allow children to communicate their experiences and emotions in an instinctive, self-healing process (White & Allers, 1994). It is expected that play therapists incorporate developmental aspects, symbolism, safety, and physical space for the therapeutic process (Thompson et al., 2004). Pediatric counseling incorporates these elements but also includes developmentally appropriate mental health counseling techniques that allow more than expression and provide movement in young children towards self-definition, contextualization, and transformation of their reality.
Finally, pediatric counseling allows counselors to develop expertise with young children within and beyond the counseling profession. One of the criticisms of the use of the term, play therapy, is the implicit positioning of play therapists as marginalized mental health professionals (Siu, 2010). Due to the fact that the term play therapy can include more than licensed mental health professionals, it lacks the credibility needed to be respected. Use of a more rigorous term and associated skills allows counselors to establish themselves as capable and useful providers for young children among the community of mental health professionals.
Culture-Centered Counseling Interventions
In addition to conceptualizing children in relation to their families and cultural values, counselors using Pediatric Counseling as an approach should incorporate culturally specific interventions. One such intervention involves the use of popsicle sticks wherein the counselor facilitates expressive and emotional releasing experiences for the child.
While popsicle sticks are typically used in play therapy with school-aged children (Landreth, Ray & Bratton, 2009), these tools are employed in pediatric counseling to create dolls that represent the family members in a child’s ecology. This project begins in session with the counselor instructing the child to creatively decorate the popsicle stick with craft materials, such as yarn for hair, felt for clothing, etc. Then, the counselor directs the parent/caregiver to continue making more dolls at home with popsicle sticks to represent other family members. Next, the counselor continues the parent(s)/child dyad or triad work in the subsequent session, asking the caregiver(s) and child to share the newly made dolls in session and describe each new represented family member. In the following sessions, the counselor uses the dolls with the child in individual counseling sessions to allow the child to utilize the dolls to articulate experiences. By asking the child and parent(s)/caregiver(s) to design the popsicle sticks to reflect their eco-system, the counselor relies on the clients own worldviews in constructing representative family members. Additionally, co-construction of knowledge is at the core of this therapeutic intervention as the child explains and articulates each member of the family as well as the dynamics between them. Thus, the use of the popsicle sticks goes beyond articulation of play to culture-centered family eco-system definition and promotion of parent-child interactions.
Another culture-centered counseling intervention reflected in pediatric counseling is the use of feeling faces to allow children to match their feelings with the emotions depicted on laminated playing cards that have the faces of real children showing various emotions. Cards are placed face up on a table in groups of five at a time. Children are asked to point out a face that appeals to them. The counselor then asks the child to draw a picture that relates to the face selected. After the picture is drawn, the counselor asks the child to express his/her own feelings about the picture. This is often used with a mirror so that the child can see an image of his/her own facial expressions. The counselor then takes a picture of the child’s facial expression next to the picture. This process is repeated with five more pictures until all the feeling face cards are exhausted. These images are studied for similar themes across pictures and facial expressions. Then, they are subsequently used for case conceptualization and associated treatment. This intervention allows the counselor to see what the children value in the faces and their associate meanings. Also, the counselor is able to see what emotional expressions children pay attention to and how they express them. Thus, use of the feeling faces activity allows the counselor to reciprocate with the child in ways that are culturally recognizable to children. By utilizing knowledge about young children’s developmental needs and experiences, providing preventative experiences for client’s, and formulating interventions from a culture-centered framework, counselors can create culturally competent direct counseling practices with young children ages 0 to 5.
Discussion
In order to promote pediatric counseling within the profession, it is important to incorporate training at the pre-service level. Counselor educators need to include young children’s developmental issues within the discussion of human development across the lifespan. Additionally, it would be beneficial to insert a full course on young children’s development as an elective. Other courses that would advance this content area include courses on: (a) multicultural counseling of young children, (b) ecosystemic issues when counseling young children, (c) pediatric counseling interventions, and (d) social justice counseling for young children. For practicing counselors, the development of a post- master’s certificate program would assist professional counselors in developing initial competence in this area. Other opportunities for professional development would include professional development institutes at annual conventions and specialized trainings wherein practitioners could earn continuing education units (CEUs).
Future Research
As stated previously, additional counseling research is warranted to advance our understanding of counseling young children. The authors suggest a Delphi study to further conceptualize key characteristics of pediatric counseling that are related to counseling pedagogy. The purpose of a Delphi study method is to use a systematic approach to elicit perceptions or judgments held by experts who are knowledgeable in a specialized area. The opinions are then refined through subsequent reviews, with the eventual outcome being a converging consensus about a given subject (Vázquez-Ramos, Leahy, & Estrada Hernández, 2007; Solmonson, Roaten, & Cheryl, 2010). Delphi studies commonly have three to five rounds of research (Mellin & Pertuit, 2009). This is a flexible and time efficient way to come to consensus and predict future ideas in the field (Fish & Busby, 2005). This method of research would be ideal in moving forward with this area of counseling. It would provide valid, reliable feedback from current experts on how to address the issue of pediatric counseling and clarify it against the backdrop of other contemporary practices utilized today.
In conclusion, the pediatric counseling paradigm has much to offer young clients, especially those aged 0 to 5 years. Scholars have stated the importance of investigating both the sources of systemic traumas and the resolution of consequent client presenting problems in accordance with clients’ cultural backgrounds. An alternative pedagogy, pediatric counseling, is in alignment with core counseling principles, such as prevention, human development, and cultural competence. Counseling young children has the potential to impact the scope and depth of counselor efficacy, especially when working with culturally diverse young clients. Through a multicultural, preventive, and developmental lens, counselors’ practices can be enriched when they have a better understanding of clients’ environmentally embedded presenting problems. Further research in conceptualizing and treating young children’s developmental concerns is central to advancing the profession.
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