Emergencies, incidents, disasters, and disease outbreaks (EIDD) affect children, young people, and their families in many ways, including across generations through epigenetic effects. Their mental wellbeing, life, and routines that continue beyond their injury, illness, or adversity can each be affected. Their reactions and responses can be influenced by the nature and extent of their exposure, personal characteristics, pre-existing vulnerabilities and strengths, and in particular by the family and social support that is offered. Almost all adverse childhood experiences are likely to increase in pandemics and following disasters due to natural and human-induced hazards. Psychosocial problems linked with emergencies are likely to emerge over the year following these events. Social connectedness and social scaffolding mitigate adversity, and promote wellbeing and recovery. This emphasises the importance of a co-ordinated and strategically aligned, psychosocially informed, and evidence-based governmental and system-wide response working across boundaries to support children and families in such crises.

We want to emphasise the importance of psychoeducation (PE) as an active intervention in clinical BPI practice. As noted already, PE was originally considered as a passive aid to medical treatments rather than an active therapeutic agent. For example, it is highly likely that PE enhances adherence and collaborative working in any intervention through explaining the implications of treatment to the patient. This is undoubtedly a useful mediating process but in BPI practice we want the therapist to utilise PE from the perspective that it acts as a therapeutic change element of treatment. For BPI practice, PE is the conversational delivery vehicle for information about how to understand mental states, engage in adaptive activities and habilitate and use new understandings and strategies to promote well-being and resilience in the face of future adversities. Whilst the focus is directly on the adolescent, such PE can also be delivered to important others such as family, carers and teachers, with the consent of the YP.

This chapter describes the clinical methods that most likely make the best use of the clinical tools described in Chapters 3 and 6. First, we describe the three BPI domains of psychoeducation, social and personal prescribing and habilitation that constitute the framework of BPI.

The Notion That The Teenage Years Have Any Particular Value In Social, Cultural Or Biological Terms Does Not Appear In Any Literature Until The Fifteenth Century. Before Then, Received Wisdom Was That Infancy And Childhood Were Followed By Adulthood And All That Goes With Being A Grown-Up Individual In Any Society. The Word ‘Adolescence’ Came From The Latin Word Adolescere, Meaning ‘To Grow Up Or To Grow Into Maturity’. Although Ongoing Maturation During The Teenage Years Is Clearly Suggested, There Appears To Be No Formal Adoption Of The Concept In Any Society Until The Early Twentieth Century. In 1904 The First President Of The American Psychological Association, Greville Stanley Hall, Was Credited With Coining The Term ‘Adolescence’. In His Study Entitled Adolescence, He Described This New Developmental Phase, Which He Hypothesised Came About Due To Social Changes. Some Of This Hypothesis Resonates Clearly With Today’S Viewpoints, Although Much Is Also Now Known To Be Incorrect.

In the previous chapter we outlined a brief history of psychotherapies since the medieval period and noted that we are now in a scientific phase that is particularly focused on establishing valid clinical effects for talking cures.

In Chapters 5 and 6 we outlined the BPI framework together with clinical principles and methods. In Chapters 7 and 8 we translate these into practical BPI practice. You will have read about the concepts and techniques in prior chapters but now you get the chance to consider them through the clinical practice lens. These two chapters can serve as clinical guides and underpin the clinical manual and protocol that was used in the IMPACT study.

To recap, there are three key practice principles of BPI.

We have noted that, in our view, when undertaking any psychotherapy there should be supervision and reflective practice throughout one’s career. Senior therapists can be as much in need of discussions about their cases as newly qualified practitioners. Until we have much improved our understanding of what intervention works for which patient and how, we recommend supervision as a key clinical tool in learning the skills and techniques of BPI. Of course, we do not yet know which of these tips is responsible for clinical effectiveness. Therefore, regular fortnightly supervision with a senior, more experienced colleague is sound practice. Table 9.1 describes key general components that should activate a discussion with your supervisor.

In Chapter 1 we described the emergence of the concept of adolescence in the early twentieth century and how it represented a new and developmentally sensitive period of ongoing mental maturation. We also noted that the talking cures were fast gaining a foothold in developed societies and adolescents were beginning to be a focus of these interventions, this being due to the clear-cut increases in mental health difficulties and emergent mental illnesses in the second decade of life. The theories and techniques of the psychotherapies were, until the 1970s, relatively uninfluenced by the emergence of the concept of adolescence and its implications for mind-brain maturation. This implies that very little of what we know about adolescents and their mental states has been taken into account when devising a talking treatment for young people.

Brief psychosocial intervention was first used as a non-manualised reference treatment for depressed adolescents receiving the antidepressant fluoxetine with or without CBT. Both the treatment groups received the forerunner of BPI, specialist clinical care, as their general clinical support. The surprise was that CBT provided no added value over fluoxetine and specialist clinical care by the end of the study, which was only a short-term outcome of some 28 weeks [1]. This was the first finding that specialist clinical care provided by psychiatrists and mental health nurses to depressed adolescents may be as clinically effective as specialised psychological treatments such as CBT.

An interesting consequence of this study was to ask: what exactly did the therapists do when delivering specialist clinical care and how was it delivered?

Major depressive disorder and bipolar disorder can occur in quite young children. However, since both conditions are more common in adolescence than in childhood, and there is a greater evidence base for medication use in this age group, we focus here primarily on adolescents. Mood disorders in children and adolescents are diagnosed using adult criteria, although this is controversial, particularly in paediatric bipolar disorder. The advent of DSM-5 (American Psychiatric Association, 2013) has brought about few changes in the classification of mood disorders: grief is no longer an exclusion criterion for depression, and increased energy/activity is now regarded as a core symptom of mania and hypomania. A new category, disruptive mood dysregulation disorder (DMDD), has been introduced with the aim of reducing inappropriate diagnosis of bipolar disorder in children and adolescents who have non-cyclical, frequent severe temper outbursts along with a persistent irritable mood. Currently, there is little research regarding the diagnosis and treatment of DMDD, but early studies suggest that it is unlikely to be a precursor of bipolar disorder, so it will not be considered further in this chapter.

Prescribing in depression

Background

The prescribing of newer-generation antidepressants to children and adolescents with depression has been controversial in the UK since the publication of the Committee on Safety of Medicines (CSM) report on selective serotonin reuptake inhibitors (SSRIs) (Committee on Safety of Medicines, 2003). This report highlighted the important matter of the nonpublication of negative trial results and questioned both the effectiveness and safety of these medications, particularly an increased risk of suicidality. Before discussing the practicalities of prescribing, we will first review the evidence for the CSM findings. The tricyclic antidepressants will not be discussed here, as the risks associated with these drugs outweigh the relatively small benefits of using them.

Evidence base for pharmacological treatment

The CSM report concluded that, of the new-generation antidepressants (a group which includes the SSRIs and antidepressants such as venlafaxine, a serotonin–noradrenaline reuptake inhibitor or SNRI), only fluoxetine showed a positive risk–benefit ratio in treating depression in young people when compared with a drug placebo (Committee on Safety of Medicines, 2003).