SUMMARY

This article updates the previous review (Azima, 1996) and includes new group applications to high risk psychiatric disorders focusing specifically on research advances in these areas. It is clear that there has been a marked shift in theoretical orientations from psychodynamic/psychoanalytic to cognitive/behavioral interactive ones, especially for short term modalities. This shift has encouraged structured and manualized approaches that can be operationalized and subjected to research investigations.
Group as a therapeutic modality has been increasingly confirmed by both clinical and research investigation, in a wide variety of areas. Clinics as well as inpatient, residential, private practice, and community programs have expanded rapidly. Applications to psychiatric, medical, neurologic, community, and social issues have grown at an unprecedented pace.

RESUMEN

Este artículo pone al día una revisión previa realizada por la autora (Azima 1996) e incluye nuevas aplicaciones grupales realizadas pacientes con trastornos de alto riesgo psiquiático y se centra específicamente en los progresos en la investigación en esos campos. Está claro que se ha producido un giro importante en las orientaciones teóricas a partir del psicoanálisis hacia aproximaciones cognitivo/conductuales interactivas, especialmente en las modalidades a corto plazo. Ese giro ha animado a utilizar aproximaciones estructuradas y manualizadas que pueden ser manualizadas y sometidas a investigaciones objetivas en una amplia variedad de áreas. La utilidad de los grupos como modalidad terapéutica ha sido confirmada por investigaciones clínicas y experimentales.
Se han expandido ampliamente programas de pacientes ingresados y ambulatorios, privados y públicos. Del mismo modo se han multiplicado espectacularmente sus aplicaciones psiquiátricas, médicas, neurológicas, comunitarias y sociales.

PALABRAS CLAVE

Grupos, niños, adolescentes.

KEY WORDS

Groups, childrens, adolescents.

INTRODUCTION

Between 1995 and 2000, somewhat more than 500 articles, chapters, books and dissertations have been written about group psychotherapy with children and adolescents. From the clinical perspective there have been advances in the treatment of previously contraindicated populations (low intelligence, organic cases, the very young, and the very difficult, acting-out child.) This article updates the previous review (Azima, 1996) and includes new group applications to high risk psychiatric disorders focing specifically on research advances in these areas.
Increasingly child group psychotherapy is becoming part of a multimodal integrative approach for outpatient and inpatient, day hospital and residential facilities. Psychoeducational approaches with children and parents have become more prevalent, as has their use in schools and communities. As is illustrated, the emerging problems of our society that have affected youth have dictated the increased use of groups for anxiety, depression, suicide, violence, oppositional defiance, drug addiction, post traumatic stress, social phobia, medical disorders, family separation and sexual abuse.
An early report by Toseland and Siporin (1986) that group psychotherapy is an efficient and cost effective treatment has been further confirmed by the meta-analysis of Hoag and Burlingame (1997). Future meta-analyses are necessary to confirm their findings. The current clinical and research overview corroborates positive outcomes in most cases for both clinical and research reports.
Clinicians have continued to be enthusiastic that group psychotherapy for children and adolescents is a treatment of choice. Young, active children can communicate with one another, often without words or symbolic reasoning, as if they have a private language. Therapists have the opportunity to observe the actual behavior of the children, to clarify the diagnosis, and gradually to interpret the meaning of their play and interactions. Psychotherapeutic and educational goals are provided in a safe, supportive, empathic setting where boundaries and rules are established by the therapists. As for adolescents, group settings are particularly advantageous because of their specific need for relationships with their peers. Reciprocal exchange of thoughts and feelings permits self disclosure in the group often is not possible in individual therapy, where rebellious silences pervade the transference to parental authority figures. In the group, the adolescents themselves are clear about what is acceptable and proper for others of their age group. Learning that problems are not unique and that they are shared by peers can promote faster sharing of information.

This literature review demonstrates a decrease in the use of the psychoanalytic model and a significant increase in cognitive-behavioral, psycoeducational and multimodal approaches. In contrast, cognitive behavioral and psychoeducational models have proliferated with accompanying clinical research. These trends have encouraged the goals of short term, managed care, and the integration with parents, community, and psychopharmacological treatments. Psychoanalytically-oriented theory remains central for long-term groups, and more traditionally trained clinicians whose goals may be more significant ego changes for their patients.

SETTING

A major task facing the therapist is the selection and balancing of the composition of the group, orchestrating the number of acting out children with the quieter, less demanding, more compliant ones and deciding on the play, activities, or toys used to engage and interest the children. The reality is that there is no such thing as an ideal composition, and a group is formed with the available referred candidates. The stronger the group, the more very disturbed children can be included.
As a rule, the children are seen and evaluated with their parents. Often observing the children over time helps clarify the diagnosis (Anthony, 1965; Liebowitz and Kernberg, 1986).
Preschool children, boys and girls 3 to 5 years of age, are seen in small groups of three, four, or five and usually by two therapists in a play or activity group. The more active or pathological the children, the greater the need for auxiliary personnel.
The latency therapy group usually is separated into early (5 to 7 years of age), middle (8 to 10 years of age), and late (10 to 12 years of age) groups. Frequently these age groups are intertwined, and more attention is placed on the composition of the range of intelligence, physical size, and diagnoses of the children. In treatment groups, latency boys outnumber girls, at a ratio of 4:1 to 8:1, depending on the population being serviced. There is some current indication of a rise in girl referrals, however. The preponderance of boys in the groups necessitates that one of the therapists or special care counsellors be male to provide a role model and to diminish acting out behavior. Some of the children from single parent families are threatened by the presence of both male and female therapists.
At times the late latency group is combined with the preadolescent group. The older boys and girls usually do better in homogeneous groups with the same sex therapist (Kennedy, 1989).
Frequency of sessions varies from once or twice a week to every day in a day hospital. A beginning group may tolerate only 15 minutes and gradually work up to 45 minutes or an hour.
Play and activities are the natural vehicles for child therapy ( Bratton and Ferebee, 1999; Sweeney and Homeyer, 1999), and in general, the less complicated and fewer the toys, the better fantasy play is encouraged. The fundamentals are a portable table and chairs, paper, pencil, crayons, playhouse, dolls, and play telephones. The toys should not be unduly stimulating but rather should focus on the projective nature of the action and production.
Through the play, the therapist and children begin to understand the meaning of the disclosures. Preparing the children to express themselves is antecedent to further working through of their problems.

SPECIALIZED GROUP APPROACHES

Humor adds a special, and necessary, dimension to work with children (Dana, 1994) A "clown club" (Smith et al., 1985) has been introduced to provide a structured fantasy approach. The therapists dress up and play clowns, to the delight of the children. The psychodrama can be expanded to include the playing of good and bad witches, angry teachers or parents, and the like.
A variety of video techniques (Gardano, 1994; Mallery and Novas, 1982) have been used with school age children. Children can produce and watch their own videos. Replaying and redoing scenes allow the children actually to see their behavior and attempt to correct it by activities that strengthen organizational skills and memory. The video camera is an invaluable tool for diagnosis, research, training and follow up. (Smead, 1996; Tellerman, 1998)
Kinetic group psychotherapy (Schachter, 1984) is a technique involving an activity period of exercises or games, followed by a verbal discussion period. The technique has been used with a wide range of children's problems, including childhood autism and depression.

The use of genograms (Davis et al., 1988) is a technique borrowed from family therapy with latency age children. The children, aided by the therapist, map out the family constellation, which helps them to focus on and question the events of the parents' marriage or separation, new alliances, and catastrophic events. The genograms are shared in the group and encourage each member to divulge hidden fears and learn to distinguish between reality and fantasy.
Other innovative techniques include storytelling, (Gersie, 1997), group sandplay, (DeDomenico, 1999), music therapy (Plach, 1996), and use of masks, puppet plays, and group emblems (Prokoviev, 1999). All such projective activities allow the children to reveal their problems in a nonthreatening manner. A sign of a maturing group process is when the children need less prepared structure from the therapists and suggest and create their own object world. Older, more verbal, intelligent, and stable children are capable of using a talking group as opposed to a holding group for the ego weak children.
For impulse ridden children (Crawford Brobyn and White, 1986), changes in the traditional models may be necessary. Some children can progress from working with another child in a dyad for a time of time to joining the group. The acting out child may be able to tolerate only one of four group sessions, until tolerance is slowly built up. Evans (1998) uses an individual therapy session before the group for children (and adolescents) who act out, are defiant, or fearful of their peers. This author terms this approach as ?active analytic?. Streider et al. (1996) reviewed a wide variety of differential diagnoses and corresponding group structures operating in outpatient treatment of latency age children.

INTERACTIONAL PSYCHODYNAMIC GROUP

This model is applicable to all age groups. The specificities of the approach for children and adolescents include the provision of activity, play, and fantasy according to developmental level, temperament, diagnosis, and goals of the treatment. The interactive context in the here and now, among the peers and the therapists, amplifies the precise nature of the communication difficulties and conveys over time the dysfunctional intrapsychic conflicts within the group paradigm. The degree of permissiveness, structure, and limit setting depends on the activity level and explosiveness of the group and the degree to which regressive acting out is desired or can be tolerated. Greater vigilance is necessary with children who are overly aggressive than with shy children. The thrust of the model is to define the emerging object relations, symbolized by the choice of play objects, and the actual interactions with other group members. The psychodynamics of the group activities are partially translated into meaningful dialogues and understanding by the children. As the therapy progresses, modifications of the explanations and interpretations are appropriately made.

CASE ILLUSTRATION

David was a husky, attractive 7 year old bully when he first came to the day hospital. He kicked the therapist and refused to have anything to do with the other children. His bravado covered his horrifying nightmares, his daily nausea in the car, and his inability to function in the classroom. When he started in the group, the members were working on a large world mural. One youngster was drawing the clinic, another the roadway, and another the school car. At this point David became very agitated and wanted to scribble over the drawing. The group members became somewhat intimidated, and the therapists attempted to calm him down, but to no avail. He was then told that, unfortunately, he could not manage the group that day and was asked to leave, with the comment "When you feel you are able to return and join the activity, please tell Sally [the Special Care Counselor who escorted the child from the room], knock at the door, and let us know when you are ready.'' It took several weeks before David was able to return to the group; when he did, he announced, ``I'll try it out.'' The other children greeted him with understanding. The group members were drawing different emotions on faces. David first drew an angry face with teeth; when he noticed that others were drawing happy or sad faces, he remarked that he often had such feelings himself. In a subsequent session two or three of the members played with hand puppets and through the play told David that they did not like to be hit. Two years later David was present when a new child joined the group. By chance he and this child again chose the puppets. When the younger child kept smashing the head of the puppet on the table, David said in a soothing voice, ``I know what it is like when you are so mad that your head feels like thunder.'' David worked through a considerable amount of rage. His somatic symptoms, including car sickness, largely disappeared, as did his repetitive drawing of cars. Such a child needed a gradual progression from dyadic to group therapy. His mother profited from parenting management. She was not a psychologically minded individual but was motivated to help her child and cooperated well with the program.

APPLICATIONS FOR CHILDREN

Anxiety Disorders

Increasing attention has been paid to the group treatment and outcome assessment of anxiety in children. Dadds et al., (1997) evaluated the effectiveness of a cognitive-behavioral and family based group intervention for preventing the onset and development of anxiety problems in children. In this study 1756 children 7 to 14 years of age, were screened for anxiety problems, using teacher nominations and children?s self reports. After recruitment and diagnostic interviews, 128 children were assigned to a 10-week school based child-and-parent focused psychosocial intervention or to a monitoring group. Both groups showed improvements immediately post intervention. However, at 6 months follow-up, the improvement maintained in the intervention group only, with reduction in the rate of existing anxiety disorders and preventing the onset of new anxiety disorders. These results indicated that anxiety problems and disorders identified by child and teacher reports, can be successfully targeted through an early intervention school-based program.

Barrett (1999) evaluated a cognitive-behavioral, family-based group intervention with 60 children, ranging in age from 7to 14 years with diagnosis of anxiety. The study divided the sample into three treatment groups: group cognitive-behavioral therapy, (CBT), group CBTplus family management, and wait list. Posttreatment 64.8% of children no longer fulfilled diagnostic criteria for an anxiety disorder compared with 25.2% of children on the wait list, and the treatment groups maintained the gain at 12-month follow up. Comparisons of self-report measures and clinician ratings of children receiving group CBT with those receiving group CBT plus family management indicated marginal benefits from the addition of family management to the group CBT.

A randomized clinical trial by Silverman et al., (1999) evaluated the efficacy of CBT with concurrent parent sessions versus a wait list control. The treatment group of children showed substantial improvement on the main outcome measures post treatment, at 3 -, 6, -and 12-month follow ups, compared with no gains on the wait list. A group CBT treatment of childhood anxiety focusing on the role of parental involvement was carried out by Mendlowitz et al., (1999) in a study of 62 parents and children. One group was subdivided and randomly assigned to one of three 12-week treatment conditions: parent and child intervention, child-only intervention and parent-only intervention. A battery of tests was used to assess child anxiety, depression, and coping strategies before and after treatment. The results showed that all treatment groups reported fewer symptoms of anxiety and depression post treatment, but children in the parent and child intervention used more active coping strategies post treatment compared with the other two treatment conditions. Parents in the parent and child intervention group reported significantly greater improvement in their children?s emotional well being compared with the other treatment conditions. The short term effectiveness of this group CBT intervention was demonstrated. Comparisons of these 3 studies assessing the effectiveness of parental involvement is difficult, but suggests this issue needs further classification.

Social Incompetence and Phobia

Groups for children emphasising cognitive behavioral and educational models demonstrate effectiveness in reducing social anxiety, shyness, and incompetence. Blonk al., (1996) studied the short-term effect of group CBT therapy for 72 socially incompetent children (8 to 12 years of age), who were experiencing poor peer relationships. The sample was divided into treatment groups (six children per group) and a wait-list control. Treatment outcome was assessed by teacher and parent reports on social behavior, sociometrics and self reported anxiety and self evaluation. Posttreatment groups showed more appropriate social behavior and an increase in peer acceptance and number of friendships. These effects were sustained at 4- and 5- month follow up assessments.
Shechtman (1993) reported increased self-esteem and close friendship in 52 elementary school children placed in 6 small counselling groups compared with matched control subjects. As might have been predicted there was an intercorrelation between intimate friendship and self-esteem.

Depressive Disorders

There has been an increase in the use of groups to alleviate mourning in children. Schoeman and Kreitzman, (1997), used 12 parallel sessions for caretakers and children, and a joint session to work through the death of a parent. MacLennan (1998) reported on the use of children?s groups for both expected and sudden death of family or friends. Glazer and Clark (1999) describe a family-centered intervention for grieving preschool children, and a multifamily and psychoeducation group was described as helpful by Fristad et al. (1998). A group play and activities therapy was described by LeVieux (1999) and an overview of loss and grief groups was provided by Keitel et al. (1998).

An outcome study by Tonkins and Lambert (1996) demonstrated the effectiveness of a short-term, 8-week bereavement psychotherapy group of 16 children, aged 7-11 years, divided into a treatment group and wait-list control group. In the treatment group that shared feelings about the death of a parent or sibling, there was a significant decrease in symptomatology on multiple measures from multiple sources, and participants were able to develop new coping strategies.

Clark et al., (1993) introduced a group for mothers exhibiting postpartum depression and their newborns. Mother and infants participated in 12 weekly group sessions, two of which included spouses or partners. The author?s report is based on 5 years of time - limited groups, which showed improvement in the mother?s depression, problem solving, mutual support, and empathy.

Trad (1994) elaborated a sequential model of mother-infant psychotherapy, integrating the mother?s individual therapy with the mother's observation of her infant?s behavior with the therapist, participation in a mother?s group, and family therapy. These last two studies suggest a preventive intervention for high-risk infants.