A qualitative exploration of Gestalt therapy and systemic pedagogy paediatric primary healthcare consultations in Agramunt (Spain)

Abstract

Introduction:

Gestalt therapy (GT) and systemic pedagogy (SP) are useful tools to approach emotional difficulties and mental health problems among children and adolescents. The main objective of this study was to explore the perceptions on GT and SP techniques in paediatric mental health-related consultations in a primary healthcare (PHC) centre in Catalonia in 2018–2019, among families, healthcare, and education professionals.

Methods:

Qualitative study, combining semi-structured interviews with families (N = 42) and professionals (N = 15), conducted after a series paediatric PHC consultations including GT and SP techniques. Interviews lasted between 15 and 90 min and were conducted at the PHC centre where GT/SP consultations took place, and at professionals’ workplaces. Socio-demographics, reasons for consultation, and quantitative ratings on the perceived effectiveness of GT/SP consultations were also collected to combine these data with the qualitative interviews. Qualitative data were analyzed descriptively using thematic analysis. Quantitative data were analyzed by calculating frequencies (percentages) for categorical variables, and means, medians, and ranges for continuous variables.

Results:

Narratives from families and healthcare professionals indicate that GT/SP consultations might have been effective in improving children and adolescents’ symptomatology and emotional health. Improved well-being within the family context was another main finding, based on families’ perceptions and experiences. Besides, GT/SP were considered acceptable for approaching emotional and mental health in PHC services, although barriers for implementation were identified.

Conclusions:

This study presents data on the potential usefulness of GT/SP to design and implement services that promote emotional and mental health among children and adolescents in PHC. Also, for the development of health policies and future research in this area.

Introduction

Primary healthcare (PHC) is the most accessible institutionalized health service for most people (Bofill Moscardó et al., 2010; Wissow et al., 2016; Mulvaney-Day et al., 2018; Brino, 2020; Charach et al., 2020). It can then be the most appropriate setting to provide comprehensive healthcare given its accessibility, continuity of care, and the confluence of health data, creating a space in which relationships of trust between service users and healthcare professionals can be developed (Bofill Moscardó et al., 2010; Ministerio de Sanidad, 2011; Buitrago Ramírez et al., 2018; Zurro, Pérez, and Badia, 2019; Brino, 2020).

An increase of mental health consultations in PHC had already been observed in Spain prior to the start of the COVID-19 pandemic. Since then, a vast amount of research has been published on the populations’ mental health needs (Jacques-Aviñó et al., 2020; Ma et al., 2021) and PHC pressures to respond to the increasing demand of (sub)clinical mental health issues (Brino, 2020; Imfeld et al., 2021). Subclinic mental health consultations correspond to 20% of PHC appointments among children and adolescents (Bofill Moscardó et al., 2010). In line with this, the National Health System’s Mental Health Strategy in Spain between 2009 and 2013 (Ministerio de Sanidad, 2011) already included the need to approach subclinical mental health issues in PHC. Some regions in Spain have also recognized different health professionals’ capacity and training to attend to mental health needs in PHC (Buitrago Ramírez et al., 2018). While a specific mental health diagnosis may not be identified, interventions to enhance psychological and social well-being can still be effective. A caring response and trusting relationship with healthcare professionals can already have a positive impact in these cases (Sabrià, 2017; Pidano et al., 2020).

Addressing mental health among children and adolescents is within PHC competencies and responsibilities (Bofill Moscardó et al., 2010; Brino, 2020). The need for healthcare consultations is usually identified through families, but also through the Child Health Program (Asociación Española de Pediatría de Atención Primaria, 2009) and the Health Promotion and Education Program (Ministerio de Educación, 2008) health promotion strategies that are routinely implemented in schools in Spain. PHC consultations are usually initiated due to recurrent physical problems in which a primary organic cause can be ruled out (e.g., headaches, abdominal pain, dizziness, tics, enuresis, among other symptoms) (Castelló et al., 2016). Some symptoms are directly related to emotional factors, adaptation processes, or problems within family systems. In such cases, children and adolescents express their distress through disruptive behaviours, fears, irritability, drug use, and self-harm behaviours, among others (Schaefer, 2012; da Silva Panizza, 2015; Fahrutdinova and Nugmanova, 2015; Lorås, 2018; Salazar Valadez and Puc Herrera, 2019). Very importantly, these symptoms and emotional manifestations alter children and adolescents’ daily life, their families and school environments (Buitrago Ramírez et al., 2018). For this reason, it is essential to address them at PHC, where nursing professionals can play a prominent role.

General protocols have been developed to ensure prevention and early detection of subclinical mental health issues, and interventions have been implemented to address mental health among children and adolescents in children and adolescents (Wissow et al., 2016; Mulvaney-Day et al., 2018; Brino, 2020; Charach et al., 2020). However, these are often unspecific and rarely applied in clinical practice (Moreno and Moriana, 2013). Gestalt therapy (GT) (Peñarrubia and Naranjo, 2008) and systemic pedagogy (SP) (Traveset Vilaginés, 2007) are approaches that include techniques based on learning through the physical body and the use of metaphors. They consider the valuable role of family systems and have already been found to be useful in mild and moderate mental health cases (von Sydow et al., 2013; da Silva Panizza, 2015; Fahrutdinova and Nugmanova, 2015; Lorås, 2018). Available evidence also suggests that these approaches can help prevent the worsening of emotional distress and physical symptoms, as well as decrease referrals to specialized mental health services (Bofill Moscardó et al., 2010). The latter aspect is especially relevant considering the pressures experienced in PHC worldwide due to the COVID-19 pandemic (Legido-Quigley et al., 2020).

Both GT and SP are appropriate for children and adolescents since they are applied through playing (with drawings, the use of dolls, theatre, or stories) as a way to discover, express, accept, and self-manage emotions (Stevens, 1992; Oklander, 1998; Goleman, 2000; Colodron, 2010; Costa Martínez, 2015). They are also useful to practice social skills and promote well-being (24). There are three main dimensions in GT and SP (the three ‘orders of love’) (Hellinger, 2011): (1) Belonging: every individual belongs to a social group (the first is one’s family), and any experience of social exclusion may cause distress and disruptions in the person’ system; (2) Hierarchical order: in every social group there is a hierarchical order, and discomfort may appear when this hierarchy breaks; (3) Balance between giving and receiving: when there is an imbalance in what an individual gives and receives, relationships worsen. Overall, disruptions in any of these three dimensions can lead to emotional and physical distress (Hellinger, 2011).

Despite previous evidence (von Sydow et al., 2013; da Silva Panizza, 2015; Fahrutdinova and Nugmanova, 2015; Lorås, 2018; Salazar Valadez and Puc Herrera, 2019), these approaches are still considered controversial (Hellinger, 2011) and consequently not generally implemented. Besides, no evidence has been found in PHC paediatric services. Nevertheless, taking a holistic perspective to understand and care for children and adolescents’ mental and physical health can have a positive impact on mental and emotional health outcomes (Bofill Moscardó et al., 2010; Moreno and Moriana, 2013; Castelló et al., 2016). The main aim of this study was to explore the perceptions on GT and SP techniques in paediatric mental health-related consultations in a PHC centre in Catalonia in 2018–2019, among families, healthcare, and education professionals.

Methods

Research design

This is a qualitative study using semi-structured individual interviews, conducted with families and professionals between 2018 and 2019. Data were collected after paediatric PHC consultations with 42 children and adolescents, using GT and SP techniques implemented in mental health-related consultations in Agramunt (Spain) in 2018–2019. Metaphoric and projective techniques, using drawings, invented tales, toy images, and dramatization were used to identify, in a quick and simplified way, children and adolescents’ emotions. The main aim of these consultations was to draw emotional awareness, not only to children and adolescents but also to their families, as they were present during healthcare consultations (9–14). The first author (TPP) was responsible for conducting the consultations on GT and SP. TPP is a certified primary education teacher and nurse, who has over 30 years of experience as a paediatric nurse in PHC. She has completed a 4-year training in Gestalt for Children and Adolescents, and other courses in GT and SP, including one on Gestalt and Psychopathology. Besides, TPP has completed postgraduate programmes on Health Education, Research in Nursing and Systemic Pedagogy. TPP’s experience was considered as optimal to conduct the consultations. Researchers ensured that participating in the study did not interfere with the healthcare of participants and the children and adolescents who participated in the GT/SP consultations.

Quality and rigour were assessed by following Guba & Lincoln’s criteria (Guba and Lincoln, 1994), by ensuring the research’s: (1) credibility (e.g., confidence in the realities presented in the findings); (2) transferability (e.g., findings are applicable to the context where the research has been conducted and data can inform other contexts); (3) dependability (e.g., findings are consistent and the research can be replicated), and; (4) confirmability (e.g., findings are true to participants’ accounts and researchers’ motivations, interests, and perspectives have been clearly exposed). We also used the Critical Appraisal Skills Programme (CASP) tool (Long et al., 2020). See Additional File 1 for more details on how the CASP checklist was used for this publication.

Participants, sampling, and recruitment

Participants were: (1) family members of children and adolescents who had taken part in a healthcare consultation using GT/SP techniques; (2) health and education professionals (nurses, doctors, teachers, pedagogues, and psychologists). Professionals were required to have some experience working with children and adolescents, or to have experience with GT/SP. One participant was a last-year nursing trainee who had experience of attending GT/SP consultations in PHC. All other professionals were registered professionals. Sampling was purposive and selective. All families of children and adolescents that had participated in the GT/SP sessions were telephoned by the principal investigator (TPP) to invite them to participate in a qualitative interview. All 42 individuals involved in GT/SP sessions accepted to take part in the study. Moreover, professionals involved in the child and youth health programmes in one PHC service and one high school were invited to participate. TPP contacted 18 by phone, and 15 agreed to participate.

Data collection

Forty-two semi-structured interviews were conducted with families, and 15 professionals (7 working in healthcare and 8 in educational settings). Interviews lasted between 15 and 90 min. Data collection with family members took place in one PHC. Interviews with professionals were conducted in their workplaces. All interviews were moderated by TPP using a previously piloted thematic guide. Interviews were audio-recorded and stored in an encrypted file. Anonymity and confidentiality were ensured at all times throughout the study. Data saturation was reached for both participant groups. Quantitative data on sociodemographic characteristics, main reasons for the consultation, and the perceived effectiveness of GT/SP techniques were also collected, to support qualitative data.

Data analysis

Thematic analysis was used to analyze qualitative interviews (Berenguera et al., 2017). The analysis process was as follows: (1) Reading of transcripts and field notes; (2) Identification of relevant topics and texts; (3) Fragmentation of the text into units of meaning; (4) Coding of texts with a mixed strategy through inductive codes and predefined codes; (5) Elaboration of themes by grouping codes. The researchers used an analytical pre-established framework, based on the objectives of the study, and considered inductive codes and emerging themes; (7) Analysis and interpretation of themes to finalise the thematic framework. LMP led the qualitative data analysis; triangulations were done with TPP and AB.

Sociodemographic characteristics, main reasons for the consultation, and the perceived effectiveness of GT/SP techniques were analyzed by calculating frequencies (percentages) for categorical variables. Means, medians, and ranges were calculated for continuous variables. Likert scale questions (with answers between 0 and 10) were categorized into three values ‘Little’ (<5), ‘Moderate’ (5–7), and ‘A lot’ (8–10). TJL performed the statistical analyses, using SPSS for Windows, version 25 (SPSS Inc., Chicago, IL).

Results

Participant characteristics, main reasons for consulting, and perceived GT/SP effectiveness

Over half of family members (N = 42) were women (59.5%). Median age was 40 years old, ranging between 18 and 70. The ages of the children/adolescents they cared for were between 4 and 18 years old (Median = 11). Most children/adolescents were referred by paediatric services (35.7%) and by family members (33.3%). Families were mostly born in Span (76.2%) and had completed secondary (47.6%) or primary (33.3%) education. Anxiety and fear (31.0%) were the most common reasons for consultating, followed by somatic symptoms (e.g., headaches) (26.2%). There was no referral to mental health services in 64.3% of cases. Moderate (42.9%) or high improvement (50.0%) was reported by families as a result of the GT/SP sessions. See Table 1 for more details.

Table 1.

Family members’ characteristics and perceived effectiveness of GT/SP consultations (N = 42)

Age (Median [min–max])	40 (18–70)
Women, n (%)	25 (59.5)
Age children/adolescents (Median [min–max])	11 (4–18)
Referral, n (%)
Paediatrics	15 (35.7)
Family members	14 (33.3)
Nursing professionals	6 (14.3)
School	6 (14.3)
Child/Adolescent	1 (2.4)
Family structure, n (%)
Two-parent family	30 (71.4)
Single-parent family	7 (16.7)
Reconstituted	4 (9.5)
Other	1 (2.4)
Region of birth, n (%)
Spain	32 (76.2)
Eastern Europe	5 (11.9)
Latin America	3 (7.1)
Other	2 (4.8)
Family members’ completed education, n (%)
Primary education	14 (33.3)
Secondary education	20 (47.6)
University education	8 (19.0)
Reason for consultation, n (% )
Fear/Anxiety	13 (31.0)
Somatic symptoms	11 (26.2)
Disruptions relationships with peers	4 (9.5)
Disruptions relationships with family members	4 (9.5)
Sadness/Apathy	3 (7.1)
Aggressiveness	2 (4.8)
Poor school performance	2 (4.8)
Eating disorders	1 (2.4)
Grief	1 (2.4)
Other	1 (2.4)
Number of GT/SP sessions, n (%)
1	9 (21.4)
2	16 (38.1)
3	8 (19.0)
>3	9 (21.5)
Time dedicated by professionals (in h), mean (min–max)	2.4 (1–8)
Referrals and previous mental health consultations, n (%)
No referral	27 (64.3)
Referral during GT/SP sessions	5 (11.9)
No consultations with mental health services	5 (11.9)
Previous consultations with mental health services	4 (9.5)
Referral mental health services at the start of GT/SP sessions	1 (2.4)
Family concern before GT/SP sessions, n (%)
Low concern	1 (2.4)
Moderate concern	6 (14.3)
High concern	35 (83.3)
Family concern after GT/SP sessions, n (%)
Low concern	18 (42.9)
Moderate concern	19 (45.2)
High concern	5 (11.9)
Improvement after GT/SP sessions, n (%)
Low	3 (7.1)
Moderate	18 (42.9)
High	21 (50.0)
Would recommend GT/SP sessions, n (%)
Low	0 (0.0)
Moderate	2 (4.8)
High	40 (95.2)

Professionals interviewed (N = 15) were aged 20–63 years old (Median = 47.5), 87.5% were women and almost all held Spanish nationality (93.7%). Their professional area was education (31.5%), psychology or pedagogy (25.0%), medicine (18.7%), and nursing (18.7%).

Main findings

Four themes were identified: (1) perceived improvement of emotional distress, (2) improvement of intra-family relationships and other social relationships, (3) positive impact of GT/SP in PHC, and (4) barriers and opportunities for the implementation of the GT/SP in PHC centres (see Table 2 for interview quotes).

Table 2.

Family members and professionals’ interview quotes

Perceived improvement of emotional distress	‘I have liked them a lot from the beginning. I think they play a lot with the subconscious (…) that story is about how he feels and what he is thinking, or how… So that also tells him to know, to see how he feels (…)’ (Parent 17 years old adolescent)
	‘I perceive her much calmer and well, above all, she also thinks that since she has spoken here with you and such, it has been like opening a door (…)’ (Parent, 14 years old adolescent)
	‘It was very freeing, being able to explain that, maybe, dad was a wolf and mum was a fox. So, each (kid) explained the animal that represented their family member, in a group setting’ (Teacher; professional)
Improvement of intra-family relationships and other social relationships	‘I have read about something related and such, since you told us, I downloaded things online, people would change their relationship with their children easily. Everything would improve […] if she is calmer if her sister bothers her, because she is not so upset as to be able to manage it well, ‘leave me alone’, and that’s it (…) before it got more to an extreme …’ (Parent, 10 years old child)
	‘Discussing with families that are worried about these topics (health and wellbeing) related to their children, with their daily life, and help them to see beyond the problem, a little bit… where can that (problem) come from, it is being super favorable to the family and the child’ (Pedagogue; professional)
Positive impact of GT/SP in primary healthcare	‘It is complementary (GT/SP) to understand the person in a more holistic way. Not only based on the system (body), but from the internal world, which each one moves us and transports us, you know?’ (Mental health nurse; professional)
	‘Having ruled out the organicity, then the suspicion is that it may be a one more emotional issue, right? Which can be more through psychosomatic expressions, repetitive tummy pains, dizziness, headaches (…)’ Family doctor; professional)
	‘It catches my attention because I see that by applying these techniques (GT/SP) you can get a lot of information from the patient, and it is not necessary, for example, to refer to a psychologist or other professionals, because perhaps doing these sessions here in the consultation (primary healthcare) the problem can be solved’ (Nursing trainee; professional)
Barriers and opportunities for the implementation of the GT/SP in primary healthcare centres	‘The problem that you find with this, so it is the lack… the lack of resources. I believe that they are consultations that are not resolved in a single visit, but that they need several visits, that you need time, and that they are things that are frequent and that the problem is the lack of resources’ (Family doctor; professional)
	‘Well, so it would be necessary (in primary healthcare) for all of us to be a little more aware at a professional level to be able to detect these cases and to be able to program a consultation’ (Family doctor; professional)
	‘I think they (other professionals and policymakers) don’t want to, they don’t want to because there isn’t time. It is not structured (primary healthcare) to be able to attend to the emotionality of the person’ (Nurse; professional)

Perceived improvement in emotional distress

Both families and professionals perceived GT/SP sessions as to have a positive impact on children and adolescents’ emotional distress. According to participants accounts, GT/SP techniques promoted the identification, acknowledgement, expression and, ultimately, the management of emotions. Participants perceived that children and adolescents seemed to experience less sadness, fear, anger, irritability, stress, anguish, and apathy. An improvement in self-esteem was also reported by family members, and professionals considered that GT/SP could support self-esteem. Some children and adolescents seemed to begin to attend to their own needs and to set healthy boundaries in their social relationships. Improvements in school performance and physical symptoms were also discussed.

Improved intra-family and other social relationships

GT/SP sessions also appeared to produce positive changes in family members. They helped them to improve their own emotional management, and contribute to healthier family relationships, even among those who embodied a passive role during the sessions. As professionals also noted, the decrease in family members’ concern when perceiving positive changes in children/adolescents, and a greater sense of control, seemed to lead to a more relaxed family environment that reduced intra-family conflicts and improved emotional management. Based on the narratives of both family members and professionals, GT/SP sessions appeared to improve social relationships in children and adolescents. Participants attributed these changes to children/adolescents’ improved mood and emotional health, as well as families’ reporting being less concerned and less in need for emotional health interventions. On the other hand, some narratives suggested that some family members were reluctant to explore their own responsibility in the difficulties expressed by children/adolescents, a perspective that was also shared by some professionals. Despite having a positive effect, family members discussed that GT/SP techniques were not always applied at home. Professionals understood that it could be challenging to involve families into applying GT/SP techniques at home and once GT/SP consultations were over.

The positive impact of GT/SP in PHC

Interviewed professionals viewed the application of GT/SP as a way to obtain richer information on the emotional health of children and adolescents. This allowed them to have a more holistic view to children and adolescents’ health. GT/SP were also tools to work on children, adolescents, and their families’ emotional and mental health. Applying GT/SP in PHC was considered to be very positive, given the high accessibility of PHC services, and the high knowledge that paediatric professionals often have of the child/adolescent and of their context. Family members also appreciated having GT/SP consultations available in PHC, given the accessibility of PHC services. Other positive aspects that professionals commented on were the potential decrease in prescriptions, and the decrease in the ‘psychiatrization’ of children and adolescents, by reducing referrals to specialized mental health services.

Barriers and opportunities for the implementation of GT/SP in PHC centres

Professionals shared that GT/SP techniques were difficult to implement in the current public health system, aswith other ‘alternative’ intervention techniques. Some professionals mentioned structural barriers such as organizational models, physical spaces to implement GT/SP, lack of funding and time constraints. These were identified as barriers to create spaces of trust and confidentiality. Overall, professionals mentioned that the GT/SP did not fit with the paternalistic perspective under which some professionals worked with, habitual clinical training and the healthcare system’ structure. On the other hand, GT/SP were not part of the curriculum at universities. This meant that training was more difficult to access, and limited the implementation of GT/SP. Reasons for the lack of access to GT/SP mentioned by participants were that the GT/SP was considered an ‘alternative psychological therapy’ and, therefore, it was not promoted or embedded in conventional health interventions.

Discussion

This study includes qualitative data on the perceptions of families and professionals around implementing GT (Peñarrubia and Naranjo, 2008) and SP (Traveset Vilaginés, 2007) techniques in PHC consultations with children and adolescents. Data were collected following the implementation of GT/SP consultations in a PHC pediatric service in Agramunt (Spain) with 42 children and adolescents, and their families. Overall, participants considered GT/SP could have a positive impact, both on emotional and physical symptoms experienced by children and adolescents. Besides, participants mentioned how they believed GT/SP could be beneficial to the emotional health of family systems, and to enhance social participation and relationships. Participants also highlighted how having GT/SP in PHC could make these techniques (and their benefits) particularly accessible to children, adolescents and their families. On the other hand, professionals referred to barriers for implementing GT/SP in PHC.

Understanding (and addressing) health during childhood and adolescence in a more holistic way, including emotional well-being, is crucial to promote full physical and mental health (Castelló et al., 2016; Nelson, 2019; Brino, 2020). Available research suggests that applying GT/SP could help reduce referral to specialized services, avoiding medicalizing some emotional problems that can be resolved over PHC consultations. It could also contribute to reduce the over-attendance of children, adolescents and their families. Above all, these approaches could help to improve the well-being of children and adolescents, and to prevent future health, educational, and social problems (Bofill Moscardó et al., 2010; Buitrago Ramírez et al., 2018; Brino, 2020). In order to attain this, non-judgemental communication between healthcare professionals and families is imperative (Pidano et al., 2020). Our research offers a description of the perceptions of families and professionals on GT/SP consultations. These are aligned with previous research and suggest their overall acceptability and favourable stance toward such techniques being implemented in PHC paediatric services. However, as participants in our study noted, it would be advisable to consider how families can apply and maintain GT/SP techniques at home.

As discussed by professionals in our research, specialized training for PHC professionals is essential (Imfeld et al., 2021). Moreover, one of the most notable barriers participants identified is the required paradigm shift in healthcare (Traveset Vilaginés, 2007), if the use of GT/SP was to be incorporated into emotional and mental healthcare consultations (Foucault, 1989; Haque and Waytz, 2012). In the contect of healthcare, this is inevitably linked to the need to change the paradigm in which health and the current healthcare system are constructed (Haque and Waytz, 2012). These changes would require to establish new roles within healthcare (Imfeld et al., 2021). The contribution of nursing professionals is of particular significance, especially in the light of their role in the implementation of child health programmes (Asociación Española de Pediatría de Atención Primaria, 2009), and health promotion programmes within educational settings (Ministerio de Educación, 2008) in Spain. It is also important to consider that, as our participants have indicated, the implementation of GT/SP may not be a significant time commitment. Nevertheless, it is essential to evaluate the necessity of restructuring and organizing material and temporal resources to accommodate this novel approach that prioritizes emotional well-being as a crucial aspect of child and adolescent health (Wissow et al., 2016).

One of the limitations of this study is that the qualitative interviews were conducted in a relatively structured manner, which may have resulted in a lack of depth in the data dollected. Additionally, we were unable to obtain the experiences of children and adolescents, which could hace provided valuable insights. These limitations must be taken into account when interpreting the results of this study and may be addressed in future research. Moreover, it is essential to examine the viability and cost-effectiveness of employing GT/SP techniques in PHC settings. It is crucial to consider the experiences of both service users and providers. Future studies could concentrate on investigating the differential impact of GT/SP and evaluating GT/SP interventions, for instance, by testing various interventions in a randomized controlled trial. Qualitative methodology can be valuable in deepening the evidence on the implementation and differential cost-effectiveness of GT/SP.

Notwithstanding the aforementioned limitations, this project offers a preliminary insight into the potential of GT/SP to address emotional issues among children and adolescents in PHC settings, based on the perceptions of families and professionals. This may provide a foundation for further research aimed at enhancing the provision of emotional health services for children and adolescents in PHC. In the light of the above, this study can be viewed as an initial step towards investigating the potential applications and implications of GT/SP techniques in the field of PHC. This is particularly relevant given the neecessity to address emotional and mental health concerns among younger populations. Nevertheless, further research is required to ascertain the acceptability, implementation and effectiveness of these techniques, as there is currently a dearth of evidence in this regard. Additionally, it would be beneficial to provide training for professionals and to review public health policies in order to facilitate the integration of GT/SP approaches.

Conclusions

This study offers an overview of the perceptions of families and professionals on the use of GT/SP to address emotional and mental health issues among children and adolescents in PHC settings. The results of this study are useful to inform future research on GT/SP and in the field of emotional and mental health. Future research could focus on investigating the acceptability, implementation and cost-effectiveness of GT/SP consultations in paediatric PHC.

Supporting information

Pujol Puyané et al. supplementary material

Pujol Puyané et al. supplementary material

Supplementary material

To view supplementary material for this article, please visit https://doi.org/10.1017/S1463423624000379

Funding statement

This study was funded by the Institut de Recerca en Atenció Primària Jordi Gol i Gurina (IDIAPJGol), through the ‘Research Projects in Primary Healthcare’ call in 2017, granted to TPP (4R18/037-1). The project received a research grant from the Carlos III Institute of Health, Ministry of Economy and Competitiveness (Spain), awarded on the call for the creation of Health Outcomes-Oriented Cooperative Research Networks (RICORS), with reference RD21/0016/0029 (Network for Research on Chronicity, Primary Care, and Health Promotion [RICAPPS]), cofunded with European Union – NextGenerationEU funds.

Competing interests

None.

Ethical standards

The authors assert that all procedures contributing to this work comply with the ethical standards of the Spanish Law on Biomedical Research (14/2007) and the Spanish Law on Data Protection (3/2018) and with the Helsinki Declaration of 1975, as revised in 2008. The study was evaluated by the IDIAPJGol Research Ethics Committee and approved on May 4, 2018 (P17/227). All participants gave their verbal and written consent prior to taking part in the study.