What is psychotherapy for children?

Introduction

Various psychological techniques designed to treat children’s behavioral, cognitive, or emotional problems are used in psychotherapy with children. The number of children with psychological disorders underscores the need for effective child psychotherapy: the Centers for Disease Control and Prevention (CDC) reported in 2013 that an estimated 13 to 20 percent of children in the United States experienced a mental disorder each year from 2005 to 2011, and that the prevalence of these conditions increased between 1994 and 2011. According to the National Institute of Mental Health, CDC data collected as part of the National Health and Nutrition Examination Survey between 2000 and 2004 also showed that only about half of the children ages eight to fifteen with mental disorders were treated for their disorder within the past year.

Children, like adults, may experience many different kinds of psychological disorders. For example, in the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-IV-TR; rev. 4th ed., 2000), published by the American Psychiatric Association, nearly forty separate disorders that primarily affect children are listed. This number does not include many disorders, such as major depressive disorder, which primarily affect adults but may also affect children. In DSM-5 (5th ed., 2013), however, children's disorders no longer have a separate chapter. Instead, each diagnostic chapter is organized chronologically, with diagnoses primarily affecting children listed before those affecting adolescents and adults. In general terms, children’s disorders can be divided into two major categories: externalizing and internalizing disorders.

Externalizing and Internalizing Disorders

Externalizing disorders are those in which children engage in activities that are physically disruptive or are harmful to themselves or others. An example of this type of disorder is conduct disorder. Conduct disorder is characterized by children’s involvement in a continued pattern of behavior that demonstrates a fundamental disregard for the safety or property of others. In contrast to externalizing disorders, internalizing disorders create greater emotional distress for the children themselves than for others around them. An example of an internalizing disorder is generalized anxiety disorder, in which the child experiences persistent, unrealistic anxiety regarding numerous situations and events, such as peer acceptance or school grades.

Types of Treatment

Psychoanalytic Therapy

In response to the prevalence and variety of childhood disorders, many different treatments have been developed to address children’s psychological problems. Historically, the earliest interventions for addressing these problems were based on psychoanalytic theory, developed by Sigmund Freud. Psychoanalysis is a type of psychotherapy based on the idea that individuals’ unconscious processes, derived from early childhood experiences, are responsible for the psychological problems they experience as adults. One of the first therapists to adapt Freud’s psychoanalysis to the treatment of children was Anna Freud, his daughter.

Psychoanalysis had to be modified for the treatment of children because of its heavy reliance on individuals’ verbalizing their unconscious thoughts and feelings. Anna Freud realized that children would not be able to verbalize regarding their experiences to the extent necessary for effective treatment. Therefore, beginning in the 1920s, she created play therapy, a system of psychotherapy in which children’s responses during play provided information regarding their hidden thoughts and feelings. Although play therapy had its roots in Sigmund Freud’s psychoanalysis, this type of therapy came to be associated with other systems of psychotherapy. For example, Virginia Axline demonstrates her version of play therapy in the 1964 book Dibs: In Search of Self; her approach is based on Carl R. Rogers’s person-centered therapy.

Behavior Therapy

In addition, in the 1920s, Mary Cover Jones was applying the principles of behavior therapy developed by John B. Watson and others to the treatment of children’s fears. Behavior therapy rests on the notion that all behavior, whether adaptive or maladaptive, is learned and thus can be unlearned. Jones’s treatment involved reconditioning, a procedure in which the object of which the child is afraid is gradually associated with a pleasurable activity. By regularly associating the feared object with a pleasurable activity, Jones was able to eliminate children’s fears.

Family Therapy

Although early child analysts and behaviorally oriented psychologists attributed many children’s problems to difficulties within their family environments, these treatment providers’ primary focus was on treating the children, not their parents. In the early 1940s, however, Nathan Ackerman, a psychiatrist trained in the psychoanalytic tradition, began to treat children in conjunction with their families. His justification for seeing all family members in treatment was that families, like individuals, possess hidden conflicts that prevent them from engaging in healthy psychological functioning. Therefore, the role of the family therapist was to uncover these family conflicts, thus creating the possibility that the conflicts could be addressed in more adaptive ways. Once these family conflicts were properly handled, the causes of the child’s psychological problems were removed. Ackerman’s approach marked the beginning of the use of family therapy for the treatment of children’s problems.

Parent Training

Another historical movement within child psychotherapy is behavioral parent training (BPT). BPT evolved from the recognition that parents are important in shaping their children’s behavior and that they can be trained to eliminate many of their children’s problems. Beginning in the late 1960s, researchers such as Gerald Patterson and Rex Forehand began to develop programs designed to target parents as the principal people responsible for change in their children’s maladaptive behavior. In this system of psychotherapy, parents were taught ways to assess and to intervene to correct their children’s misbehavior. The role of the child was de-emphasized to the point that the child might not even be seen by the therapist during the treatment process.

Cognitive and Cognitive Behavioral Therapies

In the 1970s, some psychologists, including Donald Meichenbaum, began to apply the principles of behavior therapy to not only overt but also covert behaviors (that is, thoughts). Thus, the cognitive tradition was begun. Cognitive therapies are based on the mediational model, a model based on the belief that cognitive activity affects behavior. The goal of cognitive therapy is to institute behavioral changes via modifications in thoughts, especially maladaptive ones. Many child therapies actually use both cognitive and behavioral approaches in combination: cognitive behavior therapy. The cognitive behavior approach can be conceptualized as a two-pronged approach addressing both thoughts and behaviors while emphasizing their reciprocal relationship (thought affects behavior and behavior affects thought).

Treatment Formats

It is estimated that more than two hundred different types of child psychotherapy exist; however, these specific types of therapy can be roughly divided into three larger categories of treatment based on the primary focus of their interventions. These three categories are children only, parents only, or children and parents combined.

Child-Only Format

Individual child psychotherapy, the first category of psychotherapy with children, focuses on the child alone because of the belief that the greatest amount of improvement can result when the child is given primary attention in treatment. An example of individual child treatment is psychodynamic play therapy. Originating from the work of Anna Freud, psychodynamic play therapy has as its basic goal providing the child with insight into the internal conflicts that have caused his or her psychological disorder. Once the child has gained sufficient insight, he or she is guided in handling these conflicts in more adaptive ways. Play therapy can be divided into three basic phases: initial, interpretative, and working-through phases.

In the initial phase of play therapy, the major goal is to establish a cooperative relationship between the child and the therapist. The attainment of this goal may require considerable time for several potential reasons. These reasons include a child’s unwillingness to participate in therapy, lack of understanding regarding the therapy process, and lack of a previous trusting relationship with an adult. The participation in play activities provides an opportunity for the therapist to interact with the child in a relaxed and interesting manner. The specific kinds of play utilized differ from therapist to therapist but may include competitive games (such as checkers), imaginative games involving different figures (hand puppets, for example), or cooperative games (playing catch).

Once a sufficient level of cooperation is established, the therapist can begin to make interpretations to the child regarding the play. These interpretations consist of the therapist identifying themes in the content or style of a child’s play that may relate to a psychological problem. For example, in playing with hand puppets, a child referred because of aggressive behavior may regularly enact stories in which a larger puppet “beats up” a smaller puppet. The child’s therapist may interpret this story as meaning that the child is aggressive toward others because he or she feels inadequate.

Once the child gains insight into the internal conflict that has caused his or her problematic behavior, the child is guided by the therapist to develop a more adaptive way of handling this conflict. This final process of therapy is called working through. The working-through phase may be the most difficult part of treatment, because it involves the child abandoning a repetitive and maladaptive manner of handling a conflict in favor of a new approach. In comparison to most other psychotherapies, this treatment process is lengthy, ranging from months to years.

Parent-Only Format

The second category of child psychotherapy, parent training, focuses intervention on the parents, because they are viewed as potentially the most effective persons available to alleviate the child’s problems. This assumption is based on several factors, including the great amount of time parents spend with their children, the parents’ control over the child’s access to desired reinforcers, and the parents’ understanding of the child’s behavior because of their past relationship with the child. Behavioral parent training (BPT) is the most common type of parent training program. In BPT, parents are taught ways to modify their children’s environment to improve behavior.

The initial phase of this treatment process involves instructing parents in the basics of learning theory. They are taught that all behavior, adaptive or maladaptive, is maintained because it is reinforced. The application of learning theory to the correction of children’s misbehavior involves three principles. First, positive reinforcement should be withdrawn from children’s maladaptive behavior. For example, a father who meets the demands of his screaming preschooler who throws a temper tantrum in the checkout line of the grocery store because she wants a piece of candy is unwittingly reinforcing the child’s screaming behavior. Second, appropriate behavior that is incompatible with the maladaptive behavior should be positively reinforced. In the case of the screaming preschooler, this would involve rewarding her for acting correctly. Third, aversive consequences should be applied when the problem behavior recurs. That is, when the child engages in the misbehavior, he or she should consistently experience negative costs. For example, the preschooler who has a temper tantrum in the checkout line should not be allowed money to purchase gum, which she had previously selected as a potential reward for good store behavior, as the cost for her tantrum. To produce the greatest effect, positive reinforcement and negative consequences should be administered as close as possible to the occurrence of the appropriate or inappropriate behavior.

Family Format

The final category of child psychotherapy, family therapy, focuses intervention on both the child and the child’s family. Family therapy rests on the assumption that the child’s psychological problems were created and are maintained by interactions among different family members. In this model, attention is shifted away from the individual child’s problems toward the functioning of the entire family. For example, in structural family therapy, a widely practiced type of family therapy, the boundaries between different family members are closely examined. Family boundaries represent the degree of separation between different family members or subsets of members (for example, the parent-versus-child subset). According to Salvador Minuchin, the originator of structural family therapy, families in which there is little separation between parents and children may cause certain children to misbehave as a way to gain increased emotional distance from their parents. On the other hand, families characterized by too much separation between parents and children may cause certain children to become depressed because of the lack of a confiding relationship with a parental figure. Regardless of the child’s specific disorder, all family members, not the child or parents alone, are the focus of treatment.

Efficacy of Psychotherapy

The two large questions that can be asked regarding psychotherapy for children are whether it is effective and whether one type of treatment is more effective than others. The answer to the first question is very clear: psychotherapy is effective in treating the majority of children’s psychological disorders. Two major studies in the 1980s reviewed the existing research examining the effects of child psychotherapy. The first of these studies was conducted by Rita Casey and Jeffrey Berman in 1985, and the second was conducted by John Weisz, Bahr Weiss, Mark Alicke, and M. L. Klotz in 1987. Both these studies found that children who received psychotherapy were better off than approximately 75 percent of the children who did not receive psychotherapy. Interestingly, Weisz and colleagues found that younger children (ages four to twelve) appeared to obtain more benefit from psychotherapy than older children (ages thirteen to eighteen). In addition, Casey and Berman found that girls tend to receive more benefit from psychotherapy than do boys.

As one might expect, some controversy exists in attempting to answer the second question, regarding which treatment is the most effective. Casey and Berman concluded that all treatments were equally effective; however, Weisz and colleagues found that behavioral treatments were more effective than nonbehavioral treatments. Disagreement regarding which type of psychotherapy is most effective should not be allowed to obscure the general conclusion that psychotherapy for children is clearly beneficial. Many investigators would suggest that the characteristics shared by all types of child psychotherapy are responsible for the relatively equivalent improvement produced by different treatments. For example, one of these common characteristics may be the therapist’s and child’s expectations that therapy will result in a reduction in the child’s psychological problems. In spite of the treatments’ apparent differences in rationale and method, it may be that this component, as well as other common elements, accounts for much of the similarity in treatment outcomes.

The number of psychotherapeutic approaches available to treat children’s psychological disorders has exploded since their introduction in the 1920s. Recent research has clearly demonstrated the effectiveness of psychotherapy for children. Controversy still remains, however, regarding which treatment approach is the most effective; continued research is needed to address this issue. Of greater urgency is the need to provide psychotherapy to the approximately five to ten million children with psychological disorders who are not being served. Perhaps even more cost effective, in terms of both alleviating human suffering and reducing costs, would be the development of programs to prevent children’s psychological disorders.

Bibliography

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: APA, 2013. Print.

American Psychiatric Association. DSM-5 and Diagnoses for Children. Washington, DC: APA, 2013. Digital file.

Ammerman, R. T., M. Hersen, and C. Last, eds. Handbook of Prescriptive Treatments for Children and Adolescents. Boston: Allyn, 1999. Print.

Axline, Virginia Mae. Dibs: In Search of Self. New York: Ballantine, 1990. Print.

Brems, C. A Comprehensive Guide to Child Psychotherapy. 3d ed. Long Grove: Waveland, 2008. Print.

Briesmeister, J. M., and C. E. Schaefer, eds. Handbook of Parent Training: Parents as Cotherapists for Children’s Behavior Problems. Hoboken: Wiley, 2007. Print.

Centers for Disease Control and Prevention. "CDC Features: Children's Mental Health—New Report." Centers for Disease Control and Prevention. CDC, 21 May 2013. Web. 26 June 2014.

Gordon, Thomas. Parent Effectiveness Training: The Proven Program for Raising Responsible Children. Rev. ed. New York: Three Rivers, 2000. Print.

Kendall, Philip C., ed. Child and Adolescent Therapy. 3d ed. New York: Guilford, 2006. Print.

Minuchin, Salvador. Families and Family Therapy. London: Routledge, 1993. Print.

Monte, Christopher. “Anna Freud: The Psychoanalytic Heritage and Developments in Ego Psychology.” In Beneath the Mask: An Introduction to Theories of Personality. 7th ed. Hoboken: Wiley, 2003. Print.

National Institute of Mental Health. "Use of Mental Health Services and Treatment among Children." National Institute of Mental Health. NIMH, n.d. Web. 26 June 2014.

Nemiroff, Marc A., and Jane Annunziata. A Child’s First Book About Play Therapy. Washington, DC: American Psychological Association, 1990. Print.

Perou, Ruth, et al. "Mental Health Surveillance among Children—United States, 2005–2011: Supplements." Morbidity and Mortality Weekly Report. CDC, 17 May 2013. Web. 26 June 2014.

Reinecke, M. A., F. M. Dattilio, and A. Freeman, eds. Cognitive Therapy with Children and Adolescents. New York: Guilford, 2007. Print.