Psychotherapy in children, an overview

1. By- Dr. Sunil Suthar
Psychosocial approaches
and psychotherapies as
relevant to Child Psychiatry
Under Guidance of
Dr. Yogesh Satija

2. Content
Introduction
Difference from adult psychotherapy
Psycho- education
Parent counseling
Psychodynamic Psychotherapy
cognitive-behavioral Therapy
Family Therapy
Group Psychotherapy
Play Therapy
Other Therapies
Indications

3. Introduction
 Psychotherapy is a very general term that implies treatment of mental
dysfunction by psychological (medicine) rather than physical methods.
 Dynamic psychotherapy based on the theories of Sigmund Freud and his
daughter Anna Freud, Melanie Klein, and others has been the mainstay of
individual child therapy.
 More recently, Virginia Axline adapted the ideas that Carl Rogers applied
to counselling and developed ‘play therapy' as a specific technique for
children.
 Subsequently, brief psychotherapy and interpersonal therapyhave grown
out of the need to update psychodynamic methods.

4.  Various forms of cognitive therapy are now increasingly used for children,
although they were developed for the treatment of adults. These
therapies focus on a problem-solving approach to resolve current issues,
rather than on resolving unconscious conflicts based in the past.
 The ability to distinguish fact from fantasy is an important prerequisite for
psychotherapy.
 If the therapist ignores developmental issues it is likely that treatment will
be harmful rather than helpful.
 The aim is to improve function by changing cognition and emotions
through the therapeutic relationship, by means of language, play, art, or
drama.

5. • Psychotherapy with children requires a high level of skill.
• Psychotherapy is directed more at psychopathology than normal reactions
to stress. It is therefore essential to know about the normal range of
children's responses to life events. For example, a 5-year-old child whose
mother has just died will grieve differently from a 10-year-old child,
because at 5 years of age most children have not yet developed a clear
concept of death. Grief in a 5-year-old is most strongly influenced by the
way the adults around the child react to the death, whereas a grieving 10-
year-old child, although responsive to guidance from the adults around,
will also have his or her own unique way of coping with grief. As a general
rule, the younger the child the more important it is to consider the
attitude and mental state of the parents.

6. Differences from adult psychotherapy
 Basic principles involved are quite similar to those involved in the treatment
of adults.
 The most notable difference between children and adults is the difference
in the rate of developmental change. (immaturity and lack of life experience
that children have.) This makes children highly dependent on adults for
emotional and physical security.
 Consent from the child and both parents.
 Children cannot be expected to find their own solutions without guidance
and support.

7.  Another major difference is that children do not come to treatment at
their request. They are brought by their parents. The reasons for
treatment must be explored and explained in a way that is understandable
and meaningful to the child. As a consequence, one of a therapist's first
tasks is to stimulate a child's motivation for treatment.
 The child psychotherapist must recognize the critical and central role of
the parents or caretakers in the child's life.
 Play is the central medium for communicating with younger children.
 Transference in children and adolescents is more complex than with
adults.
 Working with parents is essential in psychotherapy with children and
adolescents.

8. Psycho-Education
Goals of Psychoeducation-
 Teach parents and children about
• The child’s illness & its treatment
 Provide support
• Peers (“I’m not the only one”)
• Professionals - understand the disorder
 Adherence for pharmacotherapy
It is helpful in reduction of caregiver stress (Worry about the future, Stigma,
Guilt and blame )

9. PARENTS COUNSELLING
Following points are noteworthy in this contest (Madhavan,1990).
1) The child's actual condition should be explained in simple words to the parents.
2) Enough time must be taken while counseling.
3) Misleading, giving false information or building false hopes in parents must be avoided.
4) Information regarding professional help for treating associated conditions like seizures,
hyperactivity, psychosis etc. must be made available to the parents.
5) Attitude such over protection ie., doing everything for the child and shielding them from
any challenging situation, should be corrected as it hinders the development of whatever
capacities the child may have.

10. PARENTS COUNSELLING
6) The attitude of rejection, that is ignoring the child thinking that he is good for nothing
should be changed so that the child can be helped to learn by systematic training.
7) The parents should be made aware of what they may expect of their child
8) Some patents suffer from guilt feeling assuming that they are responsible for their child's
condition. It should be explained that the condition is due to causes over which parents
have no direct control.
9) The counselor should explain the effectiveness and role of the parents and other family
members in training a mentally retarded.
10) Some parents believe that training a mentally retarded child needs specialized skills and
they may not be able to train their child. Parents should be explained that training a
mentally retarded child dose not need complex skills and repeated training in simple
steps, they can be taught.
11) Parents should be helped to learn the skills in training through demonstrations and
observations.

11. Individual Psychodynamic Psychotherapy
 A. Freud first articulated the aims of child psychoanalysis as a return to the
path of normal development.
 Subsequent analysts have emphasized the aims of increased
mentalization, self-understanding, self-regulation, personality integration,
self-expressiveness, self-esteem, flexibility, increased frustration
tolerance, and capacity to play.
 The indications for psychodynamic psychotherapy generally include
children with internalizing disorders.
 Psychodynamic psychotherapy focus on intrapsychic conflict.
 It focuses on improving children adaptive skills and diminishing specific
symptomatology.

12. Cognitive–Behavioral Psychotherapy for
Children and Adolescents
 It emphasizes how children may use thinking processes and cognitive
modalities to reframe, restructure, and solve problems.
 generating alternative ways of dealing with problematic situations.
 multiple studies are found to be effective in the treatment of child and
adolescent mood disorders, OCD, and anxiety disorders.
 Family-focused CBT has also been used in the treatment of pediatric
bipolar disorder with promising success.
 Using a variety of components, including behavioral exposure, cognitive
restructuring, and psycho-education, CBT has been shown to be adaptable
to a variety of formats, including individual, family, and group treatment.

13. Cognitive therapy
 The only modification that is required for their use in children is to adapt
them to the developmental stage and the level of cognitive ability that the
child has reached.
 Cognitive therapy has a theoretical advantage for use in children in that its
focus is more on the present and the future, in contrast to most
psychoanalytically based psychotherapy.
 Its approach is strongly based on learning new ways of coping.
 Cognitive therapy is pragmatic and active rather than passive and
reflective.

14. Basics Principles of REBT
.
Albert
Ellis

15. Core Irrational Beliefs For Children
• It’s Awful If Others Don’t Like Me.
• I’m Bad If I Make a Mistake.
• Everything Should Go My Way; I Should Always Get What I Want.
• Things Should Come Easily to Me.
• The World Should Be Fair.

16. How Do You Introduce CBT to Children in An
Engaging and Understanding Way
• Visuals - Thought Bubbles; Cartoons; Picture Book
• Baseball Metaphor
• Butterfly Thoughts Worksheet
• Thought Flower Garden
• Rational or Irrational? Game
• Best Friend Technique
• Reverse Role Playing
• Empty Chair Technique
• Erase the Irrational
• Analyze TV Shows or Movies
• Puppets
• Rational Advice Column
• Rational Emotive Imagery
• “Meet Thoughts, Your Thought Maker” by R. Avery

17. Externalizing Problems
Beliefs Associated With
Externalizing Disorders
(Anger)
B = Musts Instead of
Preferences; Low
Frustration Tolerance;
I Can’t Stand It!
Examples:
I must have what I want!
The world should be fair!
Other people must treat me
the way I wanted them to,
and when they don’t, they
deserve to be punished!
Challenges for Anger
Related Irrational
Beliefs
Where Is It Written That
You Should Always Get
What You Want, That The
World Must Be Fair, and
That You Always Have To
Get Your Way?
Functional Disputes
How Is Your Anger Helping
You? Or, is it Like Pouring
Salt On An Open Wound?

18. Behavior Therapy
 Reinforcement / Contingency management - Parent praise (Verbal
praise, Encouragement, Attention, Affection, Physical proximity)
 Time out - is the removal of a child or adolescent from all
reinforcement for a specified period of time after a targeted
misbehavior.
 Structured class room training (to learn new material & maintain the
acquired learning, ''special schooling'').

19. Social Skills Training
• Sometimes used to teach the child skills needed in peer
relationships and other settings
 Interaction skills  Conflict resolution
 Problem-solving skills  Anger management
• Results of studies of this strategy are inconsistent
• More effective when taught in group settings such as summer
camps, school-based, and after-school settings

20. Group Psychotherapy
A number of factors, described by Irving Yalom, may contribute to the
effectiveness of groups.
 Hope: Hope may be generated by gathering with others who are
experiencing similar difficulties and by observing others actively mastering
the problems.
 Universality: Children and adolescents with psychiatric disorders often
feel isolated and alienated from peers. Working together in groups may
diffuse the isolation and help children and adolescents view their disorder
as only a small part of their overall identity.

21. Group Psychotherapy
 Imparting Information: Children and adolescents are familiar with a
format of gaining new information in a group setting, such as in school.
The group therapy format provides an opportunity to reinforce learning
when the child or adolescent helps or demonstrates what he or she has
learned to peers.
 Altruism: Helping other peers in a group setting by supporting them and
identifying with their struggles can improve a child or adolescent's self-
esteem and help them gain a sense of mastery over their own issues.
 Improved Social Skills: Group therapy is a safe format in which children
and adolescents with poor social skills can improve their interpersonal and
communication abilities under the supervision of a leader and with peers
who also benefit from the practice scenarios.

22. Individual versus group therapy
 There are no agreed guidelines to determine which child would benefit
from an individual or from a group approach to psychotherapy.
 Some children, however, find the emotional intensity of undivided adult
attention too much to cope with and learn better from others in a group
situation.
 As the selection of cases for group psychotherapy tends to be determined
by the therapist's skills, there is no clear evidence that one approach is
better than any other.
 Nevertheless, there is a growing literature on group therapy for children
and an increasing interest in this method of treatment if only because the
cost per case is likely to be less.

23. Family Therapy
• There are many models of family therapy with different theoretical bases.
• They have in common a focus on treating the family as the defined unit for
therapy: problems evolve from the family structure and history, and
although the child or adolescent may be the ‘identified patient,’ the basic
problems rest within the family.
• Varieties of Family Therapy-
1. Strategic (Haley, Madanes) – conflicts and negative pattern of
interaction
2. Structural (Minuchin) - dysfunctional patterns (ineffective closeness,
excessive distance)
3. Systemic (Bowen, 'The Milan model') - explore the way the family
system has created rules, and hierarchy.
4. Behavioral (Patterson) - identifies problematic behavior in children
and helps parents reinforces positive behavior.

24. Inpatient Psychiatric, Partial Hospital, and Residential
Treatment for Children and Adolescents
• are appropriate settings for children and adolescents with mental
disorders(with serious psychiatric disturbances ) who require a highly
structured and supervised setting for a substantial time.
• Residential settings offer many treatments, including behavioral
management, psychotherapy, medication, special education, and the
therapeutic milieu itself.
• Partial hospitalization /Day treatment programs-alternative to
hospitalization to provide short-term crisis stabilization. Family therapy,
group and individual psychotherapy, psychopharmacology, behavioral
management programs, and special education are integral parts of these
programs.
• Children who are likely to benefit from day treatment may have a wide
range of diagnoses, including autistic disorder, conduct disorder, ADHD,
and mental retardation.

25. • Education Process in Residential Treatment

26. Case
• A 7-year-old boy was brought for treatment by his working-class parents,
who were concerned about his depressive irritability and
argumentativeness, which had created great tension in the family. When
seen individually, the therapist asked the child about his understanding of
why they were meeting. The boy responded, “I don't know.” The therapist
then asked why he thought the parents had brought him, and he again
avoided the question. Later in the interview the therapist returned to the
issue while the child played out a puppet scene of different animals
fighting. The therapist explored how the animals felt, and the child said
“sad.” As the play developed, the therapist explored whether the child
might also be sad. This seemed to resonate, and the child nodded his head
“yes” and went back to playing with the puppets. As the session closed the
therapist suggested that in meeting together they might come to
understand “why you feel sad and what we can do to help you feel better.
How does that sound to you?” The boy looked up shyly and nodded his
approval.

27. Play therapy
is
– Symbolic
– The world of the child
– Acts out real life conflicts and issues
– Fun
– Play therapy is just that -- it is not a talking therapy, but it can lead to
that.
– a method of communicating in a therapeutic way with children

28. • Play therapy is generally employed with children aged 3 yrs to11 yrs and
provides a way for them to express their experiences and feelings through
a natural, self-guided, self-healing process.
• Play therapy can be divided into two basic types:
1) Nondirective play therapy (client-centered and unstructured play
therapy)– it is a method in which children are encouraged to work
toward their own solutions to problems through play. It is typically
classified as a psychodynamic therapy.
2) Directive play therapy – it is a method that includes more structure
and guidance by the therapist as children work through emotional
and behavioral difficulties through play. It often contains a behavioral
component and the process includes more prompting by the
therapist. Directive play therapy is more likely to be classified as a
type of cognitive behavioral therapy.

29. Typical Goals of Play Therapy
• Enhance child’s self
control, self-concept, and
self-efficacy.
• Help child become aware
of his or her feelings.
• Have a place where child
can feel safe in
exploration of self.
• Learn and practice self-
control and alternative
behaviors.
• Develop capacity to trust
adults.
• Develop capacity to relate
to an adult in an open,
positive and caring
manner.

30. Equipment
• Puppets
• Art
• Sand Play
• Games
• Doll Houses
• Almost any toy
• Paper and color pencil
• Cars and Trucks
• Toy guns
• Costumes, dress-up
• Water play
• Games, i.e, cards,
checkers, etc.

32. Toys Needed for Play Therapy Room
• Scary toys
– Client’s can use these to
deal with fears
– Plastic monsters, snakes,
bugs, bears, lions,
dinosaurs
• Nurturing Toys
– Client’s can use these to
play out family
relationships and events
– Doll house, dolls,
puppets, baby dolls,
kitchen set
Source: InAPT conference 2005

33. Toys Needed for Play Therapy Room
• Aggressive Toys
– Clients use these to
express anger and
aggression and explore
power and control issues
– Guns, play knives,
hammer and nails, toy
soldiers, punching bag
• Expressive Toys
– Clients use these to
explore relationships,
express feelings, deal
with problem/solution
– Crayons, paper, scissors,
paint, craft items.
Source: InAPT conference 2005

34. Four different models of Play Therapy
 Virginia Axlin, (1947) - Child-Centered Play Therapy
 Clark Moustakes, (1973) - Relationship Playtherapy
 Bernard G. Guerney, Jr. (1964) - Filial therapy
 Family Play Therapy

35. Other Therapies
 Speech/Language Therapy
– Picture Exchange Communication System
– Auditory Integration Therapy
 Occupational Therapy
– Sensory Integration

36. Psychotherapy Effectiveness
• Lack of well-controlled empirical studies makes it difficult to draw firm
conclusions
• A large well-controlled study in the United Kingdom by Kolvin et al.found
that group psychotherapy and behaviour modification produced greater
improvement in school-aged children than parent–teacher consultation or
no active treatment at all. Kolvin et al. concluded that psychotherapy is
effective.
• More research is needed!

37. Indications
• Psychotherapy usually is indicated for children with emotional disorders
that seem to be sufficiently permanent to impede maturational and
developmental forces.
• The indications for psychodynamic psychotherapy generally include
children with internalizing disorders.

38. • Intellectual disability – Special education, Social intervention, behavioral
therapy.
• Reading disorder , Mathematics disorder, Written expression disorder –
Special teaching programmes, Individual education programme.
• Communication disorder (stuttering)- Speech therapy, Therapy to reduce
anxiety and tension
• Autism- Education and behavioral intervention ( structured class room
training) is currently treatment of choice.
• Asperger syndrome- Self sufficiency and problem solving technique to
improve social behavior and peer relationship.

39. • ADHD – Family therapy, group therapy to refine social skills and increase
self esteem.
• ODD and Conduct disorder – Family therapy to teach parents how to alter
their behavior, discourage child’s oppositional behavior and encourage
appropriate behavior, social skill training, problem solving skills.
• PICA – Behavioral techniques ( Mild aversion therapy, negative
reinforcement, positive reinforcement, modeling, shaping).
• Rumination Disorder – Behavioral techniques eg. Squirting lemon juice
into infant’s mouth whenever rumination occurs.

40. • Enuresis – Behavior technique- toilet training, restricting fluid before bed,
night lifting to toilet train the child, Bell and pad apparatus.
• Encopresis - Behavioral therapy (toilet-use skills)
• PTSD – Crisis intervention, Trauma focused CBT, Eye movement
desensitization and reprocessing (EMDR).
• Separation anxiety disorder – CBT is first line treatment.( Cognitive
strategies, relaxation exercise and graded exposure)

41. References
• Kaplan and Sadock’s Comprehensive Text Book of Psychiatry 9th edition
• Kaplan and Sadock synopsis
• Oxford Text book of psychiatry
• Kolvin, I., Garside, R.F., Nicol, A.R., MacMillan, A., Wolstenholme, F., and Leitch,
I.M. (1981). Help starts here. The maladjusted child in the ordinary school.
Tavistock, London
 Kolvin, I., Macmillan, A.K., Nicol, A.R., et al. (1988). Psychotherapy is effective.
Journal of the Royal Society of Medicine, 81, 261–6.
• Clinical Child Psychiatry, Second Edition. Edited by W.M. Klykylo and J.L. Kay© 2005
John Wiley & Sons Ltd ISBN: 0-470-0220-94
• Autism Society of America −
www.autism-society.org
 Autism Speaks – 100 Day Kit −
www.autismspeaks.org
 Centers for Disease Control and Prevention −
www.cdc.gov
 American Academy of Pediatrics −
www.aap.org

42. THANK YOU