Psychiatric Treatment of Children and Adolescents

49.1 Individual Psychotherapy

Individual psychotherapy for children and adolescents can take many forms, including short- and long-term approaches within a variety of conceptual frameworks, such as cognitivebehavioral, behavioral, psychodynamic, supportive, interpersonal, and “eclectic” mixtures of these techniques. In recent years, randomized clinical trials have provided data to support the efficacy of cognitive-behavioral interventions for a wide range of childhood psychiatric disorders, including obsessive-compulsive disorder (OCD), anxiety disorders, and depressive disorders. The initial goal of any psychotherapeutic strategy is to establish a working relationship with the child or adolescent. In general, successful individual psychotherapeutic interventions with children also require establishing a therapeutic rapport with parents. To approach a child therapeutically, one needs an understanding of the normal development of a child of a given age as well as an understanding of the context in which particular symptoms emerged. Individual psychotherapy with children focuses on improving children’s adaptive skills as well as diminishing specific symptomatology. Treatment reflects an understanding of children’s developmental levels and shows cultural sensitivity toward families and environments in which children live. Most children do not seek psychiatric treatment; they are taken to a psychotherapist because of a disturbance noted by a family member, a schoolteacher, or a pediatrician. Children often believe that they are being taken for treatment because of their misbehavior or as a punishment for wrongdoing.

Children and adolescents are the most accurate informants of their own thoughts, feelings, moods, and perceptual experiences. External behavior problems are often identified by others, yet children’s internal experiences may be largely unknown. Children often can describe their feelings in a particular situation but cannot execute therapeutic changes without an advocate’s help. Thus, child psychotherapists function as advocates for their child patients in interactions with schools, legal agencies, and community organizations. Child psychotherapists may be called on to make recommendations that affect various aspects of children’s lives.

TYPES OF PSYCHOTHERAPIES

Developing a psychotherapeutic intervention for a particular child includes evaluation of the child’s age, developmental level, type of problem, and communication style. Whichever style or combination of techniques a therapist chooses to use in psychotherapy, the relationship between child and therapist is a critical element. The relationship often is the primary, if not the sole, ingredient in psychotherapy. The therapist provides a safe space in which to listen, empathize, and solve problems with the child.

John, a bright 14-year-old, was treated with brief (25 sessions) psychotherapy. The initial complaint was that his grades had dropped during the academic year; he had withdrawn from sports, was anhedonic, had difficulty relating to his peers, and whined a lot. His parents divorced when John was 7 years old. He had two younger sisters, ages 12 and 9. John “hated” his father; therefore, he missed many visitations with him, pretending that he was sick or too busy to see him. His sisters kept close contact with the father. His mother had a live-in boyfriend who moved in the year that John became symptomatic. John also “hated” the boyfriend. He felt miserable and reproached everyone in his environment. During the first two therapy sessions, two issues to be addressed were delineated: John feeling rejected by his father and mother (who had found another man) and his issues with rivalry. During the following treatment sessions, an empathetic and supportive therapist helped John acquire insight into his feelings through interpretation of his defenses, transferential manifestations, and clarifications. John and the therapist discussed strategies and activities to be carried out during the treatment period to alleviate his discomfort. By session 16, John had reestablished regular contact with his father and was able to tolerate his mother’s boyfriend. The termination phase included the integration of what had been discussed, learned, and practiced, and gave John the ability to understand his internal conflicts and find more appropriate ways of managing them. His rivalry issues had diminished, as he was also able to share his father with his sisters. His biological parents and his mother’s boyfriend were seen in parallel.
The sessions consisted of psychoeducational approaches concerning John’s developmental level of functioning and the way he perceived and experienced his environment. His parents were helped to recognize and handle John’s problems, as well their own conflicts, and strategies were proposed for facilitating John’s development. At termination, it was agreed that John would return to see the therapist for one follow-up session every 3 months in the first year and every 6 months in the following 2 years. At the 2-year follow-up, it was apparent that John had improved academically and had resumed his outside activities, such as sports. He remained sensitive to rejection, but he was able to use the skills he had learned to manage those feelings. (Courtesy of Euthymia D. Hibbs, Ph.D.)

Cognitive-behavioral therapy (CBT) is an amalgam of behavioral therapy and cognitive psychology. It emphasizes how children may use thinking processes and cognitive modalities to reframe, restructure, and solve problems. A child’s distortions are addressed by generating alternative ways of dealing with problematic situations. Cognitive-behavioral strategies have been shown in multiple studies to be effective in the treatment of child and adolescent mood disorders, OCD, and anxiety disorders. A recent study compared a family-focused CBT—the “Building Confidence Program”—with traditional child-focused CBT with minimal family involvement for children with anxiety disorders. Both interventions included coping skills training and in vivo exposure, but the family CBT intervention also included parent communication training. Compared with the child-focused CBT, family CBT was associated with greater improvement on independent evaluators’ ratings and parent reports of child anxiety but not on children’s self-reports of improvement. Family-focused CBT has also been used in the treatment of pediatric bipolar disorder with promising success.

One of the limiting factors in providing CBT to children with OCD, anxiety disorders, and depressive disorders is the lack of sufficient numbers of trained child and adolescent cognitivebehavioral therapists, and a recent study addressed the issue of the feasibility of combining a CBT via clinic-plus-Internet condition. Children who received the clinic-plus Internet condition showed significantly greater reductions in anxiety from pre- to posttreatment condition and maintained gains for a period of 12 months compared with children who received no active treatment but were on a wait-list condition. The Internet treatment was acceptable to families, and dropout rate was minimal.

A recent study of a CBT in conjunction with an attachment-based family therapy used in adolescents with anxiety disorders and their families showed that significant improvements could be achieved by using individual CBT along with a family therapy condition. Participants followed at 6 to 9 months after the treatment showed significant decreases in anxiety and depressive symptoms. Cognitive-behavior therapy has now been shown in multiple randomized clinical trials to have efficacy in the treatment of anxiety disorders in children and adolescents. Using a variety of components, including behavioral exposure, cognitive restructuring, and psychoeducation, CBT has been shown to be adaptable to a variety of formats, including individual, family, and group treatment.

Remedial, educational, and patterning psychotherapy is focused on teaching new attitudes and patterns of behavior to children who persist in using immature and inefficient patterns that are often presumed to be caused by a maturational lag. Supportive psychotherapy is particularly helpful in enabling a well-adjusted youngster to cope with emotional turmoil engendered by a crisis. It also is used with disturbed youngsters whose less-than-adequate ego functioning may be seriously disrupted by an expressive-exploratory mode or by other forms of therapeutic intervention.

At the beginning of most psychotherapy, regardless of a patient’s age and the nature of the therapeutic interventions, the principal therapeutic elements perceived by patients tend to be supportive as a consequence of therapists’ universal efforts to be reliably and sensitively responsive. In fact, some therapy may never proceed beyond the supportive level, whereas other therapy develops an expressive-exploratory or behavioral modification flavor on top of the supportive foundation.

Preschool-age children are sometimes treated through the parents, a process called filial therapy. Therapists using the strategy should be alert to the possibility that apparently successful filial treatment can obscure a significant diagnosis because patients are not treated directly. The first case of filial therapy was that of Little Hans, reported by Freud in 1905. Hans was a 5-year-old phobic child who was treated by his father under Freud’s supervision.

Although historically psychotherapy had its roots in psychodynamic theories, current evidence has shown that cognitivebehavioral therapeutic techniques are efficacious in the treatment of anxiety disorders and mood disorders in youth. Children generally are unaware of these unreal dangers, their fear of them, and the psychological defenses they use to avoid both the danger and the fear. With the awareness that is facilitated, patients can evaluate the usefulness of their defensive maneuvers and can relinquish unnecessary maneuvers that constitute the symptoms of their emotional disturbance.

Child psychoanalysis, an intensive, uncommon form of psychoanalytic psychotherapy, works on unconscious resistance and defenses during three to four sessions a week. Under these circumstances, therapists anticipate unconscious resistance and allow transference manifestations to mature to a full transference neurosis through which neurotic conflicts are resolved. Interpretations of dynamically relevant conflicts are emphasized in psychoanalytic descriptions, and elements that are predominant in other types of psychotherapies are not overlooked. Indeed, in all psychotherapy, children should derive support from the consistently understanding and accepting relationship with their therapists. Remedial educational guidance is provided when necessary.

Probably the most vivid examples of the integration of psychodynamic and behavioral approaches, although they are not always explicitly conceptualized as such, appear in the milieu of child and adolescent psychiatric therapy in inpatient, residential, and day treatment facilities. Behavioral change is initiated in these settings, and its repercussions are explored concurrently in individual psychotherapeutic sessions, so that the action in one arena and the information stemming from it augment and illuminate what occurs in the other arena.

DIFFERENCES BETWEEN CHILDREN AND ADULTS

Logic suggests that psychotherapy with children, who generally are more flexible than adults and who have simpler defenses and other mental mechanisms, should consume less time than comparable treatment of adults. Experience usually does not confirm this expectation, because children usually lack some elements that contribute to successful treatment. A child, for example, typically does not seek help. As a consequence, one of a therapist’s first tasks is to stimulate a child’s motivation for treatment. Children commonly begin therapy involuntarily, often without the benefit of true parental support. Although parents may want their children to be helped or changed, the desire often is generated by frustrated anger toward the children. Typically, the anger is accompanied by relative insensitivity to what therapists perceive as the children’s need and the basis for a therapeutic alliance. Therefore, whereas adult patients frequently perceive advantages in getting well, children may envision therapeutic change as nothing more than conforming to a disagreeable reality, an attitude that heightens the likelihood of their perceiving a therapist as the parent’s punitive agent. This is hardly the most fertile soil in which to nurture a therapeutic alliance.

Children have a limited capacity for self-observation, with the notable exception of some obsessive children who resemble adults in this ability. Such obsessive children, however, usually isolate the vital emotional components. In exploratory-interpretative psychotherapies, the development of a capacity for ego splitting—that is, simultaneous emotional involvement and self-observation—is most helpful. Only by identifying with a trusted adult and in alliance with this adult can children approach such an ideal. A therapist’s gender and the relatively superficial aspects of the therapist’s demeanor may be important elements in the development of a trusting relationship with a child.

Recognition of the importance of play constituted a major forward stride in these efforts.

PLAYROOM

The structure, design, and furnishing of the playroom are important. Some therapists maintain that the toys should be few, simple, and carefully selected to facilitate the communication of fantasy. Other therapists suggest that a wide variety of playthings should be available to increase the range of feelings that children can express. These contrasting recommendations have been attributed to differences in therapeutic methods. Some therapists tend to avoid interpretation, even of conscious ideas, whereas others recommend the interpretation of unconscious content directly and quickly.

Therapists tend to change their preferences in equipment as they accumulate experience and develop confidence in their abilities. Although special equipment—such as genital dolls, amputation dolls, and see-through anatomically complete (except for genitalia) models—has been used in therapy, many therapists have observed that the unusual nature of such items risks making children wary and suspicious of a therapist’s motives. Until dolls available to children in their homes include genitalia, the psychological content that special dolls are designed to elicit may be more available at the appropriate time with conventional dolls.

Although the choices of play materials vary among therapists, the following equipment can constitute a well-balanced playroom or play area: multigenerational families of flexible but sturdy dolls of various races; additional dolls representing special roles and feelings, such as police officer, doctor, and soldier; dollhouse furnishings with or without a dollhouse; toy animals; puppets; paper, crayons, paint, and blunt-ended scissors; a sponge-like ball; clay or something comparable; tools such as rubber hammers, rubber knives, and guns; building blocks, cars, trucks, and airplanes; and eating utensils. The toys should enable children to communicate through play. Therapists should avoid toys and materials that are fragile or break easily, that can result in physical injury to a child, or that can increase a child’s guilt.

INITIAL APPROACH

Various approaches are associated with each therapist’s individual style and perception of children’s needs, from approaches in which a therapist endeavors to direct children’s thought content and activity (release therapy, some behavior therapy, and certain educational patterning techniques) to exploratory methods in which a therapist endeavors to follow children’s leads. Although children determine the focus, therapists structure the situation. Encouraging children to say whatever they wish and to play freely, as in exploratory psychotherapy, establishes a definite structure. Therapists create an atmosphere in which they get to know all about a child—the good side as well as the bad side, as children would put it. A therapist may communicate to a child that the child’s response elicits neither anger nor pleasure but only understanding from the therapist. Such an assertion does not imply that therapists have no emotions, but it assures the young patient that the therapist’s personal feelings and standards are subordinate to understanding the youngster.

THERAPEUTIC INTERVENTIONS

Psychotherapy with children and adolescents generally is more directed and active than it often is with adults. Children usually cannot synthesize histories of their lives, but they are excellent reporters of their current internal states. Even with adolescents, a therapist often takes an active role, is somewhat less open-ended than with adults, and offers more direction and advocacy than with adults. A child or adolescent therapist often makes exclamations and expresses confrontations in which attention is directed to data of which patients are cognizant. A therapist may use interpretations, designed to expand patients’ conscious awareness of themselves, by making explicit the elements that have previously been expressed implicitly in the patients’ thoughts, feelings, and behavior. Beyond interpretation, therapists may educatively offer new information to which patients have not been exposed previously. At the most active end of the continuum are advising, counseling, and directing, which are designed to help patients adopt a course of action or a conscious attitude.

Nurturing and maintaining a therapeutic alliance may require educating children about the process of therapy. Another educational intervention may entail assigning labels to affects that have not been part of a youngster’s experience. Rarely does therapy have to compensate for a real absence of education about acceptable decorum and playing games. Children usually are not in therapy because they have never been exposed to educational efforts, but are there because repeated educational efforts have
failed. Therefore, therapy generally need not include additional teaching efforts, despite the frequent temptation to offer them.

The temptation for therapists to offer themselves as a model for identification may also stem from helpful educational attitudes toward children. Although this may sometimes be an appropriate therapeutic strategy, therapists should not lose sight of the pitfalls of this apparently innocuous maneuver.

CONFIDENTIALITY

The issue of confidentiality takes on greater meaning as children grow older. Very young children are unlikely to be as concerned about this issue as are adolescents. Confidentiality usually is preserved unless a child is believed to be in danger or to be a danger to someone else. In other situations, a child’s permission usually is sought before a specific issue is raised with parents. Advantages exist to creating an atmosphere in which children can feel that all words and actions are viewed by therapists as simultaneously both serious and tentative. In other words, children’s communications do not bind therapists to a commitment; nevertheless, they are too important to be communicated to a third party without a patient’s permission. Although such an attitude may be implied, sometimes therapists should explicitly discuss confidentiality with children. Most of what children do and say in psychotherapy is common knowledge to the parents.

The therapist should try to enlist parents’ cooperation in respecting the privacy of children’s therapeutic sessions. The respect is not always readily honored because parents are naturally curious about what is occurring, and they may be threatened by a therapist’s apparently privileged position.

Routinely reporting to a child the essence of communications with third parties about the child underscores the therapist’s reliability and respect for the child’s autonomy. In certain treatments, the report can be combined with soliciting the child’s guesses about these transactions. A therapist also may find it fruitful to invite children, particularly older children, to participate in discussions about them with third parties.

49.2 Group Psychotherapy

Group formats have been demonstrated to be useful in randomized clinical trials using cognitive-behavioral techniques to treat childhood anxiety disorders. Groups have been used for a wide range of clinical situations, including anger-management training for aggressive adolescents, social skills training, treatment of survivors of childhood sexual abuse and other traumatic events such as the September 11 World Trade Center tragedy, treatment of adolescents with social phobia and obsessive compulsive disorder (OCD), treatment of children with psychotic disorders, interventions for adolescents with substance abuse, and treatment for children and adolescents with learning disorders. A recent study formed a psychotherapy group for adolescent survivors of homicide victims. Group therapy can be done with children of all ages using developmentally appropriate formats. Group therapy can be structured to address a variety of communication skills, including issues of interpersonal competence, peer relationships, and social skill. Group psychotherapy can be modified to suit groups of children of various ages and can focus on behavioral, educational, and social skills and psychodynamic issues. The mode in which the group functions depends on children’s developmental levels, intelligence, and problems to be addressed. In behaviorally and cognitive-behavioral groups, the group leader is a directive, active participant who facilitates prosocial interactions and desired behaviors. In groups using psychodynamic approaches, the leader may monitor interpersonal interactions less actively than in behavior therapy groups.

Groups can be highly effective modalities for providing peer feedback and support to children who are either socially isolated or unaware of their effects on their peers. Groups with very young children generally are highly structured by the leader and use imagination and play to foster socially acceptable peer relationships and positive behavior. Therapists must be keenly aware of the level of children’s attention span and the need for consistency and limit setting. Leaders of preschool-age groups can model supportive adult behavior in meaningful ways for children who have been deprived or neglected. Groups for school-age children can be single sex or include both boys and girls. School-age children are more sophisticated in verbalizing their feelings than preschoolers, but they also benefit from structured therapeutic games. Children of school age need frequent reminders about rules, and they are quick to point out infractions of the rules to each other. Interpersonal skills can be addressed nicely in group settings with school-age children.

Same-sex groups are often used among early adolescents. Physiological changes in early adolescence and the new demands of high school lead to stress that may be ameliorated when groups of same-age peers compare and share. For older adolescents, groups more often include both boys and girls. Even with older adolescents, the leader often uses structure and direct intervention to maximize the therapeutic value of the group. Adolescents who are feeling dejected or alienated may find a special sense of belonging in a therapy group.

Johnny was a high-functioning, 14-year-old boy diagnosed with autistic disorder. He had been in individual and family therapy for several months before he was considered ready for group therapy. Johnny was an awkward-looking adolescent who looked and acted younger than his chronological age. His academic level was above average, but his social development was very limited. A supercilious, hypermoralistic attitude of more recent development contributed considerably to his social isolation, particularly after starting 7th grade. He was assigned to an established group of early adolescents with a mixture of clinical conditions, meeting once weekly for 75 minutes. Initially, Johnny limited his participation to monosyllabic answers to direct questions, then he would go back to reading a book on the history of Napoleon, his favorite subject and object of fascination. Group members chose to ignore him after a while. Over a period of several weeks, his interest in the book seemed to abate. Johnny brought it, but it remained unopened on his lap. He would make an occasional remark, mostly to criticize another group member for his “vulgarity.” The group
laughed at his remarks, but scapegoating could be avoided. They seemed to respect his “differentness.” Two months later, Peter, a very shy schizoid 13-year-old boy, joined the group. After a few sessions Johnny developed an unexpected interest in Peter and sat by him and encouraged him to interact with the group. Soon Johnny was not bringing a book any longer and was more actively involved with group members. He responded to social cues in a more age-typical and appropriate manner, and although he continued having morbid preoccupations with power and a fascination with Napoleon, the intensity was considerably diminished. Johnny’s growing interest in people was clinically evident. Group therapy was used in combination with individual and family therapy and psychotropic medication over 18 months. Although the group experience was only one component of the treatment plan, it became a most significant tool to help Johnny with his interpersonal deficits. (Courtesy of Alberto C. Serrano, M.D.)

PRESCHOOL-AGE AND EARLY-SCHOOL-AGE GROUPS

Work with a preschool-age group usually is structured by a therapist through the use of a particular technique, such as puppets or artwork, or is couched in terms of a permissive play atmosphere. In therapy with puppets, children project their fantasies onto the puppets in a way not unlike ordinary play. The main value lies in the cathexis afforded children, especially if they show difficulty expressing their feelings. Here, the group aids the child less by interaction with other members than by action with the puppets.

In play group therapy, the emphasis rests on children’s interactional qualities with each other and with the therapist in the permissive playroom setting. A therapist should be a person who can allow children to produce fantasies verbally and in play but who can also use active restraint when children undergo excessive tension. The toys are the traditional ones used in individual play therapy. The children use the toys to act out aggressive impulses and to relive their home difficulties with group members and with the therapist. The children selected for group treatment have a common social hunger and need to be like their peers and be accepted by them. Selected children usually include those with phobias, effeminate boys, shy and withdrawn children, and children with disruptive behavior disorders.

Modifications of these criteria have been used in group psychotherapy for autistic children, parent group therapy, and art therapy. A modification of group psychotherapy has been used for toddlers with physical disabilities who show speech and language delays. The experience of twice-weekly group activities involves mothers and children in a mutual teaching-learning setting. This experience has proved to be effective for mothers who received supportive psychotherapy in the group experience; their formerly hidden fantasies about their children emerged and were dealt with therapeutically.

SCHOOL-AGE GROUPS

Activity group psychotherapy is based on the idea that poor, divergent experiences have led to deficits in children’s appropriate personality development; therefore, corrective experiences in a therapeutically conditioned environment modify them. Because some latency-age children have deep disturbances involving fears, high anxiety levels, and guilt, a modification of activity-interview group psychotherapy has evolved. The format uses interview techniques, verbal explanations of fantasies, group play, work, and other communications. In this type of group psychotherapy, children verbalize in a problem-oriented manner, with the awareness that problems brought them together and that the group aims to change them. They report dreams, fantasies, daydreams, and traumatic and unpleasant experiences. Open discussion includes both the experiences and the group behavior.

Therapists vary in their use of time, cotherapists, food, and materials. Most groups meet after school for at least 1 hour, although other group leaders prefer a 90-minute session. Some therapists serve food during the last 10 minutes; others prefer serving times when the children are together for talking. Food, however, does not become a major feature and is never central to the group’s activities.

PUBERTAL AND ADOLESCENT GROUPS

Group therapy methods similar to those used in younger-age groups can be modified to apply to pubertal children, who are often grouped monosexually. Their problems resemble those of late-latency-age children, but they (especially the girls) are also beginning to feel the effects and pressures of early adolescence. Groups offer help during a transitional period; they seem to satisfy the social appetite of preadolescents, who compensate for feelings of inferiority and self-doubt by forming groups. This therapy takes advantage of the influence of the socialization process during these years. Because pubertal children experience difficulties in conceptualizing, pubertal therapy groups tend to use play, drawing, psychodrama, and other nonverbal modes of expression. The therapist’s role is active and directive.

Activity group psychotherapy has been the recommended group therapy for pubertal children who do not have significantly disturbed personality patterns. The children, usually of the same sex and in groups of not more than eight, freely engage in activities in a setting especially designed and planned for its physical and environmental characteristics. Samuel Slavson, a pioneer in group psychotherapy, pictured the group as a substitute family in which the passive, neutral therapist becomes the surrogate for parents. The therapist assumes various roles, mostly in a nonverbal manner, as each child interacts with the therapist and other group members. Currently, however, therapists tend to see the group as a form of peer group, with its attendant socializing processes, rather than a reenactment of the family.

Late adolescents, 16 years of age and older, often may be included in groups of adults. Group therapy has been useful in the treatment of substance-related disorders. Combined therapy (the use of group and individual therapy) also has been used successfully with adolescents.

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