The origins of psychotherapy can be traced to diverse sources (see Chapter 5 for a brief overview of psychotherapies and their roots). Freud attempted to understand the horse phobia of a child (Little Hans) in light of his own theories of development and the unconscious. Early behaviorists noted the important role of learning in fear and fear conditions, for example, the case described by Mary Jones in 1923. Over time, the field of psychotherapy as it applies to children and adolescents has expanded dramatically. The predominant mode of scientific inquiry has now shifted from a focus on single clinical case studies to research methods using groups of children in clinical trials. Modern approaches pay considerable attention to issues of study method and design, use of standard measures, manualization to ensure replicability, and so forth (see Weersing & Dirks, 2007).

An important, and immediate, issue is the question of whether psychotherapy works. The first review of psychotherapy, now six decades old, raised important questions about the effectiveness of psychotherapy, that is, over rates of improvement noted in children and adolescents. This result corresponded, in many ways, to an influential review questioning the efficacy of psychotherapy in adults. Both sets of findings were the source of much debate. Thoughtful consideration of these early efforts identified several important limitations of then available research. These included nonrandom assignment to treatment, lack of attention to independent evaluations, need for careful control and comparison groups, and so forth. Recognition of these limitations led to the development of more rigorous clinical trial research.

A large and substantive body of research is now available and it has become possible to conduct meta-analytic reviews in which the results of carefully selected studies can be pooled and analyzed. Results can then be summarized in terms of overall effect size (see Chapter 3). Typically, a statistic like the one proposed by Cohen’s d quickly conveys how different a treatment group is from a comparison group in terms of units of standard deviation. For example, a d of 0.2 would usually be termed a small effect size whereas a d of 0.8 would be viewed as large.

In the first review of this kind in psychotherapy for children, Casey and Berman (1985) noted a reasonably good effect size (0.71). Subsequent work has generally confirmed that
medium to large effect sizes are frequently observed—similar to those reported in adults. Subsequent research has also addressed issues that may moderate treatment outcome, for example, variables in child, family, environment. Interestingly, the nature of the child or adolescent’s difficulties does not appear to straightforwardly relate to degree of improvement. Children and adolescents with internalizing type problems (depression, anxiety) are as likely to profit from intervention as are those with externalizing difficulties (conduct disorder, attentional problems).

The movement toward evidence-based treatments has factored heavily in attempts to evaluate psychotherapies. To qualify as evidence based, a treatment must have been shown to work in two independent, carefully designed, controlled studies with random assignment to treatment and comparison to either a placebo or comparison treatment group. The term probably efficacious has been used when study design is less stringent, for example, through comparison of treated cases to a wait list control. Even when the efficacy of a specific treatment model has been established, typically in a highly research oriented setting, important questions surrounding the effectiveness of the treatment in real-world settings must also be addressed. The typical university setting for clinical trials offers many advantages in terms of access, for example, extensive logistical support, the potential for careful training and monitoring treatment methods over time, and so forth. If conducted as part of a research project, participation may be free or participants may even be paid for being involved. Unfortunately, only much smaller number of studies have actually addressed the issue of treatment effectiveness in more usual treatment settings, and findings have not been nearly as promising as those from clinical trials conducted in university settings. Thus, there is a major gap between what can be done in research settings and what actually happens in the community.

Attempts have been made, particularly in the areas of depression and anxiety disorders, to address these issues with some encouraging results. Studies have also examined combined treatments, for example, medication and cognitive behavioral therapy (CBT), suggesting a modest benefit from adding CBT to drug treatment. Other efforts have focused on the effectiveness of work with parents, notably in the area of parent management training, where studies evaluating both clinical use and cost-effectiveness of this approach have produced promising results, for example, in reducing the number of arrests. Given the public health and social policy significance of youth conduct problems, these results are particularly encouraging and the approach has been adapted for other populations including for substance abuse.

Psychotherapy clearly can work for children and adolescents. The question of how it works remains an important topic for research and active area of debate. The question is a difficult one to answer for many reasons. Even a highly structured treatment will usually include multiple components, any of which, or any combination of which, may be most relevant to particular problems and patients. For example, in work on anxiety using CBT, is it the targeting of maladaptive cognitions that is most important or is it the exposure to the anxiety-provoking situation, or the combination of both? Further problems arise given our limited understanding of the pathophysiology of mental conditions. It will be important for future work in this area to develop more relevant measures, for example, beyond the typical child/parent report and observation scales to more direct measures, for example, of behavior or physiology.

Insight-oriented or psychodynamic psychotherapy is the oldest of the psychotherapies and has its origins in the attempt, beginning in the 19th century, to understand mental activity, the interplay of mind and brain, and symptoms/conditions that could be related to these processes. Sigmund Freud’s contribution remains substantial and modern methods owe a considerable intellectual debt to him, for example, for the conscious and unconscious mind and the importance of developmental issues in understanding symptoms. Freud’s case of
“Little Hans” provides one of the first reports of attempts to engage in psychotherapy with children. Because of Freud’s emphasis on the importance of early experience in the analysis of adults, he and his students had a strong developmental orientation. Several of his early trainees, including his daughter Anna, began direct work with children. From early on, this work noted the importance of an awareness of development, of the role of parents, and the special complexities of work with children, for example, the role of education, the place of play activities, and so forth. In England, Melanie Klein developed the notion of play analysis as the analog of free association in adult psychoanalysis and emphasized interpretation with a focus on core issues. In contrast, Anna Freud, who moved to England with her family shortly before World War II and who had been trained as a teacher, emphasized the “educative” functions of child therapy as well as interpretation. The war in Europe and increased interest in mental health issues after the war contributed to an influx of European-trained psychiatrists and analysts to the United States. Their ideas influenced a generation of therapists and also impacted the approaches to treatment used in child guidance clinics, congregate care programs, and similar settings.

Goals of psychodynamic psychotherapy often involve changing patterns of thought, feeling, or behavior that are partly, or even fully, not in the individual’s consciousness. This process relies on the importance of the relationship with the therapist attempting to help the patient. The notion of transference arises in this regard and refers to the tendency of patients to project onto their therapist feelings stemming from earlier relationships with meaningful figures in their lives. In addition, there is a significant “real” relationship with the therapist that also may further the psychotherapeutic process; this is particularly the case in work with children. Usually, the therapist attempts to understand the patient’s difficulties in light of early history and experience as well as in the context of the direct observations and interaction with the patient. (See Ritvo & Shapiro, 2018 for a discussion.)

Freud elaborated a complex theory of psychological functioning, and, at different points in his professional life, emphasized different features, but his theory was always strongly developmental. He highlighted the interplay of biologic factors and psychological ones in both normal development and psychopathology. He emphasized the importance of sexual development and believed that the surface (conscious behaviors, thoughts, and feelings reported by people) could be studied scientifically, were multiply determined, and that aspects of unconscious or not fully conscious issues could be inferred based on observation and discussion with the patient. His theory also emphasized the importance of conflict (external or internal) in the formation of difficulties and of various “drives” (sexual or aggressive) that the individual must cope with. As a practical matter, his therapy took the form of talking, or with children, playing, to clarify the nature of conflicts, developmental arrests, and distortions. One of the goals was to make conscious patterns that would otherwise remain unconscious and continue to be acted out/acted upon in some way. Freud also viewed the tendency of the patient to relive past relationships within the therapy (transference) as important and also noted that the therapist could similarly have feelings about the patient (counter transference) that also provide useful clinical information.

Freud’s theory evolved over time but had a tremendous influence on the development of models of the mind and mental illness in the 20th century. Many aspects of Freud’s views have been incorporated into other aspects of psychology and many of his concepts have influenced educational practices and childcare. Over time, a myriad of other models and approaches have appeared. For example, one group, the ego psychologists, developed a strong interest in understanding the working of the ego. Many members of this group were interested in children’s development and child psychotherapy. Another group developed in response to some of Freud’s notions about female development and female sexuality. Another school of psychoanalytic thought, object relations theory, emphasizes the centrality of internal representations both of the self and others in typical development and psychopathology. This school has been very much concerned theoretically with the earliest development of the mind and clinically with some of the more challenging patients, for example, those with borderline personality disorders, and emphasizes issues like early modulation of aggression and ability to tolerate affect and develop relationships with parents and others.

Regardless of the specific theoretical orientation of the therapist, psychodynamic psychotherapy is centrally concerned with the therapist-patient relationship both as a lens for viewing the past and understanding how this past colors the present. The therapist looks as well for patterns in the patients’ relationships and daily life to clarify these issues. In addition, the patient has, to some degree, a “real relationship” with the therapist. For therapists working with children, this real relationship is often very much present and provides, at least in theory, a greater potential for learning from new experiences. Accordingly, there is great emphasis on how the therapist conducts themselves with the child (or adult) patient. The therapist also models a reflective and thoughtful stance encouraging examination, introspection, and insight. This attitude of respect and concern also has the benefit of encouraging the treatment alliance—the commitment of the patient to seek greater self-understanding even in the face of anxiety or unpleasant feelings.

Goals of individual psychodynamic therapy include developing an understanding of the various influences in the life of the child or adolescent and how past experience and patterns of adaptation continue to be expressed in the present, for example, as symptoms or problem behaviors. Because such therapy is typically time consuming, it often is not undertaken if a less intensive approach is available. In this regard, however, it is important to note that in contrast to other forms of psychotherapy the goals of intensive psychodynamic psychotherapy are not limited solely to symptom reduction or elimination. Rather, the goals have to do with helping the individual child or adolescent assume a more normative developmental path with increased capacities for self-regulation, improved relations with others, and an enhanced ability to take appropriate pleasure in school or work activities.

The opening phase of psychodynamic therapy usually is concerned both with fostering the treatment and engagement of the child as well as clarifying aspects of diagnosis and interpersonal dynamics. For younger children, initial visits with the parents can provide important historic information and allow the parents to establish a sense of trust in the therapist that can then be conveyed to the child. For adolescents, issues of autonomy, confidentiality, and trust may have special importance. Meeting with the parents early on also helps clarify some aspects of the therapeutic relationship with them, that is, in general, the therapist strives to maintain confidentiality for the child and typically refrains from conveying information from sessions to the parents (with certain very specific exceptions related, for example, to thoughts of suicide or aggression). Children, and particularly younger children, may choose to make use of play materials, toys, games, and other activities. For some adolescents, the use of such activities, for example, cards or chess, may also provide a structure within which the patient can be more comfortable talking “on the side” with the therapist. Negotiating the complexities of working with the child and meeting periodically with the parents can be challenging. It is important for the therapist to be aware of these complexities and cope as effectively as possible.

The initial or opening phase of treatment focuses on obtaining important information on the child/adolescent and their difficulties as well as modeling a new approach for the child in attempting to understand these difficulties. This comes about through both implicit processes (modeling, empathizing) and more explicit ones, for example, interpretation. Interpretation consists of helping the child or adolescent understand, with the therapist’s help, a new way to understand thoughts, feelings, or impulses. For younger children, the integrative process begins through ongoing commentary of the therapist on the child’s play or about the child’s behavior or language. The therapist may draw the child or adolescent’s attention to something by wondering about or questioning something with the overarching goal of helping the child become more consciously aware of defense patterns, impulses, or maladaptive ways of coping. The opening phase of treatment typically lasts for weeks to several months.

Once a treatment alliance has been established, the middle phase of the treatment will concentrate on helping the child develop a new “defense” and give up old ones. This period, usually the longest phase of treatment, can last from months to even years. By this time, the child or adolescent is actively engaged in treatment as reflected in their ability to make use of the therapist’s consistency and nonjudgmental approach. Play during this time becomes richer, and, with older children and adolescents, some activity may alternate with or gradually be replaced by talking. Difficulties in the treatment take the form of resistance, for example, the
child may actively resist coming to sessions or be silent and “bored” during session, or, in some cases, the child may be overly compliant but relatively unengaged and passively resistant. The expected moments of resistance or difficulty in therapy, expressed by a sudden shift in topic, feeling, behavior, or withdrawal, can be important clues for the therapist regarding the child’s inner experience. It is during the middle phase of treatment that the transference relationship develops most vividly. Thus, the patient will tend to experience the therapist in very specific and unique ways reflecting previous experiences, particularly with the parents. Important differences from the adult transference relationship exist, because the child continues to live with the parents, has a child-adult relationship with the therapist, and the therapist also exists as a new and real person to the child. As a result, the transference relationship in the child patient may be less deep and complex than that observed in adult patients.

During the middle phase of treatment, the work with parents includes understanding the parents’ fears and beliefs about treatment, their hopes for the child in the future, and their fantasies and unrealistic expectations, for example, that the child will be “rescued.” In some situations, the parents can see the therapist as a rival or see them as the authority figure. As much as possible, the therapist should attempt to form an alliance supporting the parents’ positive striving for their child.

The termination phase of treatment involves both the decision to terminate and the process during which treatment is ended. The decision to end treatment can come from the child, therapist, or parents. Ideally, all agree on the appropriateness of setting an end date. Sometimes, a decision will be made unilaterally because of external factors, for example, a family move. At other times, it may stem from a unilateral decision, for example, by a parent who feels threatened or ambivalent about the treatment. The final phase of treatment provides an opportunity for a review and reworking of many of the themes/issues raised earlier in the treatment. The child or adolescent’s fantasies and expectations about termination become important. The therapist will consider various factors in considering termination including the gains made and the child or adolescent’s ability to maintain these gains and the degree to which developmental process have been facilitated. Termination awakens issues of separation and loss for both patient and therapist alike. In this context regression may occur and symptoms not seen for some time may reemerge. Such situations provide the child or adolescent with an opportunity to face and discuss these issues and consolidate the insight and self-awareness that hopefully have emerged over treatment. The child or adolescent’s ability to internalize some of the therapist’s “observing ego” functions is a hallmark of a successful treatment and facilitates longer term development. As much as possible, the child/adolescent patient should be actively involved in the process of termination. Depending on the situation, a follow-up plan may be put into place; in any event, the door should be left open for the patient to return if the need arises.

In contrast to other treatments, notably CBT (see next section), the quality and quantity of research is limited and in many respects psychoanalysis and related psychodynamic psychotherapies face major challenges for the future given the absence of this research. Challenges for research include the diversity of theoretical approaches, the continued reliance on case reports rather than controlled trials, and the scarcity of rigorous research studies. Fortunately, some work has appeared based on meta-analyses suggesting important gains associated with treatment with reasonably good effect sizes for general psychiatric difficulties, specific targeted problems, and overall functioning at follow-up.

CBT is the most frequently used evidence-based treatment (see Boettcher et al., 2018). The term refers to a number of interventions designed to address both cognitive and behavioral issues that impact mental health problems. This set of techniques has its origin in learning principles and has had a very strong research basis. As a method, it has grown considerably over the past decades. In addition to being strongly data based, these techniques are readily learned, useful for focused, short-term treatment, and are both patient and clinician friendly.
CBT has been used in a wide range of disorders including anxiety disorders, eating disorders, habit and tic disorders, posttraumatic stress disorder (PTSD), conduct disorders, depression, and attention-deficit hyperactivity disorder. It has also been used in targeting social skills and maladaptive behaviors (including anxiety and depression) in individuals with autism and related disorders.

The behavioral foundations of CBT rest strongly in learning theory. This work emphasizes the central role of changing behavior with the latter being examined within a broad context, including both antecedences and consequences. This perspective helps clarify what elicits and maintains the behavior and allows for intervention aimed to disrupt some aspect of this process. It is important to understand those factors that maintain the behavior and not just those that initially seem to cause it. This approach draws on aspects of both classical and operant conditioning. The work in the 1920s by Mary Cover Jones in demonstrating the learning of fear responses in children was widely applied in the understanding of phobias in general. In phobias, continued avoidance behavior helps to maintain the phobia by preventing exposure to the fear-inducing situation and thus prevents extinction of the fear response. Aspects of classic conditioning can also be used to understand emotional reactions other than fear as well as other mental health problems including substance abuse, depression, and some psychosomatic disorders. As might be expected, treatments based on this model aim to encourage extinction of the learned maladaptive behaviors. Other techniques, for example, exposure can be used as well. Operant conditioning is similarly based on analysis of antecedents and consequences. In contrast to classic conditioning, operant conditioning can explain acquisition of new behaviors. This work, based on the work of learning theorists like Skinner, understands acquisition of new behaviors through reinforcement, for example, an association of a behavior with a positive outcome. Removal of the reinforcement would, over time, result in a decrease in the behavior. Within this model, rewards or punishments will increase or decrease the frequency of the target behavior. Aspects of operant conditioning have been well studied and widely used, for example, in the treatment of children with autism in applied behavior analysis along with parent management training for children with behavior/conduct problems as well as for many other conditions. Extinction occurs when reinforcement is no longer provided and the behavior ceases. This process may be, initially, associated with higher levels of the behavior of interest (the so-called extinction burst) before rates of the behavior decrease. Some of the common techniques derived from operant condition principles are listed in Table 28.1.