Child Psychotherapy

Robbie Adler-Tapia, PhD, is a licensed psychologist who has worked with individuals impacted by trauma, attachment, and dissociation for more than 25 years. After conducting her doctoral study on the iatrogenic effects of foster care on children, she developed a specialty with young children and their families. Dr. Adler-Tapia’s work as a psychologist, educator, researcher, and writer has taken place in community mental health and child welfare settings, statewide adolescents-at-risk programs in Pennsylvania and Arizona, and as the clinical director at Childhelp’s Children’s Center—a national nonprofit center for children who are victims of crime. Currently in private practice, Dr. Adler-Tapia provides counseling, consultation, and psychological services for children and families referred by child welfare, the Division of Developmental Disabilities in Arizona, and law enforcement. She works with emergency responders, law enforcement, and in a forensic role as an expert witness in the juvenile, family, and criminal courts. She has been coinvestigator on several research studies on the assessment and treatment of children. Recent publications include EMDR and the Art of Psycho-therapy With Children (Adler-Tapia & Settle, 2008) and the accompanying treatment manual; “Healing the Origins of Trauma: An Introduction to EMDR in Psychotherapy With Children and Adolescents” ( Adler-Tapia & Settle, 2009) in The Clinician’s Guide to Evidence-Based Practice Series, Volume 2, Treat-ment of Traumatized Adults and Children (Rubin & Springer, 2009); and “EMDR Assessment and Desen-sitization Phases With Children: Step-by-Step Session Directions” (Adler-Tapia & Settle, 2009) and in EMDR Scripted Protocols: Special Populations (Luber, 2009). Robbie has presented trainings on eye movement desensitization reprocessing (EMDR) with young children at EMDR International Associa-tion (EMDRIA) International Conferences, at the International Society for the Study of Trauma and Dissociation ( ISST-D) Conference, and at the San Diego International Conference on Child and Family Maltreatment. In 2010, she presented at the National Association of State Directors of Developmen-tal Disabilities Services (NASDDDS) Conference with Gail Ford, and in February 2011, Robbie and Gail provided a teleconference for NASDDDS on using EMDR with individuals with intellectual and developmental disabilities. In 2009, Dr. Adler-Tapia copresented at the ISST-D Conference on using EMDR to treat attachment trauma and dissociation in children. Along with her research and writing, Robbie has taught graduate-level coursework and supervised masters- and doctoral-level interns. She is an EMDRIA Certified Therapist and Approved Consultant, an EMDR Institute Facilitator, and an EMDR Humanitarian Assistance Program (HAP) Trainer. On a volunteer basis, Robbie is promoting EMDR HAPKIDS, providing EMDR HAP training throughout the United States and in Kenya, and applying for Substance Abuse and Mental Health Services Administration (SAMHSA) approval for EMDR with children.

Child Psychotherapy

Integrating Developmental Theory Into Clinical Practice

Robbie AdleR-TApiA, phd

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Library of Congress Cataloging-in-Publication Data

Adler-Tapia, Robbie. Child psychotherapy : integrating developmental theory into clinical practice / Robbie Adler-Tapia. p. cm. ISBN 978-0-8261-0673-5 1. Child psychotherapy. 2. Developmental psychology. 3. Behavior disorders in children—Treatment. I. Title. RJ504.A345 2012 618.92’8914—dc23 2012019524

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I owe more to the children whom I have had the privilege to observe than any other source of knowledge; not merely because they were objects of

study, but their gifts as teachers. Dr. Buford Jeanette Johnson

Baltimore, Maryland September, 1932

Chapter 00

vii

Contents

Preface xiAcknowledgments xv

Part I: the Need for develoPmeNtally GrouNded ChIld PsyChotheraPy

1. In Search of Mental Health and Resiliency: The Need to Integrate Developmental Theory Into Clinical Practice 1

Developmental Psychology and Theories of Human Development 3Origins of Child Psychotherapy 3Current Practice of Psychotherapy With Children 7A Need for the Integration of Developmental Psychology Into Child

Psychotherapy 9

2. Integrating Theories of Developmental Psychology to Form a Comprehensive Approach to Treatment 11

Theorists and Theories of Human Development and Developmental Psychology 11

Summary of Theories of Development 35

3. From Bonding and Attachment to Self-Regulation Theory: How Relationships Impact Human Development and Psychotherapy 37

The Impact of Attachment on the Overall Health and Development of the Individual 37

The Contributions of the Early Attachment Theorists 39Current Theories of Attachment 45Attachment, Mentalizing, Intentionality, and Self-Regulation 48The Impact of Attachment and Bonding on Child Psychotherapy 49Therapeutic Relationships in Child Psychotherapy 51Summary and Conclusions 53

4. How Advances in Neuroscience Impact Child Psychotherapy 55Neuroplasticity and Considerations for Child Psychotherapy 55Theories of Neurobiology and the Developing Brain 56Neurodevelopment, Neurobiology, and Psychotherapy With Children 58Mirror Neurons and the Reflection in Psychotherapy 60What Is Trauma and How do We Treat Children? 63

viii Contents

Research on PTSD Symptomatology in Children and Adolescents 63Autistic Spectrum Disorders 66Sensory Processing Disorders—Where Psychology Meets Occupational

Therapy 68Summary 70

Part II: assImIlatING develoPmeNtal theory INto the PraGmatICs of ChIld PsyChotheraPy

5. Getting Started With Developmentally Grounded Child Psychotherapy 71Organizing Your Office for Working With Children and Families 72Parents, Parenting, and Parenting Skills 74Child Psychotherapy That Involves Other Professionals 78Psychotherapy With Child Clients 80Opportunities for Reinforcing Positive Symptoms in Psychotherapy 84Talking to Children in Forensically Complicated Situations 85Research on Questioning Children 87How Children’s Social Styles and Temperament Effect Treatment 89Summary 91

6. The Legal and Ethical Challenges of Providing Child Psychotherapy 93Documentation for Clinical and Forensic Environments 94Requests for Records of Minors 94Documentation: What Records Should Therapists Keep and How? 96 Who Is Your Client: Working With Parents/Guardians, Schools, Child Welfare

Organizations, and Other Legal Systems 99Forensic Issues and Advocating for Children 100Providing Psychotherapy in Forensically Complicated Cases 104The Challenges to the Therapist—Personal and Professional Risk 105Internet References for Professional Organizations 107Summary and Conclusions 107

7. Assessment, Diagnosis, and Treatment Planning in Psychotherapy With Children and Adolescents 127

Ethical Guidelines 128Gathering Data From Parents 129Initial Intake 129Assessing for Attachment 133Global Assessment of Development and Functioning of Child and

Adolescent Clients 136Assessment Through the Stages of the Child’s Life 138Assessment in Psychotherapy 145Diagnosis of Children From a Strengths-Based Approach 145Psychotherapy With Children With Co-Occuring Intellectual and

Developmental Disabilities (I/DD) and Mental Health Diagnoses 149Psychotherapy With Children Exposed to Trauma 150Summary 154Internet Sources for Diagnosis and Assessment Tools 155

Contents ix

Part III: Best PraCtICes IN ChIld PsyChotheraPy

8. Theories That Inform the Practice of Child Psychotherapy 157Theoretical Orientations of Psychotherapy 158Summary and Conclusions 171

9. Integrating Theories of Developmental Psychology Into the Enactment of Child Psychotherapy 173

Case Conceptualization From a Multimodal Approach 174Strengths-Based Therapy Through the Lens of Child Development 176EMDR Case Conceptualization With a Reverse Protocol 184The Therapist’s Role in Psychotherapy With Children 201Summary 202

10. The Basics in Child Psychotherapy 205Parenting 206For Kids 209Summary and Conclusions 236

11. A Developmentally Grounded and Integrative Clinical Approach for Treating Complex Trauma and Dissociative Disorders in Children 237

Definition of Personality and Personality Development Theories 237Definition and Theoretical Conceptualization of Dissociation 238 Developmentally Grounded Theory of Dissociation in Children and

Adolescents 247 EMDR Phased Treatment Approach for Working With Children and

Adolescents With Symptoms of Complex Trauma and Dissociation 248Summary and Conclusions 264Resources for Treating Children With Dissociative Disorders 264Assessment Tools 264

12. Epilogue 265New Technology and New Information 266New Research 266New Theories and New Evidence-Based Practice 266

References 269

Index 289

Chapter 00

xi

Preface

How many people ever read the preface or foreword of a book—especially a clinical book that is about theory and clinical practice? Well if you just read that question, you obviously had some reason not to jump directly to the first chapter. Maybe you were deciding whether to spend money on another book. Maybe you wanted to know why I wrote this book or to learn more about me. For whatever reason, we are both connected for this moment, and I hope what I write conveys to you my passion about working with children and my goal of encouraging clinicians to process case conceptualization through the lens of developmental psychology—no matter what the age of your client.

Because most theories of psychotherapy are based on the belief that the etiology for the individual’s symptoms are from the past, clients often present with childhood expe-riences that drive current symptoms. This is a common belief not only in psychology, but in our culture, as well. No matter what the age of the client sitting in your office, that client’s symptoms most often have origins in childhood. That’s not always from child abuse, but perhaps from medical issues; or a parent with disabilities, depression, or even addictions issues. Some parents may have been separated from their children because of work or immigration. Clients may have experienced school stressors such as bullies or had medical issues such as asthma or even cancer.

Because these symptoms of adult mental health disorders often begin in childhood, understanding how those childhood events impact the adult client is critical to success in psychotherapy. Preventing those events and symptoms of childhood origins are the core to providing psychotherapy with children and preventing the ongoing impact of these childhood symptoms into adulthood. This phenomenon has always driven my passion for working with children. What greater contribution could I make than to help children find their way back to a healthy development and future mental health in adulthood? As a psychotherapist, I began to teach and write about the work that I was doing with children from a developmentally grounded framework. I had not realized that many child therapists did not have in-depth training in child development, so I wrote a chapter as part of another writing project—a book on a specific psychother-apy with children. As I wrote, I realized how much I learned from reading original works on areas of child development, child psychology, and child psychotherapy. I also became astutely aware that I had learned a great deal from over 30 years of practicing as a psychotherapist, and the most from being a mother for more than 20 years.

When Carolyn Settle and I wrote our book, EMDR and the Art of Psychotherapy With Children, I wrote a lengthy chapter on theoretical foundations for psychotherapy from a developmental framework; however, this chapter ultimately was deleted from our book

xii Preface

because it was quite detailed and too theory laden. That first book I cowrote focused on one specific type of psychotherapy with children—EMDR (eye movement desensi-tization and reprocessing). As a psychotherapist, I found that reviewing foundational theories from graduate school reminded me of how important theory is to the practice. However, this chapter was beyond the scope of our book. Even though this was my favorite chapter to write, I understood that, conceptually, the chapter did not fit with our book. I still wanted to write about the theoretical foundations that developmental psychology forms for the practice of psychotherapy. So that original chapter formed the basis for this book. The question that psychotherapists need to ask before practicing any type of psychotherapy is, what are the core theories that therapists need to effectively conceptualize psychotherapy from a developmental framework?

A set of core theories of developmental psychology drove my clinical practice, including theories of attachment and bonding. For many years, I would announce to my colleagues that clients had attachment issues and I would get “the look.” That “there she goes again” annoying look. And then attachment theory became popular again thanks to Dr. Bruce Perry, Dr. Dan Siegel, and Dr. Allan Schore, among others. I thank them for reminding us all of the importance of a healthy attachment in developing a healthy child, adolescent, and then adult. There is a significant body of research that explores the impact of attachment traumas on mental health; therefore, psychotherapists have once again returned to developmental roots as the foundation for health and resiliency.

With this in mind, I searched for a book that integrated theories of development into the practice of psychotherapy. To my surprise, I found no such book. There are books on specific theories that have led to methods of psychotherapy, but no book that looks at the aggregate contribution of developmental psychologists to the practice of psychotherapy. As a researcher, author, and psychologist (and mother), with my roots in human development, I realized how much that foundation played a role in my practice as a psychologist. While teaching, I realized that many therapists lacked the exposure to developmental theory as a foundation for practice. Consistently, therapists had train-ing in counseling theory, but few had training in developmental theory.

As I supervised doctoral interns, I would ask them to observe children in the waiting room of a large clinic and then return to present a summary of their observations. In one particular instance I asked a young intern to observe a 2-year-old girl who arrived with her older siblings for psychotherapy. This child was unique in that I knew her from past treatment of her older siblings, but the intern did not. After an hour, the intern returned to provide her astute observations of the child. She began to explain that the child most likely had developmental delays because the child did not communicate or make eye contact with the intern. In fact, the child moved away from the intern and observed the fish in the tank in the waiting room. The intern hypothesized that the child might even show symptoms of autism and behavioral problems because the child fussed, became angry, and pushed the intern away when she approached her. The intern spent the bet-ter part of a half hour describing the child’s symptoms of pathology, and after she had finished I began to ask her questions. Do you know this child? Since you do not, would you not expect a healthy child to see you as a stranger and someone with whom she should be cautious? Did you interview the child’s mother? Do you know when the child typically takes a nap or has a bowel movement? Do you know what language the child speaks? After I asked several more questions, the intern began to realize that she had jumped to pathology without considering any normal developmental stages that might be alternative hypotheses for this child’s presentation. Without additional instruction, the intern then suggested that she might want to continue her observations of the chil-dren and return with possible alternative hypotheses.

Preface xiii

Unfortunately, I have observed this type of conclusion of pathology very often from students and professionals alike. This is of great concern to me; therefore, I teach students and professionals to consider creating alternative hypotheses for children’s behaviors before arriving at pathology.

Initially, I thought my developmental psychology chapter would be the founda-tion for an advanced book on psychotherapy with children. That was not the case here. Instead, I decided to write the book that I wanted to reference as I taught child psycho-therapy, EMDR, and traumatology—one book that could serve as a theoretical foun-dation for the practice of psychotherapy integrating theories of human development. Even though this book focuses on the practice of child psychotherapy, the theories and treatment practice apply to any age client who presents to the therapist’s office. With the belief that many adult issues stem from childhood origins, the information in this book should be the core to the practice of psychotherapy for every therapist.

Therapists need to test developmental explanations for symptoms and behaviors before arriving at pathology. Through this lens therapists can practice a developmen-tally grounded psychotherapy with treatment interventions that accurately address the origins of clients’ symptoms. With this perspective as a theoretical foundation, thera-pists can provide the most efficacious treatment especially for children.

I deeply appreciate what I learned from the three children I gave birth to, and the thousands of children I have been blessed to have worked with as a psychotherapist. They have collectively been my teachers and, for that, I am eternally grateful.

Robbie Adler-Tapia

Chapter 00

xv

Acknowledgments

There are many people who provided support and guidance in my pursuit of this proj-ect. I am extremely grateful to each and every one of these individuals for their respec-tive roles in my life and with this book. First, my husband, editor, cheerleader, and partner; Dr. Hugo Tapia provided coffee, editing, and critical discussion in the creation of this book. My children, Michael, Max, and Maura Tapia were patient and supportive as I would hide away to write. I am honored to be their mother. There were many days that Maura did homework next to me as I wrote, or she would wait for me to finish yet another paragraph. My friends and colleagues Susan Brown, Carolyn Settle, and Susan Thompson provided expert feedback and editing for many chapters of this book. And Sheri W. Sussman from Springer Publishing who was not only a patient and expert senior editor, but also a teacher and guide in my development as a writer.

1

Part I: The Need for Developmentally Grounded Child Psychotherapy

In Search of Mental Health and Resiliency: The Need to Integrate Developmental Theory Into Clinical Practice

Adopt the pace of nature: Her secret is patience. —Ralph Waldo Emerson

Chapter 1

Either to rekindle the memory of concepts learned or to provide new information, this book explores the theoretical underpinnings of developmental psychology inte-

grated into case conceptualization in psychotherapy. Historically, the practice of psy-chotherapy has focused on symptom reduction and skill building, so that the client is not only healthier but also evidences greater ability to cope with the challenges of living. However, each symptom needs to be filtered through the lens of human devel-opment. The same symptoms in a 50-year-old client may be developmental tasks yet to be conquered for a 5-year-old. Without considering the age of the client and develop-mental life tasks expected at that age, therapists may find pathology when there is none. Therefore, the most effective psychotherapists understand that developmental theories drive case conceptualization and treatment planning for clients of any age. As Emerson suggests, the pace of nature is an imperative to successful interventions in child psycho-therapy. It is the pace of nature that must be the filter for any symptom when practic-ing psychotherapy. In this manner, psychotherapy provides the foundation for mental health and resiliency. But, psychotherapy cannot proceed without understanding how humans develop. The clinical process unfolds by examining the complicated interac-tion between the prewired capacity with which individuals are born and how the envi-ronment supports or deters from that natural course of development. Included in this book are theories that explore the interaction between the child’s internal and exter-nal worlds, how the environment impacts the child’s experience of being in the world, and how the child constructs his or her experience of living. This dynamic interaction, unique to each individual, is essential for therapists to investigate in psychotherapy.

Although not intended to be the opus of developmental theory, this book provides an overview of theories that therapists need to consider in developmentally grounded psychotherapy. Then the reader will be challenged to take that theory and use it to more effectively to treat young clients who have to be met at their individual pace of natural human development.

2 I. The Need for Developmentally Grounded Child Psychotherapy

While focusing on the treatment of children, the overall proposition of this book is that the theories and practice contained within apply to clients of all ages—to children, adolescents, and child ego states in any age body. The reader is reminded that the child client can be in a 67-year-old body, but the residual effects of childhood experiences can still be driving the symptoms presenting in the therapist’s office. Those childhood expe-riences may have interfered with healthy development for an entire lifetime.

In the remainder of this chapter, the history of child psychotherapy is reviewed. The following chapters provide an overview of theories of human development, personality development, attachment and bonding, and psychotherapy. With bonding and attachment as integral forums for survival, the impact of poor attachment on mental health will also be explored. How to assess, diagnose, and treat attachment issues, as a diagnosis or part of other mental health issues, will be presented throughout this book. What follows is an overview of brain development theories, as neuroscience now provides evidence that bonding and attachment impact both brain development and mental health. These theo-ries form the foundation for treatment planning in psychotherapy with children.

The second section of this book examines the pragmatics of child psychotherapy, including organizing the office, legal and ethical issues, assessment and diagnosis, and the developmentally informed treatment plan. This section will illustrate how child therapists can arrange clinical practice by exploring considerations for ethical issues and the unique forensic challenges that arise from practicing child psychotherapy.

The treatment-planning process dances between ethics and legal issues while being driven by the therapist’s consideration of how the client’s unique growth has unfolded. Assessing clients for developmental issues with consideration of how theory and assessment provide an ever-unfolding presentation in therapy creates a develop-mentally grounded practice in child psychotherapy. Once the assessment is completed, the therapist conducts a diagnostic process within a developmental framework, first considering stages of development before pathologizing the child’s symptoms.

After intake, diagnosis, and treatment planning, the therapist then implements evidence-based treatment. In the last section of this book, models of evidence-based practice in child psychotherapy will be reviewed with examples of what each model offers to the treatment process. These theories also describe what the therapist brings to psychotherapy based on the therapist’s belief of what therapy looks like and the therapist’s role in the relationship with the client. As theories of psychotherapy have developed, each theory has speculated the role that the therapist brings to the treatment process and how the dynamic interaction between the therapist and client can alter the course of treatment. The therapist’s awareness, understanding, and integration of devel-opment theories have a significant role in case conceptualization in psychotherapy. The client’s attachment to the therapist and the therapist’s response to the client also impact the therapeutic milieu—especially with children.

A model for how the most effective theories and methods of child psychotherapy can be integrated through the lens of child development is described to create a template for a developmentally grounded practice. This proposal for developmentally informed child psychotherapy incorporates the adaptive information process theory (Shapiro, 2007) in the enactment of eye movement desensitization and reprocessing (EMDR) while integrating skills from all areas of child development and psychotherapy.

This book concludes with an overview of basic presentations the therapist most likely will encounter in practice, with suggestions for treatment and case conceptu-alization with parents and clients. Basic issues such as sleeping, feeding, emotional dysregulation, and learning issues will be discussed with common responses and refer-ences to provide to parents through a developmentally grounded practice. These basic presentations are the everyday experiences of many psychotherapists working with

1. In Search of Mental Health and Resiliency 3

children, and summarize what can be provided to assist parents and children outside the therapist’s office. No chapter is intended to be a comprehensive review of a theory, but instead a notice to the therapist that this theory has implications for the enactment of psychotherapy. Readers are encouraged to read original works in order to explore each theory in greater depth. A comprehensive approach to child psychotherapy draws from multiple disciplines integrated into best practice.

With this overview of this book, it is first important for the therapist to understand that the current practice of child psychotherapy draws from multiple disciplines, includ-ing developmental psychology, human development, education, and pediatric medicine.

develoPmeNtal PsyCholoGy aNd theorIes of humaN develoPmeNt

A comprehensive theory of psychotherapy includes an explanation of human develop-ment (along with hypotheses of how humans grow, learn, change, interact, and relate), as well as how psychopathology occurs. Throughout history, writers have described the phases of human development including cognitive, psychosocial, and psychologi-cal development, and at times these theories have led to the development of models of psychotherapy. Yet many theories of human development have stopped short of explain-ing the development of psychopathology, much less creating treatment modalities for addressing when human development is altered by the life experiences of the individual. For example, Piaget created a theory of cognitive development, but did not expand his theory to explain how cognitive development goes awry or how cognitive development impacts mental health. The practitioner of psychotherapy needs both—to understand how development unfolds and to use those theoretical underpinnings to conceptualize the work of psychotherapy. This is true for any age client; however, in spite of the exten-sive body of work on human development, the majority of the models of psychopathology and psychotherapy are adult models with no consideration of human development. The practice of child psychotherapy has often been extrapolated from adult treatment mod-els, with practice regularly focused on the treatment of a specific mental health diagnosis such as ADHD, phobia, or other disorders of childhood. Some models of psychotherapy with children focus on individual treatment of the child, whereas other models focus on the interactions between parent and child, family therapy, group therapy, and even ther-apy in the educational environment. This leaves the psychotherapist, who works with children with a shortfall, searching for guidance to integrate theories of developmental psychology and best practices of child psychotherapy.

It has been more than a century since Freud (1909) wrote: “Analysis of phobia in a 5-year-old boy.” In that time, the literature on psychotherapy with children has expanded to include theory, case studies, research studies, and even direction on how to treat disorders of childhood; however, no comprehensive text has been published that integrates theories of developmental psychology and human development into the practice of child psychotherapy. This book will attempt to fill that void through inte-grating theory into clinical practice by describing child psychotherapy through the lens of developmental psychology.

orIGINs of ChIld PsyChotheraPy

The extensive origins of child psychotherapy can be found in theories of psychoanaly-sis, behaviorism, educational and school psychology, person-centered therapy, as well as in adult theories of psychotherapy. The internal mentalist psychoanalytical theorists

4 I. The Need for Developmentally Grounded Child Psychotherapy

believed in internal, mentalist processes driving symptoms. Behaviorists believed that the history did not matter, but instead observable behavior should be the focus of treat-ment. The client-centered therapists believed that the clinical relationship between ther-apist and child should be the focus of clinical interventions. Each theoretical paradigm has influenced the current practice of child psychotherapy. How child psychotherapy evolved in the last 110 years and influences current practices is critical for training in this field. There is a significant amount of history impacted by culture, the era in which the theorists lived, and even the gender of the therapist. No theory evolved outside of these influences. At times it is difficult to verify the actual contributor of the idea, as many professionals were developing similar ideas in different parts of the world. With no Internet and instant sharing of information, publications of thoughts and theories were disjointed. Although understanding how these theorists were involved with each other at a time when theories were shared in handwritten documents and psychothera-pists treated each other, the history of psychology and subspecialty of child psycho-therapy is fascinating. With these issues in mind, the history and contributions of each school of thought will be summarized here in order to provide the reader with an over-view of the pieces that each contributed to the field of child psychotherapy.

In 1888, a teacher Lightner Witmer learned that with additional educational ser-vices and appropriate supports that students could learn and overcome their special needs. Witmer later attended the University of Pennsylvania to study political science and law when he was introduced to experimental psychology by James Cattell. Cattell had been a student of Wilhelm Wundt in Germany before opening an experimental lab at the University of Pennsylvania. After working in the lab with Cattell, Witmer spent a year under the supervision of Wundt in Germany before returning to the University of Pennsylvania where he taught child psychology. Also at the University of Pennsylvania, Witmer opened the first documented psychological clinic that focused on studying child with learning and/or behavioral problems in 1896. Witmer is credited with coining the term “clinical psychology” and studying gifted children. In addition to his significant contributions to the field of child psychotherapy, Witmer was a founding member of the American Psychological Association.

The first cases that documented the psychological treatment of children include Sigmund Freud’s psychoanalysis of “Little Hans” (1909), Watson and Rayner’s work with “Albert B” (1920), and Mary Cover-Jones’ work with “Little Peter” (1924). The pub-lications of these classic cases in psychology along with pediatric medicine and neona-tal nursing care, family therapy, play therapy, and school/educational psychology have all influenced the current practice of child psychotherapy.

The literature suggests that Freud guided the psychoanalysis of “Little Hans,” who was reportedly the 5-year-old son of a professional colleague, Hans Graf. Graf’s wife and Little Hans’ mother was also noted to have been patients of Freud’s. In this pioneer-ing era of psychotherapy, documentation suggests that Freud supervised Little Hans’ psychoanalysis by his father, even though Freud only met Little Hans on one occasion. Hans Graf and Alfred Adler were reportedly members of Freud’s study group. Freud reportedly asked his study group to keep copious notes on the development of their own children, and this data became part of discussion in the study group. Freud is noted to have first suggested the use of play in the work with Little Hans.

Soon after, Hug-Hellmuth (1921) wrote one of the first monographs on child psycho-therapy when she published A Study of the Mental Life of the Child. Although originally published in German, the monograph was translated into English which provided a review of Hug-Hellmuth’s theory of the development of the mental life of childhood. Her conclusions stemmed from the written notes of parent observations interpreted through the lens of psychoanalysis. In 1921, Hug-Hellmuth expanded her work by

1. In Search of Mental Health and Resiliency 5

publishing an article, On the Technique of Child Analysis (Hug-Hellmuth, 1921), in which she expanded the notion of play in therapy and the importance of including parents. This seminal piece is credited with initiating the focus on child psychotherapy as a separate phenomenon from working with adults. Writers and theorists began to docu-ment the different concepts and practices necessary to provide the important work of child psychotherapy.

As the practitioners of psychoanalytic treatment continued to develop their treat-ment of child clients, behaviorists were also documenting the use of behavioral inter-vention for the treatment on young children.

In 1913, John Broadus Watson published an article, Psychology as the Behaviorist Views It, in which he suggested that psychotherapy needed to focus on how to predict and change behaviors. Watson was suggesting a paradigm shift from the unconscious, men-talist processes described by the psychoanalytic theorists to a behaviorist perspective. Psychologists should study observable behaviors with treatment focused on changing those behaviors. In this experimental pursuit, Watson began to test his theories on chil-dren. In 1920, Watson and Mary Rayner published their research on infant “Albert B,” who was used as a subject of their experiments on conditioned fear responses from the time he was 9 months of age. According to the study, “Albert B” had no clinical issues when these researchers began working with him, but they were able to document conditioned fears in the young boy. (The documentation of the conditioned fear in an initially healthy infant boy is extremely troubling, and current protections are now in place to prevent this treatment of children as research subjects.) In 1924, Mary Cover Jones used techniques of “direct conditioning” and desensitization to treat Little Peter’s fear of white rabbits and furry objects (Jones, 1924). Jones was under the supervision of J. B. Watson as she treated this young boy. With Little Peter, direct conditioning was used in a beneficial manner to help this little boy to overcome his phobia.

Over the next 50 years, as the psychoanalytical community was pioneering psy-choanalysis of children, additional publications documented the integration of play in psychoanalysis (Allen, 1942a, 1942b; Freud, 1946; Klein, 1932; Walder, 1932). Because children used play as the primary manner for self-expression and learning, therapists working with children needed to integrate play into psychotherapy.

In 1938, David Levy published a technique he entitled release therapy, in which the child is allowed to engage in free play to release the stress. The early play therapists (Axline, 1947a, 1947b, 1950, 1972; Beiser, 1955; Bender, 1955; Bryan, 1959; Despert, 1937, 1940; Freud, 1946; Ginott, 1961, 1969; Klein, 1932; Lebo, 1955; Levy, 1938; Lowenfield, 1935, 1939; Moustakas, 1953, 1959; Solomon, J. C., 1938, 1940, 1948; Taft, 1933; Woltmann, 1940a, 1940b, 1951, 1952, 1956, 1960) continued writing about the use of play in psycho-therapy with children. Some of these names are more familiar whereas others are more obscure, yet the concepts that these early writers contributed to the development of child psychotherapy are immeasurable. For the purposes of this chapter, the specific contributions to the aggregate now known as child psychotherapy will be reviewed.

Axline, Freud, and Klein are more familiar names in the origins of play therapy, as these three women expanded psychoanalysis to integrate narrative therapy, family systems, and child-focused treatment in the early 1930s and 1940s. Play therapy contin-ued to expand as writers such as Moustakas (1953, 1959, 1970) and Schaefer (1976, 1986, 1993) wrote of advanced models and techniques of play therapy by assimilating pieces of other therapeutic models such as cognitive-behavioral, solution-focused, narrative and family system’s therapy.

Simultaneously, Taft (1933) suggested that child psychotherapy focus on the rela-tionship that developed between therapist and child patient in what he called “a con-trolled environment.” Taft reportedly influenced Carl Rogers, who was developing

6 I. The Need for Developmentally Grounded Child Psychotherapy

his “person-centered” and “non-directive” clinical approach to working with clients. From 1928 to 1940, Rogers was the director of the Child Study Department of the Rochester Society for the Prevention of the Cruelty to Children and then director of the newly created Rochester Guidance Center. Rogers treated many children and cre-ated the theoretical foundation for “non-directive play therapy” (Rogers, 1942, 1949, 1950, 1951).

Solomon (1938, 1940) wrote about what he labeled “active play therapy,” and in 1948, he described play therapy techniques in greater detail. Bender (1955) offered descrip-tions of therapeutic play techniques while Beiser (1955) explored the impact of play equipment on child psychotherapy. Hambidge (1955) extended Levy’s work by empha-sizing a “structured play therapy” model. Along with his description of the “play room” to be used in child psychotherapy, Despert (1979) was one of the first to illustrate how the personality structures that he observed in preschool children could impact child psychotherapy. While Bryan (1959) and Woltmann (1940a, 1940b, 1943, 1951, 1952, 1956, 1960) initiated the integration of puppets into child psychotherapy.

These early child therapists conceptualized child psychotherapy through observing the play behavior of children and then intervening in preconceived ways to decrease the symptoms with which children presented to psychotherapy. Concepts such as games, the use of puppets, and other tools for play therapy were also discussed; yet, once again, the underlying foundation of developmental psychology was noticeably absent.

In seemingly parallel universes, developmental theories (which will be discussed in detail in Chapter 2) were also being documented in the literature but were not driv-ing child psychotherapy. Pediatrics, nursing, and education were the primary domains for treating children, with many professionals still questioning the benefit of child psychotherapy.

From the early 1960s to the present, the expansion of play therapy and various forms of adult models of therapy directed at children expanded the field. Professionals began to debate the best ways to work with children at home and in educational envi-ronments. Parents were included in treatment along with the creation of new parenting skills programs. Even though Anna Freud (1946) recommended that clinical services for children include families and educational environments, new models and programs were developed specifically for this process.

Ginott (1965) also taught skills to improve parent–child communication in an atmosphere of dignity and respect in his seminal work Between Parent and Child. Ginott wrote that parents needed better information rather than therapy to improve parenting, parent–child relationships, and ultimately, to improve the behavior of children and adolescents. Ginott (1961) labeled the specific language to be used with children as childrenese as he advocated for the use of play in child psychotherapy and wrote about group therapy for children. At this same time, Piaget derived his stages of cognitive development in children, whereas Skinner (1969) introduced radi-cal behaviorism that documented the efficacy of positive reinforcement in education and parenting.

Bernard and Louise Guerney introduced “Filial Therapy” (Guerney, 1964; Guerney, Stollak, & Guerney, 1971) in which they suggested that the parent/caregiver be included in child psychotherapy as the primary agent of change for the child. In Filial Therapy, therapists taught parents how to therapeutically play. Since the 1960s, a significant body of literature has amassed to support the current use of Filial Therapy as evidence-based practice. With recommendations for training parents and caregivers, and for includ-ing them in the child’s therapy, child psychotherapy was expanded in the educational environments where children were spending a significant amount of time and teachers were challenged with managing emotional and behavioral issues.

1. In Search of Mental Health and Resiliency 7

As counselors were placed in school settings, these professionals began to docu-ment the efficacy of play therapy not only with special needs children, but also for all children. Play therapy was used in the classroom with the therapeutic milieu created by teachers (Landreth, 1972; Muro, 1968; Myrick & Haldin, 1971; Nelson, 1966; Waterland, 1970).

In 1967, psychologist Ann Jernberg began working with a Head Start Program in Chicago and created a type of child psychotherapy she later entitled “Theraplay.” With Theraplay® (Jernberg, 1979) used paraprofessionals in the Head Start Programs while also working with parents to address children’s mental health symptoms (http://www.theraplay.org/articles/06_fall_West.htm). Theraplay is still considered an effec-tive type of child psychotherapy, especially in educational and group settings with children. The use of Theraplay was expanded to working with children with autism and pervasive developmental disorders. Current practices of Theraplay are included in Chapter 8.

Yet, the efficacy of child psychotherapy was still disputed. With this ongoing debate about the utility of child psychotherapy, writers began to create, study, and document specific theories and instructions for parents and caregivers to bring child psychother-apy into mainstream acceptance.

In 1982, Shaeffer and O’Connor co-founded the Play Therapy Association as an organization for professionals committed to providing quality play therapy and later organized credentialing for play therapists. Play therapy continues as one of the pri-mary types of psychotherapy for children as children find ways to express their emo-tions and experiences through play, art therapy, movement therapy, and other nonverbal clinical procedures.

Through the 1980s and 1990s, there was an explosion of child psychotherapy litera-ture and models of treatment as computers and the Internet provided profound avenues for the creation and sharing of ideas. The more recent development of child psycho-therapy over the last 30 years is captured in Chapter 8.

CurreNt PraCtICe of PsyChotheraPy WIth ChIldreN

Currently, play therapy is a dynamic field with the concepts of play integrated into many types of psychotherapy with children. Chapters 8 and 9 delve into current the-ories and practices of child psychotherapy with a recommendation for an integra-tive, developmentally grounded approach to treatment. Basic presentations in child psychotherapy and information for therapists to provide to parents, caregivers, and teachers are discussed in Chapter 10. A final discussion of the summary and conclu-sions that psychotherapists require for the practice of child psychotherapy conclude this integration of human development theories into child psychotherapy. What is evident is that current approaches to child psychotherapy need a developmental framework.

The majority of child psychotherapies stem from psychodynamic, humanistic or client-centered and cognitive approaches (Shirk & Russell, 1996). In addition to these theoretical orientations, a comprehensive theory of psychotherapy with chil-dren draws from multiple disciplines including neurobiology, neurochemistry and neurophysiology, anthropology, child development, as well as adult models of psy-chotherapy. Various theories of human development and psychotherapy posit that the human organism is hardwired to process information acquired through sensory input. In his Theory of Cognitive Development, Piaget (1947) wrote that the organism is hardwired with schema with which to process the information collected through

8 I. The Need for Developmentally Grounded Child Psychotherapy

sensory input. All input is assimilated into existing schemata or the schemata adjust to accommodate the newly acquired information, which then create new schema. However, Piaget’s theory did not describe what occurs when the child experiences a traumatic event. With new technology and greater but still limited understanding of the human brain, Perry (2006) suggested that the brain is not only hardwired, but organized into sections that develop at different periods of the life span. This hier-archy of neurological development and processing is impacted by both internal and external experiences.

Therapists who work with children are entangled into a complex theoretical matrix of neuroscience, physiology, and human biology intertwined with family and com-munity systems embedded in the environment and culture. The rapid unfolding of these interactive systems compels therapists to be constantly assessing development as the therapist creates interventions to treat children who have experienced distress and trauma in a manner that has changed this process of development. Why is this impor-tant? There is an extensive body of research on the impact of early life stress and trauma on health of adolescents and adults.

Klein (1919) suggested that anxiety impacts child development. Current research on an individual’s mental and physical health support her conclusions. Researchers have documented a significant link between early life stress and later mental and physical health problems, early onset of puberty, and later social relationships in adulthood (National Scientific Council on the Developing Child, 2005, pp. 283).

Improving the overall health of younger children before their behaviors become rooted in certain patterns could potentially prevent them from being affected by certain risks—so that they do not, for example, end up associating with deviant peer groups, experimenting with drugs or alcohol, and generally, as he put it, “manufacturing” other problems (Program Committee for a Workshop on the Synthesis of Research on Adoles-cent Health and Development, National Research Council, 2006).

In a study, Relationship of Childhood Abuse and Household Dysfunction to many of the Leading Causes of Death in Adults: The Adverse Childhood Experiences (ACE) Study, Felitti, et al. (1998) assessed the impact of childhood stressors on adult medical issues. By sur-veying more than 17,000 individuals who had been treated at a local health clinic with the Adverse Effects of Childhood Scale (ACES), the authors concluded that, “The find-ings suggest that the impact of these adverse childhood experiences on adult health status is strong and cumulative” (pp. 251). The authors recommended that mental health interventions are necessary to change the future of individuals who have expe-rienced childhood abuse and dysfunction in the home who are at increased risk for not only mental health issues but also medical problems. Research has not only found that childhood distress and trauma contribute to increased adult mental health and medi-cal issues, but also have impact on neurodevelopment. This topic will be discussed further in Chapter 4.

There is evidence to suggest that there are temperamental differences in how chil-dren respond to events in the environment. This is especially true in children exposed to trauma and violence.

The findings from this study support the notion that individual differences in children’s neurobiology are important factors to consider and to model in efforts to better understand heterogeneity in outcomes among children living in violent families. Future research should consider how other individual dif-ferences, such as children’s temperament (i.e., behaviorally based individual differences in children’s level of emotional reactivity and regulation; Rothbart & Bates, 2006), may influence the relationship between exposure to family

1. In Search of Mental Health and Resiliency 9

violence and emotional adjustment. This seems especially important to investi-gate, given that research has found linkages between children’s vagal reactivity and components of their temperament (e.g., Stifter & Corey, 2001). Therefore, examining the relationship between children’s temperamental characteristics in conjunction with physiology may further explain heterogeneity in children’s emotional adjustment when they are exposed to family violence. (Cipriano, Skowron, & Gatzke-Kopp, 2011, pp. 212)

In addition to the significant evidence of the negative impact of early life stressors on development, this research has documented the variability in children’s responses affected by the child’s unique temperament and physiology. Understanding individual differences in development along with theories of developmental psychology creates a fundamental basis for therapists to approach psychotherapy with all age clients.

a Need for the INteGratIoN of develoPmeNtal PsyCholoGy INto ChIld PsyChotheraPy

Current comprehensive approaches to the mental health treatment of children are lim-ited, with most practices focused on clinical interventions for treating a specific diagno-sis or presenting problems. After more than 100 years and volumes of publications on human development, developmental psychology, and various child psychotherapies, a need exists for child therapists to integrate the foundation of developmental psychology into the practice of child psychotherapy. When the therapist understands the theoreti-cal underpinnings of developmental psychology along with the goals and objectives of psychotherapy with children, treatment is more efficacious.

This book rests on the hypothesis that assessment, diagnosis, and treatment must first be filtered through the lens of developmental psychology considering unmastered stages of development and trauma exposure before considering pathology and mental illness. Every professional in the educational, medical, and mental health arenas must be trained to rule out developmental and/or traumatic etiology before resorting to men-tal illness and pathology as the explanation for symptoms. Psychotherapists must also consider the role of the parents’ symptoms as well as the community and culture within which the child is being raised when interpreting symptoms. Once developmental and traumatic hypotheses have been adequately assessed and ruled out, then and only then can professionals consider pathology and mental illness.

With case conceptualization filtered through the lens of developmental psychology, the reader will consider that pathology can actually represent skewed development in need of repair. This skewed life course leaves a developmental trail of unresolved symp-toms that later are attributed to mental health issues and even mental illness. Without considering theories of development, psychotherapists may embrace misattributions for symptom etiology, which then will interfere with the most effective and successful course of psychotherapy, especially when working with children.

At the conclusion of this book, a comprehensive approach to the treatment of clients of any age is proposed through a developmental lens. Ultimately, this book organizes phased treatment of child psychotherapy through the eight phases of the EMDR integrative treatment protocol proposed by Shapiro (1995, 2001) exploring developmental challenges, and the impact of attachment, and trauma on symptom presentation and case conceptualization. At last this book will provide comprehensive instructions for the therapist to approach a developmentally grounded psychotherapy with children from intake to treatment graduation. With this clinical approach, the

10 I. The Need for Developmentally Grounded Child Psychotherapy

goal of psychotherapy is healing, health, and resiliency. In 1995, Gordon (1995) defined resilience as,

“Resilience is the ability to thrive, mature, and increase competence in the face of adverse circumstances. These circumstances may include biological abnor-malities or environmental obstacles. Further, the adverse circumstances may be chronic and consistent or severe and infrequent. To thrive, mature, and increase competence, a person must draw upon all of his or her resources: biological, psychological, and environmental” (pp. 239).

By integrating theories of developmental psychology into child psychotherapy, psy-chotherapists can intervene at the most opportune moments to help children increase personal resources, advance self-competencies, and flourish.