Below, I explain how I generally work with kids (ages three to twelve) and their parents.
Assessment
The first step of therapy is a good assessment of the problem. Before our first session, I will ask you to complete some forms I email to you that help me understand the problems for which you are seeking therapy. Completing these forms before the first session helps with the assessment and saves more time in session for talking.
Generally, I meet with parents alone for the first session so that we can talk freely and I can answer any questions you may have. Then I meet with parents and the child in subsequent sessions.
A Family Therapy Approach
I generally meet with kids and parent(s) together versus
working with kids alone. Why is that?
First, when parents are in the session, it takes less time for younger children to
feel comfortable and open up. Second, parents are valuable sources of information. Your observations, progress reports,
and historic understanding of the child help me enormously. Finally, parents are part of the solution. It is much more effective for you to intervene with your child seven days a week than for me to do so one hour a week. I will help you help your child.
When I describe this approach, parents often ask me, “Won’t my child want to see
you alone?” Trust me -- you would be surprised how often the child prefers to have the parents in the session. (Try asking your child). Of course, if you or your child prefer that s/he child meet alone with me, we can always do so. How To Tell Your Child About Therapy
Parents often ask me how to tell their child that they will be seeing a therapist. Here's what I suggest. Tell your child you have been concerned that they are feeling unhappy. You have decided to take them to see an adult who talks with children (and their parents) in order to to help them feel happier. Tell your child that they can talk as much or as little as they want. Also tell them that the meetings will have fun parts and that we will sometimes play games (that's true!).
Talk Therapy Versus Play Therapy
During therapy sessions, I mainly talk with kids. I don't do a lot of play therapy. Why?
I was originally trained to do play therapy. However, after a few years, I decided it was not really that effective a form of psychotherapy. And the research on play therapy said the same thing -- it is often less effective than other types of therapy, such as family therapy or cognitive-behavioral methods.
So I switched to talking with kids. I found that even three and four year olds could do a lot of talking. I do use games and toys in sessions. Sometimes I use these materials as a warm up activity. Other times I use them to reward kids for doing the hard work of therapy. And sometimes I use them because kids talk more if they have something to do while we talk. Finally, I do use play therapy to help younger children communicate non-verbally But I do so in a very goal-directed way. V. Getting Started
The main goal of the first family session is to get the child relaxed and talking. I usually start out by asking parents about the child's favorite foods, games, and TV shows. Kids love talking about these topics and start jumping in without even being asked. I also like to have parents talk about the child's strengths and accomplishments. If we focus on the positives first, kids tend to relax and open up more easily. We often start talking about the problems as early as the first session. Creating A Treatment Plan
By the second or third session, I will have talked to the parents and their child about the problems, found out what everyone wants to change, and gotten lots of assessment information. This will lead me to create a treatment plan. The plan consists of a clear statement of our specific goals. The plan also lists exactly what the parents, the child, and myself will do to create change. After that, we put the plan in place and see what changes. If we get only partial results, we can change the plan and try new ideas and methods to effect change.
VII. Problems I Treat: What Helps
I treat a wide array of childhood problems. I will list some of them here and the approaches I find have helped.
1. Anger/Explosiveness
This problem can be helped by changing the child's beliefs and by reducing and/or eliminating frustrating triggers. How hard it is to treat anger depends on how quickly a child goes from calm to explosive. If a child has a "slower fuse," it gives her (and her parents) a chance to use interventions before the anger builds. But if the child moves very quickly from calm to explosive, there is no chance to have the child use interventions. In the latter case, we often try to change the environment to prevent explosions. Once a child has exploded, the best thing to do in that immediate moment is focus on helping the child calm down. Once the child is calm, then you can try interventions.
2. Anxiety
Almost all treatment of anxiety involves helping the child challenge and disprove the unnecessary or false beliefs that cause fear. Treatment also involves slowly exposing the child to the things they fear. These approaches are done gradually so as not to overwhelm the child. At other times, treating anxiety might mean making sure adults are available to help the child when he is afraid.
(Note: for anxiety disorders such as Obsessive-Compulsive Disorder (OCD), panic attacks, school phobia/separation anxiety, social anxiety/shyness, see the sections below.)
3. Attention Deficit (Hyperactivity) Disorder (ADHD)
Treating ADHD requires multiple approaches, because ADHD usually involves multiple problems. That is so because ADD or ADHD is currently conceptualized as a collection of dysfunctions in the frontal lobe of the child's brain. This brain area controls a series of skills and abilities known as "executive functions" such as attention, impulse inhibition, planning, organization, initiation of tasks, and even conscience. Thus, ADHD's symptoms can include not only impulsiveness, hyperactivity, and inattention but also problems with organization, motivation, anger; oppositional or defiant behavior, social skills, and anxiety/depression. And kids with ADHD also have learning disabilities.
The first thing I do when working with kids with ADHD is to make sure that they indeed have ADHD. ADHD can be over-diagnosed -- conditions that can appear to be ADHD, but are not ADHD, include anxiety, depression, and certain learning disabilities.
(Indeed, recent research has suggested that kids with ADD (non-hyperactive type) may instead have something called "Slow Cognitive Tempo." This condition is typified by a poor working memory (the part of our memory that holds things in our mind while we work on them -- like when we do math in our heads) and slow processing speed. A child with these problems cannot keep up with their classmates because the child processes information slowly and cannot hold information in his head well enough to think about it effectively in the moment. In class, the child appears inattentive. In fact, the child cannot keep up with the lesson and eventually gives up and pays attention elsewhere. There are very specific interventions for Slow Cognitive Tempo.)
Therapists use many interventions with kids who have ADHD. One frequent intervention is education -- making sure the child and parents understand what ADHD is and what the research says about ADHD.
Another intervention targets the child's self-esteem. By the time a child has been diagnosed with ADHD, the child has often had a few years of being rejected by some peers and being frequently disciplined by teachers. The child may have started to see themselves as a "bad" or "stupid" kid. It is important for your child to learn that they are good and capable but have a condition that needs to be, and can be, treated. It is also important for us to note and highlight your child's strengths and positive traits.
Further, kids with ADHD need a lot of structure -- schedules, rules, reminders, organizational tools, rewards and consequences. I help parents to build such structure into the child's life.
In addition to therapies for anxiety and depression (see those sections elsewhere on this page), another intervention for kids with ADHD involves the therapist attending
Individual Education Plans (IEP) meetings or coordinating interventions
with your child's school.
Finally, there is medication. I am not in a rush to put a child on medication. And I have yet to meet a parent who want to put their child on medication. Indeed, they resist strongly the idea.
On the other hand, I have seen children whose lives are significantly improved by medication. Also, if a child is suffering and also internalizing a negative self-image due to ADHD, I think it can be cruel to withhold medication. Indeed, two huge, long-term studies have suggested that the symptoms of
hyperactivity and impulsiveness cannot be treated by any therapy other
than medication.
Further, I believe many parents are misinformed about medication and, as a result, have a fear of medication. Often, the only parents I see who do not feel this way are parents who has already put another child on medication and have seen the results. This experience tends to reduce the parent's fears and misconceptions regarding medication.
Thus, there are times when I will recommend that your child try medication. However, I will respect your decision about medication. And I will take time to explore your feelings, to discuss the issue thoroughly, and to weigh the pros and cons with you.
4. Depression
The treatment of depression usually involves challenging and disproving false or unnecessary beliefs that cause depression. This is especially true of negative beliefs the child has about themselves. Another part of treating depression is helping the child have success, be it academic, social, athletic, or otherwise. There is just no substitute for success when it comes to building self-esteem and fighting depression. A third area of treatment involves making sure the child's relationships are positive, warm, and loving. These relationships include not only parents and siblings but also teachers and peers.
5. Behavioral Problems: Aggression, Defiance, Non-Compliance
The treatment of behavioral problems always involves identifying why these problems are occurring. Behavioral problems may be a manifestation of underlying anxiety, depression, learning issues, or even unidentified medical issues. Or, the behavioral problem might exist because of an underlying problem in the child's relationships with parents, siblings, or peers.
Sometimes, though, behavioral problems occur because parents are not providing enough limits or enough structure (e.g., stimulation, schedules, routines). Every child needs structure and limits to function well. Parents of years ago tended to err more on the side of not being understanding or empathic enough. Parents today err by not being firm enough. Rewards and consequences, used humanely and calmly, play a big role in good parenting.
Behavioral problems can also exist because of problems the child has with emotional regulation. I see many children who have problems because they are genetically wired to have a hard time managing emotion, be it anger, anxiety, excitement, or sadness. These kids become overly emotional and find it hard to calm down.
One question I always try to answer regarding children with behavior problems is this -- how much control do they have over their behavior? If a child has control and is deliberately acting out, we often will use rewards and consequences to help the child behave.
But if a child becomes overwhelmed and thus loses control over their behavior, rewards and consequences won't work. As any good behavioral therapist will tell you, rewards and consequences are designed to motivate a person to change their behavior. If a person cannot control that behavior, no amount of motivation will help them change the behavior.
To put it another way -- I can offer you $1000 to jump ten feet high. It won't matter how much I offer you -- you are incapable of jumping ten feet in the air. You do not control that behavior. So rewards will not help. And it would be cruel to punish you for not doing a behavior you cannot do.
If a child cannot control their behavior, we can often try to help them by changing the child's environment, making it less frustrating and making it easier for the child to succeed.
6. Homework Completion / School Problems
Whenever I hear about homework or school problems, I first want to rule out a learning disability (LD). I start by using a screening form that looks for symptoms of LD's. I will also talk to teachers. If there are signs of LD's, I will refer you to a neuro-psychologist or educational psychologist to have your child tested to see if LD's exist.
However, school problems and homework completion can be affected by things other than LD's, such as
(i) recent stress in the child's life;
(ii) a pattern of being hard to motivate academically (this is especially true with kids who have ADHD);
(iii) a child who is so smart, she got away without doing homework, and without developing study skills, for a long time. But now, due to the increasing difficulty of school in upper grades or high school, the child cannot get away with this anymore. And she now lacks the study skills to cope.
7. Obsessive-Compulsive Disorder
This problem is best treated by Cognitive-Behavior Therapy, especially a technique called "Exposure-Response Prevention." In this method, the child is gradually exposed to the feared object/situation while they prevent themselves from doing their compulsive ritual. Cognitive techniques to challenge anxious beliefs are also used.
8. Panic Attacks
Sometimes a panic attack is a response to a child having general stress and reaching the point of being overwhelmed. In such cases, talk therapy can be effective. At other times, panic attacks take on a life of their own and become the primary problem. This often occurs when the child misinterprets signs of normal anxiety as instead being the sign of some catastrophic event, such as a heart attack or loss of bodily control. At such times, a Cognitive-Behavioral approach can be effective.
9. Perfectionism
This problem often results from a sensitive child who feels deep pain over rejections or failures (real or perceived) and tries to avoid them by being "perfect." The key to successful treatment is helping the child feel less pain when rejections or setbacks occur.
10. School-Phobia/Separation Anxiety Disorder
This problem can be one of the more difficult ones to treat but it can be done successfully. Treating this problem often requires my coordinating with your child's school and teacher; I collaborate with them to suggest ways they can increase social support for your child while we work to reduce his or her anxiety.
11. Social Skills Deficits
I have treated social skill deficits many times but have come to the conclusion that often, in addition to helping the child learn social skills, I also need to help them find friends. Why? These kids often have few or no friends. And increasing their social skills does not necessarily win them new friends. After all, what's the point of having social skills if you have no one to play with?
Research shows that treating social skills takes a lot of time -- the longer the training, the better the outcome. Schools these days often have social skills training components that can be very helpful for just that reason. I supplement these programs by teaching parents how to do social skills training with their kids. That way, parents can teach their kids social skills every day and for years to come.
12. Toilet Training
I have helped numerous parents toilet train their toddlers. I have also helped parents with children as old as eight who are not yet toilet-trained. (When first contacting me, some parents lament that their child will not be trained until college. Thankfully, this scenario has yet to happen!). Older children who are still not trained often have issues such as sensory integration, strong resistance to change, and high levels of rigidity. The key to successful toilet training is combining very small steps with significant rewards.
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