Carolyn A Licht. 21st Century Psychology: A Reference Handbook. Editor: Stephen F Davis & William Buskist. Volume 2. Thousand Oaks, CA: Sage Publications, 2008.
As the 21st century unfolds, substantial percentages of young people experience significant developmental, emotional, and behavioral problems; engage in multiple high-risk behaviors; and lack the environmental support and resources fundamental for optimal health and well-being. Despite the general prosperity of the last half of the 20th century, the percentage of children living in poverty has almost doubled, rising from 15 to 28 percent (Bianchi & Caspar, 2000), with 1 in 10 of these children likely experiencing homelessness. The increasing economic and societal pressures and uncertainties about the future place children and their families at greater risk for the development of mental health problems. Between 17 and 22 percent, or 14 million of our nation’s youth, suffer from some type of mental health disorder during the course of a year; 75 to 80 percent of these children fail to receive appropriate services (U.S. Public Health Service, 2000).
These numbers underestimate the scope of the problem. They do not include a substantial number of children and adolescents who remain below the diagnostic thresholds for severity, number, or duration of symptoms but still experience adverse outcomes (increased substance abuse, school and work failure, criminal activity, teenage pregnancies, and suicide) that warrant intervention (Tolan & Dodge, 2005). A significant proportion of children do not grow out of their childhood difficulties. This failure to adjust to earlier developmental challenges may have a lasting impact on later family, occupational, and social adjustment. About 50 percent of all mental disorders in adults have an onset prior to age 14 (Kessler, Berglund, Demler, Jin, & Walters, 2005). This continuity of dysfunction across the life span heightens the necessity of early intervention, not only to reduce personal suffering but also to prevent or attenuate the direct and indirect long-term costs to society of not providing appropriate services.
Despite the high need for mental health services, families experience multiple barriers associated with participating in treatment. Among families who begin treatment, 40 to 60 percent terminate prematurely (Kazdin, Holland, & Crowley, 1997) due to factors such as socioeconomic disadvantage, minority group status, family dysfunction, difficult living circumstances, perceptions that treatment is not relevant, and a poor relationship of the parent with the therapist. Treatment success will depend, in part, on the congruence between the therapeutic interventions and the sociocultural milieu in which they are implemented (Mash, 2006). In light of the family’s central importance as a social unit and transmitter of sociocultural values, an essential step in reducing barriers to treatment and meeting the mental health needs of our youth is to better understand what constitutes “family” in the 21st century. There is, however, no single immutable definition of “family.”
Each child is a member of an immediate family that itself reflects a unique configuration of structure and relationships. The family, in turn, is embedded in its own cultural and social history. The idea of family implies an enduring emotional involvement, whether by blood or by chosen alliance. Our understanding of what constitutes the “family” has evolved to reflect different cultures and belief systems, as well as to adjust to the tumultuous social and economic changes of recent decades that have altered the landscape of family life (McGoldrick, 2003). Given that individuals belong to multiple groups, possess multiple identities, and live their lives within multiple contexts, psychologists have become increasingly wary about defining any family pattern as “normal” or essential for healthy family functioning. The idealized norm of the traditional intact nuclear family has given way to a multiplicity of familial arrangements, including multigenerational or extended families, blended families, single-parent families, cohabitating heterosexual partners, and gay or lesbian families (Walsh, 2003). Family norms can further vary as the changing demographics in the United States point to an increasingly ethnically and racially diverse population. By the year 2050, it is expected that racial and ethnic minority groups will constitute half of the total U.S. population (Bernal, 2006). An increasing number of studies support the centrality of family in children’s mental health and the notion that more effective treatment outcomes are achieved when treatment focuses on the child and relevant family subsystems (Mash, 2006). Furthermore, treatment approaches must be multisystemic and culturally sensitive, actively involving the participation of the multiple health, social service, educational, and other community resources that play a role in ensuring the mental health and well-being of children and their families.
This chapter provides a discussion of salient issues relevant to providing effective therapeutic treatments to children, adolescents, and families. Initial focus provides a brief overview of the challenges of treating children and adolescents. The importance of considering family and contextual variables in the decision-making process is underscored throughout.
The remaining focus of this chapter is on the various theoretical perspectives and treatment methods that have guided the practice of child and family therapy. The similarities and differences between relevant individual and family-oriented approaches are highlighted, followed by a discussion of the state of child, adolescent, and family psychotherapy research. Exploring the limitations in our current mental health system readily generates recommendations for the future designed to achieve the crucial goal of bridging the gap between research and practice.
Challenges of Treating Children and Adolescents
Range of Childhood Disorders
The ability to provide effective psychological services to children who suffer from emotional, behavioral, and cognitive disturbances is a growing concern in the United States. The range of problems that children manifest raises special challenges. What symptoms warrant intervention? What is the appropriate focus for diagnosis, assessment, and treatment? The need for interventions stems in part from the wide scope of childhood disorders. These are commonly conceptualized in terms of deviances involving breakdowns in adaptive functioning or reflecting “developmentally and/or situationally inappropriate or exaggerated expressions of behavior” (Mash, 2006, p. 4). There are more than 200 disorders applicable to children and adolescents (American Psychological Association, 1994; World Health Organization, 1992). Most of the clinical problems that are the basis for referring children and adolescents to outpatient and inpatient treatment settings are encompassed by the terms “externalizing disorders” (i.e., oppositional, aggressive, hyperactive, and disruptive behaviors), “internalizing disorders” (i.e., problems directed toward inner experience including anxiety, withdrawal, and depression), and “developmental disorders” (i.e., mental retardation, learning problems, and autistic spectrum disorders; Mash & Dozois, 2003).
The development of a child is the product of the continuous dynamic interactions between the child’s innate maturational processes and the experience provided by his or her multiple relationships and social contexts (Holmbeck, Greenley, & Franks, 2003). Thus, to make sound diagnostic and treatment decisions, therapists must take into consideration the unique characteristics, predispositions, and traits of the child as well as the interrelated cultural and contextual variables that derive from and surround the child. One of the challenges to this decision-making process is establishing the boundaries between what constitutes abnormal and normal functioning, which are difficult and somewhat arbitrary decisions at best (Mash, 2006). Although extreme and pervasive departures from normative functioning may be clearly identifiable focuses for therapeutic attention, many of the seemingly problematic symptoms (e.g., fears, hyperactivity, and loss of temper) associated with the externalizing and internalizing disorders of childhood are, to some degree, a relatively common part of normative development (Holmbeck et al., 2003).
Therapists make judgments of deviancy based on their knowledge of developmental norms with respect to a child’s performance relative to same-age peers and the child’s own baseline of development, as well as in the context of the child’s multigenerational family system as it moves forward across the life cycle (McGoldrick & Carter, 2003). During the natural course of the family life cycle, there are certain normative (e.g., birth of child, transition to school) and some less normative (e.g., divorce, premature death) transitional periods that challenge the relative stability of the family system (Walsh, 2003a). Families exhibit different degrees of adaptability when faced with these challenges. How an individual, or the family as a whole, responds to these transitions will influence the immediate and long-term adaptation of all members and their relationships. The balance between stressful events that heighten vulnerability and protective processes that enhance resilience will ultimately shape the course of a youth’s development and the risk for adjustment difficulties (Walsh, 2003a).
One of the most critical periods of development is the transition between childhood and adolescence. “Change” is the defining feature of the adolescent period (Holmbeck, Mahar, Abad, Colder, & Updegrove, 2006). The primary developmental changes (e.g., biological/pubertal, psychological/cognitive, and social redefinition) that occur during adolescence have an impact on the behaviors of significant others. These, in turn, influence the ways in which adolescents resolve the major issues of adolescence—namely, autonomy, sexuality, identity, and so forth (Holmbeck et al., 2006). Adolescence is a time of significant transformation in family relationships, with increased reorientation toward the peer group, school, and work contexts. Within the family, boundaries shift, psychological distance among family members changes, and roles within and between subsystems are constantly being redefined (McGoldrick & Carter, 2003). Intervention plans that take full advantage of an adolescent’s developmental strengths and resilience, and attend more centrally to links between presenting symptoms and significant family and social stressors, will more effectively fortify coping and adaptation (Holmbeck et al., 2006; Walsh, 2003a).
Source of Referral and Assessment Issues
The manner in which clinical problems are identified raises further obstacles to working with youth. Children, unlike adults, rarely refer themselves for treatment. Rather, decisions concerning the evaluation and treatment of any child are almost always made or not made by significant individuals in the child’s environment, usually parents and teachers (Mash & Terdal, 1997). Unlike adult clients, who are more readily accepted as reliable sources of information about their psychological adjustment, children and adolescents are not always considered the best sources of assessment information (Kazdin & Weisz, 2003b). The ability and willingness of youths to report on their own symptoms is a function of their age and developmental level, as well as the nature of their presenting issues.
Up to adolescence, children typically attribute problems to environmental, social, or familial factors, and may not identify themselves as experiencing undue stress or symptoms. In adolescence, youths may have increased capacity to attribute problems to internal factors, such as their own thoughts and feelings, but often differ from adults in what they consider important to change (Holmbeck et al., 2006). This can severely hinder their motivation for remaining and actively engaging in any type of therapeutic endeavor, as they may not view it as necessary or even potentially useful. It is important to adapt the format and procedures of assessment and intervention to complement the development level of the child. For example, in some cases with younger children, utilizing puppets, drawings, and play when interacting with children may facilitate communication and the gathering of information that was not accessible though direct questioning or paper-and-pencil self-report measures (Gil, 1994).
In general, parents and teachers are the primary sources of information utilized to make diagnostic decisions regarding child functioning (Kazdin, 2005). This may explain why externalizing or disruptive behavior disorders account for 30 to 50 percent of all child referrals for mental health services (National Institutes of Health, 2000). Children’s externalizing behavior disrupts the learning environment in school, prompting referral by teachers and principals, and disrupts family life, prompting referral by parents. Gathering information from multiple informants, as well as utilizing a variety of procedures (e.g., observations, interviews, and questionnaires) to collect information, is the standard practice for diagnosing childhood problems (Kazdin, 2005), but it can also raise interpretive problems related to the source of information. For example, reports and ratings gathered from multiple informants may vary in degree and severity, and occasionally even contradict one another, such as when a child is reported by teachers but not by parents as being hyperactive. Although such disagreements among sources may certainly reflect differences in the child’s behavior as a function of true differential demands of multiple settings (i.e., home and school), they may also reflect differences in the attitudes and judgments among different people. Parents’ perceptions of deviance and evaluations of their children on standardized rating scales are significantly related to their own symptoms of psychopathology, marital discord, expectations for child behavior, parental self-esteem, and reported stress in the home (Mash & Dozois, 2003). These factors can in turn influence the nature and severity of child impairment, as well as the focus and effectiveness of intervention.
Focus of Treatment
This adult referral process may also contribute to confusion regarding the optimal target for treatment. Although a child may be considered the “identified” problem, research has recognized the reciprocal transactions between the developing child and the multiple social and environmental contexts in which development occurs (Holmbeck et al., 2003). Thus, the identified problem, according to the family or school, may be a disruptive or depressed child, but the therapist, depending on his or her theoretical orientation, may understand the source of dysfunction as originating within the larger family system (e.g., marital conflict), further compounded by the community or social system (e.g., neighborhood violence) in which the family is embedded. The choice of who should be treated and which therapeutic approach to utilize is largely determined by how the presenting issues are understood and conceptualized. The decision, however, must also be guided by developmental, social, economic, and cultural factors that may hinder or facilitate the treatment process. Many adverse contextual influences have direct implication for the child’s functioning and may affect attendance and participation in treatment, as well as response to methods of intervention (Kazdin & Weisz, 2003b). Children and adolescents are not fully autonomous individuals. Even when the treatment is not identified as family-based, children typically cannot participate without, at minimum, parental support, consent, reimbursement, and transportation (Diamond & Josephson, 2005). Furthermore, certain interventions may have limited applicability with young children, who often lack the cognitive capacity to engage in certain activities without parental help. Parents also play a crucial role in reducing resistance and motivating adolescents to engage in the treatment process, as well as reinforcing treatment gains. In many instances, only the child may need to be in therapy; however, when contextual influences are either considered pertinent to the onset and maintenance of the child’s problem or seen as potential valuable ways to alter child functioning, the child’s parents/guardians, teachers, or significant others may need to be included in important ancillary, supplementary, supportive, or even primary roles in the treatment process (Kazdin, 2003). For example, if the central problem is one of a skill deficit or a child’s misperceptions of situational and social cues, then a child-oriented treatment might be appropriate. In contrast, if the child’s adjustment is more the product of a seriously disturbed environment, then modification to the social system might prove to be a more appropriate treatment goal.
Any decision regarding who should participate in therapy can only be made on the basis of a thorough intake assessment. In general, the multidimensional nature of the causes and contexts of child and family disorders have led to an increased use of combined and multimodal treatments, as well as an emphasis on developing and utilizing empirically supported and cost-effective treatments.
The Practice of Psychotherapy with Children and Families
“Psychotherapy” has no standardized, uniformly held definition. Definitions vary in terms of their underlying theoretical assumptions based on different therapeutic orientations, which in turn lead to differences in defining the goals of psychotherapy, the basic techniques, and the role of the individuals involved in the therapeutic relationship (Kazdin, 2003). This diversity precludes the existence of one therapeutic approach that can serve as the treatment of choice for all children and/or their families. At times, integrating aspects of different psychotherapy theories and methods, either sequentially or concurrently, to address both individual (intrapsychic phenomena) and system-level (intrafamilial interactional processes) variables may be helpful to permit greater treatment flexibility and adaptability (Racusin & Kaslow, 1994). In some cases a combination of medication with psychotherapy may be more effective.
Although there are numerous types of psychotherapy, there is a general consensus that all psychotherapies are psychosocial methods of learning. The focus of the learning occurs in both the intrapersonal (one’s own self-perceptions and choices) and interpersonal (how one adapts to and interacts with significant others) domains (Kazdin & Weisz, 2003b). Psychotherapy typically involves a formal interaction or interpersonal process between two or more parties. One party (the therapist) is a trained professional who provides conditions (e.g., support, acceptance, and encouragement) to foster the interpersonal relationship and systematic experiences designed to bring about modification of feelings, thoughts, attitudes, and/or behavior that have proved troublesome to the other party (the “client”). The “client” may be an individual or a combination of individuals (i.e., couple, group, family, or multiple families) who have sought or been brought to treatment, voluntarily or involuntarily. The “therapist” utilizes methods of treatment that are logically related to some theory of personality’s origins, development, maintenance, and change (Kazdin, 2003). Psychotherapy is not a quick fix or an easy answer, but rather a complex and rich process that can reduce symptoms, provide insight, and improve a child or adolescent’s quality of life and overall family functioning.
There are several different types of treatment modalities utilized with children and families, including individual, group, and family (and/or couples) formats. Within each framework, the psychotherapist may use techniques from one or a variety of theoretical orientations. Particular therapeutic approaches will vary depending on the therapist’s orientation, the age of the child, the nature and source of the presenting problem, and the resources available to the family (Ronen, 2001). Group therapy is often used as a primary therapy or as an adjunct to other types of therapy. Groups can help children and adolescents learn to cope with difficulties and change feelings and behaviors by working with a therapist and interacting with their peers who face similar struggles. For example, group therapy is a good way to help children and adolescents with difficulties learn and practice social skills. Groups can also help lessen members’ sense of isolation, provide support around a particular issue, and/or enhance relationships.
Family therapy is both a theory and a treatment modality. It looks at the entire family as a complex system having its own language, roles, rules, beliefs, needs and patterns, and posits that a person’s symptoms are a function of dynamic interactions within this family system (Cox & Paley, 1997). Treatment typically involves two or more members of a nuclear or extended family. Family therapy may also be conducted in group formats with multiple families facing similar challenges interacting with one another, and often serving as “cotherapists” in the process to bring in a more personal stance. Most family therapy meetings take place in clinics or private settings. Home-based family therapies, however, are also evident and advocate that joining the family where it lives can help overcome shame, stigma, and resistance (Nichols & Schwartz, 2004).
It is essential to utilize psychotherapeutic approaches that are responsive to the unique and varied developmental needs of children. Although older children and adolescents who participate in psychotherapy are encouraged to use their verbal skills, younger children may lack a fully developed capacity for abstract thought, a prerequisite for verbal expression and understanding of complex issues, motives, and feelings (Bratton, Ray, Rhine, & Jones, 2005). Because children more naturally express themselves through the concrete world of play and activity, they may benefit from psychotherapy with a therapist who uses play therapy techniques. Using diverse theoretical orientations, play therapy is applied to individual and group settings, as well as integrated into the context of family therapy. The two basic forms of the therapeutic play relationship are directed (structured) and nondirected (unstructured) play therapy (Landreth, Baggerly, & Tyndall-Lind, 1999). Additionally, two types of play therapy, filial therapy and parent-child interaction therapy, involve the use of parents as therapists; in both cases the parents are observed, trained, and supervised by professionals to increase positive therapeutic interactions between the parent and the child (LeBlanc & Ritchie, 2001). The play materials may vary according to theory and purpose, but should be engaging and facilitate a wide range of creative and emotional expression and exploratory play, with or without prescribed structure (Landreth et al., 1999).
Theories and Methods of Psychotherapy
Psychotherapy theory and practice do not develop in a vacuum. The prevailing economic, political, and ideological climate can have a marked effect on what kinds of psychotherapy theory or practice predominate. The wide variety of beliefs about people and pathology has resulted in the development of hundreds of therapeutic techniques for children and adolescents (Kazdin, 2000). Any single overarching theory, however, is unlikely to be appropriate to explain all forms of childhood dysfunction or to account for the full range of contributory child and family influences (Mash & Dozois, 2003). An example of theoretical differences can be reflected in the various existing explanations for child disorders. In general, most models of therapeutic change in child therapy are derived from corresponding models of adult treatment that have been adapted to the distinct and varied developmental and relational needs of children and adolescents (Barish, 2004). For present purposes, psychodynamic, humanistic, cognitive-behavioral, and family systems theories are discussed, as these perspectives underlie most current practice and are the major frameworks therapists rely on when conducting therapy with children and adolescents.
Theories of Psychotherapy
The psychodynamic perspective, which grew out of the classical psychoanalytic theory of Sigmund Freud, views emotional and behavioral symptoms as the manifestation of underlying, internal, emotional conflicts (Arlow, 2000). According to this theory, some unconscious impulses (i.e., sexual or aggressive) come into conflict with environmental constraints and moral prohibitions. To keep such threatening impulses from coming into consciousness, part of the normal energy of mental life is used to provide a constant defense, or resistance, against their acceptance. These impulses, however, are not eliminated by such defensive reactions; instead, they express themselves in indirect ways, leading to behavior that the individual is unaware of or unable to explain. Psychodynamic theorists believe that by making the unconscious conscious, individuals can have greater insight into their needs and behavior and more control over how they allow these conflicts to affect them (Arlow, 2000).
Contemporary outgrowths of traditional Freudian theory are more interpersonally oriented and include object-relations theory (e.g., Ronald Fairbairn, Melanie Klein, and others) and self-psychology (Heinz Kohut), an offshoot of the object-relational approach (Wolitzky & Eagle, 1997). Object relations theory emphasizes interpersonal relations, primarily in the family and especially between mother and child, and suggests that residues of past relationships (inner images of the self and others) affect a person in the present. Self-psychology posits that each individual’s self-esteem and vitality derive from and are maintained by the empathic responsiveness of others to his or her needs.
The “goal” of psychodynamic therapy is the experience of “truth” (Arlow, 2000). This “truth” must be encountered through the breakdown of psychological defenses. The various psychodynamic approaches to therapy employ several strategies to achieve this goal. The psychotherapist acts from a stance of therapeutic neutrality to maintain focus on the clinical process of healing, and to encourage free association that allows the person to talk about the self without being influenced by defense mechanisms (Wolitzky & Eagle, 1997). Psychodynamic therapists may also analyze and interpret dreams, resistance, and defenses in order to increase clients’ self-awareness and insight (Arlow, 2000).
It is also common, and even expected, for clients in session to experience unconsciously activated transference reactions to the psychotherapist that resemble past relationships with significant authority figures (Wolitzky & Eagle, 1997). For example, a child may direct anger at a therapist whose innocent question about his or her daily activities reevoked the child’s image of an overly critical parent. Transference allows the therapist to observe the early childhood relationships as they play out in the present. Therapists assist clients in working through their reactions and increase insight so that past relationships no longer hold power over current functioning (Arlow, 2000). Therapists from object relational and self-psychological orientations take a more empathic stance, guided by the belief that an authentic or supportive relationship with the therapist will help change an individual’s habitual patterns of living by learning new ways of relating to others and to life in general (Wolitzky & Eagle, 1997).
Child and adolescent psychodynamic therapies are offshoots of adult approaches and share with them a common theoretical framework for understanding psychological life, while also using additional techniques and measures to deal with the special capacities and vulnerabilities of children (Arlow, 2000). For instance, the young client is helped to reveal his or her inner feelings and worries, not only through words but also through drawings and fantasy play. In the treatment of all but late adolescents, parents are usually consulted to round out the picture of the child’s life. The goal of psychodynamic child and adolescent treatment is the amelioration of symptoms and of the psychological roadblocks that interfere with normal development.
Theories of Psychotherapy
The most influential psychotherapies designated as humanistic include the “client-centered” (Carl Rogers), the “gestalt” (Fritz and Laura Perls), and the “existential” (e.g., Rollo May and Irvin Yalom) approaches (Greenberg & Rice, 1997). All humanistic theorists are unified in their commitment to a “phenomenological” perspective, or “the belief in the uniquely human capacity for reflective consciousness, and in the belief that it is this capacity that can lead to self-determination and freedom” (Greenberg & Rice, 1997, p. 98). Thus, a person’s perceptions about himself or herself and the world (rather than unconscious thoughts) are believed to be central to the therapeutic process. Humanistic approaches share a unifying belief that the basic aims of the individual are the preservation of one’s self-concept and the achievement of personal growth, or “self-actualization.” Furthermore, they recognize the self-healing capacities of each individual and try to honor the whole person, including mind, body and spirit.
Client-centered theorists (Raskin & Rogers, 2000) believe that people are trustworthy and have a great potential for self-awareness and self-directed growth, given a nurturing environment characterized by empathy, acceptance, and genuineness. Gestalt theorists (Yontef & Jacobs, 2000) take a specific ecological stance that maintains that, psychologically, there is no meaningful way to consider a person apart from interpersonal relations, just as there is no meaningful way to perceive the environment except through someone’s perspective. Existentialism (May & Rollo, 1997) is a philosophy of life, rather than a comprehensive therapeutic approach, that focuses on free will, responsibility for choices, and the search for meaning and purpose through suffering, love, and work. The ultimate concerns that have particular relevance for therapy include death, freedom, isolation, and meaninglessness. People are seen as constantly changing and becoming more their “true” selves.
Humanistic theories underlie many therapeutic approaches that have been developed and adapted to meet the differing developmental needs of children and adolescents. For example, building on the client-centered approach of Carl Rogers, Virginia Axline developed a model of nondirective play therapy based on her belief that children have the ability to heal themselves, given optimal therapeutic conditions (Landreth et al., 1999). Child-centered play therapists tenaciously hold a view that emphasizes the children’s positive capacities. Children are viewed as holistic, phenomenological, forward-moving individuals. They are valued as and accepted for who they are in the moment. A child-centered play therapist views maladjustment as resulting from incongruence between what the child actually experienced and the child’s concept of self (Landreth et al., 1999).
The child-centered play therapist does not expect, require, or attempt to elicit verbalization from the child about any background information, problems, or concerns; rather, the child’s communication through play is viewed as sufficient and complete (Mader, 2000). The play therapist’s job is to provide the basic therapeutic conditions of empathy, acceptance, warmth, and positive regard, and to understand the child’s nonverbalized feelings and play (Landreth et al., 1999). The child, rather than the problem, is the point of focus. The overriding premise is to provide the child with a positive growth experience in the presence of an understanding supportive adult so the child will be able to discover, through play, his or her own internal strengths. Whether in an individual or a group play setting (Mader, 2000), the therapeutic relationship is the instrument of change.
Gestalt therapy takes a more active relational stance and utilizes activities geared to increase self-awareness (Yontef & Jacobs, 2000). The techniques of gestalt therapy include focusing exercises, enactment, creative expression, mental experiments, guided fantasy, imagery, and body awareness. These techniques have been adopted by diverse schools of therapy and are particularly applicable to working with young children and adolescents. All humanistic psychotherapists work toward an authentic meeting of equals in the therapy relationship.
Theories of Psychotherapy
The hyphenated term “cognitive-behavioral” is a hybrid representing an integration of theory. The principles upon which cognitive-behavioral therapies with youth and families are based encompass elements derived from the areas of learning, cognitive psychology, developmental psychology, social psychology, and the neurosciences (Mash, 2006). Historically, cognitive-behavior therapy (CBT) had its roots in the work of behaviorists such as Ivan Pavlov, John Watson, Joseph Wolpe, and B. F. Skinner (Wilson, 2000). Subsequent theorists such as Albert Bandura (social learning theory) and cognitive therapy and CBT originators such as Albert Ellis (rational emotive behavior therapy), Aaron Beck (cognitive therapy), William Glasser (reality therapy), and Donald Meichenbaum (CBT) brought thought and emotion into the approach (Beck & Weishaar, 2000).
Abandoning an adherence to a singularly behavioral model, the cognitive-behavioral perspective includes the relationships of cognition and behavior to the emotional state and functioning of the individual in the larger social context (Kendall, 2006b). Cognitive-behavioral theories assert that maladaptive cognitive processes predispose an individual to psychopathology and maintain dysfunctional patterns and developmental anomalies (Beck & Weishaar, 2000). The way in which a child structures experiences is based on consequences of past behavior, vicarious learning from significant others, and expectations about the future. Therefore, maladjustment is viewed as resulting from either distortions in the individual child’s interpretive activity or a deficiency or lack of basic cognitive skills for controlling behavior (Kendall, 2006b). Generally, internalizing disorders in childhood and adolescence are related to “cognitive distortions,” or thinking that is biased, dysfunctional or misguided (e.g., a depressed child’s negative view of self, the world, and the future), whereas externalizing disorders are more commonly associated with “cognitive deficits,” or the lack of ability to organize or process information and/or the absence of thinking when it would be beneficial (e.g., an aggressive adolescent’s lack of self-control, failure to employ mediational skills, and lack of social perspective taking; Kendall, 2006b).
CBT is a highly structured, collaborative, problem-solving approach that seeks to define concrete goals and uses active techniques to reach them (Kendall, 2006b). The cognitive-behavioral therapist looks at patterns of thinking and behavior and how these patterns are reinforced and maintained by the person within his or her environment. CBT seeks to change a person’s irrational or faulty thinking and behaviors by educating the person and reinforcing positive experiences that will lead to fundamental changes in the way that person copes. A functional analysis of the antecedents and consequences of thinking and behavior (and associated emotions) is performed, often using log sheets and graphs to better understand thought and behavior patterns in the context of daily routines (Mash, 2006). Once an understanding of symptoms and behavior is achieved, the therapist and client together devise a plan of action. A central component of this analysis is to identify irrational thinking patterns and automatic thoughts (e.g., dichotomous thinking, overgeneralizations, and catastrophic thinking). In order to develop more rational beliefs and healthy coping strategies, clients are then taught to challenge and reframe their negative thoughts into more positive intrepretations, using evidence from their own experience.
The mental attitude of a cognitive-behavioral therapist working with children and adolescents entails being a diagnostician, an educator, a consultant, and a coach (Kendall, 2006b). Cognitive-behavior therapists use a wide variety of techniques (e.g., breathing and muscle relaxation training, exposure and response prevention, reframing, etc.), which are dependent, to some degree, on the client’s presenting problem (Beck & Weishaar, 2000). These techniques are taught and practiced during therapy sessions and assigned as homework to facilitate their application to the natural environment. The functional assessment should be an ongoing collaborative process used to evaluate the effectiveness of interventions.
Family Systems Approaches
Theories of Psychotherapy
The field of family therapy is diverse and, as it has matured, loyalty to a particular school has given way to serious attempts to develop an integrative theoretical framework, as well as culturally sensitive and evidence-based treatment models (Mikesell, Lusterman, & McDaniel, 1995). There are multiple theoretical viewpoints and corresponding approaches to family therapy that have evolved since its inception in the mid-1950s. As a result, therapeutic interventions may take a number of forms, including (a) approaches assessing the impact of the past on current family functioning (i.e., object relations, contextual); (b) those largely concerned with individual family members’ growth (i.e., experiential); (c) those that focus on family structure and processes (i.e., structural) or transgenerational issues (i.e., family systems); (d) those heavily influenced by cognitive-behavioral perspectives (i.e., strategic, behavioral); and (e) those that emphasize dialogue in which clients examine the meaning and organization they bring to their life experiences (i.e., social constructionist therapies; Nichols & Schwartz, 2004).
Despite the diversity of theories of psychotherapy, there are some unifying principles that are shared across the various orientations. Family therapists posit that psychological problems are developed and maintained in the social context of the family (Cox & Paley, 1997). This contextual perspective relocates the responsibility for the problems and the focus of treatment from the internal world of the individual (i.e., “the problem child”) to the entire family, understanding human events in terms of interactional patterns of behavior. The family is viewed as an ongoing, living system of interrelated parts that together constitute an entity greater than the simple sum of its individual members (P. Guerin & K. Guerin, 2002). By adopting this relational frame of reference, family therapists pay simultaneous attention to the family “structure” (how it arranges, organizes, and maintains itself at a particular cross-section of time) and its “processes” (the way it evolves, adapts, or changes over time). Family therapists propose that psychological problems are best explained in terms of circular, recursive events that focus on the mutually influential and interpersonal context in which they develop (Nichols & Schwartz, 2004).
One of the more influential theories, introducing concepts relevant to many models of family therapy, is family systems theory (Bowen, 1978), which offers an integrative framework for understanding individual dysfunction and intense relationship conflict in the context of the multigenerational family system (P. Guerin & K. Guerin, 2002). Family systems theory describes how persons and family systems carry within them the roots of identity constructed through a multigenerational maturational process, involving genetics, culture, spirit, and emotion. The resulting construct of identity, for both families and individuals, is the lens through which human existence and experience is filtered and defined. The basic building blocks of the “self” are inborn, but an individual’s family relationships during childhood and adolescence primarily determine how much “self” a person will develop. One mark of a healthy family is its capacity to allow members to differentiate, or maintain their own sense of self, while remaining emotionally connected to the family (Nichols & Schwartz, 2004). An individual’s degree of differentiation of self is correlated with his or her ability to maintain autonomous thinking and resist being overwhelmed by the emotional reactivity of the family. Ineffective management of anxiety transmitted from one generation to the next is thought to be at the root of most difficulties (Bowen, 1978).
Family systems theory maintains that emotional relationships in families are usually triangular (Nichols & Schwartz, 2004). Whenever any two persons in the family system have problems with each other, they will “triangle in” a third member as a way of stabilizing their own relationship (e.g., a child becomes the scapegoat or “identified problem” to redirect focus away from parental conflict). The triangles in a family system usually interlock in a way that maintains family homeostasis, or the family’s tendency to resist change and seek to maintain its customary organization and functioning over time (P. Guerin & K. Guerin, 2002).
Family therapy is a collection of therapeutic approaches that share a belief in family-level assessment and intervention. Family therapy has a tradition of empowerment and focuses attention on family dynamics and family strengths. Despite differences in therapists’ orientations and models of family therapy, certain techniques tend to be commonly applied. Core family therapy interventions can be organized into three broad classes: (a) “here and now,” (b) transgenerational, and (c) ecosystemic (Nichols & Schwartz, 2004; Seaburn, Landau-Stanton, & Horowitz, 1995).
The primary “here and now” assessment task is the observation of family interactions to determine alliances, conflicts, interpersonal boundaries, communication and meaning, and other relational patterns (Seaburn et al., 1995). “Enactment” involves instructing the family to reenact a problematic family interaction and then demonstrating an enactment of new patterns of interaction and communication. “Reframing” (relabeling behavior in positive terms) and “prescribing the symptom” (paradoxical technique that forces the family to either give up a pattern of behaving or admit that it is under their voluntary control) are additional “here and now” methods.
Transgenerational interventions, such as returning to the family of origin and inviting extended family into sessions, emphasize the evolution of both problems and solutions across many generations. The genogram, a pictorial chart of three or more generations of the family, is one of the more effective transgenerational tools adopted by both child- and family-oriented practitioners (Nichols & Schwartz, 2004). The genogram graphically illustrates and tracks multigenerational patterns that may be reoccurring in a client’s life. Genograms can help to identify root causes of behavior, loyalties, and issues of shame within the family. It is an effective way to elicit the family story and bring absent members into the room. A family map is a variation of the genogram that arranges family members in relation to a specific problem (Seaburn et al., 1995). Common ecosystemic interventions involve expanding focus to the larger social contexts through collaboration with members of other important systems (e.g., peer group, teachers) and encouraging exploration of cultural issues in sessions.
Many family therapists strongly advocate that family therapy should include every member of the family, particularly children (Gil, 1994; Raimondi & Walters, 2004). It is often the case, however, that family therapists do not take as much notice of children in practice as they do in theory. Family therapists may inadvertently ignore or oversimplify children’s intrapsychic processes in their efforts not to pathologize children. Additionally, the youngest members of the family may be excluded from the family therapy process because family therapists may lack training or confidence in their ability to engage youngsters in a developmentally appropriate way (Raimondi & Walters, 2004). There are many advantages to including children in family therapy. Most important, the inclusion of all family members allows therapists to observe how each family member contributes to the problems and growth of the family (Gil, 1994).
One of the challenges of working with young children and their families is that the adults and young children operate in developmentally different worlds. To address these differences, family therapists have begun to integrate play therapy approaches into their treatment modalities (Gil, 1994; Wittenborn, Faber, Harvey, & Thomas, 2006). Play is a natural medium for self-expression that facilitates a child’s direct and indirect communication and allows a window through which adults can enter and observe the child’s world (Wittenborn et al., 2006). The use of play in family therapy treats children as equally important family members with valuable information to offer and assimilate. Children will use play materials to directly or symbolically act out feelings, thoughts, and experiences that they are unable to meaningful express through words (Bratton et al., 2005). Family therapists can focus both on observing the child’s play within the dynamic context of the family and on recognizing the importance of the child’s inner world.
The State of Current Practice and a Vision for the Future
The Gap between Research and Practice
Much progress has been made in the development and evaluation of interventions for childhood disorders and family dysfunction. A tremendous number (> 550) and diversity of treatments for children and families exist (Kazdin, 2000). In addition, the sheer quantity of controlled treatment outcome studies examining the effects of psychotherapy on the lives of children and their families is vast, and has left little doubt that psychotherapy has beneficial treatment effects. Yet there still is a huge gap between the number of children and families who are in need of psychological services and those that receive them.
With the advent of managed care and the increased demand for treatment accountability, there is a growing recognition of the importance of developing psychotherapy models based on carefully specified and empirically supported treatment strategies, grounded in theory and data about specific childhood disorders (Kazdin, 1997). The Society for Clinical Psychology (Division 12 of the American Psychological Association) and its offspring, the Society of Clinical Child and Adolescent Psychology (Division 23), joined together to generate criteria for, and a list of, empirically supported treatments for many of the childhood disorders (Ollendick & King, 2004). In brief, they stipulated that for a treatment to be designated as a “well-established” empirically supported treatment, evidence must be gathered from at least two “randomized clinical trials,” which are research studies that randomly assign participants to conditions (e.g., experimental treatment compared to placebo, pill, or another treatment), carefully specify the client population, utilize treatment manuals, and evaluate treatment outcome with multiple measures. A treatment is designated as “probably efficacious” if its supporting evidence is based on only one such randomized clinical trial or if the experimental group is not compared to another treatment condition.
Based on these criteria, empirically supported treatments are now available for many child and adolescent disorders, including multiple externalizing conditions ranging from chronic aggression and disobedience to the disruptive behavior disorders, multiple internalizing conditions within the anxiety-depression spectrum, autism and related developmental disorders, eating disorders, enuresis/encopresis, and some forms of substance abuse (Weisz & Kazdin, 2003). Yet even with these considerable advances, the application of these potentially valuable interventions to widespread practice remains quite limited (Tolan & Dodge, 2005). The vast majority of these tested treatments have relatively meager empirical support and many are only considered “probably efficacious.” Furthermore, the majority of the treatments deemed either “well-established” or “probably efficacious” are based on behavioral and cognitive-behavioral principles, with far fewer reflecting psychodynamic, family systems, or other theoretical perspectives (Ollendick & King, 2004). These findings reflect, in part, the scarcity of well-designed studies that have investigated nonbehaviorally based interventions, rather than evidence of the inferiority of these alternate approaches.
Although the lack of sufficient research is a substantial problem, it is not the only challenge that must be addressed to bridge the gap between research and practice. Another obstacle to transporting interventions from the research to the practice setting relates to the fact that much of the research in psychotherapy for childhood disorders is conducted under conditions that depart in many notable ways from those in real-world settings (Kazdin, 2002, 2003). This may significantly influence treatment outcome and generalizability of findings. For example, children recruited for most therapy studies, as compared to those seen in clinical settings, tend to have less severe, less chronic, and fewer comorbid conditions, and less associated dysfunction in other domains (e.g., academic failure, poor peer relations). Their families and surrounding environments also tend to be less stressful and dysfunctional. Treatment outcome may be significantly influenced by these differences, as well as by departures in the models and method of intervention implemented. Consequently, the findings from therapy research may pertain to therapy executed in a particular way and have little or unclear relation to the effects achieved in clinical practice.
Bridging the Gap
Though encouraging in many respects, our knowledge base reveals certain limitations in what is known and can be accomplished with regard to treating and preventing youth and family dysfunction. Future research needs to more fully answer why, for whom, and under what conditions treatments work, and identify the key processes or characteristics within the child or family that optimize therapeutic change (Kazdin, 2002). Additionally, efforts need to be made to identify and remove structural, linguistic, cultural, and financial barriers to treatment and to improve access to quality care (Kazdin et al., 1997). To achieve these goals, interventions that have demonstrated efficacy under controlled research conditions need to be tested on the highly diverse populations of children and families with multiple needs, problems, and co-occurring conditions that embody current clinical practice (Huang et al., 2005).
It is important to recognize that children and their families are highly heterogeneous, reflecting different cultures and belief systems, and constantly accommodating to changing life circumstances. The problem of unmet need and the growing disparities in access, quality, and outcome services for diverse ethnic and racial populations highlight the importance of working collaboratively with families to make decisions about their care (Tolan & Dodge, 2005). Therapists who work with youth and their families must be alert to the different family values, norms, and roles that other cultures may embrace, and empathically understand that other cultures may have different expectations of what constitutes treatment success (Bernal, 2006). The more families perceive treatment as relevant to their needs, the more likely that positive change will occur. Families should be encouraged to participate as partners in service, both for their own children and at the system level, in the design, implementation, and evaluation of services and supports (Huang et al., 2005).
Given the dramatic changes in family composition in the 21st century, there is an increasing need for programs that are effective in reaching all types of families. The current mental health system is a complex maze that is difficult to negotiate and introduces many obstacles that deter children and families from seeking the services they need. Diverse family challenges cannot be adequately addressed if mental health services are driven by an invariant approach or one-size-fits-all model of care. Models of therapy need to be comprehensive, integrating a broad array of services and support. They need to be individualized to adjust to the developmental and environmental needs of children and their families. Increasing the focus on prevention, early identification, and early intervention may offer the best opportunity to maximize the likelihood of positive outcomes (Huang et al., 2005). To bridge the gap between science and practice, there needs to be greater sharing of knowledge, coordination of services, and collaboration between families, treatment providers, and the various sytems that may hinder or facilitate a child’s development and ability to function. Therapists need to refocus their attention from family deficits to family strengths (Walsh, 2003a) and, through collaboration, foster family empowerment and resilience.