The current state of child psychotherapy is abysmal.

There are two primary models for child therapy, both developed during the 1950s and 60s, prior to the wealth of information emerging from scientific research over the past 50 years regarding child development and the socially mediated maturation of various brain systems during childhood.

We now understand how the brain works, what systems are involved, how these systems function, both on their own in their interactions, and how these brain systems grow and mature during childhood. 

And we now understand much more about what children’s symptom displays mean regarding the integrated functioning and dysfunctioning of the underlying brain systems. What’s more, we now understand what we can do to return children’s development to a normal and healthy developmental trajectory.

With our current knowledge of child development and the integrated operation of the various brain systems during childhood, we can solve all of the basic emotional and behavioral problems of childhood,

• child defiance and non-cooperation,
• anger control problems, aggression, and tantrums,
• poor school motivation, homework problems, and problems in maintaining attentional focus,
• hyperactivity and impulse control problems,
• children’s rude, argumentative, and negativistic attitudes
• overly anxious and overly sad emotional displays, and children’s loneliness and alienation
• post-divorce parent-child conflicts
• excessive sibling arguments and fighting

We still cannot solve brain “hardware” problems of childhood, such as problems associated with autism-spectrum disorders and mental retardation.  But for the broad spectrum of typical child emotional and behavioral problems, they are all solvable within our current scientifically based understanding of child development and the socially mediated maturation of brain systems during childhood.

Yet our current approach to child psychotherapy (i.e., play therapy and behavior therapy) is woefully archaic and cannot solve any of these problematic child behavior and child development issues. Both behaviorism and play therapy have been available since the 1960s, and yet our child behavior and child development issues remain unsolved.  We keep trying the same tired and ineffective techniques, without success and yet without changing our approach either.

A foundational paradigm shift in our approach to child therapy is long past overdue.  We need to base our approach to child therapy in the current scientific evidence regarding healthy child development and the socially-mediated maturation of brain systems during childhood. Our approach to child therapy should be based in the scientific evidence available today, not on the unsubstantiated theories offered during the early days of psychotherapy (e.g., “play therapy”) or on experiments conducted with lab rats during the 1940s and 50s (e.g., “behaviorism”).

Play Therapy

Play therapy originated from the theories of Anna Freud, the daughter of Sigmund Freud, who sought to apply to children her father’s theories of psychoanalysis. Her father, Sigmund Freud, used the techniques of free association and dream analysis with his adult patients to supposedly uncover their deep-seated psychological conflicts that were producing their symptoms. However, these techniques of psychoanalysis with adults were inappropriate for use with children because of children’s immature cognitive development.  Instead, Anna needed an alternative method to uncover children’s unconscious internal conflicts that were supposedly responsible for creating the child’s psychological and behavioral problems.

So instead of her father’s techniques of free association and dream analysis, Anna Freud proposed that children’s free play could be analyzed for its symbolic content to reveal the child’s deep-seated unconscious conflicts that were producing the child’s symptomatic behavior and emotional displays.   This was the birth of the play therapy model of child therapy.

Unfortunately, while a pleasant theory, the psychoanalytic theories proposed by Sigmund Freud and his daughter are not accurate for capturing the neuro-biological processes that are actually responsible for children’s problematic emotional and behavioral displays, so that play therapy using a psychoanalytic framework is totally pointless and produces no change in children’s problems.

The play therapy model first proposed by Anna Freud was revised from a humanistic/existential theoretical framework in the 1960s by Virginia Axline.  The humanistic/existential movement, popular during the 1950s and 60s, emphasized human growth and potential, centering on the constructs of self-actualization and personal authenticity.

Using a humanistic/existential model for “play therapy”, Axline proposed that when children are provided with non-judgmental acceptance during free play activities then their natural internal press for self-actualization and authenticity would emerge over time, leading to their psychological growth and the resolution of their symptoms (which were supposedly caused by restrictions being placed on the children’s natural tendency toward self-actualization of self-authenticity by parents and the environment).

Again, while this is a pleasant theory, this humanistic/existential theory of child development does not accurately reflect the scientifically based neuro-biological evidence of the past 50 years.

Instead, the scientific evidence has revealed the brain to be a complex self-organizing system that benefits from some “restrictions on the degrees of freedom” available to it. Imposing well-modulated restrictions on the child’s desires and impulses promotes the development of increasing complexity and integration within the brain’s underlying regulatory systems. Far from causing problems, appropriate parental (and therapist) judgment regarding children’s behavioral and emotional expressions, and well modulated restrictions placed on these displays, actually promotes healthy child development and maturation.

Both the psychoanalytic and the humanistic models for “play therapy” as a treatment approach are fundamentally flawed from the vantage of the scientific evidence regarding the socially mediated development of the brain during childhood, and both the psychoanalytic and humanistic models of play therapy are entirely pointless and ineffective.  Play therapy is nearly a complete waste of time.

I’m sure to draw some ire from play therapists over this view of play therapy as pointless and ineffective, and some play therapist advocates may cite this or that research.  I’d be happy to debate this further, but not in this blog post.  Let me just say that what occurs in the “perfect world” of research on play therapy is a far cry from what occurs in the day-to-day clinical practice of child therapists who supposedly use a play therapy model.  For many therapists, the theoretical cover provided by a “play therapy” model masks basic incompetence.  They’re just glorified playmates for the child. No therapy is taking place.

Because I know what actual child therapy is, I also know what it isn’t.  Play therapy is, for the most part, pointless.

Also, let me offer a few caveats regarding the harsh position I’m taking that play therapy is pointless and ineffective:

Caveat 1: There may be some side benefits to play therapy based on relationship features (called “intersubjectivity” in the scientific literature), but these benefits merely represent side-effects of the play therapy model, not primary treatment effects, and are based on personality qualities and the inherent relationship skill of the therapist, not on the play therapy treatment model.

It is far better to base our child therapy models on the current scientific evidence regarding the formation and function of the “intersubjective field” that directly understands and uses defined and specified therapist-child relationship features, and even more importantly specific features of the parent-child relationship, to alter the functioning of the child’s underlying regulatory networks, promoting their healthy maturation and development.

Caveat 2: The art therapy model of Violet Oaklander is not a play therapy model, it is a Gestalt therapy model of increasing the child’s self-awareness, and therefore the cognitive choices available to the child in altering behavior.  The art therapy approach of Oaklander involves the mutual exploration by the therapist and child of selected and directed art-based expressive activity.  This art-based guided approach to child therapy, that is founded in Gestalt therapy, can be helpful.

Caveat 3: Expressive play therapy models have application for the treatment of child trauma, such as child exposure to sexual abuse, physical abuse, or domestic violence, in which the child’s symbolic play activity, particularly with doll house figures representing family relationships, provides an opportunity for the child to reprocess and emotionally integrate traumatic experiences.

For the most part, however, play therapy is pointless for the wide variety of problematic emotional and behavioral displays that comprise the typical problems presenting for child therapy, such as child defiance, school behavior problems, aggression and anger control issues, hyperactivity and impulse control problems, post-divorce adjustment, etc.

For most typical child issues, play therapy, especially as practiced by most child therapists, is a complete waste of time. The parent sits in the waiting room while the therapist and child do some “magical therapy type” activity in the therapist’s office.  The parent is never provided with a theory-based explanation for the origins of the child’s problematic issues, and is never provided with a theory-based explanation of how the therapy is going to resolve the child’s issues. Nor is parent offered direction and guidance on how to respond to the child when the child presents emotional or behavioral problems during day-to-day life.

The parent is simply ask to trust that eventually, through the “magic” of therapy, the child’s problems will be resolved. But they don’t resolve. And after 6-18 months of ineffective therapy while the child’s problems at home and school continue or get worse, the parent may eventually change therapists and start the process again, with the therapist telling the parent, “I first need to establish a therapeutic relationship of trust with the child.”  And another round of 6-18 months of ineffective “child therapy” begins.

Child Behavior Therapy

The behaviorist model of child therapy is based on research conducted during the 1940s and 50s changing the behavior of lab rats using pellets of food delivered to very hungry rats and by delivering electric shocks to the rats’ feet. While collectively the procedures of the behaviorist model are called “Learning Theory” (i.e, the hungry rat learns that doing a certain behavior gets food and the electrically shocked rats learn that by avoiding a behavior they can avoid the electric shock), the principles of behaviorism can essentially be summarized as “punishing a behavior decreases the frequency of that behavior” and its corollary, “rewarding a behavior increases the frequency of that behavior.”

From a technical standpoint, it is important to note that the research on which behavioral child therapy is based involved food given to very hungry rats, and electric shocks were used as the “punishment”, while in child behavior therapy we don’t starve children and then use food as a reinforcer, nor do we apply electric shocks as punishment for misbehavior. 

So it is foundationally questionable whether the research in the 1940s and 50s on reinforcement and punishment with lab rats is actually applicable to child psychotherapy.

The principles of “behavior therapy” can actually become more complicated if the role of triggering cues for the behavior are incorporated into the treatment, but most child “behavior therapists” are fairly unsophisticated and their therapy is simply based on the punishment/reward paradigm of behaviorism.

Also of note, is that just because people place the word “therapy” in a label for what they’re doing, such as “behavior therapy” doesn’t mean that they’re actually doing any sort of therapy.  What you call something and what you actually do can be two separate things.

The actual practice of “behavior therapy” is simply using techniques of power, control, and domination to induce submissive behavior in children.  But is sounds so much nicer if we call it “therapy” than if we refer to it as the domination of children.

The typical child behavior therapy approach is reflected in most “parent training” curriculum and involves teaching parents a set of responses to their children’s “problem behavior” that includes a set of behavior-control techniques

Behavioral Techniques:

Praise for Good Behavior: Parents are typically instructed to “catch their children being good” and provide their children with praise for good behavior, under the pretext that parental praise acts as a “reinforcer” (i.e., a social reward) for children’s “positive behavior”.

Note: Praise does not actually act as a reinforcer for children, at least not in the way the behaviorists conceptualize it. The parent-child relationship is much more complex than is conceived within a behaviorist model. If parental praise changed child behavior the world would be a much simpler and better place.

“Praising child compliance did not appear to serve a reinforcement function… The practice appears to be a socially acceptable, widely used ritual.” (Roberts, 1985, p. 627)

Are parental anger and parental pleasure important factors in parenting? Absolutely. But not in the overly simplistic way the behaviorists try to use them.  The overly simplistic use of parental praise for “good behavior” does not alter child behavior. The parent-child relationship is immensely more complex than that. The role of parental emotional tone in achieving children’s healthy development will be covered in future posts.

Consistent Consequences for Negative Behavior: Punishment is typically rephrased as “consequences” in child behavior therapy to soften our role in inducing child suffering. 

We punish children, it’s something we’re doing to children.

Whereas children earn consequences.  “Consequences” are something children make us do (i.e., “I don’t want to take away all your toys, but you’re making me.”)

The “behavior therapist” will recommend that parents respond to “negative behavior” by consistently delivering “negative consequences”, so that the child will eventually learn through association that negative behavior will lead to negative consequences (i.e., suffering), in the same way that the lab rat learned to associate a behavior (called the “target behavior”) with the delivery of an electric shock (i.e., the “negative consequence” for the lab rat’s behavior). 

By consistently causing the child to suffer every time the child emits the non-desired behavior (i.e., the “target behavior”) the rational child will eventually learn to stop emitting the behavior that leads to the child’s increased suffering, in the same way that the lab rat learned to stop emitting the target behavior to avoid receiving an electric shock to its feet. Punishment (i.e., increasing the suffering of the lab rat or child) decreases the frequency of the behavior that receives the punishment.

I find it interesting that “behavior therapists” diagnose the cause of the child’s problematic emotional and behavioral displays as being the result of too little child suffering, so that the “therapy” becomes to increase the child’s suffering. 

From a scientifically based model for developmentally supportive child therapy, the problematic child behavior is called a “protest behavior” and it represents a behavioral form of communication emitted by the child’s disorganized and dysregulated brain state designed to elicit greater parental involvement for the child who is struggling to maintain emotional or behavioral regulation. The increased parental involvement “scaffolds” the child’s transition from a dysregulated emotional/behavioral state back into a calm and regulated emotional/behavioral state, thereby building through use-dependent neural processes (such as long-term potentiation and synaptogenesis) the neural pathways in the child’s brain that were used in the transition from a dysregulated to a regulated emotional/behavioral state.  Through repeated parental scaffolding of the child’s transition from a dysregulated to a regulated emotional/behavioral state, the underlying neurological pathways in the child’s brain for making this transition become stronger, ultimately leading to the emergence of the child’s own capacity for “self-regulation” without the need for parentally mediated support.

Two different models, one an animal-based model for suppressing the behavior of lab rats, and the other a scientifically based model founded in actual research on child development and the neuro-development of the brain during childhood.  In my view, we should be using the scientifically based model as the foundation for our child therapy, not the animal-based model that attributes the cause of the child’s problematic emotional and behavioral displays as being too little child suffering, so that the proposed solution is to increase child suffering.

Sometimes the “negative consequences” recommended by “behavior therapists” are to impose time-out periods where the child is forced to sit quietly in a chair or corner, and sometimes the recommended  “negative consequences” involve the loss of toys or activities that the child values in response to non-desired child behavior.  The goal of punishment (“negative consequences”) is to make the child suffer, so that the recommendations of “therapy” become to increase child suffering.

Knowing what actual child therapy is, I am appalled at the cavalier brutality of “behavior therapy” and I find it’s foundational principles to be bizarre.  Children are not rats. There are major differences between children and rats.  We should not be applying principles of behavior change developed from research on lab rats to human children.  We should base our therapy models in research on human children.  To me, this seems self-evident.

And yet, “behavior therapy” is one of the two prominent child therapy models being employed, along with “play therapy.”

Note: Can we reduce non-desired child behavior through punishment? Absolutely. Put an electric shock collar on the child and we can absolutely obtain child obedience very quickly. But we’ll also create a psychologically disturbed and unhealthy child. But if all we care about is reducing non-desired “problem behavior” then certainly we can use punishment.

All punishment strategies have negative side-effects. And simply suppressing non-desired child behavior is not the same as achieving child cooperation and healthy child development. 

As we will learn in future posts, punishment uses a particular brain system, the dominance-submission network. While we can achieve submissive behavior from children through the use of punishment, achieving submissive behavior often requires inducing high levels of child suffering, and we are typically uncomfortable brutalizing children sufficiently to achieve their submission.  Yet applying less severe forms of punishment often lacks the power to induce child submissive behavior in the face of the neuro-developmental press from “protest behavior” to elicit increased parental involvement and scaffolding support, so when we employ a punishment-based approach we wind up having to deliver frequent punishments that ultimately don’t change the child’s problematic behavior, but that do increase the frequency and intensity of negative parent-child interactions, often leading to chronic parent-child arguments and hostility.

We need to stop using a behavioral paradigm for child therapy and shift to a neuro-developmental, scientifically based paradigm for child therapy.

Star Charts and Point Systems:  Sometimes the “behavior therapist” will recommend the use of star charts and point systems that are to be placed prominently on the household refrigerator, in which the child earns daily tokens for pre-specified good behavior (called the “target behavior”), such as stars or points for doing daily chores and tasks. Sometimes tangible tokens are used for younger children, children such as poker chips or marbles placed in a jar.

These stars, points, or tangible tokens are accumulated by the child over time and are then redeemed, either daily or at the end of the week, for some desired “backup reinforcer” such as a desired toy or activity.

The “game” quality and initial challenge of earning stars and points will usually captivate the child’s involvement, but this only lasts a few weeks. Eventually the novelty of the new reward system wears off and stops motivating the child’s cooperation, and parents typically find that maintaining the star chart or point system is too time consuming, annoying, and difficult in the day-to-day stresses of parenting and daily life.

So generally, while there is some initial improvement in the child’s behavior during the first several weeks of a new star chart or point system, the child’s behavior eventually returns to its pre-chart level of non-cooperation and the star chart or point system gradually falls into disuse, generally within 4-6 weeks of when it was started.

There can nevertheless be some benefits from using a star chart or point system in changing the parents’ attitude and approach with the child, so as a parent-intervention star charts and point systems can be helpful. But they fail as a long-term solution for altering child behavior.

Star charts and point systems have been available since the 1960s. If they solved child behavior problems then our problems would be gone by now and the world would be a much happier and more peaceful place of well-behaved children. But we continue to face the same child behavior problems as we did in the 1960s, and 70s, and 80s, etc. Our problems with parenting and child behavior remain unchanged, despite our behaviorist approaches.

Behaviorism represents a failed parenting paradigm. Punishment can reduce non-desired child behavior. But the use of punishment as a primary parenting strategy is problematic and does not solve our parenting problems.  There is also research evidence that the behaviorist approach actually makes things worse (for example, there is scientific evidence that the use of behavior therapy actual makes Attention Deficit Hyperactivity Disorder worse, and that alternative relationship-based approaches can actually make ADHD symptoms better (I’ll discuss this more in future blog posts).

Knowing what I know about child development and the socially mediated development of brain systems during childhood, I am of the firm opinion that the behaviorist model of child therapy should stop. Immediately.  Today.  It makes things worse.

The application to human children of an animal-based model developed with lab rats is immensely inappropriate, and is harmful to the healthy emotional, psychological, and social development of children.

We should stop using the child “behavior therapy” paradigm immediately.

It goes beyond the scope of what I can discuss in this post, and the discussion would become far too technical, but I’d be happy to debate the issue with any professional, anytime, anywhere. The behaviorist model of “child therapy” is harmful, and it represents a grossly inappropriate application of an animal-based model to human children.

Conclusion

Our current approaches to child therapy of “play therapy” and “behavior therapy” are wrong-headed, ineffective, and in some cases counter-productive and harmful.

We have available in the scientifically established literature of the last 50 years regarding child development and the socially mediated development of the brain during childhood a clearly defined understanding of how to achieve healthy and cooperative children. Why aren’t we applying this scientific research to our approach to child therapy?

Our current approach to child therapy is abysmal. It is time for a foundational paradigm shift into new treatment models based in the current scientific evidence regarding healthy child development and the socially mediated maturation of the brain during childhood.

Craig Childress, Psy.D.
Clinical Psychologist, PSY 18857

References

Roberts, M.W. (1985). Praising child compliance: Reinforcement or ritual.  Journal of Abnormal Child Psychology, 13(4), 611-629