child therapy case study

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A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy

• Magdalena Romanowicz   ORCID: orcid.org/0000-0002-4916-0625 1 ,
• Alastair J. McKean 1 &
• Jennifer Vande Voort 1  

BMC Psychiatry volume  17 , Article number:  330 ( 2017 ) Cite this article

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Long-term effects of neglect in early life are still widely unknown. Diversity of outcomes can be explained by differences in genetic risk, epigenetics, prenatal factors, exposure to stress and/or substances, and parent-child interactions. Very common sub-threshold presentations of children with history of early trauma are challenging not only to diagnose but also in treatment.

Case presentation

A Caucasian 4-year-old, adopted at 8 months, male patient with early history of neglect presented to pediatrician with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. He was subsequently seen by two different child psychiatrists. Pharmacotherapy treatment attempted included guanfacine, fluoxetine and amphetamine salts as well as quetiapine, aripiprazole and thioridazine without much improvement. Risperidone initiated by primary care seemed to help with his symptoms of dyscontrol initially but later the dose had to be escalated to 6 mg total for the same result. After an episode of significant aggression, the patient was admitted to inpatient child psychiatric unit for stabilization and taper of the medicine.

Conclusions

The case illustrates difficulties in management of children with early history of neglect. A particular danger in this patient population is polypharmacy, which is often used to manage transdiagnostic symptoms that significantly impacts functioning with long term consequences.

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There is a paucity of studies that address long-term effects of deprivation, trauma and neglect in early life, with what little data is available coming from institutionalized children [ 1 ]. Rutter [ 2 ], who studied formerly-institutionalized Romanian children adopted into UK families, found that this group exhibited prominent attachment disturbances, attention-deficit/hyperactivity disorder (ADHD), quasi-autistic features and cognitive delays. Interestingly, no other increases in psychopathology were noted [ 2 ].

Even more challenging to properly diagnose and treat are so called sub-threshold presentations of children with histories of early trauma [ 3 ]. Pincus, McQueen, & Elinson [ 4 ] described a group of children who presented with a combination of co-morbid symptoms of various diagnoses such as conduct disorder, ADHD, post-traumatic stress disorder (PTSD), depression and anxiety. As per Shankman et al. [ 5 ], these patients may escalate to fulfill the criteria for these disorders. The lack of proper diagnosis imposes significant challenges in terms of management [ 3 ].

J is a 4-year-old adopted Caucasian male who at the age of 2 years and 4 months was brought by his adoptive mother to primary care with symptoms of behavioral dyscontrol, emotional dysregulation, anxiety, hyperactivity and inattention, obsessions with food, and attachment issues. J was given diagnoses of reactive attachment disorder (RAD) and ADHD. No medications were recommended at that time and a referral was made for behavioral therapy.

She subsequently took him to two different child psychiatrists who diagnosed disruptive mood dysregulation disorder (DMDD), PTSD, anxiety and a mood disorder. To help with mood and inattention symptoms, guanfacine, fluoxetine, methylphenidate and amphetamine salts were all prescribed without significant improvement. Later quetiapine, aripiprazole and thioridazine were tried consecutively without behavioral improvement (please see Table  1 for details).

No significant drug/substance interactions were noted (Table 1 ). There were no concerns regarding adherence and serum drug concentrations were not ordered. On review of patient’s history of medication trials guanfacine and methylphenidate seemed to have no effect on J’s hyperactive and impulsive behavior as well as his lack of focus. Amphetamine salts that were initiated during hospitalization were stopped by the patient’s mother due to significant increase in aggressive behaviors and irritability. Aripiprazole was tried for a brief period of time and seemed to have no effect. Quetiapine was initially helpful at 150 mg (50 mg three times a day), unfortunately its effects wore off quickly and increase in dose to 300 mg (100 mg three times a day) did not seem to make a difference. Fluoxetine that was tried for anxiety did not seem to improve the behaviors and was stopped after less than a month on mother’s request.

J’s condition continued to deteriorate and his primary care provider started risperidone. While initially helpful, escalating doses were required until he was on 6 mg daily. In spite of this treatment, J attempted to stab a girl at preschool with scissors necessitating emergent evaluation, whereupon he was admitted to inpatient care for safety and observation. Risperidone was discontinued and J was referred to outpatient psychiatry for continuing medical monitoring and therapy.

Little is known about J’s early history. There is suspicion that his mother was neglectful with feeding and frequently left him crying, unattended or with strangers. He was taken away from his mother’s care at 7 months due to neglect and placed with his aunt. After 1 month, his aunt declined to collect him from daycare, deciding she was unable to manage him. The owner of the daycare called Child Services and offered to care for J, eventually becoming his present adoptive parent.

J was a very needy baby who would wake screaming and was hard to console. More recently he wakes in the mornings anxious and agitated. He is often indiscriminate and inappropriate interpersonally, unable to play with other children. When in significant distress he regresses, and behaves as a cat, meowing and scratching the floor. Though J bonded with his adoptive mother well and was able to express affection towards her, his affection is frequently indiscriminate and he rarely shows any signs of separation anxiety.

At the age of 2 years and 8 months there was a suspicion for speech delay and J was evaluated by a speech pathologist who concluded that J was exhibiting speech and language skills that were solidly in the average range for age, with developmental speech errors that should be monitored over time. They did not think that issues with communication contributed significantly to his behavioral difficulties. Assessment of intellectual functioning was performed at the age of 2 years and 5 months by a special education teacher. Based on Bailey Infant and Toddler Development Scale, fine and gross motor, cognitive and social communication were all within normal range.

J’s adoptive mother and in-home therapist expressed significant concerns in regards to his appetite. She reports that J’s biological father would come and visit him infrequently, but always with food and sweets. J often eats to the point of throwing up and there have been occasions where he has eaten his own vomit and dog feces. Mother noticed there is an association between his mood and eating behaviors. J’s episodes of insatiable and indiscriminate hunger frequently co-occur with increased energy, diminished need for sleep, and increased speech. This typically lasts a few days to a week and is followed by a period of reduced appetite, low energy, hypersomnia, tearfulness, sadness, rocking behavior and slurred speech. Those episodes last for one to 3 days. Additionally, there are times when his symptomatology seems to be more manageable with fewer outbursts and less difficulty regarding food behaviors.

J’s family history is poorly understood, with his biological mother having a personality disorder and ADHD, and a biological father with substance abuse. Both maternally and paternally there is concern for bipolar disorder.

J has a clear history of disrupted attachment. He is somewhat indiscriminate in his relationship to strangers and struggles with impulsivity, aggression, sleep and feeding issues. In addition to early life neglect and possible trauma, J has a strong family history of psychiatric illness. His mood, anxiety and sleep issues might suggest underlying PTSD. His prominent hyperactivity could be due to trauma or related to ADHD. With his history of neglect, indiscrimination towards strangers, mood liability, attention difficulties, and heightened emotional state, the possibility of Disinhibited Social Engagement Disorder (DSED) is likely. J’s prominent mood lability, irritability and family history of bipolar disorder, are concerning for what future mood diagnosis this portends.

As evidenced above, J presents as a diagnostic conundrum suffering from a combination of transdiagnostic symptoms that broadly impact his functioning. Unfortunately, although various diagnoses such as ADHD, PTSD, Depression, DMDD or DSED may be entertained, the patient does not fall neatly into any of the categories.

This is a case report that describes a diagnostic conundrum in a young boy with prominent early life deprivation who presented with multidimensional symptoms managed with polypharmacy.

A sub-threshold presentation in this patient partially explains difficulties with diagnosis. There is no doubt that negative effects of early childhood deprivation had significant impact on developmental outcomes in this patient, but the mechanisms that could explain the associations are still widely unknown. Significant family history of mental illness also predisposes him to early challenges. The clinical picture is further complicated by the potential dynamic factors that could explain some of the patient’s behaviors. Careful examination of J’s early life history would suggest such a pattern of being able to engage with his biological caregivers, being given food, being tended to; followed by periods of neglect where he would withdraw, regress and engage in rocking as a self-soothing behavior. His adoptive mother observed that visitations with his biological father were accompanied by being given a lot of food. It is also possible that when he was under the care of his biological mother, he was either attended to with access to food or neglected, left hungry and screaming for hours.

The current healthcare model, being centered on obtaining accurate diagnosis, poses difficulties for treatment in these patients. Given the complicated transdiagnostic symptomatology, clear guidelines surrounding treatment are unavailable. To date, there have been no psychopharmacological intervention trials for attachment issues. In patients with disordered attachment, pharmacologic treatment is typically focused on co-morbid disorders, even with sub-threshold presentations, with the goal of symptom reduction [ 6 ]. A study by dosReis [ 7 ] found that psychotropic usage in community foster care patients ranged from 14% to 30%, going to 67% in therapeutic foster care and as high as 77% in group homes. Another study by Breland-Noble [ 8 ] showed that many children receive more than one psychotropic medication, with 22% using two medications from the same class.

It is important to note that our patient received four different neuroleptic medications (quetiapine, aripiprazole, risperidone and thioridazine) for disruptive behaviors and impulsivity at a very young age. Olfson et al. [ 9 ] noted that between 1999 and 2007 there has been a significant increase in the use of neuroleptics for very young children who present with difficult behaviors. A preliminary study by Ercan et al. [ 10 ] showed promising results with the use of risperidone in preschool children with behavioral dyscontrol. Review by Memarzia et al. [ 11 ] suggested that risperidone decreased behavioral problems and improved cognitive-motor functions in preschoolers. The study also raised concerns in regards to side effects from neuroleptic medications in such a vulnerable patient population. Younger children seemed to be much more susceptible to side effects in comparison to older children and adults with weight gain being the most common. Weight gain associated with risperidone was most pronounced in pre-adolescents (Safer) [ 12 ]. Quetiapine and aripiprazole were also associated with higher rates of weight gain (Correll et al.) [ 13 ].

Pharmacokinetics of medications is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.) [ 14 ], which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects.

There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular in the first 3 years of life there are many changes in developing brains, such as increase in synaptic density, pruning and increase in neuronal myelination to list just a few [ 11 ]. Unfortunately at this point in time there is a significant paucity of data that would allow drawing any conclusions.

Our case report presents a preschool patient with history of adoption, early life abuse and neglect who exhibited significant behavioral challenges and was treated with various psychotropic medications with limited results. It is important to emphasize that subthreshold presentation and poor diagnostic clarity leads to dangerous and excessive medication regimens that, as evidenced above is fairly common in this patient population.

Neglect and/or abuse experienced early in life is a risk factor for mental health problems even after adoption. Differences in genetic risk, epigenetics, prenatal factors (e.g., malnutrition or poor nutrition), exposure to stress and/or substances, and parent-child interactions may explain the diversity of outcomes among these individuals, both in terms of mood and behavioral patterns [ 15 , 16 , 17 ]. Considering that these children often present with significant functional impairment and a wide variety of symptoms, further studies are needed regarding diagnosis and treatment.

Abbreviations

Attention-Deficit/Hyperactivity Disorder

Disruptive Mood Dysregulation Disorder

Disinhibited Social Engagement Disorder

Post-Traumatic Stress Disorder

Reactive Attachment disorder

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MR, AJM, JVV conceptualized and followed up the patient. MR, AJM, JVV did literature survey and wrote the report and took part in the scientific discussion and in finalizing the manuscript. All the authors read and approved the final document.

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Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17 , 330 (2017). https://doi.org/10.1186/s12888-017-1492-y

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• Volume 32, Issue 6
• Very early family-based intervention for anxiety: two case studies with toddlers
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• http://orcid.org/0000-0001-5603-6959 Dina R Hirshfeld-Becker 1 , 2 ,
• Aude Henin 1 , 2 ,
• Stephanie J Rapoport 1 ,
• Timothy E Wilens 2 , 3 and
• Alice S Carter 4
• 1 Child CBT Program, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 2 Department of Psychiatry , Harvard Medical School , Boston , Massachusetts , USA
• 3 Division of Child and Adolescent Psychiatry, Department of Psychiatry , Massachusetts General Hospital , Boston , Massachusetts , USA
• 4 Department of Psychology , University of Massachusetts Boston , Boston , Massachusetts , USA
• Correspondence to Dr Dina R Hirshfeld-Becker; dhirshfeld{at}partners.org

Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive–behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent–child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

• childhood anxiety disorders
• preschoolers
• cognitive behavioural therapy

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https://doi.org/10.1136/gpsych-2019-100156

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Introduction

Anxiety disorders affect as many as 30% of children and adolescents and contribute to social and academic dysfunction. These disorders or their temperamental precursors 1 are often evident in early childhood, with 10% of children ages 2–5 already exhibiting anxiety disorders. 2 Anxiety symptoms in toddlerhood 3 and preschool age 4 show moderate persistence and map on to the corresponding Diagnostic and Statistic Manual anxiety disorders. 5 6 Well-meaning parents, particularly those with anxiety disorders themselves, may respond to a child’s distress around separating from parents or being around unfamiliar children by decreasing the child’s exposure to these situations, for example, by not having the child start preschool or by not leaving the child with a childcare provider to go to work or socialise. In the short term, such responses may impair concurrent family function, strain the parent–child relationship, and reduce the child’s opportunity for increased autonomy, learning and social development. 7 These avoidant strategies may initiate a trajectory where the child takes part in fewer and fewer activities, leading to social and academic dysfunction. 8

Members of our research team began championing the idea of early intervention with young anxious children over two decades ago, with the aim of teaching children and their parents cognitive–behavioural strategies to manage anxiety before their symptoms became too debilitating. 8 Although cognitive–behavioural therapy (CBT) has since emerged as the psychosocial treatment of choice for treating and preventing anxiety, 9 10 at that time, most protocols that had been empirically tested were aimed at children ages 7 through early adolescence, with only a few enrolling children as young as age 6. 11 We developed and tested a parent–child CBT intervention (called ‘Being Brave’) and reported efficacy in children as young as 4 years. 12 13 The treatment involved teaching parents about fostering adaptive coping and implementing graduated exposures to feared situations, and modelling how to teach children basic coping skills and conduct exposures with reinforcement. In parallel, a growing number of investigators confirmed that anxiety in preschoolers could be treated efficaciously using CBT administered either by training parents to apply CBT strategies with their children or through direct intervention with children. 14 15 Early family-based intervention using cognitive–behavioural strategies was shown to reduce rates of later anxiety and to attenuate the onset of depression in adolescence in girls. 16

The question remains as to whether early intervention can be extended even younger. With few exceptions, 17 18 most investigators do not offer direct CBT for anxiety to children under age 3 or 4, 15 and none to our knowledge have treated anxiety disorders with CBT in children under age 2.7. 15 However, we reasoned that since toddlers can also present with impairing symptoms, and since behaviour strategies can be feasibly applied even in preschoolers with poor language ability, 19 it ought to be possible to apply family-based CBT for anxiety to toddlers as well. We therefore present two cases of anxious children, ages 26 and 35 months, treated with parent and child CBT.

Recruitment

Parents of children ages 21–35 months were recruited for a pilot intervention study (a maximum of three cases) using advertisements to the community. To be included, children had to be rated by a parent as above a standard deviation on the Early Childhood Behavior Questionnaire Fear or Shyness Scale 20 and could not have global developmental delays, autism spectrum disorder or a primary psychiatric disorder other than anxiety.

Children were evaluated for behavioural inhibition using a 45 min observational protocol. 21 Parents completed a structured diagnostic interview about the child (Kiddie Schedule for Affective Disorders and Schizophrenia-Present and Lifetime) that has been used with parents of children as young as 2 years; 22 23 an adapted Coping Questionnaire, 24 in which parents assessed the child’s ability to cope with their six most feared situations; and questionnaires assessing child symptoms (Child Behavior Checklist 1-1/2-5 (CBCL), 25 subscales from the Infant Toddler Social Emotional Assessment (ITSEA) 26 ), family function (Family Life Impairment Scale 27 ) and parental stress (Depression Anxiety Stress Scale 28 ). These assessments were repeated following the intervention, with the exception of the behavioural observation for the child initially rated ‘not inhibited’. The clinician rated the global severity of the child’s anxiety on a 7-point severity scale (Clinician Global Impression of Anxiety 29 ) at baseline and rated global severity and improvement of anxiety postintervention. Participant engagement in session and adherence to between-session assignments were rated by the clinician at each visit, and parents completed a post-treatment questionnaire rating the intervention.

Children were treated by the first author, a licensed child psychologist, using the ‘Being Brave’ programme. 13 It includes six parent-only sessions, eight or more parent–child sessions and a final parent-only session on relapse prevention. An accompanying parent workbook reinforces the information presented. Parent-only sessions focus on factors maintaining anxiety; monitoring the child’s anxious responses and their antecedents and consequences; restructuring parents’ anxious thoughts; identifying helpful/unhelpful responses to child anxiety; modelling adaptive coping; playing with the child in a non-directive way; protecting the child from danger rather than anxiety; using praise to reinforce adaptive coping; and planning and implementing graduated exposure. Child–parent sessions teach the child basic coping skills; and focus on planning, rehearsing and performing exposure exercises, often introduced as games, with immediate reinforcement. All parent–child sessions were preserved from the original protocol, but two sessions teaching the child about the CBT model, relaxation and coping plans were omitted, as were two sessions in which the (older) child does a summary project and celebrates gains. Up to six child–parent sessions focusing on exposure practice were included.

In the cases that follow, identifying details are disguised to protect participants’ privacy. Parents of both children provided written consent for the publication of de-identified case reports.

Background information

‘J’ was a 35-month-old girl, the third of three children of married parents. She had congenital medical problems requiring multiple surgeries, and she continued to undergo regular follow-up procedures. J met the criteria for separation anxiety disorder with marked severity, mild social phobia and mild specific phobia. Although she was able to attend her familiar day care if handed directly to a teacher and attend a gymnastics class with a friend while her mother waited in the hall, J showed great distress if apart from her mother at home. If her mother left her sight (eg, to use the bathroom), J would sob, cry and try to open the door to get in. If her mother went out and left her with a family member, J would fuss, cry and try to come along, and would continually ask to video-call her, so her mother would cut her outings short. J also had fears of doctors’ visits, of riding in the car seat, and of walking independently up and down a staircase at home. She would approach new children only with assistance from her mother, and she was afraid to take part in gymnastics performances.

J also had some mood symptoms possibly related to her medical issues. She would intermittently have days when she was much more clingy, had uncharacteristically low energy, would want to be held, and would say ‘ow, ow’ if put down to stand. She also had difficulty staying asleep and would periodically wake up with respiratory difficulties.

‘K’ was a 26-month-old boy, the only child of married parents. He met the criteria for moderate separation anxiety disorder. Although able to go to a day care he had been attending since infancy, he showed distress at drop-off particularly at the start of each week, crying for 15 min. He feared being apart from his mother in the house: he could not tolerate his mother leaving the room even to change clothes and would cry if his mother left the playroom while K played with his father. He would get distressed if his father took him on outings without his mother. He could not be dropped off at a childcare centre at his parents’ gym, leading to their avoiding exercise. He slept in his own crib, rocked to sleep by a parent, but would wake in a panic (alert but distressed) two to three times per month, crying for over an hour until his parents took him into their bed. K also was very particular about where objects were placed in the playroom and would fuss if they were put in the wrong place. He got anxious about deviations in routine (eg, taking a different path on a walk) and had trouble throwing things away (eg, used Band-Aids).

Intervention Feasibility and Outcomes

To demonstrate feasibility, the application of the treatment protocol with both participants is summarised in table 1 . Both participants completed the treatment, in 11 and 10 sessions, respectively. For each, session engagement was rated ‘moderately’ or ‘completely engaged’ at all but one session, and homework adherence was rated as ‘moderate work’ to ‘did everything assigned’ at all but one session.

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Application of treatment protocol with both participants

The quantitative results of the treatment are presented in table 2 . Both children were rated by the clinician as having shown ‘much improvement’ (Clinician Global Impression of Anxiety-Improvement 1 or 2), and both showed changes in quantitative measures of anxiety and family function. In both families, parents rated their satisfaction with the treatment as ‘extremely satisfied’, and felt that they would ‘definitely’ recommend the intervention to a friend. They rated all strategies introduced in the intervention as ‘very-’ or ‘moderately helpful’ and rated the change in their ability to help their child handle anxiety as ‘moderately-’ to ‘very much improved’.

Quantitative changes in diagnoses, coping ability, symptoms and family function in both participants

These pilot cases demonstrate the feasibility and acceptability of parent–child CBT for toddlers with anxiety disorders. The two participating families completed the treatment protocol and were consistently engaged with in-session exercises and adherent to between-session skills practice. The cases demonstrate that basic coping skills and exposure practice can be conducted with toddlers.

Although efficacy cannot be determined from uncontrolled case studies, the cases did show promising preliminary results. Both children showed a decrease in number of anxiety disorders, both were rated by the clinician (and parents) as either ‘moderately-’ or ‘much improved’ in their overall anxiety, and both showed increases in their parent-rated ability to cope with their most feared situations. Participant 2 improved on all symptom measures as well. Most significantly, his ITSEA general anxiety, separation distress, inhibition to novelty, negative emotionality, compliance and social relatedness scores and his CBCL total score, internalising score and somatic complaints scale score normalised from clinical to non-clinical range. Participant 1 had a more complicated clinical presentation, and whereas her diagnoses and coping scores improved, her parent-rated symptom scores were more mixed, perhaps related to medical problems which impacted sleep. Beyond changes in the children’s behaviour, family life impairment was reduced for both families, and parental stress was decreased out of clinical range for participant 1. Notably, both children also showed gains in areas of competence, including prosocial peer relations and mastery motivation.

This work extends previous research demonstrating that very young children experience impairing levels of anxiety that are amenable to CBT. Previous studies have found that CBT is as efficacious with older preschool-age children with anxiety disorders as it is with school-aged youth, 14 15 with approximately two-thirds of treated youth demonstrating clinically significant improvement. There is increasing recognition that anxiety disorders start early in childhood, and that there are significant advantages to intervening proximally to their onset, before anxiety symptoms crystallise and impairment accumulates. For example, one study of 1375 consecutive referrals (mean age 10.7) to a paediatric psychopharmacology clinic found that the median age of onset of a child’s first anxiety disorder was 4 years. 30 Children seeking treatment for anxiety often present in middle childhood, for symptoms which began much earlier, exposing the child and family to undue stress for years. By teaching parents and very young children skills to manage anxiety, we hope to give families important tools to navigate the developmental transitions inherent in this age range, and to help children develop a sense of mastery during a critical developmental period. Of course, a larger controlled trial is needed to further evaluate this intervention and its efficacy over time.

Assessing and treating toddlers require a developmentally informed approach. Anxiety and other symptoms may present differently in younger children, and because of limited language and cognitive abstraction capabilities toddlers are not as able to describe their fears and worries. Because some forms of anxiety (eg, separation anxiety, stranger anxiety) are normative, determination of clinically significant levels of anxiety requires an understanding of typical development in toddlerhood and the ability to conduct a detailed assessment with parents and the child using measures normed for this age group (such as the ITSEA and CBCL 1-1/2-5). Similarly, implementing CBT with toddlers and preschoolers requires age-appropriate modifications of empirically supported techniques. The adaptations we used included increased parental involvement in planning exposures, decreased focus on child cognitive restructuring (beyond framing the practice as ‘being brave’ and redirecting the child’s attention to rewarding aspects of the situation), and adaptations to exposure exercises to maximise child participation and motivation (practising at times when the child was rested and not irritable, incorporation of games and reinforcers, and allowing the child maximal choice about when/how to carry out the exposure). The cases we presented demonstrate that existing interventions can be effectively adapted and implemented with children as young as 2 years of age. By sharing the information gleaned from our research, we hope to inform providers who may be less familiar with treating children in this age range and increase their confidence in intervening with very young children.

Acknowledgments

The authors acknowledge Jordan Holmen for assistance with data checking.

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Dina Hirshfeld-Becker earned her undergraduate degree from Harvard and her doctorate in clinical psychology from Boston University, and completed post-doctoral training at Massachusetts General Hospital. Dr Hirshfeld-Becker is currently co-founder and co-director of the Child Cognitive Behavioral Therapy (CBT) Program in the Department of Psychiatry at MGH and an associate professor of psychology in the Department of Psychiatry at Harvard Medical School. The Child CBT Program offers short-term empirically supported CBT with youths ages 3-24, research in novel treatment adaptations, and clinical training in CBT, including on-line training courses. She pioneered the development and empirical evaluation of one of the first manualized cognitive-behavioral intervention protocols for anxiety in 4- to 7-year-old children, the “Being Brave” program, and has been exploring its use with children with autism spectrum disorder and with younger toddlers and their parents. Dr Hirshfeld-Becker has published numerous articles, reviews, and chapters. Her main research interests include the etiology, development, and treatment of childhood psychiatric disorders, particularly anxiety disorders, and in the study of early risk factors for these disorders.

Contributors DRHB designed the study with input from ASC, AH and TEW. DRHB developed the intervention and treated the cases, and DRHB, SJR and AH collected, scored, analysed and tabulated the data. DRHB wrote the first draft of the manuscript, SJR drafted parts of the Results section, and AH made significant additions to the Discussion section. AH, ASC and TEW revised the manuscript critically for important intellectual content. DRHB incorporated all of their edits and finalised the document. All authors approved the final version and are accountable for ensuring accuracy and integrity of the work.

Funding This work was supported by a private philanthropic donation by Mrs. Eleanor Spencer.

Competing interests DRHB and AH receive or have received research funding from the National Institutes of Health (NIH). ASC reports receipt of royalties from MAPI Research Trust on the sale of the ITSEA, one of the instruments included in the manuscript. TEW receives or has received grant support from the NIH (NIDA), and is or has been a consultant for Alcobra, Neurovance/Otsuka, Ironshore and KemPharm. TEW has published a book, Straight Talk About Psychiatric Medications for Kids (Guilford Press); and co/edited books: ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier), and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). TEW is co/owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire), and has a licensing agreement with Ironshore (BSFQ Questionnaire). TEW is Chief of the Division of Child and Adolescent Psychiatry, and (Co)Director of the Center for Addiction Medicine at Massachusetts General Hospital. He serves as a clinical consultant to the US National Football League (ERM Associates), US Minor/Major League Baseball, Phoenix House/Gavin Foundation and Bay Cove Human Services.

Patient consent for publication Parental/guardian consent obtained.

Ethics approval All procedures were approved by our hospital’s institutional review board (Partners Human Research Committee, 2018P000376), and parents provided informed consent for themselves and their child.

Provenance and peer review Not commissioned; externally peer reviewed.

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Contemporary Case Studies in Clinical Mental Health for Children and Adolescents

Edited by jennifer n. baggerly and athena a. drewes - foreword by edward franc hudspeth.

Practicing counselors, psychologists, social workers, and graduate students emerging into mental health professions are often faced with complex cases that do not conform neatly to theoretical textbooks. It can be difficult to overcome the communication barrier and correctly interpret the awkward or shocking things children and adolescents may say in a therapeutic setting.

Contemporary Case Studies in Clinical Mental Health for Children and Adolescents is a versatile, case-based practical treatment guide for child and adolescent therapy that provides current, real-world clinical examples, undergirded by a theoretical approach. This resource provides both a succinct discussion of diagnoses and theories, as well as in-depth step-by-step treatment guidance through contemporary case studies of diverse children and adolescents, to apply and challenge typical textbook definitions. Editors Baggerly and Drewes further address the dramatic changes in contemporary issues—from the COVID pandemic, race-related events, and political unrest, to technological innovation—and how these events might impact these demographics in a therapeutic context.

Mental health professionals will find this resource a handy, modern guide and reference to better support diverse children and adolescents in their practice.

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Trauma-informed nature therapy: a case study, nature therapy can promote resiliency and trauma recovery in children.

This paper addresses the prevalence and impact of trauma on children and presents an overview of nature therapy and ways in which it can provide both restorative and preventative benefits for children experiencing adversity. A case study, along with several other examples of how trauma-informed nature therapy helped individual children, is included.

Trauma-informed nature therapy utilizes the healing elements of engaging in the natural world. This form of therapy differs from traditional trauma therapy in that it capitalizes on multisensory multisystem involvement of the body versus relying on talk therapy and cognitive processes. Nature therapy is typically conducted outdoors and led by a licensed mental health professional who looks to nature as a co-therapist in the process of healing. Engaging with nature allows the client to experience a wide range of whole-brain whole-body experiences which can promote a unique set of coping skills, including empowerment, strength, and confidence. Trauma-informed nature therapy is known “to calm the limbic system, enhance the prefrontal cortex, expand the support network, provide opportunities for physical mastery, and promote the reconstruction of the trauma narrative.”

The case study featured in this paper focuses on a young girl who was raped at the age of 15. The experience left her feeling ashamed, alone, and unlovable. One of her behavioral responses was to isolate herself from others, including animals that had always been an important part of the beloved lakeside farm where she lived. Once other-than-human elements were included in the therapeutic process, Anna became fully engaged in her therapy sessions. Nature-related therapeutic activities included interactions with the therapist’s dog, walks along the river, and kayaking. The nature-related experiences – especially the kayaking experience – helped Anna remember her own embodied power and prepared her to revisit the trauma of her rape.

This research adds support to the idea that engaging in nature can promote resiliency and trauma recovery in children. It also suggests that including the more-than-human world in therapy for children impacted by trauma may be a safe and perhaps more effective approach than traditional top-down talk therapy methods.

Fisher, C., (2022). Trauma-Informed nature therapy: A case study. Ecopsychology

http://dx.doi.org/10.1089/eco.2022.0064

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This database aims to include all available play therapy  intervention outcome research from 1995 to the present published or translated into English. Intervention must meet the definition of play therapy and outcomes must demonstrate credible quantitative methods and analyses for inclusion in the database .

The objective is an interactive, sortable database of treatment outcome research which can serve as a useful source of information regarding the evidence base for play therapy’s effectiveness.

Search Directions: You may search the database by typing a word or phrase into the Search feature below or You may search by selecting one or more of the criteria in the red drop-down menus to efficiently find articles that match a specific treatment model, research design, clinical setting, and/or outcome variable.

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Studies Included in the Database Meet the Following Criteria:

• Intervention must meet the definition of  play therapy.
• The research report has been published in a peer-reviewed journal or outlet.
• The research report is based on credible quantitative research methods and analyses including randomized controlled trials, nonrandomized quasi-experimental, single-case experimental design, and single-group repeated measures.
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View key for abbreviations of study characteristics

Play therapy (PT) treatment models identified with acronyms:

CCPT = Child-Centered Play Therapy CPRT = Child Parent Relationship Therapy CTRT = Child Teacher Relationship Therapy AdPT = Adlerian Play Therapy CBPT = Cognitive Behavioral Play Therapy

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WC = waitlist/delayed start control AC = active control COMP = comparison treatment

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Novel CHATogether family-centered mental health care in the post-pandemic era: a pilot case and evaluation

• Caylan J. Bookman 1   na1 ,
• Julio C. Nunes 1   na1 ,
• Nealie T. Ngo 2 ,
• Naomi Kunstler Twickler 3 ,
• Tammy S. Smith 3 ,
• Ruby Lekwauwa 1 , 3 &
• Eunice Y. Yuen 1 , 3 , 4 , 5  

Child and Adolescent Psychiatry and Mental Health volume  18 , Article number:  57 ( 2024 ) Cite this article

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The COVID-19 pandemic impacted children, adolescents, and their families, with significant psychosocial consequences. The prevalence of anxiety, depression, and self-injurious behaviors increased in our youth, as well as the number of suicide attempts and hospitalizations related to suicidal ideation. Additionally, parents’ mental health saw increasing rates of depression, irritability, and alcohol use combined with worsening family function, child-parent connectedness, positive family expressiveness, and increases in family conflict. In light of these statistics, we created CHATogether (Compassionate Home, Action Together), a pilot family-centered intervention using multi-faceted psychotherapeutic approaches to improve familial communication and relational health between adolescents and their parents. This paper discusses the implementation of the CHATogether intervention at the Adolescent Intensive Outpatient Program (IOP), providing an example of the intervention through an in-depth pilot case, and evaluation of the program’s acceptability and feasibility.

This paper describes a case in detail and evaluation from a total of 30 families that completed CHATogether in the initial pilot. Each family had 4–6 one-hour CHATogether sessions during their 6-week treatment course at the IOP. Before and after CHATogether , adolescents and their parents separately completed a questionnaire designed to explore their perceived family conflicts. After completion of the program, participants completed a brief quality improvement survey to assess their overall experience with CHATogether . In the reported case, the family completed Patient-Reported Outcomes Measurement Information System (PROMIS) depressive and anxiety symptoms scales, Conflict Behavior Questionnaires (CBQ), 9-item Concise Health Risk Tracking Self-Report (CHRT-SR9), and help-seeking attitude from adults during distress and suicide concerns.

The pilot case showed a trend of improvement in reported depressive and anxiety symptoms, child-parent conflicts, subfactors of suicide risk including pessimism, helplessness, and despair, help-seeking acceptability from parents for suicide concerns, and the establishment of individualized family relationship goals. Preliminary feedback from participating families demonstrated positive effects on intra-family communication and improvement in the overall family dynamic. Adolescents ( n  = 30/30) and their parents ( n  = 30/30) rated “strongly agree” or “agree” that their families had benefited from CHATogether and welcomed participation in future program development.

This study presents CHATogether as a novel family-centered intervention to address post-pandemic family mental health stress, especially when a family system was disrupted and negatively affected the mental health of children and adolescents. The intervention facilitated positive child-parent communication on a variety of topics, through tools such as emotional expression and help-seeking behavior. The reported pilot case and evaluation suggested CHATogether ’s acceptability and feasibility in a clinical context. We also provided quality improvement feedback to guide future studies in establishing the efficacy of CHATogether and other similar models of clinical family interventions.

Introduction

Since the COVID-19 pandemic, both national and regional organizations have highlighted the significant increase in mental health challenges faced by children, adolescents, and their families. As a result, the American Academy of Child and Adolescent Psychiatry, in partnership with the American Academy of Pediatrics and the Children’s Hospital Association declared a national emergency in children’s mental health in 2021 [ 1 ].

This mental health crisis has been due in part to the stress and disruption within family systems, as well as the relative isolation caused by the various constraints of the pandemic. These factors resulted in a significant increase in the utilization of children and adolescent mental health services [ 2 , 3 ]. The pandemic left a notable negative footprint on societal structures and dynamics, putting increased pressure and strain on individual families [ 4 , 5 , 6 ]. Many community support systems such as schools, places of worship, and recreational spaces were abruptly closed due to the pandemic, leaving families without vital community resources. The pandemic exacerbated existing inequalities for families with ethnic minority and low socioeconomic backgrounds [ 7 ]. Taken together, these factors disrupted parental reflective functioning and adaptive family communication [ 8 ]. The pandemic forcefully imposed a new norm – social isolation, boredom, elevated parental scrutiny, and the loss of independence – all of which negatively altered how a child or teen reacted to their parents [ 4 , 5 , 6 ].

Furthermore, there were notable changes in children’s and adolescents’ behaviors, such as an increase in difficulty concentrating, lower frustration tolerance, and a lower threshold for “general discomfort” [ 9 , 10 ]. Parents stepped into multiple new roles at home, attempting to meet the increased needs of their children. Simultaneously, they worried about health and finances, leading to increased frustration and authoritarian parenting, decreased engagement with their children, and ability to reason and self-regulate [ 4 , 11 ].

In 2019, we established CHATogether ( C ompassionate H ome, A ction T ogether), a digital community-based mental health program tailored for children, adolescents, and their families. CHATogether included different creative modalities to address cross-cultural and cross-generational needs while also promoting improved mental health among adolescents and their families. The program consisted of six core arms that include: digital interactive theater, public mental health education, research, peer support and community outreach, collaboration, and mentorship. These arms aimed to provide a feasible and successful family wellness initiative in response to the COVID-19 pandemic [ 12 ]. Through this community effort, we have witnessed the dire clinical need to address familial mental health as a one-unit system during the post-pandemic era.

In 2022, we have adapted and implemented the clinical CHATogether program at the adolescent Intensive Outpatient Program (IOP), a subacute level of mental health care that supports both adolescent patients and their families. During the IOP intake assessment, adolescents and families were routinely asked about their perception of parenting practices. Our clinical impression suggested that most families perceived each other to have challenges in at least one or more domains of effective parenting (e.g., consistency, supervision/monitoring). Moreover, a significant discrepancy between the adolescent’s and parent’s perspectives regarding these domains implicated opportunities to bridge this unmet clinical gap and improve the overall adolescent-parent dyadic functioning. This pilot evaluation aimed to (1) report on the CHATogether family-centered intervention, (2) provide a pilot case with preliminary data to exemplify how the intervention works, and (3) evaluate the acceptability and feasibility from a total of 30 families who completed CHATogether in the adolescent IOP during the post-pandemic era.

Theoretical context of  CHATogether family intervention

CHATogether is based upon a psychodynamic, bio-psycho-social model that focuses interventions on the family/social systems aspect of this dynamically interactive tripartite model. It incorporates psychotherapeutic elements from drama therapy, cognitive behavioral therapy (CBT), and psychologically focused therapies in ways that improve family relational health and communication, and adolescent mental health. The program facilitated and guided family members’ expression of unconscious conflicts, feelings, fears, and imaginings through engaging in theater skits and role-playing [ 13 , 14 , 15 ]. Drama therapy techniques allowed participants to project their internal feelings and conflicts onto skit characters [ 16 , 17 , 18 ]. As in psychodynamic play therapy, participants could experiment within the safety of displacement that theater provides [ 19 , 20 ]. Previously intolerable fears as well as emotionally charged feelings would be identified, become available for collaborative reflection, and lead to eventual conflict resolution. Drawing upon aspects from psychodynamic, CBT, and drama therapy, the clinician helped families develop better adaptive, healthier patterns of communicating feelings and behaviors as illustrated by the skits [ 21 , 22 ]. Additionally, the clinician made drama-to-life connections whereby family participants could apply what they learned to improve communication patterns amongst themselves.

CHATogether has emphasized a whole family approach [ 23 , 24 ]. Thus, it could be a therapeutic process that addresses relational conflicts within the family system, the third component of the biological-psychological-social/family model, in addition to the biological and psychological treatments the adolescents typically receive in IOP. Traditional family therapies could have low adherence due to factors such as families’ resistance to engage in treatment that require multiple sessions over many months for meaningful change to be accomplished [ 25 , 26 ]. Compared to the inpatient services or outpatient clinics, the IOP has been the ideal setting for implementing high-impact, brief family interventions given the acuity and need of the population as well as the time frame and highly structured nature of IOP treatment [ 27 ].

Participants recruitment and selection criteria

A total of 30 families with adolescents aged 12–17 years old were included in this pilot assessment of the CHATogether program (Table  1 ). The 30 participating families included teens ( n  = 30), who were accompanied by both parents ( n  = 14), mother only ( n  = 10), father only ( n  = 4), or other caregivers ( n  = 2). All adolescents were existing patients enrolled in Yale New Haven Hospital (YNHH) Adolescent Outpatient Behavioral Services from October 2022 to December 2023. Patients attended the conventional 6-week general mental health intensive outpatient program (IOP) track, which included 3 hours per day, 4 days per week of after-school group therapy, weekly medication management, and family case management for discharge planning. The goals of the general IOP emphasized the stabilization of psychiatric symptoms and safety through treatments such as medication management and learning coping strategies from group therapy. The IOP treatment patients were referred from the YNHH inpatient adolescent units, emergency department, Yale Child Study Center, and local outpatient clinics in Connecticut.

Regarding inclusion and exclusion criteria, this study included patients who have significant family relational conflicts that may hinder the conventional IOP treatment. This IOP does not typically accept patients with high acuity psychiatric conditions, including those with significant active psychosis, substance intoxication/withdrawal, active eating disorder, delirium, or developmental delay with significant cognitive impairments as these conditions can impede the ability of adolescents to fully engage in treatments. In the study, CHATogether participating adolescents and their parents/caregivers received additional treatments through at least 4–6 one-hour family sessions during the 6-week IOP. Parental consent and adolescent assent were discussed at least one week prior to the intervention.

CHATogether family session protocol

The program was delivered in-person, virtually, or using a hybrid format, depending on the parents/caregivers’ availability. A total of 3 clinicians delivered the intervention. Pre- and post-session questionnaires were individually completed by adolescents and their parents/caregivers in the first and last session of the CHATogether program.

Partly adopted from the Family Relational Assessment Protocol (FRAP) [ 28 ], the questionnaires included family relationship goals, major conflicts in the child-parent dyads, major conflicts between the parents, family losses, and major areas to change. The design encouraged the families to revisit the questions and troubleshoot together with the newfound strategies and communication (Table 2 ). The first CHATogether family session consisted of guiding the family to view a three-part theater skit in the following order: (1) problematic scenario; (2) pause and moderation; and (3) alternative scenario ( https://www.youtube.com/watch?v=6Rx7D4x1nLY ).

Problematic scenario: “A Christmas Carol epiphany in child-parent relation”

Mentalization is an essential capacity to envision the state of mind in self or others, which involves understanding and anticipating each other perspectives through a lens of curiosity and without judgment [ 8 , 29 , 30 ]. According to this theory, mentalization not only allows parents to understand their child’s behaviors and underlying feelings, but also helps parents respond to the child’s emotional needs sensitively, and ultimately improve the child’s affect regulation [ 31 , 32 ]. To introduce the concept of mentalization, the family watched the skit video, “ Parents Got All the Solutions ”. Prior to viewing the skit, parents or caregivers were prompted to mentalize the teens’ perspective in the skit, whereas adolescents were asked to mentalize the parents’ challenges in the skit.

A high school teen is trying to communicate to his father about his feelings of depression and thoughts of suicide. Being a single parent, the father in the skit has worked all day and is taking care of three children. The father is terrified because he has found several empty pill bottles in his teenager’s room and is now persistently offering “solutions” in an attempt to “fix” his son’s mental health.

Pause and moderation: learn, share, and reflect

The clinician guided the family to identify unhelpful examples of communication in the problematic scenario. In the initial half of the moderation, therapeutic interruption and facilitation were employed by the clinician to help the family focus on discussing the skit instead of directly jumping into their family conflicts. First, verbal and nonverbal communication including language, word choice, tone, body gestures, and any expressive emotion that may impede a caring conversation were discussed. Second, the clinician pointed out parental invalidation in the video and stressed the importance of validating a teenager’s emotions before offering solutions or guidance. Third, the clinician introduced the concept of “listening to understand” rather than reacting to a conflict. Additional points for discussion included the acting teenagers’ attitude in the skit, for example, their tone of voice, frustration, lack of patience, and how these can negatively impact the parents’ understanding of the situation. Lastly, the clinician guided the family to relate their own experiences to the themes illustrated in the skit, allowing the family to draw parallels between the problematic communication styles in the video to ones possibly in their own family.

Alternative scenario: establish commitment, communication exercises, and follow up

The alternative scenario of the skit “ Parents Got All the Solutions ” displayed the situation with more effective communication strategies. The family was prompted to compare and contrast the two scenarios. The clinician guided the family to reflect upon how they can practice healthy communication in their home life. Given its emotional intensity, the first CHATogether family session fostered the best opportunity for parents and their children to emotionally reconnect and establish a mutual commitment to positive change within the family. The session ended with facilitated cohesion where the clinician encouraged each family member to share their love and gratitude to each other. The family session concluded with the homework (a two-minute communication exercise every day) to be completed by the next session: (1) adolescents and parents commit a time to talk each day without stress and distraction; (2) each side takes turns to talk about their day and openly share their feelings without interruption for 2 min; (3) the listener practices mentalization while listening attentively and validating the speaker’s experiences afterward.

In the subsequent sessions, the family reflected on their communication exercises and the concepts introduced in the first session, leading to a shared learning experience. Each session also included psychoeducation on child-parent communication skills, signs and symptoms of mental health conditions illustrated from the initial skit, as well as a review of homework on skills/concepts discussed from the previous sessions. Moreover, the clinician emphasized any emerging relational conflicts in the past week and guided the family to practice their newfound communication and coping skills to reflect on or resolve the conflicts. If applicable, the clinician presented other skits involving different themes that followed a similar sequence to those described in the first session.

Data collection

Institutional review board approval from the Yale Human Investigations Committee was obtained (Protocol #2000034837). Families consented to study participation prior to the beginning of the survey. The study was entirely voluntary, and the families were welcomed to receive CHATogether treatment regardless of their participation in the study. In the case vignette, additional written consent from the family was obtained, and the case was de-identified with modifications to protect the patient’s and family’s privacy.

To measure the program’s overall acceptability and feasibility in all participating families, a 6-item-survey 5-point Likert scale (“strongly disagree” to “strongly agree”) was delivered using the HIPAA-secured Yale Qualtrics system in the last CHATogether family session. Each question also included open-ended qualitative text boxes for participants to voluntarily elaborate on their answers (Table 3 ).

The study has been collecting validated psychometric measures for the study’s next phase since December 2023. Although not a significant sample size for statistical analysis in this paper, the existing families showed a similar trend to that described in Table  4 . In the pilot case and Table  4 , the teen filled out the following outcome measures in the first and the last CHATogether sessions. Measurements included Patient-Reported Outcomes Measurement Information System (PROMIS) depression and anxiety symptoms scales [ 33 , 34 ], Conflict Behavior Questionnaires (CBQ) [ 35 , 36 ], 9-item Concise Health Risk Tracking-Self-Report (CHRT-SR9) [ 37 ], and seeking adult help for distress and suicide concerns [ 38 , 39 ]. The help-seeking attitude measurements included a three-part adapted version from Schmeelk-Cone et al. to detect (1) teens’ help-seeking acceptability from parents, (2) adult help for suicidal youth, and (3) reject codes of silence. The last item measured teens’ attitudes to resist the secrecy about their peers’ suicide concerns. A higher score indicated that the teen has a preference to reach out to an adult for help [ 38 ]. The case participant’s parents also completed the parent version of PROMIS and CBQ.

Samantha’s case

Samantha was a 16-year-old girl who struggled with major depressive disorder (MDD), generalized anxiety disorder (GAD), and suicidal ideation. She never felt safe to verbalize her emotions or suicidal thoughts due to family conflicts and perceived judgment of mental illness. Her parents felt that Samantha’s suicidal thoughts were “wrong” and “unnecessary.” They also invalidated Samantha’s sadness from bullying she received at school which involved girl-to-girl relational aggression [ 40 , 41 ]. Gradually, she secretly turned to online relationships where she was asked to share nude pictures with strangers. Several online friends proposed a suicide pact at a time when Samantha already felt emotionally distressed with nowhere to turn. Her parents never knew about these dynamics until Samantha disclosed it to her therapist, leading to her first psychiatric hospitalization.

After being discharged from the psychiatric hospital, Samantha continued to stabilize at the IOP. She either suppressed her emotions or quickly became dysregulated when her parents confronted her phone use. Her mind was occupied with dark thoughts that she did not deserve to live or that she needed to punish herself by self-harming. Similarly to before her hospitalization, none of these thoughts or actions were shared with her parents, as she believed this would result in being yelled at and criticized. She reported a complete distrust in her ability to keep herself safe. The family conflicts once led to a report to Child Protective Services concerning harsh disciplinary practices.

The course of Samantha’s  CHATogether  treatment

In session 1, Samantha and her parents were shown the skit video, “ Parents Got All the Solutions ”, as described in the methods. Each member of Samantha’s family committed to make changes in alignment with the best interests of Samantha. Facilitating cohesion within the family, they were asked to share their love and gratitude at the end of the session. They then went home with simple two-minute daily exercises of active listening and mentalization without interruption. The clinician assigned the family similar exercises after each session as described in the method session.

In session 2, the clinician first reflected on the communication exercises and then began to address the pertinent areas of child-parent conflicts within the family as identified in Table 2 . Samantha’s mother was concerned because Samantha spent too much time in her room on her phone with online strangers. Taking extreme safety measures, the mother took away Samantha’s phone, restricted all her social contacts, and ultimately did not allow her to leave home alone. Conversely, Samantha felt online friends mattered to her mental health, and was frustrated by her parents’ absolute control and lack of trust. This was an emotionally charged session that required the clinician to role-play in order to model the concepts of mentalization and validation. This demonstrated a more supportive and productive way to navigate conflicts. The clinician demonstrated possible conversing scripts for parents when Samantha expressed sadness from having no friends and being bullied at school. For example, the clinician instructed parents, “Let’s take Samantha’s perspectives by curiously envisioning her feelings, intentions, and behaviors without judgment or imposing parental assumptions (mentalization)”. “It must be really hard to face those mean bullies at school” (validation and empathy). “How can I support you to meet new friends while making sure that you are safe?” (collaborate to meet both Samantha’s and parents’ needs).

In session 3, as the clinician reviewed the communication exercises, Samantha and her parents started to show mutual reflective capacity and acknowledged that everyone needed to empathize and compromise to become a functioning family. Samantha was willing to recognize her parents’ safety concerns were valid but wanted her parents to listen to her needs without getting angry. The parents recognized that Samantha needed to make friends and develop sound judgment before she would emerge into young adulthood. They started to understand Samantha’s suffering from mental illness and began to meet her emotional needs with less judgment and criticism. However, in areas of phone use, Samantha’s mother continued to emphasize rule-following responsibilities repeatedly, which once led to disagreement between the parents. The clinician then developed a contract with measurable items for the family to collaborate on phone use. For example, the parents practiced one-time questioning Samantha’s online friend on a given day, while Samantha proactively communicated with her parents about her friend such as his or her name, age, and location to ensure safety. By the end of the session, the family was able to articulate and elaborate on their gratitude to each other.

In sessions 4 and 5, Samantha’s mother gradually realized that she was fearful of letting Samantha make friends online due to the mother’s childhood trauma. To meet Samantha and her family’s needs, a video skit on “ Intergenerational Trauma: The Shark Music ” was shown. The clinician reflected on how intergenerational trauma can play a role in one’s perception of fear and safety, and how that may impact teen-parent communication and relational health. Samantha and her parents were surprised but also relieved by this deep conversation that could ever occur within a family, and how much they were able to view from each other’s perspectives. In the last session of CHATogether , Samantha and her mother conducted the post-session questions, reflected on their progress during the program, and discussed goals for their family. Towards the end of the treatment, Samantha developed a newfound interest in music, resulting in a shared interest between Samantha and her parents as they began participating in family music lessons together. Ultimately, Samantha returned to school and made new friends in the school’s music band.

As shown in the individualized family questionnaires (Table 2 ), Samantha and her parents’ relational health improved throughout 6 CHATogether family sessions. Samantha’s parents demonstrated a great improvement in their reflective functioning and began communicating with Samantha with curiosity instead of judgment. Parents were able to learn how to regulate their emotional stress while mentalizing Samantha’s emotional needs. Consistent with the trend of these narrative data in Table 2 , Samantha’s and her parents’ scores improved across measures (Table  4 ). PROMIS T-scores decreased to the None to Slight range across informants by the post assessment. The family was able to communicate and develop a shared plan on phone use, engagement in healthy social relationships, and communication when a psychiatric crisis arises, as suggested in the reduction of CBQ reported by Samantha and her parents. Samantha’s CHRT-SR9 reduced, especially in the subfactors most closely associated with suicide risk [ 37 ], including pessimism, helplessness, and despair. There was no obvious change in Samantha’s attitude toward seeking help from a general adult during distress and suicide concerns (Item 2) but she had an increase in help-seeking acceptability from her parents (Item 1). Lastly, Samantha had no change in her attitude that youth struggling with suicide should not be left alone and should seek adult help even if a suicidal youth asked her to keep it secret (Item 3).

CHATogether ’s preliminary feedback, acceptability, and feasibility

As shown in Table 3 , preliminary feedback suggested that CHATogether is an acceptable and feasible intervention when implemented in family sessions with adolescents enrolled in the subacute IOP settings. Participating families ( n  = 30/30) strongly agreed or agreed that they were satisfied with the CHATogether treatment and that their communication and overall family functioning improved. Most of the participants felt that the program fit well with their existing IOP treatment, was convenient for their schedule, and would recommend it to others. There were 3 families who completed the program but did not follow up on the post-session questions after multiple contact attempts. There were 2 recruited families that did not complete the program as the patients were sent back to the inpatient unit due to the severity of their mental health. They did not return to IOP services after discharging from inpatients. Since we did not collect a complete set of data, these 5 families were excluded from the n  = 30.

The COVID-19 pandemic has had serious mental health effects on children, parents, and the functioning of the family unit. The case of Samantha and preliminary feedback data from participating families indicated that CHATogether is an acceptable and feasible therapeutic intervention for adolescents who are experiencing significant family relational conflict and impaired communication in ways that contribute to symptoms and limit adaptive help-seeking behaviors. The pilot clinical impressions suggested that CHATogether can lead to more compassionate child-parent communication, an overall improvement in an individual patient’s functioning, and progress towards a family’s individual relationship goals. Our data also suggested that CHATogether is an acceptable and feasible pilot program to be implemented in the IOP systems using technology to allow in-person, virtual, and hybrid deliveries of care.

A conceptualization of why  CHATogether  works

The CHATogether family-centered model has been a unique one. Adopted in part from the Brazilian playwright Augusto Boal’s “Theatre of the Oppressed” (TOp) from the 1970s [ 42 , 43 ], it aimed to promote a non-hierarchical dialogue among participants to guide imagination-based changes and collective actions in a conflictual situation [ 44 ]. By projecting family conflicts onto characters in a theater skit, one possible explanation for the therapeutic effect of CHATogether is that it symbolically displaced participants’ unconscious internal world onto the tangible yet distant theater skits [ 13 , 14 , 15 ]. Such a modality, much like children’s play, may provide a safe means for displacing feelings, impulses, and imaginings too strong or potentially overwhelming to address directly [ 19 , 20 ]. This approach could also provide participants with a window of access to unconscious and heavily defended emotions that become more consciously tolerable in the safety of displacement. Maladaptive defensive ways of coping with powerful emotions were identified and understood in ways that enhance perspective taking, effective communication, and possibilities for change. The case demonstrated how the clinician’s moderation facilitates a therapeutic process that leads to an ‘internal switch’ whereby parents experience the power of this “Aha! moment” of self-realization. Parents in the program identified this as one of the most compelling moments in the therapeutic process. Such pivotal points allowed parents to understand their children through different perspectives.

Once restored to a state of greater emotional stability, meaningful conversation between family members became possible. Another possible therapeutic benefit of CHATogether could be that the program coached parents in mindfulness practice [ 45 , 46 ] which helped in reducing emotional reactivity and maladaptive, rigid defensiveness [ 31 ]. Ego strengths including self-observation were enhanced, identified, and supported. Some parents suggested that the skills they learned helped them remain attuned to their child’s emotional needs even while very frustrated. Most importantly, clinician moderation of the CHATogether program may enhance the process of mentalization [ 8 , 29 , 30 , 31 , 32 ], facilitating mutual reflective functioning within the family. In the case of Samantha and her parents, they mentalized the experiences of the skit characters, mutually empathized with the characters’ challenges, and used this common ground and their newfound skills to improve their relationship. Such an approach could allow for the learning of multiple ways to better cope with their hyper- or hypo-aroused state of mind. Samantha and her parents were able to enhance their reflective functioning through cognitive curiosity and flexibility in their conversations with each other [ 31 ]. The program may improve reflective capacity not only between the teens and parents but also the relational health between caregivers, as Samantha’s parents reported improved communication when approaching parenting that resulted in less conflicts.

Each CHATogether session included a psycho-educational component illustrated by the contents illustrated in the skit. Integrating all three components of the bio-psycho-social model of mental health assessment and treatment, it was designed to address child-parent communication skills, signs and symptoms of psychological distress and disorder, as well as medication and its management. The clinician guided Samantha and her parents to identify the patterns of feelings, thoughts, and behaviors when comparing the problematic vs. alternative scenarios. Samantha’s family found that viewing, role-playing, and practicing homework exercises illustrated in the two skit videos, was especially useful in communicating better with Samantha [ 21 , 22 ]. The measurement-based approach in tracking pre- vs. post-session rating scales also provided objective data to reflect on the family’s progress and highlight validations of everyone’s efforts in the treatment. Over time, CHATogether not only provided Samantha and her parents with coping skills and more adaptive defenses, but it also nurtured shared growth, love, and partnerships that were collaborative rather than adversarial in the face of difficult feelings. CHATogether ’s therapeutic potential could be consistent with the family resilience framework which suggests the importance of shared belief systems in (1) meaning-making processes; (2) a positive, hopeful outlook, and active agency; and (3) transcendent values and spiritual moorings for inspiration, transformation, and positive growth [ 47 , 48 , 49 ]. This framework emphasized strengths and resiliencies within the broader context of family relationships and community resources in helping family members adjust to stress, and cope with loss. Throughout the CHATogether intervention, the family was asked to make a strong commitment to change, while aiming towards identified and shared family relationship goals. The program provided each family member with a means of processing their fears in ways other than unconscious ‘fight-flight’ patterns. It supported ways of managing more consciously experienced fears and grief, with less attacking of self or others. The CHATogether program may ultimately help to build family members’ capacities for compassion, hope, and resilience, thereby strengthening the family as a well-functioning unit.

Family mental health: treating the whole family system

Cross-sectional research suggested that parents with self-reported higher stress levels had fewer positive parenting practices during the pandemic [ 4 , 5 , 6 , 50 ]. Additionally, there could be the longer-term issue of family “scarring,” defined as prolonged problems in family relationships even after protective factors have been activated [ 51 ]. COVID-19 has led to an exacerbation of child-parent conflicts and household chaos [ 52 ]. Families have had an urgent need for interventions that can provide comprehensive support during and after times of crisis. CHATogether is a unique intervention in that it treats the whole family as the ‘patient’, and as one of three systems dynamically intertwined in the bio-psycho-social/family/community psychodynamic model of human development. Under this concept, the family should be the basis for health which catalyzes changes to improve the entire family and downstream individual functioning [ 23 , 24 ]. At the systemic level, treating the family wholistically can also be helpful in light of workforce shortages to adequately meet the rising demands of children’s mental health services [ 53 , 54 ].

The strength of the CHATogether program may be that it actively identified those factors that interfere with family functioning while therapeutically facilitating the love, cohesion, and deep devotion to one another that is the foundation of any family unit. This intervention could be especially vital for children’s and adolescents’ mental health when family function is compromised due to forces disrupting the security of jobs, food, finances, and health during the pandemic. With its focus on a deep respect for differing perspectives, CHATogether could calibrate the power dynamics within families to be more equitable and holistic.

Limitations, challenges, and future directions

The current study was a pilot trial of an innovative family-centered treatment. We have illustrated a representative pilot case with supporting preliminary data and the acceptability and feasibility from a total of 30 families voluntarily enrolled in the CHATogether program implemented at the IOP level of care. Most patients were recruited within the state of Connecticut. There are several limitations and challenges that help guide future directions. The patient/family population in the current study may not be generalizable to larger populations. This preliminary study did not answer whether the improvement of child-parent communication was solely due to participation of CHATogether and/or in part from the conventional IOP treatment that does not include this family intervention component. Sustained impacts on the participating families beyond the 4–6 sessions of CHATogether were also unknown. Moreover, we did not collect more extensive qualitative data such as focus group and/or individual interviews, which would reveal more narrative information about the feedback.

Future studies should include randomized, mixed-method, and longitudinal investigations from larger and more diverse populations to compare CHATogether and conventional IOP vs. conventional IOP alone. Such a study could examine whether family-centered treatment may provide additional benefits in adolescents compared to those receiving biological- and psychological-based treatment. The inclusion criteria for the current study included patients who demonstrated family conflicts but were not specific to a diagnosis, symptoms, or level of functioning upon entry into IOP treatment. By collecting more data with validated psychometric measures, future studies for the CHATogether program as a family intervention model could examine whether participation in the program can contribute to the reduction of clinical symptoms and suicide in specific psychiatric conditions such as major depressive disorder and generalized anxiety disorder. The Inclusion of the established measures in reflective functioning within a family would be particularly valuable in the next stage of study [ 55 ]. In addition, reproducibility and scalability to deliver CHATogether could be a challenge. In this study, we have not measured the perception of the intervention’s acceptability and feasibility from the clinicians, but the intervention team meets monthly to collect verbal feedback as the program expands. We have produced tutorial videos and a standardized protocol to minimize inter-clinician discrepancy, and we also have plans to establish a nationwide webinar training series to elevate the program’s scalability. The program has been developing a digital library to provide access to CHATogether skit videos and training manuals to the trained clinicians.

While preparing this manuscript, we produced more skit videos based on varying child, adolescent, and family mental health topics. Future videos need to incorporate social determinants of health reflected in the diverse racial, ethnic, religious, and economic backgrounds of participating families. Translations with subtitles including Spanish and Chinese could be important. CHATogether skits were created based on diverse family scenarios with consultations from patients, their families, and the treatment team. The skit simulated yet may not be fully applicable to families’ real-life scenarios. Moreover, the “problematic scenario” from the intervention may re-expose unpleasant memories in patients and families, and thus anticipatory guidance and post-session emotional support would be essential. The intervention did not fully adapt to children and adolescents who are shy, have limited verbal communication, or feel more secure in the isolated digital existence. To this end, artificial intelligence with graphic illustrations, such as Avatar Assistant , Digital Twins , and Virtual Self , would be helpful venues for neurodivergent youth and their parents to better engage, identify, and express the emotions being depicted in the CHATogether skits [ 56 , 57 , 58 , 59 ]. Although it warrants thoughtful development in the future, AI-guided CHATogether chatbots could be a scalable solution for families with limited access to the intervention. Moreover, adapting CHATogether in a social media format like that of TikTok and Instagram could be developmentally palatable to the current generation of children and adolescents [ 60 , 61 ].

The long-term psychological turmoil that young people and their parents have endured in the past few years outlasted the official end of the COVID-19 pandemic. As young people navigated difficult emotions, parents also suffered from substantial mental exhaustion. Therefore, family-centered treatment could be critically needed during this era of post-pandemic children’s mental health. This pilot study suggested that CHATogether is an acceptable, and feasible model of therapeutic intervention for children and adolescents presenting with mental health disorders by: (1) including the family as a focus of intervention within the bio-psycho-social framework of assessment and treatment; (2) providing a safe space for family members to process painful and frightening emotions during a psychiatric crisis, (3) promoting perspective taking, reflection, and more mature defenses within and between family members under stress, (4) improving effective family communication and problem solving, especially during times of crisis, and (5) restoring family cohesion after disruption, through enhanced mutual understanding, compassion, and hope within the family unit. Although more extensive studies are warranted, the results of this pilot study demonstrated the promising potential for the CHATogether program to serve as an innovative family therapeutic intervention during the post-pandemic era and beyond.

Availability of data and materials

The data would be available from the corresponding authors upon reasonable request.

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Acknowledgements

The authors would like to express special appreciation for the editing and critical review by Drs Janet Madigan, Michael Kaplan, and Linda Mayes from Yale Child Study Center, as well as Dr Rachel Ritvo from George Washington School of Medicine and Health Science. We appreciate Dr. Katie Klingensmith and Carol Cestaro, LCSW from Yale New Haven Hospital for their consultation in the development of this project. We are grateful for Willem Styles, LCSW, who provided clinical support in the program. Lastly, we express our gratitude to Dr Chiun Yu Hsu from State University of New York at Buffalo for his consultation in the psychometric measurements and critical review during the manuscript revision.

This work was supported by funds to EY, including the Riva Ariella Ritvo Endowment at the Yale School of Medicine; Yale New Haven Health System Innovation Awards; and NIH grants T32MH18268.

Author information

Caylan J. Bookman and Julio C. Nunes have contributed equally to this work.

Authors and Affiliations

Department of Psychiatry, Yale University, New Haven, CT, USA

Caylan J. Bookman, Julio C. Nunes, Ruby Lekwauwa & Eunice Y. Yuen

Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA

Nealie T. Ngo

Yale New Haven Hospital, New Haven, CT, USA

Naomi Kunstler Twickler, Tammy S. Smith, Ruby Lekwauwa & Eunice Y. Yuen

Yale Child Study Center, New Haven, CT, USA

Eunice Y. Yuen

Yale Department of Psychiatry, 300 George Street, 06511, New Haven, CT, USA

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Contributions

CB and JN are co-first authors who contributed equally and were responsible for conceptualization, data curation, and writing the original draft and the major revision of the manuscript. NKT and NN contributed to the data collection, writing, and editing of the manuscript. TS and NKT contributed to skit video production and clinical implementation. RL was responsible for study conceptualization, reviewing, and editing manuscript. EY: designed the study, supervision, clinical implementation, and writing the manuscript. All authors read and approved the final manuscript upon to submission.

Corresponding author

Correspondence to Eunice Y. Yuen .

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Ethics approval and consent to participate.

The study obtained institutional review board approval from the Yale Human Investigations Committee (#2000034837). Families consented to study participation prior to the beginning of the survey. The study was entirely voluntary, and the families were welcomed to receive CHATogether treatment regardless of their participation in the study. In the pilot case, additional written consent was obtained from the family, and the case was de-identified with modifications to protect the patient’s and family’s privacy.

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Consent was obtained from the participants for publication.

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The authors declared that they have no competing interests.

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Bookman, C.J., Nunes, J.C., Ngo, N.T. et al. Novel CHATogether family-centered mental health care in the post-pandemic era: a pilot case and evaluation. Child Adolesc Psychiatry Ment Health 18 , 57 (2024). https://doi.org/10.1186/s13034-024-00750-y

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Play Therapy

Timothy lawver.

Department of Psychiatry, Boonshoft School of Medicine, Wright State University, Dayton, Ohio

Kelly Blankenship

Play therapy is a treatment modality in which the therapist engages in play with the child. Its use has been documented in a variety of settings and with a variety of diagnoses. Treating within the context of play brings the therapist and the therapy to the level of the child. By way of an introduction to this approach, a case is presented of a six-year-old boy with oppositional defiant disorder. The presentation focuses on the events and interactions of a typical session with an established patient. The primary issues of the session are aggression, self worth, and self efficacy. These themes manifest themselves through the content of the child’s play and narration of his actions. The therapist then reflects these back to the child while gently encouraging the child toward more positive play. Though the example is one of nondirective play therapy, a wide range of variation exists under the heading of play therapy.

Introduction

In her original work on the subject of play therapy, Virginia Axline wrote, “There is a frankness, and honesty, and a vividness in the way children state themselves in a play situation.” 1 As universal as it is mysterious, imaginative play predominates the lives of most young children. More and more, we are identifying and appreciating childhood mental disorders and how they pull children away from normal functioning. This can affect their home lives, academic performances, as well as their play with peers. Play therapy offers a direct route to engage children on their terms, in their world, giving them a chance to, “play through what adults talk through.” 2 The goal is to identify and address themes that arise in the course of play, although children’s relative strengths and weaknesses do become apparent in terms of cognitive processing and social skills.

Studies have shown the effective use of play therapy in children with different psychiatric diagnoses. Using pre-test, post-test comparison design to evaluate 11 patients in an experimental group and 10 in the control group, Danger, et al., showed a benefit in improving both receptive and expressive language skills in children with speech difficulties. 3 In theory, the safe practice environment of the therapy provided an environment conducive to working on these areas without exacerbating self esteem and social anxiety issues. An exploratory study of nondirective play therapy with an autistic boy using video analysis of 16 sessions suggests both feasibility and effectiveness of play therapy with noted improvements in the child’s autonomy and pretend play, though only mild improvement in decreasing ritualistic behaviors. 4 It was the authors’ opinion in this paper that the therapeutic relationship helped to “enhance and accelerate the emotional/social development of children with severe autism,” as they were able to observe attachment behavior from the child towards the therapist.”

Legoff and Sherman ran a three-year retrospective study on children with autism spectrum disorders involved in LEGO therapy, a play therapy centered around the commercially available building blocks. 5 In a two-tiered approach, Robinson, et al., describe using filial play therapy to teach fifth-grade students to then be ‘therapeutic change agents’ in play sessions with kindergarten children identified as having adjustment difficulties. 6 Gold-Steinberg and Logan detail the use of psychodynamically oriented play therapy as an adjunct to pharmacotherapy for a child with obsessive compulsive disorder (OCD). 7 Virginia Ryan details some of the difficulties and gains in play therapy with a child in transition with serious attachment problems. 8

In another case example, play therapy was used to alleviate anxiety, which was contributing to migraine headaches in a 10-year-old child with separation anxiety disorder. 9 In this case, the boy with preexisting migraines began to experience increased anxiety in the wake of the 9/11 attacks as his father took part in the search and rescue efforts at the World Trade Center. The tracked symptom was migraine frequency, which had increased with his anxiety. Through play and art he was able to accomplish a resolution of his fears by bringing them to the surface, directly and indirectly in the content of his play and art projects. As his play and art became less dark and fearful, both his subjective anxiety and migraines decreased.

In a related case, play therapy was used as treatment for a four-year-old boy with a psychosomatic postural symptom that resolved quickly over a course of play therapy. 10 A four-year-old boy had begun tilting his head forward and to the left subsequent to his parents learning of a left kidney defect in his as-of-yet unborn sister. He also had marked regression in speech and increasingly needy or clingy behavior. Through play the therapist was able to explore his competing themes of aggression toward his younger sister, the new holder of his parents’ attention, and a fantasy-based guilt of having in some way wished his sister’s malady into existence. The head tilt, along with the regressive behaviors served as attention-seeking behavior. Also, as much of his play involved things being broken, needing to be fixed, and the idea of punishment by being hit on the head, the therapist was able to extrapolate that the symptoms also served as self punishment. By repeating these themes in the face of safe, gentle correction by the therapist, all symptoms resolved for the most part within four sessions.

Snow, et al., described two case studies followed over a six-week period. 11 One case was a three-year-old boy brought in by his grandmother for increasing aggressive behavior and violent tantrums. The other case was that of a six-year-old boy showing regressive behavior in imitation of and perhaps competition with his younger, disabled brother. The caregiver filled out the Child Behavior Checklist of Thomas M. Achenbach and Craig Edelbrock so that the authors could track the course of behavioral outcomes. The authors tracked the themes present in play from session one to session six based on a standard format. Of note was that changes in play themes in therapy were paralleled by changes in behavior at home.

Outside of the context of specific psychiatric diagnoses, play therapy has been used in a variety of other settings. Scott, et al., conducted a 10-session “client-centered” study on the use of play therapy with 26 victims of sexual abuse, ages 3 to 9. Here “client-centered” refers to a slight variation in how the play therapy session is run, although the overall format still consists of play based on themes and interests initiated by the child. However, their findings showed only mixed support for the use of play therapy in this setting. 12 A pre-test and post-test assessment battery were completed both by the patient and the primary caregiver. Many subjects showed a trend toward clinical improvement (8 of 26), but the Reliable Change Index formula failed to show a statistical difference. Baggerly advocates for the use of play therapy with homeless children to help them “gain in fantasy what [they] long for in reality.” 13

Mullen, et al., explored the use of play therapy with young people, “facing transitions as a result of relocation.” 14 He presents a case study of a middle-school–age girl upset by her family’s move to a more affluent neighborhood. She was able to work through the effects of this relocation and come to terms with the change through bringing the material up in the context of play therapy. In another study, play therapy was used in the preoperative period to reduce state anxiety scored in children. Li, Lopez, and Lee found a reduction in state anxiety scores and fewer negative emotions at induction of anesthesia. 15 Two hundred and three children admitted for day surgery were randomly assigned to experimental or control groups. In the experimental group, the children received therapeutic play while the control group received “routine information preparation.” The authors found a reduction in state anxiety scores and fewer negative emotions at induction of anesthesia. 16

A growing body of research supports the clinical effectiveness of play therapy for children with self-concept issues, behavioral adjustment, social skills, emotional adjustment, intelligence, and anxiety/fear. 17 In a review of 93 controlled-outcome studies published between 1953 and 2000, Bratton, et al., found an overall treatment effect of 0.80 standard deviations. 18 This effect was felt to be consistent over age, gender, and presenting issues. The largest effects were seen in therapies that involved the parents. The importance of conducting well-designed, outcome-based studies on play therapy is illustrated by another meta-analysis of published and unpublished play therapy outcome studies where poorly designed or incomplete studies were included. Rogers-Nicastro found only a between-group effect size of 0.18, indicating a lack of evidence to make any strong conclusions about play therapy. 19

Case Presentation: What Does Play Therapy Look Like?

Rather than focusing on a particular setting or diagnosis, the following case is presented as an introductory vignette to play therapy—an example of how a typical nondirective play thereapy session might progress.

Mike is a six-year-old boy with a diagnosis of oppositional defiant disorder. His mother’s behavioral concerns include noncompliance with adult requests, disrespecting attitude toward others (especially women), and explosive tantrums. Mike has been expelled from several daycares. Mike lives with his mother and grandmother. His parents divorced when he was four after a marriage marked by significant tension and disagreement. Mike witnessed their arguments, and on occasion, he saw his mother being hit and shoved by his father. Mike’s father has remarried and has a newborn.

The custody agreement states that Mike’s father has regular visits every other weekend and one day a week; however, he has been very inconsistent. Typically, the father misses visits or cancels at the last minute.

Mike: (Looking around the room) I don’t think I feel like playing today.

Psychiatrist: You don’t know if you want to do anything.

Practice point

The psychiatrist reflects back what the child has said. This intervention shows the psychiatrist is interested and listening to the child. The psychiatrist does not attempt to engage the child in some of the games in the playroom. It is important the child lead and the psychiatrist follow.

Mike: (Continues to look around the room. He walks over to the Play-Doh bin and gets out several colors. He starts to make several cars out of the Play-Doh.) Look at my cars!

Psychiatrist: You have three cars. You made two big cars and a little one.

Mike: They’re a family of cars. (He starts to pretend to drive them around the room.)

Psychiatrist: The family of cars is driving around together. They are staying very close to each other. (The psychiatrist continues to track what the child is doing, interpreting the play at times.)

Mike: (Suddenly the largest car crashes into the wall.) The daddy car was bad and hit a wall. No more daddy car! He shouldn’t have done that. Now he’s all gone!

Psychiatrist: That car did something bad and now he’s no longer a car. (The child seems to be escalating in anger at this point. He starts to crush all the cars and turn them into balls of Play-Doh.) The family of cars is all gone now.

Mike: Yeah, now they are all bombs. I’m going to blow up this place.

Psychiatrist: The family of cars has turned into weapons. You want to blow up this building with them. (The therapist tracks his behavior and allows him to show his anger.)

Mike: I’m going to blow you up. (He starts to throw the Play-doh balls at the therapist.)

Psychiatrist: I know you would like to blow me up by throwing those bombs at me. (This comment demonstrates the psychiatrist’s empathy with the child.) But you may not throw things at me. You may throw those bombs at that stuffed bear. (The psychiatrist points to a large bear sitting in the corner of the room.)

Practice Point

It is important to set limits in the play room when appropriate. The child should not be able to hurt himself, the psychiatrist, another person, or destroy property. A good way to set limits is this way: First, acknowledge what the child wants to do, e.g., “I know you would like to blow me up by throwing those bombs at me.” This helps to empathize with the patient and makes it more likely the limit will be followed. Second, communicate the limit to the child, e.g., “You may not throw things at me.” Third, give the child an alternative, e.g., “You may throw those bombs at that stuffed bear.” 20

Mike: (Turns to the bear and throws the Play-Doh at it.) The bear is all blown up! (He says this with a big smile.)

Psychiatrist: You are happy because the bear is blown up. (The psychiatrist appreciates his smile as being happy and reflects this feeling in her interpretation.)

Mike: The bear is alive. (He goes over and picks up and cradles the bear.) He is hurt. I don’t know if he’s going to die. (Mike goes and finds the nursery bottle and starts to pretend to feed the bear.)

Psychiatrist: You are afraid he is going to die. You are going to help the bear.

Mike: He is all better now.

Psychiatrist: You have nursed the bear back to health. He is going to be just fine. (The therapist acknowledges his anger and his fear that his anger can hurt things. The psychiatrist also acknowledges his need to know that his anger will not destroy things.)

Mike: I’m going to build a house with these blocks. (Mike walks over to the bookshelf where the blocks are stored. He gets the blocks down.) You build a small house and I’m going to build a big house. (The psychiatrist does not interact in the play until invited to by the patient. The child has invited the therapist to play blocks with him. The psychiatrist complies with the child’s request and starts to build a house.) Hey, your house is bigger than mine. Now, I’m going to have to make my house even bigger!

Psychiatrist: It’s important to you that your house is bigger than mine.

Mike: Bigger is better.

Psychiatrist: Whoever has the bigger house is better.

Mike: Can you get those people down from the shelf? They are going to live in the house.

Psychiatrist: You can get the people down off the shelf. (The therapist acknowledges Mike’s ability to do things for himself. He can satisfy some of his wants and needs.)

Mike: I think it’s too high.

Psychiatrist: I think you can reach that. (The psychiatrist continues to acknowledge his abilities and encourages him.)

Mike: (Walks over to the bookcase, reaches up and grabs the play people.) I did it!

Psychiatrist: You did it by yourself. (The psychiatrist’s comments reflect his abilities to do things for himself and affirm his self-sufficiency.) Five minutes until our time is over. (Mike continues to build on to his house with the blocks.)

Giving children a five-minute warning allows them to know that you will be leaving the room It is important to set limits in the play room soon. It gives them a chance to finish anything they feel is important. 20

Psychiatrist: Mike, our time together is over for today.

Mike: Just a few more minutes. I’m almost done.

Psychiatrist: I know you don’t want to leave, but our time is finished. When you come next week you can finish your buildings.

The limit of time is given to Mike. His feeling of not wanting to leave is empathized with and he is given an alternative.

The case described in this article is an example of nondirective play therapy. There are variations under the larger heading of play therapy that may look more or less similar to the interaction presented. For example, Trombini and Trombini detail the use of focal play therapy following Gestalt theory in children with eating and evacuation psychosomatic protest behaviors. 21 Wettig, et al., present two research projects using another style of directive play therapy trademarked as Theraplay. 22 Also, as described by Ryan, filial therapy, a variant of nondirective play therapy, can be used with children being placed with new caregivers. 23 The Masterson Approach is described by Mulherin in a case report following a mother and child for six years and relates to Masterson’s conceptual framework of “abandonment depression.” An in-depth discussion of these various theoretical outlooks and styles is beyond the scope of this paper.

With play therapy, the psychiatrist responds to the child in the language of play, by both verbal and nonverbal means. 24 This requires the psychiatrist to relearn what is often the lost language of play, which brings therapy to the level of the child within the child’s own realm. Play therapy can be a viable and engaging way to approach the treatment of the younger patient.

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