Evidence Based Treatment
REFERENCE CHART OF DISORDERS AND EVIDENCE-BASED TREATMENTS
FOR CHILDREN AND ADOLESCENTS
Adjustment Disorders:
CBT is used to improve age-appropriate problem-solving skills, communication skills, and stress management skills. It also helps the child’s emotional state and support systems to enhance adaptation and coping.Stress management is particularly beneficial in cases of high stress.Group therapy is beneficial in cases of high stress.Family therapy helps in making needed changes within the family system. These changes may include improving communication skills and family interactions and increasing support among family members.
Attention Deficit Hyperactivity Disorder (ADHD)
● Behavioral Classroom Management BCM uses contingency management strategies, including teacher-implemented reward programs, time-out procedures and daily report cards. Clinicians or parents work with teachers to develop a plan.
● Behavioral Parent Training (BPT) BPT teaches the parent to implement contingency management strategies similar to BCM techniques at home.
● Intensive Behavioral Peer
● Intervention (BPI) Intensive BPI is conducted in recreational settings, such as Summer Treatment Programs (STPs) have demonstrated.
MEDICATIONS
● Stimulant: Amphetamine,
● Dextroamphetamine
● Stimulant Dexmethylphenidate,
● Methylphenidate
● Alpha2-adrenergic Agonists:
● Clonidine Guanfacine
●
● Short-acting: Adderall, Dexedrine, Procentra
● Long-acting: Dexedrine Spansule, Adderall XR, lisdexamfetamine
● Atomoxetine (Strattera) is unique in its ability to act on the brain’s norepinephrine transporters without carrying other medications’ risk for addiction.
● Kapvay, Intuniv.
What Does Not Work
● Cognitive, psychodynamic, client- centered
● Office-based social skills training
● Traditional talk therapies and play therapy have been demonstrated to have little to no effect on ADHD symptoms.
● Neither once-weekly individual nor group office-based training have demonstrated significant improvement in social skills. (However, intensive group social skills training that uses behavioral interventions is considered well-established.)
● Dietary Interventions
● Other Medications
● Interventions include elimination of food additives, elimination of allergens/sensitivities, and use of nutritional supplements.
● Bupropion (i.e., Wellbutrin), imipramine (i.e., Tofranil), nortriptyline (i.e., Pamelor, Aventil).
Anxiety Disorders
What Works
● Behavior and Cognitive Behavioral Therapy (CBT)
● Selective Serotonin Reuptake Inhibitors (SSRIs)
● Treatments that involve learning how to replace negative thinking patterns and behaviors with positive ones including homework and exercises.
● Treatment with certain SSRIs.
What Seems to Work
● Educational support Psychoeducational information provided to parents, usually in a group settling.
Not Adequately Tested
● Play Therapy*
● Therapy that uses self-guided play to encourage expression and healing.
● Non-SSRI Medication
● Treatment with antihistamines or neuroleptics
● Psychodynamic Therapy
● Therapy designed to uncover unconscious psychological processes.
● Biofeedback
● Minimal support.
Autism Spectrum Disorder (ASD)
What Works
Applied Behavior Analysis (ABA)
Behavioral intervention aimed at improving cognitive, language, communication, and socialization skills characterized by on-going and objective measurement of behaviors, implementation of individualized curricula, selection and systematic use of reinforcers, use of functional analysis to identify factors that increase or inhibit behaviors.
Discrete Trial Teaching (DTT)
Behavioral intervention based on principles of operant learning; incorporates units of instruction used to teach and assess acquisition of basic skills.
Incorporates same sequential components regardless of skills taught.
Pivotal Response Training (PRT)
Focuses on the most disabling areas of a child’s autism by teaching children
to respond to multiple environmental cues, increasing motivation, increasing
capacity for self-management, and increasing self-initiations.
Learning Experiences: An Alternative
Peer-mediated interventions in an educational setting with children with
Program (LEAP) autism. Individualized, data-driven, and focused on generalizing learning
skills across context through saturation of learning opportunities throughout day. Family involvement is a significant part of this intervention.
Pharmacological Treatments
May be considered for maladaptive behaviors when symptoms cause
significant impairment. Antipsychotics may be used to treat aggression.
What Seems to Work
Educational and Communication- focused Interventions (TEACCH)
TEACCH (Treatment and Education of Autistic and Communication related handicapped Children) provides strategies that support the individual throughout his or her lifespan, facilitates autonomy at all levels of functioning, and accommodates individual needs.
Natural Language Methods
Speech and language pathologists often integrate communication training
with the child’s behavior program to provide a coordinated opportunity for
structured and naturalistic language learning. Instruction is designed to
provide a generative tool that will serve needs throughout the child’s life.
Picture Exchange Communication
Helps children with Autism Spectrum Disorders (ASD) acquire functional
System (PECS) communication skills. Children using PECS are taught to give a picture of a desired item to a communication partner in exchange for the item, thus linking an outcome with communication.
Other Behavioral Interventions
Joint attention behavior training, which may be especially beneficial in young, pre-verbal children, shows promise for teaching children with autism behavioral skills. Social skills groups, social stories, visual cueing, social games, video modeling, scripts, peer-mediated techniques, and play and leisure curricula are also supported by the literature.
Occupational Therapy
Occupational therapy helps develop self-care skills and shows promise in promoting play skills and establishing routines to improve attention and organization.
What Does Not Work
● Hormone Therapy: Secretin
● Avoiding Immunizations
● Research has shown secretin does not help with any autism symptoms.
● A new study evaluating parents’ concerns of "too many vaccines too soon" and autism has been published online in the Journal of Pediatrics (March 29, 2013). It adds to the conclusion of a 2004 comprehensive review by the Institute of Medicine (IOM) that there is not a causal relationship between certain vaccine types and autism.
Bulimia Nervosa (BN)
What Works
Cognitive Behavioral Therapy (CBT)
The most effective independent treatment option; it is used to change underlying eating disorder cognitions and behaviors.
Pharmacological Treatments
Antidepressants, namely Selective Serotonin Reuptake Inhibitors (SSRIs), have effectively reduced binge/purging behaviors, as well as comorbid psychiatric symptoms.
Combined Treatments
A combination of CBT and pharmacotherapy seem to maximize treatment outcomes.
What Does Not Work
● Individual Psychotherapy
● Behavioral Therapy: Compared to CBT, few individual therapeutic approaches have been effective in reducing symptoms.
● Behavioral techniques, such as exposure, have been less effective than CBT techniques.
Twelve-Step Programs
Not yet tested for efficacy and are discouraged as a sole treatment.
Depression/Dysthymia - Interventions for Children
What Works
Stark’s Cognitive Behavioral Therapy Stark’s CBT - child- only group or child group plus parent component (CBT) includes mood monitoring, mood education, increasing positive activities
and positive self statements, and problem solving.
What Does Not Work
Penn Prevention Program (PPP)
Self-Control Therapy
Behavioral Therapy
A CBT-based program that targets pre-adolescents and early adolescents who are at risk for depression.
A school-based CBT that focuses on self-monitoring, self-evaluating and causal attributions.
Includes pleasant activity monitoring, social skills training and relaxation.
Depression/Dysthymia - Interventions for Adolescents
What Works
Cognitive Behavioral Therapy (CBT)
CBT for depression focuses on identifying thought and behavioral patterns that
provided in a group setting
lead to or maintain the problematic symptoms.
Interpersonal therapy (IPT)
In IPT, the therapist and patient address the adolescent’s interpersonal
provided individually
communication skills, interpersonal conflicts, and family relationship problems.
Selective Serotonin Reuptake
Fluoxetine (Prozac, Sarafem, Fontex) and Escitalopram (Lexapro). Most
Inhibitors (SSRIs)
effective when combined with CBT although there is debate about the use of
SSRIs to treat depression in youth.
What Seems to Work
CBT provided in a group or individual setting with a parent/family component
Adolescent Coping with Depression (CWD-A)
Interpersonal Psychotherapy for Depressed Adolescents (IPT-A)
CBT for depression focuses on identifying thought and behavioral patterns that lead to or maintain the problematic symptoms.
Includes practicing relaxation and addressing maladaptive patterns in thinking, as well as scheduling pleasant activities and learning communication and conflict resolution skills.
Addresses the adolescent’s specific interpersonal relationships and conflicts, and helps the adolescent be more effective in his or her relationships with others.
Disruptive Behavior Disorders
What Works
Assertiveness training: Group
School-based group treatment for middle school youth
Assertive Training
Parent Management Training (PMT)
Programs that focus on teaching and practicing parenting skills with parents or caregivers include:
Programs
•Helping the Noncompliant Child
•Incredible Years Parent-Child Interaction Therapy
•Parent Management Training to Oregon Model
•Positive Parenting Program
Multisystemic Therapy (MST)
An integrative, family-based treatment for youth with serious antisocial and
delinquent behavior. Interventions last three to five months and focus on
improving psychosocial functioning for young people and families.
Cognitive Behavioral Therapy (CBT)
CBT emphasizes problem solving skills and anger control/coping strategies and includes:
•Problem-Solving Skills Training
•Anger Control Training
CBT & Parent Management Training
Combines CBT and PMT
(PMT)
What Seems to Work
Multidimensional Treatment Foster
Community-based program alternative to institutional, residential and group
Care (MTFC) care placements for use with severe chronic delinquent behavior. Foster
parents receive training and provide intensive supported treatment within the foster home setting.
Disruptive Behavior Disorders
Notes About Medications
Assertiveness training: Group
School-based group treatment for middle-school youth
Assertive Training
According to the American Academy of Pediatrics, the US Food and Drug Administration (FDA) has no approved indications for aggression in children and adolescents apart from irritability-associated aggression in children with autism. In other populations, recent federally supported, evidence-based reviews suggest efficacy for some psychotherapeutic agents, but primary care clinicians are urged to consult with mental health specialists before prescribing medications for aggression.
Medications are frequently used to treat comorbid conditions and are sometimes used off-label treat aggression.
Antipsychotics
Risperidone (risperdal), quetiapine (seroquel), olanzapine (zyprexa), and
Abilify (aripiprazole). Limited evidence for effectiveness in youth with intellectual disability or pervasive developmental disorder.
Stimulant or Atomoxetine
Methylphenidate, d-Amphetamine, atomoxetine. Limited evidence when comorbid with primary diagnosis of ADHD.
Mood Stabilizers
Divalproex sodium, lithium carbonate. Limited evidence when comorbid with primary diagnosis of bipolar disorder.
Selective Serotonin Reuptake
Limited evidence when comorbid with primary diagnosis of depressive Inhibitors (SSRIs)
Disorder.
What Does Not Work
Boot camps, shock incarcerations
Ineffective at best; can lead worsening of symptoms.
Dramatic, short-term or talk therapy
Little to no effect as currently studied.
Early-onset Schizophrenia
What Works
Schizophrenia is a major psychiatric illness that calls for careful, often complex and lifelong treatment. A combination of therapies is usually necessary to effectively manage the disease. Since there is no known cure for schizophrenia, treatment is aimed at reducing the severity of the disorder’s impact on life and helping the child manage symptoms.
What Seems to Work
Medication
According to National Alliance on Mental Illness, the following second generation antipsychotics are FDA approved for early onset schizophrenia in youth ages 13-17: rispiridone (Resperidol), aripipazole (Abilify), quetiapine (Seroquel) and olanzapine (Zyprexa). Several other medications are often used off-label to treat schizophrenia.
Individual Psychotherapy
Family Psychotherapy and Support
Focused on coping with the stress and daily life challenges brought on by schizophrenia and reducing symptoms.
Helps to improve family functioning, problem-solving, communication skills, and decrease relapse rates.
Social and Academic Skills Training
Includes social skills training, problem-solving, and self-help skills.
What Does Not Work
Psychodynamic Therapy
May be harmful for this population.
Habit Disorders
What Works
Habit Reversal Therapy for Tic Disorder
Treatment increases awareness of the feelings and context associated with the urges and implements a competing and inconspicuous habit in place of the tic.
What Seems to Work
Cognitive Behavioral Therapy (CBT) for recurrent hair-pulling (trichotillomania [TTM])
Treatment involves exposing children to the stimuli associated with the urge while challenging thoughts associated with high-risk situations.
Not Adequately Tested
Massed Negative Practice
Treatment involves over-rehearsal of target tic in high-risk ticking situations.
Pharmacotherapy
Prescription medications to treat habit disorders in children.
What Does Not Work
Plasma Exchange or Intravenous
Blood transfusions to alter levels of plasma or immunoglobulin.
Immunoglobulin Treatment (IVIG)
Juvenile Fire Setting
What Works
Currently no medication or psychological treatments meet these criteria.
What Seems to Work
Cognitive Behavioral Therapy (CBT) Structured treatments designed to intervene with children who set fires.
What Does Not Work
Ignoring the problem
Leaving youth untreated is not beneficial because they typically do not outgrow this behavior and ignoring these behaviors may even increase dysfunctional behavior patterns.
Satiation
The practice of repetitively lighting and extinguishing fire. Satiation may cause
youth to feel more competent around fire and actually increase the behavior.
Youths in the Juvenile Justice System
What Works
Multisystemic Therapy (MST)
Integrative, family-based treatment with a focus on improving psychosocial functioning for youth and families.
Functional Family Therapy (FFT)
Family-based program that focuses on delinquency, treating maladaptive and acting out behaviors, and identifying obtainable changes.
Multidimensional Treatment Foster
As an alternative to corrections, MTFC places juvenile offenders Care (MTFC)
who require residential treatment with carefully trained foster families who provide youth with close supervision, fair and consistent limits, consequences and a supportive relationship with an adult.
Cognitive Behavioral Therapy
Structured, therapeutic approach that involves teaching youth (CBT)
about the thought-behavior link and working with them to modify their thinking
patterns in a way that will lead to more adaptive behavior in challenging situations.
Dialectical Behavior Therapy
Therapeutic approach that includes individual and group therapy components
and specifically aims to increase self-esteem and decrease self-injurious
behaviors and behaviors that interfere with therapy.
What Seems to Work
Family Centered Treatment (FCT)
FCT seeks to address the causes of parental system breakdown while integrating behavioral change. FCT provides intensive in home services and is structured into four phases: joining and assessment; restructuring; value change; and generalization.
Brief Strategic Family Therapy
A short-term, family-focused therapy that focuses on changing family
interactions and contextual factors that lead to behavior problems in youth.
Aggression Replacement Therapy
A short-term, educational program that focuses on anger management and
provides youth with the skills to demonstrate non-aggressive behaviors,
(ART) decrease antisocial behaviors, and use prosocial behaviors.
Non-Suicidal Self-Injurious Behavior (NSIB)
What Works
Currently no medication or psychological treatments meets these criteria.
What Seems to Work
Cognitive Behavioral Therapy
Involves providing skills designed to assist youth with affect regulation and
(CBT) problem solving skills.
Dialectical Behavior Therapy (DBT)
Similar to CBT, but additionally involves an emphasis on acceptance strategies.
Obsessive-compulsive Disorder
What Works
Exposure and Response
Individual child (probably efficacious); family-focused individual and family-
Prevention (ERP) focused group treatments (possibly efficacious). ERP meets well-
established criteria for adult OCD.
Selective reuptake inhibitors (SRIs)
Clomipramine: Approved for children age 10 years of age and older.
Recommend periodic ECG monitoring.
Selective Serotonin Reuptake
Fluoxetine (Prozac): Approved for children 8 years of age and older.
Inhibitors (SSRIs)
Sertraline (Zoloft): Approved for children 6 years of age and older.
Fluvoxamine (Luvox): Approved for children 8 years of age and older.
Not Adequately Tested
Cognitive Therapy only
Systematic controlled studies have not been conducted using these
Psychodynamic Therapy approaches.
Client-centered Therapy
What Does Not Works
Antibiotic Treatments
Antibiotic treatments are only indicated when the presence of an autoimmune or strep-infection has been confirmed and coincided with onset or increased severity of OCD symptoms.
Herbal Therapies
Herbs such as St. John’s Wort have not been rigorously tested and are not
FDA-approved. In some instances, herbal remedies may make symptoms worse or interfere with pharmacological treatment.
Pediatric Bipolar Disorder (PBD)
What Works
Lithium (sometimes known as Eskalith), risperidone (Risperdal), and aripiprazole (Abilify) are the only medications approved by the U.S. Food and Drug Administration (FDA) to treat bipolar disorder in young people.
What Seems to Work
Other Medications are sometimes used off-label to treat bipolar disorder.
Anticonvulsants
Valproic acid or divalproex sodium (Depakote), lamotrigine (Lamictal),
carbamazepine (Tegretol), valproate (Depakene).
Antipsychotics
Clozapine, olanzapine, quetiapine, ziprasidone
Family-focused Psychoeducational
Family therapy format. Helps adolescents make sense of their illness, along
with their medications. Also helps to manage stress, reduce negative life
events and promote a positive family environment.
Child and family-focused Cognitive
Emphasizes individual psychotherapy with children and parents, parent
Behavioral Therapy (CFF-CBT)
training and support, and family therapy.
Multifamily Psychoeducation Groups (MFPG)
Child and parent group therapy has been shown to increase parental
knowledge and social support and promote access to services.
Not Adequately Tested
Interpersonal social rhythm therapy
No current evidence of its usefulness for youth, but has been found to be effective in adults.
Sexual Offending
What Works
Currently no medication or psychological treatments meets these criteria.
What Seems to Work
Multisystemic Therapy (MST)
Residential Sexual Offender
Treatment
Community-based Programming
Intensive family and community-based treatment addressing the multiple factors of serious antisocial behavior in juvenile sexual abusers.
May be necessary for public safety; for offenders, addresses both
sexual and non-sexual behaviors and provides milieu treatment that varies.
Effective element to treatment continuum; offers advantage of shortening residential lengths of stay, improving post-residential
transitioning.
Not Adequately Tested
Selective Serotonin Reuptake
Impacts sexual preoccupations, sex drive and arousal.
Inhibitors (SSRIs)
Substance Use Disorders
What Works
Cognitive Behavioral Therapy (CBT)
A structured therapeutic approach to teaching youth about the thought-behavior link and working with them to modify their thinking patterns in a way that leads to more adaptive behavior in challenging situations.
Family Therapy
Aimed at providing education, improving communication and functioning
among family members, and reestablishing parental influence through parent
management training. NOTE: Only specific family therapies have been tested;
not ALL family therapies are considered effective.
Multisystemic Therapy (MST)
Motivational Interviewing
Approaches
An integrative, family-based treatment focusing on improving psychosocial functioning for youth and families.
A brief treatment approach to increase motivation for behavior change. It focuses on expressing empathy, discrepancies, avoiding argumentation, rolling with resistance, and supporting self-efficacy.
What Seems to Work
Behavioral Therapies
Some Medications
Treatment that focuses on identifying specific problems and areas of deficit and working on improving these behaviors.
Psychopharmacological medication can be used for detoxification purposes, as directed by a doctor. Medication may also be used to treat co-existing psychological disorders.
Twelve-Step Programs Uses steps as principles for treating addictive behaviors.
What Does Not Work
Ignoring the Problem
Signs of substance abuse should not be ignored in youth.
Blaming/Discounting
Substance abuse can be a serious disorder that requires treatment
that is beyond an individual’s willpower or control.
DARE
Raises awareness about chemical dependency through education and training.
Trauma
What Works
Trauma-focused Cognitive Behavioral Therapy (TF-CBT)
Treatment that involves reducing negative emotional and behavioral responses related to trauma, by providing psychoeducation on trauma, addressing distorted beliefs and attributes related to trauma, and introducing relaxation and stress management techniques.
What Seems to Work
School-Based Group Cognitive
Similar components to TF-CBT, but in a group, school-based format.
Behavioral Therapy (CBT)
Psychodynamic Trauma-focused
Psychotherapies
Eye Movement Desensitization and
Reprocessing (EMDR)
Individualized to meet the specific concerns and needs of each unique trauma survivor with goal of building coping skills.
Uses eye movements, sounds, or pulsations to stimulate the brain. Can create changes in the brain that help the client overcome symptoms.
Not Adequately Tested
Child-centered Play Therapy*
Psychological Debriefing
Therapy that uses child-centered play to encourage expression of feelings and healing.
An approach in which youth talk about the facts of the trauma (and associated thoughts and feelings) and then are encouraged to reenter into the present.
Pharmacological Treatments
Treatment with selective serotonin reuptake inhibitors (SSRIs), betablockers or alpha agonsists.
What Does Not Work
Restrictive rebirthing or holding techniques
Pharmacological Treatments
Restrictive rebirthing or holding techniques may forcibly bind, restrict, coerce, or withhold food or water from children and have resulted in some cases of death and are not recommended.
Treatment with Periactin
Youth Suicide
What Works
Currently no medications/psychological treatments meet this criteria.
What Seems to Work
Dialectical Behavior Therapy (DBT)
Cognitive Behavioral Therapy (CBT)
Interpersonal Therapy
Psychodynamic Therapy
Family Therapy
Selective serotonin reuptake inhibitors (SSRIs) for co-occurring disorders
Outperformed the treatment for the control group in reducing suicide attempts. However, it did not help reduce depressive symptoms.
Psychotherapy, while not by itself an evidence-based practice, is an important component to the treatment of suicidality in youth. All are options when choosing a treatment modality.
Necessary to closely monitor youth taking SSRIs because of the risk that SSRIs can increase suicidality in youth and young adults.
Youth Suicide
What Does Not Work
No-suicide Contracts
Tricyclic Antidepressants
Study findings are diverse; there have been results that have found that contracts reduce suicidal behavior and others suggesting that they increase it.
Effectiveness has not been demonstrated. They can potentially be lethal due to the small difference between therapeutic and toxic doses.
Benzodiazepines
Should be used with great caution as they may result in impulsivity.
Barbiturates
Should be used with great caution as they may result in impulsivity.
Play Therapy Addendum
What are the Different Types of Play Therapy for Children?
Play therapy is a specialized treatment in which therapists watch kids playing and use what they observe to help them deal with emotional, mental, or behavioral issues. There are several different types of play therapy for children, including child-based, family-based, and group-based therapy. All three can be done with different levels of therapist participation. Sessions can include a range of activities, which are usually chosen based on the child's age and preferences.
Three Main Types
One of the most common types of play therapy for children is child-based therapy, in which a therapist and a child work alone. This is often used if there is a concern about the parents or abuse in the family, but can also be done simply to make the child feel more comfortable. It can be used to treat behavioral problems, anxiety, Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD), Post Traumatic Stress Disorder (PTSD), autism, and the effects of abuse.
Another commonly used technique includes the participation of the child's father, mother, siblings, or other family members. This is called family-based therapy or filial therapy, and is often used when children experience severe separation anxiety or when certain kinds of abuse are possible. The therapist may not always be directly involved in filial therapy sessions, but almost always watches them and discusses the positive and negative points with the parents afterwards. This can be as helpful for parents as for children, since they can learn parenting skills and better their relationship with the child. Classic filial therapy focuses on four main areas — structuring, empathic listening, child-centered imaginary play, and limit-setting — but each session is typically tailored to the family's specific needs.
An additional type of play therapy for children is group-based therapy. During these sessions, a large group of children plays together while the therapist watches and sometimes participates. This is meant to help build better social skills and self-esteem. It can also help therapists to treat individual children by letting them observe how the child interacts with others. It's sometimes used when a child would feel too intimidated to work with a therapist alone, but can also be used as a matter of preference or convenience.
Directive and Non-Directive
Most types of play therapy for children can be done either in a directive or a non-directive manner. The main difference between these is therapist's level of involvement. Both start with the therapist suggesting a general topic or activity, but in directive play therapy, the therapist often asks the child questions throughout the session, encourages him to talk more about certain topics, or participates in activities with the child. In non-directive therapy, the therapist generally just watches the child, and then interprets the results of the activity, like a drawing.
Generally speaking, directive therapy is seen as a Cognitive Behavioral Therapy (CBT), focusing on behavior and conscious actions, while non-directive therapy is often categorized as a psychodynamic theory. This means that it focuses on unconscious actions and beliefs. Both can be used to treat a variety of conditions, but directive therapy is often used with trauma victims, while non-directive therapy may be used to help with behavioral problems. There's no hard and fast rule though, and both therapies have been shown to be effective with many issues.
Materials and Activities
Many different materials and activities can be incorporated into play therapy, some more verbal and others more hands-on. One of the most classic activities is sandplay. During sandplay sessions, the child is encouraged to play with small objects or toys in a tray of sand, and the therapist observes the way in which the he plays, including which objects he uses and what he does with them. After watching a while, a therapist might ask the child to talk about why he chose to do certain things, like drawing a line between one toy and all the others. Other therapists might just observe him and then draw conclusions about his state of mind.
Therapists also commonly encourage children to use puppets or toys that represent themselves to talk, since they often find it easier to face uncomfortable topics if they can distance themselves. Another technique that might be used to help an anxious child is blowing bubbles. In this activity, the therapist and the child blow bubbles together, and the child learns to take deep, slow breaths — just as if he were blowing a big bubble — when he feels anxious. There's no definitive roster of activities that therapists can choose from, and some design their own techniques. All activities are generally tailored to suit the child in the session.
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Cognitive Behavioral Play Therapy
One very effective approach and method I offer children, teens and their families is Cognitive Behavioral Play Therapy (CBPT).
"You can discover more about a person in an hour of play… than in a year of conversation" Plato
What is CBPT?
Cognitive behavioral play therapy is a type of play therapy which merges the traditional and very successful Cognitive Behavioral Therapy with Play Therapy.
Cognitive Behavioral Therapy - CBT is based on the assumption that what you think affects how you feel and what you do. The research base for CBT and its benefits are lengthy. It has been used successfully with adults, adolescents, and older children. Click here to learn more about CBT. So, why not try CBT with younger children if there is so much success?
Play Therapy - There are many types of play therapy and its history is extensive. However, they all have the foundation of using play as a means to:
● Help prevent children from having difficulties,
● Help young children overcome difficulties, and
● Help young children grow and develop.
Susan Knell began using CBT with play therapy with children in the 1990’s. She began to take traditional cognitive and behavioral strategies and adjust them to the developmental age and needs of her young clients.
By adding play through puppets, dolls, art materials, toy cars and sand boxes, for example, she has been able to offer another treatment option for younger children.
Exactly how can we use CBT and Play Therapy?
CBPT could help an aggressive child learn new ways of coping. Using puppets and various situations that could cause a child to show aggression, the therapist uses puppets and shows other forms of acting. After the therapist has displayed a healthier way to cope the child is encouraged, via puppets, to model the healthy behavior.
This technique is used to:
● process a child’s aggression
● show new skills
● offer opportunities for discussion
● model new skills, and
● work through problems the child may be experiencing.
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What types of problems is CB Play Therapy helpful?
Play therapy has been found to be an effective treatment avenue for children (Bratton, Ray, Rhine, and Jones, 2005).
Specifically, CBPT has been found to be successful in treating selective mutism, anxiety disorders, separation anxiety, sexual abuse, sleep problems, acting out behavior, and the effects of parental divorce (Knell, 1993a; Knell, 1993b; Knell, 1999; Knell, 2000; Knell and Darsari, 2006; Knell and Ruma, 1996, 2003).
By implementing play with CBT techniques, CBPT gives an opportunity to work with younger children and to offer another treatment option.
What does Cognitive Behavior Play Therapy look like?
In the beginning the therapist may choose to meet with just the parents to complete a clinical interview, gather history, orientate them to CBPT, and to provide psycho-educational material. Within this interview the therapist may assist parents in introducing their child to therapy.
When the child is introduced to CBPT and therapy begins, the therapist will gage the child, the issues, and decided on direction. The first task within CBPT is to make sure the child understands the therapy.
One excellent book about CBPT is " A Child's First Book about Play Therapy" written by Nemiroff and Annuziata. It is a great book for explaining play therapy and what therapy will look like to a child.
In CBPT the goal is for the therapy to be directed by both the therapist and the child.
However, the direction can look differently with each session depending on the issues, the goals for therapy, the child’s developmental level, what is happening in the child’s life currently, and the personality of the child.
Sessions will last up to 40 minutes depending on the child with 10 minutes for the therapist, child, and parents to review the session and to determine homework for the coming week. It is very important that the child and parents work on tasks from play therapy in their home environment. These tasks helps the child move skills from the play therapy room to his or her life.
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Cognitive Behavior Play Therapy is:
● structured
● goal orientated
● short-term
● collaborative with the child and its family
● guided by both the child and the therapist
● play based
● psycho-educational
CBPT values and fosters a positive therapeutic relationship as a way for the child to feel safe, to express his or herself, and to work through difficult struggles.
Why choose CBPT for my child?
Children spend a great deal of time playing and there is an important developmental reason for this…
Children learn through play!
Children can:
a. Learn about their world through play
b. Play to model behaviors shown to them
c. Process what is happening in their lives through play
d. Experiment through play
e. Develop many skills through play.
Play is an important vehicle for children to not only discover, but to review and move forward in their development.
How can I help as a parent or guardian?
Parents please take time to play with your child or children. Take 15 minutes a day to let them decide what you are going to play with and allow them to direct the play. You will be amazed at what you learn from your child or children. Play can open doors you would never expect and allow communication between you and your child in a non threatening way.
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Where can I learn more about CBPT?
The following resources are helpful if you wish to learn more about CBPT:
Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of the outcome research. Professional Psychology: Research and Practice, 36(4), 376-390.
Drewes, A. A. (2009). Blending play therapy with cognitive behavior therapy. New Jersey: Wiley.
Knell, S. M. (1993a). Cognitive behavior play therapy. Northvale, NJ: Jason Aronson.
Knell, S. M. (1993b). To show and not tell: Cognitive-behavior play therapy in the treatment of electivmutism. In T. Kottman and C. Schaefer (Eds.), Play therapy in action: A casebook for practitioners (pp. 169-208). Northvale, NJ: Jason Aronson.
Knell, S.M. (1999). Cognitive behavioral play therapy. In S.W. Russ & T. Ollendick (Eds.), Handbook of psychotherapies with children and families (pp. 385-404). New York: Plenum.
Knell, S.M. (2000). Cognitive behavior play therapy with children with fears and phobias. In H.G. Kaduson & C.E. Schaefer (Eds.), Short term therapies with children (pp. 3-27). New York: Guilford.
Knell, S.M., & Dasari, M. (2006). Cognitive behavioral play therapy for children with anxiety and phobias. In H.G. Kaduson & C. E. Schaefer (Eds.), Short-term therapies with children (2nd ed., pp.22-50). New York: Guilford.
Knell, S. M., & Ruma, C.D. (1996). Play therapy with sexually abused children. In M. Reinecke, F. M. Dattilio, & A. Freeman (Eds.), Cognitive therapy with children and adolescents. A casebook for clinical practice (pp. 367-393). New York: Guilford.
Knell, S. M., & Ruma, C. D. (2003). Play therapy with a sexually abused child. In M. Reinecke, F. M. Dattilio, & A. Freeman (Eds.), Cognitive therapy with children and adolescents. A casebook for clinical practice (2nd ed., pp. 338-368). New York: Guilford.
FOR CHILDREN AND ADOLESCENTS
Adjustment Disorders:
CBT is used to improve age-appropriate problem-solving skills, communication skills, and stress management skills. It also helps the child’s emotional state and support systems to enhance adaptation and coping.Stress management is particularly beneficial in cases of high stress.Group therapy is beneficial in cases of high stress.Family therapy helps in making needed changes within the family system. These changes may include improving communication skills and family interactions and increasing support among family members.
Attention Deficit Hyperactivity Disorder (ADHD)
● Behavioral Parent Training (BPT) BPT teaches the parent to implement contingency management strategies similar to BCM techniques at home.
● Intensive Behavioral Peer
● Intervention (BPI) Intensive BPI is conducted in recreational settings, such as Summer Treatment Programs (STPs) have demonstrated.
MEDICATIONS
● Dextroamphetamine
● Stimulant Dexmethylphenidate,
● Methylphenidate
● Alpha2-adrenergic Agonists:
● Clonidine Guanfacine
●
● Short-acting: Adderall, Dexedrine, Procentra
● Long-acting: Dexedrine Spansule, Adderall XR, lisdexamfetamine
● Atomoxetine (Strattera) is unique in its ability to act on the brain’s norepinephrine transporters without carrying other medications’ risk for addiction.
● Kapvay, Intuniv.
What Does Not Work
● Office-based social skills training
● Traditional talk therapies and play therapy have been demonstrated to have little to no effect on ADHD symptoms.
● Neither once-weekly individual nor group office-based training have demonstrated significant improvement in social skills. (However, intensive group social skills training that uses behavioral interventions is considered well-established.)
● Dietary Interventions
● Other Medications
● Interventions include elimination of food additives, elimination of allergens/sensitivities, and use of nutritional supplements.
● Bupropion (i.e., Wellbutrin), imipramine (i.e., Tofranil), nortriptyline (i.e., Pamelor, Aventil).
Anxiety Disorders
What Works
● Selective Serotonin Reuptake Inhibitors (SSRIs)
● Treatments that involve learning how to replace negative thinking patterns and behaviors with positive ones including homework and exercises.
● Treatment with certain SSRIs.
What Seems to Work
Not Adequately Tested
● Therapy that uses self-guided play to encourage expression and healing.
● Non-SSRI Medication
● Treatment with antihistamines or neuroleptics
● Psychodynamic Therapy
● Therapy designed to uncover unconscious psychological processes.
● Biofeedback
● Minimal support.
Autism Spectrum Disorder (ASD)
What Works
Applied Behavior Analysis (ABA)
Behavioral intervention aimed at improving cognitive, language, communication, and socialization skills characterized by on-going and objective measurement of behaviors, implementation of individualized curricula, selection and systematic use of reinforcers, use of functional analysis to identify factors that increase or inhibit behaviors.
Discrete Trial Teaching (DTT)
Behavioral intervention based on principles of operant learning; incorporates units of instruction used to teach and assess acquisition of basic skills.
Incorporates same sequential components regardless of skills taught.
Pivotal Response Training (PRT)
Focuses on the most disabling areas of a child’s autism by teaching children
to respond to multiple environmental cues, increasing motivation, increasing
capacity for self-management, and increasing self-initiations.
Learning Experiences: An Alternative
Peer-mediated interventions in an educational setting with children with
Program (LEAP) autism. Individualized, data-driven, and focused on generalizing learning
skills across context through saturation of learning opportunities throughout day. Family involvement is a significant part of this intervention.
Pharmacological Treatments
May be considered for maladaptive behaviors when symptoms cause
significant impairment. Antipsychotics may be used to treat aggression.
What Seems to Work
Educational and Communication- focused Interventions (TEACCH)
TEACCH (Treatment and Education of Autistic and Communication related handicapped Children) provides strategies that support the individual throughout his or her lifespan, facilitates autonomy at all levels of functioning, and accommodates individual needs.
Natural Language Methods
Speech and language pathologists often integrate communication training
with the child’s behavior program to provide a coordinated opportunity for
structured and naturalistic language learning. Instruction is designed to
provide a generative tool that will serve needs throughout the child’s life.
Picture Exchange Communication
Helps children with Autism Spectrum Disorders (ASD) acquire functional
System (PECS) communication skills. Children using PECS are taught to give a picture of a desired item to a communication partner in exchange for the item, thus linking an outcome with communication.
Other Behavioral Interventions
Joint attention behavior training, which may be especially beneficial in young, pre-verbal children, shows promise for teaching children with autism behavioral skills. Social skills groups, social stories, visual cueing, social games, video modeling, scripts, peer-mediated techniques, and play and leisure curricula are also supported by the literature.
Occupational Therapy
Occupational therapy helps develop self-care skills and shows promise in promoting play skills and establishing routines to improve attention and organization.
What Does Not Work
● Avoiding Immunizations
● Research has shown secretin does not help with any autism symptoms.
● A new study evaluating parents’ concerns of "too many vaccines too soon" and autism has been published online in the Journal of Pediatrics (March 29, 2013). It adds to the conclusion of a 2004 comprehensive review by the Institute of Medicine (IOM) that there is not a causal relationship between certain vaccine types and autism.
What Works
Cognitive Behavioral Therapy (CBT)
The most effective independent treatment option; it is used to change underlying eating disorder cognitions and behaviors.
Pharmacological Treatments
Antidepressants, namely Selective Serotonin Reuptake Inhibitors (SSRIs), have effectively reduced binge/purging behaviors, as well as comorbid psychiatric symptoms.
Combined Treatments
A combination of CBT and pharmacotherapy seem to maximize treatment outcomes.
What Does Not Work
● Behavioral Therapy: Compared to CBT, few individual therapeutic approaches have been effective in reducing symptoms.
● Behavioral techniques, such as exposure, have been less effective than CBT techniques.
Twelve-Step Programs
Not yet tested for efficacy and are discouraged as a sole treatment.
Depression/Dysthymia - Interventions for Children
What Works
Stark’s Cognitive Behavioral Therapy Stark’s CBT - child- only group or child group plus parent component (CBT) includes mood monitoring, mood education, increasing positive activities
and positive self statements, and problem solving.
What Does Not Work
Penn Prevention Program (PPP)
Self-Control Therapy
Behavioral Therapy
A CBT-based program that targets pre-adolescents and early adolescents who are at risk for depression.
A school-based CBT that focuses on self-monitoring, self-evaluating and causal attributions.
Includes pleasant activity monitoring, social skills training and relaxation.
Depression/Dysthymia - Interventions for Adolescents
What Works
Cognitive Behavioral Therapy (CBT)
CBT for depression focuses on identifying thought and behavioral patterns that
provided in a group setting
lead to or maintain the problematic symptoms.
Interpersonal therapy (IPT)
In IPT, the therapist and patient address the adolescent’s interpersonal
provided individually
communication skills, interpersonal conflicts, and family relationship problems.
Selective Serotonin Reuptake
Fluoxetine (Prozac, Sarafem, Fontex) and Escitalopram (Lexapro). Most
Inhibitors (SSRIs)
effective when combined with CBT although there is debate about the use of
SSRIs to treat depression in youth.
What Seems to Work
CBT provided in a group or individual setting with a parent/family component
Adolescent Coping with Depression (CWD-A)
Interpersonal Psychotherapy for Depressed Adolescents (IPT-A)
CBT for depression focuses on identifying thought and behavioral patterns that lead to or maintain the problematic symptoms.
Includes practicing relaxation and addressing maladaptive patterns in thinking, as well as scheduling pleasant activities and learning communication and conflict resolution skills.
Addresses the adolescent’s specific interpersonal relationships and conflicts, and helps the adolescent be more effective in his or her relationships with others.
Disruptive Behavior Disorders
What Works
Assertiveness training: Group
School-based group treatment for middle school youth
Assertive Training
Parent Management Training (PMT)
Programs that focus on teaching and practicing parenting skills with parents or caregivers include:
Programs
•Helping the Noncompliant Child
•Incredible Years Parent-Child Interaction Therapy
•Parent Management Training to Oregon Model
•Positive Parenting Program
Multisystemic Therapy (MST)
An integrative, family-based treatment for youth with serious antisocial and
delinquent behavior. Interventions last three to five months and focus on
improving psychosocial functioning for young people and families.
Cognitive Behavioral Therapy (CBT)
CBT emphasizes problem solving skills and anger control/coping strategies and includes:
•Problem-Solving Skills Training
•Anger Control Training
CBT & Parent Management Training
Combines CBT and PMT
(PMT)
What Seems to Work
Multidimensional Treatment Foster
Community-based program alternative to institutional, residential and group
Care (MTFC) care placements for use with severe chronic delinquent behavior. Foster
parents receive training and provide intensive supported treatment within the foster home setting.
Disruptive Behavior Disorders
Notes About Medications
Assertiveness training: Group
School-based group treatment for middle-school youth
Assertive Training
According to the American Academy of Pediatrics, the US Food and Drug Administration (FDA) has no approved indications for aggression in children and adolescents apart from irritability-associated aggression in children with autism. In other populations, recent federally supported, evidence-based reviews suggest efficacy for some psychotherapeutic agents, but primary care clinicians are urged to consult with mental health specialists before prescribing medications for aggression.
Medications are frequently used to treat comorbid conditions and are sometimes used off-label treat aggression.
Antipsychotics
Risperidone (risperdal), quetiapine (seroquel), olanzapine (zyprexa), and
Abilify (aripiprazole). Limited evidence for effectiveness in youth with intellectual disability or pervasive developmental disorder.
Stimulant or Atomoxetine
Methylphenidate, d-Amphetamine, atomoxetine. Limited evidence when comorbid with primary diagnosis of ADHD.
Mood Stabilizers
Divalproex sodium, lithium carbonate. Limited evidence when comorbid with primary diagnosis of bipolar disorder.
Selective Serotonin Reuptake
Limited evidence when comorbid with primary diagnosis of depressive Inhibitors (SSRIs)
Disorder.
What Does Not Work
Boot camps, shock incarcerations
Ineffective at best; can lead worsening of symptoms.
Dramatic, short-term or talk therapy
Little to no effect as currently studied.
Early-onset Schizophrenia
What Works
Schizophrenia is a major psychiatric illness that calls for careful, often complex and lifelong treatment. A combination of therapies is usually necessary to effectively manage the disease. Since there is no known cure for schizophrenia, treatment is aimed at reducing the severity of the disorder’s impact on life and helping the child manage symptoms.
What Seems to Work
Medication
According to National Alliance on Mental Illness, the following second generation antipsychotics are FDA approved for early onset schizophrenia in youth ages 13-17: rispiridone (Resperidol), aripipazole (Abilify), quetiapine (Seroquel) and olanzapine (Zyprexa). Several other medications are often used off-label to treat schizophrenia.
Individual Psychotherapy
Family Psychotherapy and Support
Focused on coping with the stress and daily life challenges brought on by schizophrenia and reducing symptoms.
Helps to improve family functioning, problem-solving, communication skills, and decrease relapse rates.
Social and Academic Skills Training
Includes social skills training, problem-solving, and self-help skills.
What Does Not Work
Psychodynamic Therapy
May be harmful for this population.
Habit Disorders
What Works
Habit Reversal Therapy for Tic Disorder
Treatment increases awareness of the feelings and context associated with the urges and implements a competing and inconspicuous habit in place of the tic.
What Seems to Work
Cognitive Behavioral Therapy (CBT) for recurrent hair-pulling (trichotillomania [TTM])
Treatment involves exposing children to the stimuli associated with the urge while challenging thoughts associated with high-risk situations.
Not Adequately Tested
Massed Negative Practice
Treatment involves over-rehearsal of target tic in high-risk ticking situations.
Pharmacotherapy
Prescription medications to treat habit disorders in children.
What Does Not Work
Plasma Exchange or Intravenous
Blood transfusions to alter levels of plasma or immunoglobulin.
Immunoglobulin Treatment (IVIG)
Juvenile Fire Setting
What Works
Currently no medication or psychological treatments meet these criteria.
What Seems to Work
Cognitive Behavioral Therapy (CBT) Structured treatments designed to intervene with children who set fires.
What Does Not Work
Ignoring the problem
Leaving youth untreated is not beneficial because they typically do not outgrow this behavior and ignoring these behaviors may even increase dysfunctional behavior patterns.
Satiation
The practice of repetitively lighting and extinguishing fire. Satiation may cause
youth to feel more competent around fire and actually increase the behavior.
Youths in the Juvenile Justice System
What Works
Multisystemic Therapy (MST)
Integrative, family-based treatment with a focus on improving psychosocial functioning for youth and families.
Functional Family Therapy (FFT)
Family-based program that focuses on delinquency, treating maladaptive and acting out behaviors, and identifying obtainable changes.
Multidimensional Treatment Foster
As an alternative to corrections, MTFC places juvenile offenders Care (MTFC)
who require residential treatment with carefully trained foster families who provide youth with close supervision, fair and consistent limits, consequences and a supportive relationship with an adult.
Cognitive Behavioral Therapy
Structured, therapeutic approach that involves teaching youth (CBT)
about the thought-behavior link and working with them to modify their thinking
patterns in a way that will lead to more adaptive behavior in challenging situations.
Dialectical Behavior Therapy
Therapeutic approach that includes individual and group therapy components
and specifically aims to increase self-esteem and decrease self-injurious
behaviors and behaviors that interfere with therapy.
What Seems to Work
Family Centered Treatment (FCT)
FCT seeks to address the causes of parental system breakdown while integrating behavioral change. FCT provides intensive in home services and is structured into four phases: joining and assessment; restructuring; value change; and generalization.
Brief Strategic Family Therapy
A short-term, family-focused therapy that focuses on changing family
interactions and contextual factors that lead to behavior problems in youth.
Aggression Replacement Therapy
A short-term, educational program that focuses on anger management and
provides youth with the skills to demonstrate non-aggressive behaviors,
(ART) decrease antisocial behaviors, and use prosocial behaviors.
Non-Suicidal Self-Injurious Behavior (NSIB)
What Works
Currently no medication or psychological treatments meets these criteria.
What Seems to Work
Cognitive Behavioral Therapy
Involves providing skills designed to assist youth with affect regulation and
(CBT) problem solving skills.
Dialectical Behavior Therapy (DBT)
Similar to CBT, but additionally involves an emphasis on acceptance strategies.
Obsessive-compulsive Disorder
What Works
Exposure and Response
Individual child (probably efficacious); family-focused individual and family-
Prevention (ERP) focused group treatments (possibly efficacious). ERP meets well-
established criteria for adult OCD.
Selective reuptake inhibitors (SRIs)
Clomipramine: Approved for children age 10 years of age and older.
Recommend periodic ECG monitoring.
Selective Serotonin Reuptake
Fluoxetine (Prozac): Approved for children 8 years of age and older.
Inhibitors (SSRIs)
Sertraline (Zoloft): Approved for children 6 years of age and older.
Fluvoxamine (Luvox): Approved for children 8 years of age and older.
Not Adequately Tested
Cognitive Therapy only
Systematic controlled studies have not been conducted using these
Psychodynamic Therapy approaches.
Client-centered Therapy
What Does Not Works
Antibiotic Treatments
Antibiotic treatments are only indicated when the presence of an autoimmune or strep-infection has been confirmed and coincided with onset or increased severity of OCD symptoms.
Herbal Therapies
Herbs such as St. John’s Wort have not been rigorously tested and are not
FDA-approved. In some instances, herbal remedies may make symptoms worse or interfere with pharmacological treatment.
Pediatric Bipolar Disorder (PBD)
What Works
Lithium (sometimes known as Eskalith), risperidone (Risperdal), and aripiprazole (Abilify) are the only medications approved by the U.S. Food and Drug Administration (FDA) to treat bipolar disorder in young people.
What Seems to Work
Other Medications are sometimes used off-label to treat bipolar disorder.
Anticonvulsants
Valproic acid or divalproex sodium (Depakote), lamotrigine (Lamictal),
carbamazepine (Tegretol), valproate (Depakene).
Antipsychotics
Clozapine, olanzapine, quetiapine, ziprasidone
Family-focused Psychoeducational
Family therapy format. Helps adolescents make sense of their illness, along
with their medications. Also helps to manage stress, reduce negative life
events and promote a positive family environment.
Child and family-focused Cognitive
Emphasizes individual psychotherapy with children and parents, parent
Behavioral Therapy (CFF-CBT)
training and support, and family therapy.
Multifamily Psychoeducation Groups (MFPG)
Child and parent group therapy has been shown to increase parental
knowledge and social support and promote access to services.
Not Adequately Tested
Interpersonal social rhythm therapy
No current evidence of its usefulness for youth, but has been found to be effective in adults.
Sexual Offending
What Works
Currently no medication or psychological treatments meets these criteria.
What Seems to Work
Multisystemic Therapy (MST)
Residential Sexual Offender
Treatment
Community-based Programming
Intensive family and community-based treatment addressing the multiple factors of serious antisocial behavior in juvenile sexual abusers.
May be necessary for public safety; for offenders, addresses both
sexual and non-sexual behaviors and provides milieu treatment that varies.
Effective element to treatment continuum; offers advantage of shortening residential lengths of stay, improving post-residential
transitioning.
Not Adequately Tested
Selective Serotonin Reuptake
Impacts sexual preoccupations, sex drive and arousal.
Inhibitors (SSRIs)
Substance Use Disorders
What Works
Cognitive Behavioral Therapy (CBT)
A structured therapeutic approach to teaching youth about the thought-behavior link and working with them to modify their thinking patterns in a way that leads to more adaptive behavior in challenging situations.
Family Therapy
Aimed at providing education, improving communication and functioning
among family members, and reestablishing parental influence through parent
management training. NOTE: Only specific family therapies have been tested;
not ALL family therapies are considered effective.
Multisystemic Therapy (MST)
Motivational Interviewing
Approaches
An integrative, family-based treatment focusing on improving psychosocial functioning for youth and families.
A brief treatment approach to increase motivation for behavior change. It focuses on expressing empathy, discrepancies, avoiding argumentation, rolling with resistance, and supporting self-efficacy.
What Seems to Work
Behavioral Therapies
Some Medications
Treatment that focuses on identifying specific problems and areas of deficit and working on improving these behaviors.
Psychopharmacological medication can be used for detoxification purposes, as directed by a doctor. Medication may also be used to treat co-existing psychological disorders.
Twelve-Step Programs Uses steps as principles for treating addictive behaviors.
What Does Not Work
Ignoring the Problem
Signs of substance abuse should not be ignored in youth.
Blaming/Discounting
Substance abuse can be a serious disorder that requires treatment
that is beyond an individual’s willpower or control.
DARE
Raises awareness about chemical dependency through education and training.
Trauma
What Works
Trauma-focused Cognitive Behavioral Therapy (TF-CBT)
Treatment that involves reducing negative emotional and behavioral responses related to trauma, by providing psychoeducation on trauma, addressing distorted beliefs and attributes related to trauma, and introducing relaxation and stress management techniques.
What Seems to Work
School-Based Group Cognitive
Similar components to TF-CBT, but in a group, school-based format.
Behavioral Therapy (CBT)
Psychodynamic Trauma-focused
Psychotherapies
Eye Movement Desensitization and
Reprocessing (EMDR)
Individualized to meet the specific concerns and needs of each unique trauma survivor with goal of building coping skills.
Uses eye movements, sounds, or pulsations to stimulate the brain. Can create changes in the brain that help the client overcome symptoms.
Not Adequately Tested
Child-centered Play Therapy*
Psychological Debriefing
Therapy that uses child-centered play to encourage expression of feelings and healing.
An approach in which youth talk about the facts of the trauma (and associated thoughts and feelings) and then are encouraged to reenter into the present.
Pharmacological Treatments
Treatment with selective serotonin reuptake inhibitors (SSRIs), betablockers or alpha agonsists.
What Does Not Work
Restrictive rebirthing or holding techniques
Pharmacological Treatments
Restrictive rebirthing or holding techniques may forcibly bind, restrict, coerce, or withhold food or water from children and have resulted in some cases of death and are not recommended.
Treatment with Periactin
Youth Suicide
What Works
Currently no medications/psychological treatments meet this criteria.
What Seems to Work
Dialectical Behavior Therapy (DBT)
Cognitive Behavioral Therapy (CBT)
Interpersonal Therapy
Psychodynamic Therapy
Family Therapy
Selective serotonin reuptake inhibitors (SSRIs) for co-occurring disorders
Outperformed the treatment for the control group in reducing suicide attempts. However, it did not help reduce depressive symptoms.
Psychotherapy, while not by itself an evidence-based practice, is an important component to the treatment of suicidality in youth. All are options when choosing a treatment modality.
Necessary to closely monitor youth taking SSRIs because of the risk that SSRIs can increase suicidality in youth and young adults.
Youth Suicide
What Does Not Work
No-suicide Contracts
Tricyclic Antidepressants
Study findings are diverse; there have been results that have found that contracts reduce suicidal behavior and others suggesting that they increase it.
Effectiveness has not been demonstrated. They can potentially be lethal due to the small difference between therapeutic and toxic doses.
Benzodiazepines
Should be used with great caution as they may result in impulsivity.
Barbiturates
Should be used with great caution as they may result in impulsivity.
Play Therapy Addendum
What are the Different Types of Play Therapy for Children?
Play therapy is a specialized treatment in which therapists watch kids playing and use what they observe to help them deal with emotional, mental, or behavioral issues. There are several different types of play therapy for children, including child-based, family-based, and group-based therapy. All three can be done with different levels of therapist participation. Sessions can include a range of activities, which are usually chosen based on the child's age and preferences.
Three Main Types
One of the most common types of play therapy for children is child-based therapy, in which a therapist and a child work alone. This is often used if there is a concern about the parents or abuse in the family, but can also be done simply to make the child feel more comfortable. It can be used to treat behavioral problems, anxiety, Attention Deficit Disorder (ADD) and Attention Deficit Hyperactivity Disorder (ADHD), Post Traumatic Stress Disorder (PTSD), autism, and the effects of abuse.
Another commonly used technique includes the participation of the child's father, mother, siblings, or other family members. This is called family-based therapy or filial therapy, and is often used when children experience severe separation anxiety or when certain kinds of abuse are possible. The therapist may not always be directly involved in filial therapy sessions, but almost always watches them and discusses the positive and negative points with the parents afterwards. This can be as helpful for parents as for children, since they can learn parenting skills and better their relationship with the child. Classic filial therapy focuses on four main areas — structuring, empathic listening, child-centered imaginary play, and limit-setting — but each session is typically tailored to the family's specific needs.
An additional type of play therapy for children is group-based therapy. During these sessions, a large group of children plays together while the therapist watches and sometimes participates. This is meant to help build better social skills and self-esteem. It can also help therapists to treat individual children by letting them observe how the child interacts with others. It's sometimes used when a child would feel too intimidated to work with a therapist alone, but can also be used as a matter of preference or convenience.
Directive and Non-Directive
Most types of play therapy for children can be done either in a directive or a non-directive manner. The main difference between these is therapist's level of involvement. Both start with the therapist suggesting a general topic or activity, but in directive play therapy, the therapist often asks the child questions throughout the session, encourages him to talk more about certain topics, or participates in activities with the child. In non-directive therapy, the therapist generally just watches the child, and then interprets the results of the activity, like a drawing.
Generally speaking, directive therapy is seen as a Cognitive Behavioral Therapy (CBT), focusing on behavior and conscious actions, while non-directive therapy is often categorized as a psychodynamic theory. This means that it focuses on unconscious actions and beliefs. Both can be used to treat a variety of conditions, but directive therapy is often used with trauma victims, while non-directive therapy may be used to help with behavioral problems. There's no hard and fast rule though, and both therapies have been shown to be effective with many issues.
Materials and Activities
Many different materials and activities can be incorporated into play therapy, some more verbal and others more hands-on. One of the most classic activities is sandplay. During sandplay sessions, the child is encouraged to play with small objects or toys in a tray of sand, and the therapist observes the way in which the he plays, including which objects he uses and what he does with them. After watching a while, a therapist might ask the child to talk about why he chose to do certain things, like drawing a line between one toy and all the others. Other therapists might just observe him and then draw conclusions about his state of mind.
Therapists also commonly encourage children to use puppets or toys that represent themselves to talk, since they often find it easier to face uncomfortable topics if they can distance themselves. Another technique that might be used to help an anxious child is blowing bubbles. In this activity, the therapist and the child blow bubbles together, and the child learns to take deep, slow breaths — just as if he were blowing a big bubble — when he feels anxious. There's no definitive roster of activities that therapists can choose from, and some design their own techniques. All activities are generally tailored to suit the child in the session.
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Cognitive Behavioral Play Therapy
One very effective approach and method I offer children, teens and their families is Cognitive Behavioral Play Therapy (CBPT).
"You can discover more about a person in an hour of play… than in a year of conversation" Plato
What is CBPT?
Cognitive behavioral play therapy is a type of play therapy which merges the traditional and very successful Cognitive Behavioral Therapy with Play Therapy.
Cognitive Behavioral Therapy - CBT is based on the assumption that what you think affects how you feel and what you do. The research base for CBT and its benefits are lengthy. It has been used successfully with adults, adolescents, and older children. Click here to learn more about CBT. So, why not try CBT with younger children if there is so much success?
Play Therapy - There are many types of play therapy and its history is extensive. However, they all have the foundation of using play as a means to:
● Help young children overcome difficulties, and
● Help young children grow and develop.
Susan Knell began using CBT with play therapy with children in the 1990’s. She began to take traditional cognitive and behavioral strategies and adjust them to the developmental age and needs of her young clients.
By adding play through puppets, dolls, art materials, toy cars and sand boxes, for example, she has been able to offer another treatment option for younger children.
Exactly how can we use CBT and Play Therapy?
CBPT could help an aggressive child learn new ways of coping. Using puppets and various situations that could cause a child to show aggression, the therapist uses puppets and shows other forms of acting. After the therapist has displayed a healthier way to cope the child is encouraged, via puppets, to model the healthy behavior.
This technique is used to:
● show new skills
● offer opportunities for discussion
● model new skills, and
● work through problems the child may be experiencing.
What types of problems is CB Play Therapy helpful?
Play therapy has been found to be an effective treatment avenue for children (Bratton, Ray, Rhine, and Jones, 2005).
Specifically, CBPT has been found to be successful in treating selective mutism, anxiety disorders, separation anxiety, sexual abuse, sleep problems, acting out behavior, and the effects of parental divorce (Knell, 1993a; Knell, 1993b; Knell, 1999; Knell, 2000; Knell and Darsari, 2006; Knell and Ruma, 1996, 2003).
By implementing play with CBT techniques, CBPT gives an opportunity to work with younger children and to offer another treatment option.
What does Cognitive Behavior Play Therapy look like?
In the beginning the therapist may choose to meet with just the parents to complete a clinical interview, gather history, orientate them to CBPT, and to provide psycho-educational material. Within this interview the therapist may assist parents in introducing their child to therapy.
When the child is introduced to CBPT and therapy begins, the therapist will gage the child, the issues, and decided on direction. The first task within CBPT is to make sure the child understands the therapy.
One excellent book about CBPT is " A Child's First Book about Play Therapy" written by Nemiroff and Annuziata. It is a great book for explaining play therapy and what therapy will look like to a child.
In CBPT the goal is for the therapy to be directed by both the therapist and the child.
However, the direction can look differently with each session depending on the issues, the goals for therapy, the child’s developmental level, what is happening in the child’s life currently, and the personality of the child.
Sessions will last up to 40 minutes depending on the child with 10 minutes for the therapist, child, and parents to review the session and to determine homework for the coming week. It is very important that the child and parents work on tasks from play therapy in their home environment. These tasks helps the child move skills from the play therapy room to his or her life.
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Cognitive Behavior Play Therapy is:
● goal orientated
● short-term
● collaborative with the child and its family
● guided by both the child and the therapist
● play based
● psycho-educational
CBPT values and fosters a positive therapeutic relationship as a way for the child to feel safe, to express his or herself, and to work through difficult struggles.
Why choose CBPT for my child?
Children spend a great deal of time playing and there is an important developmental reason for this…
Children learn through play!
Children can:
a. Learn about their world through play
b. Play to model behaviors shown to them
c. Process what is happening in their lives through play
d. Experiment through play
e. Develop many skills through play.
Play is an important vehicle for children to not only discover, but to review and move forward in their development.
How can I help as a parent or guardian?
Parents please take time to play with your child or children. Take 15 minutes a day to let them decide what you are going to play with and allow them to direct the play. You will be amazed at what you learn from your child or children. Play can open doors you would never expect and allow communication between you and your child in a non threatening way.
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Where can I learn more about CBPT?
The following resources are helpful if you wish to learn more about CBPT:
Bratton, S., Ray, D., Rhine, T., & Jones, L. (2005). The efficacy of play therapy with children: A meta-analytic review of the outcome research. Professional Psychology: Research and Practice, 36(4), 376-390.
Drewes, A. A. (2009). Blending play therapy with cognitive behavior therapy. New Jersey: Wiley.
Knell, S. M. (1993a). Cognitive behavior play therapy. Northvale, NJ: Jason Aronson.
Knell, S. M. (1993b). To show and not tell: Cognitive-behavior play therapy in the treatment of electivmutism. In T. Kottman and C. Schaefer (Eds.), Play therapy in action: A casebook for practitioners (pp. 169-208). Northvale, NJ: Jason Aronson.
Knell, S.M. (1999). Cognitive behavioral play therapy. In S.W. Russ & T. Ollendick (Eds.), Handbook of psychotherapies with children and families (pp. 385-404). New York: Plenum.
Knell, S.M. (2000). Cognitive behavior play therapy with children with fears and phobias. In H.G. Kaduson & C.E. Schaefer (Eds.), Short term therapies with children (pp. 3-27). New York: Guilford.
Knell, S.M., & Dasari, M. (2006). Cognitive behavioral play therapy for children with anxiety and phobias. In H.G. Kaduson & C. E. Schaefer (Eds.), Short-term therapies with children (2nd ed., pp.22-50). New York: Guilford.
Knell, S. M., & Ruma, C.D. (1996). Play therapy with sexually abused children. In M. Reinecke, F. M. Dattilio, & A. Freeman (Eds.), Cognitive therapy with children and adolescents. A casebook for clinical practice (pp. 367-393). New York: Guilford.
Knell, S. M., & Ruma, C. D. (2003). Play therapy with a sexually abused child. In M. Reinecke, F. M. Dattilio, & A. Freeman (Eds.), Cognitive therapy with children and adolescents. A casebook for clinical practice (2nd ed., pp. 338-368). New York: Guilford.
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