An empirical analysis of mental state talk and affect regulation in two single-cases of psychodynamic child therapy.

Literature has shown the importance of mentalizing techniques in symptom remission and emotional understanding; however, no study to date has looked at the dynamic relations between mental state talk and affect regulation in the psychotherapy process. From a psychodynamic perspective, the emergence of the child's capacity to regulate affect through the therapist's reflection on the child's mental states is a core aspect of treatment. In an empirical investigation of 2 single cases with separation anxiety disorder, who were treated in long-term psychodynamic play therapy informed with mentalization principles, the effect of therapists' and children's use of mental state talk on children's subsequent capacity to regulate affect in play was assessed. One case was a positive outcome case, whereas the other did not show symptomatic improvement at the end of treatment. Children's and therapists' utterances in the sessions were coded using the Coding System for Mental State Talk in Narratives, and children's play was coded by Children's Play Therapy Instrument, which generated an index of children's "affect regulation." Time-series Granger Causality tests showed that even though both therapists' use of mental state talk significantly predicted children's subsequent affect regulation, the association between child's mental state talk and affect regulation was only supported for the child who showed clinically significant symptom reduction. This study provided preliminary support that mental state talk in psychodynamic psychotherapy facilitates emotion regulation in play. (PsycINFO Database Record

Short-term psychoanalytic child therapy for anxious children: a pilot study.

Few studies report treatment outcome for early childhood internalizing disorders following psychotherapy, especially psychodynamic techniques. We aimed to investigate effectiveness of a novel, developmentally appropriate, short-term psychodynamic treatment program for 4- to 10-year-olds with anxiety disorders in an outpatient setting. We conducted a quasi-experimental wait-list controlled study. Thirty children (12 females) with Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) anxiety disorders and their families received 20-25 sessions of manualized short-term Psychoanalytic Child Therapy (PaCT). We assessed outcome with standardized diagnostic interviews and parent reports of internalizing and total problems at all time points. Child puppet interviews and teacher reports were also available for pre-post treatment and follow-up analyses. While 18 families entered treatment immediately, 12 families were first wait-listed before receiving treatment. Analyses of symptom improvement were based on comparisons between groups (treatment vs. wait-list) as well as pre-post and 6-month follow-up data across all families (including wait-listed families). Among the 27 completers, 66.67% (n = 18) no longer met criteria for any anxiety disorder (59.88% in intent-to-treat analysis) while no children remitted across the wait-list interval. Parent-reported child internalizing and total problems significantly declined during treatment relative to wait-list. Child and teacher reports also revealed significant pre-post symptom reductions on internalizing and total problems. Diagnostic and symptom remission rates were maintained at 6-month follow-up except on child reports. This preliminary study adds to a growing database showing that psychodynamic treatments may offer an effective line of treatment for childhood internalizing symptoms and disorders in the eyes of clinicians, children, parents, and teachers.

Relational trauma: using play therapy to treat a disrupted attachment.

Caregiver-child attachment results in a cognitive-emotional schema of self, other, and self-other relationships. Significantly disrupted attachments may lead to pathogenic internal working models, which may have deleterious consequences; this indicates the need for early attachment intervention. The authors consider the therapy of a 3-year-old boy with aggressive behaviors who had lacked consistent caregiving. Attachment theory can account for the child's psychotherapeutic gains, despite his insecure attachment style. The authors discuss discrepancies between treatment and current research trends.

An unusual clinical phenomenon: a case of bedtime ritual with apparent sexual overtones.

A 6-year-old boy attended a psychology clinic with a history of separation anxiety, delayed bedtime and problematic daytime behaviour. In addition, his mother described that at bedtime he would rock over a particular soft toy (teddy bear) on the floor of his bedroom with the bear straddled between his legs in what appeared to be a sexualized ritual. Clinical history taking and a psychological assessment led to a diagnosis of Separation Anxiety and sleep related Rhythmic Movement Disorder (RMD). Systematic desensitization, token-reward systems and play therapy were used to reduce separation anxiety. Alternative bedtime rocking routines without sexual overtones were developed and resulted in reduced time for sleep initiation, increased total sleep time and improved daytime behaviour. This case study demonstrates a case of severe RMD used as a self-soothing and anxiety-reduction strategy which was initially misinterpreted as a sexualized activity. Caution should be exercised in misinterpreting similar case presentations. Correct diagnosis was increased in this case with a psychologist with expertise in sleep and therefore presents a potentially unmet clinical need for sleep psychologists.

Clinical presentation and treatment outcome for children with comorbid externalizing and internalizing symptoms.

This study examined the effects of comorbid separation anxiety disorder (SAD) on the expression of externalizing symptoms in children presenting with oppositional defiant disorder (ODD) as well as the treatment effects on anxiety and internalizing symptoms. Participants were 64 children with ODD seen in parent-child interaction therapy (PCIT), including 15 children with comorbid SAD. Children with ODD+SAD did not differ from children with ODD only in disruptive behavior severity at pre-treatment assessment, and children with ODD+SAD showed significant decreases in SAD symptoms at post-treatment. Additionally, children with clinical levels of internalizing behavior demonstrated significant reductions in these symptoms, along with reduction of externalizing symptoms targeted in treatment. We discuss the possibility that treatments focusing on parent-child interactions and certain parenting skills may generalize across specific child symptom constellations.

Placebo neural systems: nitric oxide, morphine and the dopamine brain reward and motivation circuitries.

Evidence suggests that the placebo response is related to the tonic effects of constitutive nitric oxide in neural, vascular and immune tissues. Constitutive nitric oxide levels play a role in the modulation of dopamine outflow in the nigrostriatal movement and the mesolimbic and mesocortical reward and motivation circuitries. Endogenous morphine, which stimulates constitutive nitric oxide, may be an important signal molecule working at mu receptors on gamma aminobutyric acid B interneurons to disinhibit nigral and tegmental dopamine output. We surmise that placebo induced belief will activate the prefrontal cortex with downstream stimulatory effects on these dopamine systems as well as on periaqueductal grey opioid output neurons. Placebo responses in Parkinson's disease, depression and pain disorder may result. In addition, mesolimbic/mesocortical control of the stress response systems may provide a way for the placebo response to benefit other medical conditions.

The use of child-centered play therapy and filial therapy with Head Start families: a brief report.

Play therapy and filial therapy show promise as effective ways to provide direct services to Head Start, addressing the needs of the children, the families, and the Head Start teachers and staff. This paper examines the utility of play and filial therapies for the Head Start population, presents a systemic explanation for the benefit of filial therapy, and provides a case example for illustration.

Restoration of play in a severely burned three-year-old child.

The critical importance of play in a child's life and, more specifically, to successful adaptation to trauma and disability is illustrated in the case report of a severely burned 3-year-old. Loss of interest in play is frequently seen in depressed children and in children whose physical ability to play has been constrained by physical illness, injury, or acquired disability. Play is important to the development of cognition, affectivity, and social learning, dimensions central to coping behavior. The aim of therapeutic treatment of a child whose interest in and ability to play have significantly declined is to physically and psychologically mobilize the patient to restore play and to free up the emotions, enhancing the child's ability to actively participate in and optimally benefit from the rehabilitation program. Clinical analysis of a 3-year-old's symbolic play and therapeutic interventions are presented.

Divorce at midlife: psychic dangers of the liminal period. Part II. Clinical considerations.

This paper presents the results of a clinical investigation into middle divorce. The second of a two part series, it explores the impact of liminality: the "betwixt and between" state often found among a newly-separated of all ages. This state may occur at more than one point in the divorce process, and is associated with heightened trauma. A therapeutic intervention procedure, the divorce ritual, is suggested as a means of ameliorating the effects of liminality.

Drawings as a therapeutic medium. The treatment of separation anxiety in a 4-year-old boy.

This paper describes a 4-year-old boy whose presenting problem was anxiety. The treatment used is of particular interest because of the graphic exposition of the development of the therapeutic alliance, the immediacy of the Oedipal issues, and the usefulness of child's drawings as a therapeutic medium. The phases of therapy are reflected in the drawings, as is identification with the therapist and the integration of loss when patient and therapist terminate.

An approach to working with the "placed child".

This paper presents an approach to working with the diagnostic and therapeutic challenges posed by the "placed child". A thorough knowledge of child development, combined with awareness of the basic tenets of crisis intervention, offers the child mental health professional guidelines to assist placed children in coping with their uncertain environment. Parents and agencies are guided toward stabilizing the child's environment, while the child is maintained in play therapy to assist him in coping with the confused and frightening emotions that attend the experience of placement separation. Three clinical cases are presented that illustrate an active short-term therapy, a form of primary prevention attempting to forestall the potential damage of unresolved placement separation crises.