i ~

CLINICAL PERSPECTIVES Associate Editor: Michael S. ]ellinek, MD.

f conver_

d. Pacific Brief Psychodynamic Psychotherapy With Young Children

~scents:a
':179-184
ROBERT ]. RACUSIN, M.D.
l srudy of
\,..
nversion
ence. Eur
Specifi.ctechniques for brief dynamic psychotherapy are nowwell munication (Greenspan, 1996). In addition, the child should
reacrions. established for adults (Davanloo, 1978; Mann, 1973; Piper et al., have some capacity to use fantasy to express important mental
1990; Sifneos, 1987). These approaches are rypically character- content, e.g., wishes, fears.
body Ian-
rhe man- ized by a single dynamic focus, selection of highly motivated , 3. Active Parent Involvement. At least one parent or guardian
80:46-52 nonpsychotic pacients with high-quality object relations and a must be willing and able to attend parent sessions and im-
nenr of a
limited number of sessionsestablished at the outset of eatment . plement suggestions for behavioral management or other
Psychiatry

LeuroIogi-
115-119
f children
!
'. Brief psychodynamic therapy models that use a fi.xednumber of
_ sessionshave also been adapted for use with selectedchild pacients
(Dulcan, 1984). Based on work with adults, some approaches
strategies.

Identifying the Focus of reatment

785-788 have included the idea of a "focalissue" and the use of a contem -
~cence: a porary understanding of a "corrective emotional experience "
ies. J Am '<
(Proskauer, 1969, 1971), while others have emphasized concomi -
tant work with the family by a single therapist (Lester, 1968 ;
, Conver-
, pauents. MacKay, 1967; Turecki, 1982). This report describes a further
extension of the use of these mode1sof short-term dynamic psy-
c nver -
iatrScand chotherapy that is applicable to children between ages 3 an:d 7
years.While still relying on a fi.xednumber of sessions,there is a
Lringwirh
lessenedemphasis on cimeand more on the expeCtationof "being
ready' to terminate eatment, reflecting young childrens cogni-
dren and
tive limitacions regarding concepts of tirne .
I rehabili-
77
)f chronic
:379-401
Patient Selection
As with all children, there are 3 primary considerations in
assigning patients to this type of treatment :
1. A Specijic, Circumscribed Set 01Symptoms or Developmental
Interftrence. To focus interpretations with precision, symptoms
must be understood as manifestacions of a central conflict that
C<Ul be defi.ned in ~t:rms of s uctural, ego psychology, or object
re1ations theory. Target symptoms should not be manifesta -
cions of psychosis, pervasive developmental disorder, untreated
attention-deficit/hyperactivity disorder, a chaotic or unsafe
environment, or a fundamental disorder of attachment (unless
~ used adjunctively to long-term treatment ).
2. The Ability to Establish a "Therapeutic Dialogue. "The child
must have the capacity to engage in symbolic play and com -
t Accepied December 21, 1999.
Dr. Racusin is Associate Pro ssor 01 Psychiatry at Dartmouth Medical School
and Di ctor 01 Child andAdolescent Psychiatry Training, Dartmouth-Hitchcock
Medical Center, Lebanon, NH
Reprint quests to Dr. Racusin, Department 01 Prychiatry, DHMC, One Medical
Center Drive, Lebanon, NH 03756; e-mail: Robert.jRacusin@Dartmouth.edu
0890-8567100/3906-0791@2000 by rhe American Academy of ChiId
and AdoIescent Psychiatry .
The process of identifying a specifi.ctreatment focus can be
broken down into 5 steps :
1. Completing a Comprehensive Evaluation and Formulation .
As with all child and adolescent psychiatric care, specifi.ctreat -
ment should be based on thorough evaluation and diagnostic
formulation (Lewis, 1996). Assessment should include devel-
opmental, medical, social, and educational history; adaptive
strengths and weaknesses; family dynamics; parental history ; .,
and current mental status. Formulation includes psychodyna -
mic understanding, as well as recognition of constitutional ,
physiological, and family factors. Adequate time is essential
for this step and, with the aid of standardized assessment
instruments, the evaluation often can be completedin 2 to 4
hours over the course of 2 to 3 visits (Racusin , 1997).
2. Identifying General Treatment Goals. These typically
include goals considered to be essential elements of most psy-
chodynamic treatments, viz., .facilitation of the use of higher
level defense mechanisms, as well as to improve a sense of
mastery and autonomy (Kernberg , 1995).
3. Dejining Specijic Treatment Goals [Or the Child. This can
take the form of an explicit statement of wanting to help the
child be able to do something that he or she wishes (at least
: ambivalently) to do, e.g., use the toilet, but is currently being
prevented byunwanted feelings. This specifi.cgoal statement
is often made in terms of the therapist's wish to "help the child
be ready" to achieve the goal through a combinacion of ther -
apy meetings imd skill development/practice at home .
4. Dejining Specijic Parental Roles and Tasks.Typically,parents
are asked to change one or more approaches to child-rearing ,
e.g., reallocating responsibilities to engage a less-involved par -
ent, implementing behavioral management techniques, or
devising ways to improve the child's status within the family.
.
5. Defining the Number 01 Treatment Sessions. Treatment
usually requires 6 to 12 sessions, with parent meetings sched -
uled after every 2 to 3 individual child appointments .

'1E 2000 ]. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 39:6, ]UNE 2000 791
 RACUSIN
reatment echnique
1. Engaging the Child in Treatment. 1\he treatment alliance is
based n the merapist's desire t help the child achieve the spe -
cific treatment g als. This desire is expressed thr ugh empathic
statements wimin me play and by reframing me sympt m(s) as
a manifestation f "smeming being in me way ' f me child's
wish f r change) viz., me central c nflict .
2. Materiats. The child sh u!d have access t b m semistruc -
tured.and unstructured play materials. Examples f the former
include puppets, d Ils/d llh use, animals, bl cks, and vehicles .
" Long distance" (e.g., plane) and emergency (e.g., ambu!ance ,
p lice car) vehicles are ofren parricu!arly relevant to memes f
separari n and danger. Unstructured mai:erials may include a
sand tray, c I ring materials, paper, and m deling clay .
3. Interventions. Treatrnent relies n b m verbal and n nver -
bal interventions, most frequently in displacement. The pur -
p se of specific interventi ns usually falls int 1 f 4 categ ries :
( 1) classificati n/reflecti ~f affect, e.g., putting feelings int
words; (2) classificari n/reflecti n f prec nsci us r unc p -
scious mental content, e.g., regressive wishes ) edipal fantasi ~;
(3) c nnecring feelings and wishes wim sympt m frmation ,
e.g., using displacement t P int ut me relari nship between
feelings and behavi r in the child's play ; r (4) devising alterna -
tive adaptive strategies f r me child, e.g., using displacement in
play t find an alternative t sympt matic behavi r which als
sarisfies a fantasy character's wish r need .
4. The Role 01 Transjerence and the "Corrective Emotional
Experience." Transference is usually n t interpreted unless it is
}t b th negative and an bstacle t treatment. The therapist's
acceptance of me child and attitude f h pe f lness bec me a
p werful m tivat r for the child t change a dysfuncti nal
"cognitive set" and t risk the behavi ral change necessary t
reli.nquish a symptQ Il. F r many children, this resp nse from
the< therapist is much different fr m that previ usly expe -
rienced by me child from parents. This "c rrective em ti nal
experience" is an imp rtant element f m st psych dynamic
treatments (Dulcan, 1984; Kernberg ) 1995).
Case Examples
Case 1. B., me lder of 2 children, was referred by her pedia -
trician at age 2 years, 11 m nms afrer 3)1m nms f unsuccessfu!
outpatient treatrnent fr st l withh lding. She acknowledged
her pr blem using me toilet and expressed a wish t be able t
use the t ilet "but n t n w ."
Brief psych dynamic psych therapy was rec mmended t
facilitate B.'s rec gnition and expressi n f her ainbivalence
t ward her y unger br mer and her wn bec ming "big.') Her
parents were als enc uraged t continue me medical regimen
necessary to maintain B.'s normal b wel f cti n, t c nrinue
the use of rewards fr B.'s "practicing" sitting n the t ilet, and
t devise age-appropriate ways fr B. t bec me increasingly
rec gnized as the "big sister . - revealed successfu! adjustrnent at scho l and wim friends .
792
In me treatment sessi ns, B. became interested in having a Conclus
"m mer" d ll comf rring a "baby)" while B. fcused attention F rce
on me "big sister." Using me sand tray, B. evenrually had the c nsider
" baby" doll disappear wim the ann uncement, "All g ne." The interven
merapist interpreted B.'s wish mat she c u!d be me nly child at time-liII
h me. B. resP nded by idenrif}ring an mer d ll as me "crying y ungd
br mer" t ward wh m her attirude quickly ev lved fr m s 1ci-
t US and caring t highlyaggressive. Interpretari n f me aggres- REFER
sive wish was fllwed by B.'s deliberately spilling sand fr m the
Davanloo
tray. This, in rn, all wed me merapist t ffer me "crrective term (
em rinal experience " f acceptance ramer man criticism . DulcanM
state (
After me f urm sessi n, B. began using the t ilet again for
Greensp a
her b wel m vements and was rep rted t have referred t her Kernberg
br mer as "p -p head)" which her parents t lerated with Psychl
Wilki
appr priate limit-setting. Treatment ended afrer 6 sessi ns. At Lester EP
6-month follow-up, both her parents and pediatrician re - 13:30
p rted n return of st I withh lding and n emergence of
new sympt ms .
,
Case 2. me middle f 3 siblings, was referred by his pedia -
trician at age 7 years, 3 m nms because f me acute nset of
fears f separari n fr m his parents afrer an epis de of teasing
by a group f lder peers at day camp. Sympt ms had general -
ized t fears f "getting Ist" if he went anywhere with ut a par -
ent and included passive suicidal ideati n. Three weeks of
parent guidance by the pediatrician, induding a trial f diphen -
hydramine (Benadryl@) f r initial ins mnia, resu!ted in no
impr vement .
After a 2-session evaluati n, T. and his parents agreed to 8
sessi ns f brief psych dynamic psychotherapy t fcus n
' s unc nsci us anger and guilt in relari n t his perfecti nist
father and depressed m mer. T.'s parents als agreed t a series
f 3 meetings t focus n decreasing perf rmance pressure n
T. at h me. In additi n, T.'s mother was referred for assess -
ment f her depressi n .
quickly experienced partial relief of his anxiety mr ugh
rhe camartic effect f describing recurrent sexualized dreams
<ind fears of p or sch I perf rmance, b m of which were met
wim me merapist's acceptance and reassurance. T. began to lok
f rward to me meetings and spent me maj rity f rime in sub -
sequent sessi ns drawing highly detailed pictures containing
memes f edipal rivalry wim his famer, fears of retaliation, and
guilt about aggressive and sexual wishes. T.'s inirial pictures were
primarily imaginary creatures, but they eV lved int clearly
human and self-referential frms. Thematic content was inter -
preted with an emphasis n countering magical minking and
n strategies for more direct and appr priate ways to express
negative affect at h me. At me same time T.'s parents were able
t increase meir tolerance fr his ccasional defiance and anger .
Treatrnent ended as schedu!ed, wim able t separate from
his parents wimout excessive anxie Fears f being teased and
suicidal idearion had also disappeared. Follow-up afrer 8 m nms
J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 39:6, JUNE 2000 J. AM
 CL1N1CAL PERSPECT1VES

Conclusions
For certain patients, chi1dand adolescent psychiatrists should
Lewis MB (1996), Psychiatric assessment of infanrs, children, and adolescenrs .
1n: Child and A lesctnt PJ)'chiatry, Lewis M, ed. Baltimore: Williams &

I
il Wilkins, pp 440--456
.he consider brief psychodynamic psychotherapy as a cost-effective MacKay J (1967), The use of brief psychotherapy with children. Can ]
PJ)'chiatry 12:269-278
rhe , intervention that is compatible both with managed care goals of Mann J (1973), Time-Limited Psychotherapy. Cambridge, MA: Harvard
Lildat , time-limited treatment and with the realization that not all Universi Press ,
rying young chi1dren respond to nondynamic approaches . Piper WE, Azim HF, McCallum M, Joyce AS (1990), Patient suitabili and :\".
;olici- outcome in short-term individual psychorherapy. ] Consult Clin PJ)'chol
58:475-481
~res- REFERENCES Proskauer S (1969), Some technical issues in time-limited psychomerapy wim
n the Da v oo H (1978), Evaluation and criteria for selection of patients for short - children.] Am Acad Child PJ)'chiatry 8 : 154-169
~ctive lt term dynamic psychomerapy. PJ)'chother PJ)'chosom 29 ( 1-4 ):307-308 Proskauer S (1971), Focused time-limited merapy wim children.] Am Acad
Dulcan MK (1984), Brief psychomerapy wim children and meir families: me Child PJ)'chiatry 10:619-639
state of me art.] AmAcad ChildPJ)'chiatry 23:544-551 Racusin R (1997), Brief psychodynamic psychorherapy wim children. 1n: Briej
,n for Greenspan SI (1996), The Growth 01the Mind. Reading, MA: Addison-Wesley Dynamic Therapy, Levenson H, Buder S, Beitman B, eds. Washington ,
oher Kernberg P (1995), 1ndividual psychomerapy. 1n: Comprehensive Textbook 01 DC: American Psychiatric Press, pp 149-171
PJ)'chiatry, 6th ed, Kaplan H1, Sadock BJ, eds. Baltimore: Williams & Sifneos PE (1987), Short-Term Dynamic PJ)'chotherapy. New York: Plenum
with
Wilkins, p 2402 Medical Book Company
ls.At i': Lester EP (1968), Brief psychomerapies in child psychiat y. Can] PJ)'chiatry Turecki S (1982), Elective brief psychotherapywith children. Am] PJ)'chother
n re- ~ 13:301-309 36:479-488
ce,of
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asing
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1;
)hen-
n no I
to 8
IS on I
onist
;eries Prevalence of A1cohol Problems Among Pediatric Residents. ]ohn R Knight, MD, ]a'Nean Palacios, Michael Shannon, MD, MPH
re on 1 Objective: To measure rhe prevalence of alcohol-related problems among pedia ic trainees. Methods: An alcoholism screening test was
;sess- administered anonymously to p a cipanrs at a mandatory subs nce abuse education and prevention program. Setting: A large urban
pedia ic residency training program. Subjects: One hundred fi f een pedia[ric residenrs attended rhe program during 3 consecu ve
years (1996-1998). Eigh y- five (740/0) screening tests were returned and 81 (70%) were analyzed. Main Outcome Measure: The 25-
Dugh
eams I item Michigan Alcoholism ScreeningTest (MAST). Differential MAST cut-points have been established to "suggest" or "indicate" a
life me diagnosis of alcoholism. Resu/ts: Twelve residenrs (15%) had scores suggestive and 6 (7%) indica ve of alcoholism, Twen y-
: met
look
f eight (35%)'admitted to having alcohol-associated amnesia (blackours), 13 (160/0) to "feeling bad" about rheir drinking , 9 ( 11% ) (0
drinking before noon, 6 (7%) to ge t ng int fights when drunk, and 2' (2%) to alcohol-rela[ed marital problems. However, only 1

t
sub - ( 1%) had gone [0 anyone for help and none admitted [0 alcohol-rela[ed problems a[ work. Conclusions: These screening da[a sugges [
rhat alcohol abuse and rdated problems exist among pediatric ees at trOubling rates. While more man one third of rhe nees
ning
had experienced a serious consequence from heavy drinking, only l',had gone fr hdp and problems were not apparent at work .
, and

I
Grea[er emphasis sh uld be placed on alcohol preven on and early interven on pr grams as a rou ne p a of pedia[ric training. Arch
were Pedia Adolesc Med 1999;153:1181-1183. Copyright 1999, American Medical Associa on .
early
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2000 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 39:6, JUNE 2000 793