KIDS on the COUCH : How Psychotherapists Are Helping Children Succeed at the Difficult Job of Growing Up

WHEN Billy Redmond was 4 years old, his teachers at nursery school called home. Billy was having trouble, they told his parents. He was becoming an extreme behavior problem. He was wetting his pants. He wouldn’t wait his turn, couldn’t work with scissors and crayons, and he was increasingly frustrated at his failures. Billy was lashing out at other kids, hitting them.

The message the Redmonds got was simple: Billy needed help.

The American Psychological Assn. estimates that 15% of the nation’s children, defined as those under the age of 18, are in need of some kind of therapy. And there is no minimum age for emotional problems. These days, even toddlers are clients of a wide array of therapies and theories and mental health professionals. “Parents seem to be more aware that children have psychological and psychiatric needs and are more open to seeking treatment than they were 10 years ago,” says Kathy Demming, who is in charge of clinical intake for child psychiatry at UCLA’s Neuropsychiatric Hospital and Institute. “Parents these days want to make sure their kids have the best possible chance in life, and if there’s a problem, they want it solved at an early age.”

Of course, 2-year-olds, 5-year-olds, even 8-year-olds don’t tell their parents they’re having emotional problems. At least not directly. They act them out. Their problems are disorders of conduct--socially disapproved behavior, including lying, stealing and general disobedience--and emotional disorders characterized mainly by such symptoms as tearfulness, sadness, social withdrawal and relationship problems. Even less severe developmental problems, the kinds that most children contend with and grow out of--temper tantrums, biting, bed-wetting, nightmares, thumb-sucking, sibling rivalry--that persist or are extreme or occur out of the normal sequence of development, can indicate deeper problems.

“With preschool-age children, the problems usually present themselves in the (nursery) school environment,” says David Paster, a West Los Angeles psychiatrist and chairman of the department of psychiatry at St. John’s Hospital in Santa Monica. “Perhaps the child is disrupting the group, not abiding by the rules of the school, may not be learning or have basic developmental or speech problems. These kids tend to get referred to therapists.” In elementary-school-age children, Paster says problems might originate with stealing and shoplifting.

Therapists working in all the mental health professions--psychiatry, psychology, psychiatric social work--see children. The process starts with an evaluation, and sometimes ends quickly; some problems are easily diagnosed and solved with consultation or limited therapy. Paster says he sees as many children just one, two or three times as he sees for three years. And Helen Reid, a clinical social worker who is the coordinator of the Cedars-Sinai Early Childhood Center, remembers one diagnosis that combined a knowledge of child psychology and development with a detective’s sensibility.

An 8-month-old baby girl was brought to Cedars-Sinai. At home, as she crawled around the floor, she was picking up pieces of lint from the carpet and eating them. In taking a history from the mother, Reid found that the baby had been weaned from the breast a few weeks before, and that during nursing, the mother had worn a kimono covered with little lint balls.

“The baby would just finger those but suck the breast,” Reid says. “When she was weaned, she would find those little things to remind her of her nursing experience.

“First of all, we got the child on a bottle. The mother had tried to wean her from the breast to a cup. We got her a pacifier to suck. It was the sucking experience she was missing.” And that was the end of lint eating.

But often a child’s problems are not solved so simply. They can be biomedical--a neurological disorder, for example--amd might require drug therapy. And sometimes, as in the case of Billy Redmond, a child must undergo a long-term, complex process that combines several elements of psychotherapy.

BILLY Redmond’s mother remembers what it was like to confront the problems her child was having. “I went through, ‘What am I doing wrong?’ ” Jane Redmond says. “I thought, ‘Am I screwing this kid up? How on earth am I ever going to get things back to normal?’ ”

Jane Redmond and her husband, Steven, a Westside attorney, seemed to have an ideal marriage. (The Redmonds’ names have been changed, as have those of all the patients and their families quoted in this story.) Steven Redmond was a success in his work, a devoted husband and father, and Jane Redmond had chosen to concentrate on rearing Billy and his older brother and younger sister. The Redmonds had noticed no emotional or behavior problems in their children until they discovered Billy’s difficulties at nursery school. They sought advice from their pediatrician, who directed them to a child psychologist. The psychologist tested him and, in light of his behavioral disorders, treated the boy by trying to get him to bring his aggressive feelings to the therapy sessions, rather than venting them at school or at home.

After a year and a half, the results were minimal. “We continued to have a lot of problems,” Jane Redmond recalls. “We couldn’t go to birthday parties because the noise was too much, and he would just go crazy. It became apparent to us that we had a child who was increasingly unhappy and increasingly depressed, and nothing was working. He had no friends. He couldn’t function in a camp situation, and he couldn’t function in a lot of things that we thought he ought to be able to function in.”

So Jane Redmond asked her own therapist for another referral, and he recommended David Paster. In the first session with Paster, Billy entered the room, turned and tried to flee. But Paster sat down in front of the door and blocked it. He didn’t physically restrain the boy; he just didn’t let him leave. Paster spent most of the first session warding off Billy’s kicks and punches, repeating over and over, “I realize you’re angry, but your mother said you have to be here, so you have to be here.”

That was the only time Billy tried to escape. Over the next several sessions, Paster was able to put together an evaluation of Billy that combined talking with his parents and teachers, observing him at school, standard developmental testing and a medical history. Paster diagnosed Billy as suffering from Attention Deficit Hyperactivity Disorder--he couldn’t concentrate, had too much energy and acted impulsively. Because ADHD is considered a physiological as well as a psychological problem, Paster prescribed Ritalin, a stimulant that is widely used to control hyperactivity. (Psychiatrists are the only mental health professionals qualified to prescribe medicine.) He suggested Billy attend a school with smaller classes and a tutoring approach, a school where Billy would get lots of attention and control.

In sessions with Paster, Billy ignored the doctor’s stock of toys; he preferred to sit in a chair and talk like an adult. “It was similar to an adult who comes in and intellectualizes all the time,” Paster says. Billy spent a lot of time talking, which Paster says is a symptom of anxiety and stress. Billy told Paster: “I’m really mad at you.” “That would sound good coming from an adult,” says the psychiatrist, “but coming from a 6-year-old, it sounds like he’s parroting somebody else.”

One day after less than a year in treatment, Paster got out his indoor basketball equipment, and he and Billy shot baskets. It wasn’t exactly what the doctor had in mind in terms of play therapy--a more specific kind of play that helps expose a child’s thought processes--but it was useful nonetheless. At first, according to his mother, Billy “really didn’t try to make a basket, didn’t dare to try to kick a ball, didn’t want to take any risks. In David’s office he could take the risk--eventually--to try and shoot the ball into the basket.”

Then Billy began to engage in the kind of play the doctor considered therapeutic. Although Paster declines to give much detail of Billy’s sessions on ethical grounds, Jane Redmond remembers that Billy spent several sessions building an “incredible” structure of Lego blocks, and she recalls a picture Billy drew that showed dramatic insight into his feelings. Billy had drawn himself, his sister and a nebulizer, a small breathing machine the Redmonds used at home to help his sister with her asthmatic attacks. The machine is about 6 inches by 6 inches by 4 inches. But when Billy drew it, he made the machine nearly three times as large as his sister. “He got himself in there somewhere, also very small,” his mother says. “By looking at that picture, you can see that to this kid the nebulizer is a very fearful, frightening, huge, humongous thing that’s about to overtake his life. Once you get that input, you can start talking about it and telling him what this nebulizer does for us. That came from the drawing.”

The play therapy, Paster says, gave the boy another outlet for the thoughts that were bottled up inside. “His aggression resolved,” Paster says, “and his problems in the classroom resolved.” Billy is now in the first grade in a special-education school for bright children with learning disabilities. The smaller classes and quieter environment, Jane Redmond says, have reduced his anxiety level, which tended to soar when he was around a group of children. He is one of the best students in his class.

THERE ARE A wide variety of approaches to child psychotherapy. Paul S. Rappoport, a clinical psy chologist writing in Parents magazine, summarized them this way: “Psychoanalytic treatment deals with unconscious motivation and emotional insight; behavioral therapy focuses on the elimination of a specific problem behavior; client-centered therapy improves self-concept by encouraging self-expression; relationship therapy increases self-esteem by providing a supportive therapeutic environment, and many therapists use a combination of all these methods.” Amid these variations, there is one constant: play therapy, the use of toys, puppets, dolls and doll houses, trucks, dinosaurs, crayons and paint. Invented by Freud’s daughter, Anna, the founder of child psychotherapy, play therapy is the tool used to pierce a child’s inner world. Play therapy is to children as free association is to adults.

“The inner life of a 5- or 6-year-old child is immensely rich,” says Dr. Ben Kohn, a Beverly Hills psychiatrist and psychoanalyst who sees many children, some very young, in his practice.

“The ideal child is not the child who comes and sits in the chair or lies on the couch and free associates,” Kohn says. “The child uses the couch, but not to lie down and say whatever comes into his mind. The child puts toys on it and plays on it, throws the pillows and builds fortresses, hides under the couch as much as on top of the couch.

“It is the most marvelous experience to watch these children and to listen to them. Their imaginations are creative, seeing the world in Technicolor. They’re ingenious. They come up with ideas that are fascinating--astounding, if you will.

“They play house, they play doctor, they play scientist, they dig, they create, they struggle. You give a child a setting with someone who’s really interested, someone who wants to hear the games, who plays, and they’ll start to free up and present these inner feelings.

“You let the child be the director of the play. They’ll either involve you or they’ll let you sort of watch them, and that already tells you a lot about how they relate to people, whether they want to be by themselves or more involved. I let them assign the role. And while we’re playing the game, I can say things in the context of the play that affect the child.”

Marie Briehl is the doyenne of child psychoanalysts. She studied with Anna Freud in Vienna in the 1920s and helped pioneer child psychoanalysis in New York in the 1930s and in Los Angeles a decade later. She is now chairman emeritus of the child analytic section of the Southern California Psychoanalytic Institute. A small woman in her 80s, she is imposing nonetheless.

“The work of a child is play,” she says matter-of-factly. “I would say (to a child), ‘What do you like to play with?’ My room has in it the things that children like. Writing materials, games, dolls, marionettes--little ones, big ones--and blocks. ‘Find out what you like.’

“The way a child selects or goes to those things will tell you a lot about his whole problem. Some children are afraid to go, afraid to choose. They don’t feel free enough to do that because they’ve never been allowed to do it.

“Sometimes they put the human figures in such places that there is no father at all, or maybe there isn’t a mother, or the mother and the father are doing things together and the children are neglected. Whatever the child does is ultimately of some value in knowing how he feels about the organization or lack of it in his own house. We then take that information and pick up on those points that seem to be significant in their relationship to the world around them; we can then better understand and diagnose their problems. And whether it’s fun, or whether it’s full of concern and anxiety, or whether he is rigid and afraid to have fun, or whether he wants to break up the whole house.”

The therapist tries to open the child’s eyes to other options in thought and behavior than the ones the child naturally adopts. This is accomplished in play therapy by suggesting other resolutions to the child’s stories. Eventually, therapists say, children understand that the alternative endings are possibilities they might try themselves.

“The purpose of therapy is to give options,” David Paster says.

THE CHEERFUL Helpers nursery school at the Cedars-Sinai Early Childhood Center offers a variation on the one-on-one therapy Billy Redmond received. In a comprehensive program that includes both individual treatment and interaction with others, each child is continually evaluated by a staff of teachers and therapists.

Helen Reid, a clinical social worker and child development specialist who is the center’s coordinator, says most of the children were referred to the center after their behavior could no longer be tolerated at other nursery schools. Cheerful Helpers has a ratio of three teachers to six students so that there is constant close supervision. The children, ranging in age from 2 1/2 to 6, spend three hours at the school four or five days a week while also undergoing one to three sessions of individual therapy a week.

“The therapy in the nursery school is called milieu therapy,” Reid says. “In other words, their milieu is kept stable at all times, and they are made, three hours a day, to behave in a socially acceptable way. It takes them out of the family system.”

Reid says the children at the nursery school are not profoundly disturbed. About a quarter of them have suffered such debilitating traumas as hospitalization or birth defects, but the rest have relatively common emotional problems. “They are children often who have a difficult time with impulse control,” she says. “But if you have an adult sitting on each side of you who’s trained, they help you calm down.”

Reid says she sees one thread of similarity in most of the children who are referred: Almost all are the first child in the family, and most have younger siblings. “They were a prince or a princess at home, and then came this competitor,” Reid says. “Just think if a husband brings home another woman and says, ‘Darling, I love you just as much as I always have, but I also love this other person, and I want her to live here with us.’ That’s what a kid feels like when a younger baby comes home. They get very angry because they feel, ‘I wasn’t good enough. Something’s wrong with me.’ If it’s not acted out with the sibling or if it’s not verbalized to the parents, that anger could get acted out with playmates. And that could make a very aggressive child.”

Reid offers the example of a child sent home from school for biting a classmate: “Then after they come back (to school) and they promise never to do it again, they have no impulse control and they bite again. Parents of the bitten child get enraged and scared. So the biter gets kicked out of nursery school.”

One of the major aims of the staff at the Cedars-Sinai nursery school is to help the children learn to express their feelings instead of channeling them into aggression. Explains Reid: “If the therapist says, ‘Gosh, it was really hard on that little boy when the mommy brought home the baby. What do you think he was feeling when that mommy brought home that baby?’--you’re trying to get him to put his feelings into words. He can at least begin to verbalize instead of throwing something or beating up on his brother.”

The nursery school’s approach “tends to be preventative,” says Saul Brown, who is chief of the department of psychiatry at Cedars-Sinai, director of the Early Childhood Center and Reid’s husband. “We don’t leap into working with the kids in a strict one-on-one situation, because most of them don’t need that sort of attention yet. The children here are rarely singled out, but they are guided toward proper behavior.”

At a weekly staff meeting with the therapists and teachers, each child’s progress is reviewed and treatment is charted for the next six weeks. Parents contribute to their children’s treatment by visiting the school once a week to watch them behind one-way mirrors. Then they attend a group meeting, conducted by a teacher and therapist, to discuss their observations. (All of the families in one classroom see the same therapist.) Parents also meet individually with the therapist once a week. If the parents need further treatment, they are referred to the Cedars-Sinai adult outpatient clinic.

Reid says parents shouldn’t feel inept when they cannot control their children’s disruptive behavior. “It’s hard to expect a parent to do this because they’re not trained, and they don’t have the time or the patience.”

The average stay at the nursery school is two years, Reid says. She estimates that two out of five students graduating to kindergarten will need to continue in special schools with smaller class size, fewer distractions and more attention from teachers.

HOW DO parents and therapists know if the process is working? Edith Wallace has worried about just that question.

Three years ago, Wallace was the unhappily married mother of two boys, 3 and 5 years old. She and her husband had stayed together out of concern for their children. The elder child, Peter, was very sensitive and bright, asking such questions as “How does God make our skin stay together?” and “Is there gravity in other universes?” As a toddler, Peter was never a problem, unlike his brother who, Wallace says, did all the “standard” things: acting out, being silly. At about the same time that the Wallaces decided to end their marriage, Peter began kindergarten. He also began to be very shy and withdrawn. While his younger brother took social situations by storm, Peter barely participated. When he did, his teacher told his parents, he interacted more with girls than boys, which was unusual for his age group.

“It was so scary facing that my kid needed help,” Edith Wallace says now. “Parents, in their bones, look at their kids and know when they need help. They just know it--whether or not they want to face it. I threw temper tantrums for months. I was impossible, but I went ahead and (sought help).”

For the last 2 1/2 years, Peter has seen a psychiatrist one to four times a week. A few months ago, his mother cut him back to twice a week, but Peter started fighting in school, and the number of sessions was increased to three a week. It worried her. She felt she had seen few results after a year and a half; she began shopping around for a new therapist. But then Peter seemed to improve.

“He came home from school one day and said, ‘Jerry had a neat shirt on,’ ” she says. “That was the first time since he started school that he told me anything of what happened in school without me reaching down his throat with a pair of pliers and pulling it out.”

And the other day, she said, Peter repeated a joke he had heard in class. “That means he’s in the social circle,” she said. “He’s hearing the jokes that are going around. He’s participating in school, and he’s even bringing some of that stuff home.”

Psychiatrist Ben Kohn says one of the most common questions parents ask about therapy is “How long will it take?” Though the time frame obviously varies with each case, he says it usually takes from six months to a year to see results, but even then, a child will need follow-up care at least once every few months. “There are a variety of goals, the most important being to help with what that person came in with: the pain, the discomforts,” says Kohn. “With children, the goal is best described as freeing up development so a child can continue along in his development sequence, so he can move along in his life. If the child is not depressed anymore, he can at least learn and move on to the next phases in his life.”

The course of Billy Redmond’s treatment is a case in point. According to Jane Redmond, the last year of therapy with David Paster (and Ritalin) has “made a real difference. He’s doing very, very well.” But the process isn’t complete. Recently, he hit one of his classmates, the first time in months that he had hit anyone. “Billy still can’t handle change,” she says. “He can’t handle changes in the routine, he can’t handle new people in the class, he can’t handle unstructured time.”

But she prefers to think of Billy’s improvement: “He’s like night and day,” she says. Little things: Where Billy couldn’t go to any birthday parties before, now he can. They must be small ones, without too much commotion, or, if they’re large and active, one of his parents goes along. He’s much happier now, less anxious and less worried. Redmond considers the way the process has worked: “Billy spent time with David and began to learn to trust David, and he also began to feel good about himself because he could make baskets. Then he began to think, ‘Gosh, I could do that. I can do it here; maybe I could try it someplace else,’ and began to get enough self-confidence to try other things. He was out today playing catch with a rag ball and a mitt. It takes a lot of time and sensitivity, but he’ll do just fine. We’re very proud of his progress.”