Therapy is the process in which a licensed mental health professional helps a child or adolescent gain a higher level of self-awareness surrounding their thoughts, feelings, and behaviors. Simultaneously, the therapist teaches the child or adolescent how to implement internal counseling strategies. With these counseling strategies in place, the child or adolescent can adjust their ineffective thought patterns to better manage their feelings.
In addition, the therapist can help the child or adolescent explore the use of research-based external coping skills, to use in conjunction with counseling strategies, to achieve a greater level of emotional and behavioral regulation. Some examples of coping skills include, but are not limited to, breathing techniques, nature sounds, laughter, and sensory stimulation.
Who Can Benefit from Child & Teen Counseling?
Therapy can be beneficial for children and teens with a wide range of issues:
- With a Diagnosis: Some children and adolescents entering therapy have a mental health diagnosis previously clarified with another provider.
- Without a Diagnosis: Others are searching for that clarification, so they begin treatment without a diagnosis.
- With Stressors: Some solely seek therapy to help manage a stressful external situation, whether time-limited or lifelong, or to navigate a major life change.
It seems rather obvious that children with mental health diagnoses from the Diagnostic and Statistic Manual of Mental Health Disorders (DSM-V), can enter therapy, but children without a mental health diagnosis can also benefit from therapy. A person may experience some symptoms of a disorder, but they may not have enough to be classified as clinically significant.
As an example, this could be a child who feels too anxious to raise their hand in school to answer a question, for fear of being wrong. Their behavioral inhibition may impact their verbal participation at school in that particular regard, but overall they are doing well at school, both academically and socially.
This means they are participating at school otherwise: They can make and retain friends, ask the teacher questions, work in small groups, and perform well on school-work. Therefore, their anxious feelings are not viewed as an actual anxiety disorder. But, they can still enter therapy to work on managing the symptoms of anxiety they experience in this particular situation to be able to more fully participate in the classroom.
Other children without a diagnosis may experience situational difficulties that are time-limited, or experience major life changes that will prove to be life-long. Some of these adjustments to life can be negative, but some can be positive and they can also cause stress. Therefore, having an objective person to express their feelings with can be just what the doctor ordered. Some of these situational examples follow:
- Their parent is getting remarried (and even if the child accepts the step-parent, it’s still an adjustment)
- The family dog passed away
- Their parent found a new job that has different hours, so the child has to help younger siblings more often with homework or cooking dinner
- They feel excited, yet nervous, to start middle school/high school/college
- Their parent got relocated, so the family had to move to a new state
- Their grandparent moved in with their family long-term
- Their sibling has a mental health issue that significantly disrupts the family unit
- They are an only child and struggle with feelings of loneliness
- They became injured and can’t play their preferred sport this season
- Their significant other broke up with them
- They are having trouble sleeping
- They feel unmotivated to do school work
Types of Psychotherapy for Children/Adolescents
It’s important to note that there are different evidenced-based treatments for different diagnoses and presenting issues. This article just touches on a few.
Cognitive Behavior Therapy (CBT)
Any form of cognitive behavior therapy (CBT) works best for children ages 7 and older, due to the abstract nature of this type of psychotherapy. CBT was developed by leading psychiatrist and professor emeritus of the University of Pennsylvania School of Medicine, Aaron T. Beck, M.D., in the 1960’s. This particular form of psychotherapy has been scientifically tested and found to be effective in hundreds of clinical trials for many different disorders, including an array of anxiety and depressive disorders.
According to two of Dr. Beck’s books, Anxiety Disorders and Phobias A Cognitive Perspective and Cognitive Therapy of Depression,1,2 CBT is based on a cognitive theory of psychopathology in which a child’s or adolescent’s thoughts regarding situations in their lives can negatively or positively influence their emotional, physiological, and behavioral reactions. Therefore, if their thought patterns can be adjusted, their feelings can be adjusted, and then their behavioral reactions can be adjusted.
These ineffective thought patterns are challenged in therapy so the child can more effectively navigate the prism through which they view their world. With a more effective and accurate prism, the child/adolescent can function better at home, school, and in community settings. CBT is well researched but cannot guarantee success or an absence of symptoms.
Dialectical Behavior Therapy (DBT)
Dialectical Behavior therapy (DBT) is a cognitive based therapy created by Marsha Linehan, Ph.D., ABPP, Professor of Psychology and adjunct Professor of Psychiatry and Behavioral Sciences at the University of Washington. DBT is used to help with emotional regulation, distress tolerance, and interpersonal effectiveness, so the child or adolescent can function better at home, school, and community settings.
DBT has been adapted to treat children and adolescents with multiple different mental health issues. According to the National Alliance on Mental Illness (NAMI),3 DBT emphasizes acceptance of uncomfortable thoughts, feelings, and behaviors, with the goal being to find a balance between acceptance and change. The therapist also helps the child or adolescent develop new external coping skills and mindfulness practices. DBT uses positive reinforcement to motivate change, emphasizes the child’s strengths, and helps translate concepts learned in therapy to the child’s everyday life. DBT is well researched but cannot guarantee success or an absence of symptoms.
Operant Conditioning and Exposure Therapy
B.F. Skinner, Ph.D. was Professor of Psychology at Harvard University and was the father of behaviorism and operant conditioning. His theory is that children and adolescents will continue behaviors that have desirable consequences and reduce behaviors that have undesirable consequences. He believes that the environment plays a large role in controlling behavior.
Gradual exposure to the feared stimuli, while shaping behaviors with successive approximations, can have successful outcomes when habituating and desensitizing to a situation. This means the child or adolescent is challenged with small challenges that flood their system, a bit uncomfortably.
Then, they are positively reinforced for meeting those challenges. Next, their challenges are gradually increased as they habituate and desensitize to their anxiety, so it doesn’t feel as uncomfortable. This process can help them function more effectively at home, school, and in community settings. Operant conditioning and exposure therapy are well researched but cannot guarantee success or an absence of symptoms.
What Parents Can Expect When Their Child is in Counseling
The therapeutic process takes time. Unfortunately, there is no magic wand for therapists to wave, so mental health issues aren’t cured; they are managed. For a child or adolescent to learn counseling strategies to manage thoughts, emotions, and behaviors, it takes time.
The child will not be learning these strategies immediately. This is because the first few sessions are focused solely on building a relationship. Therefore, the parent can’t expect major changes right away. With that said, research shows up to 50% of success in therapy is the therapeutic relationship, so it’s important the child feels comfortable with the therapist.
Individual therapy for your child is not equivalent to family therapy, nor is it the parent’s session. This is the child’s session. If the parent would like to communicate issues ahead of time so the therapist is aware of some things to work on, let the therapist know with a phone call, voicemail, or email ahead of time.
Find out if there are fees for this type of communication. If there are, and you cannot afford that, you may be able to work out a plan that includes a parent update at the beginning of a session. The therapist will stick to a time-limit boundary that you set together to ensure enough therapy time for the child. Depending on the amount of communication needed, it may also be useful to consider family therapy, or the child’s therapist might also refer your family for family therapy.
The therapist will offer psycho-education so that the child has a better understanding of their issues and can build a level of self-awareness. Once there’s more self-awareness, the therapist will teach the child specific internal counseling strategies, along with external coping skills, to manage emotions more effectively.
A common misconception is that the therapist will help the child be happy. Therapists actually aren’t trying to help the child be happy all day long; rather, therapists help the child cope with emotions that are disproportionate to the event in more effective manners. Remember, people are supposed to experience uncomfortable emotions. What’s important is how the child manages the emotion so they can continue to function in their environment.
If the child is in therapy due to the distress from an environmental circumstance, be aware that their issues may not just resolve when their situation changes for the better. The long-term effects of a situation may still require treatment after the actual problem has been solved so they can continue to function optimally across settings.
When the therapist and child are working together, the therapist will self-disclose minimally. They won’t impose their values on your child, and they won’t judge yours or your child’s values. Therapists also don’t give advice. They can offer pros or cons to situations and help the child come to their own decisions. If the therapist gives advice, there’s liability involved. If the therapist offers pros or cons, this is legal and it allows the child to take more ownership of their treatment, and create tools to make better choices in the future.
To help your child progress in treatment, a therapist will validate your child’s feelings. Be aware that validating your child’s feelings is much different than agreeing with your child. The therapist can validate that the child felt frustrated in a home situation, but that doesn’t mean the therapist agrees with the child’s perspective or disagrees with yours.
It’s important to realize a child will not work on their own issues and their role in situations if they don’t feel heard and understood first. Once the child feels supported by the therapist, the therapist can then confront them and challenge their perceptions and thought distortions. The therapist can only confront the child as much as they have supported them.
If you feel like your child needs an extra session, expect that the therapist may not be able to see your child on short notice. If it is an emergency, expect to be referred to call 911 or go to your nearest emergency room. If you do call the therapist, most will call you back by the end of the next business day. You should ask your child’s therapist how they handle urgent calls and their specific policy for getting back to you. All therapists will deliver information to you in a respectful manner, without sugar coating, and without breaking confidentiality.
How Long Does Child or Adolescent Counseling Last?
Expect therapy to last a minimum of 3 months to many years, depending on the diagnosis or combination of diagnoses or the distressing external circumstance. It can also depend on other external factors that are not the actual presenting factor, in addition to gender, age, desire, commitment level, parental buy-in, medication and medication compliance, and the child’s ability to learn, retain, and utilize information.
As an example, take a child with one diagnosis of generalized anxiety disorder, combined with a positive support system at home, school, and with friends. This child is 13 years-old, and she has a desire to feel better and seems committed to managing her anxiety. This particular child may be on the shorter end of the treatment timeline.
Next, take a child diagnosed with four diagnoses of generalized anxiety disorder, major depressive disorder, reactive attachment disorder, and borderline personality disorder tendencies. This child was adopted at age 6. Her adoptive older sister completed suicide when she was 10 (and older sister was 15). Her adoptive parents got divorced when she was 12. Her adoptive mom got remarried when she was 13 to a man whom she despises. The child struggles with self-esteem.
The child uses undesirable behaviors with friends, so she lacks a support system. She began self-injuring at age 13, and now nearing 14, she is entering a therapist’s office for the first time, angry and upset that her mom forced her into treatment. This particular child may be on the longer end of the treatment timeline.
Confidentiality
Expect that the therapist will hold to the laws of confidentiality. Confidentiality creates a psychologically safe environment for the person to express their thoughts and feelings.
Minors ages 12 and older hold their own confidentiality.
Parents can receive progress updates on treatment plan development/follow through. Be aware these progress updates are not equivalent to breaking confidentiality. Examples include: what general topics are being covered (self esteem, making and retaining friends, anxiety, etc.) and with what methods (CBT, DBT, etc.), general affect, and how receptive the child seemed in session.
The parent cannot receive actual content of what the child reports in session, unless the child (12 and older) gives the therapist permission. How these progress updates will be administered should be communicated at the beginning of treatment as to how and when these will be delivered (and if there’s extra cost for this.)
There are situations in which a therapist would want to tell a parent something the child reported, but the child (12 and older) says, “no.” As therapists, we are well aware that if we break that child’s trust and/or they get in trouble at home, the child will be less likely to work on the therapeutic issues they need to.
Therefore, confidentiality laws were put in place for a reason. They are meant to help the child progress in treatment. If there was no assurance of confidentiality, most children would be reluctant to share certain critical information, and therefore, they would actually benefit less from the therapy (that the parent is paying for).
Therapists can and will work with children on weighing pros and cons of the child sharing confidential information directly with the parent, with the hopes the child will share the information with the parent that the therapist thinks should be shared.
Other than if a child allows the therapist to break confidentiality to a parent, there are a few other reasons a therapist can and will break confidentiality to the parent:
- The child has intent, plans, and means to hurt themselves
- The child has intent, plans, and means to hurt someone else (or an animal)
- Someone in the child’s life is hurting them or threatening to hurt them.
An example of what this does not include is if your child was molested 3 years ago at a family reunion 10 states away, in which the child doesn’t anticipate seeing that person ever again. Like this situation, there are many situations that a parent would think would be obvious for breaking confidentiality, that actually are not grounds to break confidentiality. If you, as the parent, have specific questions on confidentiality, ask the therapist before the start of treatment.
There are also situations when therapists will break confidentiality to outside parties. Some examples of these scenarios include:
If the child alleges abuse or neglect with a family member with whom they live, therapists are mandated reporters and will break confidentiality to DCFS (the Department of Child and Family Services). Even if a therapist does not fully believe the child, the therapist is still mandated to call. An ethical therapist will let the child know ahead of time that they will be calling DCFS. This is to help keep the child’s trust.
The therapist can alert the parent ahead of time, but the therapist does not have to. There are times there is a court ordered subpoena for the therapist’s case-notes or the therapist themself.
If the child age 12 or older signs a two-party consent, the therapist can discuss certain areas of treatment (only areas that are listed on the consent) with the person whom they designate, such as: the child’s physician, the child’s teacher, etc. If a child is under the age of 12, the parent can solely make that decision of which two-party-consents they will sign, for whom, and for what purposes.
It should be noted that if the therapist comes across a grey-area with confidentiality, and they don’t know if they have to disclose information to the parent, the therapist can consult with their clinical director or another colleague. If that still does not provide enough clarification, different therapy licenses have different hotline phone numbers they can call for assistance. They will not disclose your child’s name, but rather the situation.
At What Age Can a Child Enter Counseling?
Children as young as toddlers can obtain a mental health diagnosis and can enter therapy. Treatment will look different across the lifespan.
Ages 2 – 7 Years Old
Children ages 2-7 will rely heavily on antecedent management. This is to proactively and reactively adjust their environmental circumstances, in an effort to help them manage their emotions and behaviors, while building relationships.
Some examples are Dr. Sheila Eyberg’s Parent-Child Interaction Therapy and Dr. Ross Greene’s Collaborative Problem Solving Model, both of which have skills that can be taught to parents and teachers, and the child will engage in more play-based therapy in the therapist’s office.
As an example, take a 4 year-old child who presents as too disinhibited. They demonstrate impulsive, incessant, and intrusive behaviors. The goal is to adjust those behaviors to use more desirable and prosocial behaviors. The therapist will teach the parent skills to use at home, so the parent may be heavily involved in the first few sessions, but eventually the therapist will work with the child mostly on their own.
In the therapist’s office, the purpose is to build rapport with the child. If the relationship is enhanced with rapport building, the thought is that the child will develop more intrinsic motivation to comply. To enhance these relationships, the therapist will try to gain an understanding of why the child is using the behaviors they are, so the child feels understood.
The therapist will use specific therapeutic skills in play therapy when the child is playing to help the child feel valued, accepted, and worthy. Once a child feels understood, valued, accepted, and worthy, the child is more likely to use more prosocial behaviors. They then receive positive feedback on these behaviors. When children receive positive social feedback, they are more likely to keep using these behaviors in an effort to continue engaging in positive interactions.
Another example is the exact opposite. Take a 4 year-old child who presents as too inhibited. This child may avert eye contact, shrink in the presence of others, cling to safe adults, and lack facial affect when others try to communicate with them. The goal is to adjust the behaviors so the child is less inhibited and more social. The therapist will teach the parent skills to use at home, so the parent may be heavily involved in the first few sessions, but eventually the therapist will work with the child mostly on their own.
In the therapist’s office, the therapist will shape the environment to create an emotionally safe space for these types of behaviors to be more effectively managed. In doing this, the therapist will try to gain an understanding of why the child is using the behaviors they are, so they feel understood.
The therapist will then use specific therapeutic skills when the child is engaged in play therapy while the child plays to help them feel valued, accepted, and worthy. Once the child feels understood, valued, accepted, and worthy, the child is more likely to feel more comfortable around others. Subsequently, the child is more likely to be less inhibited and more social.
Older Children & Teens
Once a child reaches somewhere between ages 7-12, their brains are more ready for abstract thought, so these children can participate more in traditional psychotherapy (talk therapy) with the clinician, versus play-based therapy.
As an example, take a 10 year-old child who is ready to move to traditional psychotherapy. This child is not 12 years old yet, so this child does not hold their own confidentiality. A parent is likely to be more involved in these sessions than an adolescent 12 and older. However, it’s important this child still has time with the therapist by themself.
This particular child presents as too disinhibited. They demonstrate impulsive, incessant, and intrusive behaviors. The goal is to adjust those behaviors to use more desirable and prosocial behaviors. In session, the therapist will validate the child’s feelings, so the child feels understood first. Then, the therapist will work with a specific counseling-frame in mind to teach the child skills to manage their thoughts and feelings, in an effort to produce more desirable behaviors.
If the child has an ineffective thought that they need something right now (a new pair of shoes), they may come across as incessant toward their parent. With a strong desire for immediate gratification, they lack the skill to delay gratification. In therapy, the therapist would challenge the ineffective thought that they need a new pair of shoes now. If the child can adjust that thought, they can adjust their behavior to delay their gratification. If they have the ability to delay gratification, they will not come across as so incessant with their parent.
Another example is the exact opposite. Take a different 10 year-old child who is ready to move to traditional psychotherapy. This child is not 12 years-old yet, so this child does not hold their own confidentiality. A parent is likely to be more involved in these sessions than an adolescent 12 and older. However, it’s important this child still has time with the therapist by themself.
This particular child presents as too inhibited. They may avert eye contact, shrink in the presence of others, and answer others with one-word answers. The goal is to adjust the behaviors so the child is less inhibited and more social. In session, the therapist will validate the child’s feelings, so the child feels understood first. Then, the therapist will work with a specific counseling-frame in mind to teach the child skills to manage their thoughts and feelings, in an effort to produce more desirable and prosocial behaviors.
If the child has an ineffective thought that, “This girl in my class thinks I’m weird,” the child may be experiencing feelings of embarrassment, worthlessness, etc., which can produce inhibited behaviors. In therapy, the therapist would challenge the ineffective thought that, “This girl in my class thinks I’m weird.” If the child can adjust that thought, they can feel more pride in themself and experience more ego-strength. With a stronger sense of self, the hope is their behavior will not come across as so inhibited, producing more prosocial behaviors with others.
How to Obtain a Mental Health Diagnosis for Your Child or Teen
To diagnose, a therapist will gather past history, conduct a clinical interview, discuss present symptomology and how it is interfering in the child’s home-life, social functioning, and academic functioning. An accurate diagnosis can take time. If the therapist doesn’t feel the information is comprehensive enough to make an accurate diagnosis, they will recommend a psychological-testing/neuropsychological-testing procedure.
How Much Does Child & Teen Counseling Cost?
The cost of child and teen counseling is typically between $60-150 per session. Most people with insurance can expect to pay 10%-30% of the fees as a copay. If their therapist or counselor does not accept insurance, you’ll be responsible for the entire bill. If your insurance covers out-of-network providers, ask for a superbill from the therapist to submit for reimbursement.
How Much Will Insurance Cover?
- First, call your insurance company to see what mental health providers are in-network.
- Find out what level of treatment is covered- outpatient therapy, partial hospitalization program, intensive outpatient program, inpatient treatment, residential treatment.
- Find out the level of coverage you have in terms of copays, limits of visits, and annual or lifetime maximums.
- Find out if the insurance company covers only medically necessary treatment (and how that decision is made).
Other Coverage & Payment Options
There may be other options for covering the cost of child and teen counseling besides out of pocket and private insurance. These options include:
- Public School Counseling or Social Work Services: These services are free of charge to the family, if the student qualifies for these services.
- Medicaid Eligible Clients: Some therapy offices take Medicaid, and all of the county health departments take Medicaid.
Other Costs to Consider
- Find out if (and how much) the therapist charges to communicate with you over the phone or email with a progress update
- Find out how much it costs for the therapist to call the school’s psychologist, counselor, social worker, or teacher to coordinate treatment, and for them to attend your child’s school meetings.
- Find out how much the therapist charges to write summaries for your child’s school staff with recommendations for school interventions.
- Find out how much is charged for psychological or neuropsychological testing (if needed).
How to Find a Therapist for your Child
Finding a therapist for your child can take time. It will likely take several different phone calls and time on internet searches.
- Contact your insurance company to find a list of in-network providers.
- Talk to your child’s pediatrician, as they may have a referral, even if you don’t require a referral. Many times, pediatricians work in collaboration with mental health professionals.
- Consult the department of psychology, counseling, or social work at a local college or university, as they may have graduates practicing in the community.
- If you read a positive review on a therapist, you can begin cautiously hopeful, but don’t expect a miracle. If you read a negative review, take that with a grain of salt. A therapist isn’t good or bad based on a child’s outcome or progress or regression of symptoms. There are many variables to take into consideration, which will be explored later.
Questions to Ask Your Child’s Prospective Therapist
- How long have you been practicing as a licensed therapist?
- What age-range do you treat?
- What insurance do you accept? (Make sure you don’t need a pediatrician referral first, but if you do, obtain a referral).
- My child was diagnosed with _______. Do you treat this?
- What evidenced-based approach do you use to treat this?
- How often will you need to see my child?
- How many sessions do you typically do for this particular situation?
- My child doesn’t have a diagnosis. How does that work?
- What is your cancellation policy if we can’t make a scheduled appointment?
- Can you explain confidentiality to me, including what you can/cannot tell me, and whom you can communicate with about my child?
Once you make a decision to have your child see a particular therapist, that’s not necessarily a final decision. A positive rapport with a therapist is essential, so the first appointment should be a mutual interview between the therapist and the child.
- In the first session for your child, ask if they are going to make a diagnosis.
- If you do not want your child to be diagnosed, make the therapist aware. However, the therapist may be required to give a diagnosis if you are using insurance. Sometimes this might be adjustment disorder because they are struggling with the adjustment of a new situation.
- If you don’t agree with the therapist’s approach to diagnosis, you can receive a second opinion elsewhere, or you can ask the therapist for a psychological-testing referral.
- If you feel uncomfortable with the therapist in general, you can start the process over and can choose another therapist.
Therapeutic Effectiveness
According to The Elements of Counseling,4 psychotherapy combined with human change can be difficult to research, since it’s so multifaceted. However, research does show that psychotherapy can be an effective treatment for people struggling with mental health symptomology.
There are empirically validated and supported treatments. These are standardized counseling approaches that have shown effective outcomes for certain mental health issues. With that said, the quality of the therapeutic relationship, regardless of the therapeutic orientation, has been shown as the most beneficial factor determining a positive outcome.
