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Which Talk Therapies Work Best With Teens and Children?

This blog was originally posted on Psychology Today


Life can be tough for children and teens. Stressful events like the loss of a relationship, moving to a new town, or integrating into new school environments are challenging, both emotionally and physically. Anxiety can cause our blood pressure and adrenaline levels to rise within minutes. How can we help teens and children to stay calm? Hobbies and Netflix are great, but this can also be a time when younger people turn to alcohol and junk food, or take out their stress on those around them. Over time these less helpful responses to negative emotions can turn into addiction, obesity, and/or anger problems that damage relationships.

It is an uphill battle to break out of these behavior patterns once they are well established. Teenagers may be especially ashamed to seek professional help and medication alone will not prevent powerful negative feelings again in the future. Here is where talk therapy can play an important role. The best self-defense is developing the capacity to manage negative feelings when they do come up. This is an area where mental health professionals are increasingly using neuroscience research to determine the best therapy approach—especially with teenagers and children.

Is Cognitive Behavioral Therapy Always The Best Treatment?

Cognitive behavioral therapy (CBT) is currently the most commonly recommended type of talk therapy for treating many disorders. CBT was the first form of psychotherapy scientifically tested using the most stringent criteria: randomized trials and active comparison treatment. It was developed for adults and is now used on children and teens as well.    

CBT teaches a method of regulating emotions called cognitive reappraisal which trains people to reinterpret situations from a new perspective that then changes their emotion. For example, Jane is struggling to quit smoking and sees a pack of cigarettes at the grocery store. Her immediate response might be to think about how good it will feel to buy the pack and smoke a cigarette. Using cognitive reappraisal, she can focus on how embarrassing it will be to have smoker’s breath when she kisses her boyfriend. In this way her emotional response changes from desire to disgust, making it easier to stay cigarette-free.

But One Size Does Not Fit All Ages

Due to its effectiveness, cognitive reappraisal is the most extensively studied strategy for regulating emotions. However, children and teens find the technique difficult to use. Research into human brain development offers clues: Our brains develop in a particular order: Visual regions are essentially adult-level by age five and regions for hand-eye coordination mature by high school, but some parts of the brain do not fully mature until around age 24. Cognitive reappraisal relies precisely on those late-maturing parts. Put differently, children’s brains may not yet have all the “brain hardware” necessary to use the cognitive reappraisal techniques.

None of the existing psychotherapies were intentionally designed to activate certain brain regions. But neuroimaging studies have shown that, while cognitive reappraisal uses late-maturing parts of the brain, there are other emotion regulation strategies that seem to use earlier-maturing brain regions. Since the technique of cognitive reappraisal is less effective in children, we might do better to consider some of these alternative strategies for children and teens.

Focus On If-Then Plans and Rote Strategies

CBT depends on “explicit” strategies for the regulation of emotion. Explicit here refers to conscious effort, like the effort involved in learning how to read, sounding out each word aloud before the process becomes more automatic, or implicit. Explicit emotion regulation strategies are like coming up with new dance choreography for every situation.

Implicit strategies, on the other hand, are like practicing just one dance move over and over and using it for every situation. An implicit strategy referred to as "if-then" seems to work well with teens and children.

Here is an example of an “if-then” implicit emotion regulation strategy: “If situation x is encountered, then I will perform behavior y!” John might fear blood, but could commit to the plan: “If I see blood at the horror movie, then I will stay calm and think about kittens instead.” Or John might focus on the taste of his popcorn during gory parts of the movie. With enough practice, this reaction to blood can become automatic (i.e., implicit) for John, allowing him to tolerate going to horror movies with friends.

This approach works better for children and teens because it relies on parts of the brain that develop earlier—lower and more central parts of the prefrontal cortex. These parts stand a better chance of being “ready for use” in children.

A Niche for Psychoanalytic Techniques

How do you find a therapist who can teach implicit emotion regulation strategies? Psychoanalytic psychotherapists do this all the time for children and adults alike. An important feature of psychoanalytic psychotherapy is an exploration of defense mechanisms. Defense mechanisms are the often maladaptive automatic responses that patients learned in the past without being aware of it. In other words, a defense mechanism is an implicit emotion regulation strategy.

For instance, Michael might have been rejected by a female love interest in the past and now regulates his anxiety around women by refusing to speak to them. Psychoanalytic psychotherapists engage with patients over their defense mechanisms in order to promote more adaptive and productive implicit emotion regulation strategies. Because this work inherently involves those parts of the brain that mature earlier in development, children and adolescents could likely benefit more from psychoanalysis than from CBT interventions.

In fact, psychoanalytic psychotherapy is often more effective than CBT for both children and adults. Research has shown that while both are equally effective in the short term, the effects of psychoanalytic psychotherapy continue long after the treatment has ended.

About the authors:

Dr. Genevieve Yang received her M.D. from Yale in 2018 and is currently a research track psychiatry resident at the Mount Sinai Hospital in New York City. Dr. Yang also completed a Ph.D. in Neuroscience at Yale, where she studied computational neuroscience and functional magnetic resonance neuroimaging biomarkers in schizophrenia patients. At Mount Sinai, she plans to engage in neuroimaging-based cognitive reappraisal and neurofeedback research.

Timothy Rice MD is an adult and child and adolescent psychiatrist in practice in New York, NY.  He is currently the co-chair of the World Federation of Societies of Biological Psychiatry’s Task Force on Men’s Mental Health, where he focuses on safety and risk factor reduction with male children, adolescents, and young men.  He is a member of the Association for Child Psychoanalysis, the American Academy of Child and Adolescent Psychiatry, as well as the American Psychoanalytic Association, where he is Chair of the Child Advocacy Committee.  His professional and research interests include the promotion of health and well-being in youth populations.