GERALD P. KOOCHER AND BARBARA M.

PEDULLA

Current Practices in Child Psychotherapy

The authors report on a survey of 110 psychotherapists who treat children.

The data include reports on the relative usefulness of various theoretical and
practical techniques now in use. One striking finding is that psychologists
and psychiatrists in the sample differed little in their theoretical orientations
and practices. Those interdisciplinary differences that were significant seem
predictable on the basis of training patterns. On the whole, it seems that the
variety of approaches used in psychotherapy with children is probably
narrower than that used with adult clients.

The field of psychotherapy has grown dramatically in scope and emphasis

since the concept of the "child guidance" model was developed in America
(Healy & Bronner, 1948). In the past 10 years a specialized subfield of
clinical child psychology has developed with a significant body of theoreti-
cal, clinical, and empirical literature. Substantial new volumes, with scores
of experienced contributors, describe theoretical models, develop thera-
peutic strategies, and elaborate on new techniques (Hammer & Kaplan,
1967; Haworth, 1964; Joint Commission, 1970; Williams & Gordon, 1974).
This growth was dramatized recently when one psychologist (Cummings,
1974) raised the question of whether "traditional clinical child psychology"
was already obsolete. Yet for all this body of written material, very little is
actually known about what sort of psychotherapy is currently being used
with child clients.
The purpose of this study was to survey a large number of child thera-
pists in an effort to determine who they are and how they practice their
craft. We sought to discover which therapeutic techniques and theoretical
approaches are actually being used and found useful. We also hoped to
discover whether different disciplines within the mental health community
actually differ significantly in their work with child clients. This is of special

GERALD p. KOOCHER received his PhD in clinical psychology from the University of Missouri,
Columbia. He is on the staff of the Sidney Farber Cancer Institute and faculty of the Harvard
Medical School. His current interests include the impact of loss and chronic illness on child
development, as well as psychotherapy with children and families.
BARBARA M. PEDULLA received her PhD from Boston College, where she is currently a part-
time instructor in counseling psychology. She also works as a clinical child psychologist at the
Framingham Youth Guidance Center (Framingham, Massachusetts) and maintains a private
practice.
A PRELIMINARY REPORT of these findings was presented in a symposium by the same title at
the 84th annual meeting of the American Psychological Association, Washington, D.C.,
September 1976. The listing of the authors is alphabetical, with full responsibility for the
conceptualization and execution of this study being equal in all respects.
REQUESTS FOR REPRINTS should be sent to Gerald P. Koocher, 44 Binney Street, Boston,
Massachusetts 02115.

Professional Psychology AUGUST 1977 275

CURRENT PRACTICES IN CHILD PSYCHOTHERAPY

interest in view of recent attempts by some state medical societies to create a

legal entity called "medical psychotherapy."

Method

QUESTIONNAIRE

A three-page questionnaire was prepared to address several basic content

areas. A cover letter asked the respondents to restrict their reporting to
therapy (as opposed to evaluation) cases and to children who entered
treatment prior to their 13th birthdays. We also asked that recipients for
whom the questionnaire was not applicable make such a notation on the
questionnaires and return them. All respondents were provided with a
stamped return envelope and full anonymity. The first series of questions
dealt with therapist demographic data, training, experience, licensing,
time devoted to psychotherapy with children, age and sex data on clients
seen, the nature of the prime setting in which the child clients are treated,
and the frequency of therapy sessions.
The next set of items sought information concerning therapist involve-
ment with parents and schools. These items were followed by a series of
questions on specific techniques and media (e.g., art materials, role play-
ing, hypnosis, puppet play, etc.), which the therapists were asked to rate on
a 4-point continuum: never or almost never useful, occasionally useful,
often useful, and always or almost always useful. Each therapist was then
asked to apply the same continuum in rating the relative usefulness of
various theoretical systems of psychotherapy to his/her work with children.
Space was also permitted for the inclusion of any techniques or theoretical
orientations not listed in the questionnaire.
Specific strategies for limit setting and communicating with a child
client's parents were listed in the next section of the questionnaire. These
were to be rated on another 4-point continuum, from extremely useful to
rarely useful. A list of client characteristics and diagnostic labels followed,
and the respondents were asked to rate their own relative effectiveness as
therapists with each type of client on a 4-point continuum ranging from
usually effective to seldom effective.

SAMPLE

Our goal was to locate quickly a large number of experienced child thera-
pists with a minimum of time and cost. We selected the Section on Clinical
Child Psychology of Division 12 of the American Psychological Association

276 AUGUST 1977 Professional Psychology

(APA) and the American Academy of Child Psychiatry as two groups1 likely
to have substantial numbers of members engaged in child psychotherapy.
Using the current directories of both groups, the names of members to be
surveyed were randomly selected within each of four geographic areas.
The areas used are those described in the APA's monthly Employment
Bulletin. Equal numbers of members were selected from each of the four
regions (i.e., East, West, Midwest, and South), so that a reasonable spread
of responses across geographical boundaries within the United States could
be expected.
The mailing went out to 200 psychologists and 80 psychiatrists. The
return rate for psychologists was 61.5% (n = 123), and the return rate for
psychiatrists was 43.8% (n = 35). Of the returns, 69% from psychologists (n
= 85) and 71% from psychiatrists (n = 25) could be coded and tabulated.
Approximately 30% of the questionnaires returned by both groups indi-
cated that the respondent was no longer doing psychotherapy with chil-
dren (i.e., was retired, in an administrative post, unemployed, or teaching
full time) or worked only with adolescents and adults. A small part of this
group did not disqualify themselves for these reasons but provided data
that were too incomplete for analysis (4% of those responding).

Results and Discussion

The average age of those responding was 45.5 years, with a standard
deviation of 9.8 years. As one might expect given these figures, the group
was relatively experienced in psychotherapy with children, having an
average of 13.5 years of experience, with a standard deviation of 7.2 years.
The geographic distribution of the sample included 25.5% from the East,
21.9% from the Midwest, 24.5% from the South, and 29.1% from the West.
These figures total 101% due to rounding off. Of the respondents, 71.8%
were male and 28.2% female.
Further descriptive data for the sample are displayed in Table 1. Psy-
chologists and psychiatrists differed significantly on only one background
variable. More psychiatrists were in private practice. The respondents
represented comparably broad age and experience ranges and represented
significant cumulative professional experience. Chi-square tests and t tests
yielded significant differences at the .05 level between psychologists and

1
Psychologists and psychiatrists were used as the primary reference groups of this survey
partially because of the ease in locating those with an interest in child psychotherapy.
Association directories of the two groups made selection of the sample an easy task, whereas
no such directories were readily available for other relevant mental health professions, such as
social work.

Professional Psychology AUGUST 1977 277

CURRENT PRACTICES IN CHILD PSYCHOTHERAPY

Table 1: Psychotherapists' Work Settings

Psychologists Psychiatrists
% adjusted % adjusted
Category n frequency n frequency
Community
mental health
centers 14 16.7 1 4.0
General or
pediatric
hospital 6 7.1 1 4.0
Child guidance
clinic 9 10.7 1 4.0
University training
clinic 8 9.5 2 8.0
Psychiatric
hospital 2 2.4 1 4.0
Private office 33 39.3 19 76.0
Other" 12 14.3 0 0
No response 1 1.2 0 0
Note. For psychologists n = 85 and for psychiatrists n = 25. x2 =
12.74, df = 6,p < .047.
a
Some respondents simply checked "other" but did not specify the
primary site at which they treat child clients. Others who did specify
settings listed a variety of locales, including public school, private
school, pediatric group practice, health maintenance organization,
medical school, and rehabilitation center.

psychiatrists for only 7 of the 52 questionnaire items. Because so many

significance tests were employed, the few significant differences noted
might be artifacts of chance. Still, the items on which the professional
groups differed seem to be related to obvious differences in their profes-
sional backgrounds, suggesting that the differences may indeed be mean-
ingful. Psychologists' and psychiatrists' responses are therefore discussed
separately for those questionnaire items on which the groups differed. For
all other items, the responses of the two groups are combined and dis-
cussed as a unit.

CHARACTERISTICS, OF CHILD CLIENTS

The majority of children being seen in psychotherapy, according to the

questionnaires returned, are boys. An average of 68% of the children seen
by the therapists surveyed were male, whereas an average of 32% were
female. This is not surprising considering other literature that suggests
boys tend to have more reported psychological difficulties than girls.

278 AUGUST 1977 Professional Psychology

 Very young children are also being seen in psychotherapy. The mean
age of the youngest child seen by the therapists surveyed was 4 years.
About 72% of the therapists had seen children 4 years old and younger,
with some therapists having reported the treatment of children as young as
2 years. The most common age span of child therapy clients represented in
our sample was 8-10 years.

TREATMENT SETTING AND FREQUENCY

The vast majority of these child clients (732 in all) are seen only once a
week. Another 75 children are seen twice a week, and 23 children are seen
more often. Most of the therapists who responded were treating children
primarily in private therapy, suggesting that the findings reported here
may relate largely to therapy with children whose families can afford
private treatment. A specific breakdown of the clients' socioeconomic
status was not requested, nor was any indication of the fees charged.

THEORY AND CHILD PSYCHOTHERAPY

We asked the respondents to rate the usefulness of a number of theoretical

frameworks to their own work as child therapists. The results are pre-
sented in Table 2. Family systems theory was the only theoretical orienta-
tion rated as useful by more than 60% of the therapists. Although viewing
the family and its internal interactions as a unit is a relatively new therapeu-
tic approach, it has clearly had its influence. Just as the importance of the
mother-child relationship led to the routine involvement of mothers in
simultaneous therapy, most therapists are expanding their view of the unit
for analysis and treatment to include the whole family.
Psychoanalytic theory is still a very powerful force in child psychotherapy
but is found to be more useful by psychiatrists than by psychologists.
Psychoanalytic theory was rated often or always useful by nearly all of the
psychiatrists but by only about half of the psychologists. The differences
may be rooted in the training of the two professional groups, with psychol-
ogists being exposed to more varied theoretical orientations.
The application of learning theory and behavior modification is clearly
having an influence, particularly on psychologist therapists. About half of
the psychologists surveyed found behavioral techniques often or always
helpful in their work with children, whereas only about a quarter of the
psychiatrists found them so useful. Again, this finding may reflect psychol-
ogists' exposure to this theoretical orientation.

Professional Psychology AUGUST 1977 279

CURRENT PRACTICES IN CHILD PSYCHOTHERAPY

Table 2: Therapists' Ratings of the Usefulness of

Theories
% therapists selecting category

Occa-
Theoretical Never sionally Often Always
orientation useful useful useful useful
Family systems 9' 26 44 21
Client centered 22 38 28 12
Rational emotive 49 29 20 2
Gestalt 49 35 13 3
Orgone 98 2 0 0
Psychoanalytic*
Psychologists 19 30 26 25
Psychiatrists 4 12 40 44
Behavior
modification**
Psychologists 14 31 36 19
Psychiatrists 20 52 28 0
Note. N = 110. In all categories except the last two listed, psycholo-
gists and psychiatrists did not differ significantly from each other in
category percentages, and the figures reported are for all therapists.
"X2 = 9.07, rf/= 3,/> < .05.
**X 2 = 7.89, df = 3,p < .05.

It is interesting to note that despite the popularized writings about child

therapy by such people as Virginia Axline and Clark Moustakas, client-
centered or nondirective approaches were generally not found to be useful
by the therapists surveyed. In addition, other approaches, representing
newer orientations or appearing mostly in the literature on adult therapy
(i.e., gestalt and rational emotive therapy), do not seem to be widely used.
Some respondents listed other orientations, including varieties of cogni-
tive, or educational, techniques and transactional analysis, but these were
the exceptions rather than the rule.

MEDIA, TECHNIQUES, AND PRACTICES

The therapists were also asked to rate the usefulness of some specific
techniques and media in their work with children. The results are pre-
sented in Table 3. It seems that child therapists find a few basic, traditional
tools helpful in their work, and these relate most closely to the more
psychodynamic analytic theories. Art was the only medium found often or
always useful by more than 60% of the therapists surveyed. Doll and
puppet play was found to be of varied usefulness. Newer techniques for

280 AUGUST 1977 Professional Psychology

Table 3: Therapists' Ratings of Media and
Technique Usefulness
% therapists selecting each rating

Occa-
Media or Never sionally Often Always
technique useful useful useful useful

Craft projects 27 50 18 5
Projective testing 18 27 29 26
Doll or puppet
play 8 35 41 16
Giving gifts 51 32 11 6
Role playing 17 46 28 9
Competitive
games 21 49 26 4
Physical contact 24 40 28 8
Giving food 33 40 19 8
Aversive
conditioning 83 16 1 0
Mutual
storytelling 55 32 12 1
Activity groups 43 39 14 4
Sharing personal
experiences 30 50 15 5
Hypnosis 89 10 1 0
Music 79 17 3 1
Art materials 7 25 44 24
Psychoactive
medication*
Psychologists 38 56 5 1
Psychiatrists 20 56 24 0
Free association**
Psychologists 44 30 11 15
Psychiatrists 24 28 44 4
Note. N = 110.
*X 2 = 9.22, df= S, p < .05.
**X Z = 14.81, df= 3 ,p < .01.

gathering fantasy material and giving therapeutic messages (e.g., mutual

story telling; Gardner, 1971) were not generally found to be useful. It is not
clear to what extent this reflects a lack of knowledge of the newer tech-
niques or the lack of need for additional techniques. It is also interesting
that the oldest, most traditional psychoanalytic technique, free association,
was usually not found to be helpful in child work by the majority of
therapists surveyed, although psychiatrists tended to use this technique
more often than psychologists.

Professional Psychology AUGUST 1977 281

CURRENT PRACTICES IN CHILD PSYCHOTHERAPY

Techniques not directly related to major developmental theories (e.g.,

hypnosis and music therapy) were generally found not to be helpful.
Medicines were also generally found not to be useful, although psychia-
trists found more use for them than did psychologists. This would be
expected in light of the psychiatrists' medical training and possible differ-
ential referral to them of some children with behavior problems compli-
cated by physical conditions.
Although group therapy for children has received some attention in the
literature, especially with regard to residential treatment facilities, most of
the therapists surveyed did not find group techniques helpful in their child
work. Activities that are not geared to produce fantasy material (e.g.,
games, craft projects, etc.) were generally found not to be useful. Tradi-
tional prohibitions against giving child clients gifts or food during therapy
sessions, making physical contact, or sharing personal experiences were
generally upheld by the therapists surveyed but without overwhelming
agreement.
The therapists differed widely 'in their ratings of the usefulness of
projective test data. It is especially interesting, however, that there was no
significant difference between psychologists' and psychiatrists' ratings.
This is somewhat surprising because most psychologists are likely to have
had training in projective assessment techniques, whereas this is not usual
in psychiatrists' training.

LIMIT SETTING

The therapists were asked to rate the usefulness of various policies and
strategies for limiting the destructive or potentially injurious behavior of
their child clients. These data are presented in Table 4. Most therapists felt
that it is useful to discuss the limits of permissible behavior with the child,
but there was considerable variation among therapists as to whether they
would take a more active, assertive role in stopping such behavior, even
injurious behavior. One explanation for this may lie in the fact that some
degree of permissiveness is inherent in the context of play therapy and that
overt destructive acts during therapy hours are relative rarities. Still, it is
interesting that little uniformity was evident among the therapists surveyed
on this point.

WORK WITH PARENTS

Work with parents is clearly a very important aspect of child psychother-

apy. Nearly all of the therapists (94%) indicated that most of the parents of

282 AUGUST 1977 Professional Psychology

their child clients are seen by a therapist concurrently as part of the child's
treatment plan. The majority of therapists, about 57%, indicated that they
usually see the child's parents themselves, although not with the child

Table 4; Therapists' Handling of Confidentiality and Limit Setting

% therapists using each rating
Extremely Sometimes Occasionally Never
Issue useful useful useful useful
Confidentiality

Sharing specific material

from sessions of child
with the parents 11 29 29 31
Discussing important
concerns of the child
with the parents in
general terms 49 33 14
Offering specific
suggestions to the
child's parents for
behavior management 51 30 17
Total confidentiality:
Discuss nothing about
the child's treatment
with the parents 10 15 20 55
Limit setting

Discussion of limits with the

child 51 28 18
Using physical restraint to
limit destruction of toys
or office equipment 29 25 21 25
Using physical restraint to
prevent self-injury or
injury to others 33 23 29 15
Raising one's voice as a
behavior-limiting
technique with an
acting-out patient*
Psychologists 1 25 31 44
Psychiatrists 25 25 25 25
*X* = 18.37, d/ = 3,p < .001.

Professional Psychology AUGUST 1977 283

CURRENT PRACTICES IN CHILD PSYCHOTHERAPY

present. Only 22% of the therapists generally use conjoint arrangements,

in which the child and parents, or the entire family, are seen together.
The importance of the father's, as well as the mother's, role in the child's
treatment was apparent. About half of the therapists (51%) indicated that
they routinely see both parents, and another 43% noted that they generally
arrange for some participation by the child's father. This is interesting both
as a reflection of societal change and of shifts away from the traditional
child guidance model. Psychotherapists are showing appropriate concern
for the impact of both parents on the developing child, instead of the more
traditional focus on the mother. In the traditional child guidance model,
two therapists were involved to insure the trust and confidentiality of each
party, although it has long been noted that no hard evidence existed to
substantiate the importance of the separate therapists doctrine (Ross,
1964). It seems that the majority of child therapists prefer some involve-
ment with the whole family, and are able to compartmentalize confidences
(when necessary) in such a way that mutual trust is not lost (Koocher, 1976).
The therapists were also asked to rate the usefulness of various styles of
working with the child client's parents. Most usually did not find it helpful
to share specific material from the child's sessions with his or her parents,
although about 40% did find this practice frequently useful. A majority of
the therapists did indicate that they found it useful to discuss a child's
concerns with the parents in general terms and to offer suggestions for
behavior management. About 25% of the therapists surveyed indicated
that they generally did not find it useful to share any information about
their work with the child with the child's parents.
It would be interesting to consider how the issue of confidentiality is
handled, since, as noted above, most parents are being seen by the same
therapist as the child without the child present. No specific questions were
asked regarding how parent-therapist contacts and information sharing
are discussed with the child, although this is clearly an important issue.
The proposed revision of the APA's Ethical Standards of Psychologists
includes the concept that an ethical therapist will make a serious effort to
secure the permission of a child client before sharing information.

CONTACT WITH TEACHERS

The therapists were asked to report the percentage of their therapy

patients whose teachers they consulted with about management issues and
to note the frequency of these contacts. Only 2% never did such consulta-
tion, and 21% did consultations on all of their therapy patients. The mean
percentage in this area was 63%. The frequency of therapist-teacher

284 AUGUST 1977 Professional Psychology

Table 5: Therapists' Ratings of Their Effectiveness
with Various Types of Child Clients
% therapists selecting each effectiveness
rating

Occa-
Usually sionally Slightly Seldom
Client type effective effective effective effective
Males 91 9 0 0
Females 86 12 2 0
Neurotics 82 16 2 0
Autistic children 8 20 30 42
Mentally retarded 23 35 29 13
Psychosomatic prob-
lems 36 52 10 2
Physically handi-
capped 41 40 14 5
Character disorders 25 38 26 11
School-age children 85 14 1 0
Preschoolers 63 24 11 2
Psychotic children*
Psychologists 25 29 27 19
Psychiatrists 17 63 8 12
Children with medi-
cal problems**
Psychologists 37 43 13 7
Psychiatrists 70 26 4
Note. N = 110. The "children with medical problems" category
means physical illness.
* X 2 = 9.34, d/ = 3,p < .05.
**X 2 = 8.55, df= S,p < .05.

consultations on a given patient ranged from zero to five per year, with the
most common frequency being twice a year (58.2%).

THERAPIST EFFECTIVENESS

The therapists were asked to rate their personal effectiveness with various
types of child clients. These data are presented in Table 5. Nearly all
therapists rated themselves as at least occasionally effective with most types
of child clients. The one exception to this was the case of the autistic child,
a type of client with whom most therapists reported themselves to be
infrequently effective. This is not at all surprising, given the generally
accepted difficulty in helping children who are truly autistic.

Professional Psychology AUGUST 1977 285

CURRENT PRACTICES IN CHILD PSYCHOTHERAPY

Psychologists and psychiatrists differed in their views of their own effec-

tiveness with psychotic children. Whereas 80% of the psychiatrists rated
themselves as at least occasionally effective with these children, there was
no clear trend in the responses of the psychologists sampled. Some felt
generally effective with psychotic children, whereas equal numbers did
not. This may relate to differential training of psychiatrists in settings for
more seriously disturbed children. Also, nearly all of the psychiatrists
(96%) felt at least occasionally effective with physically ill child clients,
whereas significantly fewer psychologists (90%) regarded themselves simi-
larly effective. Again, this is probably related to the psychiatrists' medical
training.

SUMMARY

The survey of 110 child psychotherapists yielded a complex set of data on

the usefulness of common practical and theoretical techniques. One of the
most striking findings is that psychologists and psychiatrists do not differ
very much in their therapeutic orientations and practices. Those interdisci-
plinary differences that do exist seem predictable on the basis of differen-
tial training experiences. The overall practice of psychotherapy with chil-
dren reflects a wide variety of approaches, although probably on a nar-
rower continuum than one would find in use with adult clients.

REFERENCES

Cummings, S. T. Is traditional clinical child psychology obsolete? In G. J. Williams

& S. Gordon (Eds.), Clinical child psychology: Current practices and future perspectives.
New York: Behavioral Publications, 1974.
Gardner, R. A. Therapeutic communication with children: The mutual storytelling tech-
nique. New York: Jason Aronson, 1971.
Hammer, M., & Kaplan, A. M. The practice of psychotherapy with children. Home-
wood, 111.: Dorsey Press, 1967.
Haworth, M. R. (Ed.). Child psychotherapy: Practice and theory. New York: Basic
Books, 1964.
Healy, W., & Bronner, A. F. The child guidance clinic: Birth and growth of an
idea. In L. G. Lowrey & V. Sloan (Eds.), Orthopsychiatry 1923-1948: Retrospect and
prospect. Menasha, Wis.: American Orthopsychiatric Association, 1948.
Joint Commission on the Mental Health of Children. Crisis in child mental health:
Challenge for the 1970s. New York: Harper & Row, 1970.
Koocher, G. P. A bill of rights for children in psychotherapy. In G. P. Koocher
(Ed.), Children's rights and the mental health professions. New York: Wiley-Intersci-
ence, 1976.

286 AUGUST 1977 Professional Psychology

Ross, A. O. Confidentiality in child guidance treatment. In M. R. Haworth (Ed.),
Child psychotherapy: Practice and theory. New York: Basic Books, 1964.
Williams, G. J., & Gordon, S. (Eds.). Clinical child psychology: Current practices and
future perspectives. New York: Behavioral Publications, 1974.

Received November 4, 1976

Announcement of Special Issue on the Law and Applied Psychology

Readers are invited to submit manuscripts for a special issue of Professional Psychology
to be entitled "The Law and Applied Psychology." Manuscripts relating to this
topic and received by November 15, 1977 will be considered for inclusion in the
special issue.
In keeping with the editorial policy of the Journal, papers should address legal
questions encountered by individuals who provide psychological services or who
train others to provide such services. Reports of empirical research as well as
papers that analyze and reflect on issues are appropriate. Issue-related papers
could include a historical perspective on the legal and psychological issue to be ad-
dressed, with an examination of the present status and future implications of the
issue. Papers that integrate and contrast the views of others in the field are especially
welcome. Case studies and program descriptions will be considered if they address
some general and important issue.
Papers should address the effects of law upon the provision of psychological
services or the application of psychological principles and skills to legal questions.
Topics may include (but need not be limited to) the following: applications of
psychology in the court room, to questions of criminal responsibility and com-
petency to stand trial, and to questions of civil law (commitment, suits); the psy-
chologist in child custody cases; problems of legal sanctions affecting the provision
of psychological services and private practice and in hospital, community mental
health, educational, and correctional settings; law and psychological assessment in
employee selection and educational decisions; the training of psychologists to meet
challenges in the interface of law and applied psychology; legislative decisions af-
fecting education and the school psychologist; legislation and the future of the
clinical psychologist as a provider of health services; and clinical psychologists in
service to law enforcement.
Additional inquiries should be sent to J. Thomas Grisso, Department of Psy-
chology, St. Louis University, St. Louis, MO 63103, or to Bruce D. Sales, Depart-
ment of Psychology, University of Nebraska, Lincoln, NB 68508.

Professional Psychology AUGUST 1977 287