by Sergio V. Delgado, MD

Dr. Delgado is Associate Professor, Child and Adolescent Psychiatry, Psychoanalysis, and Medical Director, Outpatient Services with Cincinnati Children’s Hospital Medical Center, Department of Pediatrics and Psychiatry, Cincinnati, Ohio.

Editor Note: All cases presented in the series “Psychotherapy Rounds” are composites constructed to illustrate teaching and learning points, and are not meant to represent actual persons in treatment.


The treatment of children and adolescents with psychotherapy is gradually losing ground to psychopharmacology. The author reviews the value the various forms of psychotherapy have in the treatment of children and the importance of having a clear curriculum for teaching this skill in residency programs. Although the importance of psychodynamic psychotherapy has a long history in the treatment of children, the reluctance some faculty have in recommending this form of therapy may be due to limited experience and limited knowledge of its benefits. The author highlights that a psychodynamic diagnostic evaluation is essential to assess a child’s suitability for psychotherapy. The characteristics of children who will benefit from psychodynamic psychotherapy, their defense mechanisms, and optimal characteristics of their parents are reviewed. The qualifications a psychiatrist needs to succeed in this endeavor are discussed. Two cases illustrate not only the importance in the suitability of the patient, but also the application of psychodynamic theory to practice.

Key Words

play therapy, psychodynamic evaluation, adolescent psychotherapy. patient suitability, countertransference


The goal of the contemporary child and adolescent psychiatrist is to carefully evaluate and diagnose children’s psychiatric problems and to develop treatment plans to alleviate the suffering these conditions can inflict on the children and their families. The 21st century has led to substantial progress in child psychiatry with the use of medications for the treatment of serious illnesses. Our young colleagues typically graduate from child psychiatry training programs with a broad pharmacological armamentarium. Although medications have led to great success in the treatment of attention deficit hyperactivity disorder, psychotic disorders, and mood disorders, there have been parallel concerns about the need to monitor for possible serious, adverse events. The use of antidepressants and antiepileptics may increase suicidal tendencies, and atypical antipsychotics carry the risk of inducing a metabolic syndrome.[1–3] This has led families and clinicians to reconsider the need for play therapy for young children and talk therapy for adolescents. So where does the learning of our old skill in engaging children in a psychotherapeutic process stand now?

Our training program standards require competency in the following five types of psychotherapy: brief, supportive, combined medication and psychotherapy, cognitive-behavioral (CBT), and psychodynamic (PD). McConville states that we need to “choose competently and selectively from among the often-bewildering mosaic of available therapies.”[4]Plakum suggests a “Y” model for defining competencies in training programs.[5] The stem represents shared elements of psychotherapy across schools. One branch represents psychodynamic (PD) and interpersonal (IP) psychotherapy, and the other branch cognitive behavioral therapy (CBT).[5] In general, we mostly agree that all forms of psychotherapy provide children with some form of “corrective emotional experience” with the goal of alleviating a child’s problems that interfere in the psychological wellbeing.6 Although we agree that psychotherapy somehow helps, do we have support and interest from the psychiatric faculty, who are knee deep in pharmacologic research trials, for the child psychiatrist to learn psychotherapy as a valuable and useful skill? In recent annual meetings of the American Academy of Child and Adolescent Psychiatry (AACAP), workshops and posters predominantly displayed results of pharmacological research or diagnostic rating scales. In the Journal of the American Academy of Child and Adolescent Psychiatry, although articles on psychotherapy are seen less often, there has been a very recent resurgence in appreciation of the importance of psychotherapy. It is hoped that we still have the necessary experienced faculty to teach the art of psychotherapy and provide the foundation needed in identifying the patients who will benefit from psychotherapy and what type of psychotherapy is indicated.

There is evidence that CBT is helpful for children with posttraumatic stress disorders[7] and obsessive compulsive disorders,[8] and interpersonal psychotherapy (IPT) has been shown to help adolescents with depression.[9] The value of family and group therapy for eating disorders in children continues to be widely accepted,[10] and PD psychotherapy has evidence-based studies supporting its efficacy in the treatment of dysthymia, anxiety, panic disorders, and in some cases, poorly controlled diabetes.[11–13 ]

The Antecedents of PD Psychotherapy for Children

PD psychotherapy in children began in 1909 when Sigmund Freud introduced play therapy by supervising the treatment of a five-year-old boy, Little Hans, by his father.[14] Hug-Hellmuth formally introduced play therapy in 1921.[15] Later, Anna Freud[16] and Klein[17] pioneered the study of the bio-psychosocial developmental stages of the child, with attention to ego functions, defense mechanisms, drives, and superego formation. Both outlined the technique for PD play therapy, based on the belief that the child’s play had a symbolic, unconscious meaning.

In the United States, the early play therapists were Levy, Allen, and Axline[18–20] Also, contributions by Bowlby, Winnicott, Erikson, Mahler, and Stern have further enriched theories in attachment and object relations and highlighted the importance of working with parents.[21–25] Psychodynamic psychotherapy has been taught in psychiatry training programs since 1950. It is based on the following five fundamental assumptions: 1) a central importance of the unconscious in mental functioning, (2) the symbolic meaning of behaviors, (3) the existence of internalized unconscious conflicts, (4) the idea that symptoms have meaning, and (5) the belief that transference-based thoughts and behaviors are critical.[26]

The major difficulty encountered in current training programs is the lack of experienced faculty qualified and able to teach the complex and specialized courses needed to learn, embrace, and apply these five tenets of PD psychotherapy. A mere review of PD theories, without a solid foundation in the study of the “classics” in child psychiatry, will not do justice to the complexities of the subjective and internalized experiences between the child and his or her parents’ unconscious minds and the history created by their internal worlds, as they interpret and mirror each other’s psychic subjective space.
Experienced faculty members who are psychodynamically informed are aware that there is inconsistency in a student’s ability to learn theory and to learn therapeutic skills. This foundation of learning needs to be incorporated early in adult psychiatry training, continued in child training, and continually open to observation and discussion about the applicability of the theories to practical day-to-day patient care in inpatient units, outpatient clinics, and consultation services. Evidence-based research is critical to establishing best scientific practices. At the same time, when it comes to teaching the art of PD psychotherapy, the wisdom, astute observations, and inferences of experienced faculty are often passed down orally through the clinical pearls of their work. The importance of this form of teaching cannot be emphasized enough; it is not only teaching the art of PD psychotherapy, but also providing the mentorship needed for the next generation of colleagues.

DIAGNOSTIC CLINIC: The “picture” of the child

Having reviewed the importance of PD psychotherapy, how do we then identify which child would benefit from it?

As is commonly said, a picture speaks louder than words, and what better picture than the one that emerges from interacting with a child to evaluate his temperament, attachment style, and ego functions according to his or her developmental stage. To allow the picture of the child’s internal world to emerge in the office, we need to create a psychological space to observe the content and encourage the process to develop. This task is enhanced if we astutely “watch, wait, and wonder” during our interview.[27]

At Cincinnati Children’s Hospital Medical Center, we developed a PD diagnostic clinic with senior child psychiatry residents. The residents kindly accepted my request (said jokingly) to “leave your DSM at home” for this interview. Although the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR)[28] offers an objective and descriptive view of our patients, it is atheoretical, and diagnostically it does not offer a glimpse into patients’ internal worlds nor their suitability for therapy. Our task in the consultation is to discern what has interfered in a child’s capacity to play, love, become psychologically connected to others, and develop their innate cognitive abilities further. In other words, why has their psychosocial development not proceeded at a pace consistent with their age, environment, genes, and culture?

In the diagnostic clinic, our residents learn the characteristics of children who would benefit from PD psychotherapy (Table 1), the defense mechanisms used by children who would benefit from PD psychotherapy (Table 2), and the optimal characteristics of parents with children who would benefit from PD psychotherapy (Table 3).
The consultation begins by initially gathering information about medical, family, and social history from the parents. An initial complete mental status exam of the child is usually not necessary, as the ego functions will become apparent during our observation of the child’s interactions with the parents and the clinician. As the interview develops, we will begin to understand the nature of the child’s symptoms and the defenses used to avoid painful effects.

What are “ego functions?”

I am frequently asked to clarify what ego functions are. In short, among the many functions of the ego, the most common include moderating between the drives from the id and the prohibitions from the superego, reality testing, impulse control, affect regulation, defense mechanisms, object relations, and self-reflective functioning.
For the novice conducting a PD evaluation, when the defensive nature of a child’s symptom is apparent, there is an urge to confirm the hypothesis about the origins of the conflict by asking direct questions. Nevertheless, this abrupt push to make the unconscious conscious only further disrupts the emerging therapeutic alliance.
We finish the consultation by sharing with the child and parents our understanding of the child’s symptoms and recommending a treatment plan. We refer the child to the appropriate form of psychotherapy with a written PD diagnostic evaluation, which reads like a short story to bring the patient to life, with his or her strengths and struggles.

Qualifications of the psychiatrist
The psychiatrist must be able to develop a “road map,” helping provide the patient the freedom to play or talk in a way that will lead to a deeper awareness of the self, which may be experienced as good and bad, and create the space to express emotions without fear. Each patient is unique, and we cannot predict how the origins of the symptoms will unfold, in spite of presenting with similar conflicts as other children (i.e., pre-oedipal, oedipal, or relational). Therefore, during weekly appointments, the psychiatrist needs to be alert on how to best help the child identify the conflicts that have interfered in his or her development, and to teach him or her to use healthier defense mechanisms.
An aspect usually feared, although crucial in PD psychotherapy, is to “befriend” countertransference. Countertransference is a valuable tool in gauging the progress of the therapeutic process for both parties. PD supervisors facilitate discussing countertransference with the residents by helping them feel comfortable, without fear or shame. This also applies to supervisors of CBT, IPT, and DBT. Among the most ubiquitous countertransference reactions to children are feeling one is a “better parent” than the child’s actual parent, not tolerating aggression in the sessions and colluding with the child, and feeling that the parents are overly critical or indulgent.

The alliance with the child’s parents is crucial to avoid unexpected interruptions in treatment processes. The child’s symptoms reflect the fear that the open expression of the repressed emotions will elicit a critical response from the parents, which at times is accurate. Frequently the child is viewed as a “perfect child” until the symptom or behavior is noticed. I recall a case where parents somewhat jokingly said, “Thanks for helping our daughter. You turned her into a monster.” Fortunately, the alliance with the parents was well established and they had learned to tolerate the developmentally appropriate expression of anger from their daughter.

The child psychiatrist as a therapist is in a unique position. The synergy of psychotherapy, in all its forms, with pharmacotherapy occurs when there is flexibility of their use in tandem, rather than feeling that one is better than the other.[29]

Case Examples

The following are two cases that illustrate the characteristics of children who benefit from PD psychotherapy.

Case 1. J was a 13-year-old adolescent boy whose father died in a car accident one month before his referral for psychotherapy. Prior to his death, J’s father was in good health and had a good relationship with his family. Although J was doing well in school, his mother brought him to therapy because, “since his father died, his personality has changed; he has become the class clown at school.”

When the family learned of the father’s death, J’s nine-year-old sister’s reaction was intense; J said “my sister needed my attention. She cried unstoppably.” He began to wear his father’s T-shirts to school, stating that “they help me keep going on” (identification with lost father).

J had good ego strengths, was above average intelligence, insightful, empathic, and was eager to talk about his feelings because “I know my father’s death is bothering me.”
In our session, I noticed that he was wearing three watches on his left wrist.

Psychiatrist: Why three watches?
J: My parents gave me one and my friends gave me the other two. It’s polite to wear all three.
Psychiatrist: It seems like you want to please everybody (interpretation of his over-politeness as a defense: He had previously shared he feared being angry with others).
J: My father would be proud. He tells me to do my best (identification with father influenced by his own superego pressures).
Psychiatrist: It sounds like he continues to guide you.
J: Even though my father died, I still have him in my memory. When I’m angry at my mom or my sister, I get scared that I’ll hurt their feelings. I go outside to walk and talk to my Dad. I pretty much know what he would say.
Psychiatrist: What do you think he would say about how polite you are, as if you should never get angry? (I interpret the fear of the normal element of his aggressive impulses).
J: I worry about getting mad at school. I think that’s why I act goofy, like a clown (insight).
Psychiatrist: Maybe you underestimate your family and friends. They might like you just as much, even if you are angry at times.
J: I agree. I know you think I should be able to express my anger at Dad. It feels safe to do it in here. I don’t really know, but I think my Dad could have prevented his accident if he only would have not drunk his coffee, like he usually did. I think he spilled it, got distracted, and ran into the bridge. What was he thinking? Did he realize he was leaving his kids without a dad (aspect of the transference, where he projects onto me his wish to express his repressed anger at his father)?

After six weekly sessions, he resumed his normal developmental adolescent tasks. He was happier, no longer the class clown, and excelled at school academically and socially.

Case 2. B was a five-year-old girl who was referred by her pediatrician due to severe constipation not due to medical condition. A trial of laxatives, including mineral oil, were not only unsuccessful, but also made her feel “embarrassed and sad; she would leak the mineral oil all over herself and not have a bowel movement.”

Her family was well adjusted and healthy. Her paternal grandfather had become ill from pneumonia and was hospitalized one week prior to the onset of her constipation. The grandfather had previously been medically healthy and recovered quickly. Her parents did not think this was a major stressor since “he (the grandfather) is fine now.”

During the consultation, it was apparent that B clearly was a very bright and charming girl who related well to family and friends until the symptom of her constipation began to interfere with her psychosocial development. She no longer had wishes to play with friends and preferred to stay close to home due to her abdominal pain. She would frequently ask about how her grandfather was feeling. She thought her grandfather wasn’t “funny and silly anymore,” which her parents did not feel was accurate. I recommended play therapy to help work through her regressive anal symptom, which was helping her defend against severe anxieties that were not typical for her stage of development. Prior to the symptom, she was described as “the perfect child.”

As we began the therapy, she played in a rather constricted manner. I decided not to intervene and just follow the play. By the third session, she began to play aggressively:

B: Get in the trash can…now you know how it feels!
Psychiatrist: I feel stuck.
B: You should be. You were bad. You were angry at God’s angels for making your grandfather go to the hospital (the projection of her superego anxieties onto me).
Psychiatrist: I didn’t know why he was sick. I was scared.
B: It was because he was old and old people die.
Psychiatrist: (at this point, I stepped out of the story.) What should I say now?
B laughed anxiously.
B: Ha ha! I’m happy that you are stuck in the trash. Your poop is stuck and you’re afraid that all your angry feelings will come out and fill the trash can. You are dirty.
Psychiatrist: I think children can have angry feelings. Let’s keep playing and maybe you will feel better and not worry about letting your poop out.
B: I get mad when my parents give me the poop medicine.
Psychiatrist: Maybe you’re worried about being mad at God’s angels about your grandfather and you don’t poop…
B: Yes, I’m afraid to poop because the angels could get mad and take him to the hospital again!

The next session she looked happy and said, “Guess what? I pooped at McDonalds. It was a lot! I feel better. I know it’s ok to be angry with the angels.”


Although young residents and therapists have many theoretical choices regarding how they understand a case or how they intervene, one important fact to remember is that our comments are only helpful if they make sense to the child. Once a child feels understood, he or she will guide us about what language to use and with which issues they need help. In both of the cases described here, J and B worked through their superego conflicts and were able to overcome the developmental interference in their lives.

At times, good outcomes merely represent a compelling flight into health without insight, and although there is countertransference excitement, the children do not change their maladaptive defense mechanisms. At other times, we are humbled that not all psychotherapy has good and happy endings, which may be due to relational impasses, pathology in family, fragile ego function prone to psychosis, and countertransference issues to certain patients.

Fortunately, most cases have successful endings with children making significant gains in working through the conflicts that temporarily arrested their psychosocial growth, and they resume their age-appropriate developmental tasks.

1. Center for Drug Evaluation and Research. Antidepressant use in children, adolescents, and adults. Rockville (MD): US Food and Drug Administration. Access date: April 28, 2008.
2. Center for Drug Evaluation and Research. Anti-epilepsy drugs increased the risk of suicidal thoughts in children, adolescents, and adults. Rockville (MD): US Food and Drug Administration. Access date: April 28, 2008.
3. Correll C. Antipsychotic use in children and adolescents: Minimizing adverse effects to maximize outcomes. J Am Acad Child Adol Psychiatry. 2008;47(1):9–20.
4. McConville BJ, Delgado SV. How to plan and tailor treatment: An overview of diagnosis and treatment planning. In: Klykylo WM, Kay J (eds). Clinical Child Psychiatry, Second Edition. West Sussex (UK): Wiley, 2006:91–108.
5. Plakun E. Finding psychodynamic psychiatry’s lost generation. J Am Acad Psychoanal Dyn Psychiatry. 2006;34(1):135–150.
6. Alexander F, French TM. Psychoanalytic Therapy: Principles and Application. New York: Ronald Press, 1946.
7. Cohen JA, Deblinger E, Mannarino AP, Steer R. A multisite randomized controlled trial for multiply traumatized children with sexual abuse-related PTSD. J Am Acad Child Adolesc Psychiatry. 2004;43(4):393–402.
8. March J, Franklin M, Nelson A, Foa E. Cognitive-behavioral psychotherapy for pediatric obsessive-compulsive disorder. J Clin Child Psychol. 2001;30:8–18.
9. Mufson L, Weissman M, Moreau D, Garfinkel R. Efficacy of interpersonal psychotherapy for depressed adolescents. Arch Gen Psychiatry. 1999;56:573–579.
10. Eisler I, Dare C, Hodes M, Russell GM, et al. Family therapy for adolescent anorexia nervosa: the results of a controlled comparison of two family interventions. J Child Psychol Psychiatry. 2000;41:727–736
11. Muratori F, Picchi L, Bruni G, et al. A two-year follow-up of psychodynamic psychotherapy for internalizing disorders in children. J Am Acad Child Adol Psychiatry. 2003;42(3):331–339.
12. Milrod B, Leon AC, Busch F, et al. A randomized controlled clinical trial of psychoanalytic psychotherapy for panic disorder. Am J Psychiatry. 2007;164(2):265–272.
13. Moran G, Foangy P, Kurtz A, et al. A controlled study of the psychoanalytic treatment of brittle diabetes. J Am Acad Child Adol.
14. Freud S. Analysis of a phobia in a five-year-old boy. In: Strachey J (ed). The Standard Edition of the Complete Psychological Works of Sigmund Freud, Volume 10. London: Hogarth Press, 1955:1–149.
15. Hug-Hellmuth H. On the technique of child-analysis. Int J Psychoanal. 1921;2:287–305.
16. Freud A. Normality and Pathology in Childhood: Assessment of Development. New York: International University Press, 1965.
17. Klein M. The Psychoanalysis of Children. London: Hogarth Press, 1932.
18. Levy D. Release therapy in young children. Psychiatry. 1938;1:387–390.
19. Allen F. Psychotherapy with Children. New York: Norton, 1942.
20. Axline V. Play Therapy. New York: Ballantine Books, 1947.
21. Bowlby J. Attachment and Loss, Volumne 1. New York: Basic Books, 1999.
22. Winnicott DW. The Maturational Processes and the Facilitating Environment. New York: International Universities Press, 1965.
23. Erikson E. Childhood and society. New York: Norton, 1993.
24. Mahler S, Pine M, Bergman A. The Psychological Birth of the Human Infant. New York: Basic Books, 1973.
25. Stern D. The Interpersonal World of the Infant: A View from Psychoanalysis. New York: Basic Books, 1985.
26. Shapiro T, Esman A. Psychotherapy with children and adolescents: Still relevant in the 1980s? Psychiatr Clin North Am. 1985;8:909–921.
27. Cohen NJ, Muir E, Lojkasek M, et al. Watch, wait and wonder: testing the effectiveness of the new approach to mother–infant psychotherapy. Infant Ment Health J. 1999; 20:429–51.
28. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Press, Inc., 2000.
29. Kaplan M, Delgado SV. When worlds converge: combining depth psychotherapy and psychotropic medications. Bull Menninger Clin. 2006;70(4):253–272.