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Transcript of Season 2 Episode 16:

EP: 16 Talk Therapy for Preschoolers? Here’s How and Why

Dr. Kimberly Bell: [00:00:00] Are you interested in knowing your young child in a whole new way? Understanding what’s really going on in their developing mind? Does your child say or do things that make you stop and wonder, “Where did that come from?” Welcome to the Hidden Language of Children podcast, where we explore child development and the challenges of being a parent. I’m your host, Dr. Kimberly Bell, clinical director at the Hanna Perkins Center for Child Development in Shaker Heights, Ohio, where we help children learn to understand and manage their feelings so that they can become the boss of themselves. Today. We’re flipping the format. I’m turning over the interview to our producer, Bob Rosenbaum, and he’s going to be asking me the questions. What’s up with that, Bob?

Bob Rosenbaum: Kim, let’s just say that today’s topic is right up your alley. We’re talking about mental health treatments for children. It’s a subject in which you’re the expert. And I have questions, so here we are. Ready to go?

Dr. Kimberly Bell: All right, let’s do [00:01:00] it.

Bob Rosenbaum: For starters, I think a lot of people would be surprised to learn that many children as young as five or four, sometimes even younger, are benefiting from what the general public would understand as talk therapy. After all, how does a child who can barely tell you what he or she did for preschool today going to get anything out of talking to a therapist. So tell me, what are the kinds of issues or behaviors that bring parents with young children to you? And after that we’ll get into how does the therapy work.

Dr. Kimberly Bell: Sure. It can be a surprise to think that children that young could have any worries or any troubles, but we find that children very young come to us for a number of reasons. Let’s start with something as simple as separation anxiety. They maybe have a hard time settling into preschool. Maybe they’re having a hard time settling into a childcare center, and they’re really creating these difficult moments [00:02:00] at drop off that are both painful to the child and to the parent. That is certainly something that brings people to us. Adoption is another time where families often come to us because the child may come to them with troubles or they just want to make sure that attachment and bonding process through the adoption process goes as smoothly as possible.

So that’s another reason. You may have a child who has undergone significant medical treatment that has impacted the way the child begins to feel about their body and the ownership of their body and the inside and the outside. Maybe they have to have procedures, maybe they have to have physical therapy or something else that’s intrusive to the body at a very young age that can bring people to us.

And really it’s about getting to something before it has a huge impact on the developing personality and [00:03:00] we can get development back on track much faster.

Bob Rosenbaum: In these cases that you’re talking about, you just said the child comes to you; obviously a 4- or 5-year-old isn’t going to raise their hand and say, I’d like to talk to a therapist. So how do they get to you?

Dr. Kimberly Bell: Typically they’ve either seen this podcast or they’ve heard from a neighbor or a family member that has had some kind of interaction with us but also through their pediatrician through the discharge planner. Maybe if it’s been like in the NICU (Noenatal Intensive Care Unit), or something along those lines. A social worker, anybody who’s really had contact with us refers the family to us. And then usually it really starts not with the child’s question. This really starts with the parent’s question. And oftentimes we say that we’re this agency that is for children. But this is an agency for parents. And when you think about it that way, that we are an [00:04:00] agency that helps children but is for parents, you can understand why we can bring people in from pregnancy all the way through 26 years old.

Bob Rosenbaum: Yeah. Yeah. So you just mentioned the NICU. Have you treated parents with infants?

Dr. Kimberly Bell: Yes.

Bob Rosenbaum: What kind of issues?

Dr. Kimberly Bell: Typically it’s typically it’s preventative, but it might, it usually has something to do with the child’s ability to soothe or their ability to soothe the child. And something’s getting in the way, whether it’s a medical issue, something in that parent-child relationship just doesn’t feel right to the parents.

One of the things that’s important here is we trust the gut of the parent and if it feels like something isn’t working or gelling or “Is it supposed to be this hard?” kind of questions, that’s when we, that’s when we start working on it right there.

Bob Rosenbaum: So most [00:05:00] people know the stereotype of of talk therapy. They’ve seen the New Yorker cartoons. There’s somebody lying on a couch and there’s a psychiatrist at the head taking notes and asking questions about dreams and that kind of stuff. What’s it look like when you are working with a 4-year-old or a 5-year-old?

Dr. Kimberly Bell: OK. Not at all like that. So under the age of 5, we do not bring children into therapy unless it’s a significantly unique experience. Maybe we will, but never without the parent. So it may be that the parent and the child are in the room, but under 5 we do something that we call “treatment via the parent.” This is not like a behavioral program. observe the child, we observe the parent, and then we work privately with the parent to help them to understand what is going on with their child, just generally developmentally, but also in the [00:06:00] difficult moments. And we work with the parent to alter their parenting style, and it doesn’t mean that they did something wrong. What it means is that we have assessed this child’s temperament, this child’s life experience thus far, and we work with the parent to alter the way that they interact with their child at these difficult moments that is more consistent with that child’s needs. And I don’t think I can underline that enough, because I think oftentimes people think parent guidance is, “Oh, see, I am deficient, and so I had to go to somebody to teach me how to be a parent.” But if you really think about how we become parents, we only know how we were parented. Or maybe we’ve read books, but there are so many different books and there are so many different ways to interact with your child from a parenting perspective that

sometimes you don’t always [00:07:00] know if what your parents did for you is going to work with your child. And maybe it won’t given your unique, new experiences. And so we take a look at the parent, we take a look at the child, we help the parent choose some different ways of interacting with that child and helping the child manage the difficult feeling, manage the separation in ways that work for them as a family.

Bob Rosenbaum: So a little bit of a loaded question here. Is this therapy for the child or is this therapy for the parent?

Dr. Kimberly Bell: It’s not a loaded question. I think it’s an important and interesting question. It is different because if it were therapy for the parent, we would spend time understanding the parents’ individual dynamics. What their feelings are, what their worries are. That’s individual therapy for a, for an adult. This is working with the parenting [00:08:00] part of the adult. And even if you are a parent who has struggled with mental health, it is fascinating to know that your parenting part is often your healthiest part. And we are talking to that part and we adjust that part of the self in order to help change the behavior, the reactions integrate the feelings of the very young child. So it is treatment of the child. It’s just done through the parenting.

Bob Rosenbaum: So you’re actually helping the parents to work with the child in the way that you might work with the child if their child was older and more capable of forming a relationship with somebody who isn’t their parent or their loved one, or caregiver.

Dr. Kimberly Bell: Yeah. Yeah. The other reason that we don’t bring children in before the age of 5, unless absolutely necessary is [00:09:00] because we believe that parent-child relationship is so vital. And that before the age of 5, we don’t want or need to insert a secondary intense relationship around working with feelings.

The parent-child relationship is so strong, even if it doesn’t seem to be working very well, that relationship and attachment is very strong, and it is the most effective relationship to work with very young children. Even when they come into the office to do an observation, they don’t care about developing a relationship with a therapist.

And so we leverage the already existing attachment and relationship to make some of those – I guess you could call them interventions – with the child.

Bob Rosenbaum: Yeah and so you know, that young child’s reaction to the therapist… that’s an [00:10:00] issue of brain development, right? That children who are 3 or 4 or 5 haven’t learned yet to develop complex relationships with people outside of their family, typically. Is that, is that a fair way to put it?

Dr. Kimberly Bell: Yeah. I don’t know if I would necessarily put that piece of it in the brain, per se, but emotionally they just haven’t separated from their mom and dad. You know, they, they have this mom and dad or mom and mom or dad and dad, parents. They have caregiving parents who are the center of their world and they are not interested.

They may make friends at preschool. We talk a lot about like early play is like parallel play. I’ll play next to you, but not really with you. And that it takes time to develop that cooperative play. If a child can’t do cooperative play, they certainly aren’t going to come in and do therapy with a therapist– which is based … at those young ages is based completely in [00:11:00] play.

Bob Rosenbaum: That makes a lot of sense. So, the experience of the child is not so unlike then the same experience that a child goes through when they start preschool.

They don’t know this teacher. They don’t know what the role of a teacher is.

Dr. Kimberly Bell: And the relationship between a child and a therapist is qualitatively different. We do not do caregiving, right? We don’t take them to the bathroom. Even when they’re over 5 and they’re in the office, the parent is outside waiting and if they need help to use the bathroom, or if there are tears and they are crying, or if there’s a behavior that gets out of control and they’re throwing things, we don’t do the caregiving job. We get the parent, bring them into the room, and we allow the parent to do the parenting part of it because that really separates the therapeutic relationship. So we aren’t teachers, we [00:12:00] aren’t babysitters, we aren’t childcare workers. To kids who are old over 5. I say that I’m a feelings doctor. I’m a doctor who talks to them about their feelings and tries to understand them. And sometimes that’s through watching them play . Sometimes it shows up more directly in their behavior in the office. But that’s my job and it’s a very specific role that the child doesn’t relate to very naturally. Under the age of 5.

Bob Rosenbaum: And so the age of 5 is a little bit of a a marker for you that when it might be appropriate to begin seeing a child without the parent in the room.

Dr. Kimberly Bell: Yeah, it’s kindergarten, right? If you think about the difference between a preschool child and a kindergarten child, 3-4 to 5-6, there’s a change. It’s a developmental phase change that shows a marked increase in cognitive [00:13:00] development – in brain development.

They understand reality. They understand that 1 plus 1 only and ever equals 2. That there are principles to reality that are unchanging. That’s what we call reality testing.

And that’s important for a child to do therapy.

Bob Rosenbaum: And at that age when the child is – and and I know that 5 isn’t like an absolute moment, it depends on the child obviously – but at that moment when a child is able to relate with a therapist at that level, is the parent still involved?

Dr. Kimberly Bell: Oh, absolutely. As [Donald] Wincott said, there is no baby. There is only a parent and a baby.

There is no child in therapy. There is only a parent and a child. There is no time, at least at Hanna Perkins, where our approach says, “Drop your kid off and I’ll fix ’em for you.” [00:14:00] Nobody knows the child as well as the parents. Even if I’m seeing a child four times a week, I still only spend four hours a week with that child. And so the parent work that we do is vital to making the whole thing work. That we have to be a team.

If I’m working with them in the room without their parent, what I always say to them is what you and I talk about and what we’re working on is private, but there will come a time where I say, “I think it’s time to talk to your parents. We’ve learned something about how you feel. you want to tell your parents or do you want me to help you tell your parents? Or do you want me to just tell your parents for you?” And depending on the developmental age, children will choose different things, right? There are also times where I share my understanding separately with the parents, even though I know the child’s not ready to understand it about themselves yet. So that’s like a different way of working. So I may say to parents, I think I understand why your child is having these [00:15:00] panic attacks, and we talk about that. The child may not be ready to hear it, but I can talk to the parents, and I can say, “so the next time this is happening, maybe try to treat what looks like anger as fear and panic.” That’s a common one that I do. If we were to understand it as a panic attack, how would that change the way that you respond when it happens?

We respond very differently to children’s anger versus their fear. That’s parent work right there. I just did it. That’s parent work. That’s an example of what we do, and we can do that with the parent alone or with the child and the parent as the child gets older.

Bob Rosenbaum: Now moving up the age scale, there comes a time I imagine when things between you and the child – we’re talking adolescence now – become much more private and it’s up to the child to decide what to share with the parents and the how to involve the parents. [00:16:00] When age-wise, is that roughly.

Dr. Kimberly Bell: It depends on the child. I hope everybody knows, but maybe they don’t, and I just take it for granted. Every therapist knows that the boundaries of our confidentiality with any patient it is all private unless they’re in danger of hurting themselves or someone else. That’s the legal ethical boundary. And it’s not a threat. I see it as a promise, because this work can be unnerving, and the promise that we make to our patients is that if things become unraveled and it feels like what you’re doing is a danger to yourself or to someone else, I will do what is necessary to keep you safe. That has to be really spelled out for teenagers because they crave privacy. And then we also have to talk about what’s the difference between privacy and secrecy. That’s a different conversation for us to have, but those will always be the boundaries [00:17:00] when working with children and adults.

Bob Rosenbaum: So at whatever age it is always focused on the child’s needs, and the parent’s role will vary based on the child’s needs, based on the child’s age and capabilities.

Dr. Kimberly Bell: Yeah, but there is always a role.

Bob Rosenbaum: OK. So what’s the response?

Let’s move back to the younger children . How do the parents respond and how do you know that the work is making progress?

Dr. Kimberly Bell: That’s two very different questions. How do the parents respond? In all kinds of ways that adults respond. It’s not unusual to feel challenged, to feel frustrated, to feel guilty. But there is also a sense of relief, having a new understanding. I’ve had parents say it differently. I had one parent who used to say that she now had these parenting rockstar moments.

That’s what she called them; [00:18:00] moments when she really nailed it at home. Like she nailed how to speak to her child in a way that worked and it opened the child up and it opened up communication and the behaviors improved, right? That’s one way that we measure success. And I’ve had other parents just sort of feel that parenting is something they can enjoy more. Even the hard parts. Parenting doesn’t get easier, but it can be hard and enjoyable at the same time.

How do we know it’s working? With children it’s really interesting. It’s not just the elimination of behavior. As a matter of fact, eliminate be elimination of behavior often comes second unfortunately, to this other piece, which is when a child is stuck, when a child has separation anxiety what we are looking for is forward developmental movement. There are certain milestones that we are looking for in the emotional life of [00:19:00] children. They may be subtle, which is why it’s helpful that we can point them out to the parents. But we take little successes very seriously.

That’s how we know it’s working, is “Aha. This child feels like they’ve taken this thrust forward.” I think one of the things that’s important to understand about the work that we do with children from this perspective is that we have an understanding of development that guides us, but every child is different. So we can’t can our responses, our expectations, our activities, and our words, because our understanding of development guides us.

Bob Rosenbaum: ​And how do you know when it’s all done?

Dr. Kimberly Bell: I am going to get philosophical for a minute. So [Sigmund] Freud said that the best we can hope for in life is to love and to work. That’s what he said about adults. So what does that look like for a child?

[00:20:00] Nobody is perfect. I am not giving you back a perfectly behaved child, a compliant child.

I’m giving you back a child who’s understood and who has a vocabulary for their feelings and their worries. And if that child is managing in school and has friends and is in an open, workable relationship with you, we’re done.

And let’s be clear: If you have a child who has a struggle, a learning disability, something along those lines, success at school with support is success at school. Sometimes I think parents think my ADHD child isn’t really doing well enough unless they’re doing it without a tutor or without extra time,” and that’s not true.

All of us in our adult life, we’re all excited to have tools that make our lives easier. And [00:21:00] so the success that children have, even if we have the right supports in place, should be seen as success. You don’t have to have 15 friends. You have to have one or two or three good friends. Studies have shown that’s enough friends. And are you going to have a family that never fights? No. You argue, but you have a different way of arguing and you have a different way of managing your feelings. So it’s not a perfect child, but it’s a child that is moving forward developmentally and has the ability to do their job, which is go to school and love.

Bob Rosenbaum: That’s lovely.

Dr. Kimberly Bell: Thanks.

Bob Rosenbaum: And let me ask you about the role of pharmaceuticals.

Dr. Kimberly Bell: As a general rule we do not use pharmaceuticals ourselves in our treatment plans. We work with children who come to us on [00:22:00] medication. We don’t insist that people stop the medication when they come to work with us. If the parents want to explore it that is their choice as a parent and I will discuss it at great length with them. But it is not something that is like on my list of things to do.

Maybe it’s important for people to try and understand why that is. I’m not saying that pharmaceuticals are inherently bad. I am saying that they can get in our way sometimes. When a child has got a feeling that is being medicated we don’t have access to it. So oftentimes you’ll hear therapists being frustrated because if the medication has flattened a child out they can’t get to that feeling that’s underneath.

And that can be frustrating for the work. And if that’s the case, then I have a talk with parents and we talk about the pros and the cons. I also don’t want a child who really has very big struggle, and they are suffering on a day-to-day basis. [00:23:00] I don’t want a child to suffer like that. If there is something that can be done medically to help that child manage the world in more bearable bits then I’m all for working with pharmaceuticals.

Bob Rosenbaum: Thank you, Kim. Now I’m going to turn it back over to you for a quick commercial about the Hadden Clinic for children and families here at Hanna Perkins.

Dr. Kimberly Bell: Sure. Children do not come with an instruction manual, and sometimes parenting just too hard to do alone. If you find yourself struggling with issues like the ones we’ve talked about today, the Hadden Clinic at Hanna Perkins is here for you. We accept clients of all ages, but we have some specialties that you’ll struggle to find anywhere else. We’ve provided therapeutic help for young children for 75 years, and we developed the practice of therapy via the parent. We also help new moms who are suffering from postpartum depression, anxiety, or other related issues. And we have specialists who work with children of all ages, from birth through [00:24:00] adolescence and young adulthood. We offer screenings, consultations, and psychotherapy using the approach that’s reflected throughout this podcast. It’s compassionate, highly individualized, and based on psychoanalytic thought. As a parent, if you’re looking for help for your child, yourself or your whole family, you can find contact information at our website, at hannaperkins.org.

Bob, I understand that you have a, “Let’s Rephrase That” segment lined up for us.

Bob Rosenbaum: That’s right. The shoe’s on the other foot today, Kim, we’re going to put it on you. As our regular listeners know, this is a segment in which we talk about the things that grownups say to children. And come up with some alternatives that maybe are more useful or constructive, and today’s is one of the most common.

So here’s the setup, Kim. A preschool aged child is trying to zip his winter coat. As he struggles with the fine motor skill mom is tapping her foot and looking at her watch and needs to get him in the car and out the door. They’re already late. So she bends down, takes [00:25:00] hold of the two sides of the zipper, pushes his hands aside and says, “Let me do that for you.”

Kim, what are your thoughts and is there another way to handle it?

Dr. Kimberly Bell: Yeah I understand the pressures being late for work. The morning hasn’t gone well. Let me address it in two ways. If there is time, any amount of time take a deep breath, breathe. We understand these kinds of pieces of development in the format which we’ve probably mentioned before: 1) doing for; 2) doing with; and 3) standing by to admire.

I might say something like, if I have time, I might say something like, “let’s stop.” Because the child’s already probably frustrated, right? If the child is trying and failing. Children’s frustration, tolerance can impact their fine motor skills, right? They’re not so great with it that they can manage it through frustration just like you.

Bob Rosenbaum: I am a grownup. I can vouch for that.

Dr. Kimberly Bell: So [00:26:00] let’s everybody take a breath for a second and drop, drop the zipper and say, “OK, let’s try it again. Let me help you with my words.” Yeah, that’s how I would say it. You don’t have to say it that way, but that’s the idea. Let’s try helping the child with words.

If the child is too frustrated or you don’t have time, you can say, “you did a really great job of trying. You’re frustrated. Let’s take a breath. Today, let me help you and we can try again tomorrow.” If you really need to get going, it’s not so much about what you do, it’s about how you do it. So you’re always communicating, you’re always validating the child’s efforts.

It’s OK sometimes for a child to be like, “I just can’t today.” And you can be like, “OK, some days it feels like that,” you zip for them then you get out the door. It’s the fight and the frustration and the disappointment that the child feels in their failure, [00:27:00] and the anxiety that the parent has when they’re running late. That’s what actually causes a difficult morning. If you can calm yourself and you can say, “Hey, we’re running late today, and I don’t want you to have to rush. What if I today help you with that? Or, let me get it started for you.” That’s what we call doing with; so you start the zipper. So that they’re not, struggling to get ’em connected and then they can take it the rest of the way up. Compromise. It’s all about compromise and managing the emotional interaction that takes place.

Bob Rosenbaum: Thank you. That’s all the time we have for today. So how about I take us out?

Dr. Kimberly Bell: Sure.

Bob Rosenbaum: Hidden Language of Children Podcast is a production of nonprofit Hanna Perkins Center for Child Development in beautiful Shaker Heights, Ohio.

If you know anyone who would benefit from this segment of the podcast, please like it and share it freely. We’re always happy to get questions from our listeners. If you have questions about [00:28:00] this or any other parenting topic, you can send them to our email address at HiddenLanguageofChildren@gmail.com.

If time allows, we’ll answer your questions in a future episode, and if not, we’ll get back to you directly with whatever information we can provide and offer help. You can find all of our episodes on YouTube and your favorite podcasting platform. Just search for Hidden Language of Children. I’m Bob Rosenbaum with our host, Dr. Kimberly Bell. Thank you for tuning in and we’ll see you next time.