Behavioral Therapy

A goal-oriented, therapeutic approach that treats emotional and behavioral disorders as maladaptive learned responses that can be replaced by healthier ones with appropriate training.

In contrast to the psychoanalytic method of Sigmund Freud (1856-1939), which focuses on unconscious mental processes and their roots in the past, behavior therapy focuses on observable behavior and its modification in the present. Behavior therapy was developed during the 1950s by researchers and therapists critical of the psychodynamic treatment methods that prevailed at the time. It drew on a variety of theoretical work, including the classical conditioning principles of the Russian physiologist Ivan Pavlov (1849-1936), who became famous for experiments in which dogs were trained to salivate at the sound of a bell, and the work of American B.F. Skinner (1904-1990), who pioneered the concept of operant conditioning, in which behavior is modified by changing the response it elicits. By the 1970s, behavior therapy enjoyed widespread popularity as a treatment approach. Over the past two decades, the attention of behavior therapists has focused increasingly on their clients' cognitive processes, and many therapists have begun to use cognitive behavior therapy to change clients' unhealthy behavior by replacing negative or self-defeating thought patterns with more positive ones.

Behavior therapy was used experimentally as early as 1924 to treat phobias in a three-year-old. In the 1960s it drew the attention of child psychiatrists and therapists after being used successfully with institutionalized children when all other treatment methods had failed. Behavior therapy is especially well suited for use with children whose activities are restricted in ways that make it relatively easy to achieve the environmental control necessary for its success. Also, it is generally completed within a shorter time frame than traditional psychodynamic therapy.

Techniques in behavior therapy

A number of the same techniques that behavior therapists use for adults can also be used successfully with children. The most popular ones fall under the category of behavior modification, a term that technically refers only to some of the techniques used by behavior therapists. Based on the operant conditioning principles of B. F. Skinner, behavior modification works by providing clearly specified consequences, either positive or negative, for certain types of actions. Systematic positive reinforcement encourages desirable behavior through a system of rewards, such as a particular toy, or privileges, such as a video rental or an extra half hour of watching television. A system is often established in which tokens, such as stars or stickers, can be accumulated and eventually exchanged for a reward. Often, a contract is drawn up setting forth the terms of the reward system. The opposite of positive reinforcement is either negative reinforcement, such as the withdrawal of a privilege, or simply the removal of the positive reinforcement, a technique known as extinction. An example of extinction is a time out for undesirable behavior, which removes the anticipated reward of attention (even negative attention) from adults and peers, making the behavior in question seem less desirable. Although it is a relatively slow process, extinction is a popular technique for modifying behavior in children.

Other techniques used in behavior therapy include aversive conditioning, in which a person is trained to associate an undesirable behavior with an unpleasant effect in order to lessen its appeal; systematic desensitization (exposure therapy), which works by gradually exposing a person to an anxiety-producing object or situation; flooding (implosive therapy), which involves full exposure to an anxiety-producing situation while receiving reassurance from the therapist; and modeling, in which a person watches someone else successfully negotiate an activity or situation that he finds frightening or intimidating (for example, children scheduled for surgery may be shown a video in which a child undergoes and recovers from an operation, in order to help them cope with their fears about the experience). Behavior therapists also use relaxation training consisting of techniques such as deep breathing, progressive muscle relaxation, and guided imagery; hypnosis; biofeedback; social skills training; and paradoxical intention, in which the client is encouraged to actually increase a maladaptive behavior to the point that it becomes unappealing or seems ludicrous. Behavioral approaches such as those mentioned above have been used successfully in family therapy to change long-standing unhealthy patterns of behavior and interaction among family members.

Types of problems treated by behavior therapy

Behavior therapy lends itself favorably to the types of well-defined problems for which children are often treated. A popular treatment for bed-wetting (enuresis ) that involves aversive conditioning is the bell and pad method. A pad with a sensor that detects wetness is placed in the child's bed or attached to her pajamas. At the first sign of wetness, a bell is activated by the sensor, waking the child. Behavior therapy is also used with children with separation anxiety disorder (SAD), a condition in which children four years of age or older experience distress when being separated from their parents or other individuals to whom they are closely attached. In addition to experiencing anxiety and distress at school or in other situations that separate them from their parents, children with this disorder cling to their parents when they are at home, following them around the house, trying to sleep in their bedroom, and resisting being left with babysitters. A behavioral therapist may draw up a contract with a child with SAD, in which the child agrees to very specific goals, such as staying in his own bed at night if the parent promises to read him a story or check on him a specified number of times. The measures specified in the contracts are made very easy at first and then more rigorous as success is achieved. Children with SAD have shown significant improvement after even four weeks of behavior therapy. Obsessive compulsive disorder (OCD) in children also responds well to behavior therapy. Successful techniques include exposure and response prevention, both of which involve preventing the child from engaging in the ritualistic behavior that characterizes this condition, in spite of the anxiety generated. The point is for children to see that nothing bad happens when they don't perform their rituals, and that they can live through the anxiety unharmed.

Behavior therapy is an important part of the treatment for social phobia, the fear of communicating and interacting with other people. It often needs to be combined with medication such as Prozac because children affected by this disorder must have some of their anxiety allayed before they can work with a therapist. In therapy they are taught relaxation techniques, such as guided imagery, in which they imagine themselves succeeding in feared social situations. In addition, they are given a series of small assignments aimed at improving their social skills, such as saying hello to a certain number of people every day, and there is a modest reward for completing each assignment. The therapist and/or the parents also need to coach children with social phobia on how to behave in social situations, even rehearsing what they will say in some cases. Another disorder for which behavior therapy works well is generalized anxiety disorder (GAD), which is characterized by unreasonable and excessive anxiety over a broad range of events or activities. Therapy for this condition generally consists of relaxation training and of finding ways to replace the child's fearful reaction with a normal reaction.

Another childhood disorder that is often treated by behavior therapy is attention deficit/hyperactivity disorder (ADHD), the most common childhood psychological disorder, estimated to affect anywhere from 3-9% of all children, the majority of them boys. Although medication with Ritalin or another stimulant is the most effective treatment method, therapy can reinforce the improvements in control and organization. A therapist can also coach the parents of children with ADHD in behavior therapy techniques so that they can exercise control over their children at home in a firm, consistent, and controlled manner.

Further Reading

Doft, Norma. When Your Child Needs Help: A Parent's Guide to Therapy for Children. New York: Crown Paperbacks, 1992.
Feindler, Eva L., and Grace R. Kalfus, eds. Adolescent Behavior Therapy Handbook. New York: Springer, 1990.
Fishman, Katharine D. Behind the One-Way Mirror: Psychotherapy and Children. New York: Bantam Books, 1995.
Kazdin, Alan. E. Child Psychotherapy: Developing and Identifying Effective Treatments. New York: Pergamon Press, 1988.
Koplewicz, Harold S. It's Nobody's Fault: New Hope and Help for Difficult Children and Their Parents. New York: Times Books, 1996.
Gale Encyclopedia of Childhood & Adolescence. Gale Research, 1998.