16
Integrative Psychotherapy with Children
ATHENA A. DREWES AND JOHN W. SEYMOUR
Childhood psychopathology continues at a
high and constant rate. Between 17% and 22%
of youth (under the age of 18) have experi-
enced a diagnosable emotional, behavioral, or
developmental problem (Kazdin & Johnson,
1994). This translates to more than 14 million
youth in the United States suffering significant
impairments (Prout & Fedewa, 2015). Children
are a critically underserved population despite
ample recognition of the growing rates of at-​
risk, suicidal, and antisocial behaviors, and sub-
stance abuse (Prout & Fedewa, 2015).
To complicate matters further, treatment
dropout rates for children and youth have been
found to be as high as 40–​60% (Prout & Fedewa,
2015), and there are conflicting viewpoints
on whether child psychotherapy is effective
(Weisz et al., 2017). For example, a large meta-​
analysis covering 447 studies (30,431 youths)
and synthesizing 50 years of research findings
found that youth in the treatment condition
341
fare better than those in the control condition
(63% posttreatment probability, ES = 0.46).
The strongest treatment effect was for anx-
iety (0.61), weakest for depression (0.29), and
nonsignificant for multiproblem treatments
(0.15). The findings underscored the benefits
of psychological treatments, as well as the need
for improved therapies and more representa-
tive, informative research (Weisz et al., 2017).
Although psychotherapy studies of children and
youth show efficacy when compared with no
treatment (Lebow, 2008), effectiveness drops
when conducted in real-​world settings.
Complicating child psychotherapy is the
issue of development, which is shifting and
changing, making stable measurements diffi-
cult (Lebow, 2008). The child therapist must
be familiar with human development because
much of what is viewed as problematic in chil-
dren, with the exception of severe psychopa-
thology or extreme behaviors, might be normal
342 Specific Disorders and Populations
developmental deviation. In addition, many of
the symptomatic manifestations in normal chil-
dren and in child development, such as temper
tantrums, enuresis, specific fears and anxieties
and sleep disturbance tend to disappear as a
function of development and maturation.
Another factor that contributes to the
differences between child and adult therapy is
that the child’s personality is less likely to be set
than the adult’s. The child’s defenses are not
as well established, are more pliable, and re-
spond better to therapeutic intervention once
a therapeutic relationship and cooperation is
established. On the other hand, because of the
rapid changes, child clients may be labile, with
a wider range of normal emotional and behav-
ioral responses and inconsistency in responding
to therapy.
Compounding the difficulty of treatment
with children still further is a different motiva-
tion than adults have. While adults have some
awareness that a personal problem exists, chil-
dren may not recognize or agree that there is
a problem, nor voluntarily initiate therapy.
Other adults will make this determination for
treatment, resulting in varying degrees of ac-
ceptance, compliance, and resistance from the
child. In addition, the child usually has little
understanding of the therapeutic process and
treatment objectives and may even have a dis-
torted view of and misinformation regarding
therapy.
Another major difference between child
and adult therapy is that the child has limited
verbal and linguistic development, which in
turn relates to limitations in cognition and ab-
stract thinking. Children may not think in ab-
stract terms, may lack skills to articulate their
thoughts and emotions, and may not have a suf-
ficient receptive vocabulary to fully understand
what is being asked in an interview or session.
Thus, talk therapy with children often fails un-
less play or play-​based interventions are used as
a medium of treatment (Drewes, 2009).
These and additional complexities in child
psychotherapy virtually require integrative
psychotherapies. Child clinicians trained in
one theoretical orientation or a single treat-
ment quickly find that one size cannot fit
all of the presenting problems and complex
circumstances. Since children are not simply
little adults, their treatment cannot be scaled-​
down adult treatment. Developmental stages,
systemic environments, referral reasons, and a
multitude of additional factors require a flex-
ible, integrative approach to therapy. In addi-
tion, an integrative approach with youth will
frequently involve other systems in the child’s
life, such as parents, family members, and
school personnel, and require blending indi-
vidual, parent, family, and community formats
as well.
THE INTEGRATIVE APPROACH
Foundational Concepts
“Psychotherapy integration is central to child
treatment, although at times it is not clearly
identified or developed both in the research lit-
erature and practice” (Krueger & Glass, 2013,
p. 331). The more interventions and systems
that can be combined, the more modalities
involved in the treatment, the more likely the
overall therapeutic goals are realized (Prout &
Fedewa, 2015). The treatment focus necessitates
looking at “which set of procedures is effec-
tive when applied to what kinds of patients
with which set of problems and practiced by
which sort of therapists” (Barrett, Hampe, &
Miller, 1978, p. 428). Because child psycho-
therapy demonstrates high levels of symptom
severity and comorbidity, along with parent and
family stressors, a multidimensional approach
is necessary (Kazdin, 1996, Kelley, Bickman, &
Norwood, 2010).
In addition, an integrative approach to
child psychotherapy facilitates broadening the
therapist’s theoretical conceptualization of the
child’s presenting problems and helps to im-
plement a variety of interventions (Krueger &
Glass, 2013). In contrast to linear models of
psychopathology (Gold, 1992; Pine, 1985), in-
tegrative theories of psychopathology conceptu-
alize it from the viewpoint of multicausation.
Equal weight is given to various aspects of
personal functioning, such as motives, affects,
thoughts, images, and behaviors. These are

examined through “psychic structures, de-
velopmental needs, biological and matura-
tional processes, intrapsychic motives and
conflicts, cognitive and perceptual processes
and contents, emotions, and overt actions”
(Gold, 1992, p. 56). Each of these components
are “influencing, modifying, reinforcing,
inhibiting, and perhaps even creating each
other” (Gold, 1992, p. 56), and they are seen
in a blended and unified whole. Such blending
implies a circularity as well as the containment
of multiple relationships that are seen between
the cognitive, dynamic, interpersonal, and be-
havioral aspects of the person (Coonerty, 1993).
Because cognitive styles are in the process
of formation in children, interventions must be
tailored to match them, as well as determining
what is developmentally appropriate for the
client and for their extended systems of family
and school. An integrative approach allows
for the addressing of interpersonal challenges
as well as external realities of the child client
(Krueger & Glass, 2013).
Rather than jumping from one treatment to
another, the child therapist develops a prescrip-
tive, integrative approach that broadens the
therapist’s concept. Of course, the selection of
treatments should not be ruled by a therapist’s
preferences or the staying within a comfort zone,
but rather through research evidence and clin-
ical expertise (Schaefer, 2003). The prospect of
change in one sphere of functioning frequently
leads to broad reverberations and changes
throughout multiple aspects of the client’s mal-
adaptive functioning (Coonerty, 1993).
In addition, the child’s family and
macroenvironment (e.g., poverty, poor
housing, disintegrated family structure, aliena-
tion, and disenfranchisement) add influential
components to the child’s cognitive, dynamic,
and behavioral responses (Gold, 1992). This
multiple causation model helps move the cli-
nician from narrow theoretical constraints to
address the many factors that may be causing
or maintaining pathology and inhibiting a
young person’s ability to learn and function in a
healthy manner.
Integrative treatments are not new to child
therapy. Surveys indicate that child clinicians
Integrative Psychotherapy with Children 343
utilize techniques and procedures from a va-
riety of theoretical sources in clinical work with
children (Koocher & Pedulla, 1977; Shirk,
1999; Tuma & Pratt, 1982). More than half
of surveyed child and play therapists blend
techniques (Fonagy et al., 2002; Phillips &
Landreth, 1998).
The extensive research conducted on child
sexual abuse and trauma also push for an in-
tegrative approach. For example, a three-​prong
integrated trauma treatment (Stein & Kendall,
2004) addressed problematic behaviors and
skill development through cognitive-​behavior
therapy (CBT) interventions; integrated trau-
matic memories, emotions, and buried parts of
the self through psychodynamic interventions;
and attended to the actions and reactions
in the family system that maintain dysfunc-
tional family interactions. In addition, because
trauma memories are imbedded in the right
hemisphere of the brain (Gil, 2006; van der
Kolk, 2005), the integrative use of nonverbal
treatments and strategies utilizing symbolic
language, pretend play, and creativity will help
access and activate this portion of the child’s
brain. Thus, the use expressive arts, play, and
pleasurable activities within therapy has been
found to be helpful in allowing traumatized
and abused children to create their trauma
narratives (e.g., Drewes & Cavett, 2012; Gil,
2006; van der Kolk, 2005).
Defining Integrative Child Therapies
In both the child and adult literatures, psy-
chotherapy integration typically refers to the
synthesis of diverse schools and methods of psy-
chotherapy. As well, integration refers to com-
bining two or more therapy modalities/​formats,
such as family, group, and individual therapy
(Feldman, 1988; Reeves & Bruno, 2009).
Involving the child’s parent into the treatment
process, even if only for psychoeducation, is also
considered integrative (Krueger & Glass, 2013).
Still others refer to traditional talk therapy plus
play therapy as integrative. Finally, but not
exhaustively, working across systems of care
(such as a school setting along with the home
environment) is sometimes called integrative
344 Specific Disorders and Populations

(Cook, 2007). In this chapter, we embrace all and family systems orientations in treating
four types of integration in child work. adolescents (Grehan & Freeman, 2009;
Krueger & Glass, 2013; Stricker & Gold, 1996).
There are several avenues toward devel-
Exemplars of Integrative Child Therapies
oping an integrative treatment with children.
Child therapy calls for the therapist to wear In what follows, we consider several exemplary
many hats and be skillful in changing from integrative child therapies according to the four
one therapeutic stance to another in order to routes: technical eclecticism, theoretical inte-
meet the needs of the child and of others in the gration, assimilative integration, and common
child’s life (Coonerty, 1993; Drewes, 2011a). factors (Norcross & Alexander, Chapter 1, this
At one moment, the therapist may find herself volume).
intensely involved in a deeply evocative and Technical eclecticism is prescriptive in that
often intense therapeutic relationship with the it selects the best treatment for the client and
child client in which the therapist deals with the problem. It has been described as more
the child’s internal struggles, sets limits, and practical than theoretical (Norcross, 2005),
acts as an educator or mediator with the child. with the emphasis on predicting for whom
Then, in the next moment, the therapist needs particular interventions work well, rather
to engage with a parent or school psychologist than why they work well. Exemplars here ap-
or classroom teacher. These often conflicting plied to children include multimodal therapy
and rapidly changing roles lead many child (Lazarus, 2006) and systematic treatment selec-
therapists to adopt an eclectic prescriptive style tion (Beutler, Consoli & Lane, 2005; Consoli
in which therapeutic interventions are chosen & Buetler, Chapter 7, this volume).
and then changed according to the most Technical eclecticism, utilizing prescrip-
pressing external demand (Coonerty, 1993; tive play therapy for child treatment, is seen
Drewes, 2011b). in the case study of an 11-​year-​old autistic girl
Initially, child treatment consisted of taking with behavioral difficulties (Kenny & Winick,
adult models and extending them downward 2000). Using a sequential approach, treatment
to children (Krueger & Glass, 2013). In partic- methods were chosen that built on one an-
ular, cognitive and behavioral approaches were other over time, rather than blending them to-
utilized to address behavioral management gether within one session. In this case study, the
problems through use of behavior modifica- rapport-​ building component of nondirective
tion techniques, along with addressing parent–​ play therapy was used with directive techniques
child relationship issues. Examples include in targeting maladaptive behavior and providing
modifications of the adult psychodynamic to- parent education. The rationale for using a flex-
gether with behavior therapy to treat child be- ible integrative approach was due to the mul-
havior problems, using behavior modification tidimensional aspects of the child’s behaviors
techniques along with parent–​child relational along with her developmental delays. Different
dynamics (Feather & Rhoads, 1972; West & treatment approaches were combined into a co-
Carlin, 1980), and the development of a psy- herent intervention sequence (Shirk, 1999).
chodynamic understanding of the meaning of Treatment for trauma has several effective
the child’s behavior (Krueger & Glass, 2013). integrative approaches for children. Trauma-​
One of the first integrative attempts was de- focused integrative play therapy (Gil, 2009) is
velopmentally based psychotherapy (Greenspan, a promising manualized, technically eclectic
1997), which merged an understanding of devel- treatment for children who have experienced
opmental abilities with self-​regulatory abilities complex trauma (Krueger & Glass, 2013).
into a primarily psychodynamic approach. Evidence-​based trauma-​focused cognitive beha-
Likewise, assimilative psychodynamic psycho- vior therapy (Cavett & Drewes, 2012; Cohen,
therapy maintains a strong psychodynamic Mannarino, & Deblinger, 2006, 2012; Drewes
base while integrating cognitive-​ behavioral & Cavett, 2012) is integrated with expressive

techniques, directive and nondirective play,
and mindfulness interventions.
Theoretical integration takes the best
elements of two or more approaches to therapy
and blends them with the expectation that the
result will be more than the sum of the sepa-
rate therapies. The emphasis is on integrating
the underlying theories along with an integra-
tion of therapy techniques. Exemplars are Ellen
Wachtel’s (2014) psychoanalytic-​behavioral-​
relational integration and the transtheoretical
model, which matches principles or processes
of change to the child’s stage of change
(DiClemente & Prochaska, Chapter 8, this
volume). The latter has been subject to hun-
dreds of outcome studies, including with chil-
dren and their families.
One of the earliest theoretically integra-
tive treatments for children was cognitive be-
havioral play therapy (Knell, 1993). It blends
cognitive and behavioral interventions into
play therapy, with the child’s development
informing treatment (Drewes, 2009; Knell,
1993). Problematic behaviors are seen as
stemming from maladaptive thoughts which
impact the child’s feelings and subsequently
behaviors. These maladaptive thoughts can
be modified by using play-​ based tasks and
applications in therapy while incorporating
evidence-​ supported techniques from cogni-
tive and behavioral orientations (Krueger &
Glass, 2013).
An example of theoretical integration
is ecosystemic play therapy, developed by
O’Connor (2001). The clinician considers the
child, his or her problems, and the therapy
process within the framework of the child’s ec-
osystem. It incorporates key elements of the an-
alytic, child-​centered, and cognitive-​behavioral
models of play therapy, as well as elements
of Theraplay (Jernberg, 1979; Jernberg &
Booth, 1999).
Another exemplar of theory integration is
flexibly sequential play therapy for traumatized
children (Goodyear-​Brown, 2010). A variety of
treatment techniques give the child the space
in which to disclose and adjust to the sharing
of the trauma content (continuum of disclo-
sure), as well as to restore the child’s lost sense
Integrative Psychotherapy with Children 345
of empowerment that occurs due to abuse
(experiential mastery plan). The therapist
flexibly integrates directive and nondirective
approaches. Because of all the various teaching
components, knowledge of cognitive behavioral
therapy, somatic therapies and mindfulness,
and family systems and attachment theories
are required. The therapist is not required to
be expert in every model, but a working know-
ledge of how to conduct dyadic interventions
and psychoeducational components in working
with the parent is needed.
Both parent–​ child interaction therapy
(Eyberg, 1988; Krueger & Glass, 2013) and
child parent relationship therapy (Bratton et al.,
2006) are evidence-​ based, parent training
programs that exemplify theoretical integration
for young children presenting with behavioral,
emotional, and family problems. Children’s
problem behaviors are addressed by modifying
contributing negative parent–​child interaction
patterns (Bell & Eyberg, 2002). Nondirective
play and behavioral contingencies are central
to treatment, and concepts such as attachment
and social learning theories inform the treat-
ment approach (Krueger & Glass, 2013).
Assimilative integration has also taken root in
child therapy, whereby psychotherapists work
primarily from their favorite theoretical orien-
tation and then selectively incorporate methods
from other models. Therapists maintain a home
theory and incorporate techniques from other
theoretical orientations, often reinterpreting
the meaning of the technique through the lens
of the home theory. This integrative path is fre-
quently favored by those child clinicians trained
in a single approach. Rather than discard their
theoretical foundation as they discover its lim-
itations, clinicians gradually incorporate parts
and methods from other approaches and mold
these into a new form.
Assimilative integration is common within
child treatment but can be difficult to identify
when the integration is not explicitly acknowl-
edged. Many unacknowledged integrations
occur in treatments that have strong evi-
dence base that identifies them solely as CBT
but that employ play techniques (Krueger &
Glass, 2013).
346 Specific Disorders and Populations
Coming largely from a systemic orientation,
Ellen Wachtel (2004) integrates family systems,
behavioral, and psychodynamic approaches for
the treatment of children and their families.
She conceptualizes the child’s difficulties
as embedded in and reinforced by family
interactions, although the treatment focuses
mainly on the child as the identified patient
rather than the family system. Similarly, an ad-
olescent case study illustrated this integrative
model to guide child work by adapting it to the
client’s developmental age (Clement, 2011).
The therapy draws from cognitive-​behavioral,
person-​centered, and positive psychology
orientations.
A good example of assimilative integration is
seen in a play therapy case study within a school
setting which blended three theories into a co-
hesive treatment driven by the child’s and/​
or family’s needs (Fall, 2001). Child-​centered
play therapy (the home theory) was buttressed
with evidence-​based Adlerian play therapy and
cognitive-​behavioral methods along with cor-
responding techniques (Fall, 2001), and this
was shown to be effective. Research has shown
that play therapy interventions prove useful in
meeting the treatment needs of children and
families (Landreth et al., 1996).
Common factors is an approach to integra-
tion that identifies clinical principles or change
processes shared by several psychotherapies in
the hope that these robust commonalities will
form the foundation of successful treatment. In
a review of more than 50 publications, it was
found that 41% of the proposed commonalities
had to do with change processes, while only
6% were attributed to client characteristics.
The strongest consensus across therapies was
the development of a therapeutic alliance, op-
portunity for catharsis, acquisition and prac-
tice of new behaviors, and the client’s positive
expectancies (Grencavage & Norcross, 1990).
Practice Wise is a web-​based program that helps
identify common factors across evidence-​based
child treatments and then matches them to the
clients’ needs (Chorpita, Becker, & Daleiden,
2007; Chorpita et al., 2011).
The attachment-​ focused developmental
psychotherapy of Hughes (1997) encourages
the use of an integrative model that utilizes play
therapy within family work with adoptive chil-
dren. The commonalities across each of these
treatments are the use of play therapy princi-
ples, which are utilized within sessions and at
home with the parent and child, along with
psychoeducational principles of parenting.
Of course, these four pathways to integrative
treatment are not mutually exclusive. Consider
the work of Goldenthal (2005) who created a
model that integrated psychodynamic, behav-
ioral, and contextual theories. At first blush it
appears a classic example of theoretical integra-
tion; however, the psychotherapy was prescrip-
tive in recommending the right intervention to
the right child in the tradition of technical ec-
lecticism. Furthermore, the treatment focuses
on the therapeutic relationship—​the quintes-
sential common factor—​as the central change
agent (Krueger & Glass, 2013).
All told, the multiple routes to integration
in child psychotherapy offer clinicians several
ways through which they can conceptualize
patient concerns, address both interpersonal is-
sues and environmental factors, and select from
a rich array of efficacious clinical methods.
Consequently, the clinician can select
interventions and use them in a coordinated
and efficient manner (Krueger & Glass, 2013).
ASSESSMENT AND FORMULATION
The basic task of assessment in child inte-
grative psychotherapy is similar to any other
model of working with children: a compre-
hensive assessment through multiple sources
and methods that collects data on the child’s
development (including in utero and birth his-
tory), presenting problems and circumstances
underlying them, strengths and weaknesses of
the child and family as a whole, spiritual and
community resources, cultural components,
and the family system (Coonerty, 1993; Drewes
& Schaefer, 2015). A crucial component in in-
tegrative assessment is that the child therapist
involves both the parents/​ caregiver and the
child as active collaborators in treatment and
treatment planning. The child therapist needs

to be attuned to important connections and sys-
temic interplay, working like a skilled detective
to piece together a coherent picture that is mul-
tilayered and multiconnected. Indeed, each
puzzle piece represents only a single dimension
(Coonerty, 1993). Thus, careful assessment,
be it conducted through formal measures or
informal observations, is critical to make the
optimal selection of interventions and to coor-
dinate communication among those providing
services.
Treatment planning is based on develop-
mental awareness of the child in order to pro-
vide direction throughout all stages of therapy,
monitor progress, and know when termination
can occur. Having a developmental framework
prevents establishing unreachable goals and
permits the selection of appropriate content and
the level of therapeutic interaction that is best
suited to the child. Furthermore, as suggested
earlier, the child therapist also needs to be
sensitive to developmental delays in children,
particularly in cognition and language, that
impact treatment planning and differentiate
them from behavioral or emotional disorders.
Psychological testing is not necessarily a prereq-
uisite for treatment but frequently proves useful
and, of course, is demonstrably more reliable
and valid than informal assessment.
Verbal treatment is ineffective with young
children because of their limited abstract
thinking and development; consequently, use of
non-​verbal play therapy is critical for effective
treatment (Coonerty, 1993). Verbal treatment
is ineffective in early childhood (4–​7) because
there is a primitive level of development, ego-
centric thinking, a present-​ time orientation,
along with the child struggling to develop a
constant sense of self and other. The child uses
internal fantasy without a clear fantasy/​reality
boundary. In middle childhood (8–​13), while
children may become more verbal, there is a fas-
cination with rules and complexities of the real
world along with the emergence of formal oper-
ations; abstract reasoning; and problem solving
that needs to be developed and utilized through
play-​based activities (Drewes & Schaefer, 2015).
Assessment instruments and the integrative
process with children must be consistent with
Integrative Psychotherapy with Children 347
the purpose of the assessment, acknowledging
the vital contexts and attuning to cultures of
the family system. Child therapists can utilize
numerous assessment approaches including
standardized tests, rating scales, interviews,
observations, projective techniques, and in-
formal assessment in order to develop a
complete picture from multiple angles and
informants,
There are numerous formal norm-​
referenced, standardized psychological as-
sessment tools for use with children. Popular
normative assessments include the Behavior
Assessment System for Children, Third
Edition, which offers a structured develop-
mental history for ages 2–​21 (Kamphaus et al.,
2014), Connors Comprehensive Rating Scales
for ages 6–​18 (Kollins, Epstein, & Connors,
2014), the Achenbach System of Empirically
Based Assessment for ages 6–​18 (Achenbach
& Resorla, 2014); Child and Adolescent
Needs and Strengths (CANS, 1999), and the
Devereaux Behavior Rating Scale for ages 5–​18
(Naglieri & Pfeiffer, 2014). These assessments
can be done during an intake with the parent/​
caregiver.
Observations within the initial sessions with
the child can obtain data and frequency counts,
as well as provide information for informal
hypotheses generation and in vivo identifica-
tion of strengths and weaknesses. Play-​ based
assessments allow the child therapist to look
at the quality of the child’s play and to iden-
tify consistent or clinically significant themes.
The child’s perceptions of her parents/​family,
events, and environmental/​ systemic settings
(including school) are examined. In addition,
the quality of the expression of affect, ability
to regulate affective range, and intensity and
level of enjoyment, as well as the ability to
soothe, sustain, focus, shift and inhibit atten-
tion, and levels of impulsivity and frustration
are observed. The child’s maintenance of phys-
ical boundaries, as well as the richness or pau-
city of play content, level of dependent versus
independent interactions, and whether the age
level and developmental level are congruent
with the play and child’s physical abilities are
all assessed. Informal assessment tools include
348 Specific Disorders and Populations
projective drawings, puppet interviews, and
sentence completions.
The formulation begins with the com-
prehensive assessment of the symptoms and
determinants (internal and external) of the
child’s presenting problems. An individualized
case formulation describes and explains the
child client’s most important disorders and
probable causal or contributor variables, along
with treatment plans and predicted obstacles as
a means for evaluating progress.
The child therapist then looks to prescribe
interventions to alleviate the client’s problems,
thereby formulating defined treatment goals
and detailed “nuts-​ and-​
bolts” strategies for
achieving these goals. Because the integrative
child therapist is not confined by single-​school
theories, the combination of theories and
techniques can strengthen a treatment plan.
Individual, group, and family strategies may be
integrated, as well as multiple systems of care.
A multicomponent, multimodal intervention
can thereby address the complex and multidi-
mensional psychological disorders experienced
by children.
PROCESSES OF CHANGE
Shirk and Russell (1996) proposed 11 change
processes as the basis for an integrative model
of child therapy. They fall under three broad
processes.
Cognitive: Schema transformation,
symbolic exchange, insight, and skill
development
Affective: Abreaction, emotional
experiencing, affective education, and
emotional regulation
Interpersonal: Support, corrective
relationship, and supportive scaffolding
(O’Connor, 2001)
Kazdin and Knock (2003) studied the
mechanisms underlying therapeutic change
related to symptom improvement in child
therapy. They proposed that evidence-​
based
practices can be improved with regard to
clinical applicability in real-​world settings by
studying the discrete mechanisms of therapeutic
change. Understanding how change processes
work within best practices is the critical link in
moving evidence-​based practices from research
to the service settings of usual care.
As noted earlier, play has a long history in
child psychotherapy as it is the natural lan-
guage and mode of expression for children
(Drewes, 2005). Four broad functions of play
in child work (Russ & Niec, 2011) are pro-
viding a means of expression, communication,
and relationship building; insight and working
through; practicing new forms of expression
and relating; and problem-​solving. Depending
on which methods are utilized in the integra-
tive approach, the change mechanisms prob-
ably differ. Aside from those noted earlier, any
number of the following factors may constitute
change processes.
Cognitive processes: Direct/​indirect
teaching, schema transformation,
symbolic exchange, interpretation-​
insight, skill development, competence
and self-​control, accelerated
development, creative problem solving,
fantasy compensation, and reality
testing
Emotional processes: Self-​expression and
emotional experiencing, access to
the unconscious, abreaction release
and sublimation, affective education,
emotional regulation, stress inoculation,
counterconditioning of negative affect
Interpersonal processes: Validation
and support, supportive scaffolding,
corrective relationship and attachment
and relationship enhancement, power/​
control, moral judgment and empathy
(Schaefer & Drewes, 2013)
Differential therapeutics recognizes that
some interventions are more effective than
others for certain disorders and particular clients.
A client who does poorly with one type of child
therapy may do well with another. The greater
our understanding of the change mechanisms,
the more effective the child therapist can be in

applying them to meet the particular needs of
his or her clients (Schaefer, 1999).
THERAPY RELATIONSHIP
The therapeutic relationship remains integral
to the effectiveness of child work. Indeed, the
most robust research (and clinical) finding in
the child psychotherapy literature is the strong
association between the therapeutic alliance
and treatment outcome. A recent meta-​analysis
of 42 studies of child and adolescent therapy
(3,427 clients and parents) revealed an effect
size of (d) of 0.39 for the both therapist–​child
and therapist–​parent/​caregiver relationship
(Karver et al., 2005). The association and pre-
diction of treatment success did not differ by the
type of treatment; that is, the alliance “works”
in all forms of child therapy.
That relationship can be enhanced by
soliciting feedback from the child/​family client
and by routinely monitoring outcome. This
process is the core ingredient to patient prog-
ress regardless of the therapeutic approach
taken (Duncan, 2013), as is therapist empathy,
collaboration, positive regard, and genuineness
(Norcross, 2005).
Children are clearly aware that they have
been brought to therapy by others who can also
force them to attend sessions. The usual adult
approach of asking questions, probing into per-
sonal feelings, or explaining behaviors usually
results in uncooperativeness or strong emo-
tional responses. The therapist needs to explain
what the treatment process will be like, not only
verbally but also through the use of play-​like
techniques to communicate the expectation
that the relationship is playful, creative, and
not always based in verbalizations. Offering fac-
tual transparency about the treatment process,
collaborative creation of treatment planning,
and a nonjudgmental approach toward engage-
ment will help the child to see how this thera-
peutic relationship will differ from those with
peers, teachers, parents, and others (Prout &
Fedewa, 2015).
As is most certainly the case in working with
adults, creating a safe therapeutic relationship is
Integrative Psychotherapy with Children 349
critical when working with children. The child
therapist’s behavior in the session, as well as
his or her attitude toward the client, are keenly
perceived and reacted to by children. The rela-
tionship needs to be fostered and built through
transparency, honesty in sharing information,
nonintrusiveness, reliability, attunement, and
curiosity about the client’s internal experience,
coupled with the use of play and humor within
sessions. Critical, especially with trauma work,
is the sensitive timing and depth of therapeutic
interventions.
The therapist’s role will vary depending
on the particular approach taken and its ap-
plication. Thus, the therapist may need to be
directive and structured when implementing
a behavioral approach or nondirective when
creating rapport and a therapeutic relationship
or utilizing a more child-​centered approach.
That is precisely the value of psychotherapy
integration.
METHODS AND TECHNIQUES
Integrative treatments offer systematized
methods, with the majority designed for spe-
cific child disorders. Treatment for trauma has
by far been the best developed, followed by
treatments for behavioral disorders (Krueger &
Glass, 2013). The therapeutic menu of methods
in integrative therapies canvass the entire spec-
trum of interventions. In the evidence-​based
tradition, we advocate that selection of partic-
ular methods be based on all three evidentiary
sources: best available research, clinical exper-
tise, and patient characteristics, preferences,
and cultures. Research on the efficacy of
methods aids clinical decision-​making but does
not dictate it; much depends on the skill of the
therapist (Schaefer, 2003).
As we have indicated throughout this
chapter, working with young children includes
play-​based interventions that are developmen-
tally sensitive and geared to their abilities. Play
as therapy (child-​centered, nondirective) and
play in therapy (directive), includes expressive
arts, use of miniatures to create a scene or story
in a sand tray, puppet play, drama role play,
350 Specific Disorders and Populations
music, art, therapeutic storytelling, dance, and
movement (Drewes, 2009).
DIVERSITY CONSIDERATIONS
Clearly, a child is a product of his or her nuclear
family, extended family, neighborhood, cultural
and racial heritage, school, town/​city, socioeco-
nomic status, and political situation. These sys-
temic components result in multiple causality
and feedback loops that significantly impact
treatment choices when working with children.
Poverty, poor housing, alienation, disenfran-
chisement, and cultural and gender identities
critically influence the child’s cognitive, dy-
namic, and behavioral repertoire (Gold, 1992).
Thus, child therapy attends deeply to diversity
considerations and seeks key opportunities to
provide effective social intervention beyond just
changing a child’s internal chemistry or cogni-
tion (Lebow, 2008). The child clinician needs
to account for the individual differences within
each client, creating a case formulation and
treatment plan unique to each child’s needs.
Play is a universal expression of children,
and it can transcend differences in ethnicity,
language, and other aspects of diversity. It is
important for clinicians to be aware of cul-
tural differences that may exist. A study of play
therapists found that they rated themselves as
not being knowledgeable about racial iden-
tity and feeling competent in using this know-
ledge clinically (Drewes, 2005). This may also
prove the case for many other child therapists.
All child clinicians need to be sensitive re-
garding diversity in the assessments used and
interventions chosen (especially with regard to
what population it was normed on), as well as
inclusive in the techniques and materials used
in treatment. Having culturally, racially, and
ethnically diverse therapeutic toys and materials
is crucial (Drewes, 2005).
CASE EXAMPLE
The following case illustrates integrative child
psychotherapy in that it simultaneously blended
several theoretical approaches, treatment formats,
and systems of care. Sammy is an 8-​ year-​old
Hispanic boy, in foster care, who presented with
behavioral difficulties in school due to mood
dysregulation, generalized anxiety, and depres-
sion. He struggled with his father’s death 3 years
before, along with his mother’s current wish to
surrender parental rights so he could be adopted
due to the reemergence of her cancer.
Assessment consisted of the caregiver’s com-
pletion of the Child Behavior Checklist and Child
and Adolescent Needs and Strengths (CANS) and
the child’s completion of projective drawings and
an observation of strengths and themes during
play therapy sessions. Results of the CBCL and
CANS showed clinical indicators of externalizing
and internalizing behaviors (depression, aggres-
sion), with drawings and thematic play themes
reflecting concerns about death, feelings of anger,
and lack of emotional connection in his family
environment. Over the first four sessions, I (AAD)
obtained a good sense of Sammy’s developmental
level and emotional conflicts, as well as built rap-
port and facilitated the creation of a therapeutic
relationship.
Our treatment goals were to help Sammy (1) to
build rapport and a therapeutic alliance, along
with offering control in selection of materials and
tasks and a release from traumatic material; (2) to
reduce his anxiety, anger, depression, become
aware of emotional triggers, and develop alterna-
tive coping skills; and (3) to deal with unresolved
grief and loss over his father and the pending loss
of his mother.
The treatment plan was to use child-​led psy-
chodynamic play therapy to accomplish the
first cluster of therapy goals, CBT methods for
the second cluster, and bereavement or trauma
work for the third. Parent–​child dyadic therapy
in the systemic tradition was also utilized to help
Sammy and his mother talk about the events of
his father’s death and to better understand his
mother’s wishes to have him adopted. In addition,
the therapist maintained contact with Sammy’s
school setting and foster home parents for infor-
mation regarding his progress and to coordinate
follow-​through on treatment recommendations.
Sammy was seen in individual weekly therapy
over the course of 2 years for 75 sessions. The

45-​to 55-​ minute sessions were structured and
divided into components which allowed for the
integrative use of several treatment approaches.
In the initial session, the therapist was trans-
parent in sharing with Sammy what was learned
of his history and why he was being seen, as well
as what the therapy time would be like. Using
a balloon to blow in all his anxious and angry
feelings, Sammy saw how the big balloon was
like his head and heart containing so many upset
feelings that he felt like he would “pop.” By letting
out the air a little at a time, safely and slowly, and
seeing how much smaller the balloon was getting,
Sammy better understood that this was like the
therapy time together, where he could let out his
angry feelings in a safe, slow, and manageable
way with the therapist’s help.
Next, we assessed what he felt he needed
to work on, and a treatment plan was jointly
created. Using strips of paper to write on, the ther-
apist and Sammy worked together on selecting
three problems each about home, school, and
his family for a total of nine items we would take
on in therapy. One blank piece was left which
would allow Sammy to spontaneously address
something not covered. Sammy wrote on each
strip of paper the goal selected and decorated
an envelope in which the paper strips would be
kept. Each session when he entered, the envelope
would be put out, and Sammy would get to pick
one of the pieces of paper for us to focus on. He
could put back the paper and select a different
one only once before we had to work on it. Then,
after we talked about the issue or used a directive
technique, he would strip off a small piece of the
paper and put it back. This way he saw that we
were making progress on the goal, but were still
not yet finished with it.
Prior to having Sammy enter the treatment
room, the therapist would meet for 5–​10 minutes
with the foster parent(s) regarding how Sammy
was doing in their home, at school, and on visits
with his mother. We would also discuss treatment
strategies and interventions. Then, after the foster
parent(s) left, Sammy came into the session. The
next 5 minutes were “check in” time to talk about
the week, share any information received from his
foster parents that needed to be conveyed, and
follow-​up on any CBT homework assignments.
Integrative Psychotherapy with Children 351
The next 10–​15 minutes allowed for work on di-
rective CBT-​based techniques to address treatment
goals. The next 20–​ 25 minutes were child-​ led,
which allowed Sammy to select what he wished
to play with and how and what emotional mate-
rial he wished to convey. The last 5–​10 minutes
were for clean-​up and a closing ritual of bubble
blowing or deep breathing techniques for affect
regulation and transitioning from the session.
In this first session, Sammy used his child-​
led, nondirective time to create in the sand tray,
utilizing miniatures of all aspects of life (people,
houses, trees, vehicles, etc.) to create a scene
showing me what his world was like. During
other sessions, Sammy often used toys, puppets,
art materials, and clay to express his feelings,
often nonverbally. But he frequently preferred to
use the sand tray when there were deep conflicts
around his father’s death and worries about his
mother that he did not want to talk about, but
rather wanted to show.
Over the course of treatment, Sammy delved
more deeply into his feelings and memories re-
garding his father and his death when he was 4½
years old. There were missing details to the nar-
rative of his father’s death, as well as information
lacking as to what happens when someone dies
and even where his father was buried.
Once monthly, his mother joined Sammy for
family therapy. His mother discussed with him
where his father was buried and details sur-
rounding his illness and death. The foster parents
were willing to take Sammy to the grave, where
he had a closing ceremony and left a letter to his
father (that we worked on in therapy) telling him
his feelings and that he missed him. Sessions with
Sammy’s mother allowed for discussion about
why she wanted him adopted, how she had only
one relative available who was not a viable re-
source, and that she wanted to know he was in
a good home. This was her second bout with
cancer, and she was unsure that, even if she went
into remission again, she would ultimately not die
from the disease in the near future and leave her
son an orphan with no place to go. His mother
also spontaneously shared the unknown fact that
she had been in foster care as a child and was
adopted as well. This was a good experience for
her, and she wanted to place Sammy in a loving
352 Specific Disorders and Populations
home. We worked out an “open” adoption in
which Sammy and his mother maintained contact
around holidays and birthdays with the consent of
the adoptive parents.
Through the healing powers of play and inte-
grative treatment, Sammy learned and applied
better coping strategies, accessed his previously
unexplored conflicts around his father’s death, ex-
perienced catharsis in getting out his anger and
rage over feeling abandoned, gained power and
control over his anxieties, and developed compe-
tence, self-​control, and a greater sense of himself.
Through CBT techniques, he performed creative
problem-​solving, behavioral rehearsal, and coun-
terconditioning of negative affect.
By the end of treatment, an adoptive family
was found, and we worked toward his successful
adoption. Sammy still remains with his adoptive
family and has periodic contact with his biolog-
ical mother. Just prior to termination, the CBCL
and CANS were completed by the foster parents.
Results showed Sammy’s behavioral functioning
within the average or normal range. Furthermore,
his acting out behaviors in school significantly di-
minished, going from daily aggressive and phys-
ical outbursts to minimal verbal outbursts on a
quarterly basis, and he reduced his sadness and
anxiety as seen in his frequent smiling, involve-
ment in sports, and positive-​themed drawings.
OUTCOME RESEARCH
In spite of the growth of psychotherapy integra-
tion, there is little outcome research on explic-
itly integrative child therapies (Schottenbauer,
Glass, & Arnkoff, 2005; Seymour, 2011), with
few systematic reviews of integrative treatment
for children (Krueger & Glass, 2013). That’s
the bad news. The good news is that by using,
in part or in whole, evidence-​ based child
therapies, integrative clinicians can harvest
the fruits of that vast outcome research. While
there is moderate but clear support for the ge-
neral effectiveness of child therapies, there
continues to be a need to take a cautious and
thoughtful approach to child treatment (Prout
& Fedewa, 2015).
Child behavioral therapy and outcome re-
search have begun to incorporate a more inte-
grative approach, with assimilative integration
becoming more commonplace within CBT
(Krueger & Glass, 2013). In general, a trend
has emerged of CBT integrating aspects of
other treatments, while integrative treatments
frequently utilize CBT methods.
FUTURE DIRECTIONS
Integration is clearly gaining hold in child
psychotherapy, but much work remains to be
done. More outcome research is needed, espe-
cially research identifying change mechanisms
of successful child psychotherapy, as well as
the prescriptive matching of those change
mechanisms to varying clinical circumstances.
Further research is needed to illuminate
which specific uses of play are most effective
with specific presenting problems and within
the blending of treatment approaches. Based
on our clinical observations and those of our
colleagues, we expect that future research
looking into these complex processes will wind
up providing empirical support for integrative
treatments.
Clinically, many cognitive-​
behavioral
treatments for young children would benefit
from the incorporation of other approaches,
especially less directive techniques. Treatment
and research would also be better informed
if the play-​ based techniques included the
anchoring theories behind their application.
Perhaps the most severe obstacle to inte-
gration comes from territoriality of the purists
who hold their single theory to be the best. We
advocate for work toward common definitions
and language in psychotherapy to decrease
the inconsistency of terminology. In that way,
a commonly understood experience can be
implemented in practice and measured in re-
search (Seymour, 2011).
There still is inadequate training in inte-
grative child therapy in university and intern-
ship settings. Consequently, student clinicians
are not fluid in thinking about using sev-
eral different approaches and do not feel

well-​grounded in responding to the realistic
clinical complexities of working with children.
Training in academic settings needs to furnish
ample and diverse experiences imparting tech-
nical and interpersonal skills that then lead to
establishing competence (Norcross & Halgin,
2005; Seymour, 2011).
In spite of these and other hurdles, in re-
cent years, the clinical practice of child inte-
grative psychotherapy has grown considerably.
It is important that these clinical observations
inform research process and outcome research
to further enhance the synergy between prac-
tice and research. Such convergence between
research and practice will not only allow the
therapist to borrow flexibly from multiple the-
oretical positions to tailor treatment to a partic-
ular child, but also will result in cost-​effective
interventions.
References
Achenbach, T. M., & Resorla, L. A. (2014). The
Achenbach system of empirically based
assessment (ASEBA) for ages 1.5 to 18 years. In
M. E. Maruish (Ed.), The use of psychological
testing for treatment planning and outcomes
assessment (3rd ed., vol. 2, pp. 179–​ 214).
Mahwah, NJ: Lawrence Erlbaum.
Barrett, C. L., Hampe, I. E., & Miller, L. (1978).
Research on psychotherapy with children. In S.
L. Garfield & A. D. Bergin (Eds.), Handbook
of psychotherapy and behavior change (pp. 411–​
435). New York: Wiley.
Bell, S. K., & Eyberg, S. M. (2002). Parent-​child
interaction therapy. In L. VandeCreek, S.
Knapp, & T. L. Jackson (Eds.), Innovations in Coonerty, S. (1993). Integrative child therapy. In G.
clinical practice: A source book (Vol. 20, pp. 57–​
74). Sarasota, FL: Professional Resource Press.
Beutler, L. E., Consoli, A. J., & Lane, G. (2005).
Systematic treatment selection and prescriptive
psychotherapy: An integrative eclectic
approach. In J. C. Norcross & M. R. Goldfried
(Eds.), Handbook of psychotherapy integration
(2nd ed., pp. 121–​ 143). New York: Oxford Drewes, A. A. (2009). Blending play therapy with
University Press.
Bratton, S. C., Landreth, G. L., Kellam, T., &
Blackard, S. (2006). Child Parent Relationship
Therapy (CPRT) treatment manual: A 10-​
session filial therapy model for training parents.
New York: Routledge.
Integrative Psychotherapy with Children 353
Cavett, A., & Drewes, A. A. (2012). Play applications
of TF-​ CBT skills components for young
children. In J. Cohen, A. Mannarino, & E.
Deblinger (Eds.), Trauma focused-​ CBT for
children and adolescents: Treatment applications
(pp. 124–​148). New York: Guilford.
Child and Adolescent Needs and Strengths
(CANS). (1999). Praed Foundation. https://​
praedfoundation.org/ ​ t ools/ ​ t he- ​ c hild- ​ a nd-​
adolescent-​needs-​and-​strengths-​cans.
Chorpita, B. F., Becker, K. D., & Daleiden, E. L.
(2007). Understanding the common elements
of evidence-​ based practice: Misconceptions
and clinical examples. Journal of American
Academy of Child and Adolescent Psychiatry,
46, 647–​652.
Chorpita, B. F., Daleiden, E. L., Ebesutani, C.,
Young, J., Becker, K. D., Nakamura, B.
J., . . . Starace, N. (2011). Evidence-​ based
treatments for children and adolescents: An
updated review of indicators of efficacy and
effectiveness. Clinical and Psychology Science
and Practice, 18(2), 154–​172.
Clement, P. W. (2011). A strengths-​ based, skill
building, integrative approach to treating
conduct problems in a 12-​year old boy: Rafael’s
story. Pragmatic Cases in Psychotherapy, 7,
351–​395.
Cohen, J. A., Mannarino, A. P., & Deblinger, E.
(2006). Treating trauma and traumatic grief in
children and adolescents. New York: Guilford.
Cohen, J. A., Mannarino, A. P., & Deblinger, E.
(Eds.). (2012). Trauma focused cognitive behavior
therapy for children and adolescents: Treatment
applications. New York: Guilford Press
Cook, J. R. (2007). Systems of care and the
integrative clinician: A look into the future
of psychotherapy. Journal of Psychotherapy
Integration, 17, 139–​158.
Stricker & J. R. Gold (Eds.), Comprehensive
handbook of psychotherapy integration (pp.
413–​425). New York: Plenum.
Drewes, A. A. (2005). Suggestions and research on
multicultural play therapy. In E. Gil & A. A.
Drewes (Eds.), Cultural issues in play therapy
(pp. 72–​95). New York: Guilford.
cognitive behavioral therapy: Evidence-​ based
and other effective treatments and techniques.
Hoboken, NJ: John Wiley.
Drewes, A. A. (2011a). Integrating play therapy
theories into practice. In A. A. Drewes,
S. C. Bratton, & C. E. Schaefer (Eds.),
354 Specific Disorders and Populations
Integrative play therapy (pp. 21–​ 35).
New York: John Wiley.
Drewes, A. A. (2011b). Integrative play therapy. In C.
E. Schaefer (Ed.), Foundations of play therapy
(pp. 349–​364). Hoboken, NJ: John Wiley.
Drewes, A. A., & Cavett, A. (2012). Play
applications and skills components. In J.
Cohen, A. Mannarino, & E. Deblinger
(Eds.), Trauma focused CBT for children and
adolescents: Treatment applications (pp. 105–​
124). New York: Guilford.
Drewes, A. A., & Schaefer, C. E. (2015). Play therapy
for children in middle childhood (6–​12 years).
Washington, DC: American Psychological
Association.
Drewes, A. A., & Schaefer, C. E. (2016). The
therapeutic powers of play. In K. J. O’Connor,
C. E. Schaefer, & L. D. Braverman (Eds.),
Handbook of play therapy (2nd ed., pp. 35–​60).
New York: John Wiley & Sons.
Duncan, B. (2013). What makes a master therapist?
Psychotherapy in Australia, 20, 58–​66.
Eyberg, S. M. (1988). Parent-​ child interaction
therapy: Integration of traditional and
behavioral concerns. Child & Family Behavior
Therapy, 10, 22–​46.
Fall, M. (2001). An integrative play therapy approach
to working with children. In A. A. Drewes, L.
J. Carey, & C. E. Schaefer (Eds.), School-​based
play therapy (pp. 315–​328). New York: Wiley
& Sons.
Feather, B. W., & Rhoads, J. M. (1972). Psycho­
dynamic behavior therapy. Archives of General
Psychiatry, 26, 496–​511.
Feldman, L. (1988). Integrating individual and
family therapy in the treatment of symptomatic
children and adolescents. American Journal of
Psychotherapy, 42, 272–​280.
Fonagy, P., Target, M., Cottrell, D., Phillips, J.,
& Kurtz, Z. (2002). What works for whom?
A critical review of treatments for children and
adolescents. New York: Guilford.
Gil, E. (2006). Helping abused and traumatized
children: Integrating directive and non-​directive
approaches. New York: Guilford.
Gil, E. (2009). Trauma-​ focused integrative play
therapy manual. Fairfax, VA: Childhelp
Children’s Center of Virginia.
Gold, J. R. (1992). An integrative-​systemic treatment
approach to severe psychopathology of children
and adolescents. Journal of Integrative and
Eclectic Psychotherapy, 11, 55–​70.
Goldenthal, P. (2005). Helping children and
families: A new treatment model integrating
psychodynamic, behavioral, and contextual
approaches. Hoboken, NJ: Wiley.
Goodyear-​ Brown, P. (2010). Play therapy with
traumatized children. A prescriptive approach.
New York: Wiley & Sons.
Greenspan, S. I. (1997). Developmentally based
psychotherapy. Madison, CT: International
Universities Press.
Grehan, P. M., & Freeman, A. (2009). Neither
child nor adult: Applying integrative therapy
to adolescents. Journal of Psychotherapy
Integration, 19, 269–​290.
Grencavage, L. M., & Norcross, J. C. (1990). What
are the commonalities among the therapeutic
common factors? Professional Psychology
Research and Practice, 21, 372–​378.
Hughes, D. (1997). Facilitating developmental
attachment: The road to emotional recovery
and behavioral change in foster and adopted
children. Northvale, NJ: Jason Aronson.
Jernberg, A. (1979). Theraplay. San Francisco:
Jossey-​Bass.
Jernberg, A., & Booth, P. (1999). Theraplay: Helping
parents and children build better relationships
through attachment based play (2nd ed.). San
Francisco: Josey-​Bass.
Kamphaus, R. W., & Reynolds, C. R., Hatcher, N.
M., & Kim, S. (2014). Treatment planning
and evaluations with the Behavior Assessment
System for Children (BASC). In M. E. Maruish
(Ed.), The use of psychological testing for
treatment planning and outcomes assessment
(3rd ed., vol. 2, pp. 331–​354). Mahwah, NJ:
Lawrence Erlbaum.
Karver, M., Handelsman, J., Fields, S., &
Bickman, L. (2005). A theoretical model of
common process factors in youth and family
therapy. Mental Health Services Research,
7, 35–​51.
Kazdin, A. E. (1996). Combined and multimodal
treatments in child and adolescent
psychotherapy: Issues, challenges, and research
directions. Clinical Psychology: Science and
Practice, 3, 69–​100.
Kazdin, A. E., & Johnson, B. (1994). Advances in
psychotherapy for children and adolescents:
Interrelations of adjustment, development, and
intervention. Journal of School Psychology, 32,
217–​246.
Kazdin, A. E., & Knock, M. K. (2003). Delineating
mechanisms of change in child and adolescent
therapy: Methodological issues and research
recommendations. Journal of Child Psychology
and Psychiatry, 44, 1116–​1129.

Kelley, S. D., Bickman, L., & Norwood, E. (2010).
Evidence-​based treatments and common factors
in youth psychotherapy. In B. L. Duncan, S.
D. Miller, B. E. Wampold, & M. A. Hubble
(Eds.), The heart and soul of change: Delivering
what works in therapy (2nd ed., pp. 325–​356).
Washington, DC: American Psychological
Association.
Kenny, M. C., & Winick, C. B. (2000). An integrative
approach to play therapy with an autistic girl.
International Journal of Play Therapy, 9, 11–​33.
Knell, S. M. (1993). Cognitive behavioral play
therapy. Northvale, NJ: Jason Aronson.
Kollins, S. C., Epstein, J. N., & Connors, C. K.
(2014). Connors rating scales-​revised. In M. E.
Maruish (Ed.), The use of psychological testing
for treatment planning and outcomes assessment
(3rd ed., vol. 2, pp. 215–​ 234). Mahwah,
NJ: Lawrence Erlbaum.
Koocher, G. P., & Pedulla, B. M. (1977). Current
practices in child psychotherapy. Professional
Psychology, 8, 275–​287.
Krueger, S. J., & Glass, C. R. (2013). Integrative
psychotherapy for children and adolescents: A
practice-​oriented literature review. Journal of
Psychotherapy Integration, 23, 331–​344.
Landreth, G., Homeyer, L., Glover, G., & Sweeney,
D. (1996). Play therapy interventions with
children’s problems. Northvale, NJ: Aronson.
Lazarus, A. A. (2006). Multimodal therapy: A seven-​
point integration. In G. Stricker & J. R. Gold
(Eds.), The casebook of psychotherapy integration
(pp. 17–​ 28). Washington, DC: American
Psychological Association.
Lebow, J. L. (Ed.). (2008). Twenty-​first century
psychotherapies: Contemporary approaches to
theory and practice. Hoboken, NJ: John Wiley.
Naglieri, J. A., & Pfeiffer, S. L. (2014). Use of
the Devereux scales of mental disorders for
diagnosis, treatment planning and outcome
assessment. In M. E. Maruish (Ed.), The use of
psychological testing for treatment planning and
outcomes assessment (3rd ed., vol. 2, pp. 305–​
350). Mahwah, NJ: Lawrence Erlbaum.
Norcross, J. C. (2005). A primer on psychotherapy
integration. In J. C. Norcross & M. R. Goldfried
(Eds.), Handbook of psychotherapy integration
(2nd ed., pp. 3–​ 23). New York: Oxford
University Press.
Norcross, J. C., & Halgin, R. P. (2005). Training in
psychotherapy integration. In J. C. Norcross
& M. R. Goldfried (Eds.), Handbook of
psychotherapy integration (2nd ed., pp. 439–​
458). New York: Oxford University Press.
Integrative Psychotherapy with Children 355
O’Connor, K. (2001). Ecosystemic play therapy.
International Journal of Play Therapy,
10(2), 33–​44.
Phillips, R. D., & Landreth, G. (1998). Play
therapists on play therapy: II. Clinical issues
in play therapy. International Journal of Play
Therapy, 7(1), 1–​20.
Pine, F. (1985). Developmental theory and clinical
process. New Haven, CT: Yale University Press.
Prout, H. T., & Fedewa, A. L. (2015). Counseling
and psychotherapy with children and
adolescents: Theory and practice for school
and clinical settings (5th ed.). New York:
John Wiley.
Reeves, G., & Bruno, A. (2009). Multimodal
treatments versus pharmacotherapy alone in
children with psychiatric disorders: Implications
of access, effectiveness, and contextual
treatment. Pediatric Drugs, 11, 165–​169.
Russ, S. W., & Niec, L. N. (2011). Play in
clinical practice: Evidence-​ based approaches.
New York: Guilford Press.
Schaefer, C. E. (1999). Curative factors in play
therapy. Journal for the Professional \Counselor,
14(1), 7–​16.
Schaefer, C. E. (2003). Prescriptive play therapy.
In C. E. Schaefer (Ed.), Foundations of play
therapy (pp. 306–​ 320). New York: Wiley
& Sons.
Schaefer, C. E., & Drewes, A. A. (Eds.). (2013). The
therapeutic powers of play: 20 Core agents of
change (2nd ed.). Hoboken, NJ: Wiley.
Schottenbauer, M. A., Glass, C. R., & Arnkoff, D.
B. (2005). Outcome research on psychotherapy
integration. In J. C. Norcross & M. R. Goldfried
(Eds.), Handbook of psychotherapy integration
(2nd ed., pp. 459–​ 493). New York: Oxford
University Press.
Seymour, J. W. (2011). History of psychotherapy
integration and related research. In A. A.
Drewes, S. C. Bratton, & C. E. Schaefer
(Eds.), Integrative play therapy (pp. 3–​ 19).
New York: John Wiley.
Shirk, S. R. (1999). Integrated child
psychotherapy: Treatment ingredients in
search of a recipe. In S. W. Russ & T. H.
Ollendick (Eds.), Handbook of psychotherapies
with children and families (pp. 369–​ 384).
New York: Kluwer Academic/​Plenum.
Shirk, S. R., & Russell, R. L. (1996). Change
processes in child psychotherapy: Revitalizing
treatment and research. New York: Guilford.
Stein, P. T., & Kendall, J. (2004). Psychological
trauma and the developing brain: Neurologically
356 Specific Disorders and Populations
based interventions for troubled children.
New York: Haworth.
Stricker, G., & Gold, J. (2008). Integrative therapy.
In J. L. Lebow (Ed.), Twenty-​first century
psycho­ therapies: Contemporary approaches to
theory and practice (pp. 389–​ 423). Hoboken,
NJ: John Wiley.
Tuma, J., & Pratt, J. (1982). Clinical child psychology
practice and training: A survey. Journal of
Clinical Child Psychology, 11, 27–​34.
van der Kolk, B. A. (2005). Developmental trauma
disorder: Towards a rational diagnosis for
children with complex trauma histories.
Psychiatric Annals, 35(5), 401–​408.
Wachtel, E. F. (2004). Treating troubled children and
their families. New York: Guilford.
Wachtel, P. L. (2014). Cyclical psychodynamic and
the contextual self: The inner world, the intimate
world and the world of culture and society.
New York: Routledge.
Weisz, J. R., Kuppens, S., Ng, M. Y., Eckshtain,
D., Ugueto, A. M., Vaughn-​ Coaxum,
R., . . . Fordwood, S. R. (2017). What five
decades of research tells us about the effects
of youth psychosocial therapy: A multilevel
meta-​analysis and implications for science
and practice. American Psychologist, 72(92),
79–​117.
West, M., & Carlin, M. (1980). Psychodynamic
behavior therapy in child psychiatry: An
integrative strategy. Psychiatric Journal of the
University of Ottawa, 5, 12–​16.