Brain-Based Therapy with Children and Adolescents

Evidence-Based Treatment for Everyday Practice
By John B. Arden Lloyd Linford

John Wiley & Sons

Copyright © 2008 John Wiley & Sons, Ltd
All right reserved.

ISBN: 978-0-470-13891-5

Chapter One

Changing and Staying the Same

No matter where you go, life moves forward like a heavy wheel and it never stops regardless of any circumstance. It just moves forward regardless, and I find that extremely humbling. —Lisa Kristine, Photographer

Child therapists work in the space between the stable and changeable aspects of personality and character, using the therapeutic relationship to promote a healthy adaptation to living in a complex social world. The discovery that such a relationship could change the mind ignited the psychotherapeutic revolution in psychiatry. It does not seem widely remembered that the discovery was made by pioneers who at the time were immersed in the study of the brain and nervous system. Between 1877 and 1900 (when The Interpretation of Dreams was published), Freud authored more than 100 works on neuroscience. (For an interesting discussion, see Solms & Saling, 1990.) As a neurologist, Freud revised the prevailing view of his scientific contemporaries that the brain did its work piecemeal, with specific parts performing particular tasks in a straightforward way. In a short article on aphasia, for example, Freud rejected the localization hypothesis in favor of the concept of a "speech field" in the brain (1888/1990), a view more in accord with that of modern neuroscience.

Like Freud, William James was also a neurophysiologist. While his work is ultimately less useful to clinicians than Freud's, James nonetheless laid the basis for much of current cognitive science, and in that sense was a precursor to behaviorism and cognitive behavioral therapy. In his 1890 Principles of Psychology, James discusses some ideas that came to have enduring importance in psychological studies, including associative learning, chains of operant learning, and fear conditioning. His theory of emotion was based on the idea that feelings arise not from thoughts or fantasies but rather from visceral and muscular responses to outside stimuli. The Principles of Psychology includes detailed diagrams of the brain and a review of Broca and Wernicke's areas (two areas of the brain that are key to our ability to express and understand language). Regarding the seat of consciousness, James concluded:

For practical purposes, nevertheless, and limiting the meaning of the word consciousness to the personal self of the individual, we can pretty confidently answer the question prefixed to this paragraph by saying that the cortex is the sole organ of consciousness in man. If there be any consciousness pertaining to the lower centres, it is a consciousness of which the self knows nothing. (James, 1890, p. 67)

Subsequentclinically-orientedpsychologistsfollowedAristotle,Descartes, and James in largely disregarding the brain, and followed Freud in focusing on case studies and on developmental cognitive and behavioral norms. Abandoning brain science in favor of pure psychology allowed psychotherapists to employ methods considered "unscientific" by biological scientists. These included the use of insight and empathy as ways of understanding the mind. The separation from neurology allowed therapists to grasp a truth about neuroscience that for many years eluded scientists in laboratory: the brain is exquisitely sensitive to the interpersonal environment of relationships. Particularly in childhood, relationships are as important as food and warmth.

Psychotherapy's discoveries about human nature and development outstripped what could be demonstrated in the neuroscience labs of the same period. But in pursuing the purely psychological strategy of Freud and James, those of us who have grown up in the psychodynamic and behavioral traditions postponed an important reality check on intuitive hypothesizing and speculation.

The way in which contemporary neuroscience causes us to revise the common psychodynamic understanding of unconscious phenomena exemplifies the value of an integrated neurodevelopmental model. Classical psychoanalytic theorists tended to portray the unconscious as the Puritans portrayed hell—a cauldron of aggressive and libidinal impulses threatening to spill over and destroy both the social order and the individual's cohesive sense of goodness. Later psychodynamic therapists viewed it in less vivid terms, as the repository for socially and personally unacceptable impulses. In contemporary neuroscience, if the Freudian unconscious exists at all, it is seen as a small subset of a much larger area of mental life that functions outside of awareness. Much of what the brain does never achieves consciousness, nor would there be a purpose in its doing so. Neuroscientists are careful to use the term "nonconscious" as an adjective, not (as the Freudians tend to do) as a noun. The mind, in the new neuroscience, is a process rather than a thing or a place. Neurodynamic therapists are less impressed with insight than with integrating brain functions and the psychological domains of thought, emotion, and behavior.

Neuroscientific research has demonstrated that nonconscious functioning has a developmental history that is often clinically relevant, one that clinicians should be generally aware of. A brain module that plays a key role in certain types of memories is the hippocampus (or little "seahorse") located near the center of the brain at the heart of the so-called limbic system. The hippocampus is critical in forming memories about events that can be brought to consciousness. It organizes and coordinates input not only from many other parts of the brain but from the whole nervous system in a way that permits these inputs to be stored as explicit memories. Adults who have the misfortune of losing all or part of this small brain module (such as the famous patient H.M., about whom we wrote in Brain-Based Therapy with Adults) stop coding long-term explicit memories, as was the case with H.M. immediately after the surgery that removed his left and right hippocampi.

Hippocampal functioning changes over time, by parallel developmental processes in many other brain modules. The sequence in which the underlying biology of memory emerges is clinically important: the specific loops between the hippocampus and the cortex that allow us to explicitly recall events from the past do not become functional until about age 2. We do not have the capacity to organize explicit memories before that age. No matter how much we analyze the defenses of a child or adult patient, these memories cannot be "uncovered." Infantile amnesia is not psychogenic, as Freud proposed, but an artifact of this developmental sequence. This fact about the development of the explicit autiobiographical memory system has a significant impact on the child's personality and sense of personal continuity and identity.

Other memory systems come on line earlier in life. The implicit memory system (including procedural and emotional memory), is powerfully influenced by a module located quite close to the hippocampus, called the amygdala (or "almond," so-named because of its shape). The amygdala, like the hippocampus, is bilateral; that is, it is made up of two relatively small pieces of real estate, one in each hemisphere of the brain. The amygdala is a powerful mediator of somatic reactions to stress and a potent influence in the laying down of nonconscious emotional memories. These memory systems can be sensed only through the hints and feints of behavior. Thus when we as therapists explicitly interpret a behavior that is linked to (for example) an implicit memory of repeated infantile abandonments in an 8-year-old patient, we are constructing a new narrative with the patient, and not "uncovering" it.


The mind is an example of an "emergent process," a phenomena found only in complex systems, such as a child's brain. Emergent processes are the surprising effects produced by the interaction of elements in a complex system, such as the interaction between the hippocampus and the cerebral cortex. Complex systems such as the mind/brain process transform the roles of the component subsystems themselves—very much a case of the whole being greater than the sum of the parts (Arden, 1996; Grigsby & Stevens, 2000).


Complex systems have several important qualities in common, one being that although typically they are made up of many parts, the relationship between the parts is more important than the function of any one component. For air-breathing mammals, for example, the lungs are a vital organ of the circulatory system, but lung functions are affected by larger somatic systems, especially the brain. Conversely, the lungs are much impacted by the vigor of the tiny processes in the cells that make up the lungs themselves. Children's brains are also made up of many different highly interrelated parts, or modules, which are modified by developmental phases and by experience. When a single cell reproduces itself, creating identical twin offspring, a long process of differentiating begins. One of these cellular offspring will become the great-grandparent of cells that make up the gut; the other the neurons in the visual cortex at the back of the brain. Given that the two offspring are initially identical to the parent cell, what is built-in is the capacity to respond to, among other things, the cell's location in the environment of the womb and later its location in the fetus.

When a normal baby emerges into the world a scant 9 months or so after the first mitosis, this system of intense gene-environment interaction continues the work of differentiation. Still in a premature state compared to all other newborn mammals, but with many highly differentiated systems, human babies are especially designed to attach to caregivers. In this sense, the child is a subsystem in an interactive social system of other individuals and groups. Like other living systems, the newborn's brain balances between stability and disequilibrium; and also like other living systems (von Bertalanffy, 1968), it has the capacity to organize itself (Arden, 1996). As we describe in Chapter 2, infants have emerged from the evolutionary process custommade to attract just the kind of attention they need to survive and prosper. Whatever neurological structure they bring into the world immediately begins interacting with, and is changed by, the environment.

How do complex systems organize and maintain themselves and deal with new inputs into their system? The capacity to maintain a degree of stability in a changing environment is one shared by all complex systems, whether alive or not.

An example of this self-organizing property in a nonliving system is the "behavior" of the planet Saturn and its rings. Through the telescopes of Earth-bound stargazers, Saturn's rings look like solid flat bands of color attached around the waist to the orb of the planet. Closer observation, however, shows the rings to be made up of billions of rocks hurtling around the planet at tremendous velocity. Moreover, the rings are actually discrete modules in a large, complex system, with empty space separating them.

This pattern is what students of dynamics call an attractor, a pattern of activity or structure the system can assume at minimal expense in energy. The whole system can be said to be self-organizing in the sense that a rock that happens into one of the no-fly zones between the rings will be pulled into an adjoining ring by the force of gravity. A rock that tries to go its own way must tap into some source of energy to stay out of the attractor pattern. All complex systems, including children's brains, share common elements, and this is one of them: change often requires additional energy. Resistance is not necessarily a willful act of rebellion so much as the tendency of systems (but far more complex) to remain in inertia and conserve energy (Grigsby & Stevens, 2000).

The child's brain shares some of the dynamic complexity of Saturn's ring system, including the capacity to organize and maintain itself in certain patterns of activity. Students of dynamics call these patterns "attractors" whether they are the way boulders and bits of debris orbit Saturn or are "traits" we see in a child. But the complexity of a neonate's brain dwarfs that of the giant planet's ring system. The fertilized egg and every subsequent cell in the body of the fetus retains all the information in its DNA that is required to make any of the specialized cells in the body. Every cell seems to be responsive to and changed by environmental factors. Between 10 and 26 weeks, fetuses generate on average 250,000 new neurons per minute. By birth each of these cells will be virtually exactly in the right spot, ready to sprout a precise network of dendrites, or extensions from the neuron used to communicate with colleagues. The dendrites grow in the direction of neurons that will become part of networks required to launch the brain functions that come on line at birth or in the months and years afterward.

How do these cells strike exactly the right equilibrium between stability and the capacity to change? As the internal microelectrical storms within the neuron result in the cell "firing" and discharging a cascade of neurotransmitters in the direction of colleague cells, the recipient of the transmitter reacts. The transmission electrifies or calms down the weather inside the neighboring cell, and mental life begins. There are a staggering number of cells involved in the whole system. Newborn babies have twice as many neurons as their mothers, and the pace at which they start to wire in reaction to outside stimulation is astonishing. Within an hour after birth, the infant starts to imitate the facial expressions of those around him or her (Meltzoff & Moore, 1977), and very soon prefers the configuration of human features to anything else in the visual environment (Bebee & Lachman, 2002). We do not really understand how neurons seem to "know" their proper destinations, nor how they also seem to know which other cells, sometimes far away, they should connect with. What we do understand is that the whole system is exquisitely attuned to sensing the environment; and that the environment immediately begins to play a major role in reorganizing the newborn brain. This is one of the enduring self-organizing properties of the human nervous system.

Complexity and Environmental Sensitivity

Helping children requires an appreciation of how susceptible each child is to the relationships surrounding him and some understanding of how he views the world at any particular time in his development. Relationships drive human development, and the child's relationship with her therapist is just one in a constellation of attachments to adult caregivers and peers. Helping facilitate change in a child's adaptation to the specifics of his family and the outside world is always balanced with where the child is starting from. In this context, the therapeutic process is a dialogue between the child's existing ways of interpreting feelings and events and the therapist's more developmentally advanced capacity to understand and interpret these phenomena. More than that, child therapy is a bond between two people that produces change in the brains of both participants.

The extent to which children are embedded in an interpersonal environment is illustrated by research on the effects of environments that are either deprived or particularly stimulating. Rene Spitz (1983), a psychiatrist and close associate of Anna Freud, was a pioneer in the area of exploring the interactive role of brain development and relationship-dependent learning in infancy. He originated a method of studying infants and children in relationally impoverished environments, a technique as important in our understanding of the delicate interplay of love and brain tissue in children as the study of the effects of head trauma has been in the evolving model of adult brain functioning. The principle here is that to understand how things usually work, look at what happens when they go disastrously wrong. Spitz studied medically hospitalized infants and formulated the concepts of hospitalism and anaclitic depression. Left alone for long periods of time, the infants in Spitz's studies typically actively protested and then, if no one responded, withdrew and became passive. Infantile withdrawal could become complete and lead to an ultimately fatal shutting down. Babies, Spitz proposed, can die from not being touched, spoken to, looked in the eye, smiled at, and bounced.


Excerpted from Brain-Based Therapy with Children and Adolescents by John B. Arden Lloyd Linford Copyright © 2008 by John Wiley & Sons, Ltd. Excerpted by permission of John Wiley & Sons. All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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