Child psychologist explains how kids’ therapy works — and if your child needs it

There’s a lot of talk these days — on social media and in parenting circles — about kids and therapy. But with all the noise, it can be hard to know what’s true and what actually applies to your child. Psychologist (and friend of the pod) Dr. Andy Kahn joins us today to clear up any confusion. He unpacks common questions and offers honest, stigma-free insights into how therapy for kids really works.

• 5 steps to take if you  think your child is depressed

• What is CBT?

• Questions to ask a therapist

(04:42) How do you decide if therapy is necessary?

(11:30) How do you talk to your child about starting therapy?

(15:16) What if my child doesn’t want to go to therapy?

(18:20) Will I know what’s happening in the sessions?

We love hearing from our listeners! Email us at init@understood.org.

Gretchen Vierstra: Hello and welcome to "In It," a podcast for families with kids who learn and think differently. Here, you'll find advice, camaraderie, stories of successes and yes, sometimes failures from experts and from parents and caregivers like you.

I'm Gretchen Vierstra, a former classroom teacher and an editor here at Understood.org.

Rachel Bozek: And I'm Rachel Bozek, a writer, editor, and mom who has definitely been in it.

Gretchen: Today, we're talking about therapy. How do we know if it's even a good idea for our kids? And how do we go about picking a therapist? And what part do parents or caregivers play in that therapy process? To answer these questions and more, we're talking today with our in-house expert, Dr. Andy Kahn.

Rachel: Andy's a licensed psychologist and the associate director of behavior change and expertise here at Understood. He's also the host of the podcast, "Parenting Behavior with Dr. Andy Kahn."

Gretchen: Andy, welcome back to "In It."

Andy Kahn: Welcome back. Thanks so much for having me.

Gretchen: We're always happy to have you.

Andy: It's always a pleasure.

Gretchen: So we're going to get right into it. First things first, why on a podcast for families with kids who learn and think differently, are we about to talk about psychotherapy? Does having a learning and thinking difference make kids at higher risk for mental health challenges like depression or anxiety?

Andy: And that's a great question. You know, keeping in mind that certainly the research says that the longer someone who has a learning and thinking difference goes without support, the greater the probability of having challenges like anxiety, depression, behavioral related challenges. On the more practical side, though, we have to keep in mind that a learning and thinking difference impacts things like daily social interactions, doing those day-to-day activities for kids like going to class and being able to focus and being able to communicate with other people.

So when these things aren't going well, very naturally, what happens is that as they go through the experience of feeling different, struggling to meet the environmental demands, we often see emotional and behavioral reactions. So it's incredibly common.

Rachel: Andy, you see a lot of kids with learning and thinking differences in your practice. What are some of the most common issues or struggles that they bring into your sessions? And can you give us some examples of the kinds of things you're working on with them?

Andy: Sure. So it's a pretty wide variety of differences we see in kids in terms of what's affecting them in the day-to-day life. Sort of the top handful, things like difficulties regulating their emotions, they'll get really angry or sad or or really upset about things in the day-to-day because things can be really hard for my kids when they come in for treatment.

For many of the kids, they have problems making and keeping friends. The social relationships are so important. But for kids who are challenged in managing their learning, who are challenged in just managing how they navigate the day-to-day life environments, friendships are really a big issue that come up really, really commonly. Anxiety and worry are huge. You know, for me, when I was a kid, you know, I felt with my attentional challenges that when I would get called on and I wasn't paying attention, or if I was going into a situation, I'm pretty certain I wasn't successful before, I started to get wound up and nervous about it.

So we'll see things like school refusal, school avoidance, kids not really being interested or feeling comfortable doing things that other kids their age are doing. The leading thing that I see is challenges with behavior. Kids who are getting in trouble, who are having difficulty managing environments and maybe misbehaving or getting involved in altercations with teachers and with peers. And ultimately, we see, you know, aspects of depression, lower self-confidence and self-esteem, which is really common with the kids who come in to see me.

Gretchen: It sounds like some of this is like, it's impacted, right? Because you're going to school and school is challenging because you have learning and thinking differences. And now on top of that, you're worrying or you're acting out because of it. And so it's just like compounded because of everything that's going on.

Andy: Oh, without a doubt. You know, I'd like to think of this away from diagnoses and think of it as, if something's hard for you all the time, how are you likely to feel about it? You're likely to feel less confident. You're likely to feel uncomfortable. And if situations give you a sense of no feeling of control, you use the skills and knowledge you have to get that control. So if you don't have the attention of your peer in a classroom, maybe you joke around or you knock something over or you get up out of your chair. So these are very sort of natural human responses to finding their environment's difficult. When they become a challenge and impair people in their ability to do day-to-day activities, when a kid can't navigate the classroom or isn't able to engage in a lesson or with their peers, that's when we start to think about it in terms of the therapy question.

Gretchen: Got it.

Rachel: So therapy can be expensive and you have to figure out how to meet with teachers and specialists and doctors on top of therapy sometimes. So how do you decide if it's necessary for your child to go to therapy?

Andy: Such a personal question. The word necessary is really relevant to you and your family. So if you're finding that day-to-day activities that are important for you aren't able to happen regularly, you're not able to get your kids to school, your kid isn't able to navigate their environment and to be able to do the things they need to do, necessary is when you start to see those impairments, the the inability to do the important day-to-day activities is starting to become pretty frequent, it's starting to become an impact to areas of their life that that don't feel good to you.

The balancing act, and I think the question was a little loaded because we don't live in isolation. My kid is struggling, and I've got two other kids who've got soccer and dance, and I'm working two jobs, or I don't have the time, or I don't have insurance. So all of these things make a very complicated picture out of what necessary might mean for you as a parent. Right. So for me, when I talk to parents and try to determine, "Hey, is therapy something you should be doing right now?"

You start with a gut check. Are you feeling really concerned and upset about how your child is doing in the day-to-day? Are you feeling like there are things that they need to be able to do that somehow they're just not able to get over the hump and do it? And are you finding that their environments are becoming so challenging for them that what they need to do in the day-to-day just doesn't feel good? And I think that when you gut check that, figuring out the how, the how much, the why, those things can come in time.

Gretchen: It can also be really overwhelming to choose a therapist. Are there different kinds of therapists? And how do you figure out who's the right fit? Where do people begin?

Andy: You know, you have to start from a very pragmatic perspective. First and foremost, if you have insurance, who is covered under your insurance plan? So, going into your insurance website, looking for a list of covered providers in your area, talking to people you know in your community if you're comfortable or going on a Facebook or other social media groups to find out who people are talking about.

If money and insurance isn't a factor, you know, word of mouth is going to be my favorite way to go because if someone else you know really has high praise for a clinician, great. That's a great starting place. In the real world for me, if I was needing to get treatment for my own child, I'd start with my insurance list.

So one thing that's really important is understanding the terminology. Your question said therapist. But what if someone said, "Well, can I see a counselor, a therapist, a psychologist, a social worker?" What does that even mean? And what it means is a lot of the, there are the kinds of professionals who provide the service and then there are the various words they use about it. Counseling, psychotherapy, and therapy tend to be used interchangeably. Okay. The providers might be a social worker, they might be a licensed counselor, they might be a psychologist.

So keep in mind that there are a variety of different providers. And on a website, you may actually have to select for that. So you might say, "Oh, I want to look at psychologists or counselors or LCSW," which is licensed clinical social workers. I advise people, start with the greatest number of professionals first and see if the information there is helpful to you.

Choosing a therapist also means thinking about what kind of therapy they're offering. So there's all kinds of different techniques and versions of therapy that are out there. You know, one thing that we're really focused on here at Understood is making sure that we're looking at the research. What does the evidence say is the best way to approach helping your child get treatment?

Currently, the most research-supported forms of treatment are behavioral therapy, cognitive behavioral therapy, and parent child interaction therapy. The acronym for that is PCIT. All three of those therapeutic styles really have good research around them. They're very structured, and there's very specific techniques that would be used in therapies.

And spending a little bit of time reading about all of them to see how comfortable do you feel as a parent in using those strategies and techniques? Another form of therapy that you'll very commonly hear, particularly for young kids, is play therapy. And, you know, play therapy can take 50 different shapes. So if you have really focused things you're hoping to do with your child, getting a little more information about each of these and saying, "How does it feel? How does it feel for you as a parent? How would it feel for your child to be involved in those kind of interactions?" is really important as a starting place.

Gretchen: This is probably a question maybe for when you have slightly older kids, but does the kid get a vote? Does the kid get to look at the website? Like point to someone they're interested in or read a bio or is it more important that you feel like you want to work with this person? Like what do you think about this?

Andy: Yeah, those are really great questions. And the answer is, and you've sort of hinted at this, it depends. Depending upon your child's age, certainly the older your child is, the more role you're going to have in that situation in terms of saying, "Okay, you have a voice." And certainly they can derail the process very, very easily if their involvement isn't engaged and you just pick someone for yourself.

What I would say is, I'm a huge fan of this magical parenting term that we call forced choice. Okay. You go and you select from an array of people who seem like a good fit for how you feel as a parent. And then from there, you give them the options of the handful of people you feel most comfortable with.

Sometimes, and this happens to me on a fairly regular basis, my older teens may actually have been the one who asked their parents and said, "You know, and I've been looking and here are a couple people I'm interested in." In that situation, you really want to take their preferences seriously. But you have to have conversations where you're sharing, you know, "Love to get you involved, you know, I think that makes a lot of sense. There are cost questions, there are access questions." Yeah. "The best clinicians in your area are likely to have a wait list."

Rachel: Or not taking insurance.

Andy: Right. May not take insurance, be cash only.

Rachel: Which is a huge issue.

Andy: It is. You know, it is. And at the same time, though, if you have a private insurance, you have to evaluate, will they help you submit paperwork? Because, for example, if your clinician doesn't take insurance, they might give you billing paperwork that you can submit that says, "Hey, here's an out-of-network provider," then maybe I get 50% of that paid by my insurance. So just because they don't accept insurance doesn't mean you can't be reimbursed under your plan.

But I think to answer your larger question, sure, we want our kids to have, you know, we use this word very commonly in schools, you want your kid to have agency, which is a sense of some ownership and engagement in their process. And that absolutely will maximize their outcomes. But then again, there's money, there's access, and there's comfort as a parent. And not all therapy matches are created equal.

Rachel: Yeah. So how should we talk to our kids about it if we've decided that we want them to give therapy a try? Maybe you can offer some language that parents can use if they're letting a younger kid know, "Okay, this is something we're going to do," versus an older one because I'm assuming that conversation is different.

Andy: Yeah, and it's very different. And I, the one thing I'm going to say, and maybe for our parents of younger kids who are really sort of debating this, the first caveat is that the earlier you take a swing at therapy with your younger children, the more likely your kids are to to accept it and see it as an everyday activity. Right?

And as something that can be sort of couched as, you know, "If I need help with my sink, I'll call a plumber. If I need help to learn a new skill, I call a clinician, or I call a therapist." And being sort of matter of fact about it like it's not any big deal, really does set the culture of it for your kid and your household.

If you're uncomfortable on the surface with it, and it's something that is a little bit out of your comfort zone, you want to spend a little bit of time sort of rehearsing those conversations with people you trust so that you can deliver it in terms of with a little bit of confidence.

You know, so for young kids, it's always a little easier. I always joked when I worked in schools with really young kids, the parents would say, "Well, is my child going to be nervous about working with you when they're 5 or 6?" I'm like, "I got to hold him off with a stick." Because the 5 and 6-year-olds, new person, lots of attention. You're going to sit with me. They love that. So for your younger kids, just using terminology that feels really matter of fact and open, "Hey, I've got someone I really like who I want you to talk to because they can help teach you stuff that I don't really entirely know yet, or I want us to learn stuff together as a family."

Don't single the child out as, "You know, I don't like your behavior and you need to change it up. So we're going to go talk to somebody." How about, "You know what? I think we're all overwhelmed, and we're a little confused, so we're just going to get some help." Right? Like the idea around we're in this together is really valuable language for talking about therapy because it really is, particularly for your younger kids and I would say even through middle school and high school, your family, your family needs to benefit from learning good strategies.

Everyone in your home can benefit from this. So the more you try to share the therapeutic mindset on we are learning this together, our family's trying to improve, I really want to get some support because I think it's helpful. You set the culture for your child when they're young, and they're much more likely as adolescents and even as adults in their own lives to think about accessing that for themselves. And honestly, eventually for their own kids.

So the conversations have to take that flavor. For teenagers, you know, I think buy-in is really important. Identifying with them, you know, "I'm noticing that these things are hard for you, or that, you know, some of these things are really challenging. And I know some ways maybe we can help that to help you feel better." Especially for older teens, talking about the process as belonging to them.

"This is something that the older your kids get, the more they're going to be independently engaged and involved and responsible for what they're doing in therapy." And I think that sharing that at the outset can be really really advantageous because they might say, "So wait, if I talk to them about something about you, they're not going to come back and share it?" And the answer should be no. Not unless you're unsafe or there's something going on that's dangerous in your home, or you're not being cared for. Outside of that, that therapy can belong to your teen.

And that's, for some kids, that's the first thing that really belongs only to them. Like, that's pretty cool. So when you sell that bill of goods, all teenagers are asking – and middle schoolers too – "What's in it for me? Why would I do this? And how do I make it not feel like I'm looking different or you're calling me like there's something wrong with me." And that's super important in a process like this.

Gretchen: So I just want to jump in with one other question along these lines. What if the child seems to have gotten the memo from the universe that, you know, there is this stigma and they're just like, "I'm not doing this. This isn't for me." Like, they've decided this is not something that they want to try or are willing to try. What does a parent do?

Andy: Yeah, that's a great question. So in that circumstance, I start to approach it a little bit more from a family therapy perspective. And I probably should have defined this earlier. Family therapy, for example, just defines the fact that who might be in the room for the actual therapeutic session. So it still falls in the category of behavioral, cognitive behavioral and those areas.

But when the family, assuming parent or parents or parenting partners are involved in the therapy of the child, sometimes the kids aren't going to engage and sometimes they're not interested. In those situations as a clinician myself, I'll talk to the parents about, "Well, you know, I can train you. I can give you skills." And helping parents learn the strategies, the language, the approaches so they can bring that into their household.

You know, ultimately, the therapy can be derailed if all parties involved don't want to be doing the work. But in those situations, if the kid's disengaging or refusing, but the parents are still interested, they can still be engaged in a therapy session with the child. The child would be considered the identified patient or client, but the parents can still be learning skills, creating strategies for the home and practicing them.

And for much of therapy with my very young kids, that's actually the primary focus is I'm working on educating parents on what they're seeing, how to perceive it. You know, "Oh, if you look at it in another perspective, maybe you're going to see that behavior a little differently." And then working on skill building from that perspective.

With slightly older kids and teens, for some parents, it may be that just the timing isn't right. I think it's always important that kids know that the therapy process is something that can stop and start. And it's very important not to just give up all of a sudden because if the kids are really anxious about it, uncomfortable, and they learn by having a fit, you won't go back, that's the behavior you're going to you're going to be reinforcing. Right?

And getting them back in the therapy is going to be extremely hard. Yeah. The other piece of this, let's talk about fit for a second. You know, one of the things that's really important when kids and families are talking about therapy is what we call goodness of fit, okay? Does this clinician seem to connect with me or my family? Does my kid see this clinician as someone they feel comfortable talking to?

And in the first session, that's a topic that you really want to make clear that you're evaluating the clinician's goodness of fit for you as a family. I always raise that issue myself. I've been doing this almost 30 years. So when I say to a client after they've waited a few months to get in to me, you know, "At the end of the session, I'm going to ask you, are you comfortable continuing to work with me? Because if you don't feel that you are, I really want to act quickly and get you connected to someone else."

Because it can't be about the clinician's ego. It has to be about the goodness of fit for the family. Do they feel that they can engage? And if not, it's time to figure something else out and move on.

Gretchen: You spoke about this a little bit, but I want to clarify the parent role in therapy. Yeah. So, well first of all, you said that the therapist isn't going to give you a report of what the kid said, right? Only if there's something that you need to know because of harm reasons. But otherwise, you're not going to get like a play-by-play of like, "Johnny said this, and Johnny said that," right?

Andy: Right. To a certain degree. I think Gretchen, what you'll see is it will depend on the type of therapy. In some kinds of therapy, if you're doing something very behavioral, there's going to be a technique that's taught, a strategy that's practiced, and a homework assignment that the child's going to have to use in the coming weeks.

So in those kinds of therapies, you may actually get quite a bit of information about what's happening. The kinds of information that may not be shared is, "My mom and dad really made me angry this week because they were doing something really stupid." Like those little details might not be the things that you get shared. But the techniques, the approaches, and remember as a parent, you don't have to just give up all of your sort of knowledge and control in this situation.

You can set the parameter for, for me, with a lot of my parents of young kids, I'll say the parent will attend in the beginning, share about how the week has gone, then I do strategies with the child, and at the very end, I might give them a summary. "Here are the things that your child is learning. Here's what I want them to practice." And then if I really think I have to share something about the session, I will talk to the child about that in advance and say, "You know what, what you shared was really important. I think if your mom or dad or or whoever your caregiver is knows that, maybe I can help make life a little easier for you."

But for a parent, you can help set the framework with the clinician in whatever way you're comfortable of, you know, for this. But in many cases, again, for older teens, it's often really good that they have a little bit more autonomy and control. They feel like that sharing isn't going to be as deep because obviously that's where the structure and trust of therapy comes from at that older age for kids.

Rachel: So, what signs or indicators can we look for as parents to figure out if therapy is benefiting a child?

Andy: Yes. So again, it's a little complicated, but I'll give you the, I'll give you the simplest answer I can.

Rachel: It depends.

Andy: Yeah, yeah, it does. Luckily, there are standards, though. At the very beginning, it really is important to check in with your child and yourself about how those initial sessions are going and you're just going to get a feel. Like how you're feeling, you know, are you feeling comfortable with this person? Are these interactions making sense? And asking some of those general questions of yourself and the child.

But ultimately, the therapy process really needs to include an assessment at the start, which is really learning about what's going on and what are you focused on. And then writing a plan. All good therapy should have a treatment plan that includes the problem areas you're looking at, the skills you're going to try to learn or develop to address them, and then you should be looking over that information fairly often.

In my work with families, you know, we talk about the goals pretty often, even on a session by session basis. But for, you know, for most families, it's okay to ask, you know, "What are we working on here? What's our progress? What are we seeing?" And then ultimately, looking over the course of time and asking a very honest question, "How long would I expect before I start to see something looking different or something improving?"

You know, you'll often get a sense, if something's working, you'll start to feel the flavor of it. But there's nothing like taking a little bit of data with your clinician where they say, "We're going to pay attention to how often we see something, or how often your child is doing something they weren't doing before that's really positive." And that sort of tracking can really help you know that things are moving in the right direction.

If they're not, it's always okay to ask, you know, "I'm just not feeling that we're making a lot of progress. Is there something we can shift? Or, you know, is this working?" And having those open conversations, one thing you should never forget as a parent in this situation is the clinician works for you and your family. And if they're working for you and something isn't moving along, you have every right to ask about what's going on.

"Do we need to shift our plan? Are there things that they feel could be working or not working?" And then asking the question, "Do we need a referral to somebody else?" Because in that situation, you know, one of my least favorite outcomes of therapy is that someone goes in, they have a mismatch of personalities or strategy, and then they say, "Okay, I've made a decision. Therapy doesn't work." And then they stop going.

And what I say to people when we start therapy is, therapy is a lot like the beginning of dating relationships. Some people are a match, some people aren't. You may need to try a few people before you find your person. And then once you do, then it's then you're able to get something out of the relationship. But for some people, it's hard to get in, and if you've gotten in and you're finding it's frustrating and you're spending time and money, you really have to have the mindset that you're willing to work through this over time and to continuously ask, "Is the fit good? Are we making gains? How do I know we're making gains?" because they should have a plan and then be willing to make those decisions as you go.

Gretchen: So if you are making gains, once you reach a certain goal, how do you know when it's time to say, "Okay, we don't need to do this anymore?" Because it's not, yes, it could be great to go to therapy forever, but, you know, you have to make the appointments, drive there, possibly pay for this, you know, dealing with the insurance. Like so when do you say, "Okay, we've come far enough," or I don't know, how do you get a sense of that?

Andy: In my experience, when I write a treatment plan with a family or I start to set goals as part of my assessment, it's pretty common that there are more goals that I could address than what I'm actually going to work on at one time. So, you know, if you find that you've met your goals and you're feeling like you've made progress, it's really common to say, "You know what? One of our things that we may want to do is start to reduce the frequency of our sessions to see if what we've learned is actually going to be maintained."

So if you're going weekly, you bump it out to every other week or once a month so that you can stay on that clinician's sort of on their roles. And then over time you could say, "Okay, I often use the term, hey, listen, we're going to, we graduate from this." And then I explain to them, "Life is funny. As you get older, you may run into situations where you hit another roadblock. And the idea that you can come back to therapy is a really powerful idea."

Because when things go well and you make gains, people want to hold on a little longer than they probably should. And as a clinician, if you like your client, they're making gains, they're pleasant, and you feel good during the hour, sometimes it's hard for both parties to give that up. Right. But I think it's really important to be able to say, you know what? We're going to, we're going to start to take some space here between sessions. We're going to see if it continues to go well. And then reserve the right to come back.

And I think that that's always a much more reassuring way to approach that with clients and families. I'm giving them the sense that sometimes you just, you just learn what you need to and you really can sort of leapfrog over some of the other things that might have been hard for you. But I think that's really individualized that way. But I like the tapering sessions. It keeps you on their list so you don't lose your spot completely. Right. And then it gives them the idea that, "You know, maybe people need to come back for refresher sessions." I have clients right now who are on a monthly schedule, and they come in once a month to check in. "I'm maintaining, or I'm going to need a little refresher." And they might come back for a couple of sessions before school starts. So there's a lot of different ways that you can do the process, but you just have to be open and creative and share with the clinician, "I'm curious where this is going. Like, what's our next step?"

Gretchen: Yeah. Is there anything we missed Andy that we should talk about?

Andy: You know, I just I think the thing that I would say to all families in situations like this is that therapy is a very personal thing, and taking the leap to engage your child in treatment is something that takes actually a lot of bravery. And as a parent who gets to the point where they say to themselves, "I can't figure this out. This isn't working." It takes a lot of guts to put yourself out there and say, "I need help."

And, you know, to be brave in that way, to give yourself some grace in understanding that when things aren't working, getting help is really important. And remember as a parent, you are modeling for your child that asking for help is something that has value and that is about advocating for themselves and for you as a family. And I think that's a really great strength to build, showing that getting help is an expected part of life and something that you model for your kids can actually give them a lot of positive moving forward into their adult lives.

Rachel: Well, thank you so much for chatting with us today, Andy.

Andy: Always a pleasure. Thanks so much for having me. This was fantastic.

Rachel: Thanks so much for listening today. If you have any thoughts about the episode, we'd love to hear from you. You can email us at init@understood.org.

Gretchen: And check out the show notes for this episode, where we have more resources and links to anything we mentioned.

Rachel: This show is brought to you by Understood.org. Understood.org is a nonprofit organization dedicated to empowering people with learning and thinking differences, like ADHD and dyslexia. If you want to help us continue this work, donate at understood.org/give.

Gretchen: "In It" is produced and edited by Julie Subrin, with additional production support from Cody Nelson and Andrew Rector.

Justin D. Wright mixes the show, Mike Errico wrote our theme music, and Briana Berry is our production director.

Rachel: From Understood.org, our executive directors are Laura Key, Scott Cocchiere, and Jordan Davidson.

Thanks for listening. 

Gretchen: And thanks for always being in it with us.