You might be seeking a therapist for your child, but also feel that you yourself need some support too. Perhaps a pediatrician or social worker has given you a referral for a professional to treat your child’s behavior.
How do you navigate the system to find the help you and your child need? While access to services varies depending on the health care system of your region, there are some universal considerations.
The aim of this article is to educate consumers on working with behavioral health professionals and parent coaches including family therapists, psychologists, behavior analysts, clinical counselors, or other mental health professionals.
As a consumer of behavioral and mental health services, you deserve to have the information you need to make informed decisions when finding the right therapist for you and your child.
In this article you will find details on how to get the right type of help for your child:
Chances are if you’re reading this article, you have been experiencing some behavioral challenges with your child.
You might be feeling like you’ve tried everything, have read the books (or don’t have time to!), and even taken some webinars about child behavior support. If you are feeling overwhelmed and at the end of your rope, you might benefit from the help of behavioral health professional.
Child psychologists Amy Murrell & Lisa Coyne, authors of The Joy of Parenting (2009), suggest asking yourself the following questions to determine whether you could benefit from professional help:
When did these behaviors start?
Have the behaviors of concern gotten worse or better over time?
Are these behaviors affecting learning, social relationships, development, or safety?
When you think about your child’s behaviors, are you limited from engaging in positive parenting strategies that you want to be using because you feel so overwhelmed? (p. 29-31)
Behavior analytic research shows that the longer a behavior is reinforced over time (i.e. the absence of treatment), the harder it is to treat in the future.
If a concerning behavior is worsening and affecting the child’s learning, social relationships, development, or putting themselves or others at risk, it likely warrants professional help. Furthermore, if you are feeling overwhelmed to a point at which you are struggling to implement positive parenting strategies, you might need professional support as a parent.
The aforementioned book, The Joy of Parenting, is based on the principles of acceptance and commitment therapy (ACT) and can help parents implement strategies while getting treatment for their child.
Externalizing and internalizing behaviors
Murrell & Coyne (2009) differentiate externalizing and internalizing behaviors and the appropriate treatment for both categories.
Externalizing behaviors are those that you can easily see your child engaging in. Examples are physical or verbal aggression, self-harm, impulsive behaviors, tantrums, school avoidance, lack of cooperation (i.e. refusal to follow instructions), or challenges with executive functioning skills (p. 27-29).
Internalizing behaviors can be harder to pinpoint as these are internal emotional struggles for the child, such as depression or anxiety. These can also result in avoidance of various scenarios that result in the child feeling worried or fearful (p. 30-31).
It is always important to ensure that the treatment option you choose is evidence-based, meaning it has empirical research behind it (high-quality, quantitative research studies) and has been clinically tested (p. 32).
For externalizing behaviors, behavior management parent training is an evidence-based approach recommended by Murrell & Coyne (p. 33) because of the lasting effects that parent training is shown to have. Parent training is an area in which behavior analysts are skilled. They are trained to coach parents and other caregivers in the skills needed to alter the environment and context of the child.
Often it’s the adults in the child’s life that need to make changes first. Professional behavior analysts are trained to analyze the behavior(s) of concern, the context in which they occur, and pinpoint the reason the behavior(s) are occurring in the first place. Treatment decisions are based on this analysis.
Working with a behavior analyst (BCBA) can provide much-needed support to you as a parent or caregiver if you are experiencing any externalizing behavioral challenges or skill deficits with your child.
Through a collaborative process, caregivers need to be prepared to try new strategies and be the ones to change first. A parental (or educator) training approach puts the responsibility on the caregiver to make changes. If you feel ready for this, here are just a few of the common concerns that a BCBA can help you with:
challenges with cooperation such as following instructions from caregivers
school refusal/school avoidance
elopement (i.e., running away)
challenges around technology use (i.e., leaving technology, overuse)
excessive or intense fighting with siblings
emotional reactions that are not commensurate with the situation
food refusal or aversions
social skill deficits
challenges with executive functioning skills such as impulsivity, difficulty planning, difficulty following routines
lack of flexibility and rather will engage in rigid routines or behaviors
delays in various life skills such as toileting
For internalizing behaviors, mental health professionals such as psychologists licensed clinical social workers, and clinical counsellors can be of help. However, some BCBAs are also trained in the ACT and can help you if you are seeing both internalizing and externalizing behaviors.
If you find your child is struggling with avoidance of certain scenarios, depression, or anxiety some of the following treatments are recommended:
Coyne & Murrell highlight that treating both internalizing and externalizing behaviors require a degree of support from parents. The intention is that the skills learned are maintained over time. The treatments listed above are not intended as one-and-done interventions. Change can take time and skills need to be maintained. Similar to flossing, parents who are able to maintain the support mechanisms learned over time will help their child maintain new skills and keep challenging behavior at bay (p. 34).
Where to start
There are many different therapeutic options out there and it can be hard to know what the right fit is. In The Joy of Parenting, Murrell & Coyne outline some evidence-based treatment options.
When you’re ready to get started, these are the steps to take to find the right therapist for you:
Start with your Doctor
Often a referral from your family doctor or pediatrician will be needed, especially for publicly funded services. Furthermore, it is important to start here in order to rule out any physiological issues that might be a factor in the child’s behavior (e.g. constipation, encopresis, gastrointestinal issues, allergies, neurological diagnoses, etc).
Many professionals will direct you back to a medical doctor if they suspect there are medical factors. If your child requires psychiatry or pharmaceutical interventions in relation to their mental health or behavioral needs, a referral may come from your pediatrician.
Consider the type of professional your child might need
Does your child present with externalizing or internalizing behaviors, or a combination of both?
Generally speaking, BCBAs specialize in externalizing behaviors, whereas psychologists, licensed clinical social workers, and clinical counselors specialize in internalizing behaviors. They also have different philosophical and scientific backgrounds underpinning their work.
However, there are BCBAs that are dually certified as clinical counselors and trained in ACT and are prepared to work with clients with both externalizing and internalizing behaviors. There are also psychologists who have a behavioral background, employing a behavior analytics approach to treatment.
Talk with a school counselor or special education staff
If your child’s behavior concerns are evident at school as well, consider talking with school staff for referrals to the right professional. If a formal referral is not needed from a doctor, this can be a good place to go after speaking with your pediatrician.
Consider the credentials of the professional you’re considering
Is this person licensed to practice in my area? What training and experience do they have? What college or association are they accountable to? What is in the ethics code to which they are bound? The professionals listed below all require training to at least a master’s degree level in behavior analysis, psychology, social work, clinical counselling, special education, or another related field.
Working with a professional who is educated at such a level provides legitimacy to their services, and makes it more likely that they are using evidence-based practices, as they are accountable to the oversight of a College or Board.
Understanding the type of therapy your child might need
Externalizing, or a combo of externalizing and internalizing behaviors
If you are looking for strategies that will support you in your parenting and interactions with a child who is exhibiting externalizing, or a combination of externalizing and internalizing, behaviors, a behavior analyst would be a great place to seek help.
A behavior analyst is credentialed as a board-certified behavior analyst (BCBA) through the Behavior Analyst Certification Board. They are trained to examine and understand behavior by looking at environmental factors (including interactions and relationships) that contribute to challenging behavior.
Learn more about Behavior Analysis and its scientific and philosophical principles here.
Using the science of behavior analytics, BCBAs serve families by teaching new skills and promoting prosocial behaviors while addressing challenging externalizing behaviors. This might be helping a child with ADHD develop stronger planning skills or introducing new routines to increase independence in the home.
The model used by a behavior analyst can differ depending on the practitioner, but will generally follow a coaching or consultative model. The benefit of this is that the BCBA can work with parents, caregivers, and other family members to support the child toward skill development or positive behavior change. That being said, they will often work directly with your child as well.
Making the child feel included in any work with professionals is important for their dignity. BCBAs believe in not just having the consent for services and behavior change interventions from the parent (for minors), but also the assent of the young person who is receiving services. This is not only an ethical concern, it also establishes a stronger therapeutic alliance.
BCBAs define the client as anyone that is benefiting from the behavior analytic services. This includes family members and other caregivers close to the child directly receiving therapy. This approach allows for the BCBA to provide better support to the primary client by also enhancing the skill set of those who are interacting with the child on a daily basis.
Further, taking into consideration the entire context of the child’s life enhances the overall well-being of the client and the family as a whole. This holistic approach is a defining characteristic of behavior analytic services.
Sometimes what is required is a change in the environment or context of the young person. The child is not able to make changes on their own until those around them start interacting differently. This is where a behavior analyst can help you determine why a behavior is occurring and may also suggest a mental health professional alongside behavioral services if needed.
BCBAs collaborate with other professionals to ensure optimal outcomes for their clients. This model results in long-lasting change as it is the caregivers that are able to help the child maintain strategies over time, even beyond the end of behavior analytic services.
Some BCBAs specialize in the treatment of behaviors using ACT, using behavioral techniques to help enable people to live a more psychologically flexible life and deal with challenges in a more open and functional way.
This can be a powerful technique for parents who are feeling burnt out and at the end of their tether with their child. ACT is a treatment form that is founded on behavioral science and focuses on psychological flexibility. ACT has many peer-reviewed research studies behind it and can be a powerful approach when mental health and behavioral health interact.
Further, ACT has also been shown to be effective in parent training, and some BCBAs use ACT to support parents in the coaching process as they learn new ways to interact with their child.
If you would like some additional social-emotional support through the coaching process, ask your BCBA if they are trained in using ACT parent-training protocols.
If your child is showing signs of internalizing behaviors such as negative self-talk, self-harm, lack of coping skills in the face of day-to-day challenges, trauma, depression, or anxiety, some of the following professionals can be of help:
Psychologist with a specialization in serving children and adolescents
Registered Clinical Counselor
Licensed Clinical Social Worker (‘LCSW’ depending on credentials in your region).
These professionals are trained to deliver psychotherapy through a variety of formats including talk therapy, group therapy, play therapy, or family therapy.
Many are trained in CBT, an evidence-based intervention that should be delivered by a qualified psychotherapist. Look for a professional who specializes and has experience in child therapy or working with adolescents, depending on the age of your child.
Some pediatric clinics may have a multi-disciplinary team to better serve you if your child has complex needs that transcend disciplines. Access to these services completely depends on where you live, and your local health care system, but is worth looking into—especially if you live in the US.
Behavior Analyst Michele Shilvock discusses multi-disciplinary support with me on the podcast. If you want more information about accessing such services,listen to our conversation.
Seeking the right professional
If you’re ready to work with a behavioral health professional here are some places to look:
Find a behavior analyst (BCBA)
1. To find someone local, search the BACB directory for someone in your region.
2. Google some of the following search terms:
‘Behavior Analyst or BCBA (your region)’
‘Behavior Analyst or BCBA telehealth’
3. If the young person for, whom you are seeking services, is also experiencing mental health challenges, you could check the Association for Contextual Behavioral Science and lookup an ACT therapist. Some BCBAs are trained in ACT. This database has both BCBAs and other mental health professionals.
Find another mental health professional
All of these resources are directories for a wide variety of professionals. Be sure to check their credentials to validate they suit your needs and funding situation. Use the search functions to ensure the clinician works with children or adolescents, rather than just with adults.
Sources, listed in no particular order:
Check your local health authority, hospital, non-profits or state/provincial ministry of children for publicly funded options for mental health support. In some cases, your pediatrician or child’s school might have to send a referral for services. There can be longer waitlists and shorter service time frames with publicly funded services, so always ask about wait time and length of service.