Reflective Network Therapy in the Preschool Classroom by Gilbert Kliman, MD 

© University Press of America  2011

Excerpts from the first three chapters:

 

Chapter 1   New Hope for Children with Psychiatric and Developmental Disorders

Chapter 2    Welcome to the Reflective Network Therapy Classroom

Chapter 3    Reflective Network Therapy: How To Do It Manual for Therapists, Teachers and Parents 

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 Chapter 1

NEW HOPE FOR CHILDREN

WITH PSYCHIATRIC AND DEVELOPMENTAL DISORDERS

Introduction

  For children with serious emotional, developmental and cognitive disturbances, effective treatment early in life is essential to fully support two precious human functions: loving and learning. We report here on a surprising method of therapy in which a therapist harnesses small social networks of children, teachers and parents in a therapeutic setting (usually a preschool or kindergarten classroom) for the benefit of each child. It has often produced unexpectedly rapid gains for seriously disturbed or traumatized children, and for preschoolers with autism. All had ceased being fully able to love and learn.

Measurable gains produced by Reflective Network Therapy (RNT), especially when used in a therapeutic or special education preschool class, include positive behavioral changes, improved relational skills, regularly and substantially expanded learning capacity, and increases in IQ. All of these outcomes are measurable by children’s Global Assessment Scores (CGAS) and IQ testing (WPPSI-R). Rises in IQ occur regularly. This treatment method yields very significant IQ gains in a school year for most testable children, especially those who are numb from trauma or withdrawn due to autism. With a high number of sessions, IQ rises are even more significant. It works without medication. Those who begin treatment who are already using psychotropic medications are routinely able to do without these medications within a month. The treatment is much less expensive than early intervention methods such as child psychoanalysis for anxious children or the Applied Behavioral Analysis method for children on the autism spectrum.

Just before Christmas, 2007, RNT met another milestone for replication in a community based mental health center in a state (Washington) which never had an RNT service before. Having seen videos of children being helped by the method in San Francisco, San Mateo and Argentina, Wellspring Family Services’ staff and shelter caregivers in Seattle wanted to offer Reflective Network Therapy to their child clients and some parents wanted to sign up their children for this therapeutic option.  I was supported by the Casey Family Foundation to spend three days providing initial intensive training in Reflective Network Therapy to fourteen potential RNT therapists and teachers at Seattle’s Wellspring Family Services. On the third day, I demonstrated the method for the Wellspring staff, working with children already in their program for services.

I invested my energies with Wellspring Family Services partly because of their desire to learn about RNT, but also because of the agency’s particular ability to serve substantial numbers of disturbed preschool children. Wellspring serves about 90 homeless traumatized preschoolers and infants each year as well as middle and upper class preschoolers with anxiety disorders, and children of all economic classes in the community, including some children who suffer from autism.

It was my job on the third day of training to demonstrate the method with traumatized children already known to their preschool teachers. I did so right in the agency’s shelter preschool classroom serving recently homeless families in transitional housing.

Working with the Seattle children in their old and new classrooms moved me greatly. I saw my best professional legacy –this method– once more at work, flexibly adapted for treating children in their shelter classrooms, in a new city and state, and with eager therapists and teachers learning from me how to replicate the method. We videotaped the work, providing more living proof that the Reflective Network Therapy method is especially valuable for young children who have been made numb or frantic by life’s hardships. Working with the children with whom I initiated our Seattle project were excellent teachers from the children’s own community. The teachers quickly learned to brief me about what each child had done that day. “Briefings” and “debriefings” are important techniques, which promote mentalizing and exercise reflective network effects in any RNT classroom. The children participated, playfully telling me their personal stories and showing their emotions without much prompting.

Videotapes of treatment sessions conducted at the end of this intensive long weekend training in Seattle are available for study by qualified professionals. But ingrained in my memory, without the need for taping, is Kevin (not his real name) a homeless boy I worked with whose father had been shot dead. At first, terrified of working with a stranger, Kevin hid under a sink while another traumatized but feisty child tried to climb and claw his way out the classroom door. But within only a few minutes, Kevin played with me at a doll house where he had a man doll shouting: “Let me in. I’m back. I’m home. Let me in the door.” The “man who couldn’t come back” was his focus, appropriate to a father-bereaved boy. He persisted in having the man piteously struggling to get in the home, to take his place in the family car, to get up the elevator from the garage, and into the child’s house. Within fifteen minutes the usually agitated, seemingly thoughtless and attentionally distracted little boy showed increasing calm and thoughtful focus. His sentences grew longer, his expressed vocabulary more advanced. He began speaking in paragraphs rather than short phrases. He declared what was on his mind: a missing man whom he desperately wanted to come home.

Teachers who witnessed this process later told me that their jaws dropped as they saw the immediacy of the usually distraught and anxious child’s progress. They easily understood the cognitive advantages of the method which were so manifest in Kevin’s spoken thoughts. After Kevin’s short therapy session, we had a debriefing.  Kevin and I reflected together to his teachers and the other children in the class: “Kevin is thinking a lot about a man who isn’t home but wants to get home. Kevin feels it is very important for us to know about this man. The man somehow isn’t able to get back into the home. It makes Kevin feel a lot better to tell us these thoughts. Kevin talks with bigger words and longer sentences now that he is telling us. He has lots of ideas about why the man can’t get back to his family.”

In 2010 the Seattle agency moved into a wonderful, much larger new building with multiple classrooms, made possible by support from the Seattle Downtown Rotary. Bill and Melinda Gates grant, Marritz Family fund and Lisa Minnet, and many other major donors. The expansion and new training funds enabled them to plan to later add more classes delivering Reflective Network Therapy services. The possibility of creating a model program for all economic classes of children and those suffering from varied problems gripped me. In addition the project had inherent potential for high quality video-conferencing collaboration among several agencies. These include The Children’s Psychological Health Center (for which I am the Medical Director), the Ann Martin Center, Cornerstone Argentina, the Cambridge Cornerstone project.  

We hope that text and videos of my own experience and that of other RNT therapy teams will stimulate new studies for further independent verification of our findings. To that end, we offer the support of a replication manual (see chapter 3) and a video library of in-classroom treatments. Published papers and records of scientific presentations about Reflective Network Therapy also support training in the method. We are now engaged in an effort to have transcriptions made of videotaped treatment sessions (created at various service sites) augmented with clinicians’ and teachers’ notes. Transcribed and thus readily indexed and searchable video archives add a deeper level of objective data for study by independent researchers. (See Appendix A regarding required confidentiality agreements for viewing treatment videos which are made available for training, study and research at no charge).

What is Reflective Network Therapy?

 Reflective Network Therapy is a deliberately synergistic combination of in-classroom psychological treatment for emotionally and/or developmentally disordered young children. It is the best studied of the two forms of RNT. Its techniques include individualized in-classroom psychodynamic psychotherapy for each child, briefings, debriefings, and parent guidance – all of which take place within the context of an early childhood educational process.

The network is comprised of a classroom team. The team has usually up to eight preschooler child patients (with a maximum of twelve for one group), their parents, classroom teachers and a classroom therapist. This network is dynamically engaged with each child, one at a time in the classroom, every day the class meets. A psychodynamically trained therapist intensely focuses on and attunes to each child in turn, for about a quarter an hour at a time. The session can go longer if time permits. During that attunement, the therapist tactfully and regularly verbalizes his or her reflections about the child’s feelings, and behavior, especially the therapist’s thoughts about what the child is doing and thinking in the here and now of the classroom. Children’s resistances to education, refusal of affection, and inhibited or inappropriate enjoyment of socialization are spoken about and often interpreted on the spot.

Each child hears directly from the network of helping adults who, with leadership from the in-classroom therapist, verbalize what they think and understand about what is happening in his or her behavior and play. The child is encouraged to participate in these thoughtful conversations, structured around the natural events of his own real actions in the classroom. The network reflects about the child in predictable and specific ways, including joint adult-child briefings and debriefings before and after each therapy session and at other times throughout the classroom day. Intersubjective reflections organize and semantically encode each participant’s theory of the child's own mind and to some extent reflect on the minds of all the others in the classroom. The child’s classroom peers are a vibrant part of this network. Everything happens in the real life space of the classroom, and takes advantage of what comes up between and among the children both as educational and therapeutic opportunities for growth.

The Reflective Network Therapy method differs from other interpersonal psychotherapies and educational approaches in marked ways. In other methods, children are treated psychodynamically and individually but in no other method does the child’s treatment take place exclusively within the learning and play activities of their special or regular education classroom groups. No pull-out therapy is involved. The child is simply not removed from the five day a week classroom. The children served are two to seven years old, in classrooms with small populations. Six to twelve children work best, usually with two teachers and a therapist for a group of up to eight children. The adults include one head teacher and one teacher’s aide as well as one therapist. Parents are often in the classroom and are welcome for however long the parent’s presence promotes the child’s use of the process. One on one behavioral aides are not used. However, a child’s existing aide is welcome, and urged to come at the beginning of a child’s treatment. Behavioral aides are rarely required after a few days. Medication is hardly ever recommended and children often have medications previously prescribed eliminated entirely as they improve.

Each child is a pupil as well as a diagnosed patient, treated and educated with parental permission and with the cooperation of his public or private school or day care center. In RNT’s most intensive form, a child has a psychotherapy session every day of school. Less intensive forms have been effective, two or three times a week, always right in the classroom, giving 15-20 minute long individual psychotherapy sessions per child plus briefings and debriefings with the reflective network of adult helpers and peers. The psychotherapy sessions go on within the classroom in the midst of classroom educational activities of all kinds. Sessions are witnessed, shared and inwardly or outwardly reflected on by everyone in the classroom, right in the real life space of the classroom using the themes, symbolic expressions and behaviors which arise naturally in this setting.

Before a child has an RNT session in which he is the therapist’s focus (“index patient”) the teacher and child brief the therapist about what the child and family have been doing. The child is encouraged to be an active participant and his or her parents participate when they are present. They might speak about any new events in the child’s life and any current behaviors or immediate expressions that the child may have just made in the classroom. The events could be as simple as playing with a piece of string or avoiding another child’s friendliness. The adults might comment on interactions they have just observed between the child and other children in the class. After the 15-20 minutes of individual therapy, the child and therapist close the session by a debriefing, telling the teacher together about the contents of the session. If other children show interest, they can participate in all aspects of an index child's session, provided they allow that child to “be the boss of his own session,” which means leading the play and talk.

Parents are encouraged to be in the classroom, especially but not only during the early weeks of a child’s treatment. Parents regularly receive a 45 minute guidance session in private with the head or assistant teacher each week except that once a month their parent conference is with their child’s RNT therapist. This guidance conference includes the opportunity to give and get feedback about the child’s current behaviors, preoccupations and progress.

The teachers and therapists meet as a team for 90 minutes each week, often viewing a recent videotape of their work, and always sharing the teachers' many hours of classroom behavioral observation. The teachers are expected to greatly amplify the knowledge the therapist gains in the daily therapy sessions. Similarly, the constant daily briefings before in-classroom individual therapy sessions immediately augment the therapist’s access to important themes and behaviors based on the teachers’ observations. The content of the therapy sessions varies as greatly as the individual children vary. Content may include a full range of psychoanalytically useful material such as talk, play, fantasies, dreams, interpersonal dramas, art work, responses and interpretations (the therapist’s verbalized explanation of the meaning of a patient's remarks, dreams, memories, experiences, and behavior). The content may be quite simple and seem barren at first, among children who are autistic or otherwise delayed or primitive in their development at the time therapy starts.

For decades, the method now more precisely called Reflective Network Therapy (RNT) was known as The Cornerstone Therapeutic Preschool Method. More simply, it has been called “The Cornerstone Method.” Over the years, as we gathered scientific data, documented case studies and developed the method for manualized replication, I have analyzed the data and written about the method in an effort to isolate and explain unique features of the method which make it an effective response to multiple diagnoses. A few years ago I introduced the term “Reflective Network Therapy” which is shorthand for some central and critical aspects of the method’s structure and procedures. In addition to being more specific, the term has the merit of avoiding any possible confusion with endeavors (some of them Lutheran “Cornerstone” churches and schools) which also use the word “Cornerstone” to identify themselves.

After the method’s forty five years of evolution, and its increasing emphasis on how a network of others cares about, reflects on and responds to each child’s thoughts and emotions, with that child and with each other in the child’s presence, I found that the more descriptive name “Reflective Network Therapy” is more useful. We are transitioning over to the more precise term as of this writing while several recent endeavors still have associations with the older term. Throughout this book, therefore, you may notice some instances of the terms “The Cornerstone Therapeutic Preschool Method,” “Cornerstone Method” or “Cornerstone RNT” used interchangeably with Reflective Network Therapy. As a matter of historical record since 1965, and for ease of referencing previously published articles, studies and presentation, I have retained the term Cornerstone frequently in this book, particularly in presentations of some case studies. Nothing of the method is “lost in translation”. The name “Cornerstone” was originally used when the first therapeutic preschool service using this method opened in 1965 at The Center for Preventive Psychiatry in White Plains, New York. The founders chose the name to convey “building” the foundations of personality, as the stone at the corner of a foundation is the stone upon which all else depends and by which all else is measured and built.

The method’s hallmark network always includes a small social group. It uses in-classroom briefings and debriefings about each child, and the exclusive location of the child’s treatment sessions in the real life space of the classroom. Emphasis is given to how we reflect on one child at a time, with multiple participants thinking, feeling and speaking about the child’s inner and outer world. Within a flexible and child-tailored (individualized) framework, we have settled on criteria which appear crucial and which distinguish Reflective Network Therapy techniques from other methods. We have included a statistical meta-analysis (an overview, gathering data from comparable projects into one statistical analysis) providing a comprehensive view of the data. A primary goal of presenting this book and its “how-to-do-it” manual is to help future therapeutic teams replicate the method and help researchers scientifically study our method further. The method usually initiates treatment early enough in life to make a big difference. We start during preschool and kindergarten, before the children enter first grade, hopefully before a child has become irreversibly stuck in his or her development disorder or psychiatric illness. Appropriate settings for Reflective Network Therapy are any regular preschool, therapeutic preschool or public special education classroom, day care or Head Start which includes disturbed or developmentally disordered young children. The process can be continued for as long as it helps, but a typical useful time is one or two school years. Groups of parents and children treated by RNT who started in preschool have continued to find the method positive and productive in after-school groups well beyond pre-school, (Zelman, 1996).

Twenty years after the method’s invention in and following initial publications about “Cornerstone treatment” (Kliman, 1968, 1970, 1975), Stanley Greenspan’s excellent DIR /Floortime method of bringing resistant children into affectionate emotional contact came along (Greenspan, 1992). It was initially not considering rises of IQ as one of the outcomes. In fact, that is not surprising. Reflective Network Therapy’s effect on growth of intelligence (which my psychological colleagues measure by Stanford Binet and Wechsler Preschool Scale of Intelligence IQ tests) occurred in our first therapeutic nursery school without our initially noticing the regularity of this result. It happened right under our eyes, almost immediately after we founded the first school in White Plains, New York. In the first class, a mute three year old boy with autism began to speak. Others just seemed smarter, but we didn’t start measuring them with IQ tests for another year or two. The regularity of IQ growth (as formally measured by psychologists using Stanford Binet and Wechsler Preschool Scale of Intelligence tests) was clear enough by 1970 that I assigned psychology interns the task of giving IQ tests regularly to our child patients. In 1974 I began presenting preliminary reports on the IQs of the first 11 twice-tested children. They all showed significant IQ growth. In 1976 I designed, and in 1978 I implemented, a generously funded NIMH study at the same Center, including IQ testing and retesting of the majority of 104 consecutive foster children in the design and actual project. They showed no IQ growth when treated by two forms of non-RNT therapy. The children’s results in this study are now included as a comparison group in statistical consideration of outcomes with the twice tested children treated by Reflective Network Therapy.

Curiously, the data from testing by interns and my presentations themselves, as well as the IQ testing of most of the 104 foster children in the NIMH grant project on foster care were all largely forgotten by the White Plains staff during a traumatic time. This happened when I became disabled for several years by a severe physical illness and finally moved to another state. About the same time our educational director (Doris Gorin) developed a fatal carcinoma and our executive director, M. Harris Schaeffer, PhD had to retire. The agency’s staff was psychologically overburdened. But, my associates, Arthur Zelman, Shirley Samuels and David Abrams continued working on aspects of the project. Although my earlier data on 11 consecutive RNT children with IQ rises was not included, they reported on 42 more twice-tested children at the same Center (Zelman, 1996). Without consciously recognizing their forgetting of the preceding foundational data, they renewed and brilliantly extended my cognitive research with original and deep considerations of variables related to IQ rise, such as the number of parent sessions and clinical characteristics of the families.

Fortunately, the remarkable intellectual growth of RNT treated children seen in New York has continued to occur in services over the years and continues to be seen regularly among our child patients in comparable current projects. All but two of the 69 children in Cornerstone’s twice-tested follow up series have shown the IQ rise effect. The shortest testing follow ups are eight months and the longest has been nine years. Clinical follow-ups of our earlier work span as long as 40 years. In IQ follow up studies, 63 children who were treated at the same sites, often by the same staffs, and six children in an untreated public special education control group showed no IQ rise. Unlike the RNT treated children, some children in the comparison group had declines of IQ, as did Zelman’s medicated children.

When we originally created the first therapeutic preschool using this method as a way to help children who had experienced the death of a parent, the idea was to create an educational and therapeutic service to give emotional support and preventive guidance to bereaved families with very young children. We also began working with another kind of psychological orphan ─foster children. Soon many other children with differing neurotic and behavioral problems, stressful or traumatizing life experiences and family troubles came to us for treatment as well.

In the early years of applying the method, we were often impressed with how rapidly and measurably some of the children grew, both emotionally and intellectually. Responding to an early publication of mine (Kliman, 1970), Anna Freud made an editorial comment that the child described in my paper had an unusually adult way of expressing himself (Newman, personal communication 1970). Freud was so skeptical about the accuracy with which we quoted the child’s vocabulary that we were particularly pleased with an event which occurred shortly thereafter. The child’s grateful grandfather donated a video recorder so that we could begin highly objective documentation. In retrospect, I think Anna Freud was noticing in my account (Kliman, 1970) the unlikely but nonetheless actual growth of a particular child’s intelligence and development. After a few more years, similarly striking growth became regularly and objectively noted in series of 11 and then an additional 42 twice-tested children (Zelman, Samuels and Abrams, 1985; Zelman and Samuels, 1996, Hope, 1999; Kliman, 1979, 2006), as described in later chapters.

Ultimately, a deliberately prospective (forward-looking) controlled and comparison condition study was designed by Hope (1999), who did so in a California public school special education setting. She found very strong IQ rises among ten consecutive Cornerstone treated children, but not among six control and three comparison children. Similar effects now continue to be observed in San Francisco and Piedmont, California, Cornerstone Argentina in Buenos Aires and Seattle.

Development of the Method and First Hypotheses

 I began developing Reflective Network Therapy when I was young, eager, and devoted to bringing a scientific approach to the field of child psychiatry. That field was then intellectually dominated by the subspecialty called child psychoanalysis. Freshly emerging from a combined science and psychiatry program at the Albert Einstein School of Medicine Department of Child Psychiatry in New York, I was also enrolled as a student of child psychoanalysis at the New York Psychoanalytic Institute. Imbued with scientific measurement oriented approaches since medical school at Harvard, where I studied the blood chemistry of stress hormones (Kliman, 1955), I was frustrated by the fact that child psychoanalysis at the time seemed so aloof from and even hostile to ordinary scientific methods, particularly concerning objective measurements. My year as an Interdisciplinary Fellow in Science and Child Psychiatry had allowed me to do some rigorous experiments, using objective measures, on adult psychological defenses against reading and visual recognition (Kliman, 1965; Goldberg, Kliman & Reiser, 1966). Working with children, however, appealed to me most as a doctor, because the opportunity to prevent or intervene early in psychiatric disorders was so clear and my personal heroes were preventive medicine heroes: Lister, Koch and Pasteur. Developing preventive or early treatment methods which could be tested scientifically, however, was much harder than doing the treatment work.

 I acted on the advice of Morton Reiser, MD (then a senior scientist at The Albert Einstein College of Medicine) and set up my own scientific “shop” establishing The Center for Preventive Psychiatry and within it The Cornerstone Therapeutic Nursery School (Kliman, 1968, 1970, 1980). That preschool service, especially with the emotional and supervisory support of Marianne Kris, MD, rather unexpectedly led me to be able to test therapeutic actions with several scientific hypotheses, the proofs of which turned out to have social value. Four of these hypotheses (another term for testable predictions) provide part of the hopeful message of this book:

1.  In-classroom therapy and education combined with parent guidance (Reflective Network Therapy) can regularly raise objectively measured intelligence of testable treated children. Data which comes from studying this hypothesis shows that IQ rise with RNT is very substantial (Zelman, 1996; Hope, 1999; Kliman, 2006). It does not occur among controls and comparison children. The rise is greatest among those children who would ordinarily be the hardest to treat: those with multiple psychiatric disorders, such as combinations of pervasive developmental disorder with a major depressive or posttraumatic disorder (Zelman, 1996). Traumatized children, also ordinarily hard to treat, also respond very well. Number of child in-classroom sessions and number of parent guidance sessions are both correlated with the amount of IQ gain.

2.   In-classroom RNT therapy and education combined is clinically effective compared to control and comparison groups when measured by standardized global mental health scores such as The Children’s Global Assessment Score. A chapter will describe the testing of this prediction in a public school special education class, showing Reflective Network Therapy as clinically effective, an important dimension of improvement which is missing in reports of a widely used and costly educational method called Applied Behavioral Analysis.

3.   Among RNT treated foster children, one can objectively test for reduction of a symptom called “behavioral enactment” or “the repetition compulsion”. There is a tendency for children to actively repeat traumas, and among foster children that produces new disruptions. We demonstrated that RNT in-classroom therapy reduces the repetition compulsion as measured by a practical and highly measurable index: transfer rates among homes. After millions of dollars were invested in our teams’ studies of foster children, including National Institute of Mental Health and Daniel and Florence Guggenheim grants in which I was the principal investigator (Kliman, 1982, 1987, 2006; Kliman & Schaeffer, 1990), the best scientific measurement turned out to be that simple one – rate of transfers among foster homes.  We literally counted rates of this highly damaging process: unplanned transfers (bouncing) of populations of children among foster homes. This highly quantifiable index was considered to be largely a measure of children’s behavioral enactments, which often provoke expulsions from a foster home struggling beyond its abilities to care for a traumatized child. It was used to report how many times for whatever reasons – children’s behavior or foster parent response -- caused children to “bounce” around in the sense of an unplanned removal and transfer. According to our hypothesis, if RNT treatment, rather than no treatment (control status), reduces the numbers of bounces a foster child experiences in his social service system, that confirms the treatment is reducing the foster child’s compulsion to repeat trauma. RNT treatment was applied to a population of 30 consecutive foster care preschoolers, sharply reducing the transfer measure of repetition compulsion to zero for the study year and also raising IQs. The untreated rate was 25% per year. We also designed a simpler RNT derivative, a small interpersonal network method employing a Personal Life History Book developed by our team. That simpler method was manualized, replicable, could be used in groups of up to 16 children, and also reduced bouncing very powerfully (Kliman, 1982, 1987, 2006, Bondy 1990).

4.     After some good early results, we hypothesized that therapeutic optimism is justified for use of Reflective Network Therapy with preschoolers on the autism spectrum.  Among preschool children with Pervasive Developmental Disorders, including autism, we believe there is often much capacity for developmental plasticity of their young brains. In other words, we thought many children with these brain-based disorders can be markedly responsive to interpersonal therapies, showing global mental health gains as well as IQ rise. This interpersonally based hypothesis and our interpersonally based treatment data contrasts with hypotheses and data from interventions which are symptom-targeted behavioral modifications or chemical treatments. RNT’s combination of education and treatment has demonstrated that autistic children can benefit greatly and quantifiably from this interpersonal method, showing a combination of significant IQ rises (demonstrated by changes in WPPSI-R scores) and global mental health gains (demonstrated by improvements in CGAS scores) scores as well as improvements in Childhood Autism Rating Scales (CARS). Chapter 9 of this book discusses such surprising and socially important results in more detail.

Concepts and Processes

 We conceptualize Reflective Network Therapy as an interpersonal method, one which enhances brain functions without adding medicines in the form of psychotropic drugs. Especially hard to treat by ordinary medical methods are those preschool children who have stopped loving and learning. RNT’s combination of psychotherapy and education helps many such children. Almost every child treated with RNT has improved without using the medication they formerly received. Recently, we treated and prospectively studied a series of 15 testable and later re-tested California and Argentina Cornerstone RNT children who were not medicated. All but two of the 15 had Pervasive Developmental Disorder. All children but one achieved IQ rises.  All but one had Childhood Autism Rating Scale (CARS) improvements and/or global mental health gains. In Zelman’s 1996 archival study of 52 children treated in New York, none of the 42 Cornerstone RNT children were medicated. All had IQ gains and most had mental health improvements. Four of 10 control-comparison children in Zelman’s study were medicated and received educational psychotherapy on an individual basis. In contrast to Zelman’s in-classroom treated Cornerstone RNT patients, those medicated individually treated children had IQ declines averaging 4 points. 

 The “network” concept has at least three levels or components:

 1. Interpersonal: defined as relationships between the child, peers, parents and   professional people in the child’s treatment situation.

 2.  Intrapsychic: defined as the mental representations of other persons and the emotional life of the child who is being treated.

 3. Brain and nervous system: defined as the effects on the child of having his brain neurons, synapses, and brain connective pathway development enriched. These effects result from neuronal growth and plasticity responding to stimulation by education, treatment and peer and family activities conducted for the child’s benefit.

 In practice, Reflective Network Therapy employs tuning into a child, thinking about and expressing the caring and thoughtful mirroring of a child’s inner life. The therapeutic team of adult and peer helpers (therapist, teachers, parents/primary caregivers, and classmates) externally express their thinking or internal reflections ─ tactfully sharing their perceptions about the child. They talk and express feelings about what the child is thinking and doing, as well as reflections about his or her behaviors, relationships, events and interactions within the classroom. The child’s, therapist’s, teacher’s and peers’ internal reflections of the participants, when expressed and externalized in language, emotion and complex behavior, produce thoughtful and complicated “mirroring” for the child.

Tuning in, engagement and reflection by a therapist is done in a manner which stimulates emotional as well as unemotional data-processing exercise in the child. That processing includes exercise of the limbic system and associated mirror neurons, as well as the brain’s entire cognitive apparatus. The cognitive apparatus is a widely distributed highly communicative neural system. The two brain hemispheres have parts which actively communicate with each other, so information travels multiple pathways back and forth to many brain centers and to the lower brain structures and entire physiologically involved endocrine system and whole body.

The in-classroom use of Reflective Network Therapy also gives emotionally charged, rewarding, pleasurably and positively toned support for the child in the midst of social and cognitive experiences. These charged internal reflections of others about and for the child, externalized in verbalizations and emotional expressions, reflect back to the child how he is perceived as experiencing, thinking and feeling. It teaches him how others think and feel about his mental life while enlivening his interpersonal world. Many theories of his mind and those of others are available for the child to assimilate, adopt and use.

Moreover, everyone in the network shares reflections. The child becomes a member of the reflective team on his own behalf and for the sake of others, being both constructively selfish and constructively altruistic. The team’s reflections are produced on the spot during Reflective Network Therapy’s structured and unstructured educational activities, during individual therapy sessions, and most reliably during hundreds of briefings and debriefings about what has been going on with the child to which the child is not only privy but in which the child also participates. A complex network of therapeutic interactions follows throughout the classroom day. These interactions exercise the child’s emotional and underlying brain processes, leading to mental health improvements and cognitive development. Rather than focusing on whether the child’s behavior is socially acceptable or on task, this method quickly generates internal rewards, motivation for social and cognitive tasks and develops skills which are emotionally positively charged by interpersonal transactions. Learning becomes based largely on intensive practice in exercising self-perceptions through in-classroom and team-guided family relationships.

The term “network” also underscores the value of an interdisciplinary and multigenerational team. A child’s treatment situation in RNT is deliberately designed as a multigenerational network of children, parents, teachers and therapists –with mental and emotional mirroring and reflections among all of them– right in the children’s school or real life classroom space.

The fact that therapy is conducted within the real life space of the classroom provides immediate access to a network of meaningful connections, a wealth of associative material which contributes to the interpretations a therapist can usefully make, often material shared with a child on the spot. Of course the word network has many other meanings. It captures and indicates the author’s interest in the brain’s and the rest of the body’s neural networks, and major new neurological findings being made all over the world concerning the effects of interpersonal networks and mirrored connections on the actions and development of primate brains.

Many interconnected clusters, centers and pathways of neurons are involved in the child’s brain and in his learning processes. The neurons in a child’s brain are activated by external and internal events. Recent neurological studies indicate a child’s brain neurons can be switched on and off, even kindled into high activity and growth, through seeing, hearing, touching, tasting, smelling, moving, and through processing the many layered networks which connect data and the meaning of perceptions and memories. Scientists have literally observed very special functional brain changes that are caused in primates by interpersonal events and transactions.

During Functional Magnetic Resonance Imaging (f-MRI) studies, when one primate is watching another primate perform an action, the certain brain neurons called “mirror neurons”  light up or activate in the viewer as if performing the act it is witnessing (Di Pellegrino et al., 1992). That is, one animal watching another animal performing activates not only neurons in the perceptual areas of the brain, but also the neurons in the motor areas the viewer would use if it, rather than its companion, were performing the act. Similarly, if a chimpanzee watches a keeper reach for food, its own motor neurons light up as if it, rather than the keeper, were reaching for food, neuronally mirroring the keeper’s actions and behavior. The existence of mirror neurons is probably a brain basis for empathy. Their use leads to social rather than purely solitary (or dyadic, one on one) individual learning. Using the brain’s mirror neuron system, primates, including human beings, learn from each other by viewing actions of others (Iacoboni 2005). Emotional comprehension is enhanced by perceiving the facial expressions and body language of others.

Mirror neurons probably activate when people notice other people's facial and bodily movements which help convey feeling content. However, as reviewed later in this book, autistic children and many children who have been psychologically numbed by trauma seem to lack the capacity to understand and respond to others’ feelings. They are often highly deficient or numbed in comprehending and predicting, having a theory of or caring about what is on someone else’s mind.

A review of neuroscience literature indicates the readiness of that branch of science to study and theorize about the brain functions of autistic as well as traumatized children in ways that may at least begin to explain the cognitive growth (IQ rise) which occurs in applications of Reflective Network Therapy. Functional MRI studies clearly show that the brain’s internal networks of connections (especially the white matter and inter-hemispheric connections) are deficient in autistic individuals. Autistic patients are literally deficient in their connective neural systems for using brain centers, centers that otherwise are functioning well (Just, M. 2004, 2007). In addition, among autistic children, amygdala volume in their brains is reduced. It is probably no coincidence that the amygdala is crucial to enable the processing of emotion. The autistic children with the smallest amygdalas had most difficulty distinguishing emotional from neutral expressions and had the least fixation of eye regions. They were the most socially impaired in childhood, so that social deficits literally correlated with amygdala under-development. (Nacewicz et al. 2006). We think it likely that Reflective Network Therapy exercises the emotional processing system, necessarily including the amygdala, the limbic system generally, and mirror neurons.

An analogy can be drawn to cerebral palsy which may help parents understand some of the tasks involved in helping children with autism or severe posttraumatic disorders. The therapeutic task with cerebral palsy is to help develop the child’s brain to muscle connections. With CP, many such connections are atrophied from before birth, but some are still present. Exercise helps strengthen the cerebral palsy victims’ residual brain connections to residual motor muscle systems. Similarly, the task with autism or severely traumatically numbed children includes helping develop the child’s atrophied, but still present, residual brain networks among the brain’s social, emotional and cognitive systems. Therefore, I often talk to parents of autistic children about a “kind of cerebral palsy of the brain’s emotional and interpersonal systems”, and the need for treatment to provide constructive emotional exercise for such children. Neural imaging studies in PTSD, showing atrophied areas of the emotion processing centers, suggest a similar analogy about therapeutic action is appropriate for the effects of RNT in promoting brain growth in such traumatically numbed children. . . .

Synergy of Love, Education and Therapy

 In RNT classes, preschool education includes benevolent loving, attuning with, coaxing, introducing and cautiously intriguing the child into the world of words, verbalized thoughts and abstractions. In the Reflective Network Therapy classroom, through the psychotherapist’s thousands of moments of shared patter over the course of a child’s preschool year, changes are induced during a developmentally valuable process. Because the therapist is always hovering, observing, and translating a child’s actions and play into his or her own thoughts and skilled words (a constant process in RNT) the treatment encourages each child’s developmental shift from behavior into thought expressed as semantic abstractions. This is called “mentalizing” (Fonagy, 1995, Fonagy and Target, 1996, 1998; Fonagy et al., 2002). Evolutionarily, mentalizing is developmentally and adaptively light years more advanced and efficient than action, providing a child’s mind with speedier thought and data processing abilities. Rather than only behaving about a topic (such as missing an absent Mommy, expressed as angrily breaking loved toys in the classroom) a child can now think, verbalize and contain emotions about that painful topic. A dialogue can evolve with a therapist over several minutes and over many cumulative hours of regular 15-20 minute sessions of mentalizing during which the therapist describes the child’s anger, jealousy, greed, longings or other affectively charged processes almost immediately to the child, as close as possible to the moment an event happens, and especially before the child has repeatedly acted on or forgotten the emotions involved. Here is a brief and deliberately over-simple example of the effectiveness of mentalizing during a boy’s separation-induced tantrum:

Therapist: [to teacher and child together]  Jack is showing us that he misses his Mommy. He is angry and wants to hurt her.

Child: [angrily]  I hate these toys.

Therapist: [thoughtfully, slowly, caringly, deliberately using the third person]  Some children get angry at toys when their Mommy is not here. Jack, I noticed you were angry at the toys when Mommy left.

Child: [less angrily] Mommy went home.

Therapist: [conveying her sense of discovery]  Yes, that’s why you hit the lady doll and broke the toy sink.

Child: [mournfully, agreeably]  I want Mommy here.

Like a baby’s or toddler’s parents, the RNT therapist and teacher team are regularly attuning to the child’s facial expressions, body language, rhythm of movement, tone of voice and spontaneous play choices. They are constantly recruiting the child into a dialogue or multi-person conversation. . . .

Results – More about Unanticipated IQ Gains

 Psychologists will readily recognize the importance of significant gains among RNT treated children’s IQ scores, as these measures usually change very little over time. After decades of studying the method at work and its feasibility in various settings, I am confident in predicting that Full Scale IQ gains will continue to be produced and this measure will remain robust in other settings as RNT is more widely used. The easily and objectively measured increase in the standardized intelligence quotients of so many children is compelling in its statistical proof of one of the good effects of Reflective Network Therapy. Usually an individual’s IQ test varies by only a few points when it is repeated after a patient is treated by other methods (Siegel, 1987). Thus, our results showing IQ growth with RNT treatment are generally surprising outcomes But they are even more surprising sources for therapeutic optimism about children with pervasive developmental disorders on the autism spectrum. One study reported in this book (Hope, 1999) deals with 10 out of 10 such children (an uninterrupted series) all of whom benefited. Our overall twice-tested group of 69 children, including those ten could simply not be predicted to grow this much in their intelligence.

             When I began therapeutic preschool work, I did not expect the large IQ gains our child patients experienced. I was surprised that Zelman and Samuels (1996) found the children’s IQ gains are so orderly in correlation to the amount of RNT treatment. The Zelman and Samuels findings are statistically powerful evidence that the number of sessions matters. The quantity of RNT treatment over the months of a school year is a crucial factor in the children’s intellectual improvements. In a prospective study, Hope (1999) also exquisitely confirmed that the amount of treatment was crucial. Her IQ outcome data distinguished between children who received RNT twice a week versus four times a week. The more sessions children received using this method, the greater were their IQ gains. Researchers (Zelman, 1985, 1996; Hope, 1999; Zelman and Samuels, 1996) have compared our method’s intellectual outcomes with those of classical child psychoanalysis, parent guidance, individual educational therapy, regular special education in a public school, and other psychological treatments for very young child patients at the same treatment sites, as well as with children who have not been treated. These experimental studies (some described in more detail later in this book) confirm the advantages of Reflective Network Therapy over the other forms of preschoolers’ treatment.

Objective raters (defined as professionals who were not involved in any of the children’s treatment) found an average IQ increase of one to two standard deviations. That translates to an increase of 14 to 28 points on full-scale IQ scores. This rise occurred only among children treated by RNT. No IQ rise occurred at all among the children with similar disorders treated with other methods and none among the untreated control children. All of the IQ testable RNT treated children with Pervasive Developmental Disorder showed an IQ rise upon retesting, at this writing, only two of the entire group of 69 twice-tested RNT-treated children treated for any diagnosis has failed to show a full scale IQ rise upon retesting. Again, the amount of IQ rise positively correlates with the number of classroom sessions with RNT treatment and also with parent guidance sessions as procedurally described in the replication manual. Such orderly correlations cannot be reasonably considered due to chance. Only with autistic children does another method (Lovaas, 1987) reliably give similar IQ findings (Sallows, 2002, 2005) and in most of that method’s research, highly flawed incomparable measures (such as “Developmental Quotient” erroneously compared with IQ) were involved at baseline with follow-up . . .                             

Actual Treatment Descriptions of Children with SED and PDD

The children RNT helps (and their problems) fall roughly into two categories: those with serious emotional disorders (SED) and those with pervasive developmental disorders (PDD). Often there is overlap, because a child has both an emotional and a developmental disturbance. Surprisingly, we can help these two very different kinds of children in the same classrooms. We don’t have to segregate the children by diagnosis, and can easily tailor-make each treatment to fit each individual patient. . . . 

Among children with primarily Serious Emotional Disorders (SED) you will meet in this book are:

Charles, a physically very ill and initially very frightened child who rose to the challenge of having leukemia with the help of Reflective Network Therapy. With the help of in-classroom therapy, he took the lead in his family. Actively understanding his own impending death, he took charge of communications about his illness. His mental health improved, he achieved a rich mental life, and he behaved heroically.

Jay, an overanxious boy who came to us struggling with his own aggressive cruelty, from which he recovered very well. He also became able to cope with unexpected and severe new adversities in his life, including the deaths of his father and brother and has since become a successful artist.

 Among children with Pervasive Developmental Disorders (PDD) you will meet are:

Lonny, a child with Asperger’s syndrome. Lonny was assaultive, hated to have his clothes changed and had been expelled from several preschools because of violence. He has become friendly, empathic, and a leader in sports. A ten year follow up shows that he has a very successful life, with a sustained 23 point IQ rise.

Oscar, a traumatized witness to domestic violence, had become psychologically numb and avoidant of intimacy. He had oppositional and defiant behavior, and a pronounced receptive and expressive language disorder. He has become strong, healthy, smart and capable, with a 31 point IQ rise.

Daniel, a highly anxious, sound-sensitive, change aversive, separation avoidant boy had probably been traumatized by repeated orthopedic surgeries, and also had an autism spectrum disorder. He too has grown much healthier and brighter.

Monroe, a boy from a severely intellectually and economically impoverished environment, was greatly enriched emotionally as well as cognitively by Reflective Network Therapy. His IQ rose from mental retardation to normal.

Dorian entered Reflective Network Therapy with a full blown autistic disorder, at age almost three years. When referred she was considered retarded as well as autistic; she was initially untestable. We have followed her remarkable social and cognitive progress for most of four decades. Ultimately, at a three year follow up, she had an IQ of 80. Her Full Scale IQ was 149 upon retesting at age 12. Today, in her forties, clinical interviewing confirms her emotional health has continued to be rich and strong, and her cognitive growth and delightful sense of humor has been sustained and intricately adaptive throughout adult life.  She is no longer autistic at all, though retaining remarkable gifts of memory and a pattern of thinking in pictures and cartoons.