Introduction

Functional analytic psychotherapy (FAP; Kohlenberg & Tsai, 1991; Tsai, et al., 2009) is a contextual philosophy therapy that emerged in the late 1980s. It is grounded in radical behaviorism and the concepts described by Skinner (1953, 1957, 1974) concerning private events and the role of language in the therapeutic situation. FAP understands the therapeutic situation as the fundamental interaction for behavior change. It uses functional behavior analysis to ascertain the functions of the client's problems and to act directly on behavior. Behavior is progressively shaped using natural contingencies, assuming functional equivalence between the clinical environment and the client's usual environment. To carry out this work, the therapist analyzes the clinically relevant behaviors (CRBs) and makes use of the five therapeutic rules. Type 1 CRBs are the client's problems that occur during the session, the frequency of which should be decreased. Type 2 CRBs are the client's improvements that occur in session, and type 3 CRBs are the client's interpretations of their own behavior and what they believe causes it. The first therapeutic rule consists of observing the client's CRBs; the second in evoking CRB1; the third in naturally and affectively reinforcing CRB2; the fourth in observing the effects of this reinforcement on the client's behavior; and the last in generating in the client a repertoire of describing the functional relationships between the control variables and their behaviors (Ferro-García, et al., 2015).

Historically, the flexibility in the application of FAP has allowed its combination with other contextual and cognitive-behavioral therapies, such as acceptance and commitment therapy (ACT; Hayes, et al., 1999), behavioral activation therapy (BA; Martell, et al., 2001), dialectical behavioral therapy (DBT; Linehan, 1993), or parent-child interaction therapy (PCIT; Eyberg, 1999; Eyberg & Funderburk, 2011), and for a variety of issues such as depression (López-Bermúdez, et al.., 2010), psychosis (Marín-Vila, et al., 2022), mild and severe personality problems (De Sousa, 2003; Geremias, 2014), in women victims of gender violence (Vaca-Ferrer, et al., 2020) or individuals with intellectual disability (Ascanio-Velasco, et al., 2020), as well as in different cultures and populations, although mostly in the adult population.

Official organizations, such as the Society of Clinical Child and Adolescent Psychology, Division 53 of the American Psychological Association (APA, 2012), recommend mostly cognitive-behavioral treatments based on empirical evidence and, sometimes, their combination with a medical-pharmacological treatment to work with problems in childhood and adolescence. According to Orgilés (2010), compared to psychological treatments, pharmacological treatments have shown lower efficacy for child and adolescent disorders, and therefore the former are the treatment of choice. However, their combined use for certain problems, such as attention deficit hyperactivity disorder (ADHD) in childhood or emotional problems in adolescence, is not in decline, the origin, approach, and understanding of human suffering being focused more on a neurobiological and formal perspective, rather than an existential, contextual, functional one. The study of child and adolescent therapies that deal with functional over topographical analysis is growing exponentially as with PCIT, ACT, and DBT. PCIT is a therapy indicated for children between the ages of two and seven who present behavioral problems, oppositional defiant disorder (ODD) or ADHD, or who suffer or are at risk of suffering maltreatment, although it is also effective for other problems such as depression and anxiety (Ferro-García, et al., 2021). It works on what happens in session through play and emphasizes the importance of establishing a good therapeutic relationship and the use of functional analysis of the child's behavior. The application of ACT in childhood and adolescence is well known (Halliburton & Cooper, 2015; Hayes & Greco, 2008). The child therapist can understand the function of the child's and the parent's repertoire, adapt prototypical ACT strategies, and use play to weaken the control exerted by language, as well as preventing or remedying derived problems. DBT is mostly aimed at working with adolescents with severe emotional and behavioral disorders. It focuses primarily on the concept of unconditional acceptance and validation of the client, and on the teaching of mindfulness skills, distress tolerance, emotional regulation, and interpersonal skills. Therapists must pay attention to how their behavior reinforces or punishes the adolescent's behaviors, reinforcing more adaptive expressions of distress in view of the adolescent’s history, and not reinforcing (with attention or warmth) any behavior the adolescent exhibits that is considered problematic.

Although cognitive-behavioral interventions are efficacious and effective in working with the most common problems in childhood and adolescence, they tend to focus on the intervention for specific diagnoses, and they ignore or relegate to the background the use of functional analysis to analyze behaviors and promote change in session, as well as the role and importance of the therapeutic relationship. That is why in this paper we reflect on the recommendation to intervene with FAP-a contextual, flexible and functional psychotherapy-in these populations, and we perform a systematic review of empirical studies from its emergence to the present, expanding on the contributions of other previous literature reviews (Caetano, 2019; Mangabeira, et al., 2012; Moreira & Oshiro, 2017). These reviews conclude with the recommendation of applying FAP to work on behavioral and emotional problems with children and adolescents, as well as the need for more precise empirical studies that allow a better understanding of the process and effectiveness of FAP in these populations.

Method

This paper presents a systematic review of the scientific literature on the use of FAP with children and adolescents. For this purpose, the guidelines of the PRISMA method (Page, et al., 2021) were followed.

Information Sources and Search Strategy

We reviewed papers published in Portuguese, Spanish, English, and Italian, in the Google Scholar and Researchgate databases, in the web repository of the therapy itself and in manuals, both classic (Kohlenberg & Tsai, 1991; Kanter et al., 2010) and recent (Marín-Vila, et al., 2022). Search keywords in Spanish "FAP infancia", "FAP adolescencia", "FAP niño", "FAP adolescente", and their equivalent translations in the indicated languages were used. The selection criterion was that studies had to present descriptive or experimental data on the application of FAP with children and adolescents, regardless of the problem addressed and the methodology used, and with no date restriction.

Selection and Data Collection Procedure

The search was conducted between February and April 2023. Thirty-two papers were first identified on the basis of keywords, titles, and abstracts. To screen them, the titles and, subsequently, the texts were read. One of them was discarded after reading the title, due to it not meeting the search and inclusion criteria and being only a recommended paper. A table was drawn up to assess eligibility: authors, year, publication title, country of publication, participants and age, formal diagnosis, results, and design. FAP was used to describe the intervention carried out, alone or in combination with other therapies or procedures. After classification, 14 papers were discarded: 1 because it did not deal with a child or adolescent population, 8 because they were theoretical papers, and 5 due to problems of access. Finally, 17 studies with descriptive and experimental data on the application of FAP with children and adolescents were selected. Figure 1 shows the corresponding PRISMA flow diagram.

Figure 1
PRISMA Diagram

Results

The main characteristics of the empirical studies included in the review are described below and shown in Table 1.

The study by Cattivelli, et al. (2014) was conducted with three children between 11 and 12 years old. It tests the effectiveness of combining FAP and ACT to promote social skills outside the clinical context, in an attempt to overcome the weaknesses of more traditional procedures, more specifically, generalizing to more natural contexts. In addition to shaping children's behavior in session, the authors used reports compiled by parents on the participants' progress in daily life. The results indicate an improvement in all participants in prosocial behaviors and exposure to emotional distress. Only rarely did they express avoidant behaviors in the form of aggression, opposition, or flight, so the authors indicate that the results should be interpreted with caution.

The study by Cattivelli, et al. (2012) applies FAP to work on social and school skills with five children between 11 and 15 years of age. Although the use of ACT is not indicated, the authors acknowledge the shaping of behavioral repertoires based on values, fostering flexibility, and promoting strategies of exposure to distress as well as functional language, such as touch and more adaptive verbal descriptions, in relation to their own internal experiences. The results show a significant increase in prosocial behaviors in session and in the participants' natural context. However, with several of them the increase was not so marked, as developmental aspects were not taken into consideration, indicating that the results should be interpreted with caution.

Conte's (2001) study was carried out with a 10-year-old boy with enuresis. The aim was to shape with FAP in session the kind of behavior of autonomy, and this was initiated by reinforcing in a natural way the demands for help and assertive requests to the therapist. The results indicate great improvements in the child's autonomy and in his relationship with his parents.

The study by Conte and Brandão (1999) was conducted with a 9-year-old child with interpersonal difficulties characterized by disruptive, demanding, and disobedient attitudes, as well as problems in the organization of daily routines. The authors of the study functionally analyze the child's behavior with the use of child behavior analysis and therapy (CBAT) to improve the organization of routines and FAP as the main therapeutic model to improve social interactions. One of the main distinctions between FAP and CBAT is in the therapeutic relationship. While in CBAT the therapeutic relationship is used to involve the child in the therapeutic process and motivate him/her to attend therapy, in FAP it is the therapeutic relationship itself that is the means for promoting change in the child's behavior. The aforementioned authors point out that the child achieved very positive results in interpersonal demands, that the use of the five rules was key to the therapeutic success, and they highlight the importance of adapting FAP strategies to the child's developmental level.

The work of Díaz de Neira, et al. (2021) is a group study with one hundred hospitalized adolescents, who present a variety of behavioral and emotional problems: aggressiveness, suicide attempts and ideation, depressive mood, altered eating behavior, behavioral problems in general, and psychotic problems. Through the combined use of FAP and ACT, promising results were obtained in terms of the proposed objectives and CRB2s: preventing hospitalization from being a re-traumatizing experience, promoting self-control, self-awareness, and value-oriented behavior, avoiding the construction of an identity as psychiatric patients, and maintaining eye contact. Since this is a descriptive and qualitative study, the authors indicate that the results should be interpreted with caution.

In the study by Gaynor and Lawrence (2002) on ten adolescents between 13 and 18 years of age with a formal diagnosis of phobia and depression, the programs CWD-A (Coping with Depression - Adolescents) and FAP, described with the acronym LIVE (Learning through In Vivo Experience), were applied. CWD-A aims to shape social skills with psychoeducation and role-playing exercises. Only eight of the participants completed the intervention, and the improvements in their emotional well-being were maintained at the three-month follow-up.

The work of Gosch and Vandenberghe (2004) was carried out with a 9-year-old boy with behavioral problems and ADHD. FAP and applied behavior analysis strategies were used to train parents and teacher in contingency management. The results indicate a significant improvement in behavioral problems: throwing things, punching, kicking, biting, throwing stones and objects at family members, breaking glass, challenges in class, insulting classmates, through contingency management, as well as in CRB1 with FAP with the therapist, shaping the child’s repertoire of collaboration and social interaction with natural reinforcement (during conversations and games) and with arbitrary reinforcement (with stickers after following a rule of the game).

In the study by Marín-Vila, et al. (2022), FAP was used with a 16-year-old boy diagnosed with psychosis. The results were promising after reaching the proposed CRB2 and CRB3 also appearing: identifying, understanding, and distancing himself from psychotic symptomatology, framing it within his history in relation to different traumatic events as coping responses to intense distress, distancing from delirium, and understanding it as a coping response to intense distress, attributing his own meaning to it. The boy was able to strengthen his self-structure, with a greater number of "I x" responses under private control and greater spontaneity during conversation. After one year of treatment, the work was terminated and the pharmacological treatment was eliminated.

In the work of Martín-Murcia, et al. (2011), FAP and ACT were applied with a 17-year-old girl diagnosed with an eating disorder and an obsessive personality pattern, which improved with prosocial behaviors, the congruence of action committed to values, the disappearance of problems associated with the eating disorder, the normalization of private events, and behavior that was more flexible and open to experience.

The study by Moreira (2018) was conducted on a 6-year-old child, who was a victim of sexual abuse, using CBAT and FAP. The results support the benefit of working with FAP to establish a good relationship with the child and achieve progress in prosocial behaviors as well as more natural and functional conversations. When FAP was introduced, there was a reduction in the percentage of CRB1: the tendency to isolate or withdraw, showing distrust, and establishing superficial conversations with the therapist; while there was an increase in CRB2: seeking social contact, showing an attitude of trust, and producing a greater number of self-revelations during the conversation. In addition, the child improved in the scores of withdrawal, social insecurity, activities alone and with others, pursuit of other interests, accusations, and resistance.

Moreira and Oshiro (2021) worked with an 11-year-old child victim of sexual abuse using applied behavior analysis and FAP. The results are similar to their previous work: there was an increase in the percentage of CRB2 produced as well as a decrease in CRB1 produced during the FAP phases, and the opposite when FAP was eliminated.

Newring and Wheeler (2012) applied FAP in a group of juveniles convicted or accused of sexual offenses. The authors conclude the appropriateness of using FAP to work directly on the function of committing the sexual offense, since improvements were also achieved in the proposed CRB2s: accepting responsibility for the offending behavior, identifying and intervening on cognitive distortions in the self and others, and encouraging responsibility and solidarity as well as a critical attitude about the impact of their actions on others.

Oshiro's (2011) work with a 17-year-old boy diagnosed with paranoid schizophrenia, concludes with the recommendation to use FAP in populations with this problem as a great advance was achieved in the proposed CRB2s, especially in the measures of empathy and facilitation of therapy, as well as coherent language and use of self-revelations in conversation, and the expansion of the behavioral repertoire.

Rodríguez-Bocanegra and Ferro-García (2023) present a study in which they applied PCIT, FAP, and ACT to a 7-year-old child with behavioral problems (defiance, negativism, interruptions, lies, demands, tantrums, etc.) and his parents. In the case of the child, great improvements were obtained in CRB2s: respecting turns during play and conversation, being patient, obedient, collaborative, and respectful with the therapist and with his parents. With the parents, improvements in CRB2 were also obtained, including presenting a flexible attitude towards the child's behavior, greater openness to the experience of and involvement with the therapy, and directing their behavior to valuable areas in their relationship with their child.

In the work of Velandia (2012), FAP was used with three children aged 8, 10, and 11 years for problems of social skills and behavior. Although after the intervention these were stabilized in the three children, and at the end of the processes the improvements presented had a higher frequency than the problematic behaviors, the results did not show significant changes.

In the work of Xavier (2017), FAP intervention was used with three children aged 9, 10, and 11 years with a diagnosis of ODD, with the objective of reinforcing CRB2 incompatible with problematic behavior during the therapeutic session. Behavioral problems decreased considerably, although in different ways for each participant, so the author considers the results to be inconsistent.

Finally, in the study by Xavier, et al. (2012), FAP was used with two children aged 9 and 12 years who presented school problems and challenging behavior. The results showed more notable improvements with one of them at school level, in behaviors of collaboration, requests for help, initiative, following rules, and commitment to the therapist, therefore the author describes the results of the study as inconsistent.

Table 1

Empirical Studies Included in the Review

Discussion and Conclusions

Behavioral and emotional problems in childhood are one of the most frequent reasons for consultation (Aláez, et al., 2000). They usually occur in various contexts and have a great emotional impact on children and their families, as well as on their relationships. Similarly, many adolescents come for consultation feeling empty, connected with everyone and also with no one (Pérez-Álvarez, 2023), tangled up in their thoughts, and sometimes not knowing how they feel. Most of the studies described show adequate results in the application of FAP with these populations and with these problems, and they are rigorous with the use of functional analysis to adequately guide the intervention. However, the literature that has been published on this subject is still scarce, methodologically heterogeneous, and sometimes presents inconsistent results.

A possible explanation for this phenomenon is the prevailing trend to choose and prioritize evidence-based practices of the Society of Clinical Child and Adolescent Psychology (SCCAP, 2017) to work on psychological problems. For a therapy to be considered valid, the SCCAP proposes methodological criteria and levels of evidence. FAP, as indicated by Ferro-García, et al. (2023), due to its functional and idiographic character, corresponds mainly to a single-case investigation of psychological problems that in its functional description escapes the limits of nomothetic diagnostic systems and does not adopt the criteria accepted by the scientific community. In fact, FAP is not recognized as an officially empirically supported treatment for any specific diagnostic disorder, including in childhood and adolescence.

To quote Pérez-Álvarez (2013): "the debate is not whether psychological treatments work or not, but how and why they are effective". Based on the contributions and promising results of this work, FAP could be a recommended therapy for working with children and adolescents. The very name FAP provides an answer as to how it is considered effective, as described in Valero-Aguayo and Ferro-García (2015, 2018). Firstly, it is a psychotherapy, since it makes use of dialogue to create a relationship of intimacy, produce changes in the therapeutic session, and create healthier interactions; it is in line with the usual practice of other techniques of psychotherapy and aims to achieve modifications in the lives of children and their families outside of the consultation that are preventing them from having valuable interactions. Secondly, it is analytical towards each problem and each objective with regard to what is happening inside and outside the session. And thirdly, it is functional in that it focuses on the functions of the behaviors, not so much on their forms. Furthermore, as to why it is effective, it could be said that the natural shaping of children's behavior in session allows a functional generalization to everyday life of the behaviors of the children and their families; although they may be formally different, they are functionally equivalent to the behaviors that occur in session.

Since behavioral and emotional problems are the most frequent in the child population, and mild and severe problems of the self are also very frequent in the young population, FAP-with its theory on development of the self, which hypothesizes how pathologies of the self can be developed, maintained, and intervened on-could be the most suitable psychotherapy to promote an adaptive self-development and prevent psychological problems. Considering how parents/guardians affect interpersonal interactions and other environmental contingencies from infancy, it uses the therapeutic relationship and its context to bring about change in the child's behavior. The appropriate development of the self in childhood is realized through social and verbal training carried out by the child's caregivers (Ascanio-Velasco, et al., 2020; Ferro-García & Valero-Aguayo, 2017) and aims to bring the emotions or needs under the control of one's own private stimulation without the need to turn to external stimuli in order for them to be felt and recognized. A maladaptive self-development can be established when these responses are under public control and can cause an "insecure self" if one does not know what one feels, wants, or thinks, or an "unstable self" when one's opinions are under the control of others and one is very sensitive to criticism, which can cause problems of empathy, dependence on others, feeling empty, not knowing who one is, and avoiding intimate relationships because they are aversive and unpredictable. Childhood and adolescence are therefore crucial stages to foster the development of an adaptive self and prevent psychological problems.

Another possible explanation would be the difficulty of applying this therapy with children and adolescents. Some of the challenges that the FAP therapist must assume with these populations are when:

1. 1. The child does not give detailed or accurate descriptions of his or her own private experience, environmental events, or the effects on his or her behavior. The therapist should hypothesize whether this is the child's avoidance of disclosing parental educational styles, avoiding exposure to the discomfort of talking about his or her own experiences, avoiding loss of privileges, or presenting positively to the therapist. When children are defiant, withdrawn, or suspicious in session, they may be exhibiting patterns or behaviors of the parents that tend to serve them in interactions with their parents or peers (Newring et al., 2021). Another hypothesis to consider is that the children may not really know how to identify or react to such experiences and/or how to express them, or whether or not the target behaviors are present in their repertoire.
2. 2. It is complex to define who the identified client is. It may be that the child sees his or her parents/guardians as responsible for the problem, does not believe there is a problem, or identifies other problems (Newring et al., 2021). The therapist should guide the child in the identification of the problem from a contextual perspective, framing it in the interactions that are established and not so much in the individuals who suffer it, being attentive to reinforce more flexible attitudes and, when the child attempts to contextualize the behavior of his or her parents, encouraging attention to his or her own personal histories. Although there are parents who wish to improve, there are also parents/guardians that see the child as the only one responsible for the problem, and in these cases the parenting style tends to be authoritarian (with coercive strategies and aversive consequences as the main contingency) or very permissive, paying little attention to the child. At this point, the therapist him- or herself must adapt, and he or she must adapt the therapy to the age of the child. In the case of adolescents, it should be gauged whether the therapeutic task is limited to working with the adolescent in order for him or her to tolerate the conditions associated with the parent/guardian, and to aim to clarify and live in accordance with goals and values that are meaningful to him or her (Newring, et al., 2021). In the case of children, whenever advisable, the therapist should strive to involve the parents/guardians.
3. 3. It is difficult to guide the assessment and conceptualization of the case. Adolescents tend to have more CRB1 in the early phase and less CRB2, so particular types of behavior that are already present in their repertoire should be specified. Another consideration when clarifying CRBs is prototypical value conflicts during adolescence, and multiple treatment objectives (Newring et al., 2021). It may be useful to follow the hierarchy developed by Linehan (1993) and refined by Schmidt, et al. (2002): self-injurious and suicidal behaviors, aggressive behaviors, behaviors other than the above that interfere with treatment, and behaviors that interfere with quality of life. In addition, there will be times when the case of the child and also of his or her guardians must be conceptualized. To guide this work, the conceptualization presented in Ferro-García, et al. (2009), the Functional Idiographic Assessment Template (FIAT) by Callaghan (2006), or the awareness, courage & love (ACL) model proposed by Maitland, et al. (2017) can be used.
4. 4. The therapist must take into account the conditions and events specific to this developmental group during therapy. That is, the continuous change in behavior at these ages, as well as external conditions related to variations in the social, family, school, and cultural contexts, as occurs with music, series, media, or social networks, where the environment can act as a belief system, or a way of perceiving what is valid; and internal conditions, such as hormonal, physical, affective, and existential changes. These factors can affect therapy in several ways, especially with adolescents: defining CRB and differentiating it from "normal" behavior can be difficult; what is evocative of CRB can vary, as can the reinforcing and punishing properties of stimuli; as the adolescent changes his or her mind about who he or she is and what he or she wants, he or she may have a greater or lesser ability or motivation to express and communicate these changes; and generalization is difficult, as daily life is also in constant transformation (Newring et al., 2021).
5. 5. The therapist must be sensitive to his/her role, to the complexity of the therapeutic relationship and to professional secrecy. We must not forget that the therapist embodies the role of "another adult", so attempting to break this rule requires hard work. Being in a context with an adult who does not try to impose change through lecturing, giving orders, or criticizing can be a novel, natural, and sufficient experience to break this rule. Childhood and adolescence can be seen as an opportunity to learn and improve more adaptive and validating modes of psychological functioning. In the case of children presenting behavioral and/or emotional problems, it is crucial to emphasize a good relationship with both the child and the parents, in order to improve adherence to treatment, prevent dropouts, and promote change and psychotherapeutic success. With adolescents, as indicated in Fernández-González, et al. (2016), a strong therapeutic alliance predicts better outcomes and greater adherence to the process. In addition, the therapist's values and skills are very important when creating an intimate relationship. The therapist must be knowledgeable about him/herself and his/her limitations, be warm, dynamic, authentic, genuine, collaborative, courageous, and respectful (Valero-Aguayo & Ferro-García, 2018). He or she must also be skilled in adapting playful resources to elicit CRBs, be knowledgeable and sensitive towards developmental aspects, be free of prejudice, be flexible to the subculture of language, values, and belief system typical of these ages, and make the clinical context a protected space for the minor. When dealing with an adolescent, the therapist must be especially sensitive and careful with the confidentiality of the data and may reach a dilemma where ethical, legal, and good practices clash. We mean when the life of the adolescent minor is in danger and informing the guardians of this would be, for the adolescent, synonymous with violating their trust. In this scenario, the therapist must establish a commitment to respect confidentiality while at the same time attempting to get the minor to inform his or her parents. Moreover, as De Moura (2022) points out, it should not be forgotten that the FAP approach applies behavior analysis procedures within the confines of the treatment context, so the therapist-client contact is limited to the moment of therapy. These conditions also apply to the child and adolescent psychotherapy context, because we scarcely have access to the child outside the clinical context. However, these limitations can also be an opportunity to create a more intense relationship that promotes significant changes based on the intimacy in therapy. Although the application of FAP in children and adolescents does not differ significantly from its application in adults, it is important to adapt the language, materials, and goals to their behavior, development, and age (Cattivelli, et al., 2012), in addition to considering how parents can (or cannot) contribute to solving the problem for their children. The therapist can use a more arbitrary reinforcement with younger children and in an initial phase, in order to enhance the therapeutic relationship (with stickers, toys, candies, etc.), to move on to naturally shape such changes, as recommended by Kohlenberg and Tsai (1991). With these populations it can be done through play in session and not only in the verbal situation. For younger children, games with rules can be used to elicit and shape CRBs, such as rule-following, turn-taking, or the various emotional reactions that may arise; as well as games without rules or projective tests and materials: drawings, time-series pictures, free-association, or pictorial games. For adolescents, moral choice and free association games, projective tests, music, and exercises such as writing with the non-dominant hand (Valero-Aguayo & Ferro-García, 2015) or questions can be used depending on the phase of the intervention (see Holman, et al., 2017).

In view of the above, this paper recommends the application of FAP to work on behavioral and emotional problems with children and adolescents. Although studies on its application are still scarce, the results are promising and the considerations provided are congruent, as also shown by the aforementioned review studies. It is necessary to continue assessing the suitability of FAP as the treatment of choice, or in combination with other therapies for problems of emotional distress in these populations, and their families.

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Notes

Author notes

Correspondence: mariarbpsico@gmail.com

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