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Child CBT

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Kathryn Wagner

on 3 April 2013

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Transcript of Child CBT

CBT for anxiety draws heavily on the behavioral approach (e.g. Exposure, relaxation, role playing) — usually involves skills training (awareness of bodily reactions to feelings and physical symptoms specific to anxiety) and skills practice (when child practices the actual skills learned in anxiety provoking situations) cBT or CBT? Cognitive Behavior Therapy with Children:
Developmental & Contextual Considerations Child CBT Components Early Models of CBT CBT Assessment CBT Assessment Piaget's Stages Preoperational Concrete Operational Formal Operational Studies challenging Piaget's beliefs Quakley study (2011): children able to engage in abstract thinking much earlier than Piaget believed

Wellman study (1996): pre-school children understand meaning behind thought bubbles

Flavell (2011): children ages 5-6 years are able to articulate cognitions, understand concept of talking to oneself. Children ages 11-13 benefit most from CBT ADHD *Abnormally high levels of inattention, impulsivity & hyperactivity; suffer impairment in daily life functioning
*CBT? Not so good; doesn't help primary symptoms of ADHD
*Interventions needed at the point of performance
*Behavioral aspects of CBT can be helpful
*EST: Kids Together Program (Hansen, Meissler & Ovens, 2000): 5-16 yrs; social-skills training
*Depressive disorder is much less common in children than adolescents; affects 3-5% of children (O'Connor & Creswell, 2005).

*Physical symptoms of childhood depression tend to appear as somatic complaints, irritability, & restlessness

*Cognitive symptoms of depression most commonly appear when child is in concrete operational stage (age range 7-11) & begins to develop self-consciousness and evaluate self/compare with others (Harrington, 2005).

*Depressed children show similar cognitive deficits & distortions that are similar to those found in depressed adults Rationale for CBT

*CBT is"possibly efficacious" for depressed children; "probably efficacious" for depressed adolescents (Crawley, 2005; Bolton, 2005).

*Young children: CBT works best with therapist utilizes a psychoeducational approach involving family

*Across all ages, those most likely to benefit from CBT will share certain characteristics (Crawley, 2005):
1) depressive disorder is the prominent focus/no cormorbidity
2) young person will acknowledge problem & desire to correct it
3) family must also see that problem exists
4) children must be willing to do homework DEPRESSION Examples of CBT Tx for Depression

*Core cognitive techniques include self-monitoring (e.g., charting thoughts and recording relationship between thoughts and events); cognitive restructuring; and challenging of underlying assumptions (e.g., in order to be happy child must be liked by everyone)
*Combination of CBT & medication is most effective (Harrington, 2005; Kendall, 1985)
*ACTION, manual-based treatment *excessive levels of fighting or bullying; cruelty to animals or other people; severe destructiveness to property; etc.

*relatively stable over time & predicts antisocial behavior in adult life & high rates for alcoholism, suicide, social dysfunctions & relationship difficulties (Bailey, 2005).

*assessment of CD in children must include parenting competence to screen for child abuse & treatable mental illness in parent, etc.

*children with CD tend to generate fewer verbal assertive solutions & more action-oriented/aggressive strategies to interpersonal problems Rationale for CBT with CD Conduct Disorder *Parent management training to correct escalating cycle of coercive interactions between parent and children *Children with CD think their aggressive actions will reduce negative consequences & increase their self-esteem -- this way of thinking lends it self to CBT techniques *Cognitive deficits addressed through social skills training,
use of operant techniques, modeling strategies, coaching, self-reinforcement,
recognition of physiological cues of arousal, self-calming talk, and social problem solving
*School-based treatments include Turtle Technique & Coping Power Program *CBT is applied to many childhood problems, including externalizing & internalizing problems (Bennette & Gibbons, 2001)

*Basic components: 1) recognition of how young clients come to tx; 2) use of age-appropriate models of
delivery (and assessment); 3) awareness of child's cognitive/affective development; 4) awareness of social context; 5) therapist has clear expectations for therapy

*It uses developmentally-appropriate behavioral & cognitive strategies, and covers a wide range of interventions,
including psycho-education, anger management, anxiety management, social skills training and parent training (Bolton, 2005)

*Typically relies on problem-solving templates that involve child, therapist & primary caregiver

*Not much research on CBT below the age of 8 Philip Kendall: Key thinker in CBT for Children *Director of Child & Adolescent Anxiety Disorders Clinic at Temple U

*Developed Coping Cat workbook series; author of 30+ books and 20+
tx manuals

*Developmental theory is key to effective child CBT PK on the necessity of homework: "Rather than making treatment complicated and difficult, I try to make it acceptable to kids. So we'll talk about a cafeteria of things like relaxation or talking back to your anxiety or trying things out to see how they work.You kind of walk through the treatment as a cafeteria, where you don't have to eat everything that's offered. The homework allows the child to practice a specific skill that [the CBT therapist wants teach]. It's a very important part of CBT because one hour a week with us in a safe environment isn't the real world" *Jean Piaget: "[The adolescent] is the individual who builds 'systems' or 'theories,' in the largest sense of the term. The child does not build systems...the child has no powers of reflection (i.e., no second order thoughts which deal critically with his own thinking. No theory can be built without such reflection" (Inhelder & Piaget, 1958, 339-340). *Lev Vygotsky: Cognition & action are social. Language is key in the regulation (or control) of action. Without adequate language capacity, child cannot engage in CBT. Explored relationship between cognition & action Basic Components of CBT CBT Revisions of Vygotsky & Piaget include: Social attribution & social information processing: involves attending to, encoding, & interpreting social cues John Bowlby Ideal assessments include parents & teachers Child Behavior Checklist (CBCL) Connors Parent Rating Scales Missouri Children's Behavior Checklist Assessments allow child/parent to endorse symptoms that clinician may not think to ask about Work best when events have been recalled in a recent family conversation or situation rather than asking child to think back to times when... Benefits: low cost, objective, fit with components of CBT

Disadvantages: biased raters, classify behaviors as typical/atypical, don't capture lived-experience Case Conceptualization *How client/family & therapist come to understand unique position of child's difficulties.
*Case conceptualizations must be revised often to consider child's movement through developmental stages.
*If using a manual, therapist should understand how the manual is helping advance goals of therapy.
*Attachment theory: provides a model for understanding how distorted & disordered representational models about attachments development. Utilizes story telling. Family Component *Studies that show children who receive CBT + family
component respond more positively than children who are treated with individual CBT

*Research shows that children 7-10 years but not
early adolescents (11-14yrs) are likely to benefit from family treatment component (Wopert, 2005)

*Incorporating family is important esp. if family is the
origin of child's problem

See Tables 7.2/7.3 in class handout *Easy for family & children to understand
*Problem-solving perspectives are used across developmental stages
*Empirically supported for most clinical disorders STRENGTHS OF CHILD-CBT Weaknesses & Critique *What if child can't readily identify thoughts?
*What about use of CBT with developmental/
intellectual disorders?
*Given that behavioral methods can be used with
children, what is involved in adding cognitive therapy?
*To what extent is the child's view of himself & world learned from significant attachment figures & to what extent from verbal information & modeling? Answer to Critique? Blend of Play Therapy & CBT? *structured & problem-focused but also exploratory
*appropriate for non-verbal children (Knell, 2008)
*child-directed
*play therapy + parent
*EBT: Coping Cat Program (Podell, Martin & Kendall): Manualized program of 16 sessions targeting generalized & separation anxiety disorders & social phobia. Synthesizes CBT with play, fun activities, drawing cartoons & feelings charades. * Parent-Child Interaction Therapy (Eyberg, 2004): 20 session operant intervention for parents with children 2-8 years exhibiting externalizing behaviors. EBT for Conduct Disorder Anxiety Disorders According to the text in Dobson, “anxiety becomes a disorder when the experience is exaggerated beyond what would be expected in a given situation or when it interferes with the youth’s functioning” (Crawley et. al., p. 387).

Parents of anxious children are likely to be anxious themselves and this anxiety makes parents prone to falling onto the overprotective cycle. Rationale for CBT Ex of EST: FEAR ACRONYM/ Stallard's "Learning to Beat Anxiety"

Research suggests that CBT works very well, esp. long-term (Crawley, 2005; O'Connor & Creswell, 2001).

Instructions need to be repeated continuously because anxiety often eradicates the child’s ability to think in terms of problem-solving

Bailey, V. (2005). Conduct disorders in young children. In Cognitive Behavioral Therapy for Children and Families. (pp. 207-224).Ed. Philip J. Graham.
Cambridge, UK: Cambridge University Press.
Barrett, P.M., Duffy, A.L., Dadds, M.R., & Rapee, R.M. (2001). Cognitive-behavioural treatment of anxiety disorders in children. Long term (6 year) follow up.
Journal of Counseling and Clinical Psychology, 69, 135-141.
Bennett, D.S.. & Gibbons, T.A. (2001). Efficacy of child cognitive-behavioural treatment for anti-social behavior: A meta-analysis. Child and Family Behaviour
Therapy, 22, 1-15.
Bolton, D. (2005). CBT for children and adolescents; some theoretical and developmental issues. In Cognitive Behavioral Therapy for Children and Families.
(pp. 9-24).Ed. Philip J. Graham. Cambridge, UK: Cambridge University Press.
Crawley, S., Podell, J., & Bedias, R., Braswell, L., & Kendall, P. (XXXX). Cognitive-Behavioral Therapy with Youth. In Handbook of Cognitive Behavioral
Therapy (pp. 375-410). Ed. Keith Dobson. New York: The Guilford Press.
Flavell, J.H. (2001). Developments of children’s understanding of connections between thinking and feeling. Psychological Science, 12, 430-432.
Inhelder, B. & Piaget, J. (1958). The Growth of Logical Thinking from Childhood to Adolescence. New York: Basic Books.
Keller, H. (2002). Behavioral Observation Approaches to Personality Assessment. In The Assessment of Child and Adolescent Personality (pp. 353-391). Ed. Howard M. Knoff. New York: The Guilford Press.
Kendall, P.C. (1990). The coping cat workbook. Ardmore, PA: Workbook Publishing.
Martin, R., Hooper, S., Snow, J. Behaivor Rating Scale Approaches to Personality Assessment in Children and Adolescents. In The Assessment of Child and Adolescent Personality. (Pp. 309-349) Ed. Howard M. Knoff. New York: The Guilford Press.
O’Connor, T. & Creswell, C. (2005). Cognitive behavioral therapy in developmental perspective. In Cognitive Behavioral Therapy for Children and Families.
(pp. 25-47).Ed. Philip J. Graham. Cambridge, UK: Cambridge University Press.
Pelham, W., & Walker, K. (2005). Attention deficit hyperactivity disorder. In Cognitive Behavioral Therapy for Children and Families. (pp. 225-243).Ed. Philip
J. Graham. Cambridge, UK: Cambridge University Press.
Quakley, S., Coker, S., Palmer, K., Reynolds, S. (2003). Can children distinguish between thoughts and behaviors? Behavioural and Cognitive Psychotherapy,
31, 159-169.
Wolpert, M., Doe, J., & Elsworth, J. (2005). Working with parents: some ethical and clinical issues. In Cognitive Behavioral Therapy for Children and Families.
(pp. 103-120).Ed. Philip J. Graham. Cambridge, UK: Cambridge University Press.
Wellman, H.M, Hollander, M. & Schult, C.A. (1996). Young children’s understanding of thought bubbles and thoughts. Child Development, 67, 768-788. REFERENCES *Do children benefit from COGNITIVE Behavior Therapy or just Behavior Therapy?

*Not clear what CBT with children actually involves -- discrepancy between proposed interventions & actual therapy ? At what age do children begin identifying thoughts as thoughts? At what age do children think about thinking? Meta-cognition?
Simple awareness? CBT in Developmental Context Coping Power Program (Lochman, Boxmeyer, Powell, 2008). A manualized intervention for elementary & middle school-age children who demonstrate aggressive behavior problems. Group of 4-6 students, meet weekly over 18 month period, using structured techniques that are embedded in the program, such games, beat-the-clock activities and role-plays. Includes a parenting component that runs concurrently. “Anxiety becomes a disorder when the experience is exaggerated beyond what would be expected in a given situation or when it interferes with the youth’s functioning” (Crawley et. al., p. 387)

*Some children are born with a genetic vulnerability to anxiety, manifested by child’s temperament, evidenced by high levels of arousal, emotionality and an avoidant coping style. In turn, the child’s temperament may encourage them to select environments that maintain and support their avoidance, and elicit protective behaviors from parents

*Overprotection from parents may increase child’s perceptions of the fear and decrease their perceptions of control over danger.

*Parents of anxious children are likely to be anxious themselves and this anxiety makes parents prone to the overprotective cycle. F--Feeling frightened?
E--Expecting bad things to happen?
A--Attitudes and Actions
R--Results and Rewards Katie Wagner April 3, 2013 Sensorimotor (Birth-2 yrs) Preoperational (2-4 yrs) Concrete Operational (7-11) Formal Operational (12+)
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