Cognitive Behavioral Therapy

with children and adolescents

Lindsay McAlister and Lisa Ingerski
November 27, 2006
 Outline
• Introduction to Cognitive Behavioral
Therapy (CBT)
• Definition
• Efficacy
• Common uses with children and adolescents
• Commonly used materials and resources
• Case examples
• Obsessive Compulsive Disorder (OCD) and
Social Phobia
• Psychological factors affecting diabetes - with
mixed mood
 CBT: Definition
• Diagram

Stress
Thoughts

Feelings Behaviors

• Example: depression
 CBT: Efficacy
• APA Division 12 and 53
• Guidelines for identifying and promoting
empirically “validated” or supported
treatments in psychology.
• Defining Interventions as
1. Best Support (“Well-Established Treatments”)
2. Promising (“Probably Efficacious Treatments”)
 Criteria for
“Well-Established Treatments”
I. At least two good between group design
experiments demonstrating efficacy in one or
more of the following ways:
a. Superior to pill placebo, psychological
placebo, or another treatment.
b. Equivalent to an already established
treatment in experiments with adequate
statistical power (about 30 per group; cf.
Kazdin & Bass, 1989).
 Criteria for
“Well-Established Treatments”
OR
II. A large series of single case design
experiments (n > 9) demonstrating efficacy.
These experiments must have:
a. Used good experimental designs
b. Compared the intervention to another
treatment as in I.a. (superior to placebo,
etc.)
 Criteria for
“Well-Established Treatments”
AND
Further criteria for both I and II:
III. Experiments must be conducted with
treatment manuals.
IV. Characteristics of the client samples must be
clearly specified.
V. Effects must have been demonstrated by at
least two different investigators or teams of
investigators.
 Criteria for
“Probably Efficacious Treatments”
I. Two experiments showing the treatment is
(statistically significantly) superior to a waiting-list
control group.
• Manuals, specification of sample, and
independent investigators are not required.
OR
II. One between group design experiment with clear
specification of group, use of manuals, and
demonstrating efficacy by either:
a. Superior to pill placebo, psychological placebo,
or another treatment.
b. Equivalent to an already established treatment
in experiments with adequate statistical power
(about 30 per group; cf. Kazdin & Bass, 1989).
 Criteria for
“Probably Efficacious Treatments”
OR
III. A small series of single case design
experiments (n > 3) with clear specification of
group, use of manuals, good experimental
designs, and compared the intervention to pill
or psychological placebo or to another
treatment.
 EST’s for Children and Adolescents
Anxiety “Well-Established “Probably Efficacious Treatments”
Disorders Treatments”
Specific 1. Participant Modeling* 1. Cognitive Behavior Therapy
Phobia 2. Reinforced Practice* 2. Systematic Desensitization*

Generalized None 1. Cognitive Behavior Therapy

Anxiety Dx 2. Modeling*
(GAD) 3. In Vivo Exposure*
4. Relaxation Training*
5. Reinforced Practice*
6. Family Anxiety Management
Separation None Same 6 treatments as GAD
Anxiety
Agoraphobia None None
OCD None None
Panic None None
Disorder
PTSD None None
Social None None
Phobia

* These can be considered components of CBT

 EST’s for Children and Adolescents
“Well-Established “Probably Efficacious
Treatments” Treatments”
Depressive Disorders

Major Depressive 1. Interpersonal 1. CBT

Disorder Therapy 2. Psychotropic
Medications

Dysthymic Disorder 1. Interpersonal 1. CBT

Therapy 2. Psych Med

Adjustment Disorder 1. Interpersonal 1. CBT

Therapy 2. Psych Med
 EST’s for Children and Adolescents

ADHD “Well-Established Treatments” “Probably Efficacious

Treatments”

1. Stimulant Meds 1. Social Skills Training with

2. Behavioral Parent Training Generalization
Components
3. Behavioral Classroom
Interventions 2. Summer Treatment
Programs
 EST’s for Children and Adolescents
ODD/CD “Well-Established Treatments”
1. Parent Training Based on the
book Living with Children
2. Videotape Modeling Parent
Training
“Probably Efficacious Treatments”
For Preschool-Age Children:
1.) Parent-Child Interaction
Therapy
2.) Time-Out Plus Signal Seat
Treatment
3.) Parent Training Program
4.) Delinquency Prevention
Program
For School-Age Children:
1.) Anger Coping Therapy
2.) Problem Solving Skills
Training
For Adolescents:
1.) Anger Control Training with
Stress Inoculation
2.) Assertiveness Training
3.) Multisystemic Therapy
4.) Rational Emotive Therapy
 Cognitive Behavioral Therapy
“Probably Efficacious Treatment”
• Specific Phobia
• Generalized Anxiety Disorder (GAD)
• Separation Anxiety
• Major Depressive Disorder
• Dysthymic Disorder
• Adjustment Disorder
While does not meet EST criteria, also often used for:
• Agoraphobia, OCD, Panic Disorder, PTSD, Social
Phobia
 CBT and young children?
• Piaget’s stage model of intellectual functioning
• Preoperational (2-7 years of age)
• Concrete operational (7 plus)
• Formal operational (12 and over)
• Requisite cognitive capabilities for CBT
• Self-reflection
• Perspective taking
• Understanding causality
• Reasoning
• Processing new information
• Linguistic ability
• Memory
• Early school-aged children generally
underrepresented in the CBT outcome literature
 CBT and young children?
• Efficacy of CBT with young children
• Methodological issues
• Nonclinical samples
• Short periods of time
• Narrowly specified behaviors in laboratory settings
• Problems with maintenance of tx gains
• Durlak et al. (1991)
• Used developmental level as a client variable
• Effect size for children aged between 11 and 13 nearly
twice of that for children in the concrete operational and
preoperational stages
• No other variable mediated outcome
• Preoperational group (5-7) did not differ in effect size
from the concrete operational (7-11) group
• Suggests that older group is cognitively better equipped
to modify distortions
 CBT and young children?
• Integrating cognitive developmental level
into CBT
• Minor changes to procedures or questioning
can reveal dramatic decreases in the age at
which children achieve important milestones
• Social perspective taking
• Empathic and emotional understanding
• Clear, simple instructions with familiar material
from their everyday lives
• Concrete and story-based representations
• Behaviorally active learning and imaginary
mnemonic aids
• “Bad Thought Monster” and the “Smart Thought
Man/Woman” fight each other with the help of a “Zen
Warrior” (Leahy, 1988)
• Challenge: finding appropriate metaphor for child’s
developmental level
Commonly used materials and resources
Cognitive techniques
• Cognitive Restructuring/Reframing
• Fear thermometer
• Thought record

Stress

Thoughts

Feelings Behaviors
Commonly used materials and resources
Cognitive techniques: Background
• Goal: Target maladaptive thoughts
1. Negative view of themselves (e.g., inadequate)
2. Negative view of the world (e.g., unfair)
3. Negative view of the future (e.g., I will always fail)
• Examples of maladaptive thoughts
• When things do not go the way I would like, life is awful,
terrible, horrible, or catastrophic
• Unhappiness is caused by uncontrollable external events
• I must have sincere love and approval from all significant
people in my life
Commonly used materials and resources
Cognitive techniques: Background
• Goal: Target maladaptive thoughts
• Negative Schemas
• Ways of thinking that lead individuals to perceive
and interpret experiences in a negative manner
1. Automatic, often occur rapidly in certain
situations and may be outside of person’s
awareness
2. Involve discrete predictions or interpretations
of a given situation
3. Develop out of negative experiences
Commonly used materials and resources
Cognitive techniques
• Cognitive Restructuring/Reframing
• Replace or reframe cognitive distortions or
maladaptive thoughts with more balanced
and realistic thoughts and beliefs about
oneself, the future, and the world around us
• ELVES
• E: Evidence
• L: Likelihood
• V: oVergeneralization
• E: Estimation
• S: Standards
Commonly used materials and resources
Cognitive techniques
• Fear thermometer 10
Really scared or upset
9
8
Pretty scared or upset 7
6
5
4
A little bit scared or upset
3
2
1
Not at all scared or upset 0
Commonly used materials and resources
Behavioral techniques
• Diaphragmatic breathing
• Relaxation training
• Activity scheduling
• Exposure and response prevention exercises
Commonly used materials and resources
Behavioral techniques:
• Diaphragmatic breathing
• Pinwheel
• Bubbles
Commonly used materials and resources
Behavioral techniques:
• Relaxation training
• Progressive Muscle Relaxation (PMR)
• Systematic tensing and relaxation of major muscle
groups of whole body
• With practice, goal is to learn to become deeply
relaxed rapidly
• Impossible to be tense and relaxed at same time
• Can implement skill when noticing that you are
starting to become tense and anxious
• Guided Imagery
• Visualization
Commonly used materials and resources
Behavioral techniques:
• Activity scheduling
• Pleasurable Activities
• E.g., walk dog, movie with friends, dinner with
family, play a game
Commonly used materials and resources
Behavioral techniques:
• Exposure and response prevention exercises
• In Vivo Exposure
• Real-life exposure exercises
• Practice approaching and confronting a feared
situation or object
• (e.g., germs)
• Sessions begin with easy situations and gradually
work their way up to scarier and harder situations
• Fear hierarchy
• Ideal for OCD and phobias
• Extreme versions: implosive therapy, flooding
Commonly used materials and resources
Behavioral techniques:
• Exposure and response prevention exercises
• Modeling
• Involves demonstrating non-fearful behavior in a
feared situation and showing the youth a more
appropriate response for dealing with a feared object
or event
Commonly used materials and resources
Behavioral techniques:
• Exposure and response prevention exercises
• Participant Modeling
• Combines modeling and in vivo exposure
1.Model (e.g. therapist) demonstrates fearlessness
and coping responses when confronting the
feared situation or object
2.The model assists the child in practicing
approaching and confronting the feared situation
or object.
• Sessions begin with easy situations and
gradually work their way up to scarier and
harder situations
Commonly used materials and resources
Behavioral techniques:
• Exposure and response prevention exercises
• Reinforced Practice
• Combines in vivo exposure with a feared situation or
object and rewards
• Praise, tokens, toys, hugs, etc. for approaching and
confronting a feared situation or object
• Child is rewarded for practicing approaching and
confronting a feared situation or object
Commonly used materials and resources
Behavioral techniques:
• Exposure and response prevention exercises
• Systematic Desensitization
• Based on the theory of reciprocal inhibition, one
cannot be anxious and relaxed at the same time
(Wolpe, 1958)
• Youth imagines feared object or situation while
engaging in a response that is incompatible with
anxiety
• (e.g. relaxation or play)
• Unlike participant modeling and reinforced practice,
the feared object or situation is presented in
imagination rather than real life
Commonly used materials and resources
Behavioral techniques:
• Exposure and response prevention exercises
• Additional tools
•Fear Hierarchy
•List of items from 0 (no fear) to 100 (most fear
imaginable)
•Subjective Units of Distress Scale (SUDS)
•Rating system for amount of fear
• Usually use a 0-10 scale for younger
children
•Used during exposure exercises as a way to
monitor fear response – ask for SUDS rating at
beginning of exercise then wait for value to
decrease to normal levels
 Interactive Exercises!
Thought record
• Depression
• “I can’t do anything right”
• “No one likes me”

Interoceptive exposure exercises

• Panic symptoms
 Case Examples
• Obsessive Compulsive Disorder (OCD)
and Social Phobia
• Psychological factors affecting diabetes
- with mixed mood