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Class Agenda
Midterm information
Lecture on Cognitive Behavioral Play Therapy
Activity to model Cognitive Behavioral Play Therapy technique
Distribution of case study
Group Discussion
Class Discussion
Next Class: Discussion and application of both Psychodynamic Approaches to therapy and Cognitive Behavioral Play therapy to first 4 sessions of Oliver followed by beginning of lecture Child Centered Play therapy
Cognitive Behavioral Approaches to Play Therapy
Cognitive Behavioral Play Therapy (CBPT)
Designed specifically for preschool and early elementary school children
Integrates CBT with play therapy
Emphasizes child’s involvement in therapy by addressing issues of control, mastery, and responsibility for changing one’s behavior
Offers an opportunity for depressed and/or anxious children to express and master their feelings in a safe environment
How to conceptualize Client’s problems with CBT?
Core Beliefs
Intermediate Beliefs
Situation
Automatic Thoughts
Feelingsand
Behavior
FamilyCulturePeers
HistoryPoliticsMedia
CBPT
6 Essential Components of CBPT Psychoeducation
Somatic management (Relaxation)
Cognitive restructuring
Exposure (behavioral approach)
Relapse prevention and generalization
Parent involvement
CBPT
Psychoeducation with both parents and child
Teaching about signs, symptoms, risk factors, and thoughts underlying depression or anxiety in a developmentally appropriate way (use drawings and visuals, use of puppets for preschool children)
Learn the relationship between thoughts, feelings, and behavior
Enhance child’s ability to recognize signs and symptoms of depression and/or anxiety in self
Enhance child’s understanding of how treatment will reduce symptoms
Enhance parents’ ability to understand how anxiety and/or depression impacts their child’s behavior
Teach parents strategies to best help alleviate child’s symptoms
Cognitive Model
Thoughts
FeelingsBehavior
Perceived Situation
CBPT
Somatic management (RELAXATION) Relaxation Training
Deep Breathing exercise
Muscle Relaxation exercise
Have child observe therapist teach a puppet a relaxation exercise
Examples of relaxation activities that one can engage a child in
Blowing bubbles to practice deep breathing
Visualization Exercise
Mindfulness activity
CBPT
Cognitive Restructuring Teach children skills to reframe distorted/negative thoughts
into more realistic and positive thought
Teach how “tricky” (maladaptive) thoughts are at the basis of their anxiety and/or depression
Help child identify thoughts that are underlying their anxiety and/or depression
Teach child how to be a “thought detective” and find evidence for his/her thoughts in order to determine whether the thought is “tricky” or not
Help child reframe a “tricky” thought into a more adaptive, realistic, and positive thought
Adapt how you teach to the developmental level of the child
Teach child positive statement technique
CBPT
Example of Cognitive Restructuring Activity Brain, Body, and Feelings
CBPT
Exposure Research suggests that cognitive interventions alone do not
facilitate mastery over fear or depressive feelings, thus CBPT must include behavioral interventions
Gradually and systematically exposing child to source of their anxiety (especially useful in phobias)
Have child create a ladder of fear or hierarchy of fear
Gradually and systematically expose child to situations and/or objects noted on the fear ladder while teaching them relaxation techniques to sustain the anxiety caused by the exposure
Systematic desensitization (Classical Conditioning)
Pairing unconditioned stimulus of relaxation with conditioned stimulus of anxiety provoking situation so that being exposed to anxiety provoking situation will ultimately evoke feelings of relaxation and calm just like deep breathing or muscle relaxation provides)
CBPT
Relapse Prevention and Generalization How to maintain adaptive behavior the child has learned
through CBPT so that it is generalized?
Use real life situations in modeling and role playing to achieve generalization of adaptive behavior learned through play therapy session
Introduce play scenarios that are similar to those the child may face in the future so that child can be prepared to face similar situations
Involve parents in the therapy process so that they can reinforce the skills the child has learned to better cope with their anxiety and/or depression
CBPT
Parent Involvement
Parents should always be actively involved in the treatment of their children because their actions and issues impact the child developmental outcome
Increase parents’ awareness about how they contribute or maintain their child’s behavior
Teach parents how to best help child maintain skills learned in the sessions to help them best manage his/her anxiety or depression
Teach parents how to model adaptive coping skills for anxiety and depression
Parents function as “coaches” at home and outside of sessions
Help parents build parenting skills such as
How to validate their child’s feelings (for dismissive parents)
How to reward child for having engaged in an adaptive coping skill (positive reinforcement)
How to ignore maladaptive coping skills used by child
How to model proper coping skills/problem solving
How to use problem solving skills to help child remember adaptive skills learned in the sessions
CBPT
Additional Interventions (behavioral) for CBPT Modeling
Social learning theory
Learning occurs vicariously by observing model interact with stimuli
Use of stories, cartoons, videos where model is appropriately coping with anxiety and/or depression
Step by step process of how to deal and cope with depression and/or anxiety where therapist models skills
Systematic Desensitization
Positive Reinforcement
Clarify target behavior
Making reinforcement contingent on occurrence of target behavior
Reinforcers: Praise, stickers, prize, etc.
Reinforcers can be given by therapist and/or parents
Using charts to provide a visual for target behaviors and monitor progress in obtaining reinforcer
CBPT
Shaping
Way of helping a child get progressively closer to a targeted goal
Give child positive reinforcement for closer and closer approximations to the desired response
Ex: How to shape a child to sleep in his own room
Stimulus fading, extinction, and differential reinforcement of behavior
Stimulus fading
Extinction: Gradually eliminate anxiety and fear responses by eliminating reinforcing variables such as the possibility to avoid anxiety provoking situation or obtaining parental attention when exhibiting fear reaction
Use extinction in conjunction with differential reinforcement of behavior
Ex: Parent will no longer give attention to child when exhibiting fear but rather will praise and give attention to child when child exhibits bravery and courage (School avoidance example)
CBPT
Bibliotherapy Use of self-help books for children
Book depicts a story of a child who copes with a situation similar to the one the child may be facing
Provides modeling opportunity for child to learn how to cope with a situation in an adaptive manner
Create a book and story with the patient during the session about a child going through similar situations as the patient so that patient can learn vicariously through child in the story how to best cope with certain situations
CBPT
Toys Puppets: to tell a story
Animal toys
Human figurines
Doll House
Art supplies (drawing stories or writing notes for psychoed) Paint
Crayons
Markers
Paper
CBPT
Stages of treatment Introductory/Orientation
Rapport building (play a game or play with toys)
Assessment (intake through drawing, parent interview, feeling thermometer, genogram)
Middle
Treatment plan development
Psychoeducation
Teaching of coping skills through different interventions that address treatment goals
Generalization and Relapse prevention techniques
Termination
Effectiveness of Cognitive Behavioral Play Therapy (CBPT)
Well established as an effective treatment for anxiety disorders and phobias in school-age children and adolescents
Children ages 4-8 who received CBT displayed better outcomes compared to control
Play relates to or facilitates adaptive coping strategies for daily problems and emotional regulation, both of which corresponds to successful CBT outcomes for anxiety and phobias
Major Depressive DisorderMajor Depressive Episode Criteria Diagnostic Criteria 5 or more symptoms present during same 2-week
period and represent change from previous functioning (one of the first 2 symptoms must be present) Depressed or irritable mood most of the day, nearly every day Markedly diminished interest or pleasure in all or almost all
activities Significant weight loss or gain Insomnia or hypersomnia Psychomotor agitation or retardation Fatigue or loss of energy Worthlessness or excessive or inappropriate guilt Diminished ability to think or concentrate, or indecisiveness Recurrent thoughts of death
Persistent Depressive Disorder(Dysthymic Disorder in DSM-IV) Diagnostic Criteria
Depressed or irritable mood for most of the day, for more days than not for at least 1 year.
Presence, while depressed, of 2 (or more) of the following:Poor appetite or overeating Insomnia or hypersomniaLow energy or fatigueLow self-esteemPoor concentration or difficulty making decisionsFeelings of hopelessness
Symptom Differences According to Age
Infancy and ToddlerhoodDelays in developmental
accomplishments (toilet training, sleeping habits)
Self-harming behavior (head banging, self-biting)
Self-soothing behavior (rocking, thumb sucking)
Symptom Differences According to Age
PreschoolSad appearanceVague somatic complaintsIrritabilitySleep problemsDevelopmental regression loss
of cognitive and language skills, social withdrawal
Symptom Differences According to Age
School ageSymptoms more similar to adultsLow self-esteemGuilt Loss of motivationDisruptive and aggressive
behavior/defiant behaviorSomatic symptoms
Symptom Differences According to AgeYounger adolescents (10-14
years)More anxiety symptoms:
fearfulness and nervousnessClinging behaviorsPhysical symptoms
(headaches, stomachaches)
Symptom Differences According to Age
Older Adolescents (14 to 18 years)
Loss of interest and pleasureMore negative self thoughtsIncreased thoughts of death and suicideCombination of hypersomnia and insomnia
(maladaptive coping mechanism)Verbalize sad feelings and distressTruancy, misbehavior, and drop in
academic achievementIrritability
Other symptoms of Depressive Disorder in children and adolescents
Symptoms of anxiety (frequent worries and fears, racing heart, sweaty palms, nervousness, “edginess,” nightmares, panic attacks)
Physical symptoms (headaches, stomachaches, numbness, difficulty breathing, heart pounding, etc.)
Change in personality (example – perhaps someone who is typically outgoing and participates in lots of activities becomes more silent and withdrawn)
Acting out behavior (being rebellious, breaking rules, being defiant, threatening to run away, delinquent acts)
Difficulty following rules Difficulties with group assignments Crying Withdrawal Distractibility and poor concentration Not completing assignments Seeming unmotivated or uninterested Persistent reports of boredom Difficulty learning and retaining new
material Test anxiety Extreme sensitivity to perceived
criticism Talk of or attempts to run away from
the school
Manifestation in the Classroom
Disruptive Mood Dysregulation Disorder (up to age 18 diagnosis)
Severe and recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation and that occur, on average, 3 or more times each week for one year or more
Between outbursts, children display a persistently irritable or angry mood, most of the day and nearly every day, that is observable by parents, teachers, or peers
Above symptoms to be present in at least two settings (at home, at school, or with peers) for 12 or more months, and symptoms must be severe in at least one of these settings. During this period, the child must not have gone three or more consecutive months without symptoms.
The onset of symptoms must be before age 10, and a diagnosis should not be made for the first time before age 6 or after age 18
Biopsychosocial Model of Depression
GeneticsChemical imbalance
Other medical disorders
FamilySchoolPeers
Neighborhood
Thought patternsCoping skillsSelf-esteem
Biological
PsychologicalSocial
interacti
on
Tools to assess Depressive Disorders Major Depressive Disorder or Persistent Depressive Disorder
Reynolds Adolescent Depression Scale (RADS) Assesses depressive symptomatology 30 items rated on a 4 point rating scale
Reynolds Child Depression Scale (RCDS) Screens for depressive symptoms in children in schools and clinical settings 30 items with 4 point rating scale For children grades 3 to 6
Children’s Depression Inventory (CDI) The CDI is a symptom-oriented instrument for assessing depression in children
between the ages of seven and 17 years
The basic CDI consists of 27 items, but a 10-item short form is also available for use as a screener.
Treatment of Depressive Disorders General Principle:
Help child or adolescent explore and process the factors that are contributing to his/her depression to determine how to best deal and/or diminish/eliminate them
Enhance the child’s skills that have been impacted by the depression such as problem-solving, conflict resolution, and coping skills. (CBPT)
CBT Play Therapy: Mood monitoring Social skills training Relaxation training Conflict resolution Problem solving Thinking/cognitive restructuring
Treatment of Depressive Disorders
Family Therapy When family conflict exists
Family dynamics (rigid structure) getting in the way of open family communications
When one or both parents are overly possessive and/or protective
When parents need help with managing their children’s behavior and emotions
When parents need coaching on how to better support their children emotionally
Treatment of Depressive Disorders
Play Therapy Children tend to reenact experiences through play
(repetition compulsion)
Children also tend to express and act out wishes and fantasies
It helps the depressed child act out and express internal thoughts and fears
Follow the child’s lead
Anxiety Disorders: What do We Know?
These features of anxiety can be expressed (what is universal about it)
Behaviorally : Avoidance
Physiologically: dizziness, heart racing, sweaty palms, shortness of breath/hyperventilating, feeling like going to faint
Cognitively: concentration difficulties, memory difficulties
Socially: social withdrawal
These primary features of anxiety cut across all of the DSM-5 anxiety disorders
Secondary features are the one that differentiate anxiety disorders from each other
Anxiety Disorders
FEELINGS
BEHAVIOR
THOUGHTS
Separation Anxiety: What Does It Look like?
See DSM-5 Persistent and excessive worry about losing major
attachment figure
Persistent reluctance or refusal to go to school or elsewhere because of fear of separation
Persistent reluctance or refusal to go to sleep without being near a major attachment figure
Anxiety Disorders: What Do We Know?
Generalized Anxiety DisorderPersistent and excessive
worry about a number of events or activities
Youth may worry about their school performance, their social relationships, and their health or the health of others
Anxiety Disorders: What Do We Know?
Specific PhobiasExtreme and unreasonable fears of a
specific object or situation such as dogs, loud noises, height, doing presentation in front of class or the dark
Social Anxiety DisorderExtreme and unreasonable fear of being
embarrassed or humiliated in front of other youths or adults
As a result, child may avoid school, restaurants, and parties
Anxiety Disorders: What Do We Know?
Panic Disorder
Sudden and severe attacks of anxiety
Attacks of anxiety consist of : shortness of breath, heart palpitations, dizziness, upset stomach, sweating, and fear of dying and losing control
Agoraphobia can be part of a panic disorder: avoidance of situations from which escape might be difficult (or embarrassing) in the event of having an unexpected or situation ally predisposed attack such as shopping mall, theaters, and stadiums
Developmental Progression
Children ages 4 to 9: Separation anxiety symptoms and animal fears are the predominant expression of anxiety Fear of personal harm
Fear of medical procedures
Fear of separating from caregivers
Children ages 10 to 13: Generalized anxiety disorder symptoms are the predominant expression of anxiety Fear of peer bullying and teasing
Fear of rejection
Fear of death and dying of others
Developmental Progression
Adolescents ages 14 to 17: Social anxiety disorder symptoms are the predominant expression of anxiety Fear of humiliation/criticism
Fear of embarrassment
Fear and worries about appearances
Fear of death and danger
Child self-rated fears of physical danger and punishment diminish with age (fear of being harmed)
Self-rated fears of social, humiliation and achievement evaluation (performance) increase with age
Biopsychosocial Model of Anxiety
GeneticsChemical imbalance
Other medical disorders
FamilySchoolPeers
Neighborhood
Thought patternsCoping skillsSelf-esteem
Biological
PsychologicalSocial
interacti
on
Co-Morbidity
Childhood anxiety disorders are associated with adult anxiety and depressive disorders
All anxiety disorders are very co-morbid with one another (50% to 70%)
ADHD (0% to 21%) Conduct Disorder and Oppositional Defiant
Behavior (3% to 13%) Depression (28% to 69%) Depression and anxiety often co-occur
within an individual
Tools to assess Anxiety Disorders
Revised Children’s Manifest Anxiety Scale Severity measure with 3 anxiety subscales
Social Anxiety Scale for Children-Revised Severity measure of social anxiety Self-report
Child-Behavior Checklist (CBCL) Multiple scales including Anxious/Depressed Scale Parent report
Diagnostic Interview for Children and Adolescents-Revised Structured psychiatric interview Parent, Child, and adolescent versions
Multidimensional Anxiety Scale for Children Severity measure with four main anxiety factors Self-report
Treatment
Cognitive Behavioral Play Therapy exploring thoughts, reframing
thoughts into more positive, realistic, and accurate ones
Behavior ModificationPsycho-educationRelaxation Techniques
Treatment
Family Therapy (In the case where family members model fear, anxiety and/or family dynamics contributes to child’s anxiety)
Phobias: Systematic Desensitization (relaxation and exposure to progressively more distressful stimuli)
Pharmacological Intervention: Anti-Anxiety medication like Benzodiazepines and SSRI
Case Study of Winnie
Diagnosis (es) and Why?
What insights about Winnie’s developmental outcome and personality does the psychosexual stages of Freud, Piaget’s theory, and Erickson’s psychosocial development theory provide you with? How is it helpful in helping you determine treatment goals for Winnie?
Biological, social, and psychological risk factors contributing to Winnie’s diagnosis (es)
What intake techniques and assessment tools would you use to gather more information to confirm Winnie’s diagnosis (es)? Why?
What Play therapy technique or techniques would you use to build rapport with Winnie? Why?
What would be your treatment goals for Winnie? Why?
What play therapy treatment approaches would you use to achieve treatment goals in therapy? Why? What toys or play would you use?
