Cognitive Behavioral Therapy

with children and adolescentsLindsay 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

• Example: depression

Thoughts

BehaviorsFeelings

Stress

CBT: Efficacy

• APA Division 12 and 53• Guidelines for identifying and promoting

empirically “validated” or supported treatments in psychology.

• Defining Interventions as

1.1. Best Support (“Well-Established Treatments”)Best Support (“Well-Established Treatments”)

2.2. Promising (“Probably Efficacious Treatments”)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.

ORII. 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 AdolescentsAnxiety Disorders

“Well-Established Treatments”

“Probably Efficacious Treatments”

Specific Phobia

1. Participant Modeling*2. Reinforced Practice*

1. Cognitive Behavior Therapy2. Systematic Desensitization*

Generalized Anxiety Dx(GAD)

None 1. Cognitive Behavior Therapy2. Modeling*3. In Vivo Exposure*4. Relaxation Training*5. Reinforced Practice*6. Family Anxiety Management

Separation Anxiety

None Same 6 treatments as GAD

Agoraphobia None None

OCD None None

Panic Disorder

None None

PTSD None None

Social Phobia

None None

* These can be considered components of CBT

EST’s for Children and Adolescents

Depressive Disorders

“Well-Established Treatments”

“Probably Efficacious Treatments”

Major Depressive Disorder

1. Interpersonal Therapy

1. CBT2. Psychotropic

Medications

Dysthymic Disorder 1. Interpersonal Therapy

1.CBT2.Psych Med

Adjustment Disorder 1. Interpersonal Therapy

1.CBT2.Psych Med

EST’s for Children and Adolescents

 ADHD “Well-Established Treatments” “Probably Efficacious Treatments”

1. Stimulant Meds

2. Behavioral Parent Training

3. Behavioral Classroom Interventions

1. Social Skills Training with Generalization Components

2. Summer Treatment Programs

EST’s for Children and Adolescents ODD/CD “Well-Established Treatments” “Probably Efficacious Treatments”

1. Parent Training Based on the book Living with Children

2. Videotape Modeling Parent Training

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

Feelings Behaviors

Stress

Thoughts

Commonly used materials and resources

Cognitive techniques: Background

• Goal: Target maladaptive thoughts1. 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

9

8

7

6

5

4

3

2

1

0

Really scared or upset

Pretty scared or upset

Not at all scared or upset

A little bit scared or upset

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