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1 Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director WSU Project CARE Assistant Professor Children’s Hospital of Michigan Department of Psychiatry and Psychology June 19, 2008

Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Page 1: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques

MICHAEL BUTKUS, PHD Executive Director WSU Project CARE

Assistant Professor Children’s Hospital of Michigan

Department of Psychiatry and Psychology June 19, 2008

Page 2: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Evidence based practices & CBT   Few of the hundreds of therapies for children and

adolescents meet the tests of evidence, e.g., APA’s efficacy criteria:   Well supported and possibly efficacious to

unsupported and possibly harmful   CBT has met the criteria for well supported and

possibly efficacious for a number of disorders, perhaps more so than any other type of therapy

  However, not all therapies have been empirically investigated yet.

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I. Theory

Page 4: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Foundations of CBT

  Development of CBT influenced by the works of early behaviorists: Pavlov, Skinner; later by Bandura and Wolpe and cognitive therapists: Aaron Beck and Albert Ellis

Page 5: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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CBT Definition

Enactive, performance-based procedures as well as cognitive interventions to produce changes in thinking, feeling, and behavior (Kendall, 2000).

Page 6: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Interrelationship

  Behavior, thoughts, and feelings are seen as causally related in CBT and are all treatment targets. Behavior

Thoughts Feelings

Page 7: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Role of Learning

  Learning is pivotal in the acquisition and maintenance of behavior—adaptive or dysfunctional

  Just as adaptive behavior is learned, so is maladaptive behavior

Page 8: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Learning Methods

Operant conditioning S (stimulus) R (response) +CQ (consequence) = learning (Consequence: reward or punishment)

Classical Conditioning CS (bell) CR (salivation)

US (food) UR (salivation)

Page 9: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Social Learning and CBT

  The principles of social learning theory (based on the work of A. Bandura):

  Observational learning   Imitation   Modeling

Page 10: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Influence and Context

  A child’s behavior is influenced by its environment and the environment is influenced by the child’s behavior.

  Behavior is the product of an ever changing interaction between person and environment (reciprocal determinism) (Bandura, 1977).

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CBT Domains Of Importance Interpersonal/Environmental Context

Physiology Behavior

Cognition Emotions

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Nature of CBT

  In CBT learning is more than rewards and punishments.

  Learning also depends on the manner in which children and adolescents process information cognitively.

Page 13: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Cognitive Processing

  Children (and adults) evaluate, judge, and categorize behavior.

  They actively construct information by selecting, encoding, and explaining what happens to them and others (Friedberg & McClure, 2002).

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Cognitive Processing

  How children interpret what happens to them is critical to their emotional functioning.

  Everyone, including children and adolescents, actively processes experience and information.

  Behavior is not just generated as is assumed in more classical learning theory.

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Information Processing Kinds of thinking:   Conscious thoughts

  Automatic thoughts: assumptions, expectations, attributions

  Deep seated attitudes and beliefs   products of:

  Core beliefs or Schemas

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Schemas:

  Core meaning structures that direct attention, encoding, and recall (Fiske & Taylor, 1991).

  Can be thought of as templates that actively filter information.

  Are actively constructed from a very early age and reinforced over time.

  Are protected from an early age.   Information discrepant from the core beliefs is

often nullified or transformed via cognitive distortions.

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II. Treatment

Page 18: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Aim of Treatment

Alter core beliefs to ensure sustained change in emotions and behaviors

Page 19: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Nature of CBT

  CBT attempts to understand the relationship between a child’s behavior and accompanying cognitive processes (automatic thoughts, distortions, schemas).

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CBT Treatment   Goal: help child manage their

psychopathology and move closer to the normal developmental trajectory

  How: Help child learn more adaptive problem-solving skills;

  By providing meaningful and real experiences that alter cognitive processes and content and ultimately cognitive structures that can be then used with future experiences (Kendall, 2006)

Page 21: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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The Role of the Past in CBT

  In CBT the past is de-emphasized.   The past is viewed as offering clues

re: behavior patterns, reinforcements, cognitive processes, and how the core beliefs began.

  But CBT is very “here and now” focused.

Page 22: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Relationship Importance

  In CBT (and just about all other therapies) the nature of the therapeutic relationship is important.

Page 23: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Thoughts and Feelings

  Beck and others have shown that distinct cognitions are reliably associated with distinct emotional states (content-specificity hypothesis).

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Depression Schema

  Classic negative triad: depressed individuals have negative view of the self, others, and the future—“I’m not worth anything.” “No one will like me.” “It will be this way forever.”

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Anxiety Schema

  Anxious individuals have different cognitions that are based on the cognitive distortion of catastrophizing—“the world is always dangerous.” “I must always look for danger.” “I’m not able to handle danger.”

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Causes of Emotional And Behavioral Problems In Children

  Cognitive distortions (i.e., Dysfunctional or biased information processing)

  Cognitive deficiencies (i.e., Absence of thinking)

  Disturbed beliefs   2+2=5

  Lack of appropriate behavioral skills   Inadequate problem-solving skills

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Nature of CBT

  Exposure to many behavioral experiences or events

  These are concurrently processed cognitively

  Over time new schemata are developed

  New thoughts, behavior and feelings emerge

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General CBT Format

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What to Assess?

  A, B, Cs   Antecedents or Activating Events:

cause of strong feelings and/or negative cognitions or thoughts

  Beliefs: caused by A   Consequences: negative emotions or

behaviors   Temporal course of symptoms

Page 30: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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How to Assess?

  Interview (Multisource/Multimethod)   Child, parent, teacher, significant others

  Observations   Testing

  Rating scales   Intelligence   Personality testing

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What to Target?

  Identification of:   Underlying beliefs   Assumptions   Expectations   Goals   Attributions   Automatic thoughts

Page 32: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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More Targets

  Medical factors   Environmental factors:

  Stressful life events   Modeling   Reinforcement history

  Behavioral and interpersonal skill deficits

Page 33: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Case Conceptualization: (“You need a recipe for all the ingredients”)

  Precedes goal determination, agenda setting, and use of techniques

  Requires hypothesis generation and testing

  Specifies the five elements noted above (behavioral, emotional, interpersonal, physiological and cognitive components)

  Functional Analysis of Behavior

Page 34: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Treatment Processes in CBT

  Collaborative empiricism

  Guided discovery

Page 35: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Tasks of a CBT Therapist

  Because emotional events tend to have more impact, CBT attempts to engage the child emotionally

  Treatment sessions should be fun   Treatment sessions should be real   Transfer of skills from therapist to

child

Page 36: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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What Is Done in CBT?

  Child and parents are taught cognitive and behavioral interventions and the rationale for them

Page 37: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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What Is Done in CBT?

  In-session practice   Continual assessment of

motivation and expectations   Homework

Page 38: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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What Is Done in CBT?

  Identification of factors interfering with completion of homework or other techniques

  Evaluation of effectiveness (outcome assessment)

  Modification of intervention strategies as needed

Page 39: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Quiz

Which of the following is characteristic of a CBT therapist?

1.  Diagnostician 2.  Consultant 3.  Educator 4.  Team member 5.  All of the above

Page 40: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Quiz

Which of the following is not a characteristic of a CBT therapist?

1.  Active 2.  Problem-oriented 3.  Structured 4.  Flexible 5.  Creative 6.  None of the above

Page 41: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Structure Of A Typical CBT Session

Page 42: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Session Structure

  Assess:   Current mood   Symptom level   Symptom frequency and intensity

  Review recent issues and incidents   Review homework   Set agenda

Page 43: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Session Structure

  Implement techniques and strategies to accomplish goals from agenda

  Evaluate/assess understanding of techniques taught and motivation to implement them

  Assign homework task(s)

Page 44: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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CBT Methods

  Self-monitoring/recording   Role play   In session practice of new

behaviors   Modeling

Page 45: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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CBT Methods

  Self-evaluation   Reinforcement by therapist and

self   Homework

Page 46: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Cognitive Restructuring Methods

  What’s the evidence? (Being a thought detective)

  Identify thinking errors   Over-generalization   Personalization   Magic thinking   Mind-reading   Magnification   Discounting the positive

Page 47: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Cognitive Restructuring

  Challenge dysfunctional beliefs:   What if….?   What would you tell a friend?   Playing attorney and judge

  Generating healthier alternatives   Belief Strength

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Irrational Beliefs Of Adolescents   It’s my parent’s fault I'm so miserable.   The world should be fair and just.   I must conform to my friends.   I can’t stand to be criticized.   I’ll always be the way I am.   I can’t help it.

Page 49: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Irrational Beliefs Of Children

  Others must always like me.   I'm bad if I make a mistake.   I should always get what I want.   Things should come easy to me.   Adults should be perfect.

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CBT and Clinical Conditions

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Depression   Goal Setting   Affective Education   Mood Monitoring   Cognitive Restructuring   Problem-Solving   Activity Scheduling (Behavioral Activation)   Self-esteem building

Page 52: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Bipolar Disorder   Use all methods mentioned so far but include

recognition warning signs and cycles   Plan for handling behavioral excesses   Plan for how family, child and others will

respond to the illness when it erupts   Expect long course of treatment with many

positive changes and regressions

Page 53: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Anxiety

  Exposure and Response Prevention   Systematic Desensitization   Relaxation   Breathing   Probability Estimation

Page 54: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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CBT Resources for Anxiety Problems

  Good program: Kendall’s Coping Cat   Good resource: Chorpita’s Modular CBT

for Child Anxiety Disorders, 2007   For OCD: March and Mulle, OCD in

Children and Adolescents and March and Benton, Talking Back to OCD, 2007

Page 55: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Conduct Problems

Effective strategies:   Attribution Re-training   Anger management   Structured Problem-Solving   Cognitive Restructuring   Response Cost/Contingency

Management   Behavioral Parent Training

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Conduct Problems

Effective Programs:   MST; effective for African-

American youth   Brief Strategic Family Therapy

(see Szapocznik, et.al., 2003)

  Problem-Solving Skills Training (see Kazdin, 2003)

Page 57: Cognitive-Behavioral Treatment of Children and … Cognitive-Behavioral Treatment of Children and Adolescents: Overview Of Theory and Techniques MICHAEL BUTKUS, PHD Executive Director

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Oppositional Behavior   Effective Strategies: contingency

management; DROB (differential response for other behavior)

  Effective Programs: Parent Management Training (PMT) for pre-teens; Problem-Solving Communication Skills Training (see Robin) for adolescents

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Substance Use   Difficult to recommend one particular tx

because of the diversity of substance abusing youth; broad-based, multi-component tx programs seem to work well, e.g., Multidimensional Family Therapy, MST

  Essential to include CBT with Motivational Enhancement and Staging

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CBT & Ethnic Minorities   Research still sparse but building   Key points:

  CBT works (insight-oriented txs don’t work as well)   Better response if tx is highly structured, time-

limited, pragmatic and goal-oriented;   Using culturally-responsive strategies doesn’t always

lead to better results; ambiguity in research results   Adding too many intuitively appealing culturally

responsive strategies, may alter characteristics of CBT to point it is no longer model adherent

  Recommendation: Implement CBT as designed and add more culturally-sensitive strategies as suitable

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CBT Works Best If:   Fidelity and outcome measurement are

used   Clinical judgment is used (not just blind

adherence to a manual)   Cultural factors are considered   Limitations of the techniques are

appreciated   New therapists are supervised   A working alliance based on trust is

developed early