Cognitive–behaviour therapies for children and adolescents
Topics covered:
- Introduction
- Scientific background
- Cognitive processing
- The self-system
- Self-regulation
- Cognitive development in a social context
- Cognitive deficits
- Conduct disorder and aggression
- Attention deficit and hyperactivity
- Autism
- Depressive disorder
- Anxiety disorder
- Cognitive processing
- Technique
- Therapist stance
- Assessment, goal setting, and initial formulation
- Education and engagement of the child and family
- Problem-solving
- Core cognitive techniques
- Core behavioural techniques
- Indications and contraindications
- Areas of application
- Conduct disorders
- Attention deficit and hyperactivity
- Depressive disorders
- Anxiety disorders
- Pain
- Contraindications
- Developmental stage
- Severity of disorder
- Social context
- Areas of application
- Managing treatment
- Types of CBT programme
- Settings for CBT
- Involving parents
- Combination with other interventions
- Common technical problems
- Therapist factors
- Patient factors
- Parent factors
- Length of treatment and follow-up
- Efficacy
- Conduct disorder
- Attention deficit and hyperactivity
- Depression
- Anxiety disorders
- Summary
- Training and dissemination
- References
Introduction
Increasing numbers of mental health professionals are adopting cognitive–behavioural approaches to the treatment of emotional or behavioural disorders in children and adolescents. Cognitive models view individuals as actively involved in constructing their reality. Cognitive–behaviour therapy (CBT) with young people is based on the assumption that psychiatric disorders are due, in part, to deficiencies in particular cognitive processes or skills. A wide variety of procedures are included under the broad umbrella of the term CBT. At the core is an emphasis on certain cognitive techniques that are designed to produce changes in thinking and hence changes in behaviour or mood. However, while recognizing the importance of cognitive style in the development of mental disorders among the young, cognitive–behavioural formulations also emphasize the learning process and the ways in which the child's external environment can change both cognition and behaviour. Therefore CBTs for children and adolescents usually include a cluster of behavioural performance-based procedures, and often involve the family or school in therapy.
Cognitive and behavioural therapies have been applied to many different kinds of psychopathology among the young. The treatment of some of these disorders is discussed in other chapters. In the present chapter we provide an overview of the techniques used with children and adolescents, their main areas of application, and the evidence for their efficacy. Before reviewing these issues, it is necessary to consider briefly the scientific background to the use of CBTs in this age group.
Scientific background
From their beginning, an important feature of CBTs was their grounding in theory based on empirical investigations of the role of cognition in child development. It is helpful to consider cognition under two broad headings, cognitive processing and cognitive deficits, although in reality the two cannot easily be separated.
Cognitive processing
During the past 40 years it has become widely recognized that children's personal and social development is much influenced by the ways they perceive and think about themselves and other people. Three of the most prominent themes in contemporary research are the self-system, self-regulation, and the role of context in social cognitive development.
The self-system
The key notion here is that social development involves, amongst other things, the development of a sense of self, a sense of who one is and how one fits into society. The beginnings of self-awareness appear during the second year of life, when children begin to recognize their own face and pictures of themselves. Self-concepts later in childhood are usually assessed by asking children to describe themselves. There are developmental changes in the ways that children do this. Until around 7 years of age children tend to describe themselves in physical terms or in terms of preferred activities. During middle childhood descriptions of self become more abstract statements of fact (‘I don't get into trouble at school') and include psychological traits. As children form concepts about themselves, they start to assign negative or positive values to their attributes. These self-evaluations are collectively known as self-esteem.
The self-system and self-esteem are not unitary concepts. Children may feel competent in one area and incompetent in another. Nevertheless, the concept of the self-system has several implications. First, children's concepts about themselves may influence their motivation and behaviour. Second, children not only make judgements about themselves but also about their peers. From middle childhood they begin to respond to others partly on the basis of their reputations. Children's judgements about their peers can persist for many years and are a predictor of later behavioural adjustment. (1)
Self-regulation
Another important foundation for the development of social relationships is the capacity to control one's own behaviour and conform to the rules of society. In most cultures these rules include resisting temptation, refraining from hurting others, controlling one's impulses, and resisting distraction while working. Again, there are developmental changes in many of these aspects of self-control. For instance, in laboratory studies older children are more likely than younger ones to delay gratification.
Cognitive development in a social context
Developmentalists have long been interested in the relationship between cognitive development and social context. There are two aspects of this research that are especially important to the theory and practice of CBTs. The first is the extent to which children's cognitive capacities moderate their susceptibility to the effects of life experiences. For instance, young infants are less affected by separation from their parents because they have not yet developed the capacity to form attachment relationships. Older children are less vulnerable to the effects of separation because they have acquired the capacity to maintain relationships over the period of absence. In other words, cognitive capacities can define the salience of events for children.
The second is the way that cognitive factors mediate the effects of experiences. Probably the best known example of this process is the development of selective attachments. (2,3) The main idea is that children's early experiences of interpersonal relationships are crucial to their later psychosocial development. Early insecure attachments are associated with later relationship problems. The process by which attachment insecurity becomes transformed into later psychosocial difficulties is poorly understood, but the prevailing view is that the process resides in some form of internalized representation, or working model of relationships. Children may therefore shape their later social relationships in line with cognitive concepts that come from earlier relationships with their caregivers.
Cognitive deficits
Since cognitive processing seems to be so important in the normal child's social development and responses to experiences, it would be expected that distortions or deficits in cognitive processing would be found in children with psychiatric disorders. The available data suggest that this is often the case, though the direction of causality is not well understood. There are two types of cognitive problem associated with child psychiatric disorders: general problems such as reading retardation or low intelligence, and problems that are believed to be specific to a single disorder. However, much overlap exists between the supposedly separate disorders and there are few cognitive abnormalities that are completely specific to just one problem.
Cognitive deficits and distortions have been found in many childhood psychiatric disorders. The most extensively studied conditions have been conduct disorder, attention-deficit disorder, autism, depression, and anxiety.
Conduct disorder and aggression
In social cognitive models, aggression is not simply triggered by environmental events, but rather by the ways these events are perceived. (4) Research on aggressive boys has shown a number of cognitive biases. (5) They are more likely than their non-aggressive peers to perceive hostility in the actions of others, especially when the social situation is ambiguous (e.g. when bumped into in the playground). In actual competitive discussions with non-aggressive peers, aggressive boys tend to exaggerate the peer's aggressiveness and underestimate their own aggressiveness. This view of others as hostile has some basis in reality. Aggressive children tend to come from families where aggression is frequent. In addition, they are in fact more likely to be treated aggressively by their peers and to be rejected. Antisocial treatment by other children tends to perpetuate the reciprocal hostility of the aggressive child.
Children with conduct disorder and aggression also have difficulties in solving social problems. They tend to think of rapid non-verbal action-orientated solutions to problems rather than using deliberate memory retrieval strategies to generate verbal solutions. They are more likely than non-aggressive children to choose aggressive solutions to problems and less likely to bargain or negotiate to get what they want.
Attention deficit and hyperactivity
The syndromes of attention deficit and hyperactivity comprise three clusters of behavioural symptoms: inattention, impulsiveness, and hyperactivity. Diagnostic criteria for the major schemes have differed over the years. The North American DSM has tended to have a broader definition of attention-deficit hyperactivity than the less common, and perhaps more distinctive, pattern used in the ICD. The findings from research on the neuropsychology of these problems therefore differ somewhat according to the diagnostic scheme used.
Hyperkinetic children perform poorly on tests that require sustained concentration, such as the ability to maintain vigilance over a long period or to inhibit over-rapid responses. (6) At first, abnormalities on these tests were taken as evidence of deficits in one or more of the early steps in processing information. Recent research suggests, however, that the basic processes of perception, memory, and attention are intact. (7) Current models emphasize deficits at a higher ‘executive' level of self-regulation and inhibition. The key problem is thought to be the way that children inhibit or delay behavioural responses to external cues. They are unable or unwilling to inhibit actions and to wait for delayed consequences. However, models differ in their formulation of the core problem. In some, response inhibition is seen as the primary deficit. Children with attention-deficit hyperactivity are seen as having an underlying cognitive deficit or deficits. Other models suggest that impulsivity may be better seen as an aversion to delay rather than a failure to control. (8) Such models suggest that in working with children with attention-deficit hyperactivity it is important not only to exclude irrelevant material during teaching but also to motivate these children to apply themselves to the task in hand. See also: Attention-deficit hyperkinetic disorder in childhood and adolescence)
Autism
Autism is defined by the triad of social deficits, communication problems, and restricted and repetitive interests and routines. There is a great deal of evidence to show that children with autism have serious cognitive deficits in abstraction, conceptualization, and the use of meaning. These deficits are different from, though often associated with, generalized mental retardation. Several hypotheses have been put forward to explain how they might lead to the autistic child's social difficulties. The best substantiated is the idea that autistic children lack a theory of mind that might allow them to understand that other people have feelings, beliefs, and mental states. (9) Experiments show that autistic children have difficulty understanding what other people are thinking. For instance, most children with mental retardation understand that if someone is outside the room when an object is moved from one hiding place to another, that person will look for it in the original location, not where it is now. Autistic children are much less likely to show this understanding. (See also: Autism and the pervasive development disorders)
Depressive disorder
Depressive disorder is much less common in children than in adolescents, (10) and the question therefore arises as to how old children must be before they can experience the full range of cognitive symptoms found in adult depressive disorder. Children are capable of recognizing their own emotional states from as young as 2 years of age, (11) and during the preschool years they start to differentiate the basic emotions and to understand their meaning. (12) However, even if they experience repeated failure, preschool children are not easily discouraged and they only rarely show evidence of learned helplessness. (13) With the onset of concrete operational thinking (age range 7–11 years) the child begins to discover what is consistent in the course of any change or transformation. (14) Egocentrism declines. The child starts to develop self-consciousness and to evaluate his own competence by comparison with others. (15) Self is perceived more in psychological than physical terms and concepts such as guilt and shame become prominent. Enduring and relatively stable negative attributions about the self therefore become possible. In addition, children begin to understand the implications of certain kinds of adverse events. It is at around this age, for example, that most children can understand that death is permanent. (16) At the same time the child's emotional vocabulary expands, and children start to make fine-grain distinctions between emotions such as sadness and anger. In other words, by around the age of 8 to 11 years most children can both experience and report many of the cognitions that are found in adult depression.
Depressed children show a set of cognitive deficits and distortions that are similar to those found in depressed adults. They often have low self-esteem and cognitive distortions, such as selectively attending to the negative features of an event. (17) In addition, depressed children are more likely than non-depressed children to develop negative attributions. (18) For example Curry and Craighead (19) found that adolescents with greater depression attributed the cause of positive events to unstable external causes.
Anxiety disorder
Cognitive–behavioural formulations of anxiety disorder in children emphasize three main factors: behavioural avoidance, physiological responses, and negative cognitive appraisal. Anxious children tend to show a set of cognitive distortions that include being overcritical, overly concerned about self-evaluation, and bias towards picking up a threat in an ambiguous situation. (20) They expect bad things to happen. Like their adult counterparts, they tend to catastrophize physiological symptoms of anxiety such as panic attacks (‘I am going to die').(21) As anxiety becomes severe they engage in avoidance behaviours and may eventually refuse to go to school.
Technique
Cognitive–behaviour therapists use a variety of different techniques when working with children. The choice of technique depends on many factors, including the child's developmental level, the nature of the disorder being treated, and the therapist's psychological model of the causes of the child's problems. However, most CBTs have the following features in common.
Therapist stance
The attitude or mental posture of the cognitive–behaviour therapist working with children has been described using terms such as consultant and educator. (22) The therapist is active and involved but does not have all the answers. Rather, the therapist seeks to develop a collaborative relationship that stimulates the child to think for him or herself. The idea is not to tell the child what to do but rather to give the young person the opportunity to try things out and to develop skills. There is an emphasis on the child learning through experience. Thus, as in CBT with adults, there are homework assignments in which the child carries out tasks that are agreed in the session. These are often framed as an experiment. For example, the child may feel that she is disliked by a friend who will avoid her if she can. The child and therapist may conclude that the best way of finding out is for the child to try and talk to her friend.
Assessment, goal setting, and initial formulation
The assessment aims to provide a detailed description of the presenting problem that is consistent with a cognitive–behavioural formulation of the child's difficulties. The assessment should also provide information about the child's social context and about his or her strengths and weaknesses.
The initial interview begins with a thorough review of the presenting problems and any associated symptoms. In collaboration with the child and family the therapist carries out a detailed analysis of what are often vaguely defined presenting complaints to generate more specific target problems. The aim is to generate a short list of problems that are most distressing to the child and carers and which are most amenable to treatment. Standardized measures of the child's behaviour or emotions may help in defining these problems and are often a good way of measuring change. The therapist then endeavours to identify the cognitive distortions or deficits that often accompany emotional or behavioural disorders in children (see above). Finally, an assessment is made of the child's social context in respect of family, peer relationships, neighbourhood, and education. There should be a particular emphasis on identifying strengths both within the child and within the child's family or wider social environment.
The cognitive–behavioural formulation is based on information from the initial assessment. It should be a written explanation of the problem that highlights the key cognitive and behavioural factors that are thought to play a role in the onset or maintenance of the child's difficulties. It should also reflect the role of external factors, such as family difficulties or peer problems, on the young person's views of himself and his world. The formulation is likely, then, to be multilayered and to outline several priorities for treatment. The development of a formulation is an essential part of CBT with young people.
Education and engagement of the child and family
All forms of CBT should begin with an explanation of the diagnosis and the model of treatment for the child and family. The nature of this explanation depends on the child's level of cognitive development. Young people who have developed what Piaget (14) called formal thinking skills can usually understand the kind of explanation of CBT that would be given to adults. Such an explanation might, for instance, include the relationship between the way a person thinks about himself and his environment, and his behaviour or feelings. However, many children and young adolescents find it difficult to think about thinking and require explanations that are more appropriate for their developmental stage. For example, the therapist might present to the child a story about a social situation that could have several different interpretations (e.g. a stranger knocking at the door) and explore with the child the various different thoughts and feelings that could occur. How would the child feel, for example, if he or she thought the stranger looked like the murderer shown on the evening news? Children's stories such as The Emperor's New Clothes can also be a useful way of getting over ideas such as the power of thought and belief in determining how we behave. (23)
Although CBTs are usually viewed as individual or group treatments, there is a growing trend towards encouraging parents to have a role. Parental involvement is important for several reasons. First, parents or significant others can often be very helpful in implementing a therapeutic programme. For instance, they can help to reinforce homework assignments. Moreover, they can provide information about ongoing stresses in the child's life and about the continuation of certain symptoms that the child may be reluctant to talk about (e.g. peer relationship problems, antisocial behaviour). Second, there is the practical reason that it will often be the parents who bring the child for therapy. Third, parental behaviours and attitudes may be important predisposing or maintaining factors for the child's problems. For example, it is quite common to find that parents of anxious or obsessive–compulsive children are inadvertently reinforcing avoidance behaviours.
Problem-solving
A basic ingredient of both cognitive and behavioural approaches to psychiatric disorders in children is problem-solving. Although the immediate antecedents of many emotional and behavioural disorders can often be identified as specific cognitions or affects, these are usually provoked by some kind of external problem. These problems are commonly of an interpersonal nature, involving either the family or peers. Training children in problem-solving helps them to deal with these external problems and also provides a useful model for many cognitive–behavioural procedures. Problem-solving in children involves much the same steps as in adults. The child is first encouraged to identify a solvable problem and then to generate as many potential solutions to it as possible. The best solution is chosen, the steps to carry it out are identified, and the child tries it out. Finally, the whole process is evaluated.
Core cognitive techniques
At the core of most of the cognitive therapies used with young people are techniques for eliciting and monitoring cognitions and for correcting distorted conceptualizations and beliefs about the world.
At all ages there is an emphasis on self-monitoring, that is on charting thoughts and on recording the relationship between thoughts and other phenomena such as behaviours or recent experiences. In older adolescents cognitions can be elicited using much the same techniques as in adults. In younger children it is often necessary to use more developmentally appropriate methods. For instance, cartoon drawings such as the Thought Detective (24) can help to communicate the idea that the child is actively involved in the understanding of thinking and behaviour.
Cognitive restructuring forms an important part of many CBT programmes. The first step is to identify the thought. The thought itself should be noted down. Next, arguments and evidence to support the thought should be considered. Then arguments and evidence that cast doubt on the thought should be identified. Finally, patients should reach a reasoned conclusion based on the available evidence, both for and against their thinking.
Problematic thoughts are often underpinned by characteristic attitudes and assumptions about the self or about the world. Typical examples include the view that in order to be happy the patient must be liked by everyone, or that aggression is a legitimate way of dealing with interpersonal conflicts. These attitudes cannot usually be identified using the approach used to identify problem thoughts because they are not fully articulated in the patient's mind. Rather, they are implicit rules that often can only be inferred by the person's behaviour. In the later stages of therapy with older adolescents it may be possible to encourage the patient to look for patterns in his or her reactions to situations that betray these underlying assumptions. These techniques may be particularly useful in preventing relapse.
Core behavioural techniques
In parallel with cognitive methods the therapist also uses relevant behavioural techniques. Exposure techniques are used when the client is avoiding a feared situation, such as school. Many programmes include a system of behavioural contingencies, in which a system of rewards is set up to reinforce desirable behaviours. Reward systems for children usually involve the parents, but in some programmes there is an emphasis on self-reinforcement in which the child rewards himself.
Most child psychiatric disorders are worsened by inactivity. Activity scheduling involves the scheduling of goal-directed and enjoyable activities into the child's day. The child, therapist, and caretakers collaborate to plan the young person's activities for a day on an hour-by-hour basis. Specific behavioural techniques are also used to treat certain symptoms. For example, sleep disturbance may be reduced by sleep hygiene measures. Relaxation training may be useful for somatic anxiety symptoms.
Indications and contraindications
Areas of application
CBTs have been applied to most child psychiatric disorders. Their conceptual basis is strongest for four forms of psychopathology: conduct disorders, attention-deficit hyperactivity disorders, depressive disorders, and anxiety disorders. They have also been applied in medical conditions, particularly pain.
Conduct disorders
Cognitive–behavioural programmes for young people with conduct disorder and aggression usually have a strong focus on social cognitions and interpersonal problem-solving. The aim of therapy is to remedy the cognitive distortions and problem-solving deficits that have been identified in empirical research. Several programmes have been developed and most have the following features in common. Self-monitoring of behaviour enables adolescents to identify and label thoughts, emotions, and the situations in which they occur. Social perspective taking helps them to become aware of the intentions of others in social situations. (25) Use is made of case vignettes, role play, modelling, and feedback. For example, children might be asked to describe what is going on in a picture. Anger control training aims to increase awareness of the early signs of hostile arousal (e.g. remembering a past grudge) and to develop techniques for self-control.
Problem-solving skill training attempts to remedy the deficits in cognitive, problem-solving processing abilities that are often found in aggressive young people. One of the best known programmes was developed by Shure and Spivack at Hahnemann University in Philadelphia. (26) They suggested that successful social interaction depends on several skills: ‘alternative thinking', the ability to generate multiple solutions to problems; ‘means-end thinking', the ability to choose the desired outcome to a social exchange; and ‘consequential thinking', the ability to consider the likely consequences of actions. To foster these skills they developed a programme of lessons for preadolescent children that included games, discussion, and group-interaction techniques. The programme has an emphasis on the development of simple word concepts that are necessary for subsequent problem-solving. These words emphasize that there are alternative ways of solving a problem (‘I can hit him or tell him I am cross. Hitting is different from talking'). The Hahnemann programme also aims to foster skills in emotional awareness, information-gathering, and understanding motives. Children might be asked, for instance, to guess what the group leader is thinking.
Attention deficit and hyperactivity
Programmes for children with hyperkinetic syndrome usually involve three main elements: increasing the structure of the child's environment, behavioural therapy programmes with parents, and cognitive–behavioural interventions with the child. Environmental changes emphasize the need to construct an orderly, structured environment that reduces the likelihood that the child will be overactive or impulsive. Children with attention-deficit hyperactivity need more instructions and reinforcement than other children. Some of them will require extra help in class or at times when the environment is less structured, such as during the morning break. Behavioural interventions include techniques such as reward systems (e.g. star charts) and time out.
Several cognitive procedures are used with hyperkinetic children. The general aim is to provide them with more self-control. At the core of most CBT programmes are ‘stop–think–do' approaches. The child is first taught to stop. For example, the parent may hold out a stop sign when the child is about to rush into something. Stopping in such situations should then become automatic. Then the child must learn to think out loud while performing various tasks. The intention is that the child learns to control behaviour by verbalization of thoughts, which can be monitored and corrected by the therapist or parents. Finally, the child learns techniques to recognize problems and to apply strategies to deal with them. A key strategy here is self-instruction. For example, while executing a plan the child is taught to pose questions to himself such as, ‘Stop. What am I trying to do'. The child might then reply to himself, ‘I have to put the dishes away. What is my plan? First, I should...'. Eventually, the child should be able to exert control over behaviour by inner or silent speech. These techniques are commonly taught to children using cartoons, as in the Think Aloud Programme. (27)
Depressive disorders
Many slightly different cognitive–behavioural approaches have been developed for depressed children and adolescents. (28) Most programmes have the following features. First, the therapy often begins with a session or sessions on emotional recognition and self-monitoring. The aim is to help the young person to distinguish between different emotional states (e.g. sadness and anger) and to start linking external events, thoughts, and feelings. Second, behavioural tasks may be used to reinforce desired behaviours and thence to help the young person to gain control over symptoms. Self-reinforcement is often combined with activity scheduling, in which the young person is encouraged to engage in a programme of constructive or pleasant activities. Patients are taught to set realistic goals, with small steps towards achieving them, and to reward themselves at each successful step on the way. At this stage, it is quite common to introduce other behavioural techniques to deal with some of the behavioural or vegetative symptoms of depression. For example, many depressed youngsters sleep poorly and will often be helped by simple sleep hygiene measures. Third, various cognitive techniques are used to reduce depressive cognitions. For example, adolescents may be helped to identify cognitive distortions and to challenge them using techniques such as pro–con evaluation. Techniques to reduce negative automatic thoughts, such as ‘focus on object', are also employed.
Anxiety disorders
The principal components of cognitive–behavioural treatments for children with anxiety disorder are learning to deal with anxiety and practising these skills in real-life situations. One of the most widely used programmes is the four-step coping, or FEAR, plan. (29) The acronym FEAR stands for: Feeling frightened? (awareness of anxiety symptoms such as somatic symptoms); Expecting bad things to happen? (awareness of negative self-talk); Attitudes and actions that can help (problem-solving strategies); Results and rewards (rewarding for success, dealing with failure). The programme starts with sessions to help children identify anxious feelings and to link these to anxiety-provoking situations and to somatic symptoms such as panic attacks or abdominal pain. Relaxation training is then taught. The next few sessions aim to help the child to identify anxious self-talk and to correct these thoughts using positive coping thoughts. Finally, the child is helped to practise the skills learned in the first part of the programme in increasingly realistic situations. Initially these situations may be imagined (imaginal exposure), but later they may involve trips out of the clinic ( in vivo exposure) to real-life settings that invoke anxiety, such as the school.
Pain
Cognitive–behavioural procedures are now widely used in the management of pain in children. Pain from medical procedures such as venepuncture can lead to a delay or even a failure to complete these procedures, with important consequences for the child's medical care. Distraction techniques, such as allowing the child to watch a favourite television programme, can lessen the pain. Being honest with the child (e.g. telling him what is to happen), giving him some measure of control (e.g. allowing him to decide which arm the blood should be taken from), rewarding the child afterwards, and ignoring crying may also be helpful. Cognitive–behavioural methods may also be useful as part of the treatment programme for children with unexplained pains such as recurrent headache or abdominal pain.
Contraindications
Although CBTs are being applied across an increasing number of problems, there are several relative contraindications to their use.
Developmental stage
Suppose that Ben and Simon have just moved to another town and are going to their first party. As she drops him off at the party, Ben's mother says: ‘Try to remember the names of all the other children so you can tell me about them later'. Simon's father simply says: ‘I will meet you here afterwards'. Which child will remember more names? If the children are younger than 7 or 8 years old they will recall roughly the same number of names. If they are aged 11 years or older, Ben will usually remember the names of more children than Simon. When children respond to instructions that they have been asked to remember, they are using metacognition. The term metacognition refers to children's knowledge about their own cognitive processes. It is also used to describe executive functions such as planning, activating rules, monitoring learning, and evaluating the product.
Some of the techniques used in CBT require that the patient has knowledge about cognition, or is able to use executive processes, or both. For example, many programmes require the child to complete homework assignments that may involve some degree of planning (such as phoning a friend to see if he is really cross). Younger children are likely to find this difficult as they are less likely to plan activities before carrying them out. Similarly, a key task in some cognitive programmes is to evaluate the evidence for and against a particular belief, such as that ‘My friends don't want to know me'. However, the ability to hold mental representations of ‘theory' versus the ‘evidence' emerges only gradually during adolescence. (30) Children less than 10 years of age tend to ignore evidence against their beliefs. It is only by middle adolescence that most individuals develop the skill of separating theory from evidence.
Of course, adults also have problems in evaluating evidence. For instance, university academics sometimes stick to theories despite overwhelming contradictory evidence! Moreover, since metacognitive abilities are thought to be the result of experience as well as constitution, some of them can be learned. Nevertheless, it is clear that adolescence is a transitional period in cognitive development. Developmental stage is therefore an important determinant of the best technique for the child. As a general rule, older children and adolescents respond better to cognitive treatments than younger children. (31) Different techniques may therefore need to be applied to children of different ages. Preadolescent children may need behavioural procedures or simple cognitive techniques such as self-instruction training. Adolescents are more likely to benefit from cognitive techniques such as changing automatic thoughts.
Severity of disorder
One of the criticisms that is often made of CBTs is that they may not be effective in the most severe cases of disorder. Several researchers are now starting to address this issue and CBT has been used, for example, as part of treatment programmes for very severe cases of conduct disorder. (32) Nevertheless, it has to be said that much of the research that has been conducted up to now with CBTs has been based on samples recruited from advertisements or through schools. Moreover, for some conditions there is evidence that severe cases respond less well to CBT than mild cases. For instance, Jayson et al.(33) reported that an increased severity of social impairment was associated with a reduced response to CBT in adolescents with major depression.
Social context
Emotional and behavioural disorders in young people are deeply embedded in a social context. This has implications both for how the child's problems should best be managed and for the likely response to treatment. No treatment for the child is likely to succeed if basic needs such as adequate educational opportunities or security of family placement are not met. For instance, children who are moved frequently from one home to another are unlikely to be helped by CBT, or indeed by any other kind of psychological intervention.
Managing treatment
Types of CBT programme
The ideal treatment plan for the child depends on the nature of the child's problems, but it can include individual work, group sessions, or both. Individual programmes are particularly useful in settings where the numbers of cases referred with a particular problem are not great enough to sustain a group. One-to-one work is often necessary with children whose problems are so severe that they may disrupt a group. Certain kinds of techniques, such as cognitive restructuring, are better carried out with the individual patient.
Group CBT programmes provide supervised practice of a number of skills, such as social problem-solving, in a peer setting. Practising skills with peers may increase the likelihood of the transfer of skills to real-world peer interactions. The group also provides a good opportunity to practise problem-solving skills with real-life dilemmas that arise in the group. This is, arguably, better than having to rely on staged situations such as role play.
Settings for CBT
There is now a consensus among professionals that to maximize the generalization of therapy-trained skills to other settings, it is important to involve parents, teachers, or peers in the treatment of some disorders. CBT is therefore used in several non-clinical settings. School-based interventions have become increasingly popular in recent years, especially for behavioural disorders. Examples include the Problem-solving Skills Training Programme (34) and the Good Behaviour Game. (35) These programmes typically involve problem-solving techniques and guided self-talk to reduce disruptive classroom behaviours. School-based programmes have also been developed to prevent problems such as depression. (36)
Residential programmes have been designed to apply cognitive–behavioural methods in residential settings such as children's homes or secure care facilities. An example would be behaviourally based group homes for juvenile offenders, such as Achievement Place. (37) Gains from residential programmes may, however, be lost when the child leaves. Community programmes attempt get around this problem by conducting programmes in the youth's community. Typically, these programmes attempt to ‘wrap-around' the young person and family a network of interventions (such as contingency management) and social supports.
Involving parents
The extent of parental involvement depends on the problem that is presented. There is a long history of parental involvement in the treatment of behavioural problems, where it may be crucial in ensuring that skills are transferred to the home. A typical programme is as follows. (38) Parents participate initially in educational sessions about the disorder and about its management. They then take part in group or family sessions about how to model and reinforce the skills that the young person is learning. The cognitions of the parents may then be examined. Parental beliefs about parenthood and attitudes towards the child may be crucial in determining the outcome of treatment. It seems, for example, that parents' models of their own parenting relationships predict the attachment that they will have to their children. (39) Negative attitudes towards the child, as shown by high levels of hostility and criticism, are highly predictive of outcome. (40) It may be possible to work with the parent(s) to produce changes in beliefs about the child. Finally, the family take part in conjoint family therapy sessions that may focus on, for example, ways of the family solving problems more effectively.
Less is known about how best to involve the family in cognitive–behavioural programmes for emotional disorders such as depression or anxiety. Probably the best-developed parallel parental course for children with emotional disorders is that of Clarke and Lewinsohn. (41) This course involves the mixture of parental group sessions that aim to reinforce CBT with the child and conjoint behavioural family sessions. Problems such as school refusal, separation anxiety, and phobias will often require parental involvement in exposure programmes. Behavioural techniques such as activity scheduling also require parental support.
Combination with other interventions
Most child psychiatric disorders are comorbid with other diagnoses. For example, conduct disorder and attention-deficit disorder often overlap; around one-half of children with depressive disorder also have a comorbid anxiety disorder. There is also much comorbidity between psychiatric diagnoses and problems such as peer relationship difficulties, substance abuse, educational problems, and family dysfunction. The multiple problems of children with emotional or behavioural disorders have led to keen interest in using combinations of treatments. The two best studied combinations that involve CBT are:
- combination with stimulants in attention-deficit disorder
- combination with other psychosocial treatments in conduct disorder.
The most commonly used interventions for children with attention-deficit disorder are stimulant medications such as methylphenidate. Because of its beneficial effects, at least in the short term, stimulant medication has become the standard against which other treatments are judged. However, stimulants are least effective against symptoms that are some of the strongest predictors of the eventual outcome, namely conduct symptoms, peer relationship problems, and educational failure (6). Therefore integrative intervention programmes for children with attention-deficit disorder aim to supplement medication by focusing on areas such as parenting, social competence, and educational failure.
Probably the best known of the combination treatments for conduct disorder is multisystemic therapy. (42) This is a family systems approach to treatment. The child is viewed as embedded in a number of systems including the family, school, peers, and neighbourhood. Treatment is therefore multilayered and may target school, family, or peer difficulties. Since the systems approach is also concerned with the impact that the child's behaviour may have on other people, individual treatment of the child may be included as needed in the programme. For instance, problem-solving skills training might be used to alter the response repertoire of the young person.
Common technical problems
Randomized trials have indicated the promise of CBTs in managing several child psychiatric disorders (see the next section). However, some patients fail to respond to the initial course of treatment, or drop out before treatment has been completed. Several common problems can occur during CBT with young people, and which may partly explain the lack of response.
Therapist factors
One of the most common mistakes made by trainees is taking on patients who are unsuitable for CBT. Most research studies of cognitive therapy have been based on selected cases, and clinical practice should generally be confined to the kinds of cases that have been included in these studies. Thus, for example, the effectiveness of therapy with depressed adolescents has been demonstrated almost entirely in samples without significant comorbidity. (43) It cannot be assumed that adolescents with, say, depression and severe conduct disorder will respond to treatment in the same way as those with ‘pure' depression. Another common problem is the failure to construct an adequate cognitive–behavioural formulation of the young person's difficulties. This can lead to the application of techniques in a ‘cookbook' fashion, which is not tailored to the needs of the individual.
The attitudes of the therapist may lead to problems. For example, many children who are referred for therapy are in difficult life situations and believe that their predicament cannot be resolved. In such cases the therapist may be drawn into the belief that ‘anyone would feel like that' in the same situation. This view is generally incorrect. It is important that the therapist adopts an optimistic problem-solving approach and does not catastrophize the problem.
Patient factors
The patient's beliefs can also lead to difficulties during therapy. Some young people come to treatment with the belief that all their problems will be cured by psychological therapy. It is important that they understand the limitations of cognitive therapy. Therapists must ensure that specific and realistic goals are set at the start of the course. Other youngsters denigrate the therapy in statements such as: ‘I've had five visits and nothing has changed at all'. In such cases the therapist should explain that treatment often follows a variable course, with downs as well as ups.
Many technical problems can arise during CBT with young people. One of the most common is the failure to complete homework assignments. In such cases the therapist must first think back to the previous session to ensure that the homework tasks were adequately discussed. With younger patients, for example, it is important to get them to repeat the task back to ensure that it is understood. Homework problems can often be prevented. Next, the therapist should rehearse the homework tasks during the session. The therapist must model persistence and not simply give up if the homework has not been completed. Another common problem is the adolescent who does not talk in a session. In such cases the therapist should try to take the pressure off the young person by, for example, saying that ‘I will do the talking for a while'. Once the adolescent starts talking the therapist can try to understand the source of the problem.
Parent factors
Parental attitudes can be a powerful determinant of the outcome of treatment. Some parents believe that their child is simply ‘making it up' and does not really have a problem: ‘He will grow out of it'. Some take the opposite view, and believe that the child's problems are so severe and so much part of the personality that nothing can be achieved in therapy. Careful exploration of these beliefs by the therapist, followed by an appropriate explanation, can help to modify these attitudes.
Length of treatment and follow-up
The length of treatment varies considerably according to the nature of the presenting problem. Individual programmes for adolescents with conduct disorder are often lengthy, taking up to 25 or 30 weekly sessions. Programmes for children with episodic disorders such as depression tend to be shorter, at around 12 to 16 sessions within 8 weeks.(44) Versions of CBT with as few as eight sessions have been shown to be effective. (45) Since many psychiatric disorders in children tend to be chronic, or relapsing and remitting, extended forms of CBT have also been developed. Two main varieties exist. The first involves a continuation of treatment after the acute phase of symptoms has improved. At that point the child enters into maintenance therapy, which typically involves CBT on a more intermittent basis than during the initial course of treatment. The development of continuation forms of CBT is at an early stage, but there is preliminary evidence indicating that it may help to prevent the relapse of some conditions, such as depression. (46) The second model involves periodic ‘check-ups' in which the young person returns to the therapist from time to time. (32) Any return of symptoms can be treated at an early stage.
Efficacy
Conduct disorder
Several randomized controlled studies have found benefits from cognitive–behavioural interventions with conduct-disordered or aggressive children. For example, Kazdin et al. (47) used a 20-session problem-solving skills programme with psychiatric inpatient children. Compared with two control conditions, the intervention led to significant reductions in parents' and teachers' ratings of aggressive behaviour after treatment and at 1-year follow-up. These results were replicated in two other randomized studies of problem-solving training by the same research group. (34,48) Other groups, too, have found that CBT has significant beneficial effects on antisocial behaviour that persist at 1-year follow-up. (49)
Since conduct disorders are notoriously difficult to treat, these results are very encouraging. Nevertheless, several limitations need to be borne in mind. (32) First, some children with conduct disorder do not respond to CBT. Children with comorbid diagnoses, poor peer relationships, or who come from dysfunctional families seem to be less likely to respond. Such children may do better with combination treatments such as multisystemic therapy, which seems to be effective in severely impaired cases.(50) Second, the clinical significance of the changes found in these studies is unclear. (32) Many children still have some conduct problems after treatment.
Attention deficit and hyperactivity
Behavioural interventions (such as operant approaches and token economies) improve targeted behaviours, social skills, and academic performance in children with attention deficit.(51) However, these improvements tend not to persist over time or to generalize to new situations. Moreover, behaviour modification alone is less effective than medication alone. (51)
Cognitive techniques (such as self-instruction and problem-solving) were developed in an attempt to improve the generalization of behavioural methods. However, the evidence thus far suggests that cognitive techniques are not a particularly effective treatment for attention deficit, do not generalize more than behavioural techniques, and do not supplement the effects of medication.(52) Their optimal role may be to target domains that are least likely to respond to medication, such as prosocial behaviour, and to enhance behavioural techniques.
Depression
There have been at least six randomized controlled studies of cognitive behaviour in samples of children with depressive symptoms recruited through schools. (43) The design has usually been to screen all children using a depression questionnaire and then to invite those with a high score to participate in a group intervention. In four of the trials cognitive therapy was significantly superior to no treatment.
Encouraging results have also been obtained for clinically diagnosed cases of depressive disorder. A quantitative meta-analysis of six studies found a significant improvement in the CBT group over the comparison interventions. (53) The pooled odds ratio in an intent-to-treat analysis was 2.2.
There are few data regarding the factors that influence treatment outcome. The most consistent finding thus far has been that children with severe depressive disorders respond less well than children with mild or moderately severe conditions. Research has also examined the role that changes in negative cognitions might have in predicting outcome. Cognitive therapy is not differentially more effective in cases with high cognitive distortion. Parallel parental sessions do not significantly enhance the beneficial effect of cognitive therapy with the child. (41)
Published research has several limitations. First, it is based on samples with mild or moderately severe depression. CBT may not be effective in severely depressed children. Second, much of the research has compared CBT with inactive comparison conditions such as remaining on a waiting list or psychological placebo. It is not known how CBT compares with other recognized forms of intervention, such as medication. Third, it is unclear whether cognitive or behavioural processes correlate with a better outcome. The therapeutic basis for change is therefore uncertain. Even so, CBT is a highly promising treatment for juvenile depression with replicated beneficial effects.
Anxiety disorders
Less is known about the value of the cognitive–behavioural therapies in childhood anxiety disorders. Behavioural therapy is probably a useful treatment for school refusal that is secondary to anxiety disorder. Miller et al. (54) found that behavioural treatment was more effective than being on a waiting list in decreasing children's fears. Two randomized trials suggest that CBT is also an effective treatment for anxiety symptoms. (55)
Summary
All in all, this review suggests that, when compared with either no treatment or a credible psychological placebo, the cognitive–behavioural therapies are effective for a number of mental or behavioural disorders. Similar findings have been reported in meta-analyses. (56) However, CBTs are not a ‘cure-all'. Future research will need to establish whether they are effective in severe forms of emotional disorder and how they are best combined with other treatments for conduct disorder. Another key issue is how the results from research are disseminated into clinical practice.
Training and dissemination
Many versions of CBT are available in manual form, which should help in their dissemination into routine clinical work. It has to be said, however, that there are at present only limited training opportunities to learn the approach. Many training programmes in child psychiatry and child psychology can provide some exposure to CBTs, but there are few formal training opportunities. The application of cognitive–behavioural methods requires knowledge of social learning principles and a variety of different skills. These skills can be readily taught, but this does take time. This time is likely to be well spent because there is evidence that proper training in the psychological therapies enhances clinical efficacy. (57)
How, then, can the promising results from the trials conducted thus far be disseminated into practice? The first step is better access to training in CBT. The second is the inclusion of information about CBTs in clinical practice guidelines. This is important because there is evidence that many child mental health services continue to offer treatments of unproven effectiveness.(58) Third, ways need to be found of producing versions of the cognitive therapies that are more accessible to patients. At present, only a minority of young people with treatable mental disorders are seen by mental health professionals. Many of them, however, will be seen in paediatric clinics, social services departments, or in primary-care facilities. It may be possible to develop highly structured brief interventions that can be used in these settings. CBTs could become part of the therapeutic armoury of many child health professionals.
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