Cognitive Behavior Therapy As illustrated in Table 1, the components of cognitive behavioral therapy (CBT) typically include strategies to teach a child how to change faulty cognitions that are contributing to his or her distress, and how to manage behavioral responses to improve the likelihood of healthy psychological adjustment. CBT has consistent evidence in the literature as an evidence based intervention for several mental health problems including disruptive behaviors such as aggression; internalizing disorders such as depression and anxiety; and coping with acute and chronic pain.
Mental Health Problem & Sample components of CBT Disruptive Behaviors…Table 1 • Aggression • Poor self control • Impulsivity • Guiding self statements ("Stop, Think Act") • Positive self statements ("You can solve this problem") • Verbal self-instructions ("What are all of my options to solve this problem?") • Relaxation training (controlled breathing, progressive muscle relaxation) • Reinforcement for using skills
Anxiety…Table, 2 • Nighttime fears • School refusal • Separation anxiety • Generalized anxiety • Specific phobias • Social phobia • Obsessive Compulsive Disorder • Recognition of faulty cognitions ("I can't go in that elevator"; "Everyone will laugh at me when I give my talk") • Positive self statements ("I can handle this"; "I know that's just my anxiety telling me lies") • Relaxation training • Modeling, role playing, reinforcement for using CBT skills • Exposure to a hierarchy of anxiety-producing situations
Pain management…Table,3 • Procedure-related pain • Headaches • Recurrent abdominal pain • Pain associated with chronic illness such as arthritis, cystic fibrosis • Education about pain to child and parents • Positive self-statements ("You can get through this") • Relaxation training (controlled breathing, distraction, imagery) • Guiding self-statements ("I can make it through this") • Differential reinforcement by parents of pain and well behaviors of child • Practice and problem solving
An Example of CBT • Perhaps one of the best illustrations of how CBT works can be found in the area of anxiety. Anxiety is defined by poor coping skills, ineffective problem solving, and significant physiological distress-symptoms that are all amenable to cognitive and behavioral strategies. • Well-defined intervention strategies with treatment manuals exist to teach children and their parents how to use CBT for generalized anxiety, separation anxiety, and phobia. An excellent example of a CBT program for anxiety is the Coping Cat program by Philip Kendall, Ph.D. (Kendall, 2000). • In Kendall's program, children are first taught the skills they need to cope with their particular anxiety, and given a chance to practice those skills as they expose themselves to increasingly more difficult situations that provoke their anxious responses.
Training for the children • Training for the children includes bodily awareness of anxiety responses, anxious self-talk and how to correct it, relaxation strategies, and the use of an acronym to remember the skills needed to be successful. • Each step is taught using the therapist modeling the coping skills, role play of anxiety-producing situations, and positive reinforcement for the practice or use of each strategy. • The Coping Cat program and it's variations (e.g., the Coping Koala for studies conducted in Australia) has been effective compared to wait-list controls, with treatment gains maintained at 2 and 5 years post intervention (Kendall, 1994; Kendall & Southam-Gerow, 1996). • A more comprehensive discussion of anxiety disorders and their treatment with CBT, including group CBT, can be found in Christophersen and Mortweet (2001).
Who Benefits from CBT? • Most of the studies that have been conducted on CBT have included children ages 6 or 7 and older. A child must have the cognitive maturity to be able to understand concepts such as self-talk and self-instruction. • In our practice we have found that children in at least first grade can master some of these concepts and may become more proficient at using them in times of stress over time. Of course a child must be willing to learn the skills and practice them for CBT to be effective. • This can be a treatment barrier when CBT is being used to address an issue that the child is not necessarily interested in resolving, such as anxiety about thunderstorms. • In response, most CBT programs for children incorporate reinforcement systems to encourage practice, use and mastery of the skills being taught.
A key factor for CBT success • A key factor for CBT success is the child's willingness to practice the skills when they are not anxious, angry, or in pain. • Success often depends on the parent's willingness to encourage the child to practice, including practicing with him or her, and using positive reinforcement for cooperation and successful outcomes. • Finally, many children with mental health problems suffer from comorbid disorders such as anxiety and depression. CBT has been studied in these more complex children and has been found to be effective for these children as well.