[Katharina_Manassis]_Cognitive_Behavioral_Therapy

better?” Finally, if the child clearly has the skills to manage the situation but is reluctant to apply them, sometimes restricting the child’s alternatives in the situation works best. For example, if a child knows how to use the bus but prefers to be picked up by a parent, the parent can provide bus fare and a phone card and indicate that he or she will only pick up if called. Most children will not go to the trouble of finding a pay phone, and hop on the bus instead. Providing children with cellular telephones is usually not advisable in this situation, because it makes it too easy to contact the parent. Frequent use may also have adverse effects on hearing health in children.

Strategies to improve motivation are based on the “A.B.C. rule” provided in many texts: antecedents, behavior, consequences. Examining antecedents allows one to anticipate situations where a behavior is likely to occur and plan accordingly. For example, if providing prior warnings allows a child who tantrums in response to transitions to anticipate the transition and handle it better, provide them.

Positive and negative consequences allow one to (respectively) increase and decrease repetition of the behavior subsequently. Child CBT programs generally emphasize positive consequences, not because CBT therapists are really nice people (although we may like to think we are), but because negative consequences often draw undue attention to the behavior, thus inadvertently reinforcing it. “Praise what you like; ignore what you do not like” is thus a good rule of thumb.

Both parents and therapists can be involved in providing positive consequences, and involving both is often seen as more meaningful from the child’s perspective than involving only one or the other. In therapy, every tiny effort is reinforced in an age-appropriate manner. Praise is used almost universally, and tangible reinforcements may include stars and stickers in younger children and talking time or game time in older children. In withdrawn children, sometimes even making eye contact is praised.

At home, parents can often identify what reinforcements motivate their child. If not, suggest ones that are similar to those used in therapy and beware of jealous siblings who may also need some recognition for a job well done (usually in a different area from that the client is working on). Small, frequent reinforcements that are only provided after the child attempts the desired behavior are usually more effective than lavish gifts that are either not clearly linked to behavior, or promised at some distant future date. Given young children’s limited time perspective, a reward that cannot be earned in a week is often meaningless.

If the child says something that is clearly wrong during the session (for example, labeling a thought as a feeling or vice versa), be positive about the child’s effort to answer (for example, “good try!”) and then provide the correct response. This is especially important in perfectionistic children, who sometimes become overly preoccupied with getting answers right. “Brainstorming,” where as many answers as possible are generated regardless of accuracy is sometimes a useful addition in this group. Self-conscious children are another

special group. These children may be embarrassed by praise, so simply acknowledging their work may be more helpful than lavish congratulations.

Finally, encourage children to provide themselves with positive feedback. Many child-specific manuals include self-reward, because it is helpful for most children and improves the chances they will maintain the new behavior after the therapy concludes. It is important, however, to encourage them to self-reward effort, not just successful outcomes. Some strategies need to be practiced multiple times before they become effective, so it is more encouraging to focus on attempts as well as successes. Self-reward strategies also reassure parents that they will not be expected to find creative or expensive reinforcements for their child indefinitely. Remember that CBT is hard work for the child. Therefore, self-reward is almost always deserved.

Working with Children Worksheet

For the child you are currently seeing, think about the child’s circumstances and developmental level. Try to put yourself in the child’s shoes.

List the interventions described in this chapter that might be helpful with this child:

•To develop trust and rapport. 1.

2.

•To address any cultural differences between yourself and the child (look back at the previous chapter if you are unsure).

1.

2.

•To establish “ground rules.” 1.

2.

•To address any cognitive challenges. 1.

2.

•To facilitate learning CBT strategies. 1.

2.

•To improve motivation during sessions. 1.

2.

•To improve motivation at home/between sessions. 1.

2.

Clinical Challenge

Consider how you would approach this case:

Bill is a 12-year-old boy with a primary diagnosis of dysthymic disorder (chronic, mild depression). He has attended nine CBT sessions with you, using an age-appropriate manual focusing on depressed mood. According to his mother, he was “born unhappy.” He was a very colicky baby. As a preschooler, he showed a number of sensory sensitivities (sensitive to noise, hated tags in clothing) and was easily upset by minor changes in his environment or changes in routine. At the time, these traits were thought to be due to anxiety. When he started school, he was teased by other children a couple of times. Although he had friends, he concluded “everybody hates me” and dwelled on this idea. If he got a low mark on a test, he labeled himself “stupid,” but also accused his teacher of being unfair. At home, Bill was very resentful of his younger brother George. He angrily stormed off to his room whenever his parents said a kind word to George and often accused them of being unfair. Despite his chronic unhappiness, Bill ate and slept regularly, followed the house rules, had some goals for himself, had never been suicidal, and did not meet criteria for major depression.

In CBT, Bill seemed like the model client. He participated in sessions and seemed eager to learn and practice his strategies. He even offered to teach other children what he had learned. His only complaint was that his therapist occasionally deviated from what was written in the manual, and “he shouldn’t do that.” Outside of therapy, none of Bill’s negative statements or negative behavior seemed to change.

1.What environmental factors might be interfering with Bill’s progress in therapy, and how would you address these?

2.What cognitive factors might be interfering with Bill’s progress in therapy, and how would you address these?

3.What aspects of the therapy itself might be hampering progress, and how would you address these?

References

Bagels, S.M. & Siqueland, L. (2006). Family cognitive behavioral therapy for children and adolescents with clinical anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 134–141.

Beck, A.T. (1963). Thinking and depression: I. Idiosyncratic content and cognitive distortions. Archives of General Psychiatry, 9, 324–333.

Butler, A.C., Chapman, J.E., Forman, E.M., & Beck, A.T. (2006). The empirical status of cognitive-behavioral therapy: A review of meta-analyses. Clinical Psychology Review, 26, 17–31.

Chistodoulides, T., Dudley, R., Brown, S., Turkington, D., & Beck, A.T. (2008). Cognitive behavior therapy in patients with schizophrenia who are not prescribed antipsychotic medication: A case series. Psychology and Psychotherapy, 81(Pt 2): 199–207.

Kendall, P. (1993). Guiding theory for therapy with children and adolescents. In P. Kendall (Ed.), Child and Adolescent Therapy. New York: Guilford Press.

March, J. & Mulle, K. (1998). OCD in children and adolescents: A cognitivebehavioral treatment manual. New York: Guilford Press.

Morris, T.L., Hirshfeld-Becker, D.R., Henin, A., & Storch, E.A. (2004). Developmentally sensitive assessment of social anxiety. Cognitive Behioral Practice, 11, 13–28.

Muris, P., Meesters, C., Mayer, B., Bogie, N., Luijten, M., Geebelen, E., & Smit, C. (2003). The Koala Fear Questionnaire: A standardized self-report scale for fears and fearfulness in pre-school and primary school children. Behavioral Research and Therapy, 41, 597–617.

Turner, C.M. (2006). Cognitive-behavioral theory and therapy for obsessive-compulsive disorder in children and adolescents: Current status and future directions. Clinical Psychology Review, 26, 912–938.

Wood, J.J., Piacentini, J.C., Southam-Gerow, M., Chu, B.C., & Sigman, M. (2006). Family cognitive behavioral therapy for child anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 45, 314–321.

Comorbid oppositional behaviors can be addressed by including behavior management strategies when working with parents of children in CBT (Mendlowitz, Manassis, Bradley, Scapillato, Miezitis, & Shaw, 1999). Such behaviors may also be secondary to the main disorder (for example, defiance of parents in order to be allowed to withdraw from the family in depression; oppositional behavior in response to being asked to enter feared situations in anxiety). Treatment for conduct disorder usually needs to be prioritized before pursuing CBT for anxiety or depression, given the disruptive effects of this disorder on the youth and others. Combined treatment for conduct disorder and depression has been evaluated, but found no better than a life skills/ tutoring control condition in alleviating either problem at 6- and 12-month follow-up (Rohde, Clarke, Mace, Jorgensen, & Seeley, 2004).

Anxiety disorders and attention deficit hyperactivity disorder (ADHD) co-occur frequently, and usually these children benefit from a combination of medication and behavioral or cognitive behavioral treatment (Manassis, 2007). They may not respond as consistently to stimulants as children with ADHD alone, but many still benefit from these medications (March, Swanson, Arnold, Hoza, Conners, & Hinshaw, 2000; MTA Cooperative Group, 1999). Relevant to CBT, children with this comorbidity often have difficulties with tasks that require “working memory” (the ability to simultaneously store and manipulate information) (Manassis, Tannock, Young, & Francis-John, 2007b), and many verbal CBT strategies do require this ability. CBT approaches that require less working memory, such as the imagery-based modules at the end of this book, may be considered in this population. Given their distractibility, children with comorbid ADHD may also benefit more from individual than group treatment. ADHD is highly heritable (Pliszka, Dodson, & Spencer, 2000), so parents of these children sometimes have ADHD traits that affect their organizational abilities, potentially affecting therapy.

Extremely withdrawn children can be difficult to engage in therapy. Positively reinforcing every minor sign of engagement (for example, reinforcing eye contact with the therapist), doing exercises with or for the child and reinforcing “tagging along with the therapist,” and increasing the involvement of parents or peers in therapy have all been suggested (Manassis & Young, 2001). Some withdrawn children fear criticism, so setting up “win– win” situations in therapy (situations where the child can be positively reinforced regardless of response) and ignoring mistakes can be helpful. A playful approach, with decreased emphasis on results and rewards, can be helpful for some withdrawn, self-conscious children.

A special case of withdrawal occurs in the child who is selectively mute. These children fail to speak in certain settings due to social anxiety and sometimes have language deficits or other developmental difficulties as well which should be assessed (Manassis, Tannock, McInnes, Garland,

Clark, & Minde, 2007a). Serotonin-specific medications are often helpful in combination with behavioral or cognitive-behavioral interventions (Manassis & Tannock, 2008). However, standard CBT protocols for anxiety are usually not ideal, given the lack of speech in therapy. Behavioral intervention that involves the parents and school has been found helpful, and one version of this is well described in a book by McHolm, Cunningham, Vanier, and Rapee (2005). Further therapeutic ideas can be found in the paper by McInnes and Manassis (2005).

Reality-based challenges in CBT occur when the child’s negative feelings are not entirely based on cognitive distortions, but have some basis in reality. An extreme example of this occurs in posttraumatic stress disorder, and there are child CBT protocols specific to this condition (March, AmayaJackson, Murray, & Schulte, 1998; Scheeringa, Salloum, Arnberger, Weems, Amaya-Jackson, & Cohen, 2007; Smith, Yule, Perrin, Tranah, Dagleish, & Clark, 2007). They generally emphasize reexperiencing the traumatic event in imagination during therapy sessions (called “imaginal exposure”) to allow cognitive and emotional processing of what happened, as well as overcoming avoidance of situations the child associates with the trauma. Addressing parental traumatic symptoms is important to treatment success, especially in younger children (Scheeringa et al., 2007).

Another reality-based challenge occurs in children with life-threatening allergic conditions (called “anaphylaxis”) or asthma. Allergic and asthmatic conditions have a particularly high association with childhood anxiety disorders (greater rate than expected by chance) (Papneja & Manassis, 2006), and it is unclear whether this is due to common biological substrates or the unpredictable nature of these conditions provoking anxiety. Parent– child difficulties have been found to be increased in asthmatic anxious children relative to nonasthmatic anxious children (Papneja & Manassis, 2006). Fostering calm, sensible management of both the medical condition and the anxiety in these cases requires sensitivity to the medical concerns and intervention with the family and school as well as the child (Monga & Manassis, 2006).

Reality-based challenges also occur in children who experience upsetting medical or other life events that trigger fear or sadness in most people. Cognitive-behavioral protocols specific to pain have been developed for children (Sanders, Shepherd, Cleghorn, & Woolford, 1994), but the challenges of helping children cope with frightening medical procedures, uncertain medical prognoses, and changes in self-image associated with illness or disability have received less research attention. Developing a child’s sense of mastery over the upsetting feelings in CBT (as opposed to challenging the validity of frightened/depressed thinking) is one potentially helpful approach and is emphasized in the modules at the end of this book.