[Katharina_Manassis]_Cognitive_Behavioral_Therapy

knowledge of the child than the therapist has. Also, if parents are to carry on solving problems after the group ends, they will need this skill. To encourage parents to find solutions for a problem, ask “What do other people in the group think?” or “What would other people around the table do in that situation?” This also encourages group members to help each other, which benefits both the helper and the recipient of the help.

•Encouraging parents to test out their ideas between sessions and report back on the results to “fine-tune,” if needed, to determine what works for each child. Parents are usually more amenable to this type of homework than to a written exercise, and it is far more practical. If parents do not do this, point out that the group will have little to talk about in the next session. Formal teaching is more limited in parent than in child groups, so parents’ reports are necessary “grist for the mill” of group discussions.

•Setting limits with talkers and engaging the silent types. This is the most common aspect of group dynamics that a therapist must monitor and attend to. Gentle redirection of someone who is monopolizing the conversation is an art. “That is a really good point, and we will talk more about it next week. Right now, we need to get back to…” is one example of redirecting a talker. Asking others in the group to comment on the issue is another. At the other end of the spectrum, some parents never speak unless spoken to. The therapist should create an opportunity for everyone to speak at least once during a session (for example, “What did you think about X, Helen?”), but respect some people’s need to warm up slowly or to just listen for a while.

•Remembering that parents need positive reinforcement just as much as children do. Often, they will positively reinforce each other for contributing ideas, but if someone’s contribution is not acknowledged the therapist should acknowledge it. This is often easiest to do during a problem-focused discussion by summarizing who contributed which ideas. Ideas and contributors that have not been previously acknowledged can be given additional emphasis. Positive reinforcement for attendance (for example, “Wow! You made it through that traffic mess out there!”) is helpful too, especially with members who may feel less connected to the group.

Group Dynamics

In addition to these differences from individual CBT, one must also attend to group dynamics when working with children and parents using this modality,

as illustrated in the example at the beginning of this chapter. First and foremost, children must feel safe in the group. Intervening to prevent bullying or verbal taunts is essential. The task-focused, structured nature of CBT groups also reduces anxiety and promotes a sense of safety, more so than unstructured, process-oriented groups do. For this reason, it is important to keep the group on task, as long as one does not totally ignore the members’ emotional needs as the leader in the example did. Session structure is similar to individual CBT. After an introduction to the session agenda, children review homework (though with encouragement to help each other understand any concepts that they are struggling with), learn a new CBT skill until everyone can demonstrate an understanding of it, discuss homework to be practiced between sessions, and then have some social time at the end.

Members who feel alienated from the group are not only at risk for a poor therapeutic outcome themselves, but also place other members of the group, potentially the entire group, at risk. The “ripple effect” of a single group member who is negative about the group or stops attending can impact everyone. On the other hand, too much attention to individual needs may undermine helpful group interactions. “Brainstorming,” for example, is much easier when the group is focused on solving a problem rather than addressing individual difficulties.

Balancing the needs of the group and the needs of individual members can be challenging in child CBT, but can be easier if two group therapists are present. One can be a trainee or less experienced therapist, as long as the two can work together. In this case, one therapist leads the group, keeps it focused, and ensures that CBT content is covered. The second therapist attends to group process and helps group members that may be struggling with the material, have behavioral problems, or require individual attention for other reasons. After each session, the two therapists share their experiences, including any concerns about particular members or the dynamics of the group. The problem can then be addressed promptly the next week.

Common problems include children who feel alienated from the group, have difficulty keeping up with the rest of the group, have difficulty containing their behavior in the group, attend inconsistently, or “clash” with another child, resulting in conflict. With two therapists, each child’s progress is briefly reviewed each week, so these problems can be addressed. In addition, the level of cohesion or sense of “belonging” that seems to be present in the group can be gauged. This is just as important as learning CBT principles when offering CBT in this format. Emphasizing commonalities between group members, highlighting unique contributions certain members make to the group, including a social or game time at the end of each group (often with a snack), including cooperative group challenges (for example, “let’s see how many words for feelings we can come up with as a group”), and encouraging children to help each other when they are “stuck” on a particular CBT task are all ways of improving cohesion. As in individual work, therapists who take a

genuine interest in the children’s day-to-day lives also foster a strong therapeutic alliance. Allowing children to do the same with each other, as long as it does not distract from the task at hand, also fosters allegiance to the group.

Crisis situations can arise even in the best-organized groups. This is even more likely when including children with comorbid conditions (for example, anxiety and depression). It behooves the group therapist to be aware of local emergency resources and access them promptly when the need arises. While having a group member express suicidal thoughts or lose control behaviorally (two common crises) may be upsetting to other group members, it need not be disastrous. As long as the group leader provides an explanation of what has happened and subsequent updates on how the child in crisis is doing, other children are often very sympathetic. They may, for example, want to send a get well card if the child is hospitalized or convey their continued interest in the child in some other way. Many children are reassured to see a group leader take action to prevent a group member from harming themselves or other people in the group. Parents sometimes require more reassurance than children when this occurs. They may be concerned about contagion (their own child behaving the same way as the child in crisis) or question the therapist’s competence. This is one of the few situations where talking to parents about some of what is happening in the child group may be appropriate, although the children deserve to know why this is necessary. If a crisis occurs outside the group, the affected family and child usually have their own preference about how much to share with the group, and the therapist should generally respect their wishes. Many CBT groups never encounter a serious crisis. While crises are not expected, however, preparation for them is still worthwhile.

School-Based CBT

Several child CBT programs for schools have been developed recently. The best known is the FRIENDS program by Dr. Paula Barrett and colleagues in Australia. It has been successfully demonstrated to reduce anxiety in comparison to a waitlist control condition (no intervention), so is now being adopted as part of the school curriculum in Australia and parts of Canada. It is available via the FRIENDS Web site (see references).

Before running out to buy this program, though, it is worth considering the benefits and potential pitfalls of school-based child CBT. On the positive side, school-based child CBT provides the opportunity to reach many more anxious or depressed children who could benefit. Only about 20% of children with mental health problems typically come to clinics, but 100% of children are obliged to go to school! School-based intervention may also reduce the stigma typically associated with seeing a mental health professional in a clinic or hospital. CBT is a didactic treatment, so it is very similar to learning another school subject already on the curriculum. This makes it a “natural fit” for the school environment. Furthermore, many anxietyor depression-related problems in children manifest during the school day, so

teachers are often eager to help children manage these. Therefore, they are often very receptive to CBT-based interventions.

A note of caution is warranted, however. Studies to date have focused mainly on waitlist control conditions. This means that school-based CBT has been compared to doing nothing, rather than being compared to other school-based interventions. It is therefore possible that doing something less sophisticated (for example, a well-supervised after-school program) might confer the same benefit. A structured program with positive peer interaction and positive reinforcement from a caring adult can, for example, be provided by a good sports coach, drama coach, or school newspaper organizer. It is possible that the skills learned in CBT do confer a greater benefit than one of these programs, but this possibility is still being studied.

A second consideration is whether or not CBT for a particular problem in childhood confers long-term benefit into adolescence and adulthood. Most programs are focused on one disorder or group of disorders (anxiety disorders, in the case of FRIENDS), but we know that child mental health problems fluctuate over time. Will a child anxiety program really prevent depression in adolescence? Nobody knows.

Who are the best candidates for such programs? Should they be provided to every child, because the skills can be helpful to everyone, or should we target children who are at risk for more serious problems to avoid wasting time, energy, and money on a program that is not necessary in many cases? Should children be selected based on their ability to disclose symptoms (because these children are more likely to be ready to address those symptoms), or based on others’ perceptions of their symptoms? Who (if anyone) should be excluded from such programs? There are no clear answers to these questions.

Finally, how does one implement a program in a way that the school is likely to embrace it and sustain it over time? In a school setting, it is not enough to identify suitable children who could benefit from CBT. The school board, the principal, the people implementing the program (whether teachers or mental health professionals), the parents, and the child all need to be convinced of the value of the program, or it will not be adopted in the long run. This fact implies a lot of interpersonal contact and work with the schools, quite apart from just “doing child CBT.”

Having run school-based CBT programs for several years, I do have a few suggestions. These include:

•Do not attempt school-based CBT until you are confident about using this modality clinically. You will not be able to “sell” it to the schools without that confidence. Then, always ask for the opportunity to present your program to parents of children attending each school, as this is essential to ensure child participation. Utilizing videotapes, brochures, or program Web sites can also help to publicize and market your approach.

150Cognitive-Behavioral Therapy with Children

•School personnel tend to be sensitive to the possibility of stigmatizing children attending programs with a mental health focus. Anticipate this, and find ways to reassure them. Giving your program a child-friendly, nonpsychiatric name helps. For example, we named our program “The Feelings Club” (Wilansky-Traynor & Manassis, 2004).

•Count on at least a year of planning and meeting with various school personnel before you actually start your program. Approach key leaders in mental health at the level of the school board (for example, chief psychologist, chief social worker). Find out if you need a written agreement with the school and/or school board to work with the children, if your staff will need police background checks, if you need permission to be on school premises after hours (if you are running an after-school program), if you need access to clinical backup services for emergencies, and any other requirements either by the board or the local schools.

•Do not compromise on basic CBT needs such as private space for groups, timing that allows children to attend consistently (no conflicts with bus schedules or other activities they attend), and some opportunity to meet with parents to educate them about the program and enlist their support.

•Provide ongoing support to teachers or mental health personnel who are providing the program. Most schools prefer to have the “experts” do the program first to avoid liability concerns, and then are amenable to having their staff join you in implementing it later. Independent implementation by school personnel may take several years to develop.

•Leaders in implementation will prefer to have some local decisionmaking ability, so respect their experience and solve problems with them, rather than for them. Also, remember that the principal is vital to a program’s success in a given school, so take time to get to know that person, convince him or her of the potential benefits of your program, and allay any concerns that he or she may have.

•Logistics, testimonials to your program’s success in other schools, and school board approval will be important for people who are skeptical or less directly involved, often including parents. Working these issues out ahead of time will often allay their concerns.

•Expect less parental involvement than in clinical settings, but offer to meet with parents regularly. Unlike parents of clinically referred children, many parents of children identified in the school system do not realize their children struggle with anxiety or depression. Therefore, their motivation to participate in a CBT program may be reduced.

•Most educators prefer “whole-school” to targeted interventions, because they avoid the risk of singling out certain children and

improve the emotional climate of the school. While this is laudable, most schools will not be open to adding CBT training to their curriculum, at least not initially. Curricular requirements are already too high for many teachers to manage, so few welcome another “add-on.” Demonstrating the benefits of a targeted program may, however, promote the adoption of a “whole-school” program later.

•If your program is not adopted as part of the curriculum, be clear on what types of children you are targeting. As in most child-focused CBT, the child’s main problem should relate to anxiety or depression. Children with significant behavior problems may be identified by teachers as “needing help,” but they rarely benefit from a child CBT program, especially if it is offered in a group.

•If you are planning a group intervention, use the same guidelines as for clinical groups, as outlined earlier in this chapter.

All of the above is possible, but only with a great deal of ongoing commitment over several years. In my experience, only the most dedicated child CBT providers attempt it.

CBT Group Worksheet

If you are planning a child CBT group program in your setting and have the necessary support of your organization to do so:

•What logistical issues do you need to address? Think about engaging clinicians who might refer to the group, obtaining funding for minor group supplies (snacks, stickers, etc.), having a consistent and convenient time and place for the group, collating manuals and other group materials, and having a cotherapist or other peer support. If you are obtaining consultation or supervision, you may also need families’ permission to record the group sessions.

Issues/tasks:

1.

2.

3.

4.

5.

•What manual will be best suited to the population you hope to treat? Manual:

Reason:

Cost:

•How will you assess children for group suitability, and educate referring clinicians about this issue?

Assessment procedure(s): Education for clinicians:

•How will you clarify treatment expectations for the children and families?

Procedure(s):

•How will you ensure a good therapeutic alliance with the children? Procedure(s):

•How will you ensure a good therapeutic alliance with the parents? Procedure(s): `

•How will you anticipate and address potential crisis situations? Procedure(s):

Clinical Challenge

1.You arrive to run your first child CBT group session at a school. You are informed that you will be meeting in the library, and a rather noisy “homework club” will occur at the other end of the library. The library is an open area, and soon children who are not in the CBT program begin walking by your group on the way to the lending desk and start listening in. Thirty minutes into the group, the janitor arrives and tells you the group must move because he needs to clean the area. You move the group, but 15 minutes later he returns and tells you to wrap up because he always locks the building at that hour.

a.What do you do at that time?

b.What do you do the next day?

2.You are running your first group for parents of anxious children who are participating in a concurrent CBT group program. After a round of introductions, you provide a brief description of the goals of the parent group and its relationship to the child program, and ask if there are any questions. How do you respond to the following situations?

a.A rather severe-looking gentleman in a business suit asks pointedly whether or not you have raised children yourself, and what your child CBT success rate is.

b.A cell-phone rings loudly, one mother responds, and she spends the next 5 minutes instructing her daughter on how to make lasagna for dinner as all the other parents listen.

c.Another mother volunteers that she has done CBT herself. She then describes her therapy in detail and smiles at you knowingly, monopolizing the group conversation.

d.Near the end of the session, the parents are working on a joint problem-solving exercise, discussing alternative ways to get their children to sleep independently. One mother volunteers, “I know my son, and I can’t see how any of this will help him without medication.” She turns to you, “Can you recommend something?”

References

Albano, A.M., Marten, P.A., Holt, C.S., Heimberg, R.G., & Barlow, D.H. (1995). Cognitive-behavioral group treatment for social phobia in adolescents: A preliminary study. Journal of Nervous and Mental Disease, 183, 649–656.

Asbahr, F.R., Castillo, A.R., Ito, L.M., Latorre, M.R., Moreira, M.N., & Lotufo-Neto, F. (2005). Group cognitive behavioral therapy versus sertraline for the treatment of children and adolescents with obsessive compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1128–1136.

Baer, S. & Garland, E.J. (2005). Pilot study of community-based cognitive behavioral group therapy for adolescents with social phobia. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 258–264.

Barrett, P.M. (1998). Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. Journal of Clinical Child Psychology, 27, 459–468.

Barrett, P.M., Farrell, L.J., Ollendick, T.H., & Dadds, M. (2006). Long-term outcomes of an Australian universal prevention trial of anxiety and depression symptoms in children and youth: An evaluation of the friends program. Journal of Clinical Child and Adolescent Psychology, 35, 403–411.

Barrett, P.M., Lock, S., & Farrell, L.J. (2005). Developmental differences in universal preventive intervention for child anxiety. Clinical Child Psychology and Psychiatry,

10, 539–555.

Clarke, G.N., Hornbrook, M., Lynch, F., Polen, M., Gale, J., Beardslee, W., O’Connor, E., & Seeley, J. (2001). A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents. Archives of General Psychiatry, 58, 1127–1134.

Clarke, G.N., Rohde, P., Lewinsohn, P.M., Hops, H., & Seeley, J.R. (1999). Cognitive behavioral treatment of adolescent depression: Efficacy of acute group treatment and booster sessions. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 272–279.

Dadds, M.R., Holland, D.E., Spence, S.H., Laurens, K.R., Mullins, M., & Barrett, P.M. (1999). Early intervention and prevention of anxiety disorders in children: Results at 2-year follow-up. Journal of Consulting and Clinical Psychology, 67, 627–635.

Dadds, M.R., Spence, S.H., Holland, D.E., Barrett, P.M., & Laurens, K.R. (1997). Prevention and early intervention for anxiety disorders: A controlled trial. Journal of Consulting and Clinical Psychology, 65, 627–635.

Gilham, J.E., Reivich, K.J., Freres, D.R., Chaplin, T.M., Shatte, A.J., Samuels, B., Elkon, A.G.L., Litzinger, S., Lascher, M., Gallop, R., & Seligman, M.E.P. (2007). Schoolbased prevention of depressive symptoms: A randomized controlled study of the effectiveness and specificity of the Penn Resiliency Program. Journal of Consulting and Clinical Psychology, 75, 9–19.

Gilham, J.E., Reivich, K.J., Freres, D.K., Lascher, M., Litzinger, S., Shatte, A., & Seligman, M.E.P. (2006). School-based prevention of depression and anxiety symptoms in early adolescence: A pilot of a parent intervention component. School Psychology Quarterly, 21, 323–348.

Hayward, C., Varady, S., Albano, A.M., Thienemann, M., Henderson, L., & Schatzberg, A.F. (2000). Cognitive-behavioral group therapy for social phobia in female adolescents: Results of a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 721–726.

Lock, S. & Barrett, P.M. (2003). A longitudinal study of developmental differences in universal preventive intervention for child anxiety. Behavioral Change, 20, 183–199.

Manassis, K., Mendlowitz, S., Scapillato, D., Avery, D., Fiksenbaum, L., Freire, M., Monga, S., & Owens, M. (2002). Group and individual cognitive behavior therapy for childhood anxiety disorders: A randomized trial. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 1423–1430.

Martin, J.L. & Thienemann, M. (2005). Group cognitive-behavior therapy with family involvement for middle-school-age children with obsessive-compulsive disorder: A pilot study. Child Psychiatry and Human Development, 36, 113–127.