[Katharina_Manassis]_Cognitive_Behavioral_Therapy

this area recently. Kendall, Brady, and Verduin (2001), for example, found that CBT was similarly effective in reducing pretreatment diagnoses and anxiety symptoms for anxious children with and without comorbid disorders. Rapee (2003), in a similar study, found that anxious children with comorbidity did as well as those without at the end of treatment, but not quite as well at 12-month follow-up. Both studies, however, were still done in research centers with children whose primary, most impairing problem was an anxiety disorder. This is not the same situation as that of a practitioner in a community setting seeing a child who has multiple problems including anxiety, with limited opportunity to prioritize those problems prior to starting CBT.

Low rates of ethnic minority participation were also found in most child CBT studies of anxiety and of depression (Compton et al., 2004). This is important, because cultural differences between child and therapist, or between the child and the author of the treatment manual used (see Chapter 5), may result in misunderstandings or low therapeutic engagement that can undermine CBT in community practice. Further, a need for studies of CBT with and without concurrent medication was identified, reflecting the fact that many child CBT studies to date have excluded children severe enough to require medication.

In one of the few studies that examined the issue of practice setting, Weersing and Weisz (2002) found that depressed youth treated in community mental health settings had worse outcomes than those treated with CBT in clinical trials in academic centers. Ethnic minority status and low therapy dose (in other words, few sessions provided or attended) were related to the worst outcomes, but even depressed Caucasian youth who received longerterm service in the community did not do as well as those in clinical trials.

In view of these apparent discrepancies between academic and community practice, my research group developed a group supervision program for community practitioners. We wanted to evaluate our ability to teach them child CBT techniques, and to better understand the problems community practitioners encounter when they try to do CBT in their settings. We had previously offered workshops in child CBT, but found that most community practitioners were no longer using child CBT techniques six months later because they lacked the confidence to do so independently (Barankin & Manassis, 2003).

The response to our program was overwhelmingly positive, with 85% of participants indicating they planned to do further child CBT in their settings, even at 6-month follow-up (Manassis, Ickowicz, McNeill, Picard, Chahauver, Mendlowitz, Monga, & Adler-Nevo, in press). Participants’ knowledge of child CBT improved on a short test given before and after the program, confidence using CBT increased, and participants were very satisfied with the supervision. Interestingly, the benefits seemed to be greater for older participants and participants working in settings where families and children underwent a diagnostic screen at intake. This finding was consistent with the adult CBT literature, where prior therapy experience and careful case selection are cited

as key predictors of how well people learn to do CBT (James, Blackburn, Milne, & Reichfelt, 2001).

Concerns were raised about difficulty finding suitable cases for supervision, the need for more background information about CBT and its evidence base, and a desire for more observational opportunities of “expert” clinicians. Therapists also identified difficulty adapting CBT to their clientele, their role in their organizations, the time commitment needed to do CBT, and low organizational support of CBT as potential barriers to doing further child CBT. These concerns were very helpful to improve our understanding of obstacles to CBT in the community and provided some further ideas for this book. In particular, I recognized the importance of including more of the evidence behind using CBT and of including some hypothetical “clinical challenges” in the event that the reader (like the community practitioners in our study) cannot immediately find a case suitable for child CBT.

Putting It into Practice

Now, let us begin applying some of these ideas to your clients and your practice environment. To provide a quick overview, I have summarized the possible differences between practicing CBT in academic and community settings in Table 1.1. Given the research literature just reviewed, you can see that

Table 1.1  Possible Differences between Child CBT in Academic and Community Settings

not all studies show all of these differences from community practice. It is useful to list them all, however, to get an idea of which ones may apply to your particular circumstances. They include client factors, therapist factors, organizational factors, and possibly factors related to CBT itself that are still being studied.

Client Factors

In order to study the effect of CBT on a given problem or diagnosis, researchers often seek clients who have that diagnosis and few other problems. From the researcher’s point of view, additional problems create noise in the system, making it more difficult to interpret research results. Therefore, children with additional problems are often excluded from research samples. As mentioned, there are a few, more recent studies of CBT that have tried to include some of these children, but far more studies in the literature are based on samples that excluded them. Unfortunately, in the community, children with multiple problems are the norm, reducing the relevance of research findings to community practice.

What types of problems result in children being excluded from research? Common ones include the presence of co-occurring diagnoses (either psychiatric or medical), intellectual delay or learning disability, suicidal thoughts, or use of psychiatric medication. The last two exclusions also mean that, in practice, children who participate in research are usually not severely impaired by their symptoms. Children with a first language other than English, and children in foster care or from families that have recently separated or have custody disputes are also commonly excluded.

Some research programs do compromise some of these criteria. Our own program, for example, insists only that anxiety is the most important (meaning the most impairing) problem, regardless of co-occurring disorders, and that contributing factors not amenable to psychotherapy (for example, ongoing bullying) have been addressed. We also require a minimum global IQ of 80 regardless of presence or absence of learning disability, no active suicidal behavior (even if there are some suicidal thoughts), and good enough English to understand (not necessarily read) our manuals, because experience has taught us that these requirements improve the chances of successful CBT. We allow for concurrent medication, as long as the dose is kept stable to avoid confounding medication-related and CBT-related changes in symptoms. We exclude children in unstable family circumstances, based on our experience that CBT has a better chance of succeeding when stability in the child’s home life is established first.

What allows a child and family to be included in research? In most cases, this occurs either through referral by a physician to the research center or because parents respond to an advertisement. In the latter case, parental motivation and literacy are obviously required. Once families come to research centers, they must be willing to persevere with an often rigorous screening process followed by multiple questionnaires and, in many cases, a willingness

to be randomized to either active treatment or waitlist or sham intervention. Only the most motivated families persevere with this process and, in most cases, their motivation relates to a high degree of understanding of psychological issues. Many samples are therefore biased toward more affluent, better organized, and better educated families than those typically attending community clinics.

Children who come to research centers must tolerate a similar process, and in most cases must also be psychologically aware enough to acknowledge their symptoms on standardized questionnaires. From the researcher’s point of view, this makes sense because, if the child cannot endorse a high level of symptoms at the outset, it is difficult to measure a decrease in those symptoms with treatment. In practice, only about half of young children who are diagnosed as anxious or depressed actually endorse a high level of symptoms. Thus, many children with low psychological awareness are excluded from studies but are commonly seen in community settings.

Selection criteria for CBT in the community vary a great deal. Some practitioners use criteria very similar to the ones for our clinic mentioned above. Others work in settings where they have little opportunity to select or screen clients and are simply told “this child is anxious” or “this child is depressed” and instructed to provide CBT. In the next chapter, I shall describe some ideal candidates for CBT, and how close your client should be to the ideal in order to pursue this treatment.

Children One Might Include with Caution

Another approach to more complex clients in the community may be to “include with caution.” In this case, the therapist knows that the client is challenging and perhaps not ideal for CBT, but adjusts his or her therapeutic approach and outcome expectations accordingly. Many of the cases described in this book would fall into this category.

For example, children with learning disabilities but no other poor prognostic factors may be “included with caution.” The “cognitive” element of CBT will be challenging for these children and may need simplification. CBT is highly verbal, and particularly strains a skill known as “verbal working memory” (reviewed in Manassis, Tannock, Young, & Francis-John, 2007). This skill involves the ability to simultaneously store and manipulate verbal information. If an anxious child worries about his mother being hurt or killed because she is late picking him up, for example, he could recognize that this as an exaggerated fear, then tell himself all the reasons his mother could be late that have nothing to do with injury or death, and then notice his fear subsiding. To do so, however, he must remain focused and go through several “thinking steps” involving words and memory. Children with language-based learning disabilities and many children with attention deficit hyperactivity disorder (ADHD) cannot do this (Manassis et al., 2007). Children with nonverbal learning disabilities may be