[Katharina_Manassis]_Cognitive_Behavioral_Therapy

Testing the Waters: Cognitive Readiness for CBT

In community settings, not all children come to the clinic after getting a full intellectual and academic assessment. This leaves the clinician uncertain as to what cognitive interventions the child can understand or find helpful. If other, contextual factors have been assessed, and the child is clearly a candidate for CBT in some form, it may be useful to test out the child’s ability to work with verbal and nonverbal materials before proceeding. A rough rule of thumb for what is needed to do verbally based CBT is that the child can do third-grade academic work. School expectations may vary, however, so it is helpful to obtain a more precise idea by testing certain abilities.

For verbally based approaches, the child should at least be able to grasp the connection between thoughts and feelings, and the idea that different types of thoughts can be associated with different types of feelings. For example, the therapist could ask, “Which would be most comforting if your mother was late picking you up: thinking about car accidents, thinking about the hockey game, or thinking about your mom being stuck at the office or in traffic and getting to you soon?” The child who grasps the thought–feeling connection will usually pick the final response and should be able to articulate why it is comforting to think this way. Some children do favor distraction (thinking about the hockey game), but when asked “Wouldn’t you still wonder what had happened to your mom?” can acknowledge that the worry persists. If they deny any worries, but have behavioral symptoms of separation anxiety, they may not be ideal candidates for verbally based CBT. Similarly, if they cannot see that thinking about car accidents would make them feel worse, or cannot explain why the final response is most comforting, they may struggle with verbally based CBT.

I often also have children do a short memory test: the digit span backward. This crude test of verbal working memory asks the child to repeat back a series of digits you say out loud, but in the reverse order you presented them (Needelman, Schnoes, & Ellis, 2006). If children cannot do at least five or six digits backward, they may struggle with cognitive restructuring (a key strategy in verbally based CBT approaches). For example, Philip Kendall’s F.E.A.R. plan in Coping Cat (a common child CBT program for anxiety disorders) (Kendall, 2006) includes six items: feeling frightened, expecting bad things to happen, attitudes that help, actions that help, results, and rewards. Thus, the child must be able to retain and manipulate six items to use this approach with ease.

Nonverbal cognitive interventions, by contrast, require little working memory and less psychological sophistication. They do require the child to have some capacity for externalization, though. To test this, a therapist might ask: “What have you tried to do to fight (or handle, or cope with) your anxiety?” In the ensuing discussion, most children can see that they have already fought/handled/coped with anxiety in certain situations. If they cannot see

that they have ever done anything to overcome anxiety because they cannot see anxiety as a problem to be tackled (rather than an intrinsic aspect of themselves), they may struggle with externalization.

As many nonverbal strategies rely on imagery, it is also helpful for the child to be able to work with mental images. Most children can do this quite readily and may, in fact, do it more easily than adults. The therapist might ask the child, “Imagine yourself in your favorite place in the world. Describe it to me. What do you see there, hear there, etc.?” The child who can provide at least a few specific descriptors is usually able to use imagery. A useful follow-up question is “How do you feel, now that you’re in that place?” Most children who can use imagery therapeutically will describe happy, nice, or calm feelings in their “favorite place.”

For example, Carmen was a young adolescent with a learning disability who struggled with generalized anxiety disorder. She had found a relaxation tape that included some imagery helpful in reducing her worries. After using it for a couple of weeks, she reported, “I’m not using the whole tape any more. I always come back to the same part: picturing my worries like actors crossing a stage and then exiting my mind.” For her, focusing on a concrete image was more useful than focusing on breathing or muscle relaxation, although these were also included on the tape.

Tony had mild developmental delay and severe separation anxiety. When asked what he had tried to do to handle his anxiety, he drew a blank. When the therapist pointed out that he already used his teddy bear to cope with separation from his mother occasionally, he agreed that this helped but was “not enough.” He was not willing to consider any other actions his therapist suggested to reduce his anxiety in such situations because, “It wouldn’t help get my mom there faster.” He could see no other solution to his problem than obtaining faster access to his mother and became quite angry when these were suggested. Eventually, the therapist worked on a behavioral approach with Tony’s parents to gradually desensitize him to situations involving separation because he was unwilling to learn anxiety management strategies for coping with them.

When Individual Treatment Is Preferable to Group Treatment

In community settings, large volumes of referrals often necessitate CBT group treatment. Ideally though, this should not be the only treatment format offered, because some combinations of children cannot work well together in groups, and some children have needs that are better addressed in individual treatment. It is also sometimes difficult to form certain groups in a timely manner. For example, if one is planning a group for obsessive compulsive disorder within a three-year age range and there are few referrals with this diagnosis for several months, it may not be possible to offer group treatment quickly, and individual work may need to be considered for children waiting

for this group. Families in settings where group treatment is offered should always be cautioned about this possibility to avoid disappointment or seeking treatment elsewhere.

As mentioned in the first chapter, limiting the number of disruptive children in a group to no more than one or two is essential to maintain an organized, focused group therapy. Even so, a second group therapist is usually needed to manage periodic behavior problems if such children are included. Ages of group members should be within a threeor at most four-year range, to ensure a similar level of cognitive maturity. Exceptions can be made if a child is older but cognitively immature for age, as long as the child does not stand out from the rest of the group in another important way. For example, a group of 8- to 11-year-old children can include a 12-year-old who is cognitively “young,” as long as the child has not yet developed the physique or interests of a teenager. CBT can work in single-gender or mixed-gender groups, but groups with only one member of a particular gender can be awkward. In these circumstances, the “lone boy” or “lone girl” often drops out of treatment because of discomfort in the group or a lack of common interests with other group members.

Individual treatment may be preferable to group treatment to address some children’s needs. Children who are extremely shy may feel overwhelmed in a group situation with other, less shy children (Manassis, Mendlowitz, Scapillato, Avery, Fiksenbaum, Freire, Monga, & Owens, 2002). They often contribute little to the group, are easily neglected, and may be unable to learn strategies in the group because this is a highly anxious situation for them. As with disruptive children, a skillful cotherapist may be able to focus on engaging such a child and helping him or her learn, if group is the only treatment format available. Similarly, highly distractible children may benefit more from individual than group therapy. Their need for frequent redirection to the task at hand can be difficult to meet in a group environment. Children with learning or language difficulties can also be problematic in groups, depending on how far behind their academic or linguistic skills are relative to other group members. Minor problems can often be addressed with extra help by a cotherapist (for example, scribing for the child, helping with reading, offering repeated explanations of concepts), but more significant delays may result in stigmatization for “slowing down” the pace of the rest of the group.

In deciding whether or not to include a child in a group, the above considerations must be balanced against the unique benefits children can obtain from groups (Scapillato & Manassis, 2002). Universality, the sense of not being the only one affected by a certain problem, is a group benefit that is not obtained with individual treatment. Peer support and encouragement, mutual support among parents when these are in a group, and the fact that “many heads are often better than one” in generating solutions to problems are also group-specific benefits.

When CBT Is Not Helpful

Helping children acquire skills to better manage anxious feelings may seem like a universally helpful intervention, so it is difficult to imagine situations where CBT would be harmful. A few I have encountered include:

•A boy with conduct disorder, whose anxiety prevented him from engaging in serious criminal activity. Anxiety was protective in this case.

•Vicky’s case in the first chapter: a 2-year history of school avoidance initially related to anxiety, but with many behavioral and family problems since then. Regardless of initial diagnosis, Vicky’s oppositional behavior and the family’s inability to limit it is now the main issue, and CBT is very unlikely to result in school return unless this is addressed.

•A girl who was referred for treatment of anxiety about her father’s untreated alcoholism, which sometimes resulted in abusive behavior toward her and her mother. To treat her would have tacitly condoned the father’s problem and allowed a dangerous situation to continue.

•A girl whose mother wanted her treated with CBT for school avoidance “until she feels ready to go back,” but was unwilling to work on a plan for school return. In this case, CBT would have provided an excuse for professionals not to address the enmeshed mother– daughter relationship that was preventing school return.

•A teenage boy who was depressed and suicidal to the point of trying to jump in front of a subway train (a friend stopped him). This boy’s parents felt he “just needs the right therapist” and did not see the need for urgent hospitalization. Respecting their wishes by offering CBT outside hospital would have endangered the boy’s life.

More often, we encounter situations where the likelihood of success is so slim that the time and energy required for CBT is not considered worthwhile. Working with a child who has severe mental handicaps, a family that has just separated, or parents who are too disorganized to bring the child to appointments regularly are common examples of such situations.

One may still be able to provide some helpful techniques based on CBT in these circumstances. For example, the mentally handicapped child may be able to learn diaphragmatic breathing or another relaxation technique. Similarly, the disorganized parents may be referred to a particular chapter of a CBT-based self-help book to address their child’s main fear. However, these techniques do not constitute a course of therapy, and should not be described as such in clinical notes.

Assessment Worksheet

Assessment of a child for CBT must include thorough diagnostic evaluation of the child and family and should allow one to answer certain questions. Ask yourself:

•Are you certain that the main, most impairing problem is an anxiety disorder or depressive disorder (circle)?

•Have contextual factors not amenable to CBT been addressed? Factors:

How addressed:

•Have key situations to be targeted by CBT been identified? Situation 1:

Situation 2:

Situation 3:

•Are there any standardized measures that could help you quantify the child’s symptoms and monitor progress? If not, is there another aspect of the child’s symptoms or functioning you could quantify and monitor with treatment?

Will monitor:

•Review Table 2.1. Is this child suitable for CBT as described in most manuals (that is, an “ideal candidate” or close to it)?

“Ideal” characteristics:

•Is this family suitable for supporting their child’s progress in CBT as described in most manuals?

“Ideal” characteristics:

•Will this child require additional interventions besides CBT, and when should these occur in relation to CBT (further described in next chapter)?

Additional interventions needed:

1.

2.

3.

•Will this child require a modified CBT approach, and why (further described in subsequent chapters)?

Modification(s):

•Will this child require nonverbal as well as verbal strategies (circle)? Yes, because:

No

•Will this child benefit more from group or individual CBT (circle)? Group, because:

Individual, because:

•Does this child or family have any contraindications to CBT? Yes, because:

No

Clinical Challenge

Answer the questions above in relation to Tom, the nine-year-old boy described at the beginning of the book.

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