Cognitive behaviour therapies for children and families
Cognitive behaviour therapy (CBT) is derived from both behavioural and cognitive theories. Using concepts such as operant conditioning and reinforcement, behavioural theories treat behaviour as explicable without recourse to description of mental activity. In contrast, mental activity is central to all concepts derived from cognitive psychology. Both sets of theories have been of value in explaining psychological disorders and, in the design of interventions they have proved an effective combination.
Central to that part of cognitive theory that is relevant to CBT is the concept of ‘schemas’, first described in detail by Jean Piaget.(1) A schema is a mental ‘structure for screening, coding, and evaluating impinging stimuli’.(2) The origin of mental schemas lies in the pre-verbal phase when material is encoded in non-verbal images that, as the child's language develops, gradually become verbally labelled. They form part of a dynamic system interacting with an individual child's physiology, emotional functioning, and behaviour with their operation depending on the social context in which the child is living. There are similarities but also differences between schemas and related concepts in psychoanalysis, such as Freudian ‘complexes’ and Kleinian ‘positions’.
Schemas can be seen as organized around anything in the child's world, especially objects, beliefs, or emotions. They develop from past experience. The processing of new information in relation to such schemas can usefully be seen as involving the evaluation of discrepancies between information that is received and information that is expected. If there is a discrepancy, (the information not corresponding with that expected), then during the coding process information may be distorted so that it no longer creates discomfort, or, more adaptively, it may be incorporated into a modified schema.
The theory of cognitive development that Piaget constructed on the basis of an immense amount of experimental work was characterized by stages of development. He described characteristic features of the sensori-motor (0–2 years), pre-operational (2–7 years), concrete operational (7–12 years), and formal operational (12 years onwards) stages. Before the end of a stage is reached the child is incapable of showing more advanced thinking. In particular, the child's thinking before the concrete operational stage is characterized by egocentricity and an inability to take the perspective of another person. Abstract reasoning is not possible for the child until the formal operational stage is reached.
Even though Piaget's views of the limitations of the cognitive abilities of young children have been strongly criticized especially on the grounds that he was judging egocentricity on the basis of findings obtained in highly artificial situations, Piaget remained a dominant influence in cognitive psychology and education throughout the twentieth century. It is now widely accepted that, although obviously young children are less competent than those in middle childhood and these are less competent than adolescents, cognitive competence advances much more rapidly than Piaget described and the social context in which a child's competence is investigated has a much more profound influence on performance than he allowed. Children do a great deal better in naturalistic circumstances than when they take part in experiments. Further, coaching can improve performance to a level not previously obtainable. For example, it has been shown that, with preliminary training, 3-year-old children understand that drawings of thought bubbles can represent what people think. They can distinguish between thoughts and actions, recognize that thoughts are subjective and that two people can have different thoughts about the same events.(3)
Investigation of the development of the ‘theory of mind’ held by children has revealed that between 3 and 4 years they begin to realize that other children can be deceived by appearances and hold false beliefs they themselves do not hold. This shows that, given the right circumstances, children of this young age are able to ‘de-centre’ and are not necessarily limited by egocentricity. By the age of 8 years children have such stable concepts of their own self-esteem that they are capable of reliably completing self-esteem questionnaires about their own feelings and performance in comparison to other children.(4) Some schemas in young children are however relatively unstable, gradually increasing in stability as they get older. For example, it has been shown that attributional style (the tendency to attribute adverse events either to the self or to external circumstances) does not become stable until early adolescence, though it may be identified earlier if the events are particularly salient to the child in question.(5)
It has been hypothesized(6) that maladaptive schemas developed during childhood are responsible for the formation and maintenance of adult psychopathology. Building on this model, a therapeutic approach (schema-focused therapy) based on the identification of particular maladaptive schemas has been proposed for adults. Subsequently Stallard and Rayner(7) have developed a schema questionnaire that builds on adult work to identify such maladaptive schema in 11 to 16-year-old school children.
Technique and management in the paediatric age group
Although there are certain common principles, CBT does not involve, as will be seen, a single approach that can be applied across all disorders; it is better seen as a family of approaches with certain core elements in common. In adults the type of disorder and the individual circumstances of the patient will determine the choice of therapeutic methods. In children and adolescents the cognitive level of the patient will also need to be taken into account. Though the age of the child will give some indication of the cognitive level of the child, there is wide variation in competence amongst children of the same age. Further, the therapist may use the skills of an educationist to bring the child's competence up to a level at which the child can more actively participate in therapy. Kendall(8) suggests indeed that one of the therapeutic roles that the therapist should adopt is that of educator, who needs communication skills to assist children to learn to think for themselves.
Behaviour therapy or CBT?
In principle, the decision as to whether to include a cognitive component in therapy depends on whether the clinical formulation incorporates cognitive distortions or biases. In practice, because of their cognitive limitations CBT is rarely used in children under the age of 7 years. Treatment in children younger than 7 years is predominantly behavioural, with the cognitive component limited to coping self-talk. Conditioning approaches to the treatment of feeding and sleeping problems as well as enuresis and encopresis usually have a very small or no significant cognitive component.
In some conditions such as anxiety disorders, especially specific phobias, where desensitization and reinforcement approaches are widely used in adults, the use of a mainly behavioural approach does not reduce effectiveness. A cognitive component may nevertheless be incorporated because the CBT principles of collaboration, openness, and guided discovery, usually less marked when purely behavioural approaches are applied, are advantageous to the patient.
Aids to cognitive tasks
Where experience with adults suggests that cognitive tasks add significantly to the effectiveness of treatment, as in depressive disorders and problems of social relationships, even young people in early adolescence will usually be able to co-operate as well as adults. The cognitive treatment of younger children with these conditions may be helped by the use of age-adapted techniques.(9) For example, card-sorting games have been devised to help children distinguish between thoughts, feelings, and situations. Puppets can be used to facilitate discussion as part of the assessment process, to model alternative ways the child might cope with difficult situations and to engage the child in rehearsal and practice of new skills. Story telling can provide an insight into the child's inner world; they provide a way of externalizing and accessing the child's cognitions, allow an opportunity to challenge the child's assumptions, introduce the child to more positive ways of coping, and can be used to model success and help the child gain more functional assumptions and beliefs.
Working with parents
Parents play many roles in the delivery of CBT to children and adolescents. To begin with, even up to mid-adolescence, it is nearly always parents who identify the behaviour and emotional problems that lead to advice being sought. They are the people most likely to press for psychological help. It is they who have to persuade often reluctant children and adolescents to attend and participate in a service that their offspring may fear, not without reason, will result in stigmatization.
They are then likely to play a major part in the assessment process. From mid- to late adolescence, the patient or client will be the main source of information, but before that it is the parents and teachers who will often provide most relevant information. If treatment is proposed it is they who need to give consent, though their child will also need to assent if the therapy is to have any chance of succeeding.
Once treatment planning has begun, the part that parents play will depend very much on the age of the child or adolescent, the diagnosis, family circumstances (especially the quality of the relationships between parents and child), and the degree to which the assessment has revealed that the parents as well as being the main carers are also involved in the origin and maintenance of the problem. Most explanatory theories of anxiety disorders in children, for example, point to the ways in which parents can provide inappropriately anxious models for imitation by their children. In a small scale study it has been shown that changing parental attributions can, in itself, result in improvements in problem behaviour scores on a questionnaire.(10) Parents may also be seen as clients in their own rights in parallel sessions, as co-therapists or as facilitators of therapy for their children. Therapists dealing with adolescent offspring are often in a difficult position vis-à-vis parents in that they will wish to encourage autonomy and independent decision-making in the child or adolescent, while needing the parents to monitor homework, encourage further attendance, and provide information on progress.
The involvement of parents also brings ethical dilemmas. There are three main areas of ethical concern.(11) The therapist often has to balance the different viewpoints of parents and children, a particular problem in the management of oppositional and conduct disorders where children often fail to acknowledge the existence of problems that are causing distress to their parents. There is frequently need to address family issues such as marital conflict that are clearly relevant yet not the reasons why the child has been brought for treatment. Finally, there is the need to achieve genuine collaboration with parents, making explicit their role as co-therapists. This is made easier if children are also actively involved as fellow collaborators, taking responsibility for progress and being encouraged to make suggestions for alternative approaches. A collaborative stance may however not be possible if it becomes clear that there are child protection issues with one or both parents involved in maltreatment of their children. Wolpert and her colleagues provide a useful checklist for clinicians to help assess how far they are attempting to balance different viewpoints in issues involving different family members and promoting collaboration.
Failure to engage and failure to respond
In adolescents, lack of motivation for change is often a major impediment to engagement in therapy. Not only is there often a failure to recognize the importance of a problem, to accept the need for change or to appear to understand why change is necessary, but there may also be an absence of the level of self-belief, self- confidence, or self-efficacy that is necessary before hopeful steps can be taken in the right direction. In these circumstances techniques of motivational interviewing will help the therapist to achieve engagement.(12)
The reasons for non-response to CBT in adults have been discussed by Kingdon et al.(13) Common problems include unsuitability for treatment possibly arising from misdiagnosis, resistance to treatment, an inadequate number of sessions, difficulties in the therapeutic relationship and the presence of concurrent social and/or physical pathology. Non-response in children and adolescents arises from similar issues, with, additionally, complicating problems arising from negative parental attitudes and behaviour.
Cognitive distortions and deficits
A characteristic constellation of cognitive deficits and distortions underlies the presence of anxiety disorders in children and adolescents. A central feature is the exaggerated perception of threat arising from an inability to assess accurately the seriousness of danger. Thus a deficit in perceptual competence results in cognitive distortion. The characteristic nature of the threat involved will depend to a considerable degree both on the stage of cognitive development of the child and on the social demands that are encountered during that particular phase of life. Pre-school children are most likely to be threatened by separation from parents; children aged 5 to 12 years by feared situations at school and adolescents by social situations as well as wider concerns such as environmental pollution. Certain fears and phobias such as fear of spiders and snakes appear more biologically based and are present through childhood to adolescence.
These cognitive deficits and distortions both result in and are maintained and increased by abnormal levels of physiological arousal and by behavioural avoidance of the feared situations. Autonomic arousal produces symptoms such as dry mouth, palpitations, and abdominal pain and these may be misinterpreted as implying serious threatening illness. Panic attacks may be catastrophized and taken to mean that death is imminent. Avoidance of feared situations such as separation from parents in younger children, refusal to go to school in older children or to social events such as parties in adolescence prevent cognitive testing of the reality of the supposed threat and reinforce the cognitive distortion.
The fact that anxiety disorder is partly genetically determined means that children suffering from this condition have an increased risk of having anxious parents. Such parents are likely to model anxious behaviour, especially in the way they show over-protection to their children. Anxious children are therefore likely to be exposed to social learning situations at home that will increase the risk of avoidance of feared situations. Gene-environment interactions ensure that many parents who cannot bear to be separated from their children or who are anxious every time they leave the house will transmit their fears to their children both directly and indirectly. In adolescence, anxious young people may selectively choose shy, inhibited friends who reinforce their sense of unrealistic threat.
Techniques of assessment and intervention
The assessment of children with anxiety disorders by a cognitive behaviour therapist focuses on the identification of cognitive deficits and distortions and the manner in which they are currently being reinforced, especially by avoidant behaviour. Nevertheless it is important that before enquiry is made along these lines a full history is taken of the development of anxious symptoms, the presence of other symptomatology, the situations that increase and reduce anxiety, the presence of anxiety in parents, sibs, and friends, and the measures that have already been taken, especially by parents, to improve the condition. Skilled assessment involves listening to the anxious preoccupations of both children and parents sympathetically and without any hint of criticism.
There are a number of systematic cognitive approaches to the reduction of anxiety in children of which the most widely used is the four-step coping or FEAR plan, in which F = Feeling frightened (awareness of anxiety symptoms such as somatic aches and pains), E = Expecting bad things to happen (awareness of negative self-talk), A = Attitudes and actions that can help (problem-solving strategies), and R = Results and rewards (rewarding for success, dealing with failure).(14) The ‘Cool Kids’ programme is generally similar but puts more emphasis on parent involvement.(15) When parents show significant levels of anxiety themselves, effectiveness of treatment is enhanced if parental anxiety management is included as part of treatment.(16) A self-help book for parents broadly based on the same principles provides a practical approach to the management of anxiety, using the so-called COPE programme.(17)
Treatment begins with one or two psycho-educational sessions in which the child and parent(s), together or separately, are given information about the way anxiety develops and is maintained, the manner in which the body shows anxiety (somatic symptoms), and the effects of avoidant behaviour and exposure to feared situations. It is important that these sessions are interactional with the child being encouraged to talk spontaneously about, for example, how he or she experiences somatic symptoms. The next few sessions involve children engaging in an exercise to identify their own negative thoughts, to test them against reality and to develop positive thinking in situations that have previously triggered anxiety. This will usually need to be done in imagination before it is tried out using ‘graded exposure’ in real situations. There are advantages in teaching relaxation techniques before the child embarks on exposure to feared situations. The use of imagery, such as the ‘stepladder’ approach to a hierarchy of feared situations may also be helpful. When the child makes progress, as is usually the case, rewards such as outings or other treats may be built in to the procedure.
Therapists vary in the degree to which they involve parents in management. The therapy can be delivered in a family context, parents can be seen separately from children, parents may not be seen at all, or the therapy may only be delivered to parents. Some centres use a group approach, with one or two therapists providing a group experience for parents and anxious children who go through the stages of treatment together and benefit from learning of each others’ experiences. Some programmes have now been developed for use via the Internet with minimal personal contact with the child and family. Some therapists combine CBT with the use of medication, generally not anxiolytic agents because of the risk of dependency, but tricyclics or selective serotonin reactive inhibitors.
Evaluation of effectiveness and efficacy
A systematic review of the effectiveness of CBT for anxiety disorders in childhood and adolescence identified 10 randomized controlled trials that met inclusion criteria.(18) The outcome meas-ure used was the remission of anxiety disorder. The remission rate was higher in the CBT groups (56.5 per cent) than in the control groups (34.8 per cent). The pooled odds ratio was 3.3 (CI = 1.9–5.6). The authors of this review conclude that CBT definitely provides benefit to children and adolescents with anxiety disorder, but that there is a lack of information concerning the value of CBT in younger children and that there are virtually no satisfactory studies comparing effectiveness with alternative treatments.
There is contradictory evidence concerning the importance of involving parents in therapy. Some(19,20) find little or no benefit, while others(21,22) find a trend towards benefit. A pilot study has found benefit from a programme that did not involve children directly but only involved parents seen in a group, who applied what they had learned in the group in managing the situations in which their children showed anxiety at home. Information on the use of therapy delivered via the Internet is limited, but those that exist suggest that Internet treatment is highly acceptable to families, creates minimal dropout and is effective when added to clinic treatment.(23) Dropout from more conventional treatment is likely to be high in single-parent families, ethnic minority families, and where anxiety levels are not conspicuously high.(24) There is evidence that the presence of co-morbid disorders does not reduce the efficacy of CBT.(25) The addition of antidepressants may increase the efficacy of CBT, especially in the treatment of school refusal.(26) Limited findings from long-term studies suggest that treatment benefits from the delivery of CBT to anxious children are maintained over at least 6 years.(27)
There is also evidence from controlled studies for the effectiveness of interventions, especially the FRIENDS programme(28) in the prevention of anxiety and depression in early adolescence. Stallard et al.(29) have shown how this programme can be delivered successfully by school nurses.
These evaluative studies have provided most encouraging findings for the effectiveness of CBT in this condition. However the findings also make clear that CBT, while producing worthwhile and persistent benefits in most children and adolescents with anxiety disorders, is not effective in a significant number of cases and in a significant number of others it is only partially effective. It is also less effective in socially disadvantaged groups. Finally, most evaluative studies have been carried out in highly specialist centres and there is a lack of evidence for their value in everyday practice.(18)
Cognitive distortions and deficits
The classical signs of depressive disorders, such as chronic misery and unhappiness, lack of interest in food, and motor retardation, may be seen as early as the first year of life. Infants and young children who show such symptomatology may well suffer depressive experiences similar to those of older people though in the pre-verbal phase there is no reliable method available to confirm this possibility. Awareness of feeling states develops towards the end of the second year of life.(30) By 2 to 3 years children realize that there can be a variety of personal reasons for an emotional reaction. By 4 years there is some consensus about the kind of situations that will provoke the common emotional reactions, including fear, sadness, and anger.(31) By 5 or 6 years a child is capable of understanding the concept of stability of mood, ‘always being unhappy or just now and again’, and by 7 or 8 years concepts of shame and guilt are understood at least in simplified form. Enduring and relatively stable negative attributions about the self become possible at around this age and the concept of death as a permanent state is established. By 13 to 14 years, emotional experiences of adult intensity occur and mature cognitions about different mood states will have been attained. Although the above account relates stage of development to chronological age, there is wide variation in the ages at which cognitive competence is gained. Further, the settings in which children are questioned or encouraged to express themselves freely and spontaneously, for example in play situations will greatly influence their capacity to show their abilities.
The cognitive model underlying CBT approaches to children and adolescents does not differ from that with adults. It is assumed that thoughts are the primary experience of depression and that depressed mood is secondary. Dysfunctional assumptions, including low feelings of self-worth, self-blame for events in the past, and hopelessness about the future are present either as stable features of a depressive personality or as a reaction to adverse experiences, real or imagined. Depressed children and adolescents systematically distort their experience to match their beliefs about themselves. At some point, these negative thoughts are automatically experienced without reflection. Increasingly situations are avoided because of a fear of negative outcomes. Therapy involves identifying and reality testing these negative thoughts. In addition the patient is encouraged to enter into activities that will be rewarding and disconfirm pessimistic assumptions.
Techniques of assessment and intervention
Initial assessment will involve taking a full history of the development of symptoms and the factors that reduce or exacerbate them, the child's functioning in different settings, and an account of family relationships. If the child is taken on for CBT, a typical approach(32) begins with the establishment of symptom status by the use of questionnaires such as the Children's Depression Inventory(33) in young patients and the Mood and Feelings Questionnaire(34) in adolescents. The goals of therapy are then discussed in a collaborative manner with emphasis on what the child or young person wishes to achieve. The proposed therapeutic approach is then explained together with the importance of homework outside the therapy sessions. An indication of the number of sessions likely to be required, usually 12–16, is given. In early sessions an account of the child's current daily activities is obtained. Adolescents are helped to keep a diary of their activities and moods. In a form of ‘affective education’ a check is made on the vocabulary the child uses to describe feelings and links are then established between the child's mood and the activities he or she is undertaking.
During the next sessions, in collaboration with the child, homework is planned that aims to increase activity to the level previously undertaken. Emphasis is placed on the resumption of everyday activities rather than offering treats or special occasions. At this point a problem-solving approach may be indicated. This begins with problem definition, followed by brain-storming a number of different solutions. The outcomes for different solutions are discussed and a plan developed to achieve what seems to be a satisfactory outcome. Homework involves attempts to implement the plan while keeping a record of progress and how this has influenced mood.
At least from early adolescence it will usually be possible to introduce self-monitoring procedures, in which the child identifies and notes his level of mood in relation to the thoughts he is experiencing. The child is encouraged to imagine different situations and to record how each situation makes him feel. The child is encouraged to continue this process at home, recording what happens so that his experience can be discussed in the next session. This process is accompanied by self-evaluation training, a form of cognitive restructuring in which children learn to evaluate themselves in a more positive manner. They are encouraged to consider the evidence for having a poor opinion of themselves and then to examine carefully more positive alternative explanations. This process may be expected to reduce negative automatic thoughts.
Evaluation of effectiveness and efficacy
A comprehensive evidence-based review of controlled evaluation of cognitive behavioural psychotherapy for children and adolescents with depressive disorders(35) identified 12 studies that fulfilled methodological criteria. Most reported positive outcome for CBT post-treatment and at short-term follow-up. However, studies with longer follow-up periods from 9 months to 2 years found that a sizable percentage of subjects continued to report significant depressive symptoms or a recurrence of their depressive illness.
More recently the results of a major multi-centre trial, the Treatment of Adolescent Depression study (TADS) have been reported. In this study 479 adolescents, aged 12 to 17 years with depressive disorders were allocated randomly to a combination of fluoxetine and CBT, fluoxetine alone, CBT alone and an inert pill placebo. After 12 weeks of treatment the effects of combination therapy were clearly superior to either form of monotherapy and greatly superior to pill placebo. Fluoxetine alone was superior to CBT alone and to placebo, but CBT alone was not superior to placebo. On the other hand, fluoxetine alone was accompanied by higher rates of suicidal events and this did not occur in the combined group. It seemed therefore that CBT protected against the suicidality linked to fluoxetine use. The investigators concluded that the combination treatment produced the best outcomes.(36)
The published evidence mainly relates to children and adolescents with mild or moderate depressive disorders. There is some indication both from the TADS described and from other evidence that more severe depressive disorders do not respond as well or perhaps not at all to CBT alone.(37)
Attempts to use CBT to prevent depression in adolescents have met with varied success. One universal school-based approach found no difference at 2 to 4-year follow-up in children who received a teacher-administered cognitive behavioural intervention compared with a control group.(38) In contrast, positive effects were found for a CBT intervention targeting 13–18-year-old children of parents with depressive disorders.(39) Application of the Resourceful Adolescent Programme has also been shown to produce promising results in preventing depression in younger adolescents.(40)
Cognitive distortions and deficits
Both young children with oppositional disorders and adolescents with more severe conduct disorders show characteristic cognitive distortion in their thinking. They recall inaccurately high rates of hostile cues in social situations and when neutral remarks and movements are made by their peers, they see these as hostile.(41) In competitive situations with peers they exaggerate the aggressive behaviour of others and underestimate their own aggressiveness. These distorted attributions lead them into aggressive behaviour which then triggers angry behaviour from peers so that the originally neutral environment does indeed become more hostile.
Aggressive children and adolescents also have difficulties in problem-solving, both in experimental and naturalistic situations. They prefer rapid action-orientated solutions to those that require reflective thinking before any action is taken. Underlying this tendency to prefer rapid, aggressive solutions is the fact that their social goals relate more to the need for dominance and revenge than for affiliation.(42)
Parents of aggressive children also show cognitive distortions that are of relevance to the way they discipline their children.(43) This is of relevance both to the understanding and the management of childhood conduct disorders. For example, it has been shown that mothers of children with conduct disorder tend to attribute their children's difficult behaviour to deliberate wilfulness that is not within their children's capacity to control. They perceive themselves as helpless in the face of their children's behaviour. These cognitive distortions prevent them from acting effectively as parents, for example by drawing firm boundaries between acceptable and unacceptable behaviour.
Techniques of assessment and intervention
Until the early 1980s there were really no effective, evidence-based psychological interventions for children and adolescents with conduct disorder. Since that time a number of moderately effective psychological measures have been developed. All of these, including the cognitive behavioural techniques described below are only likely to be successful if they are combined with psychosocial meas-ures directed towards the family as well as with appropriate education. All approaches require preliminary assessment of the child and family to identify the severity of the disorder and the possible presence of co-morbid disorders as well as to determine suitability for the approach envisaged.
Cognitive approaches to conduct disorder have been summarized by Lochman et al.(44) Problem-solving skills training (PSST) has been developed for children aged 7 to 13 years. The programme is delivered over 25 sessions.(45) The group leaders teach problem-solving skills such as generating multiple solutions to a problem and reflecting on the different consequences of the alternatives. The skills are applied to interpersonal situations with teachers, parents, peers, and siblings. Parent participation is a major component of the training, with parents observing the sessions and acting as co-therapists in supervising the use of the new skills in the home.
The Anger Coping and Coping Power Programme is a school-based prevention programme delivered in group sessions to 13–14-year- old children.(46) The group sessions focus on enhancing emotional awareness, anger management training, attribution retraining and perspective-taking, social problem-solving and social skills training, behavioural and personal goal-setting, and handling peer pressure.
Multi-system therapy was designed as a multi-level intervention for 12 to 15-year-olds with multiple, severe antisocial problems.(47) Highly trained and closely supervised psychologists manage individualized programmes in the home setting. A variety of treatment approaches, including parent training, family therapy, school consultation, and individual therapy are employed in association with social measures such as helping lone mothers to find employment are used. The aim is to achieve change in one area before targeting another.
Functional Family Therapy combines family systems and cognitive behavioural approaches. The programme begins with an engagement and motivation phase in which the therapist addresses maladaptive beliefs in the family system thus aiming to increase expectations for change, reduce negativity and blaming, build respect for individual differences and develop a strong alliance between family members and the therapist. Practical behavioural interventions are designed to produce change and this is followed by a generalization phase in which the family is encouraged to interact effectively with the various systems in the community with which it is in contact.
Parent Management Training Programmes usually involve parents of young children with oppositional or conduct disorders. They derive from work originally carried out by Patterson and his colleagues at the Oregon Social Learning Center. His findings established the importance of coercive parental behaviour in the development of childhood aggression. Many treatment programmes have been based on their work,(48,49) which focus on ways of reducing parental coerciveness, often in group settings. Parents are taught to pinpoint problem behaviours, to apply positive reinforcement when their children's behaviour is more appropriate and to learn problem-solving and negotiating techniques. It has been suggested that the incorporation of a cognitive component into parent training, using a ‘thoughts, feelings, behaviour cycle’ can improve effectiveness of this approach.(50)
Evaluation of efficacy and effectiveness
All of the above programmes have been evaluated in controlled clinical trials and have been shown to be moderately effective.(51–53) However, virtually all the controlled studies have been carried out in highly resourced specialist centres. There is a conspicuous lack of studies of effectiveness carried out in routine clinical care.
Attention deficit hyperactivity disorder (ADHD)
Cognitive distortions and deficits
Children with ADHD show a range of cognitive deficits of attention and concentration with a strong predisposition to impulsivity, accompanied by explosive temperament and poor regulation of affect and impulses. Until recently these problems have been explained on the basis of deficits in one of two cognitive pathways. It has been proposed that there is a deficit in executive function, based on deficient inhibitory control arising from frontodorsal striatal brain networks.(54) Such failure of control results in deficits in self-monitoring, planning, attentional control, and executive skills. Stimulant medication remedies these deficits by increasing the activity of inhibitory pathways. Alternatively the condition has been attributed to disturbances in motivational processes, manifest as aversion to delay in gratification. More recently Sonuga-Barke,(55) has proposed that both these mechanisms are supported by the evidence and that there are two distinct but complementary neurodevelopmental bases for ADHD which is thus, at least in the pre-school period, psychologically heterogeneous. As children get older and executive function matures, deficits in executive functions may become more prominent in affected children, especially in the areas of inhibition, set shifting, working memory, planning, and fluency.(56)
Techniques of assessment and intervention
Information about children with suspected ADHD needs to be obtained from both parents and school teachers as the child is likely to behave differently in the two settings. Both interviews and rating scales should be used. Observation of the child can confirm the presence of ADHD, but cannot rule it out as some children who are clearly showing symptomatology both at home and in school may appear normal in the clinic. Although it is helpful to reach a diagnosis, increasingly treatment approaches are focusing on the presence of specific impairments rather than on the presence of symptoms.(57)
Three types of psychological interventions have been found of value: ensuring the child's environment is structured and, when the child is engaged in a task that there is an absence of extraneous, distracting stimuli; counselling to parents and teachers, and behavioural and/or cognitive behavioural approaches directed to the child.
In the classroom the child will benefit if seated close to the teacher, task demands are kept short and there are interspersed periods of physical exercise. Teachers should be helped to reduce negative interactions by focusing on positive reinforcement for appropriate behaviour however brief this might be. Short periods of timeout before potentially problematic situations get out of hand may reduce the number of painful, angry confrontations. Similar principles can be applied in the home situation with parents being helped to understand and act on the principles of the identification of antecedents that result in problematic behaviour which will then have consequences that either increase or reduce the likelihood of recurrence. Positive reinforcement can be provided in the form of star charts, tokens, or other rewards. Training of parents of children with ADHD follows similar lines to training of parents with children with conduct disorder (see above) and, of course, many children show co-morbid ADHD and conduct disorder.
Cognitive behavioural approaches generally aim to achieve increased self-control. Most approaches involve encouraging appropriate self-instruction. The child is taught separate steps of self-instruction (‘Stop: What is the problem?—Are there possible plans?—What is the best plan?—Do the plan—Did the plan work?) This approach can be applied when the child is faced with cognitive tasks which would usually be tackled impulsively or to social situations that often result in confrontations, such as arguments with parents or friends.(58)
Evaluation of effectiveness and efficacy
The delivery of behavioural treatment to children with ADHD presents particular problems. As a group they are slow to respond to conditioning procedures. Their distractibility and short attention span leads to problems in co-operation. Parents are likely to show similar behavioural and cognitive characteristics to their children, so collaboration of parents in treatment regimes may be problematic. The children's lack of reflectivity is a barrier to the use of cognitive approaches.
There is no good evidence that cognitive approaches alone are significantly effective in children with severe ADHD.(59) The most thorough evaluation of behavioural approaches to date is the Multi-modal Treatment of Attention-Deficit Hyperactivity Disorder (MTA) study carried out in the 1990s. The 579 children in the study were randomly allocated to one of three conditions: medication with stimulants, intensive behavioural treatment, and a combination of the two. The behavioural approach involved a parent training component, a two-part school intervention and an intensive summer treatment programme. It can therefore hardly be regarded as typical of psychological interventions applied in everyday clinical practice. There were slight advantages to combined treatment over medication alone. Behavioural treatments alone were much less effective for ADHD, though more useful for co-morbid anxiety disorders.(60) A 9-month follow-up revealed that the effectiveness of behavioural management approaches had been maintained over this period.(61) Interpretations of the findings of this study have been divergent. Re-analysis suggests that it may well be that medication alone or in combination with behavioural treatment is strongly indicated in severely affected children, while behavioural treatment and parent training are equally effective where impairment is mild or moderate.(58)
Parent training alone is effective in pre-school children with mild or moderately severe ADHD when delivered in a specialist setting, but is not when provided as part of routine primary care by non-specialist nurses.(62)
Cognitive distortions and deficits
The core cognitive distortion in children and adolescents with obsessive–compulsive disorder (OCD) is thought to lie, as it does with adult patients, in the appraisal of responsibility.(63) This is defined as ‘the belief that one has power which is pivotal to bring about or prevent subjectively crucial negative outcomes’. Now we all do have responsibility for our actions; what makes patients with OCD different is that they take upon themselves quite unreasonable levels of responsibility. A 13-year-old might, for example, think ‘I am responsible for making sure my mother does not die’. This sense of responsibility leads to attempts both to suppress and to neutralize the unwelcome thoughts of responsibility.
‘Neutralizing’ is defined as voluntary activity intended to have the effect of reducing the perceived responsibility. ‘If I tap on my glass three times before I drink from it, my mother will not die’. But neutralizing activities increase discomfiting cognitions and this leads to further neutralizing activity. Attempts to suppress the intrusive thoughts also increase the likelihood of their recurrence. An additional complicating feature of the cognitive distortion is that, in the mind of the child with OCD, thoughts become imbued with unrealistic or magical powers. It is enough just to have a thought for it to be translated into action, so-called ‘thought-action fusion’. ‘If I allow myself to think about my mother dying this will mean that she will die’.
In general the cognitive distortions made by children and adolescents with OCD are similar to those seen in adults. However in a study comparing the various components of OCD cognitions in children, adolescents and adults it was found that children experienced fewer intrusive thoughts and these were less distressing and less uncontrollable than those experienced by adolescents and adults.(64) On the other hand, cognitive processes of thought-action fusion, perceived severity of harm, self-doubt and cognitive control were similar across the three age groups.
Techniques of assessment and intervention
The aim of cognitive therapy is to help the patient reach the view that obsessional thoughts, however distressing, are irrelevant to any activities that may be undertaken in the future. This is achieved by increasing the patient's sense of personal efficacy, predictability, controllability, and self-attributed likelihood of a positive outcome. The techniques used involve the conduct of tasks involving exposure to feared stimuli as well as response prevention, stopping the activities that reinforce the unwelcome thoughts.
The most widely applied treatment approach to OCD in children and adolescents is that developed by John March and his colleagues.(65) The treatment protocol involves 12 sessions of which the first two are spent on psycho-education and cognitive training and the next 10 sessions on exposure and response prevention with the first and last two sessions, as well as an intermediate session involving parents. The effectiveness of exposure depends on the fact that anxiety diminishes after repeated contact with a feared stimulus. Thus the anxiety of a child worried about germs will be reduced by prolonged contact with a surface the child thinks has germs on it. Encouraging parents not to provide reassurance to children who compulsively and repetitively demand it, removes reinforcement, and results in extinction of the behaviour. Some children become extremely distressed when their parents, on instruction, fail to provide such reassurance; more success is achieved by putting the child in control of reducing parents’ inappropriate behaviour. Modelling and shaping behaviours are also helpful in giving the children or adolescents the skills to expose themselves to feared stimuli. Liberal use of rewards when the child behaves appropriately is also helpful in reinforcing desired behaviour.
Evaluation of effectiveness and efficacy
The most informative findings on efficacy come from the Pediatric OCD Treatment study (POTS) Team.(66) 112 patients aged from 12 to 17 years, suffering from OCD were divided randomly into four groups: CBT alone, sertraline alone, combined sertraline, and CBT treatment and a pill placebo. Both sertraline alone and CBT alone were superior in outcome to pill placebo at 12 weeks after the beginning of treatment. But combined treatment was superior to both treatments administered separately with a clinical remission rate of 54 per cent, compared to 4 per cent for placebo.
Most studies report the results of individual treatment with children and adolescents, with limited input from parents. Initial findings suggest that for middle-school aged children, aged 8–14 years, CBT delivered with a stronger focus on parental involvement than is usually the case with adolescents is effective in reducing symptomatology(67) at least in the short-term. Success has also been reported for similar treatment provided in a group format. Group CBT is as effective as sertraline, and shows better results than sertraline at 9 months follow-up.(68) The presence of tics does not reduce the effectiveness of CBT in the treatment of OCD.(69) There are few studies investigating the longer-term effect of CBT on OCD. However it has been shown that improvement after both individual and group therapy is maintained for at least 18 months without attenuation.(70)
Application of CBT for miscellaneous purposes
There are a number of other conditions and adverse psychosocial situations occurring in childhood and adolescence in which the use of CBT is an important component of management. For a further discussion of these conditions and their management, see other sections of this book.
Chronic fatigue syndrome (CFS)
In this condition, characterized by severe fatigue and overwhelming exhaustion, with excessive sleepiness and a variety of other unexplained physical complaints, cognitive distortions involving an enhanced tendency to believe in the presence of disease in the absence of medical evidence (illness attribution), and deficits in the use of problem-solving techniques related to illness and disability have been identified.(71) The illness is not uncommon, occurring in around 2 per 1000, 11 to 15-year-olds. Rehabilitative methods, including the use of CBT have been found to be successful in adults and are also employed in the paediatric age group. A controlled clinical trial has found 10–17-year-olds with CFS to show greater improvement with CBT than a waiting list control group.(72)
Cognitive distortions in young people presenting with substance abuse commonly relate to denial they have a serious, ultimately life-threatening problem, unwillingness to believe that effective help is available, and lack of belief in their own self-efficacy to change their behaviour. There is increasing evidence from controlled clinical trials that cognitive behaviour therapies can achieve positive results.(73) Motivational interviewing preceding the use of CBT is important with many children and adolescents and this is likely to be particularly the case with those suffering from substance abuse.
Central features of both anorexia nervosa and bulimia nervosa include distorted cognitions about shape and weight. Cognitive behavioural approaches used with adults with these conditions require modification when used with adolescents, with greater emphasis on involvement of parents.(74) While CBT is the most effective treatment for bulimia in older adolescents and adults,(75) family counselling is now established as the most effective intervention for anorexia nervosa in younger patients.(76)
Post-traumatic stress disorder
This condition is characterized by disorders of thinking including repetitive, intrusive thoughts, phobic avoidance of the situation in which the individual was exposed to trauma, ‘survivor guilt’, and problems in concentration. CBT is the most effective, evidence-based technique in the management in both children and adolescents.(77,78)
Abdominal pain and headache for which no physical cause can be found are commonly seen in primary health care. Although when these conditions occur it is often difficult to establish a psychological mechanism for the pain, it is reasonably well established that management based on CBT is the most effective approach. CBT is also effective in reducing pain from organic disease as well as in reducing distress when painful paediatric procedures are carried out. For a review of the use of CBT in the management of pain in childhood, see McGrath and Goodman.(79)
Adverse psychosocial situations
Children and adolescents in adverse psychosocial situations are frequently troubled by distorted perceptions of their predicament. In particular, they may feel themselves responsible for the separation and divorce of their parents or that they have deserved the maltreatment, either physical or sexual, inflicted on them by adults who have abused them. CBT has a significant part to play in helping children adjust to parental separation and divorce.(80) It has also been shown to have demonstrable value when applied to victims of sexual abuse.(81)
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