Cognitive-Behavior Therapy for Children and Adolescents

Cognitive-Behavior Therapy for CHILDREN AND ADOLESCENTS This page intentionally left blank Cognitive-Behavior Therapy for CHILDREN AND ADOLESCENTS Edited by Eva Szigethy, M.D., Ph.D. John R. Weisz, Ph.D., ABPP Robert L. Findling, M.D., M.B.A. Washington, DC London, England Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family. Books published by American Psychiatric Publishing (APP) represent the findings, conclusions, and views of the individual authors and do not necessarily represent the policies and opinions of APP or the American Psychiatric Association. To buy 25–99 copies of this or any other APP title at a 20% discount, please contact Customer Service at [email protected] or 800-368-5777. To buy 100 or more copies of the same title, please e-mail us at [email protected] for a price quote. Copyright © 2012 American Psychiatric Association ALL RIGHTS RESERVED Manufactured in the United States of America on acid-free paper 15 14 13 12 11 5 4 3 2 1 First Edition Typeset in Revival565 and Swis721. American Psychiatric Publishing, a Division of American Psychiatric Association 1000 Wilson Boulevard Arlington, VA 22209-3901 www.appi.org Library of Congress Cataloging-in-Publication Data Cognitive-behavior therapy for children and adolescents / edited by Eva Szigethy, John R. Weisz, Robert L. Findling. — 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-58562-406-5 (alk. paper) I. Szigethy, Eva, 1962– II. Weisz, John R. III. Findling, Robert L. IV. American Psychiatric Association. [DNLM: 1. Cognitive Therapy. 2. Adolescent. 3. Child. 4. Mental Disorders— psychology. 5. Mental Disorders—therapy. WS 350.6] 616.891425—dc23 2011039536 British Library Cataloguing in Publication Data A CIP record is available from the British Library. Contents Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix DVD Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii 1 Cognitive-Behavior Therapy: An Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Sarah Kate Bearman, Ph.D. John R. Weisz, Ph.D., ABPP 2 Developmental Considerations Across Childhood . . . . . . . . . . . . . . . . . . . . . . . 29 Sarah A. Frankel, M.S. Catherine M. Gallerani, M.S. Judy Garber, Ph.D. Appendix 2–A: Tools for Assessing Developmental Skills . . . . . . . . . . . . . . . . . . . . . . . . . .62 Appendix 2–B: Practical Recommendations for Treatment Planning. . . . . . . . . . . . . . . . . . . . . . . . .65 3 Culturally Diverse Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . 75 Rebecca Ford-Paz, Ph.D. Gayle Y. Iwamasa, Ph.D. 4 Combined CBT and Psychopharmacology . . .119 Sarabjit Singh, M.D. Laurie Reider Lewis, Psy.D. Annie E. Rabinovitch, B.A. Angel Caraballo, M.D. Michael Ascher, M.D. Moira A. Rynn, M.D. Appendix 4–A: Combination Treatment . . . . . . . . . . 150 5 Depression and Suicidal Behavior . . . . . . . . . .163 Fadi T. Maalouf, M.D. David A. Brent, M.D. 6 Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . .185 Benjamin W. Fields, Ph.D., M.Ed. Mary A. Fristad, Ph.D., ABPP 7 Childhood Anxiety Disorders: The Coping Cat Program . . . . . . . . . . . . . . . . .227 Kelly A. O’Neil, M.A. Douglas M. Brodman, M.A. Jeremy S. Cohen, M.A. Julie M. Edmunds, M.A. Philip C. Kendall, Ph.D., ABPP 8 Pediatric Posttraumatic Stress Disorder. . . . . .263 Judith A. Cohen, M.D. Audra Langley, Ph.D. 9 Obsessive-Compulsive Disorder . . . . . . . . . . .299 Jeffrey J. Sapyta, Ph.D. Jennifer Freeman, Ph.D. Martin E. Franklin, Ph.D. John S. March, M.D., M.P.H. 10 Chronic Physical Illness: Inflammatory Bowel Disease as a Prototype . . . . . . . . . . . . 331 Eva Szigethy, M.D., Ph.D. Rachel D. Thompson, M.A. Susan Turner, Psy.D. Patty Delaney, L.C.S.W. William Beardslee, M.D. John R. Weisz, Ph.D., ABPP Appendix 10–A: PASCET-PI Selected Skills and Tools . . . . . . . . . . . . . . . . . . . . . 369 Appendix 10–B: Guided Imagery for Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Appendix 10–C: Information Worksheets for Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378 11 Obesity and Depression: A Focus on Polycystic Ovary Syndrome . . . . . . . . . . . . . . 383 Dana L. Rofey, Ph.D. Ronette Blake, M.S. Jennifer E. Phillips, M.S. Appendix 11–A: Healthy Bodies, Healthy Minds: Selected Patient Worksheets. . . . . . . . . . . . . . . . . . . 420 12 Disruptive Behavior Disorders . . . . . . . . . . . . 435 John E. Lochman, Ph.D., ABPP Nicole P. Powell, Ph.D. Caroline L. Boxmeyer, Ph.D. Rachel E. Baden, M.A. 13 Enuresis and Encopresis . . . . . . . . . . . . . . . . 467 Patrick C. Friman, Ph.D. Thomas M. Reimers, Ph.D. John Paul Legerski, Ph.D. Appendix 1: Self-Assessment Questions and Answers . . . . . . . . . . . . . . . . . .513 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535 Contributors Michael Ascher, M.D. Resident in Psychiatry, Department of Psychiatry and Behavioral Sciences, Beth Israel Medical Center, New York, New York Rachel E. Baden, M.A. Graduate Student, The University of Alabama, Tuscaloosa, Alabama William Beardslee, M.D. Director, Baer Prevention Initiatives, Children’s Hospital of Boston; Gardner/Monks Professor of Child Psychiatry, Harvard Medical School; Senior Research Scientist, Judge Baker Children’s Center, Boston, Massachusetts Sarah Kate Bearman, Ph.D. Assistant Professor of School-Child Clinical Psychology, Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York Ronette Blake, M.S. Project Coordinator, Weight Management Services, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania Caroline L. Boxmeyer, Ph.D. Research Psychologist, Department of Psychology, The University of Alabama, Tuscaloosa, Alabama David A. Brent, M.D. Academic Chief, Child and Adolescent Psychiatry; Endowed Chair in Suicide Studies; Professor of Psychiatry, Pediatrics, and Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Douglas M. Brodman, M.A. Child and Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia, Pennsylvania Angel Caraballo, M.D. Assistant Clinical Professor of Psychiatry; Medical Director, School-Based Mental Health Program, Columbia University Medical Center, New York, New York ix x Cognitive-Behavior Therapy for Children and Adolescents Jeremy S. Cohen, M.A. Child and Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia, Pennsylvania Judith A. Cohen, M.D. Professor of Psychiatry, Temple University School of Medicine, Philadelphia, Pennsylvania Patty Delaney, L.C.S.W. Licensed Clinical Social Worker, Medical Coping Clinic, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania Julie M. Edmunds, M.A. Child and Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia, Pennsylvania Benjamin W. Fields, Ph.D., M.Ed. Postdoctoral Fellow in Clinical Child Psychology, Nationwide Children’s Hospital, Columbus, Ohio Robert L. Findling, M.D., M.B.A. Rocco L. Motto, M.D., Professor of Child and Adolescent Psychiatry, Case Western Reserve University School of Medicine; Director, Division of Child & Adolescent Psychiatry, University Hospitals Case Medical Center, Cleveland, Ohio Rebecca Ford-Paz, Ph.D. Assistant Professor of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois Sarah A. Frankel, M.S. Graduate Student, Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee Martin E. Franklin, Ph.D. Associate Professor of Clinical Psychology in Psychiatry at the Hospital of the University of Pennsylvania; Director, Child/Adolescent OCD, Tics, Trichotillomania and Anxiety Group (COTTAGe), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Jennifer Freeman, Ph.D. Assistant Professor of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island College of Physicians and Surgeons.D. University of North Dakota. Columbus. Ph. Ph. Instructor in Clinical Psychiatry.Contributors xi Patrick C. Graduate Student. Central Office. Institute of Clinical Psychology (in Psychiatry). Iwamasa. Clinical Professor of Pediatrics. Philadelphia. Boys Town Center for Behavioral Health. Columbia University Medical Center.D. Nashville. Washington.D.. Tennessee Gayle Y. University of California Los Angeles. Gallerani. Psy. Pennsylvania Audra Langley.D.D. Carnell Professor of Psychology and Director of the Child and Adolescent Anxiety Disorders Clinic. Kendall. ABPP Laura H. and Nutrition. Ohio Catherine M.D. Assistant Professor of Psychology. Tuscaloosa. Office of Mental Health Operations. DC Philip C. Ph. M. Ph. Vanderbilt University. Temple University. Nebraska Mary A. Grand Forks. Ph. New York John E. Professor of Psychology and Human Development. Tennessee Judy Garber. CA John Paul Legerski..D. Ph. University of Nebraska School of Medicine. The University of Alabama. Semel Institute for Neuroscience and Human Behavior. Department of Psychology and Human Development. Omaha. Fristad. Friman. Los Angeles. New York. Ph. Nashville. Assistant Professor of Psychiatry and Biobehavioral Sciences. Vanderbilt University. Ph. North Dakota Laurie Reider Lewis. ABPP Professor of Psychiatry.D.S.. Alabama . Psychology. Lochman. Department of Veterans Affairs. ABPP Professor and Doddridge Saxon Chairholder in Clinical Psychology. The Ohio State University. Director.D. New York Thomas M. Assistant Professor of Psychiatry. Ph. Weight Management and Wellness Center. Division of Neurosciences Medicine. University of Pittsburgh School of Medicine.D.A. Temple University. M. Philadelphia. Department of Psychology. Clinical Associate Professor. American University of Beirut Medical Center. University of Pittsburgh. Durham.xii Cognitive-Behavior Therapy for Children and Adolescents John S. Director. Assistant Professor of Pediatrics and Psychiatry. March. O’Neil. Alabama Annie E. North Carolina Kelly A. Phillips. Duke Clinical Research Institute. Department of Pediatrics.S.D.D. Child and Adolescent Anxiety Disorders Clinic. Adjunct Assistant Professor of Psychiatry. Department of Child and Adolescent Psychiatry.P. Pittsburgh. Lebanon. B. M. Director of Behavioral Health. Research Assistant..A. Maalouf. Predoctoral Psychology Fellow. Behavioral Health Clinic. Pittsburgh. University of Pittsburgh School of Medicine. Powell. Pennsylvania Fadi T. Tuscaloosa. M. Omaha. Pittsburgh. Ph.D. New York. Creighton University School of Medicine. Pennsylvania Nicole P. The University of Alabama.D. Ph. Director. Reimers. Beirut. M. Boys Town. Research Psychologist. New York State Psychiatric Institute. Nebraska Dana L. M. Rabinovitch. Children’s Hospital of Pittsburgh. Columbia University. Western Psychiatric Institute and Clinic.H. Rofey. Pennsylvania Jennifer E. Pennsylvania . Children’s Hospital of Pittsburgh. New York Jeffrey J. Harvard Medical School. Assistant Professor of Psychiatry and Behavioral Sciences.D. Division of Pediatric Gastroenterology. Medical Coping Clinic. New York Presbyterian Hospital. Division of Child and Adolescent Psychiatry. New York Eva Szigethy. Child and Adolescent Psychiatry. Associate Professor of Clinical Psychiatry. Harvard University.. ABPP Professor of Psychology. President and Chief Executive Officer. Judge Baker Children's Center. M.D. Pediatrics. Boston. Massachusetts.D. Medical Coping Clinic. Ph.A. Weisz. Pennsylvania Susan Turner. Children’s Hospital of Pittsburgh of UPMC. Rynn. M. North Carolina Sarabjit Singh. New York.D. Professor of Psychology. Thompson. Boston. Psy. Faculty of Arts and Sciences. Unit Chief of Children’s Research Day Unit. Pennsylvania John R. M. Medical Director of The Columbia University Clinic for Anxiety and Related Disorders (CUCARD). and Medicine. Assistant Professor of Clinical Psychiatry. New York. Medical Coping Clinic.Contributors xiii Moira A. Harvard Medical School. Sapyta. Ph. Medical Director. Cambridge. Pennsylvania Rachel D. Licensed Clinical Psychologist. Massachusetts. Research Clinician.D. Pittsburgh.. Director of the Child and Adolescent Psychiatric Evaluation Service. Columbia University. Associate Professor of Psychiatry. University of Pittsburgh Medical Center. Pittsburgh.D. New York State Psychiatric Institute/Columbia University. Ph. Deputy Director of Research.D. M. Duke University Medical Center. Columbia University. Massachusetts . Children’s Hospital of Pittsburgh of UPMC. Durham. Sunovion. Fristad. Research support: Child/Adolescent Anxiety Multimodal Study (CAMS).D. acted as a consultant. Novartis. Research support: Annie E. Translational Venture Partners. Equity: MedAvante. Pfizer. M. Casey Foundation. Dulcan.D.P. Scientific Consulting Fees: Johnson & Johnson. II. and/or a government agency. Cohen. ABPP Royalties (income) from sales of books and treatment materials for the treatment of anxiety in youth Fadi T. Sepracore. M. UpToDate psychiatry section editor. Lilly. Otsuka. Pfizer. Forest. Johnson & Johnson. M. Research support: Boehringer Ingelheim Pharmaceuticals. Attention Therapeutics. Royalties: Guilford Press. Research Units on Pediatric Psychopharmacology and Psychosocial Interventions (RUPP-PI). Child and Adolescent Psychiatry Trials Network (CAPTN). New York State Office of Mental Health Mina K. LLC. a manufacturer of a commercial product.D. Speaker’s bureau: Eli Lilly John S. Rynn. Lilly. and Wyeth Mary A. M. as listed below: David A.D. Research support: National Institutes of Health Moira A. Western Psychiatric Institute and Clinic. Pediatric OCD Study (POTS) I.H. Oakstone child psychiatry review video completed in 2010 . Rofey.D. Addrenex.A. Works for the University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center.D. Substance Abuse and Mental Health Services Administration. Findling. K24. Rhodes Pharmaceuticals. KemPharm. Treatment for Adolescents with Depression Study (TADS) Dana L. Lilly. National Institute of Mental Health.D. Ph. a provider of a commercial service.D. M.D.D. Training contracts (includes funds for travel): California Institute for Mental Health. M. Royalties: Guilford Press. Noven. Scientific Advisor: Alkermes. Supernus Pharmaceuticals. Brent. and/or served on a speaker’s bureau for Abbott. Shire. Pfizer.D. Seaside Therapeutics. AstraZeneca. ABPP Royalties: MF-PEP and IF-PEP workbooks (www. Solvay.B.com) and Psychotherapy for Children With Bipolar and Depressive Disorders (Guilford Press) Philip C. Receives or has received research support.D. MultiHealth Systems.moodychildtherapy. M.. Schering-Plough. Organon. M. Validus. Pfizer (principal investigator). Jr.xiv Cognitive-Behavior Therapy for Children and Adolescents Disclosures of Interest The following contributors to this book have indicated a financial interest in or other affiliation with a commercial supporter. Maalouf.. Scion. M. Oxford University Press. Royalties: American Psychiatric Publishing Eva Szigethy. Neuropharm LTD.. Lundbeck. Honoraria: presentations for continuing medical education events Judith A. SanofiAventis. Pfizer. Ph. Royalties: Guilford Press (books). Kendall. Pennsylvania Department of Mental Health. March. National Institute of Mental Health. National Alliance for Research on Schizophrenia and Depression. M. Vivus. GlaxoSmithKline. Bristol-Myers Squibb.. Ph. Avanir.. Biovail. Research support: National Institute of Mental Health. Ph. a nongovernmental organization. Neuropharm. Royalties: Books published by American Psychiatric Publishing Robert L. Powell. John E. Patrick C. Benjamin W. Phillips. William Beardslee... Jeremy S. Lochman. Jennifer E.D.A. Nicole P.. Ph.D. Jennifer Freeman. Sarah A. O’Neil.D.D. Boxmeyer.W. B.. Patty Delaney.... Ph. M.D. Jeffrey J.C. Frankel.D. Rachel D.Contributors xv The following contributors to this book have indicated no competing interests to disclose during the year preceding manuscript submission: Rachel E. Ph.Ed.. ABPP. Gayle Y. Ph. M. Franklin. Friman. Ph. M. Susan Turner. M. Ph.. M.S. Ph. ABPP .D. Thompson. Douglas M. Annie E.D.. Ph.A. Ph. Sapyta. Julie M.. M.A. Cohen.S. Rebecca Ford-Paz.A. Psy.D... Fields. Ph.. Ph.. Sarabjit Singh..D. L. M.D.D.D. Psy... Reimers. M. M. Kelly A.D... John Paul Legerski.... John R.. Ph. Sarah Kate Bearman. Rabinovitch.. Baden.D. Ronette Blake. M... Edmunds. Ph...S.S.A.D.D.A. Gallerani. M.. M. M.S. Ph. Iwamasa.. Catherine M.D. Ph. Laurie Reider Lewis. M. Thomas M.. Angel Caraballo.. Caroline L.A. Weisz. Brodman.D.D. Martin E. Audra Langley. This page intentionally left blank . The “complete” child and adolescent psychiatrist uses therapeutic techniques.Foreword THIS book. Although each intervention has empirical support and underpinnings in theory. case examples. key clinical summary points. and clinical students. in neuropsychology and a Ph.. edited by three experts in developmental psychopathology. with coeditor John Weisz. The chapters in this accessible text speak to those therapists and their patients. with a broad and deep portfolio of research in phenomenology and pharmacological treatment of childhood psychopathology. Each chapter contains practical advice on constructing a treatment plan for the disorder or syndrome. Bob Findling. M. not only a prescription pad. in which she methodically developed and tested a model of CBT for youth with both a chronic medical illness (inflammatory bowel disease) and depression. There are many excellent books on CBT.D. Chapters include clinically relevant pearls of wisdom. residents. Ph. and self-assessment questions and answers..D. the third coeditor of this trio. John Weisz has been a pioneer in the study of what works in child mental health treatment—in both university research and community clinical settings. Mental health professionals.D. in neuroanatomy. This launched an unusual and creative path for a physician. as she completed her fellowship in child and adolescent psychiatry. is a child and adolescent psychiatrist and a pediatrician. incorporating CBT interventions—as specific as xvii . is just what clinicians and trainees are waiting for! Eva Szigethy is a child and adolescent psychiatrist with a B. and social problems. psychological. especially psychiatrists. and fellows often find the strictly manualized approaches to psychotherapy to be intimidating and difficult to implement in the real world of patients and families with multiple biological.A. but the synergy between psychiatry and psychology makes this one unique. a type of cognitive-behavior therapy (CBT). extensive literature reviews are deliberately avoided in favor of a practical how-to approach. She had the good fortune to study Primary and Secondary Control Enhancement Training (PASCET). suggested additional readings. Osterman Professor of Child Psychiatry. Chief. residents. Mary Fristad. Margaret C. noted expert in developmental psychopathology. with its illustrative DVD. on depression and suicidal behavior.D. Ph. M. Dulcan. Department of Child and Adolescent Psychiatry. Northwestern Memorial Hospital.. The next chapter. with a focus on polycystic ovary syndrome. Chicago. with inflammatory bowel disease as a prototype.D. A novel part of this chapter is a section debunking common myths and misperceptions about CBT.D. Professor of Psychiatry and Behavioral Sciences and Pediatrics.xviii Cognitive-Behavior Therapy for Children and Adolescents number. Not only would this book. on disruptive behavior disorders. on bipolar disorder. is coauthored by Judy Garber. Following a chapter on aspects of therapy with culturally diverse youth. and fellows. Head. This 13-chapter therapy manual begins with an introduction to CBT with children and adolescents. M. especially in programs that may lack faculty expertise in these techniques. structure.. with contributions by many leading lights: David Brent. John March.D. on the use of Coping Cat for anxiety disorders. In addition. and John Lochman... be a top choice for individual practitioners in any mental health discipline who wish to apply CBT to children and adolescents. The following chapters cover the range of disorders. Warren Wright Adolescent Program. Ph. A unique feature of this book is a DVD containing video vignettes (presented by actors and actual therapists) that bring to life selected CBT techniques described in the text. Philip Kendall. Mina K. on developmental considerations. there are chapters on problems with physical manifestations: pediatric chronic physical illness..D. on obsessive-compulsive disorder. M. Ph. and enuresis and encopresis—notoriously difficult disorders to treat once children become too old for star charts and simple behavioral pediatric interventions. Director. Chapter authors also discuss how developmental and cultural factors may require special attention or adaptation of techniques. it would also be ideal for classroom or seminar use with clinical students.D. obesity and depression.D. Illinois . Judy Cohen. One of the most interesting and useful sections of each chapter is how to identify and address challenges and obstacles to treatment.. Children’s Memorial Hospital.D. on posttraumatic stress disorder. there is a unique chapter on integrating CBT with psychopharmacology—a topic too often ignored. Northwestern University Feinberg School of Medicine. Child and Adolescent Psychiatry. M. format.. Ph. and content of sessions and when and how to include parents. a common complaint of practicing clinicians is that they have difficulty accessing the CBT protocols that have been tested and found to be effective.D.D. the coeditors of this volume. As a psychotherapy researcher and Medical Director of the Medical Coping Clinic at the Children’s Hospital of Pittsburgh. CBT offers the hope of changing dysfunctional trajectories during the critical developmental window of childhood and adolescence when there is optimal plasticity in brain functioning and underlying circuitry. a phenomenon that has been linked to elevated environmental stressors and their interactions with genetic and epigenetic changes in our human species. as well as xix . Szigethy and her colleagues have found that CBT has a significant impact on depression. cognitive-behavior therapy (CBT) has shown particularly strong evidence of effectiveness with children and adolescents. The challenge of making efficacious treatments accessible to clinical practitioners is of special interest to each of us.. In this setting. Although CBT has growing empirical support for efficacy in treating a variety of psychiatric disorders. Eva Szigethy. ideally in the context of an empathic patienttherapist relationship. Fortunately. and thus they have not been able to build their own proficiency in these potent interventions.Preface AROUND the world. and advances in intervention science are building an ever-richer armamentarium of treatments that can make a difference. abdominal pain. Ph. CBT uses psychotherapy techniques to correct erroneous thinking and alter maladaptive behaviors.. This appears to be particularly true for clinicians who are treating children and adolescents across a variety of psychiatric disorders. across diverse disorders and over decades of research. Among these evidence-based treatments. children are at risk. has had the unique opportunity to create a behavioral health clinic embedded within the Gastroenterology Clinic to screen pediatric patients for emotional distress and behavioral disturbances. M. advances in clinical science are expanding our understanding of the environmental and neurobiological mechanisms involved. and health-related quality of life. Rates of pediatric psychiatric disorders are increasing worldwide. obesity.A.D.D. These chapter features are complemented by introductory chapters on general developmental consideration across CBT modalities. Finally. ABPP. has repeatedly seen the practical obstacles to (as well as the feasible solutions for) incorporating evidence-based treatments into routine clinical care. As a psychotherapy researcher. including some of the algorithms used to guide such augmentation. we have addressed the growing evidence for the utility of CBT as a strategy for augmenting psychotropic medications. oppositional defiant disorder. noting modifications needed to make the techniques applicable to different age-groups and with differing levels of parental involvement. Our goal has been to provide a practical. John Weisz. This book was created to help fill the gap between clinical science and clinical practice for children and adolescents by making CBT accessible through the written word and companion videos. These experts have presented core principles and procedures. a pediatrician.xx Cognitive-Behavior Therapy for Children and Adolescents a fiscal impact in the form of decreased emergency room visits and hospitalizations. M. university professor. and treatment researcher who directs a division of child and adolescent psychiatry at an academic medical center. both in randomized effectiveness trials with clinicians in community clinics and in the impact of CBT-enhanced school and outpatient programming at Judge Baker.B. clinical vignettes. M. written by experts in CBT practice from around the world. and President and Chief Executive Officer of the Judge Baker Children’s Center. and social work. We hope this resource will allow for the dissemination of CBT-related expertise to clinicians in diverse treatment settings throughout the world so that the children and adolescents with these disorders can benefit from an approach to treatment that has such broad and growing support from clinical scientists and practitioners.. The chapters are developmentally sensitive as well. psychology. given the increased emphasis in graduate and professional training on achieving competence in psychotherapy during training. has also seen the potency of CBT. and various anxiety disorders.. Robert Findling. easy-to-use guide to the theory and application of various empirically supported CBT techniques for multiple disorders.. The content has been designed to be user-friendly for clinicians across different disciplines including pediatrics. Ph. source material from their various workbooks. medical school professor. Another unique feature of this book is the illustration of how CBT can be used to treat psychological disorders in the context of chronic physical conditions in children. . child psychiatrist. psychiatry. In addition. the material was written to be accessible and useful to both trainees and seasoned clinicians. and video demonstrations of some of the more challenging applications of CBT—including treatment of suicidality. as well as cultural and ethnic considerations. We appreciate the thoughtful Foreword prepared by Dr. and family (you know who you are) for their support. We extend additional thanks to the student actors from the top drama programs at universities in Pittsburgh. Dr. Thanks to American Psychiatric Publishing Editor-in-Chief Dr. William Beardslee (Harvard University). Dr. These valued colleagues include Dr. who agreed to demonstrate the various CBT applications on video. Mina Dulcan (Northwestern University). editorial suggestions. and encouragement in this adventure. We thank our staff. We also thank the authors of the various chapters. a career role model and a national leader of child psychiatrists in this country. Robert Hales and Editorial Director John McDuffie for their patient guidance through the editing process. and very importantly. . who performed their adolescent roles for the video with such talent and believability. and the excellent faculty colleagues from University of Pittsburgh. And we thank Debra Fox and her staff at Fox Learning Systems. David Kupfer (University of Pittsburgh). David Barlow (Boston University). Dr. who produced most of the book and whose writing skill helped us realize the vision of a how-to guide that balances academic rigor with the art of teaching. John March (Duke University). David DeMaso (Harvard University). who made the production of the highquality DVD accompanying the book possible. friends.Preface xxi We want to offer special thanks to colleagues who have meant so much to our professional life and in ways that have helped us to shape this book. And finally. we thank our pediatric patients and their families for the privilege of working with them— and through this process. learning about the curative power of CBT. and Dr. This page intentionally left blank DVD Contents Video titles and times by chapter Video title Patient name (corresponding chapter) Time (minutes) Depression and Suicide Jane (Chapter 5) 14:07 The Coping Cat Program Zoe (Chapter 7) 10:18 Obsessive-Compulsive Disorder Ashley (Chapter 9) 11:31 Polycystic Ovary Syndrome Mary (Chapter 11) 17:47 Disruptive Behavior Tim (Chapter 12) 9:48 Total time: xxiii 63:31 This page intentionally left blank 1 Cognitive-Behavior Therapy An Introduction Sarah Kate Bearman, Ph.D. John R. Weisz, Ph.D., ABPP SINCE 2000, a great deal of attention and discussion in child psychotherapy has centered around the topic of evidence-based treatments— psychosocial interventions that have been tested in scientific studies and shown to benefit youths relative to some comparison condition. An update on the status of evidence-based psychosocial treatments for children and adolescents (Silverman and Hinshaw 2008) identified 46 separate treatment protocols for child and adolescent mental health problems that meet the criteria for “well established” or “probably efficacious” therapies set forth by Chambless and Hollon (1998). The majority of the treatments designated as “well established” fall under the broad umbrella of cognitivebehavior therapy (CBT). These mental health problems span multiple diagnostic categories, including autism spectrum disorders, depressive disorders, anxiety disorders, attention problems and disruptive behavior, traumatic stress reactions, and substance abuse. CBTs are known by many specific “brand names” (e.g., trauma-focused cognitive-behavioral therapy, the Coping Cat Program, and the Adolescent 1 2 Cognitive-Behavior Therapy for Children and Adolescents Coping With Depression Course); all are unified by the guiding belief that an individual’s thoughts, behaviors, and emotions are inextricably linked and that maladaptive cognitions and behaviors can produce psychosocial dysfunction and impairment. Moreover, all CBTs approach cognitions and behaviors as malleable agents of change through which client distress and impairment may be alleviated. In this chapter, we will give a broad overview of key concepts shared across the various CBTs. Given that much of CBT development has been focused on adults, the most influential theories and applications are reviewed by drawing from literature on both adults and children, with some attention to animal studies as well. Chapter 2 will review specific practical developmental considerations in using CBT for children and adolescents. A Brief History Although the notion that individuals’ experience of the world is largely shaped by their thoughts and behaviors predates the field of psychology, some leaders in the field should be credited with laying the early foundation for modern CBT. Particularly important theoretical precursors include Pavlov (1927, 1928), whose experiments with animals using what is now known as classical conditioning highlighted the relationship between prior experience and involuntary responses, and Watson (1930), whose emphasis on the study of observable behavior and the organism’s capacity to learn new behaviors gave rise to learning theory. The more recent work of Skinner (1953) expanded the scope of learning theory to encompass detailed analysis of reinforcement processes in operant conditioning. Learning theory arguably established the ideological underpinnings of what would later be known as behavior therapy, with a number of notable contributors—among them Lazarus (1971), London (1972), and Yates (1975)—and led to the understanding that maladaptive behaviors are to a large degree acquired through learning. It followed from this perspective that additional learning experiences might be used to modify maladaptive behaviors and promote improved functioning. An early adopter of this notion, Jones (1924) used the pairing of pleasant experiences with feared stimuli to treat a child for a phobia. The work of Wolpe (1958) is one of the best-known early comprehensive approaches to the use of conditioning techniques in psychosocial intervention. Building on his research with animals and counterconditioning, Wolpe introduced the notion that anxiety in humans could be inhibited by invoking an incompatible parasympathetic response, such as relaxation, assertive responses, or sexual arousal. Likewise, the influential work of Cognitive-Behavior Therapy: An Introduction 3 Negative beliefs Situation Self World Future Bad grade on a test “I am not very smart.” “This class is stupid and a waste of my time.” “I will never do well in school.” FIGURE 1–1. Beck’s cognitive triad. Eysenck (1959) paired graded contact with feared objects or situations with training in relaxation to address phobic responses. These advances can be traced forward to systematic desensitization, assertiveness training, and related approaches to sex therapy, which continue to be in use today. These early approaches to the use of behavioral techniques in psychotherapy largely ignored the underlying cognitive processes involved in psychological dysfunction, focusing instead on shaping measurable behavior by manipulating reinforcers and using repeated exposure to fearful stimuli to uncouple the stimuli from the anxious response. In the 1960s, two approaches emerged simultaneously that thrust cognition into the forefront of psychotherapy: cognitive therapy and rational emotive therapy. Cognitive therapy, introduced by Beck (1963, 1964, 1967), posited that the way individuals perceive events and attribute meaning in their lives is a key to therapy. Specifically, Beck suggested that depressed individuals develop a negative schema, or a lens through which they view the world and process information, often because of early life experiences and negative life events—for example, the loss of a relationship or rejection by a loved one. This schema is activated in situations that remind the individual of the original learning experiences, leading to maladaptive negative beliefs about the self, the world, and the future; the conglomeration of negative beliefs across these three entities is known as the cognitive triad. This cognitive triad results in negative thinking errors in which the individual misinterprets facts and experiences and makes assumptions about the self, the world, and the future on the basis of this negative bias (Figure 1–1). Although his approach initially focused on depression, Beck extended the focus of cognitive theory of mental illness to other disorders in the 1970s (e.g., Beck 1976). Beck’s cognitive therapy in practice focused on educating the client about the relationship between thoughts and feelings and on helping the 4 Cognitive-Behavior Therapy for Children and Adolescents client to become more aware of the thoughts that preceded a change in affect. Using a gentle questioning technique, the clinician would probe these thoughts to better understand the underlying assumptions that led to the thought. For example, a person who thinks “I failed a test” may have a deeper belief that “Others will love me only if I am smart.” Once clients became adept at noticing the occurrence of these rapid, involuntary, “automatic” thoughts, Beck encouraged them to question the validity and utility of the cognition. Because these thoughts typically occur quickly and are rarely examined for their veracity, much of the therapy involved helping clients to consider how their thoughts may be inaccurate, unhelpful, or distorted. In theory, once these thoughts were repeatedly challenged, a gradual change in feelings and in behavior would result. Simultaneous to the development of cognitive therapy, Ellis (1958, 1962) introduced rational emotive therapy (RET), later named rational emotive behavior therapy. Much as in cognitive therapy, RET is predicated on the belief that an individual’s feelings are largely determined not by the objective conditions but by the way in which the individual views reality through his or her language, evaluative beliefs, and philosophies about the world, himself or herself, and others. Clients in RET learned to perceive the relationship among thoughts, feelings, and behaviors using the A-B-C model, in which activating events or antecedents (A) constitute the objective event that “triggers” the belief (B) about the meaning of the event. When the beliefs are rigid, dysfunctional, and absolute, the consequence (C) is likely to be self-defeating or destructive. In contrast, beliefs about objective events that are flexible, reasonable, and constructive are likely to lead to consequences that are helpful. Thus, in the RET model, beliefs play a mediating role in the relation between events that occur and the behavioral and emotional consequences. RET theory postulates that most individuals have somewhat similar irrational beliefs and identifies three major absolutes as particularly problematic: 1) “I must achieve well or I am an inadequate person”; 2) “Other people must treat me fairly and well or they are bad people”; and 3) “Conditions must be favorable or else my life is rotten and I can’t stand it” (Ellis 1999). Although clients may not be completely aware of these beliefs in their totality, they are able to verbalize them when queried and encouraged by the therapist—in other words, the beliefs are not unconscious but may not have been examined or articulated fully. In practice, clients in RET work with the therapist to identify the A-B-C sequences in the client’s life that are leading to impairment and distress. The therapist then teaches the client to use a series of disputing thoughts (D) to challenge or refute the dysfunctional belief. In particular, RET emphasizes distinguishing between statements that are objectively true and those that may be irrational. Once the belief has been refuted, a Cognitive-Behavior Therapy: An Introduction Antecedents Bad grade on test FIGURE 1–2. 5 Beliefs Consequences “I’m not very smart.” “I will never do well in school.” Sad feelings Decreased effort in school Effective thought Disputing thoughts “The test was hard, but I can try to do better.” “The test was difficult.” “Lots of kids did poorly.” The A-B-C-D-E model. more flexible, effective thought (E) is generated and used to replace the original belief. RET holds that clients have an existential choice about transforming their hopes, expectations, and preferences to absolutistic, rigid demands that will lead to emotional and behavioral disturbances—or conversely, seeing their hopes, expectations, and preferences as flexible and consequently to act in a healthy, self-helping manner. Figure 1–2 provides an example of the A-B-C-D-E sequence. Although the original iterations of both cognitive therapy and RET explicitly mentioned cognitive processes, later work by both Beck and Ellis noted that cognition is a facet of behavior and that behavioral components have always been present in both therapies. Indeed, in cognitive therapy, efforts are continually made to test the veracity of clients’ beliefs by using behavioral experiments. A client who feels rejected by a loved one may be encouraged to pursue activities and relationships in order to receive disconfirming information regarding the maladaptive belief (Beck et al. 1979). Likewise, RET has historically made use of behavioral activities, such as encouraging a client to do something he or she is afraid of doing, in order to demonstrate the irrationality of certain beliefs (Ellis 1962). Both the Beck and Ellis cognitive models, however, were developed in adults. Another central figure in the development of modern CBT, Donald Meichenbaum, focused on children as well as adults. Meichenbaum noted that people’s self-statements, or verbalized instructions to themselves, often appeared to guide their behavior. Much of Meichenbaum’s work focused on impulsive and aggressive children, who used fewer helpful instructional self-statements than less impulsive children (Meichenbaum and Goodman 1969, 1971). Self-instructional training (SIT) grew from these observations. In SIT, the therapist works with the client to reduce 6 Cognitive-Behavior Therapy for Children and Adolescents self-statements that produce maladaptive emotional and behavioral responses (such as frustration and aggression) and replace them with selfstatements that facilitate control of overt verbal and motor behavior. In practice, SIT took the form of the therapist first modeling selfinstructions by performing a task in front of the child while engaging in audible self-talk. Next, the child would perform the same task with instruction and encouragement from the therapist. The child would then repeat the task stating the instructions aloud and then whispering the instructions softly. Finally, the child would complete the task using only covert or internal self-instructions. Although initially used to help impulsive children slow down during performance tasks and correct themselves without becoming distressed, the same techniques have been used to good effect with anxious youngsters, who may engage in self-defeating and anxietyprovoking self-statements (e.g., “I can’t do this”; “I’ll get hurt”; “Everyone will laugh”). Nowadays, therapist modeling and helpful self-statements are a staple of several modern CBT treatments for anxiety disorders. Meichenbaum’s work is also notable for explicitly combining the cognitive and behavioral traditions to form a unified approach and for applying this unified approach in the treatment of children. Throughout the 1980s and 1990s, cognitive and behavioral theories and techniques were further merged and their application extended to include obsessive-compulsive disorder (OCD), other anxiety disorders, disruptive behavior disorders, depression, and other disorders, as discussed in subsequent chapters. Although there undoubtedly remain some purists who defend the merits of using either behavioral or cognitive strategies in isolation, most agree that cognitive and behavioral theories and strategies complement one another, and most use the label “CBT” to describe the pairing of these techniques. Common Principles As we have noted, CBT is a broad category that includes various therapies to address a range of disorders and problems, and it may emphasize different techniques, modalities, and target populations. Despite this variety, some common principles of CBT can be identified. We illustrate some of these common principles by focusing on the case of Ellen. Case Example A 9-year-old girl, Ellen, was diagnosed with major depression and attentiondeficit/hyperactivity disorder (ADHD), combined type. When Ellen was age 5, her mother was diagnosed with a serious illness at the same time that Ellen started a stimulant medication to address symptoms of ADHD. Ellen Cognitive-Behavior Therapy: An Introduction 7 had several side effects from the medication and became severely agitated and aggressive at school when her mother was undergoing intensive treatment and was largely unavailable; Ellen was briefly hospitalized. Following the hospitalization, Ellen’s aggressive and agitated behavior subsided; however, because of her sensitivity to stimulant medication, she was not medicated for ADHD symptoms. Ellen struggled in school, and although she was bright, she did not achieve highly in academic situations and was moved to a special education classroom to receive academic support. At the time that Ellen came into treatment, she was experiencing an episode of major depression: she reported feeling sad and down more often than not, experienced little pleasure from activities or events she once enjoyed, felt hopeless and guilty, and had difficulty making decisions and concentrating. In the presence of stressful situations, particularly in academic settings, Ellen would quickly become tearful, stating “I can’t do this” or “No one will help me.” Behaviorally, she would often give up on the task, refuse to reattempt the task, and withdraw. In the face of these behaviors, caregivers and teachers typically reacted with frustration, negative consequences, and finally resignation. 1. Clients and their problems are conceptualized in terms of cognition and behavior. Although no one refutes the importance of early learning and life experiences or the well-acknowledged role of biological processes and vulnerabilities (these seem evident in Ellen’s case), clinical formulations in CBT are largely focused on understanding the ways maladaptive thoughts and behaviors are maintained and lead to client distress and impairment. Whereas other factors are considered integral to development of a disorder, the CBT therapist focuses largely on how a client’s current thinking and behaviors contribute to the current difficulties. The interplay of early life experiences, situational stressors, biological or genetic factors, underlying beliefs, and current thinking and behavior is considered in forming a “working hypothesis” for how the client’s disorder developed and is maintained. This hypothesis is ever evolving and informs the treatment plan. The CBT formulation of a case like Ellen’s would consider her biological and medical vulnerabilities and earlier life experiences as contributing factors to the development of a negative self-schema, through which Ellen now processes new information and which becomes particularly activated during times of stress. Experiences such as academic challenges remind Ellen of her previous failures, confirm her beliefs that she is not capable of handling problems and that she cannot be helped, and lead to her acting-out and sullen behaviors. These behaviors are off-putting to adult figures and lead to negative consequences, which further reinforce Ellen’s belief that she is helpless. Figure 1–3 provides an example of the form such a formulation might take. In Ellen’s case, many factors are thought to be reciprocal: the maintaining factors further confirm the schema even as they are caused by it; likewise, the depressive symptoms and academic stressors interact with one 8 Cognitive-Behavior Therapy for Children and Adolescents another and with the maintaining factors. Although the CBT formulation considers all of these components, the core elements of the client conceptualization are the cognitions and the behaviors. Changing these thoughts and behaviors will be the focus of intervention. 2. CBT is largely present focused. Related to the first principle, CBT is less focused than some other types of psychotherapy on the presumed “underlying causes” or precipitants of the maladaptive cognitions or behavior. Although it is useful to understand a client’s history and to consider how the past informs current functioning, the emphasis in CBT is on what is happening for the client today. Clients beginning therapy often anticipate that they will be asked to plumb the depths of their early childhood experiences in great detail. Although the CBT therapist may consider formative events in terms of how current thinking and behavior were shaped, the approach does not subscribe to the notion that a client’s insight into and processing of early events are curative. There is little doubt that Ellen’s early experiences of behaving aggressively in school and her subsequent hospitalization during a time when family resources were limited played a role in the development of her belief that she is helpless and inadequate. This belief, coupled with symptoms of inattention and hyperactivity, is activated in the face of academic challenges and leads her to behave in a manner that often results in punishment and further confirmation that she cannot be helped. However, it is impossible to change what has happened to her in the past. Indeed, there is little evidence to suggest that discussing these past events would do much to change her current behavior. Currently, her negative view of herself, others, and the future is maintained by the thoughts she has (“I can’t do this”; “No one will help me”) and the behaviors that arise following these thoughts (giving up, refusing to do her work, becoming withdrawn and angry). These thoughts and behaviors directly lead to experiences that further confirm her view of herself, others, and the world. Thus, the CBT treatment would begin with an examination of the here-and-now circumstances that lead to the thoughts and behaviors that are problematic. Of course, there are some important exceptions. The past may become central in treatment when the content of current thoughts and beliefs directly involves past events, as is often the case in the treatment of posttraumatic stress disorder. However, even in these instances, the focus is on changing current thinking about the past, or current behavior in the presence of memories, rather than a focus on the past per se. 3. Maladaptive behaviors and cognitions are presumed to be learned. Although few would argue that all impairing thoughts and behaviors are the result of an unfortunate learning history, modern CBT stresses the impor- At the same time. ADHD =attention-deficit/hyperactivity disorder. A child with executive functioning deficits may have a more difficult time inhibiting an impulsive behavior. increasing the likelihood that he or she will try to avoid that experience.Cognitive-Behavior Therapy: An Introduction 9 Current stressors Academic difficulties Biological/genetic/ medical factors ADHD and sensitivity to stimulant medication Symptoms of depression Self-schema “I am helpless.” Life events Mother’s illness. Cognitive-behavior therapy formulation. learning experiences nonetheless reinforce or extinguish behaviors and cognitions. guilt. classical and operant conditioning) in the service of understanding how thoughts and behaviors are maintained. However. tance of established learning principles (e.. defiance. hopelessness. the times when she is able . increasing the likelihood that he or she may break a rule. Similarly. “No one will help me” Maladaptive behavior: Withdrawal. this behavior has been reinforced by the consequences that have typically followed: teachers have punished her (sent her from the room to time-out) or walked away from her—in both instances. indecision. a child who is very sensitive to anxiety cues may find it more difficult to tolerate physiological arousal. anhedonia. thereby transforming what is merely the increased likelihood of a behavior into an enduring pattern that continues and leads to impairment. increasing the likelihood that she will repeat this same thought when faced with the next similar task. difficulty concentrating Maintaining factors Negative thoughts: “I can’t do this”. and this certainly plays a large role in her propensity to give up when faced with academic demands. Genetic and biological predispositions play a role—for example. These consequences also serve to underscore her belief that she can’t do these tasks.g. The symptoms of ADHD make it more difficult for Ellen to tolerate frustration. hospitalization due to medication side effects Sadness. Certain factors may impact an individual’s predisposition to develop maladaptive thoughts and behaviors. sullen attitude Others’ reaction: Adult withdrawal or punishment FIGURE 1–3. allowing her to escape from the aversive task. and the intervention is designed to address these concerns. complete her coursework and homework. but the client (and the caregiver) is the expert in the child. that clients are controlled by unconscious desires and impulses and therefore unable to truly know what is troubling them. Ellen initially stated that she wanted to be in a regular education class rather than continue in special education. CBT therapists emphasize that both the client and the therapist have expertise: the therapist is an expert in strategies to change thoughts. and these goals are often described in objective. Ellen’s therapist used a process of questioning to understand how Ellen’s life might be different if she were no longer identified as needing extra academic help. and these goals also provided a therapeutic rationale for the interventions that the therapist introduced. although the biological predisposition contributes to the difficulties. a client’s goal to “feel better” may require further clarification: How will he or she know when that goal is achieved? What will be different in terms of behavior or thoughts? The goal or goals are frequently reviewed throughout therapy. her behaviors and cognitions are also influenced by her environmental experiences. That is. To that end. for example. Because this goal may not have been attainable. they are transparent. Having clearly defined goals allowed Ellen and her therapist to clearly measure her progress as therapy advanced. CBT focuses on specific. behaviors. When asked what she wanted to work on in therapy. but they are also well known to client and therapist alike. 4. inadvertently decreasing the likelihood that successful completion of challenging tasks will recur. CBT does not assume. Ellen wanted to feel less anxious in academic settings and to make more friends. observable terms. the CBT therapist will set goals with the client and/or with the client’s caregiver. Ellen revealed that she would like to develop strategies that would allow her to remain in her classroom. Rather. This “joint expertise” is necessary for successful treat- . CBT is collaborative and emphasizes the client’s expertise. and the interventions in therapy are understood by the client and/or caregiver in terms of how they will theoretically help move the client toward the therapeutic goals. the client’s articulated concerns are considered to be the “real” problem. For example. Transparency in CBT extends beyond setting goals and objectives. 5. the CBT therapist strives to engage the client in an active role in his or her own therapy. Importantly. Additionally. Through these queries.10 Cognitive-Behavior Therapy for Children and Adolescents to complete a challenging task are largely ignored and unpraised. Early in therapy. and feelings. Thus. clearly defined goals. and maladaptive thoughts and behaviors are reviewed regarding the obstacles they impose to achieving the goals that have been set. and do better in school. the goals in CBT are not only clearly defined in terms of behavioral objectives. A coach helps athletes hone their skills by teaching new strategies. in which the therapist asks . and providing support. feelings. A client who is asked to repeatedly confront a feared situation in a slow. course. the CBT therapist will take a less central role in prescribing and implementing such interventions. Eventually. the client knows that the purpose of these questions is to test the evidence that supports the negative thought. CBT therapists may often use the analogy of a sports “coach” to explain this role. the knowledge that the therapist possesses regarding the client’s difficulties and treatment is not a closely guarded secret—instead. Key to this process is a technique called Socratic questioning. CBT is viewed as a process of “teamwork” between the client and therapist. In work with children. the CBT therapist’s goal is not only to help the client set goals. Furthermore. the athletes must actively participate by practicing the skills and putting them into action. causes. In CBT. the therapist also provides education about the cognitive-behavioral formulation of the disorder—the way in which the client’s thoughts. graded manner understands that over time. instead supporting the client’s own use of these techniques. In other words. the therapist hopes to educate the client about his or her disorder and about the treatment strategies so that the client eventually becomes an “expert” in his or her own treatment.Cognitive-Behavior Therapy: An Introduction 11 ment. However. and prevalence. In a similar way. CBT teaches clients to identify. identify and evaluate maladaptive thoughts and behaviors. CBT typically begins with education regarding the nature of the disorder. but also to teach the client how to do these things so that the therapist is not necessary. and reappraise their own maladaptive thoughts and behaviors. for a client to learn that the scary feelings he or she has experienced have a name—panic attacks—and that they are relatively common and are caused by the misinterpretation of harmless bodily sensations. and the CBT therapist encourages the client to speak up about his or her own unique experiences. Part of the process of developing the client’s expertise is therefore education. he or she should begin to feel less fearful. the therapist is not using a technique that is unknown to the client—the process of the therapy is explained to the client in terms of how it relates to the symptoms or to the objective goals the client has set. Thus. and behaviors interact and lead to the distress or impairment he or she is experiencing. Client education also includes the therapeutic rationale for all prescribed interventions. including the symptoms. encouraging practice. for example. It can be tremendously comforting. and modify those thoughts and behaviors. when a therapist begins asking a series of questions about a client’s negative thought. evaluate. In addition to education about the disorder. An important component of Ellen’s therapy involved educating the client. however. in terms of the client’s targeted problem area. such as a game. and the client is asked to summarize the content of the session. Introducing ADHD as a problem similar to other medical problems such as allergies. this is reviewed—and obstacles to completing homework or unanticipated difficulties are discussed. If any therapeutic homework was assigned. these concerns do not necessarily form the content of the therapy session. 6. her parents. was useful for Ellen as well as her parents. rather than relying on the therapist’s opinion or the client’s subjective emotions. Next. Rather than abandon the agenda. clients generally have issues they want to discuss or concerns that have arisen over the prior week. and then by collaboratively teaching the caregiver what was done in session. Additionally. CBT therapists attempt to organize each session using an agenda. the agenda is reviewed and modified collaboratively. In turn. it was important to provide the adults in Ellen’s life with factual information about youth depression and how it may manifest as irritability in addition to the sadness more commonly addressed. which can cause difficulty but are also amenable to environmental modifications. Ellen knew that she “had ADHD” but was unaware of its common occurrence in many youths. the therapist heightens the client’s sense of expertise as he or she arrives at the conclusion. With children. The goal is twofold: by asking questions. asking questions also encourages a careful review of objective data as a means of determining the utility of the thought or behavior. Regardless of the diagnosis. In fact. the therapist informs the client of the objectives of each therapy session. As in other therapies. CBT is structured and strives to be time limited. new homework is assigned. and her teachers about the nature of ADHD and of major depression. Sessions generally begin with a brief review of the previous week. and because this is a collaborative process. Furthermore. sessions often end with some sort of engaging activity. Continuing with the theme of transparency. and her teachers were able to provide the therapist with examples of how these and other symptoms were expressed in Ellen’s day-to-day life—a perspective that was vital to personalizing the treatment for Ellen’s benefit.12 Cognitive-Behavior Therapy for Children and Adolescents a series of gentle questions regarding the utility of thoughts or behaviors. Ellen. the agenda items are discussed. rather than telling the client that the thought or behavior is maladaptive or unwarranted. Next. caregiver endorsement of the child’s . the client is asked to add topics or activities to the agenda. the CBT therapist seeks to incorporate this issue or concern into the agenda—either by linking it to an already planned topic or by including it as an additional topic that need not replace those that have been planned. her family. behaviors. for a session in which the plan was to learn how relaxing muscles and taking calming breaths could result in less distorted thinking and disruptive behavior. those specific examples introduce an opportunity to identify and evaluate negative thoughts. with a focus on providing symptom relief. For example. and perhaps modify those thoughts or behaviors. Depending on the target disorder. Likewise. examine the relationship of thoughts. facilitating remission of the disorder. They will be told that they will practice new skills until they can do them on their own and are moving toward their goals. the client is informed that initially. Despite variations in the number of sessions. The severity of some client’s problems requires treatment that greatly exceeds the 8 to 20 sessions so often described in efficacy trials. In general. for example. CBT is generally intended to be time limited. In this way. clients will be informed about the therapeutic interventions that they can expect—that they will be learning how to test how true or helpful their thoughts are. increasing client functioning. Although many manualized CBT treatments have a specific prescribed number of sessions. CBT formulates client difficulties using a cognitive-behavioral framework. these topics would be added to the agenda but would not require a change to the planned content. the therapist could skillfully use the client’s examples above as a way to make this new skill salient to Ellen and her parents. And they are told that the treatment will be time limited—that it will not last forever. 7. In an early session. in practice CBT can vary widely in length. behaviors. and CBT emphasizes helping clients learn to recognize their symptoms so they can determine when a return to therapy may be helpful. or begin slowly facing situations that have caused them anxiety. and this topic is revisited as treatment progresses. Many of Ellen’s sessions began with her or her parents wanting to discuss a recent incident. CBT clients may return to therapy for “booster” sessions when they experience a lapse. and then ending treatment. Clients and caregivers are also given an overview of the course of treatment from the beginning. CBT addresses the client’s concerns but does so in a structured way.Cognitive-Behavior Therapy: An Introduction 13 practice of new skills outside the therapy session is often key to achieving therapeutic effect. and feelings affect each other. the therapist will be teaching the client about his or her disorder and about how thoughts. places a . training clients in skills to prevent future relapse. or learn to solve problems. and emotions. CBT does not. such as a tantrum over homework completion or an emotional outburst. however. CBT is tailored to meet the particular needs of the client. typically “hold” clients in the therapeutic relationship once symptoms have remitted and gains have been maintained for a reasonable length of time. as well as plenty of time to watch television and play video games.14 Cognitive-Behavior Therapy for Children and Adolescents high premium on therapeutic interventions that have demonstrated scientific support. involved. CBT like- . each treatment is specifically tailored to the needs of the identified client. CBT emphasizes the therapist’s expertise with the disorder or problem area as a means of instilling hope and empowering the client to engage in treatment. whereas the latter might require behavioral contingencies for school attendance. for example. Because learning is a key component of CBT. CBT requires an active stance on the part of the therapist. and in much the same way. Ellen’s treatment. Consider. Because the factors that maintain the school refusal are dramatically different in these two cases.g. Avoiding school results in a decrease in anxious thoughts and feelings and is thus rewarding to the child. an effective CBT therapist takes an active. for example. Understanding the function of Ellen’s behavior was necessary to know how to address the behavior in therapy. Therefore. but it also incorporated environmental modifications to shape new behaviors and to phase out troublesome ones. required interventions that addressed her endogenous beliefs and volitional behaviors. being “punished” actually provided relief! A two-pronged approach was used to address this dilemma: 1) finding a more appropriate consequence to address instances of Ellen’s misbehavior and 2) working to improve Ellen’s perception of her classroom. Although the goal in treatment may be identical—increased attendance in the classroom—the two children and their reasons for refusal are very different. two children who both refuse to attend school. and relies on principles of learning theory—but CBT is not a one-size-fits-all treatment approach. To promote this learning. One child has anxious beliefs about what will happen at school and predicts that he will embarrass himself if called on in the classroom. so too would the interventions differ. Thought reappraisal and graduated exposure might be necessary for the former client. The new approach required actual changes (e. For example. To the contrary. being sent from the classroom was an ineffective punishment in Ellen’s case because the classroom when therapy began was a nonreinforcing environment—in other words. specific techniques used to address maladaptive behaviors and cognitions are based on the specific maintaining factors that prevent the client from achieving his or her goals. The other child finds school aversive because he lacks attention at home and has learned that avoiding school results in rewarding attention from his caregiver and one-on-one instruction. working with Ellen’s teachers to establish more frequent praise for positive behaviors) and reappraisal of Ellen’s beliefs. and directive role in treatment. 8. An effective coach does not simply sit on the sidelines observing the players. the therapist has more characteristics of a “teacher” than in some other orientations.. Ellen’s treatment again provides an example of this active therapeutic stance. upset. using relaxation strategies to manage anxious physical sensations. CBT therapists are largely concerned with making what happens in therapy relevant to what the client experiences in his or her dayto-day life. and effort to addressing the areas of concern. she became more involved in planning each meeting. providing suggestions of areas where additional attention was needed. with each committing time. the client would not necessarily volunteer some of the strategies most useful to overcoming the area of difficulty. identifying and changing negative thoughts. The therapist considers which of these strategies will be most beneficial to the client and works to introduce the intervention.Cognitive-Behavior Therapy: An Introduction 15 wise highlights the collaboration between client and therapist. Ellen’s expectations were that treatment would consist largely of open discussion and play. energy. Over time. On the basis of her prior experiences in therapy. This requires some consideration of how to make the interven- . Clients whose current thinking and behavior are self-defeating or cause difficulties are in need of new strategies. In contrast to therapies that focus mainly on the in-the-room interactions. and plans for implementation in the areas where the client experiences difficulty. Thus. 9. introduce and implement interventions that may be helpful for the client. The therapist therefore needed to initially take a very directive role in establishing the structure of each session. use client material to highlight the ways in which cognitions and behavior are causally linked to emotions. ensures that the client understands the intervention. CBT is initially quite directive. The therapist told Ellen that therapy would first focus on learning new ways to handle sad. CBT therapists approach each therapy session intent on structuring the session to maximize the time. setting guidelines for how sessions would proceed. and suggesting areas where skills might be useful. learning different strategies—for example. outside the office. CBT requires implementation in the real world. and identifying opportunities to practice her therapeutic skills. and confirm or revise the ever-evolving “working hypothesis” of the client’s case conceptualization. Therefore. Once Ellen became familiar with the strategies and accustomed to the structure of the sessions. or angry feelings. it is the CBT therapist’s job to suggest new strategies and to provide a compelling therapeutic rationale. Because therapists are often asking clients to try radically different ways of thinking or acting. the client becomes increasingly involved in the structure of sessions. In contrast to therapies that advocate following the client’s lead. but the CBT therapist remains highly involved in planning the treatment in order to deliberately progress toward the behavioral objectives or goals. or sequential problem-solving—was the aim of many early sessions. and that Ellen would be learning “new tools” for her toolbox. 16 Cognitive-Behavior Therapy for Children and Adolescents tions salient and requires both flexibility and creativity on the part of the therapist. CBT therapists generally assign some version of homework each week. the therapist should be willing to spend time in session working out the logistics of this reward program. Providing experiential in vivo opportunities wherein the client actually uses a new strategy or has the chance to test his or her beliefs is far more potent than discussing the strategy or belief in the abstract. acting out what happens outside of therapy using role-plays can promote greater generalization of therapeutic gains. For example. the potential barriers to homework completion and devise an intervention to address the noncompliance. using role-plays with her therapist and even videotaping herself in order to critique her verbal and nonverbal behaviors. Ellen had been practicing the skill of positive self-presentation in her interpersonal interactions. . For example. Ellen’s successful discussion with this teacher disconfirmed many of her beliefs about what would happen if she approached him. The therapist must actively plan for these activities and be willing to perhaps go beyond the boundaries of other types of therapies. Ellen and her therapist agreed to work on positive self-presentation with a teacher with whom Ellen found interactions especially challenging. The therapist was able to go to the school in order to coach Ellen through an interaction with this teacher. Another way in which CBT therapists press for real-world implementation is by encouraging clients to practice the strategies they learn in session in the time between therapy meetings. Likewise. Typically. it is more consistent with CBT principles to first consider the ways in which principles of reinforcement may be at work. Although this intervention required planning on the part of the therapist. Ellen practiced this skill in session. CBT therapists work to understand. The case of Ellen provides an example of this real-world intervention. the CBT therapist would try to find an opportunity to experience crowds with the client. first discussing with the teacher the plan and sharing the goals of the in vivo interaction. Because clients may struggle with homework completion. is the practice aversive and thus does noncompliance allow for escape? Is it possible to increase incentives for completion of therapeutic homework? Rather than assume the position that the therapist cannot or should not work harder than the client. with the client. if a client is fearful of crowds. CBT also addresses homework noncompliance. in ways that merely discussing or role-playing might not have achieved. If the client’s caregiver has had difficulty creating a home-rewards program to motivate behavior. particularly when she was upset. Whereas some therapies interpret noncompliance as resistance or as a behavior that is meaningful to the client-therapist relationship. Between these two levels of cognition (i. “What went through your head just then?” Using cartoons with thought bubbles similar to those often used in comic books can also be helpful. Ellen may have had several rules that governed the stressful situations: “If I don’t understand something immediately. Beck and Ellis both postulated that individuals hold certain beliefs or attitudes. others withheld help from her. I’ll never understand it”. However. attitudes. Ellen thought. that are activated during times of stress and form a lens through which new information is processed. the world. With children. the client maintains the belief. Although clients can be helped to evaluate the veracity of their automatic .” or “I can’t do this. even these may be somewhat difficult to identify at first. core beliefs and automatic thoughts) are the rules. “No one will help me. known as intermediate beliefs. At the deepest level.” or metacognition.” Identifying Thoughts and Beliefs CBT typically begins by approaching the client’s automatic thoughts because these are the most available to the client.. These are the superficial expression of the core belief—the accessible thought that flashes through the head for just an instant. and the future that they may not be recognized or articulable. I won’t have to fail. she encountered all new and potentially stressful situations with a deep-seated belief that she could never succeed. because “thinking about thinking. For example. the actual thoughts or images that go through a client’s mind in response to a given situation.” when approaching demanding tasks. Core beliefs are not generally examined in everyday life. We have also discussed automatic thoughts. despite its inaccuracy. these are known as core beliefs—beliefs so deeply ingrained with a client’s fundamental sense of self.Cognitive-Behavior Therapy: An Introduction 17 Role of Beliefs As previously discussed. “If people don’t offer help to me. instead. they are just accepted as “the way things are. in her view. a test she passed was deemed “easy”). constructed in part from early life experiences and biological vulnerabilities. It is sometimes helpful to reenact a triggering situation and then ask the child. Experiences that were inconsistent with this belief were quickly forgotten or misattributed (for example. and “If I don’t try. is not routinely asked of children. and assumptions that link the core belief to the automatic thoughts.e.” Consider Ellen once again: she never stated a belief that she was helpless. By discounting or failing to notice the experiences that disconfirm the core belief. it is because I can’t be helped”. and the world. I wasn’t paying attention—and then I did. and you suddenly start paying attention and you think . she says I didn’t pay attention. Therapist: Ah. what made the thought so upsetting was the more fundamental belief that failure to do the math problem was just another example that the cli- . So I wonder if there was anything else that connected your thought “I don’t get it” to feeling frustrated and then saying that to your teacher. and I’m talking about fractions. OK. Client: And then I said. A technique called guided discovery is often used in CBT to help the client move from automatic thoughts to intermediate beliefs. and I felt really annoyed. I just can’t do it. Therapist: Let’s imagine I’m your teacher. Client: I don’t get it. the therapist poses a question assuming that the automatic thought is true. I’d like to understand why that thought made you feel so upset.” And then you felt frustrated. others. Therapist: What does that mean about you. do you think. What would that mean? Client: Then I won’t be able to do the exercise. So if you couldn’t do the exercise. “You’re not making any sense!” and my teacher told me to go to time-out. and I never will. beginning with a maladaptive automatic thought and winnowing downward to learn more about what it means to the client. and I’m not—I just don’t ever know how to do these math problems. .. perhaps even unveiling core beliefs. What was going through your mind in that moment? Client: I don’t know. The therapist continues to ask the client questions about the thought and its meaning in relation to the client.18 Cognitive-Behavior Therapy for Children and Adolescents thoughts. “I don’t get it.. she never does! She always thinks I’m doing it on purpose. Let’s assume for a moment that you didn’t understand what the teacher was teaching. I see. Client: When I say I didn’t understand it. then what? Client: Then the teacher will ask me why I didn’t do it. Therapist: Oh. Therapist: And if the teacher asks you why you didn’t do it. so your thought was. it is often the case that further questioning about the thought will reveal a set of maladaptive assumptions or rules that are contributing to the development of these more proximal ideas. if that’s true? What does it mean that you can’t do these math problems? Client: I can’t do anything right! Whereas the thought “I don’t get it” was the most available to the client. Below is an example of this technique. Therapist: So you were working in your math group and you started to feel really frustrated.. At each step. This work is sometimes described as the downward arrow technique (Burns 1980). She always says that! Therapist: What would be the worst thing about that? Client: She won’t help me. Therapist: OK. Regardless. therefore I’ll never get it. What is the evidence that this thought is true? Not true? 2. This is a process by which the therapist and client carefully consider all available evidence and identify “clues” that support the maladaptive cognition and those that do not support the thought or belief. Reappraising Thoughts or Beliefs Although different techniques are used for specific diagnoses or problem areas. children struggle at first to generate the evidence that counters the distortion. maybe I will understand it better. so it is helpful to use a series of questions that they can ask of themselves. but if I stay calm and ask for help.Cognitive-Behavior Therapy: An Introduction 19 ent “can’t do anything right. Using the evidence that challenges the distortion. Other metaphors include presenting both sides of the case to the “thought judge” (Stark et al. Sometimes behavioral experiments are used to test beliefs—for example. and the therapist can work with the client to examine how accurate or helpful that thought may be. or having the client conduct an informal poll by asking others about their own experiences. it is sometimes helpful to use the notion of being a detective searching for clues. in actuality the goal is simply to critique the overly critical. Typically. It would be of little use to the client above if she decided to think “I am always great at math!” the next time she encountered a challenging exercise. that would be untrue! However. What is the worst that could happen? Could I live through it? What is the best that could happen? What is the most realistic outcome? . Although some people erroneously believe that the goal of examining a thought is to arrive at a positive thought. the current thinking—“I don’t get it.” When attempting to reappraise distorted cognition in children. using a list of all the evidence for and against the thought. Some examples of questions are listed below (Beck 1995). Collaborative empiricism can be done formally. or otherwise distorted thought or belief. a more realistic belief or thought can be constructed. A more helpful and accurate thought might be “This is challenging. most CBT uses some form of collaborative empiricism to scrutinize the veracity and utility of maladaptive thoughts and beliefs. trying out a behavior to see if the outcome is what the client predicted. or through a series of questions. For one thing. 1. 2006) or looking at the situation first with dark glasses and then removing the glasses to see if things look different. Is there another explanation? 3. because I can’t do anything right”—is also inaccurate. the belief “I can’t do anything right” is a clear distortion. threatening.” Further exploration might have revealed that the client’s self-perception is that of inadequacy. With continued practice. therapists should not be discouraged when clients state that they still strongly believe the original. the client will find that new beliefs begin to seem more accurate. for remembering failure experiences—but her behavior was also maintained by what happened following those times when she struggled with an academic challenge. but it takes time for it to feel right.20 Cognitive-Behavior Therapy for Children and Adolescents 4. Role of Reinforcement Principles Just as maladaptive thoughts are important to identify. Previously we noted that Ellen showed a cognitive bias. Negative reinforcement refers to reward in the form of withdrawal of an aversive condition. and modify. From a conditioning perspective. or preference. what would I tell him or her? It is important to remember that most clients have lived with their distorted thoughts and beliefs for some time and are very familiar with these cognitions. maladaptive thought or belief. At first. privilege. Ellen was usually sent to a time-out in response to her negative statements and defiance around class work. this slight change is still progress toward more useful and accurate thinking. she had “learned” that certain behaviors were paired with escape from an aversive experience. In the classroom. the key aims of CBT are identifying the behaviors that are problematic and considering how these behaviors are maintained. or material item that increases the chance that a behavior will recur. Extinction refers to the reduction in frequency or total elimination of a behavior by use of nonreinforced occurrences. What will happen if I believe this thought? What would happen if I changed my thinking? 5. Because this offered her an escape from an aversive experience. maladaptive thought to a more realistic interpretation is a bit like exchanging an old. behavior.” This transition from the familiar. Therefore. being “punished” actually made it more likely that Ellen would react similarly the next time she encountered frustration in the classroom. . worn-out shoe for a newer one: the new shoe works better. If my friend was in the same situation and had this thought. All of these basic principles are used in the CBT conceptualization of the client regarding how his or her thoughts and behaviors are maintained. evaluate. more realistic cognitions may not “feel true. Reinforcement refers to an event. Even when the client’s commitment to the original thought changes very slightly. In the simplest terms. and these behaviors were therefore negatively reinforced. and punishment refers to the contingent use of negative consequences for aversive behaviors. whatever happens immediately after a behavior plays a part in whether that behavior is repeated. these behaviors were not remarkable—they simply exemplified what a student was expected to do. and shaped to occur more frequently. known as behavioral activation.Cognitive-Behavior Therapy: An Introduction 21 On the other hand. suppose the client has a fear of spiders. However. new behaviors can be identified. It is important to remember that thoughts and behaviors do not exist in isolation from one another. In short. In the same vein. on the occasions when Ellen was able to focus her attention on the assigned task.” Attributing the success to an external force would. Therefore. Therefore. may also lead to an increase in energy and hopefulness. reinforcing activities as homework—may result in the client’s receiving some disconfirming evidence about the belief. Perhaps there is a thought like “I can only face this spider because my therapist is with me—I could never do this on my own. rather. a central tenet of CBT is that the two interact with one another and are inextricably linked to emotions. an awareness of negative cognitions is important even when the emphasis in session may be on behavioral interventions. This technique. to eliminate the reinforcement that keeps these behaviors in place. Behavioral principles also provide a road map for changing behaviors via interventions. For example. because these desired behaviors were not reinforced when they occurred. For example. even when the bulk of the work in session may focus more on one or the other. Once the undesirable behaviors are identified. the behavior actually leads to a verification of the belief. Recall that for some people. depressed clients who think “I never have any fun” may decide to decline social invitations and isolate themselves. reinforced when they occur. somewhat decrease the potency of the exposure exercise. and put forth effort. but over the course of a therapy session has repeatedly confronted a live spider in a jar and has noted that the initial fear has decreased over time. they were effectively extinguished. From the perspective of her teachers and other adults. it is wise to consider both thoughts and behavior. although some CBTs may emphasize behavioral interventions (for example. In this way. behavioral experiences are discounted because of a cognitive processing error that causes them to give more weight to experiences that confirm negative beliefs. Introducing some basic behavioral interventions—such as assigning pleasant. the CBT therapist can work with the client. behaviors can reinforce negative cognitions. the treatment of disruptive behavior disorder in youths . It is very important to check in with such a client to ascertain what meaning he or she may make of this experience. and thus it is most helpful to address behaviors that are related to maladaptive thoughts in treatment. approach the task with a positive attitude. she rarely received any attention at all. Likewise. in this case. Behavioral principles are important to CBT because they shed light on how behaviors develop and are preserved. or with the caregiver. the client-therapist relationship has been found to predict treatment outcome among clients receiving CBT for a variety of problem areas (Hughes and Kendall 2007. to foster the client’s own engagement in treatment. Research on the therapeutic relationship in many types of therapies supports the notion that the strength of the client-therapist relationship is associated with treatment outcome (Shirk and Karver 2003). Measured in a variety of ways. that CBT considers such nonspecific elements as necessary but not sufficient for an effective course of treatment. and checks in with the client repeatedly to assess the thoughts and concerns he or she has about treatment. is important in CBT as well. the few studies that have examined this empirically have . a number of “negative beliefs” remain about CBT practice and require some corrective attention. 2008. and empathy. Karver et al. and genuine. The working alliance is based on the notion that both therapist and client have expertise about the focus of treatment and that by working as a team. Common Myths and Misperceptions Although many clinicians use CBT techniques. Although some critics have suggested that the use of CBT treatments. In addition to warmth. As with all good therapy. and positive regard. the CBT client-therapist relationship is characterized by the collaborative spirit we have previously discussed. however. The use of so-called nonspecific therapy elements. it is nonetheless an important element of a successful treatment. and some may focus more on cognitive processes (as with cognitive therapy for depression). 2000). the CBT therapist works to create a therapeutic environment that is warm. Keijsers et al. The therapeutic relationship is not important in CBT. To establish this collaboration. supportive.22 Cognitive-Behavior Therapy for Children and Adolescents via behavioral parent training). the therapist is inquisitive about the client’s goals. the CBT therapist is straightforward and well informed about the nature of the client’s problems and is clear about the procedures that treatment will entail. recognizing the ways in which thoughts and behavior are mutually influential benefits both the case formulation and the intervention. seeks examples from the client’s own life that fit with the psychoeducative material. validation. At the same time. It is accurate. 1. and particularly manualized treatment protocols. such as empathy. genuineness. they can improve the client’s well-being. Although it is true that CBT does not consider the therapeutic relationship to be the principal agent of change as in some other therapies. would undermine the therapeutic relationship. treatment of symptoms is seen as insufficient. but the cause is understood as the processes that serve to reinforce and maintain the maladaptive cognitions and behaviors. Within this model. Indeed. For example. whereas the former relies on a largely inaccessible construct that would be difficult to modify. such as teachers. it is also important to note that many disorders naturally wax and wane. In CBT. the underlying cause of the disorder is very much a part of the client formulation and intervention approach. Although both models may be accurate. and perhaps unconscious. consider the case of Ellen. and symptoms may morph over time. For example. A previous therapist had suggested that Ellen’s acting-out behavior and depression were caused by anger toward her mother. and there is an emphasis among some schools of thought that therapists must uncover the latent. cause of the disorder. the acting-out behavior and the depression were seen as the result of the interaction of Ellen’s negative beliefs (“I am helpless”) and an environment that negatively reinforced her attempts to escape aversive experiences and failed to reinforce her positive behaviors. the latter formulation leads to a testable hypothesis that can be explored via intervention. 2011). and another study comparing the use of manualized CBT for youth depression to usual care services noted that the early therapeutic alliance was stronger for those youths receiving CBT (Langer et al. a youth with OCD may first present with a hand-washing compulsion and later develop a different ritualized response to anxiety. CBT addresses symptoms but not the root of the problem. Some therapeutic orientations suggest that addressing a symptom while not attending to the underlying cause of the problem will result in the later recurrence of the symptom or in a phenomenon known as symptom substitution. Successful CBT predicts such a process with the client . she turned it against herself via her depression and against other adult authority figures.Cognitive-Behavior Therapy: An Introduction 23 found the opposite. The therapist posited that because Ellen was threatened by this anger. wherein the original symptom is merely replaced with another. However. in the cognitivebehavioral approach. a strong therapeutic relationship is a key component in CBT. Alternatively. In short. 2. follow-up studies of many CBT interventions for youths do not support the notion that eliminated symptoms merely return in another form. and CBT’s emphasis on collaborative empiricism in the service of changing thoughts and behaviors may actually bolster—not weaken—the bond between client and therapist. whom Ellen unconsciously perceived as having “abandoned” her when she was young and her mother was ill. one study found that therapists who engaged youth clients in a collaborative manner formed the best therapeutic alliances with their youth clients (Creed and Kendall 2005). As for the notion of symptom substitution. As the therapist is talking. make eye contact. CBT constrains the therapist’s creativity and flexibility. slouching. Just as a good teacher makes class interesting and fun by use of activities and metaphors that capitalize on the students’ experiences. and how to differentiate between a lapse and a relapse. action-packed therapy. suppose the therapist intended to work with the client on the ways in which nonverbal behaviors (e. creative. In fact. CBT is one of the most thoroughly researched psychosocial interventions. As it has become better established as a core resource for mental health care. CBT emphasizes the use of creative approaches to introducing new behaviors and changing thoughts. and authentic in the session with the client. several new developments have emerged. This provides a perfect opportunity for the therapist to note the client’s nonverbal behaviors. the therapist helps the client and the caregiver to consider how problems may manifest in the future.g. Indeed. where the therapist makes use of the client’s thoughts and behaviors to illustrate the ways in which they contribute to the client’s difficulties. with new studies emerging that examine its utility for a wide range of problems. such as in rigorously controlled research trials. How did that impact the client’s thoughts and feelings? This is but one example of the ways in which CBT therapists have free rein to use session content in a spontaneous and creative manner. In planning for treatment termination. and suggest an experiment—for the next 5 minutes. Perhaps the biggest misperception among those new to CBT is that use of these techniques will diminish the therapist’s ability to be spontaneous. the evidence suggests that it may be somewhat less effective when treatment is delivered in the . For example. CBT is a lively. rolling eyes. how to manage these recurrences. query about his or her thoughts. From Efficacy to Effectiveness Although CBT has shown encouraging results when delivered in optimal settings.24 Cognitive-Behavior Therapy for Children and Adolescents and plans for lapses in which symptoms may transiently return. the client appears to be disinterested and bored. and nod as if interested. effective CBT is characterized by the therapist’s ability to use session content in the moment to make the principles of CBT come to life for the client. New Inroads and Challenges Currently. 3. and sighing) serve to reinforce the client’s beliefs (“No one likes me”) and also result in interpersonal conflict with others. the client will sit up straight.. avoiding eye contact. a CBT therapist does the same. even if they are unwanted or unpleasant. than the comparison conditions of usual care services. note that it is just an ephemeral thought and not a reflection of reality. 2006). and values. These newer forms of CBT have begun to generate empirical tests. and emotional states) with a nonjudgmental attitude of openness. incorporating new techniques for managing maladaptive cognitions and behaviors that are aimed at mitigating their impact on emotions. Although CBT still does better. dialectical behavior therapy. Identifying the causes for these weaker effects and increasing the focus on how CBT is implemented in the real world are important topics that are beginning to be the focus of researchers and clinicians alike (Weisz and Gray 2008. some with significant support. rather than challenging a negative thought. a number of recent treatment approaches have emerged that blend CBT principles with concepts such as mindfulness. Conclusion CBT has evolved from two distinct traditions—cognitive therapy and behavioral learning principles—to form one of the most widely practiced and thoroughly studied psychosocial treatments. cognitions. These skills have roots in Eastern meditative traditions and in practice include focusing attention on the experiences occurring in the present moment (such as sensations. and curiosity—without attempting to avoid or escape these experiences. dialectics. and it is increasingly being transported from research settings into clinical practice . and are expanding the array of techniques available to CBT therapists. The “New Wave” As CBT has developed. perceptions. Although the focus of therapies such as acceptance and commitment therapy. behaviors. acceptance. and others may be less on changing thoughts and more on increasing a client’s distance from those thoughts.Cognitive-Behavior Therapy: An Introduction 25 “real world” of typical clinical care (Weisz et al. acceptance. and continue to behave in a way that is consistent with achieving the goals the client has for himself or herself. This so-called third wave of CBT (Hayes 2004) places less emphasis on changing the form or content of thoughts and behaviors and instead emphasizes transforming the relationships that clients have with their internal experiences. a client might be encouraged to observe the thought. For example. Weisz and Kazdin 2010). on average. and emotions remains central. the causal connection among thoughts. the clinical impact is lessened when treatments are moved from academic research into frontline services. CBT continues to evolve. 1995 Association for Behavioral and Cognitive Therapies: www. I: idiosyncratic content and cognitive distortions. Guilford. are present focused. and improving adaptation and functioning in everyday life. Self-Assessment Questions 1.1. 1964 . As the subsequent chapters of this volume demonstrate. New York. and emotions. Define collaborative empiricism. active.abct.org References Beck AT: Thinking and depression. CBT offers a rich mix of techniques for addressing a myriad of disorders. Arch Gen Psychiatry 10:561–571. How are behaviors reinforced? How are they extinguished? Suggested Readings and Web Sites Beck JS: Cognitive Therapy: Basics and Beyond. 1963 Beck AT: Thinking and depression.4. Arch Gen Psychiatry 9:324–333.26 Cognitive-Behavior Therapy for Children and Adolescents contexts such as hospitals. What is a negative schema? 1. II: theory and therapy. What is the most readily available form of core beliefs called? 1.3. • Although there are numerous CBTs. and emphasize a collaborative. most share a focus on cognition and behavior. clinics.2. and structured approach to achieving clearly operationalized goals. these therapies emphasize the connection among thoughts. • Thoughts and behaviors are seen as malleable agents of change for client distress and impairment. 1. and schools. reducing impairment and distress. Key Clinical Points • Cognitive-behavior therapies can be traced back to early animal research and learning theory. behaviors. NJ. and Theoretical Aspects. Signet. Translated by Anrep GV. Am Psychol 27:913–920. 2005 Ellis A: Rational psychotherapy. and the third wave of behavioral and cognitive therapies. Citadel. 1971 London P: The end of ideology in behavior modification. Child Dev 40:785–797. Philadelphia. Behav Ther 2:369–374. 1972 Meichenbaum DH. Hoogduin CA: The impact of interpersonal patient and therapist behavior on outcome in cognitive-behavioral therapy: a review of empirical studies. Behav Ther 35:639–665. Guilford. London. and verbal control of motor behavior. Goodman J: Reflection. New York. New York. 1924 Karver M Shirk S. and client involvement. Experimental. impulsivity. Vol 1. 2000 Langer DA. Rush AJ. et al: Cognitive Therapy of Depression: A Treatment Manual. Handelsman JB. Guilford. University of Pennsylvania Press. 1980 Chambless DL. J Ment Sci 105:61–75. Behav Modif 24:264–297. J Consult Clin Psychol 73:498– 505. Pedagogical Seminary 31:308–315. 2008 Keijsers GP. alliance-building behaviors. Basic Books. 1967 (Republished as Beck AT: Depression: Causes and Treatment. New York. Shaw BF. 1969 Meichenbaum DH. New York. 1979 Beck JS: Cognitive Therapy: Basics and Beyond. J Gen Psychol 59:35–49. J Emot Behav Disord 16:15–28. New York. Hollon SD: Defining empirically supported therapies.Cognitive-Behavior Therapy: An Introduction 27 Beck AT: Depression: Clinical. 1958 Ellis A: Reason and Emotion in Psychotherapy. Secaucus. Schaap CP. 1976 Beck AT. Goodman J: Training impulsive children to talk to themselves: a means of developing self-control. 1999 Eysenck HJ: Learning theory and behaviour therapy. 1927 Pavlov IP: Lectures on Conditioned Reflexes. 1995 Burns DD: Feeling Good: The New Mood Therapy. 1998 Creed TA. McLeod BD. Behav Cogn Psychother 35:487–494. Lawrence and Wishart. Hoeber. relational frame theory. J Consult Clin Psychol 66:7–18. J Abnorm Psychol 77:115–126. New York. Kendall P: Prediction of cognitive behavior treatment outcome for children with anxiety disorders: therapeutic relationship and homework compliance. 1970) Beck AT: Cognitive Therapy and the Emotional Disorders. 2011 Lazarus AA: Reflections on behavior therapy and its development: a point of view. 1928 . Translated by Gantt WH. 2004 Hughes A. 1959 Hayes SC: Acceptance and commitment therapy. 1971 Pavlov IP: Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex. Kendall PC: Therapist alliance-building behavior with a cognitivebehavioral treatment for anxiety in youth. 1962 Ellis A: Why rational-emotive therapy to rational emotive behavior therapy? Psychotherapy (Chic) 36:154–159. et al: Relationship processes in youth psychotherapy: measuring alliance. Weisz JR: Do treatment manuals undermine youth-therapist alliance in community clinical practice? J Consult Clin Psychol 79:427– 432. 2007 Jones MC: A laboratory study of fear: the case of Peter. Oxford University Press. CA. Karver M: Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta-analytic review. New York. 1953 Stark KD. Workbook Publishing. Schnoebelen S. 2006 Wolpe J: Psychotherapy by Reciprocal Inhibition. Guilford. 1975 . 1930 Weisz JR. 2nd Edition. New York. Hinshaw SP: The second special issue on evidence-based psychosocial treatments for children and adolescents: a 10-year update. J Clin Child Adolesc Psychol 37:1–7. New York. Wiley. 2010 Weisz JR. Stanford University Press. Simpson J. 2006 Watson JB: Behaviorism. Macmillan. New York. Jensen-Doss A. Broadmore. J Consult Clin Psychol 71:452–464.28 Cognitive-Behavior Therapy for Children and Adolescents Shirk S. Am Psychol 61:671–689. 2008 Weisz JR. PA. Child Adolesc Ment Health 13:54–65. Stanford. 2003 Silverman WK. et al: Therapist’s Manual for ACTION. Kazdin AE (eds): Evidence-Based Psychotherapies for Children and Adolescents. 1958 Yates AJ: Theory and Practice in Behavior Therapy. Norton. Gray JS: Evidence-based psychotherapies for children and adolescents: data from the present and a model for the future. Hawley KM: Evidence-based youth psychotherapies versus usual clinical care: a meta-analysis of direct comparisons. 2008 Skinner BF: Science and Human Behavior. and conduct disorder (Litschge et al. Ph. One potential explanation for these medium effects is that the developmental demands of CBT may exceed a child’s capabilities. Frankel.3 to 0.S. Weisz et al. That is. typically ranging from 0. Gallerani. 2010). Litschge et al. 29 . M. Durlak et al.6 (e. anxiety (Kendall et al. T32 MH18921).. 1991.2 Developmental Considerations Across Childhood Sarah A.g.D. Judy Garber. COGNITIVE-BEHAVIOR therapy (CBT) is used with children and adolescents to treat various forms of psychopathology. CBT may be less effective for some children because This work was supported in part by grants from the National Institute of Mental Health (R01MH 64735. 2010. 2006).S. M. 2002). RC1 MH088329. 2006). Effect sizes for CBT in children are modest. including depression (Weisz et al. Catherine M. 30 Cognitive-Behavior Therapy for Children and Adolescents they are not cognitively. The idea of incorporating developmental considerations into treatment planning is not new (Eyberg et al. but rarely has it been a systematic and empirically driven pursuit (Masten and Braswell 1991. or socially developed enough to understand and apply the clinical skills being taught in therapy. Similarly. Why Is It Important to Tailor CBT Developmentally? Incorporating developmental considerations into treatment design and planning may increase treatment efficacy. Ollendick et al. Ollendick et al. As CBT for children and adolescents has been derived. Kendall 1990) and have been extended upward for use with adolescents (Kendall et al. emotionally. Stallard 2002). the extent to which this model is appropriate for less developed age groups is unclear (Grave and Blissett 2004).g. 1998. Vernon 2009). 1991). Empirical evidence of differences in efficacy as a function of age has been reported. 1998. however. 2006. For example. Nevertheless. have explicitly assessed children’s developmental level or have tested whether development moderates treatment effects (Grave and Blissett 2004. Coping Cat for anxiety. A few CBT manuals have been designed specifically for children (e. a meta-analysis of 150 studies of psychotherapy with children and adolescents found that the mean effect size for adolescents was larger than for children (Weisz et al. an earlier meta-analysis reported that children ages 11–13 benefited from CBT more than did children ages 5–11 (Durlak et al. Some developmental tailoring of interventions for children has been done informally and at a basically superficial level (e. Shirk 1999). Many CBT interventions for youth have been downward extensions of adult treatment manuals (Eyberg et al. however unintentionally.. 2001. the developmental uniformity myth that individuals with the same psychiatric diagnoses are homogeneous across developmental levels and therefore will respond similarly to treatment (Holmbeck et al. 2006). Children likely will benefit more when clinicians are aware of developmental norms and can match . linguistic changes). Few studies. 1995).. Both the downward and upward extension approach to designing treatments for children and adolescents serve to perpetuate.g. 2001). from cognitive theory of therapy in adults. Shirk 1999. Although most clinicians and researchers would argue against this myth. they remain challenged in how to translate a truly developmental perspective into practice. Holmbeck et al. in part. the actual translation of findings from basic developmental research into clinical practice has been less common (Holmbeck and Kendall 1991. 2002). Shirk 1999). restlessness. the difference between what children can learn when they have support or not [Vygotsky 1978]) when considering children’s ability to implement clinical skills with and without help from others (e. therapist or parents). 2009). it is likely that certain CBT strategies are appropriate for children. Without a clearer understanding of these demands. At her intake appointment. and overall bad mood. by matching therapeutic techniques to Karen’s actual cognitive level.g. particularly if presented in a developmentally sensitive manner. Moreover. assessment of Karen’s social skills indicates that she is appropriately socially competent. as children develop.. socially skilled girl. a focus on concrete concepts rather than abstract principles may be more effective with less cognitively advanced children (Stallard 2002). Although most clinicians recognize the importance of considering children’s levels of competence in different domains (e. Weisz and Hawley 2002). sleep problems.e. they may use skills differently depending on context.. However. cognitive. the cognitive assessment reveals that Karen has difficulties reflecting on her own thoughts and emotions. Karen presents as a well-spoken. That is. Given evidence that some children do benefit from CBT.g. . Clinicians also should be cognizant of the zone of proximal development (i. as well as problems with abstract and hypothetical reasoning. social. Indeed. 2006.. Thus.g. interactions with her teacher) rather than using abstract. CBT with children may be less effective. hypothetical (e. they may not be able to apply this skill in other situations (Sauter et al. the therapist decides to draw on Karen’s interpersonal strengths by using more concrete role-play examples based on actual situations from Karen’s life (e.Developmental Considerations Across Childhood 31 treatment strategies to children’s abilities (Holmbeck et al. For example.. however. difficulty concentrating. Case Example Karen is an 11-year-old girl referred for treatment because of her inability to sit still in the classroom. although children may demonstrate mastery of a developmental skill in one context. Weisz and Hawley 2002). emotional) when conducting therapy. The exact developmental requirements of the various therapeutic strategies that incorporate CBT have not yet been precisely articulated. “what if ”) and future-oriented scenarios. lack of motivation in school.g.. Interventions may be too elementary or too advanced if designed without consideration of developmental level. they lack information about how particular developmental limitations affect children’s ability to acquire and implement the various strategies taught in treatment (Shirk 1999. and faulty assumptions may be made about whether CBT should be used with children (Spritz and Sandberg 2010). the therapist is able to induce greater behavioral change over time. Therefore. In addition. clinicians cannot assume that older children will always benefit more than younger children from CBT approaches. 2001). In the next section. Holmbeck and Kendall 1991)..g. As such. 1991.g. given the heterogeneity of development. For example. whereas others have found that children benefit more than adolescents (e. individuation from parents) have been addressed in some treatment planning (Holmbeck et al. increased importance of peers. the changing interpersonal relationships that occur as children mature (e. one treatment goal should be to return children to a more normative trajectory (Shirk 1999). Development is significantly more complex than the linear progression of chronological age. and emotional). they are not synonymous (Durlak et al. 1995).g. as well as the relations among the individual areas of development (e. Given the importance of incorporating development into treatment design and planning. some studies have shown greater improvements in adolescents than in children receiving CBT for anxiety.. why is it that developmental approaches are not already an empirically validated and universally implemented standard of care? The translation of developmental principles into practice is neither simple nor direct. we describe what has been attempted already to tailor CBT. Clinicians also need to be mindful of the link between clinical symptoms and development.. 2006. Weisz et al. and we provide recommendations for additional ways to developmentally modify treatments for youth. 2009. Sauter et al. What Has Been Done to Developmentally Tailor CBT? Researchers and clinicians have begun paying more attention to contextual factors related to development when implementing treatments.32 Cognitive-Behavior Therapy for Children and Adolescents Although the terms age and development are often used interchangeably. and as such the integration of clinical and developmental psychology continues to be a challenge (Holmbeck et al. . not all adolescents (or even adults) will possess the developmental competencies necessary to grasp some of the abstract and hypothetical constructs involved in CBT. Because clinical symptoms may disrupt normal developmental pathways. attention should be paid to the ways in which delays in one area of development may be associated with difficulties in other developmental domains. formation of cliques. Additionally. Ollendick et al. social. cognitive. For example. The unique developmental characteristics associated with adolescence may impact adolescents’ willingness to participate in therapy as well as their ability to apply therapeutic skills (Weisz and Hawley 2002). individual treatment has been shown to be more effective with older children (Ruma et al. however. a 14-year-old adolescent boy. Whereas family-based interventions have been found to be more effective for younger children. Kendall and colleagues (2002) modified the child anxiety manual for use with adolescents at different developmental levels.Developmental Considerations Across Childhood 33 2006). and disinterested in school and social activities. Adolescents who are given appropriate control and input into how parents can be helpful in supporting their new skills may particularly benefit from parental involvement. each containing CBT techniques to be selected according to the child’s cognitive abilities. easily frustrated with others. Some developmentally based treatment manuals do exist. having parents play a directive or even “coaching” role during this developmental stage may be contraindicated. the therapist added sessions with the mother to help her understand his growing need for independence. particularly about Kevin’s recent misguided expressions of autonomy (e.g. though this may depend on other factors such as the youth’s temperament and the quality of the parent-child relationship. The most common adaptation of CBT for children has been to use ageappropriate activities to convey therapeutic skills. With Kevin’s permission. Although Kevin and his mother had always had a good relationship. Kevin began trying out more of the CBT skills he was learning in therapy at home in order to improve his relationship with his mother and steadily obtain more age-appropriate privileges. One common alteration . and in turn. Six months ago. 1996). Given the emergence of autonomy during adolescence. his mother gradually would grant him greater freedom as long as he was safe and legal. He was diagnosed with a major depressive episode and oppositional defiant disorder. mostly for treating child anxiety disorders (Sauter et al. Other CBT manuals for anxiety disorders designed specifically for children ages 7 years and older are The Coping Cat (Kendall 1990) and How I Ran OCD Off My Land (March and Mulle 1998). are exceptions rather than a widely used and available standard. Chorpita’s (2007) CBT manual for children with anxiety consists of several modules. The therapist began individual CBT with Kevin to try to elicit more behavioral activation and work on his disengaged social interaction style. breaking curfew). These developmentally sensitive manuals. 2009). Kevin became more irritable. it was clearly worsening as a result of greater conflict between them. A family problem-solving exercise was initiated where Kevin came up with the solution that he would try to talk with his mother calmly and less disrespectfully. One complicated clinical issue affected by the child’s level of social development is the amount and type of parental involvement in treatment.. For example. was an average student and socially engaged with his friends. Case Example Kevin. g. behaviorally active strategies. guided imagery) are not effective with a young child. Some programs have suggested representing cognitive distortions as coming from a “bad thought monster” (Leahy 1988) or “muck monster” (Stark et al. therapists can use more concrete pictorial or narrative formats. Some CBT programs for children have simplified the cognitive restructuring process to solely replacing negative thoughts with more positive thoughts.g. 1998). Also recommended is the use of simple. Using concrete imagery for muscle relaxation (e. thought bubbles have been used to help children identify what they are thinking (Kendall 1990). music. When presented with information that contradicts a belief.. 2005... and cartoons. Shorter attention span and limited abstract thinking in young children may hinder the use of traditional progressive muscle relaxation scripts and guided imagery. With younger children. CBT techniques such as identifying thinking errors. An age-appropriate desensitization strategy could include imagining confronting the feared situation with the help of a favorite superhero (Lazarus and Abramovitz 1962). muscle relaxation. play. with the help of a Zen warrior) or to talk back to the monster with the help of the group and therapist. tensing and relaxing hands by “squeezing lemons” [Christophersen and Mortweet 2002]) and replacing imagination-based desensitization with in vivo experiences may be more effective with younger children. simplified language. 2001). situation-specific coping statements with young children. Children are then instructed either to fight the monster (e.g. children have more difficulty than adults in revising their thoughts accordingly (Shirk 1999). its efficacy as compared to teaching children to examine their beliefs and distortions and to generate accurate and realistic counter-thoughts has not been demonstrated. and using Socratic questioning are recommended only for more cognitively advanced youth (Stallard 2002). Eyberg et al. then other counterconditioning methods (e.. progressing toward more general self-instructions and eventually using generalized statements during adolescence. For example. examining underlying beliefs. 2001). food) should be considered (Ollendick et al. When typical relaxation techniques (e. Although this “replacement” strategy allows less cognitively advanced children to engage in a form of cognitive restructuring.g. 2007).34 Cognitive-Behavior Therapy for Children and Adolescents has been to include more child-friendly materials. Using less complex behavioral techniques with younger children and more complex cognitive techniques with older children also has been recommended (Doherr et al. Systematic desensitization also has been modified for young children (Ollendick et al. Merrell (2001) provided a compendium of developmentally appropriate cognitive-behavioral methods for use with depressed and anxious children and . and activities that stimulate the imagination (Grave and Blissett 2004). Similarly. “Given that adolescents live in the ‘here and now. Moreover. thought forecasting is only recommended for older children and adolescents because “younger children may find this exercise too abstract and may not be able to generate realistic future situations” (p. in which individuals generate hypothetical scenarios and predict possible thoughts and feelings they might have in those situations. Merrell recommended that the therapist draw an “emotional thermometer” with different levels that the child can use to identify the emotional intensity of different experiences. For example. structure. 122). information is not provided regarding how clinicians can assess children’s specific levels of cognitive maturity. and . This exercise can be used with individuals of all ages. For identifying automatic thoughts. Consequently. it is important to empower them so that they have many different strategies for coping more effectively because it is difficult for them to generate ideas when they are down” (p. clinicians should use more concrete and simplified examples and questions while also providing more support. Sadness. for “Don’t Stay Depressed. to help children recognize degrees of emotional intensity. In addition. For example.Developmental Considerations Across Childhood 35 adolescents.” an activity in which adolescents detail what they can think and do and who they can turn to for support when feeling depressed.” an activity designed to help children generate ideas for coping with depressed feelings. Vernon included a section titled “Interventions for Typical Developmental Problems. 125). for “So Long. Merrell suggested that for younger children. it is easy for them to get discouraged if they aren’t able to deal with their feelings effectively. In contrast to the emotional thermometer. in which strategies were separated by age. Vernon stated. Vernon (2009) separated strategies by their appropriateness for children versus adolescents and provided a developmental rationale for most activities. although it has some limitations. Merrell recommended using thought forecasting. “Most children feel sad from time to time. In general. but Merrell recommended keeping emotional gradations simple for young children. Few activities specifically designed for younger children are presented. Age is only a crude and imprecise estimate of a child’s developmental level at any point in time.’ it is easy for them to become overwhelmed and feel hopeless when they are depressed.” in which she detailed activities for enhancing self-acceptance. relationships. All the recommended activities are either for children of all ages or for “older” or “cognitively mature” children and adolescents. Merrell’s (2001) book provides useful examples of techniques clinicians can use to teach skills to children of different ages. This concrete strategy involves them generating things they can do to feel better” (p. and feedback. but given that their sense of time is immediate. In a handbook of clinical strategies for teaching rational emotive behavior therapy techniques to youth. Vernon wrote. 89). Cognitive therapy is based on the assumption that irrational or maladaptive cognitive schemata (attitudes and beliefs). Recognize the connections between developmental skills and clinical techniques. clinicians need to 1) recognize the connections between developmental skills and clinical techniques. social. Further research is needed on how to individualize treatment techniques according to a child’s specific developmental level rather than age. Vernon’s book presents activities that incorporate age-based developmental considerations. and 4) incorporate all of this knowledge into an individualized treatment plan. (Grave and Blissett 2004. and operations (processing) influence problematic behavior. 3) use appropriate assessment tools to determine children’s developmental abilities. and discuss how cognitive. 1. we elaborate on each of these recommendations. clinicians will need to modify the therapy on the basis of their assessment of a child’s level of development in relevant domains. Until more precise guidelines are constructed for tailoring treatments developmentally. and then. In the following sections.36 Cognitive-Behavior Therapy for Children and Adolescents healthy transitions. Attention to developmental factors in CBT has increased since the 1990s. to reality-test them. What Is Needed for Clinicians to Developmentally Tailor CBT More Effectively? To effectively adapt CBT to children’s developmental levels. pp. the construction of developmentally sensitive treatment strategies generally has been an informal process not always driven by empirical evidence. 2) understand the normative trajectory of the relevant developmental skills. outline some specific clinical skills involved in CBT. The percentage of empirical articles mentioning developmental issues in treatment has increased from 26% between 1990 and 1998 to 70% between 1999 and 2004 (Holmbeck et al. Thus. either to teach new thinking skills or to challenge irrational thoughts and beliefs and replace them with more rational thinking. and emotional development can impact treatment. The aim of therapy is to help the child to identify possible cognitive deficits and distortions. 2006). cognitive products (thoughts and images). However. 401–402) . there were 42 different permutations of these 8 skills. self-instructions. knowledge of social and emotional development also is needed to provide comprehensive and effective care (Eyberg et al. is neither simple nor intuitive.” each of these skills was taught in a variety of ways. metacognition. For example. social cognition training. In addition to the many different combinations of core skills labeled “cognitive-behavior therapy. For example. social problem-solving. Identifying exactly which developmental skills are linked to which specific clinical tasks. Grave and Blissett 2004). We cataloged the specific skills described in 14 different CBT manuals for the treatment of child and adolescent depression. Table 2–1 presents the 19 main clinical skills identified and the number of treatment programs that explicitly include each skill. At the foundation of effectively tailoring treatment to developmental level is an understanding of the normative trajectory of the relevant skills. and emotion understanding. and emotional developmental skills (e. Weisz and Weersing 1999). in part because of the heterogeneity of the skills that incorporate CBT (Grave and Blissett 2004). Stallard 2002).Developmental Considerations Across Childhood 37 A variety of cognitive. 1991. As such. 1998. overgeneralizing. but these distortions actually may be developmentally normative ways of thinking in young adolescents (Spritz and Sandberg 2010). the term cognitive-behavior therapy is really an umbrella for a wide and divergent amalgamation of therapeutic techniques (Durlak et al. Durlak and colleagues (1991) reviewed CBT programs for children and identified 8 core components: task-oriented problem-solving. Within the 64 studies reviewed. and negative filtering are types of cognitive distortions described in the adult CBT literature (Beck et al. all-or-none thinking. Masten and Braswell 1991). guide expectations. Knowledge of developmental norms is needed to improve the quality of interventions with children. Familiarity with the typical course of skill acquisition can help clinicians determine if a particular child is more advanced. or delayed. . 1979.. and decrease faulty assumptions (Spritz and Sandberg 2010. Understand the normative trajectory of the relevant developmental skills. perspective taking. rewards. social skills training. social. with children being asked to make different connections depending on the treatment program (see Table 2–2). 2. roleplaying. respectively) may be necessary to learn and apply the clinical tasks described by Grave and Blissett (2004). In addition to knowledge of cognitive development. “understanding the cognitive model” was broken down into different components in each manual. on track. and other CBT elements.g. however. Holmbeck and Kendall 1991). uncontrollable stressors 8 Problem solving 7 Assertive behavior training 6 Understanding depression 6 Mindfulness 5 3. . Use appropriate assessment tools to evaluate a child’s developmental abilities. Because chronological age is not necessarily an accurate indicator of a particular child’s developmental level. a thorough developmental assessment is required. Although the importance of conducting this type of assessment has been emphasized (Holmbeck et al. Clinical assessments generally focus on evaluating children’s symptoms and diagnoses rather than on creating a developmental profile to guide treatment plans. 2006. a comprehensive evaluation of a child’s actual abilities across relevant domains is needed to match clinical strategies to the child’s specific skills (Durlak et al. For treatments to be tailored to a child’s particular developmental level. Sauter et al.38 Cognitive-Behavior Therapy for Children and Adolescents TABLE 2–1. Shirk 1999). 1991. 2009. Frequency of core clinical skills in 14 cognitivebehavior therapy manuals for youth depression Core clinical skill Number of manuals Understanding the cognitive model 14 Using skills outside of session/practice/homework 14 Cognitive restructuring 13 Goal setting 12 Behavior activation 12 Developing/maintaining/seeking social support 12 Motivation to engage in therapy 12 Identity formation 11 Types of thoughts 11 Other coping skills/emotion regulation 11 Meeting new people/conversation skills 10 Relapse prevention planning 10 Social problem-solving/conflict resolution 9 Relaxation training 8 Controllable vs. it is rarely done in practice. . 39 Frequency of components for the core clinical skill “understanding the cognitive model” in 14 treatment manuals Subskills Number of manuals Rate mood 10 Identify thoughts 13 Identify situations 7 Identify feelings 7 Identify behaviors 3 Connect situations and thoughts 7 Connect situations and feelings 8 Connect thoughts and feelings 11 Connect thoughts and behaviors 3 Connect feelings and behaviors 10 Connect situations. and b) enhance the child’s developmental competencies to prepare him or her for more advanced therapeutic . behavior 8 Connect situations. behavior 4 Assessment measures can over. 4. however. How can knowledge of clinical skills. typical development.g.Developmental Considerations Across Childhood TABLE 2–2. Therefore. thoughts. The few studies that have attempted to assess development separate from age have used measures of intellectual ability or achievement. feelings. clinicians should choose ecologically valid measures that capture abilities in both the therapeutic setting and the more challenging realworld environment. support provided [Grave and Blissett 2004]). do not examine all CBTrelevant cognitive subdomains or assess social or emotional competencies (Sauter et al.or underestimate children’s abilities depending on the context and format of the evaluation (e. Incorporate knowledge about development into treatment planning. language used. feelings 8 Connect thoughts. thoughts. 2009). in selecting an assessment battery for developmentally tailoring treatment. feelings. and assessment data be incorporated into treatment planning? At least two methods are possible: a) modify the treatment to fit the developmental level of either the individual child or a certain developmental profile (Weisz and Weersing 1999). Intelligence tests. Finally. Figure 2–1 outlines the empirical work that needs to be done to map out the specific links between the clinical techniques being used with children and the developmental demands of these techniques. The other frequently mentioned method for developmentally tailoring interventions involves clinicians beginning treatment by priming developmental skills. Stallard 2002). behavioral. 2006. from case conceptualization and goal setting to intervention selection and outcome assessment. Additionally. First. 2009. Sauter et al. create an individualized profile across multiple domains. Examples of treatment modifications include altering activities to be more or less complex.40 Cognitive-Behavior Therapy for Children and Adolescents techniques (Holmbeck and Kendall 1991). we need to catalog the clinical procedures described in the various CBT manuals for youth and then specify the developmental abilities necessary for a child to learn and use each of these therapeutic techniques. or visual (Sauter et al. Thus. Doherr and colleagues (2005) found that children taught with a curriculum designed to improve thinking skills performed better on CBT tasks than did children in a more typical curriculum. with the expectation that providing scaffolding and tapping into the zone of proximal development (Vygotsky 1978) will facilitate the later mastery of CBT techniques (Holmbeck et al. we next need to construct a reliable and valid assessment battery of these abilities from which a developmental profile can be created. Some empirical evidence indicates that development can be primed in this way (Keating 1990). In summary. different versions of treatment protocols can be designed for children at various levels of developmental maturation (Holmbeck et al. For example. multiple steps are needed to appropriately tailor therapeutic techniques to children’s developmental level. a child’s developmental level in multiple domains should inform all aspects of treatment planning. and formulate a developmentally sensitive treatment plan. Such modifications should be made on the basis of a systematic evaluation of developmental level rather than age. Shirk 1999). cognitive. 2006). with these empirically derived guidelines. Developmental Domains Cognitive Development The complex cognitive strategies taught in CBT place demands on children’s information processing and presuppose a certain level of cognitive function- . Once the developmental requirements are identified. 2009. concrete. clinicians will be ready to administer an assessment battery that measures a child’s developmental abilities. an assessment of a child’s level of cognitive development can guide the selection of CBT techniques (Sauter et al. and actions. selfreflection. 2000. metacognition. Empirical steps needed to developmentally tailor cognitive-behavior therapy (CBT) for children and adolescents and practical implications for clinicians. 2009). . Shirk 1999). 2009). feelings. Sauter et al. Metacognition involves noticing one’s thoughts. Holmbeck et al. and reasoning are especially salient (Grave and Blissett 2004. Although the specific cognitive capacities necessary for participating in CBT have not yet been explicitly determined empirically. formulate a treatment plan that matches therapeutic techniques to the child’s level of development in each domain FIGURE 2–1. 2000. As such.Developmental Considerations Across Childhood 41 Empirical research needed Catalog the therapeutic techniques described in different CBT manuals for youth Identify the specific developmental abilities necessary for children to learn and use each of these therapeutic techniques Construct an assessment battery of these abilities from which a developmental profile can be created Practical clinical implications Use this assessment battery to evaluate a child’s developmental abilities Create an individualized profile across multiple domains Using this information. ing in order to understand and apply the treatment techniques (Holmbeck et al. self-reflection is the ability to reflect on one’s own beliefs. and reasoning is the ability to connect these reflections. Therapists sometimes ask clients to role-play scenarios and to imagine possible relevant future situations as a way to more concretely practice and prepare for using the techniques outside of the session.g. and self-reflection are especially relevant (Grave and Blissett 2004. An important part of most CBT treatments is the actual implementation of the new skills outside the therapeutic setting. connecting situations. are largely hypothetical and involve future thinking. and abstract reasoning). feelings. and behaviors. thoughts.g. causal. age alone may not be an accurate marker of developmental level.g. children may be able to engage in some of the individual components of a clinical skill (e. feelings. systematic. 2006. but without having a more precise understanding of cognitive development.. 1998). using age alone could slow or even undermine the efficacy of the intervention. Disputing cognitive distortions by generating alternative explanations requires the ability to reason hypothetically. feelings. thoughts. Age frequently is used as a proxy for development because of its simplicity. they may have difficulty enacting them simultaneously in a fluid process (Holmbeck et al. and behaviors.. Other CBT techniques are multistep processes. hypothetical. That is. understanding that different thoughts can relate to different feelings in the same situation). such integration requires an even more sophisticated level of cognitive development (e. where disrupted or advanced developmental pathways can be both a cause and consequence of psychopathology. Having an understanding of normative cognitive development likely will facilitate a clinician’s ability to conceptualize a particular child’s abilities in a given context. Normative Development of Cognitive Skills In clinical samples. Exploring maladaptive cognitions by examining evidence requires the ability to think logically and systematically. logical. Such exercises. Simply concretizing exercises for children may not be sufficient. Given the bidirectional relation between development and psychopathology. however. Weisz and Weersing 1999). metacognition. and behaviors) but may struggle in putting all of the pieces together (e. identifying situations. for which the developmental skills of reasoning. an individual needs abstract reasoning to generalize from a specific example to other real-life situations. Harrington et al. To recognize appropriate times for enacting these skills. . Even when children have some of the requisite developmental skills to engage in certain activities.. an understanding of how skills emerge and progress could be more useful to clinicians than a detailed outline of ages at which skills typically occur.42 Cognitive-Behavior Therapy for Children and Adolescents Connection With CBT Techniques A central component of CBT involves reflecting on and causally linking thoughts. Developmental Considerations Across Childhood 43 Piaget (1964/2006) provided the early seminal work on children’s cognitive development. 2006). 1998. With development. developmental psychologists have shifted away from Piaget’s stagelike model to conceptualizing development as a more continuous process. However. A marker of a particularly sophisticated level of reasoning is the ability to think analogically (Grave and Blissett 2004)—that is.. proposing that children progress through sensorimotor. Maturation of hypothetical reasoning first results in an ability to imagine the outcome of future hypothetical ideas (e. and systematic as development progresses. children become increasingly able to examine multiple aspects of a situation and engage in less biased reflection (Vernon 2009). Nevertheless. Holmbeck et al. if a child lacks the reasoning ability to understand and apply analogies. Piaget provided an important foundation for understanding cognitive development. Indeed. and formal operational stages. Clinicians sometimes use analogies to help children understand new information by relating it to their existing knowledge.g. complex. preoperational. These tasks are especially difficult for less cognitively developed children when the hypothetical outcome is inconsistent with their current beliefs. and situations. Increased neural development leads to improvements in abstract reasoning (Sauter et al. More recently. and concrete connections to more internal and psychologically based associations (Grave and Blissett 2004)—underlie the ability to link thoughts. some children in earlier phases of Piaget’s developmental model can engage in more complex thinking than he originally proposed (Grave and Blissett 2004). to see subtle relations between two things that are not based on overt similarities. Causal reasoning changes throughout childhood and into adulthood—progressing from external. feelings. “What would have happened if you had done this?”) (Robinson and Beck 2000). more advanced cognitive abilities are needed to evaluate these solutions using means-end thinking (Holmbeck and Kendall 1991). As development progresses. Similarly. causal. followed by improved understanding of past hypothetical thinking (e. “What might happen if you do this next time?”). and logical. the ability to logically test hypotheses by thinking about conflicting evidence simultaneously and differentiating theory from fact develops over time (Harrington et al. including abstract. concrete operational.. logical. . then the child may end up even more confused. visible. hypothetical. Various forms of reasoning. develop over time. children become increasingly able to anticipate consequences (Keating 1990). 2009) and a decrease in concrete thinking (Vernon 2009). Although less cognitively developed children can generate solutions.g. with thinking becoming more abstract. . which is the ability to think about thinking. and generating alternatives (Holmbeck et al.44 Cognitive-Behavior Therapy for Children and Adolescents Another cognitive skill important for engaging in CBT is metacognition. 2009. 2009). As children become more psychologically minded. self-reflection is the individual’s ability to apply these reasoning and metacognitive skills to his or her own beliefs and actions. 2005). With development. even if they are not yet able to reflect on the meaning of this knowledge.” and “What is going through your mind now?” Measures of intellectual ability also have been used to assess cognitive development. Sauter et al. Assessment Because cognitive skills are changing over time. Over time. Thus. children become increasingly able to identify thoughts and to distinguish thoughts from behaviors before they later develop the more nuanced capability of differentiating thinking from seeing and knowing (Doherr et al. children gain the capacity to report their thoughts to others (Grave and Blissett 2004) and to observe the consistency and accuracy of their thinking (Keating 1990). systematic thinking. Unfortunately. Finally. the ability to think about multiple aspects of a situation and to examine contradictory evidence allows more cognitively developed children to understand there can be variation in their own strengths and weaknesses instead of viewing themselves as either “all good” or “all bad” (Grave and Blissett 2004). they also are more apt to be self-critical (Masten and Braswell 1991). Sauter et al. For example. Shirk 1999). For example. they know what they know. as children become better able to engage in self-evaluation. recognizing consequences. they engage in more spontaneous reflections on their thinking (Grave and Blissett 2004. clinicians need to be aware of the ways in which cognitive development may play a role in both decreasing and exacerbating symptoms. Some informal assessments have been used to gather information about metacognition. Example questions include “What went through your mind when. leading to a developing sense of self that gradually solidifies and becomes less modifiable (Hoffman 2008).. 2005. As such. for . it is important to assess children’s developmental level at any particular point in time. children develop an “inner monologue” that involves the ability to reflect on their own inner life (Sauter et al. more developed children are increasingly able to identify their deficiencies and to believe them to be stable and unchangeable traits. Specifically. 2009) and become aware of regulating their thoughts (Doherr et al. 2006). with emergent cognitive maturity comes increased vulnerability to certain forms of psychopathology. Children first learn to monitor their own thoughts and to recognize that they have knowledge— that is. measures can be selected on the basis of which will provide incremental knowledge to guide treatment planning for a particular child. 4th Edition (WISCIV). Connection With CBT Techniques Social skills have been defined as “learned behaviors which are socially acceptable and which permit an individual to initiate and maintain positive relationships with peers and adults” (Royer et al. A more formal assessment battery for evaluating relevant cognitive developmental skills would allow clinicians to gather more specific information needed to tailor treatment appropriately. 1999.Developmental Considerations Across Childhood 45 example. Although this is not a comprehensive catalog of all possible measures. such individualization is still in its infancy. p. Many forms of psychopathology both affect and are affected by interpersonal relationships. The recommendations in Appendix 2–B are examples of the ways in which clinicians can integrate developmental and clinical knowledge to improve treatment planning and clinical outcomes. to serve as indicators of how children think (Spritz and Sandberg 2010). Not every measure should be used for every child all of the time. more general intelligence measures may not provide a complete picture of a child’s level of cognitive development. Consideration of the social context in which children’s psychiatric problems occur and how well children negotiate their interpersonal challenges is central to their treatment. however. Subscales of intelligence measures might not be sufficiently comprehensive. Practical Recommendations for Treatment Planning Although the need to assess developmental skills has long been suggested for treatment planning. Rather. 1998. Thus. Masten and Braswell 1991). CBT . A considerable number of treatment manuals have been devoted to promoting children’s abilities to interact successfully with others (see Table 2–1). 7). the Wechsler Intelligence Scale for Children. although useful. similarities subtest measures abstract reasoning skills (Sauter et al. A list of several existing measures of cognitive development is provided in Appendix 2–A. 2009). Social Development Children’s level of social development also should be evaluated and used in treatment planning (Eyberg et al. it provides a resource of commonly used tools for assessing several important aspects of children’s cognitive development. Normative Development of Social Competence Bolstering children’s social competence is an important aim of CBT. Normatively. Holmbeck et al.g. and prosocial behavior. and beliefs of individuals other than oneself ” (p. 2008). children communicate in a seemingly “egocentric” way. CBT involves various social-cognitive abilities. children learn that perspectives different from their own exist. and seeking social support. Perspective taking presumably changes linearly from childhood to adulthood (Elfers et al. conversation skills. those with the same type of symptoms). children need social perspective-taking skills to anticipate the effects of their behavior on others (e. social problem-solving. conflict resolution. empathy. Less socially advanced children are limited in their ability to see another’s viewpoint beyond their own or to recognize that others’ perspectives even exist (Fireman and Kose 2010).. Over time. assertive behavior. Grave and Blissett 2004.. the core human ability to understand the thoughts. Role-playing. including cognitive.46 Cognitive-Behavior Therapy for Children and Adolescents manuals emphasize such social development skills as meeting new people. such as perspective taking. a commonly used CBT strategy. In particular. This capability to stand in another’s shoes is foundational for successful interactions. such that they often omit vital information about what their listener needs to know. 1999). which could exacerbate their tendencies toward rumination or deviant behaviors (Crosnoe and Needham 2004). 22). The emergence and expression of social skills stems from multiple factors and is interrelated with other areas of development. emotional. Thus. needs. children learn and master social skills through navigating relationships over the course of development. their perspective-taking ability likely will affect their responses (Weisz and Weersing 1999). 2006. For example. When children are asked to imagine hypothetical situations and the ways they and others might act. children with emotional and behavioral difficulties may have problems interacting with same-age peers and correctly appraising social situations (Quinn et al. Weisz and Hawley 2002). and biological domains (Beauchamp and Anderson 2010).g. Perspective-taking abilities are part of normal social development. that is. Selman (1980) defined perspective taking as understanding how “human points of view are related and coordinated with one another. some children form friendships with similar others (e. Moreover. Children also begin to . perspective taking is a critical social developmental skill that should be assessed and considered when designing a treatment plan for a particular child. As a result. also calls on children’s ability to see through another’s lens. This developing ability enables youth to take a more impartial position over time. helping. sharing. Such awareness leads to an understanding of the causes underlying multiple perspectives about the same situation and that external as well as internal factors contribute to personal perspectives and associated behaviors (Fireman and Kose 2010. good peer relationships are formed once children learn how to initiate and maintain positive social interactions. Adaptive social skills produce positive peer relationships and include expressing positive affect. Social skills acquired early continue to be important (e.g. As children mature socially. initiating nurturing behaviors (e.. and mastering reciprocal play (e. Such thinking is part of normative development but can be problematic when it takes the form of excessive self-consciousness or rumination. cooperating). In addition. As children become more socially advanced. but they may think that the others’ perspectives are incorrect and that only their own view reflects reality. For example. children’s “normal” processing of social information may appear to be distorted compared with that of adults (Grave and Blissett 2004). Although motivation to engage in perspective taking typically is a marker of healthy social development. Thus. prosocial characteristics such as being kind and considerate contribute to being accepted by others. 2010. children can comprehend that others have different views than their own. sharing). The cognitive advances that develop in tandem with social development facilitate children’s understanding that perspectives are created by the mind and are not exact copies of reality but are instead interpretations and representations of the world.g. although they may not yet be able to conceive of what these might be. La Greca and Prinstein 1999). some youth try to anticipate what people are thinking and often assume that they are the focus of others’ thoughts. Thus. which often is linked to a desire to engage in prosocial behavior (Eisenberg et al. Perspective-taking ability is multifaceted and various components of this skill may emerge at different times. Another important aspect of the emergence of perspective taking is the increased motivation to take another’s perspective.. thereby enhancing their peer acceptance and avoiding rejection (La Greca and Prinstein 1999). helping.Developmental Considerations Across Childhood 47 recognize that people have their own goals. being agreeable.. intentions. turn taking) (Bierman et al.g. they become better at reflecting on their own actions through the perspective of another person. this belief is often referred to as the imaginary audience (Keating 1990). Achievement of social competence in children is cultivated through their encounters with different types of challenging social situations (Spence 2003). Keating 1990). 2009). . and expectations. they develop the self-control that makes possible engaging in rule-based play and joining in prosocial behavior. attending to play partners. children who are socially adept demonstrate adaptive strategies for solving interpersonal conflicts and effectively inhibit and redirect impulsive and aggressive behaviors (Bierman et al. Some children may be singled out for victimization. although this can be time-consuming and expensive. As children become more social and cognitively advanced. Youth who are not accepted by their peers tend to have problems resolving conflict and less supportive friendships. however. particularly regarding their peer relationships and friendships. Intimacy characterizes the friendships of socially advanced youth. mature conversational skills. . their abstract and reflective thinking also allows for new levels of social distress. and think before acting aids in the formation of close dyadic friendships and the building of successful social relationships (Parker and Asher 1993). and developmentally advanced capacities for loyalty and empathy. multi-informant approaches are likely to provide the most comprehensive assessment of children’s social aptitudes and deficiencies (Spence 2003). navigating social groups and cliques. self-disclosure. particularly for females whose friendships are marked by good communication. less socially developed children tend to use more physical aggression. Finding their social niche. Assessment Assessing children’s social development. 2010). children use more indirect. Children with at least one reciprocal friendship fare much better emotionally than do those without a friend. Gaining acceptance from others. Intimacy emerges out of social perspective-taking skills. children’s burgeoning ability to take others’ perspectives. is one of the salient social challenges that children face. Children who cope effectively with peer pressure tend to be more advanced socially and cognitively and are able to act assertively in challenging social situations (Bierman et al. The importance of friendships and the influence of peers increase with development (Crosnoe and Needham 2004).48 Cognitive-Behavior Therapy for Children and Adolescents With regard to resolving interpersonal conflict. For example. In contrast. youth often evaluate themselves in comparison to their peers and judge their self-worth in terms of the social status of their friends. and trust (La Greca and Harrison 2005). Thus. and responding to peer influences are among the many social challenges youth must negotiate. generate multiple solutions to social problems. is important for constructing an age-appropriate treatment plan (La Greca and Prinstein 1999). particularly peers. over time. relational aggression. Multimethod. Children’s social competencies and skills have been assessed with role-play vignettes or questionnaires (Matson and Wilkins 2009). particularly those who are socially withdrawn or emotionally labile. 2010). Although several behavior rating scales (e.g. How is the child viewed by peers? 2.. Spence 2003). Achenbach 1991) include some items about social competence. Appendix 2–A lists several measures that can be used to assess components of children’s social development. Practical Recommendations for Treatment Planning Appendix 2–B provides examples of how knowledge about children’s social development can inform the choice of strategies to be used in therapy. . Observation of a child’s skills deficits and strengths should be an adjunctive assessment of the child’s patterns of interactions with others. whereas others are aimed at decreasing problematic interpersonal behaviors. Thus. most do not provide a focused examination of social skills per se that would inform treatment planning. conversational skills). initiating a conversation). Some of these recommendations are aimed at enhancing children’s social competence and specific social skills. What are the child’s interpersonal skills? Addressing these four issues will aid clinicians in tailoring CBT to a particular child’s social level. Some measures assess social skills that are particularly pertinent to CBT with youth (e. they may not capture this acquisition-performance disparity. although questionnaires are the most common method for assessing knowledge about social skills.. and high levels of arousal (Gresham 1997). For example. Tailoring the treatment to the developmental level of a particular child will increase the likelihood that the child will be able to grasp what is being taught. perspective taking.. actually implementing this knowledge in a real-world context may not necessarily follow. What are the child’s friends and friendships like? 3. Child Behavior Checklist. although a child may be capable of a certain social skill (e. Whether the clinician is applying a strengthbased or deficit-based approach. intrusive or anxious thoughts. Deficits in performance may be due to factors such as intense affect. and show an improvement in symptoms.g.g.Developmental Considerations Across Childhood 49 La Greca and Prinstein (1999) recommended four crucial areas to assess in children’s social functioning: 1. improving social interactions is a central focus of CBT with clinically referred youth (La Greca and Prinstein 1999). How does the child feel about his or her peer interactions? Have any aversive occurrences happened with peers? 4. apply it to his or her own life. The distinction between acquisition versus performance of social skills and interpersonal problem-solving is germane to the assessment of social development (Gresham 1997. adaptive coping. Bar-On (1997) offered a different definition of emotional intelligence. and skills that influence one’s ability to succeed in coping with environmental demands and pressures” (p. there is considerable overlap in the skills considered to constitute emotional intelligence and competence and a consensus that these skills develop over time (Mayer et al. and having an emotion vocabulary. Perceiving and identifying emotions. awareness of intensity and duration of emotions is necessary to monitor emotional expe- . including the use of self-regulation to decrease intensity or duration of emotions both for the self and for others. Understanding the connections within the cognitive model. Despite the different labels. 189). competencies. and managing emotions. empathy and sympathy. using past emotions to predict future experiences. Understanding emotions and the relations among emotions. and emotional self-efficacy. and recognizing the difference between inner emotional states and outer emotional expression. These abilities include perceiving and identifying emotions. using emotions to facilitate thoughts. the individual must be able to recognize. Salovey and Mayer (1990) defined emotional intelligence as “the ability to monitor one’s own and others’ feelings and emotions.50 Cognitive-Behavior Therapy for Children and Adolescents Emotional Development The set of emotional skills that allows individuals to effectively interact in their world has been conceptualized in several different ways. using an emotion vocabulary. For example. stress management. and differentiate among different emotions. label. and general mood. Emotion management. 14). He outlined five clusters of emotional intelligence skills: intrapersonal. 2000. interpersonal. recognizing the distinction between inner emotional state and outer emotional expression. Saarni (1999) described the development of emotional competence as consisting of a set of eight skills: an individual’s awareness of his or her own emotional state. adaptability. being aware of one’s own and others’ emotions. describing it as “an array of noncognitive capabilities. participating in cognitive restructuring. 3. awareness of relationships. Saarni 1999). and engaging in behavior activation require selffocused emotional competencies. to understand how different thoughts lead to different feelings. Connection With CBT Techniques Emotional skills particularly relevant to CBT include the following: 1. In addition. to discriminate among them and to use this information to guide one’s thinking and action” (p. understanding emotions. 2. discerning others’ emotions. 2005)..g. 2009). to multiple simultaneous or conflicting emotions (e. they become more aware of the emotions of others (Ciarrochi et al. Less emotionally mature children describe their emotional experiences in terms of physical complaints or behaviors.. Additionally.. 2008).g. The ability of children to manage their emotional experiences develops over time. children first incorporate a broader range of information into their understanding and description of their own emotions. “I feel good”). “I feel guilty”). As children begin to understand the connections between situations and emotions. the more readily children will be able to use the emotion regulation strategies taught in CBT (Suveg et al. CBT also requires other-focused emotional intelligence. children develop an understanding that emotions of different valences can affect one another (e. Such skills are central to being able to engage in CBT. “I feel embarrassed”. Emotional awareness progresses from recognition of general feeling states (e. to more specific emotions (e. to more complex emotions (e. negative feelings get better with the experience of positive emotions [Donaldson and Westerman 1986]). Normative Development of Emotional Skills The complexity of children’s emotions increases over time (Saarni 1999). 2008). Emotion regulation strategies increase in complexity as children become better able to integrate information about others’ emo- . they also begin to recognize how their emotions impact other areas of their life (Bajgar et al. Once children are cognizant of their own more complex emotional experiences. As children become able to provide more intricate explanations of their own emotional states. With increasing development. “I feel happy”). The more developed their emotion management system is. Children’s ability to regulate emotions develops throughout childhood and into adulthood. or they report feeling only one emotion at a time (Bajgar et al. individuals must be able to combine skills related to understanding their own and others’ emotions. Thus.g.g. Learning to meet people and forming and maintaining social relationships require an understanding of others’ emotional experiences..g. “I feel love and anger”) (Ciarrochi et al. To engage in social problem-solving or conflict resolution. they become better able to engage in emotional reasoning (Grave and Blissett 2004).. 2005). as well as the multiplicity of emotional experiences. children can reflect on their past feelings to inform their understanding of their current experiences (Saarni 1999). and only later are they able to think about others’ reactions in the same way (Karniol and Koren 1987). emotion recognition and an emotion vocabulary facilitate discussion of these emotional experiences in therapy.Developmental Considerations Across Childhood 51 riences outside of therapy. to hide emotions to avoid hurting someone’s feelings) (Ciarrochi et al. such as perceived versus actual awareness (Ciarrochi et al. 2009). and recognize how their behaviors affect the emotions of others.52 Cognitive-Behavior Therapy for Children and Adolescents tional experiences with management of their own feelings. a skill that typically develops faster in girls than in boys (Wintre and Vallance 1994). Mayer et al. Some performance measures assess a variety of emotional competencies (e. . self-report questionnaires. 2007. 2001. In turn. Nowicki and Duke 1994). build an emotion vocabulary. they learn to manage their emotional expressions in order to impact the emotional experience of others (e.g. 2001). Children also become increasingly able to talk about their emotions. A review of measures for assessing emotional competence in children concluded that most existing measures focus on social rather than emotional competence and that few measures focus solely on emotional competence (Stewart-Brown and Edmunds 2003). Extant measures of emotional competence include parent or teacher observations.. children become better at recognizing the difference between internal emotional experiences and external emotional expression. These recommendations emphasize helping children learn to identify their emotions. Appendix 2–A presents some existing measures of emotional intelligence or competence for children and adolescents.g.. With increasing emotional competence. and performance measures. Assessment The number of assessment tools available to measure emotional intelligence in children is limited (Luebbers et al. These different measurement methods often are not correlated. ability to recognize emotional facial expressions. Mayer-Salovey-Caruso Emotional Intelligence Test. Many of these measures either have been constructed recently or are still being developed. manage their emotions. Practical Recommendations for Treatment Planning Examples of how knowledge about children’s emotional development can inform clinical practice are presented in Appendix 2–B. Assessing a child’s strengths and deficits in emotional competence is a necessary precursor to formulating a plan for effectively implementing CBT with that child.. and thus they likely are assessing different aspects of emotional intelligence. however. 2002).g. Saarni 1999). Stough et al. whereas others assess one specific skill (e. g. Changing parents’ role in therapy (e. CBT with children should use clear.. Treatment modality.g. biweekly. social. Language and vocabulary. the link between children’s executive functions and the demands of CBT also needs to be explored.g.Developmental Considerations Across Childhood 53 Other Important Developmental Considerations 1. and other aspects of culture that could impact development (Ollendick et al. attention. weekly. Developmental level also can affect the length of sessions. group) may be more or less appropriate and/ or effective depending on the child’s developmental level. particularly within the social domain. 2. and child-specific vocabulary (Sauter et al.g. 2. more active “coaching” from parents of younger children). Conclusions and Future Directions Tailoring treatment to the developmental level of the client is essential to increasing the efficacy of CBT interventions with children and adolescents. Developments in executive functions (e.. planning) are occurring simultaneously with developments in cognitive. simple. The context in which the therapy is implemented (e. remember what was discussed within sessions. Existing strategies for modifying treatments include the following: 1. flexibility.g. Executive function. Although modifying the language used in adult treatment manuals is insufficient to achieve developmental tailoring. The child’s ability to sustain attention. such changes are nonetheless necessary. months). Clinicians also should be aware of any discrepancies between receptive and expressive language that could impact children’s abilities to understand or respond to therapeutic demands. family. monthly). Using treatment manuals designed for specific age groups. Developmental norms may not always incorporate sex. 2001). race... socioeconomic status. and overall duration of treatment (e. individual. frequency of sessions (e. and emotional development to allow children’s effective engagement in treatment (Grave and Blissett 2004). weeks. 4. number of sessions. and use the new skills outside the therapy session will affect decisions about these parameters of the treatment process. 5. Sex/race/socioeconomic status/culture. twice a week. Parameters of treatment. 3. . Therefore. 2009).. 54 Cognitive-Behavior Therapy for Children and Adolescents 3. Altering specific therapeutic activities to be more or less concrete. Key Clinical Points • Therapy likely will be more effective when matched to the child’s developmental abilities. rather than according to a systematic evaluation of children’s developmental levels in multiple domains. social.e. social. Clinicians using CBT interventions with children and adolescents will benefit from recognizing the connections between each CBT technique and distinct developmental abilities. Developmentally tailoring treatment in this way will impact how CBT interventions are delivered to children and adolescents and thereby reduce the time needed to ameliorate symptoms and improve functioning. complex. When implementing CBT techniques with children and adolescents. or visual. • Clinicians should acquire an understanding of normative cognitive. understanding the normative development of these abilities. social. and learning about methods for assessing these developmental abilities. and emotional developmental abilities especially relevant to engaging in CBT. . cognitive. and emotional development and how such development impacts children’s ability to learn and implement therapeutic strategies. and suggested several tools for assessing children’s developmental level. we provided suggestions for using this developmental assessment information to individualize treatment planning. Typically these modifications have been made on the basis of children’s age. • Age and developmental level are not synonymous. thus informing treatment planning at intake. emotional). Further research is needed to clarify the relations between specific clinical techniques and developmental abilities and to identify the most effective methods for tailoring treatment to a child’s specific developmental level in each domain (i. We identified examples of cognitive. cognitive.. provided information about typical developmental trajectories of these abilities. Use of appropriate tools for assessing a child’s developmental level across multiple domains can allow the clinician to gather information about development when the client first presents for treatment. Clinicians should assess a child’s developmental level as a part of treatment planning. Finally. behavioral. clinicians should use a developmental framework to determine the intervention strategies likely to be most effective. 4. True or False: Adolescents are always better able to engage in cognitive-behavioral strategies than are young children.” he feels discouraged and is less likely to study for the test. some of which are more developmentally appropriate than others. and emotional (e.. identification. perspective taking. emotion perception. Metacognition and perspective taking. including cognitive (e. metacognition. social (e.1. and regulation). empathy). Development level within a domain is uniform at each chronological age.. True or False: Adapting adult language to be more age-appropriate is the primary way to developmentally tailor CBT for children. C. Self-Assessment Questions 2. • Developmental skills particularly important for engaging in CBT involve multiple domains. Developmental level impacts children’s ability to both learn and apply therapeutic skills.g. Different areas of development (e. social. D. Causal reasoning and emotion identification. B. understanding.g. Different treatment strategies require different developmental skills. Hypothetical thinking and emotion management. C. reasoning... cognitive. .g.2.3. D. Which of the following is NOT a reason to use a developmentally sensitive framework in treatment planning? A. 2. 2. 2. Which of the following developmental skills are necessary to understand this connection? A.Developmental Considerations Across Childhood 55 • CBT often is used as an umbrella term for a wide range of clinical skills. Little Johnny is asked in therapy to recognize that when he thinks “I will fail this math test no matter what. B. and emotional) are interdependent. self-reflection). Self-reflection and social skills.g. 56 Cognitive-Behavior Therapy for Children and Adolescents 2. and TRF Profiles. IL. Lane R. pp 60–73 Vernon A: More of What Works When With Children and Adolescents: A Handbook of Individual Counseling Techniques. After implementing strategies designed to improve developmental skills. Rush J. Burlington. 1991 Artman L. Ciarrochi J. Research Press. Toronto. Abad M. B. Parker JDA: Emotional Quotient Inventory: Youth Version (EQ-i:YV). Multi-Health Systems. et al: Cognitive-behavioral therapy with adolescents: guides from developmental psychology. Cahan S. Allyn & Bacon. 2005 Bar-On R: The Bar-On Emotional Quotient Inventory (EQ-i): A Test of Emotional Intelligence. et al: Development of the Levels of Emotional Awareness Scale for Children (LEAS-C). 2001 Shirk S: Developmental therapy. Canada. Pincus DB. Cogn Dev 21:131–145. Canada. Department of Psychiatry. Ollendick TH. All of the above. New York. ON. Toronto. 1997 Bar-On R. 3rd Edition. 2010 Beck AT. Avni-Babad D: Age. 2009 Bajgar J. 1979 . et al: Cognitive therapy of depression. Clinicians should assess children’s developmental level A. ON. J Anxiety Disord 23:727–736. et al: The Metacognitions Questionnaire for Children: development and validation in a clinical sample of children and adolescents with anxiety disorders. Multi-Health Systems. Edited by Kendall PC. Br J Dev Psychol 23:569–586. pp 419–464 Merrell K: Helping Students Overcome Depression and Anxiety: A Practical Guide. YSR. New York. 1999.5. Before starting treatment. schooling and conditional reasoning. Suggested Readings Holmbeck GN. in Developmental Issues in the Clinical Treatment of Children. Needham Heights. 2000 Beauchamp MH. C. in Child and Adolescent Therapy: Cognitive-Behavioral Procedures. 2009 References Achenbach TM: Integrative Guide for the 1991 CBCL/4–18. Guilford. Guilford. D. MA. Guilford Press. Shaw BF. 2006 Bacow TL. Anderson V: SOCIAL: an integrative framework for the development of social skills. Ehrenreich JT. 2006. University of Vermont. Edited by Silverman WK. Before introducing a new developmentally challenging technique. New York. Champaign. Psychol Bull 136:39–64. O’Mahar K. Maydeu-Olivares A: Social problem solving: theory and assessment. Mather A. Sokol B: Perspective taking: a review of research and theory extending Selman’s developmental model of perspective taking. Lampman C: Effectiveness of cognitive-behavior therapy for maladapting children: a meta-analysis. NJ. Behav Cogn Psychother 33:201–215. The Psychological Corporation. Edited by Lerner RM. Furhman T. 2010. in Social Problem Solving: Theory. 3rd Edition. J Anxiety Disord 18:411–422. J Appl Behav Anal 10:183–195. Adv Psychol Res 54:229–262. 1986 Durlak JA. Westerman MA: Development of children’s understanding of ambivalence and causal theories of emotions. Kaplan E. J Abnorm Child Psychol 26:71–82. Torres MM. 2008 Eyberg SM. J Adolesc 31:565–582. Kose G: Perspective taking. New York.Developmental Considerations Across Childhood 57 Bierman KL. 2001 Doherr L. 1991 D’Zurilla TJ. Dev Psychol 22:655–662. 1998 Fireman GD. Chan AY. in Practitioner’s Guide to Empirically Based Measures of Social Skills (ABCT Clinical Assessment Series). American Psychological Association. Schofield HL: Developmental factors related to the assessment of social skills. San Antonio. D’Zurilla TJ. New York. 1977 Bryant BK: An index of empathy for children and adolescents. Psychol Bull 110:204–214. Illingworth V. 2007 Christophersen ER. Research. Reynolds S. DC. Supavadeeprasit S: The link between emotion identification skills and socio-emotional functioning in early adolescence: a 1-year longitudinal study. pp 229–265 Elfers T. contextual variability. 2004. Springer. Wetherly J. 2002 Ciarrochi J. Edited by Chang EC. Edited by Sandberg EH. Routledge/Taylor & Francis. Sanna LJ. 2008 Crosnoe R. Mortweet SL: Treatments That Work With Children: Empirically Supported Strategies for Managing Childhood Problems. Guilford. and the study of friendships in adolescent development. Pers Individ Dif 31:1105–1119. Needham B: Holism. et al: Moral cognitions and prosocial responding in adolescence. Vol 4: Individual Bases of Adolescent Development. Steinberg L. Kramer JH: The Delis-Kaplan Executive Function System. 2005 Donaldson SK. New York. American Psychological Association. Hersen M: Social-skills training for unassertive children: a multiple-baseline analysis. Wiley. and Training. Schuhmann EM. 2004 Chorpita BF: Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders. Washington. Heaven PC. Washington. Hoboken. Edited by Nangle DW. 2010. 2001 Ciarrochi J. pp 85–100 . Morris AS. Martin J. et al: Development and preliminary validation of the Meta-Cognitions Questionnaire—Adolescent Version. Rey J: Child and adolescent psychotherapy research: developmental issues. DC. et al: Young children’s ability to engage in cognitive therapy tasks: associations with age and educational experience. pp 119–134 Bornstein MR. in A Clinician’s Guide to Normal Cognitive Development in Childhood. Bajgar J: Measuring emotional intelligence in adolescents. Nezu AM. Child Dev 53:413– 425. pp 11–27 Eisenberg N. 1982 Cartwright-Hatton S. Bellack AS. Child Dev 75:264–279. 2004 Delis DC. in Handbook of Adolescent Psychology. McDaniel B. Spritz BL. TX. 2009. Guilford. 1962 Grave J. 1998. Edited by Silverman WK. 3rd Edition. Clin Psychol Rev 24:399– 420. Kendall PC: Clinical-childhood-developmental interface: implications for treatment. Workbook Publishing. pp 419–464 Janveau-Brennan G. 1999 Karniol R. Needham Heights. 1999. MA. O’Mahar K. Choudhury MS. in CognitiveBehaviour Therapy for Children and Families. et al: Cognitive-behavioral therapy with adolescents: guides from developmental psychology. 2000 Goodnow JJ: A test of milieu differences with some of Piaget’s tasks. NY. New York. Project Manual: Manual for the Individual Cognitive-Behavioral Treatment of Adolescents With Anxiety Disorders. Colder C. et al: The C. Edited by Kendall PC. in At the Threshold: The Developing Adolescent. Haviland-Jones JM. 1987 Keating D: Adolescent thinking. where we are. Cambridge.58 Cognitive-Behavior Therapy for Children and Adolescents Flavell JH. 2006. Edited by Lewis M. and where we should go. American Guidance Services. pp 171–198 . Workbook Publishing. Edited by Kendall PC. Circle Pines. pp 73–99 Holmbeck GN. MN. Elliot GR. 3rd Edition. Barrett LF. Allyn & Bacon. and romantic relationships: do they predict social anxiety and depression? J Clin Child Adolesc Psychol 34:49–61. Verduyn C: Clinically depressed adolescents. Abad M. pp 440–455 Holmbeck GN. in Child and Adolescent Therapy: CognitiveBehavioral Procedures. pp 334–385 Holmbeck GN. Markovits H: The development of reasoning with causal conditionals. Psychol Monogr 76:555. Cambridge University Press. et al: Working with adolescents: guides from developmental psychology.A. Edited by Feldman SS. Cambridge. Green FL. Blissett J: Is cognitive behavior therapy developmentally appropriate for young children? A critical review of the evidence. in Handbook of Emotions. PA. Dev Psychol 35:904–911. Ollendick TH. 2002 La Greca AM. 1990 Halpern-Felsher BL. Harvard University Press. pp 54–89 Kendall PC: The Coping Cat Workbook. Edited by Graham P. Guilford. Flavell ER: Development of children’s awareness of their own thoughts. Cauffman E: Costs and benefits of a decision: decision-making competence in adolescents and adults. pp 156–193 Hoffman ML: Empathy and prosocial behavior. 2004 Gresham FM: Social competence and students with behavior disorders: where we’ve been. Pergamon. 1990. New York. J Appl Dev Psychol 22:257–273. 2005 La Greca AM. Elliot SN: The Social Skills Rating System. MA. 2001 Harrington R. Educ Treat Children 20:233–249. Shapera W. 1991. Ardmore. Guilford. Hudson JL. 1990 Kendall PC. 2nd Edition. Prinstein MJ: Peer group. UK. J Cogn Dev 1:97–112. Edited by Martin PR. in Developmental Issues in the Clinical Treatment of Children. 1997 Gresham FM. New York. in Child and Adolescent Therapy: Cognitive-Behavioral Procedures. in Handbook of Behavior Therapy and Psychological Science: An Integrative Approach. Harrison HM: Adolescent peer relations. 2008. Cogn Dev 2:271–278. Ardmore. friendships. Elmsford. Koren L: How would you feel? Children’s inferences regarding their own and others’ affective reactions. Wood A.T. PA. 2000. New York. Duke MP: Individual differences in the nonverbal communication of affect: the Diagnostic Analysis of Nonverbal Accuracy Scale. Shove C. et al: A meta-analysis of social skill interventions for students with emotional or behavioral disorders. Petrides KV. Sangareau Y. Caruso DR. et al: Investigation of the construct of trait emotional intelligence in children. Vaughn MG. NY. Intelligence 27:267–298. Behav Res Ther 21:335–340. McCrea C: The empirical status of treatments for children and youth with conduct problems: an overview of meta-analytic studies. Rotatori AF. King NJ: Applying developmental theory to the assessment and treatment of childhood disorders: does it make a difference? Clin Psychol Psychother 8:304–314. Toronto. Furnham A. Wilkins J: Psychometric testing methods for children’s social skills. Res Soc Work Pract 20:21–35. Itasca. 1998 Masten AS. 2000 Mayer JD. Hagen EP: The Cognitive Abilities Test: Form 6. J Emot Behav Disord 7:54–64. MHS Publishers. Dev Psychol 29:611–621. Pergamon. 2008 Mayer JD. Caruso DR: Mayer-Salovey-Caruso Emotional Intelligence Test (MSCEIT): User’s Manual. Kavale KA. Braswell L: Developmental psychopathology: an integrative framework. Rockcastle VN. pp 187–204 Litschge CM. Mathur SR. Stough C: The development of an adolescent measure of EI. 2006 Piaget J: Development and learning (1964). 2002 Merrell K: Helping Students Overcome Depression and Anxiety: A Practical Guide. J Ment Sci 108:191–195. New York. Canada. 2010 Lohman DF. 1983 Mavorveli S. Cornell University. in Piaget Rediscovered. Guilford. Res Dev Disabil 30:249–274. Grills AE. 2001 Nowicki S. et al: Trait emotional intelligence and children’s peer relations at school. Salovey P. IL. Elmsford. pp 35–56 Matson JL. Riverside Publishing. 2009 Matson JL. 2001 Parker JG. ON. 1994 Ollendick TH. NY. Helsel WJ: Development of a rating scale to measure social skills in children: the Matson Evaluation of Social Skills with Youngsters (MESSY). 1993 Petrides KV. 2001 Luebbers S. New York. Edited by Ripple RE. 1988.Developmental Considerations Across Childhood 59 Lazarus AA. Mulle K: OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. Edited by Shirk SR. Pers Individ Dif 42:999–1009. J Nonverbal Behav 18:9–35. 1999 . Guilford. Ithaca. Plenum. Downey LA. School of Education. Eur Child Adolesc Psychiatry 17:516–526. Salovey P: Emotional intelligence meets traditional standards for an intelligence. Soc Dev 15:537–547. pp 7–20 Quinn M. Edited by Martin PR. 2007 March JS. Asher SR: Friendship and friendship quality in middle childhood: links with peer group acceptance and feelings of loneliness and social dissatisfaction. 1962 Leahy RL: Cognitive therapy of childhood depression: developmental considerations. 2006. in Cognitive Development and Child Psychotherapy: Perspectives in Developmental Psychology. 1991. Abramovitz A: The use of “emotive imagery” in the treatment of children’s phobias. in Handbook of Behavior Therapy and Psychological Science: An Integrative Approach. Research Press. Ross CM: Ross Test of Higher Cognitive Processes. Westenberg PM: Cognitive behavior therapy for anxious adolescents: developmental influences on treatment design and delivery. 2009 Vernon A: More of What Works When With Children and Adolescents: A Handbook of Individual Counseling Techniques. Edited by Bar-On R. East Sussex. Springer Science and Business Media. Comer JS. IL. pp 241–257 Stough C. 1999. PA. Beck S: What is difficult about counterfactual reasoning? in Children’s Reasoning and the Mind. Routledge/Taylor & Francis. 1990 Sauter FM.60 Cognitive-Behavior Therapy for Children and Adolescents Robinson EJ. 1999 Salovey P. Clin Child Fam Psychol Rev 12:310–335. Novato. Parker JD: Assessing Emotional Intelligence: Theory. Bitaudeau I. Emotional and Behavioural Difficulties 4:4–10. 2009 Suveg C. in Developmental Issues in the Clinical Treatment of Children. in Educating People to Be Emotionally Intelligent. and Applications (Springer Series on Human Exceptionality). and practice. et al: Changes in emotion regulation following cognitive-behavioral therapy for anxious youth. 2003 Spritz BL. New York. Burke RV. Spritz BL. Academic Press.” Ardmore. Allyn & Bacon. New York. 1996 Saarni C: The Development of Emotional Competence (Guilford Series on Social and Emotional Development). Ollendick TH. 1999 Ruma PR. J Clin Child Adolesc Psychol 38:390–401. New York. Needham Heights. Jensen P: Treating Depressed Children: Therapist Manual for “ACTION. Westport. Workbook Publishing. pp 101–119 Ross JD. 2010 Selman RL: The Growth of Interpersonal Understanding: Developmental and Clinical Analyses. Research. Sandberg EH: The case for children’s cognitive development: a clinicaldevelopmental perspective. et al: The impact of a social skills training program for adolescents with behaviour difficulties. Behav Cogn Psychother 30:297–309. 2002 Stark KD. Maurice J. Edited by Silverman WK. Champaign. Child Adolesc Ment Health 8:84–96. 2007 Stewart-Brown S. Guilford. Edited by Mitchell P. Goldman E. Edmunds L: Assessing emotional intelligence in children: a review of existing measures of emotional and social competence. Blote AW. Thompson RW: Group parent training: is it effective for children of all ages? Behav Ther 27:159–169. Maree JG. et al: Assessing therapy-relevant cognitive capacities in young people: development and psychometric evaluation of the SelfReflection and Insight Scale for Youth. 2009 . Saklofske DH. Mayer JD: Emotional intelligence. Hove. Praeger Publishers/Greenwood Publishing Group. Heyne D. Psychology Press. evidence. New York. 1980 Shirk S: Developmental therapy. pp 3–19 Stallard P: Cognitive behavior therapy with children and young people: a selective review of key issues. 2010. MA. 2009 Sauter FM. UK. 2003. Riggs KJ. pp 60–73 Spence SH: Social skills training with children and young people: theory. in A Clinician’s Guide to Normal Cognitive Development in Childhood. Heyne D. Desbiens N. Behav Cogn Psychother 38:303–317. 1976 Royer E. Imagin Cogn Pers 9:185–211. Sood E. CA. Academic Therapy Publications. Edited by Sandberg EH. CT. 2000. J Consult Clin Psychol 70:21–43. in Developmental Issues in the Clinical Treatment of Children. Weersing VR: Developmental outcome research. Hawley KM: Developmental factors in the treatment of adolescents. MA. Ollendick TH.Developmental Considerations Across Childhood 61 Vygotsky L: Interaction between learning and development. 1999. Harvard University Press. Weiss B. Edited by Silverman WK. John-Steiner V. Allyn & Bacon. pp 79–91 Weisz JR. Valeri SM: Effects of psychotherapy for depression in children and adolescents: a meta-analysis. 2002 Weisz JR. pp 457–469 Weisz JR. in Mind and Society. Cambridge. 1995 Weisz JR. et al: Effects of psychotherapy with children and adolescents revisited: a meta-analysis of treatment outcome studies. Needham Heights. McCarty CA. Han SS. 2006 Wintre MG. multiple emotions. Psychol Bull 132:132–149. et al. MA. 1978. and valence. Psychol Bull 117:450–468. Edited by Cole M. Vallance DD: A developmental sequence in the comprehension of emotions: intensity. 1994 . Dev Psychol 30:509– 514. Scribner S. 2006 Grades 7–9 Hypothetical and causal reasoning Generation of Alternatives Task Janveau-Brennan and Markovits 1999 Grades 1–6 Conditional reasoning Conditional Reasoning Task Janveau-Brennan and Markovits 1999 Grades 1–6 Reasoning and problem solving Cognitive Abilities Test.Tools for assessing developmental skills in cognitive. and logical reasoning Delis-Kaplan Executive Function System (DKEFS) Delis et al. 2001 8–89 years Conditional and logical reasoning Conditional Syllogism Test Artman et al. 2000 5 years to adult Self-reflection and insight Self-Reflection and Insight Scale for Youth Sauter et al. Cognitive development Cognitive-Behavior Therapy for Children and Adolescents . causal. social. and emotional domains Developmental skill Assessment measure Citation Age Decision making Decision-making scenarios Halpern-Felsher and Cauffman 2001 Grades 6–12 and young adults Abstract. Form 6 Lohman and Hagen 2001 5–18 years Systematic reasoning Combinations Task (CT) Goodnow 1962 10–11 years Critical thinking Ross Test of Higher Cognitive Processes Ross and Ross 1976 Grades 4–6 Metacognition Metacognitions Questionnaire for Children (MCQ-C) Bacow et al. 2009 7–17 years Metacognition Metacognitions Questionnaire for Adolescents (MCQ-A) Cartwright-Hatton et al. systematic. 2010 9–18 years 62 APPENDIX 2–A. 2004 7–17 years Metacognition Think Task Flavell et al. 2004 Revised (SPSI-R) 13 years Friendship quality Friendship Quality Questionnaire Parker and Asher 1993 7–12 years Empathy Bryant’s Index of Empathy for Children and Adolescents (BEI) Bryant 1982 Grades 1. social problemsolving skills Social Problem-Solving Inventory— D’Zurilla et al.5–32 years Social skills Social Skills Rating System (SSRS) Gresham and Elliot 1990 Grades K–6 Social skills Matson Evaluation of Social Skills with Youngsters Matson et al.Tools for assessing developmental skills in cognitive. social skills Behavioral Assertiveness Test for Children (BAT-C) Bornstein et al. and 7 Assertiveness. social. 1977 8–13 years Social development Appendix 2–A: Tools for Assessing Developmental Skills APPENDIX 2–A. and emotional domains (continued) Developmental skill Assessment measure Citation Age Social perspective-taking Interpersonal Understanding Interview Selman 1980 4. 1983 4–18 years Assertiveness. 4. 63 . emotion understanding. emotion identification. emotion management Trait Emotional Intelligence Questionnaire—Adolescent Form (TEIQue-AF) Petrides et al. emotion understanding. and emotional domains (continued) Developmental skill Assessment measure Citation Age Emotion perception. 2007 11–18 years Emotion perception. 2002 12–18 years 64 APPENDIX 2–A. emotion management Emotional Quotient Inventory: Youth Version (EQ-i:YV) Bar-On and Parker 2000 7–18 years Emotion perception. Emotional development Cognitive-Behavior Therapy for Children and Adolescents . emotion management Trait Emotional Intelligence Questionnaire—Child Form (TEIQue-CF) Mavorveli et al. emotion management Adolescent Swinburne University Emotional Intelligence Test (A-SUEIT) Luebbers et al. 2008 8–12 years Emotion perception. emotion understanding. emotion identification. emotion management Mayer-Salovey-Caruso Emotional Intelligence Test: Youth Version Mayer et al. 2006 13–17 years Emotion identification Diagnostic Analysis of Nonverbal Accuracy Scale—Form 2 (DANVA2) Nowicki and Duke 1994 6–10 years Emotion perception. social.Tools for assessing developmental skills in cognitive. recognizing the connections among them Abstract and causal reasoning Children with less developed abstract reasoning will benefit from more concrete and visual methods. and behaviors. Connecting thoughts. and behaviors on the hand) or tangible illustrations (e. then I will feel _____”) Conditional and hypothetical reasoning Avoid if-then language with children who do not display hypothetical reasoning abilities. Evaluate solutions Hypothetical. logical. and behaviors) can help show more complex concepts. . feelings in the stomach or heart. using “if-then” statements (e. string connecting thoughts. feelings.g. the body with thoughts in the head.. and emotional development Therapeutic demands Clinical recommendations Problem solving a.. social. Cognitive development 65 Developmental skills Appendix 2–B: Recommendations for Treatment Planning APPENDIX 2–B. Make sure that less cognitively developed children understand these associations before progressing.g. systematic. feelings. and causal reasoning Children with less developed reasoning ability may need more teaching about how to examine each solution. feelings. In place of role-playing. Use in vivo strategies to induce mood and help children draw connections through experiences in the moment. Differentiating thoughts. use cartoons or puppets. Practice explicit labeling of the cause and effect. feelings. and behaviors. These techniques are particularly relevant for children who grasp external constructs more readily than internal. more practice in evaluating possible solutions. and greater scaffolding from therapists and parents.g. When explaining the connections among thoughts.. psychological concepts. check children’s understanding of each relation. and behaviors. Pictures (e. Generate solutions b. “If I think ____.Practical recommendations for treatment planning based on cognitive. Children may have difficulty separating facts from their beliefs. helpful vs. unhelpful thoughts). Ask children “How do you feel when you think _____?” before moving on to the more advanced questions: “How will you feel the next time you think _____?” or “How might you have felt if you had thought _____?” Using analogies and metaphors to convey information Abstract and analogical reasoning Keep it simple. Use other cognitive restructuring strategies with less cognitively advanced children (e. Cognitive-Behavior Therapy for Children and Adolescents Cognitive development (continued) .Practical recommendations for treatment planning based on cognitive. first focus on the here and now rather than the past or future. examining evidence for and against child’s beliefs Systematic and logical reasoning Less cognitively advanced children may struggle with being impartial and may give more weight to evidence that supports their beliefs. reflecting on past and future patterns of thinking Hypothetical reasoning about the past and future Hypothetical reasoning about the past typically develops after reasoning about the future. children who have not yet developed this type of reasoning may find these strategies confusing. Although analogies and metaphors can convey information in a more memorable and attainable way. social. Clinical recommendations Cognitive restructuring. For less cognitively mature children. and emotional development (continued) Therapeutic demands Developmental skills 66 APPENDIX 2–B.g. alternative explanations. Thought monitoring and cognitive restructuring. which is necessary for cognitive restructuring.. social. “Your brain/mind told you that you like _____”). rather than asking them to remember a situation and identify past thoughts.g. Cartoons with thought bubbles can help explain thinking. although even this may be difficult for less cognitively advanced children. Clinicians need to train children to think differently (e. 67 Identifying and recognizing child’s cognitive distortions in order to modify them Appendix 2–B: Recommendations for Treatment Planning APPENDIX 2–B. first focus on identifying neutral and positive thoughts. Identifying thoughts in the present is less cognitively demanding than reflecting on past thoughts. Identifying own thoughts. self-reflection Children first need to be able to identify their thoughts in general before they can recognize their negative thinking or cognitive distortions. Thinking errors that are “typical” but maladaptive may be especially intractable. to see the gray instead of black and white) before children can overcome these thinking errors.. and emotional development (continued) Therapeutic demands Developmental skills Clinical recommendations Cognitive development (continued) Logical reasoning Some “cognitive distortions” may be normative and not linked to psychopathology. recognizing negative thinking and cognitive distortions Metacognition.Practical recommendations for treatment planning based on cognitive. Ask children “What do you like?” and then help them see that their response was a thought (e. For children who struggle with metacognition. . Identify children’s thoughts in session..g. not just that other views exist Cognitive-Behavior Therapy for Children and Adolescents Cognitive development (continued) Disputing negative thoughts. metacognition For less cognitively developed children who are unlikely to spontaneously reflect on their own thinking outside of therapy. Generalizing new skills learned in therapy to the child’s everyday life Self-reflection. caregivers will need to provide scaffolding. Advanced perspectivetherapy may be more effective if less focus is placed on disputing taking. therapists may prefer to rely on social-skills training validity of another’s view. Instead. . which might then impede therapeutic progress. Clinicians can help children recognize physiological sensations or emotional reactions that may cue them to reflect on their thinking. Social development For children who do not demonstrate advanced perspective-taking. ability to step outside own perspective and take the viewpoint of another 68 APPENDIX 2–B. motivation to change Self-reflection Children in the midst of identity formation may become anxious when confronted with information that threatens their tenuous identity. realizing the beliefs. and emotional development (continued) Therapeutic demands Developmental skills Clinical recommendations Introspection. understanding own identity. Parents can act as coaches at home to encourage children to think about their thinking.Practical recommendations for treatment planning based on cognitive. Motivational interviewing techniques may facilitate children’s decision making about change and likely will be more effective than the therapist directing children to change. social. to modify target behaviors. first have them 1) learn the concrete behaviors involved with meeting new shift and assume multiple people (e. 69 . first have children achieve mastery of their own assertive behaviors before requiring that they recognize the effect sequences that full rationale for how their behaviors affect others. being friendly. identifying intervention targeted at the child’s specific interpersonal skills what perpetuates deficits. Appendix 2–B: Recommendations for Treatment Planning APPENDIX 2–B. teachers). maintaining. behaviors in solving social Create a profile of the child’s strengths and weaknesses. and emotional development (continued) Therapeutic demands Developmental skills Clinical recommendations Social development (continued) Learning social problem-solving Evaluate child’s social competencies and deficits from multiple sources Ability to reflect on own (e. Assertiveness training. ability to For less socially advanced children who have difficulty role-playing. understanding the impact of own statements and actions on others Understanding cause-and. predicting Use simple role-play scenarios between the therapist and child to others’ social behaviors demonstrate the various possible consequences of the child’s actions. performance feedback. and ending conversations Role-taking skills.Practical recommendations for treatment planning based on cognitive. reinforcement. design an problems. starting. parents. maladaptive behaviors Build on the child’s existing skills through didactic instruction.g. introducing self. role-playing. modeling. Meeting new people. active listening).When teaching assertiveness..g. social.. then perspectives 2) watch video clips of people meeting and identify others doing these specific behaviors successfully (or unsuccessfully) without yet having to role-play or take multiple perspectives. and practice in the natural environment. involve others. the quality taking and consequences of their friendships also should be evaluated. They also might respond to their heightened distress over another’s hardship by disengaging and reducing their involvement with that person. and emotional development (continued) Therapeutic demands Clinical recommendations Developing and maintaining relationships: understanding how moods. perspective Although a child may report a healthy quantity of friends. possibly leading to emotional overarousal. For less socially adept children. and behaviors impact relationships. words. focusing on others instead of the self Empathy Some children with self-regulation difficulties may have problems with empathy such that their empathic distress for another exacerbates their own distress. . strengthening social skills Self-reflection. Teach children to monitor their moods in the context of these relationships. Help children recognize the connection between their social relationships and their mood. Clinicians can assist children in recognizing how others’ emotions affect them and can teach children strategies for appropriately managing their empathic distress and maintaining emotional control. Social development (continued) Cognitive-Behavior Therapy for Children and Adolescents Developmental skills 70 APPENDIX 2–B. help them identify when to seek support from others. Seeking social support. Understanding how relationships affect mood Self-reflection. social. social skills For more socially competent youth without clear social difficulties.Practical recommendations for treatment planning based on cognitive. anxiety. and self-focus. clinicians can enhance children’s interpersonal strengths and frame social support–seeking as a potentially healthy coping strategy for dealing with stress when done appropriately. such as asking questions to generate conversations or constructing positive statements about others. parent.g. and socially immature children with contrasting relationship styles to practice social skills and learn from each other. Conflict resolution. Social development (continued) Appendix 2–B: Recommendations for Treatment Planning APPENDIX 2–B. Pair counseling involves children being paired to provide opportunities for aggressive. social.g. Peer therapy involves a peer chosen by the child.. reciprocity.. smiling. cooperation.Practical recommendations for treatment planning based on cognitive.g. or clinician to attend one to two sessions. and emotional development (continued) Therapeutic demands Developmental skills Clinical recommendations Improving and enhancing peer relationships Social skills (e. Some skills (e. engaging in friendly greetings) will be important for less socially competent children to master first. withdrawn. making eye contact. appraising others’ intentions Pair therapy involves two children matched for their perspective-taking abilities and interpersonal negotiation strategies to promote better coordination between them.. interpersonal negotiation Perspective taking. 71 . conversational skills. co-rumination). Identify and modify maladaptive interaction patterns in vivo (e. generating questions) Less socially advanced children will be less able to converse with adults and peers and unable to engage in more nuanced interpersonal strategies. . Help children label and describe emotional experiences in vivo. Help children recognize indicators of emotional intensity (e. and awareness of emotional intensity.Practical recommendations for treatment planning based on cognitive. focus on expanding their understanding of emotional experiences through feeling identification exercises that help them define emotions. Emotional development Cognitive-Behavior Therapy for Children and Adolescents Developmental skills 72 APPENDIX 2–B. talk about emotions. recognizing multiple. facial expression cards or facial zone puzzle). identification. experiencing multiple simultaneous emotions Children who do not have the ability to reflect on their own emotional experience in a more complex manner will be unable to engage in mood monitoring outside the therapy session.g. To increase awareness of simultaneous emotions. social. simultaneous feelings Perception. emotion thermometer). Describing emotional experiences Emotion vocabulary For children with a limited emotion vocabulary. Games using pictures of people displaying different facial expressions can help children associate emotion labels with outer affective expressions (e. physiological sensations) using visual representations (e. and understanding of emotions Children who are not yet able to describe varying levels of emotional intensity will have difficulty noticing changes in their emotions following changes in their thinking or behaviors.g. Teach parents to help children describe emotional experiences as they are happening outside of the therapy session.. and recognize their experience of emotions in different situations. Learning that changes in thoughts or behavior can impact emotions Perception. teach children to “scan” for multiple feelings when in an emotional situation.. identification.. and emotional development (continued) Therapeutic demands Clinical recommendations Monitoring feelings.g. 73 Developing and maintaining social relationships Appendix 2–B: Recommendations for Treatment Planning APPENDIX 2–B. Parents can model conflict resolution methods and can coach children to use effective emotion-regulation techniques both in preparation for and during conflicts.Practical recommendations for treatment planning based on cognitive. emotional expressions. emotion management Activities designed to improve understanding of others’ emotional experiences will help children engage in conflict resolution. In session. Use interpersonal vignettes (through narratives or use of puppets) to illustrate emotional experiences in others. and emotional development (continued) Therapeutic demands Developmental skills Clinical recommendations Emotional development (continued) Awareness of emotions in others. and emotional experiences in others. emotion management Assist less emotionally developed children to generalize their own emotional knowledge in order to better understand others. Use exercises describing the therapist’s or parents’ emotional experiences. increasing emotion-regulation skills should be the focus of intervention before expecting children to engage effectively in social problem-solving. conflict resolution Awareness of emotions in self and other. social. Social problem-solving. encourage parents to talk about their emotions at home and to draw connections for the child among situations. practice and role-plays using relaxation techniques to regulate emotional experience can help prepare children for real-life conflict situations. . If a child’s emotional management skills are severely underdeveloped. This page intentionally left blank . Surgeon General 2001). nationality. Culture is defined by shared attributes of a particular group. and income level are just some of the factors that may affect the therapeutic relationship. age. norms. we discuss the importance of addressing cultural issues. religion. clinicians must learn to work effectively with people from a variety of backgrounds. sexual orientation. Ph. Ph. including a common heritage. set of beliefs. Iwamasa.S. In this chapter. Race. examine the pros and cons of using cognitive-behavior therapy (CBT) with individuals from a variety of different groups.D. and values (U. and identify overarching themes relevant to providing treatment to youth of varying backgrounds.3 Culturally Diverse Children and Adolescents Rebecca Ford-Paz. diagnosis. 75 . ability. A number of cultural influences may play an important role in shaping an individual’s identity. and treatment. immigration status. ethnicity. gender.D. IN an increasingly multicultural society. Gayle Y. including membership in more than one cultural minority group. a good CBT clinician will develop a case formulation and treatment plan specific to each client. for minors. The Surgeon General’s report on mental health disparities for racial and ethnic minorities (U. However. racial and ethnic minorities currently constitute one-third of the U. Because a sizable body of literature on cultural competence already exists (see Sue and Sue 2003. individual diversity issues should be a central component of the treatment process. Sue et al. this chapter will focus on common themes to consider when working with diverse populations across disorders.S. Surgeon General 2001) brought a number of . In contrast to this population shift. Thus. rather than attempting to discuss specific interventions with every potential cultural group. Suggested readings are provided at the end of this chapter as resources for conducting CBT with particular populations. Census Bureau 2008). Health Disparities and Evidence-Based Treatment Why is it important to consider cultural issues in the delivery of CBT? According to the U. in 2006. clinicians from any cultural group would benefit from training in cultural diversity.S. 2009 for excellent reviews).S. inadequate training in multicultural issues is a well-documented shortcoming of mental health training programs (Iwamasa 1996) and may impede the CBT clinician in achieving both clinical and cultural competence. As a result.S. thus. the American Psychological Association reported that 85% of psychologists were of European American descent. Furthermore. 2010). population and are expected to become the majority in 2042. Thus. this chapter will not focus on the particulars of achieving cultural competence. In general. Census Bureau (2008). Because other chapters of this book outline disorder-specific strategies for cultural and ethnic minority groups.76 Cognitive-Behavior Therapy for Children and Adolescents We also operationalize clinical recommendations for implementing culturally responsive CBT with children and adolescents. the assumption that clinicians of color or from other minority groups are free from cultural biases and have some inherent diversity expertise is without merit because minority clinicians receive the same training as therapists from majority cultural groups (Iwamasa 1996). Regrettably. it is inevitable that these clinicians will need to work with culturally different clients (Pantalone et al. children by 2023 (U.S. the movement toward increasing cultural competence in the delivery of evidence-based treatment (EBT) is a timely one. this demographic shift will come much sooner: racial and ethnic minorities will account for more than half of U. 452). high-quality. lesbian. Surgeon General 2001). poverty. yet they continue to be underrepresented in randomized controlled trials of EBTs.S.S. are less likely to receive mental health services when needed. violence. religious minority. ethnic minorities often terminate prematurely. A disproportionate number of children of color are referred for mental health services (Kazdin et al. child-rearing practices. 2009. Even when treated. differently abled. Surgeon General 2001).S.Culturally Diverse Children and Adolescents 77 issues to light. resulting in a relative absence of treatments that may be deemed well established for ethnic minority youth (Huey and Polo 2008). 2003). 2010. values. Similarly. Proponents of such adaptations highlight the differences among cultural groups and suggest that interventions should be tailored to the characteristics of specific groups and consider language. Controversy About Adaptation of Evidence-Based Treatment Given documented mental health disparities. customs. and distinctive stressors associated with certain cultural groups (Lau 2006. Surgeon General 2001). bisexual. More research is clearly needed to support the efficacy of CBT with ethnocultural minority youth. and are underrepresented in mental health research (U. Ethnic minorities experience disproportionately more psychosocial stressors than do non-Latino white Americans (Bernal and Scharrón-delRío 2001. and transgender (GLBT). improve more slowly. Manoleas 1996). To date. are likely to receive poorer quality of mental health care when they do receive services. no EBT (including CBT) has been tested in at least two independent. p.. betweengroup trials (with random assignment and adequate sample size) that demonstrate that the treatment is superior to placebo or alternative treatment or is equivalent to an already established treatment with ethnic minority youth. and low-income populations in the research has led some investigators to pose the following question about empirically supported treatment: “Empirically supported treatments . U. and have poorer outcomes (Cooper et al. Vera et al. These groups have less access to mental health services. and limited access to education. 1995. underrepresentation of gay. ethnic minority. 2003).. there has been a call for the adaptation or modification of EBTs to be more culturally sensitive (Bernal et al. These include social and environmental inequalities such as exposure to discrimination. expectations of child and parent behavior.for whom?” (Pantalone et al. Some investigators suggest that the failure to make cultural adaptations may lead to miscommunica- . U. perceived acceptability of the treatment. Some investigators suggest that EBT be maintained in its original form with all groups and that the intervention be culturally tailored to the individual client only when barriers or opportunities arise (Huey and Polo 2008). and treatment failure (Huey and Polo 2008). Schulte 1996). religion. Also of concern is the possibility that the active core treatment elements would somehow be diluted or delivered later in the protocol if modifications were made to the original manualized therapy (Kumpfer et al. and experts underline the methodological problems of these few studies. low therapeutic engagement. gender. The limited existing literature on culturally adapted treatment protocols with ethnic minority youth does not indicate superiority of treatment outcomes beyond improvement in treatment engagement. and retention of ethnic minorities in treatment (Kumpfer et al. again reinforcing stereotypes and making clinicians believe they do not need to provide services to groups they have not “studied” (Lau 2006. 2003). Adaptation should focus on the individual . the dearth of randomized controlled trials of EBTs with cultural minorities.78 Cognitive-Behavior Therapy for Children and Adolescents tion. Huey and Polo 2008). Lau (2006) suggested a model of selective adaptation of EBTs guided by empirical evidence. recruitment in clinical trials. value conflicts. sexual orientation. and the need for more research (Bernal et al. and that cultural adaptations to EBTs are premature or unwarranted and compromise the fidelity of the interventions and their effectiveness (Lau 2006). For example. 2002). Suggested adaptations range from the creation of entirely new treatments for different ethnocultural groups to modifying treatment components of existing EBTs to address cultural factors (Whaley and Davis 2007). that the first priority should be the dissemination and examination of treatment outcomes with cultural minority populations. 2003). These experts also argue that rigorous testing of EBTs with ethnic minority youth is limited. the lack of specific descriptions of cultural adaptations and wide variations in operational definitions of cultural adaptation make it difficult for researchers to replicate particular studies and make comparisons across trials. and so forth) (Vera et al. opponents to cultural adaptation of EBT stress the impossibility of adapting treatments for every possible cultural group and equipping providers with adequate information about each group. Vera et al. Finally. Many experts have expressed reservations about undertaking the cultural adaptation of all EBTs. 2002. 2009. Culturally adapted treatments can substantially improve engagement. The inherent assumption that cultural groups are homogeneous entities that remain unchanged over time actually lends more support to stereotypes of cultural groups and neglects the possibility of plural cultural identities (socioeconomic status [SES]. and psychological attributes of a group (Lau 2006. translation into the preferred language of the client. 2009). it is essential to consider the advantages and limitations of using this type of intervention with youth who have been underrepresented in most randomized controlled trials. It is our belief that there are some feasible and empirically informed strategies for infusing culture into assessment. Structural changes may consist of provision of treatment in alternative settings and addressing logistical barriers and basic living needs to improve treatment engagement. and implementation of CBT with diverse youth.g. Caught in the ongoing debate about the need for and the particulars of cultural adaptation. clinicians find themselves in a difficult position when trying to serve diverse youth. case formulation. there is a persistent dis- . Pros and Cons of CBT for Children of Diverse Backgrounds To provide culturally competent CBT. However. Surface-level changes may include culturally relevant examples. we share the discomfort voiced by some that the word adaptation implies that culture can be an add-on item.. engagement. Cultural adaptations may be a critical step toward integrating cultural competence and evidence-based practice (Whaley and Davis 2007). Despite the increasing popularity of multicultural therapy. behavioral. treatment planning. Zayas 2010). but these changes also may require more substantial modifications to the intervention based on a more nuanced understanding of cultural. Enhancing engagement refers to adaptations that enhance the therapeutic alliance and retention of clients in therapy. A number of other cultural adaptation models have been proposed for specific ethnocultural groups (Bernal et al. Contextualizing content requires that clinicians use novel treatment components to target risk factors and mobilize protective factors specific to the client’s cultural group or to respond to symptom presentation patterns that may require specialized intervention elements (e. somatic presentation of psychological distress). The benefit of these discussions is that there is more pressure on training programs to produce culturally competent clinicians and on researchers to diversify participants in CBT trials. usually occurring at the beginning stages of treatment (Falicov 2009).Culturally Diverse Children and Adolescents 79 and the presenting problem that have demonstrated inequitable response to EBT by contextualizing content and enhancing engagement (Lau 2006). and graphic material depicting ethnically similar families to improve perceived acceptability of the treatment. or color-blind. Thus therapists wanting to implement CBT with diverse populations should carefully con- . Organista 2006. and behaviors are interrelated. indeed. Relatedly. the clinician would expect that the basic tenets of CBT would be universal (Hays 1995. The U. CBT’s emphasis on rational thinking may overlook the importance of spirituality. 2006a. This value may directly conflict with collectivist cultures that may view direct communication as disrespectful and that prefer nonverbal and indirect behavioral communication (Nagayama Hall 2001).80 Cognitive-Behavior Therapy for Children and Adolescents interest in cultural and ethnic minority groups in the EBT and CBT literature (Hays 2006. The idea that cognitions affect emotions may. This belief that CBT is universally applicable. Pantalone et al..S. and European American descent (Balsam et al. and community (Nagayama Hall 2001). 2000. However. most ethnic minority groups value interdependence. Eastern cultures may attend more to context and relationships. and social learning and operant conditioning are processes that fit with the human experience across diverse populations (Hansen et al. harmony. logic. Hays 2006. 2003). and rational thinking as therapeutic tools is influenced by American and European cultural values (Hays 2006. Pantalone et al. culture-free. 2010). self-control. be relevant cross-culturally. mainstream cultural value of individualism (i. 2010)—that is. where the person’s “right” to express himself or herself is not a priority (Abudabbeh and Hays 2006. CBT’s focus on the individual client may clash with these values and result in missed opportunities to capitalize on a potential source of strength for many ethnic minority groups (Kelly 2006). Hoffman 2006). rely on more experience-based knowledge instead of logic.e. heterosexual orientation. Whaley and Davis 2007). In theory. thoughts. verbal ability) informs the promotion of assertiveness skills and direct expression of thoughts in CBT (Hays 1995. Vera et al. has come about from practice-oriented research that historically has focused on people of middle class. In addition. family. assertiveness training’s basis in egalitarian democratic principles runs counter to more traditional. Pantalone et al. Hays 2006. 2010. and show more tolerance for contradiction (Hoffman 2006). hierarchical family structures (based on age and gender) in less acculturated ethnic minority families. Pantalone et al. 2006. Consistent with collectivism. however. 2010). Iwamasa et al. Organista 2006). behavior is learned and can be unlearned. feelings. CBT’s emphasis on cognition. personal independence. The use of “I statements” in assertiveness training would be especially challenging for Native Americans whose preferred language does not have a word for “I” (McDonald and Gonzalez 2006). Kelly 2006) and may detract from the credibility of cognitive-behavioral strategies for coping (Falicov 2009). verbal skills. value-neutral. which may be as central and equally important as rational thinking among many cultural groups (Abudabbeh and Hays 2006. Kelly 2006. CBT’s focus on current behavior. whose spiritual beliefs about wellness emphasize harmony or balance among mind. CBT recognizes that people have the ability to control their thoughts and emotions and develop skills to deal with life situations. Fudge 1996. CBT’s educational approach helps demystify psychotherapy and familiarizes clients with the roles of therapist and client (Organista 2006). and neglect useful information about culture-based life experiences (Hays 1995). Furthermore. Huey and Polo 2008. and spirit (McDonald and Gonzalez 2006). and understandable to clients new to psychotherapeutic interventions. CBT’s action-oriented approach and focus on empowering the individual appear to be distinct advantages for cultural groups exposed to various types of oppression and stressors related to minority status (Balsam et al. these treatment aspects make CBT more appealing to those living in poverty. However. promotion of change (not underlying causes). present-oriented nature also may be appealing to cultural and ethnic minority groups for a variety of reasons. behavioral experiments and activation may help ethnocultural minority youth build strengths. 2003). 2006a). a downside to the educational approach often used in CBT is the reliance on written assignments and bibliotherapy. such as Native Americans. problem-focused. such as the experience of racism. A strength of CBT is that it is relatively clear. body. and it is incumbent on the clinician to use good clinical skills in navigating these pros and cons. 2006. On the other hand. 2006a). CBT’s emphasis on changing negative thoughts to affect feelings and behaviors aligns well with ethnocultural groups. 2003). Iwamasa et al. thoughts. who have few resources and who may frequently be in crisis (Organista 2006). Hays 2006. Its focus on specific behaviors. Paradis et al. focusing exclusively on problem behaviors may neglect nonspecific factors important to the therapeutic alliance with diverse populations (Iwamasa et al. which may not be appropriate when working with clients whose native language is not English or immigrant populations with little formal education (Iwamasa et al. expand . Rosselló and Bernal 1996). Hansen et al. a focus on the present and future may prematurely discount the client’s history.Culturally Diverse Children and Adolescents 81 sider adherence to individualistic versus collectivist values for both the child and the parents. CBT’s short-term. Likewise. Vera et al. and goal-oriented and limited time frame are consistent with the expectations that many ethnic and religious minorities have for therapy (Abudabbeh and Hays 2006. 2006a. straightforward. 2000. directive nature. For one. and emotions can be an important advantage for clients whose first language is not English (Vera et al. 2006. Additionally. Thus. the present and future focus of CBT may be both a disadvantage and an advantage when working with diverse youth. such collaborative goal-setting often includes the parents. Hays 2006. One such strength is that the directive. Vera et al. the consideration of clients’ perspectives on their progress demonstrates a respect for clients’ opinions. Organista and Muñoz 1996. For clinicians working with children. as well as for their financial and time constraints. and life circumstances and promotes a context in which cultural differences are recognized (Hays 1995.. discriminatory environmental factors that restrict an individual’s ability to effect change (Hays 2006). which also may reduce . Whereas other theoretical orientations’ intrapsychic focus implicitly locate psychopathology within the individual. and acquire skills to meet goals more effectively (Kelly 2006). structured nature of CBT likely fits with diverse clientele’s expectations of the nature of therapy. As a result. Likewise. therapists of the majority cultural group often overlook diversity issues and are inconsistent in focusing on problem solving in relation to the client’s environment (Hays 1995). abilities. Vera et al. 2. such consideration may be especially beneficial to developing and/or maintaining therapeutic rapport (Vera et al. Such collaboration demonstrates respect for the client’s values. Further. Directive and structured. There are a few potential advantages of using CBT with diverse youth: 1. culturally effective CBT emphasizes assessment throughout the course of treatment by examining social-environmental conditions that might contribute to the problems that minorities face and tailoring the intervention to the individual and his or her unique context (Balsam et al. 2006). expert) recommends a course of action to improve health. A collaborative relationship also implies that both the therapist and the client and parents possess valuable knowledge. but rather as functional or not functional given the context (Balsam et al.e.82 Cognitive-Behavior Therapy for Children and Adolescents social supports. This self-focus neglects unfair. Because many ethnic minorities are accustomed to the traditional doctor-patient relationship in which the doctor (i. Despite the potential of CBT to address contextual factors. 2003). Collaborative nature. CBT proponents have not directly addressed the impact of racism and oppression on ethnic minority clients by creating explicit strategies to deal with these negative sociocultural influences. they may have similar expectations of their therapist (Abudabbeh and Hays 2006. Critics suggest that CBT focuses too much on changing individual-level variables (thoughts and behaviors) in order to effect therapeutic change and adapt to current environmental conditions (Casas 1995. 2006. CBT does not view behavior as good or bad. Kelly 2006). 2003). 2003). Organista 2006). Another strength of CBT is its collaborative nature and determination of mutually defined goals. family and community support. -isms. Empirical support. Fudge 1996. willingness .. which are discussed in further detail throughout this section. Overarching Themes Relevant to Culturally Responsive CBT Table 3–1 lists the considerations of culturally responsive CBT.g. socioeconomic status. and community involvement and solidarity) the hierarchical distance between therapist and client (Abudabbeh and Hays 2006.Culturally Diverse Children and Adolescents TABLE 3–1. CBT has been found to be possibly (and probably. school issues. Kelly 2006). Furthermore. Compared to other types of therapies. 3. cognitive-behavioral approaches have showed the strongest record of success with minority youth (Huey and Polo 2010). including symptom manifestation. 2009). collectivism Oppression. Intersection of Development and Culture Culture influences many aspects of mental illness. for some disorders) efficacious for such youth (Huey and Polo 2008). Balsam et al. environmental factors. 2006. Thus the use of CBT with ethnic minority youth has some preliminary support from the literature and appears to be a promising intervention for a variety of internalizing and externalizing disorders. coping styles. CBT has demonstrated effectiveness for a variety of problems in ethnic minority adults (Sue et al. 83 Considerations in culturally responsive cognitivebehavior therapy Intersection of development and culture Individualism vs. and ethnic identity Acculturation and immigration issues Religion and spirituality Distinctive symptom presentation and somatic symptoms Contextual factors (e. access to services. Although there are no well-established treatments for ethnic minority children and adolescents. Paniagua 1994). and develop his or her talents (Harwood et al. the clinician is working with the family (Hansen et al. may conflict with collectivist cultures’ ideas of normative adolescent development. family. discriminatory practices. Culture is strongly associated with child socialization. inequities in the sociopolitical infrastructure. and reciprocity) and respeto (respect and deference to authority figures and elders) to the socialization of Puerto Rican children by comparing non-Latino white and Puerto Rican mothers’ responses to open-ended questions on positive and negative child qualities. Harwood and colleagues (1996) demonstrated the centrality of familismo (strong identification with. For example. diagnosis. the clinician must engage the adult bringing the child into treatment if the clinician hopes to retain the child in treatment (Crawley et al. and attachment to. in many Latino and Arab cultures. importance of family solidarity. During middle childhood. frustrations. 2000). non-Latino white mothers highlighted self-maximization (that the child be self-confident. In contrast. children are relatively powerless. and clinicians may risk a serious breach in the therapeutic relationship if they . treatment. and service delivery (Bernal and Sáez-Santiago 2006). In traditional Arab families. Because Chapter 2 focuses more directly on developmental issues in CBT with children. such as respectfulness and obedience. however. and children are expected to obey parents and not question authority (Abudabbeh and Hays 2006). and (if applicable) limited economic resources for their cultural group (Ho 1992). in this section we highlight how culture may intersect with developmental issues. ethnic minority youth become increasingly aware of their social milieu. The concept of contextualism suggests that an individual must be understood in the context of his or her family. school personnel. culture also plays a role in the creation. These factors influence self-concept formation and may contribute to feelings of inferiority. 2010). when the process of establishing an identity and a sense of autonomy while maintaining a positive relationship with parents are key experiences (Erikson 1968. shaping. the period of dependence and cohabitation with parents is extended. and resentment (Rivers and Morrow 1995).84 Cognitive-Behavior Therapy for Children and Adolescents to seek treatment. loyalty. the structure tends to be patriarchal. The Eurocentric expectation that adolescents separate from family during this stage. When a clinician works with children. be independent. With respect to treatment engagement. and other community leaders to make important decisions on their behalf. 1996). Clearly. The issue of cultural identity is particularly relevant during adolescence. dependent on parents and caretakers. and maintenance of cognitions (Dowd 2003). Compared to adults. and the family needs to be understood in the context of the culture in which it is immersed (Bernal and Sáez-Santiago 2006). Puerto Rican mothers consistently emphasized the importance of proper demeanor. Pantalone et al.. 2001. when conducting therapy with ethnic and religious minority children. identity. and violence (Safren et al. the clinician must evaluate the role of immediate and extended family when planning interventions. 2006). Koss-Chioino and Vargas 1992.S. cooperation.e. self-confidence. Latino families often include compadres or padrinos (i. Youth development may be further complicated by coming to terms with their sexual orientation and sexual identity (Safren et al. they often are exposed to overt acts of abuse. close friends of the family. networkers. valuing independence. self-reliance.. godparents) in the definition of family.g. 1996). and date same-age GLBT peers (Safren et al. dignity. In African American culture. Other important developmental issues in adolescence are the onset of puberty and emergence of sexual behaviors. GLBT youth face several stressors. 2001). 2001). family loyalty. many GLBT youth navigate the issues of sexual orientation and coming out without GLBT role models or family members who could potentially be sources of support (Safren et al. Additionally. acting as mediators. 2010. Rosselló and Bernal 1996). . and putting group interests first (Dalton et al. and caregivers as needed (Kelly 2006). “fictive kin” (e. rejection. or relationship) is a form of oppression common to many societies (Herek 1990). The collectivist worldview considers the well-being of others to supersede that of the individual and emphasizes respect (especially for elders). harassment.Culturally Diverse Children and Adolescents 85 insist on adolescent autonomy (Abudabbeh and Hays 2006. and abuse (Balsam et al. As a result. Collectivist cultures also have expanded definitions of who is family. but ethnic and religious minority groups are more likely to give priority to the community’s or family’s needs over an individual’s needs. Individualism Versus Collectivism U. members of the church community) often play critical roles in the upbringing and racial socialization of children. including confusion and internalized heterosexism as they come to terms with their sexual identity. Harwood et al. In addition to blood relatives. GLBT youth who reveal their sexual orientation (i. Thus. politeness. Certainly all cultural groups value family. Social isolation is a major issue with these youth. as they may lack access to appropriate social venues where they could meet.e. 2006). 2001). judges. 2001. competition.. Paradis et al. criticism. In stark contrast to ethnic minority youth’s identity development. self-control. develop support networks. hard work. material success. and personal happiness (Dalton et al. mainstream culture has been described as individualistic. 2001). obedience. “come out”) are often met with punishment. Heterosexism (an ideological system that denigrates and stigmatizes any nonheterosexual behavior. anti-Semitism. consideration of the effects of social oppression (discrimination against and antagonism toward a particular minority group) on the life of the child is crucial. or anti-Muslim sentiment. 2001. Children with underdeveloped cultural identities and long-term exposure to oppressive social environments often demonstrate signs of internalized oppression. Sáez-Santiago and Bernal 2003). Ethnic minority children have to learn to be bicultural (i. and optimism and is negatively correlated with loneliness. Experiences such as these will certainly affect the relationship with a therapist whose cultural background is the same as the group that the child views as oppressors (Harper and Iwamasa 2000). Likewise. Greene (1992) described the importance of racial socialization in teaching African American children how to deflect and negotiate a hostile environment. As visible minorities. 2006). and regrettably. Orthodox Jews (adhering to traditional garb). Ethnic minority youth are often targets of racism and discrimination at an early age (Harper and Iwamasa 2000). anxiety. and Ethnic Identity When working with diverse youth. Racism and discrimination have been shown to be potent risk factors for psychological and physical health problems (Kelly 2006. Positive ethnic identity is associated with increases in self-esteem. able to negotiate the dominant culture successfully) in an often antagonistic environment. GLBT clients often seek psychological services related to stressors related to the pervasive heterosexism and subsequent social rejection and conflict with mainstream culture and religious beliefs (Balsam et al. and depression (Carter et al.e. One of the best predictors of resilience to the negative influences of racism and discrimination is the formation of a positive ethnic identity (Wong et al. mastery. African American parents often strive to warn their children about racism and disappointments without being overprotective. girls. acting as role . -Isms. and devout Muslim girls (wearing a hijab) may endure sexism. Greene 1992). respectively. Positive racial socialization often involves providing children with strategies to manage specific problems. The type of oppression that has received the most attention in the psychological literature is that of racism and discrimination. coping. Greene discussed how cultural paranoia (sensitivity to potential for exploitation by whites) evolved as an adaptive defense mechanism to decrease psychological vulnerability to racism.86 Cognitive-Behavior Therapy for Children and Adolescents Oppression. children with disabilities. parents who themselves have internalized racist messages and beliefs in limited life options may pass these beliefs on to their children (Greene 1992). often overlooked because clinicians fail to ask about it.. 2003). ableism (prejudice against individuals with disabilities). with some evidence indicating that more acculturated immigrants have worse mental health outcomes than less acculturated immigrants (Vega et al. spirituality. Nonimmigrant ethnic minority groups. 1998). and exposing children to accurate and positive messages about African American people and their history (Greene 1992). tying discipline with building high self-esteem in African American children (Neal-Barnett and Smith 1996). the extent to which an individual adopts aspects of the dominant culture versus his or her indigenous culture. racial socialization is an essential and underutilized parenting and therapeutic tool that promotes mental health in ethnic minority youth. and respect for elders) and uses elder role models for younger parents. is a process pertinent to both immigrant and nonimmigrant ethnic minority populations (Klonoff and Landrine 2000). flexibility. McDonald and Gonzalez 2006). and family functioning for ethnic minority and immigrant youth cannot be overstated.. African American group facilitators. which may contribute to the high attrition rate of ethnic minorities from these types of programs. Acculturation.Culturally Diverse Children and Adolescents 87 models for handling discriminatory experiences. Acculturation and Immigration Issues The impact of immigration and acculturative stress on help seeking. unity. extended family and kinship networks. In short.g. Individuals who assimilate into the dominant culture (disregard their culture of origin’s values and adopt dominant cultural values) may undergo a loss of traditional support systems coupled with feelings of self-deprecation due to exposure . introducing African cultural values to increase cultural understanding and pride. having frank discussions with children about indirect and covert racism. The Afrocentric approach takes into account strengths embedded in African American culture (e. such as Native Americans and African Americans. In an innovative Afrocentric parent training protocol. often struggle to maintain their indigenous cultural lifestyles and values while adopting the behaviors they need to function in the dominant culture (Kelly 2006. Acculturation has been identified as a risk factor for depressive symptoms among ethnic minority groups (Sáez-Santiago and Bernal 2003). Neal-Barnett and Smith (1996) summarized an approach to behavior therapy that incorporates racial socialization to assist African American parents in preparing their children for the experience of discrimination. treatment engagement. This racial socialization component is typically lacking in other parent training programs. and ethnically similar models in clinical vignettes. Suárez-Orozco et al. and medical care without a Social Security number. and this undocumented status has been linked with increased vulnerability for socioemotional problems (Cavazos-Rehg et al. health. Refugees. or disaster. They may have been economically or educationally deprived in their home country and have experienced trauma before or during migration (Pantalone et al. Despite high levels of psychological distress. political. For example. Suárez-Orozco et al. Upon reaching adolescence and gaining understanding of their predicament. loss of social support. As a result. Family members may experience lengthy separations. In other cases. whereas English proficiency is a distinct advantage for immigrants and is associated with lower levels of depression (Sáez-Santiago and Bernal 2003). are forced to leave their country due to war. or educational reasons are usually more prepared to migrate. Sáez-Santiago and Bernal 2003). children are brought into the country without legal documentation by their caregivers and are limited after high school in accessing educational opportunities. Traditional cultural values imposed by . employment. The reason for immigration is important: Immigrants who come voluntarily for economic. 2010). The legal status of both immigrants and refugees upon arrival to the new country will dictate the access they have to services and to educational and employment opportunities. 2010). and feelings of loneliness (Interian and DíazMartínez 2007. and may know the language or be familiar with the host culture (Pantalone et al. 2007). Immigration is often associated with stressful life events that affect child development. may have a support network in the host country. 2002). these youth often experience poor mental health outcomes as a result of their severely restricted prospects (Mahoney 2008).S. women who enter the United States illegally may give birth to children who are U. Another complicating factor in the familial acculturation process is that children tend to acculturate faster than adults. 2002). families often experience an intergenerational gap in cultural values. Often legal status among family members may vary. these families often will not seek help for fear of deportation. in part due to ease of language acquisition for younger children and sometimes because adults have more difficulty adjusting to major life changes (Gil and Vega 1996.88 Cognitive-Behavior Therapy for Children and Adolescents to discrimination. on the other hand. Refugees often have little exposure to the dominant language or culture of the host country. These families are often in a constant state of anxiety about the possibility of deportation. citizens and who receive corresponding services to which their parents are not entitled. Some investigators speculate that bicultural competency (balance between native cultural norms and those of the host culture) may lead to improved mental health outcomes (McDonald and Gonzalez 2006. persecution. Native American spiritual traditions maintain that all things possess a spirit and that wellness is constituted by harmony between the three facets of a person: mind. and spirit (McDonald and Gonzalez 2006). 2002). traditional hierarchies in immigrant families can be disrupted by parents who must rely on children to translate and advocate for their families (Suárez-Orozco et al. Additionally. may strive to separate themselves from mainstream American society to maintain group solidarity and their adherence to cultural and religious practices (Paradis et al. It makes sense then that many ethnic minority individuals seek help from their primary care doctors instead of a mental health professional (Abudabbeh and Hays 2006. the CBT clinician may improve treatment engagement and perhaps also the success of interventions. Kelly 2006. Religion and Spirituality Clinicians should appreciate the central role of religion and spirituality and consider how to integrate such beliefs into conceptualization of the problem and treatment planning when working with culturally diverse individuals and families. and community leadership (Bernal and Scharrón-del-Río 2001. stomachaches. Neal-Barnett and Smith 1996).g. body. pain. Rivers and Morrow 1995) and conflict between parents and their children (Hansen et al. religious minorities. 2002). educational programming. Arab and Latino clients often present with physical complaints. curanderos) and becoming familiar with sacred writings. . The expression of psychological problems somatically is a common phenomenon in many ethnic minority groups. such as Orthodox Jews. 2006).Culturally Diverse Children and Adolescents 89 parents may contradict those of the dominant culture and cause identity confusion for ethnic minority youth (Ho 1992. Distinctive Symptom Presentation and Somatic Symptoms Alternative manifestations of psychological distress have received increasing attention in the cross-cultural literature. Also. By collaborating with clergy and spiritual leaders (e. 2000). Myers et al. and sleep disturbance (Abudabbeh and Hays 2006. A culturally competent CBT clinician should demonstrate sensitivity to these issues and attempt to utilize the strengths they may present in order to support treatment outcomes.. such as headaches. African Americans demonstrate higher levels of religious devotion and spirituality compared to other ethnic groups. and their religious institutions often are involved formally and informally in child care. two-parent households may have the resources necessary to supervise children’s out-of-session practice and therapeutic homework. poor housing conditions. CBT clinicians may need to consider assisting their young clients with connecting somatic symptoms with psychological distress in order to increase the likelihood that the youth will adequately understand the rationale behind CBT interventions. The ability of the family living in such conditions to follow through on therapy assignments (such as behavioral activation) may be significantly restricted due to these contextual factors. Resources such as strong connection to family.g. are less available to their children. diverse populations present with a number of strengths that can enhance treatment outcomes.. For these reasons. Despite these barriers to compliance and treatment.S. Undocumented families may have difficulty regularly attending appointments scheduled during typical office hours because of the unpredictable nature of underthe-table day labor or repercussions of missing a day of work (e. The intersection of undocumented legal status and low SES creates another challenge for immigrant populations. common in many collectivist cultures. as a result. The limited literacy skills of many immigrant and some ethnic minority parents provide another potential barrier to compliance with written therapy homework and behavioral plans. inadequate schools. limited access to quality health care and social services. Poverty and lack of resources often produce hopelessness and helplessness among ethnic minority clients and adversely affect their expectations for positive therapeutic outcomes (Bernal and Sáez-Santiago 2006. Surgeon General 2001). . and voluntary associations may be powerful therapeutic assets in promoting positive change in ethnic minority clients. Koss-Chioino and Vargas 1992). While affluent.90 Cognitive-Behavior Therapy for Children and Adolescents Interian and Díaz-Martínez 2007). has been found to be inversely associated with depression (Sáez-Santiago and Bernal 2003). single parents struggling to provide for their families may not have the energy or time to devote to such endeavors (Greene 1992). no benefits and likely job loss for being absent). Social affiliation. religious involvement. some parents need to work multiple jobs and. because of financial hardship. and a number of other stressors. Additionally. these parents are less likely to provide positive racial socialization to the children who most need it. gang activity. Contextual Factors Ethnic and racial minority groups are often overrepresented in lower socioeconomic strata (U. Low-income communities often are characterized by unsafe neighborhoods. g. and further help the clinician to identify areas in which he or she needs more education and training (Arredondo et al. Pantalone et al. Hays 2006. personal experience with social oppression versus privilege. 2010). To begin. basic cultural competence calls for the therapist to find a balance between educating himself or herself about the sociocultural groups to which clients belong and recognizing that each client’s experiences are unique and not necessarily dictated by group membership (Pantalone et al. Therapists must remember that they have a stimulus value (e. Therapists who have thought critically about how they will be perceived by ethnocultural minority youth will better prepare thoughtful questions and ways to recognize and address potential cultural differences..Culturally Diverse Children and Adolescents 91 Clinical Recommendations Suggestions for Beginning CBT Therapist Self-Assessment The therapeutic process needs to start with the therapist’s own self-evaluation of his or her own cultural values. dress) and that youth size them up the moment they meet regarding the therapist’s ability to help and to recognize differences between them. gender. inadequately assess individual differences. and personal biases (Arredondo and Arciniega 2001. and neglect to . including the relationship of individuals in that group with individuals from other groups institutionally. 1996). such as exposure to oppression. race. knowledge deficits. 1996. At the same time. and educationally (Arredondo et al. 2010). historically. Culturally skilled therapists are aware of their social impact on others in the form of communication differences or interpersonal style (Arredondo and Arciniega 2001). notions of acceptable behavior that may be culturally laden. 2003). therapists must be able to clearly identify their own cultural identity and the significance of belonging to that cultural group. Assessment As discussed above. Therapists must examine differences between themselves and their clients and assess their level of comfort with working with culturally diverse clients who may have different values and beliefs. Such self-evaluation can make the therapist more attuned to social and environmental stressors that shape the client’s experience. Vera et al. clinicians who overestimate the role of these issues. comfort in addressing and discussing issues of diversity and discrimination. and how the family responds to the behavior in everyday situations (Tanaka-Matsumi et al. cultural acceptability of behavior change strategies. sexual orientation. is this a culturally normative idiom of distress?). 2009). Tanaka-Matsumi and colleagues (1996) outlined the Culturally Informed Functional Assessment to assist behavioral therapists who are culturally different from their clients in identifying the functional relationship between the client’s presenting problem and the sociocultural environment. treatment planning. In addition to standard functional assessment with the client. language. clinicians will be informed of cultural factors at each step of the CBT process. and culturally approved behavior change agents) (Okazaki and Tanaka-Matsumi 2006).. 1996).g.e.. Assessment of cultural explanations for the individual’s behaviors will reveal pertinent cognitive schemas that may be targeted by interventions (e. the clinician should interview family members to explore how the presenting problem is viewed from the family’s and sociocultural group’s perspective (i. knowledge of accepted behavioral norms. discrimination or isolation where the individual lives and attends school). religion. including case formulation.. The Multidimensional Ecosystemic Comparative Approach (MECA. The clinician needs to . consider cultural differences.g. SES) and experiences in different contexts (e.g.92 Cognitive-Behavior Therapy for Children and Adolescents consider other relevant factors affecting mental health will likely have poor treatment engagement and outcomes with diverse young populations (Sue et al.g. it is inappropriate for a child to challenge the authority of an elder family member). what the family perceives as the causes of the behavior. Recommendations include the use of an interpreter or cultural informant and acculturation measures to examine the cultural identity.. The underlying assumption is that good behavioral therapists assume that each individual’s reinforcement history is unique (i. what characterizes traditional help-seeking in the cultural group. race and ethnicity. different from the therapist’s and other individuals’ from their cultural group)..e. and recognize the uniqueness of each individual. and acculturative stress. diagnosis. MECA maintains that culture develops over time through membership in a variety of domains (e. Falicov 1998) balances the universalist (assumption that Western psychotherapeutic concepts are universally applicable across cultures) and culture-specific positions to help clinicians appreciate human similarities.. The two major tasks facing CBT therapists are 1) the need to evaluate the presenting problems using functional analysis and 2) the need to assess the larger context of the client’s social network with attention to cultural influences (e. and therapeutic intervention. cultural match or mismatch with the clinician. cultural definitions of problem behavior. By adopting a culturally responsive approach to assessment. Vera et al. English proficiency. 2003). Harper and Iwamasa (2000) found that a majority of therapists talk with clients about ethnicity when the presenting problem is clearly related but otherwise do not often broach the subject. Many dominant-culture therapists fear being considered racist for bringing up the subject of race or ethnicity if the client does not do so. Assessing cultural identity. and degree of internalized oppression is central to cultural case formulation (Bernal and Sáez-Santiago 2006. young clients’ fears of being dismissed or misunderstood may make it difficult for them to bring up such issues (Harper and Iwamasa 2000). exposure to discrimination. acculturative stress. Vera et al. Despite the documented importance of assessing for these diversity issues. shame. or confusion and how these factors influence the parent-child relationship (Greene 1992). For this reason. Harper and Iwamasa 2000. The task of culturally responsive assessment may seem daunting because there are so many domains of diversity to consider and no clinician is bias-free. Ensuring that these areas of inquiry are covered in the assessment process will allow the clinician to entertain hypotheses to explain client behavior with a consciousness of what is culturally normative for this individual and the sociocultural groups to which he or she belongs. By asking “What are aspects of your race or culture that are important for me to know about in working . language preference. 2006. Hays (2008) proposed the ADDRESSING model to guide assessment and consideration of the various domains of diversity in case formulation: A—Age and generation D—Developmental and D—Acquired disabilities R—Religion or spiritual orientation E—Ethnicity S—Social status S—Sexual orientation I—Indigenous heritage N—National origin and G—Gender To avoid overgeneralizing. However. 2003).Culturally Diverse Children and Adolescents 93 assess not only the quality of the child’s self-image but also the life experiences of the parent to understand the role of racial pride. clinicians need to consider the individual’s level of acculturation compared with his or her level of involvement in the culture of origin (Balsam et al. a number of different models and tools have been developed to guide clinicians’ assessment of both risk and protective factors in the individual’s cultural environment. Another consideration is that the child’s identification will vary by context and level of exposure to oppressive and supportive social forces (e. 2010). Conditions such as SES. adequacy of . Avery had to move in with her African American Baptist father at age 10 when her mother died unexpectedly. Her father perceived that Avery had internalized racist messages and that her conflicted relationship with him was rooted in her struggling with her biracial identity. For instance. a clinician must be cognizant of the risks involved in a GLBT youth’s cultural environment before encouraging him or her to come out (Balsam et al. the clinician also should assess the degree to which the client’s selfidentity is tied to each of these diversity domains (Pantalone et al. Harper and Iwamasa 2000). if the clinician does not touch on such issues. a 14-year-old biracial (African American and white) adolescent presented for treatment with the primary concern of conflict with her father. Culturally responsive assessment also involves inquiring about contextual risk and protective factors that will inform treatment.. Avery revealed that in her opinion. educational level. gay ethnic minority youth identify more with being a member of the GLBT community than with being an ethnic minority. Some investigators maintain that failure to address ethnicity and cultural values contributes to dropout and treatment failure (Fudge 1996.g. or they themselves have not previously considered how race and ethnicity contribute to their presenting problem (Harper and Iwamasa 2000). does not value the client’s ethnicity. school vs. safety of the neighborhood. Considering that many individuals belong to more than one minority group. After having been raised by her white mother. or truly cannot understand him or her (Harper and Iwamasa 2000). Pantalone et al. 2006). With further assessment. the youth may perceive that the therapist is uncomfortable discussing the client’s ethnic minority status. her bisexual orientation and conversion from Christianity to Buddhism were the primary issues of contention between herself and her father.94 Cognitive-Behavior Therapy for Children and Adolescents with you?” or “What are your spiritual or religious beliefs?” the therapist communicates a willingness to discuss these issues (Kelly 2006). religious events. For example. Culturally competent therapists should “do their homework” to inform themselves about what questions to ask and potential influences that the diversity issues may have on the presenting problem. Often clients are relieved when the therapist asks this type of question. in many cases. 2010). Alternatively. A thorough understanding of contextual issues is crucial to being able to make clinical recommendations that are safe and have a good chance of being successful. Case Example Avery. home vs. and being accepted) are responsible for clinical improvement. receiving unconditional positive regard or respect. Hays 2006. 2003). 2010). godparents. Clients’ treatment goals may place less emphasis on cognitive and behavioral changes but rather may focus on having more involvement in a supportive faith community or having more balance in their lives (Pantalone et al. 2009). clinicians may find useful outlets to enhance treatment engagement and effectiveness by fully understanding a family’s cultural isolation versus access to a cultural community (e. It is incumbent upon clinicians to understand how previous experiences and/or misconceptions about mental health service providers may influence the client’s perception of them. conversion therapy for GLBT individuals). availability of preferred foods or cultural art. and compliance. access to nature. As mentioned before. and involvement in political or social action groups (Hays 2006). abuse..g. extended kinship. attention to nonspecific factors in therapy is central to effective treatment engagement with ethnic minority youth (Harper and Iwamasa 2000. the diagnosis and treatment planning stages should be consonant with the family’s perception of the problem and will reflect a collaborative effort between clinician.g. participation in a religious community in their preferred language. and exposure to trauma need to be well understood in order to develop effective recommendations for intervention (Crawley et al. thus signaling openness to further discuss the topic and sensitivity to the youth’s cultural context. adequacy of health care and social services. legal problems.g. Framing treatment in a culturally acceptable way is crucial in promoting treatment engagement. interpersonal support (e. and events). Tuskegee experiment. If the assessment process has been truly culturally responsive. being understood. Vera et al.Culturally Diverse Children and Adolescents 95 housing.. these misconceptions can be addressed by acknowledging cultural differences between clinician and client. 2010. Clinicians may need to be prepared to do home visits or to reach out by phone to persuade reluctant family . and disparities in mental health care that has created a deep-seated suspicion of mental health professionals of the dominant culture (e. social networks). Arguably.. client. Engagement of ethnic minority families may be particularly challenging given the stigma associated with mental health treatment and a history of exploitation..g. 2003). music. retention. Treatment Engagement and Orientation to Treatment The debate is ongoing about whether factors specific to theoretical orientation or nonspecific factors in therapy (e. and the client’s family (Vera et al. Additionally. Sue et al. To respond to the Latino cultural value of personalismo (warm interpersonal relations and personalized attention). Additionally. language proficiency. I (RFP) utilize the formal form of “you” (Usted) and formal titles (Señor/Señora. Because of the stigma involved in pursuing mental health care among many ethnic minority and immigrant populations. For example. I avoid an exclusively task-oriented orientation to therapy sessions and allow time for small talk and appropriate self-disclosure. engagement interviews to problem-solve barriers to treatment. family therapy techniques to reduce resistance and increase engagement. Other techniques such as telephone and letter prompts immediately before a scheduled session. the clinician should explain how the cognitive-behavioral . For example. Matching therapist-client characteristics (e. my clients are curious about my background and how I came to speak Spanish. ethnicity and gender). Attention to the therapeutic relationship cannot be overemphasized. Early on. and process of treatment has been shown to improve therapeutic alliance with African Americans (Kelly 2006). Usually. Rosselló and Bernal 1996). allowing time before and during sessions to engage the family in non-problem-related small talk and allocating additional time for standard rapport building may be necessary with culturally different clients (Falicov 2009). Bernal and Sáez-Santiago 2006). course. psychoeducation during the treatment engagement phase is vital. and modes of expression (the use of easily understood lay terminology and culturally appropriate metaphors) may enhance the ecological validity of therapy (Interian and Díaz-Martínez 2007.96 Cognitive-Behavior Therapy for Children and Adolescents members to join family sessions (Abudabbeh and Hays 2006). A willingness to selfdisclose often serves to relax the client. and interventions designed to increase patient participation in care have been shown to improve treatment attendance and retention of ethnic minority youth (Huey and Polo 2010). provision of explanations about the limitations of the therapist role early in therapy will help to avoid misunderstandings among ethnocultural groups who value warm interpersonal relations and expect that the provider will provide constant support and assistance (Barona and Santos de Barona 2003. 2006a). when working with Latino families.g. promote trust. and model how to discuss personal issues (Pantalone et al. This often includes discussion of where the parents of the child were raised. 2010). Nonthreatening psychoeducation about the purpose. Don/Doña) instead of first names of parents to demonstrate the cultural value of respeto and to decrease the hierarchical distance between myself and adult family members. Much of families’ anxiety can be relieved by learning about the etiology of the presenting problem and learning that they are not alone (Iwamasa et al. so I take this opportunity to model self-disclosure by explaining my cultural and family background to increase their comfort level in discussing cultural differences and personal information.. Helping the family problemsolve these issues will demonstrate a respect for the context in which families live and a willingness to discuss basic family needs. such as curanderos. deciding on a plan. Before commencing therapy. The willingness to discuss these issues nondefensively and the inclusion of important people. and should use developmentally appropriate lay language (e. Methods for Implementing CBT Consideration of cultural and contextual factors must extend from assessment throughout treatment when working with diverse youth.” or that “therapy is for rich white people. and godparents. This explanation should avoid jargon. During the culturally responsive assessment. For example. Pretherapy orientation videos for ethnic minority clients are available to enhance treatment engagement by depicting mock therapy sessions and including client testimonials by ethnically similar clients.” that “therapy is for crazy people. A careful explanation of the CBT model and how it will specifically address the client’s problems is important to treatment retention for ethnic minorities less familiar with therapy (Iwamasa et al. This means not only adding cultural elements but also using traditional CBT skills to .g.Culturally Diverse Children and Adolescents 97 clinician-client relationship differs from a traditional doctor-patient relationship to promote a collaborative treatment approach in which the client takes an active role in defining the problem. and enhance compliance with homework for youth from ethnic and religious minority groups (Harper and Iwamasa 2000). or transportation).g. attention to cultural factors in the treatment engagement phase is particularly crucial to building a therapeutic alliance and retaining the client in treatment. the CBT clinician will have identified logistical barriers as well as potential sources of support (e. Barriers may also be attitudinal in nature.. it is not uncommon for ethnic minority parents to state that they do not “believe in therapy.. Because premature termination is one of the major factors leading to poorer treatment outcomes among ethnic minority populations. 2006a). extended family. These videos may be shown in waiting rooms or privately for individuals referred to therapy (Organista and Muñoz 1996). clergy. demonstrate a comfortable stance on cultural differences by the clinician and serve to build trust. improve attitudes toward treatment. expenses. particularly when the clinician is presenting the model to children. “thinking mistakes” or “stinkin’ thinkin’ ” instead of “cognitive distortions”).” It will be necessary for the therapist to address these attitudinal barriers through psychoeducation and perhaps the use of the aforementioned therapy preparation videos. and negotiating homework (Hays 1995). the clinician should take time to address potential barriers to treatment compliance. extended family that can help with child care. . With Latino adolescents. Organista 2006. When there is a clash between personal and family obligations (individualism vs. Creativity as a clinician is a great asset in flexibly implementing CBT with diverse youth. and 3) teaching the adolescent how to cope with negative feelings and cognitions (Sweeney et al. For example. As part of culturally responsive assessment. This requires an awareness that a particular behavior may be considered adaptive in one context and maladaptive in another. 2010). an emphasis on family-focused intervention may be most effective when working with ethnically and religiously diverse youth (Falicov 2009. the therapist should be careful not to impose his or her values. Encouraging families to share migration narratives has been a helpful adaptation to family therapy to reduce misunderstandings and to decrease silent suffering (Falicov 2009). family can be integrated into CBT sessions post–treatment engagement. Additionally. Family-Focused Interventions Because of the emphasis on collectivism in many ethnic cultures. the module of family communication was emphasized to address intergenerational gaps in values. 2006). 2005). the therapist should already understand family structures and backgrounds as well as how clients’ behaviors affect the family and vice versa (Pantalone et al. 2010). The Treatment for Adolescents with Depression Study demonstrated that involvement of extended family supported compliance among African American youth in CBT (Sweeney et al. collectivism). It is the therapist’s role to help the youth anticipate the potential social consequences of certain decisions (Pantalone et al. to improve the likelihood that the child will accept CBT strategies (Harper and Iwamasa 2000). Paradis et al. Therapists also should ensure that the new behaviors learned in therapy are positively reinforced by the social environmental contexts in which youth live (Harper and Iwamasa 2000). 2) teaching the family positive communication and negotiation skills. pathologize. In a trial of CBT for depressed Latino adolescents that demonstrated treatment effectiveness.98 Cognitive-Behavior Therapy for Children and Adolescents address diversity issues. Kumpfer et al. 2002. 2005). the clinician may incorporate culturally appropriate metaphors and work cognitive restructuring into a child’s affinity for writing raps. or criticize. familismo was considered in the assessment and treatment engagement phases by assessing and addressing parent goals in the treatment process (Rosselló and Bernal 1996). Therapists normalized cultural differences to alleviate family stress and facilitated discussion about the values and beliefs of the host culture and culture of origin with the following goals: 1) promoting understanding between parents and adolescents. clinicians may want to simplify the A-B-C-D-E method (based on Albert Ellis’s work). the normalization that Naomi was likely attracted to the boy and he to her.Culturally Diverse Children and Adolescents 99 Case Example Naomi. . Cognitive restructuring can focus on personal strengths that were unaffected by the disability to dispute the belief that “Nothing will ever be the same. as well as learn to evaluate relationships with peers and with potential boyfriends. In many cases. which teaches the client to identify the Activating event. 2006). and Effects of disputation. and the possibility that Naomi might choose to defy her mother if she perceived the mother as being overly restrictive. These sessions included a discussion of the reality of the mother not being able to supervise her daughter 24 hours a day. Cognitive Restructuring As one of the core CBT skills. Family therapy focused on allowing the mother to explain her values and express her concerns about dating while supporting Naomi to resist peer pressure. youth with disabilities often need assistance in decatastrophizing the impact of their disability (Mona et al. For example. cognitive restructuring with diverse youth parallels its use in majority populations. A culturally competent CBT clinician will strive to integrate what is known about the child’s cultural values and environment into the teaching and implementation of this skill. single mother) about her mother’s traditional belief that girls should not date until after college (consistent with the mother’s upbringing). cognitive restructuring can be a powerful tool to use with youth to address diversity issues. Consequences (feelings and behaviors). Naomi was unable to engage her mother in open communication and started dating behind her mother’s back. Due to the Filipino cultural taboo against discussing sexuality and intimate relationships and her mother’s vehemence about her not dating. Disputation of irrational beliefs. Individual therapy helped Naomi weigh the pros and cons of continuing to deceive her mother versus choosing to be a nonconformist and not follow her peers’ examples. the likelihood that Naomi might stop seeking her advice and would be more vulnerable to peer pressure if communication remained strained. Beliefs about the activating event. a 16-year-old Filipina girl raised in the United States. presented with conflict with her mother (a first-generation immigrant. Parent-centered sessions provided psychoeducation about how difficult it is to bridge two cultures and the risks to Naomi if she did not have a parent to talk with about her challenges.” For diverse youth. and this will give me an edge in getting a job!” A common misconception is that CBT is less helpful with diverse youth because of its emphasis on individual-level variables—that is.”). to see more positive situational elements that have been overlooked. however. Even when there is no distorted cognition. A parallel can be drawn to youth exposed to trauma. 2003). Many GLBT youth and their families are troubled by heterosexist thinking. For example. Vera et al.g. Being bilingual is an ability I have that will be valuable to me in other settings. but I’m learning more every day. the “Yes. Organista and Muñoz 1996. on challenging distorted cognitions about negative events in order to help the individual adapt to the environment (Casas 1995. clinicians can use cognitive restructuring to reframe the impact of these undeniably negative events and help the youth generate more productive self-talk (e. When ethnocultural minority youth experience injustice in an antagonistic environment (e.100 Cognitive-Behavior Therapy for Children and Adolescents Organista and Muñoz (1996) described how A-B-C-D-E can be difficult to master and as a result discarded by Latino clients. One day I might be fully bilingual. my English language skills are not so strong now.. cognitive restructuring can be used to assign responsibility and positively affect mood. the therapist is not laying blame on the child for the traumatic event but rather equipping the child with a coping skill that will allow him or her to react to the situation in the healthiest way possible (e. adjusting their mind-set to fit the environment might be seen as maladaptive for their mental health. They suggested that instead of labeling cognitions as irrational or distorted. thus other skills. such as problem solving. “I am not responsible for the teacher being racist. but. “Yes. meaning making). such as “Gays and lesbians are more promiscuous and are not ca- . By focusing on cognitions. a first-generation immigrant adolescent from the Sudan struggling to learn English might say.g.” technique may be presented as a way to challenge clients to consider more realistic alternatives... In the case of youth who have experienced trauma or uncontrollable environmental circumstances (as is often the case for cultural minority populations). might be more appropriate to alleviate distress.. For example. Cognitive restructuring is particularly useful for ethnocultural minorities because it can be used to challenge cognitions stemming from internalized oppression. and to make half-truths into whole truths (Organista and Muñoz 1996). The challenge for the CBT clinician is to help the youth question whether a cognition is rational before engaging in cognitive restructuring. a Latino student thinking “It’s not fair that the teacher gives me detention when I speak Spanish in school” is not experiencing a distorted cognition but rather is accurately labeling an experience of oppression. exposure to oppressive societal factors).g. Culturally responsive CBT clinicians recognize the injustices facing diverse youth and acknowledge that distorted cognitions are not always the source of the problem.. 2006. needs to be done in a respectful way so as not to alienate the young person or his or her family. presented for individual therapy for depression.” GLBT youth may experience some relief through systematic analysis and correction of cognitive errors and adaptation of more constructive self-talk. therefore. and other faiths (Ellis 2000). African American youth are at risk of adopting beliefs such as “Being black means I’ll never be good enough”. He was struggling to reconcile his Catholic identity with his sexual orientation. Kuehlwein 1992). 2001). Jewish. who enjoy more positive mental health (Pargament 1997). 2010).g. however. same-sex relationships can be fulfilling) (Balsam et al. Research has shown that devout individuals who believe in an angry. clinicians are encouraged to focus on the well-being of the youth as a way to guide therapeutic intervention.Culturally Diverse Children and Adolescents 101 pable of having a stable. Case Example José. and “Black men don’t do school.. In the cases that young clients or the parents present with views that conflict with the clinicians’ beliefs. Clinicians are encouraged to inquire what the youth’s and parents’ religious beliefs are in relation to the situation at hand. Psychoeducation about the clinician’s role can highlight the intention to help the youth (and sometimes the family) feel better by adopting adaptive and hopefully religiously congruent thinking. He had internalized negative messages. . determining whether these beliefs are exacerbating or relieving the youth’s distress (Walker et al. 2010). Safren et al.” Clinicians can assist ethnic minority youth in challenging these beliefs and developing more realistic and positive selfstatements to combat the internalization of negative messages (Fudge 1996. In the case of exposure to racial discrimination or harassment. Glassgold 2009. punitive God and perceive a lack of support from their religious community tend to suffer more psychological distress in contrast to those who believe in a loving God. committed relationship with one partner. Such religious disputation of disturbance-creating beliefs can be a potent catalyst for religious clients and is a strategy used by some clergy in the Christian. doing well in school means that I’m not a black man. including messages from a gay-affirmative therapy approach (e. “Being black means acting in a particular way”. This approach may require consultation with a clergy member to provide the family with the necessary reassurance that the treatment is acceptable (Walker et al. the clinician can use scriptures and religious anecdotes to challenge maladaptive cognitions (Neal-Barnett and Smith 1996). homosexuality is not an illness. same-sex attractions are normal variants of sexual orientation. Knowing that religion and spirituality are central to the culture of many ethnocultural youth. Such disputation when carried out by clinicians working with young children. Kelly 2006. a 17-year-old gay Catholic adolescent from Mexico. or working out at the gym without thoroughly assessing such contextual factors may inadvertently put the child in danger of crossing gang lines and exposing himself or herself to violence. do not require payment. such as “When my father and my mother forsake me. alternative theories and interpretations of biblical passages. going to the park. knowledge. He also was able to critically analyze and generate positive self-talk. or are readily available to low-income families (e.” and therefore felt as though he was a bad Catholic. then why is there not one mention of sexual orientation in the Ten Commandments or in all of Jesus’ teachings?” Often cognitive restructuring with diverse youth is most effective in combating the effects of oppression when the therapist is able to access and enhance the client’s strengths (be they developing a positive ethnic identity or a belief in a loving God) and use them in therapy. For Latinos. Follow-through on behavioral activation may be highly dependent on how it is viewed by the family. and other cultural norms. focusing on themselves and improving their own moods may cause problems for more traditional families who value familismo.. A clinician who recommends that a child living in the inner city exercise regularly by walking or running around the neighborhood. assumes access to parks. Behavioral Activation When designing behavioral activation for diverse youth.102 Cognitive-Behavior Therapy for Children and Adolescents such as “Homosexuality is a sin. José utilized religious readings. Additionally. such as “If nonheterosexual orientation is so completely unacceptable. safety of neighborhoods. to help him cope with some of his family’s rejection as he disclosed his sexual orientation. I engaged José in collaborative research into same-sex relationships in the Bible. Cognitive restructuring helped José adapt beliefs based on Scripture that emphasized his compliance with Christian ideals. Therefore. Additionally. free admission days at museums. respectively (all of which demonstrate the clinician’s lack of skill. and presumes that the family has the resources to pay for private gym membership. Recognition that much of his distress emanated from this punitive belief that an integral part of identity was abhorrent to his God and religion guided my (RFP) decision to use scriptures to counteract this internalized oppression. and understanding of the client). and contradictions in Scripture. traditional gender roles dictate that Latinas take on a caretaking role in the family by helping around the house . gender roles. common to Christian GLBT older adolescents. mall walks) (Organista 2006). visiting friends. Clinicians need to help children identify activities that are congruent with their environment. the clinician should attend to contextual factors such as income. then the Lord will take me up” (Psalm 27:10).g. activity schedules that include activities for the youth to do with and without family are more likely to be well received (Organista 2006). I (RFP) found a Chinese American agency near where Ming lived and suggested that she and her mother investigate some of the classes and recreational activities. To address her mother’s concern that Ming was not serious enough about academics. Behavioral activation may also serve as a useful complement to cognitive restructuring to buffer youth from oppressive influences by connecting them to culturally specific networks and religious institutions (Hays 1995). We also discussed that the youth group field trips could help her get to know her new city. Problem solving is especially relevant to ethnocultural minority youth’s contextual . GLBT youth. In these cases. in particular. physical exercise.g. English classes (for those whose first language is not English).Culturally Diverse Children and Adolescents 103 with child care. she is better able to care for her family (Organista 2006). She reported that the only other Asian students were “Gothic” (an offshoot of punk culture). behavioral activation might be more well received if instead of framing it as a way for the client to take care of herself. For African American and Latino youth. which might help Ming improve her writing for standardized testing. I explained that the agency also provided academic assistance such as tutoring and English-language classes. For children who manifest psychological distress primarily in somatic symptoms. enhance positive ethnic identity development. Such culturally attuned behavioral activation interventions may decrease social isolation. Sweeney et al. local cultural organizations. cleaning. clinicians can connect youth with church communities. Case Example Ming is a 13-year-old girl who emigrated from China at age 11 and recently relocated to a new city in the United States. and mentoring as part of their behavioral activation interventions (Interian and DíazMartínez 2007. In order to increase her social activity level. We discussed how classes on Chinese cultural heritage might lead Ming to meet other youth with whom she would feel more connected. the clinician proposes the rationale that when the client takes care of herself. 2001).. and chores. She feels isolated and different at her new school because most of the students are African American. and improve overall mental health. 2005). Problem Solving Problem solving is another useful complement to cognitive restructuring when there is an environmentally based problem (Hays 2006). distraction) in conjunction with relaxation techniques may be an intervention that is easily understood by the family (Interian and Díaz-Martínez 2007). behavioral activation (e. benefit from assistance in identifying appropriate agencies and organizations that will allow them to build social support networks and experience more positive events (Safren et al. a group with which she did not identify. She and her mother viewed this teacher as often discriminating against Kadija (e. using family problem-solving to address discriminatory practices at the child’s school can empower parents to file complaints. rather than emotional. may need additional culturally relevant exposures coupled with relaxation training and problem solving to decrease chronic . CBT with ethnic minority youth may require a higher level of intervention in the larger community than CBT with dominant cultural groups.104 Cognitive-Behavior Therapy for Children and Adolescents experiences that may negatively influence their mood and behavior because of the focus on effecting change on the environment. Her mother attempted to advocate for her daughter by talking to the teacher. and strengthens positive ethnic identity (Kelly 2006). Therapists can help youth (already disempowered because of their age) draw on community and family resources to address unjust treatment. Case Example Kadija is a 13-year-old African American girl who was having significant difficulty getting along with a particular teacher at school. Through the use of problem solving and a review of communication skills in different cultural contexts during therapy. Effecting change on the community level and healing a community of oppressive influences resonates with Afrocentric values of responsibility and self-determination. which only seemed to exacerbate the teacher’s discriminatory behavior. Latino Student Association. seek out a new school. their parents) successfully change their environment may serve to increase their self-efficacy and willingness to implement learned coping skills in subsequent situations. Panic attacks brought on by stressors related to the client’s minority status. request to speak to someone’s supervisor. the family was able to enlist the help of an African American teacher who was willing to facilitate this discussion and identify assertive. Exposure Therapy Traditional exposure therapies for anxiety and panic disorders have included interoceptive exposure to somatic symptoms evoked during a panic attack. Helping ethnocultural minority children (and at times.g.g. but she had a strong emotional reaction to the teacher and would end up raising her voice. however. For example. Gay-Straight Alliance). Problem solving can promote external change in the contingencies in the environment that may maintain child symptoms (Kelly 2006). or consult an attorney. methods of opening discussion of the issue with school staff.. blaming only her for something a group of students did). empowers clients to use more active coping styles. This intervention may entail empowering the child or family to start an ethnocultural youth group at the school or in the community when one does not already exist (e.. an 8-year-old Dominican boy and observant Jehovah’s Witness. Organista and Muñoz (1996) suggested that instead. 2006). For example. Assertiveness Training Traditional assertiveness training stresses the rights of the individual. He was experiencing blasphemous obsessions about swearing at or hating God that were highly embarrassing and distressing to him and his family. such as at home or in religious communities (Hays 1995. Case Example Nicolas. With a solid understanding of OCD and the rationale for exposure and response prevention. he and his mother were willing to proceed with exposures to acting out his obsessions (e. presented with obsessive-compulsive disorder (OCD). At the same time. the clinician may help youth recognize that assertive communication is inappropriate or may need to be used sensitively in other contexts..Culturally Diverse Children and Adolescents 105 stress levels. I (RFP) worked with the family in psychoeducational sessions to help them understand the nature of OCD and how obsessions were often ego-dystonic and not stemming from a budding rebellion or defiance. Assertiveness may be described as an effective communication skill in mainstream America that will serve the youth well in school and in pursuing a professional career. 2006a). For religious clients. We worked collaboratively to externalize OCD and separate it from Nicolas’ identity by making OCD the “bad guy” who bothered Nicolas with the most personally distressing thoughts it could generate. Koss-Chioino and Var- . CBT clinicians need to be mindful of cultural factors that may alter effectiveness.g. which may pose problems for youth from more collectivist cultural backgrounds. the therapist needs to be careful not to engage the client in something that is specifically prohibited by religious law (Paradis et al. clinicians may need to address the role of shame with Asian American clients by weighing the pros and cons of the client experiencing short-term embarrassment while completing exposures versus the long-term consequences of not doing the exposures (Iwamasa et al. coming out to specific individuals can be planned as clinicians would plan any other exposure—using a hierarchy of how difficult it would be to come out to particular individuals (Glassgold 2009). swearing at God). A breach in the therapeutic relationship may occur if the CBT clinician is perceived as trying to impose his or her cultural value system on a child or family by empowering the child to put his or her needs above those of the family or community. When engaging the client in exposure therapy. For GLBT youth. clinicians should frame assertiveness training as a way to help children develop bicultural competency. ethnic minority youth can strengthen assertiveness skills and effectively anticipate and manage problematic situations (Fudge 1996).. respeto. expectations. the therapist may assist more acculturated adolescents in negotiating a looser attachment to the family without completely abandoning traditional cultural values (Koss-Chioino and Vargas 1992). In combination with cognitive restructuring to challenge negative internalized messages. By discussing cultural values. man’s role as protector of the family) (Koss-Chioino and Vargas 1992. and family roles. Organista 2006).. male pride. Interventions to Promote Positive Ethnic and Cultural Identity Development Despite consistent findings that experiences of oppression and discrimination have adverse effects on mental health. Bandura (1982) discussed that central to the development of a sense of positive self-worth and effectiveness is . warmth.” and/or asking permission— for example. Through role-play and examples from role models. When such cultural adaptations are made. Culturally sensitive framing of assertive communication may include prefacing statements. there is a remarkable lack of emphasis in the CBT literature on techniques to develop self-efficacy and positive ethnic and cultural identity. such as “With all due respect...106 Cognitive-Behavior Therapy for Children and Adolescents gas 1992). assertiveness training can help them anticipate situations and generate and rehearse appropriate responses that focus on desired outcomes instead of the oppressive script of “acting black” (Fudge 1996). This approach to assertiveness training avoids devaluation of traditional communication patterns in particular cultural contexts (Organista and Muñoz 1996). assertiveness training can present youth with alternatives to the extremes of either aggression and hostility or passivity and withdrawal. For African American youth.e. “Would you permit me to express how I feel about that?” (Comas-Díaz and Duncan 1985).. emphasis on positive interactions and avoidance of conflict) in Latino cultures (Interian and Díaz-Martínez 2007. kindness. When using assertiveness training in Latino family therapy. assertiveness can be a useful tool for diverse youth. The therapist needs to be mindful of culture-based protocols of communication. Comas-Díaz and Duncan (1985) were the first to write about how Latinas could communicate assertively without seeming confrontational. which demonstrates respeto for his role as head of the family and to appeal to his machismo (i. A good deal of attention in the literature has been given to conducting assertiveness training with Latino populations. Organista 2006).e. and simpatía (i. clinicians can ask the father’s permission to allow the wife and children to state their opinions or express feelings. leading to increased self-confidence and self-esteem. identify when it occurs.g. desirable quality) (Fudge 1996). label academic achievement as a positive. Behavior change can result in empowerment and an increased ability to alter the environment.. By exposing youth to positive role models of their own group through bibliotherapy (e. In the case of some ethnic minorities. Therapists can appeal to these youth’s responsibilities as black men to help others with similar problems by changing the contingencies (e. The Autobiography of Malcolm X). behavior therapy is especially well suited to increasing youth’s sense of control and self-efficacy in disempowered young minority populations (Fudge 1996). Therapists can teach youth behavioral analysis to help them analyze antecedents and contingencies that are capable of being altered (Fudge 1996). and understand the experience. advocating for the child at school).g.Culturally Diverse Children and Adolescents 107 the individual’s acquisition of skills necessary to master the environment. the parent is used as a role model to demonstrate to children how to handle certain situations (e. The final phase assists parents in not reinforcing negative racial stereotypes by showing them how to provide more positive racial images by sharing family folklore and other stories and symbols of racial pride (Greene 1992). gain a sense of belonging and solidarity. Positive ethnic identity would alter expectations regarding personal competency and would give children the courage to engage in more adaptive behaviors even if not reinforced by some members of their peer group. Although racial socialization is not a suitable treatment focus for all forms of psychopathology. For example. The first phase of racial socialization educates children to label racism accurately. In the second phase. and strive collaboratively to modify systems-level problems and repair injustices. internalization of racism contributes to difficulty accurately assessing personal competence and resisting negative behaviors that are reinforced by peers (Fudge 1996). therapists can discuss with African American boys the negative behavior that is often reinforced by peers who have internalized racist messages.. The third phase of racial socialization is to provide emotional support for the expected angry emotional reaction to injustices. Greene (1992) recommends that it be used proactively to promote self-esteem and not solely in response to discrimination. Through involvement in political activity or ethnoculturally based youth groups. therapists can help youth learn vicariously about positive ethnic identity development (Fudge 1996). youth can appreciate the interdependence between their own needs and those of the larger cultural community. Racial socialization has been identified as a therapeutic tool for clinicians to use when interested in promoting positive ethnic identity development in diverse young clients (Greene 1992).. . Because of the emphasis on behavior change.g. and worldviews to build the foundation of self-awareness (Iwamasa et al. beliefs. Training programs for all types of mental health professionals need to improve preparation of clinicians to work with culturally diverse populations in addition to training them in EBTs (Vera et al. and problem solving. so that Esmeralda was exposed to role models. and enhance treatment outcomes (Yutrzenka 1995). 2006b). poor self-esteem. Hence. but also because of the deemphasis of culture in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000) by relegating cultural formulation to an appendix as opposed to inclusion of such issues as an inherent part of multiaxial assessment (Hays 2008). focusing on Latino leadership and higher education. cultural issues need to be raised in supervision to promote the competence of clinicians in training (Iwamasa et al. I recommended seminars at the nearby university that were open to the community. Clinical CBT supervisors need to be willing to examine their own values. famous Latinas in the United States and answer questions about them to help her draw connections between their ethnic backgrounds and hers. attitudes. behavioral activation. culturally responsive assessment in clinical practice is inconsistent in part because of the lack of training. Every week. I (RFP) engaged Esmeralda in a variety of activities meant to bolster positive ethnic identity development. Additionally. 2003). as well as racial socialization. 2006b). service provision. and academic decline.108 Cognitive-Behavior Therapy for Children and Adolescents Case Example Esmeralda is a 12-year-old Guatemalan girl exhibiting oppositional behavior at home. including cognitive restructuring. . such as Latino politicians and college students. I also helped the family find ethnic minority college students at the local university who were willing to donate time to tutor Esmeralda after school to help increase her self-efficacy in her classes. To accomplish this goal. improve client perceptions of therapist sensitivity. I had Esmeralda read a printout from a Web site featuring successful. Likewise. Future Directions The topics covered in this chapter illustrate the need for a coherent approach to integrating cultural competence and CBT. In addition to parent training and school consultation. and research. a number of changes must occur in the fields of mental health training. Diversity and cultural competence training has been demonstrated to increase knowledge about ethnocultural populations among trainees. therapists may foster positive ethnic identity development in their young clients through a combination of CBT techniques. Key Clinical Points Tips for Culturally Responsive Assessment • Conduct a cultural self-assessment and assess differences between yourself and your client. there is a need for mainstream manuals to demonstrate applications of standard modules with diverse populations (Huey and Polo 2010). instead focusing on mediators and moderators of treatment outcomes for one specific ethnic group at a time (Bernal and Scharrón-del-Río 2001. 1996) to avoid your own blind spots and incorrectly estimating the importance of diversity issues. CBT’s ongoing assessment and tailoring of the interventions to the individual make it particularly useful with clients from a wide variety of cultural backgrounds. . Hypothesis-testing research with specific ethnocultural groups may then examine questions of efficacy and effectiveness of traditional CBT as well as culturally tailored protocols (Bernal and SáezSantiago 2006. Discovery-oriented research on how to modify treatments with culturally diverse youth. however. • Assess the primary cultural identity of the client and consider how this might vary depending on context. In the meantime. including both quantitative and qualitative methods. future research should integrate hypothesis-testing and discovery-oriented research and move away from cross-cultural comparisons.Culturally Diverse Children and Adolescents 109 Research must focus on culturally sensitive assessment and treatment response of minority populations to traditional CBT as well as culturally adapted protocols. Huey and Polo 2010). • Focus on risk and protective factors in the cultural and contextual environment. CBT clinicians. should commit to incorporating cultural diversity issues into their treatment plans by educating themselves about the cultural groups to which their clients belong and using the tools and resources available to them. In addition to research that tests cultural adaptations of CBT strategies and manuals. it is possible for CBT clinicians to provide culturally responsive interventions using the resources we have outlined in this chapter. • Use a form of cultural assessment such as ADDRESSING (Hays 2008) or the Culturally Informed Functional Assessment (TanakaMatsumi et al. Specifically. would inform the development of culturally adapted protocols. • Arrive at treatment goals collaboratively and frame treatment goals in culturally congruent language. Bernal and Scharrón-del-Río 2001). • When appropriate. normalize help seeking. • Provide psychoeducation in easy-to-understand language to address common misconceptions. Which of the following is NOT a strength of CBT when implemented with ethnocultural minority youth? A. It is time limited and problem oriented. and make explicit how treatment will help. B. Tips for Culturally Responsive Treatment Engagement • Pay attention to nonspecific factors and work to reduce the hierarchical distance between you and the client to promote a collaborative therapeutic relationship. It involves collaboration in defining treatment goals. problem solving. Self-Assessment Questions 3. • Directly address diversity issues using CBT tools such as cognitive restructuring. C.1. D.110 Cognitive-Behavior Therapy for Children and Adolescents • Understand the complexities of expectations about relationships between the child and his or her family members. It is focused on intrapsychic. • Recognize and address cultural differences between you and the client. unconscious processes. • Communicate hope and willingness to assist the child and parents with addressing the presenting problem. . It is focused on the present and future. • Be careful with competing cultural values when conducting assertiveness training and make sure that your client uses the skill in culturally appropriate ways and only in appropriate contexts. • Address logistical and attitudinal barriers to treatment engagement. • Support the development of positive cultural identity and racial socialization. • Target somatic symptoms when they are the idiom of distress and explain how CBT strategies will impact physical well-being. inclusion of family in treatment may support treatment compliance and improve outcomes for ethnocultural minorities. behavioral activation. and exposure. CBT Interventions With Diverse Children and Adolescents • Develop interventions that are likely to be successful and culturally acceptable in the context in which the child lives. One of his core beliefs is that “only white kids do well in school. Antoine is a 9-year-old African American boy who is struggling in school. Behavioral activation. Time-out. Accessed April 19. D. C. D. Racial socialization. CBT with an Iraqi (Muslim) 12-year-old girl with externalizing problems might be enhanced by A. home vs.g. C. Emphasis on assertiveness training in all contexts. 3.4. B.3. and organizational change for psychologists. school)? A. D. Assertiveness training. 3. Internalized oppression. practice. Parent training protocols with ethnic minority youth may improve treatment retention and outcomes by including an emphasis on A. Acculturation stress.aspx. B. . 2011. Ableism. The clinician must be especially cautious in implementing which CBT skill because of its cultural acceptability in different settings (e.2. 3. Natural consequences. C.apa. training. Suggested Readings and Web Sites Population-Specific Information American Psychological Association: Guidelines on multicultural education.5. Behavioral activation. Problem solving. research. B. C. Feelings as facts. August 2002.org/pi/oema/resources/ policy/multicultural-guidelines. Family-focused sessions. Individual-focused sessions. Physical discipline. B. Available at: http://www.” This belief is an example of A. D. Cognitive restructuring.Culturally Diverse Children and Adolescents 111 3.. J Consult Clin Psychol 62:197–206.org/pi/oema/index. Couns Psychol 26:5–21.112 Cognitive-Behavior Therapy for Children and Adolescents American Psychological Association: Practice guidelines for LGB clients: guidelines for psychological practice with lesbian. 2011. and bisexual clients. American Psychological Association. Asian American Journal of Psychology. 2008 Tanaka-Matsumi J. 1998 Sue S. American Psychological Association.apa. Assessment Hays PA: Addressing Cultural Complexities in Practice: Assessment. Lam KN: The Culturally Informed Functional Assessment (CIFA) Interview: a strategy for cross-cultural behavioral practice. and Therapy.aspx. gay. Diagnosis. 2009 Yutrzenka BA: Making a case for training in ethnic and cultural diversity in increasing treatment efficacy.pdf.aspx Council of National Psychological Associations for the Advancement of Ethnic Minority Interests: Psychological treatment of ethnic minority populations. Available at: http://www. 1996 Multicultural Training and Supervision to Promote Cultural Competence Ancis JR. Seiden DY. 2011. 2nd Edition. 2006 Additional resources such as peer-reviewed journals are also an excellent source of current literature on treatment with culturally diverse populations. Practice. Iwamasa GY: Culturally Responsive Cognitive-Behavioral Therapy: Assessment. Hays PA. Washington. Office of Ethnic Minority Affairs home page: www. November 2003. et al: The case for cultural competency in psychotherapeutic interventions. Annu Rev Psychol 60:525–548. Washington. DC. Available at: http://www. Cogn Behav Pract 3:215–233. American Psychological Association. Couns Psychol 29:548–569.apa. 2001 Kiselica MS: Beyond multicultural training: mentoring stories from two white American doctoral students. and Supervision. Nagayama Hall GC. Accessed April 19. Zane N. Accessed April 19. February 2011. DC. and Journal of Black Psychology. Szymanski DM: Awareness of white privilege among white counseling trainees.apa.org/pi/lgbt/resources/guidelines.org/pi/ oema/resources/brochures/treatment-minority. Examples include Cultural Diversity and Ethnic Minority Psychology. 1995 . 1996 Balsam KF. DC. Washington. J Community Psychol 34:121–132. Safren SA: Affirmative cognitive-behavioral therapy with lesbian. Sbrocco T. 2003 Bernal G. Santos de Barona M: Recommendations for the Psychological Treatment of Latino/Hispanic Populations. 2006 Bernal G. Practice. pp 223–243 Bandura A: Self-efficacy mechanism in human agency. 2009 Carter MM. J Anxiety Disord 15:555–569. 2006 References Abudabbeh N. J Multicult Couns Devel 29:263–273. Edited by Hays PA. 2009 Lau AS: Making the case for selective and directed cultural adaptations of evidence-based treatments: examples from parent training. Lewis EL. 2001 Arredondo PT. and Supervision. Practice. Arciniega GM: Strategies and techniques for counselor training based on the multicultural counseling competencies. Association of Black Psychologists. American Psychological Association. Washington. Text Revision. Brown SP. 1982 Barona A. and Supervision. 2001 Bernal G. pp 141–159 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Am Psychol 37:122–147. 2006. Iwamasa GY. Cultur Divers Ethnic Minor Psychol 7:328–342. et al: Operationalization of the multicultural counseling competencies. American Psychiatric Association. Domenech Rodríguez MM: Cultural adaptation of treatments: a resource for considering culture in evidence-based practice. Martell CR. Sáez-Santiago E: Culturally centered psychosocial interventions. 2000 Arredondo PT. DC. Edited by Hays PA. Prof Psychol Res Pr 40:361–368. 2001 .Culturally Diverse Children and Adolescents 113 Research on Cultural Adaptations Bernal G. Jiménez-Chafey MI. 4th Edition. Washington. and bisexual people. Washington. J Multicult Couns Devel 24:42–78. Toporek R. 2006. Domenech Rodríguez MM: Cultural adaptation of treatments: a resource for considering culture in evidencebased practice. Iwamasa GY. Jiménez-Chafey MI. Hays PA: Cognitive-behavioral therapy with people of Arab heritage. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. DC. American Psychological Association. et al: Parental bonding and anxiety: differences between African American and European American college students. Clin Psychol (New York) 13:295–310. Prof Psychol Res Pr 40:361–368. Scharrón-del-Río MR: Are empirically supported treatments valid for ethnic minorities? Toward an alternative approach for treatment research. DC. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. gay. Prof Psychol Res Pr 26:309–315. 1985 Cooper LA. 2000 Erikson EH: Identity: Youth and Crisis. Psychol Women Q 9:463–475. et al: Cognitive behavioral therapy with youth. Gonzales JJ. 1992. 2009 Greene BA: Racial socialization as a tool in psychotherapy with African American children. Oxford. cognitive-behavioral therapy. Guilford. Hispanic. J Soc Pers Relat 13:437–458. 1996 Gil AG. San Francisco. Cogn Behav Pract 7:54–60. New York. 2000 Harper GW. 1995. Child Dev 67:2446–2461. Vega WA: Two different worlds: acculturation stress and adaptation among Cuban and Nicaraguan families in Miami. in Handbook of Cognitive-Behavioral Therapies. Beidas RS. Spitznagel EL: Legal status. 2009 Fudge RC: The use of behavior therapy in the development of ethnic consciousness: a treatment model. et al: The acceptability of treatment for depression among African-American. 2000 Harwood RL. emotional well-being and subjective health status of Latino immigrants. 1996 Glassgold JM: The case of Felix: an example of gay-affirmative. Edited by Dobson KS. Wandersman: A Community Psychology: Linking Individuals and Communities. 2003 Ellis A: Can rational emotive behavior therapy (REBT) be effectively used with people who have devout beliefs in God and religion? Prof Psychol Res Pr 31:29–33. et al: Culture and class influences on Anglo and Puerto Rican mothers’ beliefs regarding long-term socialization goals and child behavior. DC. 1998 Falicov CJ: Commentary: on the wisdom and challenges of culturally attuned treatments for Latinos. 1996 Hays PA: Multicultural applications of cognitive-behavior therapy. 1995 Hays PA: Introduction: developing culturally responsive cognitive-behavioral therapies. 1968 Falicov CJ: Latino Families in Therapy: A Guide to Multicultural Practice. Practice. Iwamasa GY: Cognitive-behavioral therapy with ethnic minority adolescents: therapist perspectives. 2001 Dowd ET: Cultural differences in cognitive therapy. 3rd Edition. New York. New York. pp 311–335 Cavazos-Rehg PA. in Comprehensive Textbook of Psychotherapy: Theory and Practice. Duncan JW: The cultural context: a factor in assertiveness training with mainland Puerto Rican women. Gallo JJ. Guilford. Pragmatic Case Studies in Psychotherapy 5:1–21. CA. Zayas LH. 2003 Crawley SA. and Supervision. Cogn Behav Pract 7:37–53. Washington. American Psychological Association. pp 375–410 Dalton JH. Norton. 2010. Med Care 41:479–489. Edited by Bongar BM. Fam Process 48:292–309. Ventura-Cook E. Cogn Behav Pract 3:317–335. Sedlar G: Cognitive-behavior therapy for ethnic minority adolescents: broadening our perspectives. J Natl Med Assoc 99:1126– 1131. Podell JL. CA. Edited by Hays PA. Koss-Chioino JD. Edited by Vargas LA. 2006. 2007 Comas-Díaz L.114 Cognitive-Behavior Therapy for Children and Adolescents Casas JM: Counseling and psychotherapy with racial/ethnic minority groups in theory and practice. UK. Zamboanga BL. and white primary care patients. Belmont. Beutler LE. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. Jossey-Bass. Schoelmerich A. Behav Ther 26:247–249. Iwamasa GY. Oxford University Press. pp 63–81 Hansen DJ. pp 3–19 . Wadsworth. in Working With Culture: Psychotherapeutic Interventions With Ethnic Minority Children and Adolescents. Elias MJ. J Fam Psychol 9:402–417. 1992. 2006. CA. Iwamasa GY. 1992. Kazdin AE. American Psychological Association. Vargas LA: Through the cultural looking glass: a model for understanding culturally responsive psychotherapies. Stolar MJ. in Comprehensive Casebook of Cognitive Therapy. Alvarado R. Polo AJ: Evidence-based psychosocial treatments for ethnic minority youth. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. and Supervision. Practice. 2008 Herek GM: The context of anti-gay violence: notes on cultural and psychological heterosexism. 2008 Huey SJ Jr. Iwamasa GY. Edited by Weisz JR. 1990 Ho MK: Minority Children and Adolescents in Therapy. and Supervision. Practice. Hinton D: Cognitive-behavioral therapy with Asian Americans. J Clin Child Adolesc Psychol 37:262–301. pp 97–116 Klonoff EA. Plenum. 2006b. Edited by Hays PA. 2010. 1995 Kelly S: Cognitive-behavioral therapy with African Americans.Culturally Diverse Children and Adolescents 115 Hays PA: Addressing Cultural Complexities in Practice: Assessment. Washington. Washington. New York. 1996 Iwamasa GY. 2006 . CA. Washington. Dattilio FM. American Psychological Association. Edited by Freeman A. Prev Sci 3:241–246. 2000 Koss-Chioino JD. pp 267–281 Kazdin AE. J Interpers Violence 5:316–333. 2006 Huey SJ Jr. Koss-Chioino JD. pp 451–465 Interian A. J Black Psychol 26:235–261. DC. Sorocco KH: Multicultural cognitive-behavioral therapy supervision. 2006a. pp 117–140 Iwamasa GY. Cogn Behav Pract 14:84–97. Díaz-Martínez AM: Considerations for culturally competent cognitivebehavioral therapy for depression with Hispanic patients. Cogn Behav Pract 3:235–254. pp 1–22 Kuehlwein KT: Working with gay men. Guilford. Clin Psychol (New York) 13:295–310. DC. and Supervision. Pai SM. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. and Therapy. 1992 Hoffman SG: The importance of culture in cognitive and behavioral practice. Practice. Edited by Hays PA. New York. Newbury Park. Iwamasa GY. San Francisco. 2nd Edition. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. 2002 Lau AS: Making the case for selective and directed cultural adaptations of evidence-based treatments: examples from parent training. 2007 Iwamasa GY: On being an ethnic minority cognitive behavioral therapist. Landrine H: Revising and improving the African American Acculturation Scale. in Evidence-Based Psychotherapies for Children and Adolescents. Marciano PL: Risk factors for dropping out of treatment among White and Black families. Cogn Behav Pract 13:243–245. Hsia C. DC. Edited by Hays PA. et al: Cultural sensitivity and adaptation in family based prevention interventions. American Psychological Association. DC. Jossey-Bass. Washington. Smith P. pp 249–255 Kumpfer KL. American Psychological Association. Edited by Vargas LA. in Working With Culture: Psychotherapeutic Interventions With Ethnic Minority Children and Adolescents. 2nd Edition. Sage. Polo A: Assessing the effects of evidence-based psychotherapies with ethnic minority youths. Diagnosis. 2006. 1996 Okazaki S. 2010. Edited by Hays PA. pp 445–464 Paradis CM. DC. 2006. in Handbook of Cognitive-Behavioral Therapies. American Psychological Association. pp 152–187 . May 2008. Practice. Iwamasa GY. Cultur Divers Ethnic Minor Psychol 8:138– 156. Edited by Aponte JF. Edited by Hays PA. Washington. pp 23–45 Mona LR. American Psychological Association. Iwamasa GY. 2006. DC. 1994 Pantalone DW. Iwamasa GY. Guilford. Edited by Hays PA. New York. pp. Guilford. Edited by Hibbs ED. 1996 McDonald JD. 2011. and Supervision. and Supervision. Practice. Practice. Rodriguez N. Cogn Behav Pract 3:351–369. Sage. and Supervision. and Supervision. Edited by Dobson KS. pp 73–96 Organista KC. American Psychological Association. DC. Manoleas P: The Cross-Cultural Practice of Clinical Case Management in Mental Health. in Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice. Washington. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. 2006. Martell CR: Cognitive-behavioral therapy with diverse populations. 2002 Nagayama Hall GC: Psychotherapy research with ethnic minorities: empirical. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. Iwamasa GY.116 Cognitive-Behavior Therapy for Children and Adolescents Mahoney D: Undocumented adolescents: building hope. Edited by Hays PA. J Consult Clin Psychol 69:502–510. 199–222 Myers HF. Needham Heights. Smith JM Sr: African American children and behavior therapy: considering the Afrocentric approach. New York. and Supervision. Washington. Cukor D. 2001 Neal-Barnett AM. Morrow CA: Understanding and treating ethnic minority youth. Washington. 1996 Paniagua FA: Assessing and Treating Culturally Diverse Clients: A Practical Guide. ethical. pp 97–116 Organista KC: Cognitive-behavioral therapy with Latinos and Latinas. Available at: http://findarticles. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. in Psychological Interventions and Cultural Diversity. Clinical Psychiatry News. Washington. CA. 1997 Rivers RY. Haworth. Cogn Behav Pract 3:255–270. and conceptual issues. Lesser I. American Psychological Association. MA. New York. 2006. American Psychological Association. Iwamasa GY. Allyn & Bacon. Accessed April 19. DC. et al: Ethnic differences in clinical presentation of depression in adult women. in Culturally Responsive Cognitive-Behavioral Therapy: Assessment. 1996. Tanaka-Matsumi J: Cultural considerations in cognitive-behavioral assessment. Romesser-Scehnet JM. Muñoz RF: Cognitive behavioral therapy with Latinos. Edited by Hays PA. Iwamasa GY. American Psychological Association. Gonzalez J: Cognitive-behavioral therapy with American Indians. Practice. pp 164–180 Rosselló J. Jensen PS. 3rd Edition. DC. Cameron RP: Cognitive-behavioral therapy and people with disabilities. DC. Thousand Oaks. Friedman S: Cognitive-behavioral therapy with Orthodox Jews. pp 161–175 Pargament KT: The Psychology of Religion and Coping.com/p/articles/mi_hb4345/ is_5_36/ai_n29439768/. Washington. 1995. Wohl J. Practice. Bernal G: Cognitive-behavioral and interpersonal treatments for depressed Puerto Rican adolescents. Prof Psychol Res Pr 41:174–180.census. Eccles JS. A contrarian view. and Native Americans. pp 521–538 Walker DF. Kolody B. Hollander G. Ruberu M. 2003. Bernal G: Depression in ethnic minorities: Latinos and Latinas. 2010 . Thousand Oaks. Trimble JE. J Behav Ther Exp Psychiatry 27:119–126. Surgeon General: Mental health: culture. 2002 Sue DW. Robins M. Sameroff A: The influence of ethnic discrimination and ethnic identification on African American adolescents’ school and socioemotional adjustment. et al: The case for cultural competency in psychotherapeutic interventions. Arch Gen Psychiatry 55:771–782. gay. 2001. 2003 Yutrzenka BA: Making a case for training in ethnic and cultural diversity in increasing treatment efficacy. Edited by Bernal G. Thousand Oaks. issues. A supplement to Mental Health: a report of the Surgeon General.gov/library/mentalhealth/cre/execsummary-1. Vila D. Seiden DY. Vega W. Sue D: Counseling the Culturally Different. Nagayama Hall GC.Culturally Diverse Children and Adolescents 117 Sáez-Santiago E. 4th Edition. 1996 U. in Handbook of Racial and Ethnic Minority Psychology. Fam Process 41:625–643.html.S.S. U. in Handbook of Racial and Ethnic Minority Psychology. Reese JB.gov/newsroom/releases/archives/ population/cb08-123. 2005 Tanaka-Matsumi J. CA. Cogn Behav Pract 17:198–202. J Pers 71:1197–1232. Todorova I. and ethnicity. 2003 Sue S. Hughes JP: Addressing religious and spiritual issues in trauma-focused cognitive behavior therapy for children and adolescents.surgeongeneral. 2011. 2010 Whaley AL.html. and strategies for practice with racial/ethnic minorities. 2007 Wong CA. Available at: http://www. Wiley. Accessed April 19. Louie J: “Making up for lost time”: the experience of separation and reunification among immigrant families. Alegría M: Cognitive-behavioral therapy: concepts. Annu Rev Psychol 60:525–548. Vol 4. 1995 Zayas LH: Seeking models and methods for cultural adaptation of interventions: commentary on the special section. et al: Lifetime prevalence of DSM-III-R psychiatric disorders among urban and rural Mexican Americans in California. Aguilar-Gaxiola S. Zane N. CA. Accessed April 19. Trimble JE. Davis KE: Cultural competence and evidence-based practice in mental health services. Leong FTL. and bisexual youth. 2009 Sweeney M. Edited by Bernal G. Sage. Am Psychol 62:563–574. Leong FTL. Cogn Behav Pract 3:215–233. New York. et al: African-American and Latino families in TADS: recruitment and treatment considerations. 2011. Lam KN: The Culturally Informed Functional Assessment (CIFA) Interview: a strategy for cross-cultural behavioral practice. 1996 Suárez-Orozco C. 2003. Available at: http:// www. et al: Cognitive-behavioral therapy with lesbian. Cogn Behav Pract 12:221– 229. 1998 Vera M. pp 401–428 Safren SA. Vol 4. Sage. 2008. J Consult Clin Psychol 62:197–206. Census Bureau: An older and more diverse nation by midcentury. Cogn Behav Pract 8:215–223. race. Hart TA. 2001 Schulte D: Tailor-made and standardized therapy: complementary tasks in behavior therapy. African Americans. August 14. This page intentionally left blank . B. Empirical evidence now exists to support the combination of both pharmacotherapy and CBT in the pediatric mental health sector for optimal outcome. M.A. Rabinovitch.D. Moira A.4 Combined CBT and Psychopharmacology Sarabjit Singh. M. Rynn. SINCE the 1990s. which informs everyday clinical practice. Although the evidence supporting the efficacy of both interventions is rela119 . Annie E. Pharmacotherapy has become an important treatment tool for clinicians treating children and adolescents with psychiatric disorders. Laurie Reider Lewis. Angel Caraballo.D. a well-established psychosocial intervention. Michael Ascher. Psy. M. M.D. the field of mental health has significantly expanded its knowledge base on the treatment of pediatric psychiatric disorders through empirical research.D. Another effective treatment modality for many of these disorders is cognitive-behavior therapy (CBT).D. This is most evident in the area of pediatric psychopharmacology. . and attention-deficit/hyperactivity disorder [ADHD]). clinicians face challenges regarding the use of combined treatment (CBT plus pharmacotherapy). and reduced serotonin functioning may cause insomnia and depression (Hamrin and Scahill 2005). and the medication timing of dose and dosage may need to be adjusted to minimize adverse reactions. However. CBT is often perceived to be more acceptable. they all share the common property of effecting serotonin transporter inhibition. For example. When an SSRI is initiated. restlessness. evidence for these treatments has increased our understanding of the effectiveness of psychopharmacological intervention in child and adolescent psychiatry. such as the indications for use of the combination approach versus monotherapy treatment. In addition. parents of anxious children with no prior treatment history have been found to prefer CBT to medication for the treatment of their child’s anxiety disorder. Although each of the SSRIs has individual pharmacological profiles. given the lack of treatment guidelines. anxiety disorders.120 Cognitive-Behavior Therapy for Children and Adolescents tively comparable for many psychiatric disorders. Finally. We subsequently present evidence for combined treatment with CBT. insomnia. most parents and children prefer psychotherapy as a first-line intervention. serotonin is believed to affect sleep and appetite. 2007). Abnormalities of serotonin function are believed to be critical in the etiology of depression and anxiety. Medication is often used in conjunction with CBT when symptoms are in the moderate to severe range or when treatment with CBT has not provided symptom resolution. Some of the better-known and common adverse effects associated with SSRIs include gastrointestinal upset. and sexual dysfunction. we briefly review the psychopharmacological treatment evidence for the most common pediatric psychiatric disorders (depression. we substantively discuss clinical characteristics that might be useful in guiding the clinician to select the most appropriate treatment approach for a given patient. believable. it generally takes 3–4 weeks to show evidence of an effect. Pharmacotherapy Treatment Depression The evidence-based literature supports the use of a class of antidepressants called the selective serotonin reuptake inhibitors (SSRIs) for children and adolescents. The clinician should carefully monitor the patient for the emergence of side effects during treatment. In this chapter. and effective than medication (Brown et al. Results were mixed in studies of non-SSRI antidepressants in children and adolescents. Currently fluoxetine is the only medication to yield three positive double-blind placebo-controlled trials to support its efficacy (Emslie et al. 2002a). 2003). no studies have been designed to assess the efficacy of bupropion for pediatric depression. When venlafaxine ER was studied in the pediatric population. and headaches. discontinuation syndrome is possible and should be watched for. 2003).Combined CBT and Psychopharmacology 121 The only medications approved by the U. Paroxetine (Paxil) was shown to have antidepressant activity in adolescents on some primary and secondary measures Keller et al. 2006). 2009. nausea.. 2006. it was found to be effective only in depressed adolescents (Emslie et al. A meta-analysis of tricyclic antidepressants (TCAs) for the treatment of pediatric depression found that they are not more efficacious than placebo (Ryan and Varma 1998). and in overdose their cardiovascular effects and high lethality (Varley 2001). sedation). memory changes. Two studies have shown escitalopram to be more efficacious than placebo in adolescents (Emslie et al. the syndrome may occur after the patient stops taking the medication. blurred vision. sertraline. including anticholinergic effects (e.g. therefore. To date. constipation. von Knorring et al. The efficacy of citalopram over placebo is supported by one of two published studies (Wagner et al.S. 2008). thus. . 1997. whereas two other studies did not demonstrate efficacy versus placebo (Berard et al. 2002b. 2006). and paroxetine. there are fewer concerns about discontinuation syndrome. the time it takes for the plasma concentration of a drug to reach half of its original concentration). TCAs are not recommended at this time. Two parallel placebo-controlled trials of sertraline showed statistically significant differences with sertraline compared with placebo when the data were pooled (Wagner et al. These medications include citalopram.e. Food and Drug Administration (FDA) for the acute and maintenance treatment of major depressive disorder in children and adolescents are fluoxetine for ages 8–18 and escitalopram for ages 12–17. 2004b. Escitalopram has the safest profile of all the SSRIs regarding interactions with other medications. This medication has an intermediate half-life. Discontinuation syndrome is a flu-like condition consisting of symptoms such as malaise. They are considered inappropriate for children and adolescents because of their significant side effects. Emslie et al. 2007). such agents are still considered offlabel treatments at this time. Despite positive studies indicating the effectiveness of other SSRIs in the treatment of pediatric depression. Given its long half-life (i.. Trials of nefazodone and mirtazapine resulted in unpublished negative double-blind. confusion. placebo-controlled depression trials (Emslie et al. Wagner et al. 2001. dry mouth. Subsequently. As with major depression. 1992). When CBT and medication are used in combination. SSRIs are the first-line medication for the treatment of anxiety disorders. or sertraline (Walkup et al. In addition. acute interpersonal conflict greatly predicted suicidal events. Vitiello et al. 2008). and venlafaxine ER (March et al. they are more efficacious than either treatment alone (Walkup et al. In the Treatment for Adolescents with Depression Study (TADS. The FDA developed a medication guide recommending that children treated with an SSRI be followed weekly during the first 4 weeks of treatment and biweekly from weeks 4 to 8. Three of the most rigorous randomized controlled trials (RCTs) investigated the efficacy of treating children diagnosed with one or several anxiety disorders (i. For panic disorder.e. 2006). Each of these studies provides strong evidence for the efficacy of SSRIs in treating GAD. fluoxetine (Beidel et al. 2007). the FDA conducted a meta-analysis of 24 placebo-controlled trials of antidepressants in pediatric populations (both published and unpublished). separation anxiety disorder. 2001. 2007) have been found beneficial in the treatment of social anxiety. social phobia. Patients must be monitored and observed closely for long periods after an antidepressant has been started. Paroxetine (Wagner et al. with only transient and mild adverse effects associated with higher doses (Masi et al. in 2004. 2003). 2008). 2007) for the treatment of GAD. and social phobia) with the following SSRIs: fluvoxamine (Research Unit on Pediatric Psychopharmacology Anxiety Study Group 2001). daily use of paroxetine demonstrated significant improvement in subjects. 2%) increased risk for suicidal behavior or ideation (Hammad et al. 2004a). generalized anxiety disorder [GAD].. 2009). the FDA issued a black box warning on all antidepressants. Studies have demonstrated the efficacy of sertraline and venlafaxine ER (Rynn et al. an open case series . Food and Drug Administration 2007). Alprazolam in a very small trial of avoidant adolescents demonstrated benefit but lacked statistical significance over placebo (Simeon et al. and/or separation anxiety disorder.S. Anxiety Disorders CBT and pharmacotherapy are the treatments with the broadest evidence of efficacy for pediatric anxiety disorders. and found that antidepressants pose a twofold (4% vs. stating that these medications may increase the risk of suicidal thinking and behavior in children and adolescents.122 Cognitive-Behavior Therapy for Children and Adolescents Although efficacy of some SSRI medications has been well established. fluoxetine (Birmaher et al. Patients should subsequently follow up with their physicians on a monthly basis beyond that time (U. 2001). symptomatology consistent with psychosis or mania may arise during treatment with stimulants and represents adverse effects. and lisdexamfetamine. 1996). According to Mosholder et al. such as atomoxetine. Some researchers have found that most tics that emerge during treatment are transient. mixed amphetamine salts.and D. 1999) and sertraline (March et al. insomnia. and headache. 1999). and chronic tics are rather rare (Gadow et al. (2009). It is believed that inattention and/or hyperactivity may be the result of insufficient dopamine and norepinephrine activity. which is detailed in the section “Review of Combination Treatment. increase norepinephrine synaptic concentrations (Solanto 1998). 2004). As compared with other anxiety disorders. Attention-Deficit/ Hyperactivity Disorder Hundreds of studies conducted since the 1960s have consistently shown the efficacy of stimulant medication in improving symptoms associated with ADHD in children and adolescents. The recommended initial psychopharmacological treatment of ADHD is a trial with one of the medications currently approved by the FDA (Pliszka 2007). weight loss. In children and adolescents with comorbid Tourette’s syndrome . Both fluvoxamine (Labellarte et al. The two nonstimulant medications that are currently FDA approved for ADHD are atomoxetine and guanfacine XR. OCD symptoms often need to be treated with higher dosing. Evidence reflecting the benefits of stimulant medication was demonstrated by the Multimodal Treatment Study of Children With ADHD (MTA).” in “Attention-Deficit/Hyperactivity Disorder” later in this chapter.Combined CBT and Psychopharmacology 123 documented the benefits of citalopram in school refusers with panic disorder (Lepola et al. respectively. Some of the better-known adverse effects associated with stimulant use are suppression of appetite. Children with a preexisting heart condition should receive a consultation with a cardiologist before initiation of treatment with a stimulant medication (Pliszka 2007). 1998) have FDA approval for the treatment of obsessive-compulsive disorder (OCD) in patients ages 8–17 and 6–17. The FDA-approved stimulant medications for the treatment of ADHD include dextroamphetamine. Stimulant medication primarily increases synaptic concentrations of dopamine whereas nonstimulant medications. D.L-methylphenidate. Fluoxetine has been found to be effective and is currently FDA approved for the treatment of pediatric OCD in patients ages 7–17 (Rossi et al. It is controversial whether or not tics occur more often in children and adolescents treated with stimulant medication. CBT plus fluoxetine. Additionally. This section reviews the evidence. and decreased appetite. 1997). which must be monitored when a patient is taking the norepinephrine reuptake inhibitor atomoxetine. and ADHD. The FDA has issued black box warnings for atomoxetine. fluoxetine alone was superior to CBT alone. . A common approach used by clinicians is the combination of medication and CBT for residual symptoms. the two medications can be combined with good effect. 2004). Review of Combination Treatment Since 2000. 30% of patients experienced an exacerbation of tics while on stimulant medication (Castellanos et al. TADS (March et al. multisite study designed to compare four different interventions: CBT alone. The combination (fluoxetine plus CBT) was superior to placebo plus CBT.124 Cognitive-Behavior Therapy for Children and Adolescents and ADHD. Further investigation is needed to make definitive statements concerning the relationship between tics and stimulant medication. include gastrointestinal distress. and CBT plus placebo. desipramine. issues to consider. The trial showed that combination treatments held an advantage over CBT or pharmacotherapy. because of risks of hepatotoxicity and suicidality. Depression There has been empirical support for the combination of CBT and pharmacotherapy for depressive disorders. however. sedation. fluoxetine alone. and approaches to the childhood psychiatric disorders of depression. to fluoxetine alone. 1998). specifically for adolescents with moderate to severe depression. 2004) was a large. Adverse effects. When patients do not respond to either stimulant medication or atomoxetine. and to CBT alone. There is growing evidence for the efficacy of combination treatment for childhood psychiatric disorders. more research is needed in this area to establish the safety of this combination (Brown 2004). Other agents such as bupropion. and modafinil have shown efficacy and are currently recommended as second-line treatments for ADHD (Banaschewski et al. The literature also supports the use of alpha-adrenergic agonists such as clonidine and guanfacine (both FDA approved) as second-line treatments (Newcorn et al. anxiety disorders. Chapters 1 and 2 present the studies supporting this evidence-based treatment for children and adolescents. Appendix 4–A at the end of this chapter summarizes the evidence for these approaches in children and adolescents. numerous trials have demonstrated the efficacy of CBT for various psychiatric disorders. g. Melvin et al. Of note. however. Goodyer et al. switching to venlafaxine. switching to a different SSRI plus CBT. Melvin et al.Combined CBT and Psychopharmacology 125 Because only about 60% of adolescents with depression show an adequate clinical response to initial treatment trial with an SSRI. They detected a weak CBT effect and small. In summary. especially if monotherapy fails (e. 2008) RCT studied the relative efficacy of four treatment strategies in adolescents who continued to exhibit depression despite an adequate medication trial. only a scarcity of research demonstrated the relative or combined efficacy of these interventions. the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA. further research is needed to help identify patient clinical characteristics that might direct a clinician to consider initiating a combination approach first. and their combination in treatment of adolescents with depression. The authors concluded that while all treatments led to a reduction in symptoms of depression. a switch to another SSRI was just as efficacious as a switch to venlafaxine and resulted in fewer adverse effects. the combination of CBT with a switch to another antidepressant resulted in a higher rate of clinical response than did a medication switch alone. (2006) compared CBT alone. (2007) concluded that for adolescents with major depression. incremental improvements compared with monotherapy. Anxiety Disorders In the treatment of anxiety disorders. or switching to venlafaxine plus CBT. Brent et al. Predictors of better response to pharmacological management include less severe depression. and the absence of nonsuicidal self-injurious behavior. there is no evidence that the combination of CBT plus an SSRI in the presence of routine clinical care contributes to an improved outcome compared with the provision of routine clinical care plus an SSRI alone. studies of combined treatment for major depressive disorder have shown conflicting results but overall support consideration. Over the past several years. The interventions included switching to a different SSRI. However. Additionally. (2005) tested a collaborative care CBT program adjunctive to SSRI treatment in a primary care setting (treatment as usual). the field of mental health has focused on studying . The authors concluded that for adolescents with depression who had not responded to an adequate initial treatment with an SSRI. 2006). sertraline alone. less family conflict. and many patients remain symptomatic. Until recently. the advantages of a combined approach were not evident. predictors and moderators have been difficult to identify from these studies (Compton et al. both CBT and pharmacotherapy are considered efficacious as monotherapies. 2004). often symptom resolution is not complete.. Clarke et al. There has been considerably less work studying the efficacy of combined treatments for posttraumatic stress disorder (PTSD). Future studies will need to assess the long-term efficacy and safety of this combined approach. but the effect size of improvement was smaller than that of CBT alone. GAD. Sertraline was shown to be more effective than placebo. The Pediatric OCD Study (POTS) was designed to look at the combined efficacy of CBT and pharmacotherapy. Attention-Deficit/ Hyperactivity Disorder The largest clinical trial conducted to evaluate the efficacy of different treatment modalities for ADHD is the MTA. (2007) examined the potential benefits of adding an SSRI (sertraline) to trauma-focused CBT for improving PTSD and related psychological symptoms in children who experienced sexual abuse. Subjects were assigned to one of the four treatment arms: CBT only. but the combination of the two therapies showed a superior response rate. The authors concluded that an initial trial of trauma-focused CBT or other evidence-supported psychotherapy should be started for most children with PTSD symptoms before adding medication (Cohen et al. 2007). The Child/Adolescent Anxiety Multimodal Study (CAMS. Overall. 2008) was a multisite RCT of 488 children (ages 7–17 years) with a primary diagnosis of an anxiety disorder (separation anxiety disorder. the authors concluded that children and adolescents with OCD should be treated with CBT alone or CBT plus an SSRI. Thus. pharmacotherapy only (sertraline 25– 200 mg). the combined treatment arm (stimulant and behavioral treatment) and stimulant treatment alone provided greater symptom improvement for core symptoms of ADHD than did the behavioral treat- . Walkup et al.126 Cognitive-Behavior Therapy for Children and Adolescents the effectiveness of combination versus monotherapy treatment of a variety of disorders. Monotherapy with either CBT or pharmacotherapy reduced the severity of anxiety. combination of CBT and sertraline. or placebo only. social phobia). Only minimal benefit was noted in adding sertraline to trauma-focused CBT. there is support for the use of combined CBT and pharmacotherapy for maximum benefit in the short-term treatment of anxiety disorders. All treatments were found to be safe and well tolerated. with a slightly superior response rate seen for combination therapy as opposed to CBT alone (Pediatric OCD Treatment Study (POTS) Team 2004). Cohen et al. Patients treated with CBT either alone or in combination with medication showed more improvement. The study found that at 14-month follow-up. and children in all the “conditions” were receiving assorted treatments and a variety of self-selected combinations. a clinician often still faces a dilemma in making a careful determination as to which intervention approach will provide the best result and the needed relief of symptoms. with particular attention to the factors discussed in the . Clinical Implication and Application In the preceding sections. Evidence for such interventions is seen across various disorders. these longitudinal findings need to be interpreted with caution because no random assignment was in effect. careful consideration should be taken when deciding to initiate pharmacotherapy. Clinical Characteristics In selecting an individualized treatment strategy. However. Lacking specific guidelines to determine the appropriate modes of treatment for particular disorders. and reading achievement—combination treatment was consistently more effective than routine community care.Combined CBT and Psychopharmacology 127 ment arm (MTA Cooperative Group 1999). At 24-month and 8-year follow-ups. Interestingly. internalizing symptoms. the greatest predictors of outcome were initial severity of symptoms and continued medication compliance (Molina et al. especially if psychotherapy alone could result in a significant reduction of symptoms. we recommend a detailed assessment. Such an approach by no means guarantees success. 2009). This variability in approach among clinicians leads to suboptimal treatment response. but it can help clinicians more confidently select an approach that might lead to greater treatment success for the patient. whereas medication alone and behavioral treatment alone were not as effective (MTA Cooperative Group 1999). clinicians commonly use their best clinical judgment on the basis of their sum total of clinical experiences. we have outlined the evidence for use of pharmacotherapy and for combined treatment with pharmacotherapy and CBT. with the most compelling evidence existing for depression and anxiety. Despite emerging evidence in recent years for combined treatments. parent-child relations. a careful assessment should help clinicians identify factors that could guide them in making their clinical decisions. Although no one strategy will fit all cases. beginning with a combined treatment strategy is most effective. teacher-rated social skills. Although evidence to date suggests that for some disorders. when areas of functioning were reviewed—such as oppositional or aggressive symptoms. Individuals who have had a positive experience with psychotherapy in the past are more likely to reengage in psychotherapy. 1. In a clinic population. These factors may have value in informing the treatment selection process. Thus. families and most practitioners typically prefer CBT for the younger age group. however. We have provided three main categories. System factors 3. Brent et al.128 Cognitive-Behavior Therapy for Children and Adolescents remaining sections of this chapter. Prior experience of treatment. may want their treatment driven by the clinician only. Practitioner factors For example. most of the studies investigating combination treatment recruited adolescent populations. it is not uncommon to see children ages 7–12 years or even younger presenting with anxiety or depressive disorders. With attention to these factors. and pharmacotherapy may be more acceptable to them. 2004. the age of the child at presentation becomes an important factor in determining which intervention to choose first. 2008). clinicians can make informed decisions regarding which intervention to choose first and if unsuccessful. Such individuals readily agree to a CBT approach. Brent et al. The mean age for many of the trials is approximately 15 years. It is essential that clinicians build on the positive transference for a successful outcome. a positive experience with medications (for medical or psychiatric reasons) makes the patient more willing to agree to a medication trial. TASA. Other patients. Patient factors 2. TORDIA. with the majority in the age range of 12–18 years (TADS. They may want to be an active participant in the treatment process. Therefore. since 2000. and discussion of the various factors within these categories follows. A patient’s prior experience with an intervention has a significant impact on his or her current choice for treatment. Patient Factors Patient Perspective Patients may envision themselves playing an important role in their treatment. Similarly. These patients may not be strong candidates for CBT. even if medications are considered. when a given intervention should be changed or augmented with another treatment. 2009. March et al. It is also important for the clinician to explore the meaning of medication . Psychological mindedness. Patient preference. whereas medications tend to address the physiological and biological aspects of the illness. such as information regarding treatments obtained from the Internet.” then the patient may view it as a fixable problem. psychoeducation is a key component of treatment. Clinicians should be respectful of the patient’s preference in choosing an intervention. and patients will see the benefit of each intervention. CBT helps patients learn ways to mitigate stress. family members. this is not necessarily an excluding factor. Understanding of illness. Patients who conceptualize their illness on the basis of a medical model are more likely to agree to a medication trial or a combined approach. It is important for clinicians to educate the patient and family about all potential treatment options and assist them in making an informed treatment decision after discussing the pros and cons of each intervention. as patients’ perspectives on their treatment may have a major influence over outcomes. If depression is understood as a disorder that has resulted from a “chemical imbalance” or “dysregulated neurotransmitters. peer opinions. if patients believe that their illness has been caused by their being “weak” (psychologically). Clinicians should help patients understand the diathesis-stress model: the complex interaction of biological and genetic factors (predisposition) with the environment and life stressors (Morley 1983). or that their illness results from stress or being overwhelmed by external factors such as school. Psychoeducation regarding the biological basis of many disorders and the role of medications.Combined CBT and Psychopharmacology 129 and taking medication. This concept promotes the use of a combined approach. this will lead to an improved therapeutic alliance and increased treatment success. Irrespective of the intervention chosen. However. Clinicians need to . These patients may be concrete and inflexible in their thinking. However. Patients with cognitive limitations may not be able to engage with CBT. discussion regarding stigma of being on medications. correctable with medication. On the other hand. then they may feel more comfortable with CBT so that they can learn skills to cope with their problems. As noted above. and alleviating fears pertaining to side effects are essential components of psychopharmacological interventions and should be used to help the patient make an informed decision. at times it could be informed by other factors. health educators at school. solve problems. and most importantly. a patient’s preference is generally guided by his or her prior experience. and develop coping skills. making the process of rendering CBT difficult. social networking Web sites. Furthermore.g. or combined). Although previous studies recommended CBT for mild to moderate pediatric anxiety cases only (James et al. patients who have greater strengths verbally and who are psychologically minded have the potential to be strong candidates for CBT. recent research supports the use of combined treatment (Walkup et al. However. For moderate to severe symptoms. symptom reduction is seen as early as week 3 or 4. then the recommendation is to initiate CBT first.. 2008). for a variety of patients. Similarly. for moderate to severe anxiety disorders. pharmacotherapy. patients might not be able to participate in CBT if they have significant symptoms. monitoring of progress and adherence).130 Cognitive-Behavior Therapy for Children and Adolescents modify their techniques and treat patients according to their intellectual and emotional age rather than their chronological age. This is more likely to be the case for disorders such as ADHD. symptom reduction occurs later in treatment (Keeton and Ginsburg 2008). Severe symptoms could become a hindrance to compliance with psychotherapy appointments and could also lead to a general feeling of hopelessness and a pessimistic outlook (e. In contrast. and it is too hard to do . Clinicians also could emphasize more of the behavioral aspects of the treatment over the cognitive components. more recent evidence from CAMS (Walkup et al. 2007).g. early improvement also leads to overall successful treatment (Westra et al.. medications (alone or combined with CBT) are recommended. for which the evidence of medication as the main intervention is very strong. Continuous monitoring is needed and a switch to a combined approach should be made if symptoms worsen. if the severity is mild. For depressive and anxiety disorders. Clinical wisdom supports the recommendation that the more severe the symptoms. 2004) indicates that adolescents with moderate to severe depression have the best chance of clinically significant improvement at 12 weeks if they start with a combination of medication and CBT. “I am feeling terrible. Data from TADS (March et al. the more strongly medication should be considered. These patients can implement newer skill sets. Symptom Severity It is essential to assess the severity of symptoms before determining which intervention should be initiated first (CBT. CBT principles can assist with pharmacological management (e. Patients with cognitive limitations may more often receive treatment with medications in combination with supportive therapy. 2008) shows that CBT is an effective intervention for patients with moderate to severe symptoms and is a relatively riskfree intervention compared to pharmacotherapy. However. Some clinicians might consider pharmacotherapy as the only intervention. and with CBT. 2005). With medication treatment. decreased energy. it is difficult to teach the skills necessary to cope effectively with those triggers. Symptom type.. Therefore. both in session (e. decreased or increased appetite. Therefore.g. Clinicians recognize that symptoms often vary among patients with the same diagnosis. and contingency management.. For example. such as insomnia. self-regulation. symptom reduction with medication could make implementing CBT difficult: in a patient who no longer has anxiety arousal or symptoms. do also respond to medications such as SSRIs or benzodiazepines. Notwithstanding. Severity of symptoms is an important factor in determining which intervention to choose first. then a trial of CBT is warranted. exposures) and outside session (e. Physiological or neurovegetative symptoms of depression. There could be a predominance of a subset of symptoms. social skills. generally respond well to medications. distorted thinking. especially if the profile reflects a combination of symptoms. pharmacotherapy). and avoidance behaviors. problems solving. the combined approach should be considered as first-line treatment. weight loss or weight gain. If the patient’s symptom pattern is overwhelmingly that of hopelessness. Patients with depression and/or anxiety can present with a vast array of symptoms that can be classified as 1) physiological symptoms or 2) cognitive symptoms or maladaptive behaviors. medications should be strongly considered. a combined approach can have its challenges. guilt. reframing and replacing maladaptive patterns of thinking (cognitive distortions). and poor concentration. such as insomnia. physiological symptoms of anxiety disorders. If any of the aforementioned symptoms are a significant part of the patient’s presentation. and increased heart rate. CBT techniques focus on identifying triggers for automatic thoughts. The patient’s symptoms can guide the clinician in choosing which intervention to start with (CBT vs. Regulation of physiological symptoms leads to quick reduction in distress and impairment and therefore increases compliance with the intensive work of CBT. greater symptom reso- . CBT also helps in providing a framework to understand the role of medication and so helps in improving medication adherence. or a particular symptom (e. relaxation training. and a combined approach of CBT and pharmacotherapy is recommended if symptoms are severe. Similarly.g. in severe cases.g. the clinician should note the key symptoms that constitute the illness. A combined approach is likely to yield better results as evident from faster improvement.. insomnia) could be the cause of most impairment for the individual. sweating. palpitations. anger management. although in many cases a combined approach might be the best. homework assignments).Combined CBT and Psychopharmacology 131 the things I need to feel better”). and increased sustainability of improvement (March et al. synergistic effects are often seen when the same symptom is targeted using a combined approach. especially with respect to her insomnia and feeling less overwhelmed. . the health of her mother. The worries were about her school performance. and the role of medications in addressing target symptoms of anxiety and insomnia. She reported a long-standing history of excessive worries. its course. 2004. Onset of symptoms was described as “sudden. 2008). Feliciana has been attending school regularly and has been symptom-free for the past 4 months. Case Example Feliciana is a 10-year-old Latino girl with no formal psychiatric history who was referred by her pediatrician to the emergency room secondary to impairing symptoms of anxiety over the past 2 months. a combined approach (CBT and fluoxetine) was recommended and agreed on. Feliciana reported significant improvement in symptoms. Although CBT was the preferred intervention by the parent. She also reported feeling sad. and school refusal. Walkup et al. The CBT therapist focused on psychoeducation. and CBT techniques can provide a basis for preventing future psychopathology when the patient learns. cognitive restructuring. She was able to successfully start attending school on a regular basis after week 6 of treatment. and behavior modification. Psychoeducation was provided to the parent by discussing the disorder. identification of triggers. She was medically discharged from the emergency room and given a provisional diagnosis of GAD. and overwhelmed. Feliciana reported some improvement in her anxiety symptoms. vomiting. The mood symptoms were in the context of her getting “tired” of her anxiety. and someone breaking into their house. stress management skills. relaxation breathing. frustrated. By week 3. problem solving. separation anxiety disorder and panic disorder were ruled out. Feliciana was maintained at that dose for the next 5 months. Feliciana reported daily symptoms of nausea. feeling nervous. CBT was tapered to once every 2 weeks and then monthly sessions. For example.132 Cognitive-Behavior Therapy for Children and Adolescents lution. considering the severity of symptoms (progressive worsening of anxiety leading to school refusal) and symptom profile (severe insomnia and other physiological symptoms).” and a recent change in school with subsequent difficulty in adjusting to the new environment was the main stressor. trembling. and having occasional feelings of dizziness. earthquakes. the relationship between her parents. with resolution of most of her symptoms. By week 12. She reported symptoms suggestive of a panic attack (heart beating too fast and breathing rapidly). At presentation. for example. Fluoxetine was started at 10 mg for 2 weeks and then increased to 20 mg. appetite disturbance (not eating anything during school time and nighttime overeating). Because the different approaches are not necessarily isolated entities. insomnia is quickly and effectively treated with both CBT and medication: pharmacotherapy can treat the immediate symptoms. Other symptoms included initial insomnia >3 hours (as a result of worrying about school). However. Comorbidities generally indicate the need for a combined approach for better outcomes. Although medications are considered the first-line intervention for children with ADHD. As shown by the MTA. such as social phobia with ADHD and mood disorders. medication management may be challenging and risky for patients who are actively abusing substances. behavioral therapy can address non–core symptoms of ADHD. a combined approach is recommended if there are significant comorbid disorders.Combined CBT and Psychopharmacology 133 This case highlights the effectiveness of a combined approach. Other common comorbidities with ADHD include learning disorders. For example. The synergistic effects of medication and CBT were seen in this case. Of note. for example. depression. lack of improvement or suboptimal improvement after 6–8 weeks of treatment typically becomes an indication for a combined approach (Keeton and Ginsburg 2008). Participation in psychotherapy was assessed to be difficult because of the severity of symptoms. it is reflective of the severity of illness and lack of response to one intervention. the therapist could increase CBT ses- . Additional measures such as appropriate classroom placement are helpful to address comorbid learning disorders if present. and anxiety disorders. oppositional defiant disorder (ODD) is commonly seen as a comorbid disorder in children with ADHD. For patients with primary depressive and anxiety disorders. A clinician could argue that CBT alone on a trial basis could have been employed first. a combined approach was deemed appropriate. Specialized CBT for this patient population would provide an important treatment component. Comorbidities are extremely common and are viewed by many clinicians as a rule rather than an exception for pediatric psychiatric disorders. Parent training for ADHD and ODD and behavioral modification therapy for ODD are effective interventions to implement in such cases. An alternative to a combined approach would be to intensify the same intervention. pharmacotherapy or CBT might be the only intervention indicated in the absence of comorbidities. but given the symptom severity. combined treatment may be warranted. for significant complex comorbidities. Provided that the lack of improvement is not due to noncompliance with recommendations (therapy or medications). with comorbid substance use. Treatment Response In patients who started with monotherapy (CBT or pharmacotherapy alone). and a concern that the patient may have struggled initially with the CBT work. such as poor social skills and low selfesteem (MTA Cooperative Group 1999). Comorbidity. presentation to the emergency room. medication had been discontinued by her parents. talking excessively. or a combined approach?” Owing to successful remission of core symptoms of ADHD on medications. and immediate improvement in symptoms of ADHD was noted. Jonna initially expressed willingness for a medication trial of an SSRI to target symptoms of anxiety as well. her anxiety symptoms worsened. Regarding her symptoms of inattention. and suicide (paternal uncle with unknown psychiatric diagnosis). About 1 year ago. The possibility of stimulants worsening her anxiety was considered. Family history was relevant for anxiety disorder (mother. over the next several months. This led to negativistic thinking (“I will never get better”). Jonna met criteria for ADHD and was willing to restart medications. Jonna was previously diagnosed with ADHD. debate and soccer teams. until age 13. appearing as if she was driven by a motor. successful remission of symptoms following psychotherapy). Jonna did not meet criteria for a specific anxiety disorder but had worries and anxiety related to school pressure. forgot to hand in homework assignments that were completed. CBT. distractibility. a 14-year-old Jewish adolescent girl in ninth-grade regular education at a coed Jewish private school. which resulted in more impairment and academic decline. Jonna was restarted on medication. and art group. In light of her strong desire to apply to a number of competitive universities. However. bipolar disorder (father). Other symptoms included losing items (like her debit card). Symptoms of inattention and impulsivity were negatively impacting her academics regarding time needed to complete her assignments. ability to focus in school. had difficulty organizing tasks. 30 mg. The need for medications to address ADHD was clear. Additional areas of clinical concern included Jonna’s anxiety related to succeeding at school and being a competitive candidate for college. Benefits far outweighed the side effects (mild loss of appetite). blurting out answers in class before being called on. Jonna had signed up for a plethora of extracurricular activities at school. presented to the outpatient clinic with symptoms of inattention. measuring up to her peers and older sibling. but this seemed unlikely because Jonna was persistently anxious even during times of an extended drug holiday. impulsivity related to speaking out of turn. including the environmental and drama clubs. Case Example Jonna. combined type. and hopelessness. at age 7 and was successfully treated with Adderall XR. often appeared dazed (as reported by teachers and peers). We conducted a detailed as- . and poor concentration. and was easily distracted. low self-esteem. and her peer relationships. sad mood. “Should we treat comorbidities with an SSRI. and often interrupting others in conversation. Jonna and her parents noted that she frequently made careless mistakes in her homework and exams. and meeting her future goals. but the question was.134 Cognitive-Behavior Therapy for Children and Adolescents sions to twice weekly or the psychiatrist could increase the dose of medication or add other agents. and poor organization. Hyperactive and impulsive symptoms that were currently noted included fidgeting. Jonna recognized the need to seek treatment for her anxiety and depressive symptoms to achieve overall better outcome. However. a medication consult was done and an SSRI recommended along with continuation of CBT (combined approach). Her symptoms of anxiety and depression were mild to moderate in severity. and cultural systems in which they are embedded. we initially considered only CBT to be a reasonable choice. social. At week 10. and she expressed eagerness to learn a new skill set to address her symptoms. Jonna reported worsening of symptoms (new stressors had emerged). After 4 months of CBT and medications. Following a careful assessment of a variety of factors. She also felt that although core symptoms of ADHD were in good control. Jonna was available to commit to weekly therapy sessions. Her symptom profile was suggestive of symptoms being primarily “cognitive” as opposed to “physiological.Combined CBT and Psychopharmacology 135 sessment of all factors to decide the next intervention. Jonna’s symptoms completely resolved. She discontinued the SSRI after 6 months of treatment and continued with CBT and Adderall XR for her ADHD. she still needed to learn to be less forgetful and more organized. we decided to continue with CBT as the monotherapy to address symptoms of anxiety and depression.” Jonna’s mother had had a positive experience in psychotherapy to achieve remission of anxiety symptoms. However. Jonna reported symptoms being less intense. Parental Attitudes Treatment choice. “it is an excess of normal anxiety. Lack of improvement was evident at subsequent sessions. owing to lack of significant improvement at week 8. Jonna went on to do exceedingly well in school. a combined approach was chosen. which gets exacerbated by stress”). system factors also mediate treatment choices. and she wanted to augment positive effects of medication treatments. These system factors are especially critical to consider when working with youth. and her understanding of anxiety disorder (in her own words. In most cases. to which the patient responded well. System Factors In addition to patient factors that may influence clinical decision-making regarding the use of a specific treatment approach. parents are the ultimate arbiters of the type of treatment in which their child will engage. Other factors we considered included Jonna’s high IQ. her being articulate and psychologically minded. Six weeks after initiation of CBT treatment. The way parents conceptualize the nature of their child’s psychiatric condition and associ- . All of the above led us to recommend CBT along with continuation of stimulants for ADHD. This case highlights several important steps in determining which intervention to choose. school. because these patients are heavily dependent on and influenced by the family. Seeing early improvement and excellent participation and compliance. 1 week after this decision was made. she was extremely reluctant to even consider employing psychotropic medication when the recommendation was made by her daughter’s clinician after a trial of CBT failed to address some unremitting neurovegetative symptoms of the illness. Generally speaking. and experiences. she reported not liking “the way it made me feel” and stopped taking her medication against medical advice. because if a parent trusts the integrity of the diagnostic process as well as that of the clinician. Unfortunately. At the age of 45. he or she is more likely to trust the verity of a diagnosis and to accept and ultimately follow through with a given treatment recommendation for the child. as well as an understanding of the role of genetic factors involved in psychiatric disorders. Strengthening the alliance between parents and the clinicians treating their children is an especially important goal. and yeah.” . understanding. Parental attitudes about psychiatric treatment for their child can also be shaped by their own psychiatric history and/or experiences with mental health professionals (Moses 2011). One issue that Moses (2011) highlighted is the extent to which parents believe a diagnosis to be credible or accurate. Case Examples Mariela is the 50-year-old mother of a 16-year-old girl with major depression. Rebecca is blessed with the same curse. and the feelings were often too difficult to bear.” Consequently. She immediately advocated for the use of psychotropic medication to address her daughter’s symptoms because she had found them helpful in the treatment of her own anxiety disorder. During the first appointment of her daughter’s psychiatric evaluation. in the following statement to the intake clinician: “Why make Rebecca wait for longer than she should to feel some relief? I did the whole psychotherapy stuff first. Paula is the 40-year-old mother of a 10-year-old girl with impairing symptoms of social anxiety. as illustrated in the following case examples. I learned some things—but at the end of the day. Mariela was prescribed an SSRI for symptoms associated with a debilitating major depressive episode. a strong treatment alliance between clinician and parent is widely acknowledged in the literature as a significant variable in promoting adherence to treatment (American Academy of Child and Adolescent Psychiatry 1998). She explained that her negative experience was exacerbated by the fact that “my doctor didn’t listen to me.136 Cognitive-Behavior Therapy for Children and Adolescents ated treatment needs following the assessment and recommendations of a mental health professional is often linked to their own personal preferences. be it in favor of a single or combined approach. my body was my body and my genes were my genes. Paula detailed her own experience with severe anxiety and outlined a family history significant for anxiety disorders and depression. She expressed this preference. On some occasions. whereas European Americans are more inclined to consider neurobiological explanations for behavioral and emotional problems and are therefore more open to the use of psychotropic medication in the treatment of their children (Carpenter-Song 2009). and they are perhaps more sensitized to a medical conceptualization of their children’s psychiatric condition. the child taking psychotropic medications on a long-term basis for the treatment and prevention of major depressive episodes will influence treatment plan implementation (Ryan 2003).Combined CBT and Psychopharmacology 137 The latter case example (Paula) illustrates the position of Moses (2011) that those parents who have participated in their own mental health treatment in the past may be ultimately more inclined to conceptualize their children’s psychiatric issues in a manner consistent with mental health professionals’ diagnostic and treatment paradigms. African American families tend to be skeptical of more medicalized. Demographic variables were also examined in a study of the use of psychostimulant drugs in children across the United States. culture. A number of demographic variables are likely to influence parental attitudes about mental health treatment and parents’ styles of managing their children’s mental health issues. which found a positive correlation between the use of psychostimulants and a higher level of affluence. 1987). as in the case of maternal depression (Ryan 2003). Ultimately. a parent’s mental illness may negatively impact the parent’s effectiveness in accessing mental health treatment for the child. these findings illustrate the need for clinicians to assess the sociocultural lens through which patients . potentially pathologizing ways of understanding. for example. and ethnicity also contribute greatly to parental attitudes about mental health conceptualization and treatment. which may result in negative attitudes about a medical conceptualization of their child’s mental health problems and the use of psychotropic medication. How parents comprehend the scope and context of their child’s problems and the attitudes they possess about treatment are important variables to consider when deciding on and recommending a treatment approach. Less-educated parents are less likely to use psychiatric terms to explain their child’s problems (Moses 2011). and treating their children’s mental health issues (Carpenter-Song 2009. geographic regions with greater population density. For example. 2005). Demographics. higher rates of noncompliance with both medication and psychotherapy were discovered among families of children from lower socioeconomic backgrounds (Brown et al. Moses 2011). talking about. A parent’s distress about the prospect of. One variable is a parent’s level of educational attainment. and higher rates of health care access (Bokhari et al. Race. In general. for example. Regarding the role of parents and family in a combined treatment context. Treatment compliance. as covered in more detail in Chapter 3. 2008). Logistical Concerns and Availability of Resources The level of parental impairment and logistical concerns (such as a parent’s ability to get a child to treatment and the parent’s ability to afford treatment) also influence treatment compliance and should be evaluated by the treating clinician to help determine the treatment of choice. A combined treatment approach integrating individual and family-based psychosocial interventions with pharmacotherapy was also favored in the treatment of bipolar disorder in youth for similar reasons (Schenkel et al. a young single mother of three. In general. for her. Consequently. a single father. and achievement of treatment goals. and target overall family functioning in the support of better treatment engagement. Project (Kendall et al. retention. is critical—and assessing and acknowledging whatever attitudes about treatment a parent or caregiver may hold can enhance treatment outcomes. compliance. 2002) for the treatment of anxiety disorders in children and adolescents. his own mental illness limited his ability to competently administer psychotropic medication to his 12-year-old son.T. Parental or familial attitudes about the child’s mental health treatment impact the extent to which a family may be willing and/or able to adhere to treatment recommendations. Diamond and Josephson (2005) advocated for a combined approach to treating ADHD that integrates pharmacotherapy and a psychosocial family intervention in order to address parental concerns about medication side effects.138 Cognitive-Behavior Therapy for Children and Adolescents view different mental health treatment approaches. For Mona. thus highlighting the need for family involvement in psychotherapy in order to enhance positive treatment effects. who had moderate symptoms of anxiety and depression. consistent parental involvement in the mental health treatment of the child. nurture parental competency. In the case of Horacio. Michael. such as the Coping Cat (Kendall 1990) and C. the likelihood of being able to get her 10-year-old daughter to psychotherapy on a weekly basis was limited.A. whether in the case of a singular psychotherapy or pharmacotherapy approach or a combined approach. the clinician thought it more appropriate to focus on supporting attendance at weekly individual psychotherapy sessions to address . a once-monthly medication management appointment with a psychopharmacologist was much more feasible. actively incorporate parent sessions into protocols. CBT treatments for youth. school-based mental health programs are important systems-level interventions that can help bridge the gap between mental health providers and children with mental health needs (Nemeroff et al. Proximity to practitioners is one concern. Access to mental health care is another system factor that impacts clinical decision-making. For instance. 2002). the media attention paid to the possible negative side effects of psychotropic medications in youth and the . (2002) pointed out how. for example. Unfortunately.Combined CBT and Psychopharmacology 139 Michael’s socioemotional concerns through CBT. Societal Factors The larger social. Location of treatment is another consideration in clinical decisionmaking. many favor cheaper drug therapy over more expensive counseling alternatives (Bokhari et al. Mukolo et al. Geography also plays a role in clinical decision-making. In some communities. This reality may increase access to psychotropic medication and may ultimately strengthen a clinician’s recommendation for a combined treatment when accompanied by data about the potency of such an approach in treating certain types of psychiatric disorders in youth. Given the larger number of children going to school with unmet mental health needs. access to a mental health practitioner qualified to provide psychotherapy or pharmacotherapy to a child or adolescent may be limited. In recent years. and whenever and wherever possible. Geography. to intervene at the family level to support an improvement in Michael’s and the family’s overall level of functioning. and political zeitgeist by which a child and his or her family is influenced is another system factor that can inform the clinician’s attitudes about treatment and associated treatment choices. Stigma. Bruce et al. then greater access to psychopharmacologists may support a recommendation for pharmacotherapy. In many societies. given how dependent they are on others within their extended family and social system to gain access to care. increasingly higher rates of uninsured patients have resulted in a higher unmet need for care (Bruce et al. Health insurance companies have become a major influence in this regard. the lower the rates of access to care and treatment for affective disorders in youth. intellectual. 2008). 2005). negative assumptions exist about mental health issues and treatment. (2010) noted that children with mental health concerns are particularly vulnerable to stigmatizing contexts. in rural communities. Health insurance. the greater the distance to health care providers. if a youth is being seen in a hospital-based clinic. the high frequency of advertisements and information about psychotropic medications evident in a wide variety of outlets such as television. in spite of the negative press (mentioned in the above paragraph) (Sparks and Duncan 2004).” Practitioner Factors Both patient and system factors that inform decision-making practices for the selection of a single or combined treatment are mediated by a third variable: practitioner factors. which may influence parents to advocate more forcefully for a psychopharmacological approach to treating their child’s mental illness. In the United States. These ideas are reflected in the statement of a 42-year-old mother of an 8-year-old son participating in weekly individual CBT sessions for separation anxiety: “Everyone I know has a kid who is either in therapy or is on meds for something or other if they are not in therapy or on meds themselves. In the case of Martina. the Internet. The following factors should be considered: • Qualifications of the practitioner can influence the treatment choice made. Is the practitioner who is considering a single or combined treat- . their pessimistic view of allopathic approaches to health care was prevalent in the close-knit South American community from which the family had recently emigrated. socially acceptable views of mental health treatment. and interacts with demographic and geographical factors that were mentioned above to influence treatment decisions. and print media has led to more widespread knowledge and acceptance of pharmacotherapy as a viable treatment option. Her parents readily agreed to psychotherapy but were resistant to pharmacotherapy because of the “bad things we have heard lately”. the stigma associated with taking psychotropic medication is an example of a barrier to effectively treating affective disorders in children (Bruce et al. The clinician should consider the influence of his or her own specific characteristics when making treatment recommendations and/or assisting youth and families with the treatment decision-making process. this stigma was influenced by cultural factors. A number of societal factors may contribute to more positive. This case highlights how geographical proximity to others with similar perspectives serves to influence and normalize individual attitudes about a certain issue. radio.140 Cognitive-Behavior Therapy for Children and Adolescents consequent application of black box warnings on certain classes of medications have furthered the stigma about pharmacotherapy. In these instances. 2002). for example. a 15-year-old depressed adolescent. It is almost like ‘the thing to do’— check that off the list along with extracurriculars and tutoring. Popular culture. This shift is generally consistent with a movement in modern American culture to popularize psychology and mental health treatment in general. In recent years. a more recent statistic possibly linked to changes in medical training—namely. In addition. as it does families and consumers of health care services in general. increasing the amount of pressure they face to balance issues such as service. empirical support for use of the combination treatment approach has grown. . Consideration of all these factors and creation of an inventory of the patient’s clinical characteristics will help clinicians in providing individualized care and achieve the desired outcome. and biases. • Insurance company influence impacts practitioners’ choices. such as practitioner preferences. knowledge of the research base demonstrating efficacy and effectiveness of various treatment approaches to treating youth. however. 2001). practitioners are pressured by a need to be held accountable to both consumers and third-party payers for the effectiveness and efficacy of interventions. that dictate treatment decision-making practices (American Academy of Child and Adolescent Psychiatry 1998). there are certain practitioner factors that could influence the choice of the treatment approach. cost. there is still the need for developing guidelines to direct when to use these treatments alone or in combination. In the current health care climate. and expertise and comfort level of a practitioner in the areas of CBT and pharmacotherapy are related to other important practitioner characteristics. attitudes. as well as guidelines for sequencing approaches. and treatment outcome in a managed care context (Burlingame et al. • Age of the practitioner has been cited in the literature as relevant to clinical decisions. It is not uncommon for clinicians to use a combined treatment approach (CBT plus medication) to improve outcomes when the use of a single intervention is suboptimal and/or symptom remission is incomplete. the educational background. How a practitioner balances these issues directly affects treatment decision-making practices.Combined CBT and Psychopharmacology 141 ment a psychologist or psychiatrist? Clearly. a greater emphasis on the role of psychotropic medication in treating mental health conditions. It seems that there is a higher ratio of younger physicians to older practitioners willing to prescribe psychotropic medications. awareness of practice recommendations about treating youth with mental health needs (Winters and Pumariga 2007). Conclusion CBT and pharmacotherapy have been shown to be efficacious interventions to treat many psychiatric disorders in children and adolescents. We suggest that a detailed assessment with special attention to child and parent factors and system factors would assist a clinician in making treatment decisions. Key Clinical Points • There are times when the primary diagnosis necessitates a combined treatment approach of CBT and pharmacotherapy (e. • Many factors guide clinical decision-making in the recommendation of a specific treatment approach. • The available evidence suggests that the use of combination treatment (CBT plus medication) is a safe and effective treatment approach. and Multimodal Treatment Study of Children With ADHD. . Pediatric OCD Study. and the role of the practitioner making the recommendation. E. ADHD) is supported by research findings from major studies such as the Treatment for Adolescents with Depression Study. especially for pediatric mood and anxiety disorders. Sertraline. mood and anxiety disorders. The only other medication besides fluoxetine that the U.g. future research is needed to help understand the moderators and mediators of an optimal treatment response. Children/Adolescent Anxiety Multimodal Study. Imipramine. Treatment of SSRI-Resistant Depression in Adolescents. the context of the system factors. • Assessment will result in an inventory of clinical characteristics that reflect the child and parent factors. attention-deficit disorder or ADHD). Escitalopram. depression. which indicate a promising outcome for a combined treatment approach. anxiety. Paroxetine.. Self-Assessment Questions 4. B.142 Cognitive-Behavior Therapy for Children and Adolescents With the encouraging results of major studies conducted since 2000.. Many factors need to be considered before recommending this treatment approach. Fluvoxamine. Food and Drug Administration has approved for the treatment of major depressive disorder in adolescents (12–17 years) is A. D.S. • Efficacy of the combined treatment approach to treat a variety of psychiatric disorders in youth (e. C.1.g. it is important to consider these factors in the context of a thorough case evaluation and assessment before making treatment decisions. with some studies showing efficacy of combined treatments and others the advantages of a combined approach. D. Take a detailed history and make a decision on treatment interventions on the basis of the inventory of factors.4. CBT is consistently better than pharmacotherapy and thus should be the first line of treatment. Combined treatments (CBT and pharmacotherapy) showed a superior response rate compared to CBT or pharmacotherapy alone.2. CBT is the most effective intervention for children and adolescents. D. Let the patient decide. No intervention was shown to be better than placebo. assess for various factors. None of the above statements is true. The results are mixed. the clinician should A.Combined CBT and Psychopharmacology 143 4. Pharmacotherapy is consistently better than CBT and thus should be the first line of treatment. and then always start with a combined approach (CBT plus pharmacotherapy) because it has been shown to be the most efficacious. B. Always start with CBT first and switch to medications if CBT does not work. C. The results were inconclusive. Pharmacotherapy is the most effective intervention for children and adolescents. . Always start with pharmacotherapy first and then add CBT if symptom resolution has not been achieved by pharmacotherapy alone. 4. C. Take a detailed history. 4. the following statement is true: A.3. B. C. E. Which of the following statements is true regarding evidence for combined treatments (CBT plus pharmacotherapy) for depression? A. On the basis of the results of the Children/Adolescent Anxiety Multimodal Study (CAMS). D. For a 13-year-old patient presenting with a first episode of major depression. such as symptom severity and patient and parent preferences. B. E. E. Combined treatments (CBT and pharmacotherapy) are always better than either treatment alone. Guilford.org References American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children and adolescents with depressive disorders. Nemours Foundation. C. B. Prior experience with treatment.org Anxiety Disorders Association of America. U.com/annenberg/copecaredeal National Alliance for the Mentally Ill. Annenberg Foundation Trust at Sunnylands with the Annenberg Public Policy Center of the University of Pennsylvania. www. Medline Plus: Child mental health.aacap. TeensHealth. 2nd Edition.org Family Guide to Keeping Youth Mentally Healthy and Drug Free. Guilford.psych.adaa. 1998 Asbahr FR.org Attention-Deficit Disorders Association. www.html.nimh. www. March JS (eds): Anxiety Disorders in Children and Adolescents.gov/ medlineplus/childmentalhealth.add. All of the above.nlm. Substance Abuse and Mental Health Services Administration. Ito LM. Castillo AR.samhsa.nami. and Practice.nih. Research. 2004 American Academy of Child and Adolescent Psychiatry. D.org National Institute of Mental Health. New York. Comorbidities. J Am Acad Child Adolesc Psychiatry 37(suppl):63S–83S. www. Available at: http://www.gov MindZone. Availability of resources. www.org American Psychiatric Association. www. www. J Am Acad Child Adolesc Psychiatry 44:1128–1136. Severity of symptoms.family. Which of the following are important factors to consider when deciding which intervention to choose from? A. et al: Group cognitive-behavioral therapy versus sertraline for the treatment of children and adolescents with obsessive-compulsive disorder. 2005 .teenshealth. 2004 Morris TL. E. 2011.S.gov National Institutes of Health.144 Cognitive-Behavior Therapy for Children and Adolescents 4. www. Accessed April 19.fhidc.nih. New York. National Library of Medicine. www.5. Suggested Readings and Web Sites Leahy RL (ed): Contemporary Cognitive Therapy: Theory. 2001 Carpenter-Song E: Caught in the psychiatric net: meanings and experiences of ADHD. Carpenter DJ. Miranda J. 2008 Brent DA. 2005 Cohen JA. Wynne ME. 2004 Beidel DC. 2003 Bokhari F. et al: Tracking the influence of mental health treatment: the development of the Youth Outcome Questionnaire. Compton S. Emslie G. Borchardt CM. Mosier JI. Scheffler RM: An analysis of the significant variation in psychostimulant use across the U. J Child Adolesc Psychopharmacol 14:129–136. et al: A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. et al: Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. et al: A pilot randomized controlled trial of combined trauma-focused CBT and sertraline for childhood PTSD symptoms. Roessner V. et al: Fluoxetine for the treatment of childhood anxiety disorders. Greenhill LL. et al: Compliance with pharmacological and cognitive treatments for attention deficit disorder. Pharmacoepidemiol Drug Saf 14:267–275. J Am Acad Child Adolesc Psychiatry 36:589–596. Deacon BJ. Mannarino AP. Debar L. Cult Med Psychiatry 33:61–85. J Am Acad Child Adolesc Psychiatry 46:1622– 1632. 2002 Burlingame GM. March JS. Sallee FR. et al: SET-C versus fluoxetine in the treatment of childhood social phobia. Axelson DA. et al: Controlled stimulant treatment of ADHD and comorbid Tourette’s syndrome: effects of stimulant and dose. 2004 Bruce ML. placebo-controlled trial of paroxetine in adolescents with major depressive disorder. Wells KB. 2007 Brown RT. J Am Acad Child Adolesc Psychiatry 44:888–898. J Child Adolesc Psychopharmacol 16:59–75. Perel JM. Behav Res Ther 45:819–828. 2004 . Clarke G: Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. Tuner SM. et al: The Treatment of Adolescent Suicide Attempters (TASA): predictors of suicidal events in an open treatment trial. Dittman RW. Mayes R. Wells MG.S. Eur Child Adolesc Psychiatry 13 (suppl 1):I102–I116. 2000 Birmaher B. J Am Acad Child Adolesc Psychiatry 26:521–526. et al: Barriers to reducing burden of affective disorders. Giedd JN. J Am Acad Child Adolesc Psychiatry 43:930–959. Borden KA. JAMA 299:901–913. Lynch F. 2006 Bernstein GA. J Am Acad Child Adolesc Psychiatry 48:987–996. 1997 Clarke G. 2007 Compton SN. et al: An international. Elia J. Brent D. J Am Acad Child Adolesc Psychiatry 39:276–283. 2009 Brown AM. 2007 Berard R.Combined CBT and Psychopharmacology 145 Banaschewski T. J Am Acad Child Adolesc Psychiatry 42:415–423. Clin Psychol Psychother 8:361–379. Perwien AR. 2009 Castellanos FX. et al: Nonstimulant medications in the treatment of ADHD. et al: Parents’ perceptions of pharmacological and cognitive-behavioral treatments for childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 46:811–819. multicenter. Monk K. Abramowitz JS. 1987 Brown TE: Atomoxetine and stimulants in combination for treatment of attention deficit hyperactivity disorder: four case reports. 2005 Brent D. Fong R. Ment Health Serv Res 4:187–197. pediatric bipolar disorder and mental health treatment among a diverse group of families in the United States. et al: Imipramine plus cognitivebehavioral therapy in the treatment of school refusal. Am J Psychiatry 165:459–467.1002/14651858. 2006 Hamrin V. Issues Ment Health Nurs 26:433–450. Rush AJ.: CD004690. 2001 Kendall PC: The Coping Cat Workbook. Laughren T. 1997 Emslie GJ. J Child Adolesc Psychopharmacol 12:299. PA. Kutcher S. et al: Efficacy and safety of nefazodone in the treatment of adolescents with major depressive disorder (abstract). J Am Acad Child Adolesc Psychiatry 44:872–887. et al: Paroxetine treatment in children and adolescents with major depressive disorder: a randomized. Rynn MA. Arch Gen Psychiatry 54:1031–1037. J Am Acad Child Adolesc Psychiatry 45:709–719. J Am Acad Child Adolesc Psychiatry 46:479–488. Wagner KD. Ardmore. et al: “The C. Josephson A: Family based treatment research: a 10-year update. 2002 . et al: Venlafaxine ER for the treatment of pediatric subjects with depression: results of two placebo-controlled trials. Kennard BD. et al: Long-term methylphenidate therapy in children with comorbid attention-deficit hyperactivity disorder and chronic multiple tic disorder. Int Rev Psychiatry 20:159– 164. 2005 Emslie GJ. Sverd J. Workbook Publishing. et al: Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. double-blind. 1990 Kendall PC. PA. 2008 Keller MB. placebocontrolled trial of fluoxetine in children and adolescents with depression.A. Wilkinson P.pub2. Heiligenstein JH. 2006 Emslie GJ. Korotzer A. Project” Workbook for the Cognitive Behavioral Treatment of Anxious Adolescents. Cochrane Database of Systematic Reviews 2005. Choudhury MS. 2007 Hammad TA. Keeton CP. Racoosin J: Suicidality in pediatric patients treated with antidepressant drugs. Yeung PP. Nolan EE. CD004690. et al: Efficacy of paroxetine in the treatment of adolescent major depression: a randomized. et al: Fluoxetine versus placebo in preventing relapse of major depression in children and adolescents. DOI: 10. Findling RL. Wagner KD. Ardmore. Mayes TL. multicenter. randomized clinical trial. Weinberg WA. 2009 Gadow KD. placebo-controlled trial.T.146 Cognitive-Behavior Therapy for Children and Adolescents Diamond G. 1999 Goodyer I. Ryan ND. Strober M. Workbook Publishing. 2005 James AACJ. Ventura D. Arch Gen Psychiatry 63:332–339. Art. Weatherall RRW: Cognitive behavioural therapy for anxiety disorders in children and adolescents. et al: Escitalopram in the treatment of adolescent depression: a randomized placebo-controlled multisite trial. Ginsburg GS: Combining and sequencing medication and cognitivebehaviour therapy for childhood anxiety disorders. et al: Fluoxetine for acute treatment of depression in children and adolescents: a placebo-controlled. Dubicka B. J Am Acad Child Adolesc Psychiatry 48:721–729. BMJ 335:142. controlled trial. 2008 Emslie GJ. J Am Acad Child Adolesc Psychiatry 40:762–772. 2002a Emslie GJ. No. 2002b Emslie GJ. randomized. et al: A double-blind. Soler A. Arch Gen Psychiatry 56:330–336. Issue 4. Scahill L: Selective serotonin reuptake inhibitors for children and adolescents with major depression: current controversies and recommendations. 2007 Emslie GJ. J Am Acad Child Adolesc Psychiatry 41:1205–1215. Hudson JL. Findling RL. 2007 Masi G. 2011 Mosholder AD. et al: Establishing ongoing. Harrison M. Swanson JM. 1998 Pediatric OCD Treatment Study (POTS) Team: Cognitive-behavior therapy. Arch Gen Psychiatry 56:1073–1086. Wallston KA: The stigma of childhood mental disorders: a conceptual framework. Entusah AR. J Am Acad Child Adolesc Psychiatry 46:894–921.Combined CBT and Psychopharmacology 147 Labellarte MJ. Neurochemistry. Tonge BJ. The MTA Cooperative Group. 1998 March J[S]. and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. J Am Acad Child Adolesc Psychiatry 47:328–338. Pharmacopsychiatry 29:30–32. et al: Hallucinations and other psychotic symptoms associated with the use of attention-deficit/hyperactivity disorder drugs in children. et al: Alpha 2 adrenergic agonists. Faul L. Petrycki S. 2009 Morley S: The stress-diathesis model of illness. Wolkow R. et al: Fluoxetine. early identification programs for mental health problems in our schools: a feasibility study. Toni C. and their combination for children and adolescents with obsessivecompulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. 2006 Molina BS. sertraline. et al: Paroxetine in child and adolescent outpatients with panic disorder. Leinonen E. Walkup JT. Biol Psychiatry 46:1567–1578. Ginsburg GS. Mucci M. J Am Acad Child Adolesc Psychiatry 49:92–103. et al: The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. cognitive-behavioral therapy. 2007 . Levitt JM. Biederman J. 2001 Melvin GA. Gelperin K. 2004 Pliszka S: Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. Pediatrics 123:611–616. Silva S. JAMA 292:807– 820. 2010 Nemeroff R. 2004 March JS. King NJ. and clinical guidelines for use in children. J Am Acad Child Adolesc Psychiatry 48:484–500. 1999 Lepola U. efficacy. et al: The treatment of anxiety disorders in children and adolescents. Hinshaw SP. Schulz K. Koponen H: Citalopram in the treatment of early-onset panic disorder and school phobia. J Child Adolesc Psychopharmacol 11:151–157. Pediatr Clin North Am 45:1099–1122. J Am Acad Child Adolesc Psychiatry 45:1151–1161. 1996 March JS. Biol Psychiatry 62:1149–1154. viii. Heflinger CA. 1999 Mukolo A. Multimodal Treatment Study of Children with ADHD. et al: A comparison of cognitive-behavioral therapy. Hammad TA. Rynn M. quiz 198. 1983 Moses T: Parents’ conceptualization of adolescents’ mental health problems: who adopts a psychiatric perspective and does it make a difference? Community Ment Health J 47:67–81. JAMA 280:1752–1756. sertraline. and their combination for adolescent depression. J Psychosom Res 27:86–87. JAMA 292:1969–1976. 2008 Newcorn JH. 2009 MTA Cooperative Group: A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. et al: A randomized controlled trial of venlafaxine ER versus placebo in pediatric social anxiety disorder. et al: Sertraline in children and adolescents with obsessive-compulsive disorder: a multicenter randomized controlled trial. 1992 Solanto MV: Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration. et al: Parent-child interactions in pediatric bipolar disorder. Accessed April 19. et al: Efficacy and safety of extended-release venlafaxine in the treatment of generalized anxiety disorder in children and adolescents: two placebo-controlled trials. placebo-controlled trial of citalopram for the treatment of major depression in children and adolescents. Siqueland L. Ann Gen Hosp Psychiatry 3:2.fda.pdf. Rynn M. et al: Cognitive-behavioral therapy. Stein MB. 1998 Sparks JA. randomized. Am J Psychiatry 164:290–300. 2003 Ryan ND. Robb AS. Ethical Hum Psychol Psychiatry 6:25–39.gov/downloads/Drugs/DrugSafety/ ucm088660. 2006 Wagner KD. Yeung PP. placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Duncan BL: The ethics and science of medicating children. Olsson GI. J Am Acad Child Adolesc Psychiatry 31:29–33. Findling RL. 2004a Wagner KD. 2008 Simeon JG. placebo-controlled study of citalopram in adolescents with major depressive disorder. Albano AM. Behav Brain Res 94:127–152. JAMA 290:1033–1041. 2004 U. West AE. 2008 . double-blind. 2001 Rossi A. N Engl J Med 359:2753–2766. 2011. Varma D: Child and adolescent mood disorders—experience with serotonin-based therapies. 2001 Rynn MA. J Clin Psychol 64:422–437. 2001 Vitiello B. Paediatr Drugs 3:613– 627. et al: A multicenter. Donda P: Fluoxetine: a review on evidence based medicine. et al: Clinical. Int J Methods Psychiatr Res 12:44–53. 2009 von Knorring AL. Berard R. Am J Psychiatry 161:1079–1083. Varley CK: Sudden death related to selected tricyclic antidepressants in children: epidemiology. N Engl J Med 344:1279–1285. Riddle MA. Food and Drug Administration: Medication guide: antidepressant medicines. depression and other serious mental illnesses. Ambrosini P. 2007 Schenkel LS.148 Cognitive-Behavior Therapy for Children and Adolescents Research Unit on Pediatric Psychopharmacology Anxiety Study Group: Fluvoxamine for the treatment of anxiety disorders in children and adolescents. Am J Psychiatry 158:2008– 2014. Rohde P. double-blind. J Clin Psychiatry 70:741–747. Knott V. Arch Gen Psychiatry 61:1153–1162. Biol Psychiatry 44:336–340. Harral EM. and neurophysiological effects of alprazolam in children and adolescents with overanxious and avoidant disorders. mechanisms and clinical implications. Rickels K: Placebo-controlled trial of sertraline in the treatment of children with generalized anxiety disorder. 2004b Walkup JT. or a combination in childhood anxiety. Piacentini J. cognitive. et al: Suicidal events in the Treatment for Adolescents with Depression Study (TADS). 2004 Ryan ND: Child and adolescent depression: short-term treatment effectiveness and long-term opportunities. Silva SG.S. et al: A randomized. 2007. J Clin Psychopharmacol 26:311–315. Available at: http://www. 2003 Wagner KD. sertraline. Barraco A. et al: A randomized. and suicidal thoughts or actions. et al: Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials. 1998 Rynn MA. Ferguson HB. Thomsen PH. homework compliance. and initial change in cognitive-behavioral therapy for anxiety. J Consult Clin Psychol 75:363–373. 2007 . J Am Acad Child Adolesc Psychiatry 46:284–299. Pumariga A: Practice parameter on child and adolescent mental health care in community systems of care. Dozois DJ.Combined CBT and Psychopharmacology 149 Westra HA. 2007 Winters NC. Marcus M: Expectancy. 8% PBO Results suggest that CBT +FLX in the treatment of adolescents with MDD has best benefit-risk trade-off. severe CD. dose. Of note. 10–40 mg/day 12 weeks Participants were randomly assigned to one of four conditions: PBO FLX alone CBT alone CBT+ FLX Double-blind assignment: FLX alone.6 years) MDD Comorbidities: anxiety disorder. 2004) Cognitive-Behavior Therapy for Children and Adolescents Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. CBT+FLX N=439. limitations. multisite Ages 12–17 years (mean age=14. thought disorder. duration of treatment N.2% CBT alone 34.6% FLX 43. clinically significant suicidal thinking decreased from baseline in all treatment groups. PDD. or had poor response to treatment that included CBT Primary and secondary outcome results Comments.Medication. adverse events FLX+CBT>PBO FLX+CBT >FLX alone and CBT alone FLX>CBT aCGI: 71% FLX+ CBT 60. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents 150 APPENDIX 4–A . failed two SSRI trials. diagnostic qualifications. OCD/tic disorder Exclusions: bipolar disorder. age. depression. receiving concurrent psychotropic or psychotherapeutic treatment. substance abuse or dependence. Depression TADS (March et al. comorbidities FLX. disruptive behavior disorder. PBO alone Unblinded assignment: CBT alone. 2005 Participants who had been prescribed SSRIs by their TAU pediatric provider before study enrollment were randomly assigned to CBT+SSRI or TAU+ SSRI (control condition). Weak CBT effect was detected. adverse events Depression (continued) Clarke et al. Comorbidities: schizophrenia No advantage of CBT +SSRI Exclusions: significant over TAU +SSRI on other developmental or intellectual primary outcome measure.07) supporting CBT) CBT+ SSRI>TAU + MDD SSRI. depression.04). nearly significant trend mean age=15. Primary outcome results: N= 152 aCES-D results showed a Ages 12–18 years (mean age= 15. (P=. Appendix 4–A: Combination Treatment APPENDIX 4–A 151 .29 years. duration of treatment N. dose. disability. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) Medication. possibly because of 1) small sample and 2) unexpected reduction in SSRI pharmacotherapy in CBT condition. diagnostic qualifications. age. High attrition posttreatment and at follow-up among adolescents. Participants who were randomly assigned to CBT +SSRI received five to nine individual CBT sessions. limitations. comorbidities Primary and secondary outcome results Comments.3 years. TAU.07) and Short Form-12 Mental Component Scale (P=. Secondary outcome results: Significant CBT advantage was found on Youth Self Report—Externalizing (P=.Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. suicidal risk MDD recovery. 3 years) asymptomatic) MDD. AEs: fatigue. active suicidality. comorbidities Primary and secondary outcome results Comments. yawning. multisite Ages 12–18 years (remission=8 weeks (mean age=15. anxiety disorder. CD/ 71.3% SERT psychotic disorder. limitations. 2006 SERT. PBO condition was not included.5–100 mg 12 weeks Participants were randomly assigned to one of three conditions: CBT SERT alone CBT+ SERT aDepressive diagnosis N= 73. restlessness. adverse events Depression (continued) Melvin et al. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) 152 APPENDIX 4–A . headache. Few participants with severe depression were included. for partial reading disorder.4% CBT ODD. concentration. cannabisremission: related disorder NOS.Medication. age. however. drowsiness. but relatively low dose of SERT was prescribed. enuresis. 12. other severe psychiatric disturbance requiring acute hospital admission COMB showed greater response in MDD postacute treatment. insomnia.7% CBT+ SERT Exclusions: bipolar disorder. depression. nausea Cognitive-Behavior Therapy for Children and Adolescents Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. dose. All treatments had DDNOS significant improvements Comorbidities: adjustment or at the end of acute phase. BDD 46. 33. diagnostic qualifications. substance abuse. duration of treatment N. suicidal ideation. increased appetite. dysthymic disorder. CD. Participants with previous optimal trial with SSRI+CBT were excluded. global learning disability 153 Primary and secondary outcome results Appendix 4–A: Combination Treatment APPENDIX 4–A . depressive psychosis. bipolar disorder. CGI-I). comorbidities Comments. symptoms of suicidality for both treatment groups for most outcomes reduced over time. Results suggest that for adolescents with moderate to severe depression. combination CBT +SSRI in the context of routine care contributes to improved outcome at 28-week follow-up compared with SSRI and routine care alone. CDRS-R. Neither severity nor comorbidity influenced results of COMB. duration of treatment N. anxiety disorders. tiredness. If no response. Of note. and reduced appetite. increasing to 20 mg/day for 5 weeks. limitations. adverse events No benefit of SSRI+CBT over SSRI alone across aHealth of the Nation Outcome Scales for Children and Adolescents and secondary outcome measures (participantrated mood and feelings questionnaire. depression. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) Medication. 10 mg/day for 1 week. 2007 Participants were randomly assigned to SSRI alone or SSRI+CBT (28 weeks) SSRI treatment: FLX. N= 208. diagnostic qualifications. Most common AEs: headaches. multisite Ages 11–17 years Moderate-severe major or probable major depression Comorbidities: suicidality. tic disorder. increase was considered at 6 weeks (to 40 mg on alternative days for 1 week followed by 40 mg/day for 5 weeks) and again at 12 weeks (60 mg on alternative days for 1 week followed by 60 mg daily for 5 weeks). eating disorders Exclusions: schizophrenia. dry mouth. Depression (continued) Goodyer et al. alcohol abuse.Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. nausea. 30 mg/day on average. 60 mg/day maximally. age. dose. 150–225 mg 12 weeks Treatment arms: Switch to new SSRI alone Switch to new SSRI+CBT Switch to VLX alone Switch to VLX+CBT CBT+ MED > MED switch N= 334 (231 completed alone protocol through week 12). AEs: sleep difficulties. mean CGI score ≤2 +CDRS-R of treatment-arm averages) score reduction by 50% MDD 54. in addition to CBT. skin problems. Participants were nonresponders to initial treatment with SSRI for depression. VLX switch=SSRI switch multisite aAdequate clinical response: Ages 12–18 years (mean age= 15. duration of treatment N. 20–40 mg Fluoxetine.5% MED switch alone Adolescents with treatmentrefractory depression may benefit from a switch to a new SSRI or VLX. 20–40 mg Citalopram. accident/injury. flu-like aches. musculoskeletal issues Cognitive-Behavior Therapy for Children and Adolescents Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety.9 years.Medication. comorbidities Primary and secondary outcome results Comments.8% withdrew due to AEs. diagnostic qualifications. Attrition: 30. adverse events Depression (continued) TORDIA (Brent et al.8% CBT +MED 40. depression. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) 154 APPENDIX 4–A . 2008) Paroxetine. gastrointestinal issues. dose. irritability. limitations. age. 20–40 mg Venlafaxine (VLX). Appendix 4–A: Combination Treatment APPENDIX 4–A . limitations. greater hopelessness. higher number of previous suicide attempts. developmental n= 18). psychosis. depression. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) Medication. Significant qualification: made disproportionate treatment perhaps warranting further suicide attempt 90 days assignment (MED alone. comorbidities Primary and secondary outcome results Comments. risks for MDD. in COMB group than either suicide events and for reattempts DDNOS. Given that 40% of suicidal events Exclusions: bipolar disorder. multisite outcome were not detected Ages 12–18 years suicidal events was higher among treatment arms. and lower levels of functioning. dysthymic disorder. examination of this intervention. age. MDD +dysthymic MED alone or CBT alone. TASA CBT alone. adverse events Depression (continued) TASA (Brent Participants were allowed et al. MED+TASA CBT. more hospitalizations 6 months before study. were lower in the current study disorder likely due to than in comparable samples. 2009) to choose to be randomly assigned or to select their treatment. n= 93. before intake n= 15.Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. increased safety planning and disorder. groups had higher interviewer. substance Significant group therapeutic contact early in dependence differences: monotherapy treatment may be useful. diagnostic qualifications. occurred 4 weeks from intake. dose.and selfreported rates of depression. duration of treatment N. Three treatment conditions were available: Psychotherapy (TASA CBT) MED management TASA CBT +MED management 6 months 155 aSuicidal event: rate of Although differences in suicidal N= 124. 4% (n= 16) Cognitive-Behavior Therapy for Children and Adolescents Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. comorbidities Primary and secondary outcome results Comments. Attrition rate: 25. eating disorder. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) 156 APPENDIX 4–A . duration of treatment N. COMB (CBT +IMI) was more effective than PBO on most outcomes. and CBT alone. TASA (Brent et al. diagnostic qualifications. no differential effect of treatment type on suicidal outcomes was found among CBT+ MED. MDD Exclusions: ADHD. limitations. 2000 IMI Dosage monitored via blood levels (150 µg/L–300 µg/L) 8 weeks Participants were randomly assigned to one of two conditions: CBT+ IMI PBO+ IMI N= 63 School refusal Ages 12–18 years (mean age=13. adverse events Depression (continued) When group differences were controlled.9 years) Comorbidities: One or more anxiety disorder. 2009) (continued) Anxiety disorders Bernstein et al. bipolar disorder. drug and/or alcohol abuse. bipolar or affective disorder in first-degree relative aOutcome measures = weekly school attendance: IMI>PBO ARC-R: IMI>PBO RCMAS: IMI>PBO CDRS-R: IMI>PBO BDI: IMI=PBO Results support multimodal approach to treating school refusal in adolescents (MED +CBT). age. MED alone. depression. dose.Medication. CD. mental retardation. Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. motor overactivity. depression. limitations.8 years. comorbidities Primary and secondary outcome results Comments. stomachache Appendix 4–A: Combination Treatment APPENDIX 4–A 157 . diarrhea. enuresis. dose. Treatment-emergent AEs in MEDtreated patients: decreased appetite. diagnostic qualifications. mean For remission of treatment-arm averages) (CY-BOCS≤ 10): COMB OCD and CBT >SERT alone=PBO Both CBT alone and CBT + SSRI may be effective in treating childhood OCD. adverse events Anxiety disorders (continued) POTS (Pediatric OCD Treatment Study [POTS] Team 2004) SERT. age. 25–200 mg/day 12 weeks Participants were randomly assigned to one of four conditions: PBO SERT alone CBT alone CBT+SERT aCOMB> CBT alone= N= 112 Ages 7–17 years SERT alone>PBO (mean age= 11. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) Medication. nausea. duration of treatment N. limitations.Medication. AEs: SERT>group CBT: increased weight loss Group CBT> SERT: increased nausea.1 years. weight gain Cognitive-Behavior Therapy for Children and Adolescents Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. diarrhea. duration of treatment N. psychosis. depression. borderline personality disorder. age. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) 158 APPENDIX 4–A . neurological disorders other than Tourette’s syndrome or any organic brain disorder Significantly higher compliance rates in SERT group Psychotherapy (group CBT) may have more lasting effects in the treatment of pediatric OCD than MED (SERT) alone. bipolar disorder. comorbidities Primary and secondary outcome results Comments. mean 9-month follow-up: of treatment-arm averages) group CBT >SERT Comorbidities: MDD (only if secondary to OCD) and other major Axis I disorders Exclusions: MDD (if primary diagnosis). increased appetite. PTSD. adverse events Anxiety disorders (continued) Asbahr et al. 2005 SERT. 25–200 mg/day 12 weeks Participants were randomly assigned to one of two treatment conditions: Group CBT alone SERT alone aCY-BOCS N= 40 OCD 12 weeks’ acute treatment: Ages 9–17 years group CBT =SERT (mean age= 13. trembling. sweating. dry mouth. dose. abdominal pain SERT=group CBT: irritability. PDD. headaches. ADHD (if primary diagnosis and/or if psychostimulants were required). diagnostic qualifications. 15 of 22 participants who were in the “clearly impaired” range at pretreatment (CGAS< 60) had moved into the “not clearly” range on the CGAS: 9 TF-CBT+ SERT. Ages 15–17. n=10 (45. GAD. dose. reportable child abuse episodes. AEs were defined as suicide attempts. depression. Cohort was not representative of sexually abused children requesting clinical treatment. females only Demographic information (% total participants): Ages 10–11. including the following: PTSD diagnosis: At posttreatment. 6 TF-CBT+PBO. duration of treatment N. Treating childhood PTSD with psychotherapy first. PDD 159 Primary and secondary outcome results Appendix 4–A: Combination Treatment APPENDIX 4–A . Anxiety disorders (continued) Cohen et al. 14 of 20 participants with PTSD no longer met criteria for diagnosis (8 TF-CBT + SERT.7%). limitations. anorexia nervosa. panic disorder Exclusions: schizophrenia. mental retardation. adverse events TF-CBT +SERT= TF-CBT +PBO Clinically meaningful improvement occurred on several measures. Ages 12–14. diagnostic qualifications. ODD. comorbidities Comments. n= 7 (31.5%). 6 TF-CBT+PBO). and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) Medication. n= 5 (22. substance abuse NOS (but not use). age. No significant group × time differences between the two groups. Global impairment status: At posttreatment.Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. or psychiatric hospitalization Only one AE occurred over course of study between groups (one psychiatric hospitalization for ODD). other active psychotic disorder. 50–200 mg/day 12 weeks Participants were randomly assigned to receive one of two treatments: TF-CBT +SERT TF-CBT +PBO N= 22 Sexual abuse–related PTSD Ages 10–17 years. 2007 SERT. then following with MED. drug overdoses.8%) Comorbidities: MDD. might be most effective. 7% CBT* GAD. 25–200 mg/day CAMS (Walkup et 12 weeks Participants were al.05) Serious AEs: SERT+CBT: one psychiatric hospitalization SERT: one psychiatric hospitalization. age.7% SERT+ CBT* (mean age=10. OCD. SAD. ODD. and fidgeting more common in SERT (P<. fatigue. CBT: insomnia. psychotic disorders. dose.3%) on SERT and 15 (19. 2007 (continued) SERT. adverse events Anxiety disorders (continued) Cohen et al.7%) on PBO 6-month open-label continuation phase for responders AEs: SERT vs. and/or social 54. diagnostic qualifications. multisite Ages 7–17 years 80. nonresponders to two trials of SSRI or prior CBT trial Dropout rates: 23 (17. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) 160 APPENDIX 4–A . comorbidities Primary and secondary outcome results Comments.Medication. one medical hospitalization Cognitive-Behavior Therapy for Children and Adolescents Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. substance >PBO use disorders. depression. duration of treatment N.7 years) 59. restlessness.7% PBO Comorbidities: ADHD. PDD.9% SERT* phobia 23. 2008) randomly assigned to one of four conditions: PBO SERT alone CBT alone CBT+SERT Double-blind assignment: SERT and PBO groups Unblinded assignment: SERT +CBT group Significant result: Most symptom improvement for TF-CBT+ SERT group occurred between weeks 3–5 (to be expected in a trial using SERT). limitations. bipolar disorder.001) PTSD. *(P < . CD SERT+ CBT> CBT =SERT Exclusions: MDD. aCGI-I score= 1 or 2: N= 488. sedation. PBO: ns SERT vs. chronic greater benefits than MED serious tics or Tourette’s management for core ADHD syndrome. or COMB did not yield significantly personality disorder. ongoing or previously unreported abuse. neuroleptic MED non-ADHD symptom and in previous 6 months. MED: Dextroamphetamine (1. MED behavioral therapy or internalizing disorder. suicidal or homicidal ideation 161 Methylphenidate hydrochloride 28-day titration period 5–20 mg (or higher if patient’s weight >25 kg) If inadequate response was achieved.COMB=MED management routine community care that for treatment of core III scales and on SIB. For ADHD symptoms.4%) Pemoline (1.Study Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety.3%) Bupropion (0. neurological or medical illness. multisite worrying.3%) Haloperidol (3%) 13-month follow-up period after initial titration phase Appendix 4–A: Combination Treatment APPENDIX 4–A . dose. patients were given alternative. duration of treatment N. adverse events ADHD MTA (MTA Cooperative Group 1999) AEs: Most severe was depression. major positive functioning outcomes.9 years factors. management>intensive Comorbidities: ODD. psychosis. limitations.0%) IMI (0. bipolar included MED. CD. age. history of intolerance to MTA MEDs. comorbidities Primary and secondary outcome results Comments. diagnostic qualifications. or irritability and could outcome measures show ADHD (combined type) have been due to nonmedication COMB and MED Ages 7–9. depression. Results on 19 primary N= 579. but it may have enough to require separate provided modest advantages for treatment. special management was superior to community care learning disability behavioral treatment and to Exclusions: <80 on all WISC. ADHD symptoms disorder. OCD serious symptoms. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) Medication. PARS=Pediatric Anxiety Rating Scale. SAD=separation anxiety disorder. CGI-I=Clinical Global Impression—Improvement scale. and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued) Cognitive-Behavior Therapy for Children and Adolescents Note. TAU=treatment as usual. TASA=Treatment of Adolescent Suicide Attempters. SSRI=selective serotonin reuptake inhibitor. Child Version. AE=adverse event. depression. CBCL=Child Behavior Checklist. MFQ=Mood and Feelings Questionnaire. SCARED=Screen for Child Anxiety Related Emotional Disorders. CY-BOCS=Yale-Brown Obsessive Compulsive Scale. 162 APPENDIX 4–A . ns=not significant. IMI=imipramine. FLX=fluoxetine. PDD=pervasive developmental disorder. a Primary outcome measure. SIB=Scales of Independent Behavior. ARC-R=Anxiety Rating Scale for Children—Revised. TORDIA=Treatment of SSRI-Resistant Depression in Adolescents. CDRS-R=Children’s Depression Rating Scale—Revised. WISC-III=Wechsler Intelligence Scale for Children—3rd Edition. PTSD=posttraumatic stress disorder. NOS=not otherwise specified. SERT=sertraline. CD=conduct disorder. ODD=oppositional defiant disorder. MTA=Multimodal Treatment Study of Children With ADHD. CGAS=Child Global Assessment Scale. DDNOS=depressive disorder not otherwise specified. POTS=Pediatric OCD Treatment Study. RCMAS=Revised Children’s Manifest Anxiety Scale. MDD=major depressive disorder. PBO=placebo. CES-D=Center for Epidemiologic Studies—Depression Scale. TF-CBT=trauma-focused cognitive-behavior therapy. OCD=obsessive-compulsive disorder.Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety. MED= medication. TADS=Treatment for Adolescents with Depression Study. BDI=Beck Depression Inventory. COMB=combination treatment. GAD=generalized anxiety disorder. BDD =body dysmorphic disorder. CAMS=Child/Adolescent Anxiety Multimodal Study. recurrent.5 Depression and Suicidal Behavior Fadi T. S This chapter has a video case example on the DVD (“Depression and Suicide”) demonstrating CBT for a depressed and suicidal adolescent. 1996. 2006) and are associated with significant functional impairment in school and work. M. Bridge et al. David A. M. Brent. These conditions are a leading cause of morbidity and mortality in the pediatric age group (Brent 1987. CBT for Depression Empirical Evidence Depressive disorders in children and adolescents are common. 163 . frequent legal involvement. Maalouf. 1998).D. Kandel and Davies 1986).D. and impairing. Depression is prevalent in 1%–2% of children and 3%–8% of adolescents (Lewinsohn et al. and increased risks for substance abuse and completed suicide (Birmaher et al. CBT and usual care had similar remission rates of 75% at the end of treatment (Weisz et al. One other study has compared CBT plus usual care. the difference in acute phase response rate between medication alone and combination was not statistically significant in TADS. these results are actually consistent with the results from the ADAPT sample. was younger. However. and had to fail to respond to a brief psychosocial intervention—all factors that mitigate against CBT being effective (Curry et al. Harrington et al. In this study. consisting of antidepressant medication provided in primary care. In a more recent study that randomly assigned depressed youth to CBT versus usual care. 2005). which also resulted in fewer outpatient visits for usual care and a lower adherence rate to antidepressant treatment. After 18 weeks of treatment. 2009). 2009b). CBT has the strongest evidence base to support its efficacy in the treatment of pediatric depression compared with other therapies. with the best-studied psychotherapy being cognitive-behavior therapy (CBT) (Birmaher et al. 334 depressed adolescents who had not responded to an adequate trial with an SSRI antidepressant were randomly assigned to a . Renaud et al. however. CBT monotherapy did not perform better than pill placebo and was inferior to medication monotherapy for acute treatment (March et al. 2006. The content of the psychotherapy was very dense. Weisz et al. 2004). 2007). and this was especially true in those with more severe depression. CBT showed advantages over usual care in engaging parents. shortening time to remission. 1998. in fact. which had more severe depression. 1998. however. to usual care alone (Clarke et al. Consequently. and it is possible that too many skills were offered. in the Treatment for Adolescents with Depression Study (TADS). 2007).164 Cognitive-Behavior Therapy for Children and Adolescents Clinical guidelines for the acute management of child and adolescent depression recommend the prescribing of antidepressant medications. In the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study. The Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). and requiring less additional medication. Wood et al. 2000. 1996). Brent et al. 2006. 1998). Although these findings may seem to be at variance with TADS. The reasons why CBT was not more effective are not clear. There were nonsignificant trends favoring the combination treatment. which compared the efficacy of medication alone to that of CBT plus medication in depressed adolescents. psychotherapy. found no difference between medication monotherapy and combination treatment (Goodyer et al. 2009. at too low a dose. the CBT-only treatment “caught up” with combination and medication-only treatments (Kennard et al. or both. Clinical trials and meta-analyses have shown that CBT monotherapy is effective for the treatment of depression (Birmaher et al. depression is the result of an interaction between cognitive vulnerabilities and stressful life events. 2008). CBT appears to be more effective in those youths from more advantaged socioeconomic backgrounds (Asarnow et al. 1998. Depressed children and adolescents have been shown to have the same cognitive distortions and bias to negative events as depressed adults. the greater the number of comorbid conditions. Garber et al. CBT is not more effective than usual care in preventing depression in offspring of parents with a history of depression (Garber et al. Their automatic negative thoughts lead to depressive feelings that are associated with maladaptive behaviors (e. 2009). referred to as schemas. 1998). 2009). These cognitive vulnerabilities. CBT appears to perform particularly well in depressed adolescents with comorbidity. Barbe et al. when experiencing life stressors.g. suicidal ideation. 2000. 2009. 2010). but it performs less well in patients with a history of maltreatment or current parental depression. CBT is a treatment whose results are robust in patients with comorbidity. Feeny et al. engage in negative thinking as a result of these schemas. Studies have found that adolescents with higher levels of cognitive distortion are less likely to respond to CBT (Brent et al. 2009). CBT has also been shown to be effective in preventing the onset of depression in adolescents who are at high risk because of subsyndromal depression. the stronger the performance of CBT plus medication compared with medication alone (Asarnow et al. 1998. and hopelessness. compared to those who received a medication switch alone (Brent et al. In the TORDIA study. Interestingly. 2009. a previous history of depression. in the presence of current parental depression. Lewis et al. are formed early in life and are shaped by life experiences. Curry et al. CBT is also less efficacious compared with other treatments in patients who have a history of abuse and in those whose parents are currently depressed (Asarnow et al. 2009). 2004.. Brent et al.Depression and Suicidal Behavior 165 medication switch with or without CBT. and/or a parent with a history of depression (Clarke et al. social withdrawal). In general. Depressed youths have negative thoughts about themselves and the . 2006). Ginsburg et al. The CBT Model According to the cognitive diathesis-stress model (Beck 1967). Depressogenic schemas are cognitive structures based on a negative internal representation of the self and the environment (including others). There was a higher response rate with those who received both the medication switch and CBT. Marital and parent-child discord also militate against CBT efficacy (Birmaher et al. especially anxiety (Brent et al. Vulnerable individuals. 2001. However. 2009). but family sessions can take place as needed (typically 3–6 sessions during the treatment course). 2000). it is important to explore the reasons and whether anything can be done to make the skills more easily and readily usable. and social skills training. behavioral activation. have been relevant to most depressed youths: psychoeducation. In order to achieve this goal.166 Cognitive-Behavior Therapy for Children and Adolescents world around them. and they selectively attend to negative stimuli in their environment (Maalouf and Munnell 2009). 1998). Clarke et al. If the youth did not practice the CBT skills. at the beginning of each individual session. In addition to cognitive models. review the material covered . behavioral.. Next. Most of these sessions are individual sessions. In addition. At times. cognitive restructuring. Review his or her current mood symptoms and assess the youth’s suicide risk. the therapist typically checks in with the parent for 5–10 minutes. 2003. these strategies may include family interventions and relaxation techniques. a girl who isolates herself in her room and declines an offer to go out with her friends because of depression would most likely feel more depressed secondary to social isolation). problem solving. Acute treatment typically consists of 12 weekly sessions of 60–90 minutes each. Curry et al. This disruption causes individuals to use maladaptive skills to control their depressive feelings when these skills can only lead to worsening of these feelings (e.g. there are behavioral models of depression. Application CBT treatment is not a long-term treatment but rather is time limited. other specific intervention strategies are selected on the basis of an assessment of the cognitive. This behavioral model posits that life stressors cause a disruption in normal adaptive behavior. The different CBT components are summarized in Table 5–1. of which social learning theory has been the most prominent (Lewinsohn et al. emotion regulation. Session Format Start by setting the agenda for the session together with the youth. and environmental variables contributing to the depressive symptoms. Then review events that took place since the last session and the CBT skills that were practiced. CBT for youths with depression aims to target the above-mentioned maladaptive cognitive processes and behavioral patterns that contribute to low mood. a repertoire of techniques is used in CBT. and this disruption leads to and tends to perpetuate depression. Although specific CBT manuals vary in the extent to which they emphasize one technique over the other (Brent and Poling 1997. we will focus here on techniques that in our clinical experience. mood monitoring. and evaluating the consequences of each. 167 Cognitive-behavior therapy (CBT) with depressed youth: main components Component Content Psychoeducation Defining depression. generating different solutions. Mood monitoring Making the youth aware of different emotions and asking him or her to keep a mood diary.Depression and Suicidal Behavior TABLE 5–1. Relaxation Teaching diaphragmatic breathing. Social skills training Teaching effective communication skills such as greeting. and guided imagery as a means to cope with stressful situations. Emotion regulation Introducing the concept of intensity of emotions using a feelings thermometer and making the youth aware of physiological and psychological cues associated with the different intensities. monitoring for recurrence of depression. . identifying its causes and treatments. Behavioral activation Asking the youth to increase time spent in pleasurable activities on a daily basis and educating him or her that mood does not need to improve before engaging in these activities. Elicit feedback from the youth as you go along in the session and then agree with the youth on a homework assignment. in the previous session. progressive muscle relaxation. Problem solving Training the youth to solve problems by identifying what the problem is. Cognitive restructuring Guiding the youth to recognize distortions in his or her thought process and helping the youth to come to a more adaptive way of thinking. Relapse prevention Providing booster sessions to help reinforce the CBT model. Teaching emotion regulation strategies such as opposite action. active listening. including the homework given. Devote the rest of the session to teaching a new set of skills. Rehearse the skills with the youth using role-play. Typically done over one to two sessions with family and youth. introducing the different CBT concepts to them. Family interventions Educating family members about depression and treatment. and preparing for future stressors. and addressing high expectations by setting clear goals for treatment. and maintaining eye contact through role-playing. and setting treatment goals. This technique serves more than one purpose: 1) it helps you highlight to the child that he or she does not feel bad at all times (this is especially helpful in children who tend to dismiss positive emotions and report in the session that they “never feel good”).” Ask the youth to keep a mood diary by recording his or her mood at least three times a day along with the event associated with the specific mood. Psychoeducation is the first component of a successful CBT intervention. There is a tendency for youths to come up initially with a vague and nonspecific goal for treatment. review the fact that depression can be caused by many factors. such as “If you were not depressed. 2009). Ask the child about his or her goals for treatment and elicit from the parents support of these goals. such as “I want to feel better. and emotions and how they are interrelated. Next.” and so forth. Mood monitoring. “Doing better in school. Hearing from the child and the family a summary of the presenting problem helps you personalize subsequent components of CBT during the treatment course. It is typically done in one to two sessions conducted with both the youth and the parents.168 Cognitive-Behavior Therapy for Children and Adolescents Specific CBT Components Psychoeducation. Use the illustration of a feelings thermometer and have the youth rate his or her mood on a scale of 0 to 10. which include targeting maladaptive behaviors and thoughts with the goal of alleviating negative emotions associated with depression. and 2) it helps the youth identify activities that make him or her “feel good” and that can be built on for use later in therapy in the behavioral activation module. Psychoeducation can be a powerful intervention tool. This step helps reassure the child and family that what they are experiencing is a known condition that many people go through. Mood monitoring is an important component of CBT that helps increase the youth’s awareness of emotions. what would you be doing differently?” and here the youth may state. Use these sessions to explain to the family that depression is a condition that affects thoughts and feelings. . and multiple family therapy groups that feature this component have been shown to improve the outcome of children with mood disorders (Fristad et al. Children and parents are often confused about the nature of the disease and the type of treatment. in which 0 corresponds to feeling “very bad” and 10 to feeling “very good. and explain that there are successful interventions that include medications and therapy.” You may want to help the youth identify more concrete goals by asking him or her questions. behaviors.” “Going out more with friends. Introduce the family to the basic principles and goals of CBT. review the rationale behind CBT by explaining to the family the triad of thoughts. Help them practice this strategy to solve problems with increasing difficulty to help them gain mastery of the skills. Encourage yourself to implement the solution. Depressed teens often struggle with impaired problem-solving skills. 3. Depressed youths need to experience success with this strategy in order to believe in it and use it more generally.” Automatic thoughts are based on assumptions that are the product of schemas. Generalizing these skills may involve some challenges. Cognitive restructuring.g.. An example of an automatic thought is “I am not going to have a date for the prom. . 4. They often find it difficult to generate solutions to problems they encounter in their daily lives mainly because of the cognitive deficits associated with depression. conflict with peers or parents). having friends over after hours. If. guide her to evaluate the options by identifying the consequences of each and to choose the most suitable solution that doesn’t leave her depressed or hopeless. or not doing anything differently. namely difficulty concentrating. Elicit different possible solutions. which may include negotiating other hours with her parents. These automatic thoughts 1) are rapid and reflexive. Next. Start first with introducing the youth to the concept of learning problem-solving skills by explaining that everybody faces daily problems and that these can be more helpfully solved when not feeling down or hopeless. Relax when faced with a problematic situation. The problem-solving module teaches depressed teens to systematically work through problems that would typically cause them to feel down and hopeless. and 4) negatively influence emotions and behaviors. a depressed girl talks about a verbal altercation with her parents every time she doesn’t abide by curfew hours.Depression and Suicidal Behavior 169 Problem solving. Youths may give up on this technique if they attempt to apply it to complex problems prematurely. difficulty planning. 2) are accepted as valid. coach her to identify the problem as such and then to brainstorm solutions. train the youth to brainstorm solutions to problems that youths typically encounter (e. 6. One key aspect of CBT is identifying and remediating automatic thoughts and beliefs. Next. 5. for instance. 3) may be triggered by internal or external events. Identify what the problem is. Encourage the youth to bring in problems of his or her own and teach how to solve these problems using the following problem-solving steps: 1. 2. Choose the best solution. Evaluate them by predicting the consequences of each. and psychomotor slowing. and slow return to baseline. In general. dismissing the positive) that a person with depression may have. ask the youth to record automatic thoughts on a four-column dysfunctional thoughts record. there may have been damage done by the .170 Cognitive-Behavior Therapy for Children and Adolescents Start by teaching the youth about the most common cognitive distortions (e. the following statements may be helpful (Bonner 2002): • “A very FAST emotional response: it does not take much to get the ball rolling. for example. and the ball gets rolling very rapidly down the hill to the land of emotion dysregulation.” • “A very BIG emotional response: emotions are felt and expressed with much intensity. By asking a series of gentle questions. 1993): high sensitivity to emotion stimuli. Then elicit automatic thoughts from the youth by asking. more adaptive way of thinking. it must be made an explicit part of the information shared in teaching emotion regulation skills.. it quickly becomes a BIG ball. Start by translating these three components into everyday language for the youth. and consequence while trying with the youth to understand the context in which automatic thoughts occur. 4.” • “A very SLOW return to being calm or relaxed: it takes a long time to roll the ball back up the hill. What is the evidence? What are the errors in my thinking? What is the best and worst thing that could happen? What is the most realistic concern? What are the effects of my thinking this? What are some alternative thoughts? Emotion regulation. To generalize this skill outside the therapy session. as shown in Figure 5–1. 6. high reactivity. the following questions are useful for the youth to ask himself or herself (Brent and Poling 1997): 1. overgeneralization. when the ball gets rolling down the hill.g. It is helpful to be familiar with Linehan’s definition of the three components that constitute vulnerability to emotion dysregulation (Linehan et al. Because the problem of emotion dysregulation is so central to the depressed adolescent’s problems. 2. “What images and thoughts go through your mind when a specific event occurs?” Introduce the paradigm of antecedent. 5. making it difficult to think clearly. 3. belief. dichotomous thinking. the clinician can guide the youth to recognize distortions in his or her thought process and help him or her come to a new. 4. Thought record. 3. 4. so extra distress may have been added to whatever got the ball rolling in the first place.Depression and Suicidal Behavior Distressing situation 171 Negative automatic thoughts associated with the situation Feelings resulting from the thought or situation Evidence for and against the thought 1. 3. Evidence for 2. which corresponds to an irreversible point of losing control. Evidence against 1. 3. 2. FIGURE 5–1. 2. Ask the youth to identify different feelings corresponding to different temperature readings on the thermometer before the strength of his or her feelings would reach the top of the thermometer. 1. Then help the youth identify the physical and psychological cues as- . 1.” Next. 2. 4. 4. use the HEAR ME acronym to educate the youth about other vulnerabilities that can make emotion regulation more difficult (Bonner 2002): H =Health (take care of your physical illness) E = Exercise regularly A =Avoid mood-altering drugs R=Rest (balanced sleep) M=Master one rewarding activity daily E = Eat a balanced diet The clinician can illustrate one way to regulate emotions by using the picture of a blank feelings thermometer. 3. ball as it sped down the hill. if he or she feels angry and at the same time tries to smile. Finally. such as anger.g. Behavioral activation.. It is important to get severely depressed adolescents moving and motivated in order for them to engage in cognitive therapy. muscle tension. Generalizing these skills to apply them outside the therapy session can be challenging for youths. inexpensive. and facial expressions that go with the emotion. The clinician may want to illustrate this concept by focusing on one emotion.” The clinician can then educate them that they do not have to . and actions strongly influence how people experience their emotions. ask the youth to identify the point where he or she needs to take action before getting to the irreversible point of dyscontrol. and identify what the adolescent can do (e. Then ask the youth to increase the amount of time during the day that he or she spends engaging in these activities and to note the mood associated with the activity. Work with the youth—and here the clinician may want to elicit the help of the family—to schedule activities that give the youth a sense of pleasure or accomplishment. Begin by asking the youth to make a list of up to 10 activities that he or she enjoys doing.g. it is sometimes possible to change how someone experiences an emotion by altering the posture. taking a warm bath). and relax his or her posture. take some deep breaths.” remind him or her about activities that were mentioned in previous sessions and that he or she appeared to have enjoyed. walking away from the situation. behavior. and legal. If the youth is reluctant to engage in the brainstorming because “I do not enjoy anything. Explain that most people find that if they make an angry face and also make their body language consistent with this feeling. calling a friend. For this reason.172 Cognitive-Behavior Therapy for Children and Adolescents sociated with these feelings (e. These activities must be safe. rapid breathing). Clinicians should give behavioral technique priority over cognitive interventions in severely depressed adolescents. Tell the youth that the opposite is also true—that is. facial expressions. Introduce this term by telling the youth that this method is based on the fact that bodily posture. then he or she will less likely act impulsively on the angry feeling. Adolescents may also state that they “often do not feel like doing anything.. they actually find themselves experiencing anger. Increasing pleasurable activities can also be used with less depressed adolescents. Another important emotion regulation skill is opposite action. rehearsing situations that are very likely to happen in the near future and reenacting situations that happened in the recent past are key factors that help youths master these skills and make it more likely that they will use them when faced with emotionally charged situations. Thus. Social skills training. Case Example Jessica is a 15-year-old white adolescent girl referred by her pediatrician due to concerns regarding her mood. followed by monthly booster sessions for 3 months. her parents wondered whether Jessica was ill given how much she was sleeping. a 6-month CBT continuation treatment phase is recommended. and her low energy level. her lack of appetite and sudden weight loss. Jessica presents in session wearing overly baggy clothes and with disheveled hair.. and active listening through role-playing—and models effective communication skills. . Initially. music classes.Depression and Suicidal Behavior 173 wait for their mood to improve in order to engage in pleasurable activities. On the contrary. work with the parent on freeing up some of the youth’s time to make room for those activities that the youth considers pleasurable. In this module. and yawns throughout the initial session. in which sessions occur weekly for 4 weeks and biweekly for 2 months. This phase typically consists of 8–11 sessions. She is soft-spoken and allows her mother to speak for her unless she is specifically addressed. making appropriate eye contact. 2008. home chores). They lack appropriate social skills and are overly sensitive to criticism. which Jessica has always loved. She reports that Jessica is “always irritable” and has rarely interacted with family members or even friends for the past month.g. review the skills learned during acute treatment and monitor for any recurrence of symptoms. even theater. Jessica’s mother reports that she is extremely concerned about her daughter. She slumps in her chair. Include family sessions as part of this treatment phase. the clinician teaches the child the basics of initiating and maintaining a conversation—including greeting others. Hence. with a minimum of 3 family sessions. Relapse prevention. Many of these children struggle with making and maintaining friendships. However. 1996). If the youth’s schedule is fully booked with school and other activities that the adolescent doesn’t necessarily consider pleasurable (e. which leads to further social isolation and reinforces their depressed mood. maintains a flat affect. She explains that Jessica has been slowly dropping out of all her extracurricular activities. after 12 weeks of acute treatment. CBT continuation treatment has been shown to be effective in preventing relapse in youths whose major depressive episode has remitted over a 6-month period (Kennard et al. medical concerns were ruled out after they met with the pediatrician. Social skills training is another important treatment focus for depressed youths. increasing the time they spend engaging in these activities may by itself lead to improvement in their mood. During this treatment phase. Kroll et al. Once Jessica and her mother were able to clearly understand depression. With the help of this skill. and even theater. including schoolwork. The clinician then taught Jessica about how thoughts affect feelings and provided common examples of maladaptive thoughts. Jessica has little chance of changing her mood. she continues to experience negative thoughts. and she explained that she has not experienced any thoughts about suicide and that she would never do this to her family. which supported the idea that when she took part in social or pleasurable activities. her mood was improved—and that her mood was low when she isolated herself. In the following session. including becoming more active with friends and theater. Jessica’s therapist informed her that she was reporting clinically significant symptoms of major depressive disorder. Jessica admitted that she frequently views situations as “all or nothing” and that this can cause her to feel sad and blue. as well as improving school performance. Jessica was taught how to monitor her mood using a feelings thermometer. the therapist then explained how CBT could be beneficial. feelings. Once asleep. her appearance. Jessica was then taught how to challenge these negative thoughts and was assigned thought records to complete. and thus when she wakes. She also recognized that she can become overly focused on negative events that occurred throughout the day and ignore positive events. Jessica decided to try calling her friends more frequently and asking them to take part in activities. Her grades have been dropping recently. At the next session. Jessica mentioned that she had been feeling lonely and felt that her friends were leaving her out. as if nothing will ever turn out right for her. Jessica brought in completed feelings thermometers. The therapist was able to link this information with the symptoms Jessica reported during the initial session. She gradually became better at recognizing and challenging . Jessica held her mother’s hand. By the end of the session. Jessica was able to understand that when she thinks “No one ever calls me anymore. she tends to isolate herself by going to her room and falling asleep. even though this has never been an issue for her in the past. The clinician then met individually with Jessica to teach a problem-solving skill. The therapist explained the relationship of thoughts. Her mother gently pointed out that Jessica had not been returning phone calls or text messages lately. The next few sessions focused on Jessica’s thought records and cognitive challenges. Jessica reported that she was very hard on herself and never felt she was as good as her friends in all areas of her life. She was then assigned to begin monitoring her mood three times daily and to note the situation when she also noted her mood.” she feels sad—and that when she is sad. Jessica was able to calmly brainstorm some solutions for her current peer difficulties and to weigh the pros and cons of each solution. and she reported that she has been having a difficult time focusing in class. During the first therapy session.174 Cognitive-Behavior Therapy for Children and Adolescents During intake. and behaviors and explained that CBT helps individuals change the way they think and behave to help them decrease negative feelings. Jessica was able to form some goals. The clinician then provided Jessica and her mother with education regarding depression. Jessica became emotional when admitting that at times she feels hopeless. because repetition of these behaviors among adolescents is common 3–6 months after the first suicide attempt. Jessica’s solution for improving her relationships with friends was beginning to work. and she was feeling very pleased with her progress. and her mood ratings were improving. Wood et al. 2004. Empirical evidence on individual psychotherapies such as dialectical behavior therapy (DBT) has not yet been supported in RCTs. Although the TADS group reported CBT and CBT-plus-medication treatments as more effec- . Family. CBT for Suicide Empirical Evidence Although suicide is the third leading cause of death among adolescents in the United States (Bridge et al. and she was reporting improved social relationships. and brief adjunctive psychosocial intervention models have had mixed success in reducing self-injury in adolescents (Huey et al. She and the therapist agreed that she would come back to review skills monthly for the next 3 months.” Jessica continued to monitor her mood and use her skills taught in previous sessions. no individual psychotherapies have been shown effective in randomized controlled trials (RCTs) in reducing suicidal behavior in youths. Eventually. including theater. Jessica was feeling confident about her ability to manage her mood on her own. Jessica left therapy feeling proud of her ability to cope with her emotions and improve her mood. All of Jessica’s followup sessions were positive and focused on refreshing any skills that were needed. Jessica’s mother reported feeling relieved and felt that the “old Jessica is back. The importance of suicide prevention interventions lies in their efficacy to prevent future suicide attempts in recent attempters. and the next few sessions focused on emotional dysregulation. 2006). At this point. In particular. despite such treatment showing efficacy in a quasi-experimental study (Rathus and Miller 2002). At the same time. Generalizing evidence-based therapies used with depressed adolescents to suicidal adolescents may not be adequate because many of the trials that established efficacy of these therapies excluded suicidal adolescents. Jessica focused on forming a more balanced sleep routine and meal patterns. Jessica’s mood ratings continued to improve. 2001). Overall. group-oriented. Jessica still reported a tendency to react quickly to any social cues she perceived as negative. and Jessica began to increase her time spent in pleasurable activities.Depression and Suicidal Behavior 175 her cognitive distortions. The next few sessions focused on behavioral activation. Jessica was taught the HEAR ME tips for self-care and was assigned to work on applying these to her daily life. and case conceptualization. This phase involves 5 components: chain analysis. psychoeducation. to refrain from suicidal behavior. to help them develop more adaptive coping skills—and ultimately. the clinician helps the youth identify the series of events that led to the recent suicidal crisis. Goodyer et al. An acute treatment phase. CBT-SP involves the parents and the adolescent in treatment. psychiatry emergency contact numbers) resources to use as coping strategies when . the work in this component aims to reveal concurrently the youth’s precipitating thoughts. Acute Treatment Phase Initial phase (4 sessions). Suicide Prevention The Treatment of Adolescent Suicide Attempters (TASA) study developed a cognitive-behavior therapy for suicide prevention (CBT-SP. friends. 2008. and actions. The efficacy of CBT-SP is worth testing in the future.12. 2009). which lasts about 24 weeks. the clinician helps the youth identify internal (distracting activities) and external (family. feelings. CBT-SP consists of two treatment phases: 1. The acute treatment phase typically lasts for 12 weekly sessions in total. identifying reasons for living. safety planning. this result has not been replicated in other studies (Brent et al. 2009) that is feasible and accepted by adolescent suicide attempters. which consists of up to 6 sessions tapered in frequency and lasts for an average of 12 weeks. This treatment was piloted in a mostly open study of 124 depressed adolescent suicide attempters and resulted in a 6-month hazard of recurrence of suicidal behavior that was less than has been reported in similar samples (hazard ratio = 0. CBT-SP aims primarily to reduce suicide risk factors among adolescents who are recent attempters. and c) end phases. 2007.176 Cognitive-Behavior Therapy for Children and Adolescents tive in reducing suicidal ideation and events compared with medication alone. b) middle. 2. We here summarize the different components of CBT-SP. Stanley et al. which is divided into a) initial. • Safety planning: Here. 2004). Brent et al. A continuation phase. • Chain analysis: In this component. March et al. CBT-SP draws from the principles of CBT and DBT. The clinician introduces cognitive. The clinician aims to test the efficacy of skills learned thus far by having the youth review the recent attempt during the session. Continuation Phase In this 12-week treatment phase. End phase (3 sessions). • Discuss a future high-risk scenario and debrief. The clinician prepares the youth to deal with any future fluctuations or episodes and assesses the need for ongoing treatment. • Have the youth review the event of the attempt or suicidal crisis using skills acquired so far and highlight what he or she could have done differently. Jane presented in session as sad and tearful.g.Depression and Suicidal Behavior 177 faced with suicidal urges. • Identifying reasons for living: In this component. following these recommended steps: • Prepare the youth by providing the rationale of this task. was referred to the clinician by an emergency room physician at the local children’s hospital after she was treated for a suicide attempt. go over the course of treatment.. an adolescent who recently attempted suicide. • Have him or her review the indexed attempt or suicidal crisis. This technique aims to help youths stay safe by not engaging in suicidal behavior at least until the next session. S Case Example Jane. Middle phase (5 sessions). the clinician helps the youth identify reasons to live and sources of hope that he or she can hold on to when having a suicide crisis. and identify accomplishments. the clinician and patient review the skills learned in the acute treatment phase. chain analysis) and treat depression and suicidal ideation in Jane. and family interventions in the form of skills training via modules chosen on the basis of the particular needs of each youth as determined during the case conceptualization phase. The following case example on DVD illustrates CBT techniques to assess (e. She did not . • Psychoeducation: The clinician educates the youth and family about suicide risk factors and behaviors and about the goals of therapy. a 17-year-old adolescent girl. behavioral. in which she swallowed a bottle of her mother’s sleeping pills. • Case conceptualization: The clinician and patient determine target problems and deficits revealed in the chain analysis and identify the personalized strategies that are needed to reduce suicide risk in the adolescent. the therapist provided Jane and her family with education about suicide and risk factors. her level of energy and ability to concentrate decreased. Jane said that she decided she could no longer deal with the stress and took the bottle of pills quickly. these peers had made new friends and gradually drifted off except for her best friend. When she went home one day from school. Jane reported that she hated high school and that she attempted suicide because she was extremely hopeless that anything would ever get better. and she began to have difficulties problem solving. Jane could only say. because Jane’s attempt and suicidal thoughts generally focused on ingestion. especially when her parents began to cry. When faced with a social problem at school after the breakup with her boyfriend. Jane reported that she was willing to do this and felt bad about how she had upset her family. One risk factor in particular was discussed with Jane’s family: leaving prescription medications lying around the home. .178 Cognitive-Behavior Therapy for Children and Adolescents make eye contact and was soft-spoken. she agreed to tell a parent or call the local crisis center. This led to low self-esteem. The therapist then discussed the idea of forming a safety plan so that Jane could be sure to keep herself safe in between sessions. and through the years. She had one group of peers that she had made friends with in elementary school. During the next few sessions. This list began to grow. and this was causing her unwanted negative attention from others. the therapist provided a series of open-ended questions about what was happening in Jane’s life before the event. She found herself feeling embarrassed and lonely and told herself that she was a “loser” and that “no one would notice” if she didn’t exist. This conceptualization of Jane’s suicidal behavior helped the therapist to then form a treatment plan for the middle phase of Jane’s acute treatment. In addition. She admitted that she continues to have suicidal thoughts and would like a plan for managing these thoughts. In addition. and Jane began to overly focus on her difficulties with peers. the clinician discussed with Jane what led up to her suicide attempt. In addition. If her thoughts continued or she began to experience a suicidal urge. she was unable to think of an adequate solution and became hopeless. Jane and her family agreed that she did well following through with her safety plan. Jane agreed to a plan where she would initially try to get her mind off the thought by listening to music. Once Jane became depressed. Throughout sessions it became apparent that Jane had difficulties making new friends. the therapist began to form a case conceptualization regarding Jane’s suicidal behavior. and Jane became more motivated for treatment. Jane was aware of her social difficulties and embarrassed by her lack of popularity.” However. Jane recalled that she was having a particularly bad week in school because her best friend was out sick and she did not have anyone to sit with at lunch. “I hate school. Initially. This focused on Jane’s difficulties with social skills. what Jane was thinking about. During the first session. Jane and her family added reducing risk factors to the safety plan. She cried at times throughout the session. These sessions focused primarily on establishing rapport with Jane and helping her to begin to think about why her life was in fact worth living. After discussing this event. Jane said that her ex-boyfriend had spread a rumor about her. Jane reported that she “did not think” and that she never considered how this would affect her family. and how she was feeling. identifying and disseminating the most effective components of these therapeutic techniques is needed in order to better tailor them into a personalized approach for depressed and/or suicidal adolescents and to make treatment as beneficial and cost-effective as possible. that she had learned generally worked for her when she needed to distract herself. cognitive challenging for decreasing Jane’s tendency of focusing on the negative. Jane was also able to discuss which skills she felt would work best for her in future stressful situations. Jane was able to effectively apply the problem-solving skill in session to find solutions both for feeling lonely at lunch and handling the made-up rumor. The clinician asked Jane to think about her previous suicide attempt and to discuss what skills she could have used to prevent herself from getting to that point. being cognizant of the relevant cultural and ethnic factors of the youth’s presenting problems is essential for every therapist in building a therapeutic alliance with youths and their families and for treatment to succeed. while delivering CBT. . as well as teaching skills focused on improving mood. therapists are reminded to keep a cultural perspective. Jane was able to discuss some active coping skills. In addition. In the TORDIA study. This evidence suggests that problemsolving and social skills training modules may be more cost-effective to disseminate for use in the community than other CBT modules. Maladaptive beliefs and behaviors are learned and perpetuate in a social context. By the end of treatment. CBT is often unavailable in many settings and may increase the financial costs of treatment. Jane reported that she no longer experienced either suicidal ideation or depressive symptoms. hence. 2009a). In addition. such as going for a jog or playing a video game. Therefore. Lastly. The last three sessions focused on summarizing these skills to ensure that Jane would be able to apply them in the future. Caveats and Conclusion Despite the evidence supporting the role of CBT in treating depression in adolescents. Jane participated actively in learning these techniques and reported improvements in her mood at each session. the therapist spent about five sessions focusing on continuing to assess for safety. participants who received more than nine CBT sessions and those who received the problem-solving and social skills treatment modules were more likely to have a good treatment response (Kennard et al. and problem-solving skills for helping Jane to cope in an effective manner with life stressors. she was able to discuss how she was focusing on the negative and putting herself down and to challenge these negative thoughts in session.Depression and Suicidal Behavior 179 During the middle phase of Jane’s acute treatment. HEAR ME skills for improving her energy level and decreasing emotional lability. for instance. The therapist focused on social skills training for making new friends. A 13-year-old girl with a history of depression gets easily irritable at school and becomes aggressive with teachers and friends. Self-Assessment Questions 5. • CBT components. Switch to venlafaxine. such as psychoeducation. B. Emotion regulation Safety planning. emotion regulation.2. Treat with the same SSRI for a period longer than 12 weeks. C. cognitive restructuring. 5. . A 14-year-old Hispanic boy diagnosed with a major depressive disorder has not responded to a trial of a selective serotonin reuptake inhibitor (SSRI). Switch to another SSRI and add CBT. • Continuation CBT treatment is effective in preventing relapse after depression remission over a 6-month period. mood monitoring. behavioral activation. • CBT for suicide prevention aims to reduce suicide risk factors among adolescents who recently attempted suicide by helping them develop more adaptive coping skills and ultimately refrain from suicidal behavior. B.180 Cognitive-Behavior Therapy for Children and Adolescents Key Clinical Points • CBT is effective in preventing depressive disorders in at-risk youths and when combined with medications in treating pediatric depression. Switch to another SSRI. • CBT for youths with depression aims to target maladaptive cognitive processes and behavioral patterns that contribute to low mood through a repertoire of techniques. The next management step that the youth would most likely respond to is to A. D.1. and social skills training. Cognitive restructuring. Exposure and response prevention. need to be individualized to the particular youth. The most helpful CBT technique to include in her treatment plan is A. problem solving. C. D. B. et al: Treatment of selective serotonin reuptake inhibitor-resistant depression in adolescents: predictors and moderators of treatment response. Social skills training. A feasible and acceptable therapeutic intervention with a depressed adolescent who recently attempted suicide is A. This is an example of A. B. J Am Acad Child Adolesc Psychiatry 48:330–339. Cognitive restructuring. Social skills training. D. Williamson DE. You tell your depressed adolescent youth that it is important to schedule activities that he or she finds pleasurable and to engage in these activities on a regular basis.3. New York. 2000 . 2009 Barbe RP. 1970) Birmaher B. et al: Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder. B. CBT used with depressed youths. et al: Lifetime history of sexual abuse. C. Behavioral activation. Birmaher B. 5.5. Experimental. Behavioral activation. Hoeber. J Am Acad Child Adolesc Psychiatry 35:1427–1439. Brent DA. Interpersonal therapy.4. and Theoretical Aspects. Emotion regulation. 5. clinical presentation. C. Arch Gen Psychiatry 57:29–36. References Asarnow JR. You see an adolescent youth with depression who is having difficulty initiating and maintaining relationships with peers. Cognitive restructuring. Emotion regulation. and outcome in a clinical trial for adolescent depression. Cognitive-behavior therapy for suicide prevention. D. Part I. The most helpful CBT technique to include in the treatment plan of this youth is A.Depression and Suicidal Behavior 181 5. Relaxation techniques. 2004 Beck AT: Depression: Clinical. 1967 (Republished as Beck AT: Depression: Causes and Treatment. Clarke G. University of Pennsylvania Press. D. Ryan ND. J Clin Psychiatry 65:77–83. et al: Childhood and adolescent depression: a review of the past 10 years. Philadelphia. Emslie G. 1996 Birmaher B. Bridge JA. C. Kolko D. et al: Practice parameter for the assessment and treatment of children and adolescents with depressive disorders.net/shared/jbbu7c4xc7. 2002. et al: Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS). Star Center Publications. 2008 Brent DA. Poling K: Cognitive Therapy Treatment Manual for Depressed and Suicidal Youth. J Am Acad Child Adolesc Psychiatry 48:987–996. J Am Acad Child Adolesc Psychiatry 37:906–914. Walters K. J Clin Child Adolesc Psychol 38:814–825. 2003. AACAP Work Group on Quality Issues. 2000 Curry J. 1987 Brent DA.182 Cognitive-Behavior Therapy for Children and Adolescents Birmaher B. et al: A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. J Am Acad Child Adolesc Psychiatry 26:87–91. Hornbrook M. J Child Psychol Psychiatry 47:372–394. Duke University. 2007 Bonner C: Emotion Regulation. in Evidence-Based Psychotherapies for Children and Adolescents. 1997 Brent DA. et al: The Treatment of Adolescent Suicide Attempters study (TASA): predictors of suicidal events in an open treatment trial. 2009 Bridge JA. 2001 Clarke GN. Brent DA: Correlates of the medical lethality of suicide attempts in children and adolescents. pp 120–134 Clarke G[N]. Edited by Kazdin AE. et al: A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents. Available at: http:// www. Silva SG. Greenhill LL. 2009 Ginsburg GS. 2011. et al: Cognitive measures of adolescent depression: unique or unitary constructs? J Clin Child Adolesc Psychol 38:790–802. JAMA 301:2215–2224. Birmaher B. Accessed April 19. Brent D. Silva SG. 2009 Garber J. Compton S.box. 1998 Brent D. Weisz JR. J Am Acad Child Adolesc Psychiatry 46:1503–1526. Lynch F. Lewinsohn PM: Cognitive-behavioral group treatment for adolescent depression. PA. 2006 Clarke GN. Wells K. New York. 2006 Feeny NC. Brent DA: Adolescent suicide and suicidal behavior. Kolko DJ. Clarke G: Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. 2009 . et al: Prevention of depression in at-risk adolescents: a randomized controlled trial. Durham. et al: Cognitive Behavior Therapy Manual for TADS. Simons A. et al: Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Jacobs RH. Arch Gen Psychiatry 66:1013–1021. Weersing VR. et al: Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. Pittsburgh. Goldstein TR. Guilford. DeBar LL. Verducci JS. 2009 Fristad MA. Brent D. Reinecke MA. et al: An exploratory analysis of the impact of family functioning on treatment for depression in adolescents. DeBar L. J Am Acad Child Adolesc Psychiatry 45:1427–1439. and Distress Tolerance Skills for Adolescents: A Treatment Manual. J Am Acad Child Adolesc Psychiatry 44:888–898. Emslie G. Clarke GN. NC. Lynch F. 2005 Curry J. Rohde P. JAMA 299:901–913. Interpersonal Effectiveness. Arch Gen Psychiatry 58:1127–1134. Silva SG. Clarke GN. Arch Gen Psychiatry 43:255–262. Henggeler SW. J Am Acad Child Adolesc Psychiatry 48:1005–1013. J Am Acad Child Adolesc Psychiatry 35:1156–1161. Rohde P. J Am Acad Child Adolesc Psychiatry 37:1005–1007. Steelev JR: Major depressive disorder in older adolescents: prevalence. Tonev S. feasibility. 1998 Lewis CC. 2010 Linehan MM. Brent DA. October 27–November 1. HI. et al: Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model. Harrington R. and acceptability. et al: Pilot study of continuation cognitive-behavioral therapy for major depression in adolescent psychiatric youths. 1996 Lewinsohn PM.Depression and Suicidal Behavior 183 Goodyer I. Armstrong HE: Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline youths. 2008 Kennard BD. Emslie GJ. JAMA 292:807– 820. Weersing VR. 2004 Rathus JH. and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. 2009b Kroll L. J Am Acad Child Adolesc Psychiatry 43:183–190. et al: Impact of childhood trauma on treatment outcome in the Treatment for Adolescents with Depression Study (TADS). Petrycki S. Rowland MD. Campbell F. Suicide Life Threat Behav 32:146–157. Shoebridge P. et al: Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. Arch Gen Psychiatry 50:971–974. Dubicka B. et al: Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. 1998 Stanley B. 2007 Harrington R. Silva S. et al: Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. 2009a Kennard BD. Clin Psychol Rev 18:765–794. 1986 Kennard BD. Nguyen LJ. Baugher M. and clinical implications. 2004 Kandel DB. et al: Fluoxetine. 2002 Renaud J. Brown G. 2009 March J. 1993 Maalouf F. Simons AD. Mayes TL. et al: Remission and recovery in the Treatment for Adolescents with Depression Study (TADS): acute and long-term outcomes. Brent DA. et al: Meta-analysis of CBT for depression in adolescents. risk factors. cognitive-behavioral therapy. 2009 . BMJ 335:142. J Am Acad Child Adolesc Psychiatry 37:1184–1190. J Am Acad Child Adolesc Psychiatry 49:132–140. J Consult Clin Psychol 77:1033–1041. J Am Acad Child Adolesc Psychiatry 47:1395–1404. Munnell R: Cognitive control and emotion processing impairments in adolescent depression: state vs. trait? Presented at the 56th annual meeting of the American Academy of Child and Adolescent Psychiatry. 1998 Huey SJ Jr. Jayson D. et al: Effective components of TORDIA cognitive-behavioral therapy for adolescent depression: preliminary findings. Honolulu. J Am Acad Child Adolesc Psychiatry 48:186–195. Wilkinson P. Miller AL: Dialectical behavior therapy adapted for suicidal adolescents. Davies M: Adult sequelae of adolescent depressive symptoms. Heard HL. et al: Rapid response to psychosocial treatment for adolescent depression: a two-year follow-up. et al: Randomized trial of group therapy for repeated deliberate self-harm in adolescents. Harrington R. 2009 Wood A. Valeri SM: Effects of psychotherapy for depression in children and adolescents: a meta-analysis.184 Cognitive-Behavior Therapy for Children and Adolescents Weisz JR. 2006 Weisz JR. Southam-Gerow MA. J Child Psychol Psychiatry 37:737–746. Trainor G. et al: Cognitive-behavioral therapy versus usual clinical care for youth depression: an initial test of transportability to community clinics and clinicians. Moore A: Controlled trial of a brief cognitive-behavioural intervention in adolescent youths with depressive disorders. J Am Acad Child Adolesc Psychiatry 40:1246–1253. Rothwell J. 1996 Wood A. Gordis EB. 2001 . McCarty CA. Psychol Bull 132:132–149. J Consult Clin Psychol 77:383–396. Ph. and addressing psychosocial stressors that may impact the course of disorder).D. mitigating symptom exacerbation. childhood-onset and early adolescent–onset bipolar disorder appear phenotypically similar to adult mixed manic. albeit adjunctive.D. even when medicated. and frequently treatment-resistant bipolar disorder. Fristad.. these youth.g. preventing or delaying the onset of future mood episodes. are likely to relapse (Geller et al.6 Bipolar Disorder Benjamin W. ABPP PHARMACOLOGICAL treatment (mood stabilizers or atypical antipsychotics) is considered the first-line approach to manage pediatric bipolar disorder (McClellan et al.. 2007). especially from the standpoint of illness management (e.. Empirical Support A small but growing literature base supports the use of cognitive-behavior therapy (CBT) in the treatment of pediatric bipolar disorder (Table 6–1). The refractory nature of pediatric bipolar disorder underscores the important. Ph. 2002). thus. However. Mary A. chronically cycling. role of psychotherapy in treating the disorder. M. promoting healthy and affectively moderating lifestyle choices.Ed. Fields. 185 . and overall symptoms) and global functioning found in Pavuluri et al. attention-deficit/hyperactivity disorder (ADHD). 2004 Improvement in child symptoms (mania. 2009 Improvement in child manic symptoms and psychosocial functioning (parent rated) Decrease in child depressive symptoms. 2007 Improvement in child symptoms (mania. no control West et al. psychosis. decrease in parenting stress. sleep disturbance.Intervention Study design Citation(s) Significant findings Null findings Open trial. and overall symptoms) and global functioning CFF-CBT maintenance program plus medication management Open trial. depression. Studies of CBT-based interventions for the treatment of pediatric bipolar disorder . depression. 2004 maintained over 3-year follow-up CFF-CBT adaptation for group treatment plus medication management Open trial. aggression. no control Pavuluri et al. aggression. psychosis. increase in parent knowledge of and perceived self-efficacy in dealing with child’s disorder Cognitive-Behavior Therapy for Children and Adolescents Child. no control West et al. ADHD. improved child psychosocial functioning (child rated). sleep disturbance.and family-focused cognitive-behavior therapy (CFF-CBT) or RAINBOW program for pediatric bipolar disorder CFF-CBT plus medication management 186 TABLE 6–1. 2006 Improvement in child depressive and manic symptoms and overall behavior problems. less episode or mania. 2008 Reduction in time to recovery Treatment group as compared from any mood episode or with control group: More mania. gains maintained or increased 15 months posttreatment with continued medication management and trimonthly FFT-A booster sessions FFT-A plus medication management Randomized controlled trial (control= “Enhanced Care” plus medication management) Miklowitz et al. weeks free time spent in depressive of all mood disorder episodes. no control Miklowitz et al. Studies of CBT-based interventions for the treatment of pediatric bipolar disorder (continued) 187 . greater remitted from mania. increase in time to favorable and rapid recovery recurrence of any mood from depressive symptoms. more favorable or hypomania trajectory of depression Bipolar Disorder TABLE 6–1. more overall reduction in mood favorable trajectory of mania severity.Intervention Study design Citation(s) Significant findings Null findings Family-focused treatment for adolescents with bipolar disorder (FFT-A) FFT-A plus medication management Open trial. more weeks without symptoms. and time depressive symptoms. 2004. improved interpersonal functioning Interpersonal and social rhythm therapy for adolescents with bipolar disorder (IPSRT-A) IPSRT-A plus medication management Open trial. increase in child-perceived social support from parents. 2002. improvement in global functioning Psychoeducational psychotherapy (PEP) Multifamily psychoeducational psychotherapy (MF-PEP) plus treatment as usual Randomized controlled trial Fristad et al. no control Goldstein et al. and attitude toward treatment. depressive and general psychiatric symptoms. support. improved service utilization Decrease in child mood severity. increase in positive family interactions. Studies of CBT-based interventions for the treatment of pediatric bipolar disorder (continued) . 2003 Treatment group as compared with control group: Improved parental knowledge of mood disorders. no control Hlastala et al. decrease in negative family interactions Cognitive-Behavior Therapy for Children and Adolescents Dialectical behavior therapy (DBT) for adolescents with bipolar disorder DBT plus medication management 188 TABLE 6–1. depressive symptoms.Intervention Study design Citation(s) Significant findings Null findings Open trial. and suicidality Decrease in manic symptoms. improved parental skills. increase in childperceived social support from peers. 2007 Decreased affective lability. 2010 Decreases in manic. 2009 Treatment group as compared with control group: Decrease in overall mood severity. improved family climate and global functioning Bipolar Disorder TABLE 6–1.Intervention Study design Citation(s) Significant findings Null findings Psychoeducational psychotherapy (PEP) (continued) MF-PEP plus treatment as usual Randomized controlled trial Fristad et al. Studies of CBT-based interventions for the treatment of pediatric bipolar disorder (continued) Improved treatment utilization 189 . Mendenhall et al. 2009. improved service utilization Individual-family psychoeducational psychotherapy (IF-PEP) plus treatment as usual Randomized controlled trial Fristad 2006 Improvement in overall child mood severity and family climate IF-PEP Case studies Leffler et al. 2010 Decreased manic and depressive symptom severity. Treatment feasibility has been found to be high. in combination with closely supervised medication man- . and global functioning as rated by therapists.190 Cognitive-Behavior Therapy for Children and Adolescents Although only a minority of this research (with roots in the more sizable literature involving psychosocial treatment for adults with bipolar disorder) focuses on treatment nominally identified as CBT. FFT-A was designed to be implemented in twenty-one 50-minute sessions over a 9-month period. 2007). restructuring negative cognitions. child-only and parent-only sessions. including the establishment and maintenance of healthy routines. The program is composed of 12 hourlong sessions implemented over 6 months. Miklowitz and colleagues (2004. Booster sessions focus on potential barriers to treatment. regulating affect. social skills training. psychosis. problem-solving techniques. A maintenance model of CFF-CBT. (2004) have developed child. although the use of random assignment and independent evaluators in future trials will help to evaluate the true efficacy of the program. Parents have indicated high satisfaction with the treatment protocol and efficacy. and the identification of a useful and accessible social support system. in which both parents and children participate. suggest the addition of a CBT-oriented adjunctive treatment may hold promise for effecting and maintaining therapeutic gains with a pediatric bipolar disorder population. symptoms of attention-deficit/ hyperactivity disorder. Pavuluri et al. building self-efficacy and coping skills. 2008) have developed familyfocused treatment for adolescents with bipolar disorder (FFT-A). aggression. and they unexpectedly miss (“no showing”) an average of less than one session. sleep disturbance. CFF-CBT is delivered in conjunction with medication management and organized around seven general components. An adaptation of Miklowitz and Goldstein’s (1997) family-focused treatment for adults. Participation in an open-label trial of CFF-CBT has been associated with improvement in mania. 2006. and a session for siblings to participate along with parents.and family-focused cognitive-behavior therapy (CFF-CBT. also referred to as the RAINBOW program) for children and adolescents with bipolar disorder. depression. families attend most sessions. has also been developed (West et al. Preliminary results of the maintenance model—the addition of which has successfully maintained improvement in symptom severity and global functioning associated with CFF-CBT over a 3-year follow-up period—along with results of the original CFF-CBT trial. Meetings include combined family sessions. in which the original treatment is followed by psychosocial booster sessions and continued medication management. interventions designed for youth with bipolar disorder are largely based on techniques traditionally associated with CBT and implement strategies consistent with it. (2007) have piloted the use of dialectical behavior therapy (DBT) for adolescents with bipolar disorder. The addition of trimonthly maintenance therapy sessions and continued pharmacological management over the 15 months following initial treatment with FFT-A has resulted in overall maintenance of these treatment gains— although as might be expected given the cyclical nature of bipolar disorder. and treatment noncompliance. Treatment has demonstrated feasibility (i. parents. and participants have reported satisfaction with both the psychotherapeutic approach and patient progress. 2004). Treatment aims to promote understanding of bipolar disorder.’s (2006) DBT manual for suicidal adolescents. The primary aim of treatment is to improve affect regulation (the lack of which lies at the core of bipolar disorder). and maintaining low levels of conflict in the home) demonstrated a longer time to recovery from depressive episodes. as well as in behavioral problems. more time spent in depressive episodes. the intervention utilizes both family skills training and individual therapy (36 total treatment hours) implemented over the course of 1 year and delivered as an adjunctive treatment to medication management. FFT-A has been associated with substantial improvement in depressive and manic symptoms. 2004). high attendance and minimal dropout). including its etiology and factors contributing to its course and outcome. Goldstein et al.g. interpersonal dysfunction. the addition of psychoeducation. symptoms appear to wax and wane throughout the follow-up period (Miklowitz et al. medication compliance. 2008).e. depressive .. including suicidality. Modifications for adolescents with bipolar disorder include family involvement in treatment. as compared with patients receiving FFT-A.Bipolar Disorder 191 agement. and higher depression severity scores over time. FFT-A is primarily composed of psychoeducation and skills training in the areas of communication and problem solving and allows for the involvement of the patient. patients receiving enhanced care (consisting of three psychoeducational family sessions focusing on relapse prevention. Clinically significant improvements have been found in the areas of affective lability. 2006). over the course of an open trial (Miklowitz et al. and taking action to modulate manic and depressive mood states). and siblings. Based on adaptations of Miller et al. FFT-A plus pharmacotherapy has also demonstrated superiority over an enhanced care intervention combined with pharmacotherapy (Miklowitz et al. recognizing the signs that mood is becoming dysregulated. Although neither treatment appreciably impacted manic symptoms in this study. identifying particular mood states.. along with other features of bipolar disorder. and skills training specifically applicable for bipolar disorder (e. as well as to equip patients and families with the skills to positively impact the course of the disorder (Miklowitz et al. and childonly groups for the majority of each meeting. depressive. IPSRT-A. employ family involvement. The authors have not yet investigated the mechanisms through which improvement was effected. also based in part on interpersonal psychotherapy for adolescent depression. has recently been adapted for use with adolescents with the disorder (IPSRT-A.e. IPSRT-A was found to be feasible (i. Further. with children continuing to improve through 18-month follow-up (Fristad et al. manic symptoms at intake were generally mild. an empirically supported adjunctive treatment for adults with bipolar disorder. nonspecific therapeutic factors (e. and effective communication.. an earlier version of MF-PEP consisting of six 75-minute sessions was also associated with positive clinical outcomes (Fristad et al. although randomized controlled trials are necessary. symptom . 2010).g. and overall psychiatric symptomatology. 2009). support). These programs. The multifamily format of PEP (MF-PEP) includes eight weekly 90-minute sessions. 2003).192 Cognitive-Behavior Therapy for Children and Adolescents symptoms. delivered alongside treatment as usual. Participation in a randomized controlled trial of MF-PEP has been associated with significant improvements in overall child mood severity. ultimately leading to better management of the disorder through more adaptive family functioning and optimized utilization of available services. and the promotion of structure and routine in the areas of social activities and sleep. 2009). 2003. 2010). psychoeducation. Whereas improvement in manic symptoms has been nonsignificant. addressing salient interpersonal difficulties. but break into parent. Hlastala et al. problem solving. Fristad and colleagues have developed psychoeducational psychotherapy (PEP) treatment programs for use with children with bipolar disorder (Fristad 2006. 2002. In an open trial (Hlastala et al. affect regulation.. Fristad et al. 2002. as well as in global functioning. As intended. in which parents and children meet in a large group at the beginning and end of each session. calling into question whether treatment gains were due to the specific aims of therapy or related to other. The primary components of IPSRT-A include psychoeducation regarding bipolar disorder. high attendance and minimal dropout) and satisfactory to adolescent participants. Patients’ interpersonal functioning also did not demonstrate significant improvement. with the aim of increasing parent and child understanding of bipolar disorder and factors that may impact its course. uses both individual therapy sessions and family psychoeducation (16–18 total sessions) delivered over the course of 20 weeks as an adjunctive treatment to medication management. making a significant decrease difficult to achieve. and skill building in the areas of symptom management. and suicidality (in terms of both ideation and attempts). significant improvements were found in the areas of manic. Finally. Interpersonal and social rhythm therapy (IPSRT). in order to evaluate the true significance of these findings. Miklowitz et al. 2009). delivered over the course of sixteen 50-minute sessions. the similarities. itself. cognitive restructuring. Larger-scale trials are necessary. treatment) (Mendenhall et al.Bipolar Disorder 193 improvement was mediated by better utilization of services. Characteristics of CBT for Bipolar Disorder Although each of the above treatments has unique qualities.e. Thus. Although little research has examined the impact of expressed emotion on the course of pediatric bipolar disorder. preliminary data reported by Miklowitz et al.. several of the interventions used in the treatment of . knowledge of. 2010). and affect regulation. In addition to family involvement in the logistics of initiating and maintaining treatment. has also been associated with improvement in mood symptom severity through 12-month follow-up. suggesting expressed emotion may exert a powerful effect on bipolar disorder in younger patients as well. and PEP. This model has been extended to twenty 50-minute sessions with four optional “in the bank” sessions. 1988). 1986. was mediated by parents’ beliefs about treatment (i. particularly of CFF-CBT. however. because of the impact of family dynamics on the course of bipolar disorder. are striking. All involve working with the family. and attitude toward. initial case studies indicate it has good consumer evaluations and is associated with improved mood and family functioning (Leffler et al. a phenomenon that. research indicates that families likely play a pivotal role in the ultimate success or failure of treatment. primarily the parents. as well as improved family climate and treatment utilization and high consumer satisfaction in a randomized controlled trial (Fristad 2006). hostility. skill building in communication. and are conceptualized to work in an adjunctive manner to medication management. problem solving. but also some attention is paid to sibling relationships. a term referring to family interactions characterized by criticism. High levels of expressed emotion. CFF-CBT and PEP also include specific units on working with schools. All involve psychoeducation. have been associated with poorer illness course in adults with both depressive and bipolar disorders (Hooley et al. (2006) indicate that adolescents with bipolar disorder living in high–expressed emotion families evidence higher levels of mood symptoms than those in low–expressed emotion families. and emotional overinvolvement. FFT-A. An individual-family version of PEP (IF-PEP). life stress has also been associated with a poorer course of illness. Having thus established the importance of involving both families and patients in treatment. effective CBT is applied as an adjunctive intervention. however.e. information regarding comorbid diagnoses. CFF-CBT.. found adolescents suffering from higher levels of chronic stress (including family-related stressors) demonstrated less improvement in both depressive and manic symptoms.g. the issue becomes what materials to employ in the course of intervention. provided with information that they are able to both process and utilize with the intent of becoming more active and competent members of the treatment team— are more likely and more able to make choices that are optimally beneficial to the patient and his or her mental health. as implemented in the psychosocial interventions described earlier. to supplement and support first-line pharmacotherapy. Kim et al. In addition to the role that negative family interactions may play in bipolar disorder. 2000). (2007). another aim of psychoeducation. The rationale for including psychoeducation in treatment is that families and patients who are educated about this disorder—that is. 1990) (i. the role of different treatment providers. given the high rates of medication noncompliance in children and adolescents who are prescribed medication for bipolar disorder (Kowatch et al. Instead. CBT for bipolar disorder is not intended to serve as a stand-alone treatment. Psychoeducation. Thus. is to foster an appreciation for the essential role medication plays in treatment. as well as empathic responses toward the affected child. better symptom management and fewer episodes of relapse) and for max- . FFT-A. is a crucial first step in the provision of CBT. while simultaneously addressing the limitations of pharmacotherapy. and the importance of healthy routines in the management of bipolar disorder. Accomplishing this is no small task.194 Cognitive-Behavior Therapy for Children and Adolescents pediatric bipolar disorder (e. or teaching patients and their families about bipolar disorder. certain topics and themes are included in all CBT for bipolar disorder. These include the biological basis of bipolar disorder. as well as choices that are ultimately healthy for the patient’s family. symptoms of the disorder and methods for managing increases in these symptoms.. Psychoeducation involves much more than supplying informational handouts or recommended reading lists (though such materials may certainly be provided as part of the process) (Basco and Rush 1996). for example. As previously noted. Though the specific content of psychoeducation is necessarily fluid and subject to the growing research base regarding bipolar disorder. PEP) attempt to improve family interactions through promoting effective problem-solving and intrafamilial communication. increased adherence allows for maximum benefit from psychopharmacological regimens (Strober et al. Guidelines for identifying bipolar disorder in youth have been described elsewhere in considerable detail but generally include 1) obtaining a complete developmental history. Clinicians may also find an individual-family format desir- .e. Refer parents or other family members for individual treatment. The individual-family format outlined here. Both the cognitive and behavioral components of CBT are well represented in the treatments reviewed above for youth with bipolar disorder. cognitive restructuring. 2005). which are often necessary as individual responses to medication appear over time. is often more convenient for families. parents. a family history of mood and related disorders. and behaviors on which CBT is based—is provided in the remainder of this chapter. participants may benefit from opportunities to learn from the successes and struggles of others. Areas of skill building and skill refinement generally include effective problem-solving and communication techniques. and who may appreciate the more individualized consultation and privacy offered by such a format. and once the patient’s mood symptoms have been stabilized enough pharmacologically that retaining information and learning new skills are possible (Kowatch et al. A description of these techniques— emphasizing the bidirectional relationship between emotions. The primary advantage of conducting treatment in a multifamily format is the social support parents and children often experience through interaction with individuals facing similar issues. child. data from multiple informants (i. however. Once parents and children have a working knowledge base regarding bipolar disorder. a longitudinal examination of symptoms. Although a multifamily group format for PEP has been developed (MF-PEP). the therapeutic protocol described herein is designed for use in an individual-family format (IF-PEP). treatment progresses to increasingly skill-based content.. Fields and Fristad 2009a). 2009. In addition. and methods to enhance affect regulation. 2) systematically ruling out alternative medical and psychiatric diagnoses. thoughts. and 3) determining any comorbid diagnoses (Danner et al. and school). 2005). as needed. to reduce the overall level of dysfunction in the family (Kowatch et al. who may not wish to delay treatment until a new group can begin.Bipolar Disorder 195 imally efficient medication adjustments. Application The initiation of CBT for a child or adolescent with bipolar disorder should occur after assessment and diagnosis by a mental health professional familiar with the disorder. reinforcing newly introduced concepts for the child and updating the parent in regard to the child’s session content. especially in distinguishing feelings (e.g. happy) from thoughts (e. the general format of sessions is described. but parents participate at the beginning and end of each session. Each week’s project is an extension of whatever lesson has been worked on in that session and typically involves recording/monitoring the newly learned skill. in light of CBT’s emphasis on understanding and effectively employing the interactional relationship between feelings. allowing you to maintain engagement and continuity with all participants while also offering opportunities for private consultation with children and parents.. and behaviors. thoughts. General Structure of Sessions Sessions alternate between child-focused and parent-only sessions. These elements share much in common with the other CBT treatments for bipolar disorder in youth reviewed above. Homework (which is best referred to as “projects. IF-PEP. Reconvening at the end of a child session allows the child to “teach” that week’s material to parents.” “My mom is mad at me. then key elements of each session are discussed... a particularly large and involved school project may portend an increase in manic symptoms). and any particularly stressful or notable events that have occurred since the last visit and may impact the course of the child’s disorder (e. First.g. and often both as a family exercise. “I’m not sick enough to be here.196 Cognitive-Behavior Therapy for Children and Adolescents able.” “I’m a bad kid”).g. you will spend the majority of time working individually with the child. mad. parents. bored. Child sessions begin with a review of mood states (the first session usually requires some teaching to establish the practice of rating one’s emotions). This distinction is critical. Parents familiar with what their children have been working on in treatment are better able to reference meaningful concepts between sessions and encourage their children to use recently acquired skills. sad. In child-focused sessions. may need additional assistance with this step.” as few children cherish additional homework assignments) is assigned at the end of each session to children. Children also frequently . both because billing for services may be simplified and because many clinicians do not have access to a number of families appropriate for inclusion in multifamily group treatment. in particular. Meeting with both parents and child at the outset of each child session allows for collaborative review of assignments from previous weeks and provides a chance to touch base with parents in terms of the child’s general progress and mood. Younger children. Below appears an outline of one version of CBT. a death in the family or parent losing a job may increase the child’s vulnerability to depressive symptoms. the need for autonomy grows. for example. Child sessions end by teaching and reviewing. middle. mad. Early in treatment. and “normal” are often all they articulate. another significant adult caregiver (e. the more involved the parent will be in the session. might warrant the involvement of siblings earlier in treatment to best address the family’s needs.. Helping children become aware of a broader range of mood states is a beginning step in learning to regulate their own affect.Bipolar Disorder 197 begin therapy with a very limited vocabulary regarding emotions—sad. Developmental adaptations are always important to keep in mind. instead of waiting for the presentation of relevant material later in treatment. These types of alterations prevent treatment from being delivered in a cookie-cutter or impersonal fashion. then late adolescence. grandparent. and one closing session involving parents and child) dedicated to covering specific psychoeducational matter and skill-building exercises and up to four sessions reserved for additional coverage of particularly challenging content or for crisis management. Similarly. If a child has only one parent. the attending parent should communicate session content to the other and enlist this parent in utilizing the skills learned in treatment. In general. who may require varying levels of instruction and consultation. one family session involving siblings. 8 parent-focused sessions. Material can be presented in fewer meetings. one session with parents and school personnel. Though involving both parents in treatment is ideal. Expect up to twenty-four 50-minute sessions. for instance. as needed.g. breathing exercises that children can use as a calming technique. the child then rates the intensity of that mood. Excessive sibling conflict. the younger the child. as needed. with approximately 20 sessions (9 child-focused sessions. and are intended to lead to higher therapist and family satisfaction. aunt) may participate in treatment as well. They should be adapted to suit the needs of particular families. After labeling his or her current mood.” This routine encourages both accurate labeling and heightened awareness of the intensity of one’s emotions—fundamental skills needed before affect regulation will be successful. rely on a visual scale—a feelings thermometer—to illustrate how feelings can range in intensity from a healthy “middle” range to maladaptive and occasionally dangerous “highs” and “lows. In the not uncommon event that both parents have significant contact with the child but only one is able to attend treatment. As youth approach early. it may not be practical. for a family logistically unable to attend the full complement of sessions or for parents who begin treatment with considerable knowledge of the child’s condition. a family encountering an especially vexing issue may benefit from prioritization of that concern. . The sequence and number of sessions allotted to covering particular therapeutic content are suggested guidelines. 2) to help the child develop realistic treatment goals. Your motto for treatment is. and solution-focused approach to managing the disorder. “It’s not your fault. Parent session 1: setting the proper tone. mood charting. it is a card the family has been dealt and a challenge the entire family can and must confront. complete obliteration of any future symptoms is not realistic. while concurrently establishing a positive. as opposed to a “cure. which include the importance of regular attendance and practicing skills between sessions. Set the stage for establishing feasible treatment goals. goal setting. Underscore this perspective in future sessions by providing information regarding the biological etiology of bipolar disorder and by helping to distinguish the child from his or her symptoms. Begin the introductory session together with the parents and child.” Although no one is to blame for the child’s diagnosis. Share your expectations. taking steps to build friendships. and 3) to teach diaphragmatic breathing to use as a calming technique. inviting parents to rejoin at the end of the session to review progress and discuss activities to be completed before the next session. Finally. While with the child. After accomplishing the above. and developing a plan to address school concerns are all realistic and doable over the course of treatment.198 Cognitive-Behavior Therapy for Children and Adolescents Session 1 Child session 1: purpose of treatment. introduce both parents and child to the concept of bipolar disorder as a “no fault” disorder.” is the ultimate goal. Given the probable lifetime waxing and waning of symptoms. proactive. but it’s your challenge. improving family life through concrete actions. the planned duration of treatment. leading to a better outcome for the child. Revisiting this message throughout the course of treatment serves to alleviate guilt and shame surrounding the disorder. Successful management of the disorder. Orient them to the purpose of treatment. and symptoms of bipolar disorder. spend most of the remainder of the session with the child alone. emphasize that better understanding gained from this education along with skill building should improve treatment utilization and decrease family conflict. rating feelings. However. The first parent-only session includes presenting basic information about the diagnosis of bipolar disorder and information on tracking mood symptoms. you have three tasks to accomplish: 1) to help the child develop a basic understanding of his or her mood disorder as well as any comorbid conditions. and the potential for maintenance sessions after the initial course of intervention. The most important aim of . diagnosis and symptoms of bipolar disorder. Bipolar Disorder 199 the session. If parents express a deeper curiosity and would benefit from information regarding particular neuroanatomical and neurochemical abnormalities.. symptom duration. No one. while also easing parents’ fears that they are responsible for their child’s problems. and impairment necessary to meet diagnostic criteria. occupy an inordinate amount of family resources. different in size) and that these abnormalities. receive an unfortunate and often unfair share of the blame for these issues. Helping parents view bipolar disorder as a brain disorder can assist them in approaching their child’s mood and associated behavioral issues with compassion. including its high genetic heritability. including the symptoms. though the level of sophistication that will be useful to parents can vary significantly. attempting to alleviate parental guilt over the child’s diagnosis by introducing information on the heritability of bipolar disorder can inadvertently lead to more self-blame by some parents. hypoma- . and be extremely difficult to manage. in conjunction with chemical irregularities in the brain that affect how messages are sent between brain structures. as the saying goes. may be to set the tone for an empathic. you can pick your friends but not your relatives. so that terms such as mania. Without proper psychoeducation. Ironically. however. Provide parents with information on how bipolar disorder is diagnosed. selects his or her own genes. Providing information to parents regarding the neuroanatomy and neurochemistry putatively involved in bipolar disorder can also help place the disorder in a biological light. Parents. Essential to establishing this tone is the presentation of bipolar disorder as a no-fault diagnosis (briefly touched on in the introductory session). refer them to additional up-to-date scientific findings (see References at the end of this chapter for suggestions). Reminding parents of this can be useful in reframing unproductive and guilty cognitions regarding their child’s diagnosis. leading to a decline in positive interactions within the family and an increase in expressed emotion (discussed earlier as a potentially significant factor in the course of bipolar disorder). of course.g. it is sufficient to explain that various structures of the brain appear different in bipolar disorder than in typical brains (e. hopeful. parents can begin to view their affected child as selfish and willfully disruptive. Youth with bipolar disorder can exhibit exceedingly aversive behaviors. often in the form of criticism from friends and family who attribute the child’s behavioral difficulties to nothing more than poor parenting. in turn. are thought to be involved in the symptoms of bipolar disorder. In session. and solution-focused approach to treatment. who feel guilty over passing down the disorder. beginning with a focus on the biological nature of the disorder. This process requires helping parents develop familiarity with clinical nomenclature. Remember. In particular. In addition.. Reviewing mood logs at the beginning of each session helps to reinforce their importance with parents. thereby enlisting the child as a more informed and active participant in treatment. Session 2 Child session 2: “Naming the Enemy”. Although it is often difficult for parents to retrospectively report on a child’s mood fluctuation and potential triggers for this variation when they come in to a session. without fear of confusion.200 Cognitive-Behavior Therapy for Children and Adolescents nia. is an important tool in monitoring treatment progress in a child with bipolar disorder (Young and Fristad 2009). or the process of recording changes in a child’s mood. as well as the potential for suicidality. II. Regardless of whether psychotic symptoms are present. or not otherwise specified [NOS]. Mood charting. cyclothymia).. bipolar I. so too should parents. A multitude of different formats have been proposed for charting mood. describe psychotic symptoms that can occur in the course of pediatric bipolar disorder. T h e p r i m a r y goals of this session are twofold: 1) to assist the child in differentiating symptoms of bipolar disorder from his or her “self. and major depressive episode can be used meaningfully in treatment.g. child getting less sleep than usual) can impact the course of their child’s disorder. present a rationale for the child’s particular diagnosis (i. parents need to be aware this is a potential complicating feature of the disorder. depending on the future course of symptoms (e. along with how these symptoms differ from those of bipolar disorder.e. . a current diagnosis of bipolar II disorder would progress to bipolar I disorder in the event of a manic or mixed episode). address any other diagnoses the child may have been assigned.. interparent conflict. as well as an explanation for how this diagnosis is subject to change. and the level of detail that is appropriate depends on the family. Because youth with bipolar disorder are at elevated risk for suicidal behavior.g. Not only can this process help parents give treatment providers useful information in guiding medication adjustments. medications. even a low level of information provided consistently is typically of greater value than a high level of information provided sporadically. parents who have spent even a couple of minutes each day detailing their child’s mood and the events of that day are typically much more able to provide useful information. but such charting can also aid parents’ understanding of how psychosocial and somatic stressors (e.” and 2) to instill a firmer understanding of the use of medication in treatment for bipolar disorder. Just as children should be introduced to the differences between mood symptoms and symptoms of other disorders. To this end. “mean to brother. and how to provide useful feedback to the provider on how the medicine is working.” have the child write positive qualities about himself or herself (e. as opposed to being surmountable and temporarily obscuring the child’s positive qualities.. with two columns splitting the page below. Then. “artistic. and potential methods of mitigating these side effects (e. in which patients are encouraged to objectify problematic symptoms as separate from the self. In the left-hand column. inspired by the concept of “externalizing the symptom” (White and Epston 1990). including dosages. All too often. children should have an awareness of what they are taking. while simultaneously encouraging more positive self-esteem in children often in need of just such a boost. In the right-hand column. The child will do this again at home with his or her parents. how to manage the nearly inevitable side effects that occur with medications. labeled “Self.g. covering the child’s positive qualities with the half of the paper listing symptoms. children take medications with no knowledge of the names and dosages. who often struggle to ensure daily medication adherence. taking the medication with food for prescriptions causing stomach upset. symptoms can come to be seen by the child and others as static and reflective of the child’s true self. Raising the topic of treatment provides a segue into discussing the role medications play in managing bipolar disorder. it can be very helpful in changing the language families use to describe symptoms (rather than negative attributes about the child). fold the right side of the paper over the left. As medication adherence is essential to treating bipolar disorder. After the lists are complete.. Identifying symptoms of bipolar disorder as an external “enemy” reconceptualizes the problem as a challenge to be overcome rather than a burden to be passively endured. and explain that treatment can help “uncover” the child’s positive qualities once more. common side effects.Bipolar Disorder 201 The first goal can be addressed with the exercise Naming the Enemy (Fristad et al. keeping a bottle of water nearby for those causing dry mouth). Over time. refold the paper so the right side is behind the left side. To implement Naming the Enemy.” “good sense of humor. review information with the child about the medications he or she is taking.g. the reasons for doing so.” “cries a lot. Explain how the symptoms of bipolar disorder can cover up the wonderful attributes the child has to offer.. Children invested with this knowledge gain an additional stake in their treatment—a sense of ownership likely to be welcomed by parents.” “brags too much”). let alone the purpose of these prescriptions. write the child’s name at the top of a page. the symptoms each medication is intended to address. Note that a discussion of why the medication has been prescribed may necessitate consultation with the . 1999).” “helps Grandma”).g. have the child write his or her mood symptoms as the child understands them (e. .. and necessary measures to ensure safety (e. In addition to the necessity of using medication regularly and according to directions. competent medication providers should alter prescriptions in response to feedback from parents and the patient to optimize treatment response. but ensure that parents understand the reason for each medicine the child is taking. In particular. Parents should also know that the best way to handle concerns regarding a perceived inadequate response to medication or impairing side effects is through a thoughtful analysis of the costs (side effects) and benefits (symptom relief) of continued administration. and even type of medication are not uncommon or indicative of substandard treatment. decisions regarding alteration or discontinuation of somatic treatment should not be undertaken without proper medical supervision. as medications are often used off label or to counteract side effects of other medications. Be prepared to review fundamentals of taking medication. This approach also applies once medications begin to relieve symptoms or even appear to resolve them completely. communicate to parents that medications are not a panacea and only part of managing what is typically considered a chronic illness. benefit from information regarding the treatment their children are receiving. the target symptoms for which they are designed. too.g. including a mood-medication log that records treatment response and side effects. in combination with careful consultation with the prescribing physician. enables the physician to proceed in the safest and most efficient manner. administration time.202 Cognitive-Behavior Therapy for Children and Adolescents child’s psychiatrist or pediatrician. take as soon as possible or wait until the next scheduled dose). blood draws for monitoring mood stabilizer levels). Although it is clearly parents’ prerogative to make important choices about their child’s health.g. parents need to be aware that somatic treatments may require some time to take maximum effect and that medication adjustments are a routine part of refining a bipolar disorder treatment regimen. Help parents understand the basic classes of medications. Polypharmacy may be necessary. Parent session 2: medication and other treatments. and their common side effects.. such as what to do when a dose is missed (e. Familiarizing parents with the limitations of pharmacotherapy is necessary to foster realistic expectations of treatment and the prospective course of bipolar disorder. On the contrary. Parents. Changes in dosage. Despite the primary role of psychopharmacology in treating bipolar disorder. management of symptoms rather than elimination of the disorder. in the morning or evening. with food or without). as .g. parents should be clear regarding their child’s current medication regimen and the purpose of medication in treating bipolar disorder—in short. Effective communication. when and how medications are to be taken (e. as well as how those side effects can be managed. ” Her mother. participating in a social skills group. pharmacotherapy may be recommended until mood symptoms have remained dormant for several months. one acute antidepressant-induced manic episode versus multiple depressive and hypomanic episodes). Emily’s father views medication as a crutch—moderately helpful in the short term. It also seemed like my dad always had problems with depression. Mom: Between mood problems and diabetes. If so. Dad: I struggle with depression. receiving electroconvulsive therapy) for bipolar disorder or comorbid conditions while engaged in a CBT program. Upon beginning psychoeducational psychotherapy. and there was some talk about my grandmother having manic depression. Emily’s parents are vocal regarding their medication concerns. On the one hand. and it seems like half my cousins have been on antidepressants. Therapist: Diabetes runs in your family? Mom: I actually have an insulin pump. Depending on the extent and nature of the child’s mood history (e. the therapist’s first step is to provide basic psychoeducation regarding the biological nature of bipolar disorder. too. but ultimately undermining Emily’s ability to “really deal with her problems. in spite of frequent medication adjustments. Case Example: The Medication Dilemma Emily is an 11-year-old girl who received a diagnosis of bipolar I disorder a year ago after a manic episode that resulted in hospitalization. too.Bipolar Disorder 203 it may be that medication is not only alleviating symptoms but preventing their return. Mom: My sister is also bipolar. on the other hand. After the therapist discusses the high heritability of the disorder. has grown weary of Emily’s incomplete symptom remission. seems like our family can’t catch a break. My mom was diabetic. Therapist: So is there a difference between a diabetic who needs insulin and someone with bipolar disorder who needs medication? . she has undergone numerous medication trials. The therapist uses this opportunity to address Emily’s father’s aversion to Emily taking medication. Since then. or other treatments may have been proposed. and so is my brother. this session is an opportunity to discuss these other treatment options and to provide basic information regarding the purpose of such therapies.. In response to these concerns.g.g.. It is possible that children may be receiving other treatments (e. or maintained indefinitely for prophylactic reasons. Emily’s parents are able to identify a familial pattern. better. Therapist: And I’m not trained to prescribe medications either. and I like that she takes time to explain what the medications are for. though. so when you say Emily’s not “better.. . and they’re very important in managing bipolar disorder. That’s why the medication is essential.” Mom: I hate to say it. sometimes talks about sexual things— it can be so embarrassing and frustrating.” it sounds like you’re saying that she still has some symptoms. Dad: But we’re not doctors. though.. Mom: Not me.. And that’s after who knows how many med changes. Therapist: I don’t think there are many parents who love the idea of their child needing medications. Therapist: Right. Mom: Oh. . but it’s not like she’s ever been . I think we should make sure we’re working with her in the most effective way. Without my pump. This is an opportunity for the therapist to foster an appreciation for the active role Emily’s parents can play in the complex task of medication management of bipolar disorder. we may never totally get rid of all those issues. and we can’t tell her what medications to prescribe. . and it sounds like you feel comfortable with her. too. She still has rages sometimes. And has she needed to be hospitalized since starting her medications? Mom: No. Therapist: Those are important qualities in a physician. but only if manic symptoms like Emily’s are stabilized first. she’s been really supportive.normal. Therapist: Let’s talk about what you mean by “better. but. Therapist: OK.204 Cognitive-Behavior Therapy for Children and Adolescents Dad: Well.. (To the mother:) Managing your diabetes involves more than just taking insulin. Mom: That’s true. yes. It was awful. We can make sure the doctor has the most complete information about Emily. and really. I’m really careful. I just don’t like it. Dad: But maybe Emily’s bipolar disorder isn’t that bad. so before making a big change like switching doctors. It also sounds like. that her medications have helped reduce her symptoms. sometimes diabetes can be controlled with diet and exercise. I’m in trouble. has nights where she’s up forever. Maybe she can manage without it if she just had the right—I don’t know—tools. But how can we be sure she’s on the right medications? Dad: Yeah. but let’s look at Emily’s history. sometimes it seems like her psychiatrist is just throwing darts at a dartboard. right? . How were her symptoms before she began the medication? Dad: She ended up in the hospital. Therapist: Finding the best medication or even combination of medications can definitely be a long process. Dad: I don’t know. But Emily’s doctor has a lot of experience working with kids like Emily. Dad: Maybe if we had a different doctor? Therapist: Maybe. though. Therapist: Research would suggest that learning coping skills may be enough to address depression. As long as Emily is taking the medications as prescribed.Bipolar Disorder 205 Mom: Sure. This involves structuring an environment conducive to sleep and may require relocating a television or video game system to another room and setting guidelines for hours of use. are important steps. Therapist: That monitoring is just as important with bipolar disorder. but rather on establishing lifelong healthy eating habits. Much as sleep can play a role in mania. Her symptoms can change so much from week to week. watch my weight. the dosage adjusted. In this first session devoted to healthy routines. and she can see details of how Emily’s symptoms have fluctuated without you having to recall them on the spot. the child will pick a second goal from this list in his or her seventh session. but it’s so hard to keep track of everything. including helping the child maintain a healthy weight. The emphasis here should not be on dieting. Dad: Yes. and exercise is an important aspect of regulating mood. many ways in which a child can increase activity levels also increase social interaction. or both. When you take Emily to see the psychiatrist. Regulating sleep. and develop strategies for those goals to succeed. or a martial arts class. Additionally. Session 3 Child session 3: establishing healthy routines. often in the face of intense carbohydrate cravings. Inadequate sleep can trigger mania (Malkoff-Schwartz et al. provide an overview of these three topics. and have the child pick the topic he or she finds most troublesome to focus on first. 2000) and is a frequent cause of increased irritability. Increasing physical activity has several added benefits. playing in the park where other kids have gathered. . nutrition. which can lead to self-esteem concerns. you can actually take the log to her. The next time you go to the psychiatrist. I have to watch what I eat. for example. set goals for proper rest. a focus on healthy food choices is often beneficial. the doctor can make the most informed decision about whether Emily’s medications should be changed. Many medications prescribed for youth with bipolar disorder lead to weight gain. 1998. exercise has been found to decrease depressive symptoms (Pollock 2001). even day to day. Reviewing fundamentals of nutrition guidelines and troubleshooting how the child can make wiser food choices. Monitor the child’s progress with this first goal in each subsequent session. Thus. Therapist: That’s why the daily mood logs we will discuss are so important. Help the child identify any dysfunctional sleep practices. which also has physical and mental health benefits. Before I got my pump. I bet she asks you lots of questions about her symptoms. I had to monitor my sugar levels regularly. not to mention very real health concerns of type 2 diabetes and hypertension. through a team sport. This exercise provides an opportunity to identify gaps in provided services and to address misconceptions parents may have about the responsibilities or capabilities of different treatment team members.. and conceptualizing the group as a team pursuing a common goal (i. Healthy behaviors that become normative for the family as a whole are more likely to be permanently adopted by the individual child. reporting . is integrally tied to how the child’s family functions. it can be easier to maintain a positive therapeutic relationship and can reduce frustration over the limited time a psychiatrist may have to engage in a discussion regarding effective problem-solving or the inability of a psychologist to arrange a medication refill. Whereas treatment providers may change over time depending on the child’s needs and logistical considerations (e. This discussion should emphasize the active role of parents and children on the treatment team. Children with bipolar disorder also frequently require school-based services. diet. Further. frequently operating out of different agencies or offices. When parents understand.e. Both parents and children will learn skills in treatment to make them more effective contributing members to the treatment team. Identifying these individuals. particularly for younger children. their role and training. Parent session 3: understanding the mental health system and the school system. changes in insurance coverage). rating school behavior. for example. exercise. and most of all. they should be able to construct a representation of their child’s mental health treatment team and their educational team..206 Cognitive-Behavior Therapy for Children and Adolescents This session will likely require more parental involvement..g. By the end of the session. Children with bipolar disorder often require mental health treatment teams composed of a range of service providers.g. that their child’s psychiatrist may focus largely on medication management and depend on the child’s psychologist to provide behavioral intervention and any necessary psychoeducational testing. your task is to help parents understand the mental health system and the school system in relation to their child. parents are constant members of the team and should feel empowered to serve as their child’s primary advocates. The professionals who provide these services work in collaboration with clinical treatment providers (e. and the service each team member typically provides. Parents need a fundamental understanding of the child’s current treatment providers. parents familiar with the role of each service provider are better able to identify the most useful contact to consult with questions that arise over time. family moves. In this session. Changing patterns of sleep. successful management of the child’s disorder) are necessary for optimal treatment utilization. elucidating the role each can or should be playing. . Second. In addition to neurocognitive deficits these students may exhibit. physical cues. feelings and actions. 2006). attention. This should include copies of all correspondence sent to or received from school. other health impaired [OHI]. school professionals also compose an educational team. Review with parents the various types of school personnel who might be beneficial for their child. an Individualized Education Program. Encourage a cooperative. parents need to understand what school services are potentially available. Thus. so they have a more comprehensive and realistic understanding of what schools can provide.e. encourage parents to keep a binder containing all materials related to the child’s school services. and behaviors impact each other.. 2002. 1995). Third. 2004. Additionally. Begin by helping the child to identify a . dates and brief descriptions of phone calls and voice mails. coach parents on how to ask questions when they are unclear regarding any procedures or expectations. clinical treatment providers. then translating this knowledge into skills to relieve or prevent symptoms and impairment. requiring both academic and behavioral intervention to adapt successfully to the demands of school (Geller et al. and the myriad school labels and classification systems (e. Session 4 Child session 4: triggers. coping tool kit.g. review information described above with parents. solution-focused relationship among parents. a 504 plan vs. implementing behavior plans constructed in conjunction with therapists). severe behavior handicap [SBH]) so they can begin to determine how best to advocate for their child in the school setting. and processing speed. and school service providers that will facilitate better utilization of available services (Fields and Fristad 2009b). or IEP). routinized steps. feelings. Review with parents several concrete steps they can take to enhance their child’s school-based services. Undertaking this practice with children requires a developmentally appropriate approach that organizes the process into manageable. First. Competent school personnel will appreciate parents’ concern for their child and appreciate the opportunity to clarify information before miscommunication can sow conflict. Pavuluri et al. fluctuating symptoms of mania and depression during the course of the disorder can also impact school performance (McCarthy et al.Bipolar Disorder 207 suspected medication side effects to parents. including impairment in memory. Wozniak et al. Perhaps the technique most identified with CBT is increasing patient awareness of how thoughts. and notes taken at any meetings with school personnel. the different mechanisms of school-based support (i. Youth with bipolar disorder frequently evidence significant dysfunction in the school setting. while adolescents may prefer to make a list that can be tucked into a school binder or posted on their bedroom wall. Younger children often enjoy constructing and decorating an actual shoebox or other container for this purpose. the child grabbed the video game controller from her brother and threw it against the wall (actions). A child could indicate. using that strategy when thoughts are starting .. In response to her anger. She could tell she was becoming angry because her “forehead got wrinkled” and she began biting her lip (somatic sensations). that she became angry last week when her mother allowed a sibling to play the video game she was hoping to play (the “trigger”). relaxation tools might include reading a book or listening to soothing music. and social (CARS becomes a useful acronym to remember these categories—just as a car can take someone places he or she wants to go. active tools might include shooting baskets or playing on the jungle gym. Often children claim no awareness of physical indicators of mood states. but it won’t work when the child is at school. To help the child successfully identify an assortment of coping responses. breaking a button and rendering the game unplayable. an event that elicited negative feelings. Regardless of the chosen format. children often begin to respond. Similarly. however. the tool kit should include a range of coping strategies that can be implemented in a variety of situations and in response to a number of maladaptive or “hurtful” emotions. If you provide examples (e. and the somatic sensations that accompanied those feelings. Creative “tools” might include drawing or playing the piano. active. Talking to a trusted teacher or using one of the breathing techniques taught in therapy.208 Cognitive-Behavior Therapy for Children and Adolescents recent trigger. for example. break strategies down into four basic categories: creative. For example. riding a bike might be an excellent strategy for the child to use at home when feeling grumpy. listening to dance music when feeling sad is a reasonable and adaptive strategy to use at home. would work in a school setting. on the other hand. Coping strategies need to match the child’s situation and mood. After identifying an example that illustrates how negative feelings can lead to negative choices and behaviors. face flushing when angry. As a result of these actions. these coping CARS take a person to the mood state he or she prefers).g. Next. the next step is to assist the child in developing a coping tool kit. stomach tightening when afraid). have the child identify actions he or she took in response to these negative feelings. relaxation. This tool kit will contain reminders of effective strategies—identified by the child—to help the child regain control of his or her emotions and self-soothe. she was unable to play the game at all and was yelled at by her mother (consequences). along with the eventual consequences of these actions. and social tools might include calling a friend on the phone or playing with the family dog. can make the child appear intolerant.g. while at the same time extraordinarily needy and unsure of himself or herself. self-centered. Fristad et al. Families with children who have bipolar disorder often inadvertently engage in negative interactional cycles characterized by a focus on negative behaviors. Selecting a soothing activity instead (e. To enhance communication between parents and children.. feelings. “My child doesn’t care about my feelings”. The use of the word appear is notable. Keeping in mind developmental needs. and action box. “My spouse never wants to help out when Joey is raging”) and then using the traditional CBT technique of reframing negative or hurtful thoughts in a more positive or helpful manner. Children cannot control the feelings they experience. use the same cartoon version for both parents and children in their respective sessions. frustration.Bipolar Disorder 209 to race hypomanically could provide excess stimulation. a cartoon version of the link among thoughts. but they can take responsibility for their actions and choose to respond to feelings in a helpful manner. The silhouette of a cartoon figure is connected to a thought bubble. taking a bath) would be a more appropriate choice in this circumstance. A child with bipolar disorder presents significant challenges for a family. 2008). assigning blame for these behaviors (directed at both the affected child and parents). potentially exacerbating symptoms and leading to poor decisions.g. and domineering. feelings heart. wild. coercive behavior. lazy. accompanied by the text “Something Happens!” and an oval for the child to record the triggering event. Addressing negative family cycles begins with first identifying negative cognitions (e. and actions was developed. and eventual feelings of rejection and isolation for parents and children. rather than emblematic of core personality flaws considered largely beyond the reach of therapeutic intervention. The contrast between helpful and hurtful thoughts is quite salient. The cartoon has a light switch at the bottom of the page. as it orients parents to the treatment’s emphasis on progress and serves as a reminder of the ultimate goal of CBT for bipolar disorder—helping the child (and the family as a whole) to function more effectively in the face of bipolar disorder. instead of identifying who is most at fault. The concept of choice is of considerable significance in this exercise and a theme to be emphasized throughout treatment. called “ThinkingFeeling-Doing” (TFD. Parent session 4: negative family cycles. along with those of commonly comorbid conditions such as behavioral and anxiety disorders.. with space to record the “hurt- . in that it is likely more accurate (and certainly more helpful) to view the child’s aversive behavior as a manifestation of the disorder. Symptoms of a child’s mood disorder. each of which are divided in half. Thinking-Feeling-Doing. while also noting how much easier it is to act positively in response to problem-focused. “This is an opportunity to help Makayla learn how to manage these emotions. Thus. Next. parents could reframe the event in a way that emphasizes learning something from the experience (e. have parents recall the negative thoughts that accompanied these feelings (e. the first area on which to focus is negative thinking. help parents to generate ideas for actions that would have been more helpful in this situation.” they could reframe the event in a way that differentiates the child from the symptom (e. Instead of thinking “Makayla is so selfish. “We’ll never be a normal family”. For exam- . helpful thoughts.. frustration.210 Cognitive-Behavior Therapy for Children and Adolescents ful” or negative thought. To explain TFD.g. Although it might seem easiest just to eliminate the frustrating event in the first place. Once parents have identified the negative feelings and thoughts that arose in response to an event. Ask parents to notice the negative cycle that occurs: negative feelings lead to negative thoughts. and parents deserve to hear this from someone who understands the challenges they face on a daily basis and who is supportive of their desire to seek help... Simply acknowledging these inevitable and understandable thoughts is a requisite step in this approach and provides an opportunity to validate the frustration and hurt experienced by parents struggling with a child with a mood disorder (e.g. or fatigue) and that they didn’t feel they handled particularly well (e. It’s not easy raising a child with bipolar disorder. begin by asking parents to identify a recent event that triggered negative feelings in themselves (e. Then help parents understand where they can intervene to break the cycle. and action in the upper half. feeling. “Makayla threw a tantrum just as we were leaving for a nice dinner—the babysitter refused to deal with her.g. “Makayla’s really struggling with her manic symptoms this week. and helpful ways of thinking about the event. Encourage parents to brainstorm more positive.g. and action in the lower half and the “helpful” or positive/desired thought.g. Alternatively. “I can imagine how disappointing it was to anticipate a relaxing night out and to have that fall through at the last minute”)..g... feeling. Next. Further. anger. this isn’t always under parental control. she’s been much more irritable and hasn’t been sleeping much”). “What’s the use of trying?”). went to my room. “I yelled at Makayla.. and we had to cancel our night out”). which lead to negative behaviors. have them specify the actions they took in response to these thoughts (e. because the babysitter might not have been able to help her through this as well as we can”). “Makayla is so selfish”. and cried”). sadness. negative feelings are part and parcel of raising a challenging child.g. realistic. especially when the issue stems from a child experiencing mood symptoms. Fortunately we were still here. receiving detention.. identify the problem. • First. feelings. As with the parents. and finally guide the child through the experience of restructuring thoughts and choosing more adaptive behaviors to alleviate emotional dysregulation. then reevaluate their predictions in light of actual outcomes. discuss hurtful cognitions and actions arising in response to the negative feelings. helpful thoughts and actions beget more positive feelings. This session introduces the TFD exercise to the child. Sessions 5 and 6 Child session 5: Thinking-Feeling-Doing. They could take a long walk together after the situation at home calmed down sufficiently and order takeout from one of their favorite local restaurants. it is also beneficial to frame symptoms of the child’s disorder as problems. • After a problem has been identified (e. in which the child focused on identifying triggers. identify and acknowledge the negative emotions associated with that event. a hallmark of CBT that encourages clients to predict (or hypothesize) the consequences of actions. accompanying somatic responses and negative affect. Whereas hurtful cognitions and responses beget more negative feelings. have the child brainstorm ways in which he or she can regain control of his or her emotions in the face of a challenging sit- .Bipolar Disorder 211 ple. but also positively impacts parents’ emotions. parents could help the child choose a calming strategy from her tool kit and could make a plan to call her psychiatrist the next day to voice concerns that the child’s manic symptoms are increasing. This session builds on the work from the previous session. and actions together. This approach employs hypothesis testing. Parent session 5 and child session 6 both focus on developing an effective approach to problem solving. most of the techniques used will be described here only once. due to the similarity of material presented in each session. instead of yelling at the child and retreating to the bedroom to cry. not getting enough sleep). This new step adds in the role of cognition and links thoughts. and hurtful actions. reinforcing earlier content regarding depersonalization of symptoms as an external enemy. help the child recall an upsetting event. Parent session 5/child session 6: effective problem-solving. Although parent and child sessions on problem solving are conducted separately. Generating these more adaptive thoughts and actions not only moves the family toward effectively managing the problem.g. Although selected “problems” can be incidents that the child finds upsetting (much as in TFD). Alejandro frequently says he can’t help it. However. he or she should plan to use the strategy again in the future. Alejandro’s school behavior has improved with medication management and the implementation of special education services. Alejandro. and actions are integrated and affect each other. Because excessive emotional reactivity can compromise problem-solving skills (Pavuluri et al. selecting. The real me is usually nice to Paul. this session builds on the work of the previous sessions. feelings. 2004). and implementing sound decisions. Therapist: So. as the child now has an understanding of how thoughts. when Alejandro tends to be at his best. like I show him how to build things. But that’s not the real me. . on the other hand. If. Using a brainstorming approach. For example. including the identification of a “safe spot” where Alejandro can go when feeling overwhelmed. Case Example: Making Responsible and Reasoned Choices Alejandro is a 9-year-old boy who was diagnosed with bipolar disorder NOS 2 years ago. a child dealing with anger over receiving a detention might generate suggestions that range from “Ask the teacher what I did wrong and try to avoid doing this in the future” to “Refuse to attend detention. have the child think through the pros and cons of each action. Again.212 Cognitive-Behavior Therapy for Children and Adolescents uation. After doing so. Most importantly.” • Then. select an appropriate plan of action and encourage the child to implement the solution next time the situation arises. have the child generate a list of possible solutions to the problem. When this occurs. taking into account what has proven previously unsuccessful. his parents are concerned that Alejandro continues to blame others for his outbursts at home. draw the child’s awareness to the results of his or her decision. That’s my bipolar.” The therapist begins a discussion of effective problem-solving with Alejandro by bringing up an issue Alejandro identified earlier in treatment. remember when we talked about some of your symptoms. If the child’s choice solves the problem. the child’s choice fails to ameliorate the situation. and blames his actions on his “bipolar. a new strategy should be considered next time. write down every suggestion made before weighing their merits. as well as an adjusted schedule that places his most demanding courses early in the day. • Next. a child needs to calm down affectively before he or she is likely to be successful in generating. and one thing you identified was hitting Paul when you get angry? Alejandro: That happened yesterday when Paul knocked over the Lego castle I was building. and the bad things were that you got yelled at and had to go to time-out. I have bipolar disorder. Therapist: OK. 213 . What are some other things you could have done. because that can seem hard sometimes.(pauses to let Alejandro answer). You can’t just say. . it’s not my fault? Therapist: Yes. Therapist: So those were bad things about choosing to hit Paul. That means it’s your responsibility to make good choices. I hit him. tell Mom? Therapist: Good! Let’s look at those two choices and see what the good and bad things are about each one. even when you’re feeling angry. “Oh well. or I could talk to Mom and she could rub my shoulders. I couldn’t play with them anymore that day. so the first step in making a good choice is calming down so you can think more clearly. But it is your challenge. or just for a little while? Alejandro: Just a second. besides hitting Paul? Alejandro: I don’t know. and when I said that I still wanted to play with my Legos. Did it feel good for a long time. Dad said that because I hit Paul.. It’s not my fault. Alejandro: It’s really hard. yes. That’s what I tell my mom. Therapist: Is it harder to think of good choices when you’re very angry or when you’re more calm? Alejandro: When I’m angry. it felt good. “That’s no excuse. So now we’re going to talk about how to make good choices. and Dad wouldn’t have yelled at me. What’s something in your tool kit you could use to calm down if you’re angry at Paul? Alejandro: I could squeeze my stress ball very hard. yeah.. Therapist: OK. Therapist: Right. Oh. I mean. It made me feel better. Then Paul started to cry and Dad came and yelled at me and gave me a time-out.do you remember? Alejandro: Um. Dad always says. your Legos got taken away and you couldn’t even rebuild your castle. What did you do yesterday when Paul knocked over your castle? Alejandro: I told you. . it is still your.Bipolar Disorder Therapist: Is it your fault that you have bipolar disorder? Alejandro: No. Therapist: OK. Therapist: You have a great memory! Now let’s think of another solution to your problem. Are there any good things about hitting Paul? Alejandro: No. And in the end.” Alejandro: Oh. Therapist: So the good thing about your choice was that you felt better for just a second.” Therapist: Right. I tell her I’m too mad. We talked about ways to calm down earlier when you made your tool kit. right? Alejandro: Yeah. But even though having bipolar disorder is not your fault. I can’t help it. Now what about your other choice— telling Mom? What are the good things about telling your mom? Alejandro: She would know that it was Paul who did something wrong and not me. the therapist poses questions by giving Alejandro choices (e. although the rate of this progression is specific to each individual child.g. Structured practice. Therapist: Maybe so. Therapist: OK. Therapist: Does she usually say that? Alejandro: No. Children are likely to require less such scaffolding as they become more experienced with analyzing problematic situations and their outcomes. So in the end. To this end. in which each step of the problemsolving process is explicitly addressed. Also. they would make Paul go play with his own toys. however. set a clear and realistic agenda with the parent at this . Issues with schools are particularly common. it felt good.. Alejandro: Yeah.. But it would be hard to make the exact same castle that I made before. when. I’m pretty good at making castles. Did it feel good for a long time. as opposed to posing completely openended questions that may be difficult for the child to answer. Often after learning more about how the mental health system and educational system can work on behalf of a child. use this session to plan the nuts-and-bolts of how. what do you think would have happened if you had told your mom instead of hitting Paul? Alejandro: I would get to play with my Legos without Paul interrupting me. or inviting members of the school staff to attend a therapy session.g. Examples include your going to a school meeting. then it doesn’t sound like that’s very likely. or just for a little while?”). parents will return to treatment with specific questions about how to implement effective change. Parent session 6: revisiting the mental health team and educational team. Assuming there are sufficient school issues to warrant direct communication with the school. and where to accomplish this task. For instance. In addition. he is responsible for the choices he makes. In this interaction. the therapist helps guide Alejandro through the process of making a good choice in a developmentally appropriate manner. use this session to plan for the pending school professional session (parent session 7). video conferencing. But maybe the next castle you made would have been even better. the therapist makes it clear that although Alejandro is not responsible for having bipolar disorder. “OK. conference calling.214 Cognitive-Behavior Therapy for Children and Adolescents Therapist: And would you have been sent to time-out? Alejandro: No. the therapist helps the child to deepen his analysis of the situation by asking follow-up questions (e. is essential. “Is it harder to think of good choices when you’re very angry or when you’re more calm?”). Therapist: And are there any bad things about telling your mom? Alejandro: Maybe she would say I was being a tattletale. and other staff pertinent to the child’s school. tutor. set reasonable goals around that behavior. and begin to track it. resource room teacher. addressing maladaptive communication patterns between parents and children as well as every dyad in the family is important. paraprofessional. Progress on the child’s first goal should have been monitored at each session since the child began tracking sleep. school counselor. the problem “I need to lose 15 pounds before my senior pictures” may not lead to a successful outcome in a teenager 2 months before the event. revisiting these routines is in order. At this session. Impaired communication. Often. Session 8 Child session 8: nonverbal communication. has been identified as a possible influence on the course of bipolar disorder.Bipolar Disorder 215 session (i. and likely are at least somewhat familiar with the concepts. nutrition. Parent session 7: school treatment team. intervention specialist or special education teacher. children may benefit from separate presentations about verbal and nonverbal communication. work with him or her to apply those skills to increase compliance. because the child has now learned problem-solving skills. or exercise. behavioral specialist. Research indicates children with bipolar disorder tend to struggle with interpreting . Session 7 Child session 7: revisiting healthy routines. Parents can usually absorb information. In contrast. For example. Thus. physical or occupational therapist. Suboptimal treatment adherence regarding healthy behaviors is common. but changing the problem to “I need to cut out most of the junk food in my diet” is more likely to lead to concrete but not extreme behaviors that can be maintained over a lifetime. regular education teacher. district special education coordinator.. child’s IEP chair. can typically practice using effective verbal and nonverbal communication in a single session (as will be discussed in parent session 8). This might be the school psychologist. school social worker. What should be communicated? What questions need to be answered? What concerns does the parent have?).e. principal or vice principal. including the presence of expressed emotion. Use this session to problem-solve and share information directly with the previously identified member(s) of the child’s school. the first step of identifying the problem is very important to successful problem-solving. with eventual integration of the two topics. have the child select the topic of second most importance. Given the importance of healthy routines in maintaining affective stability. school nurse. denying. which can be framed as a game of charades. Parent session 8: communication. eye contact. keeping instructions brief. one individual sends a message. provide guidelines for more adaptive communication. including staying positive and calm. let parents know that asking questions and restating what the listener believes the other to be saying can be effective methods of eliminating confusion. the process can be infinitely more complicated and involves issues such as how each member of a communication dyad interprets the other’s verbal and nonverbal cues. Next. both verbally and nonverbally. which is then received by another individual. and being direct. level of personal space. interrupting. . rehashing past or unrelated conflicts. Though many children have some concept of helpful and hurtful language. In particular. This second individual then sends a message.216 Cognitive-Behavior Therapy for Children and Adolescents nonverbal cues. posture. gestures. ask parents to monitor their use of hurtful communication. Begin by discussing the communication cycle. After explicitly identifying and eliciting examples. That is. Use of these strategies in interactions with all members of the family can significantly reduce the level of expressed emotion and confusion in the home. Addressing how parents communicate. In reality. The intent here. especially facial expressions. paying attention to others’ verbal and nonverbal cues. thus. After drawing parents’ attention to these negative interactions. raise the child’s awareness of nonverbal communication cues and provide practice in accurately interpreting these signals.. This activity. including name-calling. they are often less aware of how nonverbal signals (i. devoting a session specifically to nonverbal communication is considered beneficial. listening to the child rather than lecturing. and tone of voice) can influence interactions. and lecturing. also requires identification of the basic communication cycle that was discussed with the child in child session 7. Further. however. of course. provide common examples of hurtful communication. Next. Encourage practice of these communication strategies.e. taking turns speaking. is only to establish basic rules requisite to effective communication. which is received by the first individual. parents can employ this general technique (either asking the child to interpret the nonverbal cues of others to confirm comprehension or using the child’s own nonverbal cues to gauge his or her current emotional state) in the course of everyday interactions to increase the child’s facility with this often deficient skill and to enhance communication. introduce an activity in which the child and an adult take turns guessing the emotions displayed by the other. A problem in any step of this cycle has the potential to disrupt communication and understanding. Additionally. then have them identify more helpful communication they could implement instead. blaming. should be practiced by the child and parents before the next child session. facial expressions. begin this session with a quick review of the communication cycle. including contact information for mental health care providers. making prior arrangements for how to handle it in case it becomes a concern is preferable to attempting to design and implement appropriate measures in the midst of a crisis. a list of all medications the child is taking. Even if suicidal behavior has not been an issue for the child.g.e. medications (both prescription and over-the-counter). large gatherings. A child who has progressed to full-blown mania. They should have easy access to essential information. particularly coping techniques involving relaxation.Bipolar Disorder 217 Session 9 Child session 9: verbal communication. parents should limit stimulation such as loud music. because behavioral activation may exacerbate symptoms of mania. overscheduling of events. An adolescent experiencing an increase in depression may not feel like keeping plans to attend a movie with friends. An initial rule of thumb is to address symptoms before they escalate to levels where the child and parent are less able to use the tools and skills with which they have been equipped in treatment. Parents should have prearranged places to lock away guns. Encourage the child to use his or her tool kit. and intake of caffeine or sugar. and any relevant insurance information. and toxic household cleansers. express your feelings. describe the situation... for example. parents should encourage the child to use his or her tool kit. Using helpful words involves standard training in assertive communication—i. including attempts to keep the child’s sleep schedule as normal as possible. bright lights. Parents benefit from specific coaching on how to handle troublesome symptoms. when depressive symptoms appear. Then. state your desired outcome. Being a good enough parent isn’t good enough to know how to manage the unique symptoms of bipolar disorder. is unlikely to successfully employ his or her coping tool kit or to engage in effective problem-solving. knives. A child who ex- . As a follow-up to the session on nonverbal communication. focus on helping children to differentiate between helpful and hurtful words (e. heavy physical exertion. especially tools that involve physical activity and staying socially engaged. Routines should be kept consistent and healthy habits maintained. Making the distinction between helpful and hurtful language increases children’s awareness of how they are speaking and how their words are impacting others. “D’Shaun keeps coming in my room. but doing so (and engaging in other healthpromoting behavior) may help to mitigate symptoms and prevent eventual progression into a major depressive episode. and it’s making me angry” vs. Likewise. “D’Shaun’s being a brat!”). With the onset or increase of the child’s manic symptoms. Parent session 9: managing symptoms of bipolar disorder. Additionally. Hospitalization. the clinician should validate siblings’ often conflicting emotions (e. regardless of age or relationship to the child. Family Session: Working With Siblings Easily lost in the wake of a child suffering from bipolar disorder are the needs of siblings. or therapy for themselves.g. all family members.. Including these children in the treatment process reminds parents that the impressive needs of the patient do not diminish those of their other children. and set aside time for exercise. Especially with children who have demonstrated significant physical aggression toward themselves and others. discuss with parents beforehand the level of information to impart on the basis of the relative sophistication of siblings. helping parents secure training in administering therapeutic holds may be advisable. should make time for themselves and for enjoyable activities with others. as well as knowing when (and how) to call the police for assistance. which should be undertaken in the absence of the patient to encourage siblings to communicate openly. Use your knowledge of the family and its resources to help parents identify sources of emotional support and how to utilize them (e.218 Cognitive-Behavior Therapy for Children and Adolescents presses an immediate intent to harm himself or herself and who may have the ability to do so should be immediately referred for emergency services. the child with bipolar disorder should have an awareness of how information about the illness will be presented to siblings. meditation. support groups for parents of children with mood disorders. Parents are often so overwhelmed with the demands of managing their child’s disorder that they don’t realize the necessity of self-care. if consistent with the family’s beliefs). spiritual or religious groups. not a sprint.g. other “refueling” activities. Remind parents this is a marathon. should never be used punitively or as respite for overstressed parents. including online forums. They need to give self-preservation a high priority. particularly if parents have any doubt about their ability to constantly monitor the child and ensure safety. in order to allay fear of embar- . In addition. concern for the patient and yet frustration over the disruption the disorder often causes). Managing the symptoms of a child with bipolar disorder also requires parents to manage the inherent stress of dealing with a chronically ill child. out of understandable yet counterproductive concern for the child. family and friends who feel comfortable supervising the child for short periods.. In this session. Stress that hospitalization is a setting for short-term stabilization of acute symptoms and a means of returning children to everyday routines as efficiently as possible. if necessary. Those who do recognize the need often feel guilty about considering their own needs. As parents are often unsure how much information to give siblings about the child’s condition. Cultural Considerations Due to the relative infancy of research regarding psychosocial interventions for youth with bipolar disorder. then as needed over the course of his or her development. while also maintaining appropriate boundaries that avoid placing excessive responsibility on these other children. evidence-based guidelines for making culturally specific adaptations to a CBT program of this type are not yet available.” . This session should serve as a graduation ceremony. you can follow a family as long as needed. Of course. middle school to high school.Bipolar Disorder 219 rassment. When the end of the intensive initial treatment phase is reached. as siblings have the same familial risk as the child with bipolar disorder. A key challenge in this session is balancing the need to involve siblings in helping to create an environment conducive to the health of all members of the family. An ideal model of care is one in which you as the family clinician are able to see the child intensively to begin treatment. Often. in times of both symptom exacerbation and remission.” signifying successful completion of an intense course of treatment and recognition of their hard work. referral for an evaluation and treatment of one or more siblings may also be in order. this translates to additional sessions around times of transition—elementary school to middle school. sustained awareness that recurrence is possible. emphasize the importance of the family and child continuing to use skills learned during the intervention. deserve praise for tackling their child’s disorder and their commitment to the well-being of their child and family—a proactive approach that if maintained should continue to pay dividends into the future. In lieu of such information. too. Closing Session: Summary and Graduation Up to four additional sessions to review necessary information and skills have been built into the treatment model that has been tested. an emphasis on sensitivity to the specific needs of each family is likely the most optimal approach (see Chapter 3). high school to college. clinically. Parents. consistent application of these skills. Children can be provided with a developmentally appropriate “diploma. and medication adherence provide the best possible prognosis for the child in the future. Finally. Although symptoms will almost inevitably fluctuate to some degree. A strength of the intervention described here is that it allows for therapists to adjust content to meet the family “where they are” as opposed to “where they should be. On one hand. therapy urges compassion and tolerance for the maladaptive emotions these children often cannot control. they are often able to identify the manner in which mood symptoms fluctuate in concert with other symptoms (e. The opportunity to finally express these negative thoughts (e. Identifying overly negative and maladaptive thinking and helping individuals to reframe situations from a more helpful perspective can be exceptionally powerful and enlightening. treatment urges children (and parents) to take responsibility for their actions. As parents become more adept at observing fluctuations in their child’s mood (perhaps through the use of mood logs). suggesting a purposeful quality to his or her actions.g. for example. sometimes speak of a blank look in their child’s eyes or a feeling that the child is “gone” when in the midst of a moodinduced rage. a rise in mania may be indicated not just by increased irritability but by increased irritability accompanied by markedly agitated movements and increased speech). Heightened insight into how mood and behavioral symptoms tend to manifest in their particular child leads to more confidence in choosing when to give the child more leeway and when to stand firm. Aside from educating parents about how the symptom presentation of bipolar disorder differs from behavioral disorders. In contrast.. identifying particular cues that indicate the source of a child’s inappropriate behavior can often benefit parents.. “The way my husband avoids interven- . helping parents to differentiate mood from behavioral symptoms (i. Bringing Unspoken Negative Thoughts to the Forefront A good deal of CBT for bipolar disorder is directed at helping parents and children break the negative cycles that too often typify interactions within these families. Parents. a child throwing a tantrum in the course of testing limits may be described as having a mischievous or petulant look. “Why can’t my child just be normal?” “He feeds off making me unhappy”. the “can’ts” from the “won’ts”) is a particularly relevant exercise. regardless of their emotions.. Striking an appropriate balance— knowing when to give way and when to push back—can be difficult for parents. on the other hand.220 Cognitive-Behavior Therapy for Children and Adolescents Special Challenges to Treatment Distinguishing Mood From Behavioral Symptoms Given the extremely high levels of comorbidity between bipolar disorder and behavioral disorders.e.g. Once negative cognitions have been brought to the forefront and stripped of the guilt that so often accompanies them. Psychoeducational materials stress the need for close communication with the prescribing physician and consistent adherence to the prescribed medication regimen.Bipolar Disorder 221 ing with our daughter. the intervention’s focus on providing families with a sound knowledge base and the development of essential skills (e. • Similarly. medication management in the absence of psychosocial intervention is likely to result in suboptimal outcome and is therefore best viewed as a necessary but not sufficient condition of effective treatment. problem-solving) should appeal to clinicians who wish to equip their patients with more than just a “band-aid” to address immediate concerns.. Key Clinical Points • CBT for child and adolescent bipolar disorder is adjunctive to medication management. parents can begin to examine their thoughts from a fresh perspective more conducive to progress. especially when the parents are interacting with an empathic therapist who responds to the presence of these thoughts with a sense of understanding (though without confirmation that the thoughts are accurate or helpful). • Helping the family to create a home environment consistent with maintenance of the child’s long-term mood stability requires the develop- . I’d be better off raising her alone”) is often uncomfortable for parents but can be ultimately cathartic and empowering. even after symptoms have subsided. Parents who are more informed regarding the nature of bipolar disorder and effective management of symptoms are better equipped to serve as the eyes and ears of their child’s treatment team. chronic course.g. adjunctive treatments for pediatric bipolar disorder. the intervention described in this chapter (IF-PEP) has shown promise in helping patients and families to meet the challenges of this complex illness. effective communication. Conclusion While additional research is needed to further refine CBT-based. Because bipolar disorder is typically believed to have a lifelong. • The involvement of families in treatment is essential. Children with similar information are also more likely to take an active role in their own treatment. illness course is likely influenced by ___________________________. Social problems. If the child is of well above-average intelligence. problem solving. CBT. C. 6. communication training. As a stand-alone treatment. psychological. a combination of biological. and behaviors. and self-care. a combination of biological. All of the above.4. __________ is/are considered the first-line treatment(s).222 Cognitive-Behavior Therapy for Children and Adolescents ment of a number of skills in both parents and child. Due to impaired parenting. C. Only when a strong family history of bipolar disorder is identified. D. A 14-year-old adolescent girl is diagnosed with bipolar I disorder. C. Medication induced. Mood stabilizers or atypical antipsychotics.1. B. Self-Assessment Questions 6. D. and social factors. B. cognitions. Although the etiology of bipolar disorder is thought to be largely ___________________. including affect regulation. the child’s level of intelligence. Suicidal ideation. 6. Academic problems. A. C. B. Antidepressants. B. D. In conjunction with mood stabilization with medication. • Breaking maladaptive family cycles typified by negativity. . CBT would be considered an appropriate treatment strategy for a child with bipolar disorder A.2. Children with bipolar disorder are at increased risk for A. psychological. biological factors. 6. D. and poor communication requires an understanding of the interrelatedness of emotions. A. The result of trauma. Electroconvulsive therapy.3. criticism. Biological. and social factors. Family involvement. C. Residential treatment. IL. Use of a therapist of the same sex as the child. Oxford University Press. 2007—a book for parents Web Sites The Balanced Mind Foundation: www.Bipolar Disorder 223 6.thebalancedmind. features “BPChildren Newsletter” . Evanston. New York. Rynn MA: Mind Race: A Firsthand Account of One Teenager’s Experience With Bipolar Disorder. Psychoeducational testing.bpchildren. B. New York. IL. www. 2004—a book for parents Jamieson PE. Available at: Child and Adolescent Bipolar Foundation (CABF): (800) 256–8525. 2003—a book for parents to share with school professionals Child and Adolescent Bipolar Foundation: The Storm in My Brain. New York. Suggested Readings and Web Sites For Families Books Andersen M. 2006—–a book for adolescents Miklowitz DJ.com—for parents and children. _____________ is almost always recommended as a part of CBT for a child with bipolar disorder. Guilford. Goldberg Arnold JS: Raising a Moody Child: How to Cope With Depression and Bipolar Disorder. Guilford. et al: Understanding and Educating Children and Adolescents With Bipolar Disorder: A Guide for Educators. George EL: The Bipolar Teen: What You Can Do to Help Your Child and Your Family. Field R.org—a book for children Fristad MA. 2003. The Josselyn Center. Kubisak JB. Northfield. D.5. A.org—for parents and adolescents BPChildren: www.bpkids. Arch Gen Psychiatry 66:1013–1021. 1999 Fristad MA. 2009 Web Sites Juvenile Bipolar Research Foundation (JBRF): www. Gavazzi SM. Fristad MA. Clinical Psychology: Science and Practice 16:166–181. Fristad MA: Assessment of childhood bipolar disorder. Soldano KW: Naming the enemy. Washington. et al. 2008 Fristad MA. Arnold LE. 1996 Danner S. pp 239–272 Fristad MA: Psychoeducational treatment for school-aged children with bipolar disorder. Fristad MA: The bipolar child and the educational system: working with schools. Bipolar Disord 4:254–262. in A Clinical Manual for the Management of Bipolar Disorder in Children and Adolescents. Rush AJ: Cognitive-Behavioral Therapy for Bipolar Disorder. Goldberg Arnold JS. Clin Child Fam Psychol Rev 12:271–293. 2006 Fristad MA. American Psychiatric Publishing. Walters K. 2009a Fields BW. 2011 Kowatch RA. 2009 . Goldberg-Arnold JS. American Psychiatric Publishing. Leffler J: Psychotherapy for Children With Bipolar and Depressive Disorders.org— includes a Listserv for therapists treating children with bipolar disorder MF-PEP and IF-PEP workbooks can be ordered directly from www.com References Basco MR. Goldberg-Arnold JS. Gavazzi SM: Multi-family psychoeducation groups in the treatment of children with mood disorders. J Fam Psychother 10:81–88. Findling RL. Findling RL. Guilford. Edited by Kowatch RA. New York. Verducci JS. Fristad MA. 2003 Fristad MA.bpchildresearch. J Marital Fam Ther 29:491–504. 2009b. et al: Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. J Fam Psychother 18:81–103. Gavazzi SM: Multifamily psychoeducation groups (MFPG) for families of children with bipolar disorder. Fristad MA. 2009 Fields BW.224 Cognitive-Behavior Therapy for Children and Adolescents For Clinicians Books Fristad MA. 2002 Fristad MA. Guilford. New York. et al: A Clinical Manual for the Management of Bipolar Disorder in Children and Adolescents. et al: Early onset bipolar spectrum disorders: diagnostic issues. Dev Psychopathol 18:1289–1306.moodychildtherapy. Davidson KH. Washington. DC. DC. Leffler JM: Thinking-feeling-doing. 2004 McClellan J. Anderson B. Early T: Factors influencing service utilization and mood symptom severity in children with mood disorders: effects of multifamily psychoeducation groups (MFPGs). Anderson BP. Biuckians A. 2010 Hooley J. Fristad MA. McClellan JM. et al: Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. Fristad M. Axelson DA. Arrese D. Biuckians A. Birmaher B. J Affect Disord 82 (suppl 1):S113–S128. Arch Gen Psychiatry 65:1053–1061.Bipolar Disorder 225 Geller B. Frank E. Frank E. Orley J. Klaus NM: Psychoeducational psychotherapy (PEP) for children with bipolar disorder: two case studies. 2002 Goldstein TR. Craney JL. Findling R: Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. Suppes T. J Am Acad Child Adolesc Psychiatry 46:820–830. Birmaher B. Richards JA: Early onset bipolar disorder: a family treatment perspective. 2004 Miklowitz DJ. Kowatch R. et al: Family factors and the course of bipolar affective disorder. 1986 Kim EY. et al: Interpersonal and social rhythm therapy for adolescents with bipolar disorder: treatment development and results from an open trial. J Am Acad Child Adolesc Psychiatry 44:213–235. J Consult Clin Psychol 77:463– 473. McGlashan A. 1998 Malkoff-Schwartz S. Depress Anxiety 27:457–464. Fristad MA. 2000 McCarthy J. 2007 Kowatch RA. Goldstein MJ. et al: Family focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. et al: Effect size of lithium. Kotler JS. et al: Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. 1988 Miklowitz DJ. 2007 Hlastala SA. et al: Sustained attention and visual processing speed in children and adolescents with bipolar disorder and other psychiatric disorders. et al: Social rhythm disruption and stressful life events in the onset of bipolar and unipolar episodes. divalproex sodium. et al: Treatment guidelines for children and adolescents with bipolar disorder. et al: Family focused treatment for adolescents with bipolar disorder. Bolhofner K. 2007 Mendenhall AN. Guilford. J Am Acad Child Adolesc Psychiatry 39:713–720. Am J Psychiatry 159:927–933. Br J Psychiatry 148:642–647. George EL. 2008 . Axelson DA. J Am Acad Child Adolesc Psychiatry 46:107–125. 2005 Leffler JM. 2006 Miklowitz DJ. Goldstein M: Bipolar Disorder: A Family Focused Treatment Approach. et al: Life stress and the course of early-onset bipolar disorder. Birmaher B. Carmody TJ. New York. Axelson DA. Psychol Med 30:1005–1016. 2010 Malkoff-Schwartz S. and carbamazepine in children and adolescents with bipolar disorder. 2000 Kowatch RA. 1997 Miklowitz DJ. Teasdale JD: Levels of expressed emotion and relapse in depressed patients. 2009 Miklowitz D. J Affect Disord 99:37–44. J Fam Psychother 21:269– 286. Nuechterlein KH. Dev Psychopathol 18:1247–1265. Miklowitz DJ. et al: Stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes. Arch Gen Psychiatry 55:702–707. Psychol Rep 95:39–47. Arch Gen Psychiatry 45:225–231. Lampert C. Rathus JH. Norton.and family focused cognitivebehavioral therapy for pediatric bipolar disorder: development and preliminary results. Graczyk PA. et al: Relapse following discontinuation of lithium maintenance therapy in adolescents with bipolar I illness: a naturalistic study. et al: Child. et al. Guilford. Findling RL. Fristad MA. Epston D: Narrative Means to Therapeutic Ends. 2007 West AE. Morrell W. DC. 2004 Pavuluri MN. New York. 2009 White M. J Am Acad Child Adolesc Psychiatry 43:528–537. pp 217–238 . et al: Neurocognitive function in unmedicated manic and medicated euthymic pediatric bipolar patients. Henry DB. J Am Acad Child Adolesc Psychiatry 34:867–876. 1990 Wozniak J. Jacobs RH. American Psychiatric Publishing. 2006 Pollock KM: Exercise in treating depression: Broadening the psychotherapist’s role.and family-focused cognitivebehavioral therapy for pediatric bipolar disorder: pilot study of group treatment format. Linehan MM: Dialectical Behavior Therapy With Suicidal Adolescents. Pavuluri MN: Maintenance model of integrated psychosocial treatment in pediatric bipolar disorder: a pilot feasibility study.226 Cognitive-Behavior Therapy for Children and Adolescents Miller AL. Biederman J. J Can Acad Child Adolesc Psychiatry 18:239–246. Westerholm R. et al: Child. Kiely K. Edited by Kowatch RA. in A Clinical Manual for the Management of Bipolar Disorder in Children and Adolescents. 1990 West AE. Washington. Henry DB. 2001 Strober M. J Clin Psychol 57:1289–1300. Fristad MA: Working with patients and their families. Am J Psychiatry 163:286–293. Schenkel LS. Am J Psychiatry 147:457–461. 2006 Pavuluri MN. et al: Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. Subhash A. New York. 2009. 1995 Young ME. J Am Acad Child Adolesc Psychiatry 46:205–212. Ph.A. O’Neil. M. ABPP ANXIETY disorders are commonly experienced by youth. Douglas M.A. 2004. separation anxiety disorder (SAD). M. Preparation of this chapter was facilitated by research grants awarded to Philip C. Costello et al.A. specific phobias. Edmunds. and posttraumatic S This chapter has a video case example on the DVD (“The Coping Cat Program”) demonstrating CBT for an anxious child. Julie M. 227 . Anxiety disorders in youth include generalized anxiety disorder (GAD).A. Kendall. Brodman. Kendall (MH MH080788 and UO1MH63747).. social phobia. M. Cohen.D. 2004). obsessive-compulsive disorder. Jeremy S.7 Childhood Anxiety Disorders The Coping Cat Program Kelly A. M. with reported rates of 10%–20% in the general population and primary care settings (Chavira et al. Philip C. Such reviews appearing earlier than 2008 and applying Chambless and Hollon’s (1998) criteria for evidence-based treatments conclude that CBT for youth with . Empirical Evidence Cognitive-behavior therapy (CBT) for youth anxiety has been found to be effective in several randomized clinical trials conducted in the United States (e. In two follow-up studies of different samples of anxious youth (3.35 and 7. 1997. Barrett et al. Anxiety disorders do not remit with time.228 Cognitive-Behavior Therapy for Children and Adolescents stress disorder (American Psychiatric Association 2000). 1991)..g. 2003). Kendall et al. the results of these trials indicate that between 50% and 72% of children with GAD. such trials indicate that between 10% and 37% of youth who receive pill placebo. if left untreated. Kendall et al. 1996). depression. 2003). Anxiety disorders in children are also associated with difficulties in academic achievement (Ameringen et al. although not all participants are responders.. The consequences of untreated anxiety disorders in youth highlight the need for early intervention. we focus on a treatment for three youth anxiety disorders (GAD. Anxiety in youth places children at increased risk for comorbidity (Verduin and Kendall 2003) and psychopathology in adulthood (e.4 years after treatment).g. substance abuse. Walkup et al. and/or SAD who receive CBT do have a positive response—they no longer meet criteria for their presenting anxiety disorder following treatment. the wait-listed youth in such trials were offered treatment following the initial wait-list period. Nauta et al. In this chapter. 2003. 2008b. because generally. Kendall 1994. Manassis et al. The maintenance of therapeutic gains has been found up to 7 years posttreatment. social phobia. In contrast. and future emotional health (Beidel et al. social phobia. and the Netherlands (e. are associated with impairments in adulthood. 2004). Canada (e. Additional studies with similar outcomes have been conducted in Australia (e. Kendall et al. or active comparison treatment for their anxiety disorder have a positive response following treatment (Barrett et al.. wait-list assignment. 80%–90% of successfully treated children continued to not meet criteria for their presenting anxiety disorder (Kendall and Southam-Gerow 1996. Kendall et al.. 2004). 1996.g.g. social and peer relations (Greco and Morris 2005).. rates of long-term treatment maintenance following CBT have not been compared with a control group. 2008). and most. Nauta et al.g. It is pleasing to note that reviews of the evaluation literature support the utility of CBT for childhood anxiety disorders. To date. 2008b. 2002). anxiety. SAD) that have similar features and high rates of co-occurrence. Collectively. . 1997. 2006) also have empirical support. 2006b) is a manual-based individual CBT for youth with considerable empirical support when compared with a wait-list control condition. Treatment Planning There are several important issues to consider when implementing CBT for childhood anxiety. and parent. Wood et al. the core principles of CBT for child anxiety are highlighted throughout the chapter.. Walkup et al. Silverman et al. 2008). CBT for childhood anxiety disorders targets the somatic.g. recognition and management of somatic symptoms.g. For a discussion of the theoretical underpinnings of CBT for childhood anxiety disorders. and behavioral aspects of anxiety. 2008b. the format and length of treatment. and pill placebo (Kendall 1994. and exposure. Although we describe the implementation of the Coping Cat Program to treat GAD. the Coping Cat Program. Manassis et al.Childhood Anxiety Disorders 229 anxiety disorders is probably efficacious (Albano and Kendall 2002.. multi-informant approach to assessment. and family CBT (e. 1996).g. The Coping Cat Program (Kendall and Hedtke 2006a. 2000). active comparison treatment. CBT Approaches Consistent with a cognitive-behavioral model (Kendall 2010). such as Social Effectiveness Therapy for socially phobic youth (Beidel et al. Given studies published since these reviews (e. Individual CBT with an added parent component (e. Kazdin and Weisz 1998. may include a greater emphasis on social skills training. it is reasonable to suggest that the treatment be considered efficacious. we describe the CBT approach used at the Child and Adolescent Anxiety Disorders Clinic of Temple University. 2006. such as assessment. Kendall et al. Ollendick and King 1998. 2002). 2008).. 2008). Walkup et al. Assessment We recommend a multimethod. In this chapter. We consider each of these issues below. Several CBT approaches to treating child anxiety have been developed and the majority have core treatment components in common: psychoeducation. social phobia. Other CBT approaches. youth self-report measures.g. and/or SAD specifically. cognitive restructuring.and teacher- . Barrett et al. cognitive. see Gosch et al. group CBT (e. and the structure and content of sessions. Clinical interviews. As operationalized in one study. Achenbach and Rescorla 2001) is a 118-item parent report of behavioral problems and social and academic competence.e. 2005) and provide information on the child’s areas of disturbance. youth anxiety disorders have been treated within a group format. social activities. and the Teacher Report Form (TRF. and peer interactions.e. For child self-report. Achenbach and Rescorla 2001) is a parallel teacher report. Length of Treatment The Coping Cat Program is designed as a 16-session program. treatment was 14 sessions provided within 12 weeks (Walkup et al. Silverman and Albano 1996). Format Typically. Silverman et al.230 Cognitive-Behavior Therapy for Children and Adolescents reports provide useful information regarding the presenting symptoms and related impairment across settings. 2008a). 1997).. In accordance with the concept of “flexibility within fidelity” (e.g.. Kendall et al. parent and teacher measures of overall child symptomatology are informative. help with implementation of the program). Therapists who wish to work with parents in the sessions (family CBT) can consult the family therapy manual (Howard et al. . provide the therapist with information about the child) and as collaborators (i. with two specific parent sessions included in the program. but the CBCL and TRF effectively discriminate between externalizing and internalizing disorders (Seligman et al. March et al. One is the Multidimensional Anxiety Scale for Children (MASC. The MASC has been found to have good psychometric properties (March et al. 1997. 2002) and sensitivity to treatment-related changes (Kendall et al. The CBCL and TRF do not alone diagnose anxiety disorders. 1997). there are several options. the Coping Cat Program involves child-focused therapy. Silverman et al. Wood et al..g. 2008). 1999). MASC-P). 2004. In the Coping Cat Program. 2001. a semistructured diagnostic interview administered separately to parents and children. In addition to parent versions of self-report anxiety measures (e. 1994. The MASC is a 39-item self-report measure of children’s anxiety symptoms over the past 2 weeks. some youth may require slightly more or fewer than 16 sessions. see also Aschenbrand et al. The ADIS-C/P has demonstrated favorable psychometric properties (Rapee et al. The Child Behavior Checklist (CBCL.. parents serve as consultants (i. 2000). Additionally. We use the Anxiety Disorders Interview Schedule for DSM-IV—Parent and Child Versions (ADIS-C/P. in vivo exposure tasks.Childhood Anxiety Disorders 231 Structure of Sessions The Coping Cat Program is designed to be implemented in weekly childfocused sessions lasting 50–60 minutes.g. The majority of each session is devoted to psychoeducation (phase I) or exposure (phase II) content. Therapists interested in using the Coping Cat Program with an anxious child should consult the therapist manual (Kendall and Hedtke 2006a) and the child’s workbook (Kendall and Hedtke 2006b). problem solving. cognitive restructuring) to help youth identify and cope with anxiety. There are two parent sessions. The content of the Coping Cat Program is described below. and a computerassisted version of the treatment (Camp Cope-A-Lot. whereas the workbook contains corresponding client tasks. Content of Sessions The Coping Cat Program combines behavioral strategies (e. 2002a. The therapist manual and the client workbook are designed to be used together: the manual guides the sessions of the treatment. and exposure. The therapist presents these strategies to the child as a tool set that she may carry with her and draw from when she is feeling anxious. In addition to the core CBT components of psychoeducation. skills for managing somatic symptoms. Overview: The Coping Cat Program The overarching goal of the Coping Cat Program is to teach youth to recognize signs of anxiety and use these signs as cues for the use of anxiety management strategies. and each may be scheduled for the same day as an adjacent child-focused session. Each session ends with an assignment of a STIC task (i. Each child-focused session begins with a review of the weekly homework assignment (referred to as a STIC [Show That I Can] task). cognitive restructuring (changing self-talk). and contingent reinforcements) with cognitive strategies (e. . 2002b). The program has two phases of eight sessions each. modeling..e. relaxation training.g. the Coping Cat Program also places emphasis on coping modeling and homework assignments to practice newly acquired skills. Kendall and Khanna 2008) has been evaluated in research (Khanna and Kendall 2010).. whereas phase II emphasizes exposure to anxietyprovoking situations. A similar program is available for adolescents (Kendall et al. Phase I focuses on psychoeducation. homework) and a fun activity or game. the child learns to identify when she is feeling anxious and to use anxiety management strategies.. Within the psychoeducation phase. Coping Modeling An important component of the Coping Cat Program is for the therapist to serve as a coping model for the child. and then success. 1. In the last eight sessions (phase II). Modification of anxious self-talk using coping thoughts and the use of problem solving to develop a way to cope with anxiety more effectively. reward the child for STIC task completion. practicing the newly acquired skills. 2. The therapist demonstrates the skill first. Finally. using relaxation). Recognition of anxious self-talk and expectations. and problem solving. and then success.232 Cognitive-Behavior Therapy for Children and Adolescents The strategies include identifying bodily arousal. whereas a coping model demonstrates encountering a problem. using coping thoughts. engaging in relaxation. Therapists serve as a coping model by demonstrating their own anxiety.. STIC tasks provide the child with an opportunity to test out and practice each of the skills learned in session. The therapist serves as a “coach. 3. developing a strategy to deal with the problem. recognizing anxious thoughts (self-talk). Anxiety management strategies are taught in a sequence that allows the child to build skill upon skill. ask the child to complete weekly homework assignments (STIC tasks). strategies that helped them cope with the anxiety. the therapist provides exposure tasks for the child to approach anxiety-provoking situations and to use the skills learned in the first eight sessions. Psychoeducation In phase I. Consistent with behavioral theory. Throughout treatment. . the therapist encourages the child to role-play scenes alone. the therapist presents four important concepts. The exposure tasks are guided by a collaboratively determined hierarchy so that the child practices skills in increasingly anxiety-provoking situations. Weekly Homework Homework is an important component of the Coping Cat Program. Recognition of bodily reactions to anxiety and management of these symptoms (e. The therapist continues to serve as a coping model throughout treatment as each new skill is introduced.” teaching the child the necessary skills and guiding the child to practice the skills while in real anxietyprovoking situations. A mastery model demonstrates success.g. then asks the child to participate with him or her in role-playing. and repeated contact with the avoided stimuli or situation. Zoe’s feared situations include speaking to adults. met criteria for a diagnosis of social phobia at the intake assessment. S Case Example: The Coping Cat Program We illustrate the Coping Cat Program using the case of a youth named Zoe. and apply these four concepts. referred to as the FEAR plan.” She has great difficulty maintaining eye contact. To teach these concepts to the child. to help the child learn. the therapist guides the child through exposure tasks—creating anxiety-provoking situations and helping the child practice the FEAR plan during anxious arousal.Childhood Anxiety Disorders 233 4. systematic.. (See the DVD for a demonstration of the FEAR strategy and STIC assignment. She is easily embarrassed. habituation). whereas anxietyprovoking situations for a child with separation anxiety might include waiting for a parent who is late. giving presentations. she “freezes up. . For example. later exposure tasks are more anxiety provoking than earlier ones. anxiety-provoking situations for a child with social phobia might include playing a game with a new person or peer. and afraid that others will laugh at her in social situations. Self-reward for effort (partial or full success) in facing anxiety-provoking situations. reading aloud in class. The purpose of exposure is prolonged. F = Feeling frightened? E = Expecting bad things to happen? A = Attitudes and actions that can help R = Results and rewards Exposure Tasks In phase II. and asking questions in class. When Zoe is faced with a social situation.) Zoe. Be sure to tailor the exposure tasks to each child according to the child’s specific anxieties and fears. remember. the therapist uses an acronym.e. The exposure tasks increase in difficulty over the course of the second half of treatment. a 10-year-old girl. The goal is to have the child remain in the situation until she has reached an acceptable level of comfort (i. Her parents report that Zoe’s distress is highly impairing and affects her academic performance. To begin. During the game. The therapist introduces The Coping Cat Workbook and Zoe is assigned a STIC task from the book (e. After introducing the program.g. The therapist shares with Zoe that they will learn skills that can help kids when they are feeling worried or scared. the therapist and Zoe spend the last 10 minutes playing Guess Who? Session 2: Identifying Anxious Feelings The aim of the second session is to help the child learn to distinguish anxious or worried feelings from other feelings. Zoe’s eye contact improves slightly and the therapist notes that she seems more relaxed. such as how often and for how long the two of you will meet. The therapist lets Zoe know that they will save time at the end of the session to play the game together. they will focus on knowing what to do about feeling anxious. The therapist gives Zoe an overview of what the session will involve. they will focus on recognizing and learning about anxiety. On the day of her first appointment. Finally.234 Cognitive-Behavior Therapy for Children and Adolescents Session 1: Building Rapport and Treatment Orientation Because the child-therapist relationship is so vital. “Write about a time you felt great”). The therapist and child should spend the first part of the session getting to know one other by asking questions or playing an icebreaker game. The therapist points out to Zoe that they will work as a team. give the child a brief overview of the program and share logistics of the program with the child. the therapist shares some of the logistics of the Coping Cat Program with Zoe. Zoe enters the therapy room without looking at the therapist. At the end of the session. a main goal of the first session is to build rapport with the child. and in the second half. such as “What is your favorite TV show?”). This encourages the child’s participation in treatment and emphasizes that you and the child will be a collaborative team working together. review the STIC task from session 1 and give an appropriate reward. Next. The therapist asks Zoe to look around the room and see if there are any interesting games that she would like to play later in the session. The therapist and Zoe agree that she will earn stickers for each STIC task completed and can exchange those stickers for rewards every four sessions. Zoe finds the game Guess Who? and brings it to the therapist.. She encourages Zoe to ask questions and is enthusiastic when Zoe talks. end the session by playing a game or engaging in another fun activity. The therapist invites Zoe to make herself comfortable. with the therapist as the coach. After the get-to-know-you game. ask the child if she has any questions. She explains to Zoe that for the first half of the program. As promised. assign the child an easy STIC task (homework) from The Coping Cat Workbook and plan a reward for completing the task. If the child did not do the STIC . They play a get-to-know-you game (asking each other for personal facts. Be a coping model rather than a mastery model—everything doesn’t always go well! Discuss the child’s own anxiety. The therapist shares with Zoe that everyone (including the therapist) feels anxious at times. and ask how she notices when she is in an anxiety-provoking sit- .Childhood Anxiety Disorders 235 task. disclose a time when you felt anxious and how you handled it.. Once the child has a general understanding that different feelings correspond to different expressions. such as a racing heart or stomach butterflies. the therapist introduces Zoe to the concept that different feelings have different physical expressions.g. Together they pick out two stickers as Zoe’s reward. which is used to rate anxiety on a scale from 0 to 8 (see the therapist manual for details). and the child’s responses in the anxiety-provoking situation.. normalize the child’s own experience of fears and anxiety. feeling happy. discuss with the child how different feelings have different physical expressions. Next. First. feeling sad). Zoe and her therapist begin to develop a fear hierarchy of anxiety-provoking situations by categorizing the things Zoe is afraid of into easy. store clerk) as a medium fear and giving an oral presentation as the most challenging fear. discuss somatic symptoms that might occur when someone is feeling anxious.. Figure 7–1) using the ratings from the feelings thermometer. Next. Zoe is assigned a STIC task: record one anxious experience and one nonanxious experience in her workbook. Ask the child to describe somatic responses that people have when anxious. Zoe wrote about feeling great during a recent soccer game. To serve as a coping model. With the child. During this project. The therapist and Zoe also play a brief feelings charades game. Zoe identifies talking to a new adult (e. The therapist listens with interest to the account of Zoe’s soccer game. Zoe and her therapist begin session 2 by reviewing her STIC task. The purpose of the program is to help Zoe learn to recognize when she is feeling anxious and then to use skills to help herself cope. medium. complete it together. Zoe and her therapist play a game of Guess Who? before the session ends. Zoe and the therapist note that different facial or physical expressions (e. Collaborate with the child to list various feelings and their corresponding physical expressions. Session 3: Identifying Somatic Responses to Anxiety The main goal of this session is to teach the child to identify how her body responds to anxiety. including the types of situations that are difficult.g. They take turns acting out various feelings and having the other person guess the feeling. a smile. head hanging down) are linked to different emotions (e. begin to construct a hierarchy (or FEAR ladder. Zoe and the therapist create a feelings dictionary by cutting out pictures of people with various expressions from magazines and labeling the pictures with the emotions depicted.g. and challenging categories. Introduce the feelings thermometer. . Source.236 Cognitive-Behavior Therapy for Children and Adolescents Yo u FEAR Ladder up there! ’re Getting hig r. Reprinted from Kendall PC. first in low anxiety–provoking situations and then in more stressful situations. Next. The therapist and Zoe start session 3 by reviewing Zoe’s STIC task and putting stickers in her bank. introduce the F step: Feeling frightened? In the F step. the child will ask herself.. uation. practice identifying these responses (via coping modeling and role-playing). he No tt high.. The therapist mentions several . Used with permission. Ardmore. “How does my body feel?” and will monitor her somatic responses associated with anxiety. the therapist introduces today’s topic: identifying the body’s reaction to anxiety. After practice with identifying somatic responses. Hedtke K: Coping Cat Workbook. 2006. Workbook Publishing. FEAR ladder.. 2nd Edition. PA. Next. oo FIGURE 7–1. with Zoe permitted to be creative in her artwork. These somatic re- . Finally. Together. the therapist assigns a STIC task from the workbook. The therapist briefly outlines the treatment program. The therapist talks with the parents to learn more about situations where Zoe becomes anxious. The parents describe Zoe’s reaction in several recent social situations. offer specific ways that the parents can be involved in the program. The therapist acts as a coping model by sharing with Zoe that she blushes (gets red in her face) when she feels anxious. She shares with the parents that she has enjoyed meeting with Zoe and notes some of Zoe’s strengths. Begin by providing an outline of the entire treatment program. Zoe and her therapist create a body drawing depicting Zoe’s somatic reactions to anxiety. Review the F step by suggesting to the child that when she is feeling anxious. her body has somatic responses that may serve as cues. her stomach starts to hurt. Invite the parents to discuss any concerns that they may have. medium. noting what Zoe has learned so far and what will happen in the remainder of treatment. Acknowledge the previous parent meeting. the goal of the first parent session is to encourage parental cooperation with the program and to answer the parents’ questions or concerns. such as refusing to order for herself in a restaurant. Finally. The therapist meets with Zoe’s mother and father. Session 5: Relaxation Training A main aim for the child in session 5 is learning to relax. At the end of session. Zoe shares that when she has to answer a question at school aloud. The therapist asks Zoe if she has any questions about the parent session and if there is anything specific the therapist should or shouldn’t say when meeting with the parent(s). and be prepared to provide a very brief recap. the therapist and Zoe discuss what kinds of bodily reactions they have during anxiety-provoking situations of varying degrees (low. Session 4: First Parent Meeting Although parents have been involved already (providing information about the child). and ask for any input they feel will be helpful regarding their child’s anxiety. The therapist explains that a parent can be involved in treatment by providing information about Zoe’s anxiety and by helping to carry out therapy tasks at home.Childhood Anxiety Disorders 237 possible physical expressions of anxiety. high). such as sweating or a stomachache. and she and Zoe kick around a Nerf soccer ball for 5 minutes. the therapist reminds Zoe that she has the next week off as the next session will be with her parent(s). The therapist asks Zoe to think about other ways that someone’s body might react when he or she is nervous. The therapist introduces this process of paying attention to what’s happening in Zoe’s body as a cue that Zoe is “Feeling frightened?” as the F step. Practice relaxation with the child using coping modeling and role-play. The therapist suggests that Zoe can use the CD to practice these skills at home. the therapist and Zoe invite Zoe’s parents into the session. Then. Zoe has accumulated enough stickers to trade in for a small prize. The therapist and Zoe engage in a robot–rag doll exercise (Kendall and Braswell 1993) and note the difference between feeling tense and feeling relaxed. The therapist suggests that even when Zoe can’t complete an entire relaxation session. Discuss the difference between feeling tense and feeling relaxed. progressive muscle relaxation. After introducing the concept of thoughts or self-talk. The therapist begins Zoe’s session 5 by mentioning the parent session and inviting her to ask questions. the child will ask herself. The therapist asks Zoe how her body feels after a few deep breaths. Next. She asks Zoe to take a deep breath and then let it out slowly. The therapist recalls that when Zoe has to answer a question in class. The therapist explains that our bodies provide cues when we are feeling nervous. Discuss self-talk with the child and describe the connection between anxious thoughts and anxious feelings. “What is my self-talk?” and monitor the thoughts associated with anxiety. Next. and relaxation aids such as relaxation CDs. Session 6: Identifying and Challenging Anxious Self-Talk The goal of this session is to learn to identify and challenge anxious selftalk. The therapist introduces relaxation as a tool that Zoe can use when she is anxious. She also asks Zoe to consider times when relaxation may be useful. she gets a stomachache and feels tense. Work together to discriminate anxious self-talk from coping self-talk. they discuss when and where Zoe will be able to practice her relaxation during the coming week (her STIC task). and these cues can be signals for us to relax. introduce the E step of the FEAR plan: Expecting bad things to happen? In the E step. the therapist and Zoe practice deep breathing. Next. The therapist suggests that Zoe sit comfortably on a beanbag chair. focusing on how her body feels. Practice the use of various . The therapist links this bodily response to the F step (Feeling frightened?) of the FEAR plan. Zoe “teaches” her parents relaxation and everyone follows along with the CD. Together. the therapist introduces relaxation. Introduce useful ways to relax. She gives Zoe a CD with the therapist’s voice guiding her through a progressive muscle relaxation exercise. which can be reduced by relaxation.238 Cognitive-Behavior Therapy for Children and Adolescents actions may be associated with tension. she may be able to take deep breaths Afterward. use exercises in The Coping Cat Workbook to help the child generate thoughts that might occur with various feelings. The therapist and Zoe practice relaxation together with the therapist serving as a coping model. including deep breathing. they review Zoe’s STIC task. Zoe plans to practice each night in a comfortable chair in her bedroom. They also look through magazines and give people in the pictures a thought bubble. The therapist introduces Zoe to the idea that thoughts are connected to feelings. Coping thoughts Trying is the most important thing. Zoe reports that she was able to relax while listening to her CD and that her mom joined in some nights. “What’s in my thought bubble? Am I expecting bad things to happen?” and that Zoe will start to pay attention to her . she will ask herself. She tells Zoe that in this step. types of coping self-talk using the first two steps in the FEAR plan (see Tables 7–1 and 7–2). I can do it! I will be proud of myself if I try.Childhood Anxiety Disorders TABLE 7–1. so I can do it again. Everyone makes mistakes sometimes. The therapist helps Zoe differentiate between anxious self-talk and coping self-talk. The therapist introduces the E step (Expecting bad things to happen?) of the FEAR plan. What’s the worst that can happen? It’s probably not as scary as I think it is. I will try my best. how likely do I think this is going to happen? What is a coping thought I can have in this situation? What is the worst thing that could happen? What would be so bad about ____________________? TABLE 7–2. I have done it before. No one is perfect. Zoe and the therapist begin session 6 by reviewing the STIC task from last week. 239 Questions the child can ask himself or herself to challenge anxious self-talk Do I know for sure this is going to happen? What else might happen other than what I first thought? What has happened in the past? Has this happened to anyone I know? How many times has it happened before? After collecting evidence. They work on a thought-bubble exercise in Zoe’s Coping Cat Workbook. How would you try to find them?” The therapist and Zoe go through the steps of problem solving. review the F and E steps. Zoe and the therapist practice coping self-talk and review the F and E steps of the FEAR plan. Zoe’s therapist assigns a STIC task from the workbook.240 Cognitive-Behavior Therapy for Children and Adolescents thoughts when she is anxious. Next. Describe the four steps of problem solving (i. Zoe’s therapist assigns a STIC task from the workbook. evaluate the potential solutions. Next. having some fun along the way as they include silly solutions in their brainstorming. At the end of the session. Session 7: Attitudes and Actions: Developing Problem-Solving Skills The main goal of session 7 is to introduce problem solving as a strategy for coping with anxiety. To end the session. Zoe and the therapist review the STIC task and pick out stickers to place in the bank. “Attitudes and actions that can help. Introduce the concept of self-rating and self-rewarding for effort. the therapist reviews the F and E steps with Zoe by asking her to describe what they stand for. explore potential solutions.” In this step. and she and Zoe play a game of tic-tac-toe. Serve as a coping model by describing a situation where you experienced some distress but were able to fully cope with the anxiety. The therapist gives the following example: “You can’t find your shoes. rate your effort. and then give yourself a reward. the therapist guides Zoe in using problem solving in low and high anxiety– provoking situations. They play a game on the clinic Wii for the final 5 minutes of the session.. Following Zoe’s explanations. She begins the discussion of problem solving with a concrete. nonstressful situation.e. nonstressful situation. Session 8: Results and Rewards The aim of session 8 is to introduce the final step of the FEAR plan: Results and rewards (Figure 7–2). define the problem. Review the FEAR plan and then work with the child to identify a stressful situation and apply the FEAR plan together to get through it. Introduce problem solving as a tool to help the child deal with anxiety. Slowly build to practicing problem solving in anxious situations. the therapist presents the idea that now that Zoe knows how to check what’s going on in her body and her thoughts when she is nervous. select the preferred solution). Collaborate with the child to create a list of possible rewards that are both material and social. have the child practice using problem solving in a concrete. The therapist introduces the A step in the FEAR plan: Attitudes and actions that can help. After they have practiced with a nonstressful situation. it’s time to learn how to cope with that anxiety. introduce the A step. Together. To begin. the child learns that she may take action and change her reactions when feeling anxiety. . The therapist briefly describes the process of problem solving. First. a high-five from the therapist. Source. and answering questions in class. The therapist introduces the final step in the FEAR plan: Results and rewards.. FEAR steps. They review the steps of the FEAR plan. 2006. and they discuss the difference between a reward and an award. baking cookies with her mom. Zoe and her therapist begin by reviewing the STIC task. Reprinted from Kendall PC. The therapist explains that Zoe may feel anxious during the practices but now she has the FEAR plan to help her cope. Zoe and her therapist review Zoe’s fear hierarchy. The therapist assigns Zoe a STIC task from her workbook. The therapist also reminds Zoe that she is going to meet with her parents again next time. a new soccer ball) that she might be able to earn for completing challenging tasks in and out of session. 2nd Edition. Together they create a Coping Keychain with a personalized FEAR plan for Zoe to use as a keychain and when she is feeling anxious. Let her know that the FEAR steps will need to be practiced in the same situations more than once. starting with a situation that makes the child only a little anxious—an easy one. Used with permission.Childhood Anxiety Disorders 241 Feeling frightened? Expecting bad things to happen? Attitudes and actions that can help Results and rewards FIGURE 7–2. . Together. Inform the child that the next part of the program involves practicing the FEAR steps in anxiety-provoking situations. Ardmore. Workbook Publishing. which includes speaking to an adult she doesn’t know that well. Remind the child that the practice will be gradual. Zoe and her therapist practice self-reward for effort through the exercises in the workbook and role-plays. Zoe and the therapist create a list of potential rewards (e. Hedtke K: Coping Cat Workbook. PA. reading in front of others. The therapist asks Zoe what she thinks about rewards.g. The therapist tells Zoe that the next part of treatment involves practicing the skills Zoe has learned in the program thus far. They end the session by kicking around the Nerf soccer ball. but to “turn down the volume” on Zoe’s anxiety so she can cope in social situations. Zoe’s mother emphasizes that Zoe needs practice presenting or reading in front of others. give the parents an opportunity to ask questions or discuss concerns. The therapist agrees that this is an important situation for practice. The therapist reminds the parents that the goal of treatment is not to get rid of all Zoe’s anxiety. Zoe now has the tools to cope with these upsetting situations. Finally. After this overview of exposure tasks. Inform the parents that it is expected that the child will feel some anxiety during the exposures. She introduces the exposure tasks by explaining that Zoe has learned ways to cope with her anxiety in social situations and that now she will get to practice in real situations. and lets the parents know that she may ask for their help in planning some of the exposures. the therapist reviews Zoe’s fear hierarchy with her parents. Practice using the FEAR plan . in and out of session. The therapist notes that most children feel anxiety during the practices. Both of Zoe’s parents attend the second parent meeting. Sessions 10 and 11: Practicing in Low Anxiety–Provoking Situations The goals of sessions 10 and 11 are similar: to practice the FEAR plan in a low anxiety–provoking situation. Zoe’s mother expresses some concern about putting Zoe in upsetting situations. The therapist begins the session by giving them an overview of the remainder of treatment. solicit the parents’ assistance in the planning of exposure tasks.242 Cognitive-Behavior Therapy for Children and Adolescents Session 9: Second Parent Session The second parent session aims to provide an opportunity for the parents to learn more about the upcoming exposure tasks. both imaginally and in vivo. pick a low anxiety–provoking situation (see Table 7–3 for examples of exposure tasks). and this is OK. she will gain a sense of mastery and her anxiety will be reduced in future situations. As Zoe starts to face her fears. Remind the parents that the goal of treatment is not to remove all of the child’s anxiety. Together. This goal is accomplished through practicing the FEAR plan in anxiety-provoking situations. Finally. but to reduce the amount of distress experienced and to help the child learn to manage it. Begin by describing the rationale behind exposure practice and the difference between avoidance and approach. Begin by reminding the child that the program shifts from learning skills to practicing using the skills in real situations (not unlike learning a sport and then playing a real game). as this fear is currently causing interference in the school setting. The therapist validates this concern and reminds Zoe’s parents that Zoe and the therapist will start with the least challenging practice and work their way up the hierarchy. GAD X Yes Yes Yes No Game No Game Yes No Balloons X No Yes 243 Therapist arranges for the parent to pick up the child late from session Props needed Childhood Anxiety Disorders TABLE 7–3. Have people ask questions during the speech or presentation Social phobia X Buy something from a street vendor or at a store Social phobia X Trip in front of a group of people Social phobia X Wear strange makeup and make hair look messy in front of others Social phobia X Call a friend on the phone Social phobia X X SAD Go in the elevator to various floors Play a game where the rules keep changing Play a game with a new person Find the therapist in a different part of the building Therapist and child pop balloons Others needed?a Yes Money X Yes Makeup X X GAD (afraid of change)b X X Social phobia X GAD X Social phobia X SAD. Examples of exposure tasks . Have people whispering during the speech or presentation 2.Description of exposure Out of session Disorder In session Give a speech or presentation or do show-and-tell: 1. thunderstorms.244 TABLE 7–3.. social phobia X Money Yes Surveys: the child goes around the building asking various people different questions (e. perfectionism) GAD. ask the child to go in part of the building where other staff are and have someone say. Examples of exposure tasks (continued) Others needed?a X Toilet paper No Social phobia. markers No Yes Cognitive-Behavior Therapy for Children and Adolescents Props needed Description of exposure . What’s your favorite ice cream flavor?) Social phobia X Make a worry box and place worries in the box only to be looked at once a day for a designated amount of time GAD X “Break the rules” or “get in trouble” (e. GAD X Objects for treasure hunt Yes Pay a food vendor with the wrong amount of money (good for fear of embarrassment. vomit) Specific phobia X X Pictures or videos No Sit in a room with the lights off (dark) Specific phobia X X Timer No Disorder In session The child walks around with toilet paper stuck to his or her shoe Social phobia Treasure hunt: the child receives a list of people and/or objects to find in the building and goes alone to find these people (the people then have to sign a paper to indicate the child found them) Out of session Yes X Shoebox. insects... “No kids allowed here!”) GAD X Look at pictures or watch videos of a feared stimulus (e.g.g.g. SAD=separation anxiety disorder. paper No Note. specific phobia Therapist and child take a ride on a bus. 245 .g.Examples of exposure tasks (continued) Description of exposure Props needed Others needed?a Fake test No X Paper for script or tape recorder No X X Money for trip No Specific phobia. GAD=generalized anxiety disorder. call back to change or cancel the order) Give the child or have someone else give the child a pretend injection Draw a “mystery challenge” or “mystery practice” out of a jar or hat Out of session Childhood Anxiety Disorders TABLE 7–3. GAD X X Specific phobia GAD (fear of uncertainty)b Disorder In session Take a difficult “test” and receive a “poor grade” GAD X Read or record an imaginal exposure script about the child’s worst fear (e. world ending) and read or listen to the script repeatedly until anxiety decreases by 50% GAD X GAD. bSymptoms targeted are included in parentheses. or other feared form of transportation Therapist and child go to the top of a tall building Call to order pizza or takeout on the phone (to make it more difficult. GAD X X Social phobia. parents dying.. aIn addition to therapist. No Money if actual order Yes X Syringe Yes X Jar or hat. train. providing ratings of her anxiety using the feelings thermometer. Ask for ratings on the feelings thermometer before. the therapist asks. or even notice. prepare for the exposure task. Together. The therapist asks Zoe to talk through the FEAR plan. and everyone makes mistakes. The therapist has Zoe close her eyes and pretend that she is asking the survey questions. Ask for ratings on the feelings thermometer before. Make the imagined situation as real as possible by using props or details. Zoe plans to ask survey questions about favorite sports. Zoe rates her anxiety at a 5 before asking the first person her survey questions. and the ratings decrease to a 2 by the fifth person. Zoe successfully completes the imaginal exposure task. Then have the child walk through all the steps during the imaginal exposure task. She and her therapist decide to kick a soccer ball outside for 5–10 minutes as a reward for completing the challenge. and every minute during the imaginal exposure. They probably won’t make a big deal of it. Zoe is able to ask her survey questions of five unfamiliar people. plan an exposure task for the next session. They begin by agreeing on a situation that makes Zoe a little anxious. Next. she imagines herself doing a good job (not perfect) and receiving her reward. Develop a FEAR plan and negotiate a reward for completing the in vivo exposure. “What did you notice about your anxiety during the survey?” and Zoe responds that it went down. A general guideline is to have the child stay in the situation until her ratings decrease by about 50%. Zoe and the therapist develop a FEAR plan for coping with the challenge. Throughout the exposure. She is having the anxious thought “What if I mess up one of the questions?” She shares the coping thought “It’s no big deal if I mess up. and . after. the therapist reminds Zoe that they are going to start “doing challenges”—practicing the FEAR plan in real-life situations. it’s time for an in vivo exposure task. A main goal of the exposure is to assist the child in approaching (not avoiding) until she feels an acceptable level of comfort in the anxiety-provoking situation. and at a regular time interval (every minute or two) during the in vivo exposure. With the child. Next. after. It is important to help the child prepare and think through any possible roadblocks or other outcomes to the task. To end the session. Finally. Zoe and her therapist prepare for the in vivo exposure task. Afterward. Serve as a coping model by thinking aloud about the situation. First. such as conducting a survey of several unfamiliar adults. At the beginning of Zoe’s session 10. reward the child for effort. Write out the FEAR plan for the specific situation in The Coping Cat Workbook.” She also practices taking deep breaths to help herself cope. Zoe and her therapist practice the FEAR plan by having Zoe imagine herself in the situation. Zoe shares that she knows she is feeling frightened because her stomach hurts.246 Cognitive-Behavior Therapy for Children and Adolescents through an imaginal exposure. the therapist asks for Zoe’s ratings of her anxiety and provides her own ratings as well. After the exposure task. it’s OK because everyone makes mistakes. Sessions 14 and 15: Practicing in High Anxiety–Provoking Situations The goal of sessions 14 and 15 is to apply the skills for coping with anxiety in high anxiety–provoking situations through both imaginal and in vivo exposure tasks. As a reward. but she reminded herself that everyone makes mistakes. Sessions 12 and 13: Practicing in Moderately Anxiety-Provoking Situations The goal of sessions 12 and 13 is for the child to apply the FEAR plan in both imaginal and in vivo situations that are moderately anxiety-provoking. Zoe and the therapist invite two unfamiliar clinic staff members to join them in the therapy room. Zoe provides ratings of her anxiety on the feelings thermometer while she practices. The therapist and Zoe agree to go get a special snack together as a reward. Zoe and her therapist develop the FEAR plan for today’s challenge—Zoe will read a passage from a book in front of two members of the clinic staff. Together. the therapist and Zoe plan a challenge for the upcoming session and complete a brief relaxation exercise together. Zoe and the therapist talk about the challenge. Zoe and the therapist plan at-home challenges and next week’s exposure task before heading out for a treat. goes to the front of the room.Childhood Anxiety Disorders 247 the task became easier. Zoe’s session 14 begins with a review of her STIC task and at-home challenges. Zoe agrees that she will practice the FEAR plan in one low anxiety–provoking situation (an at-home challenge). The therapist and Zoe note that the other audience members did not seem to notice the mistakes. Even if I do. Zoe and her therapist prepare for today’s high-level exposure by de- . Zoe shares that her stomach hurt at first. but it wasn’t a big deal. Zoe is very proud of her effort and accomplishment today. “What if I mess up? They will laugh at me!” Zoe and her therapist come up with the coping thought “It’s not likely that I will mess up because I’ve practiced. it’s time for the challenge. For her STIC task. First. Zoe and the therapist play soccer outside the clinic. Zoe and her therapist begin session 12 by talking about Zoe’s at-home challenges from the prior week. and then reads a passage from her book. Zoe takes a deep breath. Zoe shares that her stomach hurts already and that she is thinking. Next. Finally. Zoe is proud of how well she coped with them and excited about the rewards. Afterward.” Zoe is reminded of a TV star who made a few slips when interviewed. Zoe practices reading the passage to the therapist and talks through the FEAR plan. She “messed up” a few times. but both her stomach and her anxiety felt better once she started. Invite the family to check in in approximately 1 month—to report progress and positive outcomes or additional concerns. Zoe. Zoe and her therapist head out to the nearby fast-food restaurant for the challenge. during.248 Cognitive-Behavior Therapy for Children and Adolescents veloping a FEAR plan. and Termination The goal of the final session is to practice using the FEAR plan for a final time (in session) and to allow the child to “produce” a commercial to show off and celebrate her success. Zoe provides ratings on the feelings thermometer before. Review the child’s treatment gains with the family. Zoe’s mother. Zoe is able to complete the task and enjoys her snack as a reward. such as going out for ice cream or having a pizza party. Session 16: Final Practice. what she is expecting (“They will laugh at me for the mistake”). Prepare for and conduct a final exposure. invite the parents and/or others to watch the commercial. Then. The therapist explains that the commercial is something to show off what she has learned and accomplished and to teach other kids about the FEAR plan. efforts. and what she can do to help herself cope during the challenge (take deep breaths. Zoe’s challenge today is to order food for herself but purposely make a mistake and need to change the order. Provide the child with an official certificate (provided as the last page of The Coping Cat Workbook) to commemorate completion of the program. The therapist reminds Zoe about the “commercial” that she can create in the final session. and after the exposure task. give a final reward for participation. the therapist. The therapist helps Zoe to identify aspects of the exposure task that may generate anxiety. Discuss the child’s performance. but suggest that with continued practice there will be continued improvement. Finally. During Zoe’s final session. Zoe and the therapist put the finishing touches on Zoe’s commercial (a collage that includes the FEAR plan and pictures of some of Zoe’s at-home challenges). Commercial. Zoe immediately decides she would like to create a collage and the therapist encourages her to keep thinking about what she would like to include in the collage. After practicing in the therapy room. the Coping Cat Program). Zoe and the therapist complete one final imaginal and in vivo exposure task: a personal speech in front of a group of clinic staff members. have some fun producing the commercial! The commercial should be a celebration of the child’s progress.. Zoe describes how her body will feel (stomachache). and success in treatment.g. again noting effort and progress. If the child chooses. and the therapist plan challenges for the remaining two sessions. Note that it is normal for there to be difficult times ahead in terms of coping with anxiety. and Zoe’s parents review . It is an opportunity for the child to teach others about how to manage anxiety (e. The therapist and Zoe plan for a reward of eating the snack that she orders. Zoe. use the coping thought “Everyone makes mistakes”). However. (2003) found comparable outcomes for white and Latino youth who received exposure-based CBT for their anxiety. research on treatment outcomes has implications for how therapists treat diverse clientele. 2004). A majority of the participants in randomized controlled trials examining the efficacy of CBT for anxious youth have been white. The therapist reminds the family about calling to check in next month. bear in mind that research on cultural differences is based on group averages. research shows that Latino youth tend to report higher rates of somatic symptoms compared with white youth (Canino 2004. it is important for therapists to be aware of the cultural factors that can impact the perception. her family. symptom expression. Asian American youth tend to exhibit somatic symptoms as early signs of anxiety (Gee 2004). Treadwell et al. and African American youth tend to score higher than white youth on measures of anxiety sensitivity (Lambert et al. Zoe. For example. However. The therapist presents Zoe with a certificate of completion and a list of all the challenges she completed in the program with a little ceremony. limiting the examination of race and ethnicity as potential moderators of treatment outcome. (1995) found comparable outcomes for white and African American youth who received the Coping Cat Program for their anxiety. the available literature suggests some differences in symptom expression among anxious youth. they have been found to predict lower rates of treatment-seeking behavior and higher attrition rates among racial and ethnic minority groups . In addition to informing therapist expectations for symptom expression. Nevertheless. Cultural Considerations Given the rich cultural diversity in most countries. Though limited. more research is needed regarding the responses of Asian American youth to CBT for anxiety. available literature suggests that CBT is an appropriate treatment option for youth from various racial and ethnic groups. Pina et al. Although race and ethnicity have not been found to moderate treatment outcomes. Pina and Silverman 2004). To conclude. and the therapist have a pizza party to celebrate Zoe’s successful completion of the Coping Cat Program.Childhood Anxiety Disorders 249 Zoe’s progress in treatment. therapists can have confidence in choosing CBT as a treatment choice for anxious youth from various cultural backgrounds. They list ways that Zoe can keep practicing her skills at home. and treatment of anxiety in youth. 2008). Although Asian American youth responded similarly to others in one study (Walkup et al. on the basis of the available findings. etiology. It is possible that therapists will find these same patterns when working with diverse youth. clinicians will likely encounter variations in symptom expression in youth from the same cultural background. Instead. We do not advise eliminating the core components of CBT (i. use measures that have been validated for the cultural group of the child being assessed or choose culture-specific assessment instruments (when available). Given the variation found within cultural groups. we recommend spending additional time building rapport with these clients and their families. Sood and Kendall 2006). If this occurs. as well as seeking to identify and address the specific barriers inhibiting their involvement in treatment. Assessment Before treatment begins. 2006. However. we advocate adopting an open mind-set that seeks to understand and personalize treatment for each individual client. For example.. Conceptualization Develop treatment goals and tailor treatment for individual clients based on knowledge of cultural norms. during the A step. it is possible that therapists will encounter difficulty initially engaging and then maintaining in treatment some youth from minority racial and ethnic groups. and reliance on family or church for mental health needs.250 Cognitive-Behavior Therapy for Children and Adolescents (Hwang et al. Possible reasons for these findings include the presence of stressors (e. it is important not to establish strict protocols for all members of a cultural group. Supplement questionnaires with interviews to gather contextual information and to better understand the client’s and parents’ worldview (Gee 2004). psychoeducation and exposure). we do encourage therapists to flexibly adapt the treatment to meet the needs of diverse clients. Treatment Be flexible when delivering treatment.g. Given these findings. unfamiliarity with treatment. low socioeconomic status). and behavior are influenced by contextual factors. and treatment.g. With each client.. To accomplish this. the normative age at which a child sleeps in her own bed may vary by cultural background. For example.. regardless of his or her background. lack of trust in psychology. cognition. An ecological approach involves evaluating how a client’s affect. Hwang et al. assess the client’s presenting problem with an eye for contextual factors. An ecological approach is warranted at each stage of the therapeutic process: assessment. conceptualization. 2006) encourage therapists to adopt an ecological approach to assessment and therapy practices.e. including cultural background. the therapist might enlist various cultural and/ . we and others (e. This information guides and prioritizes treatment goals. and family practices. 2001). among childhood anxiety disorders (Kendall et al. Even when ADHD is controlled. Each of these challenges is discussed.. assess which disorder is primary and causes the greatest interference. and parental psychopathology. for example. not the exception. the therapist and the youth may opt to construct one hierarchy incorporating fears across various domains. because youth with comorbid ADHD may benefit from very clearly structured sessions. first construct a hierarchy for social fears corresponding to the child’s social phobia and then complete a hierarchy for GAD fears). If. 2006). 2006. varying cognitive abilities. Although research indicates that the presence of comorbidity does not affect the efficacy of the Coping Cat Program (Kendall et al. we encourage a collaborative dialogue among the therapist. such as attention-deficit/hyperactivity disorder (ADHD). Be amenable to discussing such factors as culture. consider providing the youth with a written agenda at each session and reinforcing on-task behavior with rewards. . religion. challenges exist when implementing CBT for the treatment of childhood anxiety disorders.g. Overall.) Potential Obstacles to Treatment As with any treatment.. Comorbidity Comorbidity is the rule. When constructing a list of graduated exposure tasks. noncompliance. (For a more detailed discussion on cultural considerations when treating anxious youth. First. client. Alternatively.g. see Harmon et al. including two brief vignettes demonstrating strategies for addressing the potential obstacles. check that the ADHD is adequately managed (e. through medication and/or behavioral intervention). it can still complicate intervention practices for treating anxiety. Potential obstacles include comorbid psychopathology. as is typical. Children with a primary anxiety disorder may also present with a comorbid externalizing disorder. the therapist and the youth may decide to create multiple hierarchies addressing different sets of situations and then complete each hierarchy sequentially (e. and often the client’s parents regarding contextual factors. making some flexible adjustments may be necessary in the implementation of the intervention nonetheless (while maintaining its fidelity). For instance. 2001). a child presents with multiple anxiety disorders.Childhood Anxiety Disorders 251 or religious beliefs and practices as coping thoughts or actions to help the youth (Harmon et al. For example. To help solidify gains and foster a sense of accomplishment. Because Chloe has difficulty reading and writing. In session. brief manner and by having children focus on just one or two steps. The therapist can provide visual and aural reminders of coping strategies to facilitate recall of session information. keep in mind the youth’s developmental level and cognitive abilities. Case Example Chloe is a 7-year-old who was diagnosed with SAD. 2002b) is for adolescents. The Coping Cat Program (Kendall and Hedtke 2006a) is for treating children ages 7–13 years. Younger children or children with cognitive limitations can benefit from the simplification of some of the cognitive-behavioral concepts.T. She and her therapist begin today’s session by reviewing a STIC task that Chloe completed at home during the week. her mother jotted down a few notes in Chloe’s workbook about Chloe staying in her bedroom by herself for the night. For example. Parents may help cue children to follow the steps outside of therapy.g. it may be easier for them to rely on one or two general coping thoughts such as “I can do this!” or “I will be brave!” rather than 1) having to generate a wide range of novel responses to various situations or 2) having to self-reflect to identify what type of “thinking trap” they commonly fall into. an adaptation of the Coping Cat. 2002a. such as “What were you feeling when you were first in your room all by yourself?” “What did you think might happen?” . Project Manual (Kendall et al.. The Being Brave program (Hirshfeld-Becker et al. The therapist spoke to Chloe’s mom on the phone before the therapy session to find out how the exposure task went because Chloe sometimes has trouble accurately recalling and reporting her experiences. Similarly.252 Cognitive-Behavior Therapy for Children and Adolescents Developmental Level and Cognitive Abilities Throughout treatment. particularly for children with cognitive limitations. Chloe shows the therapist a picture she drew of herself completing the exposure task. pretending to squeeze lemons in their hands) and use it to help relax when facing an anxietyprovoking situation. One such project that youth often find enjoyable and beneficial is creating a photo album documenting the exposure tasks completed during treatment. The therapist asks Chloe a few questions. The C. 2008). children can choose their favorite part of progressive muscle relaxation (e. For example.A. the various programs are best matched for youth with an IQ>80. relaxation strategies can be simplified by demonstrating them in a fun. Regarding overall cognitive functioning. youth may create index cards with brief statements or pictures reminding them of the FEAR plan or specific coping thoughts and actions. incorporate the use of creative projects for children to take home. was developed for children ages 4–7 years and includes a greater emphasis on parent training. g. youth with comorbid ADHD may have difficulty organizing material used in therapy. noncompliant youth may benefit from a more frequent reward schedule (smaller. Immediate positive reinforcement at home. such as “Were you feeling happy?” or “How about angry?” before Chloe endorses feeling “scared. Although youth typically need to complete several tasks before earning enough points to obtain a tangible reward. and it is important to understand the problem and address it. if a child fails to complete the STIC task at home. Highlight that there are typically no right or wrong answers—what you are interested in is their thinking and feelings. more frequent rewards).. Accordingly. Keep in mind that throughout treatment. and/or lose resources they need to complete it.g. For all youth. workbook) in one location at home where they know they can find them. hanging a schedule on the wall). from their parents. On the sticker chart is a picture of the prize that Chloe is working toward (a small stuffed animal). STIC tasks) is not permitted..” Chloe states that she used her coping card that she made with the therapist in the previous session to remind her to tell herself. Youth may avoid completing STIC (homework) tasks due to anxiety. in response to the first question. For younger children. but praise them for effort and trying their best. Chloe states that she is not sure how she felt. Don’t judge youth for the quality of their work. can be taught and emphasized. Chloe and the therapist set up these activities with her mother before completing the exposure task. For example..g. use time at the start of the session to complete the work.Childhood Anxiety Disorders 253 and “What did you tell yourself to help?” Sometimes the therapist has to prompt Chloe. The therapist reinforces such effort by enthusiastically telling Chloe that she is proud of her for showing that she can be brave. forget they have homework. The therapist can also take time to try to figure out when the youth is more likely to complete certain tasks during the week and provide appropriate reminders (e. Be sure to reward youth for completion of STIC tasks either at home or at the start of the session. which she puts in her workbook. “I can do this!” She notes that when she got really nervous. . For instance. she colored a picture. The therapist provides her a few foils. avoidance of anxiety-provoking situations (e. You can use this opportunity to practice the necessary coping skills. it is helpful to inform parents of the child’s homework task and request that they remind their child to complete it. Chloe receives two stickers of her choice. Noncompliance With STIC Tasks or Exposure Tasks Youth may not complete the STIC tasks (homework assignments) for multiple reasons. it may be helpful to have them keep their therapy materials (e. Chloe and the therapist reviewed her FEAR plan in the therapy room. you are asking them to do the opposite of what they have been doing for some time. The therapist remains undeterred and calmly goes through the FEAR plan again. but this challenge is different!” . just encourage the child to complete the exposure task anyway. If an exposure task is too difficult. She stares at her coping card. but it is sometimes appropriate to scale back the task for the moment. The exposure task is to go up to the tenth floor of the building by herself in the elevator.) Occasionally. She is on the verge of tears. Establishing a strategy of approach to feared stimuli. And as usual.254 Cognitive-Behavior Therapy for Children and Adolescents Reluctance or outright opposition to doing an exposure task can impede progress in treatment if not handled well. but there may need to be smaller steps along the way. difficulties can still arise when completing an exposure task. children with anxiety disorders have difficulty facing feared situations. On occasion. a child may claim not to need to complete an exposure task because “it doesn’t make me anxious. Chloe identifies that she is feeling nervous and states that she is worried that someone will kidnap her if she is alone in the elevator. the therapist tells Chloe. Be supportive and reinforce efforts made by the youth.” Don’t argue the point. Chloe is about to complete a moderately anxiety-provoking exposure task. and the therapist senses that a meltdown is moments away. and allow the youth to help you construct their own hierarchy—a collaborative process that helps increase motivation and buy-in for the exposure tasks. ask the youth to 1) complete a variation of the exposure task that may be less anxiety-provoking or 2) repeat a previous exposure task to increase a sense of mastery. even when all the necessary preparations have been made. looking for inspiration. can be fostered during the skill-building phase of treatment and reinforced when completing exposure tasks. and Chloe is now standing in front of the elevator. In a sense. Not surprisingly. the use of meaningful rewards can facilitate cooperation. Ultimately. but she is still unwilling to complete the exposure task. youth who deny experiencing anxiety—but who have parents who claim otherwise—can be persuaded to complete exposures to prove their parents wrong. you do not permit the child’s verbal statement to serve as a way to avoid doing the task. For example. it can be broken down into smaller steps. We encourage youth to face the anxietyprovoking situation. However. Chloe responds. anxiously clutching her coping card that reminds her to be brave. (In this way. “I know. “I know you can be brave and do this. the youth still needs to attempt the difficult exposure task. and Chloe refuses to go in. so the therapist does so for her while stating that Chloe can do this task. Unflustered.” She reminds Chloe of all her accomplishments so far. as opposed to one of avoidance. Chloe refuses to push the button for the elevator. The elevator doors close without Chloe placing a foot inside. Explain the rationale for completing exposure tasks. The elevator doors open. recognizing . Conclusion CBT for child anxiety has been found to be effective in several randomized controlled trials. Parental Psychopathology Although the Coping Cat Program is largely a child-focused. There are two specific parent sessions built into the program. but she takes a peek at her sticker chart and notices she is one sticker away from that adorable teddy bear she has so longed for. Now that Chloe’s inertia has been overcome. Chloe appears reticent. high-fives the therapist when she gets back from her courageous. parental psychopathology is a potential obstacle to favorable outcomes. walkie-talkie-free journey. parents play an important role in the intervention. Within the psychoeducation phase. the therapist can help parents manage their own anxiety using the same cognitive-behavioral strategies taught to the children. parents may express anxiety about allowing their child to be in an anxiety-provoking situation. the therapist can explore what is the worst that can happen. exposure task). and what can they do to help. but parents are involved even more as they help youth implement exposure tasks outside of the therapy setting. Chloe agrees to complete the tenth-floor challenge next week and to complete other exposure tasks at home during the week.e. Although they have run out of time for the session. For example.. The strategies include identifying bodily arousal. and although parental anxiety management is not a necessary part of treatment. the therapist suggests that Chloe go up one floor without the walkie-talkie. and with a big smile. Parental anxiety is common when working with anxious youth. In these instances. As such. engaging in relaxation. The therapist has Chloe repeat an exposure in which she goes up on the elevator one floor by herself with a walkie-talkie so she can talk to the therapist. what can the parents tell themselves to help. how likely is that scenario.Childhood Anxiety Disorders 255 The therapist waits and then tells Chloe that this is a really difficult challenge—and maybe they should try other challenges first to get more practice. Chloe musters the energy to complete the challenge. individual treatment. The Coping Cat Program is a manual-based CBT for anxious youth that comprises two phases of treatment: psychoeducation and exposure. Note that parental anxiety management is not the focus of treatment and it is not a substitute for parents’ own treatment when necessary. The therapist praises Chloe again and acknowledges that she can earn her teddy bear today if she completes one more challenge (i. the child learns to identify when he or she is feeling anxious and to use anxiety management strategies. Chloe receives a sticker for completing this exposure. D. noncompliance. Self-Assessment Questions 7. A 16-year-old white adolescent girl with primary social phobia. . A 6-year-old Hispanic girl with primary separation anxiety disorder and a specific phobia of blood. the child practices the skills learned in the first phase through exposure tasks. cognitive restructuring (changing anxious self-talk). multiple exposure tasks. C. in order to address these potential barriers and individualize treatment. and culture. A 13-year-old African American adolescent boy with primary generalized anxiety disorder and comorbid attention-deficit/hyperactivity disorder (ADHD) managed with stimulant medication. The main goal of exposure is to have the child approach (not avoid) anxiety-provoking situations and remain in the situations until she has reached an acceptable level of comfort. the Coping Cat Program should be implemented flexibly while maintaining fidelity. varying cognitive abilities. recognition and management of somatic symptoms. and a learning disability. R= Results and rewards. obesity. In the second phase of treatment.256 Cognitive-Behavior Therapy for Children and Adolescents anxious thoughts (self-talk) and using coping thoughts. age. B. The exposure tasks are guided by a collaboratively determined hierarchy so that the child practices skills in increasingly anxiety-provoking situations. All of the above. and parental psychopathology. Key Clinical Points • The core components of CBT for child anxiety are psychoeducation.1. and problem solving. • Exposure tasks are a key component of the several versions of CBT for child anxiety. • We recommend that the Coping Cat Program be implemented flexibly while maintaining fidelity. Which of the following clients is an appropriate candidate for CBT for child anxiety? A. and importantly. However. Treatment can be individualized according to the child’s comorbidities. cognitive ability. • The Coping Cat Program uses the FEAR plan to describe the concepts learned in the psychoeducation phase of treatment: F=Feeling frightened? E= Expecting bad things to happen? A=Attitudes and actions that can help. Potential obstacles to implementing CBT for child anxiety may include comorbid psychopathology. 2. It’s unlikely that I will fail the test because I studied pretty hard. I think. A 12-year-old boy with generalized anxiety disorder expresses worry about an upcoming test. C.e.3. There’s no way I’ll fail. 7. The best role for her parents in CBT treatment is A. 7. Behavioral activation. Which of the following is NOT a core component of CBT for child anxiety? A. he thinks.Childhood Anxiety Disorders 257 7. D. I have plenty of time to bring up my grades before the end of seventh grade. Parents as collaborators in conducting exposure tasks involving the child’s separation from the parent(s). B. Parents as co-clients in treatment. No parental involvement in the child’s treatment. with treatment for the child and treatment for the parents. B. 7... All I have to do is study every day before the test and then I won’t fail. C. because of parental concerns about causing the child too much stress. The teacher likes me. Even if I fail seventh grade. Eliminating at-home exposure tasks for an 11-year-old girl with social phobia. D. Exposure tasks.4. Which of the following is NOT an example of an appropriate flexible implementation of CBT for child anxiety (i.5. Parents as consultants regarding the child’s symptoms and impairment. Simplifying cognitive restructuring to the use of a single coping thought (“I can do it!”) for a 7-year-old boy with primary separation anxiety disorder who didn’t fully grasp the concept of self-talk. A 7-year-old girl diagnosed with separation anxiety disorder presents for treatment. “I’m worried that I am going to fail. and then I’ll have to repeat seventh grade!” Which of the following is a reasonable coping thought in this situation? A. C.so why bother studying? D.. Cognitive restructuring.. a flexible application that maintains treatment fidelity)? A.. Psychoeducation. Even if I did fail this one test. .. B. I still have my friends . B. Cogn Behav Pract 17:142–153. 2010. Suggested Resources Treatment Manuals Kendall PC. New York. pp 143–189 Kendall PC. 2005 Podell JL. Edited by Kendall PC. 4th Edition. Ardmore. 2009 Further Reading Beidas RS. Cogn Behav Pract 17: 132–141. Hedtke K: The Coping Cat Workbook. Benjamin CL. Using frequent breaks and additional rewards for an 8-year-old boy with primary generalized anxiety disorder and comorbid ADHD who is having difficulty staying on task in session. D. PA. PA. Cogn Behav Pract 12:136–150. 2010 . 2nd Edition. Khanna M: CBT4CBT: Computer-Based Training to Be a Cognitive-Behavioral Therapist (for Child Anxiety). due to parental beliefs and preferences regarding a shared family bed. Mychailyszyn M. Edmunds J. et al: Flexible applications of the Coping Cat Program for anxious youth.258 Cognitive-Behavior Therapy for Children and Adolescents C. et al: The Coping Cat Program for anxious youth: the FEAR plan comes to life. Hedtke KA et al: Considering CBT with anxious youth? Think exposures. Downplaying “sleeping in own bed” as an exposure task for a 9year-old girl with primary social phobia. in Child and Adolescent Therapy: Cognitive-Behavioral Procedures. 3rd Edition. Ardmore. Puleo CM. Ardmore. 2010 Kendall PC: Treating anxiety disorders in youth. Workbook Publishing. Robin JA. Workbook Publishing. Hedtke K: Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual. Workbook Publishing. PA. 2006a Kendall PC. 2006b Training DVD Kendall PC. Guilford. Youth. Journal of Cognitive Psychotherapy: An International Quarterly 20:301–310. J Clin Child Adolesc Psychol 33:269–271. Bailey K. Burlington. Hennessey K. J Clin Child Adolesc Psychol 34:735–746. Workbook Publishing. 2004. J Consult Clin Psychol 64:333–342. Ginsburg G: The role of gender and culture in treating youth with anxiety disorders. Keeler G. Stein M. Morris T: Factors influencing the link between social anxiety and peer acceptance: contributions of social skills and close friendships during middle childhood. Rapee R: Family treatment of child anxiety: a controlled trial. Masek B. 2000 Ameringen MV. Petrila J. Mancini C. Behav Ther 36:197–205. Harv Rev Psychiatry 16:113–125. Angelosante AG. Hollon SD: Defining empirically supported treatments. J Consult Clin Psychol 66:5–17. Chu B. Henin A. 2005 Harmon H. Turner SM: Stability in anxious symptomatology in children. et al: Child anxiety in primary care: prevalent but untreated. Morris TL: Behavioral treatment of childhood social phobia. Edited by Levine B. American Psychiatric Association. Journal of Cognitive Psychotherapy: An International Quarterly 20:247–262. Mauro CF. 2004 Costello E. 2006 Hirshfeld-Becker DR. 2003 Aschenbrand SG. Text Revision. Flannery-Schroeder E. 2006 Greco L. 4th Edition. Dadds M. 2000 . 1991 Beidel DC. Depress Anxiety 20:155–164. PA. 2008 Howard B. Research Center for Children. et al: Cognitive-behavioral intervention with young anxious children. Ardmore. Kendall PC: Cognitive behavioral therapy for children and adolescents with anxiety disorders: clinical research advances. in Mental Health Services: A Public Health Perspective. Farvolden P: The impact of anxiety disorders on educational achievement. Oxford University Press. J Abnorm Child Psychol 24:257–269. Krain A. 1998 Chavira D. J Clin Child Adolesc Psychol 33:272–275. 2004 Gosch EA. Washington. New York. DC. and Families. University of Vermont. Rescorla LA: Manual for School-Age Forms and Profiles. J Anxiety Disord 17:561–571. 2001 Albano AM. 2002 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Mustillo S. 2000 Canino G: Are somatic symptoms and related distress more prevalent in Hispanic/ Latino youth? Some methodological considerations. et al: Prevalence of psychiatric disorders in children and adolescents. 2004 Chambless DL. Turner SM. J Consult Clin Psychol 68:1072–1080. et al: Principles of cognitive-behavioral therapy for anxiety disorders in children.Childhood Anxiety Disorders 259 References Achenbach TM. Int Rev Psychiatry 14:129– 134. 2005 Barrett P. 1996 Beidel DC. et al: Cognitive-Behavioral Family Therapy for Anxious Children: Therapist Manual. Fink CM. pp 111–128 Gee CB: Assessment of anxiety and depression in Asian American youth. Langle A. Kendall PC: Discriminant validity and clinical utility of the CBCL with anxiety disordered youth. Workbook Publishing. Workbook Publishing. Choudhury MS. PA. theory. Cogn Behav Pract 13:293–303. 1994 Kendall PC: Guiding theory for therapy with children and adolescents. et al: Flexibility within fidelity. Wood JJ. 2nd Edition. Edited by Kendall PC. Ardmore. Hudson JL. Project” Workbook for the Cognitive Behavioral Treatment of Anxious Adolescents. 2002a Kendall PC. PA. 2006a Kendall PC. pp 3–24 Kendall PC. Mendlowitz S. Ardmore. J Consult Clin Psychol 72:276–287. J Consult Clin Psychol 64:724–730. 1996 Kendall PC. Scapillato D. J Am Acad Child Adolesc Psychiatry 47:987–993. Furr JM. J Consult Clin Psychol 65:366–380.4-year follow-up. Ardmore. 2006 Kazdin AE. et al: Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7. Southam-Gerow M: Long-term follow-up of treatment for anxiety disordered youth. Cooley MR. 2002b Kendall PC. 3rd Edition. Campbell KD.T. Hudson JL. Project Manual: Manual for the Individual Cognitive-Behavioral Treatment of Adolescents With Anxiety Disorders. 2002 . Workbook Publishing. Choudhury MS. Weisz J: Identifying and developing empirically supported child and adolescent treatments. 2nd Edition. New York. 2006b Kendall PC. PA. J Consult Clin Psychol 66:8–35. Ardmore. Brady EU. Flannery-Schroeder E. Guilford. J Consult Clin Psychol 62:100–110. 4th Edition. J Clin Child Adolesc Psychol 33:248–259. Lin KH: Cognitive-behavioral therapy with Chinese Americans: research. et al: Group and individual cognitivebehavior therapy for childhood anxiety disorders: a randomized trial.A. and clinical practice. Guilford. in Child and Adolescent Therapy: Cognitive-Behavioral Procedures. et al: “The C. Khanna M: Camp Cope-A-Lot: The Coping Cat DVD. 1997 Kendall PC. Braswell L: Cognitive Behavioral Therapy for Impulsive Children. Ardmore. et al: Assessing anxiety sensitivity in innercity African American children: psychometric properties of the Childhood Anxiety Sensitivity Index. 2010. 2004 Kendall PC. Verduin TL: Comorbidity in childhood anxiety disorders and treatment outcome. J Consult Clin Psychol 78:737– 745. 2001 Kendall PC. 2008a Kendall PC.260 Cognitive-Behavior Therapy for Children and Adolescents Hwang WC. et al: Therapy for youths with anxiety disorders: a second randomized clinical trial. Kendall PC: Computer-assisted cognitive-behavioral therapy for child anxiety: results of a randomized clinical trial. J Am Acad Child Adolesc Psychiatry 40:787–794. 2010 Lambert SF. Workbook Publishing. Hudson JL. PA. Panichelli-Mindell SM. 1993 Kendall PC. 2008b Khanna M. Workbook Publishing.A. J Am Acad Child Adolesc Psychiatry 41:1423–1430. Safford S. et al: The C. Gosch E. 2008 Kendall PC. Flannery-Schroeder E. Hedtke K: Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual.T. Gosch E. 2004 Manassis K. et al: Cognitive-behavioral therapy for anxiety disordered youth: a randomized clinical trial evaluating child and family modalities. J Consult Clin Psychol 76:282–297. 1998 Kendall PC: Treating anxiety disorders in children: results of a randomized clinical trial. PA. Hedtke K: The Coping Cat Workbook. New York. the State-Trait Anxiety Inventory for Children. 2002 Wood JJ. Kendall PC: Ethnicity and gender in relation to adaptive functioning. et al: A comparison of completers and noncompleters of exposure-based cognitive and behavior treatment for phobic and anxiety disorders in youth. 2004 Pina AA. Piacentini JC. referral source. reliability. Piacentini J. Sullivan K. J Clin Child Adolesc Psychol 31:335–342. and treatment outcome in children from an anxiety clinic. N Engl J Med 359:2753–2766. or a combination in childhood anxiety. Kurtines W. J Am Acad Child Adolesc Psychiatry 40:937–944. Pina AA. Chicago. Silverman WK. Albano AM. Viswesvaran C: Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. sertraline. J Anxiety Disord 9:373–384. Flannery-Schroeder EC. J Clin Child Adolesc Psychol 2:290–295. and the Child Behavior Checklist. J Am Acad Child Adolesc Psychiatry 33:984–992. Graywind Publications. 2008 Wood JJ. 1996 Silverman W. J Am Acad Child Adolesc Psychiatry 42:1270–1278. Silverman WK: Clinical phenomenology. and validity. Piacentini JC. Kendall PC: Differential occurrence of comorbidity within childhood anxiety disorders. King NJ: Empirically supported treatments for children with phobic and anxiety disorders: current status. et al: Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. Weems CF. Presented at the annual meeting of the Association for Behavioral and Cognitive Therapies. et al: Cognitive-behavioral therapy.Childhood Anxiety Disorders 261 March JS. Scholing A. et al: The Multidimensional Anxiety Scale for Children (MASC): factor structure. 2001 Silverman WK. 2006 . Kendall PC: Ethnicity in relation to treatment utilization. Pina AA: Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. 1999 Silverman WK. Ginsburg G. 1994 Seligman LD. somatic symptoms. J Am Acad Child Adolesc Psychiatry 45:314–321. J Am Acad Child Adolesc Psychiatry 36:554–565. IL. 2006 Treadwell KR. 2008 Sood ED. 2003 Walkup J. Langley AK. et al: Cognitive-behavioral therapy for children with anxiety disorders in a clinical setting: no additional effect of cognitive parent training. et al: The utility of measures of child and adolescent anxiety: a meta-analytic review of the Revised Children’s Anxiety Scale. CO. et al: Reliability of the DSM-III-R childhood anxiety disorders using structured interview: interrater and parent-child agreement. Boulder. J Consult Clin Psychol 67:995–1003. Ollendick TH. 2004 Silverman WK. J Clin Child Adolesc Psychol 33:557–565. Dadds MR. 1995 Verduin TL. Bergman RL. diagnostic status and outcomes at a child anxiety clinic. Southam-Gerow M: Family cognitive behavioral therapy for child anxiety disorders. Parker J. 1998 Pina AA. 2003 Rapee RM. 2003 Ollendick TH. et al: Treating anxiety disorders in children with group cognitive-behavioral therapy: a randomized clinical trial. J Clin Child Psychol 27:156–167. 1997 Nauta M. J Consult Clin Psychol 71:701–705. and distress in Hispanic/Latino and European American youths with anxiety disorders. Saavedra LM. Barrett PM. Emmelkamp P. diagnostic status. J Clin Child Adolesc Psychol 37:105–130. J Clin Child Adolesc Psychol 33:227–236. Albano AM: Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. This page intentionally left blank . Several cognitive-behavior therapy (CBT) models have been found to be efficacious in addressing childhood PTSD and related problems following trauma exposure. disaster and war. Posttraumatic stress disorder (PTSD) symptoms are common in trauma-exposed children.8 Pediatric Posttraumatic Stress Disorder Judith A. MORE than two-thirds of children and adolescents (hereafter referred to as “children”) experience trauma. 2006).D. many children with significant trauma symptoms and functional impairment do not meet full PTSD diagnostic criteria according to DSMIV-TR (American Psychiatric Association 2000) because of criteria that may be less developmentally appropriate for children. Cohen. M. 2002). domestic violence. Scheeringa et al. Ph. 263 . However. terrorism. Audra Langley.D. CBT models have been tested for children who have experienced sexual abuse. community violence. and multiple trauma exposures. such as a sense of foreshortened future (Meiser-Stedman et al. with half of these children experiencing multiple traumatic events (Copeland et al. 2008. impairment cuts across multiple domains of functioning as described in the case examples below (e. Stein et al. and anger (American Psychiatric Association 2000. Several complementary theories explain its complex symptoms. Studies indicate that interpersonal violence such as child sexual or physical abuse. CBITS has been tested in two RCTs for children exposed to community violence (Kataoka et al. that early and/or multiple traumatic exposures lead to increasingly negative outcomes for children. Case Examples Mariel.g. these emotions are often associated with physiological arousal in such forms as rapid heartbeat. represented by the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS. Cognitive-Behavioral Theory for PTSD PTSD was only officially recognized in the Diagnostic and Statistical Manual of Mental Disorders in 1980 (American Psychiatric Association 1980). Other CBT models have been tested for single-episode traumas (Smith et al. which emphasizes the broad applicability of CBT interventions for traumatized children across different types of traumas and a broad developmental spectrum. 2006) has been evaluated in eight randomized controlled treatment trials (RCTs) for sexual abuse. and domestic and community violence have a clearly negative impact on children.264 Cognitive-Behavior Therapy for Children and Adolescents This chapter will focus on two types of CBT trauma treatment models: 1) individual CBT. 2003). helplessness. Described later in this chapter. is referred for a mental health evaluation because of several recent episodes of getting into fights with boys at school. p. and multiple traumas among children ages 3–17 years (reviewed in Cohen et al. these models include largely overlapping components. 1998). and 2) group (primarily school-based) CBT.. According to learning theory. 463). fear. represented by trauma-focused cognitive-behavior therapy (TF-CBT). TF-CBT (Cohen et al. Traumatic experiences are by definition accompanied by negative emotions such as horror. elevated blood pressure. neglect. 2007) and for war-exposed children and adolescents. Mariel’s main problems are the fighting at school and fall- . domestic violence. flushing. Her mother brings Mariel to you for an initial evaluation. and that if left untreated. 2003. Felitti et al. According to the mother’s report. 2009). Stein et al. age 8 years. 2003). and sweating. PTSD results from overgeneralization and failure of extinction of fear and other negative emotions. however.Pediatric Posttraumatic Stress Disorder 265 ing grades. and that when he is in class. difficult. When you meet with Joaquin. you ask if he has recently experienced any frightening. is referred to the schoolbased social worker by his math teacher. he hasn’t been able to stop thinking about what happened and worrying that it could happen to him or his family and feeling sick to his stomach. Mariel endorses witnessing domestic violence between her parents and the following symptoms: Mariel loves her father but has scary thoughts about him hurting her mother. people. he has difficulty concentrating and appears sad and socially withdrawn.e. sights. or very stressful events. he and his best friend witnessed a gang shooting in the park on their walk home. Since then. the teacher has noticed that Joaquin misses class frequently. that his grades are dropping. For example. His teacher explains that Joaquin is typically a conscientious student. a 14-year-old middle school student. they reminded her of her father and thus served as trauma reminders and elicited the same feelings she experienced during the traumatic event. “People fighting. and he replies that 3 months ago. prompting him to walk out of class. stating that he is sick to his stomach. sounds. but some boys at school remind her of this fear. She says. She tries to push these thoughts out of her head.. They make her very mad sometimes. you ask Mariel whether anything bad or scary has happened to her. the boys themselves were not dangerous or violent. but because they were loud males. Likewise. fighting at home. She can’t concentrate at school or sleep at night because she is always worried about what her father will do. She doesn’t want to spend time with her friends like she used to. “No. He feels upset each time he sees his best friend and feels sad and alienated from his peers in general. Joaquin often asks for a pass to the bathroom or to the nurse’s office. Joaquin became upset when he was around his best . During the evaluation. he raised his voice to get the class’s attention. Mariel became angry around boys at school. especially in math. Joaquin. “Do you mean the fights that have happened at school?” to which Mariel replies. “How do they expect me to concentrate on my math test when I can’t stop thinking about the sound of that bullet and the look on that gangster’s face when he spotted us before we ran?” Classical conditioning occurs when neutral cues that either were present at the time of the initial trauma or have enough resemblance to trauma reminders (i. For the last couple of months. and Joaquin jumped visibly in his seat and became very upset. and socially popular.” You ask. Her mother also reports that recently Mariel has started going to the school nurse’s office with headaches. or places that were present at that time and remind the child of the original trauma) become associated with the negative emotions and physical responses the child had at that time and begin to elicit those same responses.” You administer a brief interview to assess trauma exposure and symptoms of PTSD. The teacher explains that last week. and she is more jumpy and irritable than she used to be. or children may come to these cognitions through faulty deductive reasoning (e. In Joaquin’s case. although his friend was simply another witness to the traumatic event. “Other children aren’t treated badly. such as magical thinking or causal misattributions... As avoidance becomes more generalized. these skills can be important components of a trauma treatment plan. Therefore.e. being responsible for the trauma (i.g.e.. both because he didn’t want to think about it and because he didn’t want to burden his hardworking mother. Children who have experienced long-standing. Memories and thoughts about the trauma can also become conditioned trauma reminders and trigger highly negative physical and psychological responses in traumatized children. Operant conditioning may teach children to avoid such cues in order to reduce the likelihood of experiencing these negative emotions. Avoiding thinking and talking about the experience also meant avoiding his guilt and fear that not being able to stop the shooting meant that he was incompetent to protect his siblings and mother. I must be treated badly because of something bad about myself ”). because most traumatized children have experienced multiple episodes of interpersonal violence and reminders of these experiences are so internally and externally ubiquitous that it is difficult to totally avoid them. the perpetrator. For example. . therefore. it is rarely successful. or bullying peers may have told the child he or she was worthless or deserved to be maltreated). Children. which contributed to her avoidance of friends or social situations.. or domestic violence often lack skills such as affect expression. As avoidance is reinforced (i. a neglectful parent. Children with high levels of avoidance or emotional numbing may have trouble using optimal coping strategies such as implementing a safety plan or seeking help from supportive adults when violence occurs. In addition. These cognitions may have been modeled for children (e. or being undeserving of love or care from others (i. severe. he hadn’t even shared his traumatic experience with his mother and siblings.e. self-blame). such as being inherently defective or damaged (i. are prone to developing maladaptive cognitions about the cause and/or impact of having experienced trauma. self-soothing. and affective and behavioral regulation. the child will learn to avoid talking about or being around trauma reminders.g. shame). low self-esteem).. he became a cue to the traumatic experience. even intermittently). particularly in younger children.266 Cognitive-Behavior Therapy for Children and Adolescents friend. if it successfully keeps the child from feeling bad. Mariel loved her father but was scared of him and tried to avoid him when he was “mad. something his father had implored of him as the oldest son when he was deported to their country of origin last year.” She also avoided talking or thinking about her family situation. and/or interpersonal traumas such as child maltreatment. neglect.e. like adults.. there can be cognitive developmental issues. Including parents or other caregivers (hereafter referred to as “parents”) in CBT for traumatized children produces significant improvement in parents’ mental health (e. Several self-report instruments.. having maladaptive cognitions related to the trauma. general cognitive coping skills. children often underreport PTSD symptoms due to trauma avoidance (not wanting to think or talk about the trauma or symptoms associated with it) or due to general child unreliability in reporting externalized symptoms such as anger or behavioral problems. Some evidence supports the use of brief skills in the absence of exposure components for the following groups of traumatized children: 1) younger children (4–11 years) who have relatively high levels of behavioral problems (e. 2001). having frightening recurrent thoughts about the trauma. labeling feelings. Mariel’s mother did not think Mariel was aware of the domestic violence occurring .g. Assessment A major challenge to effectively treating traumatized children is that child PTSD symptoms can be very difficult to accurately identify. and support of the child. avoiding trauma reminders or thoughts about the trauma.g. such as developing a trauma narrative and undertaking in vivo exposure to generalized trauma cues. or parents may minimize these problems. but not always.g. parenting skills. affective modulation. parents may be unaware of the child’s internal trauma symptoms (e. Including parents in assessment is helpful in gaining additional information about children’s behaviors. assess PTSD symptoms. emotional distress). How CBT is applied depends on this accurate assessment. and 3) parent-child relationship building components. and problem solving. Many models also include an active parent component that focuses on enhancing parenting and the parentchild relationship. CBT models that include all three components generally have more evidence for improving PTSD and related trauma problems than models that include only a single component. shame.. 2) cognitive. such as self-blame. For example. they begin with skills-based interventions such as relaxation. and 2) children who have relatively mild levels of PTSD symptoms (UCLA PTSD Reaction Index levels <23 at the start of treatment) (CATS Consortium 2010). Exposure-based or trauma-specific interventions. being hypervigilant about the trauma recurring.Pediatric Posttraumatic Stress Disorder 267 Most CBT models for traumatized children integrate these various needs into their intervention components. depression. such as the UCLA PTSD Reaction Index for DSM-IV. However. Typically. or fear of trusting others).. CBT models for PTSD typically include 1) behavioral. However. are usually provided after the earlier coping skills. Deblinger et al. g. aggressive. Other trauma-associated behavior problems include self-injury. stomach- . anger. She also did not feel her usual happiness around her friends (flat affect). Mariel’s mother had made no connection between Mariel’s fighting in school and the father’s behavior at home.268 Cognitive-Behavior Therapy for Children and Adolescents in the home and was shocked to learn that her daughter had serious PTSD symptoms related to these occurrences. including headaches. but he also would very quickly “fly off the handle” for what appeared to others as minor things.g. such as someone bumping into him or a teacher raising his or her voice to get the class’s attention. “going from 0 to 60. Mariel was aggressive toward boys in part because they reminded her of her father’s aggression toward her mother.. aggression).. sleep problems. angry outbursts that are a manifestation of general behavioral dysregulation.” not being able to soothe oneself after becoming upset) and dissociation. as well as affective dysregulation (e. but clinicians should also ask about sadness. Mariel both loved and feared her father. substance use and abuse. His anxiety generalized to other outdoor settings. as well as the park where the shooting occurred. • B—Biological changes: A variety of biological changes can be manifested as somatic symptoms or illness. and he refused to let his younger siblings play outside when they were under his care in the afternoons and on weekends when his mother was working. Joaquin exhibited sadness and anxiety in his classes and at home and had lost interest in what he used to find enjoyable. Joaquin avoided his best friend. and irritable. It was not safe for her to show anger at home. She was afraid of them but also angry because they reminded her of times when her father had hurt her mother. or flat affect. To optimally assess children for PTSD symptoms. consider the ABCs of trauma impact: • A—Affect: The classic feelings associated with PTSD are anxiety and fear. Parents are typically more focused on children’s externalized trauma symptoms (e. but she was angry and experienced affective dysregulation at school. Traumatized children may also display problem behaviors learned or modeled during their traumatic experiences. who was with him during the shooting. • B—Behavior: Avoidance of trauma reminders and cues is a prominent behavior associated with PTSD. anger. irritability. that justice is served). flashbacks.e. • S—School interference: Difficulty in school may occur because of recurrent intrusive thoughts about the trauma. survivor guilt (“Why am I still alive when someone else died?”). poor grades. trouble relaxing. and he felt guilt and shame for not being able to stop the shooting and for potentially endangering his family by being a witness to gang-related violence. trying to numb oneself.Pediatric Posttraumatic Stress Disorder 269 aches. • C—Cognition: Ask about maladaptive cognitions. Joaquin blamed himself for what happened because he came home later than usual that day. the general notion that “the world is a dangerous place. Mariel thought that her father’s “bad moods” and his subsequent abuse of her mother were in part her fault because they were sometimes preceded by her father yelling at her. Likewise. poor attendance.” and other inaccurate or unhelpful thoughts. hyperalertness and increased vigilance to danger. Mariel experienced trauma reminders in school. generalized loss of trust in adults and supportive social systems. and decreasing grades. loss of faith in the social contract (i. and hyperresponsiveness to sensory stimuli. and hyperarousal. including self-blame. jumpiness. ongoing attempts to avoid thinking about the trauma. Children who are biologically on alert may react in very negative ways to occurrences that they perceive as threatening and that lead these children to lash out in anger or to defend themselves. leading to her trouble concentrating and declining grades. . Mariel reported frequent headaches at school. Joaquin exhibited difficulty concentrating. Joaquin was able to avoid going to school and walking near the park (on the route between school and home) by complaining of stomachaches.. when he felt anxious or overwhelmed at school. which leads to generalized distance from cognitive tasks. Because of intrusive thoughts. distractibility. muscle pains. shame.” “I can’t do anything”). School problems may include difficulty with concentration and attention. trouble sleeping. and classroom behavior problems. and possible trauma reminders in the school setting. incompetence (“I can’t stop bad things from happening or protect myself or my family. he frequently asked for a pass to go to the bathroom or to the nurse’s office with the same complaint. among others. difficulty learning. feeling different. associating with deviant peers. race. 2009) and school-based (Jaycox et al. Joaquin’s feelings of sadness and guilt and his isolation from his best friend left him feeling very different from his peers and made him withdraw from all social activity. educational system. and other social and relationship problems often resulting from loss or lack of trust in others. 2009) child CBT trauma treatments document that these treatments share many common treatment components (described later in this section). community. • Ask about potential barriers to participation in mental health treatment. Mariel felt alienated from her friends and became socially isolated. religion.270 Cognitive-Behavior Therapy for Children and Adolescents • S—Social and relationship problems: These problems may include new or increased fighting. The following strategies are effective for engaging even multiply traumatized children and their parents: • Ask what the family wants and expects from mental health treatment. or other factors that may . Children and parents may feel betrayed by a trusted person. including differences between the family and yourself based on ethnicity. feeling that old friends don’t understand. and/or society at large that allowed such an unfair thing to happen. In addition to these core components. socioeconomic status. and feeling different or alienated from others. When the trauma was perpetrated by a parent or other caregiver or over a long period of time. Treatment Concepts Treatment Engagement Treatment engagement is essential for effectively treating any family but is especially critical in addressing the needs of traumatized individuals. two general treatment concepts are critical when implementing CBT for traumatized children: 1) engaging families in treatment and 2) use of gradual exposure throughout the treatment process. Likewise. attachment is often negatively impacted. Application Reviews of individual (Cohen et al. this may be more challenging with traumatized children and their parents. criminal justice system. social withdrawal. their faith. Because successfully engaging families in psychotherapy requires that they trust the clinician. because trauma typically has a negative impact on trust. they are not agreeing to engage in traumafocused treatment.” “domestic violence. Be conscious not to avoid talking about children’s trauma experiences (the opposite of gradual exposure). Do not wait for children to give you a cue or otherwise show you that they are ready to talk about their traumatic experiences. 2010. Gradual exposure is a critical part of trauma CBT models.g.” “your father’s death. or say “I’m sorry” when talking directly about children’s trauma experiences.Pediatric Posttraumatic Stress Disorder 271 lead the family to doubt your ability to understand their problems or needs. As you implement subsequent CBT components. McKay and Bannon 2004).” Do not use the term “down there” to refer to private parts (e.” “the car accident”). connect them to children’s trauma experiences by asking how children will implement these components when they are reminded of the traumatic events they experienced.” “penis. Do not use euphemisms such as “the scary thing.. purposefully.” “breasts”). and another type of treatment should be offered (Cohen et al. and/or degree to which you introduce trauma-related material during each subsequent treatment session. and incrementally increase the intensity. These behaviors may seem inconsequential. use euphemisms.” or “passing away. look away.” “the upsetting situation.” “anus. and see whether the family can accept this information. few children will . you may lower your voice. you may avoid the topic of the trauma or do so indirectly by communicating that trauma is embarrassing or difficult for you to talk about. “vagina. This may be the case when you start using trauma CBT models. duration. It is important not to do anything that inadvertently models avoidance to children or parents. Because avoidance is a core feature of PTSD. Either out of embarrassment or in an attempt to convey empathy. “sexual abuse. If the family doesn’t understand or accept this explanation.” “the events of September 11th. For example. • Explain your understanding of the child’s problems and their relationship (if any) to the child’s trauma experiences. Children who have experienced trauma are apt to blame themselves or feel ashamed about what happened. Refer to traumatic events by their accurate descriptions (e.. Children or parents may interpret these behaviors to mean that you think what happened was shameful. but they communicate to the child that you are not ready to hear or talk about the child’s trauma.g. Gradual Exposure Gradual exposure refers to the process through which you gradually. It is important to make a conscious effort not to do these things. in family sessions. Core Components Parenting Component When feasible. teachers may receive some instruction regarding how to support the implementation of CBT skills in the educational setting. and/or teachers about the impact of trauma. children and parents often do not make a connection between what the child has been through and the current difficulties they are having. family or cultural beliefs. Psychoeducation can reverse the negative impact of inaccurate information and normalize traumatic experiences. This will enhance children’s optimal use of such skills in school and help teachers understand manifestations of trauma symptoms in the classroom. to actively attend to and praise desired behaviors while attending less to undesired behaviors). It is up to the clinician to provide sufficient trauma-related exposure so that when children reach the part of treatment where they need to describe the details of their personal trauma experiences. as well as to parallel other CBT components. In school-based trauma treatments. Educate children. provide them with written information about what the child is learning in treatment so that the parents can reinforce the skills their child is learning. or in a combination of these formats. This may be accomplished in parallel parent groups. in parallel individual child and parent sessions. Also share information about how many children experience the type(s) of trauma the child has experi- . Help them to understand the child’s current symptoms from a trauma perspective. normalize these problems as common reactions to traumatic events while providing hope for recovery. so that trauma-focused treatment makes sense. Behavioral parenting skills might include encouraging parents to use active praise.. this will not overwhelm them.272 Cognitive-Behavior Therapy for Children and Adolescents spontaneously talk about traumatic experiences. If parents can’t attend sessions regularly.e. selective attention (i. Help parents understand the connection between the child’s behavior problems and past traumatic exposure. or other reasons. and appropriate contingency reinforcement and other reward and punishment procedures that are tailored to the specific child behaviors. Moreover. parents. They may also feel alone because they do not understand that trauma is a common experience that they share with many other children and families. Psychoeducation Many children and parents have inaccurate information about trauma because of societal stigma. include parents in CBT treatment of child PTSD in order to provide effective parenting skills. ” .Pediatric Posttraumatic Stress Disorder 273 enced. problem solving. Be cautious about encouraging children to express a range of feelings outside of therapy (e. Use games or other engaging activities to encourage children to label and express new emotions that they may not be used to talking about. Information sheets about child trauma are available on the Web site of the National Child Traumatic Stress Network (www. by seeking social support. Their responses will assist you in developing tailored relaxation strategies for preempting. rushing pulse. if a child gets a bad grade on a test. Cognitive Coping Cognitive coping is a specialized skill for helping children to regulate upsetting emotions and negative behaviors. “I’m stupid. and ideally. with the perpetrator or other family members) unless you are sure that it is safe for children to do so. negotiating. learning skills in turning down the volume of their symptoms. Parents or other caregivers need to support children as they start to use these skills outside therapy. Younger children may need ongoing assistance from parents or other adults to implement relaxation strategies. individual therapy). Help children recognize maladaptive (inaccurate and/or unhelpful) thoughts that are related to their negative emotions and how these in turn are connected to their behaviors.. Ask children what the earliest manifestations or antecedents of physical trauma-related symptoms are.g. help them to identify the early warning signs of these symptoms (i. preventing.e.... and/or “turning down the volume” (i. recognize them when they first start to occur). For example. and ask them to keep a record of when these early signs occur during the week. Help children gain skills to manage difficult emotions—for example. Teach parents these strategies so that they can encourage their children to use them. he might think.e. and learning optimism. Group settings may offer fewer opportunities for tailoring interventions to individual needs.g. Affect Expression and Regulation Skills It is very important to be aware of whether the children you treat are living with ongoing violence. increased muscle tension. Relaxation Skills Help children and parents understand and recognize the physiological impact of trauma (e. Individualize different relaxation skills if the setting allows (e. using humor and faith. pounding head. “seeing red”).nctsn.g.. decreasing the intensity) of these symptoms when they occur in specific settings.org). stomachache. . Include as many episodes as needed to capture the important traumas the child has experienced. but plan at the beginning what to include in the narrative so that you leave enough time to include everything. It may be helpful to start the narrative with paragraphs or chapters about “Who I am” and “My relationship with the perpetrator before the trauma started” (if appropriate) before proceeding to “What happened during the trauma episode I am describing. Examine with the child whether another thought besides “I’m stupid” could explain getting a bad grade (e.g.g. This will maintain the balance between present (skills). . as the child is developing the narrative. Typically. asking the teacher or a parent for help with studying. hopeful. Allow the child to choose which trauma to start with. Practice this for a variety of ordinary (non-trauma-related) situations and help the child generate alternative thoughts in order to feel better. not giving up). “I can do better if I ask for help”). “I didn’t study enough”.” Each trauma episode should include thoughts. “I didn’t study the right things to do well on this test”. past (narrative). paying more attention in class. Also be proportionate in timing so that the narrative component of therapy lasts no more than about a third of the total treatment duration. studying harder. including all of the important types of trauma the child experienced. you will be sharing this with the parent or caretaker in preparation for joint sessions. “The teacher picked really hard questions”. help the child develop a trauma or life narrative. Through several sessions. you will not start processing details of the traumatic experiences with the child until after he or she has developed a personal trauma narrative. Ask the child how he would feel if he focused on one of these thoughts instead of the thought “I’m stupid” and how this feeling (e.g. better. “I didn’t understand the material on that test”. described in the next section. “Trauma Narration and Processing. and planning for the future (final components). OK) might lead to different behavior (e. and body sensations.. Parents typically need to practice cognitive coping also.” Trauma Narration and Processing Develop a narrative of the child’s trauma experiences. Provide cognitive coping skills to parents and help them to start processing their difficult feelings about the child’s trauma experiences.. Then return to what the child has already written (or produced in another format) and begin to cognitively process maladaptive trauma-related cognitions about core traumatic experiences using cognitive coping methods described above.274 Cognitive-Behavior Therapy for Children and Adolescents leading him to feel very upset and to not pay attention or to misbehave in school because he has given up any hope of success there. A final chapter about “How I have changed” is also important. feelings. As with other components. Pediatric Posttraumatic Stress Disorder 275 In Vivo Mastery of Trauma Reminders If the child has developed generalized fear of neutral cues.e. develop an alternative activity for the joint session or do not have a conjoint session. for the parent to hear it from the child’s own mouth is likely to be highly emotional for both the child and parent. no real danger is associated with it). In order to prepare for these. because stopping in the middle will worsen rather than improve the child’s avoidance symptoms... is extremely angry or emotionally unstable).g. for children who have immediate safety concerns (e. Conjoint Child-Parent Sessions As treatment is nearing an end. Gauge the parent’s ability to cope with this and to support the child during this process. and 2) if the family and other adults are in full support of the exposure plan and committed to supporting graduated exposure. they are living with a perpetrator of domestic vio- . If the parent is not supportive (for example. and move forward together toward treatment termination. Enhancing Safety and Future Developmental Trajectory Remember that after trauma. Before terminating treatment. Help the child and parent develop optimal ageappropriate safety skills for their life situations. address safety later in treatment so that children do not feel shame or embarrassment about safety strategies they may have failed to use to protect themselves previously. Remember that although you have already shared the narrative with the parent. This component should only be used 1) if the cue is safe (i. enhance optimal child-parent communication about the child’s trauma experience. calls the child a liar. the most important thing many children and parents have lost is their belief that the world is a safe place or that others have benign intentions. address treatment closure issues that may be particularly salient for children who experienced the traumatic death of a family member. if the parent still does not believe the child. meet with the child and parent separately for 10–20 minutes before bringing the child and parent together for the rest of the session. Typically use the joint sessions to help the child share the trauma narrative with the parent. you may elect to use graduated exposure exercises to help the child master increasingly challenging trauma cues that are associated with generalized fear responses. Usually. However. have two to three conjoint sessions with the child and parent together. 2010). juvenile justice. Either group or individual CBT trauma therapy is likely to be helpful for most traumatized children.. If the child’s school does not offer trauma treatment. if no group is available. However. Although group or school-based treatment may be optimal for some children. Jaycox et al. because treatment cannot be tailored to the individual child’s needs to the same degree). group therapy has helped many children with severe initial symptoms. school-based group or individual CBT trauma treatment may become a feasible option (Jaycox et al. For example. you must know not only about alternative treatment approaches but also 1) which (if any) options are available at the child’s school and 2) which (if any) are acceptable to the child’s family. pediatric.e. these are only guidelines. Group treatment may be most appropriate for children who 1) have somewhat less severe symptoms (i. and other aspects of group therapy. however. As more schools become proficient at providing trauma-focused CBT treatment. it may be feasible to offer group therapy in outpatient settings that serve sufficient numbers of traumatized children. you will probably need to address safety issues early in treatment instead of later. do not suggest this option unless you know that it is available at the child’s school. 2009. and/or 3) might particularly benefit from peer support. However. social skills training. to select an optimal CBT treatment model for a specific traumatized child.276 Cognitive-Behavior Therapy for Children and Adolescents lence or with ongoing community violence). and other providers who are working with traumatized children. offer individual therapy and vice versa. educational. Selecting an Optimal CBT Model and Logistics Several different child CBT trauma models have been empirically tested (Cohen et al. 2009). Case Management It may be important to collaborate with systems of care such as child welfare. Be aware that many individual child treatments . and these considerations are less crucial than providing some form of effective treatment. Individual treatment may be most appropriate for children who 1) have more severe symptoms (because individual therapy can be more easily tailored to individual needs) and/or 2) have experienced child abuse or domestic violence (parents often have concerns about their children talking about these experiences with other children). 2) can only access treatment in school settings. . fun activities for implementing all of the core components. play is the medium through which you will accomplish most effective therapy. and involved in these activities. Developmental Adaptations Child CBT trauma models (and TF-CBT in particular) have been used and tested for children ages 3–17 years with relatively minor adaptations on the basis of children’s developmental level. positive outcomes have been documented without parental involvement for TF-CBT and other individual child CBT models (e. Adaptations for preschoolers and adolescents are briefly described. Often they resent having to come to therapy.g. If they are coming because of trauma-related issues. Deblinger et al. the most important consideration is to offer a form of treatment that the family will attend. storytelling. when deciding on a treatment plan. an M&M. Preschool (Ages 3–7 Years) Even very young children are able to use the core treatment components with positive outcomes if these components are provided appropriately for their developmental level (e. and most importantly. 2001). which is a reasonable duration of treatment for the clinician to suggest as a starting point. or exciting guessing games.. judge) wanted them to. funny. Thus. a sticker. excited. Although inclusion of parents is always optimal. and some may need more. Weiner et al. you may hear com- . Deblinger et al.. Providing psychoeducational information. lavish praise such as “Oh my goodness. learning about relaxation.Pediatric Posttraumatic Stress Disorder 277 such as TF-CBT are also effective without parent involvement. ensuring that families understand that some children may need fewer sessions. or other activities for you to play with young children during therapy sessions. although you may consider factors such as symptom severity and the availability of group treatment (including in the child’s school). especially if they are coming because someone else (parent.g.g. Because play is the primary activity of preschool children. talking about feelings. and talking about “what your brain is telling you” (cognitive coping) can all be made into enjoyable. 1996. Providing small prizes (e. soothing. Adolescents (Ages 13–17 Years) Traumatized adolescents are often challenging to engage in treatment for a variety of issues. Most CBT models are 10– 12 sessions. Cohen and Mannarino 1993. It is important to develop engaging. teacher. you are SO SMART!”) after children give each correct answer keeps young children engaged. 2009). American Indian (Bigfoot and Schmidt. 2003). “Why should I be punished (by coming to therapy)?” “I’m not crazy”. developmentally. whereas language and examples were adapted to be culturally.” Start by validating these concerns as teenagers have a right to these feelings—they are not being brought to therapy because they were responsible for the trauma or because they are “crazy. 2009) • TF-CBT for Latino immigrant (Kataoka et al. 2005) and American Indian children (Morsette et al. across the three models used in diverse settings (schools. as well as any other concerns they may have about starting therapy. and Zambian HIV-affected sexually abused children (Murray 2007) • KidNET for international war refugee immigrants to Germany (Ruf et al. or “I don’t want to talk to a shrink. in press). Addressing these concerns at the outset is a natural segue into psychoeducation about the impact of trauma and will also give you a chance to ask them what they are hoping to get out of coming to therapy. In each case. and refugee camps and clinics). Cultural Adaptations At least three child CBT trauma models have been culturally adapted and pilot-tested: • CBITS for Latino immigrant children (De Arellano et al. both to assess cultural variations of how traumatized children presented clinically and in adapting the intervention itself. These are critical parts of engaging youth in psychotherapy (McKay and Bannon 2004) and have been used effectively to retain traumatized youth in TF-CBT. These might include child-related challenges. Obstacles to Treatment You may encounter many obstacles when first starting to implement child CBT trauma treatment. “What happened was not my fault”. clinics. Interestingly. 2010) In all cases.” but almost always because of emotional or behavioral problems that often are related in some way to the traumatic experiences they have had. the models gained culturally sensitive engagement and implementation techniques that have achieved strong acceptability and positive initial outcomes among children cross-culturally.278 Cognitive-Behavior Therapy for Children and Adolescents plaints like “I didn’t do anything wrong”. such . all of the models retained their core components. and contextually salient to the child or children being served. these adaptations recognized the importance of engaging local consumers in the adaptation process. You select cards that focus on domestic violence.edu/tfcbtconsult). and provide psychoeducation about domestic violence and examples of children’s safety skills (e.” You say. When talking about safety.. going to school. children who have serious affective or behavioral dysregulation (whether or not related to trauma). and she says that it is hers.e. You also provide information about PTSD: that having problems like hers has a name. brushing your teeth. doing your homework. Because there are immediate safety concerns. usually but not always caused by the child’s negative behaviors. a new online resource has been developed through funding by the Annie E. parents who have their own severe trauma history (and thus raise concerns about whether they can handle hearing the material this type of treatment might raise). Mariel seems relatively comfortable talking about these topics. Mariel puts all of the jobs in the correct containers until she comes to keeping the family safe. You use the metaphor of children wearing a backpack and parents carrying suitcases. paying the bills. children and/or parents who come in each week with a new crisis. “We’ve talked about things you can do to keep YOU safe.” Mariel agrees to your talking about the family’s need for more safety with her mother. Casey Foundation. you also address safety during this first session instead of waiting until later in treatment. don’t get between adults during a fight. By the end of the session. To help therapists who face these common problems. Anita. You draw a suitcase and a backpack. and then list a variety of jobs (e. buying food. you ask Mariel whether she would like to play a game or draw pictures. that they are common after children experience really scary things like domestic violence.. “I know it’s supposed to be the parents’ job. Case Examples Mariel: Individual TF-CBT During the first session.. not the child’s backpack. When meeting with Mariel’s mother. Keeping your family and your parents safe is a grown-up job. you tell her that one of the best predictors of children recovering from PTSD is .g.g. You play What Do You Know? (CARES Institute 2006). You ask her whose job it is to do this. how and when to call 911). but they don’t do it so I have to. Mariel says she is afraid that she cannot keep her family safe. TF-CBTConsult (www. and it belongs in the grown-up suitcase. don’t play with matches. only cross the street on a green light. that threatens your ability to follow the treatment plan).Pediatric Posttraumatic Stress Disorder 279 as children who are highly trauma avoidant. keeping the family safe) on note cards and ask Mariel to put the cards in the correct container according to which jobs belong to parents and which jobs belong to children. at the first session. going to work.musc. Then she says. and “crises of the week” (i. and that children can get better from PTSD. She chooses to play a game. Anita denies that her husband would ever seriously hurt her. Once in school. so she is already on her way toward getting over this. 3.280 Cognitive-Behavior Therapy for Children and Adolescents “having a parent like you who believes and supports her child through therapy. she will have a picture of butterflies. including a local domestic violence treatment center. which makes her feel safe. and additional information about the father’s controlling behavior. She will arrive 5 minutes early so that she has time to look at the butterfly picture before class begins.” You ask. this might help her to feel safer right now. You suggest that if Mariel could have a safety plan. She loves butterflies. Mariel already has that. and the school develop the following plan in order to address Mariel’s headaches in school: 1. You provide Anita with written information about domestic violence that describes these behaviors as being part of a pattern of domestic violence. so these will be her focus during visualization. If she starts getting a headache. Anita also agrees to talk to Mariel about calling her aunt Carolina if she is afraid. You teach Mariel progressive relaxation and focused breathing. who is the closest to Anita in her family. she will tell her mother. “Help me understand what it is like at your house. Anita becomes tearful. Anita tearfully admits that she has been too ashamed to tell them. but because Mariel loves her and needs her.” Anita is visibly relieved to hear you say this. and you do not want anything to happen to her. You also provide her with information about other resources for domestic violence. “I understand why she feels that way. who will practice these relaxation strategies with her before she leaves for school. During the next session. Mariel tells you that her mother talked to her about safety and said that she could call her aunt Carolina if she was scared about her parents’ fighting. You then describe to Anita Mariel’s concerns about safety and her belief that she must keep the family safe. my husband has been angry a lot. In her backpack.” Anita gradually confirms more about what Mariel has told you. Carolina. You ask whether any of Anita’s friends or relatives know about how her husband treats her and Mariel and whom Mariel could call on the phone when she is afraid. You encourage Anita to consider telling her sister. her mother. Anita agrees to this idea but does not know what to include in the plan. If she is not relaxed. 2. Mariel says that she feels safer since her mother told her this. and it must not feel safe to her sometimes. and suggest that it might be helpful for her to look online and consider going to this center to seek counseling or other services. and in collaboration with Mariel. She is so lucky to have you here. Mariel will use visualization. she will go to her first classroom. She will sing her favorite song in her head (a lullaby her mother used to sing to her). Her teacher will come to her desk if she puts her hair in a . not only because you care about her. You tell her that you and Mariel are both very concerned about her safety. She will keep this vision in her head when she is walking to school and will use deep breathing and progressive muscle relaxation on the way to school. When getting ready for school. but says. she will have a special signal (putting her hair in a ponytail) that her teacher recognizes as her help signal. Are there other grown-ups you can ask to help you feel better? How about at home—are there other adults you can ask for help?” Mariel says. “So that’s another way to feel better—reaching out to adults who can help you feel safe is called asking for support. that helps me feel less scared. “Mommy. confused (when she doesn’t understand what her teacher says in school). “Sometimes. other kids like to get active. Anita says.” You say.” You then ask what kids can do to feel better when they have upsetting feelings like being sad or angry. she will be allowed to go to the nurse’s office to get some aspirin. if she was worried or scared. Let’s see if we can figure out some other ways to help you feel better. other kids talk to their moms or a friend. “I was surprised that Carolina said this.” You say.” Anita agrees to practice the above relaxation strategies with Mariel.Pediatric Posttraumatic Stress Disorder 281 ponytail and will ask her to do her deep breathing and butterfly visualization exercise. “I call Aunt Carolina. and excited (when she gets a present).” You ask. and she is able to name times when she has felt happy (when her mother is happy). but I’m really relieved that I told her. “Has that been helping you to feel better?” Mariel says. Anyone at school you can ask for help?” Mariel . but you say.” You say. anxious (when her father comes home in a bad mood). angry (when the boys at school are loud). “Once I just called her to talk—I just liked knowing I could talk to her. You and Mariel play Emotional Bingo.” Mariel thinks for a minute and says. Anita explained that she and Mariel were getting help for the problem. after which she will return to class. sad (when her parents fight).” She has also been using the relaxation strategies in school and has had fewer headaches. you begin working on affective expression and modulation skills. “So Mommy is someone you can ask for help when you’re feeling sad or scared. “When her family gets along and is happy. When she can’t think of a time she has felt hopeful. I feel so much better now that someone knows about this. if Daddy isn’t fighting with her. Mariel reports that she called her aunt Carolina twice this week. Mariel has a second visualization exercise to use as well. You meet alone with Anita. “I bet sometimes it’s really hard not to think about your parents fighting. If this doesn’t work. She can do this at her desk quietly without attracting the attention of other children in the class. During the following session. day or night. She says. and other kids have a hobby or something else they like to do. but she actually said she was proud of me for coming to therapy. Once she called when she was upset. I thought she would put me down for staying with him. who tells you that she told her sister Carolina about the domestic violence. Carolina was very upset when she heard this but was supportive of Anita and quickly agreed to Mariel calling her anytime. Is there anything you can do to help yourself feel better when you’re upset?” Mariel says. “When would another child feel hopeful?” Mariel says. “Yes. and this helped her feel safer. you ask. “Does that help you feel better?” Mariel says. Mariel is not sure at first. and Carolina was relieved and told Anita that she was proud of her for telling someone about it and getting help.” You say. “Some kids go to their rooms and read a book. I wasn’t sure it was the right thing to do. “I try not to think about things that upset me. Mrs. her aunt. Mariel calls her aunt.” You say. Mrs.282 Cognitive-Behavior Therapy for Children and Adolescents says. Anita and Mariel are very reassured and leave for the center. Anita reports that she is still living with her husband but has gone to her first session of a women’s support group at the domestic violence center. She agrees to try to talk to one of the helping grown-ups at school before she loses her temper. Jones thanked her for “using your words” instead of fighting. When you meet with Mariel. You also introduce the use of thought stopping (e. You tell her that she is already in danger and that she needs to get help immediately. However. and you praise Mariel for using the coping skills you just discussed. is really nice. my teacher.g. She likes the idea that she can be in charge of her thoughts and draws a stoplight to practice thought stopping. she tells you that her headaches have decreased significantly at school. Anita agrees to this plan. she is worried about leaving him because she has read that perpetrators can become deadly when their wives try to leave. You emphasize that you are very concerned about her because no one should be beaten and mistreated the way she is. This comment was very reinforcing to Mariel. you start by meeting briefly with Anita to follow up on what has happened since the last session. “So those are two other people you can talk to if you are feeling upset.” and to her surprise.. Anita tells you that her husband found out that she is bringing Mariel to therapy. After practicing this. Mariel hugs her mother and asks whether she can call her aunt Carolina. Her husband has beaten her up severely twice this week. Tomas. You meet together with Anita and Mariel to explain to Mariel that her mother is taking her to a special place that helps mothers and children to deal with domestic violence. You meet with Anita to address affect regulation skills. and her teacher when she is feeling scared or upset and has not had any new episodes of fighting. She has heard a lot of frightening stories. Jones. You offer to help Anita call the local domestic violence program from your office and arrange for her and Mariel to go directly to this program from your office. but Anita is determined to get Mariel the help that she needs. is nice too. On the positive side. “Mrs. And the school nurse. Anita says OK. You say that maybe sometimes Aunt Carolina could even go with Mariel and her mom to the domestic violence program. You introduce cognitive coping by asking whether Mariel has had any upsetting feelings during the past . and these have made her both more scared to stay and more scared to leave. She shows you several bruises on her body. The following week. He has demanded that she stop coming. She is not sure what to do. She has talked to her teacher about “feeling mad. She asks you if you think she and Mariel are in danger. She’s been helping me do my breathing at school this week. and she felt very pleased with her new skills. who says she will meet them as soon as she can catch the bus to the domestic violence center.” You then work with Mariel to identify the early signs of getting mad at school and to recognize these early warning signs before she loses her temper and starts fighting with boys at school. She is continuing to talk to her mother. she agrees to bring the drawing to school and practice thought stopping when she has intrusive thoughts about her father at school. Mariel is doing better in school. and she has met with a legal advocate there. using the visual image of a red light when Mariel has intrusive scary thoughts at school when she is trying to do schoolwork). how would you feel?” Mariel says. “What about this thought: Maybe they thought that you didn’t want to play with them anymore because it’s been so long since you’ve wanted to spend time with them. We both have black hair and brown eyes. I live with my mother and father in Oakland. Of course it did. I don’t like to eat peas. Chapter 1: All About Me Hi. but my family in my house is just three peo- . Chapter 2: My Family I have a very big family that includes lots of aunts. You encourage Mariel to use cognitive coping during the coming week when she is upset and to replace maladaptive thoughts with more accurate and/or more helpful ones. I am 8 years old. and read. Usually we can say our feelings in one word. I go to school at St. “So. Christopher’s School. As she is writing it.” You say. for the first time in a while I felt like playing with some of my friends during lunch. mad. like we talked about last week. sing and dance. if I thought my friends didn’t like me anymore. what did you do?” Mariel says. “I never thought of that. When you felt sad. “I might have asked them if I could play with them. “I don’t know. So when you thought. maybe they didn’t like me anymore. You say.” You say. Mariel writes the following trauma narrative. During the next three sessions. too. I guess I wouldn’t feel so bad. When we have a feeling. but none of them asked me to play with them.” You say. I like to play with dolls. did you? So maybe your friends thought you still wanted to stay by yourself? If you thought that.” You say. I would feel sad. you share it with Anita during her individual sessions. my name is Mariel. and my best friend is Barbara. My favorite food is pizza. I want to be a teacher when I grow up. Mariel.” You say. we often have a more complicated thought that is connected to it. uncles. So this is how we would write this down” (Figure 8–2). When you felt sad. “That’s right. cousins. Thoughts are connected to feelings. “And if you didn’t feel so bad. this was the thought that made you feel sad. She says. like something we are telling ourselves in our head that is more than a one-word feeling. You say.Pediatric Posttraumatic Stress Disorder 283 week. what were you thinking? What was your brain saying to you?” Mariel says. what you felt. So when you felt sad.. this is how we would write this down to show the connection between what you thought. So I’m really glad that you are so good at recognizing your feelings. and three grandparents. what sentence were you telling yourself in your head about your friends?” Mariel says. that’s exactly what I mean by a thought. I guess it was saying that I feel sad.. “Um.” You say. or happy. I felt really sad. and how you acted” (Figure 8–1). like a sentence. like sad. You didn’t ask them to play either. “Sad is what you were feeling. maybe my friends don’t like me anymore. “Great job. “That’s a perfect example. You meet again with Anita to introduce her to cognitive coping and to encourage Mariel to use this in the coming week. but they are a little different. “Yes. “What if you had a different thought instead of that they didn’t like you? Can you think of any other thought a child could possibly have in this situation?” Mariel thinks for a minute and shakes her head no. “I went back inside and sat in the bathroom by myself. what might you have done?” Mariel says. I have to get her out of here.. I was afraid he would hurt her or kill her and who will love me then? I am sick when I think about this. “My husband perpetrated the violence. He and Mommy were fighting. so I did not go and it made my stomach hurt more and more.” Anita sobs at this point. and I heard her head hit the wall. What will happen if he doesn’t love me and Mommy anymore? I felt sad and scared about what he would do to Mommy. I can’t even stand to think about it. He does not love me anymore. I had to go to the bathroom. but she’s known all along. and until now you didn’t understand what Mariel’s trauma experiences have been like. She is sobbing and says she had no idea that Mariel knew about this episode. and it was bad a lot at home. I can protect her”. but all night long he was hitting and yelling and kicking and she was crying. I can’t believe it. she might not have talked about this and . I felt really mad. I heard Daddy call her bad names. This makes him look like a monster. I can’t let her live through this one more minute. and she said she fell down but I knew it was because of Daddy.. and me. That was when we had a happy family. I wish I had hit him. My father had trouble with working. like about when I was 5. . The next day she had a black eye and her face was swollen up. I am not a good child. saying. I tried not to hear. Daddy. Daddy played with me and said he loved me. I heard the door slamming and Mommy crying. One time I remember was when Daddy came home. and his anger was bad. but I was too sick and too scared. She is growing up with these horrible things. He yelled. “I thought I had hid it from her. “You have both been the victims in this story. She says. and he was really mad. My parents were not happy like before. and I’ve let it happen. I can hardly live with myself knowing that I let. and I cried to sleep at night. “Daddy is mad at me. “Now that I understand what Mariel has gone through. And Mommy cried all night and so did I. but I know Daddy was hitting Mommy. Chapter 3: Fighting My parents started to not be happy when I was little. things were better. When you read this to Anita. and I just wanted to stop him and hit him.” You say.284 Cognitive-Behavior Therapy for Children and Adolescents ple: Mommy. she is shocked. he said really bad things to her over and over so that I held my hands over my ears so I couldn’t hear. I was scared to tell her what I heard. I can’t believe I let my own child live through this. I thought.” My stomach hurt. not me”. He yelled at me to get in my room right now. and I was praying and please let it stop. When I was little. “What is wrong with you?” I ran to my room crying. but I was afraid it would make him madder. but I was so afraid that he would kill her. It was so bad.g. in preschool. “How could I not see—how could I think she wouldn’t know?” You validate Anita’s pain and support her use of cognitive processing to replace these maladaptive thoughts with more accurate and helpful ones (e. “If I hadn’t brought her to therapy. How does hearing about her experiences change this for you as her mother?” Anita says. so I just hugged her and went to school. “I—I just. FIGURE 8–2.Pediatric Posttraumatic Stress Disorder 285 Situation: My friends didn’t play with me. New feeling: Not so bad. New behavior: Ask them if I can play with them. New thought: They didn’t know I wanted to play with them. FIGURE 8–1. Behavior: I went in the bathroom and stayed by myself. Mariel’s new cognitive triangle. Mariel’s initial cognitive triangle. Situation: My friends didn’t play with me. . Feeling: Sad. Thought: They don’t like me anymore. Mariel makes a configuration with blue away from red and yellow. I am not the only one. At the next session. and why can’t she make him be nicer? I never want to get married. when blue and red live in one place and yellow lives somewhere else. It will get better someday. “Mariel is getting better.286 Cognitive-Behavior Therapy for Children and Adolescents gotten better”.” Mariel completes her narrative with Chapter 4. Anita and Mariel meet together with you for Mariel to read her narrative to her mother (until now you have been reading it to Anita in her in- . Now you explain that there will be a Chapter 4. Chapter 4: How I Have Changed Since I have come to therapy. but they will attend their appointment as scheduled. Then you explain that the family changed in Chapter 3. and sad. I miss Daddy but not the fighting. I met other kids who had domestic violence. It happens to lots of kids. It makes me sad to think that he is alone but then I remember all the fighting. Why can’t they love each other like they did before? Why does he have to be so mean. yellow. Tell a grown-up if you are scared. I didn’t make Daddy get mad. That was worse than anything else. I would tell other kids it’s not their fault. You take out three cans of Play-Doh and use the metaphor of Mariel (blue Play-Doh). But all three people are still part of a family even if they live in different places. She is relieved that her mother is safe but mad at both of her parents for “making it be like this. You ask Mariel to show what shape the family looked like in Chapter 3. so their shapes were very different from in Chapter 2 when they were all happy together. they were not the same as in Chapter 2: red and yellow were fighting. Mommy (red Play-Doh). During the following week. Mariel thinks and makes a circle of blue and red. You might make it worse. Mariel makes a circle with red. I don’t want my mother to get hurt again. which are mashed together with her fists. He needs to get help for doing domestic violence. and Daddy (yellow Play-Doh). and I don’t want to go back to the way it was. I call Aunt Carolina or Mommy or talk to my teacher when I feel sad or worried. but not scary. with yellow on the outside. I feel sad that our family is not together. Don’t get in the middle of grown-ups when they fight. and yellow together. and blue was hiding from yellow sometimes. mad. I worry about Daddy living alone and if he is okay without us. You ask what the feeling is. blue. “Sad. I have learned that grown-ups have to keep kids safe.” You validate Mariel’s sadness and anger at losing the family she had. The police came to my house and brought us to the shelter. then there was red. At the start of their family. and blue. Anita calls to tell you that she and Mariel have moved to the shelter. and she says. I have learned a lot about domestic violence. You are not alone. and she says that she is relieved. you ask Mariel how she has been. You ask Mariel to put them into a shape that shows the family in Chapter 2 of her story. there was just red and yellow. So how will their shapes change in this chapter? You ask Mariel to show what their shapes will look like in this next chapter. It’s quieter than fighting. and this is largely because I’ve been a good mother to her”). Mariel and her mother have just moved to a small apartment near Carolina and her family. and behaviors for each point and discuss that scary or traumatic events affect everything about us—all three of these things—and provide an example of how they are linked and affect each other. the two of you agree that he could benefit from a group you are offering at school. Joaquin: Group CBITS During your initial meeting with Joaquin. When you ask each of the six participants to briefly state why he or she is in the group. Joaquin says that he “saw a kid get shot on the way home from school. She recognizes that Joaquin has become sad. you also introduce the reinforcement chart so that the students see how they will be rewarded for participation and practice. You get permission from Joaquin’s mother to include him in a 10-week CBT group at school for students who have been exposed to very stressful or traumatic events. and that their father was deported last year. At the end of treatment. tired. you facilitate a game with the students so they can get to know one another and feel comfortable talking in the group. She agrees that she would like Joaquin to receive support and learn coping skills so he can feel better. and after you have provided him with some information. she is doing well and her UCLA PTSD Reaction Index has fallen to within the normal range. making it feel impossible for her to accompany Joaquin or provide transportation for services. and Mariel’s symptoms have significantly improved. she knows that they live in a dangerous neighborhood. he thinks they could get shot. feelings. so she is grateful that he can attend a group at school. you provide his mother with some brief information about the skills that Joaquin will be learning and let her know he will be given the opportunity to talk about the experiences he has been through.” and so he yells at them not to go outside . Joaquin joins in and says that he sees how what happened to him makes him think that if he goes to the park again or lets his siblings play outside. During the first group session. While you have her on the phone. Although his mother is not aware of the shooting. you create a triangle with thoughts. You talk about the prevalence of violence and trauma among youth and what those words mean. Next. You give her your contact information and ask her to provide you with any alternative contact information for her and best times to contact her if needed. you assess his PTSD symptom level (which is in the moderate to severe range). and sick to his stomach over the last few months. She has started to visit with her father at her paternal grandmother’s house.” You discuss confidentiality. this has decreased her worry about her father. Joaquin smiles when he realizes that two other students name similar interests to his and that there is another youth who is the eldest in his family and whose father does not live with them. and the group arrives at a set of “group rules”. She agrees to do her best to get time off to attend parent sessions at the school when possible. and that he does not like to go to school. After others talk. that he does not have any patience with his siblings. that the kids see fights at school.Pediatric Posttraumatic Stress Disorder 287 dividual sessions) and to fine-tune safety plans. These fears make him feel “crazy nervous. His mother works two jobs and has three younger children. They are sent home with a similar form for parents to write in goals they have for their child. you review common reactions to stress and trauma. you are able to normalize why that symptom would occur and provide hope for how the group may help it improve. right? In this group. After some introductions and brief sharing at the meeting. You highlight the issue of avoidance and why it is important for youth to be able to process and digest their experiences by telling their stories. You provide handouts for the content of both sessions in case some parents do not return for the second session.288 Cognitive-Behavior Therapy for Children and Adolescents and doesn’t hang out with his friends anymore near the park. but just like not wanting to talk or think about the trauma. For example. You emphasize that students will be practicing skills between sessions at home and that they may need support in doing so. you transition into teaching different forms of relaxation training. or scared) and ask for ratings before and after the relaxation exercises. anxious. where 0 is feeling OK and 10 is feeling very. You talk about how this CBITS group can help him and the others learn to think. Joaquin offers that one reaction may be to not want to go places or see people that remind you of what happened. and behaviors. you have scheduled an early morning parent session. we’ll be learning about how to cope with some of these bad feelings so you can get back to doing those things. you ask students to fill out a goals worksheet to give you information to better understand what each student hopes to get out of the group and for you to begin to individualize their treatment plans. which Joaquin’s mother attends along with a couple of other parents from the group. progressive muscle relaxation. and answer any questions. and as each is discussed. you facilitate a discussion with the students about common reactions to stress and trauma.. feel. You reinforce him for participating and state. explain the rationale for the group. including deep breathing. have the parents engage in the same relaxation training exercises you will do with the students. discuss the link among thoughts. where many symptoms that come up are related to physiological arousal. rating how you feel on a scale of 0–10. and positive imagery. and you have provided time in the room in case anyone wants to speak to you afterward. At the end of the first group session. feelings. You explain that the next parent group will be in 3 weeks and that you will further discuss avoidance and exposure along with problem solving.e. feelings. very upset. The week after the first session. and behaviors make sense given what he went through. avoiding situations or people that remind you of the shooting can keep you from doing normal things that are an important part of your life. Can anyone else relate to what Joaquin just said about avoidance?” Following the discussion of common reactions. You notice that some parents exchange contact information. The group supports him by saying that those thoughts. You explain the idea of a feelings thermometer (i. In the second group session. especially as they work toward getting back to doing things that they may have been avoiding. “Avoidance is common and makes sense because you may feel better for the moment. and act in a way that makes them feel better so that each person can get back to doing what he or she likes and needs to do that is safe. You give students a “Common Reactions to Stress or Trauma” handout to take to their parents. and ask them if they are com- . I started thinking that I should get home so my brothers and sister wouldn’t be alone. However. During the initial discussion.Pediatric Posttraumatic Stress Disorder 289 fortable doing so. Joaquin uses positive imagery of his “safe and happy place” (his grandmother’s kitchen in El Salvador) and imagines the feeling of warmth and calm and the good smells of his favorite foods there that comfort him. it reminds Joaquin of his brother’s Yu-Gi-Oh! Power (Japanese video animation) cards. you monitor each student’s practice with relaxation and cognitive coping. it was starting to get dark. Carlos pushed me. In addition. you ask them to practice some form of relaxation two times during the next week and report back. to share with their parents which reactions they may be experiencing. and we cut through by the rec [recreational center] like we always did on the way home. Joaquin reports that he finds taking deep breaths before his tests in class useful. When he has thoughts about the shooting. Carlos. Joaquin shares the following: “My best friend. including his family being robbed and temporarily separated while crossing the border into the United States 7 years ago. we saw two guys from a gang pointing a gun at a high school kid in a big jacket near the other corner of the rec. . They were cursing and yelling back and forth. He later reports that he has been able to find privacy in the bathroom at home to do muscle relaxation and that helps him feel “less angry” when his siblings frustrate him. Between sessions. you find out that Joaquin has experienced other traumatic events. Joaquin reports that it is the recent shooting that is causing him the most distress currently. Carlos and I took off for home. The next thing I knew there was the gunshot—loud in my ears—and the other gangster looked right in my eyes. In addition to the group sessions. and I stayed after school for a while that day because some kids were playing basketball and we watched. You let him know that you are going to jot down parts of the story as he tells it. You ask Joaquin to tell you the story of what happened the day of the shooting and to add information so you can imagine what is happening as if it is projected onto a movie screen in front of you. during weeks 3 and 4 you meet individually with Joaquin twice to work on his trauma narrative (and with each student one to three times). and I felt frozen. a home invasion 5 years ago. So finally. Joaquin decides this could be something for him to try when his stomach is bothering him and when teachers or kids are loud. like I was just stuck in time and didn’t know what to do. and his father being deported during a raid at his workplace last year. You spend the next two group sessions reviewing and practicing cognitive coping (similar to the description in “Mariel: Individual CBT”). and we both started running through the park. When you ask group members to write down a couple of helpful thoughts on a small card to carry with them. so he begins to carry the power card in his pocket to remind him to check his thoughts and to use helpful and accurate thinking when negative thinking gets in his way. allowing each student to practice how to replace negative thoughts with more helpful and accurate thoughts. because I’m supposed to take care of them after school. When we got past the corner of the building. When we got to the park on 3rd Street. and when another group member mentions that she is trying to do deep breathing and positive imagery when she gets headaches. you refer back to the individual treatment plans you have started and add new information gleaned from these sessions. You also offer to invite his mother to join you for a third individual session next week in case he doesn’t find a time to do it himself during the week. but in a “nice way. My mom looked so tired and worried that I was sick. When my mom came home from work that night.” You then use that information to ask Joaquin for ideas about how he can be respectful and show support for other group members. family structure. She works all the time since they sent my dad back to El Salvador. Carlos went straight to his house. Joaquin thinks that he is ready to talk to his mom about what happened. You help him think through and plan a good time to talk to her and role-play how it might go. Following individual sessions with each group member. I couldn’t say it. or after he has shared the information. and I went to mine.” At the conclusion of the second individual session. you want to be sure that these issues are addressed with in vivo exposure and/or problem solving. You ask if there are parts of his story he would like to continue working on in the group. and note particular skills that will be important for each individual based on his or her presentation. and I was shaking and just told the kids to leave me alone. either way. and I just couldn’t tell her what I saw. For example. He states that he would “like others to be paying attention and not be messing around” and that “others will also have a turn so I am not the only one sharing. You make a note of these things for him. it is much easier for Joaquin to talk about what he went through. You then help him plan for later group sessions. on his mom’s day off from work. you want to ensure he finds a relaxation technique that really works for him. providing support and assistance in reframing some of his maladaptive thoughts about what happened and his role in it. He agrees that he will play basketball or video games at his cousin’s house. and so forth. Likewise. We just ran until it burned too much to run. Joaquin agrees to do the same for the others and also to look at them while they are talking. I just went to the bathroom at home and sat on the ground.” You work with Joaquin to retell his story several times over the two sessions. I was still shaking and had a stomachache. We didn’t even know if the boy was killed or nothing. we didn’t even shout out or warn anyone there. something he used to do frequently and hasn’t done in a while. because Joaquin’s anxiety since the shooting has generalized to his friend and is interfering with his home life in that he is refusing to let his siblings play outside. My dad told me to take care of her and my brothers and sister until he could figure out how to get back.290 Cognitive-Behavior Therapy for Children and Adolescents We were so scared. and we were home by then. You also note that Joaquin would like to share his story with . some of which he may want to keep private and some of which he may be willing to share with the group. You encourage Joaquin to do something fun this week to take care of himself because he has been working through difficult stuff. not straight at their eyes. You also prepare Joaquin to be supportive in the group by first asking what he may need from the group in order to feel supported and comfortable. including symptoms. which will provide continued practice at processing his trauma memory. because of Joaquin’s somatic complaints and jumpiness. By the second session. or weekends?”). She tells you that things are very difficult for her now that she is supporting her family alone and that she sometimes does not know how they will survive financially. You begin group session 6 by checking in with group members about their progress with in vivo exposures and how they used their coping strategies to manage their anxiety during exposure practice. you focus on things that students may have been avoiding since their traumatic event. you help Joaquin list steps for allowing the kids to play outside. You assess the extent to which parents. letting him or her know that beginning in session 5. You invite parents to the second parent session and briefly review the information you will be providing in case they do not attend. or extended family may be available to provide support and /or transportation if needed during that practice. You also help him create a hierarchy of gradual steps for getting back in touch with Carlos. you also try to make phone contact with each parent.Pediatric Posttraumatic Stress Disorder 291 his mother and that the family may benefit from a referral to some community and social resources given the father’s deportation. other caregivers. He constructs the steps and ratings shown in Figure 8–4. helping each one refine his or her hierarchy of gradual approach steps. Joaquin reports that he let his siblings play outside two times at their cousin’s house and . as shown in Figure 8–3. and he accords each step with a rating of how anxious it will make him feel to do so (at present). Each child makes a list of things he or she has been avoiding but would like to be able to do again. You circulate to each student. He will also text message Carlos after school one day. so you provide her with information on the remaining sessions over the phone. You praise her again for being involved with Joaquin’s program even though she is so terribly busy. he will practice letting his siblings play outside at his cousin’s house. After assessing for the safety of having siblings play outside (“Do other children in the neighborhood play outside?” “Did your siblings used to be able to play outside safely?” “Is there a place it is safest to be while playing outside?” “Is it safe to do so during the day. getting feelings thermometer ratings for each of the steps. During group session 5. Some time before session 5. and that he has stopped letting his siblings play outside when he cares for them. you realize she will not be able to attend the parent session. In your phone conversation with Joaquin’s mother. Joaquin decides that this week. She shares with you that Joaquin told her about the shooting and that he is starting to talk with her about other things when he is upset. You validate her concerns and reinforce all she is doing for the well-being of her children and family. Joaquin lists that he has been avoiding Carlos. his best friend. youth will begin working on concrete steps toward things that may be anxiety provoking or that they have been avoiding that they want or need to be able to do. where he has started hanging out again on weekends. evening. and having each student choose one to two things that can feasibly be practiced over the next week that are rated at 3–4 or under on his or her feelings thermometer. You refer Joaquin’s mother to a community agency that provides resources and services for recent immigrants and to a nonprofit legal aid group that may be able to provide her with information regarding her husband’s status and any options the family may have for reuniting. Joaquin describes that he played outside at home with his siblings over the weekend and that he has been eating lunch with Carlos and his old group of friends again. who is there. Next. He even went in the house to play video games while they played outside at one point. You decide to do a relaxation exercise with the group. joked. explaining that students can show their drawing to the group and talk about what is happening in the picture if they like. and afterward you help to focus everyone back to the present by asking about what classes they have next and who is doing what after school that day. how they are feeling. being respectful that each may do something very different. Next. You ask how it all worked out. He also sent a text message to Carlos. or they can tell about a different part of their story. you review in vivo exposure practice and progress. You pause intermittently and ask for students to show you their feelings thermometer ratings on their fingers so that you have a sense for when ratings have gone down across the group and you can move forward. he or she can take a few minutes to write out the story instead—and either keep it private or read it to you at the end of the . he felt much more anxious than he anticipated (he had written an 8 on his practice sheet for his feelings thermometer rating at the time). and so forth (they do not answer. First. You again help each student decide what his or her next in vivo steps will be and then distribute the students’ drawings from the previous week and allow some time for them to finish their drawings. but use your guidance to create an individual exposure experience even though they are in a group setting). and Joaquin says that Carlos was surprised and happy to hear from him.” You use the opportunity to remind the group that the next time they feel upset or anxious. You then guide the group through an imaginal exposure. They texted back and forth a few times. you lead the group in a verbal sharing of part of each student’s story. You allow students to draw without instructions or asking questions about what they are doing. you provide art supplies and paper and ask each student to draw a picture of part of his or her story. you remind each student of the parts of the story that he or she wanted to continue digesting in group. and ended with “See ya at school. but as soon as he sent the text. You let them know that if someone does not feel like sharing verbally that day. In group session 7. Joaquin draws a picture of him and Carlos near the corner of the recreational center and the two boys holding another one at gunpoint on the other side of the building. On the same form. they can reflect back on how they have felt that way before and what coping strategies helped them get through it. what they are thinking. and remember that things may even turn out well. you focus on allowing students to continue processing their trauma memory. Joaquin had logged his automatic thoughts and alternative helpful thoughts for why Carlos didn’t get right back to him and noted that he took some deep breaths to reduce his anxiety. You then help each group member decide on which in vivo steps he or she is ready to progress to in the coming week. by passing each student the notes you took during his or her individual sessions. You check in with students to see how they are feeling as they finish their drawings.292 Cognitive-Behavior Therapy for Children and Adolescents that it got easier for him by the second time. In group sessions 6 and 7. The students imagine a particular point in their story as you slowly ask questions to guide them to think about what they are picturing—engaging their senses around what is happening. 4 Siblings play outside at cousin’s house. Joaquin’s hierarchy of exposure tasks with anxiety group session. 5 Siblings outside in yard with Joaquin (weekends). 2 FIGURE 8–3. 7 Hang out with Carlos at Joaquin’s house. 5 Hang out with Carlos at lunch with a group of other kids. describing what he saw at the park to the group. 8 Siblings outside in yard with Joaquin (weekdays). listing potential actions someone could take and making links to the underlying thoughts. ratings. 3 Imagine siblings playing outside with Joaquin supervising. what’s up” message. You ask the group for ideas of problems they encoun- . 5 Say hello to Carlos during two passing periods. 4 Text message him a “Hey. You then lead the group through another drawing or imaginal exposure and end the group in a similar fashion to group session 6. Joaquin’s anxiety ratings. Group sessions 8 and 9 focus on problem solving to enable group members to look at options for managing their real-life problems. you review students’ progress with in vivo practice and plan for continued movement up their hierarchy. 6 Siblings outside in yard while Joaquin is inside (weekends). At the outset of group session 8. 2 FIGURE 8–4. Hang out with Carlos at Carlos’s house. Joaquin shares his drawing.Pediatric Posttraumatic Stress Disorder 293 Siblings outside in yard while Joaquin is inside (weekdays). You illustrate the link between thoughts and actions by working through an example with the group. which reviews the skills they have learned thus far. Toward the end of group session 9. the people they can go to when they feel upset or need advice. Most of the students exchange contact information with one another. You remind parents of the skills their children have learned and how to reinforce them at home. and that he is no longer asking for passes out of class. She also reports that she has followed up with the community referral you have given her and has an appointment with a legal advocate to discuss immigration options and community and social services her family may be eligible for. and you let them know that although the group is ending. that his concentration and participation level have improved.294 Cognitive-Behavior Therapy for Children and Adolescents ter in daily life. with his or her name on it. and parents fighting with each other. including small cards for them to write helpful thoughts on. You also note that he has reconnected with Carlos. and a piece of paper for each student. even having him over to his house. Joaquin’s mother is very grateful for the changes she sees in Joaquin. in- . You ask the group if they would like to check in before the semester ends and have a booster session. Group session 10 includes a celebration of each student’s progress. is spending time with extended family on the weekends. You emphasize that there are many things a person cannot control in situations like these. You reassess student PTSD symptom levels and find that Joaquin’s PTSD scores have significantly decreased. and the group agrees this is a great idea. Joaquin’s math teacher reports that he is coming to class more settled down. CBT Jeopardy. and pros and cons for problem-solving issues that come up. has been allowing his siblings to play outside before dark. You discuss plans for celebrating their success in the final session. you engage the students in a trivia game. such as a worry stone to rub. Conclusion Individual (TF-CBT) and group (CBITS) trauma-focused CBT have been extensively tested and found to be effective for traumatized children. The situations include someone writing something bad about you on the bathroom wall. but someone can always control how he or she thinks about the situation and what he or she decides to do. and is attending class on a more regular basis. You also get information about students’ classroom functioning from their teachers. You contact parents of group members to let them know that the group has ended and how to contact you if any concerns arise. relaxation scripts or reminders. a teacher yelling at you. steps they want to continue to make with their hierarchy. you will still be at school each week and how to contact you if they need anything. the handing out of certificates of accomplishment. and lists of things that make them happy. passed around for each student to write something positive and to be taken home afterward. You hand out a small bag or folder with reminders of their CBT skills and ways to take care of themselves. marked by your verbal acknowledgment of each child. You engage the group via games and teamwork in brainstorming and in rating and selecting potential actions for these situations. All of the above. and C only. Self-Assessment Questions 8. Therapists being mindful not to model avoidance. in vivo mastery of trauma reminders. Child trauma-focused CBT interventions have been successfully disseminated to large numbers of providers in the United States and internationally. F. including the skills-based components. and cognitive coping skills. B.Pediatric Posttraumatic Stress Disorder 295 cluding those with multiple traumatic exposure and comorbid difficulties. and safety planning. C. Future research will examine to what extent these dissemination efforts have changed outcomes for traumatized children. affective modulation skills. Key Clinical Points • CBT treatment is appropriate for children who have significant trauma symptoms even if they do not meet full PTSD diagnostic criteria. • Gradual exposure is a core feature of most CBT trauma treatments for children. Some models also include conjoint child-parent sessions. Which of the following is a characteristic of gradual exposure? A. Other CBT treatments for traumatized children have also shown efficacy for improving PTSD symptoms. . D. to the child’s trauma in some way. E. • Skills-based components of child CBT trauma treatments include psychoeducation. • Trauma-specific components of child CBT treatments include developing a trauma narrative. A. Connecting each component. Incrementally increasing the duration and intensity of traumatic material in each sequential treatment component. Instructing children to think about their trauma experiences for at least an hour every day. B. parenting skills. selecting the optimal treatment is primarily a matter of feasibility and accessibility. • Individual and group CBT models are both effective.1. relaxation skills. 2.4. Thoughts. B. Longmont. D. Which of the following factors may be considered in choosing between individual and group CBT trauma treatments? A. Which of the following may inadvertently communicate trauma avoidance to children during therapy? A. Attempting to show empathy by changing voice tone or volume when talking about trauma. What treatment parents will accept.5. Change in body language. D. antecedents. D. A. Preparatory statements when introducing traumatic themes. B. Sopris Educational Press. and C only. Suggested Readings and Web Sites Cohen JA. New York. feelings. Thoughts. Created new models for different ethnic groups. Using euphemisms for traumatic experiences. behaviors. C. B. Guilford. D.296 Cognitive-Behavior Therapy for Children and Adolescents 8. All of the above. behaviors. Accessibility of school-based treatment. Retained all core components of the efficacious treatments. B. beliefs. Severity of symptoms. E. 8. B. All of the above. Found that manuals cannot be properly translated into other languages. 8. C. C. CO. 8. Mannarino AP. Connections among which of the following three components form the basis of cognitive coping? A. Antecedents. 2003 . consequences. behaviors. Deblinger E: Treating Trauma and Traumatic Grief in Children and Adolescents. 2006 Jaycox L: Cognitive Behavioral Interventions for Trauma in Schools. consequences. C. Cultural adaptations of CBT trauma treatments have A. Thoughts. Found some core components to be ineffective with certain populations. F.3. 3rd Edition. http://tfcbt.edu References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders.org TF-CBTConsult: An online consultation tool for therapists maintained by the National Crime Victims Research and Treatment Center. et al: Community outreach program for child victims of traumatic events: a community-based project for underserved populations. 2006 CATS Consortium: Implementation of CBT for youth affected by the World Trade Center disaster: matching need to treatment intensity and reducing trauma symptoms.Pediatric Posttraumatic Stress Disorder 297 CTGWeb: A free online training course for applying TF-CBT for childhood traumatic grief that provides 6 free continuing education credits upon completion. Mannarino AP. 2010 Cohen JA. 2002 De Arellano MA. Guilford. in Applications of TraumaFocused Cognitive-Behavioral Therapy.edu/tfcbtconsult TF-CBTWeb: An online training course that offers 10 free continuing education credits upon completion. Berliner L. Schmidt S: Applications for Native American and Alaskan Native children: honoring children—mending the circle.musc. American Psychiatric Association. 1993 Cohen JA. et al. DC. 1980 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. J Trauma Stress 23:699–707. J Interpers Violence 8:115–131. New York. New York. DC. 2006 Cohen JA. 2010 Copeland WE. Mannarino AP: A treatment model for sexually abused preschoolers. Text Revision. in press CARES Institute: What Do You Know? A therapeutic card game about child sexual and physical abuse and domestic violence. www. Mannarino AP. Child Abuse Negl 34:215–224. Arch Gen Psychiatry 64:577–584. Mannarino AP. Mannarino AP: Trauma-focused CBT for children with trauma and behavior problems. 4th Edition. et al: Cognitive-behavioral therapy for children. 2nd Edition. as well as a host of other resources for clinicians and families. Deblinger E: Treating Trauma and Traumatic Grief in Children and Adolescents. New York. Deblinger E. Angold A. Deblinger E. Keane TM.edu The National Child Traumatic Stress Network: Provides information sheets about child trauma.musc. 2000 Bigfoot DS.musc. Guilford. pp 223–244 Cohen JA. American Psychiatric Association. Washington. Edited by Cohen JA. Edited by Foa EB. 2005 . Guilford. Behav Modif 29:130–155. Deblinger E.nctsn. http://ctg. www. Friedman MJ. 2009. Keeler G. et al: Traumatic events and posttraumatic stress in childhood. Washington. Waldrop AE. in Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. Lippmann J. 2003 McKay MM. et al: A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. Perrin S. 2007 Ruf M. et al: Children's mental health care following Hurricane Katrina: a field trial of trauma-focused psychotherapies. 2001 Felitti VJ. Child Maltreat 6:332–343. J Trauma Stress 23:437–445. Am J Prev Med 14:245–258. Amaya-Jackson L: School-based treatment for children and adolescents. Yule W. J Trauma Stress 23:223–231. 2008 Morsette A. Wright MJ. Schauer M. Baltimore. et al: A school-based mental health program for traumatized Latino immigrant children. Stein DB. MD. Jaycox LH. et al: Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. in Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. New York. 2010 Scheeringa MS. Mannarino AP. 2007 Stein BD. Am J Psychiatry 165:1326–1337. Steer R: Comparative efficacies of supportive and cognitive-behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. J Behav Ther Exp Psychiatry 40:169–178. Jaycox LH. pp 327–345 Jaycox LH. Neuner F. 2006 Smith P. Edited by Foa EB. Am J Psychiatry 163:644–651. Hunt JP. 1996 Deblinger E. 2009 . Bannon WM: Engaging families in child mental health services. Child Adolesc Psychiatr Clin N Am 13:905–921. 2004 Meiser-Stedman R. et al: Cognitive Behavioral Intervention for Trauma in Schools (CBITS): school-based treatment on a rural American Indian reservation. J Am Acad Child Adolesc Psychiatry 42:311–318. et al: The PTSD diagnosis in preschooland elementary school-age children exposed to motor vehicle accidents. Guilford. et al: Cognitive behavior therapy for PTSD in children and adolescents: a preliminary randomized controlled trial. Steer R: Sexually abused children suffering posttraumatic stress symptoms: initial treatment outcome findings. Glucksman E. Nordenberg D. et al: Narrative exposure therapy for 7.to 16-yearolds: a randomized controlled trial with traumatized refugee children. Keane TM. 2010 Kataoka S. Smith P. Anda RF. Stauffer LB. JAMA 290:603– 611.298 Cognitive-Behavior Therapy for Children and Adolescents Deblinger E. Friedman MJ. et al: Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. 2009 Murray LA: HIV and child sexual abuse in Zambia: an intervention feasibility study (NIMH Grant No K23 MH77532). 2003 Weiner DA. Lyons JS: Evidence-based treatments for trauma among culturally diverse foster care youth: treatment retention and outcomes. 2009. Child Maltreatment 1:310–321. Stolle D. Schneider A. Kataoka SH. 1998 Jaycox LH. The Adverse Childhood Experiences (ACE) Study. Cohen JA. J Am Acad Child Adolesc Psychiatry 46:1051–1061. Swaney G. Children and Youth Services Review 31:1199–1205. et al. Stein BD. Johns Hopkins University. 2001. 1988. youth with OCD need to be aggressively treated with empirically supported approaches S This chapter has a video case example on the DVD (“Obsessive-Compulsive Disorder”) demonstrating education and exposure and response prevention methods of CBT for an adolescent with obsessive-compulsive disorder. Jennifer Freeman.9 Obsessive-Compulsive Disorder Jeffrey J. Ph.D. M. Considering that both a long duration of illness and early onset are strongly associated with OCD persistence (Stewart et al. Sapyta. Martin E. 2004).D. OBSESSIVE-COMPULSIVE disorder (OCD) is a serious mental health condition with a prevalence rate of 1%–3% across various epidemiological studies (Flament et al. Sasson et al. Ph. Franklin. Among adults with OCD. Valleni-Basile et al.D. M. John S. 1996). 299 . Ph. approximately one-half began struggling with symptoms during childhood or adolescence (Rasmussen and Eisen 1990). March.H.D.P.. Since the mid-1990s. we present the empirical evidence for cognitive-behavioral approaches in pediatric OCD in both clinical and research settings. This chapter begins with a general review of the CBT treatment outcome literature and then illustrates our particular CBT approach for pediatric OCD. Bolton and Perrin 2008. we discuss common issues that arise in special populations. For clinicians seeking to better serve patients with OCD. From our years of experience in successfully treating youth. we describe the various theoretical models within the CBT framework used to treat OCD and how elements of these various models are typically implemented within pediatric OCD protocols. de Haan et al. 2007). the published uncontrolled evaluations led to randomized studies evaluating the efficacy of CBT (e. which led eventually to open clinical trials involving these protocols (Franklin et al. 1998. First.g. . Storch et al. this chapter is geared toward improving implementation of an exposure and response prevention (E/RP) approach. we have developed a CBT approach that facilitates treatment compliance and avoids common pitfalls that may lead to ineffective implementation of CBT principles. and cognitivebehavior therapy (CBT) has consistently been shown to be the monotherapy of choice for OCD in youth (Abramowitz et al.300 Cognitive-Behavior Therapy for Children and Adolescents as soon as the disorder is identified. in press. Second. particularly for individual and family-based formats (Freeman et al. there has been significant work developing CBT interventions for pediatric populations with OCD. Our research group did a quantitative review of the child and adolescent CBT literature.. Efficacy studies in youth have consistently demonstrated large effect sizes for CBT interventions.. Finally. including treatment-resistant patients referred from seasoned CBT therapists. these interventions began with age-downward extensions of protocols found efficacious with adults. Barrett et al. particularly for children with OCD content related to scrupulosity or sexual obsessions. 2001. March 1998). Franklin et al. 2007). Empirical Support Since the mid-1990s. we explain in detail our clinical assessment. 2006). there remains a need to disseminate this efficacious approach from treatment laboratories to frontline clinicians. Collectively. Although the superiority of CBT as a monotherapy or in combination with serotonin reuptake inhibitor (SRI) treatment is clear. there have been tremendous advances in the treatment of pediatric OCD. treatment planning. Next. Pediatric OCD Treatment Study Team 2004. Initially. 2004. 1998. and treatment approach for pediatric OCD. simply stated. 1998. For example. Franklin et al.g. there is evidence indicating that CBT can be applied more intensely (e. large CBT effect sizes have been demonstrated in community-based effectiveness trials with fewer methodological controls than efficacy trials (Nakatani et al. the authors acknowledge it is difficult to compare pure behavioral and pure cognitive therapy approaches. Although a meta-analysis comparing the relative effectiveness of E/RP and pure cognitive treatment suggests superiority of E/RP (Abramowitz et al. . 2007). 1998. CBT has proved to be effective even when applied flexibly outside of efficacy trials. skill-based CBT work occurring in session is the main driver for improvements in functioning and symptom reduction. A final interesting development in pediatric OCD involves the equitable effects demonstrated from outpatient versus intensive approaches. 2002). the judicious use of cognitive therapy during psychoeducation and initial exposure planning can be helpful for patients beginning a CBT program. demonstrating remarkably similar improvement in outcome to a weekly CBT approach (Franklin et al. Although we will discuss later how an overemphasis on cognitive techniques can attenuate the impact of E/RP. Although most CBT treatment for pediatric OCD is delivered weekly. In Norway. notwithstanding the various CBT protocols in use. E/RP. 1994. The evidence to date suggests that OCD can effectively be treated with CBT. This suggests that the specific. Both the American Academy of Child and Adolescent Psychiatry (1998) and the American Psychological Association (Task Force on Promotion and Dissemination of Psychological Procedures 1995) have concluded that CBT including E/RP elements is the treatment of choice for both children and adults with OCD. given their overlap in treatment implementation. observably sustained as long as 9 months after treatment termination (Bolton and Perrin 2008. 2007). Storch et al. regardless of the treatment session schedule. Wever and Rey 1997).Obsessive-Compulsive Disorder 301 The effects of CBT interventions in these populations are durable after treatment.. one session per day). March et al. 2009). an open trial involving community therapists and their supervisors showed that having access to OCD experts periodically (every 3–4 weeks) led to treatment effects comparable to those of efficacy trials (Valderhaug et al. is a collection of behavioral techniques that provide a systematic way of both approaching fear-inducing triggers (exposure) and avoiding fear-neutralizing rituals or other safety behaviors simultaneously. CBT for OCD may also include cognitive therapy elements such as cognitive restructuring. This “supervision of supervisors” model indicates that the quality of care by frontline clinicians in areas without extensive OCD expertise can be significantly enhanced with only periodic contact with expert supervisors. intrusive thoughts. which occur routinely in most people. because they serve to immediately reduce an individual’s dis- .. behaviors related to avoiding situations that evoke physiological fear will also be reinforced. compulsive rituals. Beck 1976). operant conditioning models were described specifically for OCD (e.. Cognitive researchers argue that most forms of psychopathology stem from individuals having and overvaluing dysfunctional beliefs (e. Using this descriptive framework. as described in earlier learning models. From this initial work.g.. With successive E/RP trials. Cognitive Belief and Appraisal Cognition-based theoretical models expanded on earlier efforts to explain the etiology of OCD. The theoretical models closely tied to E/RP have their start in early learning models.g..g. the physiological response to the exposed trigger will gradually reduce (i. habituation). When escape behaviors involve learned. If the patient then refrains from performing the ritual. a patient begins by exposing himself or herself to an OCD-related trigger that elicits a moderate level of fearful arousal. As a patient habituates to the OCD trigger.302 Cognitive-Behavior Therapy for Children and Adolescents Theoretical Models Behavioral Learning Most protocols used today are based on principles derived from conditioning models or belief and appraisal models applied to the development and maintenance of OCD symptoms (Taylor et al. Salkovskis 1989.e. Compulsions are reinforced by negative reinforcement. the behavior will be negatively reinforced. 1996) explain that ephemeral.g. the patient will experience a gradual decline of the physiological arousal. In a typical successful E/RP exercise. unlearned escape responses) occur in situations where physiologically mediated anxiety is experienced (Mowrer 1960). In addition. Cognitive theorists for OCD (e. and subsequent situations where similar anxiety-provoking stimuli occur will more likely reproduce this learned anxiety-reducing behavior. 2007). an individual could be considered to have OCD. may become obsessions when these thoughts are interpreted as having serious consequences for which the individual is personally responsible. If an individual performs a behavior that succeeds in reducing anxiety. Rachman and Hodgson 1980). The two-factor model of fear describes a process in which unconditioned behavioral responses (e.. the extinction of OCD behaviors typically follows. E/RP is thought to work because it makes those learned connections between safety behaviors and the physiological experience of anxiety more ambiguous (see Foa and Kozak 1986). it should be emphasized that there is no evidence that any one of these can uniquely account for the symptom variability observed in OCD patients (Himle and Franklin 2009). particularly to promote sustained practice in E/RP activities and remove family involvement in escape and avoidance behaviors that reinforce OCD. 2003. superstitious or magical thinking. Our treatment approach emphasizes a neurobehavioral framework. 2002). March and Mulle 1998).g. a belief that a thought is morally equivalent to performing the action). Combining the expert consensus of its members.g. techniques used in other treatment approaches (e.. Although it has been shown that using pure cognitive therapy techniques (e. motivational interviewing.Obsessive-Compulsive Disorder 303 tress. many of these cognitions have been observed as ways to differentiate children with OCD from control subjects and those with other anxiety disorders (Barrett and Healy 2003). However. Application Assessment A thorough clinical assessment is necessary to determine whether OCD is present and if it should be considered primary over other comorbidities. which combines biological. If . An enduring legacy of the early cognitive theorists includes articulating the various themes of dysfunctional beliefs found in OCD obsessions. The final cognitive domains included inflated responsibility.. a collaborative group of OCD treatment experts outlined additional cognitive domains involved in obsessive content (Obsessive Compulsive Cognitions Working Group 1997). Advancing on Salkovskis’s seminal ideas. Cognitive theorists also advance the argument that compulsions persist because they prevent individuals from having opportunities to test whether obsessions lead to their unrealistic predictions of harm (Salkovskis 1989). thought-action fusion (e. developmental. Next.g. perfectionism. learning. the Obsessive Compulsive Cognitions Working Group outlined the most common cognitive domains involved in OCD.. mindfulness-based treatments) can also be useful in the flexible implementation of this program. Although these cognitive constructs were not necessarily specified for child and adolescent OCD. the nomenclature of cognitive content is quite useful in setting up exposures that directly target the core fears of an individual. overestimation of threat. intolerance of uncertainty or doubt. Despite the distinctions in theoretical explanations of OCD. we describe our CBT approach in more detail. and family dynamic models (Freeman et al. and concerns for controlling thoughts. Socratic questioning) in isolation is not effective over and above applying E/RP techniques (Abramowitz et al. A normally developing child can get deeply immersed in specific interests. 1997) and Anxiety Disorders Interview for Children (ADIS. However. we also use sections of the Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-P/L. Yale Global Tic Severity Scale (YGTSS. Scahill et al. 1989). if the severity of OCD symptoms would make E/RP hard to tolerate. We also routinely use the Multidimensional Anxiety Scale for Children (MASC. Finally. these behaviors are either not developmentally appropriate or are extreme .304 Cognitive-Behavior Therapy for Children and Adolescents other comorbid conditions are identified. In children. Leckman et al.g. at times due to a patient’s age or comorbidity rule-outs. if OCD-appearing behavior could be better described in terms of other disorders with intrusive thoughts or repetitive behaviors (e. or have behaviors that are stereotypic in nature. SRI medication treatment should be considered. In general. identifying family factors such as family dynamics related to OCD behaviors (e. family accommodation) and history of OCD members is also of tremendous importance. For example. become rigidly rule bound. the clinician must consider carefully whether E/RP should be the primary focus of treatment for the patient. Schopler et al. 1997). March et al. OCD Versus Developmentally Appropriate Behavior Differentiating between OCD-related obsessions and rituals and developmentally appropriate behaviors is important.. Table 9–1 describes the assessment battery that is used in our collaborative treatment studies and respective clinics. Kovacs 1981) to screen for comorbidities and improve treatment planning. Piacentini et al. Furthermore. impulse-control disorders or tic disorder. we use the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS. Kaufman et al. These clinical considerations are important to determine whether a CBT approach is appropriate for a given family. then the best approach would not normally involve E/RP.g. For children with OCD. and Children’s Depression Inventory (CDI. respectively). we describe a few key assessment considerations for every potential CBT candidate. 1997). Next. it is also important to determine whether observed behaviors are clinically significant or fall within the range of normal development (Evans et al.. or Childhood Autism Rating Scale—High Functioning. 2010) as appropriate. Silverman and Albano 1996) for most children and adolescents. Child Obsessive-Compulsive Impact Scale—Revised (COIS-R. 1997). 2nd Edition (CARS2. 2007). The assessment process that occurs in our treatment clinic is described in detail below. Measure 305 Typical obsessive-compulsive disorder (OCD) assessment battery Age (years) Target Notes Interviews ADIS 8–17 DSM-IV criteria for anxiety disorders. CARS2-HF=Childhood Autism Rating Scale—High Functioning. DSM-IV=Diagnostic and Statistical Manual of Mental Disorders.Obsessive-Compulsive Disorder TABLE 9–1. COIS-R=Child Obsessive-Compulsive Impact Scale—Revised. these behaviors can become more profound during transitions or times of stress. MASC=Multidimensional Anxiety Scale for Children. 4th Edition. ADIS=Anxiety Disorders Interview for Children.and child-rated scales Child-rated anxiety symptoms Includes normed severity and validity ratings Self-report CDI COIS-R 7+ MASC 8–19 Note. In either OCD or nonclinical individuals. 2nd Edition. CDI=Children’s Depression Inventory.and child-rated scales OCD-related functional impairment Includes parent. in their manifestation when compared with same-age peers. However. K-SADS-P/L=Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version. YGTSS=Yale Global Tic Severity Scale. CY-BOCS=Children’s Yale-Brown Obsessive Compulsive Scale. for children with . ratings on severity and impairment Preferred for ruling out anxiety comorbidities CARS2-HF 6–17 High-functioning autism spectrum behaviors Best when ruling out autism spectrum– related stereotypies and rigidity CY-BOCS 5–17 OCD symptoms and severity Score of 16 indicates clinically significant OCD K-SADS-P/L 5–17 Full range of DSM-IV criteria Preferred for ages <8 years and children with wider range of comorbidities YGTSS 5–17 Motor and vocal tics and severity 7–17 Depression symptoms Includes parent. pervasive. Furthermore. For these reasons. Granted. feared consequences of not completing tic. in the presence of these obsessions.306 Cognitive-Behavior Therapy for Children and Adolescents OCD. but they are not reflective of OCD because the urge does not contain thoughts (i.g. these behaviors are typically more acute. receiving special treats or favors) may be differentially diagnosed with oppositional defiant disorder. For example. a careful assessment should differentiate OCD symptoms from these other conditions. A few classes of disorders have behaviors that resemble obsessions or compulsions but are clearly not OCD. attention-deficit/hyperactivity disorder. children with significant OCD symptoms often have comorbid disorders. particularly tic disorders.. some disorders with similar behaviors can be differentiated more clearly. pacing. Motor tics functionally are like OCD compulsions because they reduce uncomfortable physical urges. particularly if no clear obsession-related fear is apparent and other defiant behaviors are similarly observed with other adults. Importance of Identifying the Child’s Core Fears One common pitfall for clinicians using CBT for OCD is not having an adequate understanding of the child’s core fears. hand flapping. and oppositional defiant disorder. OCD Versus Differential Diagnoses Several childhood disorders involve behaviors that resemble OCD symptoms. discomfort. save for immediate relief of uncomfortable urge).e. Furthermore. children who are “obsessed” with topics that interest them or who exhibit functional rigid or repetitive behaviors cannot be considered to have OCD without evidence of ego-dystonic content. Therefore. Children who attempt to exhibit rigid control of parent behavior (e. swaying) can at times be self-stimulating or enjoyable. demanding play activities be always dictated by the child. With this pure OCD context in mind. because many of these differential diagnoses will not benefit primarily from E/RP. Some examples of developmentally appropriate behavioral routines are listed in Table 9–2.. a behavior is considered a compulsion if it only serves to reduce or neutralize the negative affect associated with obsessions. Repetitive behaviors that children approach because they are considered fun or enjoyable are never considered OCD. this task may be dif- . which means that the child experiences only fear. A cardinal characteristic of OCD obsessions is that they are both intrusive and ego-dystonic. resisting family routines. or guilt when contemplating their content.. and they do not appear to be preceded by an ego-dystonic obsession. stereotypies found in autism (e. and hard to resist even with parental encouragement.g. g. vomiting)? For a girl with scrupulosity obsessions. Source. may also show superstitious behavior in relation to making good things happen (e. rules in classroom settings) and may get upset if rules are altered or broken. but this format can be tailored to the specific needs and motivation of the family. But from the start of the assessment and continuing into treatment. the specific fears may be a blend of two or more of these themes. video games) or with particular people (e. does she fear only that her mom will be mad at her or that there is a chance she will go to hell for the offense? These crucial details will assist the therapist in developing a well-targeted fear hierarchy for E/RP activities later in the program. bedtime goodnight). As discussed in the earlier section “Empirical Support.” but why? Does the child fear getting sick himself or dread getting loved ones sick? If the child gets sick. Very aware and can get upset about imperfections in toys and/or clothes.g. Age (years) 307 Developmentally appropriate rigidity found in children Normal behavioral rigidity and rituals 1–2 Strong preference for rigid routines around home rituals (e.. a child may avoid things that are “germy. Overview of Treatment Program The treatment protocol is typically 12–14 sessions delivered weekly. the clinician should at every opportunity attempt to understand the specific characteristics of OCD triggers and the feared consequences of not completing OCD rituals.Obsessive-Compulsive Disorder TABLE 9–2.. 1997..g. one ses- . Pokémon cards). Note that in particular cases. pop stars). ficult especially with younger children.. who may not be articulate or have complete insight into their obsessions.g. 5–6 Keenly aware of the rules of games and other activities (e. For example. does she fear she might die or just experience acute illness (headaches. performance in sports). 3–5 Repeat same play activity over and over again.. 12+ Become easily absorbed in particular activities enjoyed (e. Adapted from Evans et al..g.g. sore throat.g.” the clinician can apply this protocol efficaciously in either weekly or intensive (e. Freeman and Garcia 2009. 6–11 Engage in superstitious behavior to prevent bad things from happening and may show increased interest in acquiring a collection of objects (e. Some typical obsession and compulsion themes we see in children are described in Table 9–3. if she doesn’t confess to her mom.. 308 Cognitive-Behavior Therapy for Children and Adolescents sion per weekday) outpatient formats with similar results. Regardless of the chosen session schedule, the general structure of the program is the same: 1) psychoeducation, 2) externalization from OCD, 3) mapping the hierarchy and identifiying family involvement in OCD, 4) engagement in “bossing back” strategies, and 5) graded E/RP and family disengagement from OCD. However, because of developmental considerations for insight and maturation, we do adjust our protocol emphasis on the basis of the child’s age. For an older child or adolescent, the treatment focus can be primarily with the child. In this format, parental check-ins will be only at the beginning and end of sessions, with periodic family sessions scheduled when needed (see March and Mulle 1998). For younger children or in families with extensive family involvement in rituals and avoidance of OCD triggers, parents should be involved in most sessions, with a focus on differential attention, appropriate modeling of CBT skills, and scaffolding assistance to the child in ways that do not reinforce OCD symptoms (Freeman and Garcia 2009). Contingency management should also be developmentally appropriate for the child. The clinician should help parents provide appropriate rewards and privileges for the child completing assigned homework and using CBT skills spontaneously in unplanned situations. The clinician must also be explicit that the plan will reward behaviors reflecting good effort toward CBT practice, not necessarily results. Psychoeducation The first task of the protocol is to ground the family in the neurobehavioral model for OCD and highlight elements of the treatment program. By the time a family comes to treatment, they have likely experienced excessive distress, conflict between family members, fears of stigma, and feelings of hopelessness. Therefore, the clinician’s initial focus should involve presenting OCD as a neurobehavioral condition that is no one’s fault, as well as providing hope that there are now proven tools to manage OCD’s influence on the child and the larger family. Depending on the clinician’s comfort level with describing recent advances in the understanding of OCD, it may be helpful to briefly emphasize the point that OCD is a condition in the brain, albeit influenced by how the individual and family interact with OCD behaviors. Metaphors involving descriptions of “brain hiccups,” ineffective “circuits,” or broken “alarms” have been used effectively. An example of a typical explanation to the family is given below. In recent years, we have learned a lot about what OCD is and how it can be treated in families. The first thing to understand is that OCD is no different from other medical conditions found in childhood, like asthma or di- Obsessive-Compulsive Disorder TABLE 9–3. 309 Common obsessive-compulsive disorder (OCD) themes found in children and adolescents OCD theme Related obsessions Related compulsions Contamination Getting sick or dying from germs, dirt, chemicals, or other contaminants Getting others ill from own germs or fluids Feeling uncomfortable when in contact with surfaces that are sticky, wet, and so forth Washing or cleaning Reassurance seeking Actively avoiding contact with feared targets (e.g., “surgeon hands”) Harm Harm or death coming to child or family Child “losing control” and causing harm to others Reassurance seeking Checking Superstitious behaviors Loss of essence Fear of losing or doubt about retaining own vitality, personality, or humor Essence can be lost or tainted when personal objects are misplaced or when one is in contact with individuals with undesirable traits (e.g., nerds) Hoarding Superstitious behaviors Checking Ordering/ arranging Need to have things just right, equitable, or symmetrical Counting Repeating Ordering and arranging Scrupulosity Feelings of moral or religious doubt Intrusive “bad words” Ego-dystonic sexual thoughts Confessing Praying Reassurance seeking abetes. Where asthma is a problem in your lungs affecting your breathing, OCD is a problem in your brain that affects how you can control thoughts, feelings, and behavior. As you might know, our brain is like a powerful computer. It has places to store information we need to remember, places that handle new information coming in from our senses, and electrical wires or “circuits” that connect each part of the brain to every other part of the brain. Some circuits even help us stay safe by sounding an alarm to our bodies when we might be in danger. Every animal you know has circuits like this, and when danger is around, these circuits help the body get ready for action. Now for kids with OCD, these danger circuits do not work as they should. For some kids, these alarm circuits go off much too loud when compared to the real danger. So when they (describe a fear trigger similar 310 Cognitive-Behavior Therapy for Children and Adolescents to the child’s obsessions), their brain alarm goes off loudly even if there is no real danger. These kids might even know that they are not in that much danger, but that alarm circuit sounds off anyway! For other kids, the circuits might not be too loud, but once they go off it’s very hard for those alarms to shut off. For example, when the alarm goes off for (insert obsession) and (describe a relevant repetitive compulsive behavior), they either don’t feel better for long or spend a lot of time trying to do it “just right.” Again, they might know that they are safe by (doing the compulsion), yet their alarm circuit does not remain quiet for long. During the above psychoeducation portion, it is helpful to make the neurobehavioral portion tailored to the families’ interest and clinical needs. Some families are quite interested in a brief, focused discussion of the role neural circuits play. As a clinician, it is good to dwell a little more here if there are concerns that the child is “just being manipulative” or a particular parent is being labeled as merely coddling the child. For example, describing hypothetical situations that parents and children can relate to with a touch of humor (walking in a park, tripping, and accidentally putting your hand in dog poop) can be an excellent way to describe how the cortical-thalamic-striatal-cortical circuit is activated for everyone and to make the point that excessive hand washing can have some adaptive merit in specific situations! The heritability of OCD can be described as having a “birthmark” near these circuits, which leads to OCD behaviors. After the biological components of OCD have been explained adequately, it is then important to discuss how CBT and other behavior changes can influence these “loud and leaky” circuits. This explanation should be tailored carefully to the amount of insight the child has. So as I have been discussing, OCD is primarily a brain thing. A lot of people with OCD know that these alarms don’t make sense and the behaviors they do to feel better don’t work for long—yet they continue to do them because the circuits in their brain will otherwise make them feel extremely uncomfortable. But the fact that these feelings come from a birthmark on your brain is actually good news. Your brain is an incredibly flexible organ and can rewire itself slightly when it learns how to do something new. Think about how your brain works. Every time you learn something new, the brain slightly rewires itself, some circuit connections get stronger, and some get weaker. This is wonderful when we’re dealing with brain birthmarks and leaky circuits! If you had a similar problem in your kidney, you might have to have surgery in order to fix it. But because we are dealing with the brain, we can help make the brain healthier simply by learning new things and practicing new skills. The new things I’m going to teach you come from a program called cognitive-behavior therapy, or CBT. There has been a lot of research already showing that CBT works for kids just like you. Not only can kids feel better Obsessive-Compulsive Disorder 311 after doing this program, but their brains look different. It’s true! Researchers have taken pictures of people’s brains with OCD before this treatment and then taken pictures of those people’s brains after the people worked with this program for 3 months. Amazingly, after a relatively short time, their brains actually don’t look as much like OCD brains anymore. And the only thing these kids have changed in those 3 months was how to think and act toward their OCD in a different way. So what do you think, do you want to learn more? At this point, the clinician should check in about any questions the family has about OCD as a neurobehavioral disorder and assess the overall treatment engagement of each participant. After these issues have been addressed, the clinician can continue by describing the nuts and bolts of OCD and how CBT can help. At this point, we should probably talk a little more about what OCD is. As you know, OCD involves things called obsessions and compulsions. Do you know what exactly makes something an obsession or compulsion? First, let me say that having obsessions or compulsions is actually quite normal. (Looking at parents) If you ever had an annoying song stuck in your head for awhile, you had a brief obsession. Similarly, if you ever found yourself checking and double-checking something very important, you were having compulsions. But when these behaviors are happening every day, becoming increasingly distressful, and they are getting in the way of life, that’s when someone is considered to have OCD. Obsessions are persistent ideas, thoughts, pictures, or sounds that get stuck in someone’s head even though the person doesn’t want to think about them. These thoughts that get stuck are either stressful or gross, and the person would do anything to not think about them. Now, compulsions are things people do, either in their head or where others can see them, to try to feel better about the obsessions they are thinking about. Typical compulsions include hand washing, checking things, counting, arranging, and doing things just right; they may even involve other people by causing the person with OCD to repeatedly ask for reassurance from someone. Let me stress that although someone with OCD spends a great deal of time doing these compulsions, they would rather not be doing them. They only do them to “change the subject” or feel less bad about an obsession they are having; these compulsions are never fun. After the initial introduction of obsessions and compulsions, it’s often helpful to illustrate how a typical OCD pattern works (Figure 9–1). OCD episodes typically involve a sawtooth pattern that begins with the child at low distress. Once a child encounters an OCD-relevant trigger, anxiety increases to the point where a compulsion is performed, which then leads to a repetitive pattern of repetitive compulsions and oscillating anxiety. (This pattern is explained to a parent in a dialogue example in the section “Mapping the OCD Hierarchy and Identifying Family Involvement” later in this chapter.) 312 Cognitive-Behavior Therapy for Children and Adolescents Externalization From OCD The transition from psychoeducation to the start of active treatment usually begins with introducing externalization from OCD. The therapist should save enough time in the first session with the child to adequately address this concept. As we discuss in our previous treatment manuals on this topic, externalization cumulates into giving OCD processes a nickname for younger children or calling it simply “OCD” for older children. Even before the clinician brings up externalization explicitly, his or her language about the child’s issues should be consistent with externalization from the first meeting onward. For example, with a young child worried that germs might kill her mother, the therapist might say, “[OCD/nickname] makes you worry that your mom will likely die if she gets sick from germs.” The initial introduction of externalization, particularly for kids with less insight about their OCD, should be conducted carefully. The clinician should focus on validating the child’s specific values that OCD is preying on, while drawing the distinction between these values and the avoidant and ineffective processes OCD forces families to do. On the basis of how the family is describing the child’s OCD, the therapist should use active listening to then reflect back their frustration with OCD as “tricky” or “annoying” but also validate the underlying value tied to the core fear; this approach helps to highlight externalization and build rapport. Therapist: The last thing for today is how we can start bossing back these worries you are having. We have discussed already how OCD involves a part of your brain hiccupping or not acting like it should, and that part of the brain may be making you feel bad in a way that is not as strong or loud as in other kids. Child: But I don’t want to get sick ... and I definitely don’t want Mom to get sick either. Therapist: You absolutely don’t want to get sick, and you also care about your mom so much that you don’t want her to get sick either. Child: That’s right. Therapist: And most people, myself included, don’t like getting sick, not at all. Child: The thought of getting sick from germs is just so gross. Therapist: Absolutely—when you think about germs, OCD seems to be yelling in your ears so loud that you just have to avoid germs and wash whenever you think you’re germy. Child: That’s right. Therapist: And that must be so annoying. Child: Yeah. Therapist: I wonder what other kids your age feel when they think about germs? Do you think they need to wash their hands as much? Do you think their brains are screaming at them as loud? Obsessive-Compulsive Disorder 313 10 Worry/anxiety rating 9 C 8 7 6 O 5 4 3 T 2 1 E/RP 0 Time FIGURE 9–1. Example of drawing used in psychoeducation session to explain typical obsessive-compulsive disorder pattern. T= trigger; O=obsession; C= compulsion; E/RP= exposure and response prevention. Child: Maybe not. Therapist: So I wonder if that might be something we work on together: you can still care for your mom and do things that are good for your health, but we are also going to boss back OCD so he’s not as annoying and yelling at you so loudly. Child: Sounds good. Mapping the OCD Hierarchy and Identifying Family Involvement Before the process of skill building and E/RP can begin, the family must learn about how OCD is working in the family and the specific hierarchy of their child’s symptoms. Some of these objectives might already be accomplished through the assessment and initial psychoeducation portion of the program. However, as the clinician begins to understand—through the functional analysis of the child’s triggers—the child’s particular obsessive content, subsequent compulsions, and family accommodation of OCD, 314 Cognitive-Behavior Therapy for Children and Adolescents the clinician should begin to conceptualize the best way to structure the graded E/RP that will be implemented later in the program. The use of an OCD fear thermometer to build the fear hierarchy will help the child and family get a little insight into the relative distress each OCD symptom causes. When the clinician reviews the hierarchy, it is important to carefully verify the feelings thermometer ratings that the child has given, making sure that the ratings correspond to the level of difficulty or fear the child anticipates when trying to alter or eliminate the ritual. This task has the potential to be confusing if not done correctly, because it is possible that the level of general distress or fear associated with a certain symptom is not the same as the distress or fear associated with trying to resist that ritual. For example, a child may rate the distress or fear associated with doing his or her handwashing ritual as a 4 but may rate the distress or fear associated with not doing (or resisting) this ritual as an 8. Finally, there are often examples where a child may resist OCD differently outside the presence of family members. For example, sometime children may be better at resisting rituals, even if they feel general distress, at school or around peers than they are at home. Identified instances where the child can resist for a time, due to fear of peer rejection or other motivation, could be a good place to start building E/RP tasks that can tried later on. Case Example Crystal is a 7-year-old white girl who has become increasingly concerned about germs in the past few months. At school, she has been learning that there are very dangerous germs out there that can get people very sick, and she must be careful not to touch germy things without washing her hands thoroughly. At home, she has been increasingly checking in with her mom about whether certain places are completely clean from germs. If something has not just been washed, she will ask her mom if it’s clean enough and the chances she will get sick if something is mostly clean. Crystal’s parents, at first, were very patient with her concern about cleanliness, explaining in detail how she’s safe from most germs. They even thought it was nice that she was becoming aware of germs and taking an active role in washing her hands, but lately things have become increasingly concerning. Crystal is beginning to avoid touching anything that she thinks could have germs. She even has begun avoiding her little brother, a toddler who is still in diapers and puts his hands in his mouth and touches things all over the house. Crystal’s hands are getting pink with the amount of washing she is doing, and she checks with her mom almost constantly about things related to germs. Therapist: So I want to understand better how Germy makes you feel bad. Child: OK. Obsessive-Compulsive Disorder Therapist: So we talked a little bit about how Germy makes you feel bad before. But I have here a way you can tell me a little better, with what is called a fear thermometer. As you can see, it has some faces next to numbers that go from 0 to 10. You can see that next to the 0, there is a smiley face—meaning Germy is not talking to you and you are not feeling bad. Next to 10 is a frown face—meaning Germy is talking to you a lot and it can be like one of the worst times Germy was messing with you. Child: OK. Therapist: Now before we go into how Germy is at home, I want to check in on how you are feeling now. What do you think your number is right now, from 0 to 10? Child: About a 2. Therapist: Oh, about a 2. You don’t feel completely relaxed, but you don’t feel very bad either? Child: Yes. Therapist: OK, now when you are home, what’s a typical thing Germy can talk to you about that makes you feel bad? Child: Germy says I might get sick because I touched something my brother touched. He sticks his hands in his mouth all the time. It’s gross. Therapist: That can be gross. So if you were close to touching something, like a toy, that you just saw Jack touch after his hands were in his mouth, what number would that be? Child: A 10, maybe a 12. Therapist: Wow.. .so even if you didn’t actually touch it, Germy would make you feel that your thermometer was as high as it could go? Child: Well, if I did touch it, that would be the highest. If I didn’t touch it, but it was close to me, probably a 9. Therapist: 9/10. (Near the 10 on fear thermometer, the therapist writes, “Touch toy Jack’s wet hands just touched.” At 9: “Close to wet toy, no touching.”) Most kids might think that stuff that their kid brother drools on might be gross. ... Does Germy have you also worry about stuff that Jack might not have touched for a while? Child: Well, anything that is Jack’s might have germs on it, I guess. Therapist: So, if you were to touch something that is Jack’s, like his high chair, what would that number be? Child: 10. Therapist: What if he hadn’t been in it in a while? Like after lunch, Mom had washed his high chair tray and put it back on the high chair. What would be your number if you touched that? Child: If Mom cleaned it and he hadn’t touched it? Probably a 9... . He eats there and gets his food everywhere. Therapist: So for places that Jack touches, even if they have been cleaned, Germy can get loud, yelling at you about germs? Child: Yes. Therapist: What if it’s a part of the high chair he can’t touch? What about the back of the high chair seat that is too tall for him to reach? Child: Probably a 5. 315 316 Cognitive-Behavior Therapy for Children and Adolescents Therapist: (Writes near 5: “Back of Jack’s seat—where he can never reach.”) Now, what if instead of you touching the back of the seat directly, we have something else touch it first, like a new pencil— and then you touch the pencil? Child: Hmmm. ..not very high, maybe a 3. Therapist: So if something clean touches something dirty, and you touch the clean thing, Germy doesn’t yell at you as loudly. Child: Yes. Therapist: So let’s take another clean pencil. But instead of touching the back of his seat, it would touch Jack’s high-chair tray that Mom just cleaned. What would your number be if you touched the pencil that touched the tray Mom just cleaned? Child: Well, if it was a 9, probably about a 7. After summarizing and validating Crystal’s anxiety about touching anything she normally sees (toys with toddler drool can be gross), the therapist then curiously asks about things that could be safer. Notice that when this line of questioning led to most objects receiving a high fear rating, even if they were washed and not touched by Crystal’s brother, the therapist switched gears to things Crystal’s brother never touches. Typically, children will lower their fear ratings for these hypothetical targets they have not thought about. Finally, once some targets are determined, even if they are only hypothetical ones in the middle range of the thermometer, the therapist should inquire about elements that might be manipulated in a future E/RP exercise (touching something clean that briefly touched a “dirty” item). If some gradients can be found in these milder targets, the clinician can then go back and reassess these same gradients at the higher numbers. It’s likely that the clinician will be more successful in finding anxiety gradients at the higher ranges if they can first be fleshed out in the lower ranges. S Next, the case of Ashley, a 14-year-old white adolescent girl, is featured on the DVD accompanying this book. Ashley’s case is identical to that of Crystal, except for her age. The video illustrates an educational component about OCD followed by E/RP work, demonstrating an appropriate developmental approach with an adolescent. The text example of a younger child and video example of an adolescent allow for the illustration of similar points in a developmentally appropriate manner. In both examples, several things are occurring that accumulate information about the child’s OCD as well as set the stage for future exposures. First, the therapist is discussing OCD content with the child in an open way, which for kids who spend a great deal of time avoiding thinking about OCD is a minor exposure in itself. Second, the therapist’s stance about OCD in this phase of treatment should be nonplussed about the content but curious about how the child’s OCD works. It is important for cli- Obsessive-Compulsive Disorder 317 nicians not to get ahead of themselves by challenging the child’s inaccurate OCD-inspired beliefs. Simply gather information to set up future E/RP work. Third, especially for children who rate most OCD triggers as very high, it is important to start introducing degrees of separation from the usual OCD triggers. Identifying family involvement in OCD symptoms should be approached with the same sensitivity used in introducing externalization of OCD, with an acknowledgment of the child’s and family’s underlying values. This task will be particularly important for families with a history of OCD, as well as for families with a parent who has been accused of facilitating OCD behaviors. At every opportunity, validate the parents’ desire to reduce their child’s suffering and be effective parents. Proper psychoeducation and mapping of OCD processes at home can allow the parents to view OCD as something that interferes with these two values. Using externalization language (e.g., “OCD has the whole family running in circles”) and painting OCD as tricky, an enemy, or inconsistent with the family’s values can all be useful in building rapport and getting everyone united against OCD processes. The following communication between the therapist and Crystal’s mother demonstrates psychoeducation with an adult and parental coaching. Therapist: Now, from all the research that has been done in OCD, we understand pretty well how OCD works in families. Let me describe for you how OCD works and see if it makes sense to you (see Figure 9–1). So if we draw here (the y-axis) how stressed Crystal can feel on a scale of 0 to 10 and this line (the x-axis) is just time, let’s draw out how OCD might work at home. So let’s say she’s having a normal day (draws a horizontal line near the 2 on the fear axis), but then she accidentally touches her baby brother’s high chair as she walks past it (writes a “T”). Now on a typical day, what happens next? Mother: Crystal gets extremely upset. Therapist: OK, so she starts feeling really anxious (draws line at a 45-degree angle), and then what happens? Mother: She will walk up to me and start saying, “Mom, I just touched Jack’s high chair. Am I going to be OK? Am I going to get sick?” Therapist: And then what happens? Mother: Well, of course, I tell her that she’s OK and there’s nothing to worry about, just like I always do. Therapist: And does that help? Mother: Yes, she typically is not as upset with a little reassurance. Therapist: (Stops upward line at about 8/10; now draws the line turning downward at a 45-degree angle from the apex; writes “C” at the apex of the first sawtooth) OK, so her anxiety starts coming down. And is that all it takes? Does it go all the way down to 0, and she’s good for the rest of the day? 318 Cognitive-Behavior Therapy for Children and Adolescents Mother: No, it might help for a few minutes, but then she’s touched something else and is coming back to ask me if she’s dirty. Therapist: Oh, so after a few minutes she’s getting increasingly anxious again (draws line moving up again at a 45-degree angle), and then what happens? Mother: I’m again explaining to her that she’s OK, which reassures her, but then this goes on all day when we’re home together... . Therapist: So she comes to you upset, you again explain the facts and reassure her that she’s safe and nothing will happen... . (draws downward, completing the second sawtooth) Mother: Explaining things to her all the time is not helping, is it? Therapist: Well, I don’t know, what do you think? How will the pattern go as you go through the day? Mother: It just keeps going up and down through the day, and my reassurance never satisfies her. (Therapist draws a repeating sawtooth pattern.) Therapist: So let me summarize how it seems OCD is working with Crystal. Crystal is fine until she becomes confronted with some sort of OCD trigger, or the T here. Then, those OCD alarm circuits begin going off and making Crystal feel very anxious (draws an “O” near first upward line). When that happens, all she wants to do is to make those thoughts and feelings stop, so sometimes she will go wash her hands and other times she will check in with you about whether she’s safe, or the O here. That washing or cleaning works very well in the short term; she gets nearly immediate relief. But the relief is short-lived and starts the pattern we have been talking about. Mother: So what should we do? I feel in the moment I’m helping her feel better, but I am afraid I’m part of these rituals. I just don’t see any other way to help her! Therapist: You are not expected to. No parent gets a manual on how to help their kid in every situation. And for most kids, a little bit of reassurance, perhaps with some facts about how germs work and how our bodies are equipped to fight them off, actually makes them feel better. But for a child with OCD, where those leaky circuits are never quite satisfied with Mom and Dad’s reassurance, we see this sawtooth pattern over and over again. And as you guys know from trying to help Crystal, this response can actually set up a pattern that a kid will go through for hours and hours. Mother: So what should I do instead? Therapist: What we’ll do here is teach you a different strategy. It will take a few weeks to teach you and several more weeks to practice. As we get in the program, we’ll be able to teach everyone in the family how to approach this differently so OCD doesn’t win. We may have certain situations where Crystal’s OCD is triggered and it goes up, but instead of Crystal falling into the trap of a compulsion, we will teach you and Crystal other things you can do instead. What we know by seeing lots of kids with OCD is that when the family does these other skills they learn in CBT, the anxiety does not go down immediately (uses a different colored marker to draw gradual habituation our program is separated into two major categories: 1) E/RP and 2) elements that facilitate engaging in E/RP. Bossing-Back Strategies For active treatment components. reminding . we also will teach Crystal how to proactively boss back OCD on her own. by helping her approach the triggers she’s currently avoiding or trying to neutralize with compulsions.Obsessive-Compulsive Disorder 319 line). but it goes gradually yet steadily down to where it was before the trigger happened. it is important not to emphasize these activities too strongly as a means to reduce stress beyond the first few sessions. and add other bossing-back skills that will facilitate future E/RP adherence. We have found that for some kids. when OCD shows up. Simply put. cognitive resistance). And these peaks will become less extreme over time. Identifying OCD thoughts and feelings as external to the child and subsequently interacting with these thoughts and feelings with a level of detachment is at the heart of E/RP and the process leading to habituation.g. and the time it takes for her body to recover will decrease. the two major categories are 1) externalization from OCD and 2) cognitive therapy elements such as cognitive restructuring and constructive self-talk. an early misplaced E/RP exercise can sabotage treatment irrecoverably. We do this by teaching her an approach called exposure and response prevention. introduce symptom monitoring.g. the less her body reacts to those triggers..e. our clinical experience and meta-analytic reviews show that E/RP is the primary active component for symptom reduction in OCD. As discussed earlier. In contrast.. what to do instead of the compulsion that begins that sawtooth pattern. her body will get calm all by itself. Although cognitive restructuring activities can be important to a family before a given E/RP exercise (e. or E/RP.. we have found cognitive restructuring strategies helpful only in very specific situations. When we use E/RP. We will first teach you and Crystal. The bossing-back strategies we have found to be the most helpful for treatment success are those consistent with externalizing OCD. we will be teaching you how to encourage or reward her when she does her E/RP practice. Second. What we know from working with lots of kids with OCD is that the more a kid practices E/RP. The general approach looks like this. Within bossing-back strategies (i. To get her to do this. Although this may suggest that clinicians should rush to do E/RP. we will help her actively practice feeling what OCD makes her anxious about in small doses (draws an upward line at about 4/10) and using those skills to show her that she doesn’t have to do any compulsions. What is the likelihood we will contract swine flu if we touch this table?). which is why we carefully establish the CBT model. an overemphasis on talking back to OCD with coping thoughts during acute stress (e. It is much easier to convert partial to full success than it is to willy-nilly identify an E/RP task that “sounds good. the clinician can adjust the targets accordingly. about the same. including targets on the low (1–3). going down a little bit” or “OK. Graded Exposure and Response Prevention and Family Disengagement Only after rapport building. it’s important not to begin exposures too high on the hierarchy. establishing OCD externalization with the child. and high (7–10) ranges on the child’s fear thermometer. We find that children can . the clinician should encourage the child to maintain awareness or contact with the feared trigger until he or she feels at least a 50% reduction in the initial stated stress. For the most part. As the child is doing the exposure. The therapist must be vigilant to deemphasize anything that could potentially become an emerging mental ritual. Once the clinician can observe how well the child participates in targets exclusively in the low range. mapping common OCD processes in the child and greater family. the clinician can reflect the number the child reports with “OK. Once an E/RP begins. but absolutely try for 90%–100% reduction if habituation is occurring quickly. The therapist’s primary goal is to make those initial E/RP sessions relevant to the child’s core fears but not so distressing that the child engages in safety behaviors.320 Cognitive-Behavior Therapy for Children and Adolescents themselves that “I’m safe” or “These germs can’t really kill me”) can elicit OCD-reinforcing mental safety behaviors at times when an emphasis on habituating to the stress without additional efforts to promote safety would be more effective. The clinician may check in on the child’s fear level about every 30–60 seconds. medium (4–6).” The first E/RP activities should focus on targets that are well fleshedout on the child’s hierarchy. Although the clinician will have a good understanding of the child’s hierarchy.” we recommend having a thorough discussion of areas where the child already has some success resisting rituals. and setting up enough cognitive training to portray OCD compulsions as ineffective can E/RP training be initiated. cognitive strategies should only be used before and never during E/RP to maximize effectiveness. We recommend that clinicians use only enough cognitive training to make the child’s engagement in E/RP effective and to facilitate approaching activities the child was otherwise avoiding due to OCD-related triggers.” but should not try to reduce distress by reminding the child of coping thoughts or other things that can take away from feeling the distress. As discussed earlier in the section “Mapping the OCD Hierarchy and Identifying Family Involvement. there are some non-zero risks to doing things like touching dirty surfaces or eating off the floor. the story should also bring in details that will involve as many sensory descriptors as possible.g.. take some time to flesh out some gradients of separation (e. If after some E/RP successes the only remaining targets are in the high range. perhaps over several weeks. Subsequent E/RP targets should generally hit in the low to moderate range of the fear thermometer at the child’s pace. but children do respond to these ways to fight their OCD.. fears involving going to hell. Granted.g.. particularly if the task is first demonstrated by a supportive therapist willing to do it with them. hurting others. To do this seamlessly before an exposure. including as much of the child’s language as possible will give it the maximum benefit. As the clinician tells the story. “This is taking too long”) to overt experiential avoidance. In these cases. the therapist may never need to get out of the low to lower midrange of exposure difficulty. Only then should the clinician switch to the next OCD fear. The imaginal exposure should then be taped in session and the tape provided to the child to replay at home. The arc of the story should begin with a typical trigger that elicits obsessions related to the feared consequence. The clinician will typically find behaviors ranging from losing focus (e. Imaginal exposure can be useful for obsessional content that cannot be done in vivo (e. Like any well-conducted guided imagery exercise. These re-exposures should be done at home in a quiet place without other distractions. Often targets that were initially identified as moderate will be considered lower by the child after some E/RP success. The therapist should adhere to several key principles that will facilitate effective E/RP in session. the family should already have some E/RP success in the fear target area and the rationale for doing the exposure should be carefully explained and understood. the therapist can talk about the plan for the child while dem- . If the clinician finds that a child’s anxiety begins to plateau or go down and then begins to go up again. Before an imaginal exposure is proposed. the therapist should always demonstrate first and join the child in exposures as much as possible. eventually leading to an imagined catastrophic conclusion.. There is nothing that the therapist shouldn’t do that is reasonably safe in the service of the patient. such as mental rituals.Obsessive-Compulsive Disorder 321 usually report significant reduction in distress between 30 seconds and 10 minutes.g. going to prison). continue E/RP by moving up the hierarchy on that particular fear until the child achieves habituation to the core fear. First. Once a child is successfully habituating to the initial targets. touch something clean that first touched something appearing very dirty) from the very high targets (e.g. touch something dirty). the clinician might want to explore later (not then) what was happening at that moment. It is important that the clinician flesh out the plot of the imaginal exposure collaboratively with the patient first. do not disengage from an E/RP until the child habituates or has experienced at least a 50% reduction. touch the table. advancing to middle or high school) or any acute stressful time. unless the child is no longer getting anxious at home when these E/RPs are attempted. A recent text from one of our clinics describes in steps how to systematically put this program into place for the parents while concurrently working with the child (Freeman and Garcia 2009). Allowing parents to see how the therapist conducts symptom monitoring.322 Cognitive-Behavior Therapy for Children and Adolescents onstrating the task concurrently (e. unless the family has demonstrated several successes with E/RP that they did independently at home. session frequency can be scaled back and relapse prevention strategies can be introduced. It’s important to normalize the fact that OCD can try to come back.. OCD mapping. Once the child begins demonstrating little distress while doing E/RP on his or her hierarchy and otherwise not exhibiting distress or interference from OCD in home. Most of the skills taught are consistent with other parent training approaches involving differential attention and scaffolding more responsibility to the child regarding distress management.g. when planning in-session E/RP. the family should be educated about the potential for OCD to return at some point. “So the first thing we can do against OCD is take our finger like this. and E/RP exercises will also provide them a model on how to do similar behaviors at home instead of accommodating OCD. OCD can look different when children age because of developmental changes in concerns and val- . subsequent sessions will be devoted to going ever higher up the hierarchy as the child habituates to previous triggers. transitions.g. Finally. Second. school. In conjunction with E/RP work for the child. it’s best to first initiate any increase in exposure intensity in a treatment session. For this reason.. Relapse Prevention Once E/RP activities have been introduced and successfully implemented in session and during in-home practice. Effective relapse prevention involves anticipating when OCD might likely try to return and using CBT skills proactively to boss back symptoms as they occur. budget enough time at the end of sessions if a new E/RP exercise is to be attempted. Third. Allow the family to practice these new exposures at home without escalating them. particularly in times of developmental changes (e. but also to stress that the family and child now have the tools to boss it back effectively when it is identified for what it is. the clinician must also be mindful of helping the family disengage from OCD accommodation and related behaviors. and then quickly touch it on our tongue”). or social situations. Therefore. the therapist should discuss any proposed exposure matter-of-factly in front of the child. or sexual obsessions in families who are deeply religious. the therapist must clearly explain to the family that the child’s OCD is not a result of their religious beliefs. These families may pose some unique challenges (e. OCD typically preys on the core values of the individual. Huppert and Siev (2010) recently discussed some excellent approaches to treating religious individuals with scrupulosity obsessions that we have used with success in treating children. Rather. Once OCD has been established as the main presenting problem. the sawtooth pattern typically demonstrated in OCD (see Figure 9–1) rarely changes. The therapist can explore this concept in detail during psychoeducation and the initial effort of externalization of OCD from the family’s religious tradition. 1996). One particular cultural consideration that routinely comes up in our clinic is treating children with scrupulosity. Although reviews in the pediatric OCD literature find little support for race or ethnicity moderating treatment effects. If the therapist can paint OCD as opportunistically messing with their faith.Obsessive-Compulsive Disorder 323 ues (see Table 9–2). regardless of the therapist’s personal beliefs. being overly concerned about sinning) to clinicians trying to treat OCD symptoms through exposure. the therapist may be able to discuss some distinctions between the religious practices of devout peers and how OCD might be distorting . however. the child should be provided significant support and encouragement to use his or her CBT skills using praise and/ or other rewards that work for the family in other areas. leading to scrupulosity in children who are religious. Rather. Some families could even be skeptical of the therapist’s motives.. More research is required in tailoring CBT interventions to minority populations before we can comment further on how to tailor our treatment to better serve them. Parents should be encouraged to be vigilant for signs of OCD but not to overprotect their child from stress or triggers related to it. yet continuing to be supportive and validating of the family’s spiritual values. The therapist’s stance should be at all times respectful and supportive of the child’s wish to have a more fulfilling religious life.g. harm. the reality is that OCD symptoms are often misdiagnosed or underdiagnosed in minority populations (Hatch al. particularly if the therapist doesn’t share the family’s particular religious tradition. Cultural Considerations CBT may need to be altered in order to be sensitive to the context of specific cultural backgrounds. Families should also be encouraged to seek a phone chat or booster session with their therapist if symptoms do reappear and initial attempts of addressing it independently from treatment appear not to be working. It is critical for families to understand that it is not their fault and that these behaviors are not the child’s fault. one mother once said it was OK to do exposures regarding sinful images because “OCD puts these in his head all day anyway. particularly in geographical areas that do not have medical centers that routinely treat children with OCD. the effects of CBT for children and adolescents appear to be both robust and durable. This will remain a pressing challenge to the field. When used in combination with serotonin reuptake inhibitors. Key Clinical Points • OCD is a neurobehavioral condition that can be treated effectively. Conclusion Since focused empirical attention began in the mid-1990s. The family must provide the therapist with guidance on the boundaries about what their faith considers intentionally sinning (e. but rather how to disseminate this approach to a wider variety of trainees and community clinicians. although as noted earlier. weekly treatment as described above for approximately 12–14 weeks appears to be sufficient.. collaborative discussions with the family’s clergy could also be useful. CBT for pediatric OCD has blossomed into an empirically supported treatment for an often severe and disabling condition.324 Cognitive-Behavior Therapy for Children and Adolescents the child’s sincere attempts to live a religious life. Families must first buy into individual and family externalization of OCD if subsequent CBT . As is the case in treatment studies for adults with OCD. Most older children can articulate a perceived distinction between the true joy or awe of being spiritually connected versus the emptiness felt when doing compulsive rituals. The therapist should provide sufficient time to discuss the rationale for engaging in exposures and collaboratively discuss how these can be done in a manner with which the family is comfortable. the format of sessions can be accelerated with little impact on overall efficacy. Therefore. the primary challenge moving forward is less about improving the techniques.” In some cases.. but recent studies suggesting that a “supervision of supervisors” community model can yield comparable results to efficacy studies involving academic medical settings is encouraging and should be a focus of replication. For example.g. worshipping the devil) versus doing things that elicit anxiety because they increase the person’s risk of sinning (e. Exposures for scrupulosity need to be handled sensitively and explicitly discussed ahead of time with both the child and family.g. saying out loud the word devil). Educate the family that OCD might look different when it returns (due to developmental changes or shifts in . family accommodation makes the child less anxious over time). • Effective relapse prevention involves anticipating when OCD might likely try to return and using CBT skills proactively to boss back symptoms as they occur. In a developmentally appropriate fashion. Discuss the literature about how CBT can treat OCD effectively. Finish up an E/RP target completely before moving up the fear hierarchy.Obsessive-Compulsive Disorder 325 techniques are to be successful. • E/RP targets should be chosen very carefully. assign slightly less difficult exposures to be done at home. but the child has the final say in pacing. the clinician should emphasize that OCD’s game is to prey upon what each family member cares about most. the clinician should initiate any new or more difficult E/RP exercises in session first. other techniques can be useful if they facilitate progress toward E/RP targets. For example. particularly in the initial exercises. De-emphasize anything that could become an emerging ritual. E/RP work should be approached collaboratively with the family. • Until the clinician feels that the family is proficient in doing E/RP at home. • Successful treatment requires teaching families how OCD operates for them and dispelling myths about OCD (e. as long as the child is moving forward on OCD targets.. Initial targets should be in areas where the child is already successful at times. That being said. and E/RP should be the therapist’s primary tool. It also can be useful in drawing a clearer distinction between what each person cares about and what is being distorted by OCD. including changes in brain activity. • Habituation is the therapist’s primary ally. each family member participating should understand that OCD is negatively reinforced through the child’s compulsions and any corresponding family accommodation of OCD. therefore. This depiction of OCD as clever and opportunistic can be effective in framing OCD content and family accommodation in a nonblaming and validating fashion. This work will also assist the clinician in developing a plan on what to target in E/RP and at what pace. and these E/RP tasks should not be terminated until the child feels a 50% reduction in distress. Remember to be vigilant for signs that the therapeutic work is being exploited by OCD. note whether a patient is using coping thoughts during exposures or is allowing anxiety to continue unabated. the child is best served doing some form of E/RP every day. • To facilitate OCD externalization.g. B. 10. CBT treatment research has indicated that the most efficacious component for decreasing obsessive-compulsive disorder (OCD) symptoms is A. Most effective when delivered in a weekly outpatient format. Research by Storch and colleagues has indicated that CBT with exposure and response prevention (E/RP) is A. What is considered to be the threshold for clinically significant OCD on the Children’s Yale-Brown Obsessive-Compulsive Scale (CYBOCS)? A. D. Intolerance of uncertainty or doubt. D. B. Socratic questioning. the child should not be overprotected from stress but rather be encouraged to use CBT skills to cope. Self-Assessment Questions 9. but the process of OCD reinforcement (i. Equally effective in either a weekly or daily outpatient format.1. 9. Thought-action fusion.4. B. Most effective when delivered in a daily outpatient format. E. D. 20. 30. . C. When OCD attempts to make a comeback. B. Which of the following is not considered relevant to at least some OCD cognitions? A. 9.. Feared consequence of not relieving urges. Overestimation of threat. the sawtooth pattern) rarely changes. Prolonged exposure. 16.326 Cognitive-Behavior Therapy for Children and Adolescents the child’s interests/values). D. Exposure and response prevention. Progressive muscle relaxation. C. 12. 9.3.2. C. C.e. Equally effective in either an outpatient or inpatient format. 2006 Wagner AP: Up and Down the Worry Hill: A Children’s Book About Obsessive-Compulsive Disorder and Its Treatment. New York. Washington. Either B or D. C. Garcia A: Family Based Treatment for Young Children With OCD: Therapist Guide. Roblek T: Cognitive-Behavioral Treatment of Childhood OCD: It’s Only a False Alarm: Therapist Guide. 2007 March J. When the child and parent experience a 90% reduction in initial distress. Oxford University Press. Selected Readings For Clinicians Freeman J. Guilford.” New York. Guilford. 2007 For Children and Families Chansky T: Freeing Your Child From Obsessive-Compulsive Disorder: A Powerful. Crown Publishing. E. Practical Program for Parents of Children and Adolescents. Oxford University Press. When the child experiences a 90% reduction in initial distress. Magination Press. B. New York. Mulle K: OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. New York. Mobile. 2001 Huebner D: What to Do When Your Brain Gets Stuck: A Kid’s Guide to Overcoming OCD.5. DC. When the child experiences a 50% reduction in initial distress. D. Either B or C. F. 1998 Piacentini J.Obsessive-Compulsive Disorder 327 9. 2008 March J. Langley A. When is an E/RP exercise typically considered to be successfully completed? A. Lighthouse Press. When the child and parent experience a 30% reduction in initial distress. New York. AL. 2000 . Benton C: Talking Back to OCD: The Program That Helps Kids and Teens Say “No Way”—and Parents Say “Way to Go. International Universities Press. Rapoport J. New York. Cashman LA. J Behav Ther Exp Psychiatry 39:11–22. Buitelaar JK. Cogn Behav Pract 8:297–304. Healy LJ: An examination of the cognitive processes involved in childhood obsessive-compulsive disorder. Tolin DF. 2001 Franklin ME. 1988 Foa EB. 1998 Barrett PM. habit. et al: Behavior therapy versus clomipramine for the treatment of obsessive-compulsive disorder in children and adolescents. Psychol Bull 99:20–35. 2009 Freeman JB. et al: Treatment of pediatric obsessive-compulsive disorder: a case example of intensive cognitive-behavioral therapy involving exposure and ritual prevention. 1998 Franklin ME. Sapyta J. 2003 . 2006 American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children and adolescents with obsessivecompulsive disorder. Franklin ME. Behav Ther 36:55–63. 1986 Franklin ME. Carter A. Behav Res Ther 41:285–299. March JS. Whiteside S. Perrin S: Evaluation of exposure with response-prevention for obsessive compulsive disorder in childhood and adolescence. New York. J Am Acad Child Adolesc Psychiatry 37:412–419. Garcia A: Family Based Treatment for Young Children With OCD: Therapist Guide. March JS: Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial. Healy Farrell L. et al: Cognitive-behavioral treatment of pediatric obsessive-compulsive disorder: an open clinical trial. JAMA (in press) Freeman J. 2004 Beck A: Cognitive Therapy and the Emotional Disorders. et al: Obsessive compulsive disorder in adolescence: an epidemiological study. Leckman JF. Romanian Journal of Cognitive and Behavioral Psychotherapies 2:89–104. J Child Adolesc Psychopharmacol 13 (suppl 1):S71–S80. Kozak MJ. Garcia AM. 1976 Bolton D. and perfectionism: the prevalence and development of compulsive-like behavior in normal young children. 2002 Abramowitz J. Hoogduin KA. Freeman J. Whitaker A. J Am Acad Child Adolesc Psychiatry 43:46–62. 2008 de Haan E. J Am Acad Child Adolesc Psychiatry 27:764–771. et al: Family based treatment of early onset obsessive-compulsive disorder. Kozak MJ: Emotional processing of fear: exposure to corrective information. Deacon B: The effectiveness of treatment for pediatric obsessive-compulsive disorder: a meta-analysis. et al: Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) Randomized Controlled Trial. 1998 Evans DW. et al: Ritual. Foa EB: Empirical status of cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analytic review. Oxford University Press. Fucci C.328 Cognitive-Behavior Therapy for Children and Adolescents References Abramowitz JS. J Am Acad Child Adolesc Psychiatry 37:1022–1029. Child Dev 68:58–68. 2003 Barrett P. J Am Acad Child Adolesc Psychiatry 37(suppl):27S– 45S. 1997 Flament M. Behav Res Ther 35:667–681. Edited by Jenike M. 2009 Obsessive Compulsive Cognitions Working Group: Cognitive assessment of obsessive-compulsive disorder. 2007 Hatch M. Minichello WE. Peris TS. 1998. Cogn Behav Pract 16:29–39. 1998 March JS. Mosby. in ObsessiveCompulsive Disorders: Practical Management. 1994 March JS. Choate-Summers ML. Franklin M: The more you do it. 3rd Edition. 1996 Himle M. Siev J: Treating scrupulosity in religious individuals using cognitivebehavioral therapy. Friedman S. 1989 Kaufman J. reliability. PA. Biol Psychiatry 61:337–343. and validity. 2007 Rachman S. Riddle MA. Micali N. et al: Cognitive behavioral treatment for young children with obsessive-compulsive disorder. Mulle K. Mulle K: OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. the easier it gets: exposure and response prevention for OCD. 1997 Pediatric OCD Treatment Study Team: Cognitive-behavioral therapy. 1997 Mowrer OH: Learning Theory and Behavior. J Am Acad Child Adolesc Psychiatry 28:566–573. J Clin Child Adolesc Psychol 36:645–653. Baer L. J Am Acad Child Adolesc Psychiatry 36:980–988. et al: The Multidimensional Anxiety Scale for Children (MASC): factor structure. Birmaher B. pp 400–420 March J. sertraline. 1990 . Guilford. Philadelphia. Child Adolesc Ment Health 14:133–139. NJ. Sullivan K. Wiley. Eisen J: Epidemiology of obsessive compulsive disorder. Bergman RL. Parker JD. 2004 Piacentini J. Herbel B: Behavioral psychotherapy for children and adolescents with obsessive-compulsive disorder: an open trial of a new protocoldriven treatment package. Acta Paedopsychiatr 46:305–315. New York. J Am Acad Child Adolesc Psychiatry 36:554–565. Hodgson RJ: Obsessions and Compulsions.Obsessive-Compulsive Disorder 329 Freeman JB. 1960 Nakatani E. et al: Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. et al: The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity. Mataix-Cols D. and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. J Clin Psychiatry 51 (suppl 2):10–13. Cogn Behav Pract 3:303–315. 1981 Leckman JF. 2009 Huppert JD. JAMA 292:1969–1976. et al: Functional impairment in childhood OCD: development and psychometrics properties of the Child ObsessiveCompulsive Impact Scale—Revised (COIS-R). Prentice Hall. New York. Paradis C: Behavioral treatment of obsessive-compulsive disorder in African Americans. J Am Acad Child Adolesc Psychiatry 33:333–341. Englewood Cliffs. Hardin MT. et al: Outcomes of cognitive behaviour therapy for obsessive compulsive disorder in a clinical setting: a 10-year experience from a specialist OCD service for children and adolescents. Moore PS. 1997 March J: Cognitive behavioral psychotherapy for pediatric OCD. Brent D. Cogn Behav Pract 17:382–392. 1980 Rasmussen S. 2010 Kovacs M: Rating scales to assess depression in school-aged children. pp 157–168 Scahill L. J Am Acad Child Adolesc Psychiatry 36:844–852. Graywing. Edited by Griez EJL. 2001. et al: Long-term outcome of pediatric obsessivecompulsive disorder: a meta-analysis and qualitative review of the literature. Chopra M. Geffken GR. Washington. Purdon C. Edited by Rapee RM. J Am Acad Child Adolesc Psychiatry 35:898–906. McKay D: Cognitive-behavioral models of obsessivecompulsive disorder. Summerfeldt L. 1995 Taylor S. Van Bourgondien ME. Jenike M. New York. Riddle MA. et al: Obsessive-compulsive disorder: diagnostic considerations and an epidemiological update. Los Angeles. 2nd Edition (CARS2). Merlo LJ. Rey JM: Juvenile obsessive compulsive disorder. Götestam KG. Amiaz R. DC. 1989 Salkovskis PM: Cognitive-behavioral approaches to the understanding of obsessional problems. et al. Aust N Z J Psychiatry 31:105–113. Abramowitz JS. et al: An open clinical trial of cognitivebehaviour therapy in children and adolescents with obsessive-compulsive disorder administered in regular outpatient clinics. American Psychological Association. TX. in Psychological Treatment of OCD: Fundamentals and Beyond. Wiley. 2007 Task Force on Promotion and Dissemination of Psychological Procedures: Training and dissemination of empirically validated psychosocial treatments: report and recommendations. 2007 Valleni-Basile L. Guilford. Wellman GJ. McSwiggin-Hardin M. Western Psychological Services. Larsson B. 2004 Storch EA. J Am Acad Child Adolesc Psychiatry 46:469–478. Edited by Antony MM. 2007. Behav Res Ther 45:577–589. 1996 Wever C. CA. New York.330 Cognitive-Behavior Therapy for Children and Adolescents Salkovskis PM: Cognitive-behavioral factors and the persistence of intrusive thoughts in obsessional problems. Geller DA. et al: The Childhood Autism Rating Scale. pp 103–134 Sasson Y. Faravelli C. 2010 Silverman W. 1996 Stewart SE. et al: Incidence of obsessive-compulsive disorder in a community sample of young adolescents. pp 9–29 Valderhaug R. Albano AM: Anxiety Disorders Interview Schedule for DSM-IV: Parent Version. 1996. in Anxiety Disorders: An Introduction to Clinical Management and Research. et al: Children’s Yale-Brown Obsessive Compulsive Scale: reliability and validity. Acta Psychiatr Scand 110:4–13. et al: Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches. 1997 . Clin Psychol 48:3–23. in Current Controversies in the Anxiety Disorders. Waller J. 1997 Schopler E. San Antonio. Nutt D. Garrison C. Behav Res Ther 27:677–682. 10 Chronic Physical Illness Inflammatory Bowel Disease as a Prototype Eva Szigethy. For example.. particularly in youth with chronic physical illness. John R. Ph. Such disease-related neurobiological manifestations may adversely impact illness-related attitudes (e.D.g.. M.A.D. inflammation.D. L. K23 MH064604. M.g. low contingency related to control over the disease leading to helplessness and pessimism) and coping behaviors (e.D.. Ph. which in turn can influence emotional regulation and cognitions.S. physiological processes in the body can impact brain functioning (e.D. Weisz. Thompson.. infection. and 1DP2OD001210 from the National Institutes of Health. William Beardslee. 331 . R01MH077770.g. In addition. Psy. Susan Turner. ABPP THERE is increased evidence for a relationship between psychological and physical processes.C. Rachel D. Patty Delaney.W. medical nonadherence). M. or metabolic dysregulation). psychiatric comorbidities and functional physical symptoms not This work was supported by grant nos.. We will first summarize the empirical findings on CBT as applied to general medical conditions.. Empirical Evidence on CBT for General Medical Conditions Randomized controlled trials testing the effectiveness of CBT compared with alternative forms of treatment in physically ill pediatric populations are limited. Szigethy et al. In the pediatric medical population. and sick-role behavior). Strunk 1987). which focuses on the application of another CBT model to address obesity and depression among female adolescents with polycystic ovary syndrome and associated binge eating. damaged sense of self. we will then illustrate the theory and application of one empirically supported CBT approach that combines individual and family sessions to target depression and physical illness–related problems using pediatric inflammatory bowel disease (IBD) as a model illness. poorer medical outcome. and increased mortality (Karwowski et al. gastrointestinal symptoms. and medical nonadherence. and emotional well-being. readers are directed to Chapter 11. pessimistic illness perceptions. medical prognosis. such negative cognitive schemas and maladaptive coping strategies can interfere with optimal development in youth with lifelong physical conditions. For the remainder of the chapter. the goal of CBT is to help youth attribute realistic meanings to illness-related life events and challenge dysfunctional thoughts and behavior patterns (e. 2009. denial that interferes with medical compliance. abdominal pain.g. Studies to date (Table 10–1) have focused on both specific illness- . Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI. Left untreated. One of the most empirically supported treatment approaches for psychological aspects of medical illness is cognitive-behavior therapy (CBT). CBT can also help youth with physical illness deal with symptoms of pain and fatigue. Lernmark et al. it is often necessary to provide psychological treatment alongside standard medical care in order to promote treatment adherence. pessimism. will be described in detail with a case example to illustrate effective implementation. More specifically.332 Cognitive-Behavior Therapy for Children and Adolescents caused by an underlying medical condition have been reported in pediatric physically ill populations (Burke and Elliott 1999). functional impairment. 2007). For further guidance on using CBT with chronic physical illness. Because psychopathology in adolescents with physical illness has been associated with higher health care utilization. decreased quality of life. which was modified to help depressed youth with IBD cope with malaise. 1999. 2001). which focuses specifically on skill deficits and habits of thought that underlie and prolong depression in youth. social role-play. unsuccessful interactions and social rejection). A central task .Chronic Physical Illness 333 related factors (e.. hopelessness. group. disengagement or avoidant social style. systematic desensitization.. family conflict. variations in CBT approach and dose. Furthermore. with individual.g. poor self-soothing skills. The SAT perspective holds that these skill deficits and cognitive habits can generate sad affect and make youth vulnerable to overt depressive symptoms in response to adverse. making it challenging to determine which elements comprise the most “active ingredients” in CBT. PASCET Theory The original PASCET program is a structured CBT approach developed by John Weisz and his team (2009) for the treatment of depression in youth. however. these deficits and habits may actually generate their own stressful cascade (e. Treatment modality has also varied. Skill deficits often include poor activity selection. damaged self. and different outcomes assessed. such as anxiety and depression. and conflict resolution. relaxation. but learned helplessness can also compromise immune system functioning. or ambiguous life events. and inferior performance in academic or extracurricular domains (Hammen and Rudolph 1996. The PASCET program is based on the Skills-and-Thoughts (SAT) depression model. stressful. which then stimulate further depression. and/or lack of control leading to low-level persistence in coping with stress and challenges (Gladstone and Kaslow 1995. 1992).g. 1992. various components of CBT have been studied.g. Weisz et al. Habits of thought include 1) negative cognitions (e. is difficult to integrate and interpret given the wide diversity of presenting medical conditions. The existing literature. problem solving. contingency contracts. and health-related quality of life) and psychiatric comorbidities. 1992). Youth with chronic physical illness are likely to be even more predisposed to such skill deficits (from loss of social practice time due to physical disease flares) and cognitive habits (from having to deal with a medical stressor out of their control). and family-based interventions having some empirical support (see Table 10–1). Weisz et al. failure to find the “silver lining”). inappropriate self-blaming. catastrophizing. Not only can this cycle disrupt psychological functioning. and 3) perceived helplessness. 2) rumination over depressogenic events and cognitions. Moreover. social isolation. including cognitive restructuring. thus leading to a worsened illness course in physically ill populations (Sieber et al. adjustment to illness. specific subpopulations of youth sampled.. in a cyclical fashion (Hammen and Goodman-Brown 1990). 2007 Cancer Chronic fatigue syndrome Cognitive-Behavior Therapy for Children and Adolescents N 334 TABLE 10–1. Poggi et al. Positive effects were maintained at long-term follow-up. CBT 2. Chalder et al. overall problems. Asthma Burkhart et al. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population . Control CBT group showed greater improvement in internalizing symptoms. Knoop et al. Stulemeijer et al. Education No difference found between treatment conditions on school attendance. 2008. Control CBT group associated with greater treatment adherence in asthma self-monitoring. and social skills. Control CBT group showed greater improvement in fatigue severity. Standard care Participants receiving brief hypnosis and coping skills treatment before bone marrow aspirations reported less pain and pain-related anxiety postprocedure than control subjects. attention. CBT 2. and social adjustment. fatigue. 2010 63 Randomized controlled trial Family 1. and school attendance. Liossi and Hatira 1999 30 Randomized controlled trial Individual 1. somatic complaints.Study Type of intervention Design Findings 77 Randomized controlled trial Individual 1. CBT 2. functional impairment. Coping skills 2. 2009 40 Nonrandomized controlled trial Individual 1. Hypnosis 3. 2005 71 Randomized controlled trial Individual 1. CBT 2. Inflammatory bowel disease Szigethy et al. Multisystemic 2. and perceived control. PASCET-PI Decrease in weight and depressive symptoms.Study Type of intervention N Design Findings 41 Randomized controlled trial Individual 1. CBT 2. PASCET-PI 2. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population (continued) Polycystic ovary syndrome Rofey et al. Standard care CBT group reported less abdominal pain and fewer school absences at short-term and long-term follow-up. Grey et al. 2000 77 Randomized controlled trial Group 1. and medical selfefficacy and less impact of diabetes on quality of life at long-term follow-up. 2005 Type 1 diabetes 335 . Ellis et al. 69 Randomized controlled trial Family 1. 2007 Chronic Physical Illness TABLE 10–1. Standard care Coping skills group showed improved glycosylated hemoglobin (A1C) levels. Coping skills 2. Standard care Multisystemic treatment group had a decreasing number of inpatient admissions and lower medical costs. 2006. 2005c 31 Randomized controlled trial Family 1. global functioning. 12 Open trial Individual 1. No differences in functional disability and somatization. 2009 Recurrent abdominal pain Robins et al. diabetes. Standard care PASCET-PI associated with greater improvement in depression. Behavioral systems levels. Multisystemic 2. Coping skills 2. Treatment adherence and relational outcomes 3. 2008 104 Randomized controlled trial Behavioral systems treatment associated with improved A1C Family 1. frequency of blood glucose testing. 2007 127 Randomized controlled trial Family 1. Grey et al.Study Type of intervention Design Findings Ellis et al. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population (continued) . and diabetes-related stress. 2005a. or familial functioning. Multisystemic therapy associated with short-term improvements in metabolic control. 2006. PASCET-PI=Primary and Secondary Control Enhancement Training for Physical Illness. Education conflict. Coping skills group did not fare better statistically than education group on measures of distress. Cognitive-Behavior Therapy for Children and Adolescents N 336 TABLE 10–1. medical outcome. inpatient admissions (decreased). 2009 82 Randomized controlled trial Group 1. Education Type 1 diabetes (continued) Note. quality of life. treatment adherence. 2005b. Standard care were variable and not maintained at long-term follow-up. Standard care Wysocki et al. and decreased family 2. Some improvements in treatment adherence lost at long-term follow-up. 2007. a flexible toolbox approach is utilized to choose those skills that will be most applicable to each youth’s specific problems and situations. Weisz et al. Perceived control assumes a contingency between action and outcome (Weisz et al. by learning to apply primary control to distressing conditions that are modifiable and appropriate secondary control to those conditions that are not modifiable. primary control involves an individual’s efforts to cope by making objective conditions (e. In the PASCET model. This working knowledge is enhanced through structured exercises with a therapist and through in vivo practice activities that the youth engages in outside the treatment context. 1994). Taken together. secondary control (Weisz et al. 1984b. the activities the individual engages in) conform to his or her wishes. whereas the secondary control skills (i. how youth can THINK differently to change expectations and adjust to objective conditions) are covered in the latter half of the treatment. Reduction in depression is seen as coming about gradually. Weisz and Stipek 1982. 1982. both skills help individuals to realistically assess situations they cannot control and to derive adaptive meaning in order to facilitate acceptance. 1984a. In general.Chronic Physical Illness 337 in treatment is to break this cycle of reciprocal influence and self-generated stress by providing clients with a collection of solution-relevant tools in the hopes of helping these youth counter depressive symptoms and boost their immune functioning. the skill deficits are addressed by primary control coping strategies that are taught in the PASCET program. through a growing working knowledge of various primary and secondary coping strategies that may be used to combat depressive symptoms and the conditions that trigger them. The PASCET model recognizes that not all youth exhibit the same skill and cognitive-habit deficits predisposing to depression. The primary control skills (i. 1982). and THINK is an acronym for skills involving secondary control techniques (Appendix 10– . ACT is an acronym for skills involving primary control techniques. In contrast. The change model that drives the PASCET program grows out of the two-process model of perceived control and coping (Rothbaum et al.e. 1997) involves an individual’s efforts to cope by adjusting himself or herself (e. The model holds that depression may be addressed. how youth can ACT to change their environment) are covered in the first half of the sessions.. the therapist collaboratively assists in the youth’s selection of coping skills that are most relevant and most likely to be helpful. in part.. Accordingly..e.g.. and the habits of thought described in the SAT model are addressed by secondary control coping strategies. Thus. This change model aligns with the SAT depression model previously described. his or her beliefs or interpretations of events) to fit objective conditions so as to influence their subjective impact without altering the events themselves.g. and fatigue even when the disease is in remission. with the eventual goal of establishing automatic and more stable behavioral repertoires to counter the negative mood and thought-inducing effects of depression. which includes Crohn’s disease and ulcerative colitis.338 Cognitive-Behavior Therapy for Children and Adolescents A). The original PASCET program involved 10 structured sessions with the individual youth. extracurricular activities. corticosteroids) with negative side effects. Pediatric patients with IBD have shown increased rates of anxiety and depression. It is hypothesized that the ACT skills help the youth reverse behavioral inhibition and passivity by inducing positive or reinforcing appetitive behaviors. focused on learning the ACT and THINK skills. Youth with IBD often miss a significant amount of school. as well as long-term sequelae (e. For these reasons. pubertal and growth retardation).g. and social time with friends. The onset of pediatric IBD is most often between ages 10 and 20. negative distortions and attributional style). followed by 1–4 individually tailored sessions involving 1) applications of the most relevant PASCET coping skills to important situations or problems in the youth’s life and 2) planning for future applications of the PASCET skills after the treatment has ended. Not only is . or medications (e.. is a chronic and debilitating autoimmune disease consisting of abdominal pain. The 10 structured sessions included in-session exercises and take-home practice assignments. these early changes are reinforced with repetitive practice of the skills. with an unpredictable course requiring frequent medical procedures.g.. and weight loss. IBD was chosen as a model physical illness on which to base modifications of PASCET to address problems related to a medical disease.. bloody diarrhea. The individual sessions were supplemented by three parent sessions designed to help parents support the practice of the new coping skills in their children. The resulting mood improvement likely makes the youth more receptive to the THINK skills aimed at reversing erroneous cognitive processing (i. 2009). and there is a growing literature showing that stress can lead to exacerbations of IBD course (Tang et al. functional abdominal pain. PASCET-PI: Inflammatory Bowel Disease as a Model Illness Pediatric IBD. The developmental plasticity of the brain during childhood provides a critical window in which to stamp in such cognitive and behavioral changes. surgeries. Using the principles of learning theory. which is particularly relevant for youth who must deal with lifelong physical diseases.e. guided by a workbook that each youth used throughout the program and kept afterward. but these positive effects were maintained 1 year posttreatment compared to the standard care group (Szigethy et al. In addition. improve quality of life. youth who had more pessimistic illness narratives and received PASCET-PI showed significantly more optimistic attitudes toward having IBD and more positive contingency and active coping post–CBT treatment (McLafferty et al. especially negative illness perceptions or cognitive misconceptions about his or her IBD. 1. 2007). including improved medical compliance. 2007. . Recent data from our laboratory suggest that depressed youth with IBD receiving CBT have increased metabolism in the dorsolateral prefrontal cortex. Although other factors could account for these positive changes in the CBT group. Other investigators have shown that a modified CBT approach using the Coping Cat Program (see Chapter 7) for IBD-related anxiety in children has a positive impact on patient outcomes (Reigada et al. 2009). 2010). PASCET-PI integrated three components into the program. Not only did the PASCET-PI group show improved depressive severity and global functioning posttreatment. 2006). but our studies show a positive impact of PASCET-based CBT in terms of reduced depression and improved functioning (Szigethy et al. 2004) and randomized trial compared with a medical treatment-as-usual condition (Szigethy et al. integration of a more positive attitude toward and active coping with IBD. Domains In addition to the traditional focus of PASCET-based CBT on altering maladaptive skills and cognitions. Empirical Evidence Our PASCET-PI model was empirically tested in both an open trial (Szigethy et al. Moreover. 2010). which is linked to emotional regulation relative to healthy matched controls (Szigethy et al. and decrease patient suffering.Chronic Physical Illness 339 there support in adults with IBD that CBT can improve emotional disturbances. collectively these results are consistent with PASCET-PI having a positive effect on both emotional and physical aspects of IBD. IBD severity (as measured by validated disease activity measures as well as circulating inflammatory markers) was reduced at 6-month follow-up in youth receiving PASCET-PI. Emphasis on the physical illness narrative of the youth. There are several potential mechanisms to explain the impact of PASCETPI on IBD activity. 2006. 2010). and a brainmediated effect on the peripheral immune system. it is important to target maladaptive behaviors associated with IBD.340 Cognitive-Behavior Therapy for Children and Adolescents 2. Hörnsten et al. feelings of loss of control. Parents also are asked about their experiences. youth write about their illness experience. and encouraging active coping strategies over passive ones (Gil et al. 2010. positive and negative aspects of having a physical illness. Physical Illness Narrative Narrative-based treatments emphasize the construction of meaning as a central concept and goal (Grinyer 2009. and their thoughts about how they can affect the course of their disease (Appendix 10–A). 2004). including perceived causes and fears of their physical illness and its effects on everyday life. such as medication adherence and disability from pain. Studies have shown that such self-understanding and shared understanding with a therapist are important components of resiliency (Focht and Beardslee 1996). learning self-management skills. Therapists can assist youth and their parents in the reconstruction of narratives that have become too negative (or restrictive) by formulating alternative narratives that more fully incorporate life events into a coherent and positive story using PASCET skills. fear of not reaching full physical or functional potential. 2010). More intensive family work using a cognitive psychoeducational model developed by Beardslee and colleagues (1996). and using narrative approaches has been linked to improved coping with illness (Pennebaker 1997). 3. 1989). For example. The modifications in PASCET-PI were drawn from examples in the adult literature that suggest a beneficial impact of such interventions on coping with physical illness—highlighting the importance of increasing patients’ knowledge of disease process and understanding of illness perception (Barlow et al. and embarrassment are common and may predispose youth to depression (McLafferty et al. fear of disease relapse. 2009. Physical Illness–Related Problems In addition to addressing the youth’s illness perceptions. 2011). in youth with IBD. The Beardslee model is helpful in facilitating parents’ developmentally appropriate support of their child and helps eliminate environmental influences that may be preventing the youth from letting go of sick-role behavior. Bernstein et al. including the effect of IBD on family life and how they cope with having a child with a physical illness. These commonly in- . poor body image. rejection by peers. Enhanced coping strategies targeting disease-specific problems. In PASCET-PI. . 2. explaining depressive symptoms as extra-intestinal manifestations of IBD instead of as an additional and stigma-inducing psychiatric diagnosis is helpful and recommended. and cognitive coping strategies. Medication nonadherence is an important issue to address and often can be effectively targeted through cognitive restructuring and active problem-solving. biofeedback. 3. perceived social rejection due to physical illness). 2001). Daily practice of relaxation and calming techniques alone with minimal therapist contact has been shown to yield increased functionality in daily activities and decreased health care utilization (Gil et al. 1.g. provides valuable education to the youth and his or her family. distraction. but also decreased IBD-related inflammatory markers (Mawdsley et al.. In adults with IBD.. including negotiating academic and occupational limitations. hypnosis. Family Involvement Living with a chronic physical illness often involves a host of psychosocial stressors in addition to the demands of addressing illness symptoms and medical treatment. excessive preoccupation with eating or bathroom access. hypnosis not only improved quality of life.g. and facilitating problem solving around social limitations related to physical illness (e. Educating the family and youth about IBD in consultation with the appropriate medical specialist is important to correct any misperceptions about IBD and its treatment. 4. communication difficul- . traumatization.g. or medication side effects). Miller and Whorwell 2008). The development of such coping strategies not only can help the youth overcome depressive symptoms but also may serve to buffer the effects of stress on IBD flares and improve daily functioning. and avoidance of unpleasant external factors (e. how to share aspects of having a chronic physical illness with peers to increase support). invasive procedures. For example. including relaxation.Chronic Physical Illness 341 clude social withdrawal. Several strategies have been incorporated into PASCET-PI to help with these types of problems. medical visits. how to choose and maintain fun activities during IBD disease flares) address an important facet of the youth’s life and enhance coping skills. Enhancing social skills through focused social problem-solving (e. inactivity. utilizing in-session role-plays that target cognitive distortions and related feelings in settings with peers (e. financial burden and medical coverage.g. 2008. Teaching strategies to reduce abdominal pain.. Cohen and Brook 1987). Depressed children are more likely to have parents who are depressed. adolescents and their families participate in three family psychoeducational sessions corresponding to the beginning. family psychoeducational sessions modeled after the clinician-facilitated family preventive intervention of Beardslee (1990) are provided. Families of children who have physical illness have increased rates of psychological distress and poor communication (Engstrom 1999). deal with stigmatization. and parental depression may interfere with compliance with both medical and psychological treatments (Beardslee et al. psychosocial deficits. and lack of adequate leisure-work balance (Barakat and Kazak 1999). Brent et al. Training parents to become CBT . Beardslee’s Family Talk Intervention has been tested in a long-term randomized trial and has received very high ranks in the National Registry of Effective Programs. middle.342 Cognitive-Behavior Therapy for Children and Adolescents ties. increased dependence on parents because of physical illness–related issues and altered parenting styles (overprotection or excessive lenience) can make the transition through adolescence particularly tumultuous. 1993). and decreasing risk factors for future depression (Beardslee et al. and help families develop more effective communication. address salient parental concerns about their adolescent and family. Parents can experience difficulties related to the impact of the youth’s physical illness on the family system. To meet the special needs of this population. This approach can help families identify affect. there is evidence that families of children with comorbid depression and physical illness deserve special attention. We have chosen those core components most relevant to PASCET adaptation and integrated them with treatment of the child. and resistance to the concept of illness. personal needs. Parents often focus most of their attention on the ill child and struggle to balance their jobs. and decrease noncompliance. In PASCET-PI. It has been adapted for use with low-income African American and Latino families and used in country-wide programs in Scandinavia and Costa Rica. Beardslee’s work has shown the critical importance of linking cognitive material to an individual’s narrative life experiences (Beardslee and Podorefsky 1988. 1993. Although the normal developmental push during this critical period is toward separation and individuation from the nuclear family. increasing family understanding and communication. Content areas that are covered during these separate family sessions help parents reinforce the child’s ability to use PASCET-PI skills to cope. Focht and Beardslee 1996). and the needs of their other children effectively. deliver education about depression and resiliency in adolescents. Cognitive approaches have been shown to be quite effective in educating families about childhood depression. and how parents respond to these difficulties directly influences how the rest of the family copes. and end of the individual CBT protocol. 1997. In addition. and a thorough exploration of the youth’s social functioning can facilitate the development of a comprehensive case formulation. In addition to modifications in content to incorporate physical illness– related realms. it is also important to consider potential obstacles to treatment progress. Case Formulation The successful application of the PASCET-PI skills is dependent on the formulation of the case and the integration of psychological and physical illness–related information. On the part of the therapist.Chronic Physical Illness 343 coaches for their children not only provides an active and constructive focus of parental energy. . We have found the phone sessions most helpful and effective when the initial session is conducted face-to-face with the ongoing therapist. Just as in the original PASCET. Application The following section will outline the application of the PASCET-PI intervention for youth with IBD and comorbid depression. but the role may also help them to avoid maladaptive parental coping practices such as distancing. the key to making the phone sessions productive is ensuring that youth have their PASCET-PI workbook at hand and that their environment is private and free from distractions. In addition to a thorough psychiatric and medical history. Collectively. with emphasis on the case formulation and content of both the individual and family sessions. denial. assessment of how the youth shows depressed feelings. there is a preventive tone to these family sessions. in that parents are building strengths that will help promote long-term resilience in the family. Parents participate in 3 sessions during the approximately 3-month intervention. The following is an example of a case history and formulation for PASCET-PI. and overprotection of the sick child. Furthermore. both the youth and parents work from a PASCET-PI workbook. as well as personal and familial strengths so that these factors can be used as building blocks to target more maladaptive areas of coping. Additionally. an evaluation of precipitating events or situations. structural changes include the choice of phone sessions for up to 60% of the total sessions and coupling face-to-face sessions with medical appointments to improve compliance with therapy. this type of reformulation of the classic psychiatric evaluation into a CBT-based assessment can help the therapist hypothesize a priori regarding which ACT and THINK skills will be most applicable to the youth. The youth receives 9 individual sessions and up to 3 flexible sessions to stamp in the skills most useful to the child. and decreased physical activity. Stressors include decreased academic performance. He has been on intermittent steroid therapy for the past 4 years and identified that he sometimes feels down when his steroid dose is high. He missed more than 40 days of school during the past 6 months due to the abdominal pain. difficulty self-soothing. Kyle’s mother works as a high school teacher. PASCET-PI formulation: A 13-year-old white adolescent boy with long-standing Crohn’s disease presents with worsening depressive symptoms over the past 6 months. Skill deficits and cognitive habits: Kyle’s skill deficits include difficulty negotiating social conflicts with peers.. modeling of sick-role behavior and possibly learned helplessness by his father may also be a contributing factor to Kyle’s maladaptive coping. his anxiety about falling behind in school. and how Kyle is coping with having Crohn’s disease. He presented for a psychiatric evaluation with a 6-month history of feeling sad and frustrated. resulting in a downward drift in his usually above-average grades. marital conflict between parents. insomnia. with increased focus on pain. He also had increased complaints of stomach pain that were out of proportion to the degree of Crohn’s disease activity (as determined by inflammatory markers from his blood and endoscopy). being sensitive to the feelings of others. Family history is positive for colitis. how their parental conflicts may be affecting Kyle.344 Cognitive-Behavior Therapy for Children and Adolescents Case History Kyle is a 13-year-old Hispanic adolescent boy in the eighth grade. and biking. and hypothyroidism could predispose Kyle to depression. He was diagnosed with Crohn’s disease 4 years ago. being restricted in physical activities because of his physical illness. soccer. posttraumatic stress disorder. having a good sense of humor. Kyle’s parents are concerned about his depressive symptoms and stomach pain. and displaying skill at video games. alcohol dependence.g. Kyle identified stressors as feeling isolated from his friends. intermittent hopelessness. and the constant tension between his parents. difficulty eliciting positive social reinforcement from adults in his life. interpersonal difficulties with peers. decreased school attendance with resulting failing grades. His father is often unemployed. depression. and coping with a chronic physical illness. often withdrawing from conflicts at home and burying herself in her work. and hypothyroidism on the paternal side. and difficulty setting goals in different life do- . decreased motivation and energy. anxiety. the problems he has been having with his classmates (e. who were frequently arguing and contemplating divorce. increased social isolation and peer conflict. Kyle’s strengths include being bright and future oriented. he received his first suspension from school for fighting with a peer in the cafeteria). he reported difficulty in negotiating conflicts between his school and neighborhood friends. Kyle reported being good about taking his morning medications but has variable compliance with the evening doses. IBD and steroid use in addition to family history of depression. increased abdominal pain (in the absence of objective evidence of Crohn’s flare). having a variety of interests. and he stays home with Kyle during missed school days. and low selfesteem. When he did spend time with his friends. In addition. Cognitive habits include lack of perceived control over his environment with resulting helplessness. information on how the youth has responded to the various components of the PASCET-PI program (i. In this process of tailoring and fitting treatment to the patient. explain that this therapy will involve learning different ways of doing things and of thinking about things to help improve mood. ACT and THINK for relaxation. the therapist should rely on an evolving formulation. This aim will be achieved over 9–12 weekly sessions.e. (STEPS and POWER skills are discussed further in the following section “Individual Sessions..Chronic Physical Illness 345 mains. incorporating both developmental growth and changes related to the course of the depression and/or the youth’s environment (e. physical illness flare).” respectively. “My friends will think I’m weird if they know I am diseased”). but their central aim is the application of the PASCET-PI skills that will best fit the youth’s life. As in other CBT protocols. “I can’t do anything fun because of my Crohn’s”. and hopelessness.g. Individual Sessions The following section will provide an overview of the individual youth sessions according to the PASCET-PI intervention. Using the following skills (i. The maintenance sessions are designed to be highly flexible. Session 1: mood monitoring. STEPS problem-solving skills. As the treatment reaches the flexible final sessions 10–12. Continual reformulation of the case is essential to achieving the best-fit coping skills for the youth.) This initial formulation is refined through information gathered during individual and parent or family sessions. deliver psychoeducation about depression and IBD.. Table 10–2 provides an outline of each session following the ACT and THINK skill format.. negative cognitive distortions (e. introduce the ACT and THINK chart (see Appendix 10–A). which parts the youth seemed to like and use effectively)..g. A carefully developed formulation is especially critical to the success of the maintenance sessions. The key components of session 1 are to explain the purpose and process of the sessions. Together these negative behaviors and thoughts make him even more vulnerable to feeling depressed. with the most important steps in suc- . there is an increasing emphasis on identifying the particular lessons and coping skills of the PASCET-PI program that seem most likely to help the youth’s depressive symptoms and address the cross-section between mental and physical well-being.e. and input from the youth to determine the best-fit coping skills.” in “Session 2: Problem Solving” and “Session 6: Talents. and explain mood monitoring. parental divorce. and POWER skills) along with family sessions aimed to increase parental communication and Kyle’s sense of primary control. start by assessing the youth’s weekly ratings of mood. generate a list of both general and IBD-related problems. The STEPS approach teaches a type of decision matrix to produce a range of solutions. or perhaps it can be linked to other life stressors that are not directly related to IBD.” Listen with the intent of making an inventory of illness-related problems that can be used to apply the STEPS problem-solving technique. After the therapist and youth complete the STEPS worksheet in session. Review the assignment from the previous week and process any difficulties with the youth. highlighting the importance of examining potential outcomes and providing a way for the youth to decide the order in which to try each solution. and medication compliance. . The key components of this session are completing the illness narrative questions and teaching STEPS problemsolving (Appendix 10–A). Finally. having the youth prioritize the list from smallest to largest problems. For each day of the week. These two types of skills will be used to target problems related to IBD and other life problems. Next. have the youth rate his overall mood on a scale of 1 to 10 (1=very bad and 10=very good). fatigue.346 Cognitive-Behavior Therapy for Children and Adolescents cess being regular attendance to learn new skills and consistent practice of the skills between sessions. changes in sleep and appetite. For youth who do not have a current IBD flare-up. deliver psychoeducation about how depression can be caused by chemicals released in the gut during IBD flare-ups. For this session and each subsequent session. depression may be a response to the realization that they have a lifelong chronic illness. Next. and increased sensitivity to pain. Younger children may prefer drawing their “illness stories. After the youth completes the illness narrative (see Appendix 10–A). the important take-home message for patients is that applying ACT and THINK coping skills can help facilitate positive changes in mood in either of these causes. Session 2: problem solving. open-ended manner. explain the two types of skills: ACT skills to learn new behaviors and THINK skills to change thinking about what distresses the patient but that are not in his power to change. introduce the new skill for this session: learning to be aware of mood and how it relates to what the patient is doing (or not doing). IBD symptoms. Next. Together with the youth. Appendix 10–A provides mood thermometers for this activity. affecting the brain and causing depressed mood. have the youth choose a word or phrase that best describes his mood for the day and also list good things and bad things that happened that day. Irrespective of the root cause. the practice assignment will be for the youth to complete the worksheet during the week with another problem—trying out the solutions for each problem and examining the impact each solution may have on his mood. discuss any negative or pessimistic answers in an empathic. Find agreement on importance of physical activity and exercise.g.. Session 3: activities. the more likely that compliance will improve. Session 5 Teach about showing positive self and improving social skills. other activities discussed include helping others as a way to distract from the youth’s own problems and engaging in moderate exercise. The main purpose of this session is to teach a variety of behavioral activation options. Sessions 7–8 Address negative cognitive distortions about physical illness.g. ACT and THINK skills (see Appendix 10–A). Sessions 9–12 Review skills learned and personalize skills. Maintenance sessions 1–6 Reinforce use of coping skills. because exercise has been shown to help keep IBD in remission among adults (e.Chronic Physical Illness TABLE 10–2. more . Several types of activities are covered. 347 Outline of individual sessions for Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI) Session Goals Session 1 Introduce PASCET-PI. extracurricular school activities. This is also a good session to work on problem solving if medication nonadherence is an issue.. including activities that can be completed alone and are feasible in terms of access and cost. Session 4 Apply relaxation techniques and hypnotherapy for pain and immune system. The more the youth is involved with generating solutions. This behavioral activation is meant to help the youth socialize and expand his horizons. Session 6 Focus on developing the youth’s talents and skills. and activities that involve a group or club (e. yoga. and education about inflammatory bowel disease (IBD). Session 3 Establish which activities the youth enjoys. walking. job pursuits for older teens). community class or activity. especially if having IBD has prevented him from participating in his usual activities. In addition. activities that can be completed with others. Session 2 Initiate completion of physical illness narrative and apply problem-solving techniques for IBD. Creating a list of physical activities that are tolerable and available for the youth is important. Today we will work on learning to relax and use the power of our mind to help shift the blood from the head to the hands. the better the results will be. In addition to the words used during hypnosis. hearing the waves. Hand temperature is caused.. counting from 1 to 10) should be used before providing the hypnotic suggestions in the scripts and to reorient the youth back to full conscious alertness (e. In addition. and boost immune system functioning. biodots (which change color based on skin temperature. We will use biodots to test how well our attempts are working.g. These techniques involve muscle relaxation. the amount and type of physical activity should be determined in consultation with their gastroenterologist. with any improvements noted. Listening to music is another way in which . diaphragmatic breathing. proper trance induction and deepening techniques (e. similar to mood rings) can also be used to make practice more fun and to give biofeedback to the youth that he can change his bodily functions. tension headaches are often caused by too much blood in the brain.g.. When too much blood is in our head. ignore pain. by the distribution of blood in our body. in large part.. One way to measure the amount of stress we are holding in our body is to measure the temperature in our hands. feeling the warmth of the sun. less blood is in our body. The youth’s mood should be monitored before and after the relaxation sessions. As in all hypnotic sessions. slowed breathing rate) during the trance.348 Cognitive-Behavior Therapy for Children and Adolescents structured sports). Notice the color of the biodot as we go through some relaxation training. Here’s a biodot to place on the back of your hand or another area of skin. and thus. our hands are colder. including our hands. seeing the beach. the more closely the therapist’s voice cadence matches the youth’s changing physiology (e. Hypnotic scripts are provided in Appendix 10–B for youth experiencing either abdominal pain or active IBD inflammation. and so forth). For youth who have active IBD. Session 4: calm.g. and visual imagery in which the youth imagines a happy or calm place using all his senses (e. smelling the seabreeze.. counting back from 10 to 1).g. The aim of this session is to teach calming techniques to help the youth relax. The purpose of these scripts is to help the youth facilitate attentional control. for example. The practice tool for this session will consist of making a CD of the relaxation exercises completed during the session so that the youth can practice these techniques at home. which causes pain. So. This fact is useful to know because it is also the case that too much blood in one area can cause pressure. The following is an example of how the biodots can be introduced to provide a type of ramification for the relaxation experience. what the youth says). Session 5: confidence. and sad. Second. the positive ways seem to make a person feel better and to make others feel better about being with that person. introduce the concept of showing a negative and positive self. judging which of the two shows a self that he and others will like better. First. Avoid creating a positive-self profile that might seem arrogant or obnoxious to adults. have the youth compare the negative. Next.” Instead. a skill that can require practice like any other skill that is learned.and positive-self videos. negative. the therapist really does want to know what the youth thinks about these two different videos. For the video. make a videotape during which the youth acts gloomy. the key idea to emphasize is that all individuals have the capacity within themselves to behave in different ways. then as his positive self. a final issue to remember is to be aware of the impact of new behaviors on both peers and adults. even if it is likely to evoke a positive reaction from peers. This skill is taught through the following exercises. There are certain pitfalls to avoid during this session. Likewise.g. first as his negative self. A second pitfall to avoid is implying in any way that showing a positive self is the same thing as “faking it. The primary aim of this session is to help the youth understand the meaning of confidence as believing in himself. In the case of Kyle. avoid coach- . As the therapist and the youth work on identifying positive-self behaviors. and what the youth thinks the consequences of positive and gloomy behavior may be for how he feels and how others feel about him. even if the youth feels down about having IBD. Reviewing the illness experience and problem list generated in session 2 may also give clues of specific events or experiences to use with the youth. Instead. including the reactions of others. one scenario may be with a peer with whom he had a conflict. That is.Chronic Physical Illness 349 youth can relax. Feeling confident involves being optimistic about interactions with others. does his best to present a positive self. Finally. after coaching and practice. Incorporating soothing music or the youth’s favorite songs into the recording can be helpful in creating a calming experience. it is useful to use a role-play. particularly if it is relevant to the youth’s life.. The practice assignment for this session is to have the youth practice his positive-self skills with others and write about the experience. The therapist could role-play the peer while Kyle would be himself. and identify specific behaviors that go with the specific features of the youth’s negative and positive self (e. Avoid criticizing the youth’s depressed self. how the youth looks and acts. It is helpful to use real-life experiences as anchoring points for how a youth shows these attributes. make another videotape during which the youth. the exercises should be presented in the context of exploration and curiosity. to explore with the youth how IBD influences his negative self. Use therapeutic judgment liberally in coaching the youth to come up with his positive-self skills.. which are organized according to the steps associated with each letter in the POWER acronym. Introduce the idea that everyone has had someone with whom they have had difficulty getting along in a particular situation. Session 6: talents. • Problem with a relationship. Having the youth pick a relatively specific problem (e. there are concrete things someone can do to improve a relationship with another person. Ask the youth to identify a goal involving some talent or skill he wants to develop.g..g. Relationship improvement takes action. develop new skills. Which negative parts do I have the power to change? Explore the good and bad aspects of making a change. and collaboratively identify some of the small steps that would need to be mastered on the way to that goal. This step involves identifying a specific problem the youth is having with another person. and learn social problem-solving to improve social skills. When going through the POWER steps with the youth. have the youth pick one person to focus on to complete the POWER worksheet on his own and to try out one of the solutions to improve the relationship with this person. Further.. Outline the positive and negative parts of the relationship. make sure to hit on the following basic ideas. This session is particularly important when illness symptoms are preventing youth from doing their usual activities or from developing opportunities for socialization. planning realistic steps. and practicing until the youth masters each of the small steps and reaches his desired goal. The therapist can give common examples from other youth or from his or her own life (e.g. improving relationships with others can help the youth feel good. an argument with a specific friend in the cafeteria yesterday) versus a more general one (e. The second part of this session focuses on teaching the youth social problem-solving skills using the POWER steps (Problem with a relationship. Appendix 10–A) to improve relationships with others. disagreements with a parent). For the practice assignment. . have the youth begin practicing one of the steps. Tell the youth that just like there are STEPS to solving other problems. I fight with my friends) will make the subsequent steps of the problem solving easier. arguments. The main concept is that developing a skill takes three steps: goal setting. The goals of this session are to work with the youth to further develop existing talents. For the weekly practice assignment. breakups.350 Cognitive-Behavior Therapy for Children and Adolescents ing the client to behave in a way that adults might like but that his peers may find “nerdy” or socially undesirable. people can forget about the positives when they become focused on the negatives. Often it is much easier to see from an outside perspective how frustrating and futile it is to have a mission of changing another person. This step is a specific application of one of the main tenets of the PASCET model: deciding when to have primary control (changing the environment) versus secondary control (changing one’s own thinking) of a situation and changing personal actions or thinking accordingly. During the first few sessions. With time. help him decide which parts he has control over or has the power to change. This step is the most difficult and germane to the process of improving a relationship. Case Example Kyle initially presented as quiet and lethargic.Chronic Physical Illness 351 • Outline the positive and negative parts of the relationship. Encourage him to make a commitment about when he will attempt to make the change. • Explore the good and bad aspects of making a change. • Which negative parts do I have the power to change? Looking at each of the negative parts of the relationship that the youth has listed. This step simply involves the youth actually trying out one of the listed solutions and seeing how it works. • Relationship improvement takes action. It may be a good idea to illustrate this point using an example of someone the youth knows or a hypothetical person who is caught up in trying to change another person. In this step. but also on establishing rapport. The main way rapport was established with Kyle was by linking ACT skills with the concerns he reported during the illness narrative. Explain that often the things that are not within a person’s control are the characteristics or qualities of the other person. Kyle became more invested in treatment. Explore with the youth whether the positive aspects of the relationship outweigh the negative ones. A big step in improving a relationship is to overcome this tendency and recognize that there are both good and bad things about the relationship. Sometimes when a person is having difficulty with another person. He yawned several times throughout the session and did not display consistent eye contact. Oftentimes. it is difficult to think about things that are going well in the relationship or that he does like about the other person. help the youth examine the potential outcomes of each of the proposed solutions for changing something about the relationship. He was receptive to learning about the ACT and THINK skills and began to complete his mood monitoring assign- . even though it is clear that the positives outweigh the negatives. the clinician focused not only on psychoeducation and introducing ACT skills. His mood tended to be better on days when he was busier. and Kyle agreed that he was happier when he was doing something social than when he was home alone. as well as support him while he gradually increased his time in school until attending full-time again. Kyle followed through with this assignment. as he increased spending fun times with friends. However. Kyle rated his academic problems as most upsetting to him currently. and his mood ratings began to gradually improve. active. each step was applied to Kyle’s concerns regarding his dropping grades and poor attendance. Kyle openly discussed how his mood was lower on days when he stayed at home and did not spend time with friends. With the help of the clinician. Eventually. Kyle’s parents joined in at the end of one session to sign a release for the clinician to contact the school guidance counselor in order to begin the process of obtaining accommodations in the school setting for Kyle because of his health condition. he began to assume that others thought he was “weird” and therefore he needed to prove he was cool by fighting with others. as well as how to deal with his friend’s possible reactions. and helpful activities in which he could participate. therefore. Kyle was able to pick the solution of speaking with his teachers and parents about 1) getting a tutor to help him to catch up on the work he had missed and 2) starting to return to regular school attendance. He was excited when the clinician explained that given his illness. focusing on talents. The clinician helped Kyle by role-playing how he would bring this subject up with his friend. the closer he became with them and the less conflict he experienced with them. Kyle formed a list of pleasurable. but that choosing not to tell them caused him to feel more isolated from them. The STEPS problem-solving skills were then introduced to Kyle. Kyle was surprised when his friend was “really cool” about it. After sharing this information with his friend. Another ACT skill that proved beneficial for Kyle was the set of STEPS problem-solving techniques. Kyle realized that it was his choice whether to open up to his friends. the school would likely agree to a specialized plan focused on providing him with extra time and support to catch up academically. his fighting behavior decreased. This pattern was discussed. Kyle reported that one of the most concerning things about his illness currently was that he was not able to tell his friends what was going on for fear of being teased. and together with the clinician. This fear had caused him to feel isolated from his friends. Kyle was pleased with how problem solving worked for him and therefore was also quite receptive to the POWER skill introduced during session 6. Kyle said that . He formed the solution of telling his best friend about his IBD diagnosis and seeing how he would react. especially his best friend. social. He also noted that the more time he spent with peers. Kyle explained that when he was not hanging out with friends a lot. This discussion naturally led to introducing the ACT activities skill by reminding Kyle that his mood ratings were better when he did fun activities and lower when he isolated himself. he became less defensive and no longer felt the need to appear tough. He was assigned to take part in at least one of these per day and to rate his mood both before and after taking part in the activity.352 Cognitive-Behavior Therapy for Children and Adolescents ments. The primary skill to be delivered focuses on the T (“Think positive”) in THINK and marks the beginning of the cognitive portion of this cognitive-behavioral treatment. After learning and practicing these techniques. or personalizing. Although Kyle’s mood ratings were gradually improving with the use of ACT skills. and is defined as taking personal responsibility for negative events. one way that people can control their feelings in situations that they cannot change (e. he felt a lot better once his illness wasn’t a big secret. the rationale of this session is based on the idea that how individuals think about events or situations will affect how they feel. The practice assignment involves the youth logging his negative thoughts each day with an associated mood rating on a scale from 1 to 10. E “Exaggerating—imagining a disaster” refers to Beck’s concept of catastrophizing (i..e. Next. Kyle began to experience less pain and also felt a higher amount of control over his symptoms. Even though he wasn’t as close to his friend as he was before the IBD diagnosis. and hypnosis. This session represents the transition from the ACT to the THINK skills. His IBD weekly ratings began to decrease. his IBD ratings did not initially improve because Kyle was reporting high amounts of pain.g. BLUE thoughts are loosely based on Beck’s model (1967) of cognitive errors: B “Blaming myself ” refers to Beck’s concept of excessive responsibility. This is a defining feature of secondary control coping. visualization. the youth categorizes each of these thoughts according to the BLUE . imagining that the outcome of an event will be catastrophic or that the event itself is catastrophic). having a physical illness) is by changing their thoughts about those situations. U “Unhappy guessing” refers to jumping to conclusions—basically. assuming that someone who did not say “hi” to you dislikes you). Kyle was open to the idea that some of his pain might be related to anxiety regarding school rather than IBD symptoms alone.Chronic Physical Illness 353 this made a big difference for him. Session 7: think positive. making negative predictions on the basis of scanty evidence (e. especially in the mornings before school.. As is true for all cognitive therapies. Therefore.g. including breathing techniques. Kyle especially benefited from the hypnosis skills and found that he could reduce his level of pain when he practiced this technique regularly. He was taught calming skills. L “Looking for the bad news” is related to Beck’s concept of selective abstraction and refers to selectively attending to negative aspects of experiences.. and no replaying bad thoughts. Finally. the youth will identify a less negative (or more neutral) way of thinking and rate his associated mood. the clinician moved on to teaching the THINK skills in later sessions.” Session 8: help from a friend. Second.354 Cognitive-Behavior Therapy for Children and Adolescents letters. When they juxtapose the current situation and a potentially worse situation. younger children can often identify negative thoughts but have difficulty with the idea that these can be replaced with positive thoughts. For example. by the end of treatment. Alternatively. introduce how seeking feedback from a trusted other person can be helpful in catching negative thinking. he continued to maintain some hopeless and negative cognition regarding his illness. Finally. . his pattern of exaggerating the negative impact of IBD on his life was also discussed. Kyle practiced countering these thoughts and replacing them with more helpful thoughts. In these situations. The therapist explained to Kyle the relationship between thoughts and feelings and introduced the concept of BLUE thoughts. Kyle was able to recognize his pattern of “looking for the bad” by overly focusing on how IBD negatively affected him. explain the proverb “Every cloud has a silver lining. First. The focus of this session is to develop and use alternative methods to reverse negative thinking.” which may be an example of looking for the negative. For example. Kyle was functioning at a much higher level. but I’m not. the current situation will not seem as bad. there is something good that he can focus on instead. Kyle’s illness narrative slowly began to change. However. it can be developmentally challenging to work purely in the cognitive realm for some youth. He also began regularly practicing “finding the silver lining” because this helped him to challenge his tendency to focus on the negative. instead of saying. Case Example Once Kyle’s symptoms were beginning to lessen due to the ACT skills. For the practice assignment. In addition. At this point in the treatment. his thoughts had become much more realistic. Kyle was able to recognize when his thoughts were making him feel worse and then work to challenge these thoughts. “It could be worse—I could be so sick that I would need to be in the hospital.” and link it to the idea that even in bad or negative situations. help the child come up with a list of activities he can utilize to distract himself from negative thoughts as a way of feeling better. some youth understand this concept better by imagining how their situation could be worse. Most of the time. the youth might think. the child is asked to try out all three of these skills during the week and to rate his mood before and after each attempt. Have the youth identify three people he could turn to for help in identifying and altering negative or pessimistic thoughts. identify the silver lining. “I hate having IBD. Although initially his thoughts about his illness caused him to feel sad. Chronic Physical Illness 355 Sessions 9–12: keep trying. In fact. particularly in social. the overarching goal is to introduce the idea that often one skill alone is not enough to optimally improve the youth’s mood. it can be useful for the youth and therapist to switch roles. six monthly booster sessions can be provided. and youth who are struggling to learn PASCET-PI coping skills or having trouble implementing the skills into their daily routines. Thus. and Plan C for specific problems. For the remaining sessions 10–12. but it also helps symbolize a transition in the sessions. role-plays. as well as the introduction of some skills that might be needed in the future. the focus is on the application of the most personally relevant PASCET-PI skills for the youth’s current problems. Maintenance sessions. functional. In session 9. These sessions follow the format of the flexible sessions in terms of reinforcing coping skills to address current problems and to anticipate future problems. encourage the youth to think of three ACT and THINK skills that would be most helpful in the given situation in an effort to develop plans for future action (Appendix 10–A). brainstorming. In the final structured session (session 9). with the youth taking a more active role in problem solving and generating solutions. and the youth identifies a list of current life and IBD-related problems. it is often the combination of different skills that can lead to the best outcome. Plan B. youth with comorbid anxiety problems. the ACT and THINK chart is reviewed. or physical illness domains. it is essential to obtain a thorough interval history of the following information since the preceding session: • Depressive symptoms and mitigating circumstances • Physical illness course • Environmental stressors (family. These additional sessions may be most helpful for youth experiencing only partial remission of depressive symptoms. The session content will consist of focused discussions. To achieve these objectives. a considerable part of each of these later sessions will be devoted to collaboratively designing and troubleshooting the practice assignments for the following week. After completion of the acute phase of treatment. For each problem. peers) . and other exercises aimed at practicing and reinforcing the application of specific PASCET-PI skills to potentially depressogenic events and conditions that are present in the youth’s daily life. youth from more chaotic or less supportive families. with the therapist as the depressed youth and the youth as the therapist who helps the “client” to develop Plan A. This role reversal not only allows the youth to experience mastery. school. To solidify this concept of having several plans. youth experiencing IBD flare-ups during the course of therapy. The goals of these family sessions are threefold. Individual family sessions are held at the beginning. the therapist can decide on a case-by-case basis how these family sessions will best assist the youth in the family’s ultimate goal of learning more adaptive ways to cope with having IBD. if available) joins the therapist and youth for a 5-minute summary conference to discuss the main points of the session (excluding information the youth does not want to share) and the youth’s practice assignment for the upcoming week. a parent (or both. including teaching about depression and the interface of depression and physical illness. helping to develop a sense of hope about the future. At the end of each individual youth session. and helping the family reinforce the youth’s ability to cope with depression and physical illness by using PASCET-PI skills. To help families increase their behavioral problem-solving repertoire.356 Cognitive-Behavior Therapy for Children and Adolescents • Problems encountered in implementing PASCET-PI skills • Positive outcomes resulting from PASCET-PI skill use Family Sessions Individual youth sessions are complemented by contact with parents in two forms. . However. the first session involves only the parents or parental figures in the youth’s life. Incorporate parents in a developmentally appropriate manner. The format of the family portion of the overall PASCET-PI protocol is a short-term. given differences in family structure and degree of impairment. the central tool in the family sessions is to apply a modified version of the STEPS skills for family problem-solving. a variety of strategies are employed. and the subsequent two sessions involve first the parents alone and then include the youth so the therapist can help develop more constructive interactions between the parents and the child. and linking cognitive information to both the individual and family perspectives on affective illness and the unique life experience of the family. Ideally. intensive. middle. which the parent is encouraged to assist the youth with. educating the family about depression and comorbid physical illness. including explaining the treatment program and soliciting the parent’s perspective on the youth’s depression and coping with IBD. but encourage the adolescent to share the CBT coping skills learned with the parent at the end of the session. family-based intervention. discuss confidentiality of the specific topics brought up by the adolescent. and end of the youth’s treatment. Just as the crux of the individual PASCET-PI is to help the adolescent develop primary and secondary control. Each family session is outlined below. Help the parents adopt a more appropriate perspective on the adolescent’s behavior. psychoeducational. For example. including dealing with the physical illness. balancing firm control with warmth and granting autonomy. Players earn the sticks by saying something nice or doing something nice for someone else in the family. each family member contributes to the generation of solutions and gives input examining what is good and bad about each solution. Finally. if the youth says. Next. introduce the family STEPS problem-solving exercise. This activity uses the same STEPS worksheet completed by the youth in individual session 2..g. The goals of this session are to gather information. introduce the family de-stressing game described below. Next. The idea of the game is for each player to get as many popsicle sticks in colors other than his or her own from family members by the end of the game. Help the parents develop goals for how they might change their communication style with their child (e. blue. as well as provide helpful tips for modifying school plans and improving medication adherence (see information worksheets in Appendix 10–C). in which everyone’s opinions are valued and communication is open. Family de-stressing game: Each family member gets five popsicle sticks in a certain color (red.” the youth would get a stick from his father. yellow. gently ask for the parents’ perspectives about the youth’s problems and the IBD-related illness experience of both the youth and the family. providing a rationale for how these skills apply to their current situation and their child’s difficulties. If the youth is present for the session. Explain how decreased communication or negatively expressed emotions toward the youth can maintain a youth’s depressive or pessimistic stance (Figure 10–1). green. For example. Family session 2: parents as facilitators. Educate the family about the relationship between IBD and depression. stop nagging and praise the youth for going to school every day). “Dad. and to deliver brief psychoeducation and apply skill building at the familial level.Chronic Physical Illness 357 Family session 1: parents as partners. Finally. Review the ACT and THINK skills that have been covered with the youth to date and how parents can reinforce these skills. have him participate and possibly even lead this part of the family session. I really appreciate you spending time with me yesterday. The main goal of this session is to socialize the family to the cognitive-behavioral model. provide an overview of PASCET-PI structure and the ACT and THINK chart. educate parents about how improving family communication can help their child cope better. This exercise teaches families how to problem-solve in a respectful way. ask for feedback from the parents about their child’s progress and ongoing problems. First. If the youth’s mother baked him . First. orange. which aims to reduce stress at home by building more positive interactions between family members. review ACT and THINK skills. develop an understanding of the parents’ perspectives on the youth and family situations. and highlight the importance of positive communication. or purple) or other unique token identifiers. however. At the same time. Treating her own symptoms allowed her to more effectively support Kyle’s new healthy lifestyle. In this session. Kyle was able to explain that he often felt “put in the middle” of his parents arguing and that this made him feel like he “cannot win. This education helped Kyle’s mother to realize that she herself was also depressed. In this way. Next. Follow-up family sessions also focused on problem-solving some difficulties within the family unit. As in previous sessions.” Therefore. Kyle’s father was also encouraged to support Kyle’s new healthy lifestyle by providing Kyle with praise and special attention when he was using coping skills and reducing attention when Kyle was not following through. Case Example While Kyle’s individual sessions were greatly helpful for improving his mood and functioning. Kyle noticed great improvement in his interactions with his family. but ideally each game should be played for 5–7 days. The therapist can act as a mediator for this interaction. Kyle’s parents attended the first session without Kyle to learn about CBT and how they could support Kyle in his treatment. Although this intervention was not easy for the couple and at times they made mistakes. the secondary gain of getting more special time with his father when he did not go to school dissipated. particularly in adolescents with physical illness. he would give one of his sticks to her. the clinician helped Kyle’s parents to agree to discuss marital problems privately and to avoid including Kyle in these discussions. She was referred for outside treatment and attended those sessions. Negative comments or interactions are ignored.358 Cognitive-Behavior Therapy for Children and Adolescents cookies. these perspectives are provided in the presence of the youth so that there can be in vivo STEPS problem-solving completed with the family unit to address unresolved problems or issues. the youth is encouraged to review the ACT and THINK skills and to communicate to the parents how they can be most helpful in reinforcing new skills. Key Clinical Points Several general considerations can optimize the outcome of using CBT to treat depression. and his reported level of stress within the family was reduced. the family sessions also played a large role in his improvement. the parents are encouraged to give their perspectives about their child’s progress and ongoing problems. The family decides as a unit when they will begin and end the game. Family session 3: parents as coaches. and this change also helped to improve Kyle’s attendance. facilitating the youth’s long-term maintenance of treatment gains. . The main goal of this session is to have the parent-child dyad determine the best way that parents can become CBT coaches. the fun and interesting aspect cannot be built into the manual very successfully. Help from a friend. what is fun and interesting for a 12-year-old boy may not be at all fun or interesting for a 16-year-old girl. it becomes the therapist’s job to make the sessions enjoyable and engaging by designing clever. Identify the silver lining. witty. Of course. . No replaying bad thoughts. As such. Keep trying—don’t give up. CBT= cognitive-behavior therapy. The key to success in using Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI) to enhance coping with physical illness is balancing rapport and didactic education in a manner that is fun and that allows the youth to take on a progressively more active role in problem solving throughout the course of therapy. Talents. Sessions can also be completed bedside if the patient is medically hospitalized. • Balancing rapport and education. Modified behavior Improved mood ACT and THINK skills Improved communication Family communication and impact on youth’s de- ACT= Activities.Chronic Physical Illness 359 Downward spiral of youth’s depression Depressed mood Negative thinking Negative behavior Family processes Negative expressed emotions Decreased communication Upward spiral with CBT for youth Adaptive thinking Education FIGURE 10–1. and memorable ways to present and illustrate the main points of each session. The therapist should also be flexible whenever possible in coordinating therapy sessions with medical appointments or visits for medication infusions. • Flexibility. THINK= Think positive. pression. Calm and Confident. Instead. This review is an important opportunity for the therapist to provide positive reinforcement for the youth’s work. and the review should not be rushed to get to the remaining session content. After the initial session. painting. • Toolbox reminder. they may have limited awareness of feelings or believe that certain feelings are unacceptable. the therapist should ascertain that the youth understands the notion and then move on.g. concepts. it may be beneficial to incorporate extra exercises to reinforce the lesson learned. which may help in designing examples and setting up future assignments. • Developmental considerations. Additionally.g. The cognitive-behavioral therapist models treating each person in a respectful way and models appropriate listening behavior. drawing.360 Cognitive-Behavior Therapy for Children and Adolescents • Review. and skills are essential to make the CBT experience a positive one for the youth. each subsequent session begins with a review of the previous week’s material and practice assignment. The ACT and THINK chart encompasses numerous different ways of coping with depression and a chronic physical illness. Age-calibrated adjustments in presenting issues. He or she also helps parents and kids find their strengths. Not all of the tools will be useful for each youth. and efforts should be made to facilitate this transition. • Respect. Tap into the youth’s creativity and interests to help personalize the treatment tools for him (e. Thus.g. or writing a story about the use of the skill). and they often develop unusual beliefs about why they are sick or why they need to go to the hospital. the therapist must not oversell a particular coping skill from the ACT and THINK list because of a sense that a youth rejects the idea or will not use it. Prepubertal youth (i.... “It will only last a minute” and “This will only hurt a little bit”) and may manifest avoidant behaviors when faced with procedural stressors. making a collage or drawing to illustrate a particular skill. the practice assignment will often lead quite naturally into the new session material. playing the role of the doctor). They may have difficulty comprehending concepts like duration and quality (e. Instead. thus. Thus. spending time on the practice assignments is worthwhile. Moreover. it is important to use . The therapist should make sure that the process and content of the therapy is perceived and interpreted within a framework of the youth’s developing cognitive capacity (see Chapter 2). the practice assignment serves as an opportunity for the therapist to note consistencies and patterns in the youth’s approach.. and roleplay (e. ages 9–12) may still have concrete thinking. Youth may express feelings through activities like playing. Remember that CBT is a skill-building treatment based on the toolbox concept. For those skills that a particular youth appears to find especially helpful.e. Along these lines. It is important to involve teens in treatment planning and to foster a developing sense of autonomy from family and close peer relationships.g..g. The adolescent’s ambivalence about his sick role is a common source of treatment nonadherence. especially when procedures involve loss of functioning (e. • Regression. including relaxation imagery and cognitive reframing. especially those with anxious tendencies..g. phone sessions. their growing abilities for abstract thinking enable them to draw on a wider range of strategies for coping with anxiety and stress. Medical procedures can impinge on these tasks. colostomy). Give consideration to flexible alternative solutions (e. Rapid physical changes associated with puberty produce heightened self-awareness and concern about appearance. Developing a sense of identity and belonging are important adolescent tasks that are often interrupted by the presence of a chronic illness.” • Autonomy and treatment nonadherence. reminder calls from the therapist about homework. The acceptance of authority and relinquishment of control needed to undergo medical procedures can be difficult for this age group and may foster feelings of helplessness and dependence. addressing parental contributions to the problem). In addition. continue to educate both the adolescent and the family about normal adolescent processes to normalize development (e. Adolescent patients may become resistant and nonadherent in an effort to regain a sense of control and independence in the medical context. and behaviors) and inferring causal links between events that occur in close physical or temporal proximity. Fortunately. Address noncompliance with attendance or practice assignments immediately and directly by problem solving with the adolescent and examining mitigating environmental factors. resulting in misconceptions about the reasons for the procedure. • Model of joint empiricism. misunderstandings about the nature of the illness or procedure. Sometimes if extremely stressed or when sick with a flare-up. This can result in a return to magical thinking (such as attributing events in their lives to their own thoughts.. older youth can regress to coping styles used in earlier times of their lives. feelings. or a mistaken belief that the illness or procedure is “punishment. links between puberty and poor body image. parent’s role in helping the adolescent transition from a “child” status that involves adult monitoring to an “adult” status that requires more self-management). Undergoing medical procedures can also regress some teens.Chronic Physical Illness 361 these modalities as vehicles to deliver PASCET-PI skills. Endorse a model of joint empiricism with the older adolescent from the onset of therapy by focusing on . • Therapist education about IBD. adolescents who have missed substantial amounts of school because of their illness need the problem-solving steps planned for school reentry to be realistic in scope and timing. • Etiology of depression does not preclude CBT. sophistication in verbal and nonverbal communication. Although a detailed understanding about the etiology and treatment of pediatric physical illnesses is not essential in working with physically ill youth.g. and delayed physical growth and sexual maturation. family distress. and that both aspects can lead to missed social and academic opportunities.g.. parents and school). and later with other resources (e. Remember the school is a laboratory for developing not just academic competence. • Therapeutic alliance. It is important for the therapist to keep in mind that physical illnesses can be both a physical and a psychological stressor. Even a depressed state that is heavily influenced by biological factors may.362 Cognitive-Behavior Therapy for Children and Adolescents the problems raised by the adolescent and other jointly identified goals. all increasing the risk for depression. some understanding of the physical and psychological manifestations of the physical illness involved will enhance the therapist’s ability to apply the coping skills taught to this comorbid population. be treated effectively by a psychosocial intervention such as PASCET-PI. can be instrumental in the development and execution of the plan. For example.. . addressing parental criticism or shame-inducing comments. Initial collaborative negotiation between the adolescent and therapist.. Use the structure that the CBT sessions provide and consider the use of phone sessions to help meet the adolescent’s needs. degree of social judgment). capacity for perspective taking and empathy. It is important to consider that cause and cure are not inextricably linked. This is essential in adequately assessing which aspects of the environment the youth has control to change and which aspects need the help of the therapist to resolve (e. and a genuine respect for the adolescent’s strengths can help with rapport building and establish a strong working alliance. in principle. but social skills and personal coping strategies. warmth. patience.g. Another key component to forming an adequate therapeutic alliance is an assessment of the adolescent’s interpersonal skills (e. • Social environment. Pay attention to the social environment at school and in the home. Expect a more tentative therapeutic alliance and frequent comparison of the therapist to other adult figures. using school resources to provide more social or academic opportunities). Empathy. D. C. Recognizing negative thought patterns and challenging them with more helpful thoughts. B. Taking part in relaxation training techniques such as deep breathing and hypnosis. leading to a hopeless view regarding health and a decreased participation in healthy behaviors. D. B.Chronic Physical Illness 363 Self-Assessment Questions 10. such as inflammation. can negatively impact brain chemistry.2. resulting in psychological disturbances. A preexisting mental health concern can negatively impact physical illness by decreasing healthy behaviors. 10. Also. There is no relationship between physical illness and mental health concerns. and social activities. C. D. Parent sessions focused on education regarding CBT and how parents can best support their child. All of the above. The relationship is bidirectional. Activity scheduling: being encouraged to take part in an increased variety of activities. Teaching the youth skills focused on how to behave differently when feeling upset. helpful.3. The tool of identifying the silver lining so that the youth begins to find the positive in her situation. Teaching the youth skills focused on changing negative thoughts regarding illness. Symptoms of physical illness. A 14-year-old adolescent girl with comorbid Crohn’s disease and depression spends most of her time lying in bed in her bedroom. Which of the following coping skills is a primary control tool that will likely help her change this negative behavior? A. .1. including pleasurable. which of the following treatment components will likely be most useful for improving mood and positive coping? A. When CBT is used for the treatment of a youth with a chronic physical illness. Psychological difficulties can negatively impact a youth’s perception of control over illness. Which of the following best describes the relationship between psychological and physical processes? A. physical illness processes can contribute to increased psychological concerns by increasing both internal and external stressors. 10. isolating herself. B. physically active. C. such as increasing pleasurable activities. Smart Thot. Increasing participation in pleasurable or rewarding activities. 10. B. Improving self-soothing skills. Crown House Publishing. CT. Crown House Publishing. for hypnosis training and certification: www. Bethel. 2009 Wester WC. 2005 Thomson L: Harry the Hypno-Potamus: More Metaphorical Tales for Children.net Avery RR: Meet Thotso.e. Focus on making the sessions collaborative and fun by learning about the teen’s interests and linking skills with the teen’s illness narrative. Do not make any adaptations. Which of the following developmental adaptations may be most useful for this situation? A. CT. Leave out the ACT (i.asch. 2008 Dudley CD: Treating Depressed Children.5. China. Identifying negative thought patterns and learning to change them. Talents) skills when conducting treatment in order to focus more on the complex skill of cognitive challenging..364 Cognitive-Behavior Therapy for Children and Adolescents 10. When working with a 17-year-old adolescent boy. Oakland. Suggested Readings and Web Sites American Society of Clinical Hypnosis. D.4. Your Thought Maker. Calm and Confident. Using the therapeutic relationship as a model for outside relationships. Sugarman LI: Therapeutic Hypnosis With Children and Adolescents. B. the therapist notices that he appears bored when presented with the information. New Harbinger Publications. Bethel. Activities. Crown House Publishing. 1997 Thomson L: Harry the Hypno-Potamus: Metaphorical Tales for the Treatment of Children. Increase parent participation in the teen’s sessions to ensure that he participates actively. CA. CT. D. C. as this would decrease the overall efficacy of the treatment. C. Norwalk. Which of the following is not a focus of treatment according to the Skills-and-Thoughts (SAT) theory? A. 2007 . in Cognitive Aspects of Chronic Illness in Children. Psychosomatics 40:5–17. 1996 Beardslee WR. Brook J: Family factors related to the persistence of psychopathology in childhood and adolescence. Am J Psychiatry 154:510– 515. Frey MA. 2007 Chalder T. Hoeber. et al: Response of families to two preventive intervention strategies: long-term differences in behavior and attitude change. Diabetes Care 28:1604–1610. Salt P.Chronic Physical Illness 365 References Barakat LP. et al: Testing an intervention to promote children’s adherence to asthma self-management. Mulligan K. 2011 Brent DA. Inflamm Bowel Dis 17:590–598. 2010 Cohen P. Podorefsky D: Resilient adolescents whose parents have serious affective and other psychiatric disorders: importance of self-understanding and relationships. et al: Family-focused cognitive behaviour therapy versus psycho-education for chronic fatigue syndrome in 11. Gastroenterol Nurs 33:11–18. J Am Acad Child Adolesc Psychiatry 32:770–774. Kazak AE: Family issues. Lavori PW. 1997 Beck AT: Depression: Clinical.to 18-year-olds: a randomized controlled treatment trial. Philadelphia. Deary V. Naar-King S. Versage EM. Keller MB. et al: Sustained change in parents receiving preventive interventions for families with depression. Guilford. 2005b . Oakley MG. pp 333–354 Barlow C. J Am Acad Child Adolesc Psychiatry 35:774–782. J Am Acad Child Adolesc Psychiatry 32:723–730. Experimental. Pediatrics 116:826–832. et al: The effects of multisystemic therapy on diabetes stress among adolescents with chronically poorly controlled type 1 diabetes: findings from a randomized. Psychol Med 40:1269–1279. Edited by Brown RT. New York. 1993 Burke P. 1999. et al: The impact of parental affective disorder on depression in offspring: a longitudinal follow-up in a nonreferred sample. Rayens MK. Promislow S. Rothberg PC. and Theoretical Aspects. 1987 Ellis DA. Psychiatry 50:332–345. Cooke D. Frey MA. Wright E. Carr R. McKain B. controlled trial. 1990 Beardslee WR. Husain K. 1988 Beardslee WR. Elliott M: Depression in pediatric chronic illness: a diathesis-stress model. Poling K. 2010 Beardslee WR: Development of a clinician-based preventive intervention for families with affective disorder. 1999 Burkhart PV. et al: Use of multisystemic therapy to improve regimen adherence among adolescents with type 1 diabetes in chronic poor metabolic control. et al: Information needs and preferences of recently diagnosed patients with inflammatory bowel disease. New York. 2005a Ellis DA. Naar-King S. J Nurs Scholarsh 39:133– 140. 1970) Bernstein KI. 1993 Beardslee WR. et al: A psychoeducational program for families of affectively ill children and adolescents. J Prevent Psychiatry and Allied Disciplines 4:39– 60. Am J Psychiatry 145:63–69. University of Pennsylvania Press. et al: A critical review of self-management and education interventions in inflammatory bowel disease. 1967 (Republished as Beck AT: Depression: Causes and Treatment. in Child Psychopathology. Templin T.366 Cognitive-Behavior Therapy for Children and Adolescents Ellis DA. 1990 Hammen C. Lundman B: Personal understandings of illness among people with type 2 diabetes. et al: Coping skills training for youth with diabetes mellitus has long-lasting effects on metabolic control and quality of life. Fisher L. 2009 Grinyer A: Contrasting parental perspectives with those of teenagers and young adults with cancer: comparing the findings from two qualitative studies. 2004 Karwowski CA. Anthony KK. J Pediatr Psychol 30:656–666. Cognit Ther Res 14:215–227. 2008 . et al: Efficacy of cognitive behavioral therapy for adolescents with chronic fatigue syndrome: long-term follow-up of a randomized. J Pediatr 137:107–113. Kaslow NJ: Depression and attributions in children and adolescents: a meta-analytic review. et al: Daily coping practice predicts treatment effects in children with sickle cell disease. Whittemore R. 2008 Lernmark B. 1989 Gil KM. Abrams MR. et al: The effect of hypnosis on systemic and rectal mucosal measures of inflammation in ulcerative colitis. et al: Multisystemic treatment of poorly controlled type 1 diabetes: effects on medical resource utilization. controlled trial. Stulemeijer M. J Consult Clin Psychol 75:168–174. J Adv Nurs 47:174–182. Barkley RA. Int J Clin Exp Hypn 47:104–116. Hatira P: Clinical hypnosis versus cognitive behavioral training for pain management with pediatric cancer patients undergoing bone marrow aspirations. Fam Process 35:407–422. 1995 Grey M. 2001 Gladstone TR. Naar-King S. 1999 Focht L. et al: Symptoms of depression are important to psychological adaptation and metabolic control in children with diabetes mellitus. Davidson M. et al: Effects of coping skills training in school-age children with type 1 diabetes. Sandström H. 1996 Gil KM. Am J Gastroenterol 103:1460–1469. Jaser S. Szigethy E: Strategies to improve quality of life in adolescents with inflammatory bowel disease. Boland EA. 2009 Hammen C. Carson JW. 1999 Mawdsley JE. 2005c Ellis DA. J Consult Clin Psychol 57:725–731. Frey M. J Pediatr Gastroenterol Nutr 28:S28–S33. Phillips G. Diabet Med 16:14–22. et al: Multisystemic therapy for adolescents with poorly controlled type 1 diabetes: stability of treatment effects in a randomized controlled trial. Persson B. de Jong L. pp 153–195 Hörnsten A. Edited by Mash EJ. Keljo D. 1996. Eur J Oncol Nurs 13:200–206. Macey MG. Goodman-Brown T: Self-schemas and vulnerability to specific life stress in children at risk for depression. Inflamm Bowel Dis 15:1755– 1764. Jenkins DG. Guilford. Beardslee WR: “Speech after long silence”: the use of narrative therapy in a preventive intervention for children of parents with affective disorder. 2000 Grey M. 1999 Liossi C. J Pediatr Psychol 26:163–173. Rudolph KD: Childhood depression. J Abnorm Child Psychol 23:597–606. et al: Sickle cell disease pain: relation of coping strategies to adjustment. 2009 Knoop H. Pediatrics 121:619–625. New York. Res Nurse Health 32:405–418. 2007 Engstrom I: Inflammatory bowel disease in children and adolescents: mental health and family functioning. Naar-King S. Glutting JJ. J Am Acad Child Adolesc Psychiatry 46:1290–1298. Whorwell PJ: Treatment of inflammatory bowel disease: a role for hypnotherapy? Int J Clin Exp Hypn 56:306–317. Noll RB. Advances in the Inflammatory Bowel Diseases. 2005 Szigethy EM. Smith SM. de Jong L. 1982 Sieber WJ. et al: Thematic analysis of physical illness perceptions in depressed youth with inflammatory bowel disease. 2004 Szigethy EM. Abstracts from the CCFA National Research and Clinical Conference. p 194 Robins PM. 1992 Strunk R: Deaths from asthma in childhood: patterns before and after professional intervention. Fiselier. Craig AE. 2006. Craig A. 2007 Szigethy EM. Rodin J. Carpenter J. Liscio M. 2009. et al: Modulation of human natural killer cell activity by exposure to uncontrollable stress. J Pers Soc Psychol 42:5–37. Pastore V. 2009 Rothbaum F. 2010. et al: Cognitive-behavioral therapy for depression in adolescents with inflammatory bowel disease: a pilot study. Iobst EA. Abstract from the CCFA National Research and Clinical Conference. et al: Cognitive-behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. National Harbor. Abstract presented at the 22nd annual meeting of the North American Society for Pediatric Gastroenterology. and Nutrition. Whitton SW. New York. 2009 . 2008 Pennebaker JW: Writing about emotional experiences as a therapeutic process. et al: Cognitive-behavioral treatment for youth with IBD and co-morbid anxiety disorders: results of an open pilot (abstract P-152). Disabil Rehabil 31:1066–1073. Levy-Warren A. Szigethy EM. et al: Profile of depression in adolescents with inflammatory bowel disease: implications for treatment. p E59 McLafferty L. Craig A. 2009 Reigada L. Hepatology. 1987 Stulemeijer M. October 2010 Miller V. Masia Warner C. J Am Acad Child Adolesc Psychiatry 43:1469–1477. Poster presented at the 57th annual meeting of the American Academy of Child and Adolescent Psychiatry. Psychol Sci 8:162–166. Snyder S: Changing the world and changing the self: a twoprocess model for perceived control. T. J Pediatr Psychol 30:397–408. Inflamm Bowel Dis 15:69–74. et al: A randomized controlled trial of a cognitive-behavioral family intervention for pediatric recurrent abdominal pain. BMJ 330:14. pp 673–674 Szigethy EM. Pediatr Asthma Allergy Immunol 1:5–13.Chronic Physical Illness 367 McLafferty LP. J Pediatr Psychol 34:156–163. Hardy D. 2005 Rofey DL. November 12–14. et al: Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression. MD. Weisz JR. Levine A. Courtright R. et al: Qualitative narrative analysis of physical illness perceptions in depressed youth with inflammatory bowel disease (abstract 133). et al: Psychological intervention in young brain tumor survivors: the efficacy of the cognitive behavioural approach. Kenney E. et al: Cognitive behaviour therapy for adolescents with chronic fatigue syndrome: randomised controlled trial. Benkov K. Brain Behav Immun 6:141–156. Larson L. Kenney E. et al: Longitudinal effects of cognitive behavioral therapy for depressed adolescents with inflammatory bowel disease (abstract P-0086). 1997 Poggi G. 5th Annual Advances in the Inflammatory Bowel Diseases. 1997 Weisz JR. Buckloh LM. Rothbaum FM. Buckloh LM. Am Psychol 39:955–969. et al: Brain processing of illness perception in depressed adolescents with inflammatory bowel disease. Harris MA. competence. et al: Perceived contingency of skill and chance events: a developmental analysis. Dev Psychol 18:898–905. Am Psychol 39:974–975. treatment adherence.368 Cognitive-Behavior Therapy for Children and Adolescents Szigethy EM. J Consult Clin Psychol 62:324–332. 2001 Weisz JR. 2009 Weisz JR. Sleep Med 10:597–603. J Consult Clin Psychol 65:703–707. and the development of perceived control. Dev Psychopathol 4:627–653. 1984a Weisz JR. Behav Ther 39:33–46. Harris MA. Blackburn TF: Standing out and standing in: the psychology of control in America and Japan. Blackburn TF: Swapping recipes for control. 2007 Wysocki T. contingency. Harris MA. Gordis EB. 1982 Weisz JR. and coping in child and adolescent depression: research findings. Stipek DJ: Competence. J Abnorm Psychol 110:97–109. controlled trial of Behavioral Family Systems Therapy for Diabetes: maintenance and generalization of effects on parent-adolescent communication. Jones NP. and metabolic control. 2009 Wysocki T. October 2010 Tang Y. 2008 . 1992 Weisz JR. et al: Randomized. Turek FW. MD. Buckloh LM. Diabetes Care 30:555–560. Southam-Gerow MA. Silk J. J Consult Clin Psychol 77:383–396. Rudolph KD. Sweeney L. 2006 Wysocki T. Poster presented at the 6th annual NIH Director’s Pioneer Award Symposium. McCarty CA: Control-related beliefs and depressive symptoms in clinic-referred children and adolescents: developmental differences and model specificity. Bethesda. Yeates KO. 1984b Weisz JR. J Pediatr Psychol 31:928–938. 1982 Weisz JR. et al: Randomized trial of behavioral family systems therapy for diabetes. 1994 Weisz JR. Southam-Gerow MA. Granger DA. therapeutic implications. Hum Dev 25:250–281. et al: Cognition. et al: Cognitive-behavioral therapy versus usual clinical care for youth depression: an initial test of transportability to community clinics and clinicians. Preuss F. Robertson D. McCabe MA. et al: Sleep deprivation worsens inflammation and delays recovery in a mouse model of colitis. Thurber CA. Denning MD: Primary and secondary control among children undergoing medical procedures: adjustment as a function of coping style. Rothbaum FM. et al: Effects of behavioral family systems therapy for diabetes on adolescents’ family relationships. et al: Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training. developmental concerns. No negative thinking allowed. Stop thinking about things that make me feel bad. practice! T: Think positive. Set a goal. Note. activities that I enjoy. Keep trying ideas from my ACT and THINK chart until I feel better. plan steps to reach the goal. Figure out what’s good about my situation. activities that keep me busy. K: Keep trying—don’t give up. Change BLUE (negative). then practice. Develop a special talent or skill. Stay confident— show a positive self. H: Help from a friend. practice. activities with someone I like. Stay calm—make myself relax. I: Identify the silver lining. The spelled-out terms for STEPS and BLUE are included next in this appendix.Appendix 10–A: PASCET-PI Selected Skills and Tools 369 Appendix 10–A PASCET-PI Selected Skills and Tools • • • • • • • ACT and THINK skills STEPS problem-solving worksheet BLUE thoughts Physical illness narrative Mood thermometers for practice activities POWER relationship problem-solving Maintenance plan ACT and THINK skills A: Activities. . T: Talents. Do activities that solve problems [use STEPS]. realistic thoughts. Think things over with someone I trust. unrealistic thoughts into positive. and activities that help someone else. C: Calm and confident. Get my mind on something else. N: No replaying bad thoughts. great! If it did not work. Good: Bad: 3. T Think of solutions: Thinking of as many solutions as possible will increase the likelihood of coming up with the answer that will best solve the problem. Good: Bad: 4. Good: Bad: P Pick one and try it out: Which one will you try? S See if it worked: If it worked. Examine each one: What good and bad things might happen if you did this? What is good.370 Cognitive-Behavior Therapy for Children and Adolescents STEPS S Stay calm and Say what the problem is: Solving problems creatively happens best if a person is calm and relaxed. easy. Good: Bad: 2. BLUE thoughts B: Blaming myself L: Looking for the bad news U: Unhappy guessing E: Exaggerating—imagining a disaster . 3. Active STEPS to problem solving. the first step in problem solving is staying relaxed. bad. Thus. 4. 2. or difficult about each solution? 1. then go back to your list of solutions and try another one. E 1. 9. How much control do you think you have over your inflammatory bowel disease and why? 7a. Can you change the course of your illness (make it better or make it worse)? 7b. What are your thoughts about what caused your inflammatory bowel disease? 1b. How has having inflammatory bowel disease changed how you feel about your body? 4c. How has your inflammatory bowel disease changed your life? 4b. How do you think it works to cause your inflammatory bowel disease? 2a. How has your inflammatory bowel disease made things different for your family? 5a. Think about all of the symptoms of inflammatory bowel disease that you’ve had in the past 2 weeks. How do you feel about having inflammatory bowel disease? 3b. What are they? 2b. What are they? 3a. When you are sick with your inflammatory bowel disease. What things can you do to make your inflammatory bowel disease better or worse? 8a. Think about all of the problems you have had related to your inflammatory bowel disease. in which 1= poor job and 10 =excellent job. how do you make yourself feel better? 10. Is there anything bad about having inflammatory bowel disease? What? 6. Rate how well you have been taking care of your illness over the past month using a scale of 1 to 10. What was happening in your life when your illness started? . How is the treatment of your inflammatory bowel disease going? 4a.Appendix 10–A: PASCET-PI Selected Skills and Tools 371 Physical illness narrative About my physical illness 1a. What do you do to make your inflammatory bowel disease better or worse? 8b. Is there anything good about having inflammatory bowel disease? What? 5b. 372 Cognitive-Behavior Therapy for Children and Adolescents How I Felt Before Solution #1 Solution #2 Solution #3 Solution #4 Mood thermometers. 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 very good sort of good so-so sort of bad very bad very good sort of good so-so sort of bad very bad very good sort of good so-so sort of bad very bad very good sort of good so-so sort of bad very bad How I Felt After 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 very good sort of good so-so sort of bad very bad very good sort of good so-so sort of bad very bad very good sort of good so-so sort of bad very bad very good sort of good so-so sort of bad very bad . It can be with a friend. O Outline the positive and negative parts of the relationship: Positive W E R Negative 1. 3. Which negative parts do I have the power to change? 1. Good: Bad: Relationship improvement takes action! Decide on one of the things I have the power to change about the relationship. 2. Good: Bad: 3.Appendix 10–A: PASCET-PI Selected Skills and Tools I have the POWER to improve relationships. 373 . teacher. P Problem with a relationship: Name one. Relational problem-solving skill. romantic interest. 2. Part: How? 3. Good: Bad: 2. Part: How? 2. Part: How? Explore each one: What good and bad things might happen if I try to change part of the relationship in this way? List the good and bad results for each “How?” listed above. family member. and do it. etc. 3. 1. 1. .374 Cognitive-Behavior Therapy for Children and Adolescents Keep trying What happened when I felt bad: Use ideas from the ACT and THINK chart to come up with THREE PLANS for feeling better: Plan A Letter from the ACT and THINK chart: What this client should do: Plan B Letter from the ACT and THINK chart: What this client should do: Plan C Letter from the ACT and THINK chart: What this client should do: Maintenance plan. your cheeks. and toes.. Now begin to focus in on the feelings in your right fingers and right hand and let go of whatever tension may be in those muscles—just relax— you will feel relaxation like a warmth or perhaps a pleasant tingling sensation—let it happen—naturally. arms. feel the tension flushed from your body. That’s great—you’re doing well. your jaw is loose and relaxed—feel the relaxation spreading around your ears—over your head—down the muscles of your neck. .. .Appendix 10–B: Guided Imagery 375 Appendix 10–B Guided Imagery for Pain Management Before starting this exercise... .. Induction Make yourself as comfortable as you can either sitting or lying down. the descriptions and words used by the youth are what the therapist will incorporate into the script. . hands. no need to tense any of your muscles . let’s turn your attention to the muscles of your head and neck .. Gently close your eyes. . . further down over your shoulders. .. . Now do the same on your left side.now. all you need to do is listen to my voice. and over your stomach—let it flow further down the muscles of your left and right legs—over your knees. the therapist will be asking him for verbal feedback to make sure that he is able to visualize the scene being described to him. and fingers are relaxed—keep feeling relaxed.. .let it spread up your left arm and forearm..now both your left and right shoulders.. .... back. Let the youth know that some children have mastered this skill so well that they have been able to call on it during surgery.. Sometimes it is useful to imagine the relaxation as warm waves of water that begin at the top of your head and trickle gently over the muscles of your face.smooth out the muscles in your forehead—above your eyebrows—down the muscles of your face—over your eyes. forearm .. . arms. it is important to have the youth describe the location of his pain. feeling comfortable and relaxed—let your body go. . thus avoiding the need for anesthesia or pain medications. . and down to your feet—and with each gentle wave of water.feel relaxation now spreading over your shoulders. . Now focus on the muscles in your stomach—relax these . . upper arm.. feet. as well as the intensity and severity of his pain... . . let the feeling of relaxation spread gradually up your right hand . begin with relaxing the muscles in your left fingers and hand. legs... upper arm . Although the youth will have his eyes closed during the exercise.. . .and into your left shoulder. and into your right shoulder—let go of the tension—relax. just relax... down your back. You’re doing great—just keep relaxing like that. . . You may want to picture each number in your head as I call it out. . and with each number I call out. how much pain are you experiencing in your (name body part)? Focus your attention on your (name the body part). called the thalamus.. smooth. In this way. more and more relaxed.376 Cognitive-Behavior Therapy for Children and Adolescents muscles. imagining the exact place you feel your pain and the type of pain you feel. To help you relax even more.. just a carefree. and you are going to become even more relaxed. . .6. .. rhythmic. stomach) and paint your (name the body part) with an imaginary paintbrush. Relax. . and saying the word calm every time you let out a breath—do that for a few minutes until I return to talk to you once again (1–3 minutes). When you are ready. feel your whole body getting heavier and looser. . just relax. . feeling carefree.. . .. gentle state of relaxation.and still more relaxed as we continue. deeper and deeper relaxed.. . 3.. deeper and deeper into a relaxed.listen to your breathing.. the control center for all your feelings..g. releasing all the tension. Let’s begin—1. Paint the entire area that causes you pain. you will be able to chase away any pain or discomfort. think quietly to yourself of the word calm—this will help you to associate the word calm with the calm and relaxed state you’re now in—so that at any time in the future you can bring on this state of deep relaxation just by breathing rhythmically. no cares or concerns. you are feeling your whole body become totally relaxed. completely and totally relaxed. . When you are asked. your body continues to become more and more deeply relaxed. When you look inside this room. slowly. Now you are in a deep state of relaxation. I’m going to count slowly from 1 to 10. You will be able to shift your body to become more comfortable.) Good. 2. imagine a cable or wire connecting your (name the body part) to your brain. Now.. more and more—further and further relaxed.7. On a scale from 1 to 10.. comfortable state.. you’re very relaxed.. . In Trance Now focus on your body. you are going to feel even more comfortable and even more relaxed—even when you think it’s impossible to relax any further—there’s always more relaxation you can enjoy just by letting go.9.. Can you see this cable? (Wait for a response. without worries or concerns. You will stay in this relaxed state until I tell you to wake up.this is the breathing of deep relaxation . including pain. effortless. Please imagine your (name a body part that the patient verbalized to you—e.. Thank you.. .8. imagine a room in your brain.. 4. you will be able to verbally communicate these areas in your body to me without breaking your trance (pause). you are doing a great job. I would like you to try the following exercise—every time you let out a breath. it is a bright room and you see four walls—each wall is covered by light switches from the ceiling to the floor.. 5. Now. .and 10. Scan your body and notice the places that cause you pain.. and this will not disturb your relaxation or your concentration. please tell me which areas of your body experience pain (pause and wait for the response).. Now turn your attention to your breathing. . leaving you tension-free and calm. 1 being hardly any pain and 10 being the most pain you have ever had.. Finish the exercise on the lowest pain setting the child can achieve. and with each number on the switch that you see. Keep turning the switch lower and lower.Appendix 10–B: Guided Imagery 377 As you look around at these switches. You look around the room until you find the switch that has the word “(name the body part)” under it. you see it is labeled from 1 to 10. 8. What is the lowest number you can see the switch turned to? Encourage the child to keep imagining this until he can visualize the switch being at least a 4 or 5.) Now imagine the setting being cranked up to a 10. Did you find this switch? Good. . 9. and continue reinforcing his control over the switch and the corresponding change in pain experienced. (Wait for a response. Now visualize yourself turning the light switch down in the control room from 10. you see that each switch has a piece of tape under it with the name of a body part. imagine the pain becoming less and less intense. with 10 being the most intense pain setting and 1 being almost no pain. Describe how your (name the body part) feels right now. Describe what setting the light switch you are imagining is at. the most intense (name the body part) pain imaginable. Now as you look closely at this switch. • Communicate with you and your child’s medical team about possible flares or other difficulties noticed. and an individualized educational plan. Should My Child’s Teacher Be Told? Yes. especially in the beginning. so the school may not understand it or may confuse it with less serious disorders. Your child may choose not to tell peers. Your gastroenterologist can provide you with a letter as well as a pamphlet from the Crohn’s and Colitis Foundation of America explaining IBD. but this may change. Should My Child’s Friends Be Told? Respect your child’s wishes—he or she should decide whether to tell friends about the illness. . • Facilitate administration of medications by the school nurse so that your child is not singled out at inappropriate times. • Provide makeup work and extra help if your child is absent for long periods of time. or provide a private bathroom or nurse’s facility. and the special needs that children with IBD may have. teachers should be told about your child’s illness and symptoms and what they can do to help: • Give your child permission to leave class to use the bathroom without asking each time. as well as school policies on absences and making up work. tutoring options. Inflammatory bowel disease (IBD) is uncommon. Handling Academic Concern • Meet with your child’s principal and teacher to discuss a catch-up plan for long absences.378 Cognitive-Behavior Therapy for Children and Adolescents Appendix 10–C Information Worksheets for Parents Helping Your Child Reintegrate Into School After Being Absent for Physical Illness Working With Schools You are your child’s helper in dealing with the school system. the ways it can affect school function. It will be important for you to get to know the contact people in the school. Section 504 of the Americans With Disabilities Act Prohibits Schools That Receive Federal Funds From Discriminating Against Children With Medical Disabilities A 504 plan is a map of needed assistance for students with medical disabilities. but you will need to work with the school to get these accommodations implemented. Chronic Physical Illness in a Child or Adolescent Can Cause Parents to Become Overprotective: What Can You Do? • Foster independence by encouraging your child to take responsibility for some medical routines (taking medications and calling the doctor). and be available to assist your child. and having one in place can smooth reentry after absence for illness. • The child should be allowed a reasonable time after he or she has recovered from the episode to complete missed schoolwork. Your gastroenterologist can provide you with a letter stating that IBD is a medical disability and the types of accommodations frequently needed. If you believe your child needs special supports or services to participate fully in school. • Whenever possible. IBD can be a medical disability. • Be clear on expectations for each class and the consequences of not keeping up with schoolwork. • Create a homework plan—set reasonable goals for completing homework. . Accommodations that are commonly needed include the following: • When the child needs to miss school for medical reasons. you must write to your school district and explain the type of assistance you believe is needed. • It is medically necessary that the child be able to self-limit physical activity. • It is medically necessary that the child have unrestricted access to a bathroom. encourage your child to make decisions and to try new things and activities. bring over necessary books. designate time in the day as homework time. the child should not be penalized for it. • The child should be given the assignments for missed work in writing. so that you won’t have to constantly remind him or her. including examinations.Appendix 10–C: Parent Information Worksheets 379 • Set up a buddy system with one of your child’s friends who will keep track of homework assignments. and let your child know what went on in school that day. but I don’t like to think or talk about that now that I’m feeling OK. but it’ll go away when I stop taking it” may be helpful in diffusing curiosity. but I feel better now. . • Carry extra underclothing. Handling Teasing and Name Calling Depending on your child’s comfort level.380 Cognitive-Behavior Therapy for Children and Adolescents • Praise small steps of independence in your child. This is especially important. Even a shrug and an “I don’t know” can stop questions. • Speak to the coach or activity supervisor about modifications that could be made to facilitate your child’s participation (e. Handling Curiosity and Questions About the Illness • Again. or “Yeah. bathroom breaks in art class or music lessons). matter-of-fact statements like “That’s because I have to take strong medication. Reintegration Into Extracurricular Activities • Although prolonged high-dose steroid therapy may make contact sports such as football or wrestling ill-advised (ask your doctor). • Visit the nurse’s office when necessary. fewer laps if easily fatigued in basketball. a good strategy is often a nonchalant response such as those given above.g. so I can come back to school”. Encourage Your Child to Find Practical Ways of Dealing With the Illness at School • Learn where the nearest bathrooms are. • Let your child know that he or she can make casual responses without going into too much detail.. I was feeling sick. for example.” • If questions are about medication side effects (such as a puffy face). ignoring is best. it is up to your child to determine whether he or she will tell classmates about the illness. • Encourage participation in fun activities with your child’s friends. your child should be able to do anything he or she feels like doing. If that is unsuccessful. “I was sick and in the hospital. Initiating a Preventive Plan Before Illness • It may be helpful to begin creating a plan before a disease flare-up so that a system for your child to stay connected academically is already in place. because teens with physical illness can miss out on social opportunities due to sickness. and statistics about how these students integrate back into school or college in the future. the side effects of some IBD medications (e. • With the lost socialization opportunity of school contact with peers. as they are very sensitive to changes in body shape and size. Many adolescents make statements such as “That will never happen to me” or “I could never get that.g. Having a chronic illness is stigmatizing. It is also important to keep in mind that some inflammatory bowel disease (IBD) medications have cosmetic side effects.. . severe immune suppression). and taking medications in front of peers may be embarrassing for adolescents. • Make sure to research computer-based school programs you are considering.. academic rigor. Understanding How Physical Illness Issues May Influence Compliance As noted above.g. irritability. It is important to set firm yet empathic limits. Creating a Consistent Behavioral Plan With Input From Your Teenager • Consider the level of parental supervision needed to keep your child medically compliant. it is essential for children and adolescents who are homeschooled to have other social opportunities with peers. • Peer issues play an important part in medical compliance.Appendix 10–C: Parent Information Worksheets 381 • Familiarize yourself with the necessary contact persons and the school’s policies regarding absences. What About Homeschooling? • Consult with the medical team if there is any medically necessary reason for the child to be homeschooled (e. making them particularly undesirable for teenagers.” The ideas adolescents have about being invincible may contribute to medical noncompliance. for credentials. • Adolescent omnipotence: the belief in invulnerability to harm. Improving Medical Compliance of Your Teenager or Child Understanding How Developmental Factors Can Influence Compliance • Physical illness can interfere with adolescents’ ability to separate from their parents and create their own identity because they are more dependent on caretakers. puffiness) may keep adolescents from complying with their course of treatment. weight gain. • Although it is important to reinforce compliant behavior. the K stands for “Keep trying—don’t give up. Below are some helpful hints for improving medical compliance. . Recording symptoms in a journal and dating each entry may help your child remember exactly how he or she was feeling when the doctor asks. You can use this as an example or come up with a new system that would work better for your family. • Keep track of symptoms and report them rapidly to your child’s doctor. It is crucial that you and your child feel supported and respected by the treatment team. think about ways to improve it and keep trying until it works. phone calls). If this is not true for your family. Also. like brushing his or her teeth or eating meals. it is also important to discuss ways in which medical noncompliance can be addressed. let the doctor know about any medical compliance issues and/or side effects your child may be experiencing from his or her IBD medications. 1. 3. 2.382 Cognitive-Behavior Therapy for Children and Adolescents • Try setting up a reward system with your child to reinforce medical compliance. Improving Communication With the Medical Team • Always feel comfortable discussing any treatment concerns or communication issues with your doctor. For example.g. Keep a medication calendar. • To make it easier for your child to remember his or her medications. use home-based visual cues or reminders (e.” Apply this to the various plans you and your child come up with to improve medical compliance.. You may remember creating a similar plan to reward your child for completing his or her practice assignments. please discuss this with your doctor and therapist. Have your child take medications at the same time as another activity he or she does every day. Have your child take medications at the same times every day. Pillboxes are great investments. You and your child may want to think about certain privileges that can be taken away if medications or medical appointments are missed. If one system doesn’t work. In addition. organize all medications so that it is easy to figure out when each medication should be taken. • Use ACT and THINK coping skills to improve medical compliance. 2006). The myriad health risks associated with childhood and adolescent obesity include cardiovascular complications. 383 . has been shown to track into adulthood (Fuentes et al. Ph. S This chapter has a video case example on the DVD (“Polycystic Ovary Syndrome”) demonstrating CBT for a depressed adolescent with obesity. approximately 17% of children and adolescents are obese. Centers for Disease Control and Prevention data. insulin resistance. M. Jennifer E. Obesity. 2003. M. Supported by grants K12HD-043441. 2001. K23HD-HD061598. 1999).S.D. ACCORDING to U. Freedman et al. Ronette Blake.S. and chronic inflammation (Ford et al. Phillips. with significant medical sequelae into adulthood (Ogden et al.11 Obesity and Depression A Focus on Polycystic Ovary Syndrome Dana L. along with cardiovascular disease.S. Rofey. Furthermore. Azziz and Kashar-Miller 2000. but typically includes insulin resistance and inflammation (Apter et al. two theories exist: 1) hypothalamic/pituitary dysregulation of luteinizing hormone and follicle-stimulating hormone leads to increased ovarian androgen production. Polycystic Ovary Syndrome as a Model Physical Illness Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age. 2002). Knochenhauer et al. 2003). and guardians (Davison and Birch 2004).384 Cognitive-Behavior Therapy for Children and Adolescents Hemmingsson and Lundberg 2005. Hollinrake et . Wardle and Cooke 2005). Morin-Papunen et al. 2006). Lewy et al. The majority of adolescents with PCOS are overweight or obese. excess production of male hormones by the ovaries). Latner and Stunkard 2003. In contrast to the well-established physical health consequences. 2004. NeumarkSztainer et al.. for example. Thus. and 3) exclusion of other known disorders (Azziz et al. 2002). symptoms of depression have been found to be common comorbidities of the PCOS diagnosis (Elsenbruch et al. irregular ovulation.e. Although the exact etiology of PCOS is unknown. and obesity might play a significant role in the pathophysiology of associated physical symptoms. However. Neumark-Sztainer et al. It is well known that obesity influences the phenotypic expression of PCOS. Obesity appears to be closely associated with PCOS. the psychological correlates of obesity in childhood are less clear (Friedman and Brownell 1995. The spectrum of metabolic abnormalities for adolescents with PCOS is complicated. obese patients with PCOS have more severe cardiometabolic risk factors compared to their lean counterparts (Yildiz et al. Himelein and Thatcher 2006. more than half of the patients with PCOS are either overweight or obese. 2010). Palmert et al. a diagnosis of PCOS requires the following: 1) clinical or biochemical evidence of hyperandrogenism (i. 1998). and 2) hyperandrogenism occurs secondary to insulin resistance. 2008). 1995. the negative impact of obesity-related stigma may have lasting effects on emotional well-being (Phillips et al. 1999). 2003. 2001. 2003. Magarey et al. in the United States. Legro 2002. teachers (Bauer et al. According to criteria resulting from an expert conference sponsored by the National Institutes of Health in April 1990. 2) infrequent. growing evidence suggests that obese youth often exhibit depressive symptoms and are often the targets of bias by peers (Kraig and Keel 2001. similar to long-term physical consequences. and rates have been exponentially increasing at 5%–10% prevalence each year (Arslanian and Witchel 2002. Moreover. To our knowledge. a growing body of evidence indicates damaging psychosocial consequences of severe overweight (BMI percentile ≥85). 2007. Psychological Correlates of Pediatric Obesity In addition to the adverse physical health effects of pediatric obesity (BMI percentile ≥95). being the target of rumors. 2003). To date. Pierce and Wardle 1997). 2003). 2004). Preliminary findings reveal 1) testosterone levels that are slightly elevated and significantly related to depression after controlling for weight (Weiner et al. Obese children are rejected more often by peers and are more likely to be socially isolated than their nonoverweight counterparts (Pearce et al. Healthy Minds—a manualized CBT intervention created to address concomitant obesity and depression in female adolescents with PCOS. only two studies have carefully explored the relationship among laboratory values. and 2) higher body mass index (BMI) and insulin resistance in depressed women (Rasgon et al. 2002. 2003. These include weight-based teasing (Eisenberg et al. Teasing and Social Rejection Weight-based teasing encountered by obese youth may take several forms. and being ignored. In this chapter. and provide an overview of the theory and application of Healthy Bodies. . or otherwise socially excluded. and depression and anxiety (Goodman and Whitaker 2002).Obesity and Depression 385 al. data that have been collected from 2008 through 20011 reveal a rate of depression in adolescents with PCOS with rates of approximately 50% (n=119) in a treatment-seeking sample. depression. 2004). body dissatisfaction and low self-esteem (Eisenberg et al. provide empirical evidence for cognitive-behavior therapy (CBT) to treat obesity. Therefore. and weight in adult women with PCOS. we review the psychological consequences associated with childhood obesity. Strauss and Pollack 2003). avoided. The intriguing aspect of the relationship between obesity and depression is that it is biochemical in nature. Weiner et al. adolescents with PCOS present as an ideal treatment-seeking pediatric population given the high comorbidity of obesity and depression. social isolation and discrimination (Latner and Stunkard 2003). More recent data reveal an alarming trend that may involve physical bullying as well (see review by Puhl and Latner [2007]). Rasgon et al. 2003. including verbal remarks such as name calling. However. the relationship between self-esteem and obesity appears to be stronger when obese children are compared with their nonobese peers. along with parental weight criticism. 2004. although comprehensive reviews of self-esteem and obesity reveal this relationship to be modest (French et al. Prospective studies examining the development of low self-esteem and obesity generally show that excess weight in children predicts future low self-esteem (Brown et al. particularly girls. 1998. body dissatisfaction may have a negative impact on self-esteem in obese children. 2002. 2004) data also demonstrate that body mass is inversely related to self-esteem in children. Further. Hesketh et al. Prospective data demonstrate that weight-based peer teasing. exhibit greater body dissatisfaction than their normal-weight peers (Ricciardelli and McCabe 2001. 1995. weight-related teasing has been shown to account for associations between weight and body dissatisfaction in youth (Lunner et al. van den Berg et al. mediates the relationship between overweight and low self-concept in obese adolescents (Davison and Birch 2002). 1996) and clinical (Zeller et al. 1997) rather than global self-esteem. 2003). 1994). as a retrospective study of adults reported an association between childhood weight-based teasing and adulthood body dissatisfaction (Grilo et al. Further. Anxiety and Depression To date. This result appears to extend into adulthood. 2000. Tiggemann 2005). Wardle and Cooke 2005). Wardle and Cooke 2005). Some studies demonstrate no significant differences for anxiety symptoms between overweight and . Low Self-Esteem The internalization of weight-based discrimination may have negative implications for self-esteem in obese youth. More recent data document a mediation effect for body dissatisfaction in the association between obesity and self-esteem in a sample of elementary school children (Shin and Shin 2008). Davison and Birch 2001. Weight-based teasing has been associated with poorer self-esteem and an increased likelihood of depression among adolescents (Eisenberg et al. Strauss 2000. 2002). the evidence supporting an association between anxiety-related disorders and pediatric obesity is inconclusive.386 Cognitive-Behavior Therapy for Children and Adolescents Body Dissatisfaction Reviews conclude that obese children. Epidemiological (French et al. specifically on measures of physical self-perception (Braet et al. Lewinsohn et al. In contrast. 2000). which replicates previous work in obese samples (Goodman and Whitaker 2002). 2003. in treatment-seeking clinical samples. Franko et al. obese children appear to display higher levels of depression than normal-weight controls (Britz et al. (1997) noted a positive predictive relationship between depressive symptoms at age 14 and both BMI and obesity at age 22. 2006). Rofey et al. no clear association between child psychopathology and obesity has been established. More recently. an empirically validated intervention to target both weight and mood is warranted. Research generally shows that community-based samples of obese children do not differ in levels of depression compared to averageweight peers (Brewis 2003. Regardless of the causal relationship. Pine et al. recent studies have investigated whether depression experienced in childhood affects obesity in young adulthood. 2009a). An extensive literature spanning several decades has addressed the importance of the relationship between weight and mood. Thus. Because mood disturbances commonly occur during childhood (Dahl and Spear 2004. Erermis et al. more research is needed. Buddeburg-Fisher et al. 2005). 1997. particularly regarding the elucidation of any directional relationships. Two prospective studies did not show that obesity predicted depression in adolescent girls (Stice and Bearman 2001. (2005) extended these data and traced depressive symptoms at ages 16 and 18 to an increased risk of obesity in adulthood. specifically depression (Faith et al. 2002). 2006. 2004). other evidence indicates that it is childhood depression that predicts the development of obesity in both children (Goodman and Whitaker 2002) and adults (Anderson et al. 2000. (2009a) found that depression and anxiety (in girls) and anxiety (in boys) predict BMI percentile over time in a nonobese sample.Obesity and Depression 387 normal-weight children (Tanofsky-Kraff et al. Rofey et al. 1993). . Evidence of a relationship between obesity and depression in children is also mixed. Stice et al. However. given the high rate of obese children presenting with depression. 2000. 2003. 2004) and adolescents (Lamertz et al. Wardle et al. 2009a). Richardson et al. In contrast. 1999). As for cause-and-effect relationships. Eisenberg et al. yet the possible long-term negative sequelae of these disorders reinforce the need for future research. A more recent longitudinal investigation of childhood psychopathology and body mass in youth ages 8–18 years showed a significant increase in anxiety for obese boys as compared to control subjects (Rofey et al. whereas research among boys demonstrates a modest relationship between chronic obesity and higher levels of depression over time (Mustillo et al. 2002. obese adolescents participating in an inpatient weight-loss program reported higher lifetime prevalence of anxiety disorders as compared with nonobese control subjects (Britz et al. 2003). Franko et al. nutrition and lifestyle) (Miller and Silverstein 2007). long-term improvements in psychological factors (e. and eating behaviors. 1984.g. more assertiveness.388 Cognitive-Behavior Therapy for Children and Adolescents An efficacious (and effective) intervention is crucial given the long-standing relationship between these two variables and the high likelihood that patients present with constellations of both obesity and depressive symptoms. a number of strategies have been shown to help prevent or reduce childhood obesity. Epstein et al. although likely due to a combination of factors. 1988). Epstein et al. Renjilian et al. has been largely attributed to the influence of environmental factors (i. In addition. and greater need sharing. 1990. 1983. depression) have been noted in children who have completed weight-loss programs (e. CBT helps patients gain insight into the connections among their thought processes. 1984. 1985. (See Chapter 5 for empirically supported treatments for childhood depression. the goal of CBT is to assist youth in reducing self-defeating thoughts around wellness behaviors. Similarly. Rocchini et al.) Empirical Research in Behavioral Treatments for Pediatric Obesity Fortunately. Katch et al. 2001) contributes significantly to pediatric weight-loss efforts. In pediatric obesity..e. Levine et al. 1988. It is important to assist the patient in identifying more adaptive coping strategies..g. including cognitive distortions re- . CBT strategies attempt to address issues that may have been overlooked in early behavioral programs. 1995. findings suggest that the involvement of both children and parents in treatment (Brownell et al. When applied in this context. emotional responses. Epstein et al. and research demonstrates the positive health impacts of weight-loss interventions for pediatric populations (Becque et al. 1988. empirically supported treatments for pediatric obesity typically include nutritional education (Emes et al. Rocchini et al. Kingsley and Shapiro 1977. 1995). The increased prevalence of childhood obesity. and evidence indicates that some combination of caloric restriction and exercise education has a greater impact on weight loss than one isolated component (Epstein et al. 1988). 2001). CBT One of the most empirically validated modalities for psychosocial aspects of obesity is CBT. 1985) and the promotion of increased physical activity (Epstein and Goldfield 1999. such as less emotional eating. Thus.. pharmacotherapy. problemsolving techniques.g. Motivational interviewing techniques aimed toward enhancing adherence to dietary and exercise recommendations in children and families could play a key role in promoting safe and effective long-term weight management. the inclusion of cognitive treatment components in laboratory-based investigations of childhood and adult weight loss has shown favorable results (Brownell et al. and motivational issues. Duffy and Spence (1993) randomly assigned 27 overweight children (ages 7–13 years) to eight sessions of either behavioral management or combined behavioral-cognitive treatment. Coates and Thoresen 1981. strategies (e. it appears that the two approaches to pediatric weight loss may be equally valuable. Williams et al. although additional research is needed to establish whether differences in outcome may exist between behavioral treatment and cognitively based strategies. One early cognitive-behavioral treatment program for children ages 9–13 years involved a 9-week program that included dietary and activity self-monitoring. Similar to behavioral programs. 2004).” motivational interviewing seeks to resolve ambivalence and strengthen clients’ reasons for engaging in positive behavior change consistent with their goals and values (Miller and Rollnick 1991). and both groups of children demonstrated significant improvements in weight at 6. cognitive strategies for managing negative self-statements. 2004). instruction in self-monitoring.. Motivational interviewing is a therapeutic strategy aimed at helping individuals to explore ambivalence about making behavioral changes and has been suggested as a possible tool for helping achieve dietary and physical activity modifications (DiLillo et al. bariatric surgery) (Miller and Silverstein 2007). 1984). No differences between treatment groups were noted.and 9-month follow-up. Thus. and specific weight-loss goals and barriers to healthy behavior. compliance issues often lead the families of obese children and adolescents to seek alternative. 1993). cognitive components are typically used in conjunction with dietary and physical activity education. Although some evidence suggests that a behavioral approach to pediatric obesity may be superior to cognitive strategies (Herrera et al. Motivational Interviewing Although CBT is considered to be the safest modality for weight loss in youth. Senediak and Spence 1985. 1983. though riskier.Obesity and Depression 389 garding body image and eating. Children in the cognitive treatment group lost significantly more weight than control subjects and retained their weight loss at 3-month follow-up. and assertiveness training (Kirschenbaum et al. Using reflective listening and methods to elicit “change talk. . insufficient data exist to determine the efficacy of motivational interviewing for the prevention or treatment of pediatric obesity in children (Resnicow et al. and improving weight status in adults. both 6-month and 1-year follow-up assessments indicated no significant BMI differences between the motivational interviewing group and control subjects. To date. 2005). In one of the treatment conditions. this study demonstrated the feasibility of implementing a physician office–based obesity prevention program using motivational interviewing. Dunn et al. patients in the minimal intervention and intensive intervention groups showed a trend of decreasing BMI-for-age percentiles. Unfortunately. only two pediatric weight-loss interventions have employed motivational interviewing techniques. 2006). At 6-month follow-up. was aimed at the prevention of overweight among children ages 3–7 years (Schwartz et al. Some data suggest that motivational interviewing assists in promoting more healthful eating habits. Go Girls was a church-based nutrition and physical activity program designed for overweight African American adolescent females. girls received four to six motivational interviewing telephone counseling calls focused on participants’ progress. Patients in the control group received usual care. but these findings are not consistent (Berg-Smith et al. whereas those in the minimal intervention group received one motivational interviewing session and those in the intensive intervention group received two motivational interviewing sessions during office visits.390 Cognitive-Behavior Therapy for Children and Adolescents Research on motivational interviewing for the treatment of obesity in pediatric populations is limited. although results were not statistically significant. Decreases in families’ eating-out behavior and high-calorie snacking were also noted. although children’s weight changes failed to reach significance. Smith et al. 2007). 2007) and Go Girls (Resnicow et al. conducted from 2004 to 2005. at present. yet promising. Thus. little research has been done in the area of motivational interviewing and pediatric weight loss. Several techniques are broad-based CBT concepts that may overlap with tech- . Key CBT Techniques Targeting Pediatric Obesity A variety of CBT techniques are used to target obesity (see Chapter 5 for how some of these same techniques assist with depression in children). Thus. 1999. Pediatric Research in Office Settings clinicians were trained to provide motivational interviewing to patients during office visits. increasing physical activity. 2001. and these are the Healthy Lifestyles Pilot Study (Schwartz et al. The Healthy Lifestyles Pilot Study. 1997). Thus far. relationship to mood) and physical activity (type. . In a CBT obesity treatment. Goal Setting Setting goals is important for achieving success and overcoming challenges. duration.g. calories.e. linked by the fact that cognitive change is the primary aim of CBT. For obese patients. is the most important skill taught in standard behavioral programs. and general lifestyle (i. see “Suggested Readings and Web Sites” at the end of this chapter for sources). Being able to accurately measure caloric intake and energy expenditure assists patients and their families in reaching weight-loss goals.. Physical activity refers to any movement that occurs throughout the course of the day. (Note that some data also support the efficacy of pharmacological and surgical interventions in the treatment of the most severe cases of pediatric obesity. setting weekly reasonable goals for nutrition. Therefore.Obesity and Depression 391 niques presented in other chapters throughout this book.5–1 pound per week. and Blood Institute and The Obesity Society recommend low caloric intake that is intended to induce a caloric deficit greater than 500 kcal/day and thus assist children in losing approximately 0. specific guidelines are given for girls trying to lose excess body weight. or recording food intake (time. a certain percentage of calories should come from protein versus carbohydrates). positive thinking) is a major component. physical activity. small. manageable changes typically lead to an increased heart rate and subsequent weight loss. Lung. steps taken). Self-Monitoring Self-monitoring. amount. Behavioral Facets Dietary Guidelines The National Heart. Moreover.. with consideration given to medical factors (e. Physical Activity The American College of Sports Medicine recommends 60 minutes per day of physical activity for children. physical activity during a CBT obesity treatment should focus on activities targeted to the abilities of obese patients. These key ingredients can be broken down into behavioral and cognitive facets. problem solving is encouraged by identifying what the problem is. generating different solutions. Relaxation Training Diaphragmatic breathing. the essence of stimulus control in pediatric obesity consists of removing the high-risk foods from the home. manageable aspects of behavioral activation are discussed (e. more consistent and variable physical activity.392 Cognitive-Behavior Therapy for Children and Adolescents Stimulus Control and Family Involvement Family-based involvement is a key CBT component in managing the participant’s environment. In the intervention. Family members are educated about the relationship between obesity and depression.” we discuss the concept that everyone in the family can benefit from healthy lifestyle changes. and guided imagery are also taught during the intervention. . As more data show that aberrant eating patterns may be due to emotionally stimulating events. Because CBT encourages practice between sessions. putting tennis shoes on as a first step to being more active). progressive muscle relaxation. as well as ways to help the participant engage in a healthier lifestyle. Cognitive Skills Problem Solving This lifestyle skill is emphasized to address healthier food intake. especially surrounding food intake and energy expenditure. 1995).g. patients may be assigned “experiments” or to set their own goals. Moreover. Behavioral Activation The participant is reminded to increase time spent in pleasurable activities on a daily basis. small. Research on adolescent obesity treatment indicates that family involvement is crucial for maximized success (Epstein et al. to help the participant cope with stressful situations.. relaxation training becomes an even more salient component of obesity treatment. and roadblocks to positive thinking. Given that some family members may feel as though “this is not fair. Given the nature of obesity. Homework and Between-Session Assignments Patients are encouraged to set their own goals. and evaluating the consequences of each solution. showed favorable initial results in a pilot trial (Rofey et al. By the end of the intervention. introducing a healthy plate that incorporates a starch. In addition.Obesity and Depression 393 Cognitive Restructuring When using this critical component of CBT for obesity. Healthy Bodies. the coach (i. participants should be able to provide countering alternatives to minimize stressors and maladaptive thinking surrounding the presenting problem.g. Further. The resulting intervention. countering ways to reduce negative thinking. 2009b). we incorporated depressive targets from the manual for Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI. increasing pedometer steps per day). 1995). and dietary changes (Epstein et al. 2001)—promotes greater decreases in percentage overweight in children. Szigethy et al. along with motivational interviewing concepts to elicit intrinsic motivation while decreasing resistant behaviors (Table 11–1 shows key components of Epstein’s program that have been integrated into HBHM). Healthy Minds: A Manualized Intervention Leonard Epstein and colleagues have shown that family-based lifestyle change—including the incorporation of exercise into daily living (Epstein et al. Healthy Minds (HBHM). Relapse Prevention This skill is used to help reinforce the CBT model and monitor for recurrence of weight gain and/or depression and to prepare for future stressors.. following a <5 g fat/>2 g fiber/<10 g sugar guideline. protein. 2007. we have expanded on Epstein’s family-based weight management program (the Traffic Light Diet. decreasing sedentary behaviors (Epstein et al. 2008). HBHM. which has recently been extended to recruit adolescents with PCOS and depression. 2009. see Chapter 10 for discussion of this model) to target depressive symptoms in these physically ill adolescents. In the creation of Healthy Bodies.e. . and fruit or vegetable with appropriate portions for each meal.. therapist) encourages the participant to identify dysfunctional thinking and identify more adaptive. who are then randomly assigned to the HBHM manualized treatment versus treatment as usual. Epstein and Squires 1988) to incorporate more client-centered tools for adolescents with PCOS (e. the distinction between lapses (“slip-ups”) and relapses is discussed with the patient to prevent lapses from becoming relapses. 1985. decreasing depressive symptomatology) can have on the participant. The PASCET model has been repeatedly validated in youth with obesity and depression and in youth with depression and physical illness (see Chapter 10 for extensive empirical evidence of this treatment). Two trials have been conducted testing this specific.e. 1984.” The reasoning behind this term is not to undermine the utility of mental health counseling but instead to increase intrinsic motivation. After the content is reviewed. there is an attempt to reduce stigma and increase compliance by emphasizing the health focus and decreasing pathologizing the patient. an open trial (Rofey et al. 1981. Moreover.. 2009b) was conducted to evaluate the . 2008). Following the intensive portion of the intervention. resistance training.. because many adolescents with PCOS have failed therapy on numerous occasions. in which the participant meets on a weekly or biweekly basis with her coach. 2001. and secondarily. Each session begins with the behavior coach going over the manualized treatment (i. family involvement is strongly encouraged as data show this to be one of the best predictors of obesity management and depression treatment. increasing physical activity.. Empirical Research and Results In HBHM. cardio) and depending on her level of existent physical movement. video. Weisz et al.g. The type of physical activity is provided on the basis of the participant’s interest (e. combined treatment. 2000. 2009) were adapted to treat depression in a physically ill sample.394 Cognitive-Behavior Therapy for Children and Adolescents HBHM uses CBT and motivational interviewing to educate and motivate PCOS patients to make lifestyle changes through eight intensive oneon-one sessions with a behavior coach. 1995.g.e. walking. The therapist is typically referred to as a coach. and aspects of Epstein’s family-based pediatric weight management program (the Traffic Light Diet) and additional motivational interviewing–compliant goal setting were used to target improving nutrition. treatment continues with three booster sessions. the coach or an exercise physiologist completes 15–20 minutes of physical activity with the patient. Epstein et al. 2007. First. see Epstein and Goldfield 1999.. facets of PASCET (Szigethy et al. and decreasing sedentary behavior. in which the participant meets monthly with the coach to check in on her progress. An emphasis is placed on healthy lifestyle goals. several focus groups were conducted that indicated the participant’s desire to “avoid psychotherapy. on the impact that positive thinking (i. During the entire intervention. the content of each session) for approximately 45 minutes. Epstein’s weight management program has been empirically validated since the 1980s and in more than 25 randomized controlled trials (e. GREEN foods)... Stimulus control Getting high-fat. This open trial revealed that a manual-based CBT approach to treat depression in adolescents with PCOS and obesity appears to be promising. Twelve adolescents with PCOS. RED foods). playing soccer). walking) and purposeful exercise (e. YELLOW foods). a physical illness narrative (meaning of having PCOS). 395 Key components of the Traffic Light Dieta incorporated into Healthy Bodies.. Healthy Minds Component Description Self-monitoring Writing down food intake and steps taken in an effort to heighten selfawareness. Decreasing sedentary time and increasing physical movement a Epstein Limiting screen time per night (excluding schoolwork) and assisting the child to identify fun ways to move that incorporate everyday lifestyle activities (e.e.e. feasibility and effectiveness of an enhanced CBT.g.. and Squires 1988. HBHM. for physical (obesity) and emotional (depression) disturbances in adolescents with PCOS. Changes to enhance the weight management portion of the current HBHM manual include the following: more nutritional compo- .e. Family-based components Having a supportive person who assists the child in weight-loss endeavors and serves as a model or coach. Subsequently.g. Depressive symptoms on the Children’s Depression Inventory (CDI) significantly decreased.Obesity and Depression TABLE 11–1. a comparative treatment trial has been under way for approximately 2 years. Traffic Light Guide (caloric restriction) Focusing on increasing foods with < 2 g of fat (i.6 (SD±2). and family psychoeducation (family functioning). and depression underwent eight weekly sessions and three family-based sessions of CBT enhanced by lifestyle goals (nutrition and exercise). high-calorie foods out of the house to decrease temptation. and decreasing foods with >5 g of fat (i. obesity. moderating foods with 2–5 g of fat (i.. from an average of 104 kg (SD±26) to an average of 93 kg (SD±18). Weight showed a significant decrease across the eight sessions. from a mean of 17 (SD±3) to a mean of 9. This 11-session “dose” is an initial active-phase treatment for adolescents with obesity and co-occurring mood disturbance presenting within a clinical setting.10). Treatment Overview Table 11–2 provides an overview of the behaviors targeted in HBHM.24) at session 1 to 7.82 kg (SD=25. with an end goal of a randomized controlled trial that incorporates other sites across the country to recruit the number of adolescents with PCOS needed to exhibit findings that can be generalized. and a decreased score on the CDI.2 kg [SD=23. on average.63 kg (SD=21.45) at session 11. 4 biweekly sessions. and 3 monthly booster sessions.396 Cognitive-Behavior Therapy for Children and Adolescents nents addressing eating healthy with PCOS.. However. standard endocrine management of PCOS) has not been completed. and incorporation of more motivational interviewing. Family-Based Sessions Incorporating the family into the treatment plan is crucial for success. A similar trend was seen between session 1 and session 11 (the last booster session).e. from an average score of 12. with weight significantly decreasing. Additionally.11 (SD=6. an 11-session intervention is implemented. parents and other family members dictate what food choices the adolescent has at home. more intensive HBHM treatments may be more efficacious. data from 39 participants with PCOS who received treatment as usual showed that they gained approximately 2 pounds (starting weight = 99. 63 participants will have received HBHM and approximately 50 participants will have received treatment as usual. Fifty participants (thus far) have participated in this comparative treatment trial. 50 patients receiving HBHM have experienced significant decreases in weight.85 (SD=8.6]) over the same time frame as young women receiving HBHM. By the end of the trial.10 kg (SD=26. Although recruitment for the treatmentas-usual group (i.05 (SD=8.6] and posttreatment weight = 101. the lifestyle habits of adolescents tend .30 kg (SD=23. approximately 2 pounds. Because 8–12 sessions have been empirically validated for adolescents with major depression and 4–12 sessions have been associated with significant initial weight loss for adolescents presenting to outpatient obesity centers. Currently.8 kg [SD = 20.92). Often. the acknowledgment needs to be made that longer. from an average of 105.94) to an average of 104. and decreased CDI scores.36 (SD=6. from a mean of 13.42) to an average of 99.48) to a mean of 10. from an average of 103. who lost.20). These data will continue to be collected. extension of treatment from 8 sessions to 11 sessions through a combination of 4 weekly sessions. During this session.Obesity and Depression TABLE 11–2. (For clarity in further discussion. special occasions. being active. and psychological versus physiological hunger 4 Using the Traffic Light Guide and other self-selected tools to increase health and wellness 5 Staying motivated.. “coach” will refer to the therapist or behavior coach. and avoiding food traps 3 Managing emotions. and staying positive 8 Overcoming barriers. and not to the parent as coach. targeting and working with parents is important. eating meals as a family). Healthy Minds Session Behaviors 1 Overview of the program. Healthy Minds plan 3 Reflecting on the intervention a Subsequent to eight sessions above. developing a healthy body image and self-esteem 7 Being more self-aware with regard to eating. Additionally. HBHM strives to motivate parents to make changes to the home environment and to serve as coaches for their child. increasing physical activity. the behavior coach discusses ways that the parents can create this environment through their grocery store purchases and cooking habits (e. therefore. everyday lifestyle movement. unless otherwise indicated.) The first parent session focuses on creating a home environment that encourages healthy eating habits. description of healthy eating and physical activity.g. parents are encouraged to create an eating environment that encourages healthy food consumption habits (e.g. and difference between dieting and lifestyle change 2 Logging food and movement. and decreasing sedentary behavior 6 Changing self-talk to be more positive. and eating out Monthly booster sessionsa 1 Coping with polycystic ovary syndrome 2 Adjusting to the Healthy Bodies.. reading food labels. avoiding sneak eating. to be heavily influenced by parents’ habits. baking instead of frying foods). planning ahead for healthy meals. Through three parent sessions. . 397 Overview of behaviors targeted by session in Healthy Bodies. working with change and adherence talk. the coach guides and encourages parents to use positive reinforcement (such as praise) by describing the utility of this strategy. The second parent session focuses on parenting strategies that the parent can use to encourage healthy behaviors and discourage less healthy habits. The coach will discuss the difference between reinforcement and punishment. describing in detail the difference between positive reinforcement (giving something to encourage a behavior) and negative reinforcement (taking something away to discourage a behavior). seeking elaboration on important or unclear points. 2006). Asking open-ended questions. the behavior coach describes all of the tools that the participant has been educated to use so that parents can encourage use within the home environment. use of open-ended questions. values. motivational interviewing techniques elicit health behavior change by enhancing intrinsic motivation (Resnicow et al. Here. complete with calorie charts from many restaurants. attend. Motivational Interviewing Components While CBT serves as the empirically validated therapeutic approach in HBHM and teaches adolescents how to reduce their physical and emotional disturbances. and ideas about what is healthy or adaptive. preferences. and identifying and affirming strengths are common themes throughout the HBHM intervention. HBHM draws on motivational interviewing components to enhance the likelihood that adolescents with PCOS who are struggling with weight and mood disturbances will enter. and supporting the patients’ selfefficacy. Motivational interviewing emphasizes the potential for participants’ own goals. In this modified therapy.398 Cognitive-Behavior Therapy for Children and Adolescents Many parents cannot easily cook every meal at home due to time constraints. CBT and motivational interviewing serve as complementary approaches. The coach also provides brief assertiveness training and techniques for setting limits and rules within the home. An engagement session that transpires at the first meeting with each participant uses the key principles of motivational interviewing (Miller and Rollnick 2002): suspension of the clinician’s assumptions. encouraging the patient to tell her own story. The third parent session focuses on preparing parents to serve as coaches at home by providing an overview of the content that the behavior coach has covered with the participant during the intervention. and participate actively in the CBT protocol. During this session. The work of motivational interviewing is to place the patient’s personal perspective at the center of the discussion and not to have the be- . rolling with patients’ resistance. expression of empathy and reflective listening. so the coach also addresses ways that parents can encourage healthy food choices when dining out. the clinician does take on an expert role. Although these values and beliefs cannot (and should not) be eliminated. At specific points during the interview. although the coach may have significant experience reading about therapeutic intervention strategies. Just as in CBT. but the clinician either defers to the patient’s expertise on her own life or offers his or her own views as alternatives for the patient to consider if the patient is willing to do so. Unlike closed questions. given that clinicians can never be certain that their understanding is correct. open-ended questions cannot be answered with a “yes” or “no” and do not pull for specific information. clinicians do not make interpretations of the patient’s hidden motives or of the presumptive causes of the patient’s behavior. where health is of utmost concern. the coach must work to suspend them during the encounter with the patient. Affirmation—or expression of . The clinician expresses empathy through the technique of reflective listening. the patient should talk for two-thirds of each session. Most coaches inevitably bring a set of values and beliefs about what constitutes healthy or adaptive behaviors. accepting. These statements are made with humility. rather. nonjudgmental manner. the patient is the only expert on her own life. feelings.Obesity and Depression 399 havior coach express his or her own desires (i. Empathy is defined as an accurate understanding of the patient’s communications and experience. even at these moments. however. they draw the patient out and encourage her to express her thoughts. as if from inside the patient’s world. but is a supportive advocate for the patient’s well-being. especially in the case of pediatric obesity. The coach employs open-ended questions throughout HBHM.. Affirmations. Moreover. and presented in a warm. in general. the coach does not insist on his or her own perspective in the face of patient resistance. Although clinicians may go beyond the explicit statements the patient makes and convey their understanding of the underlying meanings or feelings that the patient is expressing. Suspension of behavior coach’s biases. Open-ended questions can be used both to gently guide the direction of the session and to encourage the patient to elaborate on something the clinician believes is important. and concerns. There will be times when the clinician will be talking more. However. meanings. Open-ended questions. Empathy and interpretations using reflections. in which the patient’s words.e. for the coach to avoid the impulse of “righting the wrong”). and/or feelings are communicated back to the patient in the form of a statement. providing psychoeducation about depression and overweight and about the nature of CBT. the clinician is not neutral. 400 Cognitive-Behavior Therapy for Children and Adolescents sincere appreciation by the clinician of the patient’s efforts and strengths in coping with life challenges or the patient’s participation in the treatment process—is an effective way of communicating this support. Summarizing. Bringing together several of the patient’s previously expressed thoughts, feelings, or concerns, often including the coach’s understanding of how these fit together, has several important functions. Summarizing can help the coach ensure correct understanding of the patient’s situation, help the patient see connections between things she has been saying (linking summaries), and prepare the way for the coach to shift focus or move on to the next part of the session (transitional summaries). Patients are almost always more willing to follow the coach once they feel confident that their own agenda has been understood. Working with resistance talk. Patients are expected to be ambivalent about whether they are really depressed, need to lose weight, or want to be working more intensively with a coach. From this perspective, resistance simply reflects the negative side of ambivalence, and rather than challenging or confronting it, the clinician seeks to understand and work with it (i.e., rolling with resistance). Techniques for working with resistance include the following: • Working with change and adherence talk: Change talk and adherence talk are the “positive” side of ambivalence—indications that the patient desires to work at overcoming her eating habits, physical activity behavior, or depression. A patient’s change and adherence talk also indicate that she would like to receive help, sees a need for treatment and/or change, has reasons for committing to treatment and/or change, or believes she has the ability to succeed at changing or sustaining a commitment to treatment. • Supporting self-efficacy: Self-efficacy refers to a patient’s beliefs about how likely she is to succeed at something she tries to do. Self-efficacy plays a key role in engaging patients in treatment. No matter how much the patient comes to believe she needs support, a patient who doesn’t believe that she can succeed at treatment is unlikely to try very hard to stick with it. S Case Example Mary, a 16-year-old, overweight, depressed adolescent girl diagnosed with PCOS, was referred by her family doctor. Mary currently lives at home with her parents, who are also overweight, and her older brother, who is athletic and is not overweight. Mary is currently in the eleventh grade and attends a local public high school. Obesity and Depression 401 Mary has been overweight for most of her life, and she currently has a BMI of 32. In addition to struggling with weight-loss issues, most recently, Mary has found herself struggling academically and socially: her grades have plummeted from As and Bs to Cs and Ds, and she is brutally teased by her classmates because of her weight. Mary states that she has stopped doing her homework because she won’t do well on it anyway, and she recently failed a science test. Mary has started to eat her school lunch by herself because she is teased when she eats with classmates. Mary finds herself feeling depressed 4 out of 7 days of the week and often isolates herself during these periods, preferring to spend time alone in her bedroom watching television or sleeping. Mary’s mother states that during these episodes, Mary is irritable and argumentative and usually ends up crying when confronted. Lately, Mary has been truant from school, refusing to attend school at least once a week because she “feels sick.” Mary often finds herself feeling out of control when she is eating, and these bingeing episodes usually occur during her postschool snack. In the past, Mary has tried a national weight loss program, a popular fad diet, and diet pills. She lost weight with all three approaches but gained it all back within a few months. Mary states that she eats fast food weekly and knows that she “shouldn’t” because it is “bad.” Mary is frustrated and believes that she is incapable of losing weight permanently and believes that nothing will ever work, so why should she try? At the beginning of the therapeutic intervention, Mary, a straight talker, quickly admitted that she is not happy to be seeing a counselor and feels that her mother is forcing her to be involved. Mary states that she doesn’t care to be told what to do by someone who doesn’t understand her personal situation. However, by Mary’s second session with her new counselor, she has admitted that she does not dread attending sessions anymore. She has started to consistently complete her in-between session assignments but always prefaces her discussion about them by saying that she’s sure that she “didn’t do it right.” Application Session 1: Introduction to the Program During this session, the behavior coach will introduce the purpose of The PCOS Lifestyle Program. The coach will discuss the definition of lifestyle change and how this differs from a diet. There will be ongoing conversations about all-or-nothing thinking and how it may be more helpful to the patient to engage in behaviors that are sustainable. The concept of weight maintenance, gain, and loss will be elucidated using calorie-in/calorie-out scales with an emphasis on caloric intake and energy expenditure. Also, it may be helpful to discuss the patient’s previous successes or failures, which may serve as building blocks for future goals. The next objective of this session is to discuss the link between PCOS and depression and to assess how the participant is personally affected by 402 Cognitive-Behavior Therapy for Children and Adolescents depression. The coach will help the participant to connect sadness through emotions, thoughts, and behaviors (Appendix 11–A, Worksheet 1). Note that some patients may have depressive symptoms but not depression per se. Coaches should be cognizant of how they phrase “depression” and allow the adolescent to claim or disclaim the symptoms. Assist the adolescent in making a connection between family history, stressful life events, PCOS, and focusing on negative experiences. Following this discussion, a general overview of CBT and how it can help with weight loss and mood is provided. The coach also introduces the general concepts for the ACT and THINK acronyms: that people can control their feelings by 1) how they act and/or 2) how they think (see Chapter 10, Appendix 10–A, for the ACT and THINK chart). The session includes a get-acquainted exercise designed to build rapport, in which the participant talks about three of her strengths. This exercise not only allows the coach to get to know the participant but also serves to emphasize positive thinking over negative self-thoughts. Note that some participants may be so depressed that they cannot think of three strengths. If this happens and the coach has given the participant plenty of silence, the coach should help the patient in order to reduce any discomfort in the first session. For example, the coach can say, “Would it be OK if I shared something with you that I noticed from our work today that I think is one of your strengths?” Additionally, depending on rapport, the coach can then highlight the fact that the participant had difficulty coming up with three strengths. This observation can serve as a building block to emphasize empowering the participant to think positively, both generally and about herself. Following this exercise, the participant sets three specific lifestyle goals to accomplish over the course of the program (Appendix 11–A, Worksheet 2). Note that if the participant sets a specific weightloss goal, direct her to break it down into behaviors that are realistic (not idealistic) and that could lead to weight loss. Toward the end of the session, the coach should also start the weight tracker (Appendix 11–A, Worksheet 3) that will be used at the beginning of each session when the participant gets weighed. Discuss what it feels like for the participant to get weighed. In very rare exceptions, weights are not shared with the participant; otherwise, explain that actual weight is important as a concrete measure of behavioral changes that the participant is making throughout the program. The session concludes with an explanation of the first practice assignments: 1. Having the participant monitor her mood using the Mood Monitoring sheet (Appendix 11–A, Worksheet 4). Obesity and Depression 403 2. Setting goals for the next week (Appendix 11–A, Worksheet 2). 3. Using the ACT and THINK chart before the next session (Chapter 10, Appendix 10–A). Session 2: Eating Well With PCOS There are four main goals for session 2: 1. 2. 3. 4. Discuss lifestyle goals and wellness accomplishments over the past week. Review the ACT and THINK chart. Introduce the PCOS food pyramid. Establish food and activity logging. To begin the session, thermometer ratings are used to gauge the participant’s perception of her current levels of eating healthy, being active, feeling good, and feeling bad (Appendix 11–A, Worksheet 5). Research has shown that in adolescents with depression, feeling “good” and “bad” are actually two distinct facets of emotion. In other words, on separate mood thermometers for feeling good and feeling bad, an adolescent can feel mildly good but still feel really bad (i.e., depressed kids ruminate about bad things but have difficulty savoring good events). After the participant states a number, ask what that number means to her. The coach can also use motivational interviewing to better understand why the number is a 5 and not a 4. The coach will also discuss the worksheet “What It’s Like When I Feel Good” (Appendix 11–A, Worksheet 6) with the participant. At this point, focus on helping the patient to identify that feeling good isn’t just a feeling, but that it makes other people feel a certain way toward her and that it has somatic and behavioral consequences as well. Proper nutrition plays a large role in the management of PCOS, and this session focuses on how to eat healthy with PCOS. For the next several pages of the manual (not provided here), allow the patient to read the information about a healthy diet, if she would like to. We don’t want this activity to get too monotonous, especially if the patient already knows the material. Instead, focus on the fact that even very minimal weight loss has a long-standing impact on health. Also emphasize that the participant is not going on a diet, but instead making lifestyle changes that will become part of her life. The coach then discusses different weight management tools (the PCOS Pyramid, 5/2/10 Guideline, Healthy Plate [Appendix 11–A, Worksheets 7–9, respectively], and the Traffic Light Diet) but encourages the participant to select only those tools that work best for her. This session concludes with a discussion about the role that self-monitoring plays in weight loss with a focus on 1) tracking weight, 2) monitor- 404 Cognitive-Behavior Therapy for Children and Adolescents ing food and physical activity, and 3) making conclusions about the relationship between weight and mood. Lifestyle and mood goals are set for the following week. Session 3: Managing Your Emotions There are five objectives for session 3: 1. 2. 3. 4. 5. Discuss goals and accomplishments over the past week. Review the lifestyle log and how it was to wear the armband.1 Learn about emotional eating versus overeating. Introduce the concept of craving and how to pay attention to hunger. Explore self-talk and common cognitive errors. The coach will start this session by reviewing the concept of emotional eating versus overeating and explore whether these are challenges for the patient. The coach will discuss these concepts by normalizing both types of eating and attempting to elicit intrinsic motivation to identify these situations. The participant may have a lot of shame surrounding these concepts, and at times, her self-disclosure may also be warranted. If nothing is disclosed, the coach can say something like “Other young women with PCOS share with me that after school is their high-risk time. And I guess carbs are the hardest to resist.” The coach will also address how negative thinking can lead to emotional eating by reviewing different cognitive distortions (e.g., “I’ve always failed when I’ve tried to lose weight, so I’ll never be able to”); revealing what negative self-talk (e.g., “I didn’t go to the gym today so my weight loss efforts are a total failure”) can lead to, with a focus on eating and wellness (e.g., concession of weight loss goals); and discussing how to overcome overeating. The coach will want to return to the ACT and THINK chart to illustrate that some of the skills used for addressing negative mood can also help with overeating and emotional eating. Next, the session focuses on overcoming overeating by discussing food cravings and PCOS. Many women with PCOS experience food cravings, 1As part of the HBHM research protocol, participants wear a BodyMedia SenseWear armband that measures physical activity and sleep. Participants are given a watch that records the number of steps they take each day. The armband not only provides data for the research protocol, but it also serves to provide insight to the participants. Summaries are provided to each participant the session after she wears the armband. Obesity and Depression 405 especially for starchy foods. The coach will discuss that these cravings can sometimes lead to overeating, but more importantly, will focus on pointers for combating food cravings cognitively. When cravings won’t stop, the coach also provides pointers for how to cope with them behaviorally. There are worksheets to complete after review of the session. One of the most important worksheets for this program is the cognitive restructuring worksheet, Cognitive Self-Monitoring (Appendix 11–A, Worksheet 10). Generally, the coach completes the first example provided and asks for the patient to provide another example to elucidate the concept. Emphasize that the “Countering (alternatives, evidence)” column may be the most challenging. Stress the importance of using material from this session in the patient’s daily life after she leaves the session meeting place. Because the coach and patient exercise at the end of each session, coaches periodically meet participants outside the clinical setting. Relaxation training is also incorporated. Typically, coaches allow the patient to pick one of three relaxation methods (deep breathing, imagery, or progressive muscle relaxation), but some patients may want to try each one. Feel free to be creative and let the patient guide the activity (e.g., yoga with deep breathing). Encourage the patient to practice these skills (e.g., turning negative thoughts into positive thoughts, relaxation training). Session 4: The Traffic Light Guide There are three objectives for session 4: 1. Educate about nutrition labels. 2. Introduce the Traffic Light Guide (Epstein and Squires 1988). 3. Discuss portion sizes. The coach will discuss nutrition labels with the participant; typically, the patient may know what the nutrition label shows but may feel confused about exactly what to concentrate on changing. Go back to the 5/2/10 guideline and ask if the patient has used this tool. Explain that the Traffic Light Guide is yet another tool that she may find helpful. Emphasize that some people like it, whereas others find it too elementary. Overall, >5 g fat=RED food, 2–5 g fat=YELLOW food, and <2 g fat=GREEN food. Although reducing red foods to one or two per day is a goal, ask the participant what would seem reasonable for her. Encourage the patient to record the red foods as an in-between session assignment and to reduce those foods by one or two items the subsequent days until she reaches the goal that was agreed on. Explain that the Traffic Light Guide fits well with the PCOS Eating Plan. The PCOS Eating Plan contains primarily green and yellow foods, and the coach can use the PCOS Pyramid (see Appendix 11–A, Worksheet 406 Cognitive-Behavior Therapy for Children and Adolescents 7) to help guide appropriate serving sizes. Focus on portion sizes and portion distortion. Be aware that most adolescents know this information but that implementing the knowledge is a challenge. Remember to set goals with the patient: logging food intake, physical activity, and mood; labeling red foods consumed; and any other goals. Session 5: Having Fun While Moving There are three objectives for session 5: 1. Discuss physical activity. 2. Discuss My Activity Pyramid. 3. Set physical activity goals. The coach will begin this session by eliciting from the participant what she thinks the difference is between physical activity and exercise and discussing her response. Physical activity is any activity that causes the body to work harder than normal and can involve a number of daily tasks, whereas exercise is a planned, structured, and repetitive movement done to improve or maintain physical fitness. Additional ways in which physical activity can be increased should be discussed. The coach will also discuss the different types of physical activity with the participant: aerobic exercise—activity that increases breathing and heart rate; resistance exercise—exercise that increases the ability to exert or resist force and makes the muscles stronger; and stretching— activity that improves flexibility by warming up and lengthening the muscles. After showing the participant the activity pyramid (Appendix 11–A, Worksheet 11), probe for understanding. Ask about anything that stands out or that she finds surprising. Clarify any confusion. At the end of the session, help the participant set realistic physical activity and exercise goals to complete before session 6. Although working out every day is ideal, emphasize realistic goals. Share with the participant that setting idealistic goals sometimes leads to failure and an exacerbation of negative mood symptoms. Set physical activity goals and encourage the participant to use her pedometer to increase the number of steps taken. Session 6: A Focus on Body Image There are three objectives for session 6: 1. Introduce and define body image. 2. Discuss myths that impact body image. 3. Introduce eight steps for building a better body image. Obesity and Depression 407 Body image is a concept that most participants have explored in the past. The coach should discuss how the patient defines body image and how her thoughts about her body affect her behavior using the worksheet provided for the session (not included here). This session also includes a list of myths about body image. Going through each myth and discussing whether the participant has heard it before and whether she believes it can be helpful. Then discuss why it is not true, referring to the facts section underneath each myth. Last, the coach shares with the participant a list for developing a healthier body image, Eight Steps for Building a Better Body Image (Appendix 11–A, Worksheet 12). Read through this list with the participant, or have the participant look through the list, and discuss the steps that she would find most helpful or that stand out for her. Goals for this session include identifying lifestyle goals (see Appendix 11–A, Worksheet 2) and completing the body image worksheet, Helpsheet for Change: My Desire for Change (Cash Body Image Workbook 1997). Session 7: Being More Self-Aware There are four objectives for session 7: 1. Introduce and define self-awareness. 2. Discuss challenges to maintaining a healthy lifestyle. 3. Introduce the STEPS problem-solving worksheet (see Chapter 10, Appendix 10–A). 4. Discuss in-between session assignments. First, assess the patient’s level of familiarity with the term self-awareness, asking what she thinks it might mean. Many participants have never heard this term used before in this context, so it is important to discuss its meaning. Once the general definition is discussed and understood, discuss what it means to be aware when eating. This type of self-awareness involves focusing on what she is eating and drinking and noticing all of the physical and mental sensations that occur before, while, and after the item is consumed. Next, the coach should discuss awareness of physical activity. Start by assessing what the participant thinks this could mean and discussing her experience with physical activity awareness. Awareness of physical activity generally means noticing how her body feels when in motion: breathing, heart rate, muscle movements, posture, coordination, and flow (or being “in the zone”). Discuss with the participant whether she has experienced any of these things during physical activity. Last, discuss the participant’s awareness of her mood. This means paying attention to her emotions, knowing how she is feeling, and recognizing ways that she can 408 Cognitive-Behavior Therapy for Children and Adolescents change her emotions. The coach can then practice the mood awareness activity with the patient by focusing on the patient’s ability to control her emotions (Appendix 11–A, Worksheet 13). Note that more succinct distinctions for the concepts of mood, emotion, and affect are given in other manualized treatments but that HBHM focuses on overall emotion, and at times, depressive symptoms. During this session, the coach will also discuss challenges to maintaining a healthy lifestyle. The coach will talk about food temptations that seem to be everywhere, inappropriate portion sizes that have become common practice, and environmental cues that can signal overeating. Allow the participant to openly talk about challenges that she may face. Given that most people encounter problems and challenges throughout life, it is important to learn how to effectively manage them. During this session, the coach will introduce the STEPS worksheet, allowing the participant to apply this method of problem solving to an example that she has faced recently. This week, the participant should complete the STEPS worksheet for one challenge she faces between now and the next session. Talk about journaling and how this relates to self-awareness, and set a goal with the participant for her to journal a certain number of days. Set any additional wellness goals that the participant would like to achieve. Session 8: Planning Ahead for Continued Success There are two objectives for session 8: 1. Review wellness goals from previous sessions, the STEPS problemsolving worksheet, and any journaling. 2. Discuss strategies for planning to make healthy choices. The coach should make sure that the participant understands how to use the problem-solving worksheet when faced with a challenge; see if the participant can state the challenge, brainstorm possible solutions, weigh pros and cons of each solution, try one out, and assess whether that solution worked. Planning ahead for the future is important to ensure future success when challenges are faced. During this session, the coach will discuss with the participant ways to plan ahead for daily meals, snacks, physical activity, special occasions, and challenges to positive thinking. An entire packet is available highlighting healthier choices while dining out, with a special emphasis on meals and foods that fall within the 5/2/10 Obesity and Depression 409 guideline. Because this is the last session in the intensive intervention (before the monthly booster sessions), goals are set that highlight continued change. Encourage the patient to call to move the appointment to an earlier date if challenges arise. Commend the participant for completing the intensive part of the intervention and make sure to set wellness goals. Booster Sessions After the intensive part of the intervention, participants are encouraged to attend three monthly booster sessions. For some young women, these are maintenance sessions where they check in on their weight and mood. For others (and contrary to the outcome in some pediatric obesity treatments), young women begin to use the skills that they have learned and begin to lose more weight and feel more positive. Booster session 1 concentrates on the patient’s physical illness narrative (see Chapter 10, Appendix 10–A). This serves to assist the coach and patient in better understanding what it means for the patient to have PCOS. Booster session 2 focuses on living with PCOS and attaining support from the patient’s environment. Topics that may be discussed consist of support networks and feeling uncomfortable talking with peers about having PCOS. Booster session 3 centers on reflecting not only about the program but also about having PCOS (Appendix 11–A, Worksheet 14). Although some participants decide that this session is the end of their HBHM journey, we offer participants follow-up sessions in our clinical PCOS program. Conclusion and Caveats Obesity in pediatric and adolescent populations has reached epidemic proportions in the United States. Depressive disorders in children are common, recurrent, and impairing. Depression is prevalent in 1%–2% of children and 3%–8% of adolescents (Lewinsohn et al. 1998). Existent interventions for obese adolescents have excluded patients experiencing comorbid conditions. Given the long-standing link between obesity and depression and the questions many providers have expressed about which disorder to treat first, HBHM provides an infrastructure with a model physical illness (PCOS) in which adolescents present frequently with both obesity (~70%) and depression (~50%). Fortunately, several evidencebased pediatric obesity and depression treatments have been successful in promoting weight loss and in improving mood in adolescents. As reviewed 410 Cognitive-Behavior Therapy for Children and Adolescents here, the inclusion of complementary therapeutic strategies has been shown to be effective in enhancing standard pediatric weight management programs. As can be seen in Chapter 5, similar strategies have been shown to be efficacious in childhood depression. Both behavioral (Aragona et al. 1975; Brownell et al. 1983; Coates et al. 1982; Epstein and Wing 1980; Epstein et al. 1995; Flodmark et al. 1993) and cognitive (Brownell et al. 1983; Coates and Thoresen 1981; Senediak and Spence 1985; Williams et al. 1993) techniques, used in conjunction with dietary and activity change strategies, have demonstrated favorable results for weight loss and depression remittance in adolescents. By targeting dietary, activity, and other behavioral skills in both adolescents and parents, family-based behavioral programs have been shown to be more effective than targeting children alone (Epstein et al. 1981; Epstein et al. 2008) and benefit all family members by encouraging reciprocal weight loss and a positive home environment between parent and child (Wrotniak et al. 2004). Although data supporting the efficacy of motivational interviewing techniques in weight-loss interventions are sparse, these strategies may provide additional safe, cost-effective methods for enhancing motivation for behavior change, especially in psychiatrically ill adolescents who have repeatedly failed at weight loss or mood improvement. Even in more severe cases of obesity, when practitioners may consider additional approaches such as pharmacotherapy or bariatric surgery, these therapies can make a significant contribution to enhancing patients’ quality of life and compliance with the weight-loss intervention (Kalarchian and Marcus 2003). Moreover, careful consideration of which patients may benefit from this combined intervention is crucial. For example, providers should think of excluding patients from HBHM who have a family history of major depressive disorder, have been hospitalized for psychiatric reasons in the past, or have active suicidal ideation. In these cases, a more direct CBT approach to treat only the depressive disorder, possibly along with antidepressants, should be considered. Key Clinical Points • Many facets that underlie maladaptive eating and a lack of physical activity also relate to problematic mood symptoms. • Before the introduction of Healthy Bodies, Healthy Minds (HBHM), most pediatric obesity interventions excluded adolescents with comorbid mood symptoms. A manualized treatment, HBHM aims to provide more broad-based CBT techniques that will assist an adolescent struggling with both weight management concerns and mood symptomatology. Carefully selecting patients who may benefit from HBHM is crucial in optimizing the likelihood of its utility. Frequently. B. patients who have depressive thinking secondary to body image concerns and compromised self-esteem may greatly benefit from HBHM. the motivational interviewing components of HBHM are not be appropriate for adolescents with depression who need more intensive treatment (see Chapter 5 for their treatment).2. Obsessive-compulsive traits.Obesity and Depression 411 • Although CBT serves as the content for HBHM treatment. recurrent. Moreover. Which is not typically a psychological correlate of adolescent obesity? A. • HBHM was validated for adolescents with PCOS who exhibit difficulties abiding by healthy lifestyle goals. Many adolescents with PCOS and/or obesity may have difficulty with cognitive skills required for CBT. • Although CBT and motivational interviewing skills are summarized as a blueprint. However. Low self-esteem. • Although the sessions are numbered sequentially. as well as managing their depressive symptoms. For example. patients will cycle back to previous sessions on an as-needed basis. Why is polycystic ovary syndrome an appropriate physical illness for a CBT approach? A. D. . Depression. if a patient presents with long-standing. Compromised body image. severe major depressive disorder. motivational interviewing components assist in working with adolescents who may exhibit resistant behaviors. more intensive treatment that targets solely mood symptoms may be warranted.1. • Continuation of CBT treatment is effective in preventing relapse once weight maintenance and positive thinking are achieved. Self-Assessment Questions 11. adolescents will learn a skill and then regress due to either a lapse or environmental circumstances. CBT helps adolescents restructure their psychosomatic complaints. cultural and age-specific aspects from the patient’s perspective need to be addressed to optimize treatment outcome. B. this intervention may need to be individualized on the basis of each patient’s needs. 11. CBT assists adolescents in better understanding why they are obese. Conversely. C. D. Both parents are obese. et al: Safety and efficacy of bariatric surgery: longitudinal assessment of bariatric surgery. 11.9. Stimulus control. Which of the following CBT techniques is most logical to employ with this child and his family? A. CBT can target both the obesity and depression that these adolescents may experience. Obsessive-compulsive disorder. D. Self-monitoring. and they question why they should have to change their habits for their child. Eating disorder not otherwise specified. Cognitive restructuring. Montalbano JK: Pharmacotherapeutic options for overweight adolescents. 2007 Dunican KC. C. 2007 . C.3. Affirmations. 11. Posttraumatic stress disorder.4. 11. C. Which comorbid condition may CBT assist in the treatment of adolescents with obesity and depression? A. B. Suggested Readings and Web Sites Belle SH. Nondirective empathy. Open-ended questions. high-calorie food in the home. Alcohol dependence.5. Courcoulas AP. Ann Pharmacother 41:1445–1455. He complains that his family has a lot of high-fat. Desilets AR. Behavioral activation. Surg Obes Relat Dis 3:116–126. B. D. D. Berk PD. An 8-year-old boy comes into the clinic with a body mass index percentile of 99.412 Cognitive-Behavior Therapy for Children and Adolescents C. Reflective listening. B. Which of the following is not a key strategy used during motivational interviewing as a complementary approach to CBT? A. CBT can activate adolescents to exercise more frequently. et al: Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Guilford. Allison KC: Depression and obesity. J Clin Endocrinol Metab 80:2966–2973. 2002 Azziz R. et al: A longitudinal study of childhood depression and anxiety in relation to weight gain. J Pediatr Endocrinol Metab 13:1303–1306. Expert Opin Pharmacother 9:1339– 1350. 2007 Kushner RF: Anti-obesity drugs. Carmina E. 2006 . program managers. Am J Psychiatry 164:328–334. www. and trainers. training resources.motivationalinterviewing.motivationalinterview. Naumova EN. Dewailly D. 1975 Arslanian SA. 2003 Wadden TA.org Motivational Interviewing Network of Trainers: Provides resources for information on motivational interviewing.Obesity and Depression 413 Kalarchian MA. and implementation of motivational interviewing among clinicians. et al: Relationship of childhood behavior disorders to weight gain from childhood into adulthood. Noll RB. 2009 Rofey DL. Butzow T. Kolko RP. Szigethy EM. 2008 Rofey DL. J Appl Behav Anal 8:269–278. 2006 Apter D. supervisors.org References Anderson SE. Faith MS. 2009 Stunkard AJ. Cassady J. includes general information about the approach. Iosif A. Witchel SF: Polycystic ovary syndrome in adolescents: is there an epidemic? Curr Opin Endocrinol Diabetes 9:32–42. and information on reprints and recent research. adoption. 2004 Motivational Interviewing: Provides materials designed to facilitate the dissemination. Marcus MD. 1995 Aragona J. Stunkard AJ: Handbook of Obesity Treatment. J Pediatr Psychol 34:156–163. Cohen P. New York. Ambul Pediatr 6:297– 301. Child Psychiatry Hum Dev 40:517–526. as well as links. 2nd Edition. et al: Positions statement: criteria for defining polycystic ovary syndrome as a predominantly hyperandrogenic syndrome: an Androgen Excess Society guideline. Kashar-Miller MD: Family history as a risk factor for the polycystic ovary syndrome. Biol Psychiatry 54:330–337. Levine MD. www. Laughlin GA. J Clin Endocrinol Metab 91:4237–4245. et al: Metabolic features of polycystic ovary syndrome are found in adolescent girls with hyperandrogenism. et al: Cognitive-behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. 2000 Azziz R. Drabman RS: Treating overweight children through parental training and contingency contracting. J Adolesc Health 23:7--19. 1993 . Siegfried NJ. Psychother Psychosom 68:325–332. 2004 Duffy G. 2003 Britz B.414 Cognitive-Behavior Therapy for Children and Adolescents Bauer KW. Obes Res 12:86–94. Spear LP (eds): Adolescent Brain Development: Vulnerabilities and Opportunities. Rocchini AP. Health Educ Behav 31:34–46. Katch VL. J Pediatr Psychol 22:59–71. et al: Coronary risk incidence of obese adolescents: reduction by exercise plus diet intervention. The Dietary Intervention Study in Children (DISC) Research Group. 2002 Davison KK. Int J Obes Relat Metab Disord 24:1707–1714. Yang YW. Health Educ Res 14:399–410. 1982 Dahl R. Am J Hum Biol 15:446–460. Ziegler A. Birch LL: Processes linking weight status and self-concept in girls at ages 5 and 7 years. McMahon RP. Klaghofer R. 1983 Buddeburg-Fisher B. Vandereycken W: Psychological aspects of childhood obesity: a controlled study in a clinical and nonclinical sample. 1999 Cash TF: The Body Image Workbook: An Eight-Step Program for Learning to Like Your Looks. 2001 Davison KK. Int J Eat Disord 1:37–48. Killen JD. Reed V. et al: A brief motivational intervention to improve dietary adherence in adolescents. Pediatrics 71:513–523. Birch LL: Family environmental factors influencing the developing behavioral controls of food intake and childhood overweight. Pediatr Clin North Am 48:893–907. et al: Changes in self-esteem in black and white girls between the ages of 9 and 14 years: the NHLBI Growth and Health Study. 1988 Berg-Smith SM. Brown KM. Dev Psychol 38:735–748. et al: Associations between body weight. J Child Psychol Psychiatry 34:1043–1050. 2004 DiLillo V. Mervielde I. Stunkard A: Treatment of obese children with and without their mothers: changes in weight and blood pressure. Pediatrics 81:605–612. Stevens VJ. Cogn Behav Pract 10:120–130. Behav Ther 12:383–399. Birch LL: Predictors of fat stereotypes among 9-year-old girls and their parents. 1981 Coates TJ. 2000 Brown KM. Smith WD: Incorporating motivational interviewing into behavioral obesity treatment. Biro FM. Spence SH: The effectiveness of cognitive self-management as an adjunct to a behavioural intervention for childhood obesity: a research note. 1997 Brewis A: Biocultural aspects of obesity in young Mexican schoolchildren. 1998 Brownell K. Slinkard LA: Parent participation in a treatment program for overweight adolescents. et al: Rates of psychiatric disorders in a clinical study group of adolescents with extreme obesity and in obese adolescents ascertained via a population based study. 2008 Coates TJ. New York Academy of Sciences. Austin SB: “How can we stay healthy when you’re throwing all of this in front of us?” Findings from focus groups and interviews in middle schools on environmental influences on nutrition and physical activity. Thoresen CE: Behavior and weight changes in three obese adolescents. 2nd Edition. 1999 Braet C. 2004 Davison KK. psychiatric disorders and body image in female adolescents. CA. New York. Oakland. Kelman J. 2004 Becque MD. Siegfried W. New Harbinger Publications. et al: Is obesity a risk factor for psychopathology among adolescents? Pediatr Int 46:296–301. Deroo L. Jorge MA: Obesity-depression associations in the population. Obes Res 9:171–178. 1988–1994. MA. Geliebter A: Emotional eating and obesity: theoretical considerations and practical recommendations. et al: Do children lose and maintain weight easier than adults: a comparison of child and parent weight changes from six months to ten years. Adapt Phys Activ Q 7:314–324. 2000 Epstein LH. Obes Res 3:411–417. Kalarchian MA. and sexual satisfaction in women with polycystic ovary syndrome. Obesity 16:318–326. Paluch RA. Wing RR. Penner BC. 2002 Flodmark CE. Moreau M. 1993 Ford ES. Valoski AM. Squires S (eds): The Stoplight Diet for Children. et al: Effects of diet plus exercise on weight change in parents and children. 1984 Epstein LH. MD. Beecher MD. et al: An activity based weight control program. 2003 Elsenbruch S. psychosocial well-being. Pediatrics 91:880–884. J Consult Clin Psychol 49:674–685. 2008 Erermis S.Obesity and Depression 415 Dunn C. J Clin Endocrinol Metab 88:5801–5807. Hahn S. Ohlsson T. Ryden O. 2001 Epstein LH. et al: Child and parent weight loss in family based behavior modification programs. et al: Quality of life. Koeske R. Arch Pediatr Adolesc Med 154:220–226. Aspen. in Overweight and Weight Management: The Health Professional’s Guide to Understanding and Practice. Addiction 12:1725–1742. Matz PE. 1981 Epstein LH. J Pediatr 107:358–361. Arch Pediatr Adolesc Med 157:733–738. Wing RR: Aerobic exercise and weight. 2004 Faith MS. Boston. 1999 Epstein LH. Story M: Associations of weight-based teasing and emotional well-being among adolescents. Little. et al: Effect of diet and controlled exercise on weight loss in obese children. et al: Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy. 2003 Emes C. Kowalsky D. et al: C-reactive protein and body mass index in children: findings from the Third National Health and Nutrition Examination Survey. Tamar M. Med Sci Sports Exerc 31(suppl):S553–S559. Neumark-Sztainer D. Rivara FP: The use of brief interventions adapted from motivational interviewing across behavioral domains: a systematic review. 1988 Epstein LH. Wing RR. reducing high energy–dense foods to treat pediatric obesity. Velde B. Gaithersburg. 2001 Eisenberg ME. Addict Behav 5:371–388. et al: Decreasing sedentary behaviors in treating pediatric obesity. Raynor HA. J Consult Clin Psychol 52:429–437. 1997. pp 439–465 Faith MS. Wing RR. et al: Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity. 2001 . J Pediatr 138:486–492. Allison DB. Goldfield GS: Physical activity in the treatment of childhood overweight and obesity: current evidence and research issues. Gordy CC. Edited by Dalton S. 1980 Epstein LH. 1995 Epstein LH. J Psychosom Res 53:935–942. Koeske R. Gordy CC. Paluch RA. Gillespie C. Brown. Galuska DA. 1990 Epstein LH. Cetin N. 1985 Epstein LH. et al: Increasing healthy eating vs. et al: Teasing. Wilfley DE. 2007 Kalarchian MA. 2003 Katch V. Johnston C. Keel PK: Weight-based stigmatization in children. Waters E: Body mass index and parent-reported self-esteem in elementary school children: evidence for a causal relationship. 2001 . Whitaker RA: Prospective study of the role of depression in the development and persistence of adolescent obesity. Pediatrics 110:497–504. Story M. Lundberg I: How far are socioeconomic differences in coronary heart disease hospitalization. Becque M. et al: Increased risk of depressive disorders in women with polycystic ovary syndrome. Abreu A. all-cause mortality and cardiovascular mortality among adult Swedish males attributable to negative childhood circumstances and behaviour in adolescence? Int J Epidemiol 34:260–267. Behav Ther 8:30–36. 1999 French SA. Behav Ther 15:485–500. Leon G.416 Cognitive-Behavior Therapy for Children and Adolescents Franko DL. and self-esteem in a clinical sample of obese women. Key TJ. Obes Res 41:27–33. et al: Prevalence of the polycystic ovary syndrome in unselected black and white women of the southeastern United States: a prospective study. Marks C. body image. et al: Basal metabolism of obese adolescents: inconsistent diet and exercise effects. Fertil Steril 87:1369–1376. Harris ES. 2003 Goodman E. Marcus MD: Management of the bariatric surgery patient: is there a role for the cognitive behavior therapist? Cogn Behav Pract 10:112–119. Shapiro J: A comparison of three behavioral programs for the control of obesity in children. Steele R: Comparison of cognitive and behavioral treatments for pediatric obesity. 1995 French S. 1977 Kirschenbaum DS. Thompson D. Pediatrics 3:1175–1182. Srinivasan SR. Tomarken AJ: Effects of parental involvement in behavioral weight loss therapy for preadolescents. Maifeld M. Thatcher SS: Depression and body image among women with polycystic ovary syndrome. Brownell KD. Addict Behav 19:443–450. et al: The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. 2006 Hollinrake E. Wake M. Obes Res 3:479–490. Striegel-Moore RH. Child Health Care 33:151–167. Dietz WH. Notkola IL. 2005 Herrera E. 1988 Kingsley R. Int J Obes Relat Metab Disord 28:1233–1237. 1996 Friedman MA. Perry CL: Self-esteem and obesity in children and adolescents: a literature review. Int J Obes Relat Metab Disord 27:716–721. 2005 Freedman DS. 2002 Grilo CM. 2004 Himelein MJ. Brownell KD: Psychological correlates of obesity: moving to the next research generation. 1998 Kraig KA. 1995 Fuentes RM. J Clin Endocrinol Metab 83:3078–3082. Psychol Bull 117:3–20. et al: Does adolescent depression predict obesity in black and white young adult women? Psychol Med 35:1505–1513. 2004 Hesketh K. et al: Self-esteem and changes in body mass index over 3 years in a cohort of adolescents. Shemeikka S. 1984 Knochenhauer ES. Perry C. J Health Psychol 11:613–625. et al: Tracking of body mass index during childhood: a 15-year prospective population-based family study in eastern Finland. Int J Obes Relat Metab Disord 25:1661–1666. 1994 Hemmingsson T. Am J Clin Nutr 48:565–569. Kahsar-Miller M. 1994–2004. Silverstein JH: Management approaches for pediatric obesity. Obes Res 11:452–456. 2002 Morin-Papunen L. 2000 Magarey AM. 2001 Lunner K. Pediatrics 111:851–859. Koivunen R. Prevalence and incidence of depression and other DSM-III-R disorders in high school students. et al: Are obese adolescents and young adults at risk for mental disorders? A community survey. et al: Predicting obesity in early adulthood from childhood and parental obesity. Ringham R. Erkanli A. Lester RC. Guilford. Int J Obes Relat Metab Disord 27:505– 513. 2002 Ogden CL. 1993 Lewinsohn PM. body image. J Nutr Educ 3:3–9. 2003 Neumark-Sztainer D. risk factors. J Clin Endocrinol Metab 87:1017–1023. et al: A cross-cultural examination of weight-related teasing. J Pediatr Endocrinol Metab 5 (suppl 5):1367– 1378. Clin Psychol Rev 18:765–794. et al: Weight-teasing among adolescents: correlations with weight status and disordered eating behaviors. Rollnick S: Motivational Interviewing: Preparing People for Change. JAMA 295:1549–1555. Obes Res 10:1152–1160. Harris T: Beliefs and attitudes about obesity among teachers and school health care providers working with adolescents. et al: Prevalence of overweight and obesity in the United States. Stunkard AJ: Getting worse: the stigmatization of obese children. Nat Clin Pract Endocrinol Metab 3:810–818. 2006 Palmert MR. 2002 . 2007 Miller WR. 2003 Legro RS: Detection of insulin resistance and its treatment in adolescents with polycystic ovary syndrome. et al: Obesity and psychiatric disorder: developmental trajectories. Hops H. Witchel SF. 1991 Miller WR. 1998 Lewy VD. Rohde P. Jacobi C. Gordon CM. Story M. Rollnick S: Motivational Interviewing: Preparing People to Change Addictive Behavior. et al: Adolescent psychopathology: I. 2002 Latner JD. Boulton TJ. et al: Metformin versus ethinyl estradiol–cyproterone acetate in the treatment of nonobese women with polycystic ovary syndrome: a randomized study. Thompson KJ. New York. 2002 Levine M. Roberts RE. Danadain K. Falkner N. 2003 Miller JL. Int J Obes Relat Metab Disord 26:123–131. Daniels LA.Obesity and Depression 417 Lamertz CM. J Clin Endocrinol Metab 88:148– 156. Carroll MD. Vauhkonen I. Story M. 2003 Mustillo S. J Abnorm Psychol 102:133–144. Guilford. et al: Screening for abnormal glucose tolerance in adolescents with polycystic ovary syndrome. New York. 2001 Lewinsohn PM. et al: Is family based behavioral weight control appropriate for severe pediatric obesity? Int J Eat Disord 30:318–328. Int J Eat Disord 28:430–435. 1999 Neumark-Sztainer D. Kartashov AI. and clinical implications. Seeley JR: Major depressive disorder in older adolescents: prevalence. Werthem EH. Yassouridis A. and eating disturbance in Swedish and Australian samples. Worthman C. et al: Early metabolic abnormalities in adolescent girls with polycystic ovarian syndrome. Kalarchian M. J Pediatr 138:38–44. Wardle J: Cause and effect beliefs and self-esteem of overweight children. Rollnick S: Motivational interviewing for pediatric obesity: conceptual issues and evidence review. Davis R. Anderson J. J Affect Disord 74:299–304. 2001 Richardson L. Diabetes Care 20:52–54. et al: Individual versus group therapy for obesity: effects of matching participants to their treatment preferences. and the health of the nation’s children. Davis R. J Pediatr Psychol 34:156–163. et al: A longitudinal study of childhood depression and anxiety in relation to weight gain. Hwang S. et al: Motivational interviewing to improve adherence to a behavioral weight-control program for older obese women with NIDDM: a pilot study. Psychol Bull 133:557–580. Pediatrics 82:16–23. 1988 Rofey DL. Child Psychiatry Hum Dev 40:517– 526. Kolko RP. Rofey D: Childhood obesity: highlights of the American Medical Association (AMA) Expert Committee Recommendations. Dietz W. 2009b Schwartz R. 2007 Rasgon NL. 2006 Ricciardelli LA. et al: A longitudinal evaluation of adolescent depression and adult obesity. Bearman SK: Body image and eating disturbances prospectively predict growth in depressive symptoms in adolescent girls: a growth curve analysis. Dev Psychol 37:597–607. et al: Cognitive-behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. 2002 Phillips J. and depression in obese Korean children. Shin MS: Body dissatisfaction. et al: Results of go girls: a weight control program for overweight African-American adolescent females. American Academy of Family Physicians 38:411–419. 2001 Resnicow K. Taylor R. Cohen P. Obes Res 10:386–393. et al: Blood pressure in obese adolescents: effect of weight loss. et al: Office-based motivational interviewing to prevent childhood obesity: a feasibility study. et al: Depression in women with polycystic ovary syndrome: clinical and biochemical correlates. Nezu A. 2003 Rocchini AP. 2009a Rofey DL. overt and relational peer victimization. Arch Pediatr Adolesc Med 157:739–745. 2001 . Heckemeyer CM. Clin Psychol Rev 21:325–344. J Am Diet Assoc 106:2024–2033. Behavioural Psychotherapy 13:256–287. 2005 Resnicow K. McCabe MP: Children’s eating concerns and eating disturbances: a review of the literature. Rao RC. 2010 Pierce JW. and romantic relationships. Obes Res 13:1739– 1748. 1997 Stice E. self-esteem. 1997 Pine DS. J Child Psychol Psychiatry 38:645–650. Latner JD: Stigma. Arch Pediatr Adolesc Med 161:495–501. Noll RB. Boergers J. Hull E. 2003 Renjilian D. Katch V. Perri M. Kratt PP. 2007 Senediak C. Prinstein MJ: Adolescent obesity. Brook J. 1985 Shin N. et al: Psychiatric symptoms in adolescence as predictors of obesity in early adulthood: a longitudinal study. Hamre R.418 Cognitive-Behavior Therapy for Children and Adolescents Pearce MJ. Baskin M. Spence S: Rapid versus gradual scheduling of therapeutic contact in a family based behavioural weight control programme for children. obesity. Szigethy EM. J Consult Clin Psychol 69:717–721. Am J Public Health 87:1303–1310. J Pediatr 152:502–506. 2008 Smith DE. Poulton R. Iosif AM. 1997 Puhl RM. Inflamm Bowel Dis 8:1127–1128. Obes Res 12:1576–1586. Wilfley DE. 2004 Tiggemann M: Body dissatisfaction and adolescent self-esteem: prospective findings. and psychopathology in overweight and normal-weight children. Craig AE. Cooke L: The impact of obesity on psychological well-being. Azziz R: Impact of obesity on the risk for polycystic ovary syndrome. 2004 Weisz JR. Thompson JK. et al: Depression in adolescent obesity: cultural moderators of the association between obesity and depressive symptoms. Williamson S. Carpenter J. Knochenhauer ES. et al: Cognitive-behavioral therapy for adolescents with inflammatory bowel disease and subsyndromal depression. body fat. Bollella M. Johnson F. Int J Eat Disord 32:46–51. Pollack HA: Social marginalization of overweight children. Psychosom Med 66:356–362. Yanovski SZ. Gordis EB. J Consult Clin Psychol 72:53–61. Body Image 2:129–135. 2005 Wardle J. 2008 Zeller MH. 1993 Wrotniak BH. Roehrig H. 2009 Williams CL. et al: Psychological adjustment of obese youth presenting for weight management treatment. Arch Pediatr Adolesc Med 157:746–752. Pediatrics 105:e15. and general psychological functioning in adolescent females: a replication using covariance structure modeling in an Australian sample. 2003 Szigethy EM. Best Pract Res Clin Endocrinol Metab 19:421–440. J Consult Clin Psychol 77:383–396. Wertheim EH. J Abnorm Psychol 109:438–444. 2007 Szigethy E. Carter BJ: Treatment of childhood obesity in pediatric practice. Hayward C. 2006 Weiner CL. Cameron R. Ehrmann DA: Androgens and mood dysfunction in women: comparison of women with polycystic ovarian syndrome to healthy controls. 2005 van den Berg P. 2000 Strauss RS: Childhood obesity and self-esteem. Int J Obes (Lond) 30:634–643. et al: Eating-disordered behaviors. 2009 Tanofsky-Kraff M. Saelens B. Epstein LH. Southam-Gerow MA. et al: Cognitive-behavioral therapy versus usual clinical care for youth depression: an initial test of transportability to community clinics and clinicians. Hardy D. 2004 Yildiz BO. J Clin Endocrinol Metab 93:162–168. eating disturbance. et al: Development of body image. 2004 . et al: Body image and eating related factors predict onset of depression in female adolescents: a longitudinal study. 2002 Wardle J. Kenney E. Paluch RA. et al: Girls connect: effects of a support group for teenage girls with inflammatory bowel disease and their mothers. Ann N Y Acad Sci 699:207–219. Primeau M.Obesity and Depression 419 Stice E. J Am Acad Child Adolesc Psychiatry 46:1290–1298. 2000 Strauss RS. Arch Pediatr Adolesc Med 158:342–347. et al: Parent weight change as a predictor of child weight change in family based behavioral obesity treatment. I’m going to study for the test. thoughts. Negative thought I’ll never pass the test anyway.420 Cognitive-Behavior Therapy for Children and Adolescents Appendix 11–A Healthy Bodies. I’m not going out tonight. Positive thought Positive behavior My friends like me. Healthy Minds: Selected Patient Worksheets Session 1: Introduction to the Program Worksheet 1 The Guiding Principles of Wellness Thoughts Emotions Behaviors How our emotions. Positive emotion Happiness Positive thought Positive behavior I can do well if I try. Going out will help me. Positive emotion Confidence . Negative behavior I’m not studying. Negative emotion Sadness Negative emotion Hopelessness Positives Bring Us Up. Negative thought Negative behavior I look terrible. and behaviors are connected: Negatives Bring Us Down. I/we will: Goal 3: To achieve this goal. things that may get in the way of success) and ways that you can overcome these challenges. so that your goals can be achieved. Goal 1: To achieve this goal. not idealistic. I/we will: Goal 2: To achieve this goal. It is important to be as specific as possible and to write down the steps that you will take to achieve these goals. Make sure to be realistic. We also will ask you to think of barriers (that is. I/we will: .Appendix 11–A: HBHM Selected Patient Worksheets 421 Session 1: Introduction to the Program Worksheet 2 Healthy Lifestyle Goals Now. take some time to think about three specific lifestyle goals that you would like to begin to work toward. Healthy Minds Weight Tracker Initials: Gender: Birth date: Session 1 2 3 4 5 6 7 8 9 10 11 12 Height Weight BMI Percentile .422 Cognitive-Behavior Therapy for Children and Adolescents Session 1: Introduction to the Program Worksheet 3 Healthy Bodies. Describe mood Day Monday Tuesday Wednesday Thursday Friday Saturday Sunday Mood rating (1–10) Good things that happened today Bad things that happened today Changes in my eating (e.g. Then write down what good and bad things happened that day.g. irritable. felt like eating more or less than usual) . Rate your mood for the day on a scale of 1–10 (1 being worse mood/more bored than ever. happy. write down what your mood was for most of each day (e.. bored. grumpy).. 10 being best mood ever/rarely bored). sad. angry.Appendix 11–A: HBHM Selected Patient Worksheets 423 Session 1: Introduction to the Program Worksheet 4 Mood Monitoring Practice assignment: During the next week. 424 Cognitive-Behavior Therapy for Children and Adolescents Session 2: Eating Well With PCOS Worksheet 5 Ratings Eating Healthy Being Active 10 Wonderful 10 Wonderful 5 Better than Nothing 5 Better than Nothing 1 Not so Well 1 Not so Well Feeling Good Feeling Bad 10 Great 10 Worst Ever 5 OK 5 OK 1 Not so Well 1 Not so Bad . Appendix 11–A: HBHM Selected Patient Worksheets Session 2: Eating Well With PCOS Worksheet 6 What It’s Like When I Feel Good Things I do or things that happen to me that make me feel good: How my body feels when I feel good: How I look when I feel good: What thoughts I have when I feel good: How I act when I feel good: 425 . cere 4-6 servings als Fr Fresh and frozeuits n whole fruits 3 servings Vegetables Non-starchy ve geta 5 servings bles .426 Cognitive-Behavior Therapy for Children and Adolescents Session 2: Eating Well With PCOS Worksheet 7 Tool 1: The PCOS Pyramid The PCOS Pyramid reflects current nutrition recommendations for girls and women who have PCOS. cheese 3 servings Meat Fatty fis lean meat/ph. 3-4 servings Dairy Low-fat milk. we recommend you make choices according to the pyramid. ric ins e. we have provided copies of this pyramid. Sweets Lower sugar varieties 1 serving Fats & ils (healthy O fats) Olive and cano nuts. To be sure you’re getting the nutrients you need. bread. flaxseeladoils. yogurt. which you can use daily to help guide your food choices. At the end of this session. ou 3 servings ltry Whole Gra Pasta. Vitamin C 10% Iron 57% *Percent Daily Values are based on a 2. Too much fat or sugar may cause weight gain and too little fiber may leave you feeling hungry.500 80g 25g 300mg 2. fiber. FIBER. you will be getting two times the amount of fat. Limit SUGAR to less than 10 grams per serving. fiber. it is important to look at the fat. more than 2 grams of fiber per serving. If you eat two servings. • • % Daily Value* 3% 2% 0% 9% 7% 14% Limit TOTAL FAT to less than 5 grams per serving. and sugar. Nutrition Facts Serving Size 1 cup (30g) Amount Per Serving Calories 111 Calories from Fat 16 Total Fat 2g Saturated Fat 0g Trans Fat Cholesterol 0mg Sod ium 213mg Total Carbohydrate 22g Dietary Fiber 4g Sugars 1g Protein 4g Vitamin A Calcium 10% 12% This is the recommended serving size.com By choosing items that fit the guidelines for fat. To choose healthy items.400mg 300g 25g Calories per gram: Fat 9 • Carbohydrate 4 • 2. Start by looking at the labels of items you have at home and decide if the foods are healthy items to keep around the house. 427 . Your daily values may be higher or lower depending on your calorie needs: Calories Total Fat Less than Sat Fat Less than Cholesterol Less than Sodium Less than Total Carbohydrate Fiber 2. you will have healthier foods at home to put together for meals and snacks.000 calorie diet. Increase FIBER to at least 2 grams per serving. and SUGAR in this item are for this serving of the food.Appendix 11–A: HBHM Selected Patient Worksheets Session 2: Eating Well With PCOS Worksheet 8 Tool 2: Reading Nutrition Labels & the 5/2/10 Guideline The Nutrition Facts label can be used to help you choose healthier items. Healthier items will have less than 5 grams of total fat per serving.400mg 375g 30g Protein 4 NutritionData. and less than 10 grams of sugar per serving. and sugar content of the food. and sugar. The amounts of TOTAL FAT.000 65g 20g 300mg 2. fiber. potatoes Corn. LOGGING your eating habits and physical activity plays a very important role in weight management and lifestyle change. Attempt to follow the HP at each meal to eat a nutritious. Benefits of Logging: Shows eating and physical activity patterns so that you can see your habits Helps you to plan physical activity into your daily routine Assists you in identifying benefits and challenges Helps you set realistic goals to make lifestyle changes Tracking your weight every week when you meet with us also is useful when trying to make healthy changes to lose weight. bread. FRUIT SALAD VEGGIES 2 cups total STARCH: Rice. balanced diet. It is important to follow the serving sizes listed on the HP as well. . See the Portion cheat sheet. pasta. cereal 1/2 to 1 cup LOW-FAT MILK OR YOGURT 1 cup PROTEIN: Meat (3-4 oz = size of palm) Beans (1 cup) Milk or yogurt (1 cup) Cheese (1 oz =1 slice) Peanut Butter (2 tbsp) Egg (1) Now it is time to put what you have learned into action.428 Cognitive-Behavior Therapy for Children and Adolescents Session 2: Eating Well With PCOS Worksheet 9 Tool 3: Healthy Plate (HP): HP is a model of how meals should typically look. There are more important things in life.Appendix 11–A: HBHM Selected Patient Worksheets 429 Session 3: Managing Your Emotions Worksheet 10 Cognitive Self-Monitoring Trigger/Event Automatic thought I don’t have a date for the prom. I have lots of good friends and family. Anxiety (0–8) 6 Problem (0–100%) 75% Countering (alternatives. no one likes me. Realistic problem (0–100%) 10% Anxiety (0–8) 3 . evidence) Many girls weren’t asked yet. It’s because of my looks. “Inactivity” burns the least number of calories. rollerblading) Everyday Ac tivities: As of (cleaning your room. The higher the MET. playing outside. yoga . Vigorous activities require MET levels of 3. whereas “Active Aerobic & Recreational Activities” burn the most. videogames) Flexibility & Stre 2-3 times a we ngth: ek (stretching. Moderate activities require between 2. rope climbing.0 METs and will not help you lose weight. so times a week ccer. in a short period of time. the more calories you burn while doing the activity. They make your body work hard and will help you to lose weight. push-ups) Active Aero bic & Recrea tional Activ ities: 3-5 (basketball.0 and 2. computer. You’ll be surprised how many calories you can burn by increasing your “Everyday Activities. going shopping) * Adapted from the USDA’s MyPyramid by the University of Missouri Extension These levels correspond to how many calories you are burning. Sedentary activities require less than 2.0 or higher.430 Cognitive-Behavior Therapy for Children and Adolescents Session 5: Having Fun While Moving Worksheet 11 My Activity Pyramid* Inactivity: Cut down < 2 hrs per day (TV. taking th ten as possible e stairs. METs are an estimate of the intensity of a particular activity and are based on your resting metabolic rate (or the amount of energy your body uses while at rest). . They are better than sedentary activities but not as healthy as vigorous activities.9 METs.” Your armband and pedometer/watch will help tell you how many calories you are burning on the weekends that you wear it. swimming . but it is important to recognize these thoughts and challenge yourself to come up with countering and healthier ones.Appendix 11–A: HBHM Selected Patient Worksheets 431 Session 6: A Focus on Body Image Worksheet 12 Eight Steps for Building a Better Body Image Step 1: Discover your body image strengths and weaknesses. You have your own distinctive appearance and your own experience of how you look. Step 5: In this step. we will talk about the negative ways of thinking from Session 2 and learn how to identify these mental mishaps. it only prevents you from having fun. Step 8: Planning ahead for possible challenges is an important step for staying healthy. Feeling self-conscious or even ashamed about your looks impairs your ability to feel in charge of your life. Step 6: A negative body image may lead you to act in ways that protect you from uncomfortable feelings (for example. Step 3: A negative body image is emotionally draining. you feel what you think. At times (and sometimes frequently). how you see yourself will be our focus. Step 2: Why do you have a negative body image? We know that body image stems from your developmental past as well as from the current forces in your life. Most people have assumptions about the importance of looks— this can sometimes lead to trouble. Step 7: Creating a positive body image is important. How you feel about your looks is influenced by the beliefs you have about yourself. Even though someone else may see it differently. We discussed these assumptions or myths and their opposing facts. Identifying the times when you are thinking negatively is a huge first step to feeling better about yourself. not going out with friends because you don’t like the way you look). . We will focus on where your beliefs about your body image originate. It will be important to continually check in with yourself to make sure you are staying on track. the negative thoughts will come back. Avoidance can sometimes make your body image worse—after all. Step 4: Typically. Learning that these behaviors are self-defeating will be an important step for change. Can you be more aware of your mood? Can you choose to keep some of those emotions after leaving the room? Create Awareness The first step to making changes in your food choices. . You are encouraged to continue keeping a journal to help you increase your awareness of your own unique needs. selfish. you begin to feel that emotion. happy. and humorous. jealous. You have already been doing this by keeping a journal. You can also decide how much you want to turn each knob. What knobs would you choose? Would you turn them all the way? Let’s assume you step out of the room and are back to your normal self. Keeping a journal will also show you that you don’t have to “go on a diet” and “exercise all of the time” to lose weight. There are a set of knobs on the wall. and each one has a different label: angry. You can choose to turn any or all of the knobs. and when you feel most positive.432 Cognitive-Behavior Therapy for Children and Adolescents Session 7: Being More Self-Aware Worksheet 13 Activity: Pretend you are in a room all by yourself and the door is closed. such as which foods give you lasting energy and more satisfaction. greedy. and mood begins with increasing your awareness of your current habits. As you turn each knob. what types of physical activity you enjoy. but a balanced approach to healthy living will support you in feeling your best—physically and emotionally. sad. You may have found from your own experience with logging that this has been an important tool for raising your awareness in many areas. physical activity. how are you different? Is there anyone in particular who you would like to thank for his or her support throughout this process? If so.Appendix 11–A: HBHM Selected Patient Worksheets Booster Session 3: Reflection Activity Worksheet 14 Reflection Activity: You have come a long way. We would like to hear your reflections about this process. who and why? For our purposes. can you please provide feedback on the intervention delivered? • Are there any changes you would recommend? • How was it to work with your coach? • Would you recommend this intervention to someone else? Anything else you would like to tell us about this process? 433 . What helped you make positive changes? How could this process have been better? Compared to the beginning of these sessions. This page intentionally left blank . Powell. 435 . Rachel E. includes the diagnosable disorders of oppositional defiant disorder (ODD) and conduct disorder (American Psychiatric Association 2000). ABPP Nicole P. sometimes in unwitting ways from the adults and peers around these chil- S This chapter has a video case example on the DVD (“Disruptive Behavior”) demonstrating CBT for an adolescent with oppositional defiant disorder. and rule-breaking behaviors typically have poor abilities to self-regulate and inhibit their prepotent impulsive and antisocial behaviors. These externalizing behaviors lead to external social reinforcement.D. Boxmeyer.A. Caroline L. and delinquent behavior. THE focus of this chapter. Children with these recurrent patterns of hostile. Ph. disruptive behavior disorders (DBD) in children and adolescents. disobedient. Ph.D. Lochman..D. Ph. M. Baden.12 Disruptive Behavior Disorders John E. noncompliant. as well as behavioral patterns of aggressive. the parenting component of these interventions has been shown to produce particularly robust reductions in conduct problems and delinquent behaviors (Beauchaine et al. 2002. Research on cognitive-behavior therapy (CBT) programs has examined CBT interventions that have both parent and child components and CBT interventions that focus only on parents or only on children. These other programs target many of the same cognitive. 1992.90) for cognitive-behavioral interventions targeting conduct problems (for review.47–0. and can be maintained by children’s social-cognitive processes (Matthys and Lochman 2010).436 Cognitive-Behavior Therapy for Children and Adolescents dren. 2005. Webster-Stratton and Hammond 1997). and behavioral processes that are the focus of the Coping Power Program. Empirical Research Several reviews have examined the efficacy of psychosocial treatments for conduct problems in children and adolescents in comparison to no treatment or wait-list control conditions (Kazdin 2005. Lochman and Wells 2004). research suggests that cognitive-behavioral interventions that include a child component focusing on social problem-solving and social skills development together with a parent-management training component produce broader positive effects and better maintenance of behavioral improvements over time than interventions with either component in isolation (Kazdin et al. Meta-analytic reviews suggest a range of medium to large effect sizes (0. Farmer et al. In addition. emotional. a CBT program for preadolescent children with disruptive behaviors. We will also provide an overview of results of several other examples of treatment and prevention programs with substantial cognitive-behavioral elements for children with DBD. and most cognitivebehavioral programs have substantial operant reinforcement elements. These reviews indicate that a vast majority of the empirically supported treatments for conduct problems in youth are based on behavioral or cognitive-behavioral theoretical frameworks (Brestan and Eyberg 1998. Parent-only interventions are more likely to be delivered to families with younger children with DBD.g. Kazdin and Weisz 1998. Lochman and Pardini 2008). Many traditional behavioral programs have cognitive-behavioral elements (e. we will first briefly summarize the results of intervention research with the Coping Power Program. so that there are few strictly behavioral or strictly cognitive programs in this area of psychopathology. Nock 2003. In the sections below. and as a group.. Nock 2003). stress management sessions during behavioral parent training). However. these programs cover three different developmental peri- . see Nock 2003). using path analytic techniques.to sixth-grade children in school or clinic settings. 2004). were most apparent for the children and parents who received the full Coping Power Program with child and parent components (Lochman and Wells 2004). substance use. 2007). 2008. 2007). children’s attributional biases. the Coping Power Program produced decreases in self-reported delinquency. Coping Power reduced the overt aggression of children with ODD or conduct disorder in Dutch outpatient clinics in comparison with care-as-usual children (van de Wiel et al. 2008). their perceptions of their parents’ consistency. indicate that the intervention effect for both intervention groups on outcomes at the 1-year follow-up were mediated by intervention-produced improvements in children’s internal locus of control. Later in the chapter. Wells et al. in comparison with the control group. and children’s expectations that aggression would not work for them (Lochman and Wells 2002). and aggressive behavior at school at follow-up assessments 1 year after the end of intervention (Lochman and Wells 2003.Disruptive Behavior Disorders 437 ods (Matthys and Lochman 2010). Other dissemination studies have found that Coping Power reduces externalizing behavior problems in comparison with control groups when implemented by regular school counselors in urban and suburban settings (Lochman et . In contrast. Mediation analyses. but has been successfully adapted for younger and older children. Long-term follow-up analyses of this sample 4 years after the end of intervention indicated that the Coping Power Program also had preventive effects by reducing adolescent marijuana and cigarette use in children who participated in the Coping Power Program in comparison with care-as-usual children (Zonnevylle-Bender et al. In a dissemination study that used a clinical sample. person perception. Results indicated that the Coping Power intervention effects on lower rates of parent-rated substance use and of delinquent behavior at the 1-year follow-up. boys’ teacher-rated behavioral improvements in school during the follow-up year appeared to be primarily influenced by the Coping Power Child Component. the other with both boys and girls). discussion of the Coping Power Program components will provide the structure for the discussion of CBT techniques for children with DBD. In comparison to randomly assigned control groups in two separate samples (one sample with only boys. Coping Power Program The Coping Power Program was derived from earlier research on the Anger Coping Program (Lochman 1992). Coping Power was originally designed to be implemented with fourth. Coping Power has cognitive-behavioral child and parent components (Lochman et al. and increases in positive parenting in comparison with wait-list control conditions (Webster-Stratton and Hammond 1997. The parent training component has repeatedly produced significant reductions in child conduct problems at home. Coping Power in dissemination studies has also been found to reduce children’s disciplinary suspensions from schools (Cowell et al. child. Research findings regarding the effectiveness of the Incredible Years parent. evidence suggests that overall improvements evident in reductions in children’s behavior problems as the result of the parenting intervention can still be seen at 3-year follow-up (Webster-Stratton 1990). Programs in the Preschool and Early Childhood Years Universal Prevention Programs The Promoting Alternative Thinking Strategies (PATHS) program is an example of a teacher-delivered universal prevention program that seeks to promote general social-emotional competencies and cognitive skill building in elementary school children (Greenberg and Kusché 2006). and had reported decreases in self-reported and teacher-reported conduct problems and externalizing behavior compared with children in control groups (Greenberg and Kusché 2006. in school with teachers. and when used with specialized populations. were better at problem solving. 2008). Results at 1. 2009). 2001). a child training program (Dinosaur School). The Incredible Years child intervention has also been shown to produce significant reductions in the amount of conduct problems children exhibit at home and school and to produce increases in social problem- . Peterson et al. 2008. In addition. and teacher training interventions alone and in combination have been impressively replicated across multiple samples. Treatment and Targeted Prevention Programs The Incredible Years program includes parent training. 2006a). when used with children with DBD in Puerto Rico (Cabiya et al. Webster-Stratton et al.438 Cognitive-Behavior Therapy for Children and Adolescents al. decreases in negative parenting.and 2-year follow-up indicated that children receiving the PATHS intervention were better at understanding emotions. Greenberg et al. such as deaf children who have aggression problems in residential settings (Lochman et al. when used with aggressive children in a more abbreviated 24session format (Lochman et al. and with peers. 2001). and a teacher component for young children with DBD (Webster-Stratton 2005). 2004). 2009). 1999). and more recent versions of the intervention have also included parent training and child problem-solving and social skills training (Hawkins et al. Longitudinal research conducted with the SSDP has found significant prevention or reductions of alcohol use (Hawkins et al. 1992). and decreased reports of pregnancy for females and causing pregnancy for males (Hawkins et al. 1992). as compared with PSST or parent-focused interventions alone (Kazdin et al.Disruptive Behavior Disorders 439 solving skills in comparison with wait-list control conditions (WebsterStratton and Hammond 1997. 1999). The SSDP includes training for teachers to increase the use of nonpunitive classroom behavioral management strategies such as positive reinforcement. improved academic achievement. This program is targeted for school-age children ages 7–13 years who have severe antisocial behavior. Treatment and Targeted Prevention Programs A program similar in structure to the Coping Power Program in the preadolescent age range is the Problem-Solving Skills Training Plus Parent Management Training (PSST+PMT) program. a combination of both treatments is optimal for most outcomes (Kazdin et al. reductions in delinquency. Lonczak et al. . Webster-Stratton et al. this program has a component addressing parent training and a component addressing prosocial problem-solving skills among children with DBD. and less student-reported school misbehavior (Hawkins et al. 2001). 1999). In addition. Similar to Coping Power. students receiving the prevention program reported more positive feelings and stronger commitment to school compared with control groups. Although PSST has been found to do better than parent management training at increasing children’s social competence at school and reducing self-reports of aggression and delinquency. 2004). The combination of PSST with a parent-focused intervention was found to produce the greatest improvements in statistical and clinical significance in reducing children’s aggressive and delinquent behaviors. a lower frequency of sexual intercourse and number of sexual partners. The inclusion of both child and parent components produced the most significant improvements in children’s behavior at 1-year follow-up (Webster-Stratton and Hammond 1997). 1999. Programs in the Preadolescent Years Universal Prevention Programs The Seattle Social Development Project (SSDP) is a universal prevention program designed to reduce aggression by creating a positive school environment. youth in psychiatric crisis (i. improvements in family functioning at posttreatment. adolescent sexual offenders. marijuana.440 Cognitive-Behavior Therapy for Children and Adolescents Programs in the Adolescent Years Universal Prevention Programs The Life Skills Training Program is an example of a universal prevention program designed to prevent substance abuse in adolescents (Botvin and Griffin 2004).and communitybased treatment program that has been implemented with chronic and violent juvenile offenders. The program has been shown to be highly effective in reducing alcohol. homicidal. Several investigations have shown that families who receive MST report lower levels of adolescent behavior problems.g. and polydrug use in a series of randomized controlled efficacy trials and in two effectiveness studies. has indicated reductions in aggressive and disruptive behavior and improvements in problem-solving abilities. family. with adolescents in in-school programs for multisuspended youth and in inpatient and incarcerated settings.. Conceptual Framework A contextual social-cognitive model serves as the basis for many CBT programs for children and adolescents with DBD and is based on empirically . and maltreating families (Henggeler and Lee 2003). contingency management. school. substance-abusing juvenile offenders. Multisystemic therapy (MST) is an intensive family. 1995. cognitive reflectivity. 1992). and community (Henggeler et al. 1992). behavioral contracting). Evaluations of the effectiveness of MST with chronic and violent juvenile offenders have produced promising results. and adultrated impulsivity and self-control (Feindler and Ecton 1986). social skills. Although the techniques used within these treatment strategies can vary. including their peers. and lower recidivism in a 4-year follow-up in comparison with alternative treatment conditions (Borduin et al.. tobacco. many of them are either behavioral or cognitive-behavioral in nature (e. Treatment Programs The Art of Self-Control is a cognitive and behaviorally oriented group (and individual) adolescent control program (Feindler and Ecton 1986). Henggeler et al. Outcome research for this program.e. suicidal. The program was developed for middle school students. psychotic). MST is an individualized intervention that focuses on the interaction between adolescents and the multiple environmental systems that influence their antisocial behavior. 4) unclear directions and commands. and 6) lack of parental supervision and monitoring as children approach adolescence. and race and gender appear to moderate the relation between peer rejection and negative adolescent outcomes. The relations between parenting factors and childhood aggression are bidirectional. ranging from poverty to more general stress and discord within the family (Loeber and Stouthamer-Loeber 1998). as child temperament and behavior also affect parenting behavior (Fite et al. The match between the race of students and their peers in a classroom influences the degree of social rejection that students experience (Jackson et al. 1992) include 1) nonresponsive parenting at age 1. Family Factors A wide array of factors in the family can affect child aggression. 3) harsh. Lochman and Wayland (1994) found that peer rejection ratings of African American children within a mixedrace classroom did not predict subsequent externalizing problems in adolescence. such as parent criminality. 5) lack of warmth and involvement. Malleable risk factors that are incorporated into CBT interventions include risks in the family context. and in turn. Aggressive children who are also socially rejected exhibit more severe antisocial behavior than children who are either aggressive only or rejected only (Lochman and Wayland 1994). Parenting processes linked to children’s aggression (Patterson et al. Children’s aggression has been linked to general family background factors. they can experience an accumulation of risk factors. in the peer context. can influence child behavior through their effect on parenting processes. substance use and depression. Similarly. poverty. especially for children with difficult temperaments. inconsistent discipline. 2) coercive.Disruptive Behavior Disorders 441 identified risk factors that predict children’s antisocial behavior (Lochman and Gresham 2008). For example. whereas peer rejection ratings of white children were associated with future disruptive behaviors. with the pacing and consistency of parent responses not meeting children’s needs. build on one another. and stressful life events. whereas peer rejection can pre- . increasing the probability that they will eventually display serious antisocial behavior (Loeber 1990). 2006). Peer Factors Children with disruptive behaviors are at risk for being rejected by their peers. All of these family risk factors interrelate with one another. 2006). As children develop. escalating cycles of harsh parental demands to child noncompliance starting in the toddler years. and in social cognitive processes and emotional regulation. children’s physiological arousal. stresses the reciprocal interactive relationships among children’s initial cognitive appraisal of problem situations. based on social information processing theory (Crick and Dodge 1994). Aggressive children have cognitive distortions at the appraisal phases of social-cognitive processing because of difficulties in encoding incoming social information and in accurately interpreting social events and others’ intentions. it can fail to do so with girls (MillerJohnson et al. and community. Adolescents who have been continually rejected from more prosocial peer groups because they lack appropriate social skills turn to antisocial cliques for social support (Miller-Johnson et al. which guide the maladaptive action-oriented and nonverbal solutions they generate for perceived problems (Dunn et al. A contextual social-cognitive model (Lochman and Wells 2002).and revenge-oriented social goals (Lochman et al. as they excessively infer that others are acting toward them in a provocative and hostile manner (Dodge et al.442 Cognitive-Behavior Therapy for Children and Adolescents dict serious delinquency in boys. it may be difficult for children to extricate themselves from aggressive behavior patterns. In the appraisal phases of information processing. 1993). As children with conduct problems enter adolescence. 1999). peers. they tend to associate with deviant peers. The tendency for aggressive children to associate with one another increases the probability that serious antisocial behavior will later occur (Fite et al. They tend to have dominance. The level of physiological arousal will depend on the individual’s biological predisposition to become aroused and will vary depending on the interpretation of the event (Williams et al. operate to intensify the fight-or-flight response. 1997. Because of the ongoing and reciprocal nature of interactions. and reactively aggressive children have a hostile attributional bias. 1997. 2003). Lochman and Dodge 1994). and interfere with the generation of solutions. and contextual experiences with family. The level of arousal will further influence social problem-solving. aggressive children have been found to recall fewer relevant nonhostile cues about events (Lochman and Dodge 1994). and their behavioral response. their efforts to think about solutions to the perceived problems. 1999). children begin to form stable patterns of processing social information and regulating their emotions. Aggressive children also have cognitive deficiencies at the problemsolution phases of social-cognitive processing. . Social Cognition On the basis of children’s temperament. Lochman and Dodge 1994). biological dispositions. 2007). school-age children. rewards. the program is also appropriate for younger elementary and middle school students. Nonetheless.Disruptive Behavior Disorders 443 Aggressive children frequently have low verbal skills. As noted earlier. children’s schematic beliefs and expectations affect each of these information processing steps (Lochman and Dodge 1998. teacher consultation) and program length.. Coping Power groups typically include five to seven students and two coleaders. 1997) and for youth who have callous-unemotional traits consistent with early phases of psychopathy (Pardini et al. and adolescents. 2003). they evaluate aggressive behavior in a positive way at the next processing step (Crick and Werner 1998) and expect it will lead to positive outcomes for them (Lochman and Dodge 1994). parent training. most CBT programs for youth with conduct problems incorporate common elements such as goal setting. the program has been successfully adapted for use with individual students and for implementation in clinical settings.through sixth-grade students. and a number of CBT programs have been developed for this purpose. one of whom takes on the role of delivering the program content while the other coleader monitors and manages group behavior. managing anger. using the Coping Power Program as an example. Deficient beliefs at this stage of information processing are especially characteristic for children with proactive aggressive behavior patterns (Dodge et al. 1999). Still other differences among CBT programs involve the inclusion of multiple components (e.g. Indeed. whereas others are designed to treat youth with clinical diagnoses. CBT programs are available for preschool-age children. Application Cognitive-behavioral interventions are frequently applied to the treatment of conduct problems in children and adolescents. cognitivebehavioral elements for treatment are described. Originally designed for delivery to small groups of students in schools. 2008) is a 34session manualized cognitive-behavioral intervention targeting aggression and other disruptive behaviors in fourth. Coping Power Child Component The Coping Power Child Component (Lochman et al. With minor modifications. When aggressive children consider possible solutions to socially challenging situations. which contributes to their difficulty in accessing and using competent verbal assertion and compromise solutions. Some CBT programs focus on prevention of conduct problems. In the following sections. . Zelli et al. and problem solving. In the school setting. At the end of the week. and handling peer pressure (examples of these activities are discussed later in this chapter in the section “Main Foci”). students and leaders work together to identify an individualized. “I will complete my math class work before going to the computer”). and for completion of program-related activities between sessions (e. for appropriate participation in group activities. Opening Activities At the beginning of each session. Next. When disruptive behaviors continue after this consequence is delivered. students may be excused from the remainder of the session. anger management. operationally defined target behavior (e. incorporating rewards for appropriate behavior and consequences for disruptive behaviors. On a daily basis. Sessions are highly structured.. teachers provide written and verbal feedback to the child. perspective taking. session-specific activities in between. but students are encouraged to delay gratification and work toward accumulating points to purchase more desirable items. and students lose the opportunity to earn a point after three such warnings. emotion awareness. students bring their . The Coping Power Child Component curriculum comprises seven main foci: goal setting. ask students to recall key points from the previous session. At the end of each session.444 Cognitive-Behavior Therapy for Children and Adolescents Coping Power group leaders meet with students individually on a monthly basis to build rapport. as described later in the section “Goal Setting”).g. working toward individual goals. Each week. A token economy forms the basis of the behavior management system. organization and study skills.. Students earn points for following group rules. ask students to produce their weekly goal sheets for review. assess and ensure comprehension of material. serving as the main tool by which students practice target behaviors between sessions. and conduct a brief review of the previous session’s content. following a standard format of recurring opening and closing activities with topicbased. Group Behavior Management A group behavior management system is included in the program. students are given the opportunity to visit the program’s prize box.g. and individualize the program as needed. The goal sheets are an integral part of the Coping Power Program. leaders also maintain regular communication with classroom teachers. social problem-solving. Leaders provide warnings or “strikes” for inappropriate behaviors. Small prizes worth only a few points are available. Goal sheets also provide students and leaders with feedback about the students’ behavioral progress in the classroom. . to raise Cs to Bs.g. local business owners. the Coping Power Child Component includes two sessions that directly address students’ study habits.Disruptive Behavior Disorders 445 goal sheets to the Coping Power meeting and are awarded one point for each day the goal was achieved. and allow students to spend or save their points. to be promoted to the next grade). providing coaching and support as needed. Given the frequency with which externalizing problems co-occur with behavioral difficulties in the school setting. This activity serves as a reward for the students as well as an opportunity for leaders to observe peer interactions. ask each student to provide positive feedback to another student in the group. then help students to identify personally meaningful long-term goals to work on for the current school year (e. Main Foci Goal setting. Other activities in the goal-setting component involve students interviewing or listening to an interview with an adult who set goals during his or her youth and later achieved them. Obtain input from teachers. Organization and study skills. Students who fail to earn the free-play period use the time to discuss their difficulties with a leader and to problem-solve better choices for future meetings. For example. Students can then use these short-term goals on the weekly goal sheets. and college athletes can be effective role models for this task. The initial Coping Power Child Component sessions introduce the concept of goal setting. a theme that is continued for the duration of the program. bringing books home. Have students discuss the impor- . commenting on the student’s prosocial behavior during the meeting or on a time the other child used appropriate coping between the previous and current meetings. a student who strives to raise his or her grades might identify daily short-term goals such as accurately writing down homework assignments. Students may work on a short-term goal for 1 week or several weeks. Closing Activities At the end of each session. Community leaders. review points earned by each student during the meeting. announce point totals. until they have mastered the goal or until it is apparent that the goal requires modification for the student to achieve success. Finally. and completing and turning in homework. Assist students in breaking down these long-term goals into manageable steps. award a brief free-play period to all students who have displayed appropriate behavior during the meeting. Next. pencil. Next. By concentrating on the task.446 Cognitive-Behavior Therapy for Children and Adolescents tance of organization to academic success and participate in activities that highlight the effectiveness of good organization. Emotion awareness. Anger management. have students participate in distraction exercises in which they practice directing their focus away from an annoying situation. have students use a thermometer analogy to help them recognize the range of intensity with which emotions occur. classroom noise may cause them to feel annoyed and a teacher’s reprimand may lead them to feel mad. To help them manage low levels of anger. such as progressive muscle relaxation exercises and guided imagery. Other activities involve identification of helpful and unhelpful study habits and planning for completion of larger projects. relaxation. As a precursor to anger management training. noting the decreased time and effort required to locate items when the backpack has been organized. including distraction. failing to recognize the range in intensity of their experience and resultantly missing early opportunities to manage their angry feelings. ask students to bring their backpacks to the meeting and direct them to find a common item (e. Next. Games and role-plays are used to bring the concepts to life for students. students participate in several sessions designed to normalize the experience of various emotions and to help them accurately recognize and label their feelings. For example. “mad” in the middle. list of spelling words) as quickly as possible.. . and “furious” at the top).. and coping self-statements. Students learn several active strategies for selfcontrol in the anger management unit.g. whereas they may become furious when peers make disparaging comments about their family members. then complete the activity again. For example. other group members can be directed to make noise and taunt a target student while he or she engages in a memorization task. Help students to describe various emotions in terms of associated physiological sensations.g. Subsequently. Labels are given to emotions at varying levels on the thermometer (e. “annoyed” at the bottom. teach relaxation techniques. the student learns that he or she can keep his or her anger from escalating and that thinking about or doing other things can be an effective way to control angry feelings. behaviors. Additionally. For example. students can implement anger management skills before they become flooded with emotion and while their anger is still at a manageable level. These activities are helpful to students who might experience their feelings in an on-off manner. help students to organize their materials. Assuming they have learned to recognize their earliest signs of anger in the emotion awareness sessions. use the thermometer analogy to help students recognize that different events may evoke different levels of anger for them. and cognitions. Using puppets keeps the task fairly impersonal. The differing viewpoints highlight how the same event can be perceived differently by different people. In the third and final step.. For example. behavioral terms. In the initial activities. Although the activity can be challenging for leaders and students. students can be asked to interview a teacher. In the second step. make sure to encourage students to consider more benign alternatives. have students act out a situation and then interview each other about their perceptions of the events. “I won’t let this get to me”) to manage their anger. Perspective taking. make the task more challenging by having one student use coping statements in response to direct taunts by other group members. the experience of appropriately managing anger in a real-to-life situation can be particularly salient and corrective for students. The clinician can engage students in discussions and role-plays to illustrate individual differences in perspectives. Because the tendency to make hostile inferences about others’ intentions is common among Coping Power participants. help students learn to carefully assess the problem situation and to define the problem in objective.g. and 3) Consequences. and accept even “bad” choices as discussion points for the next step. In the first step. Work with students to develop mastery in the use of a structured social problem-solving model. have students generate a list of possible choices that could be enacted in response to the problem. Provide coaching or interrupt the activity if students demonstrate problems maintaining control. PICC. Lead activities involving perspective taking in peer relationships and in interactions with teachers. Closely monitor this activity. 2) Choices. The next set of sessions targets the problems with perspective taking commonly seen in children with disruptive behavior problems. For example. as it is designed to elicit mild to moderate levels of anger in students. Social problem-solving. The PICC model comprises three steps: 1) Problem Identification. ask students to discuss the likely consequences for each of the choices that have . Lead additional roleplays and games to foster awareness of how difficult it can be to accurately understand another person’s intentions. asking questions that allow the teacher to correct common student misperceptions about disciplinary procedures and classroom management. in problem situations.Disruptive Behavior Disorders 447 A sequence of progressively more challenging activities is built into the program to teach students to use coping self-statements (e. Encourage students to think broadly about choices. When students demonstrate proficiency with the puppet task. allowing students to focus on learning the skill without eliciting strong feelings. have students use puppets to practice using self-statements in response to peer teasing. Have students discuss their involvement in groups or cliques.g. Lead students in role-plays to practice using the strategies. Although new content is introduced to parents in each session. Handling peer pressure. and teacher-student problems. write a script. generate ideas for depicting several choices and consequences.g. Ask students to self-identify personal strengths and leadership qualities and discuss how they can use their abilities to become involved with prosocial peer groups. Also discuss peer pressure that may occur outside school (e. and a main goal of this unit is for students to learn to identify and effectively manage peer-pressure situations. and family problem-solving. Include peer conflicts. Coping Power Parent Component The Coping Power Parent Component includes sixteen 90-minute sessions that are held during the same 16. The activity provides an engaging way for students to solidify their understanding and to gain additional practice using the PICC model. Parent sessions also include a focus on stress management.448 Cognitive-Behavior Therapy for Children and Adolescents been proposed. violence and gang activity). Discuss the meaning of peer pressure and reasons students might give in to it. Finally. Use hypothetical problem situations as well as examples of problems from students’ own lives to illustrate the use of the PICC model. Have students decide on a problem situation to portray. Help students identify a variety of ways to resist peer pressure. and encourage them to consider the implications that associating with various groups might have for them. as well as the negative outcomes associated with aggressive and antisocial solutions. The final sessions in the curriculum focus on peer relationships. in students’ neighborhoods) and open the discussion to general neighborhood problems if relevant (e. work with students to create a video that explains and demonstrates the PICC model in action. such as making an excuse and finding other friends to hang around with. problems with siblings. Moreover. As a final activity in the social problem-solving unit. building family cohesion and communication. Many elements of the Coping Power parent sessions derive from well-established parent training programs and focus on nurturing positive parenting skills. have students rate the various choices and consequences and identify the solution with the highest likelihood of success. an additional aim of the parent sessions is to teach parents how to reinforce the skills their children are learning in their groups. all .. and act out their ideas on video. Parent groups are led by two coleaders and include up to 12 parents or parent dyads.to 18-month time period as the child sessions.. Clarify the benefits of choosing prosocial options. in which parents develop cognitive coping strategies for stressful events and learn to recognize the connection between cognitive perceptions and beliefs and related emotions. discuss how thoughts can contribute to feelings and subsequent behaviors in parenting situations.g. homework). an assignment notebook in which the teacher initials each homework assignment) and discuss how parent-teacher conferences might provide additional academic support for children. In the second session. The Coping Power Parent Components described below are typical of most programs for parents of youths with DBD. with an aim of adapting session activities to best address the specific problems and issues that group members present. interactive worksheets. Efforts should be made to help parents create a system that will work well for them given their particular demands. Also discuss how parents might monitor their child’s progress. Practice in session. Introduce the notion of active relaxation as a way to reduce stress.. Strategize with parents about what support structures might be useful (e. Provide parents with potential questions they might ask during these conferences.. a protected homework time.Disruptive Behavior Disorders 449 sessions include a review of previous session content and activities to facilitate the generalization of skills (e. Stress Management Introduce the topic of stress management by defining stress and leading parents through a discussion of how stress can undermine their positive parenting behaviors. Ask parents for their ideas about how they might take care of themselves to reduce stress. and ask parents to practice between sessions. Academic Support in the Home Leaders introduce the idea of a homework completion system that would allow for increased parent-teacher communication about homework and thereby promote children’s academic success. Leaders deliver this intervention in a flexible manner. role-plays. In reviewing this model.g. Brainstorm possible systems (e. Encourage parents to establish a homework system with input from their child. in which phone calls are not accepted and the television is off). and role-play with parents. It is important to acknowledge parents’ concerns about the level of time and energy required to implement these strategies..g. Emphasize that additional support structures are needed to increase children’s likelihood of homework completion. discuss time management as a way to reduce stress and introduce the cognitive model of stress and mood management. Role-play a stressful parent-child situation with . the centerpiece of this work is role-play. Antecedent Control: Giving Effective Instructions and Establishing Rules and Expectations Revisit the ABC Chart and point out the ways in which instructions can be the antecedents to compliant or noncompliant behaviors... the number of times per week they will engage with their child in a certain activity) for the coming week. whereas clear instructions often precede child compliance. Also introduce the importance of parentchild “special time” and help parents set goals for special time (e. Ineffective instructions often precede child noncompliance. engage parents in a debriefing discussion about what they think about ignoring and how they felt about the roleplays. and consequences (C).g. Leaders should first model a parent-child interaction in which the parent ignores the child’s escalating behavior. Discuss how parents might modify children’s behavior by rewarding good behavior with positive consequences..450 Cognitive-Behavior Therapy for Children and Adolescents parents and identify the thoughts and feelings that resulted in a behavioral overreaction by the parent. labeled praise) and introduce a tracking system whereby parents will become more aware of their child’s positive and negative behaviors. Although these discussions lay important groundwork.g. and Improving the Parent-Child Relationship Present the basic social learning model using an ABC Chart to introduce the concepts of antecedents (A). Work with parents to identify positive consequences (e. Basic Social Learning Theory. Identify the qualities of “good” and “bad” instructions and work with parents to identify specific examples. Praise.g. Be prepared to address negative reactions parents might have to the concept of ignoring. First define minor disruptive behavior (e. behavior (B).g. Parents should then role-play a similar scenario. changing the television channel repeatedly) and distinguish these behaviors from more serious transgressions that cannot be ignored (e. a favorite dessert.. Then discuss how to appropriately ignore. Ignoring Minor Disruptive Behavior The focus here is on managing children’s minor disruptive behaviors through ignoring. beating up a sibling). After these role-plays. “Bad” instructions include buried instruction (the instruction is buried in other un- . Also engage parents in an open-ended conversation about punishment for major misbehavior. with an aim of helping parents find alternatives to physical punishment and lengthy. and explain why physical punishment is often ineffective in curbing children’s misbehavior. location. These role-plays will give parents additional practice and aid in the generalization of skills.. Encourage parents to practice giving good instructions and monitoring whether their child subsequently complies. significant other. length). Incorporate role-plays of parents implementing these discipline techniques and children protesting.. Solicit parents’ ideas regarding punishments. In discussing rules and expectations with parents. unspecified grounding. Also emphasize the importance of keeping expectations age-appropriate. healthy parent-child relationship will become increasingly important as . Ask parents to identify the behaviors that will result in time-out and to name their time-out procedures (e. chained instructions (too many instructions at one time). vague instructions. Family ProblemSolving.g. strategize with parents about how to handle child misbehavior on the way to timeout and while in time-out. Discipline and Punishment Introduce the concept of punishment. making the bed). provide a definition of punishment. “Tommy. and Family Communication Ask group members to invite their spouse.g. A distinction is made between rules and expectations.g. you just hit your sister and that is against our behavior rules”) so that children are made more aware of the rules.. and their labeling of noncompliance. Discuss parents’ concerns for their child as he or she matures. whereas behavior expectations establish the behaviors that children should increase (e. and indirect instructions (instruction is given as a question). and discuss parents’ reactions and attitudes toward the time-out procedure. Introduce other discipline techniques..g.Disruptive Behavior Disorders 451 related talk). Introduce the time-out procedure. or other important caretakers in the child’s life to this session. such as the removal of privileges and the assignment of chores. Emphasize that having a positive. hitting). Outline the steps for time-out. their positive reinforcement of compliance. Coach parents in how to establish behavior rules and expectations at home and encourage them to track their child’s compliance. emphasize the importance of labeling rule violations (e. Behavior rules establish the behaviors that children should decrease (e. Family Cohesion Building. These differences require . the use of common assessment or intervention procedures for children and families.g. Thus. and obstacles to. Parents may model and promote the use of physically aggressive problem-solving strategies by their greater dependence on corporal punishment. Another factor that may interfere with easy dissemination of CBT techniques is that children may receive conflicting messages from parents and other authority figures (such as school personnel) about the use and value of aggression. as well as by actively teaching their children to retaliate when confronted with physically or verbally aggressive situations. Also present a communication system for helping parents monitor their child’s outings with peers.. Cultural Issues Culturally competent clinicians are those who can anticipate the culturally related appropriateness of. clinicians should attend to how contextual variables may have an effect on problem behaviors and on children’s and families’ abilities to generate a culturally relevant range of alternative solutions to their problems. Parents are encouraged to follow through with family cohesion–building activities. going to a park). Brainstorm strategies for how families might build their cohesion both in the home (e.452 Cognitive-Behavior Therapy for Children and Adolescents the child grows older. Ethnic and community factors can require some adaptations in the delivery of CBT for children and adolescents with DBD (Lochman et al. how is that negotiated? Are family members satisfied with the way they communicate? Introduce the notion of a family meeting as one way to preserve positive parent involvement in children’s lives and to tackle potential problems before they arise. family game nights) and outside of the home (e. when working with minority children and families. Describe (and show) how through worksheets and videotaped role-plays the children are coached in this problem-solving model—and encourage parents to use this model to resolve family conflicts. Lead parents through a discussion about their ongoing family communication patterns. Present the steps of the problem-solving PICC model. Guide parents through a discussion regarding how they might establish family meetings at home. especially among minority low-income individuals.. 2006b). These parents’ messages can result from their ongoing struggle to protect their children from danger in their impoverished neighborhoods and from their efforts to inculcate responsibility for safety and personal rights.g. Do family members have a way of talking with each other about their concerns? When someone wants to change a preestablished rule. way more than she does anyone else. Tim: My teacher is so mean. skill generalization. behavioral rehearsal. Tell me what happened. S Coping Power Child Component Tim is a 15-year-old boy who has been diagnosed with ODD and attentiondeficit/hyperactivity disorder (ADHD). coping self-statements. Was that enough for you to get suspended? Your mom said you spent the rest of the day in the vice principal’s office.Disruptive Behavior Disorders 453 discussion. All I did yesterday was get up to sharpen my pencil. What happened after she put your name on the board? Tim: I threw my pencil down. Tim has been seeing a psychiatrist for medication treatment for ADHD. has difficulty accepting responsibility for actions. I called her a bad name. you feel like your teacher gets onto you a lot. What was it that she got onto you about yesterday that led to you getting suspended? Tim: I KNOW my teacher gets onto me a lot. monitoring emotional activation.. increasing ability to see things from others’ perspectives. skill acquisition. and she put my name on the board. Clinician: Your mom said you got in some trouble at school yesterday. She always gets on my case. Case Examples The following two case examples illustrate key points and challenges of CBT for children with DBD addressed through the Coping Power Child Component and the Coping Power Parent Component. I wasn’t even saying it . generation of alternative solutions.g. I got fed up with her getting onto me so much and not anybody else. Clinician: So. His psychiatrist referred him to outpatient CBT when he continued to exhibit behavior problems while on stimulant medication. Behavioral techniques demonstrated: Functional behavior assessment. Clinician: So you got up to sharpen your pencil. Tim: I got suspended for disrespecting the teacher. too. Clinician: It sounds like you started feeling angry when your teacher put your name on the board and that you must have said something or done something that she thought was disrespectful enough to send you to in-school suspension. and it accidentally bounced off my desk and hit the teacher. and your teacher put your name on the board. and intervention can focus initially on the utility of less aggressive solutions in certain environments (e. Cognitive techniques demonstrated: Reducing hostile attribution bias. the child’s school). Clinical challenges: Blames others. angers easily. hitting the teacher with your pencil. Clinician: Well. She got on Jamal’s case for asking to go to the bathroom. She lets other people sharpen their pencils all the time. Clinician: That’s right. Do you think she put your name on the board just to make you mad? Tim: No. Do you remember when you interviewed your teacher to get to know her better and find out where she is coming from? Tim: Yeah. that could be it. If she hadn’t made such a big deal out of it. I forgot about her getting on Jamal’s case until just now. And what did she say about why she has rules for the classroom? Tim: So that we know what is expected of us and to help us learn. Clinician: So do you think that maybe she’s just trying to get better at enforcing her rule about staying in your seat as testing gets closer. She said that she wants us to get better about staying in our seats. Clinician: What do you remember learning about her during that interview? Tim: She didn’t like having a lot of homework when she was in elementary school. but it’s all her fault. I was just talking to myself.454 Cognitive-Behavior Therapy for Children and Adolescents to her. so let’s think about how the situation might have gone differently if you had told yourself that instead. So let’s think again about the situation that happened yesterday. She wouldn’t have even heard me say it if she hadn’t been standing right in my space. I guess maybe she could have just been trying to enforce her rule. Clinician: Is it safe to say that what happened after you got your name on the board—getting angry. what did you say to yourself when your teacher put your name on the board? . and you and Jamal happened to be the first ones who got in trouble now that she is enforcing the rule more strictly? Tim: Yeah. She should just back off and leave me alone. Clinician: OK. Clinician: Do you think she put your name on the board just because she doesn’t like you? Tim: Maybe—it sure seems like she doesn’t like me a lot of the time. By the way. so you weren’t even the only one who got in trouble for getting out of your seat? Tim: No. let’s take a look at that. Clinician: Can you think of any other reason why she might have put your name on the board? Tim: Well. And what did she say about what she wants most for her students? Tim: She wants us to enjoy learning and do well so that we can get a good education and have a good life someday. and calling her a name—caused you to get suspended? Tim: Yeah. Clinician: That’s right. none of that would have happened. Clinician: That sounds like what she said. and she even got in trouble for talking too much in class sometimes. Clinician: Oh. especially because we’re getting close to testing time. I should just not make a big deal of it right now and go back to my seat and try to borrow a pencil from Terri instead. so that was an example of how you can use your thoughts to help keep from getting so angry that you do something that causes you to get in trouble.. As your teacher in the role-play. Clinician: Good.” I said. and I felt proud of you for not getting angry or making it a big deal. and she really wants us to do a better job of staying in our seats for the next few days. Do you think it would help you to control your anger and act that way more often? Tim: Yeah. Clinician: What was it like for you to try to use a coping statement to control your anger when I wrote your name on the board? Tim: It was hard at first because I wanted to talk back to you. “She’s mean and she has it out for me. That seemed like a big improvement for you. you got really angry and threw your pencil and called her a name. you could have said to yourself. Now. Clinician: Well then. Stephens seems like she is getting nervous for our standardized testing. but when I remembered that Jamal had already gotten in trouble and that you were starting to get nervous about the testing coming up. How about if you start to respond like you did yesterday.” Tim: That probably would have been a better thing to do. it helped me calm down. “She’s a [something I can’t repeat]. and I’ll start to write your name on the board for getting out of your seat.. So how about if we act out the situation from yesterday and see how it goes? I’ll pretend I’m Mrs. I noticed that you responded differently than you usually do. When you told yourself that your teacher is mean and has it out for you. Clinician: That’s an example of a coping statement that you could have used in the situation with your teacher to control your anger and stay out of trouble. probably. but then try to catch yourself and use a coping statement instead? We’ll keep acting out the rest of the scene for a while and see how it goes. what do you think might have happened if you had noticed yourself getting angry and said a coping statement to yourself instead? Tim: Like what? Clinician: Like.” Clinician: And what happened to your anger on your anger thermometer when you said that to yourself? Tim: I got real mad and that’s when I threw my pencil. Now. (The clinician and Tim conduct a role-play of the situation. . which is what led you to get suspended. so you’ve given a really good example about the way that our thoughts are related to our feelings. Stephens. Clinician: OK.Disruptive Behavior Disorders Tim: I said. it’s much easier to talk about using coping strategies to stay calm than it is to do in real life. how can you use what we’ve been talking about today to help you have a better week? 455 . “Mrs.) Clinician: What did you think of that? Tim: It went better. and it could help you get feedback from your parents and teacher to see how you do. need for clearer behavioral contingencies to foster compliance at home. Clinician: OK. We’ll see how it goes. do you have a preference about who I meet with first today? Anna: I don’t care. why don’t I go ahead and meet with your mom first today. behavioral contingencies. Clinical challenges: Overextended mother with her own mental health and social support needs. Naomi hardly speaks with Anna at home because she is too tired when she gets off work to deal with Anna’s “attitude. Naomi (with Anna and clinician in the waiting room): Will you want to meet with me or Anna today? Clinician: I would like to meet with each of you individually for part of the time today and to spend some time with both of you together. behavioral monitoring. Clinician: All right then—because I met with you first last week. Anna’s father lives in a different state. Tim: Sure. She has received prior mental health services to deal with her own mood disorder and a past abusive relationship.456 Cognitive-Behavior Therapy for Children and Adolescents Tim: I can try to think of where the other person is coming from and try to use coping statements to stay calm instead of getting angry.” Anna currently spends most of her free time in her room. There are some games you can play in the waiting room. Clinician: How would you feel about bringing your mom in and telling her what we’ve been talking about so she knows how to help you work on your goal this week? Tim: That’s fine. so let her know if you need your mom or need anything else. stress management. is there anything else we should talk about before she comes in? Coping Power Parent Component Naomi is a 34-year-old single mother of three children. Who would you like to see first? Clinician: Anna. Clinician: That sounds like a good idea. poor parent-child bond as a result of frequent conflictual parent-child interactions. . balancing parent and child involvement in therapy. and she sees him one to two times a year. positive reinforcement. who has been getting into trouble for fighting and refusing to follow directions at school. Would that be something you might want to pick as your goal on your goal sheet for the week? Then you could earn points for working on it. tell me how your week has been. Anna: OK. extinction and planned ignoring. OK? We’ll make sure to get you in about 25 minutes. Cathy should be at the front desk the whole time. Clinician (to Naomi as they enter the therapy room): So. Cognitive and behavioral techniques demonstrated: Parent-child special time. Naomi is currently seeking treatment for her youngest daughter. Anna (age 8). Anna. Naomi: OK. I don’t have the money to let her get one at the salon. Clinician: That’s fine. and helps you out around the house. I was going to take her shopping on Wednesday night. but Anna blew up about something. Clinician: That sounds fun. puts effort into her schoolwork. so I was thinking of asking her if she would like to watch it with me instead of watching it in her room. Clinician: Would that be a good day to try to do something with Anna? Naomi: Actually. But the pedicure never happened. to make sure you’re noticing the times she follows directions. great. Clinician: That sounds like a nice thing for the two of you to do together. because money is tight right now. I had to go without pay those 2 days. How did those things go for you this week? Naomi: Not very well. I did not think it was a good idea to reward her like that. It would also be nice for you to find something the two of you can do that is interactive as well. Clinician: OK. I was pretty mad at Anna. but I have all of the stuff to give her one at home. we talked about helping you reconnect with Anna in two ways. I’m sorry to hear that. so needless to say. so let’s think about how you might be able to do that this week. 457 . I was going to do it a few weeks ago. We talked about having you try to set aside some special time to do an activity with Anna that you thought she would enjoy to help you two reestablish a positive bond. The important thing is that you make it a priority and set the time aside and find something that you think you’ll both enjoy. like taking her shopping. It’s still important to not give up on the goal of you two having some positive time together though. Clinician: Gosh. what do you think might be a fun. Now. inexpensive thing you and Anna could do on Friday? Naomi: Well. Then I had to work overtime to make up for the days I missed at work. she has been begging me to let her get a pedicure. Last week. We also talked about having you use a tracking grid to catch her being good. Clinician: Those do sound like real barriers to doing something special with Anna this week. I know you are probably exhausted at night when you get home from work. The principal really let me have it when I went to check her back in on Friday. it would because her brother and sister go to their aunt’s house for a few hours after school on Fridays. Naomi: We both like watching the same singing competition on television. I can’t even remember what it was. Do you have any ideas about what you could do? Naomi: Well. so we have not had a chance to do that yet.Disruptive Behavior Disorders Naomi: It’s been pretty rough. Are there any nights that you get home earlier or that are less hectic for you? Naomi: I’ve been trying to leave a little bit early on Friday afternoons. but when she got in serious trouble at school that day. It does sound like you had a difficult week. I had to keep Anna home from school on Wednesday and Thursday because she got in a fight. Have you ever done that before? Do you think Anna would like it? Naomi: Well. it might need to be something that doesn’t cost very much money. Clinician: Do you want to take out your calendar and do that right now? Naomi: There. For example. Maybe I could do that on Friday so I’ll be more relaxed when I hang out with Anna. . she pretty much takes care of herself a lot of the time. What will it take to make sure you have the time to do that? Naomi: I just need to write it in on my calendar like any other appointment. did you pay any more attention to Anna’s behavior? Naomi: I did pay more attention to her behavior early in the week. How do I do that? Clinician: Well. Clinician: Great.. such as following your directions. I have to confess. I just did it. Naomi: Yeah. For example. Naomi: Well. “I’m sorry to hear that. and helping you around the house. sometimes in order to keep special time special. Tell me how that went this week. if she tells you that she had a bad day at school. I did notice that there are quite a few things that she does around the house that I tend to overlook. It might also help to be cautious about how you react to things she brings up. It is easier to be more patient with them when we’ve had some time to rejuvenate ourselves. The other thing we were going to follow up on was whether you were able to pay attention to how often Anna exhibited some of the target behaviors we’ve set for her. don’t make a big deal of it. because I’m gone for work. We talked a few weeks ago about how parenting is stressful and about how our own feelings of stress affect our mood and our interactions with our children. Clinician: Even though you didn’t fill out the sheet. both the walking and the special time with Anna.” instead of jumping in with an inquiry such as “Why? Did you do something wrong?” It can help if you’re in the right frame of mind to interact calmly with her. Sorry. . you might say.. I have a coworker who is always asking me to walk with her for exercise on our lunch break. I think she helps her brother and sister with the dinner dishes some before I get home from work and she does keep her room pretty clean. you’ll have to try to keep the mood pretty light with Anna beforehand so there aren’t any major blowups. Clinician: That sounds like a great idea. She gets herself dressed for school in the morning and fixes herself breakfast. putting more effort into her schoolwork. I would really like to do it but never make time for it. honey.458 Cognitive-Behavior Therapy for Children and Adolescents Clinician: So it sounds like to make it work. it was just that kind of a week. if you don’t approve of how she’s wearing her hair when you pick her up. you’ll have to let things go with Anna that you wouldn’t ordinarily let go. before she got in trouble at school. Any chance you’ll get some time to yourself before you spend time with Anna on Friday? Naomi: Well. Clinician: Like what? Naomi: Well. I’ll check back next time and see how it goes. I forgot all about the sheet you gave me until right before we came here. Clinician: That seems like an important lesson for you to draw on in the future. Naomi: I did try that a few times this week. What did you learn from that? Naomi: I learned that it helps to pick my battles. Clinician: What I would like you to do is to make an effort to praise her for her effort around the house several times this week and then to pay attention to what effect it has on her willingness to help out around the house and also on your relationship. Would you like to use the time to tell her that you appreciate what she does to help out around the house and also to talk about what you might do together on Friday? Naomi: That sounds good. We were able to have some nice time together before bedtime several nights this week. such as telling Anna that you appreciate her effort in getting herself ready in the morning and cleaning up the kitchen at night. where even the littlest thing could lead to a big rift between us. Clinician: Great. Clinician: That’s terrific. We’ll follow up next time to see if it made any difference. It went better than I expected. I’ll try to do more of that this week. We will still need to talk about what happened at school on Wednesday. and I guess that’s what should be more important than having a perfectly clean bathroom. especially with Anna. because those are all things I think she should be doing because she’s part of the family and we all have to do our part. Naomi: Yeah. Quick labeled praise. In the past. Clinician: It’s appropriate to have expectations for your children to help out around the house. when I’ve tried to make her come back and clean these things up. Anna even cleaned out the sink on her own at one point. .Disruptive Behavior Disorders Clinician: It sounds like you noticed quite a few things that she’s doing already to help out around the house that you weren’t very aware of before. Perhaps we can use it as an opportunity for Anna to show you the approach she’s learning to stop and think about the best way to solve problems when she is angry. we’ll talk about that. 459 . Did you say anything to Anna about that? Naomi: Not really. It’s almost time for us to bring Anna back in. it’s important to recognize where she is already showing effort in this area and to provide her with some positive reinforcement.. I decided to let it go a few times this week. can you give me an example? Naomi: Yeah. Tell me about how that went this week. The other side of the equation that we talked about last time is that it can also be helpful to ignore small annoyances that could lead to a big blowup and might be better left alone. Naomi: That sounds good. I’ll go get Anna. it has led to a big blowup right before bedtime. lets her know that you notice and appreciate these things and can help her feel very encouraged.. so that you can help her use it at home. it drives me crazy when Anna tracks water in the hallway after she takes a bath and then she leaves the sink messy and sticky after she brushes her teeth. too. The difference is that in trying to improve Anna’s compliance at home. Clinician: Yes. emotional awareness and self-regulation. they generate fewer verbal assertion and compromise solutions to their social problems. The clinician and parents may reinforce appropriate behaviors that are “positive opposites” of inappropriate behaviors. When compared with their peers. The major foci of the Coping Power Child and Parent Components are described and are illustrated with case examples. is described in detail. Coping Power is based on a contextual social-cognitive model and has been tested in a series of efficacy and effectiveness studies. lack of warmth and positive attention. When evaluating their responses. • Social problem-solving is an especially common element of most evidence-based CBT programs for children with conduct problems and can be delivered through discussion. homework exercises. role-play. The Coping Power Program.460 Cognitive-Behavior Therapy for Children and Adolescents Conclusion This chapter summarizes research-supported prevention and treatment programs for DBD. • Key elements of most CBT programs include a focus on children’s behavioral goals. • Numerous deficits in social information processing and problem solving have been found. • Positive reinforcement is effective not only for increasing the amount of appropriate behaviors but also for decreasing the amount of inappropriate behaviors. Key Clinical Points • Problematic parenting practices that are especially associated with children’s aggressive behavior include harsh punishment. social problem-solving skill training. and avoidance of deviant peer processes. and they then have a bias in attributing hostile intentions to others. and poor monitoring. • Peer factors that can contribute to the development and maintenance of children’s aggressive behavior are high levels of peer rejection and involvement in deviant peer groups. they consider aggressive solutions acceptable and expect that aggressive solutions will lead to positive outcomes for them. perspective taking and attribution retraining. used in targeted prevention and treatment interventions for aggressive children. and creation of therapeutic products such as videos. Children with aggressive behavior and DBD attend to fewer nonhostile cues in social situations than their peers do. inconsistent discipline. . she can articulate appropriate responses to problems such as peer teasing. but she tends to act out aggressively when confronted with real-life problems. Identifying consequences for aggressive behaviors. Which of the following areas should Amanda’s therapist focus on first? A. B. The most effective treatment for his referral problems is which of the following? A. Intermittent explosive disorder. Cognitions. C. Cognitive-behavioral interventions with parent and child components. C.2. Behaviors. B. 12. C. Social problem-solving. When his therapist asks about his feelings. 15-year-old Tim assumes that his teacher “has it out for him” when she puts his name on the board for getting out of his seat to sharpen his pencil.3. A 10-year-old boy with a history of aggressive. Tim’s CBT-oriented clinician seeks to help him see the situation from his teacher’s perspective to modify his initial A. D. age 11. Relational aggression. B. his responses are limited to “happy” and “mad. disruptive behavior at home and at school is referred for psychological treatment. his therapist should work on helping him recognize which of the following? A.1. D.Disruptive Behavior Disorders 461 Self-Assessment Questions 12. . Cognitive-behavioral interventions with the child alone. has been referred for therapy because of her frequent angry outbursts. Relationship therapy with the child. B. 12. Anger management strategies. C. Physiological sensations. D.” In seeking to broaden his recognition of various feeling states. When she is calm. Hostile attribution bias. Amanda. Reactive attachment. David is a 10-year-old boy who attends individual therapy to address his diagnosis of oppositional defiant disorder. All of the above. 12. Perspective taking. D. Parent training alone.4. In one of the clinical vignettes in this chapter. Hart KJ (eds): Comparative Treatment of Conduct Disorder.462 Cognitive-Behavior Therapy for Children and Adolescents 12.272 kids. DC.5. Text Revision. American Psychiatric Association. Nelson MM. Boggs SR: Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. moderators. Compton SN. New York. Eyberg S: Effective psychosocial treatments for conduct-disordered children and adolescents: 29 years. 1998 Cabiya JJ. et al: Review of the evidence base for treatment of childhood psychopathology: externalizing disorders. 2010 Nelson WM III. Reid MJ: Mediators. Naomi has sought mental health services to reduce her daughter Anna’s disruptive behavior. The clinician is likely trying to help Naomi use which of the following? A. 2000 Beauchaine TP. Interam J Psychol 42:195–202. and 5. Mood management. J Clin Child Psychol 27:180–189. Suggested Readings Eyberg SM. 2008 Farmer EM. D. Gonzalez K. Discipline. Padillo-Cotto L. and predictors of 1-year outcomes among children treated for early onset conduct problems: a latent growth curve analysis. Behavioral rules and expectations. Webster-Stratton C. 2004 Brestan E. 4th Edition. J Consult Clin Psychol 70:1267–1302. Washington. 2008 . 2005 Borduin CM. Finch AJ. Springer. 2002 Matthys W. et al: Multisystemic treatment of serious juvenile offenders: long-term prevention of criminality and violence. J Clin Child Adolesc Psychol 37:215–237. J Consult Clin Psychol 63:569–578. The family’s CBT-oriented clinician has asked Naomi to praise Anna’s prosocial behaviors (such as following directions and helping out around the house) and to ignore minor disruptive behavior (such as whining or not cleaning out the sink thoroughly). Griffin KW: Life skills training: empirical findings and future directions. J Consult Clin Psychol 73:371–388. 82 studies. UK. Mann BJ. J Prim Prev 25:211–232. 2006 References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. Oxford. B. Contingency management. Burns BJ. C. Cone LT. Wiley-Blackwell. Lochman JE: Oppositional Defiant Disorder and Conduct Disorder in Childhood. In another clinical vignette in this chapter. et al: Effectiveness of a cognitive-behavioral intervention for Puerto Rican children. 1995 Botvin GJ. et al: A “vaccine” against violence: coping power. 1992 . Bass D: Cognitive problem solving skills training and parent management training in the treatment of antisocial behavior in children. Kosterman R. Mahwah. J Consult Clin Psychol 60:953–961. Lee T: Multisystemic treatment of serious clinical problems. 2006. Jensen PS. Smith LA: Family preservation using multisystemic therapy: an effective alternative to incarcerating serious juvenile offenders. 2006 Fite PJ. Harnish JD. Arch Pediatr Adolesc Med 153:226–234. Werner NE: Response decision processes in relational and overt aggression. J Consult Clin Psychol 60:733–747. Pergamon. 2008 Crick NR. 1998 Kazdin AE. Bumbarger B: The prevention of mental disorders in school-aged children: current state of the field. 2nd Edition. DC. 1992 Jackson MF. in Handbook of School Violence and School Safety: From Research to Practice. Ecton RB: Adolescent Anger Control: Cognitive-Behavior Techniques. Colder CR: Social problem-solving skills in boys with conduct and oppositional defiant disorders. Aggress Behav 23:457–469. Guilford. Lochman JE. Powell N. Siegel TC. Barth JM. Horstmann S. Child Dev 77:1325–1337. Melton GB. Weisz JR: Identifying and developing empirically supported child and adolescent treatments. Edited by Hibbs ED. Furlong M. 2002 Feindler EL. Domitrovich C. 1997 Farmer EM. et al: Classroom contextual effects of race on children’s peer nominations. 1986 Fite PJ. Dodge KA: A review and reformulation of social information-processing mechanisms in children’s social adjustment. American Psychological Association. and family based treatment of aggressive and antisocial child behavior. Linebarger J. Catalano RF. J Consult Clin Psychol 66:19–36. et al: Pathways from proactive and reactive aggression to substance use. Edited by Jimerson SR. in Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice. Lochman JE. Washington. Pediatr Rev 29:362–363. Weisz JR. 1998 Dodge KA. 2003. in Evidence-Based Psychotherapies for Children and Adolescents. pp 301–322 Henggeler SW. Psychol Addict Behav 21:355–364. Psychol Bull 115:74–101. New York. 1999 Henggeler SW. Colder CR. Compton SN. parent. et al: The mutual influence of parenting and boys’ externalizing behavior problems. Lochman JE. Burns BJ.Disruptive Behavior Disorders 463 Cowell K. NJ. Prevention & Treatment. Colder CR. Kusché CA: Building social and emotional competence: the PATHS curriculum. Child Dev 69:1630–1639. Lochman JE. New York. 1994 Crick NR. pp 395–412 Greenberg MT. 2006 Kazdin AE: Child. J Appl Dev Psychol 27:151–164. et al: Preventing adolescent health-risk behaviors by strengthening protection during childhood. 2007 Greenberg MT. et al: Reactive and proactive aggression in school children and psychiatrically impaired chronically assaultive youth. et al: Review of the evidence base for treatment of childhood psychopathology: externalizing disorders. pp 445–476 Kazdin AE. J Consult Clin Psychol 70:1267–1302. Edited by Kazdin AE. J Abnorm Psychol 106:37–51. 1997 Dunn SE. Erlbaum. 2005. March 2001 Hawkins JD. Gage SM. and boys’ age. J Am Acad Child Adolesc Psychiatry 33:1026– 1035. Am Psychol 53:242– 259. pp 29–57 Lochman JE. pp 33–81 Lochman JE. Edited by Kendall PC. et al. Behav Ther 34:493–515. Boxmeyer C. Wayland KK: Aggression. 1992 Lochman JE. in Rutter’s Child and Adolescent Psychiatry. Wells KC: The Coping Power Program for preadolescent aggressive boys and their parents: outcome effects at the 1-year follow-up. Powell N. 1998 Lochman JE. New York. et al: Masked intervention effects: analytic methods addressing low dosage of intervention. 1994 Lochman JE. 1990 Loeber R. J Consult Clin Psychol 62:366–374. 1994 Lochman JE. Dev Psychopathol 14:945–967. 2004 Lochman JE. Powell NR. 5th Edition. Edited by Mayer MJ. Guilford. Clin Psychol Rev 10:1–42. planning and adaptation: importance of developmental models. Journal of the American Deafness and Rehabilitation Association 35:39–61. in Child and Adolescent Therapy: Cognitive-Behavioral Procedures. 1998 . et al: Cognitive-behavioral assessment and treatment with aggressive children. assessment. 1993 Lochman JE. J Consult Clin Psychol 72:571–578. White KJ: Social goals: relationship to adolescent adjustment and to social problem solving. in Cognitive-Behavioral Interventions for Emotional and Behavioral Disorders: School-Based Practice. 2002 Lochman JE. Whidby JM. 2003 Lochman JE. Blackwell. 3rd Edition. Lenhart LA: Coping Power Child Group Program: Facilitator L01 Guide. Pine D. J Abnorm Child Psychol 21:135–151. et al.464 Cognitive-Behavior Therapy for Children and Adolescents Lochman JE: Cognitive-behavioral intervention with aggressive boys: three year follow-up and preventive effects. 2009 Loeber R: Development and risk factors of juvenile antisocial behavior and delinquency. Edited by Rutter M. London. 2001 Lochman JE. Wells KC: Contextual social-cognitive mediators and child outcome: a test of the theoretical model in the Coping Power program. New Directions for Evaluation 110:19–32. et al: Effects of social-cognitive intervention for aggressive deaf children: the Coping Power Program. Van Acker R. Wayland KK. 2008. pp 1026–1045 Lochman JE. Dodge KA: Distorted perceptions in dyadic interactions of aggressive and nonaggressive boys: effects of prior expectations. Dev Psychopathol 10:495–512. Stouthamer-Loeber M: Development of juvenile aggression and violence: some common misconceptions and controversies. Dodge KA: Social-cognitive processes of severely violent. Boxmeyer C. New York. 2006b. 2008 Lochman JE. Gresham FM: Intervention development. Powell N. 2006a Lochman JE. Oxford. moderately aggressive and nonaggressive boys. et al: Dissemination of the Coping Power program: importance of intensity of counselor training. J Consult Clin Psychol 77:397–409. Wells KC. context. FitzGerald DP. 2008. New York. social acceptance and race as predictors of negative adolescent outcomes. Lochman JE. Wells KC: Effectiveness study of Coping Power and classroom intention with aggressive children: outcomes at a one-year follow-up. Pardini DA: Cognitive-behavioral therapies. Guilford. Bishop D. J Consult Clin Psychol 60:426–432. 1990 Webster-Stratton C: The incredible years: a training series for the prevention and treatment of conduct problems in young children. Coie JD. Matthys W. 2010 Miller-Johnson S. Wiley-Blackwell. Catalano R. Matthys W. Eugene. J Pers Soc Psychol 77:150–166. van de Wiel NM. New York. Hamilton EB. Lochman JE: Oppositional Defiant Disorder and Conduct Disorder in Childhood. 2003 Pardini DA. Jensen PS. Maumary-Gremaud A. Oxford. 2nd Edition. child. Dishion TJ: Antisocial boys. J Consult Clin Psychol 65:93–109. 2005. 1999 Nock MK: Progress review of the psychosocial treatment of child conduct problems. Clinical Psychology: Science and Practice 10:1–28. Edited by Hibbs ED. 2004 Wells KC. et al: Aggressive and nonaggressive boys’ physiological and cognitive processes in response to peer provocations. 2007 Webster-Stratton C: Enhancing the effectiveness of self-administered videotape parent training for families with conduct-problem children. Lochman JE. Cohen-Kettenis PT. J Clin Child Adolesc Psychol 32:568–576. 1992 Peterson MA. Reid JB. DC. J Abnorm Child Psychol 18:479–492. Journal of Applied School Psychology 25:183–196. 1997 Webster-Stratton C. et al: Relationship between childhood peer rejection and aggression and adolescent delinquency severity and type among African American youth. UK.Disruptive Behavior Disorders 465 Lonczak HS. Castalia. Lenhart LA: Coping Power Parent Group Program: Facilitator Guide. OR. Frick PJ: Callous/unemotional traits and social cognitive processes in adjudicated youth. Lochman JE. 2007 . Huang B. Behav Modif 31:298–312. Reid MJ. Dodge KA. et al: Preventive effects of treatment of disruptive behavior disorder in middle childhood on substance use and delinquent behavior. Oxford. et al: The social predictors of adolescent alcohol misuse: a test of the social development Model. Hammond M: Treating children with early onset conduct problems: a comparison of child and parent training interventions. Russell AD: Starting well: facilitating the middle school transition. et al: The effectiveness of an experimental treatment when compared with care as usual depends on the type of care as usual. 1999 Zonnevylle-Bender MJS. Lochman JE. et al: The distinction between beliefs legitimizing aggression and deviant processing of social cues: testing measurement validity and the hypothesis that biased processing mediates the effects of beliefs on aggression. in Psychosocial Treatments for Child and Adolescent Disorders: Empirically Based Strategies for Clinical Practice. 2003 Zelli A. 2001 Matthys W. Phillips NC. J Clin Child Adolesc Psychol 33:105–124. 2008 Williams SC. and teacher training. J Am Acad Child Adolesc Psychiatry 46:33–39. J Am Acad Child Adolesc Psychiatry 42:364– 371. J Emot Behav Disord 7:137–146. J Stud Alcohol 62:179– 189. American Psychological Association. Washington. pp 507–555 Webster-Stratton C. Lochman JE. 2009 van de Wiel NM. 2003 Patterson GR. Hammond M: Treating children with early onset conduct problems: intervention outcomes for parent. This page intentionally left blank . and forced urinesoaked pajama wearing are among the many aversive treatments reported in a review of ancient approaches to incontinence (Glicklich 1951).D. Thomas M. and clothing coupled with ineffective methods for managing infection. Reimers. ALTHOUGH incontinence continues to be one of the leading causes of child abuse in this country. John Paul Legerski. Another concern may have been the unpleasant olfactory sensations resulting from close contact with soiled bedding and clothing in homes where air circulation may have been poor.D.13 Enuresis and Encopresis Patrick C. Friman. Ph. The health-based consequences of prolonged incontinence during that time could be severe due to the limited means for cleaning bedding. beds. But perhaps the question of whether incontinence was a bigger threat to health in antiquity than it is now could at least partly explain why treatments were so harsh. children with urinary or fecal accidents today fare much better than children of antiquity. Ph. buttock and sacrum burning. Fortunately for many in467 . The methods then used to attain continence seem freakishly harsh given the benign nature of the problem. Penile binding. Ph.D. practitioners and parents have mostly abandoned physically harsh treatments for incontinence and now use methods that are much more humane from a physical perspective and much more effective from an outcomes perspective. The chapter is divided into two sections. American Psychiatric Association 2000) include repeated urination into beds or clothing at least twice a week for at least 3 months after the age of 5 years or the attainment of a 5-year level of development if the child has a developmental disability. The diagnostic criteria in the Diagnostic and Statistical Manual for Mental Disorders. and challenges to treatment. the ac- . First. For example. it does play a role. Although the cognitive dimension of CBT is minimal in CBT treatment of incontinence. and therefore we refer to treatments for enuresis and encopresis as CBT throughout the chapter. and to a lesser but still significant extent. one for enuresis and one for encopresis. Enuresis Diagnosis and Prevalence Enuresis is the collective term for chronic urinary accidents occurring after the conventional age of completed toilet training. The biobehavioral view has proven superior in at least two important ways. diagnosis). This is a book devoted to cognitive-behavior therapy (CBT). the most potent force was the advent of behavioral theory and the conditioning-type treatments derived from it. characterological. the implications of diversity. Behavioral theory and treatment inaugurated a veritable paradigmatic shift in the approach to and management of enuresis. or psyche. Clinicians do not have direct access to the mechanics of a child’s soul. Additionally. or psychopathological terms in favor of a biobehavioral view emphasizing genetic predispositions coupled with environmental circumstances. it leads much more directly to treatment options. Although many forces contributed to the shift in the treatment of children with incontinence. Second. encopresis. it does not disparage afflicted children to the degree that the moral. theoretical perspectives on treatment. 4th Edition. but they do have direct access to the circumstances that initiate and/or perpetuate incontinence. and psychopathological views do.468 Cognitive-Behavior Therapy for Children and Adolescents continent children (unfortunately not all). and CBT for incontinence involves the strategic manipulation of circumstances to establish continence.. behavioral theory eschewed historical tendencies to interpret incontinence in moral. and each section includes brief descriptions of the conditions (i. a brief review of empirical support. character. characterological.e. the assembly of an optimal treatment. Text Revision (DSM-IV-TR. g. and diurnal. Reviews of the literature show that the success rate of the alarm is higher and its relapse rate lower than any other method. 2008). the most frequently presenting type. Mellon and McGrath 2000). Friman 2007. Outcomes from alarmbased treatment range as high as 80% for success and as low as 17% for relapse (Christophersen and Friman 2010. Friman 2007.” Following the section on theoretical perspectives below. including drug treatment and empirically supported nondrug treatments. 2008. and 3) because there is very little published research on treatment of diurnal enuresis. 1996. as many as 8% of boys and 4% of girls are still enuretic at age 12 (Byrd et al. such as retention-control training. Among the . However. Friman 2007. 2008). Prevalence estimates range as high as 25% for 6-year-old boys and 15% for 6-year-old girls (Gross and Dornbusch 1983). This chapter will focus almost solely on primary nocturnal enuresis for three reasons: 1) because it is.. resulting in treatment “packages. mixed. Theoretical Perspectives Early psychological theory attributed the cause of enuresis to defective intrapsychic variables (Sperling 1994). diuretics) or a general medical condition. we will describe the treatment components and the treatment packages that have the most empirical support. One problem with interpreting the review literature on alarm treatment is that adjunctive components are often added to improve effectiveness. just as it is for the nocturnal type and the nocturnal portion of the combined type.Enuresis and Encopresis 469 cidents must not be directly due to the physiological effects of a substance (e. and although enuresis is much less prevalent by the teenage years. however. Empirical Support The primary active component in all empirically supported CBT treatments for enuresis is the urine alarm. 2) because empirically supported treatment is the same for primary and secondary cases. For example. it should be considered the most empirically supported treatment for all types of enuresis—nocturnal. DSM classifies enuresis into primary (in which the child has never achieved urinary continence) and secondary (in which incontinence develops after a period of continence) cases and subdivides it into three subtypes: nocturnal. because the effectiveness of the urine alarm when used alone ranges as high as 70% and because it is the central component of the major treatment packages. by a very wide margin. diurnal. and combined nocturnal and diurnal. it is not rare. the forward march of science has significantly reduced the relevance of the psychopathological perspective on enuresis (Christophersen and Friman 2010. At present. the incontinent child is typically included in all discussions of treatment—and the child’s understanding of the condition. First. the dominant theoretical perspective on enuresis is the biobehavioral model. Friman 2007. albeit a supportive rather than a directly active one. for at least four reasons. Friman 2007. its likely course. the benefits of treatment. the abundance of scientifically secured outcomes of CBT (especially but not only alarm based). The relevance of cognitive theory that emerged following the initial study has diminished to almost nil. cognitive) approaches to treatment of enuresis (Christophersen and Friman 2010. Those manipulable events provide the behavioral source material for CBT for successful treatment. there is a role for cognition in the treatment of enuresis. the findings are dramatically inconsistent. Ronen et al. Two other papers describing successful cognitive therapy were published by the same group (Ronen and Wozner 1995. 2008. Fourth and finally. 2008). with over 50 years of research showing the routine success of behavioral approaches and the routine failure of purely psychological (e. 1995). regardless of whether afflicted children live with afflicted blood relatives. however. completes a . but they essentially report the same findings. Third. 1992).g. It is extremely important that the child be made aware that the condition is not due to any psychological or characterological deficiency on his or her part. Mellon and McGrath 2000). the original study is flawed methodologically in several ways (see Houts 2000 for a thorough critique). Treatment Components Urine Alarm Bed devices. and the value of full compliance is important for treatment progress. a cognitive perspective on enuresis emerged following a report of cognitive therapy competing favorably with conditioning treatment in a comparative trial (Ronen et al. However. 2000. For a brief time in the 1990s. which assumes that enuresis results from a combination of genetic predisposition and manipulable environmental events (Christophersen and Friman 2010. The urine alarm uses a moisture-sensitive switching system that when closed by contact with urine-seeped bedding. the authors made no attempt to explain how a purely cognitive approach could so powerfully influence a problem that has such a fundamentally biological basis. despite the ease of their application. Houts 1991.. Second.470 Cognitive-Behavior Therapy for Children and Adolescents many contributors to this turn of events are the absence of scientifically secured outcomes of treatment based on that perspective. and research showing the significant role a family history of enuresis plays in the genesis of enuresis. Specifically. and this too is a cognitive rather than a behavioral matter. the findings still have not been independently replicated. after more than 15 years. vibrating. Actual alarm use can be divided into different methods.g. The bed device typically involves two aluminum foil pads. In the parent-focused method. absorption of urine by the pajamas completes an electrical circuit between the two wire leads and activates the alarm. vibrator). When the child wets during the night.. the alarm awakens or alerts the parent. Retention-Control Training Retention-control training (RCT) was developed following the observation that many enuretic children had reduced functional bladder capacity. Child. who then waken the child and guide him or her through the training steps. with the perforated pad on top. Parent-focused methods are obviously dependent on the saliency of the alarm stimulus. either a very loud alarm or periodic checking is necessary to allow parents to readily attend to accidents.g. light. resetting the alarm..and parent-focused methods. Pajama devices. the alarm often alerts parents first. by small alligator clamps) on or near the pajama bottoms.g. A range of stimuli are available for use with the pajama devices and include buzzing. Pajama devices are similar in function. going to the bathroom to complete (or attempt) urination. can be extended to the parents’ auditory range (e.Enuresis and Encopresis 471 small-voltage electrical circuit and activates a stimulus that is theoretically strong enough to cause waking (e. with a cloth pad between them. Two wire leads extending from the alarm are attached (e. and with the bed-device wire leads. Our clinical experience suggests that optimal treatment compliance is attained only with parent-focused practice. initially at least. one of which is perforated. In the child-focused method. collecting in the cloth pad. the awakened child turns off the alarm and completes a series of treatment steps. A urinary accident results in urine seeping through perforations in the top pad. yet simpler in design than bed devices. and going back to bed. The alarm itself is either placed into a pocket sewn into the child’s pajamas or pinned to the pajamas. bell. The bed pads are placed under the sheets of the target enuretic child’s bed. buzzer. and causing contact with the bottom sufficient to complete an electrical circuit and activate a sound-based alarm mechanism. in their bedroom). the alarm awakens the child. For the pajama device. who independently completes treatment steps. ringing. The treatment steps vary across published accounts and guides but generally include full arousal. who awakens the child and guides him or her through treatment steps. In principle. In practice. the primary characteristic of which is frequent small volume urinations . depending on the primary roles of the child and parent.. changing bedding and pajamas. and lighting. establish a regular time to begin training each day and ensure that it is concluded at least a few hours before bedtime.472 Cognitive-Behavior Therapy for Children and Adolescents (Muellner 1960. has been used in enuresis treatment packages for years. called stream-interruption exercises. When they reach their limit. Waking Schedule This treatment component involves waking enuretic children and guiding them to the bathroom for urination. The early use of waking schedules typically required full awakening. Use a reward system (discussed in the section “Reward Systems” later in this chapter) to maintain motivation. Encourage enuretic children to drink as much of their favorite beverage as they can and forestall urination as long as they can. When they have mastered “wet practice. 16 oz of water or juice) and delaying urination as long as possible. but subsequent modifications to the procedure involved only partial awakening and conducting waking ses- .” teach them “dry practice” by telling them to employ the same urogenital contractions they use with wet practice. Rewards can be delivered for increasing the amount of fluid drunk. Starfield 1967). RCT expands functional bladder capacity by having children drink extra fluids (e.. 1961. including changes in arousal. 10 times on three separate occasions a day. often with sessions that occurred in the middle of the night. managing urinary urge in lighter stages of sleep.g. There are multiple potential benefits. increased access to the reinforcing properties of dry nights. Kegel and Stream-Interruption Exercises Kegel exercises involve purposeful manipulation of the muscles necessary to prematurely terminate urination or to contract the muscles of the pelvic floor (Kegel 1951. have them urinate in a washable receptacle that is designed to measure volumes of fluid. and reduction in the length of time children must hold their urine. To use RCT. and/or exceeding the previous amount of urine produced. These exercises were originally developed for stress incontinence in women. Explain that the goal for each target urination is to produce more urine than was produced with the previous target urination. followed by a 5-second rest. and a version of Kegel exercises. 1961. Clinicians train children to conduct Kegel exercises by having them start and stop their urine flow multiple times during active urinations at least once a day. Muellner 1960). increasing the time between urinations. thereby increasing the volume of their diurnal urinations and expanding the interval between nocturnal urges to urinate (Muellner 1960. Teach children to hold the contraction for 5–10 seconds. Starfield and Mellits 1968). . and pajamas to a presoiled state is a standard part of empirically supported treatment packages for enuresis. bed clothing.. have the parent awaken the child one half-hour earlier. and thus we recommend its inclusion in all treatment for enuresis. merely place tracing paper over the urine spot and trace it and then compare it with previous tracings. 7 dry nights. and is used primarily to enhance the maintenance of treatment effects established by alarm-based means. It has not been evaluated independently of other components. have the parent who goes to bed latest wake the incontinent child and take him or her to the bathroom for urination. To measure these decreases. A plausible possibility is that they sustain the enuretic child’s motivation to participate in treatment. Friman 2007. Houts and Liebert 1985). decreases in the size of the urine stain can be used as the criterion for earning a reward. the extent of its contribution to outcome is unknown. it is impossible to determine their independent role in treatment. Overlearning Overlearning is a nocturnal version of RCT. 2008). they are a component of multiple empirically supported programs. However. and they are routinely recommended in papers describing effective treatment (Christophersen and Friman 2010. Reward Systems Although contingent rewards alone are unlikely to cure enuresis. Like the RCT procedure. Cleanliness Training Some form of consequential effort directed toward returning soiled beds. especially when the system reinforces success in small steps. If the bed is already wet. With the current state of the literature. Overlearning is an adjunctive strategy only. and thus. it should not be initiated until a dryness criterion has been reached (e. Thus.Enuresis and Encopresis 473 sions just before the parent’s normal bedtime. this method requires that children drink extra fluids—but just before bedtime rather than during the day. To use the waking schedule. If dry nights are initially infrequent and motivation begins to wane. wake the child 15 minutes earlier the next night.g. Continue making the wake times earlier until the child’s original bedtime is reached. with no loss of effectiveness. as is its relevance to the training of responsibility in childhood. After one week of accident-free nights. its contribution to the logic of treatment is obvious. Using this method allows parents to reward their incontinent child for small amounts of progress made on the way to continence. The child or parent draws a dotted picture of an item the child would like and the parents are willing to buy. we assert that it should not be part of any treatment plan. Second. and thus potentially increases motivation (this system can also be used for accident-free days or successful defecations in encopresis treatment programs).g. it is probably the easiest form of treatment to conduct. with one exception. First. no research of any kind has ever shown fluid restriction to contribute to the success of an enuresis treatment program. Despite these characteristics of fluid restriction. 1979) and other side effects of imipramine. Desmopressin is a synthetic antidiuretic that concentrates urine. have the parent buy the item and give it to the child. it continues to be an integral part of most treatments. thus allowing it to hold more urine before urinary urge. accidentfree night. when all the dots are connected. would be relatively easy to measure. Third. We base our position on the absence of evidence for several compelling reasons.. thus decreasing urine volume and intrabladder pressure. Because of alarming reports of the potential cardiotoxic effects of imipramine overdose (Herson et al. We mention fluid restriction here because despite the complete absence of supportive evidence. its effects. determine the amount of money parents would be willing to let their child have on a daily basis and divide that amount into the cost of the item. Fluid Restriction Listing fluid restriction among treatment components with well-established contributions to effective treatment presents an anomaly. if there were to be any. Specifically. Each time the child reaches a specified criterion (e. smaller urine spot).474 Cognitive-Behavior Therapy for Children and Adolescents An example of a reward system we often use in enuresis treatment programs involves a dot-to-dot drawing. if an enuretic child drinks fluids to excess before bedtime. fluid restriction is probably the most widely used intervention for enuresis in the world. Specifically. Medication There are two primary drugs used for treatment of enuresis: imipramine (Tofranil) and desmopressin (DDAVP). desmopressin briefly emerged as the most preferable medication for enuresis . Thus. then his or her fluid intake should be reduced—not because of the enuresis. have him or her connect one dot. it appears to make the bladder less sensitive to filling. To determine the number of dots. it still has absolutely no empirical support. The former is a tricyclic antidepressant whose mechanism for reducing bed-wetting is not clear. but because of the excess. However. the stringency of the waking schedule and the cleanliness training was reduced. Empirically Supported Treatment Packages The oldest. and rewards for success. These rulings are likely to have a notable impact on interventions for enuresis. Initially evaluated for use with a group of adults with profound mental retardation. reports by the U. 2008). In addition to the bed alarm. its initial composition included overlearning. 1974). Friman 2007. Houts and Liebert 1985). and the findings show that the alarm is the critical element and that the probability of success increases as additional components are added (Bollard and Nettelbeck 1982. Optimal Treatment Planning An optimal treatment plan is presented in Table 13–1. the clinician’s initial concern should be to obtain .S. Food and Drug Administration 2007). Friman 2007. During the assessment phase (steps 1–4). Food and Drug Administration (FDA) in 2007 alerted the public to potential dangers posed by desmopressin. Component analyses have been conducted on both dry-bed training and FSHT programs. Psychologists may be able to successfully capitalize on the resulting gap in treatment options available to medical providers by offering evidence-based CBT alternatives such as those offered here. it has been systematically replicated numerous times across child populations. hourly awakenings. given the pervasiveness of the problem and the popularity of desmopressin as a treatment. and overlearning. the FDA has ruled that the intranasal form of desmopressin not be used for treatment of enuresis and has recommended only very cautious use of the tablet form (U. Other similar programs have also been developed. In subsequent iterations. the best known and most empirically supported of which is full-spectrum home training (FSHT. Specifically. Children treated for enuresis with the intranasal form of desmopressin are particularly susceptible to severe hyponatremia and seizures. positive practice was eliminated. Multiple variations are now available (Christophersen and Friman 2010. best-known. intensive cleanliness training. and RCT was added. Houts et al. some persons taking desmopressin are at risk for developing a sodium deficiency in their blood—a condition called hyponatremia—that can result in seizures and death.S. close monitoring. empirically supported treatment package is dry-bed training (Azrin et al. 2008). intensive positive practice (of alternatives to wetting).Enuresis and Encopresis 475 treatment (Christophersen and Friman 2010. RCT. Therefore. FSHT includes use of the alarm. cleanliness training. 1986). especially when delivered in its most popular form—intranasal spray. and/ or punishing their child for wetting.. although the type of enuresis (primary or secondary) does not appear to moderate treatment outcomes. Establish a trial treatment period. including the most effective parental response to accidents. 2. Initial treatment 5. Sample enuresis treatment plan Assessment 1. child . 7. Help parent and child select and purchase the type of alarm to be used (see Table 13–2). shaming. 3. add an overlearning component. 6. During the initial treatment phase (steps 5–7 of Table 13–1). do not proceed with direct treatment until a medical examination is completed and pathophysiological variables are ruled out. initiate collection of data on wet and dry nights or documentation of size of urine spot (using tracing paper to draw outline of the spot). However. When 14 consecutive days of dryness have been achieved. the child and parents should be informed that numerous other children. are also afflicted with enuresis. the clinician provides information about enuresis. many probably in the child’s neighborhood and school. firmly instruct the parents to avoid blaming.476 Cognitive-Behavior Therapy for Children and Adolescents TABLE 13–1. With the child in attendance. Monitoring progress and planning for termination 8. Then obtain the child’s cooperation in treatment and work with the child and family on a treatment plan. When initial dryness goal is achieved (e. base the number and selection of treatment components on child readiness. Negotiate for inclusion of as many treatment components as child and parents are willing and able to perform. and overlearning. Assess developmental and motivational readiness and tailor treatment according to findings. 1994). There is some evidence that children who wet less frequently and children who wet only at night have a better prognosis (Houts et al. Discuss the elimination of punishment with parents and child. One to two weeks before treatment. retention-control training. 1 week). For example. Next. 4. discontinue alarm. Address relapses by resuming use of treatment components that have been discontinued. Refer child for physical exam.g. 10. a history of wetting episodes. 9. a twoparent. rewards).95 Vibrating Enuresis Alarm $65. Kegel exercises. overlearning. various combinations of sounds and light Bedwetting Store Ashton.Enuresis and Encopresis TABLE 13–2.com/ index.com $75. cleanliness training.. buzzer PottyMD Knoxville.00 SleepDry Pajama.e.bedwettingstore. RCT. prescribe fewer components but strive to ensure the alarm is one of . buzzer Star Child Labs Santa Barbara.pottypager. and responsibility training with the alarm. CA (800) 346-7823 http://sleepdryalarm. and family resources (see Table 13–2 and Suggested Readings and Web Sites at the end of this chapter for information on obtaining necessary materials. For example.php $50. NY (800) 832-8697 http://enablingdevices. verified at time of writing.com $84. reward system. vibrating Enabling Devices Hawthorne.00 Potty Pager Pajama. waking schedule. CO (800) 497-6573 www.95 Wet Call Bed pad. and parent willingness. “Titrate” the components in the plan over time in accord with family resources and motivation until a cure is obtained.bedwettingstore. buzzer Ideas For Living Boulder. TN (877) 768-8963 http://wetstop. When families have fewer resources or less motivation to conduct treatment. buzzer Bedwetting Store Ashton. such as the alarm).com Note.com $53.95 Pajama. MD (800) 214-9605 www. middle-income family with a motivated 10-yearold bed-wetting child whose parents are also motivated could start with all treatment components at once (i. 477 Sample urine alarms Device Type Manufacturer Cost Wet-Stop Pajama. MD (800) 214-9605 www.com $84. Manufacturer and pricing information subject to change. one-wage earner. alarm. Strive to include the waking schedule.95 Malem Bedwetting Alarm Pajama. prescribe the treatment components that can readily be performed independently (e. so schedule follow-up contact as a routine element of treatment.g. the potential for relapse is a serious concern. The chances for cure are less likely when fewer components are used (especially if the alarm is not used) but still higher than if no treatment were used. see Friman 1986. add adjunctive components with primary emphasis on RCT and stream interruption. however. such as Nigeria. Cross-cultural research also indicates that although enuresis is more prevalent in the United States than in Europe and other developed countries such as Thailand and China. at which point more components can be added. Implications of Diversity The major diversity issue in studies of enuresis involves gender. If not. If an alarm can be obtained. The final steps of treatment involve progress monitoring and planning for termination (steps 8–10 in Table 13–1). Enuresis is also more prevalent in populations that have lower socioeconomic status or that exhibit significant psychosocial deviancy. Kegel exercises. Furthermore. but its effects increase even further with addition of other treatment components). prescribe only components that can be independently completed by the child. either because the parents will not purchase one or because the child is not capable of using it without assistance. this may preclude use of the alarm. When 14 consecutive days of dryness have been achieved. RCT. possibly a waking schedule activated by the child’s alarm clock).478 Cognitive-Behavior Therapy for Children and Adolescents them. the active involvement of the child may lead to increased involvement by the parents. If the home situation changes in a way that heightens motivation or frees up more resources.. As with most enuretic treatments. discontinue the alarm. On the basis of the abundance of evidence indicating this disparity. 2007). older children or sophisticated younger children may be able to use it independently with training provided by the clinician or the clinical team. one group of epidemiological researchers has recommended changing the diagnostic criteria for boys from age 5 to age 8 because the proportion of enuretic girls at age 5 is about the same as the proportion of boys at age 8. . such as children in institutionalized settings (for reviews covering this material. it may be more prevalent in some developing countries. If progress is limited. self-monitoring. The implication of this position is our recommendation that clinicians consider delaying treatment for boys who at age 5 meet criteria for enuresis but who clearly lack the motivation to participate in treatment or the maturity to benefit from it. In the rare case in which the child is motivated but the parents are much less invested. renegotiate treatment to include more components (remember that the alarm is effective. Unfortunately. Enuretic boys outnumber enuretic girls by as much as 3 to 1. If the enuretic child is not motivated. As mentioned earlier. For this reason. in the child. alarm treatment in these cases may be contraindicated. for dry nights. ranging from direct and indirect expressions of frustration to harsh physical discipline. Although fewer than 10% of cases are attributed to these causes. it is paramount to refer all enuretic children to a physician for a physical examination before beginning CBT in earnest. which range from multiple dry nights for some children to mere performance of treatment steps for others. When physiopathic causes are ruled out. and motivation levels are cardinal concerns. A final challenge involves nonadherence to treatment. Prescribing effective treatment can reduce the risk. . or even compliance with components of treatment. developmental level. especially for children with multiple nightly accidents. disclose that dry nights could be slow in coming.. use a system that rewards progress in small increments—for example. describe continence as a skill that can be attained readily with diligent practice of treatment steps. To increase motivation. and schedule periodic booster clinic visits and/or telephone calls to monitor progress. suspend treatment for 3–6 months and schedule a follow-up with the child and family at that point. higher motivation. assess for motivation and capacity to perform prescribed treatment steps and refrain from prescribing steps that children are unwilling or unable to perform. diabetes. and advanced maturation in enuretic girls versus boys. we recommend that clinicians assess for a history of punishment and obtain a verbal commitment from parents (with the enuretic child present) to never again punish or even criticize the child for having accidents.Enuresis and Encopresis 479 Challenges to Treatment One critical challenge to treatment is the rare but real possibility of a physiopathic cause of enuresis (e. The difference in ages is due to the lower incidence of enuresis. With no access to effective treatment. Help parents identify signs of progress. To limit child nonadherence. decreases in the size of the urine spot. parents. follow similar steps: assess for motivation and capacity and prescribe only steps that parents are willing and able to perform. To limit parental nonadherence. parents faced with their child’s chronic incontinence are at risk for directing punishing responses to their child’s accidents. but to eliminate it altogether. age. For example.g. incontinence is a major cause of child abuse. urinary tract infection). or both. we recommend that CBT be forestalled until enuretic boys are at least 7 years old or until girls are at least 5 years old (unless either younger boys or girls are highly motivated). Another challenge to treatment involves punishment. More generally. The psychologist explained the role of family history in the cause of enuresis and that it was unlikely that any form of psychopathology played a significant determining role. Tommy and his mother drew a picture of the video game using dots and the psychologist provided a handout describing . He explained to the parents that fluid restriction had never shown a significant role in reducing nocturnal accidents unless incontinent children were shown to be drinking excessively before bed. aunts and uncles. According to the parents. beyond some moderate resistance to bedtime. psychiatric. and Kegel exercises. in the presence of the parents. Also. he has been very concerned about learning how to have dry nights. and Tommy selected a new video game as his reward. but routinely earns grades in the B range. and from that point forward. developmental. In fact. and social response to accidents could cause psychological problems if it was aversive and perpetuated. He had a friend along for the trip and was embarrassed by the friend’s discovery of his accident. He is well liked in school and has at least two good friends. and his parents about working harder to stay dry. a reward system. During the history. he explained to Tommy that children who wet their bed should never be punished for wetting. Tommy has been nocturnally incontinent since birth and to the best of their memory. However. he drew a picture of the bladder and explained how the process of urination worked and how the alarm system. responsibility training.480 Cognitive-Behavior Therapy for Children and Adolescents Case Example Tommy is a white 8-year-old boy who lives at home with his natural parents and two younger siblings. has never had a dry night. Additionally. and that person began treatment by conducting a joint interview with Tommy and his parents. Finally. he explained that the parental. he solicited Tommy’s participation in treatment and reviewed all of the available treatment options he had at his disposal. Tommy and his parents selected all of the treatment components that were described. which included the urine alarm. He is in the second grade and works a little below his potential. RCT. a girl age 5 and a boy age 3. along with the other treatment components. family. At home. Jointly. His medical. he does not pose any behavior problems. While in the doctor’s office. the physician referred Tommy and his parents to a psychologist specializing in CBT. Following the physical examination. and educational histories are unremarkable. the parents selected the dot-to-dot program. The referral concern involved primary nocturnal enuresis. they complained that he sometimes has more than one accident at night. who did a routine physical examination including a urinalysis. would influence Tommy’s system and help him learn how to have dry nights. it was revealed that Tommy’s father had a history of nocturnal enuresis that ended at about age 9. For the reward system. waking schedule. Although approached by grandparents. and ruled out all organic causes for nocturnal enuresis. His parents brought him to his primary care physician. Following that. he exhibited little interest in continence until a recent episode involving an accident while on a camping trip. His relationship with his siblings is described as positive. he also communicated that it would be fine for Tommy to have water before bed as long as he didn’t drink an excessive amount. the effectiveness of urine alarm treatment when used alone is high and can be raised even higher when combined with any or all . Although the amount of clinical contact varies. exceeded only by divorce and parental fights (Van Tijen et al. the alarm began to awaken Tommy. one that has not been shown to play a role in the treatment of enuresis. The parents obtained the urine alarm by consulting the Bedwetting Store online. for this case. the parents initially complained that he slept through the alarm and that its sound awakened one or the other of them. high relapse. However. but he would also alert one of his parents to help him. And finally. as the program progressed. and the rest was done by telephone follow-up. he began sleeping through the night without the alarm going off. into young adulthood. The outcome of the case was successful. The parents also asked to include one other component in the treatment program. but that very well could play a role in the social acceptability of treatment. Conclusion: Enuresis Enuresis is the third most distressing experience reported by children. and 3) it eliminates much of the expense. The psychologist also asked that the parents monitor progress along with Tommy using a calendar to be attached to the refrigerator that could be easily inspected by them and by Tommy. at which point he would take himself to the bathroom. with considerable negative social consequences and disruption of family life. Left untreated. eventually one or two times a week. Urine alarm treatment is an easily used. and they then would wake him and take him to the bathroom. the parents asked whether it might be helpful if when Tommy said his prayers at night. Specifically. he could ask for God to help him have a dry night. and ultimately ending with only one or two accidents per month. highly effective method for treating one of the most prevalent and chronic of all childhood problems. which attached to the pajamas. In fact. enuresis will likely persist for years. At that point. and the brand they selected was the Nytone. the psychologist saw Tommy and his parents for the initial session and then Tommy with one parent for two subsequent sessions. Furthermore. As the program progressed further. and potential side effects of medication treatment. It represents an enormous breakthrough for enuretic children because 1) it does not involve the physically aversive experiences typical of ancient treatments. and his accident would be so small that it didn’t require that he do anything about the accident until his typical wake-up time. although Tommy did not have a dry night for the first month or so. and in some cases.Enuresis and Encopresis 481 the reward system for the parents to bring home. 2) its effectiveness undermines the historical psychopathological characterization of enuresis. 1998). and the psychologist agreed that it would be a good idea. the psychologist terminated care and recommended that the parents stay in touch if questions arose. at which point he would turn it off. the alarm would quickly awaken Tommy. . 3) chronological age of at least 4 years (or equivalent developmental level). it seems appropriate to pointedly ask why.g. Rates of fecal incontinence have shown to be 4. except through a mechanism involving constipation.7).4% in primary care pediatric settings (Loening-Bauck 2007).482 Cognitive-Behavior Therapy for Children and Adolescents of a variety of adjunctive treatment components (Houts et al. enemas. At this point in the evolution of alarm-based treatment. In cases of encopresis without constipation. stools are generally well formed. clothing or floor). laxatives) or a general medical condition. treatment efforts for this subtype focus on the remediation of psychological and behavioral problems (Friman 2008). whether voluntary or unintentional. 10th Revision (ICD-10. with soiling intermittent and deposited in a toilet. Two subtypes are identified with the DSM-IV-TR criteria for encopresis: with constipation and overflow incontinence (787. laxatives).. Individuals with this subtype typically have stools that are poorly formed. and 4) the determination that the behavior is not exclusively due to a physiological effect of a substance (e. Children with encopresis without constipation typically present with comorbid emotional and behavioral problems. A Dutch popula- . it seems safe to assert that this method should be part of the armamentarium of every child therapist seeing children with enuresis. Encopresis Diagnosis and Prevalence The diagnostic criteria for encopresis outlined in DSM-IV-TR (American Psychiatric Association 2000) include 1) repeated passage of feces into inappropriate places (e. Only small amounts of feces are passed in the toilet and successful treatment usually involves intervention components aimed at relieving the constipation (i. with boys three to six times more often affected than girls (Schonwald and Rappaport 2008).. and if it is not. Similar criteria are outlined in the International Statistical Classification of Diseases and Related Health Problems. Prevalence rates in the United States are estimated to be around 1%– 3%. 1994). with continuous leakage during the day and in rare cases at night.6) and without constipation and overflow incontinence (307. 2) at least one such event a month for at least 3 months.g.e. World Health Organization 2007). For the subtype with constipation. thus. there should be evidence of constipation from a physical examination by a physician or a history of having a bowel movement on no more than three occasions during a week. Biofeedback represents a fourth. Empirical Support An obstacle to supportive research for CBT treatment of encopresis involves the transdisciplinary. 2000) included a review of randomized controlled published studies involving medical. 2005). and 3) regulating dietary intake (Christophersen and Friman 2010). because successful treatment almost always involves all three (Christophersen and Friman 2010). psychological. McGrath et al. and various types of monitoring.1% of children ages 5–6 years and 1. functional constipation. Mildly aversive components are also sometimes used. in the form of overcorrection practices in which the child participates in cleaning himself or herself and the soiled clothing after a bout of encopresis (Reimers 1996). (2000) found that no published study at the time met criteria frequently used by psychologists to determine which interventions can be declared empirically well established (Chambless and Ollendick 2001). Two extensive behavioral interventions plus medical interventions also were shown to meet the efficacy criteria for the treatment of constipation plus incontinence.6% of children ages 11–12 years experienced soiling incidents once a month (van der Wal et al. behavioral. enhanced health education. This review found that anal sphincter biofeed- . biobehavioral approaches to the disorder that are most frequently used. 2) encouraging regular bowel movements with the use of facilitative medications. Medical interventions have traditionally focused on three areas: 1) cleansing the bowels. CBT approaches emphasize the use of positive reinforcement to motivate the child’s adherence and success in using appropriate toileting practices. In their most basic forms. behavioral. Many CBT treatment programs also incorporate stimulus-control procedures. and comparable rates were found in the United Kingdom (Joinson et al.Enuresis and Encopresis 483 tion-based study found that 4. It is virtually impossible to tease out the unique cognitive. Two studies using a combination of medical plus behavioral interventions were shown to be probably efficacious. 2000). A number of studies have examined the effectiveness of these different treatment modalities. or biomedical components. Another study published at the same time (Brooks et al. 2007). and biofeedback treatments for encopresis. In their meta-analysis. enhanced scheduling. These CBT approaches are often administered alone or used to supplement biomedical interventions put into place. and stool-toileting refusal in preschool-age and school-age children. less commonly used biomedical-CBT approach that appears to have no greater level of effectiveness than behavioral-medical interventions (Brooks et al. Despite the similarities in outcomes across these two approaches. this viewpoint is so deeply rooted in antiquated theory and so resistant to the influence of abundant contrary scientific evidence that it can be discarded as nonsense with impunity (Sperling 1994). CBT or a referral to mental health services should be considered. Sperling 1994). The predicate for the initial position involved infant sexuality (Freud 1905/1953). particularly when a child presents with behavioral problems. Theoretical Perspectives There have been multiple theoretical perspectives on encopresis throughout history. Although no actual research confirmed or even supported this perspective. Historically.484 Cognitive-Behavior Therapy for Children and Adolescents back in the treatment of pediatric fecal elimination dysfunctions was no more effective in treating encopresis or functional constipation than comprehensive medical-behavioral intervention. and education (van Dijk et al. As a blatant and disturbingly mainstream example. despite there being no supportive scientific evidence. learning/behavioral. but the current dominant viewpoint involves a combination of biological. These researchers found that the outcomes for the CBT approach and conventional treatments were comparable. the paradoxical constriction of the external anal sphincter did not appear to influence the treatment outcome of either biofeedback or medical-behavioral interventions. 2000. a bowel diary. early unpleasant toileting experiences were thought to determine personality and behavior (Freud 1905/1953). and as the position evolved. Another randomized controlled trial compared treatment outcomes of CBT and the conventional approaches involving the use of laxatives. The authors of this study noted that in some circumstances. Furthermore. Levine (1982) and colleagues described . The problem with this position involves its association with psychodynamic theory. vestiges of this position remain operative to this day (Friman 2002). medical-behavioral interventions may have certain advantages given that these approaches are generally less intrusive than procedures used in biofeedback interventions. we will refer to it as the CBT perspective. the description of encopresis without constipation in DSM-IV-TR (American Psychiatric Association 2000) includes an association with anal masturbation. we describe the CBT techniques that can be used to successfully assess and treat encopresis. and cognitive components. In early attempts to sketch an account of encopresis consistent with the CBT theoretical perspective. 2008). a sexualized perspective on toilet training and incontinence remained (Aruffo et al. Below. and consistent with the theme of this book. Avoidance of discomfort associated with bowel movements negatively reinforces toileting resistance. has suggested that constipation usually precedes toileting refusal. and bowel-training history before developing a treatment plan. and toileting resistance (Christophersen and Friman 2010. We recommend that clinicians surrender the decision of whether to involve specialists to the primary care physician. Assessment Obviously assessment is an important dimension of CBT treatment for any disorder. 2008). Although it will often be helpful to gain the child’s perspective on these issues. the theoretical perspective with the most empirical support and that which leads most directly to effective treatment is the CBT model that emphasizes defecation dynamics. As for the clinician’s own assessment. but it is particularly important to conduct a thorough assessment of the child’s behavioral. the cardinal variable in this account is constipation. Parent Intake Below. and thus it is more likely to be the primary influence. it is possible that the resistance rather than the constipation is the more important consideration. Other research has shown that children who resist toilet training often have histories of painful bowel movements and/or constipation (Luxem et al. which increases the difficulty and discomfort that accompany bowel movements.Enuresis and Encopresis 485 a developmental trajectory resulting from disordered defecation dynamics (rather than disordered psychodynamics) and their subsequent influence on toileting behaviors. highlighting those issues that are relevant to the assessment and treatment of encopresis. successful toileting resistance leads to stool withholding. Not surprisingly. Research on this question.. family mental health history. This approach allows both parties to be less inhibited when sharing sensitive information (e. disordered fecal toileting.g. we will highlight a few general questions that are likely to be included in the standard clinical assessment. doing so prematurely could lead to unnecessarily invasive and expensive biomedical evaluations. the cli- . it is critical with encopresis to refer all cases to the primary care physician for a physical examination before initiating treatment (as with enuresis). 1997). Friman 2007. In sum. Additionally and most importantly. negative behaviors or attributes of the child). In turn. family. It is not necessary to refer affected children to a gastroenterologist. we recommend that it be conducted separately with the parents and then with the child (age 4 and above). which has the same effects on bowel movements as constipation itself—and thus. however. children with a history of distended colon or megacolon. If motor skills are significantly delayed or if cognitive and speech/language skills are below a 2-year level. celiac disease. but they continue to have bowel movements because fecal matter moves around the fecal impaction. ask the parents to document the amount of stool softener provided to their child and the time of day . Additionally. or other similar conditions do not rule out behavioral treatment for encopresis. but certainly have significant medical implications. All developmental skills need to be at least at a 2-year age level. Some children with constipation also experience a solid fecal mass in their colon. the condition must be managed before behavioral treatment is initiated. and in some cases. Is there a history of developmental delays or ongoing difficulties? It is important that the child possess developmental skills that allow for effective management of toilet training. consideration should be given toward delaying intervention. The presence of loose or soft stool in this scenario can lead parents to wrongly assume that the child is not constipated. Is there a history of constipation? If the child is constipated. Children with a history of constipation or fecal impaction often also present with a history of a distended colon. Relevant medical diagnoses or histories such as Hirschsprung’s disease. megacolon. allowing the child to pass what are typically loose or soft stools. Miralax is currently the most common stool softener prescribed for children with constipation. Are there any relevant medical problems? A variety of medical conditions can significantly contribute to a child’s constipation and/or bowelrelated difficulties. Children with a recent or past history of constipation will likely be on some type of stool softener. Children with this history can experience limited or poor feedback regarding the volume of fecal matter in the rectal vault. the child needs to be ambulatory to the point that he or she is able to independently remove his or her clothing and is able to walk (or run) to the bathroom when he or she feels the urge to defecate. In general.486 Cognitive-Behavior Therapy for Children and Adolescents nician may choose to reserve some of these questions for the parent intake when considering the age of the child and the sensitivity of the questions. Having parents monitor and document their child’s stooling pattern (see Figure 13–1) will help the clinician to monitor the frequency of stools and will provide valuable information to the child’s primary care physician. If a client is using Miralax or some other type of stool softener. warrant close monitoring and periodic follow-up with their primary care physician. or who have a chronic history of stool impaction and constipation. Crohn’s disease. and working closely with the medical professional is imperative. The timing of stool softener can sometimes have an effect on the pattern of the child’s bowel movements. Hard and dry Stool assessment chart. creamy 5. formed 7. Liquid. What are the quality of the child’s diet and quantity of daily exercise? The child’s dietary habits and level of exercise can impact both the frequency and consistency of his or her bowel movements. soft 6. formed 8. Hard. See Difficulty With Stool Passage Scale. Loose. Watery 2.Enuresis and Encopresis 487 Name: Date of birth: Stool Assessment Date Number of stools in toilet Number of soiling episodes Consistency of stools a Difficulty ratingb Medicine taking Medicine amount a Enter number from Stool Consistency Continuum. Normal. b Difficulty With Stool Passage Scale Was passing a stool a problem? 0 1 No problem Some problem 2 Severe problem Stool Consistency Continuum 1. In general. 3. Water ring with formed particles 4. Soft. that it is taken. formed FIGURE 13–1. learn- . . Although high-fat diets are often blamed for fecal impaction or infrequent stools in some children. Are there any behavioral or emotional difficulties? Some studies (Cox et al. 2002) have suggested that children with encopresis have a higher percentage of related or comorbid behavioral difficulties that can interfere with treatment planning. the effect of high-fat diets is idiosyncratic.488 Cognitive-Behavior Therapy for Children and Adolescents ing that a child has a “typical” diet and level of physical activity is probably sufficient. For clinicians working with children with encopresis and these comorbid behavioral problems. age-based behavioral profile to identify relevant behavioral difficulties. Children who are not under good instructional control or who present with high levels of hyperactivity or oppositional defiant–type behavior present with additional challenges when managing encopresis. in which the balance is tilted in one direction or another—then it may be necessary to have a discussion with the parents about balancing their child’s diet and possibly increasing their child’s level of physical activity. it is helpful to have the parents provide a description or log of a typical day regarding their child’s diet and physical activity. it is important to determine if the child has ever experienced partial or complete success with either urine or bowel training. soiling accidents. Achenbach and Edelbrock 1983) will provide a good.g. if any. if the behavioral concerns are specific to the encopresis. bowel training. and focus on how the parents manage resistance on the part of their child. However. punishment techniques have been used. it may be necessary to prioritize working with the parents and child to help improve instructional control and to reduce levels of noncompliance or oppositional behavior before behaviorally managing the child’s encopretic symptoms. On the other hand. The use of any number of standardized behavior checklists (e. or both. if a child presents with a dietary history that is atypical—that is. and the level of success achieved. then moving forward with a treatment plan for managing the encopresis is warranted. as well as the length of time spent during the training process. Question the parents about the type of approach that they have used and the use of both positive reinforcement and punishment. Many children present with no experience with . What was the child’s experience with toilet training? Ascertain at what age the parents started toilet training. Child Behavior Checklist. Both fat and fiber intake can impact the bowel habits of some children. In some cases. This description will allow an assessment of whether a child has a diet that is high in fat or low in fiber. whether the parents focused on urine training. and other setbacks. It is especially important to determine to what level. Determine the child’s response to the parents’ training efforts. Finally. and painful stools (Borowitz et al. with no interest or intention of attempting to void in the toilet. Ask parents to describe their general routine for managing their child’s toileting habits and include questions pertaining to scheduled sit times on the toilet. The frustration caused by the child’s lack of success or the onset of soiling accidents will cause parents to develop a variety of approaches and routines to manage their child’s toileting habits. This includes children who hide in their room or in a quiet part of the house while they intentionally have a bowel movement. Other children appear to have what can be considered an “accident” when they pass fecal matter into their clothing because of the loose consistency of their stool or because they did not respond quickly enough to the physical urge to have a bowel movement. Children resist going into the bathroom and/ or sitting on the toilet for a variety of reasons. For some children. the parents’ response when they see their child gesturing that he or she is about to have a bowel movement. 2003. the soiling episode clearly involves some volitional control. How frequently does the child have soiling incidents? Assess what percentage of the child’s bowel movements result in some type of soiling episode. whereas other children experience a soiling episode of some type with each bowel movement. Levine 1982). How do the parents respond to their child’s resistance to toileting? The manner in which parents respond to their child’s resistance toward sitting on the toilet and toward having bowel movements is an integral com- . constipation. Some children with encopresis will have occasional successful bowel movements in the toilet. and the length of time that the child is expected to sit on the toilet. What is the routine for managing the child’s toileting? The toileting routine used by parents of encopretic children will likely vary from the approach that they used when they were initially toilet training their children. Some children exhibit significant levels of resistance toward having a bowel movement because of a history of painful bowel movements or discomfort associated with the use of enemas or suppositories. Has the child developed a resistance to approaching the bathroom and toilet? It will also be important to assess the child’s resistance to the bathroom or the toilet itself.Enuresis and Encopresis 489 complete success in the area of bowel training. This avoidance can lead to a reciprocally devolving process composed of toileting resistance. or children who have a bowel movement in their clothing regardless of where they are. while others have experienced months or even years of success before the onset of the encopresis. and time-out. Parents’ responses to their child’s resistance will range from pleading to corporal punishment. whereas other parents will offer large rewards for small goals (e. voiding). Parent who are frustrated with managing their child’s soiling episodes often rely on verbal reprimands. Also. What type of underclothing does the child usually wear? The type of underclothing that children wear can have an important effect on their success with managing encopresis. the types of rewards that they have offered. no accidents for 1 month) that must be met to earn small rewards..g. Obtaining the child’s perception of the physical cues to which he or she attends when the toileting urge occurs is . Learn the terminology parents and child use to describe bowel movements and the toileting practices that are in place. length. sitting.. Therefore. Allowing children to wear diapers and Pull-Ups beyond the developmentally appropriate age inhibits motivation to use the toilet and is an obstacle to success. edible or tangible rewards. How do the parents respond to successful bowel movements? Make a note as to whether the parents have used verbal praise. or some type of activity reward. Some children insist on putting on a Pull-Up when they need to have a bowel movement.g. For example. Therefore. training pants. because children who have experienced significant levels of punishment are likely to engage in stool holding or experience increased soiling episodes. determine which behaviors parents have targeted for change (e. only to be accommodated by their parents. In general. and severity of the parents’ use of punishment during their attempts to manage their child’s encopresis. corporal punishment. obtaining details about parents’ responses to their child’s resistance can often shed some light on the severity of the avoidance behavior as well as the contingencies that are contributing to the child’s negative behavior. Pull-Ups. some parents will establish unreasonable goals (e. Child Intake Conducting the child intake assessment separately will allow the clinician to obtain more accurate information and perceptions from the child without him or her being influenced by the parents’ presence. determine the schedule and intensity of rewards used by parents.. regardless of the management approach used. and regular underwear and their current use of all of these throughout the day.490 Cognitive-Behavior Therapy for Children and Adolescents ponent of the treatment plan. sticker charts. it is important to identify the frequency.g. Ask parents about their child’s history with the use of diapers. each successful bowel movement). and the frequency with which these have been distributed. and any rewards that may be available to him or her for successfully voiding in the toilet. the treatment of disorders such as anxiety. we have developed a simple task analysis to allow clinicians to determine where in the toileting process their client is having success and where he or she needs intervention. This should be reiterated with the parents as well. we have outlined below a . and leave the bathroom. The steps below compose the task analysis that we typically use. it is perhaps more prudent to develop a treatment plan based on the point in the toileting process where children are struggling. or make an effort to have a bowel movement independently? Review with the child his or her understanding of any scheduled sit times that have been put in place.Enuresis and Encopresis 491 important. Accordingly. 2. 4. Finally. Some children with encopresis have never successfully voided in the toilet. does the child ignore them. depression. For example. wash hands. the child is either successfully voiding in the toilet 100% of the time or he or she is not. Thus. Because of that. the treatment goals that involve helping him or her to learn to successfully and reliably have all bowel movements in the toilet. and attention-deficit/hyperactivity disorder (ADHD) involves the assessment and treatment of a constellation of symptoms that constitute the disorder. whereas other children have had good success with toilet training and are having only occasional accidents. For example. children vary regarding where they fall in the appropriate bowel movement continuum. the treatment approach and the nature of the initial treatment session(s) will be dependent on where each child falls on the task analysis continuum. 1. Replace clothes. Have a successful bowel movement. Enter the bathroom. seek the parents’ assistance. whereas encopresis can be assessed and defined in a much more concrete manner—that is. what consequences are in place for soiling accidents. Thus. meeting with the child separately will provide an opportunity to discuss. remove clothing. and sit on the toilet. 5. 3. Attend to anticipatory physical cues. his or her perception of personal responsibilities regarding toileting practices. at the child’s level. This will allow discussion with the child about how he or she responds to those physical cues. Treatment The treatment of encopresis does not follow the same course as that of other disorders. flush. Thus. Children who are being evaluated for encopresis are experiencing problems with one of the above steps. Use toilet paper and clean self adequately. and encouraging more physical activity. Mechanics. If the child has a diet that is inadequate in fluid intake and/or low in fiber. he or she is likely to lose colonic sensation. Levine 1982) or some other visual aid can be beneficial when educating parents about the mechanics of the GI system in general and about how fecal impaction and constipation affect the colon in particular. This positioning makes it difficult for them to adequately relax or to use proper musculature when attempting to have a bowel movement. It is important to help parents understand that when their child’s colon becomes stretched from impaction. Most parents. or even spanked. do not have a thorough or full understanding of how the gastrointestinal (GI) system works. understandably. Diet and exercise. and corrective approaches that can be used on their own or in combination. and exercise is a critical part of the treatment approach. Parents’ increased understanding of the mechanics of the colon. proactive. A small stepstool can make a large difference in the mechanics needed for a child to have a successful bowel movement. Young or physically small children will often sit on the toilet with their feet dangling. Parental demeanor. ensure that there is solid support for the child’s feet when he or she is seated on the toilet and attempting a bowel movement. The role of stool softeners. This explanation will also help parents understand that in most cases. increasing fluids.g. or if the child does not get an adequate amount of exercise. their child for having accidents. diet. By the time that parents bring their child for management of encopresis.. thus adversely affecting the normal bowel movement cycle. and it is important for parents to know the importance of any needed changes in these areas. Punitive . along with the importance of keeping their child’s stools soft.492 Cognitive-Behavior Therapy for Children and Adolescents number of treatment approaches that focus on educational. then it will be important to educate parents about the benefits of balancing the child’s diet. A diagram (e. To avoid this problem. will hopefully help parents establish and maintain good compliance with their child’s daily regimen of stool softeners as well as the behavioral recommendations that are offered to them. All of these factors will help promote normal bowel activity (Dwyer 1995). along with the behavioral intervention. their child’s encopresis is not intentional and that there are clear physical factors that need to be addressed. they are likely to be frustrated and to have yelled or screamed at. Educational Approach The gastrointestinal system. Enuresis and Encopresis 493 or severely negative responses to a child’s soiling episodes hinder the treatment process or cause secondary negative behaviors. Some sample contingencies will be described later in the section “Successful Bowel Movements. The treatment goals should focus on having the child sit anywhere from 15 to 20 minutes after each meal for a period of 5 to 10 minutes. it is important for children to respond consistently and in a timely manner to physical cues and urges to have a bowel movement. day care providers. Regardless of the reasons. Positive or Proactive Approaches Responding to physical cues. or general defiance with the toileting regimen. Parents should not physically guide or place their child on the toilet if the child is being resistant. Also. encourage them to prompt their child to sit on the toilet or to offer to escort the child to the bathroom. It is important to promote a routine of having the child sit on the toilet on a regular basis and at scheduled times. it will be important to help the child feel comfortable . If the child is in day care or is school age. This will only serve to create or exacerbate negative associations either with sitting on the toilet or with the toileting regimen. then it will be important to provide appropriate education to teachers. hiding soiled underwear. Before having a bowel movement. and so forth regarding the child’s encopresis and toileting regimen. many children will posture themselves in a certain way or will quietly remove themselves to another room. One alternative contingency is to teach the child that sitting on the toilet at the assigned times has more positive than negative consequences. and others have normal sensation yet ignore physical cues for a variety of reasons. Treatment success is not possible without this response. Children with encopresis often respond inconsistently to physical cues to have a bowel movement.” Shaping and scheduling sit times. Caregivers outside the home. When parents observe these behaviors. Explain to teachers that the child may need to take more frequent toileting breaks and/or that making use of the nurse’s bathroom (if one is available) may be necessary. Help parents understand that maintaining a neutral and matter-of-fact demeanor will help to place the emphasis on their child’s behavior and choices regarding the toileting process. such as stool holding. Some children have limited sensation. To accomplish this goal. keeping an extra set of clothing at the school or day care will be helpful for many children. It will be important for the clinician to reinforce the importance of the child’s response to these cues and urges. Having the child sit after meals is designed to coordinate with the increased activity of the GI system following meals. The advantage of some type of candy or food reward is that it is immediate. have parents “practice” having their child sit on the toilet for very brief (30–60 seconds) periods of time. 2008). and in particular voiding in the toilet. work toward fading out scheduled sit times and promoting and reinforcing independence. Continued use of a timer to regulate the time spent sitting will also continue to be important. As treatment progresses. with the parent verbally praising or rewarding the child in some small way for participating. the use of some type of tangible reward seems to be important toward promoting successful bowel movements. The small size of the food . As mentioned above. help parents establish a routine for regular sit times. an ideal time for children to sit on a regular basis is 15–20 minutes after a meal. initially. tangible rewards can help to promote cooperation. because the child will know that the time that he or she spends sitting on the toilet is limited. the opportunity to promote and reinforce successful bowel movements increases dramatically. it is important to make use of some type of reward system to promote both sitting on and voiding in the toilet (van Dijk et al.494 Cognitive-Behavior Therapy for Children and Adolescents with sitting on the toilet and reaching a level of relaxation that will facilitate a successful bowel movement. This can be done multiple times throughout the day. As the child’s level of cooperation increases. Once children are sitting cooperatively. efforts can be made toward promoting successful bowel movements. These and other shaping techniques should be used to promote teaching the child to sit cooperatively for a length of time that will provide him or her with the opportunity to relax and have a bowel movement. The use of a timer can help facilitate the child’s cooperation. For young children. meaningful. This tends to be particularly effective for young children. This will hopefully increase the probability for the child passing stool in the toilet. or better yet. the use of small. scheduled sit times will be important. Because encopretic children naturally resist sitting on the toilet. the amount of time can be increased until the child is sitting on a regular basis for 5–10 minutes. with the child sitting for 5–10 minutes. and relatively inexpensive. Once sitting cooperatively has been accomplished. Below are several types of tangible rewards that can be used to promote both sitting on and voiding in the toilet. Once children are cooperatively sitting on the toilet for 5–10 minutes. However. Until the natural contingencies associated with sitting and successfully voiding in the toilet become evident to the child. Successful bowel movements. Candy dispensers. For young children. sitting on the toilet independently after responding to a physical urge to have a bowel movement. Sticker charts. he or she will earn one of the rewards and will be allowed to unwrap it. These types of rewards could be used to promote both sitting on and voiding in the toilet. starting with small rewards and working up toward something larger. Wrapped rewards. inexpensive trinkets at a local novelty store and wrap them using aluminum foil or some other wrap. Depending on the child’s level of motivation and the value that he or she attributes to earning stickers. a sticker would be placed on one of the circles. The parent should discuss with the child the different types of activities or rewards that the child would like to earn. Once the child has earned four stickers. the parent and child should work together to rank the items from least expensive and motivating to most expensive and motivating. who are understandably concerned about their child’s nutrition. These types of rewards are often useful for children ages 3–6. Many children are motivated to put forth additional effort to void in the toilet in order to earn the “mystery reward.Enuresis and Encopresis 495 reward also does not tend to be problematic for most parents. the clinician might ask a 4-year-old child to draw four circles on a piece of paper and decorate it to signify its use for documenting sitting and voiding. provide some intermediate reward for cumulative progress. the visual and immediate benefits of having this type of reward evident for sitting and/or voiding are often necessary. Each time that the child voids in the toilet. The main point here is that for young children especially. This type of strategy will provide immediate feedback to the child for his or her successfully sitting and voiding. The child should be told that each time that he or she voids in the toilet. The parent then writes the names of the . To implement this strategy. tangible rewards. the parents select a jar in which some type of token will be placed. For example. For example. Have the parents purchase small. he or she would earn an additional (not easily accessible) reward. Once a series of four or five rewards has been identified. For children who can count to a particular number or who understand quantity. The reward should be placed in a basket that is visible to the child but not easily accessible.” Reward jar. consideration should be given toward providing an additional reward for earning a set number of stickers. We recommend placing the dispenser on a bathroom counter or in a location that is visible to the child but not easily accessible. the use of a sticker chart can be very motivating toward reinforcing both sitting and voiding. the child could receive one Skittle (or other similar small candy) for sitting and several for passing stool into the toilet. The use of a reward jar is likely more appropriate for older children (age 5 and older) and should be combined with immediate. and at the same time. as well as to maintain positive toileting and bowel habit routines. sitting). A variety of other activities and toys can be used in this manner. Access to a special activity or item. “skid marks”).g. For example. it will be important to work with parents to help reduce these interventions. poker chips.496 Cognitive-Behavior Therapy for Children and Adolescents items on pieces of masking tape and places them on the jar in order. Fading rewards. The size of the token will depend on the size of the jar and how quickly the parent wants the child to earn the rewards. marbles. more sit times or bowel movements) to earn the same reward. The parents should put a limit on how much time that the child has access to it. The child will earn one token each time that he or she sits on the toilet cooperatively and two tokens each time that he or she voids in the toilet. ideally in the bathroom. Many children with encopresis will continue to have minor soiling episodes (e.g.g. Once the child has filled the reward jar. movie. but only for a limited amount of time. or by eventually fading the use of specific rewards for less critical behaviors (e. beginning with the least expensive–motivating reward on the bottom and ending with the most expensive–motivating reward at the top of the jar. if he or she so chooses. the process can start over.. once the child has successfully had a bowel movement in the toilet. with the child selecting new rewards. if the parent purchases a special book.. cotton balls. with the book then being put away until the next time that the child has a bowel movement in the toilet. This might include a special book. or some other activity that can be set aside and only provided to the child once he or she has voided in the toilet. then the parent and child might sit and read the book for 15 or 20 minutes after the child has successfully had a bowel movement. Have parents identify an activity or item to which the child will have access. Cleaning technique. This technique is probably most suitable for older children (age 5 and above). This is best accomplished by increasing the demands on the child (e. The tokens should be in a visible place. The tokens could include things such as pennies. Once the behavior has been established. then either the child can earn fewer tokens for previously targeted behaviors or the number of tokens needed to gain access to a reward can be increased. Reward systems should be put in place to initiate and shape behavior. If a reward jar is used. These are often caused mostly by a child’s poor wiping technique. The child will continue to receive immediate. tangible rewards for sitting on or voiding in the toilet but will also add tokens to the reward jar. to maintain its value. and so forth. but it can certainly be used with younger children. video game. It may be necessary for parents . Parents should review with their child his or her progress and how closely the child is getting toward earning the next reward.. points. If a soiling episode has occurred. Older children should be reminded to wipe and clean themselves appropriately.g. If possible. have parents follow the steps below after a soiling episode: 1. 2. help the parent understand the difference between mild soiling due to poor hygiene and unintentional minor soiling that can be associated with the use of stool softeners. Instruct the parents to provide some type of reinforcement to their child when his or her underwear is found clean (e. the parents should bring this to the child’s attention and inform the child that he or she will need to change and assist with the cleanup. matter-of-fact demeanor is important to reducing avoidant behavior on the part of the child and keeping the focus of the consequences on the child’s behavior. The rationale behind an overcorrection procedure is to place the responsibility for the soiling episode on the child while also apply- . based on their age and developmental ability. matter-of-fact demeanor to the best of their ability.Enuresis and Encopresis 497 to check the technique that their young children (under age 5) are using to make sure that they are wiping appropriately. Whether soiling occurs intentionally or unintentionally. verbal praise) to enhance compliance with the monitoring procedure. a treat. less effective punishment techniques such as time-out. Maintaining a neutral.. 3. Some children will occasionally pass small amounts of stool with the addition of fiber and Miralax (or other laxatives) to their daily regimen. and verbal reprimands. corporal punishment. An overcorrection technique is usually an effective consequence that is naturally associated with the child’s soiling accident. 4. Have parents check their child’s underwear periodically to make sure that the child has not soiled himself or herself. Parents can check the child’s underwear periodically to monitor this. The parents should be educated that these types of minor soiling episodes may occur until the amount of stool softener needed to promote regular bowel movements is reduced. an effective response to soiling episodes is an important component of successful treatment (also see the section “Challenges to Treatment” later in this chapter). Children should be expected to help clean themselves and their clothing to the best of their ability. In general. Use of this type of approach will remove the need for parents to use other. Emphasize to parents that it is important that they maintain a neutral. Corrective Approach Parents need an effective way to respond to their child’s soiling episodes (Reimers 1996). This will reinforce for the child that sitting on the toilet and having a bowel movement is much more efficient and less time-consuming than taking the time to clean himself or herself and his or her clothing. The parents should focus on taking 10–20 minutes for the cleanup process to be completed. This activity also enhances the effect of the overcorrection procedure.” In other words. It is unlikely that the child will defecate. The child should then put on clean clothing and be redirected to his or her normal activities. At least some early research on prevalence indicates encopresis is much more frequent in boys than girls. bubbles. with the ratios ranging from 3:1 to 6:1 (Fritz and Armbrust 1982. 6. Although this suggestion is consistent with our own experience. but it is important for the parent to reinforce what is expected of the child. Some children who have been wearing soiled clothing for an extended period of time or who are chronically soiled may need the benefit of a sitz bath to help prevent a rash. it has been questioned by others. who have suggested it is merely a reflection of biased population sampling (Fritz and Armbrust 1982). Some of the relevant research was conducted in foreign countries (Bellman 1966). beyond the occasional suggestion that encopresis is more likely to be found in families with lower incomes (van der Wal et al. Because the consequence is logically connected to the child’s soiling episode and behavior. losing privileges) that are not directly connected to the child’s soiling episode. Emphasize to the parents that they should make every effort to make the overcorrection procedure “inconvenient. very little is found in the peer-reviewed literature on the subject. the parents should not make the cleanup process easy and time efficient. 1978). 5.. 2005). Implications of Diversity There is much less epidemiological research on encopresis than there is on enuresis. it avoids the pitfalls associated with using punitive consequences (e. Once the child has adequately cleaned himself or herself and appropriately placed the soiled clothing in its proper place. The purpose for such soaking is for the child to avoid developing a rash.498 Cognitive-Behavior Therapy for Children and Adolescents ing a mild to moderate negative consequence for the soiling episode. Wright et al. time-out. One way of extending the overcorrection procedure is to have the child sit in a few inches of bathwater (with no toys. but the samples were primarily whites from industrialized cul- . As with enuresis. the prevalence rate of encopresis is much higher for boys. he or she should return to the bathroom and sit on the toilet for a brief period of time to practice appropriate toileting.). In terms of cultural variation in encopresis.g. bubble bath. etc. Any resistance by the child to participate should result in him or her having no access to other preferred activities. Challenges to Treatment The most frequent and difficult challenge to treatment involves resistance and noncompliance. We recommend avoiding time-out when possible. For children who avoid entering a bathroom at all. In sum. Most children will acquiesce to sitting on the toilet for a few minutes in order to gain access to their preferred activities. and so forth. it may be necessary to spend some time working with the parents on developing more effective parenting skills and focusing on improved levels of instructional . with the parent reminding the child of his or her choice to either play while sitting on the toilet or not play at all. Once this occurs. Gradually increase the expectations for the child. stickers. playing a game. Some children are resistant toward sitting on the toilet or entering the bathroom because of their painful bowel movement history or their negative experience with the training process that has been used. This could include reading. on the basis of extant empirical literature. efforts can be made toward shaping him or her to sit on the toilet. This may involve starting with the child sitting on the toilet fully clothed while parents engage in some simple activity. For children who are highly resistant toward sitting on the toilet or entering the bathroom. such as having him or her go from being fully clothed to sitting in his or her underwear to finally sitting unclothed on the toilet. it might involve having them play some portable video game or read a magazine while sitting. such as reading a book. tangible reward (e. For many children. For younger children. Additionally. the use of some type of simple. listening to music. there are no significant implications of diversity to highlight here. until the child is able to sit long enough to relax.g. small food items) may be helpful toward motivating them to follow the directions. or other fun activities to help eliminate the negative associations of being in the bathroom. many children would rather sit in time-out than sit on the toilet..Enuresis and Encopresis 499 tures and thus not substantially different from the populations studied in the United States. some type of shaping approach can be helpful by first establishing positive associations with the bathroom itself. listening to music. the use of some simple contingency management (described earlier) will be effective enough to promote compliance with sitting on the toilet. because it further creates negative associations with the toileting regimen and increases conflict between the parent and child. it will create an opportunity to shape more cooperative sitting for longer periods of time. Once the child is able to engage in other activities that are pleasurable in the bathroom. For older children. His parents had begun toilet training him when he was about 2½ years of age. it would likely be prudent to return to the management of the encopresis.) CBT Evaluation During the intake assessment. Outside of the encopresis. Given the long-standing soiling episodes and toileting difficulties. Once these goals have been accomplished. Sam and his parents were referred to a CBT psychologist. and at times. Most recently. Sam was otherwise compliant with demands made of him. Sam’s medical history was unremarkable. which led to constipation and large. who admitted Sam to the hospital for a fecal impaction clean-out. spanking. the psychologist reviewed with Sam’s parents his past medical history and their efforts to toilet train Sam. painful bowel movements.500 Cognitive-Behavior Therapy for Children and Adolescents control across a number of domains. Sam would also hide when having a bowel movement. The parents had used a variety of sticker charts and other tangible reward systems to motivate Sam to void in the toilet. and loss of privileges. as well as some forms of punishment to address Sam’s soiling episodes and resistance to sitting on the toilet. the parents noted no significant behavioral concerns. In time. Sam would frequently attempt to hold his stool for as long as possible. Sam’s pediatrician continued to monitor his constipation and toileting difficulties. The therapist obtained a thorough description of the toilet-training strategies the parents had used as well as their use of different punishment techniques. Despite taking Miralax. He continued to be resistant to his parents’ attempts to toilet train him. Sam had been placed on a regimen of Miralax for management of the constipation. He met all developmental milestones as expected. he had seen a gastroenterologist. This increased his parents’ frustration and led to additional forms of punishment. He took no medication other than Miralax for periodic constipation. (It is important to note here that we did not refer Sam for a physical examination because he was referred to us by his primary care physician. His parents had reinstituted various toilet-training attempts approximately every 6 months up to the current time. The punishment strategies included time-out. Case Example Sam was a 5-year-old boy who was referred because of recurring soiling episodes. The parents had used a variety of positive reinforcement programs. with some apparent overflow incontinence multiple times each day. He had never been successfully toilet trained. hide his soiled underwear. he had begun engaging in some stool-holding behavior. Sam would urinate in the toilet but was not having bowel movements in the toilet. The psychologist also learned . This would often lead to him having a large bowel movement every 2–3 days. The parents noted that their efforts had not caused any significant improvements in Sam’s voiding in the toilet. outside of toileting requests. the consistency of Sam’s stools (a chart was provided to the parents to help them record stool consistency). Sam responded. and the amount of medicine taken. a rating of the difficulty that Sam had with passing a stool.” Following the intake assessment. the psychologist met with the parents and asked them to collect data on Sam’s soiling episodes and their toilet-training practices. None of his bowel movements occurred in the toilet. Sam indicated that his “tummy hurt” when he needed to “go poop. Data Collection Sam’s parents were provided with a data form that allowed them. “No. as well as how they responded to Sam’s successful bowel movements and accidents. corporal punishment. the parents were asked to record the number of times that Sam hid his soiled underwear.” Sam was also questioned about his awareness of physical cues and urges to have a bowel movement. Based on these data and Sam’s history. their level of frustration increased. Additionally. Sam’s par- .” When asked if he tried to sit on the toilet and have a bowel movement when his tummy hurt. A timer was set to help Sam know how much time he needed to remain seated. any medicine that he was taking. It was learned during the intake with Sam that he was afraid to sit on the toilet because he said that it “hurt” when he had bowel movements while sitting on the toilet. the following treatment recommendations were put in place: 1. it was learned that Sam was having a large bowel movement approximately every 2 days.Enuresis and Encopresis 501 that the parents used time-out. Sam was to be rewarded in some small way for sitting cooperatively on the toilet. to record the number of bowel movements that Sam had in the toilet. Sam was expected to sit on the toilet for a period of 5 minutes after each meal. it will hurt. During the first treatment session. The parents indicated that as their efforts met with limited success. Sam also had approximately five small liquid soiling accidents each day. Sam also commented that he did not want his parents to know when he had a soiling episode because he “didn’t want to get in trouble. Sam sat on the toilet only on two occasions during the first week. They were also asked to journal their efforts toward prompting Sam to have a bowel movement. and restricting access to preferred activities each time that Sam refused to sit on the toilet or any time that he had a soiling episode in his clothing. Treatment Sessions Session 1. the number of soiling episodes. all were soiling episodes. Sam’s parents agreed to read a book to Sam or allow him to play a video game on a portable video game console while he was sitting. The punishment techniques had been used for the past 6–12 months. on a daily basis. The psychologist met separately with Sam. They purchased a small candy dispenser. . Sam’s cooperation with sitting had improved. The parents continued to have Sam assist with the cleanup associated with any soiling episodes. that were meaningful to Sam in order to reinforce his use of the toilet. Sam also seemed more excited about having bowel movements in the toilet than about the tangible rewards that he had received for them. He was now sitting fairly cooperatively on the toilet 70% of the time. such as action figures. Rather. The parents were encouraged to make the cleanup process mildly aversive while maintaining a neutral. The frequency of his soiling episodes had decreased to approximately two times per day. They wrapped the toys in aluminum foil and placed them in a basket that was placed on a shelf out of Sam’s reach. but visible to him. and Sam earned one Skittle for successfully sitting on the toilet for 5 minutes (Sam seemed excited about the opportunity to earn the Skittles). 2. Sam lost the opportunity to play outside for the remainder of the day after his parents discovered the hidden. Sam continued to have frequent minor soiling accidents and became increasingly agitated when he was required to help his parents with cleaning his clothing and himself. The parents were very excited because Sam had had two successful bowel movements in the toilet (one small. 3. soiled underwear. matter-of-fact demeanor. Sam was told that he would be able to unwrap one of the items any time that he had a bowel movement in the toilet. The parents were asked to provide no verbal reprimands or any form of punishment to Sam for having a soiling episode. Sam was to be provided with no bathtub toys. they were instructed on how to engage Sam in assisting them with cleaning himself and his soiled clothing and placing new clothing on himself to the best of his ability. Sam continued to sit cooperatively and was now sitting on the toilet approximately 90% of the time requested. he had hidden his underwear after a minor soiling episode. He had thus far not voided in the toilet but was now having approximately one bowel movement per day in his clothing. one large) during the past week. then Sam was expected to soak in a bathtub for 5–10 minutes to reduce the possibility of rash. The parents were instructed to provide one of the items to Sam no matter how small the stool was that he passed in the toilet.502 Cognitive-Behavior Therapy for Children and Adolescents ents rarely provided any candy or sweets to him at home. At the next follow-up treatment session 1 week later. The parents agreed to provide Sam with a piece of candy for sitting cooperatively. On two occasions. The parents agreed to purchase small toys and other items. Session 3. Session 2. The parents noted that his resistance toward sitting had decreased. His parents also noted that there were no instances in which Sam had hidden his soiled underwear. If Sam had multiple soiling accidents and the parents were concerned about a possible rash. Sam had had only two minor soiling episodes during the past 2 weeks. Sam was now voiding completely independently in the toilet and was having no soiling episodes. and medical complications that result from chronic untreated cases of encopresis are greater than the complications that arise from untreated enuresis. The parents were encouraged to contact the psychologist with any questions that arose in the future. Final session. Sam was now having all bowel movements in the toilet.” he would go to the bathroom and attempt to have a bowel movement. The components of the treatment protocol were reviewed with the parents and Sam.Enuresis and Encopresis 503 Session 4. both of which occurred while he was busy playing outside. emotional. They were to continue to have Sam assist with any cleanup for minor soiling episodes. He also shared with the psychologist the action figures that he had earned over the past 2 weeks. telling the psychologist how many times that he had gone “poop” in the toilet. Sam’s parents reported that the soiling episodes had almost completely ceased. Sam was praised for his progress. and they were asked to return in 1 month. Although effective treatment for encopresis is . unfortunately no similar type of research has been conducted on how distressing encopresis is for affected children. Conclusion: Encopresis Although enuresis is one of the most distressing experiences reported by children (Van Tijen et al. Sam was now voiding independently the majority of the time. which helped to reduce the minor soiling episodes. 1998). the psychological. and it was evident that he was very proud of his accomplishment. The parents noted no instances in which Sam either hid to have a bowel movement in his clothing or hid his soiled underwear. and his encopresis had resolved fully. social. Session 5. Sam was much more cooperative and clearly expressed his satisfaction with the progress that he had made. the parents reported significant improvement in Sam’s level of cooperation and the frequency of his bowel movements in the toilet. Sam’s parents were working with the pediatrician to reduce and eventually eliminate the Miralax dosage. Two weeks later. and instead to reward Sam only if he had a bowel movement in the toilet independently. Sam was seen 8 weeks later. Sam was also able to tell the psychologist that each time that he felt his “tummy hurt. The parents were instructed to discontinue regular sit times after meals. It was also suggested that they consult with Sam’s pediatrician to receive recommendations on possibly titrating his Miralax dosage. Sam occasionally would have very small amounts of liquid stool in his underwear. but the parents attributed these to the loose consistency of his stools. Furthermore. and final recommendations were offered. The treatment components were again reviewed with the parents. Our clinical experience suggests that encopresis is even more distressing for afflicted children than enuresis. 504 Cognitive-Behavior Therapy for Children and Adolescents more invasive and potentially embarrassing for affected children and their families than treatment for enuresis. and mistreated for centuries. When psychological abnormali- . Nonetheless. The CBT approach incorporates the physiology of elimination. effective treatment always involves cognitive and motoric behavior changes. it can actually involve less effort. psychological variables are viewed as critical to active participation in treatment. constipation. As with CBT for enuresis. scientists and practitioners working in the latter half of the twentieth century supplied a more accurate. the emphasis in CBT treatment for these disorders is mostly on the cognitive and emotional behavior of those affected. These characterizations have led to empirically supported treatments. Fortunately for them. and even more so to the moral and characterological understanding and approach of antiquity. The CBT understanding and approach to enuresis and encopresis is substantially superior to the historically psychogenic understanding and approach. Conclusion Enuretic and encopretic children have been misunderstood. Classic examples of CBT application include treatment for anxiety. it does not view psychological variables as necessarily causal. Those conditions are more dominantly psychological. misinterpreted. with the caveat that they be highly familiar with the physiology of defecation. With encopresis. For example. this form of treatment is also characterized as biobehavioral in other work (Christophersen and Friman 2010. CBT for encopresis is not an obvious example of CBT. but their approach typically is mostly biomedical. and the best known of these have been described in this chapter. or habit disorders. however. 2008). Although in this chapter we refer to the general category for these treatments as CBT. all of the parental treatment efforts occur during the day. and thus with the exception of cases involving drug treatments. and CBT provides methods for using or modifying these variables to promote participation. Rather. and although it also incorporates the psychological state of the child. physicians are the major first line of defense against encopresis. whereas with enuresis. important treatment efforts are needed at night. there is a substantial cognitive-behavioral dimension to the condition. Presently. and as we hope we have clearly demonstrated. and therefore encopresis is an appropriate target for CBT-trained therapists. depression. humane. the condition is quite obviously dominantly biomedical and so too is its most significant cause. and treatment-relevant characterization of these conditions. Friman 2007. family. The psychogenic approach virtually ignores the physiology of elimination and views psychological variables as dominantly causal.g. they are more likely to be viewed as a consequence rather than a cause of either condition. it provides no methods for using these same variables to promote participation. causes. • The child and parents should be educated about enuresis with emphasis on definition. • Because of the health risks associated with medications used for treatment of enuresis. Crohn’s disease) should be conducted before behavioral consultation is sought. • The most empirically supported treatment by a wide margin is alarmbased treatment. Key Clinical Points Enuresis • A physical exam of the child that includes a urine analysis should be included in the assessment phase. From the CBT perspective. Although the psychogenic approach views psychological variables as relevant to participation in treatment. when accompanied by empirically supported CBT. • Punishing the child for having soiling accidents should be avoided because of the risk for stool holding and a reduction in cooperation with the behavior plan. Encopresis • A physical exam to rule out fecal impaction and gastrointestinal diseases (e. can alleviate incontinence completely—and eliminate or dramatically minimize the possibility of the harmful overinterpretation and unhealthful forms of treatment that have tarnished the health care approach to incontinence in children throughout history. prevalence. This unified approach. and treatment options. cognitive-behavioral therapist.Enuresis and Encopresis 505 ties are present. and treatment options. • All forms of punishment for urinary accidents should be abolished. • The child and parents should be educated about encopresis with emphasis on definition. causes. but ideal management results from a partnership with the child. the evaluation and treatment of enuresis and encopresis always require the direct involvement of a physician. .. medication should not be used as a primary treatment agent. prevalence. and physician. physicians are solely responsible for assessment and diagnosis. 13. Family history. D. D. • The child’s stool consistency. and soiling accidents should be monitored closely throughout treatment. Involvement of the physician is best left to the psychologist’s discretion. Self-Assessment Questions Enuresis 13. Because enuresis is a medical condition. C. 13. Psychopathology. It is a psychopathological condition medically but not psychologically. Because enuresis is a psychological condition.3. All cases of enuresis should be referred to a physician for an initial evaluation so that potential medical causes can be detected and treated or ruled out. It is a psychopathological condition. It is a benign condition.506 Cognitive-Behavior Therapy for Children and Adolescents • Shaping the child’s cooperation for sitting on and voiding in the toilet through positive behavioral strategies should be the center of any intervention plan. successful bowel movements. which of the following is most accurate? A. C. 13. B. Which of the following is true of drug-based treatment for nocturnal enuresis? . Which of the following statements best characterizes enuresis? A.2. B.1. D. B. C. there is no need to involve a physician.4. Which of the following does not have strong evidence supporting its role as a cause of enuresis? A. Regarding physician involvement in the initial assessment of enuresis. It is a psychopathological condition psychologically but not medically. Difficulty arousing from sleep. Reduced functional bladder capacity. B. D.6. Higher. D. Medical treatment only. Dietary modifications. Because of unhealthy side effects and temporary results. C. Not available for the general population. Sodium intake. B. . B. Drugs are highly effective as treatment for enuresis and should always be considered as primary treatment. Encopresis 13. C. B. and the therapist should choose between them.Enuresis and Encopresis 507 A. From a treatment standpoint. D. Lower. Alarm-based treatment.7. the prevalence rate for encopresis is A. the research suggests that which treatment modality is most efficacious when treating encopresis? A. C. Drugs are highly ineffective for treatment of enuresis and should never be considered in a treatment plan. Scheduled toilet visits. 13. Which of the following factors is not known to contribute to the development of encopresis? A. D.5. drugs should be considered only as adjuncts to treatment. About the same. Volitional stool-holding. with consultation by a psychologist. 13. History of painful bowel movements. Fluid restriction. D. Both drugs and biobehavioral treatment methods are effective as primary treatment for enuresis. C. 13. Behavioral treatment only. Fiber intake. Compared to enuresis. Collaborative medical and behavioral treatment. C.8. Retention-control training. B. Which of the following treatments for diurnal enuresis has the most empirical support? A. Encopresis is primarily a behavioral disorder. 2001 . including medical. C. Biofeedback does not increase treatment rates above those achieved with conventional treatment alone. and it should generally be avoided. Regarding physician involvement in the management of encopresis. further involvement by a physician is not needed. whether involvement by a physician is needed. American Psychological Association. 13. D. at their discretion. It is a condition that has many contributing factors.10. and nutritional. Because there is a strong behavioral component to encopresis. Which of the following best characterizes encopresis? A.508 Cognitive-Behavior Therapy for Children and Adolescents 13. C. There is no support for the use of biofeedback.11. especially when combined with medical and behavioral interventions. B. The contributing factors for encopresis are not well known. B. Which of the following is true about the role of biofeedback treatment for encopresis? A. Mortweet SL: Treatments That Work With Children: Empirically Supported Strategies for Managing Childhood Problems. behavioral. 13. DC. All cases of encopresis should be referred to a primary care physician to rule out potential medical causes. Washington. D. Suggested Readings and Web Sites Christophersen ER. It has demonstrated superior long-term effects over traditional medical interventions. C. D. B. All cases of encopresis should be referred to a pediatric gastroenterologist.9. Biofeedback has been shown to be a critical and essential treatment component. Psychologists should decide. which of the following is most accurate? A. Encopresis is primarily a medical condition. Edelbrock C: Manual for the Child Behavior Checklist and Revised Behavior Profile. Penguin.html The Web site for the University of Virginia Health Sciences Center features a tutorial for patients and families. J Pediatr Psychol 25:225–254. 2006 Vemulakonda VM. DC.Enuresis and Encopresis 509 The Journal of the American Academy of Child and Adolescent Psychiatry October 2001 issue provides an extensive review of the research literature on enuresis and encopresis.com/viewarticle/546017.wikipedia. Accessed July 28.medicine. For a variety of toilet training accessories: www. Murphy L: Empirically supported treatments in pediatric psychology: constipation and encopresis.org/online/famdocen/home/children/parents/toilet/ 166.pottytrainingconcepts.aacap. McGrath ML.org/ az/Site1755/mainpageS1755P0.soilingsolutions.virginia. 1983 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 2006. Jones EA: Primer: Diagnosis and Management of Uncomplicated Daytime Wetting in Children.html References Achenbach TM.bedwettingstore. IN.com Diurnal enuresis: http://en.childrenshospital. Indianapolis.com Bedwetting facts: www. Sheldon GG: The Pocket Idiot’s Guide to Potty Training Problems. 2000 .com FamilyDoctor. 2011. Mellon MW.org/wiki/Diurnal_enuresis General information and products for all aspects of child incontinence: www. Nat Clin Pract Urol 3:551–559. Text Revision. 4th Edition. Available at: http://www.pottymd. “Chronic Constipation and Enuresis”: http://www.edu/clinical/departments/ pediatrics/clinical-services/tutorials/constipation/home The Bedwetting Store: www.medscape. University of Vermont. American Psychiatric Association. Burlington. 2000 (a comprehensive review of the empirically supported treatments for constipation and encopresis) Schonwald AD.org: “Stool Soiling and Constipation in Children”: http:// familydoctor.com For more information on toilet training and the Toilet School at Children’s Hospital Boston (Massachusetts): http://www.org/cs/root/facts_for_families/bedwetting Bedwetting general information: http://en. Washington.org/wiki/Bedwetting Bedwetting and soiling information and treatment: www.wikipedia. Ann Behav Med 22:260–267. et al: Precipitants of constipation during early childhood. Cambridge. Cox DJ. J Pediatr Psychol 27:585–591. 1974 Bellman M: Studies on encopresis. Saunders. functional constipation. Elkin TD. Tam A. MA. Reitman D. Foxx RM: Dry bed training: rapid elimination of childhood enuresis. 2010 Cox DJ. 1983. Strupp KR: Encopresis and anal masturbation. London. Friman PC: Elimination Disorders in Children and Adolescents. Behav Res Ther 20:383–390. Rumack BH: Magical thinking and imipramine poisoning in two school-aged children. ON. Lanphear NE. 1951 Gross RT. et al: Review of the treatment literature for encopresis. J Pediatr Psychol 25:219–224. in Handbook of Assessment. 2002 Dwyer JT: Dietary fiber for children: how much? Pediatrics 96:1019–1022. mechanisms. et al: Bed-wetting in US children: epidemiology and related behavior problems. 1986 Friman PC: The psychopathological interpretation of routine child behavior problems: a critique and a related opportunity for behavior analysis. pp 575–586 Herson VC. and Treatment. Nettelbeck T: A component analysis of dry-bed training for treatment for bedwetting. Crocker AC. Hoboken. Morris JB Jr. and stool-toileting refusal. 2000 Byrd RS. Vol 2: Children and Adolescents. Armbrust J: Enuresis and encopresis. in Handbook of Evidence-Based Therapies for Children and Adolescents. 1953. Borowitz SM. Roberts MC. Annu Rev Psychol 52:685–716. PA. Sneed TJ. Cox DJ. May 2002 Friman PC: Encopresis and enuresis. Ibarra S. 1995 Freud S: Three essays on the theory of sexuality (1905). Pediatr Clin North Am 5:283–296. Pediatrics 8:859–876. 1991 Houts AC: Commentary: treatments for enuresis: criteria. Vol 7. Carey WB. pp 589–621 Friman PC: Evidence based therapies for enuresis and encopresis. Schmitt BD. Wiley. 1982 Glicklich LB: An historical account of enuresis. in The Standard Edition of the Complete Psychological Works of Sigmund Freud. J Am Board Fam Pract 16:213–218. J Am Psychoanal Assoc 48:1327–1354. 1966 Bollard J. pp 136–243 Friman PC: A preventive context for enuresis. pp 311–333 Fritz GK. 1979 Houts AC: Nocturnal enuresis as a biobehavioral problem. Canada. 2001 Christophersen ER. Invited address at the 28th Annual Convention of the Association for Behavior Analysis. 2003 Brooks RC. 2008. Philadelphia. Ollendick TH: Empirically supported psychological interventions: controversies and evidence. 2007.510 Cognitive-Behavior Therapy for Children and Adolescents Aruffo RN. New York. and health care policy. Behav Ther 22:133– 151. 1982 Borowitz SM. 2000 . et al: Psychological differences between children with and without chronic encopresis. Case Conceptualization. 1996 Chambless DL. NJ. Springer. Edited by Steele RG. et al. Hogarth Press. Edited by Levine MD. Edited by Hersen M. JAMA 241:1926–1927. Pediatr Clin North Am 33:871–886. Behav Res Ther 12:147–156. 2000 Azrin NH. Translated and edited by Strachey J. Toronto. Copen RM. Pediatrics 98:414–419. Hogrefe. Weitzman M. Dornbusch SM: Enuresis. Acta Paediatr Scand 170(suppl):1–137. in Developmental-Behavioral Pediatrics. Food and Drug Administration: Desmopressin acetate (marketed as DDAVP Nasal Spray. Berman JS. 1994 Starfield B: Functional bladder capacity in enuretic and nonenuretic children.htm.S. Springfield. 1967 Starfield B. DDVP. Edited by Wolraich ML. Wozner Y: A self-control intervention package for the treatment of primary nocturnal enuresis. Rappaport LA: Elimination conditions. 2007 Kegel AH: Physiological therapy for urinary stress incontinence. and bed-wetting. Jason Aronson. 1997 Loening-Baucke V: Prevalence rates for constipation and fecal and urinary incontinence. . Thomas. 1968 U. 1982 Luxem MC. NJ. Rahav G. PA. Available at: http://www. Dworkin PH. 2000 Muellner SR: Development of urinary control in children: some aspects of the cause and treatment of primary enuresis. 1960 Muellner SR: Obstacles to the successful treatment of primary enuresis. daytime wetting. Minirin. Wozner Y.fda. J Cogn Psychother 9:249– 258. Pediatrics 120:E308–E316. Peterson JK. 1951 Levine MD: Encopresis: its potentiation. Accessed April 26. 2007 McGrath ML. 2011. JAMA 172:1256–1261. Behav Ther 17:462–469. Christophersen ER. Arch Dis Child 92:486–489. Heron J. Drotar DD. Child Fam Behav Ther 14:1–14. et al: Behavioral-medical treatment of pediatric toileting refusal. 1986 Houts AC. Purvis PC. JAMA 146:915– 917. Liebert RM: Bedwetting: A Guide for Parents. J Pediatr 72:483–487. Northvale. Abramson H: Effectiveness of psychological and pharmacological treatments for nocturnal enuresis. Butler R.gov/Drugs/ DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ ucm107924. 1995 Ronen T. DDAVP. et al: A United Kingdom population-based study of intellectual capacities in children with and without soiling. in Developmental-Behavioral Pediatrics. Child Fam Behav Ther 17:1–20. Mosby. Pediatr Clin North Am 29:315–330. and alleviation. JAMA 178:843–844. McGrath ML: Empirically supported treatments in pediatric psychology: nocturnal enuresis. 1994 Joinson C. Philadelphia. Whelan JP: Prevention of relapse in full spectrum home training for primary enuresis: a components analysis. 2007. Wozner Y: Self-control and enuresis. 2008. Behav Modif 20:469–479. J Pediatr Psychol 25:193–214. FDA Alert.Enuresis and Encopresis 511 Houts AC. Rahav G: Cognitive interventions for enuresis. 1961 Reimers TM: A biobehavioral approach toward managing encopresis. J Dev Behav Pediatr 18:34–41. 1992 Ronen T. 2000 Mellon MW. 1995 Schonwald AD. IL. pp 791–804 Sperling M: The Major Neuroses and Behavior Disorders in Children. J Consult Clin Psychol 62:737– 745. and Stimate Nasal Spray). Mellon MW. 1996 Ronen T. December 4. J Pediatr Psychol 25:225–254. Murphy L: Empirically supported treatments in pediatric psychology: constipation and encopresis. J Pediatr 70:777–781. 1985 Houts AC. evaluation. DDAVP Rhinal Tube. Mellits ED: Increase in functional bladder capacity and improvements in enuresis. 1978 . 10th Revision. Version for 2007. 2008 Van Tijen NM. Available at: http:// apps. controlled trial. Schaefer AB. Namdar Z: Perceived stress of nocturnal enuresis in childhood.int/classifications/apps/icd/icd10online. 2005 van Dijk M. University Park Press. 1998 World Health Organization: International Statistical Classification of Diseases and Related Health Problems. 2011. Accessed April 26.512 Cognitive-Behavior Therapy for Children and Adolescents van der Wal MF. Messer AP. Solomons G: Encyclopedia of Pediatric Psychology. MD. Wright L. Br J Urol 81 (suppl 3):98–99. et al: Behavioral therapy for childhood constipation: a randomized. Benninga MA. Bongers ME. Hirasing RA: The prevalence of encopresis in a multicultural population. J Pediatr Gastroenterol Nutr 40:345–348. de Vries GJ.who. Pediatrics 121:E1334–E1341. Baltimore. This schema is activated in situations that remind the individual of the original learning experiences.2.1. through which an individual views the world and makes sense of new information. 513 . 1.APPENDIX 1 Self-Assessment Questions and Answers Chapter 1: Cognitive-Behavior Therapy: An Introduction 1. What is the most readily available form of core beliefs called? Answer: Automatic thoughts are the most readily available form of core beliefs. What is a negative schema? Answer: A negative schema is an information processing “lens. the world. leading to maladaptive negative beliefs about the self. and the future.” informed by early life experiences and negative life events. Answer: Collaborative empiricism is a process by which the therapist and client carefully consider all available evidence and identify “clues” that support the maladaptive cognition and those that do not support the thought or belief. How are behaviors reinforced? How are they extinguished? Answer: Behaviors are reinforced when an event. Cognitive-Behavior Therapy for Children and Adolescents Define collaborative empiricism. Different areas of development (e. cognitive.3. privilege. B. 2. Causal reasoning and emotion identification. Which of the following developmental skills are necessary to understand this connection? A. Which of the following is NOT a reason to use a developmentally sensitive framework in treatment planning? A. Developmental level impacts children’s ability to both learn and apply therapeutic skills. Chapter 2: Developmental Considerations Across Childhood 2. social.3. D. Answer: C..4. C.2. True or False: Adolescents are always better able to engage in cognitive-behavioral strategies than are young children.1. Different treatment strategies require different developmental skills.g. 2.514 1. Development level within a domain is uniform at each chronological age. Metacognition and perspective taking. . B. material item or behavior that follows a behavior is rewarding. 1.” he feels discouraged and is less likely to study for the test. Extinction refers to the reduction in frequency or total elimination of a behavior by use of nonrewarding occurrences. Little Johnny is asked in therapy to recognize that when he thinks “I will fail this math test no matter what. and emotional) are interdependent. Answer: False. 2. D. B. B. B. . True or False: Adapting adult language to be more age-appropriate is the primary way to developmentally tailor CBT for children. Which of the following is NOT a strength of CBT when implemented with ethnocultural minority youth? A. Physical discipline. unconscious processes. C. C. It is focused on the present and future. Answer: D. Answer: False. Chapter 3: Culturally Diverse Children and Adolescents 3. C. Clinicians should assess children’s developmental level A. D. It is focused on intrapsychic. Racial socialization.4.5. D.Appendix 1: Self-Assessment Questions and Answers 515 C. Parent training protocols with ethnic minority youth may improve treatment retention and outcomes by including an emphasis on A. Natural consequences. Answer: C. After implementing strategies designed to improve developmental skills. Before introducing a new developmentally challenging technique. Before starting treatment. It is time limited and problem oriented. 2.1. 2. Time-out. Hypothetical thinking and emotion management. It involves collaboration in defining treatment goals. All of the above. Answer: D. Self-reflection and social skills. Answer: B. D. 3. Acculturation stress. C. Family-focused sessions.516 Cognitive-Behavior Therapy for Children and Adolescents 3. Behavioral activation. Ableism. D.5.1.g.4.3. B. D. school)? A. Answer: A. CBT with an Iraqi (Muslim) 12-year-old girl with externalizing problems might be enhanced by A. C. Individual-focused sessions. C. . Answer: C. Problem solving. Assertiveness training. 3. home vs. The only other medication besides fluoxetine that the U. Feelings as facts. Internalized oppression. Sertraline. 3.” This belief is an example of A. Chapter 4: Combined CBT and Psychopharmacology 4. Cognitive restructuring. B. One of his core beliefs is that “only white kids do well in school. Emphasis on assertiveness training in all contexts. C. Behavioral activation. B. D. The clinician must be especially cautious in implementing which CBT skill because of its cultural acceptability in different settings (e. Escitalopram. B.. Answer: B. Food and Drug Administration has approved for the treatment of major depressive disorder in adolescents (12–17 years) is A.S. Antoine is a 9-year-old African American boy who is struggling in school. Paroxetine. For a 13-year-old patient presenting with a first episode of major depression.3. Combined treatments (CBT and pharmacotherapy) are always better than either treatment alone. D. D. such as symptom severity and patient and parent preferences. B. CBT is consistently better than pharmacotherapy and thus should be the first line of treatment. the following statement is true: A.2. E. Always start with CBT first and switch to medications if CBT does not work. the clinician should A. with some studies showing efficacy of combined treatments and others the advantages of a combined approach. 4. Combined treatments (CBT and pharmacotherapy) showed a superior response rate compared to CBT or pharmacotherapy alone. None of the above statements is true. E.4.Appendix 1: Self-Assessment Questions and Answers 517 D. No intervention was shown to be better than placebo. The results are mixed. Take a detailed history and make a decision on treatment interventions on the basis of the inventory of factors. Answer: B. On the basis of the results of the Children/Adolescent Anxiety Multimodal Study (CAMS). CBT is the most effective intervention for children and adolescents. Which of the following statements is true regarding evidence for combined treatments (CBT plus pharmacotherapy) for depression? A. 4. Pharmacotherapy is the most effective intervention for children and adolescents. B. The results were inconclusive. Answer: D. Pharmacotherapy is consistently better than CBT and thus should be the first line of treatment. E. 4. Answer: C. C. . Imipramine. B. Fluvoxamine. C. E. Switch to venlafaxine.1. B. . Chapter 5: Depression and Suicidal Behavior 5. Let the patient decide. 5. Switch to another SSRI. Severity of symptoms. All of the above. The most helpful CBT technique to include in her treatment plan is A. and then always start with a combined approach (CBT plus pharmacotherapy) because it has been shown to be the most efficacious. Take a detailed history. C. B. Always start with pharmacotherapy first and then add CBT if symptom resolution has not been achieved by pharmacotherapy alone. assess for various factors. D.5. D. Comorbidities. The next management step that the youth would most likely respond to is to A. Answer: E. E. A 14-year-old Hispanic boy diagnosed with a major depressive disorder has not responded to a trial of a selective serotonin reuptake inhibitor (SSRI). Exposure and response prevention.518 Cognitive-Behavior Therapy for Children and Adolescents C. D. C. Prior experience with treatment. Availability of resources. Answer: B. 4. Switch to another SSRI and add CBT. Which of the following are important factors to consider when deciding which intervention to choose from? A. Treat with the same SSRI for a period longer than 12 weeks. Answer: C.2. A 13-year-old girl with a history of depression gets easily irritable at school and becomes aggressive with teachers and friends. 3. Cognitive restructuring. Cognitive-behavior therapy for suicide prevention. Cognitive restructuring. CBT would be considered an appropriate treatment strategy for a child with bipolar disorder .4. 5. 5. C. You see an adolescent youth with depression who is having difficulty initiating and maintaining relationships with peers.1.Appendix 1: Self-Assessment Questions and Answers 519 B. Social skills training. B. Interpersonal therapy. D. Relaxation techniques. Social skills training. Emotion regulation. C. D. C. Emotion regulation D. Emotion regulation. Chapter 6: Bipolar Disorder 6. C. The most helpful CBT technique to include in the treatment plan of this youth is A. Answer: C. 5. Safety planning. Behavioral activation. CBT used with depressed youths. B. This is an example of A. D. B. Answer: C. You tell your depressed adolescent youth that it is important to schedule activities that he or she finds pleasurable and to engage in these activities on a regular basis. Answer: D. Cognitive restructuring. Behavioral activation.5. A feasible and acceptable therapeutic intervention with a depressed adolescent who recently attempted suicide is A. Answer: D. and social factors. Only when a strong family history of bipolar disorder is identified. Answer: B. Antidepressants. B. Answer: C. Mood stabilizers or atypical antipsychotics. C. . D. psychological. and social factors. All of the above. B.2. Electroconvulsive therapy. 6. Answer: B. Suicidal ideation. D.3. If the child is of well above-average intelligence. Academic problems. 6. biological factors. A. D. Social problems. a combination of biological. C. CBT. illness course is likely influenced by ___________________________. Answer: D. Although the etiology of bipolar disorder is thought to be largely ___________________. Medication induced. the child’s level of intelligence. _____________ is almost always recommended as a part of CBT for a child with bipolar disorder. a combination of biological. A. B.520 Cognitive-Behavior Therapy for Children and Adolescents A. C. A 14-year-old adolescent girl is diagnosed with bipolar I disorder. Biological. __________ is/are considered the first-line treatment(s). Due to impaired parenting. 6. C. B. Children with bipolar disorder are at increased risk for A. As a stand-alone treatment.4.5. D. 6. psychological. The result of trauma. In conjunction with mood stabilization with medication. Use of a therapist of the same sex as the child. Treatment manuals exist for CBT for child anxiety for youth ages 4–17. 7. The clients described in A. D. Although behavioral activation is a component of some CBT protocols for child depression. Behavioral activation. and a learning disability. C. obesity.2.1. D. Psychoeducational testing. Answer: D. A 6-year-old Hispanic girl with primary separation anxiety disorder and a specific phobia of blood. B. Psychoeducation. Cognitive restructuring. Which of the following clients is an appropriate candidate for CBT for child anxiety? A.3. D. B. 521 Family involvement. B. The best role for her parents in CBT treatment is . A 7-year-old girl diagnosed with separation anxiety disorder presents for treatment. Chapter 7: Childhood Anxiety Disorders 7. Which of the following is NOT a core component of CBT for child anxiety? A. C. B. All of the above. Residential treatment.Appendix 1: Self-Assessment Questions and Answers A. it is not a common core component of CBT approaches to child anxiety. Exposure tasks. and CBT for child anxiety can be implemented with flexibility for youth with learning differences and comorbid conditions. C. Answer: A. 7. A 16-year-old white adolescent girl with primary social phobia. Answer: D. A 13-year-old African American adolescent boy with primary generalized anxiety disorder and comorbid attention-deficit/hyperactivity disorder (ADHD) managed with stimulant medication. and C are all appropriate candidates for CBT for child anxiety. There’s no way I’ll fail. “I’m worried that I am going to fail.e. he thinks. Though it might seem tempting to include parents as co-clients. because of parental concerns about causing the child too much stress. Parents as collaborators in conducting exposure tasks involving the child’s separation from the parent(s).. B. Answer: D. but the best role for them in this case is as collaborators. Which of the following is NOT an example of an appropriate flexible implementation of CBT for child anxiety (i. This coping thought is realistic about the probabilities of the various feared outcomes. 7. Parents as co-clients in treatment. Answer: C. Simplifying cognitive restructuring to the use of a single coping thought (“I can do it!”) for a 7-year-old boy with primary separation anxiety disorder who didn’t fully grasp the concept of self-talk. and then I’ll have to repeat seventh grade!” Which of the following is a reasonable coping thought in this situation? A. No parental involvement in the child’s treatment. with treatment for the child and treatment for the parents. Parents can and do serve as consultants.. . Even if I fail seventh grade..so why bother studying? D. The teacher likes me. the core component of treatment will be graduated exposure to the feared situation—specifically. It’s unlikely that I will fail the test because I studied pretty hard. Eliminating at-home exposure tasks for an 11-year-old girl with social phobia. A 12-year-old boy with generalized anxiety disorder expresses worry about an upcoming test. B. I still have my friends. I have plenty of time to bring up my grades before the end of seventh grade. C. 7. separation from parents. Even if I did fail this one test.522 Cognitive-Behavior Therapy for Children and Adolescents A. C. D. Parents as consultants regarding the child’s symptoms and impairment.. Parents can be involved as collaborators in planning and carrying out the exposure tasks. All I have to do is study every day before the test and then I won’t fail..5.. a flexible application that maintains treatment fidelity)? A. I think. B.4. Thoughts. and culture. and C only. comorbidities. D. to the child’s trauma in some way. This application would not be an example of “flexibility within fidelity” because the child will not face her fears in settings other than the therapy clinic. and D are all appropriate ways to individualize CBT for child anxiety according to age. The therapist should review the rationale behind exposure tasks with the parents and the importance of allowing the child to learn to cope with the distress. Connections among which of the following three components form the basis of cognitive coping? A. Downplaying “sleeping in own bed” as an exposure task for a 9-year-old girl with primary social phobia. Which of the following is a characteristic of gradual exposure? A. Thoughts. D. due to parental beliefs and preferences regarding a shared family bed. .2. behaviors. Answer: A. beliefs. behaviors. A. C. B. Answer: E. feelings. including the skills-based components.1. Answer: B. while maintaining treatment fidelity. Antecedents. Chapter 8: Pediatric Posttraumatic Stress Disorder 8. Therapists being mindful not to model avoidance. 8. Using frequent breaks and additional rewards for an 8year-old boy with primary generalized anxiety disorder and comorbid ADHD who is having difficulty staying on task in session. antecedents.Appendix 1: Self-Assessment Questions and Answers 523 C. B. behaviors. consequences. D. consequences. C. Instructing children to think about their trauma experiences for at least an hour every day. Thoughts. F. Connecting each component. A. B. C. All of the above. E. Incrementally increasing the duration and intensity of traumatic material in each sequential treatment component. B. A. Answer: D. . What treatment parents will accept. B. C. Which of the following may inadvertently communicate trauma avoidance to children during therapy? A. C. F. B. D. and C only. Accessibility of school-based treatment. All of the above. Cultural adaptations of CBT trauma treatments have A. All of the above.3. Severity of symptoms.4. Attempting to show empathy by changing voice tone or volume when talking about trauma. Created new models for different ethnic groups. Answer: B. Using euphemisms for traumatic experiences. Prolonged exposure.5. B. Change in body language. Socratic questioning. Which of the following factors may be considered in choosing between individual and group CBT trauma treatments? A. 8. CBT treatment research has indicated that the most efficacious component for decreasing obsessive-compulsive disorder (OCD) symptoms is A. E. 8. Preparatory statements when introducing traumatic themes. D. Answer: F.1. Chapter 9: Obsessive-Compulsive Disorder 9. D.524 Cognitive-Behavior Therapy for Children and Adolescents 8. Retained all core components of the efficacious treatments. C. Found that manuals cannot be properly translated into other languages. Found some core components to be ineffective with certain populations. B. Appendix 1: Self-Assessment Questions and Answers 525 C. Progressive muscle relaxation. D. Exposure and response prevention. Answer: D. 9.2. Research by Storch and colleagues has indicated that CBT with exposure and response prevention (E/RP) is A. Most effective when delivered in a weekly outpatient format. B. Most effective when delivered in a daily outpatient format. C. Equally effective in either a weekly or daily outpatient format. D. Equally effective in either an outpatient or inpatient format. Answer: C. 9.3. What is considered to be the threshold for clinically significant OCD on the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)? A. B. C. D. E. 10. 12. 16. 20. 30. Answer: C. 9.4. Which of the following is not considered relevant to at least some OCD cognitions? A. B. C. D. Feared consequence of not relieving urges. Thought-action fusion. Overestimation of threat. Intolerance of uncertainty or doubt. Answer: A. 9.5. When is an E/RP exercise typically considered to be successfully completed? 526 Cognitive-Behavior Therapy for Children and Adolescents A. When the child and parent experience a 30% reduction in initial distress. B. When the child experiences a 50% reduction in initial distress. C. When the child experiences a 90% reduction in initial distress. D. When the child and parent experience a 90% reduction in initial distress. E. Either B or D. F. Either B or C. Answer: F. Chapter 10: Chronic Physical Illness 10.1. When CBT is used for the treatment of a youth with a chronic physical illness, which of the following treatment components will likely be most useful for improving mood and positive coping? A. Teaching the youth skills focused on changing negative thoughts regarding illness. B. Parent sessions focused on education regarding CBT and how parents can best support their child. C. Teaching the youth skills focused on how to behave differently when feeling upset, such as increasing pleasurable activities. D. All of the above. Answer: D. When using CBT, the behavioral, cognitive, and family skills introduced are all equally important to the overall outcome of improving mood and positive coping for youth. Ultimately, CBT is a toolbox approach, and the best treatments provide youth with several options for coping with negative situations they may encounter in the future. 10.2. Which of the following best describes the relationship between psychological and physical processes? A. Symptoms of physical illness, such as inflammation, can negatively impact brain chemistry, resulting in psychological disturbances. B. There is no relationship between physical illness and mental health concerns. Appendix 1: Self-Assessment Questions and Answers 527 C. The relationship is bidirectional. A preexisting mental health concern can negatively impact physical illness by decreasing healthy behaviors. Also, physical illness processes can contribute to increased psychological concerns by increasing both internal and external stressors. D. Psychological difficulties can negatively impact a youth’s perception of control over illness, leading to a hopeless view regarding health and a decreased participation in healthy behaviors. Answer: C. The relationship between physical illness and psychological processes is bidirectional. This supports providing mental health treatment alongside medical treatments in order to promote medical adherence and to increase quality of life and feelings of well-being. 10.3. A 14-year-old adolescent girl with comorbid Crohn’s disease and depression spends most of her time lying in bed in her bedroom, isolating herself. Which of the following coping skills is a primary control tool that will likely help her change this negative behavior? A. The tool of identifying the silver lining so that the youth begins to find the positive in her situation. B. Taking part in relaxation training techniques such as deep breathing and hypnosis. C. Recognizing negative thought patterns and challenging them with more helpful thoughts. D. Activity scheduling: being encouraged to take part in an increased variety of activities, including pleasurable, physically active, helpful, and social activities. Answer: D. Choices A and C are secondary control techniques; they focus on changing the youth’s perception in order to improve mood. Choice B is a primary control tool; however, relaxation training would not be the most helpful skill for decreasing the youth’s isolative behavior. Activity scheduling is a primary control tool because it encourages the youth to behave in a different way to change the negative situation. 10.4. Which of the following is not a focus of treatment according to the Skills-and-Thoughts (SAT) theory? A. Identifying negative thought patterns and learning to change them. 528 Cognitive-Behavior Therapy for Children and Adolescents B. Improving self-soothing skills. C. Using the therapeutic relationship as a model for outside relationships. D. Increasing participation in pleasurable or rewarding activities. Answer: C. Choices A, B, and D all describe components of the SAT theory, which focuses on improving negative cognitions as well as behavior patterns. Choice C describes the interpersonal therapy approach. 10.5. When working with a 17-year-old adolescent boy, the therapist notices that he appears bored when presented with the information. Which of the following developmental adaptations may be most useful for this situation? A. Leave out the ACT (i.e., Activities, Calm and Confident, Talents) skills when conducting treatment in order to focus more on the complex skill of cognitive challenging. B. Focus on making the sessions collaborative and fun by learning about the teen’s interests and linking skills with the teen’s illness narrative. C. Increase parent participation in the teen’s sessions to ensure that he participates actively. D. Do not make any adaptations, as this would decrease the overall efficacy of the treatment. Answer: B. When working with teens, it is especially important to create a collaborative relationship and to link the skills presented with the reported concerns in the illness narrative. Making these adaptations will likely strengthen the efficacy of the treatment. Because teens are often seeking independence, increasing parental participation in individual sessions would likely not increase the therapist’s rapport with the teen. It is important for therapists to present both ACT and THINK (i.e., Think positive, Help from a friend, Identify the silver lining, No replaying bad thoughts, Keep trying—don’t give up) skills to patients of all ages with whom they are working; these are the key components of the treatment. Appendix 1: Self-Assessment Questions and Answers 529 Chapter 11: Obesity and Depression 11.1. Which is not typically a psychological correlate of adolescent obesity? A. B. C. D. Low self-esteem. Compromised body image. Depression. Obsessive-compulsive traits. Answer: D. 11.2. Why is polycystic ovary syndrome an appropriate physical illness for a CBT approach? A. CBT helps adolescents restructure their psychosomatic complaints. B. CBT assists adolescents in better understanding why they are obese. C. CBT can target both the obesity and depression that these adolescents may experience. D. CBT can activate adolescents to exercise more frequently. Answer: C. 11.3. Which comorbid condition may CBT assist in the treatment of adolescents with obesity and depression? A. B. C. D. Obsessive-compulsive disorder. Posttraumatic stress disorder. Eating disorder not otherwise specified. Alcohol dependence. Answer: C. 11.4. Which of the following is not a key strategy used during motivational interviewing as a complementary approach to CBT? A. B. C. D. Open-ended questions. Nondirective empathy. Affirmations. Reflective listening. Answer: B. 530 Cognitive-Behavior Therapy for Children and Adolescents 11.5. An 8-year-old boy comes into the clinic with a body mass index percentile of 99.9. He complains that his family has a lot of highfat, high-calorie food in the home. Both parents are obese, and they question why they should have to change their habits for their child. Which of the following CBT techniques is most logical to employ with this child and his family? A. B. C. D. Behavioral activation. Self-monitoring. Stimulus control. Cognitive restructuring. Answer: C. Chapter 12: Disruptive Behavior Disorders 12.1. A 10-year-old boy with a history of aggressive, disruptive behavior at home and at school is referred for psychological treatment. The most effective treatment for his referral problems is which of the following? A. Parent training alone. B. Cognitive-behavioral interventions with the child alone. C. Cognitive-behavioral interventions with parent and child components. D. Relationship therapy with the child. Answer: C. 12.2. David is a 10-year-old boy who attends individual therapy to address his diagnosis of oppositional defiant disorder. When his therapist asks about his feelings, his responses are limited to “happy” and “mad.” In seeking to broaden his recognition of various feeling states, his therapist should work on helping him recognize which of the following? A. B. C. D. Physiological sensations. Behaviors. Cognitions. All of the above. Answer: D. Appendix 1: Self-Assessment Questions and Answers 531 12.3. Amanda, age 11, has been referred for therapy because of her frequent angry outbursts. When she is calm, she can articulate appropriate responses to problems such as peer teasing, but she tends to act out aggressively when confronted with real-life problems. Which of the following areas should Amanda’s therapist focus on first? A. B. C. D. Social problem-solving. Perspective taking. Anger management strategies. Identifying consequences for aggressive behaviors. Answer: C. 12.4. In one of the clinical vignettes in this chapter, 15-year-old Tim assumes that his teacher “has it out for him” when she puts his name on the board for getting out of his seat to sharpen his pencil. Tim’s CBT-oriented clinician seeks to help him see the situation from his teacher’s perspective to modify his initial A. B. C. D. Intermittent explosive disorder. Hostile attribution bias. Reactive attachment. Relational aggression. Answer: B. 12.5. In another clinical vignette in this chapter, Naomi has sought mental health services to reduce her daughter Anna’s disruptive behavior. The family’s CBT-oriented clinician has asked Naomi to praise Anna’s prosocial behaviors (such as following directions and helping out around the house) and to ignore minor disruptive behavior (such as whining or not cleaning out the sink thoroughly). The clinician is likely trying to help Naomi use which of the following? A. B. C. D. Behavioral rules and expectations. Mood management. Discipline. Contingency management. Answer: D. 532 Cognitive-Behavior Therapy for Children and Adolescents Chapter 13: Enuresis and Encopresis Enuresis 13.1. Which of the following statements best characterizes enuresis? A. It is a benign condition. B. It is a psychopathological condition. C. It is a psychopathological condition medically but not psychologically. D. It is a psychopathological condition psychologically but not medically. Answer: A. 13.2. Regarding physician involvement in the initial assessment of enuresis, which of the following is most accurate? A. Because enuresis is a psychological condition, there is no need to involve a physician. B. Because enuresis is a medical condition, physicians are solely responsible for assessment and diagnosis. C. Involvement of the physician is best left to the psychologist’s discretion. D. All cases of enuresis should be referred to a physician for an initial evaluation so that potential medical causes can be detected and treated or ruled out. Answer: D. 13.3. Which of the following does not have strong evidence supporting its role as a cause of enuresis? A. B. C. D. Family history. Reduced functional bladder capacity. Difficulty arousing from sleep. Psychopathology. Answer: D. 13.4. Which of the following is true of drug-based treatment for nocturnal enuresis? A. Drugs are highly effective as treatment for enuresis and should always be considered as primary treatment. Appendix 1: Self-Assessment Questions and Answers 533 B. Drugs are highly ineffective for treatment of enuresis and should never be considered in a treatment plan. C. Both drugs and biobehavioral treatment methods are effective as primary treatment for enuresis, and the therapist should choose between them. D. Because of unhealthy side effects and temporary results, drugs should be considered only as adjuncts to treatment. Answer: D. 13.5. Which of the following treatments for diurnal enuresis has the most empirical support? A. B. C. D. Scheduled toilet visits. Retention-control training. Alarm-based treatment. Fluid restriction. Answer: C. Encopresis 13.6. Compared to enuresis, the prevalence rate for encopresis is A. B. C. D. Lower. Higher. About the same. Not available for the general population. Answer: A. 13.7. Which of the following factors is not known to contribute to the development of encopresis? A. B. C. D. Fiber intake. History of painful bowel movements. Volitional stool-holding. Sodium intake. Answer: D. 13.8. From a treatment standpoint, the research suggests that which treatment modality is most efficacious when treating encopresis? A. Medical treatment only. B. Behavioral treatment only. 534 Cognitive-Behavior Therapy for Children and Adolescents C. Collaborative medical and behavioral treatment. D. Dietary modifications, with consultation by a psychologist. Answer: C. 13.9. Regarding physician involvement in the management of encopresis, which of the following is most accurate? A. All cases of encopresis should be referred to a primary care physician to rule out potential medical causes. B. All cases of encopresis should be referred to a pediatric gastroenterologist. C. Psychologists should decide, at their discretion, whether involvement by a physician is needed. D. Because there is a strong behavioral component to encopresis, further involvement by a physician is not needed. Answer: A. 13.10. Which of the following best characterizes encopresis? A. It is a condition that has many contributing factors, including medical, behavioral, and nutritional. B. Encopresis is primarily a medical condition. C. Encopresis is primarily a behavioral disorder. D. The contributing factors for encopresis are not well known. Answer: A. 13.11. Which of the following is true about the role of biofeedback treatment for encopresis? A. It has demonstrated superior long-term effects over traditional medical interventions. B. Biofeedback does not increase treatment rates above those achieved with conventional treatment alone. C. There is no support for the use of biofeedback, and it should generally be avoided. D. Biofeedback has been shown to be a critical and essential treatment component, especially when combined with medical and behavioral interventions. Answer: B. Index Page numbers printed in boldface type refer to tables or figures. ABC Chart, 450 ABCs of trauma impact, 268–270 A-B-C-D-E sequence, 4–5, 99–100 Abstract reasoning, 43, 66 Acceptance, and peer relationships, 48 Acceptance and commitment therapy, 25 Acculturation, and cultural issues, 87– 89 ACT (acronym) chronic physical illness and, 337– 338, 346, 353–354, 355, 357, 359, 369, 382 obesity and, 402 Active stance, of therapist in CBT, 14– 15 Activities, and chronic physical illness, 347–348, 380. See also Exercise; Physical activity ADAPT (Adolescent Depression Antidepressants and Psychotherapy Trial), 164 Adaptation, and cultural issues in CBT trials, 79 ADDRESSING model, for assessment, 93 ADHD. See Attention deficit/ hyperactivity disorder Adherence, to treatment for enuresis, 479. See also Compliance Adherence talk, and motivational interviewing, 400 ADIS (Anxiety Disorders Interview for Children), 304, 305 ADIS-C/P (Anxiety Disorders Interview Schedule for DSMIV—Parent and Child Versions), 230 Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT), 164 Adolescents and adolescence. See also Age behavioral plan and chronic physical illness in, 381–382 Coping Cat Program for anxiety disorders in, 252 cultural identity and, 84 developmental adaptations of CBT for PTSD in, 277–278 developmental characteristics and efficacy of CBT for, 32, 33 obesity and prevalence of anxiety, 387 prevalence of depression, 409 Adolescent Swinburne University Emotional Intelligence Test (A-SUEIT), 64 Aerobic exercise, 406 Affect, and PTSD, 268, 273. See also Emotion(s); Mood Affirmations, and motivational interviewing, 399–400 535 and cultural issues. 69. 229–230. 52. 249–251 efficacy of CBT for. 122–123 potential obstacles to treatment of. 131. 251–255 prevalence of. 80. 250 cultural issues and. 106. 230–256 cultural issues in. Preschool children adaptation of CBT for children and. and suicidal behavior or ideation. 133.536 Cognitive-Behavior Therapy for Children and Adolescents African Americans anxiety disorders and. and disruptive behavior disorders. 479 desensitization strategy and. and disruptive behavior disorders. and organization of CBT sessions. 249 Assertiveness training. 227 psychopathology in parents and. 86–87. 229 assessment of. 130. and childhood obesity. 229–230. 98. 307 challenges to treatment of enuresis and. 107 peer rejection and disruptive behavior disorders in. See also Case formulation. 228–229 pediatric psychopharmacology and. 30 of therapist. 267–270 Asthma. 32 Agenda. 334. 450–451 Antidepressants. 391 American Psychological Association. 34 diagnosis of encopresis and. 91–95 developmental considerations in. 89. and cognitive development. 122. 105. 96. 250 combined therapy for. 441. See also Selective serotonin reuptake inhibitors. 305 Anxiety Disorders Interview Schedule for DSM-IV—Parent and Child Versions (ADIS-C/P). 66 Anger management. 218 disruptive behavior disorders and. 441 Anxiety. 476 of OCD. Diagnosis of anxiety disorders. 441 Age. 442 Art of Self-Control program. 229–231 Anxiety Disorders Interview for Children (ADIS). 86 Antisocial behavior. 44–45. 125–126. 438. 303–307 of PTSD. 137 cultural issues and. 156–160 Coping Cat Program and. Casey Foundation. 301 American With Disabilities Act. 38–39. 437. See also Chronic physical illness . 446–447 Annie E. 279 Antecedent control. 43. 304. 76. 442–443 American Academy of Child and Adolescent Psychiatry. Tricyclic antidepressants Anti-Semitism. 379 Analogies. 301 American College of Sports Medicine. 249 combined therapy and. and Section 504. 485–491 of enuresis. 386– 388 Anxiety disorders approaches in CBT for. 141 use of term development and. 105–106 Assessment. 101. 62– 64 of encopresis. 440 Asian Americans. 230 Arab Americans. and cultural issues. 103. 89 Arousal. 166 Aggression bipolar disorder and. and disruptive behavior disorders. 482 efficacy of CBT as function of. 48–49. 12. 255 treatment planning and. 85. 33–34 behavioral rigidity in OCD and. See also Adolescents and adolescence. 84. and disruptive behavior disorders. 219 efficacy of CBT for. and encopresis. 307 PTSD and. 63 Beck. 102–103 537 depression and. of incontinence. 220–221 BLUE thoughts. of depression. 193– 195 clinical applications of CBT for. 35. 3–4. 123. 107 for pediatric obesity. 7–8 encopresis and. 220 OCD and developmentally appropriate. Neurobiology Bipolar disorder characteristics of CBT for. 251–255 cultural issues and. 161 comorbidity and. See also Aggression. 268– 269. and theoretical models of OCD. 304–306. Behavioral activation. 483–484 Biological changes. 17. Disruptive behavior disorder conceptualization of problems in terms of cognition and. 278–279 BAT-C (Behavioral Assertiveness Test for Children). 21 Behavioral Assertiveness Test for Children (BAT-C). 231 cultural identity and. 63 Behavioral learning. 17. 340–341 mood symptoms of bipolar disorder and. 133. 251 differential diagnosis of OCD and. A. 268 weight loss programs and. See also Biobehavioral view. 167. 34 OCD and dysfunctional. 124 Attention deficit/hyperactivity disorder (ADHD) cognitive-behavior therapy formulation and. 370 BMI (body mass index). 390 . and PTSD. 97 PTSD and. in PTSD. See also Learning theory Behavioral model. 5. 172–173 obesity treatment and. 169–170 Avoidance. of encopresis and enuresis. 123–124 Autism. 353 Behavior. 185–193 refractory nature of pediatric. 303 role of in CBT. 347– 348 cultural issues and. 252 Beliefs development and. 17–20 Bibliotherapy. 385. 468 Biodots. 195–219 cultural issues in. 133 Coping Cat Program for anxiety disorders and. 306 Automatic thoughts. 391 Behavioral activation chronic physical illness and. See also Logistical concerns anxiety disorders and. 266. Behavior therapy. to treatment. 306 pharmacotherapy for. 353–354. 271 Barriers. 302. 126–127.T. 468 Behavior therapy for ADHD. 166 Behavioral theory. 107 Biobehavioral view.. 488 inflammatory bowel disease and maladaptive. 348 Biofeedback. 64 Atomoxetine. 185 special challenges to treatment of. 9 combined therapy for.Index A-SUEIT (Adolescent Swinburne University Emotional Intelligence Test). 63 Being Brave program. 392 reinforcement principles and. 387. 133. 388–390 BEI (Bryant’s Index of Empathy for Children and Adolescents). 254–255 of cultural issues. and suicidal ideation. 358 of combined therapy. 409 Bossing-back strategies. 305 Case conceptualization. 400 Child abuse. See Cognitive-behavioral therapy CBT-SP (cognitive-behavioral therapy for suicide prevention). 231 CAMS (Child/Adolescent Anxiety Multimodal Study).T. 470–481 of obesity. 241. 264–265.A. and motivational interviewing. 134– 135. 160 . 242. 453–459 of encopresis. 186. 431 Body mass index (BMI). 479. 334. 236– 237. and obesity. 103. 305. 500–503 of enuresis. 212– 214 of chronic physical illness.and family-focused cognitive-behavior therapy). and chronic physical illness. 343–345 C. 488 CBITS (Cognitive-Behavioral Intervention for Trauma in Schools). 304. 124. 193 Chain analysis. See also Chronic physical illness Candy dispensers. 177–179 Case formulation. 386. 132. 173–175 of development. and encopresis. 43 CBCL (Child Behavior Checklist). 203–205. 176 Change talk. 252 Causal reasoning. 2nd Edition). 319–320 Brainstorming approach to bipolar disorder. 101–102. 235. 390 Booster sessions. 385. 344– 345. 239–240. 287– 294 of suicidal ideation. and bipolar disorder.538 Cognitive-Behavior Therapy for Children and Adolescents Body image. 396 Centers for Disease Control and Prevention. 494–495 Caregivers bipolar disorder and. 126. 197 encopresis and. 212 to disruptive behavior disorders. and suicide prevention. 136 of common principles of CBT. 238. 351–353. 452 Bryant’s Index of Empathy for Children and Adolescents (BEI). 279–287. 6–16 of Coping Cat Program for anxiety disorders. 406– 407. 278. 31. 348–349 Camp Cope-A-Lot. See also Sexual abuse Child/Adolescent Anxiety Multimodal Study (CAMS). 177 Case examples of bipolar disorder. 230. 233–234. 354. 264. 108 of depression. 160 Cancer. 387. 161 Calming techniques. Project. 176 CDI (Children’s Depression Inventory). 287–294 CBT. 130. 304. 105. and obesity treatment. and childhood obesity. 467. and incontinence. 94. and OCD. and chronic physical illness. 33 of disruptive behavior disorders. 314–319 of PTSD. 49. 130. 138. 493 CARS (acronym). 190. 395. 252–253. 63 Bullying. 99. 208 CARS2 (Childhood Autism Rating Scale—High Functioning. 246–249. 385 Bupropion. 383 CFF-CBT (child. 126. 400–401 of OCD. Obesity. 468. 123. See also Cognitive restructuring. 287–294 Cognitive-behavioral therapy (CBT). Patients. 304. 304. 252 conceptualization of problems in terms of behavior and. 230. 186. 91–108 for depression. 331–332 Citalopram. 62 Cognitive-Behavioral Intervention for Trauma in Schools (CBITS). Child abuse. 34. 278. 304. Obesity. 270–278 Coaches. 127–141 cultural issues and. 399 Cognition-based theoretical models. 488 Child. Chronic physical illness. 49. Form 6. of CBT for bipolar disorder. 1–2 history of. 395. 334 Chronic physical illness. 302–303 Cognition and cognitive skills. 392– 393 PTSD and. 269 role of in treatment of enuresis. Combined therapy. 193 Childhood Autism Rating Scale— High Functioning. Development. 334–336 encopresis and. Efficacy. 209. specific disorders Children’s Depression Inventory (CDI). 470 Cognitive Abilities Test. 396 Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS). See Adolescents and adolescence. and obesity. 212 Chronic fatigue syndrome. 303–323 for PTSD. 304. Age. 443–452 for obesity. 266. Metacognition anxiety disorders and. specific disorders common myths and misperceptions in. as theme in CBT for bipolar disorder. 6–16 evidence-based treatments and. 473 Clinical applications. Cognitive therapy. Enuresis. 305 Children. 390–393 for OCD. Treatment planning.and family-focused cognitivebehavior therapy (CFF-CBT). Primary and Secondary Control Enhancement Training for Physical Illness efficacy of CBT for. Encopresis. 40– 44. 486 guided imagery for pain management and. 7–8 developmental issues in. 166–175 for disruptive behavior disorders. 305 Choice. 195–219 combined therapy and. 305. 121. 2nd Edition (CARS2). 65–68 obesity and lifestyle changes. 375–377 inflammatory bowel disease as model illness in studies of CBT for. Clinical applications. and enuresis. Culture. See also Polycystic ovary syndrome. 338–358 information worksheets for parents and. 22–24 common principles of. See also Assessment. 2–6 . Chronic physical illness. of OCD. Preschool children. Development. 378–382 relationship between psychological and physical processes in. 332–333. 264.Index Child Behavior Checklist (CBCL). 305 Child Obsessive-Compulsive Impact Scale—Revised (COIS-R). Behavioral therapy. 154 539 Cleanliness training. 190. 158. 451–452 COIS-R (Child ObsessiveCompulsive Impact Scale— Revised). 3 Cognitive triangle. 127–141 depression and. 130. 309 Contextualism. 382 disruptive behavior disorders and. 167. 80–81. 66 Cognitive theory. between therapist and patient common principles of CBT and. 176 Cognitive restructuring cultural issues and. and themes in OCD. and encopresis. 220 combined therapy and. and disruptive behavior disorders. 150–156 Communication bipolar disorder and. 304. 85. 349–350 Conflict resolution bipolar disorder and. 90 Contextual social-cognitive model. 272 Control. and history of CBT. 159. 62 Conditional Syllogism Test. 197 treatment planning recommendations and. of enuresis. 99–102. 215–217 chronic physical illness and. 43 Conditional Reasoning Task. 133. 22 cultural issues and. 440–443 Contingency management. 138 culture and potential barriers to. 156.540 Cognitive-Behavior Therapy for Children and Adolescents Cognitive-behavioral therapy (CBT) (continued) new challenges for. 169–170 obesity and. 156–160 clinical implications and application of. 153. 482. 160. and social skills. 152. 125–126. 62 Conduct disorder. 10–12. 20–22 Cognitive-behavioral therapy for suicide prevention (CBT-SP). 359. for OCD. 19 Collectivism. 161 Competence. 130. See also Adherence anxiety disorders and. 84. 504 Contamination. 194–195 chronic physical illness and. of psychiatric disorders anxiety disorders and. 126–127 anxiety disorders and. 97 importance of in treatment of enuresis. 133. 73 Constipation. 71. 3–4 Cognitive triad. 337 . and chronic physical illness. 82–83 Collaborative empiricism. 285 Cohesion building. 486–487. 24–25 role of beliefs in. 79. 451–452 Comorbidity. 253–255 bipolar disorder and. and chronic physical illness. See Disruptive behavior disorder Confidence. 485. 470 Cognitive therapy. and cultural issues. 381– 382 combined therapy and. 393 treatment planning and. 131. for disruptive behavior disorders. 305 Collaboration. as cultural issue. 103 depression and. 151. 499 PTSD and. 17–20 role of reinforcement principles in. 470 Concrete thinking. 251 bipolar disorder and. 308 Contingency reinforcement encopresis and. 133. 62 Combined therapy ADHD and. 124–125. 98 Combinations Task (CT). 46–48 Compliance. 131. 478 evidence-based treatment and. See Disruptive behavior disorder DBT. 53–54 impact of on efficacy of CBT. 124 Desmopressin (DDAVP). 381 cultural issues and. 438 Delinquent behavior. 205 obesity and. 150–156 efficacy of CBT for. 40–45 emotions and. 124–125. See also Popular culture anxiety disorders and. 33. 72–73 future directions in. 437–438. in cognitivebehavior therapy manuals. 337 coping tool kit for bipolar disorder. 76. 323–324 pros and cons of CBT for children of diverse backgrounds. 219 clinical recommendations and. 64 Day care. to treatment of encopresis. 498–499 enuresis and. See also Chronic physical illness CT (Combinations Task). See also Major depressive episode chronic physical illness and. 474–475 Development anxiety disorders and. 75 developmental considerations and. 53. 497–498 Crohn’s disease. 474–475 Deafness. 452–453 encopresis and. The (Kendall 1990). 92 Culture. 359 clinical applications of CBT for. 29– 30 information needed to adapt CBT to stages of. 278 CY-BOCS (Children’s Yale-Brown Obsessive Compulsive Scale). 166–175 combined therapy for. 217 PTSD and. 91– 108 combined therapy and. 137–138 definition of. for anxiety disorders. 208–209. 52. for disruptive behavior disorders. 79–83 PTSD and. and disruptive behavior disorders. 138 Coping Cat Program. and encopresis. 48–49. 38. 386–388. 83–85 diagnosis and treatment of encopresis and. 436. 53. 39 Corrective approach. 249–251 bipolar disorder and. 62 Culturally Informed Functional Assessment. 64. 131. 305 541 DANVA2 (Diagnostic Analysis of Nonverbal Accuracy Scale—Form 2). 83–85 disruptive behavior disorders and. 44–45. 36–40 . 443–459 Coping skills chronic physical illness and. and aggression in residential settings. 76–77 OCD and. 62– 64 compliance issues in chronic physical illness and. 493 DBD. 38–39. 486 domains of. 304. 384–385. 338. 50–52. 130. 273–274 Core beliefs. 437 Delis-Kaplan Executive Function System (DKEFS). 409 pediatric psychopharmacotherapy for.Index Coping Cat. 17 Core clinical skills. 163–165 exercise and. 133. 252 assessment and assessment tools. 77–79 mental health disparities and. See Dialectical behavior therapy DDAVP (Desmopressin). 120–122 Desipramine. 230–256 Coping Power Program. 62 Depression. 277–278 social skills and. of CBT. 335–336 Diagnosis. and enuresis. 487–488. 12–13 Eating environment. 426–427 Differential diagnosis. 129. 32 Dextroamphetamine. 397–398 EBT. 152. 64 Diagnostic and Statistical Manual of Mental Disorders (DSM). 11 cultural issues in CBT and. 332– 333. 199–200 of encopresis. of CBT anxiety disorders and. 468–469 Diagnostic Analysis of Nonverbal Accuracy Scale—Form 2 (DANVA2). 215 encopresis and. 68–71 treatment of enuresis and level of. 482. 82 Discipline. 443–459 cultural issues in. 123. 24–25 encopresis and. 191–192 newer forms of CBT and. of CBT as cultural issue. 185–193 chronic physical illness and. 165–166 Diet bipolar disorder and. 81 encopresis and. 161 Diabetes.542 Cognitive-Behavior Therapy for Children and Adolescents Development (continued) OCD and. 155 Duration of treatment anxiety disorders and. 397–398. 228–229 bipolar disorder and. 108. 25 suicidal ideation and. 263. See Evidence-based treatment Ecological approach. 52. 468. and disruptive behavior disorders. 479 treatment planning and considerations of. 62 Dot-to-dot drawing. 53 PTSD and. 341 Efficacy. 175 Diathesis-stress model. 275–276. See Diagnostic and Statistical Manual of Mental Disorders Dysthymic disorder. 205. 30–36. 304–306. See also Psychoeducation common principles of CBT and. 49. 484 Dialectical behavior therapy (DBT) bipolar disorder and. 266. 393. 474 Downward arrow technique. 163–165 disruptive behavior disorders and. 451 Discontinuation syndrome. 403. 492 obesity and. 436. 405–406. 264. 440–443 Coping Power Program for. to anxiety disorders. 483–484 . 306 Directive nature. 39– 40. 436–440 DKEFS (Delis-Kaplan Executive Function System). 334–335 depression and. 18 Dry-bed training. 206. 437–438. and reward systems. 250 Education. 166 developmental considerations and. 475 DSM. 45–49. 188. 452–453 efficacy of CBT for. Case Formulation. 109 Disruptive behavior disorder (DBD) clinical applications of CBT for. of OCD. 492–493 inflammatory bowel disease and. See also Assessment. and weight loss. 230 depression and. 195. 443–452 conceptual framework for. 482 of enuresis. 307 PTSD and. 63. 277 time-limited structure of CBT and. Differential diagnosis of bipolar disorder. 121 Discovery-oriented research. 65–73 use of term age and. 436–440 effectiveness as focus of research on CBT and. 391. 193–194 . 206. See also Physical activity bipolar disorder and. 404–405 PTSD and numbing of. 481–482 EQ-i:YV (Emotional Quotient Inventory: Youth Version). 302. 470– 475 543 cultural issues in studies of. 82. 271–272. and OCD. 406 Expectations.Index impact of development on. 469. 482 efficacy of CBT for. 293 Expressed emotion. 500–501 challenges to treatment of. 391. 50. 488 obesity and. 478 diagnosis of. 469– 470 urine alarms and. A. 316. 70. Race combined therapy and. 304. 64 E/RP (exposure and response prevention). and treatment planning recommendations. 499–500 cultural issues and. 167. Feelings thermometer.. 5. 246. 86–87 mental health disparities and. 1–2 cultural issues in. 215 chronic physical illness and. 446 encopresis and. 233. of OCD obsessions. and regulation of emotions. 300–301 psychosocial aspects of obesity and. and evidencebased treatment. 487–488. See also Culture. 137 experience of oppression and. 64. 270 Evidence-based treatment (EBT) CBT protocols and. Mood concepts of emotional competence and emotional intelligence. 388–389 suicidal ideation and. and development. 205. 498–499 diagnosis of. 253–255 cultural issues and. Expressed emotion. See also Exposure therapy Escitalopram. 4. 53 Exercise. and behavior rules in disruptive behavior disorders. 72– 73 disruptive behavior disorders and awareness of. 17 Emotion(s). 121 Ethnicity. and bipolar disorder. 76– 77 treatment engagement and. See also E/RP Coping Cat Program for anxiety disorders and. 485– 491. 470–471. 301. 77–79 Executive functions. 469 theoretical perspectives on. 502 Enhancing engagement. 319– 323. 484– 485 treatment planning for. 76. See also Affect. 51 depression and regulation of. 29–30 OCD and. 468–469 prevalence of. 451 Experiences. 317. 104–105 PTSD and. 266 Emotional Quotient Inventory: Youth Version (EQ-i:YV). 306 Ellis. 347– 348 encopresis and. 50–52. 175–176 Ego-dystonic character. 64 Empathy. 503 prevalence of. 479 components of treatment for. 52 Exposure therapy. 243–245. 492 obesity and. 491–498. 477. 170–172 development and. 79 Enuresis challenges to treatment of. 483–484. 482–483 theoretical perspectives on. 399 Encopresis assessment and treatment of. 307–308. 391 bipolar disorder and. 121. 93. 86 Gender culture and roles of. 492 Gay. 124. 236. 228. 246– 248. 100– 101 exposure therapy and. lesbian. 198 disruptive behavior disorders and. 392. 121. 167. See Gay. 470. 197. 475 FEAR plan. 193 Family history. 160. See also Family history bipolar disorder and. 271– 272 . Parents. 252 Fears. 390 Gradual exposure. 291– 292. and encopresis. 193 Family-focused treatment for adolescents with bipolar disorder (FFT-A). 475 GAD. 20 Eysenck. 80. 220–221 chronic physical illness and. 105 social oppression and.. 154 Fluvoxamine. 243–245 Generation of Alternatives Task. 122. of enuresis. and OCD. lesbian. 63 Friendships. 314–316. 139 Germany. 498 enuresis and. 88–89. 199 OCD and. 341– 343. 474 Fluoxetine.J. 235. 446 FFT-A. and depression. 167 FDA (U. and enuresis. 359 combined therapy and. 242. 190–191. 52 Externalization. 122. 312–313 Extinction. Food and Drug Administration). and PTSD. 187. 356–358. Family therapy. and enuresis. 478 Generalized anxiety disorder (GAD). 402 GLBT. and transsexual (GLBT) youth behavioral interaction and. 482. 404–405 Friendship Quality Questionnaire. 3 Family. 150. 395. 62 Genetics. 320–321. 403. Siblings bipolar disorder and negative cycles in. 103 cognitive restructuring and. 168. 288. See also Genetics Family therapy. clearly defined. 278 Get-acquainted exercise. bisexual. 35. 313–314. 306–307 Feelings thermometer. H. 102–103 encopresis and. 424. bisexual. and reinforcement. and KidNET for refugees. and diet. 98 disruptive behavior disorders and. 396–398 OCD and.S. importance of. 238–241. 48.544 Cognitive-Behavior Therapy for Children and Adolescents Expression. and clinical decisionmaking. and transsexual youth Goals and goal-setting behavioral facets of obesity and. 310 Geography. 123 Food cravings. 92– 93. 445 focus of CBT on specific. 372. 320–322 success or failure of treatment for bipolar disorder and. and regulation of emotions. 209. and treatment for obesity. 10 Go Girls program. 171. See Generalized anxiety disorder Gastrointestinal system. See Family-focused treatment for adolescents with bipolar disorder Fluid restriction. and Coping Cat Program. See also Family history. and OCD. See also Peer relationships Full-spectrum home training. 441 obesity and. 233. 122. 246. 138 cultural issues and. 205–206. 139. Mental health care system. 33 Hyperandrogenism. Physical examination Health insurance. and termination of treatment. 161 Harm. 276. 467. 109. See also Encopresis. 475 Hypothesis testing. 10th Revision (ICD-10). 85 Individualized Education Program (IEP). 207 Induction. 66 ICD-10 (International Statistical Classification of Diseases and Related Health Problems. 231. 161. and combined therapy. 207 IF-PEP (individual-family version of PEP). 141 Healthy Bodies. 390 Healthy routines. 193. use of term. 479. 393–409. for pain management. 215 HEAR ME (acronym). and combined therapy. 43. and themes in OCD. See Latino/ Latina Homeschooling. and guided imagery for pain management. 384 545 Hypnotic scripts. for healthy diet. See also Chronic physical illness Insomnia. 199–200 Hyponatremia. 385 Intermediate beliefs. 132 Insulin resistance. and bipolar disorder. See also STIC tasks. 392 Hospitalization. 348 Hypomania. 218 How I Ran OCD Off My Land (March and Mulle 1998). and cultural issues. 385. 482 . 444 for PTSD. Enuresis Incredible Years program.Index Graduation ceremony. 10th Revision). 375–377 Guidelines. 438–439 Individual-family version of PEP (IF-PEP). 196 Coping Cat Program for anxiety disorders and. 395. 420–433 Healthy Lifestyles Pilot Study. and cultural issues. and chronic physical illness. 193. of thoughts and beliefs. 449 obesity and. 397. 156. and bipolar disorder. 232 disruptive behavior disorders and. 106–108 IEP (Individualized Education Program). 17 International Statistical Classification of Diseases and Related Health Problems. 482 Identification. 47 Imipramine. 335. 391 Haloperidol. Workbooks bipolar disorder and. 195–196 Imaginal exposure. 375–376 Inflammatory bowel disease. 338–358. 84. and cultural issues. 219 Group therapy for disruptive behavior disorders. 321 Imaginary audience. Healthy Minds Health care. 381 Homework. 287–294 Guanfacine. and child abuse. 171 Hispanic Americans. 123 Guided discovery. See Chronic physical illness. 474 Immigration. 371. 87– 89 Incontinence. 18 Guided imagery. See Healthy Bodies. 195–196 Individualism. 17–19 Identity. 309 HBHM. 80. 211 Hypothetical reasoning. 86– 87. and polycystic ovary syndrome. Healthy Minds (HBHM). 205. M. 304. 48. 198 Coping Cat Program for anxiety disorders and. 309 Maintenance sessions chronic physical illness and. 305 Mastery model. 8–10 Learning theory. 84– 85.C. 90 Logistical concerns. 249.. 497. 217 sleep patterns and. 52. 2 K-SADS-P/L (Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version). and cultural issues. of maladaptive behaviors and cognitions. 2 Learned helplessness. 81. See also Barriers combined therapy and.. 355– 356. 2. and chronic physical illness. 103. 276–277 London. 304. 444–445 In vivo mastery. 62 MCQ-C (Metacognitions Questionnaire for Children). 100. 102. 472 KidNET. Metaphors cultural issues and. See also Psychopharmacology . 484. 89. and themes in OCD. and encopresis. 188. 90 Life Skills Training Program. 192 Interpersonal Understanding Interview. 188. 64 MCQ-A (Metacognitions Questionnaire for Adolescents). 200. and enuresis. Social learning theory Legal status. 43 Medication.546 Cognitive-Behavior Therapy for Children and Adolescents Interpersonal conflict. 305 Kegel exercises. P. of immigrants and refugees. 230. See also Behavioral learning. 374 obesity and.A. 63 Introductory sessions bipolar disorder and. See also Miralax Lazarus. 232 Matson Evaluation of Social Skills with Youngsters. 206 use of term. and history of CBT. and social skills. 98. 192 Joint expertise. 409 Major depressive episode. 63 Mayer-Salovey-Caruso Emotional Intelligence Test.. 278 Language. 333 Learning. 199–200 MASC (Multidimensional Anxiety Scale for Children). 62 Means-end thinking. 53. 271 development and. and bipolar disorder. 217 Mania management of symptoms. 138–139 optimal model of CBT for PTSD and. 72 Latino/Latina. 106. A. See also Analogies. 482. of coping. 234 Coping Power Program for disruptive behavior disorders and. 97 description of traumatic events and. 275 IPSRT-A (interpersonal and social rhythm therapy for adolescents with bipolar disorder). 2 Loss of essence. 10–12 Jones. 278 Laxatives. 96. and cultural issues. of trauma reminders. 88. and therapist/patient collaboration in CBT. 71 Interpersonal and social rhythm therapy for adolescents with bipolar disorder (IPSRT-A). 440 Literacy. and new approaches in CBT. 161 MF-PEP (multifamily format of PEP). 196–197. Hospitalization. 200. 274 National Heart. 195 Minor disruptive behaviors. Logistical concerns. Self-monitoring Mood. 206. 5–6 Mental health care system. 124 Monitoring. See also Emotion(s). Mood monitoring bipolar disorder and. 195 Multimodal Treatment Study of Children With ADHD (MTA). 192–193. 339– 340.Index for chronic physical illness. 200 Mood disorders. See also Mood monitoring. See also Laxatives Mirtazapine. See Multimodal Treatment Study of Children With ADHD Multidimensional Anxiety Scale for Children (MASC). 123. 398–400. 342 Native Americans. 389–390. and bipolar disorder. See also Comorbidity. 474 Meditative traditions. 25 Megacolon. 123. 308–310 Methylphenidate. 440 MTA. 384 National Registry of Effective Programs. and cultural issues. 214–215. of enuresis. and encopresis. 477–478. 67 definition of. 486 Meichenbaum. 62 Metaphors cognitive development and. Lung. specific disorders Metacognition cognitive development and. 121 . 497. and Blood Institute. 341 for enuresis. 450 Miralax. Donald. 348– 349 Naming the Enemy. 167. 486. 304. 161 Multisystemic therapy (MST). and bipolar disorder. 278 Nefazodone. 66 OCD and. 89. and relaxation exercises. 92 Multifamily format of PEP (MF-PEP). 305 Multidimensional Ecosystemic Comparative Approach (Falicov 1998). 402. 387 Mood charting. 192–193. for disruptive behavior disorders. 81. 121 Modafinil. 44. 133. and obesity. and bipolar disorder. and bipolar disorder. 371 PTSD and descriptions of trauma. 220–221 relationship between weight and. 423 Motivation. and treatment planning for enuresis. 345– 346 depression and. 168 obesity and. 133 Mood-medication log. 476. 394. 201 Narratives chronic physical illness and. 80. 41. 62 Metacognitions Questionnaire for Children (MCQ-C). 202 547 Mood monitoring chronic physical illness and. and combined therapy. 17 Metacognitions Questionnaire for Adolescents (MCQ-A). 440 Music. 126–127. 391 National Institutes of Health. 230. 403 MST (multisystemic therapy). 479 Motivational interviewing. and themes in OCD. 497– 498 Overlearning. 126. 471. 53 time-limited structure of CBT and. 306. 299 theoretical models of. 303–323 combined therapy for. 386– 388. 393– 409 key CBT techniques for. See also Introductory sessions Outcome. 303–307 clinical applications of CBT for. 437 study of age and encopresis in. and guided imagery. 82. 323–324 efficacy of CBT for. and trial of CBT for OCD. cultural issues in videotapes for. 157. and encopresis. See Obsessive-compulsive disorder ODD. 473 Overprotectiveness. 97. and bipolar disorder. and motivational interviewing. 309 Orientation. 158 cultural issues in. 384–385. and client-therapist relationship. 384. 303 Obsessive-compulsive disorder (OCD) assessment of. 391 Obsessive Compulsive Cognitions Working Group. 399. 102 Ordering/arranging. 22 Nonverbal communication. 122–123 . See also Socratic questioning Operant conditioning. 13 Nutrition labels. 199.548 Cognitive-Behavior Therapy for Children and Adolescents Negative reinforcement. 301 Number. 133. See also Biological changes “New Wave. See also Disruptive behavior disorder Oppression. 123 prevalence of. See also Efficacy Overcorrection. 172 Oppositional defiant disorder (ODD). 482–483 Neurobiology. 398 Netherlands Coping Power Program for disruptive behavior disorders and. 405. 385. 198 Nonspecific therapy elements. and enuresis. and emotion regulation. and PTSD. 20. 197 developmental considerations and. 215–216 Norway. Healthy Minds intervention for. 22–23. 427 Obesity behavioral therapy for. 86–87. and psychopharmacology. and bipolar disorder. 388–390 depression and. 302–303 OCD. of sessions bipolar disorder and.” and recent treatment approaches in CBT. 300–301 pharmacotherapy for. ethnic minorities and experience of. 398. 379–380 Pain management. The. 266 Opposite action. See Oppositional defiant disorder Open-ended questions. 390– 393 polycystic ovary syndrome and. 488. and parents of children with chronic physical illness. 385–388 Obesity Society. 375–377 Pajama devices. 100. 383 psychological correlates of in childhood. 25 “No fault” disorder. 409 Healthy Bodies. 477 Panic disorder. bipolar disorder as. and enuresis. 384–385 prevalence of. 46–47.. 154 PASCET-PI. See Primary and Secondary Control Enhancement Training for Physical Illness Past. 394. and societal factors in mental health care. 398 Posttraumatic stress disorder (PTSD) assessment of. 252 Physical activity. 471. See also Reinforcement principles encopresis and. 401– 409 Pediatric OCD Study (POTS). and Coping Power Program for disruptive behavior disorders. 47 disruptive behavior disorders and. 198–199. 438 Patients collaboration with therapist in CBT. 447 Photo album..P. 384–385. See also Family Afrocentric model of training for. 196. 488 obesity and. 70. 237. 448–452. 485–490 enuresis and. 138 Coping Cat Program for anxiety disorders and. 275 Paroxetine. 270–278 . 378–382 combined therapy and. 209–212. J. 33 encopresis and. 128–132 needs of as focus of CBT. 121. 93 developmental level of child and involvement of in treatment. of social skills. 22 combined therapy and. 126. 483–484 obesity and. 13–14 Pavlov. 68. 10–12.Index Parents. 408–409. 8 PATHS (Promoting Alternative Thinking Strategies). 188–189. 140 Positive reinforcement. 357. 206–207. See also Chronic physical illness Popular culture. and encopresis. 165 PTSD and. 135–136. 122–123. See also Exercise encopresis and. 448 PTSD and. 272. 49 Perspective taking. 335. 242. 391. 493 Physical examination encopresis and. 192. 485 enuresis and. 395. 2 PCOS. 255 Coping Power Program for disruptive behavior disorders and. 197. See Polycystic ovary syndrome PCOS Lifestyle Program. 216. 406. 193 Performance. 157 549 Peer relationships achievement of social competence and. 479 Piaget. and social skills. 161 PEP (psychoeducational psychotherapy). for continued success in obesity treatment. 217 chronic physical illness and. and focus on present in CBT. I. 430 Physical cues. 456–459 cultural issues in assessment and. 267–270 clinical applications of CBT for. See also Treatment planning Play. 202–203. 393–409. 270 treatment planning recommendations and. and Coping Cat Program. 441. 214. 479 prevention of depression in children of parents with history of. 445 Polycystic ovary syndrome (PCOS). 87 bipolar disorder and. The. 43 Planning. 71 Pemoline. 392 Problem-Solving Skills Training Plus Parent Management Training (PSST+PMT). 240 cultural issues and. 369– 374. 347. 451–452 obesity and. 129–130 Psychopharmacology. 211–212 chronic physical illness and. and encopresis. 394 Proactive approaches. 438 Prosocial behavior. of obesity. 169 disruptive behavior disorders and. 383 of OCD. 333. 126. See also Education bipolar disorder and. 447–448. 439 Promoting Alternative Thinking Strategies (PATHS). and peer relationships. and developmental adaptations of CBT for PTSD. 278–279 POTS (Pediatric OCD Study). 227 of anxiety in obese adolescents. See also E/RP. of suicide. 159 cultural issues and. 384. 493–497 Problem solving bipolar disorder and. 198–199 chronic physical illness and. 177 Psychoeducational psychotherapy (PEP). 192. 103–104 depression and. 120–122 PTSD. 96–97 depression and. 373 cognitive development and treatment planning. Relapse prevention Primary control. 469 of obesity. 317–319 PTSD and. 81 Prevalence of anxiety disorders. 308–313. 201–203 depression and. 8. See Posttraumatic stress disorder . 277 Present focus. 194. 332. 129 Coping Cat Program for anxiety disorders and. 167. See also Combined therapy. 439 Psychodynamic theory. 393. 346– 347. 65. and combined therapy. 123–124 anxiety disorders and. 90 risk factors for disruptive behavior disorders and. 176–179. See also Socioeconomic status cultural issues and. 482–483 of enuresis. and chronic physical illness. 232–233 cultural issues in. 122–123 bipolar disorder and. 337 Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI). 272–273 suicidal ideation and. 342 combined therapy and. 188–189. 385–388 Psychological mindedness. 69. 278 obstacles to treatment of. 350–351 Preschool children. 337–358. 167. 193 Psychological correlates. 387 of depression in obese children and adolescents.550 Cognitive-Behavior Therapy for Children and Adolescents Posttraumatic stress disorder (PTSD) (continued) cognitive-behavioral theory of. 264–267 combined therapy for. of CBT. 73 Coping Cat Program for anxiety disorders and. 409 of encopresis. 484 Psychoeducation. 157 Poverty. 299 Prevention. Medication ADHD and. 47 PSST+PMT (Problem-Solving Skills Training Plus Parent Management Training). 370. to treatment of encopresis. 350. 441 POWER steps program. 168 OCD and. 185. 126. 489–490 motivational interviewing for obesity and. 105. 471–472. See also Child. and cultural issues. 186. 3. 107. 94. of emotions. 170–172 551 Reinforcement principles. and calorie charts. 479 Puppets. and Coping Power Program for disruptive behavior disorders.Index Puerto Rico Coping Power Program for disruptive behavior disorders and. for enuresis. 76– 77 treatment engagement and. 481 OCD and. 251. See also Positive reinforcement. 478 Real world. and negative influences of racism and discrimination. 471–472. 270 Racism. Culture. 86 Resistance encopresis and. 66. 405 PTSD and. 101–102. 438 cultural issues for mental health care in. 67 Reasons for living. 84 Punishment definition of reinforcement and. 167. 34 obesity and. 190. 3. 273 Religion cultural issues and. Native Americans. 335 Refugees. 177 Recurrent abdominal pain. 15–16 Reappraisal. 478 Rewards. Ethnicity. 323–324 stress management with bipolar disorder and. for enuresis. and cognitive development. 86– 87. 447 Race. 478 obesity and. 167 modification of for age levels. 89. 41. 83. 248 Coping Power Program for disruptive behavior disorders and. 137 mental health disparities and. 19–20 Reasoning. 252 cultural issues and. 20–22 Relapse and relapse prevention depression and. 322–323 Relaxation techniques chronic physical illness and. of thoughts or beliefs. and suicide prevention. 406 Responsibility training. 278 Regulation. 4– 5. 167. 490 enuresis and. 51–52. 4– 5. 35–36 Retention-control training (RCT). 82. 35–36 RCT (retention-control training). and cultural identity. 270 Resilience. See also African Americans. 473. 240–241. 73. 400 Resistance exercise. See also Oppression RAINBOW program. 173 enuresis and potential for. 392.and family-focused cognitive-behavior therapy Rational emotive therapy (RET). Racism combined therapy and. 88. 341. 477 Restaurants. 393 OCD and. 43. 445 . implementation of CBT in. 237–238. 20 disruptive behavior disorders and. Token economy Coping Cat Program for anxiety disorders. 398 RET (rational emotive therapy). role of in CBT. 103 depression and. 451 encopresis and. 348–349 Coping Cat Program for anxiety disorders and. 473. 218 treatment engagement and. and enuresis. 429. 473– 474. 304. 493 PTSD and. 207.. 305 Scheduling. 126. 5–6 Skills-and-Thoughts (SAT) depression model. 156 Scrupulosity. 449 encopresis and. 238–240 Sertraline anxiety disorders and.552 Cognitive-Behavior Therapy for Children and Adolescents Rewards (continued) encopresis and systems of. 449–450 Ross Test of Higher Cognitive Processes. and cognitive development. 68. 44. 378– 381 disruptive behavior disorders and. 272 Selective serotonin reuptake inhibitors (SSRIs). See also Waking schedule Schemas. 472. and Coping Cat Program. 176 Role-playing. 62 Self-talk. 176–177 SAT (Skills-and-Thoughts depression model). 432 Self-control. 159. 85 Shaping approach. 158. B. 253–255 Siblings. and PTSD. 214–215 chronic physical illness and. 122. 67. 153 Self-awareness. 159. 157. 395. 206–207. 151. and disruptive behavior disorders. 2 . 494–496 enuresis and systems of. 400 Self-esteem. 333. and bipolar disorder. 160 depression and. See also Monitoring. 490. 278 Sexual behavior. 309. and social skills. 151 Schools and school systems bipolar disorder and. 337 Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-P/L). 379 Selective attention. 391. 125. 441 for suicide. 14. 125. 96 Self-efficacy. 333. 499 Show That I Can (STIC) tasks. 276 refusal to attend. 386 Self-instructional training (SIT). 269. and cognitive diathesisstress model. 451 Safety PTSD and enhancement of. to treatment of encopresis. 447. and obesity. 121. 165 Schizophrenia. 323–324 Seattle Social Development Project (SSDP). 47 Self-disclosure. 275– 276 suicide prevention and planning for. 122. 41. 121. 232. 477 Risk factors for disruptive behavior disorders. and encopresis. and chronic physical illness. 231. and cultural issues. 403–404. 62 Rules. 493–494. 337 Skinner. and cultural issues. 70 Self-Reflection and Insight Scale for Youth. See Socioeconomic status Sexual abuse. 5–6 Self-monitoring. 234–235. and depression 120. and PTSD. 123. 197. and obesity. of Americans With Disabilities Act. 152 SES. and themes in OCD.F. and behavior expectations in disruptive behavior disorders. 218–219 SIT (self-instructional training). 407–408. 337 Section 504. Mood monitoring Self-reflection. and motivational interviewing. and obesity. 439 Secondary control. 395 Stool assessment chart. See also Religion SPSI-R (Social Problem-Solving Inventory—Revised). 63 STEPS problem-solving skills. and combined therapy. 449–450 Stretching. and disruptive behavior disorders. 218 chronic physical illness and family de-stressing game. 84. 235–237. 249 cultural issues and. 34. 445–446 Substance abuse. 103 Special time. 45–49. 270 Socratic questioning. 173 development and. 253–255 Stigma. of parents with child. See also Conflict resolution. 45 depression and. 232. and disruptive behavior disorders. See Selective serotonin reuptake inhibitors SSRS (Social Skills Rating System). 243– 245 Social Problem-Solving Inventory— Revised (SPSI-R). 234–235. 11–12. 357–358 disruptive behavior disorders and. 495 Study skills. 103 Socioeconomic status (SES) assessment and. 478 immigrant populations and. Peer relationships chronic physical illness and. 63 SSDP (Seattle Social Development Project). 450 Social phobia. 80. See also Open-ended questions Solution-focused approach. 200. 206. 90 treatment engagement and. 92. 472. 175–179 combined therapy and. 441. and cultural issues. 160. 437 Subtypes. 93 combined therapy and. 139– 140 Stimulant medication. 370 STIC (Show That I Can) tasks. 442–443 Social information processing theory. 63. 228. and disruptive behavior disorders. 68– 71 disruptive behavior disorders and. 243–245 Social cognition. 406 Sticker charts. 357. and disruptive behavior disorders. 392. 63 Social support networks. 228. and bipolar disorder. 442 Socialization. 199 553 Somatic symptoms anxiety disorders and. and exercise. 83. 217–218 black box warning on antidepressants and. 63 Social rejection childhood obesity and. See also Insomnia. 487 Stream-interruption exercises. of encopresis. 137 enuresis and. 122. 447–448 Social Skills Rating System (SSRS). 441–442 Social skills. and obesity. 385 disruptive behavior disorders and. 215. 124 CBT for. 167. and enuresis. and GLBT youth. 89. 482 Suicide and suicidal ideation bipolar disorder and. 160. and rewards. 123–124 Stimulus control. 350 definition of. for ADHD. 205. 155 . 194. 341. 86–87. 133. 356. Waking schedule Social anxiety disorder. 450 Spirituality. 231. 89–90. and disruptive behavior disorders. 439 SSRIs. 107 Social learning theory.Index Sleep. 198. 478 Stress and stress management bipolar disorder and. to bipolar disorder. and cultural issues. See also Rewards TORDIA. 249 misperceptions of CBT and. 484. See Feelings thermometer THINK (acronym) chronic physical illness and. 24 Thermometer. 131–132 culture and expression or presentation of. See Trauma-focused cognitive-behavioral therapy TFD (Thinking-Feeling-Doing). 135–140 TADS. 355. See Tricyclic antidepressants Teacher Report Form (TRF). 140–141 culture and self-assessment of.554 Cognitive-Behavior Therapy for Children and Adolescents “Supervision of supervisors” model. 491 TCAs. 306 Time. 220–221 combined therapy and severity of. of treatment bipolar disorder and. chronic physical illness and development of. 499 Toilet training. See Treatment for Adolescents with Depression Study Talents. 239 identification of. 25 Thought forecasting. 62 Third wave. and encopresis. 485. and bipolar disorder. 19–20 Tic disorders. 369. 128. 385. 23–24 Systematic desensitization. See Treatment of SSRIResistant Depression in Adolescents . 89–90. 14–15 collaboration with patient in CBT. 155– 156. 23– 24 Symptom substitution. Past. 488–489. 346. See Duration. 301 Symptoms bipolar disorder and management of. of CBT. 402 Thinking-Feeling-Doing (TFD). 130–131 and type of. 219 Coping Cat Program for anxiety disorders and. 217–218. 17–19 reappraisal of. 386 TEIQue-AF (Trait Emotional Intelligence Questionnaire— Adolescent Form). 170. and treatment of encopresis. 209–211 Think Task. 353–354. 350–351 TASA (Treatment of Adolescent Suicide Attempters). and bipolar disorder. of CBT for OCD. 66 Coping Cat Program for anxiety disorders and. 385 TF-CBT. 353 cognitive development and monitoring of. 64 Termination. 491 Token economy. 444. 230 Teamwork. and therapist/patient collaboration in CBT. 171 Thoughts and thinking chronic physical illness and. 22 combined therapy and. and childhood obesity. 10–12. 176 Task analysis. 11 Teasing. 248 Testosterone. 209–211 Therapeutic relationship cultural issues in. 64 TEIQue-CF (Trait Emotional Intelligence Questionnaire— Child Form). 22–23 Therapists active stance of in CBT. 34 System factors. 35 Thought record. and encopresis. and disruptive behavior disorders. 96 importance of in CBT. 91 misperceptions about CBT and creativity and flexibility of. and combined therapy. 359. Present Time-outs. 357. 337– 338. 382 obesity and. 39–40. 483 Urine alarms. 376–377 Trauma. Psychopharmacology. 49. 45 Weight gain. 265–266. and pharmacotherapy for bipolar disorder. and study of age and encopresis. 271 narratives of. 125.. 122. and guided imagery for pain management. 179 TRF (Teacher Report Form). 32–36. 122. Cognitive-behavioral therapy. 475–478 Treatment of SSRI-Resistant Depression in Adolescents (TORDIA). Census Bureau.S. and cultural issues. 278. See also Imipramine Triggers..Index Tourette’s syndrome. 267 Ulcerative colitis. Combined therapy. 122. 80. 205. 402. 125. J. 53 Treatment planning. Efficacy. 403. 4th Edition (WISC-IV). and bipolar disorder. 164– 165. 208 UCLA PTSD Reaction Index for DSM-IV. 472– 473. 150. See also Posttraumatic stress disorder cultural issues and. 270–271 Treatment modality. 164. 2 Workbooks. 52. See also Planning adaptation of CBT for developmental stages. 76 U. 128. 274 reminders of. and developmental considerations. 154. 98. 275 Trauma-focused cognitive-behavioral therapy (TF-CBT). 277. 123–124 Traffic Light Diet. 393. 121. Outcome. 124. 64 Trance. 130. 229–231 555 encopresis and. 155– 156. 348 Waking schedule. 128. J. 126. 2 Wechsler Intelligence Scale for Children. 491–498 enuresis and. Termination. 469. 338 United Kingdom. B. 231 . and enuresis. 477. Food and Drug Administration (FDA). 349 for orientation. 481–482 U. 395. 97 Visual imagery. 45 Wolpe. 95–97 PTSD and. 477 Watson. 128.S. See also Homework chronic physical illness and. 230 Tricyclic antidepressants (TCAs). Treatment planning Treatment for Adolescents with Depression Study (TADS). 475 Values. 394. 121. 64 Trait Emotional Intelligence Questionnaire—Child Form (TEIQue-CF). 65–73 anxiety disorders and. 88–89 Venlafaxine. Behavior therapy. 470– 471. for enuresis. 279–287 Treatment. See Barriers. 405–406 Trait Emotional Intelligence Questionnaire—Adolescent Form (TEIQue-AF). See also Obesity Weight tracker. 422 WISC-IV (Wechsler Intelligence Scale for Children. 264. Treatment engagement. 175–176 Treatment of Adolescent Suicide Attempters (TASA). 176 Treatment engagement cultural issues in. 154 Videotapes chronic physical illness and. 100 language and description of events. 343 Coping Cat Program and. 4th Edition). Compliance. . 40 . 7. 420–433 Wrapped rewards. 495 Yale Global Tic Severity Scale (YGTSS). 278 Zone of proximal development. J. 304. 305 Zambia. A. 15 Worksheets. 405.556 Cognitive-Behavior Therapy for Children and Adolescents Working hypothesis. and TF-CBT for HIVaffected sexually abused children. 402. and obesity. 305 Yates. 407. 403. 408. 2 YGTSS (Yale Global Tic Severity Scale). 304. 31.