Cognitive Behavioral Therapy (CBT) for children

1. Cognitive Behavioral Therapy (CBT) for children Carolyn R. Fallahi, Ph. D.

2. CBT proven effective for adults • CBT effective for: • Depression • Generalized anxiety disorder • Social phobia • Obsessive compulsive disorder • Substance abuse & dependence • Agoraphobia • Panic disorder

3. Can we use this treatment for children? • Theory: we can apply the principles of CBT to children with developmental modifications. • Why? • Children make systematic errors in thinking (cognitive distortions). • Children have skill deficits that maintain the problem. • Theory behind CBT: person’s thinking influences his/her mood & thus, modifications to thinking will result in changes in mood & behavior (Beck).

4. Example: Separation Anxiety Disorder • Main clinical features of SAD. • The anxiety must be beyond what is expected developmentally*. • Prevalence of SAD = 4% in children & young adolescents.

5. SAD Phobic avoidance (e.g. child tries to avoid separation from parents) Catastrophic interpretations (e.g. I will not be able to handle it). Panic symptoms (e.g. autonomic arousal, palpitations, perspiration, hyperventilation, shaking, fear). Panic Disorder with Agoraphobia Phobic avoidance Catastrophic interpretations Panic symptoms Conceptualization

6. The Process for SAD

7. Panic Disorder Explanation of the nature of anxiety & panic Anxiety-management strategies, e.g. Barlow’s work. Barlow’s prescriptive treatment – integration of a spouse or partner in exposure-based treatment. SAD Historically, focus on medication, psychodynamic therapy, family therapy, or behavior interventions. Might the approach we take with PD with agoraphobia be helpful for children? Treatment of Panic Disorder with Agoraphobia versus SAD

8. Theoretical Reasoning • If we only focus on behavioral therapy, then we are tied to environmental contingencies. • This does not take care of the cognitive distortions also seen in children. • What about working with the parents? We need a model.

9. Case History • 6-year-old boy, 1st grade. • History of panic attacks in relation to SAD. • Symptomotology includes: • Clinging • 1 panic attack / day, at least • “really scared” • ANS symptoms: shake, weak legs, sweat, cry, scream. • Worries: parents will die; I might get kidnapped.

10. Applying CBT to this case • Phase I: Psychoeducation for the parents & patient about the nature of anxiety & the model for CBT. • Phase II: Development of CBT coping strategies. • Phase III. Graded exposures & family work. • Phase IV. Booster Session.

11. Phase I • Psychoeducation • Parents informed of treatments • Child told stories to help him understand the treatment, e.g. the purpose of exposure.

12. Phase II • Developing the skills to cope with exposure. • Patient not forced to do anything doesn’t feel ready for. • Graded exposures, e.g. choose an exposure where the child has a high chance of succeeding, e.g. parents standing outside of the office door for progressively longer periods. Patient earns chips for initiating & completing exposures. • Contingency management, e.g. chip system, plastic poker chips turned in for prizes or treats. • Distraction techniques • Coping self-statements, e.g. “I can be brave”; “I can do this”; “My parents will not leave me”; “I am not in danger”

13. Phase III • Usually by the 3rd session, we can begin Phase III. • Develop a stimulus hierarchy, starting with exposures that provoked little anxiety, e.g. parents sitting in a nearby office. • Increase exposures that create strong feelings of anxiety, e.g. parents taking a walk outside the office building.

14. Phase III • Distraction strategies taught. • Counting game, A-B-C game. • Counting game: counting backward from 10, stating “blast off” & taking a deep breath. • A-B-C game: generate words that begin with A, B, & C. Repeat the chain with new words. • Exposures paired with pleasurable activities, e.g. playing with blocks or toy cars. • Patient states positive self-coping statements before each exposure.

15. Phase III • Patient questioned before each exposure about his fear or threat prediction. • After each session, he was asked: • What happened? • How accurate was your prediction? • What did this experience teach you?

16. Family Work • Parents = co-therapists. • Homework assignments that occur in patient’s home. • Sessions are 20-25 minutes per night at home. • This important = increases likelihood of generalizability & allows the patient to practice in the settings where panic occurs (state-dependent learning).

17. Family Work • Assess for problems with parents • Overprotectiveness • Excessive reassurance • Aversive parent-child interactions, e.g. belief that the child should just “pull himself up by his bootstraps.” This negative set could lead to yelling or teasing which increases anxiety in the child. • Education for parents on behavioral principles, e.g. positive reinforcement, shaping.

18. Phase IV • Booster session: review strategies & attribute the child’s success to his use of coping strategies. • This increases sense of self-efficacy (patient’s capability to produce an effect). • Scheduled 4 weeks after last session. • Issues of relapse addressed.