Cognitive Behavioral Therapy

1. Cognitive Behavioral Therapy with children and adolescents Lindsay McAlister and Lisa Ingerski November 27, 2006

2. Outline • Introduction to Cognitive Behavioral Therapy (CBT) • Definition • Efficacy • Common uses with children and adolescents • Commonly used materials and resources • Case examples • Obsessive Compulsive Disorder (OCD) and Social Phobia • Psychological factors affecting diabetes - with mixed mood

3. CBT: Definition • Diagram • Example: depression Thoughts Stress Feelings Behaviors

4. CBT: Efficacy • APA Division 12 and 53 • Guidelines for identifying and promoting empirically “validated” or supported treatments in psychology. • Defining Interventions as • Best Support (“Well-Established Treatments”) • Promising (“Probably Efficacious Treatments”)

5. Criteria for “Well-Established Treatments” • At least two good between group design experiments demonstrating efficacy in one or more of the following ways: • Superior to pill placebo, psychological placebo, or another treatment. • Equivalent to an already established treatment in experiments with adequate statistical power (about 30 per group; cf. Kazdin & Bass, 1989).

6. Criteria for “Well-Established Treatments” OR • A large series of single case design experiments (n > 9) demonstrating efficacy. These experiments must have: • Used good experimental designs • Compared the intervention to another treatment as in I.a. (superior to placebo, etc.)

7. Criteria for “Well-Established Treatments” AND Further criteria for both I and II: • Experiments must be conducted with treatment manuals. • Characteristics of the client samples must be clearly specified. • Effects must have been demonstrated by at least two different investigators or teams of investigators.

8. Criteria for “Probably Efficacious Treatments” • Two experiments showing the treatment is (statistically significantly) superior to a waiting-list control group.  • Manuals, specification of sample, and independent investigators are not required. OR • One between group design experiment with clear specification of group, use of manuals, and demonstrating efficacy by either: • Superior to pill placebo, psychological placebo, or another treatment. • Equivalent to an already established treatment in experiments with adequate statistical power (about 30 per group; cf. Kazdin & Bass, 1989).

9. Criteria for “Probably Efficacious Treatments” OR • A small series of single case design experiments (n > 3) with clear specification of group, use of manuals, good experimental designs, and compared the intervention to pill or psychological placebo or to another treatment.

10. EST’s for Children and Adolescents * These can be considered components of CBT

11. EST’s for Children and Adolescents

12. EST’s for Children and Adolescents

13. EST’s for Children and Adolescents

14. Cognitive Behavioral Therapy “Probably Efficacious Treatment” • Specific Phobia • Generalized Anxiety Disorder (GAD) • Separation Anxiety • Major Depressive Disorder • Dysthymic Disorder • Adjustment Disorder While does not meet EST criteria, also often used for: • Agoraphobia, OCD, Panic Disorder, PTSD, Social Phobia

15. CBT and young children? • Piaget’s stage model of intellectual functioning • Preoperational (2-7 years of age) • Concrete operational (7 plus) • Formal operational (12 and over) • Requisite cognitive capabilities for CBT • Self-reflection • Perspective taking • Understanding causality • Reasoning • Processing new information • Linguistic ability • Memory • Early school-aged children generally underrepresented in the CBT outcome literature

16. CBT and young children? • Efficacy of CBT with young children • Methodological issues • Nonclinical samples • Short periods of time • Narrowly specified behaviors in laboratory settings • Problems with maintenance of tx gains • Durlak et al. (1991) • Used developmental level as a client variable • Effect size for children aged between 11 and 13 nearly twice of that for children in the concrete operational and preoperational stages • No other variable mediated outcome • Preoperational group (5-7) did not differ in effect size from the concrete operational (7-11) group • Suggests that older group is cognitively better equipped to modify distortions

17. CBT and young children? • Integrating cognitive developmental level into CBT • Minor changes to procedures or questioning can reveal dramatic decreases in the age at which children achieve important milestones • Social perspective taking • Empathic and emotional understanding • Clear, simple instructions with familiar material from their everyday lives • Concrete and story-based representations • Behaviorally active learning and imaginary mnemonic aids • “Bad Thought Monster” and the “Smart Thought Man/Woman” fight each other with the help of a “Zen Warrior” (Leahy, 1988) • Challenge: finding appropriate metaphor for child’s developmental level

18. Commonly used materials and resources Thoughts Stress Feelings Behaviors Cognitive techniques • Cognitive Restructuring/Reframing • Fear thermometer • Thought record

19. Commonly used materials and resources Cognitive techniques: Background • Goal: Target maladaptive thoughts • Negative view of themselves (e.g., inadequate) • Negative view of the world (e.g., unfair) • Negative view of the future (e.g., I will always fail) • Examples of maladaptive thoughts • When things do not go the way I would like, life is awful, terrible, horrible, or catastrophic • Unhappiness is caused by uncontrollable external events • I must have sincere love and approval from all significant people in my life

20. Commonly used materials and resources Cognitive techniques: Background • Goal: Target maladaptive thoughts • Negative Schemas • Ways of thinking that lead individuals to perceive and interpret experiences in a negative manner • Automatic, often occur rapidly in certain situations and may be outside of person’s awareness • Involve discrete predictions or interpretations of a given situation • Develop out of negative experiences

21. Commonly used materials and resources Cognitive techniques • Cognitive Restructuring/Reframing • Replace or reframe cognitive distortions or maladaptive thoughts with more balanced and realistic thoughts and beliefs about oneself, the future, and the world around us • ELVES • E: Evidence • L: Likelihood • V: oVergeneralization • E: Estimation • S: Standards

22. Commonly used materials and resources Cognitive techniques • Fear thermometer Really scared or upset Pretty scared or upset A little bit scared or upset Not at all scared or upset

23. Commonly used materials and resources Behavioral techniques • Diaphragmatic breathing • Relaxation training • Activity scheduling • Exposure and response prevention exercises

24. Commonly used materials and resources Behavioral techniques: • Diaphragmatic breathing • Pinwheel • Bubbles

25. Commonly used materials and resources Behavioral techniques: • Relaxation training • Progressive Muscle Relaxation (PMR) • Systematic tensing and relaxation of major muscle groups of whole body • With practice, goal is to learn to become deeply relaxed rapidly • Impossible to be tense and relaxed at same time • Can implement skill when noticing that you are starting to become tense and anxious • Guided Imagery • Visualization

26. Commonly used materials and resources Behavioral techniques: • Activity scheduling • Pleasurable Activities • E.g., walk dog, movie with friends, dinner with family, play a game

27. Commonly used materials and resources Behavioral techniques: • Exposure and response prevention exercises • In Vivo Exposure • Real-life exposure exercises • Practice approaching and confronting a feared situation or object • (e.g., germs) • Sessions begin with easy situations and gradually work their way up to scarier and harder situations • Fear hierarchy • Ideal for OCD and phobias • Extreme versions: implosive therapy, flooding

28. Commonly used materials and resources Behavioral techniques: • Exposure and response prevention exercises • Modeling • Involves demonstrating non-fearful behavior in a feared situation and showing the youth a more appropriate response for dealing with a feared object or event

29. Commonly used materials and resources Behavioral techniques: • Exposure and response prevention exercises • Participant Modeling • Combines modeling and in vivo exposure • Model (e.g. therapist) demonstrates fearlessness and coping responses when confronting the feared situation or object • The model assists the child in practicing approaching and confronting the feared situation or object.  • Sessions begin with easy situations and gradually work their way up to scarier and harder situations

30. Commonly used materials and resources Behavioral techniques: • Exposure and response prevention exercises • Reinforced Practice • Combines in vivo exposure with a feared situation or object and rewards • Praise, tokens, toys, hugs, etc. for approaching and confronting a feared situation or object  • Child is rewarded for practicing approaching and confronting a feared situation or object 

31. Commonly used materials and resources Behavioral techniques: • Exposure and response prevention exercises • Systematic Desensitization • Based on the theory of reciprocal inhibition, one cannot be anxious and relaxed at the same time (Wolpe, 1958) • Youth imagines feared object or situation while engaging in a response that is incompatible with anxiety • (e.g. relaxation or play)  • Unlike participant modeling and reinforced practice, the feared object or situation is presented in imagination rather than real life

32. Commonly used materials and resources Behavioral techniques: • Exposure and response prevention exercises • Additional tools • Fear Hierarchy • List of items from 0 (no fear) to 100 (most fear imaginable) • Subjective Units of Distress Scale (SUDS) • Rating system for amount of fear • Usually use a 0-10 scale for younger children • Used during exposure exercises as a way to monitor fear response – ask for SUDS rating at beginning of exercise then wait for value to decrease to normal levels

33. Interactive Exercises! Thought record • Depression • “I can’t do anything right” • “No one likes me” Interoceptive exposure exercises • Panic symptoms

34. Case Examples • Obsessive Compulsive Disorder (OCD) and Social Phobia • Psychological factors affecting diabetes - with mixed mood