Cognitive Behavioral Therapy CBT for children Carolyn R

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

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

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). 3

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. 4

Conceptualization • 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 5

The Process for SAD Makes catastrophic Interpretations about Being separated from Parents This activates child’s ANS = anxiety. Reinforcement of Catastrophic Interpretations. 6

Treatment of Panic Disorder with Agoraphobia versus SAD • 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? 7

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. 8

Case History • • • 6 -year-old boy, 1 st 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. 9

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. 10

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

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” 12

Phase III • Usually by the 3 rd 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. 13

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. 14

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? 15

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). 16

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. 17

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. 18