CBT in Children

COGNITIVE
BEHAVIOR
THERAPY IN
CHILDREN
Dr. Manu Sharma
Ms. Malar

“If psychiatrists are not trained in CBT, it
leaves them therapeutically impotent, and
therefore less able to lead a
multidisciplinary team”

Introduction
CBTs represent a large portion of empirically

supported treatments
cognitions or thoughts can influence
emotions and behaviors across a variety of
situations
Panic disorder- Clark (1986, UK) and Barlow
(1988, USA)
“enactive, performance-based procedures as
well as cognitive interventions to produce
changes in thinking, feeling and behavior”
(Kendall, 1993)

Adapting CBT for children
and adolescents
Extrapolate from findings with adults
As with adult CBT, the therapy model

continues to evolve and is beginning to be
evaluated
Pacing the content and speed of therapy
Limitations in metacognition and ineptitude
in labelling feelings
Major deficits in social skills or interpersonal
problem-solving
Higher use of behavioral techniques

Assessment
Modes of Assessment
 Behavioral interview
 Self-monitoring
 Rating scales
 Information from other people
 Direct observation of behavior in clinical
settings
 Role play
 Behavior tests

Behavioral interview
Initial analysis of the problem situation:

Behavioral excess/deficits/assests
Clarification of the problem
ABC Technique
Motivational analysis
Developmental analysis
Sociological changes
Behavioral changes
Biological changes
Coping, avoidance, beliefs

Behavioral interview
Cognitions
 At the moment you were feeling anxious, what
was going through your mind?
 What were you thinking to yourself?
 What were you saying to yourself?
 Did you have an image in your mind at the time?
 Did you see anything in particular?
 What were you afraid might happen?
 What was the worst thing you thought might
happen?

Behavioral interview
Self-Monitoring
 Requires the patient to collect information on
their problems between sessions
 Needs to be specific with clearly defined
targets
 What to collect: Frequency, intensity &
duration of the targets
 Provide patients with a record form
 Keep it as simple as possible
 Record information as soon possible after the
event

Thought diary.

©2001 by The Royal College of Psychiatrists

Behavioral interview
Rating scales
CBCL
K-SADS
BDI- children version
CARS
Conner’s parent/teacher’s rating scale

CBT formulation
Incorporates consideration of the following:
 Predisposing Factors
 Precipitating Factors
 Perpetuating Factors
Consideration of these factors & thereby guide
any therapeutic intervention

CB Methods
Socratic questioning
Guided discovery
Evidence
Advantages & disadvantages
Identifying errors in thinking
Generating rational explanations
Imagery
Role play
Social skills, Assertiveness training

Behavioral methods
Relaxation
Breathing exercises
Exposure
Desensitization
Behavioral activation
Activity scheduling
etc

Application
The content of the cognition may be typical

of the disorder or mood.
“no one will love me, I will be alone”; “it will be
a disaster”; “it’s not fair”
Cognitive distortions: emotional disorders,
OCD, depression, somatization, PTSD
Cognitive deficit of social skills and problemsolving: Conduct disorder, ADHD

The cognitive model of
depression
Early experience
Parents quarrel and separate
Father leaves home
Formation of dysfunctional core beliefs
“I always drive people away”,
“I’m no good”, “I’m worthless”
Development of dysfunctional
assumptions
“Unless I always please people, they’ll reject
me”,
“If people get to know me, they’ll see I’m no

The cognitive model of
depression
Critical incident
Boyfriend goes out with another girl
Assumptions activated
Negative automatic thoughts
“It’s my fault”, “I’ll never have another friend”,
“No one loves me”, “I’ll be alone forever”,
“I’m worthless”
Symptoms

CBT for depression
Setting the agenda for the session,
Review of ‘homework’ from the previous session,
Goal setting of tasks for the session and practising

tasks in the session.
Homework is agreed, which may involve tasks practised
in the session and problem-solving to anticipate
difficulties.
Frequent summarizing with feedback.
Making a problem list not only clarifies things, but also
enables the young person to experience CBT as
collaborative, in that the therapist is trying to understand
the young person’s perspective and priorities.

CBT for depression
1. Self-control skills, self-consequation

(reinforcing themselves more, punishing themselves
less), self-monitoring (paying attention to positive
things they do), self-evaluation (setting less
perfectionistic standards for their performance) and
assertiveness training;
2. Social skills, including methods of initiating
interactions, maintaining interactions, handling
conflict, and using relaxation and imagery;
3. Cognitive restructuring, involving confronting
children about the lack of evidence for their
distorted perceptions

Anxiety disorders
Pathological anxiety—catastrophisation,

underestimate of the coping resources and
the likely rescue factors from the feared
event.
Negatively distorted cognitive appraisal,
where the child is likely to be obsessively selffocused, hypercritical, concerned about
Physiological alerting and arousal leading to
somatic sensations--behavioral avoidance-

Anxiety disorders
A modified thought diary
Subjective units of distress scale
The aim is to enable the child to recognize triggers

and early signs of anxious arousal.
 The child is then taught anxiety management
skills such as applied relaxation and positive
imagery.
The catastrophising cognitions may be challenged
Positive self-talk is developed-- “If I just sit still
and get on with my work, I will begin to feel
better”.

Anxiety disorders
FEAR-a 16-session programme (Kendall et al, 1990)
Feeling frightened? (Awareness of bodily cues,
identifying anxiety and learning to relax)
Expecting bad things to happen? (Identifying
and correcting maladaptive self-talk by using
positive self-talk)
Attitudes and actions that can help. (Coping
and problem-solving strategies)
Results and rewards. (Self-evaluation and
coping with failure)

Anxiety disorders
Family Anxiety Management (FAM) (Barratt et
al, 1996)
This teaches parents contingency
management (rewarding appropriate coping
behaviour and extinguishing avoidance
behaviour)
Coping Cat/Koala program

Cognitive model of obsessive–compulsive disorder.

©2001 by The Royal College of Psychiatrists

OCD
Other distortions:
The belief that thinking something is the
same as doing it – thought–action fusion;
 undue sensitivity to responsibility for
omission (“If I don't remove every speck of
dirt, someone might become contaminated”).

OCD
The aim is to enable the child to appreciate

that anyone can have odd thoughts and
the way to deal with them is to ignore
them.
Trying to avoid, suppress or neutralize the
thoughts will only cause them to return more
strongly than before.
The therapist might use stories about habits
and intrusive thoughts and the effects of
control.

Conduct disorder
Tend to attribute hostility to others and

underestimate their own aggression in any
conflict.
When upset they anticipate fewer feelings of
fear or sadness, interpreting strong feelings as
anger and react aggressively.
They value aggression as effective in
problem-solving and enhancing their selfesteem.

Conduct disorder
Children with conduct disorders find it hard to

generate verbal assertive (negotiating)
solutions to IP problems.
And resort to action-oriented and aggressive
solutions.
Anger management programmes help
adolescents to identify their aggressive
behaviour and the conditions that provoke
and maintain it.

Conduct disorder
CBT must be part of a multi-modal approach
Social-skills training
Rewarding prosocial behaviour ,

supplemented by instruction, discussion,
modelling strategies, rehearsal, prompting
and feedback.
Role-play and the use of videotape feedback.
Problem-solving skills training
Concepts of fairness, safety and what the
other person feels

ADHD
Self-instructional progs--Core problems of

inattentiveness, impulsivity and restless
overactivity
(the inability to ‘stop, look, listen and think’).
Results have been variable and disappointing.
The training has frequently been too short,
unrelated to clinical need

The five-step
approach
1 Watching a trainer model and talk through a
task, including planning and talking through
possible difficulties (cognitive modelling)
2 Carrying out the task, prompted by a trainer
3 Carrying out the task, prompting themselves
aloud
4 Carrying out the task, prompting themselves
by whispering
5 Carrying out the task silently using covert
self-instruction/self-talk

Pain management
Behavioral: contracting, time out, modelling,
parental counselling
Cognitive: Relaxation, distraction, imagery,
coping skills, social skills

Child sexual abuse
“ I am being hurt physically (sexually) by this
adult.
Either I am bad or this adult is.
But adults do things for your good.
This is called punishment.
That’s what this adult told me, that I was being
punished for being bad.
So its my fault and I must deserve this.
Therefore I am as bad as whatever is done to
me.
If I am hurt often, it means I must be very bad.”

Child sexual abuse
I.
 Intrusion
Self-related
Threat
Memory encoding

II.
Loving and hating; wanting & fearing
Experiencing trust & betrayal together
Living with distorted IP boundaries

Child sexual abuse
Therapy focuses on:
Discourse
Self-empowerment (did the best you could as
a child)
Life-skills

Other areas
Eating disorders
School refusal
Somatization
Dissociative disorders

Issues
The younger the child, the more the parents

will need to be included in the therapy
 Avoiding reassurance for a child with OCD
and using positive reinforcement for
compliance with a child with a conduct
disorder.
Family's structure and its belief system
Complementary behavioral input for parentsODD, CD
Engaging the child or adolescent

Advantages of CBT
Educative and instructive
Short-term
Emphasizes getting better rather than feeling

better
Cross-cultural
Structured
Can be researched and the psychotherapy
with max evidence

Limitations
Cognitive maturity of children
Inept in labelling feelings, thoughts
Mental retardation
Developmental problems
Severe symptoms
Psychotic symptoms

Conclusion
C-B therapists need the ability to engage their

patients and create a collaborative working
alliance.
C-B treatments are generally specific for
particular conditions.
A psychoeducational element of giving info by
discussion supplemented with fact-sheets is
important.
Cited as generally more effective for children
than non C-B interventions.