CBT in Children

7/26/2019 CBT in Children

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BEHAVIOR

THERAPY IN

CHILDRENDr. Manu SharmaMs. Malar


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If psychiatrists are not traine in CBT! it"ea#es the$ therape%tica""y i$potent! antherefore "ess a&"e to "ea a$%"tiiscip"inary tea$'


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IntroductionCBTs represent a large portion of empirically

supported treatments

co(nitions or tho%(hts can inuenceemotions and behaviors across a variety ofsituations

Panic disorder Clar! "#$%&' ()* and Barlo+

"#$%%' (S,*-enactive' performancebased procedures as

+ell as cognitive interventions to producechanges in thin!ing' feeling and behavior

")endall' #$$/*


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Aaptin( CBT for chi"ren

an ao"escents01trapolate from 2ndings +ith adults

,s +ith adult CBT' the therapy model

continues to evolve and is beginning to beevaluated

Pacing the content and speed of therapy

3imitations in $etaco(nitionand ineptitude

in labelling feelingsMa4or de2cits in social s!ills or interpersonal

problemsolving

5igher use of behavioral techni6ues


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,ssessment)oes of Assess$ent

Behavioral intervie+

Selfmonitoring7ating scales

Information from other people

Direct observation of behavior in clinical

settings7ole play

Behavior tests


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Behavioral intervie+Initial analysis of the problem situation8

Behavioral e1cess9de2cits9assests

Clari2cation of the problem

,BC Techni6ue

Motivational analysis

Developmental analysis

Sociological changesBehavioral changes

Biological changes

Coping' avoidance' beliefs


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Behavioral intervie+Co(nitions

,t the moment you +ere feeling an1ious' +hat+as going through your mind:

;hat +ere you thin!ing to yourself:

;hat +ere you saying to yourself:

Did you have an image in your mind at the time:

Did you see anything in particular:;hat +ere you afraid might happen:

;hat +as the +orst thing you thought mighthappen:


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Behavioral intervie+*e"f+)onitorin(

7e6uires the patient to collect information on

their problems bet+een sessions


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Thought diary.

2001 by The Royal College of Psychiatrists


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Behavioral intervie+Ratin( sca"es

CBC3

)S,DSBDI children version

C,7S

Conner?s parent9teacher?s rating scale


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CBT formulationIncorporates consideration of the follo+ing8

Predisposing =actors

Precipitating =actorsPerpetuating =actors

Consideration of these factors > thereby guideany therapeutic intervention


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CB MethodsSocratic 6uestioning

@uided discovery

0vidence,dvantages > disadvantages

Identifying errors in thin!ing

@enerating rational e1planations

Imagery

7ole play

Social s!ills' ,ssertiveness training


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Behavioral methods7ela1ation

Breathing e1ercises

01posureDesensitiAation

Behavioral activation

,ctivity scheduling

etc


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App"icationThe contentof the cognition may be typical

of the disorder or mood.

-no one +ill love me' I +ill be alone -it +ill bea disaster -it?s not fair

Cognitive distortions8 emotional disorders'CD' depression' somatiAation' PTSD

Cognitive de2cit of social s!ills and problemsolving8 Conduct disorder' ,D5D


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The co(niti#e $oe" of

epressionEar"y e,perience

Parents 6uarrel and separate

=ather leaves home-or$ation of ysf%nctiona" core &e"iefs

-I al+ays drive people a+ay'

-I?m no good' -I?m +orthless

De#e"op$ent of ysf%nctiona"ass%$ptions

-(nless I al+ays please people' they?ll re4ectme'

-If eo le et to !no+ me' the ?ll see I?m no


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The co(niti#e $oe" of

epressionCritica" incient

Boyfriend goes out +ith another girl

Ass%$ptions acti#ate

Ne(ati#e a%to$atic tho%(hts

-It?s my fault' -I?ll never have another friend'

-


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CBT for depressionSetting the agenda for the session'

7evie+ of home+or!? from the previous session'

@oal setting of tas!s for the session and practising

tas!s in the session.5ome+or! is agreed' +hich may involve tas!s practised

in the session and problemsolving to anticipatediEculties.

=re6uent summariAing +ith feedbac!.

Ma!ing a problem list not only clari2es things' but alsoenables the young person to e1perience CBT as

collaborative' in that the therapist is trying to understandthe young person?s perspective and priorities.


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CBT for depression./ *e"f+contro" s0i""s! se"f+conse1%ation

"reinforcing themselves more' punishing themselvesless*' se"f+$onitorin( "paying attention to positive

things they do*' se"f+e#a"%ation"setting lessperfectionistic standards for their performance* andasserti#eness trainin(

2/ *ocia" s0i""s' including methods of initiatinginteractions' maintaining interactions' handling

conict' and using rela1ation and imagery

3/ Co(niti#e restr%ct%rin(' involving confrontingchildren about the lac! of evidence for theirdistorted perceptions


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,n1iety disordersPathological an1ietyFcatastrophisation'

underestimate of the coping resources andthe li!ely rescue factors from the fearedevent.


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,n1iety disorders, modi2ed thought diary

Sub4ective units of distress scale

The aim is to enable the child to recognize triggersand early signs of anxious arousal.

The child is then taught an1iety managements!ills such as app"ie re"a,ation an positi#ei$a(ery.

The catastrophising cognitions may be challengedPositi#e se"f+ta"0 is developed -If I 4ust sit still

and get on +ith my +or!' I +ill begin to feelbetter.


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,n1iety disorders-EARa #&session programme ")endall et al' #$$G*

-ee"in( fri(htene: ",+areness of bodily cues'identifying an1iety and learning to rela1*

E,pectin( &a thin(s to happen4 "Identifyingand correcting maladaptive selftal! by usingpositive selftal!*

Attit%es an actionsthat can help. "Coping

and problemsolving strategies*Res%"ts an re5ars. "Selfevaluation and

coping +ith failure*


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,n1iety disorders=amily ,n1iety Management "-A)* "Barratt etal' #$$&*

This teaches parents contin(ency$ana(e$ent "re+arding appropriate copingbehaviour and e1tinguishing avoidancebehaviour*

Coping Cat9)oala program


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Cognitive model of obsessivecompulsive disorder.

2001 by The Royal College of Psychiatrists


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CDther distortions8

The belief that thin!ing something is thesame as doing it H tho%(ht6action f%sion

undue sensitivity to responsi&i"ity foro$ission "-If I dont remove every spec! ofdirt' someone might become contaminated*.


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CDThe aim is to enable the child to appreciate

that anyone can ha#e o tho%(hts anthe 5ay to ea" 5ith the$ is to i(nore

the$/

Trying to avoid' suppress or neutraliAe thethoughts +ill only cause them to return morestrongly than before.

The therapist might use stories about habitsand intrusive thoughts and the eJects ofcontrol.


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Conduct disorderTend to attribute hostility to others and

underestimate their o+n aggression in anyconict.

;hen upset they anticipate fe+er feelings offear or sadness' interpreting strong feelings asanger and react aggressively.

They value aggression as eJective inproblemsolving and enhancing their selfesteem.


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Conduct disorderChildren +ith conduct disorders 2nd it hard to

generate verbal assertive "negotiating*solutions to IP problems.

,nd resort to actionoriented and aggressivesolutions.

An(er $ana(e$ent pro(ra$$es help

adolescents to identify their aggressivebehaviour and the conditions that provo!eand maintain it.


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Conduct disorderCBT must be part of a multimodal approach

Socials!ills training

7e+arding prosocial behaviour 'supplemented by instruction' discussion'modelling strategies' rehearsal' promptingand feedbac!.

7oleplay and the use of videotape feedbac!.Problemsolving s!ills training

Concepts of fairness' safety and +hat theother person feels


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,D5DSelfinstructional progsCore problems of

inattentiveness' impulsivity and restlessoveractivity

"the inability to stop' loo!' listen and thin!?*.

7esults have been variable and disappointing.

The training has fre6uently been too short'

unrelated to clinical need


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The 7#e+step

approach# ;atching a trainer model and tal! through atas!' including planning and tal!ing throughpossible diEculties "cognitive modelling*

K Carrying out the tas!' prompted by a trainer

/ Carrying out the tas!' prompting themselvesaloud

L Carrying out the tas!' prompting themselvesby +hispering

Carrying out the tas! silently using covertselfinstruction9selftal!


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Pain managementBeha#iora"8 contracting' time out' modelling'parental counselling

Co(niti#e8 7ela1ation' distraction' imagery'coping s!ills' social s!ills


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Child se1ual abuse - I am being hurt physically "se1ually* by thisadult.

0ither I am bad or this adult is.

But adults do things for your good.

This is called punishment.

That?s +hat this adult told me' that I +as being

punished for being bad.So its my fault and I must deserve this.

Therefore I am as bad as +hatever is done tome.

If I am hurt often' it means I must be very bad.


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Child se1ual abuseI.

Intrusion

SelfrelatedThreat

Memory encoding

II.

3oving and hating +anting > fearing01periencing trust > betrayal together

3iving +ith distorted IP boundaries


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Child se1ual abuseTherapy focuses on8Discourse

Selfempo+erment "did the best you could asa child*

3ifes!ills


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ther areas0ating disorders

School refusal

SomatiAationDissociative disorders


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IssuesThe younger the child' the more the parents

+ill need to be included in the therapy

,voiding reassurance for a child +ith CDand using positive reinforcement forcompliance +ith a child +ith a conductdisorder.

=amilys structure and its belief systemComplementary behavioral input for parents

DD' CD

En(a(in( the chi" or ao"escent


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,dvantages of CBT0ducative and instructive

Shortterm

0mphasiAes getting better rather than feelingbetter

Crosscultural

Structured

Can be researched and the psychotherapy+ith ma1 evidence


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3imitationsCognitive maturity of children

Inept in labelling feelings' thoughts

Mental retardationDevelopmental problems

Severe symptoms

Psychotic symptoms


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ConclusionCB therapists need the ability to engage their

patients and create a collaborative +or!ingalliance.

CB treatments are generally speci2c forparticular conditions.

, psychoeducational element of giving info by

discussion supplemented +ith factsheets isimportant.

Cited as generally more eJective for childrenthan non CB interventions.

CBT in Children

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