Cognitive-Behavior Therapy for Children and Adolescents

Cognitive-Behavior Therapy for

CHILDREN AND ADOLESCENTS

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Cognitive-Behavior Therapy for

CHILDREN AND ADOLESCENTS Edited by

Eva Szigethy, M.D., Ph.D. John R. Weisz, Ph.D., ABPP Robert L. Findling, M.D., M.B.A.

Washington, DC London, England

Note: The authors have worked to ensure that all information in this book is accurate at the time of publication and consistent with general psychiatric and medical standards, and that information concerning drug dosages, schedules, and routes of administration is accurate at the time of publication and consistent with standards set by the U.S. Food and Drug Administration and the general medical community. As medical research and practice continue to advance, however, therapeutic standards may change. Moreover, specific situations may require a specific therapeutic response not included in this book. For these reasons and because human and mechanical errors sometimes occur, we recommend that readers follow the advice of physicians directly involved in their care or the care of a member of their family. Books published by American Psychiatric Publishing (APP) represent the findings, conclusions, and views of the individual authors and do not necessarily represent the policies and opinions of APP or the American Psychiatric Association. To buy 25–99 copies of this or any other APP title at a 20% discount, please contact Customer Service at [email protected] or 800-368-5777. To buy 100 or more copies of the same title, please e-mail us at [email protected] for a price quote. Copyright © 2012 American Psychiatric Association ALL RIGHTS RESERVED Manufactured in the United States of America on acid-free paper 15 14 13 12 11 5 4 3 2 1 First Edition Typeset in Revival565 and Swis721. American Psychiatric Publishing, a Division of American Psychiatric Association 1000 Wilson Boulevard Arlington, VA 22209-3901 www.appi.org Library of Congress Cataloging-in-Publication Data Cognitive-behavior therapy for children and adolescents / edited by Eva Szigethy, John R. Weisz, Robert L. Findling. — 1st ed. p. ; cm. Includes bibliographical references and index. ISBN 978-1-58562-406-5 (alk. paper) I. Szigethy, Eva, 1962– II. Weisz, John R. III. Findling, Robert L. IV. American Psychiatric Association. [DNLM: 1. Cognitive Therapy. 2. Adolescent. 3. Child. 4. Mental Disorders— psychology. 5. Mental Disorders—therapy. WS 350.6] 616.891425—dc23 2011039536 British Library Cataloguing in Publication Data A CIP record is available from the British Library.

Contents Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix DVD Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii

1

Cognitive-Behavior Therapy: An Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 1 Sarah Kate Bearman, Ph.D. John R. Weisz, Ph.D., ABPP

2

Developmental Considerations Across Childhood . . . . . . . . . . . . . . . . . . . . . . . 29 Sarah A. Frankel, M.S. Catherine M. Gallerani, M.S. Judy Garber, Ph.D. Appendix 2–A: Tools for Assessing Developmental Skills . . . . . . . . . . . . . . . . . . . . . . . . . .62 Appendix 2–B: Practical Recommendations for Treatment Planning. . . . . . . . . . . . . . . . . . . . . . . . .65

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Culturally Diverse Children and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . 75 Rebecca Ford-Paz, Ph.D. Gayle Y. Iwamasa, Ph.D.

4

Combined CBT and Psychopharmacology . . .119 Sarabjit Singh, M.D. Laurie Reider Lewis, Psy.D. Annie E. Rabinovitch, B.A. Angel Caraballo, M.D. Michael Ascher, M.D. Moira A. Rynn, M.D. Appendix 4–A: Combination Treatment . . . . . . . . . . 150

5

Depression and Suicidal Behavior . . . . . . . . . .163 Fadi T. Maalouf, M.D. David A. Brent, M.D.

6

Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . .185 Benjamin W. Fields, Ph.D., M.Ed. Mary A. Fristad, Ph.D., ABPP

7

Childhood Anxiety Disorders: The Coping Cat Program . . . . . . . . . . . . . . . . .227 Kelly A. O’Neil, M.A. Douglas M. Brodman, M.A. Jeremy S. Cohen, M.A. Julie M. Edmunds, M.A. Philip C. Kendall, Ph.D., ABPP

8

Pediatric Posttraumatic Stress Disorder. . . . . .263 Judith A. Cohen, M.D. Audra Langley, Ph.D.

9

Obsessive-Compulsive Disorder . . . . . . . . . . .299 Jeffrey J. Sapyta, Ph.D. Jennifer Freeman, Ph.D. Martin E. Franklin, Ph.D. John S. March, M.D., M.P.H.

10

Chronic Physical Illness: Inflammatory Bowel Disease as a Prototype . . . . . . . . . . . . 331 Eva Szigethy, M.D., Ph.D. Rachel D. Thompson, M.A. Susan Turner, Psy.D. Patty Delaney, L.C.S.W. William Beardslee, M.D. John R. Weisz, Ph.D., ABPP Appendix 10–A: PASCET-PI Selected Skills and Tools . . . . . . . . . . . . . . . . . . . . . 369 Appendix 10–B: Guided Imagery for Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 375 Appendix 10–C: Information Worksheets for Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378

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Obesity and Depression: A Focus on Polycystic Ovary Syndrome . . . . . . . . . . . . . . 383 Dana L. Rofey, Ph.D. Ronette Blake, M.S. Jennifer E. Phillips, M.S. Appendix 11–A: Healthy Bodies, Healthy Minds: Selected Patient Worksheets. . . . . . . . . . . . . . . . . . . 420

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Disruptive Behavior Disorders . . . . . . . . . . . . 435 John E. Lochman, Ph.D., ABPP Nicole P. Powell, Ph.D. Caroline L. Boxmeyer, Ph.D. Rachel E. Baden, M.A.

13

Enuresis and Encopresis . . . . . . . . . . . . . . . . 467 Patrick C. Friman, Ph.D. Thomas M. Reimers, Ph.D. John Paul Legerski, Ph.D.

Appendix 1: Self-Assessment Questions and Answers . . . . . . . . . . . . . . . . . .513 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535

Contributors Michael Ascher, M.D. Resident in Psychiatry, Department of Psychiatry and Behavioral Sciences, Beth Israel Medical Center, New York, New York Rachel E. Baden, M.A. Graduate Student, The University of Alabama, Tuscaloosa, Alabama William Beardslee, M.D. Director, Baer Prevention Initiatives, Children’s Hospital of Boston; Gardner/Monks Professor of Child Psychiatry, Harvard Medical School; Senior Research Scientist, Judge Baker Children’s Center, Boston, Massachusetts Sarah Kate Bearman, Ph.D. Assistant Professor of School-Child Clinical Psychology, Ferkauf Graduate School of Psychology, Yeshiva University, Bronx, New York Ronette Blake, M.S. Project Coordinator, Weight Management Services, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania Caroline L. Boxmeyer, Ph.D. Research Psychologist, Department of Psychology, The University of Alabama, Tuscaloosa, Alabama David A. Brent, M.D. Academic Chief, Child and Adolescent Psychiatry; Endowed Chair in Suicide Studies; Professor of Psychiatry, Pediatrics, and Epidemiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Douglas M. Brodman, M.A. Child and Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia, Pennsylvania Angel Caraballo, M.D. Assistant Clinical Professor of Psychiatry; Medical Director, School-Based Mental Health Program, Columbia University Medical Center, New York, New York ix

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Cognitive-Behavior Therapy for Children and Adolescents

Jeremy S. Cohen, M.A. Child and Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia, Pennsylvania Judith A. Cohen, M.D. Professor of Psychiatry, Temple University School of Medicine, Philadelphia, Pennsylvania Patty Delaney, L.C.S.W. Licensed Clinical Social Worker, Medical Coping Clinic, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania Julie M. Edmunds, M.A. Child and Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia, Pennsylvania Benjamin W. Fields, Ph.D., M.Ed. Postdoctoral Fellow in Clinical Child Psychology, Nationwide Children’s Hospital, Columbus, Ohio Robert L. Findling, M.D., M.B.A. Rocco L. Motto, M.D., Professor of Child and Adolescent Psychiatry, Case Western Reserve University School of Medicine; Director, Division of Child & Adolescent Psychiatry, University Hospitals Case Medical Center, Cleveland, Ohio Rebecca Ford-Paz, Ph.D. Assistant Professor of Psychiatry and Behavioral Sciences, Northwestern University Feinberg School of Medicine, Chicago, Illinois Sarah A. Frankel, M.S. Graduate Student, Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee Martin E. Franklin, Ph.D. Associate Professor of Clinical Psychology in Psychiatry at the Hospital of the University of Pennsylvania; Director, Child/Adolescent OCD, Tics, Trichotillomania and Anxiety Group (COTTAGe), University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Jennifer Freeman, Ph.D. Assistant Professor of Psychiatry and Human Behavior, Warren Alpert Medical School of Brown University, Providence, Rhode Island

Contributors

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Patrick C. Friman, Ph.D. Director, Boys Town Center for Behavioral Health; Clinical Professor of Pediatrics, University of Nebraska School of Medicine, Omaha, Nebraska Mary A. Fristad, Ph.D., ABPP Professor of Psychiatry, Psychology, and Nutrition, The Ohio State University, Columbus, Ohio Catherine M. Gallerani, M.S. Graduate Student, Department of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee Judy Garber, Ph.D. Professor of Psychology and Human Development, Vanderbilt University, Nashville, Tennessee Gayle Y. Iwamasa, Ph.D. Department of Veterans Affairs, Central Office, Office of Mental Health Operations, Washington, DC Philip C. Kendall, Ph.D., ABPP Laura H. Carnell Professor of Psychology and Director of the Child and Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia, Pennsylvania Audra Langley, Ph.D. Assistant Professor of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, CA John Paul Legerski, Ph.D. Assistant Professor of Psychology, University of North Dakota, Grand Forks, North Dakota Laurie Reider Lewis, Psy.D. Instructor in Clinical Psychiatry, Institute of Clinical Psychology (in Psychiatry), Columbia University Medical Center, College of Physicians and Surgeons, New York, New York John E. Lochman, Ph.D., ABPP Professor and Doddridge Saxon Chairholder in Clinical Psychology, The University of Alabama, Tuscaloosa, Alabama

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John S. March, M.D., M.P.H. Director, Division of Neurosciences Medicine, Duke Clinical Research Institute, Durham, North Carolina Kelly A. O’Neil, M.A. Child and Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia, Pennsylvania Fadi T. Maalouf, M.D. Assistant Professor of Psychiatry, Department of Child and Adolescent Psychiatry, American University of Beirut Medical Center, Beirut, Lebanon; Adjunct Assistant Professor of Psychiatry, Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania Jennifer E. Phillips, M.S. Predoctoral Psychology Fellow, University of Pittsburgh, Pittsburgh, Pennsylvania Nicole P. Powell, Ph.D. Research Psychologist, Department of Psychology, The University of Alabama, Tuscaloosa, Alabama Annie E. Rabinovitch, B.A. Research Assistant, New York State Psychiatric Institute, Columbia University, New York, New York Thomas M. Reimers, Ph.D. Director, Behavioral Health Clinic, Boys Town; Clinical Associate Professor, Department of Pediatrics, Creighton University School of Medicine, Omaha, Nebraska Dana L. Rofey, Ph.D. Assistant Professor of Pediatrics and Psychiatry, University of Pittsburgh School of Medicine; Director of Behavioral Health, Weight Management and Wellness Center, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania

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Moira A. Rynn, M.D. Associate Professor of Clinical Psychiatry, Columbia University; Unit Chief of Children’s Research Day Unit; Deputy Director of Research, Division of Child and Adolescent Psychiatry; Director of the Child and Adolescent Psychiatric Evaluation Service, New York State Psychiatric Institute/Columbia University; Medical Director of The Columbia University Clinic for Anxiety and Related Disorders (CUCARD), New York, New York Jeffrey J. Sapyta, Ph.D. Assistant Professor of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina Sarabjit Singh, M.D. Assistant Professor of Clinical Psychiatry, Columbia University, New York Presbyterian Hospital, Child and Adolescent Psychiatry, New York, New York Eva Szigethy, M.D., Ph.D. Associate Professor of Psychiatry, Pediatrics, and Medicine; Medical Director, Medical Coping Clinic, Division of Pediatric Gastroenterology, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh, Pennsylvania Rachel D. Thompson, M.A. Research Clinician, Medical Coping Clinic, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania Susan Turner, Psy.D. Licensed Clinical Psychologist, Medical Coping Clinic, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania John R. Weisz, Ph.D., ABPP Professor of Psychology, Faculty of Arts and Sciences, Harvard University, Cambridge, Massachusetts; Professor of Psychology, Harvard Medical School, Boston, Massachusetts; President and Chief Executive Officer, Judge Baker Children's Center, Harvard Medical School, Boston, Massachusetts

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Disclosures of Interest The following contributors to this book have indicated a financial interest in or other affiliation with a commercial supporter, a manufacturer of a commercial product, a provider of a commercial service, a nongovernmental organization, and/or a government agency, as listed below: David A. Brent, M.D. Works for the University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, Western Psychiatric Institute and Clinic; Research support: National Institute of Mental Health; Royalties: Guilford Press; UpToDate psychiatry section editor; Honoraria: presentations for continuing medical education events Judith A. Cohen, M.D. Research support: Annie E. Casey Foundation, National Institute of Mental Health, Substance Abuse and Mental Health Services Administration; Royalties: Guilford Press (books); Training contracts (includes funds for travel): California Institute for Mental Health; Pennsylvania Department of Mental Health; New York State Office of Mental Health Mina K. Dulcan, M.D. Royalties: Books published by American Psychiatric Publishing Robert L. Findling, M.D., M.B.A. Receives or has received research support, acted as a consultant, and/or served on a speaker’s bureau for Abbott, Addrenex, AstraZeneca, Biovail, Bristol-Myers Squibb, Forest, GlaxoSmithKline, Johnson & Johnson, KemPharm, Lilly, Lundbeck, Neuropharm, Novartis, Noven, Organon, Otsuka, Pfizer, Rhodes Pharmaceuticals, SanofiAventis, Schering-Plough, Seaside Therapeutics, Sepracore, Shire, Solvay, Sunovion, Supernus Pharmaceuticals, Validus, and Wyeth Mary A. Fristad, Ph.D., ABPP Royalties: MF-PEP and IF-PEP workbooks (www.moodychildtherapy.com) and Psychotherapy for Children With Bipolar and Depressive Disorders (Guilford Press) Philip C. Kendall, Ph.D., ABPP Royalties (income) from sales of books and treatment materials for the treatment of anxiety in youth Fadi T. Maalouf, M.D. Speaker’s bureau: Eli Lilly John S. March, M.D., M.P.H. Equity: MedAvante; Scientific Consulting Fees: Johnson & Johnson, Lilly, Pfizer; Scientific Advisor: Alkermes, Attention Therapeutics, Avanir, Lilly, Pfizer, Scion, Translational Venture Partners, LLC, Vivus; Royalties: Guilford Press, MultiHealth Systems, Oxford University Press; Research support: Child/Adolescent Anxiety Multimodal Study (CAMS); Child and Adolescent Psychiatry Trials Network (CAPTN); K24; National Alliance for Research on Schizophrenia and Depression; Pfizer (principal investigator); Pediatric OCD Study (POTS) I, II, Jr; Research Units on Pediatric Psychopharmacology and Psychosocial Interventions (RUPP-PI); Treatment for Adolescents with Depression Study (TADS) Dana L. Rofey, Ph.D. Research support: National Institutes of Health Moira A. Rynn, M.D. Research support: Boehringer Ingelheim Pharmaceuticals, National Institute of Mental Health, Neuropharm LTD, Pfizer; Royalties: American Psychiatric Publishing Eva Szigethy, M.D., Ph.D. Oakstone child psychiatry review video completed in 2010

Contributors

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The following contributors to this book have indicated no competing interests to disclose during the year preceding manuscript submission: Rachel E. Baden, M.A.; William Beardslee, M.D.; Sarah Kate Bearman, Ph.D.; Ronette Blake, M.S.; Caroline L. Boxmeyer, Ph.D.; Douglas M. Brodman, M.A.; Angel Caraballo, M.D.; Jeremy S. Cohen, M.A.; Patty Delaney, L.C.S.W.; Julie M. Edmunds, M.A.; Benjamin W. Fields, Ph.D., M.Ed.; Rebecca Ford-Paz, Ph.D.; Sarah A. Frankel, M.S.; Martin E. Franklin, Ph.D.; Jennifer Freeman, Ph.D.; Patrick C. Friman, Ph.D.; Catherine M. Gallerani, M.S.; Gayle Y. Iwamasa, Ph.D.; Audra Langley, Ph.D.; John Paul Legerski, Ph.D.; Laurie Reider Lewis, Psy.D.; John E. Lochman, Ph.D., ABPP; Kelly A. O’Neil, M.A.; Jennifer E. Phillips, M.S.; Nicole P. Powell, Ph.D.; Annie E. Rabinovitch, B.A.; Thomas M. Reimers, Ph.D.; Jeffrey J. Sapyta, Ph.D.; Sarabjit Singh, M.D.; Rachel D. Thompson, M.A.; Susan Turner, Psy.D.; John R. Weisz, Ph.D., ABPP


Foreword THIS book, edited by three experts in developmental psychopathology, is just what clinicians and trainees are waiting for! Eva Szigethy is a child and adolescent psychiatrist with a B.A. in neuropsychology and a Ph.D. in neuroanatomy. She had the good fortune to study Primary and Secondary Control Enhancement Training (PASCET), a type of cognitive-behavior therapy (CBT), with coeditor John Weisz, Ph.D., as she completed her fellowship in child and adolescent psychiatry. This launched an unusual and creative path for a physician, in which she methodically developed and tested a model of CBT for youth with both a chronic medical illness (inflammatory bowel disease) and depression. John Weisz has been a pioneer in the study of what works in child mental health treatment—in both university research and community clinical settings. Bob Findling, M.D., the third coeditor of this trio, is a child and adolescent psychiatrist and a pediatrician, with a broad and deep portfolio of research in phenomenology and pharmacological treatment of childhood psychopathology. There are many excellent books on CBT, but the synergy between psychiatry and psychology makes this one unique. The “complete” child and adolescent psychiatrist uses therapeutic techniques, not only a prescription pad. Mental health professionals, especially psychiatrists, and clinical students, residents, and fellows often find the strictly manualized approaches to psychotherapy to be intimidating and difficult to implement in the real world of patients and families with multiple biological, psychological, and social problems. The chapters in this accessible text speak to those therapists and their patients. Although each intervention has empirical support and underpinnings in theory, extensive literature reviews are deliberately avoided in favor of a practical how-to approach. Chapters include clinically relevant pearls of wisdom, case examples, key clinical summary points, suggested additional readings, and self-assessment questions and answers. Each chapter contains practical advice on constructing a treatment plan for the disorder or syndrome, incorporating CBT interventions—as specific as xvii

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number, structure, format, and content of sessions and when and how to include parents. Chapter authors also discuss how developmental and cultural factors may require special attention or adaptation of techniques. One of the most interesting and useful sections of each chapter is how to identify and address challenges and obstacles to treatment. A unique feature of this book is a DVD containing video vignettes (presented by actors and actual therapists) that bring to life selected CBT techniques described in the text. This 13-chapter therapy manual begins with an introduction to CBT with children and adolescents. A novel part of this chapter is a section debunking common myths and misperceptions about CBT. The next chapter, on developmental considerations, is coauthored by Judy Garber, Ph.D., noted expert in developmental psychopathology. Following a chapter on aspects of therapy with culturally diverse youth, there is a unique chapter on integrating CBT with psychopharmacology—a topic too often ignored. The following chapters cover the range of disorders, with contributions by many leading lights: David Brent, M.D., on depression and suicidal behavior; Mary Fristad, Ph.D., on bipolar disorder; Philip Kendall, Ph.D., on the use of Coping Cat for anxiety disorders; Judy Cohen, M.D., on posttraumatic stress disorder; John March, M.D., on obsessive-compulsive disorder; and John Lochman, Ph.D., on disruptive behavior disorders. In addition, there are chapters on problems with physical manifestations: pediatric chronic physical illness, with inflammatory bowel disease as a prototype; obesity and depression, with a focus on polycystic ovary syndrome; and enuresis and encopresis—notoriously difficult disorders to treat once children become too old for star charts and simple behavioral pediatric interventions. Not only would this book, with its illustrative DVD, be a top choice for individual practitioners in any mental health discipline who wish to apply CBT to children and adolescents, it would also be ideal for classroom or seminar use with clinical students, residents, and fellows, especially in programs that may lack faculty expertise in these techniques. Mina K. Dulcan, M.D. Margaret C. Osterman Professor of Child Psychiatry; Head, Department of Child and Adolescent Psychiatry, Children’s Memorial Hospital; Director, Warren Wright Adolescent Program, Northwestern Memorial Hospital; Professor of Psychiatry and Behavioral Sciences and Pediatrics; Chief, Child and Adolescent Psychiatry, Northwestern University Feinberg School of Medicine, Chicago, Illinois

Preface AROUND the world, children are at risk. Rates of pediatric psychiatric disorders are increasing worldwide, a phenomenon that has been linked to elevated environmental stressors and their interactions with genetic and epigenetic changes in our human species. Fortunately, advances in clinical science are expanding our understanding of the environmental and neurobiological mechanisms involved, and advances in intervention science are building an ever-richer armamentarium of treatments that can make a difference. Among these evidence-based treatments, cognitive-behavior therapy (CBT) has shown particularly strong evidence of effectiveness with children and adolescents, across diverse disorders and over decades of research. CBT offers the hope of changing dysfunctional trajectories during the critical developmental window of childhood and adolescence when there is optimal plasticity in brain functioning and underlying circuitry. CBT uses psychotherapy techniques to correct erroneous thinking and alter maladaptive behaviors, ideally in the context of an empathic patienttherapist relationship. Although CBT has growing empirical support for efficacy in treating a variety of psychiatric disorders, a common complaint of practicing clinicians is that they have difficulty accessing the CBT protocols that have been tested and found to be effective, and thus they have not been able to build their own proficiency in these potent interventions. This appears to be particularly true for clinicians who are treating children and adolescents across a variety of psychiatric disorders. The challenge of making efficacious treatments accessible to clinical practitioners is of special interest to each of us, the coeditors of this volume. As a psychotherapy researcher and Medical Director of the Medical Coping Clinic at the Children’s Hospital of Pittsburgh, Eva Szigethy, M.D., Ph.D., has had the unique opportunity to create a behavioral health clinic embedded within the Gastroenterology Clinic to screen pediatric patients for emotional distress and behavioral disturbances. In this setting, Szigethy and her colleagues have found that CBT has a significant impact on depression, abdominal pain, and health-related quality of life, as well as

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a fiscal impact in the form of decreased emergency room visits and hospitalizations. As a psychotherapy researcher, university professor, and President and Chief Executive Officer of the Judge Baker Children’s Center, John Weisz, Ph.D., ABPP, has also seen the potency of CBT, both in randomized effectiveness trials with clinicians in community clinics and in the impact of CBT-enhanced school and outpatient programming at Judge Baker. Robert Findling, M.D., M.B.A., a pediatrician, child psychiatrist, medical school professor, and treatment researcher who directs a division of child and adolescent psychiatry at an academic medical center, has repeatedly seen the practical obstacles to (as well as the feasible solutions for) incorporating evidence-based treatments into routine clinical care. This book was created to help fill the gap between clinical science and clinical practice for children and adolescents by making CBT accessible through the written word and companion videos. Our goal has been to provide a practical, easy-to-use guide to the theory and application of various empirically supported CBT techniques for multiple disorders, written by experts in CBT practice from around the world. These experts have presented core principles and procedures, clinical vignettes, source material from their various workbooks, and video demonstrations of some of the more challenging applications of CBT—including treatment of suicidality, oppositional defiant disorder, obesity, and various anxiety disorders. Another unique feature of this book is the illustration of how CBT can be used to treat psychological disorders in the context of chronic physical conditions in children. The chapters are developmentally sensitive as well, noting modifications needed to make the techniques applicable to different age-groups and with differing levels of parental involvement. These chapter features are complemented by introductory chapters on general developmental consideration across CBT modalities, as well as cultural and ethnic considerations. Finally, we have addressed the growing evidence for the utility of CBT as a strategy for augmenting psychotropic medications, including some of the algorithms used to guide such augmentation. The content has been designed to be user-friendly for clinicians across different disciplines including pediatrics, psychiatry, psychology, and social work. In addition, given the increased emphasis in graduate and professional training on achieving competence in psychotherapy during training, the material was written to be accessible and useful to both trainees and seasoned clinicians. We hope this resource will allow for the dissemination of CBT-related expertise to clinicians in diverse treatment settings throughout the world so that the children and adolescents with these disorders can benefit from an approach to treatment that has such broad and growing support from clinical scientists and practitioners.

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We want to offer special thanks to colleagues who have meant so much to our professional life and in ways that have helped us to shape this book. These valued colleagues include Dr. David DeMaso (Harvard University), Dr. William Beardslee (Harvard University), Dr. John March (Duke University), Dr. David Kupfer (University of Pittsburgh), and Dr. David Barlow (Boston University). We also thank the authors of the various chapters, who produced most of the book and whose writing skill helped us realize the vision of a how-to guide that balances academic rigor with the art of teaching. We appreciate the thoughtful Foreword prepared by Dr. Mina Dulcan (Northwestern University), a career role model and a national leader of child psychiatrists in this country. And we thank Debra Fox and her staff at Fox Learning Systems, who made the production of the highquality DVD accompanying the book possible. We extend additional thanks to the student actors from the top drama programs at universities in Pittsburgh, who performed their adolescent roles for the video with such talent and believability, and the excellent faculty colleagues from University of Pittsburgh, who agreed to demonstrate the various CBT applications on video. Thanks to American Psychiatric Publishing Editor-in-Chief Dr. Robert Hales and Editorial Director John McDuffie for their patient guidance through the editing process. We thank our staff, friends, and family (you know who you are) for their support, editorial suggestions, and encouragement in this adventure. And finally, and very importantly, we thank our pediatric patients and their families for the privilege of working with them— and through this process, learning about the curative power of CBT.


DVD Contents

Video titles and times by chapter

Video title

Patient name (corresponding chapter)

Time (minutes)

Depression and Suicide

Jane (Chapter 5)

14:07

The Coping Cat Program

Zoe (Chapter 7)

10:18

Obsessive-Compulsive Disorder Ashley (Chapter 9)

11:31

Polycystic Ovary Syndrome

Mary (Chapter 11)

17:47

Disruptive Behavior

Tim (Chapter 12)

9:48 Total time:

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1

Cognitive-Behavior Therapy An Introduction Sarah Kate Bearman, Ph.D. John R. Weisz, Ph.D., ABPP

SINCE 2000, a great deal of attention and discussion in child psychotherapy has centered around the topic of evidence-based treatments— psychosocial interventions that have been tested in scientific studies and shown to benefit youths relative to some comparison condition. An update on the status of evidence-based psychosocial treatments for children and adolescents (Silverman and Hinshaw 2008) identified 46 separate treatment protocols for child and adolescent mental health problems that meet the criteria for “well established” or “probably efficacious” therapies set forth by Chambless and Hollon (1998). The majority of the treatments designated as “well established” fall under the broad umbrella of cognitivebehavior therapy (CBT). These mental health problems span multiple diagnostic categories, including autism spectrum disorders, depressive disorders, anxiety disorders, attention problems and disruptive behavior, traumatic stress reactions, and substance abuse. CBTs are known by many specific “brand names” (e.g., trauma-focused cognitive-behavioral therapy, the Coping Cat Program, and the Adolescent 1

2


Coping With Depression Course); all are unified by the guiding belief that an individual’s thoughts, behaviors, and emotions are inextricably linked and that maladaptive cognitions and behaviors can produce psychosocial dysfunction and impairment. Moreover, all CBTs approach cognitions and behaviors as malleable agents of change through which client distress and impairment may be alleviated. In this chapter, we will give a broad overview of key concepts shared across the various CBTs. Given that much of CBT development has been focused on adults, the most influential theories and applications are reviewed by drawing from literature on both adults and children, with some attention to animal studies as well. Chapter 2 will review specific practical developmental considerations in using CBT for children and adolescents.

A Brief History Although the notion that individuals’ experience of the world is largely shaped by their thoughts and behaviors predates the field of psychology, some leaders in the field should be credited with laying the early foundation for modern CBT. Particularly important theoretical precursors include Pavlov (1927, 1928), whose experiments with animals using what is now known as classical conditioning highlighted the relationship between prior experience and involuntary responses, and Watson (1930), whose emphasis on the study of observable behavior and the organism’s capacity to learn new behaviors gave rise to learning theory. The more recent work of Skinner (1953) expanded the scope of learning theory to encompass detailed analysis of reinforcement processes in operant conditioning. Learning theory arguably established the ideological underpinnings of what would later be known as behavior therapy, with a number of notable contributors—among them Lazarus (1971), London (1972), and Yates (1975)—and led to the understanding that maladaptive behaviors are to a large degree acquired through learning. It followed from this perspective that additional learning experiences might be used to modify maladaptive behaviors and promote improved functioning. An early adopter of this notion, Jones (1924) used the pairing of pleasant experiences with feared stimuli to treat a child for a phobia. The work of Wolpe (1958) is one of the best-known early comprehensive approaches to the use of conditioning techniques in psychosocial intervention. Building on his research with animals and counterconditioning, Wolpe introduced the notion that anxiety in humans could be inhibited by invoking an incompatible parasympathetic response, such as relaxation, assertive responses, or sexual arousal. Likewise, the influential work of

Cognitive-Behavior Therapy: An Introduction

3

Negative beliefs

Situation

Self

World

Future

Bad grade on a test

“I am not very smart.”

“This class is stupid and a waste of my time.”

“I will never do well in school.”

FIGURE 1–1.

Beck’s cognitive triad.

Eysenck (1959) paired graded contact with feared objects or situations with training in relaxation to address phobic responses. These advances can be traced forward to systematic desensitization, assertiveness training, and related approaches to sex therapy, which continue to be in use today. These early approaches to the use of behavioral techniques in psychotherapy largely ignored the underlying cognitive processes involved in psychological dysfunction, focusing instead on shaping measurable behavior by manipulating reinforcers and using repeated exposure to fearful stimuli to uncouple the stimuli from the anxious response. In the 1960s, two approaches emerged simultaneously that thrust cognition into the forefront of psychotherapy: cognitive therapy and rational emotive therapy. Cognitive therapy, introduced by Beck (1963, 1964, 1967), posited that the way individuals perceive events and attribute meaning in their lives is a key to therapy. Specifically, Beck suggested that depressed individuals develop a negative schema, or a lens through which they view the world and process information, often because of early life experiences and negative life events—for example, the loss of a relationship or rejection by a loved one. This schema is activated in situations that remind the individual of the original learning experiences, leading to maladaptive negative beliefs about the self, the world, and the future; the conglomeration of negative beliefs across these three entities is known as the cognitive triad. This cognitive triad results in negative thinking errors in which the individual misinterprets facts and experiences and makes assumptions about the self, the world, and the future on the basis of this negative bias (Figure 1–1). Although his approach initially focused on depression, Beck extended the focus of cognitive theory of mental illness to other disorders in the 1970s (e.g., Beck 1976). Beck’s cognitive therapy in practice focused on educating the client about the relationship between thoughts and feelings and on helping the

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client to become more aware of the thoughts that preceded a change in affect. Using a gentle questioning technique, the clinician would probe these thoughts to better understand the underlying assumptions that led to the thought. For example, a person who thinks “I failed a test” may have a deeper belief that “Others will love me only if I am smart.” Once clients became adept at noticing the occurrence of these rapid, involuntary, “automatic” thoughts, Beck encouraged them to question the validity and utility of the cognition. Because these thoughts typically occur quickly and are rarely examined for their veracity, much of the therapy involved helping clients to consider how their thoughts may be inaccurate, unhelpful, or distorted. In theory, once these thoughts were repeatedly challenged, a gradual change in feelings and in behavior would result. Simultaneous to the development of cognitive therapy, Ellis (1958, 1962) introduced rational emotive therapy (RET), later named rational emotive behavior therapy. Much as in cognitive therapy, RET is predicated on the belief that an individual’s feelings are largely determined not by the objective conditions but by the way in which the individual views reality through his or her language, evaluative beliefs, and philosophies about the world, himself or herself, and others. Clients in RET learned to perceive the relationship among thoughts, feelings, and behaviors using the A-B-C model, in which activating events or antecedents (A) constitute the objective event that “triggers” the belief (B) about the meaning of the event. When the beliefs are rigid, dysfunctional, and absolute, the consequence (C) is likely to be self-defeating or destructive. In contrast, beliefs about objective events that are flexible, reasonable, and constructive are likely to lead to consequences that are helpful. Thus, in the RET model, beliefs play a mediating role in the relation between events that occur and the behavioral and emotional consequences. RET theory postulates that most individuals have somewhat similar irrational beliefs and identifies three major absolutes as particularly problematic: 1) “I must achieve well or I am an inadequate person”; 2) “Other people must treat me fairly and well or they are bad people”; and 3) “Conditions must be favorable or else my life is rotten and I can’t stand it” (Ellis 1999). Although clients may not be completely aware of these beliefs in their totality, they are able to verbalize them when queried and encouraged by the therapist—in other words, the beliefs are not unconscious but may not have been examined or articulated fully. In practice, clients in RET work with the therapist to identify the A-B-C sequences in the client’s life that are leading to impairment and distress. The therapist then teaches the client to use a series of disputing thoughts (D) to challenge or refute the dysfunctional belief. In particular, RET emphasizes distinguishing between statements that are objectively true and those that may be irrational. Once the belief has been refuted, a


Antecedents Bad grade on test

FIGURE 1–2.

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Beliefs

Consequences

“I’m not very smart.” “I will never do well in school.”

Sad feelings Decreased effort in school

Effective thought

Disputing thoughts

“The test was hard, but I can try to do better.”

“The test was difficult.” “Lots of kids did poorly.”

The A-B-C-D-E model.

more flexible, effective thought (E) is generated and used to replace the original belief. RET holds that clients have an existential choice about transforming their hopes, expectations, and preferences to absolutistic, rigid demands that will lead to emotional and behavioral disturbances—or conversely, seeing their hopes, expectations, and preferences as flexible and consequently to act in a healthy, self-helping manner. Figure 1–2 provides an example of the A-B-C-D-E sequence. Although the original iterations of both cognitive therapy and RET explicitly mentioned cognitive processes, later work by both Beck and Ellis noted that cognition is a facet of behavior and that behavioral components have always been present in both therapies. Indeed, in cognitive therapy, efforts are continually made to test the veracity of clients’ beliefs by using behavioral experiments. A client who feels rejected by a loved one may be encouraged to pursue activities and relationships in order to receive disconfirming information regarding the maladaptive belief (Beck et al. 1979). Likewise, RET has historically made use of behavioral activities, such as encouraging a client to do something he or she is afraid of doing, in order to demonstrate the irrationality of certain beliefs (Ellis 1962). Both the Beck and Ellis cognitive models, however, were developed in adults. Another central figure in the development of modern CBT, Donald Meichenbaum, focused on children as well as adults. Meichenbaum noted that people’s self-statements, or verbalized instructions to themselves, often appeared to guide their behavior. Much of Meichenbaum’s work focused on impulsive and aggressive children, who used fewer helpful instructional self-statements than less impulsive children (Meichenbaum and Goodman 1969, 1971). Self-instructional training (SIT) grew from these observations. In SIT, the therapist works with the client to reduce

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self-statements that produce maladaptive emotional and behavioral responses (such as frustration and aggression) and replace them with selfstatements that facilitate control of overt verbal and motor behavior. In practice, SIT took the form of the therapist first modeling selfinstructions by performing a task in front of the child while engaging in audible self-talk. Next, the child would perform the same task with instruction and encouragement from the therapist. The child would then repeat the task stating the instructions aloud and then whispering the instructions softly. Finally, the child would complete the task using only covert or internal self-instructions. Although initially used to help impulsive children slow down during performance tasks and correct themselves without becoming distressed, the same techniques have been used to good effect with anxious youngsters, who may engage in self-defeating and anxietyprovoking self-statements (e.g., “I can’t do this”; “I’ll get hurt”; “Everyone will laugh”). Nowadays, therapist modeling and helpful self-statements are a staple of several modern CBT treatments for anxiety disorders. Meichenbaum’s work is also notable for explicitly combining the cognitive and behavioral traditions to form a unified approach and for applying this unified approach in the treatment of children. Throughout the 1980s and 1990s, cognitive and behavioral theories and techniques were further merged and their application extended to include obsessive-compulsive disorder (OCD), other anxiety disorders, disruptive behavior disorders, depression, and other disorders, as discussed in subsequent chapters. Although there undoubtedly remain some purists who defend the merits of using either behavioral or cognitive strategies in isolation, most agree that cognitive and behavioral theories and strategies complement one another, and most use the label “CBT” to describe the pairing of these techniques.

Common Principles As we have noted, CBT is a broad category that includes various therapies to address a range of disorders and problems, and it may emphasize different techniques, modalities, and target populations. Despite this variety, some common principles of CBT can be identified. We illustrate some of these common principles by focusing on the case of Ellen.

Case Example A 9-year-old girl, Ellen, was diagnosed with major depression and attentiondeficit/hyperactivity disorder (ADHD), combined type. When Ellen was age 5, her mother was diagnosed with a serious illness at the same time that Ellen started a stimulant medication to address symptoms of ADHD. Ellen


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had several side effects from the medication and became severely agitated and aggressive at school when her mother was undergoing intensive treatment and was largely unavailable; Ellen was briefly hospitalized. Following the hospitalization, Ellen’s aggressive and agitated behavior subsided; however, because of her sensitivity to stimulant medication, she was not medicated for ADHD symptoms. Ellen struggled in school, and although she was bright, she did not achieve highly in academic situations and was moved to a special education classroom to receive academic support. At the time that Ellen came into treatment, she was experiencing an episode of major depression: she reported feeling sad and down more often than not, experienced little pleasure from activities or events she once enjoyed, felt hopeless and guilty, and had difficulty making decisions and concentrating. In the presence of stressful situations, particularly in academic settings, Ellen would quickly become tearful, stating “I can’t do this” or “No one will help me.” Behaviorally, she would often give up on the task, refuse to reattempt the task, and withdraw. In the face of these behaviors, caregivers and teachers typically reacted with frustration, negative consequences, and finally resignation.

1. Clients and their problems are conceptualized in terms of cognition and behavior. Although no one refutes the importance of early learning and life experiences or the well-acknowledged role of biological processes and vulnerabilities (these seem evident in Ellen’s case), clinical formulations in CBT are largely focused on understanding the ways maladaptive thoughts and behaviors are maintained and lead to client distress and impairment. Whereas other factors are considered integral to development of a disorder, the CBT therapist focuses largely on how a client’s current thinking and behaviors contribute to the current difficulties. The interplay of early life experiences, situational stressors, biological or genetic factors, underlying beliefs, and current thinking and behavior is considered in forming a “working hypothesis” for how the client’s disorder developed and is maintained. This hypothesis is ever evolving and informs the treatment plan. The CBT formulation of a case like Ellen’s would consider her biological and medical vulnerabilities and earlier life experiences as contributing factors to the development of a negative self-schema, through which Ellen now processes new information and which becomes particularly activated during times of stress. Experiences such as academic challenges remind Ellen of her previous failures, confirm her beliefs that she is not capable of handling problems and that she cannot be helped, and lead to her acting-out and sullen behaviors. These behaviors are off-putting to adult figures and lead to negative consequences, which further reinforce Ellen’s belief that she is helpless. Figure 1–3 provides an example of the form such a formulation might take.

In Ellen’s case, many factors are thought to be reciprocal: the maintaining factors further confirm the schema even as they are caused by it; likewise, the depressive symptoms and academic stressors interact with one

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another and with the maintaining factors. Although the CBT formulation considers all of these components, the core elements of the client conceptualization are the cognitions and the behaviors. Changing these thoughts and behaviors will be the focus of intervention. 2. CBT is largely present focused. Related to the first principle, CBT is less focused than some other types of psychotherapy on the presumed “underlying causes” or precipitants of the maladaptive cognitions or behavior. Although it is useful to understand a client’s history and to consider how the past informs current functioning, the emphasis in CBT is on what is happening for the client today. Clients beginning therapy often anticipate that they will be asked to plumb the depths of their early childhood experiences in great detail. Although the CBT therapist may consider formative events in terms of how current thinking and behavior were shaped, the approach does not subscribe to the notion that a client’s insight into and processing of early events are curative. There is little doubt that Ellen’s early experiences of behaving aggressively in school and her subsequent hospitalization during a time when family resources were limited played a role in the development of her belief that she is helpless and inadequate. This belief, coupled with symptoms of inattention and hyperactivity, is activated in the face of academic challenges and leads her to behave in a manner that often results in punishment and further confirmation that she cannot be helped. However, it is impossible to change what has happened to her in the past. Indeed, there is little evidence to suggest that discussing these past events would do much to change her current behavior. Currently, her negative view of herself, others, and the future is maintained by the thoughts she has (“I can’t do this”; “No one will help me”) and the behaviors that arise following these thoughts (giving up, refusing to do her work, becoming withdrawn and angry). These thoughts and behaviors directly lead to experiences that further confirm her view of herself, others, and the world. Thus, the CBT treatment would begin with an examination of the here-and-now circumstances that lead to the thoughts and behaviors that are problematic.

Of course, there are some important exceptions. The past may become central in treatment when the content of current thoughts and beliefs directly involves past events, as is often the case in the treatment of posttraumatic stress disorder. However, even in these instances, the focus is on changing current thinking about the past, or current behavior in the presence of memories, rather than a focus on the past per se. 3. Maladaptive behaviors and cognitions are presumed to be learned. Although few would argue that all impairing thoughts and behaviors are the result of an unfortunate learning history, modern CBT stresses the impor-


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Current stressors Academic difficulties

Biological/genetic/ medical factors ADHD and sensitivity to stimulant medication

Symptoms of depression Self-schema “I am helpless.”

Life events Mother’s illness; hospitalization due to medication side effects

Sadness, anhedonia, guilt, indecision, hopelessness, difficulty concentrating

Maintaining factors Negative thoughts: “I can’t do this”; “No one will help me” Maladaptive behavior: Withdrawal, defiance, sullen attitude Others’ reaction: Adult withdrawal or punishment

FIGURE 1–3.

Cognitive-behavior therapy formulation.

ADHD =attention-deficit/hyperactivity disorder.

tance of established learning principles (e.g., classical and operant conditioning) in the service of understanding how thoughts and behaviors are maintained. Certain factors may impact an individual’s predisposition to develop maladaptive thoughts and behaviors. Genetic and biological predispositions play a role—for example, a child who is very sensitive to anxiety cues may find it more difficult to tolerate physiological arousal, increasing the likelihood that he or she will try to avoid that experience. A child with executive functioning deficits may have a more difficult time inhibiting an impulsive behavior, increasing the likelihood that he or she may break a rule. However, learning experiences nonetheless reinforce or extinguish behaviors and cognitions, thereby transforming what is merely the increased likelihood of a behavior into an enduring pattern that continues and leads to impairment. The symptoms of ADHD make it more difficult for Ellen to tolerate frustration, and this certainly plays a large role in her propensity to give up when faced with academic demands. At the same time, this behavior has been reinforced by the consequences that have typically followed: teachers have punished her (sent her from the room to time-out) or walked away from her—in both instances, allowing her to escape from the aversive task. These consequences also serve to underscore her belief that she can’t do these tasks, increasing the likelihood that she will repeat this same thought when faced with the next similar task. Similarly, the times when she is able

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to complete a challenging task are largely ignored and unpraised, inadvertently decreasing the likelihood that successful completion of challenging tasks will recur. Thus, although the biological predisposition contributes to the difficulties, her behaviors and cognitions are also influenced by her environmental experiences.

4. CBT focuses on specific, clearly defined goals. Early in therapy, the CBT therapist will set goals with the client and/or with the client’s caregiver, and these goals are often described in objective, observable terms. For example, a client’s goal to “feel better” may require further clarification: How will he or she know when that goal is achieved? What will be different in terms of behavior or thoughts? The goal or goals are frequently reviewed throughout therapy, and maladaptive thoughts and behaviors are reviewed regarding the obstacles they impose to achieving the goals that have been set. Importantly, the goals in CBT are not only clearly defined in terms of behavioral objectives, but they are also well known to client and therapist alike. That is, they are transparent, and the interventions in therapy are understood by the client and/or caregiver in terms of how they will theoretically help move the client toward the therapeutic goals. CBT does not assume, for example, that clients are controlled by unconscious desires and impulses and therefore unable to truly know what is troubling them. Rather, the client’s articulated concerns are considered to be the “real” problem, and the intervention is designed to address these concerns. When asked what she wanted to work on in therapy, Ellen initially stated that she wanted to be in a regular education class rather than continue in special education. Because this goal may not have been attainable, Ellen’s therapist used a process of questioning to understand how Ellen’s life might be different if she were no longer identified as needing extra academic help. Through these queries, Ellen revealed that she would like to develop strategies that would allow her to remain in her classroom, complete her coursework and homework, and do better in school. Additionally, Ellen wanted to feel less anxious in academic settings and to make more friends. Having clearly defined goals allowed Ellen and her therapist to clearly measure her progress as therapy advanced, and these goals also provided a therapeutic rationale for the interventions that the therapist introduced.

5. CBT is collaborative and emphasizes the client’s expertise. Transparency in CBT extends beyond setting goals and objectives; the CBT therapist strives to engage the client in an active role in his or her own therapy. To that end, CBT therapists emphasize that both the client and the therapist have expertise: the therapist is an expert in strategies to change thoughts, behaviors, and feelings, but the client (and the caregiver) is the expert in the child. This “joint expertise” is necessary for successful treat-


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ment, and the CBT therapist encourages the client to speak up about his or her own unique experiences. Furthermore, the knowledge that the therapist possesses regarding the client’s difficulties and treatment is not a closely guarded secret—instead, the therapist hopes to educate the client about his or her disorder and about the treatment strategies so that the client eventually becomes an “expert” in his or her own treatment. In other words, the CBT therapist’s goal is not only to help the client set goals, identify and evaluate maladaptive thoughts and behaviors, and modify those thoughts and behaviors, but also to teach the client how to do these things so that the therapist is not necessary. In work with children, CBT therapists may often use the analogy of a sports “coach” to explain this role. A coach helps athletes hone their skills by teaching new strategies, encouraging practice, and providing support. However, the athletes must actively participate by practicing the skills and putting them into action. In a similar way, CBT is viewed as a process of “teamwork” between the client and therapist. Part of the process of developing the client’s expertise is therefore education. CBT typically begins with education regarding the nature of the disorder, including the symptoms, causes, course, and prevalence. It can be tremendously comforting, for example, for a client to learn that the scary feelings he or she has experienced have a name—panic attacks—and that they are relatively common and are caused by the misinterpretation of harmless bodily sensations. In addition to education about the disorder, the therapist also provides education about the cognitive-behavioral formulation of the disorder—the way in which the client’s thoughts, feelings, and behaviors interact and lead to the distress or impairment he or she is experiencing. Client education also includes the therapeutic rationale for all prescribed interventions. In CBT, the therapist is not using a technique that is unknown to the client—the process of the therapy is explained to the client in terms of how it relates to the symptoms or to the objective goals the client has set. Thus, when a therapist begins asking a series of questions about a client’s negative thought, the client knows that the purpose of these questions is to test the evidence that supports the negative thought. A client who is asked to repeatedly confront a feared situation in a slow, graded manner understands that over time, he or she should begin to feel less fearful. Eventually, the CBT therapist will take a less central role in prescribing and implementing such interventions, instead supporting the client’s own use of these techniques. CBT teaches clients to identify, evaluate, and reappraise their own maladaptive thoughts and behaviors. Key to this process is a technique called Socratic questioning, in which the therapist asks

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a series of gentle questions regarding the utility of thoughts or behaviors. The goal is twofold: by asking questions, rather than telling the client that the thought or behavior is maladaptive or unwarranted, the therapist heightens the client’s sense of expertise as he or she arrives at the conclusion. Furthermore, asking questions also encourages a careful review of objective data as a means of determining the utility of the thought or behavior, rather than relying on the therapist’s opinion or the client’s subjective emotions. An important component of Ellen’s therapy involved educating the client, her family, and her teachers about the nature of ADHD and of major depression. Ellen knew that she “had ADHD” but was unaware of its common occurrence in many youths. Introducing ADHD as a problem similar to other medical problems such as allergies, which can cause difficulty but are also amenable to environmental modifications, was useful for Ellen as well as her parents. Additionally, it was important to provide the adults in Ellen’s life with factual information about youth depression and how it may manifest as irritability in addition to the sadness more commonly addressed. In turn, Ellen, her parents, and her teachers were able to provide the therapist with examples of how these and other symptoms were expressed in Ellen’s day-to-day life—a perspective that was vital to personalizing the treatment for Ellen’s benefit.

6. CBT is structured and strives to be time limited. Regardless of the diagnosis, CBT therapists attempt to organize each session using an agenda. Continuing with the theme of transparency, the therapist informs the client of the objectives of each therapy session, and because this is a collaborative process, the client is asked to add topics or activities to the agenda. As in other therapies, clients generally have issues they want to discuss or concerns that have arisen over the prior week; these concerns do not necessarily form the content of the therapy session, however. Rather than abandon the agenda, the CBT therapist seeks to incorporate this issue or concern into the agenda—either by linking it to an already planned topic or by including it as an additional topic that need not replace those that have been planned. Sessions generally begin with a brief review of the previous week, in terms of the client’s targeted problem area. Next, the agenda is reviewed and modified collaboratively. If any therapeutic homework was assigned, this is reviewed—and obstacles to completing homework or unanticipated difficulties are discussed. Next, the agenda items are discussed, new homework is assigned, and the client is asked to summarize the content of the session. With children, sessions often end with some sort of engaging activity, such as a game, and then by collaboratively teaching the caregiver what was done in session. In fact, caregiver endorsement of the child’s


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practice of new skills outside the therapy session is often key to achieving therapeutic effect. Many of Ellen’s sessions began with her or her parents wanting to discuss a recent incident, such as a tantrum over homework completion or an emotional outburst. In general, these topics would be added to the agenda but would not require a change to the planned content. For example, for a session in which the plan was to learn how relaxing muscles and taking calming breaths could result in less distorted thinking and disruptive behavior, the therapist could skillfully use the client’s examples above as a way to make this new skill salient to Ellen and her parents. Likewise, those specific examples introduce an opportunity to identify and evaluate negative thoughts; examine the relationship of thoughts, behaviors, and emotions; and perhaps modify those thoughts or behaviors. In this way, CBT addresses the client’s concerns but does so in a structured way.

Clients and caregivers are also given an overview of the course of treatment from the beginning, and this topic is revisited as treatment progresses. In an early session, for example, the client is informed that initially, the therapist will be teaching the client about his or her disorder and about how thoughts, behaviors, and feelings affect each other. Depending on the target disorder, clients will be informed about the therapeutic interventions that they can expect—that they will be learning how to test how true or helpful their thoughts are, or learn to solve problems, or begin slowly facing situations that have caused them anxiety. They will be told that they will practice new skills until they can do them on their own and are moving toward their goals. And they are told that the treatment will be time limited—that it will not last forever. Although many manualized CBT treatments have a specific prescribed number of sessions, in practice CBT can vary widely in length. The severity of some client’s problems requires treatment that greatly exceeds the 8 to 20 sessions so often described in efficacy trials. Despite variations in the number of sessions, CBT is generally intended to be time limited, with a focus on providing symptom relief, facilitating remission of the disorder, increasing client functioning, training clients in skills to prevent future relapse, and then ending treatment. CBT clients may return to therapy for “booster” sessions when they experience a lapse, and CBT emphasizes helping clients learn to recognize their symptoms so they can determine when a return to therapy may be helpful. CBT does not, however, typically “hold” clients in the therapeutic relationship once symptoms have remitted and gains have been maintained for a reasonable length of time. 7. CBT is tailored to meet the particular needs of the client. CBT formulates client difficulties using a cognitive-behavioral framework, places a

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high premium on therapeutic interventions that have demonstrated scientific support, and relies on principles of learning theory—but CBT is not a one-size-fits-all treatment approach. To the contrary, specific techniques used to address maladaptive behaviors and cognitions are based on the specific maintaining factors that prevent the client from achieving his or her goals. Therefore, each treatment is specifically tailored to the needs of the identified client. Consider, for example, two children who both refuse to attend school. Although the goal in treatment may be identical—increased attendance in the classroom—the two children and their reasons for refusal are very different. One child has anxious beliefs about what will happen at school and predicts that he will embarrass himself if called on in the classroom. Avoiding school results in a decrease in anxious thoughts and feelings and is thus rewarding to the child. The other child finds school aversive because he lacks attention at home and has learned that avoiding school results in rewarding attention from his caregiver and one-on-one instruction, as well as plenty of time to watch television and play video games. Because the factors that maintain the school refusal are dramatically different in these two cases, so too would the interventions differ. Thought reappraisal and graduated exposure might be necessary for the former client, whereas the latter might require behavioral contingencies for school attendance. Ellen’s treatment, for example, required interventions that addressed her endogenous beliefs and volitional behaviors, but it also incorporated environmental modifications to shape new behaviors and to phase out troublesome ones. Understanding the function of Ellen’s behavior was necessary to know how to address the behavior in therapy. For example, being sent from the classroom was an ineffective punishment in Ellen’s case because the classroom when therapy began was a nonreinforcing environment—in other words, being “punished” actually provided relief! A two-pronged approach was used to address this dilemma: 1) finding a more appropriate consequence to address instances of Ellen’s misbehavior and 2) working to improve Ellen’s perception of her classroom. The new approach required actual changes (e.g., working with Ellen’s teachers to establish more frequent praise for positive behaviors) and reappraisal of Ellen’s beliefs.

8. CBT requires an active stance on the part of the therapist. An effective coach does not simply sit on the sidelines observing the players, and in much the same way, an effective CBT therapist takes an active, involved, and directive role in treatment. Because learning is a key component of CBT, the therapist has more characteristics of a “teacher” than in some other orientations. To promote this learning, CBT emphasizes the therapist’s expertise with the disorder or problem area as a means of instilling hope and empowering the client to engage in treatment. CBT like-


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wise highlights the collaboration between client and therapist, with each committing time, energy, and effort to addressing the areas of concern. CBT therapists approach each therapy session intent on structuring the session to maximize the time, introduce and implement interventions that may be helpful for the client, use client material to highlight the ways in which cognitions and behavior are causally linked to emotions, and confirm or revise the ever-evolving “working hypothesis” of the client’s case conceptualization. Over time, the client becomes increasingly involved in the structure of sessions, but the CBT therapist remains highly involved in planning the treatment in order to deliberately progress toward the behavioral objectives or goals. In contrast to therapies that advocate following the client’s lead, CBT is initially quite directive. Clients whose current thinking and behavior are self-defeating or cause difficulties are in need of new strategies. The therapist considers which of these strategies will be most beneficial to the client and works to introduce the intervention, ensures that the client understands the intervention, and plans for implementation in the areas where the client experiences difficulty. Because therapists are often asking clients to try radically different ways of thinking or acting, the client would not necessarily volunteer some of the strategies most useful to overcoming the area of difficulty. Therefore, it is the CBT therapist’s job to suggest new strategies and to provide a compelling therapeutic rationale. Ellen’s treatment again provides an example of this active therapeutic stance. On the basis of her prior experiences in therapy, Ellen’s expectations were that treatment would consist largely of open discussion and play. The therapist therefore needed to initially take a very directive role in establishing the structure of each session, setting guidelines for how sessions would proceed, and suggesting areas where skills might be useful. The therapist told Ellen that therapy would first focus on learning new ways to handle sad, upset, or angry feelings, and that Ellen would be learning “new tools” for her toolbox. Thus, learning different strategies—for example, identifying and changing negative thoughts, using relaxation strategies to manage anxious physical sensations, or sequential problem-solving—was the aim of many early sessions. Once Ellen became familiar with the strategies and accustomed to the structure of the sessions, she became more involved in planning each meeting, providing suggestions of areas where additional attention was needed, and identifying opportunities to practice her therapeutic skills.

9. CBT requires implementation in the real world, outside the office. In contrast to therapies that focus mainly on the in-the-room interactions, CBT therapists are largely concerned with making what happens in therapy relevant to what the client experiences in his or her dayto-day life. This requires some consideration of how to make the interven-

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tions salient and requires both flexibility and creativity on the part of the therapist. Providing experiential in vivo opportunities wherein the client actually uses a new strategy or has the chance to test his or her beliefs is far more potent than discussing the strategy or belief in the abstract. Likewise, acting out what happens outside of therapy using role-plays can promote greater generalization of therapeutic gains. The therapist must actively plan for these activities and be willing to perhaps go beyond the boundaries of other types of therapies. For example, if a client is fearful of crowds, the CBT therapist would try to find an opportunity to experience crowds with the client. If the client’s caregiver has had difficulty creating a home-rewards program to motivate behavior, the therapist should be willing to spend time in session working out the logistics of this reward program. The case of Ellen provides an example of this real-world intervention. Ellen had been practicing the skill of positive self-presentation in her interpersonal interactions, particularly when she was upset. Typically, Ellen practiced this skill in session, using role-plays with her therapist and even videotaping herself in order to critique her verbal and nonverbal behaviors. Ellen and her therapist agreed to work on positive self-presentation with a teacher with whom Ellen found interactions especially challenging. The therapist was able to go to the school in order to coach Ellen through an interaction with this teacher, first discussing with the teacher the plan and sharing the goals of the in vivo interaction. Although this intervention required planning on the part of the therapist, Ellen’s successful discussion with this teacher disconfirmed many of her beliefs about what would happen if she approached him, in ways that merely discussing or role-playing might not have achieved.

Another way in which CBT therapists press for real-world implementation is by encouraging clients to practice the strategies they learn in session in the time between therapy meetings. CBT therapists generally assign some version of homework each week. Because clients may struggle with homework completion, CBT also addresses homework noncompliance. Whereas some therapies interpret noncompliance as resistance or as a behavior that is meaningful to the client-therapist relationship, it is more consistent with CBT principles to first consider the ways in which principles of reinforcement may be at work. For example, is the practice aversive and thus does noncompliance allow for escape? Is it possible to increase incentives for completion of therapeutic homework? Rather than assume the position that the therapist cannot or should not work harder than the client, CBT therapists work to understand, with the client, the potential barriers to homework completion and devise an intervention to address the noncompliance.


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Role of Beliefs As previously discussed, Beck and Ellis both postulated that individuals hold certain beliefs or attitudes, constructed in part from early life experiences and biological vulnerabilities, that are activated during times of stress and form a lens through which new information is processed. At the deepest level, these are known as core beliefs—beliefs so deeply ingrained with a client’s fundamental sense of self, the world, and the future that they may not be recognized or articulable. Core beliefs are not generally examined in everyday life; instead, they are just accepted as “the way things are.” Consider Ellen once again: she never stated a belief that she was helpless; in her view, others withheld help from her. However, she encountered all new and potentially stressful situations with a deep-seated belief that she could never succeed. Experiences that were inconsistent with this belief were quickly forgotten or misattributed (for example, a test she passed was deemed “easy”). By discounting or failing to notice the experiences that disconfirm the core belief, the client maintains the belief, despite its inaccuracy. We have also discussed automatic thoughts, the actual thoughts or images that go through a client’s mind in response to a given situation. These are the superficial expression of the core belief—the accessible thought that flashes through the head for just an instant. Ellen thought, “No one will help me,” or “I can’t do this,” when approaching demanding tasks. Between these two levels of cognition (i.e., core beliefs and automatic thoughts) are the rules, attitudes, and assumptions that link the core belief to the automatic thoughts, known as intermediate beliefs. For example, Ellen may have had several rules that governed the stressful situations: “If I don’t understand something immediately, I’ll never understand it”; “If people don’t offer help to me, it is because I can’t be helped”; and “If I don’t try, I won’t have to fail.”

Identifying Thoughts and Beliefs CBT typically begins by approaching the client’s automatic thoughts because these are the most available to the client. With children, even these may be somewhat difficult to identify at first, because “thinking about thinking,” or metacognition, is not routinely asked of children. It is sometimes helpful to reenact a triggering situation and then ask the child, “What went through your head just then?” Using cartoons with thought bubbles similar to those often used in comic books can also be helpful. Although clients can be helped to evaluate the veracity of their automatic

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thoughts, it is often the case that further questioning about the thought will reveal a set of maladaptive assumptions or rules that are contributing to the development of these more proximal ideas. A technique called guided discovery is often used in CBT to help the client move from automatic thoughts to intermediate beliefs, perhaps even unveiling core beliefs. The therapist continues to ask the client questions about the thought and its meaning in relation to the client, others, and the world. This work is sometimes described as the downward arrow technique (Burns 1980), beginning with a maladaptive automatic thought and winnowing downward to learn more about what it means to the client. At each step, the therapist poses a question assuming that the automatic thought is true. Below is an example of this technique. Therapist: So you were working in your math group and you started to feel really frustrated. What was going through your mind in that moment? Client: I don’t know. I wasn’t paying attention—and then I did, and I felt really annoyed. Therapist: Let’s imagine I’m your teacher, and I’m talking about fractions, and you suddenly start paying attention and you think ... Client: I don’t get it. Therapist: OK, so your thought was, “I don’t get it.” And then you felt frustrated. Client: And then I said, “You’re not making any sense!” and my teacher told me to go to time-out. Therapist: Ah, I see. So I wonder if there was anything else that connected your thought “I don’t get it” to feeling frustrated and then saying that to your teacher. I’d like to understand why that thought made you feel so upset. Let’s assume for a moment that you didn’t understand what the teacher was teaching. What would that mean? Client: Then I won’t be able to do the exercise. Therapist: Oh, OK. So if you couldn’t do the exercise, then what? Client: Then the teacher will ask me why I didn’t do it. Therapist: And if the teacher asks you why you didn’t do it. .. Client: When I say I didn’t understand it, she says I didn’t pay attention. She always says that! Therapist: What would be the worst thing about that? Client: She won’t help me; she never does! She always thinks I’m doing it on purpose, and I’m not—I just don’t ever know how to do these math problems. I just can’t do it, and I never will. Therapist: What does that mean about you, do you think, if that’s true? What does it mean that you can’t do these math problems? Client: I can’t do anything right!

Whereas the thought “I don’t get it” was the most available to the client, what made the thought so upsetting was the more fundamental belief that failure to do the math problem was just another example that the cli-


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ent “can’t do anything right.” Further exploration might have revealed that the client’s self-perception is that of inadequacy. Regardless, the belief “I can’t do anything right” is a clear distortion, and the therapist can work with the client to examine how accurate or helpful that thought may be.

Reappraising Thoughts or Beliefs Although different techniques are used for specific diagnoses or problem areas, most CBT uses some form of collaborative empiricism to scrutinize the veracity and utility of maladaptive thoughts and beliefs. This is a process by which the therapist and client carefully consider all available evidence and identify “clues” that support the maladaptive cognition and those that do not support the thought or belief. Collaborative empiricism can be done formally, using a list of all the evidence for and against the thought, or through a series of questions. Sometimes behavioral experiments are used to test beliefs—for example, trying out a behavior to see if the outcome is what the client predicted, or having the client conduct an informal poll by asking others about their own experiences. Although some people erroneously believe that the goal of examining a thought is to arrive at a positive thought, in actuality the goal is simply to critique the overly critical, threatening, or otherwise distorted thought or belief. Using the evidence that challenges the distortion, a more realistic belief or thought can be constructed. It would be of little use to the client above if she decided to think “I am always great at math!” the next time she encountered a challenging exercise. For one thing, that would be untrue! However, the current thinking—“I don’t get it, therefore I’ll never get it, because I can’t do anything right”—is also inaccurate. A more helpful and accurate thought might be “This is challenging, but if I stay calm and ask for help, maybe I will understand it better.” When attempting to reappraise distorted cognition in children, it is sometimes helpful to use the notion of being a detective searching for clues. Other metaphors include presenting both sides of the case to the “thought judge” (Stark et al. 2006) or looking at the situation first with dark glasses and then removing the glasses to see if things look different. Typically, children struggle at first to generate the evidence that counters the distortion, so it is helpful to use a series of questions that they can ask of themselves. Some examples of questions are listed below (Beck 1995). 1. What is the evidence that this thought is true? Not true? 2. Is there another explanation? 3. What is the worst that could happen? Could I live through it? What is the best that could happen? What is the most realistic outcome?

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4. What will happen if I believe this thought? What would happen if I changed my thinking? 5. If my friend was in the same situation and had this thought, what would I tell him or her? It is important to remember that most clients have lived with their distorted thoughts and beliefs for some time and are very familiar with these cognitions. At first, more realistic cognitions may not “feel true.” This transition from the familiar, maladaptive thought to a more realistic interpretation is a bit like exchanging an old, worn-out shoe for a newer one: the new shoe works better, but it takes time for it to feel right. Therefore, therapists should not be discouraged when clients state that they still strongly believe the original, maladaptive thought or belief. With continued practice, the client will find that new beliefs begin to seem more accurate. Even when the client’s commitment to the original thought changes very slightly, this slight change is still progress toward more useful and accurate thinking.

Role of Reinforcement Principles Just as maladaptive thoughts are important to identify, evaluate, and modify, the key aims of CBT are identifying the behaviors that are problematic and considering how these behaviors are maintained. In the simplest terms, whatever happens immediately after a behavior plays a part in whether that behavior is repeated. Reinforcement refers to an event, behavior, privilege, or material item that increases the chance that a behavior will recur. Negative reinforcement refers to reward in the form of withdrawal of an aversive condition. Extinction refers to the reduction in frequency or total elimination of a behavior by use of nonreinforced occurrences, and punishment refers to the contingent use of negative consequences for aversive behaviors. All of these basic principles are used in the CBT conceptualization of the client regarding how his or her thoughts and behaviors are maintained. Previously we noted that Ellen showed a cognitive bias, or preference, for remembering failure experiences—but her behavior was also maintained by what happened following those times when she struggled with an academic challenge. In the classroom, Ellen was usually sent to a time-out in response to her negative statements and defiance around class work. Because this offered her an escape from an aversive experience, being “punished” actually made it more likely that Ellen would react similarly the next time she encountered frustration in the classroom. From a conditioning perspective, she had “learned” that certain behaviors were paired with escape from an aversive experience, and these behaviors were therefore negatively reinforced.


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On the other hand, on the occasions when Ellen was able to focus her attention on the assigned task, approach the task with a positive attitude, and put forth effort, she rarely received any attention at all. From the perspective of her teachers and other adults, these behaviors were not remarkable—they simply exemplified what a student was expected to do. However, because these desired behaviors were not reinforced when they occurred, they were effectively extinguished. Behavioral principles are important to CBT because they shed light on how behaviors develop and are preserved. Behavioral principles also provide a road map for changing behaviors via interventions. Once the undesirable behaviors are identified, the CBT therapist can work with the client, or with the caregiver, to eliminate the reinforcement that keeps these behaviors in place. Likewise, new behaviors can be identified, reinforced when they occur, and shaped to occur more frequently. It is important to remember that thoughts and behaviors do not exist in isolation from one another; rather, a central tenet of CBT is that the two interact with one another and are inextricably linked to emotions. Therefore, it is wise to consider both thoughts and behavior, even when the bulk of the work in session may focus more on one or the other. Recall that for some people, behavioral experiences are discounted because of a cognitive processing error that causes them to give more weight to experiences that confirm negative beliefs. Therefore, an awareness of negative cognitions is important even when the emphasis in session may be on behavioral interventions. For example, suppose the client has a fear of spiders, but over the course of a therapy session has repeatedly confronted a live spider in a jar and has noted that the initial fear has decreased over time. It is very important to check in with such a client to ascertain what meaning he or she may make of this experience. Perhaps there is a thought like “I can only face this spider because my therapist is with me—I could never do this on my own.” Attributing the success to an external force would, in this case, somewhat decrease the potency of the exposure exercise. In the same vein, behaviors can reinforce negative cognitions, and thus it is most helpful to address behaviors that are related to maladaptive thoughts in treatment. For example, depressed clients who think “I never have any fun” may decide to decline social invitations and isolate themselves. In this way, the behavior actually leads to a verification of the belief. Introducing some basic behavioral interventions—such as assigning pleasant, reinforcing activities as homework—may result in the client’s receiving some disconfirming evidence about the belief. This technique, known as behavioral activation, may also lead to an increase in energy and hopefulness. In short, although some CBTs may emphasize behavioral interventions (for example, the treatment of disruptive behavior disorder in youths

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via behavioral parent training), and some may focus more on cognitive processes (as with cognitive therapy for depression), recognizing the ways in which thoughts and behavior are mutually influential benefits both the case formulation and the intervention.

Common Myths and Misperceptions Although many clinicians use CBT techniques, a number of “negative beliefs” remain about CBT practice and require some corrective attention. 1. The therapeutic relationship is not important in CBT. Although it is true that CBT does not consider the therapeutic relationship to be the principal agent of change as in some other therapies, it is nonetheless an important element of a successful treatment. As with all good therapy, the CBT therapist works to create a therapeutic environment that is warm, supportive, and genuine. The use of so-called nonspecific therapy elements, such as empathy, validation, and positive regard, is important in CBT as well. It is accurate, however, that CBT considers such nonspecific elements as necessary but not sufficient for an effective course of treatment. In addition to warmth, genuineness, and empathy, the CBT client-therapist relationship is characterized by the collaborative spirit we have previously discussed. The working alliance is based on the notion that both therapist and client have expertise about the focus of treatment and that by working as a team, they can improve the client’s well-being. To establish this collaboration, the CBT therapist is straightforward and well informed about the nature of the client’s problems and is clear about the procedures that treatment will entail. At the same time, to foster the client’s own engagement in treatment, the therapist is inquisitive about the client’s goals, seeks examples from the client’s own life that fit with the psychoeducative material, and checks in with the client repeatedly to assess the thoughts and concerns he or she has about treatment. Research on the therapeutic relationship in many types of therapies supports the notion that the strength of the client-therapist relationship is associated with treatment outcome (Shirk and Karver 2003). Measured in a variety of ways, the client-therapist relationship has been found to predict treatment outcome among clients receiving CBT for a variety of problem areas (Hughes and Kendall 2007; Karver et al. 2008; Keijsers et al. 2000). Although some critics have suggested that the use of CBT treatments, and particularly manualized treatment protocols, would undermine the therapeutic relationship, the few studies that have examined this empirically have


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found the opposite. Indeed, one study found that therapists who engaged youth clients in a collaborative manner formed the best therapeutic alliances with their youth clients (Creed and Kendall 2005), and another study comparing the use of manualized CBT for youth depression to usual care services noted that the early therapeutic alliance was stronger for those youths receiving CBT (Langer et al. 2011). In short, a strong therapeutic relationship is a key component in CBT, and CBT’s emphasis on collaborative empiricism in the service of changing thoughts and behaviors may actually bolster—not weaken—the bond between client and therapist. 2. CBT addresses symptoms but not the root of the problem. Some therapeutic orientations suggest that addressing a symptom while not attending to the underlying cause of the problem will result in the later recurrence of the symptom or in a phenomenon known as symptom substitution, wherein the original symptom is merely replaced with another. Within this model, treatment of symptoms is seen as insufficient, and there is an emphasis among some schools of thought that therapists must uncover the latent, and perhaps unconscious, cause of the disorder. In CBT, the underlying cause of the disorder is very much a part of the client formulation and intervention approach, but the cause is understood as the processes that serve to reinforce and maintain the maladaptive cognitions and behaviors. For example, consider the case of Ellen. A previous therapist had suggested that Ellen’s acting-out behavior and depression were caused by anger toward her mother, whom Ellen unconsciously perceived as having “abandoned” her when she was young and her mother was ill. The therapist posited that because Ellen was threatened by this anger, she turned it against herself via her depression and against other adult authority figures, such as teachers. Alternatively, in the cognitivebehavioral approach, the acting-out behavior and the depression were seen as the result of the interaction of Ellen’s negative beliefs (“I am helpless”) and an environment that negatively reinforced her attempts to escape aversive experiences and failed to reinforce her positive behaviors.

Although both models may be accurate, the latter formulation leads to a testable hypothesis that can be explored via intervention, whereas the former relies on a largely inaccessible construct that would be difficult to modify. As for the notion of symptom substitution, follow-up studies of many CBT interventions for youths do not support the notion that eliminated symptoms merely return in another form. However, it is also important to note that many disorders naturally wax and wane, and symptoms may morph over time. For example, a youth with OCD may first present with a hand-washing compulsion and later develop a different ritualized response to anxiety. Successful CBT predicts such a process with the client

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and plans for lapses in which symptoms may transiently return. In planning for treatment termination, the therapist helps the client and the caregiver to consider how problems may manifest in the future, how to manage these recurrences, and how to differentiate between a lapse and a relapse. 3. CBT constrains the therapist’s creativity and flexibility. Perhaps the biggest misperception among those new to CBT is that use of these techniques will diminish the therapist’s ability to be spontaneous, creative, and authentic in the session with the client. In fact, effective CBT is characterized by the therapist’s ability to use session content in the moment to make the principles of CBT come to life for the client. CBT is a lively, action-packed therapy, where the therapist makes use of the client’s thoughts and behaviors to illustrate the ways in which they contribute to the client’s difficulties. For example, suppose the therapist intended to work with the client on the ways in which nonverbal behaviors (e.g., slouching, avoiding eye contact, rolling eyes, and sighing) serve to reinforce the client’s beliefs (“No one likes me”) and also result in interpersonal conflict with others. As the therapist is talking, the client appears to be disinterested and bored. This provides a perfect opportunity for the therapist to note the client’s nonverbal behaviors, query about his or her thoughts, and suggest an experiment—for the next 5 minutes, the client will sit up straight, make eye contact, and nod as if interested. How did that impact the client’s thoughts and feelings? This is but one example of the ways in which CBT therapists have free rein to use session content in a spontaneous and creative manner. Just as a good teacher makes class interesting and fun by use of activities and metaphors that capitalize on the students’ experiences, a CBT therapist does the same. Indeed, CBT emphasizes the use of creative approaches to introducing new behaviors and changing thoughts.

New Inroads and Challenges Currently, CBT is one of the most thoroughly researched psychosocial interventions, with new studies emerging that examine its utility for a wide range of problems. As it has become better established as a core resource for mental health care, several new developments have emerged.

From Efficacy to Effectiveness Although CBT has shown encouraging results when delivered in optimal settings, such as in rigorously controlled research trials, the evidence suggests that it may be somewhat less effective when treatment is delivered in the


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“real world” of typical clinical care (Weisz et al. 2006). Although CBT still does better, on average, than the comparison conditions of usual care services, the clinical impact is lessened when treatments are moved from academic research into frontline services. Identifying the causes for these weaker effects and increasing the focus on how CBT is implemented in the real world are important topics that are beginning to be the focus of researchers and clinicians alike (Weisz and Gray 2008; Weisz and Kazdin 2010).

The “New Wave” As CBT has developed, a number of recent treatment approaches have emerged that blend CBT principles with concepts such as mindfulness, acceptance, dialectics, and values. These skills have roots in Eastern meditative traditions and in practice include focusing attention on the experiences occurring in the present moment (such as sensations, perceptions, cognitions, and emotional states) with a nonjudgmental attitude of openness, acceptance, and curiosity—without attempting to avoid or escape these experiences, even if they are unwanted or unpleasant. This so-called third wave of CBT (Hayes 2004) places less emphasis on changing the form or content of thoughts and behaviors and instead emphasizes transforming the relationships that clients have with their internal experiences. For example, rather than challenging a negative thought, a client might be encouraged to observe the thought, note that it is just an ephemeral thought and not a reflection of reality, and continue to behave in a way that is consistent with achieving the goals the client has for himself or herself. These newer forms of CBT have begun to generate empirical tests, some with significant support, and are expanding the array of techniques available to CBT therapists. Although the focus of therapies such as acceptance and commitment therapy, dialectical behavior therapy, and others may be less on changing thoughts and more on increasing a client’s distance from those thoughts, the causal connection among thoughts, behaviors, and emotions remains central.

Conclusion CBT has evolved from two distinct traditions—cognitive therapy and behavioral learning principles—to form one of the most widely practiced and thoroughly studied psychosocial treatments. CBT continues to evolve, incorporating new techniques for managing maladaptive cognitions and behaviors that are aimed at mitigating their impact on emotions, and it is increasingly being transported from research settings into clinical practice

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contexts such as hospitals, clinics, and schools. As the subsequent chapters of this volume demonstrate, CBT offers a rich mix of techniques for addressing a myriad of disorders, reducing impairment and distress, and improving adaptation and functioning in everyday life.

Key Clinical Points • Cognitive-behavior therapies can be traced back to early animal research and learning theory; these therapies emphasize the connection among thoughts, behaviors, and emotions. • Thoughts and behaviors are seen as malleable agents of change for client distress and impairment. • Although there are numerous CBTs, most share a focus on cognition and behavior, are present focused, and emphasize a collaborative, active, and structured approach to achieving clearly operationalized goals.

Self-Assessment Questions 1.1.

What is the most readily available form of core beliefs called?

1.2.

What is a negative schema?

1.3.

Define collaborative empiricism.

1.4.

How are behaviors reinforced? How are they extinguished?

Suggested Readings and Web Sites Beck JS: Cognitive Therapy: Basics and Beyond. New York, Guilford, 1995 Association for Behavioral and Cognitive Therapies: www.abct.org

References Beck AT: Thinking and depression, I: idiosyncratic content and cognitive distortions. Arch Gen Psychiatry 9:324–333, 1963 Beck AT: Thinking and depression, II: theory and therapy. Arch Gen Psychiatry 10:561–571, 1964


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Beck AT: Depression: Clinical, Experimental, and Theoretical Aspects. New York, Hoeber, 1967 (Republished as Beck AT: Depression: Causes and Treatment. Philadelphia, University of Pennsylvania Press, 1970) Beck AT: Cognitive Therapy and the Emotional Disorders. New York, Basic Books, 1976 Beck AT, Rush AJ, Shaw BF, et al: Cognitive Therapy of Depression: A Treatment Manual. New York, Guilford, 1979 Beck JS: Cognitive Therapy: Basics and Beyond. New York, Guilford, 1995 Burns DD: Feeling Good: The New Mood Therapy. New York, Signet, 1980 Chambless DL, Hollon SD: Defining empirically supported therapies. J Consult Clin Psychol 66:7–18, 1998 Creed TA, Kendall PC: Therapist alliance-building behavior with a cognitivebehavioral treatment for anxiety in youth. J Consult Clin Psychol 73:498– 505, 2005 Ellis A: Rational psychotherapy. J Gen Psychol 59:35–49, 1958 Ellis A: Reason and Emotion in Psychotherapy. Secaucus, NJ, Citadel, 1962 Ellis A: Why rational-emotive therapy to rational emotive behavior therapy? Psychotherapy (Chic) 36:154–159, 1999 Eysenck HJ: Learning theory and behaviour therapy. J Ment Sci 105:61–75, 1959 Hayes SC: Acceptance and commitment therapy, relational frame theory, and the third wave of behavioral and cognitive therapies. Behav Ther 35:639–665, 2004 Hughes A, Kendall P: Prediction of cognitive behavior treatment outcome for children with anxiety disorders: therapeutic relationship and homework compliance. Behav Cogn Psychother 35:487–494, 2007 Jones MC: A laboratory study of fear: the case of Peter. Pedagogical Seminary 31:308–315, 1924 Karver M Shirk S, Handelsman JB, et al: Relationship processes in youth psychotherapy: measuring alliance, alliance-building behaviors, and client involvement. J Emot Behav Disord 16:15–28, 2008 Keijsers GP, Schaap CP, Hoogduin CA: The impact of interpersonal patient and therapist behavior on outcome in cognitive-behavioral therapy: a review of empirical studies. Behav Modif 24:264–297, 2000 Langer DA, McLeod BD, Weisz JR: Do treatment manuals undermine youth-therapist alliance in community clinical practice? J Consult Clin Psychol 79:427– 432, 2011 Lazarus AA: Reflections on behavior therapy and its development: a point of view. Behav Ther 2:369–374, 1971 London P: The end of ideology in behavior modification. Am Psychol 27:913–920, 1972 Meichenbaum DH, Goodman J: Reflection, impulsivity, and verbal control of motor behavior. Child Dev 40:785–797, 1969 Meichenbaum DH, Goodman J: Training impulsive children to talk to themselves: a means of developing self-control. J Abnorm Psychol 77:115–126, 1971 Pavlov IP: Conditioned Reflexes: An Investigation of the Physiological Activity of the Cerebral Cortex. Translated by Anrep GV. New York, Oxford University Press, 1927 Pavlov IP: Lectures on Conditioned Reflexes, Vol 1. Translated by Gantt WH. London, Lawrence and Wishart, 1928

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Shirk S, Karver M: Prediction of treatment outcome from relationship variables in child and adolescent therapy: a meta-analytic review. J Consult Clin Psychol 71:452–464, 2003 Silverman WK, Hinshaw SP: The second special issue on evidence-based psychosocial treatments for children and adolescents: a 10-year update. J Clin Child Adolesc Psychol 37:1–7, 2008 Skinner BF: Science and Human Behavior. New York, Macmillan, 1953 Stark KD, Simpson J, Schnoebelen S, et al: Therapist’s Manual for ACTION. Broadmore, PA, Workbook Publishing, 2006 Watson JB: Behaviorism. New York, Norton, 1930 Weisz JR, Gray JS: Evidence-based psychotherapies for children and adolescents: data from the present and a model for the future. Child Adolesc Ment Health 13:54–65, 2008 Weisz JR, Kazdin AE (eds): Evidence-Based Psychotherapies for Children and Adolescents, 2nd Edition. New York, Guilford, 2010 Weisz JR, Jensen-Doss A, Hawley KM: Evidence-based youth psychotherapies versus usual clinical care: a meta-analysis of direct comparisons. Am Psychol 61:671–689, 2006 Wolpe J: Psychotherapy by Reciprocal Inhibition. Stanford, CA, Stanford University Press, 1958 Yates AJ: Theory and Practice in Behavior Therapy. New York, Wiley, 1975

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Developmental Considerations Across Childhood Sarah A. Frankel, M.S. Catherine M. Gallerani, M.S. Judy Garber, Ph.D.

COGNITIVE-BEHAVIOR

therapy (CBT) is used with children and adolescents to treat various forms of psychopathology, including depression (Weisz et al. 2006), anxiety (Kendall et al. 2002), and conduct disorder (Litschge et al. 2010). Effect sizes for CBT in children are modest, typically ranging from 0.3 to 0.6 (e.g., Durlak et al. 1991; Litschge et al. 2010; Weisz et al. 2006). One potential explanation for these medium effects is that the developmental demands of CBT may exceed a child’s capabilities. That is, CBT may be less effective for some children because

This work was supported in part by grants from the National Institute of Mental Health (R01MH 64735; RC1 MH088329; T32 MH18921).

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they are not cognitively, emotionally, or socially developed enough to understand and apply the clinical skills being taught in therapy. Empirical evidence of differences in efficacy as a function of age has been reported. For example, a meta-analysis of 150 studies of psychotherapy with children and adolescents found that the mean effect size for adolescents was larger than for children (Weisz et al. 1995). Similarly, an earlier meta-analysis reported that children ages 11–13 benefited from CBT more than did children ages 5–11 (Durlak et al. 1991). Few studies, however, have explicitly assessed children’s developmental level or have tested whether development moderates treatment effects (Grave and Blissett 2004; Holmbeck et al. 2006). The idea of incorporating developmental considerations into treatment planning is not new (Eyberg et al. 1998; Ollendick et al. 2001; Shirk 1999; Vernon 2009). Nevertheless, the actual translation of findings from basic developmental research into clinical practice has been less common (Holmbeck and Kendall 1991; Shirk 1999). Some developmental tailoring of interventions for children has been done informally and at a basically superficial level (e.g., linguistic changes), but rarely has it been a systematic and empirically driven pursuit (Masten and Braswell 1991; Ollendick et al. 2001). Many CBT interventions for youth have been downward extensions of adult treatment manuals (Eyberg et al. 1998; Stallard 2002). A few CBT manuals have been designed specifically for children (e.g., Coping Cat for anxiety; Kendall 1990) and have been extended upward for use with adolescents (Kendall et al. 2002). As CBT for children and adolescents has been derived, in part, from cognitive theory of therapy in adults, the extent to which this model is appropriate for less developed age groups is unclear (Grave and Blissett 2004). Both the downward and upward extension approach to designing treatments for children and adolescents serve to perpetuate, however unintentionally, the developmental uniformity myth that individuals with the same psychiatric diagnoses are homogeneous across developmental levels and therefore will respond similarly to treatment (Holmbeck et al. 2006; Shirk 1999). Although most clinicians and researchers would argue against this myth, they remain challenged in how to translate a truly developmental perspective into practice.

Why Is It Important to Tailor CBT Developmentally? Incorporating developmental considerations into treatment design and planning may increase treatment efficacy. Children likely will benefit more when clinicians are aware of developmental norms and can match

Developmental Considerations Across Childhood

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treatment strategies to children’s abilities (Holmbeck et al. 2006; Weisz and Hawley 2002). The exact developmental requirements of the various therapeutic strategies that incorporate CBT have not yet been precisely articulated, however. Without a clearer understanding of these demands, CBT with children may be less effective, and faulty assumptions may be made about whether CBT should be used with children (Spritz and Sandberg 2010). Interventions may be too elementary or too advanced if designed without consideration of developmental level. Given evidence that some children do benefit from CBT, it is likely that certain CBT strategies are appropriate for children, particularly if presented in a developmentally sensitive manner. For example, a focus on concrete concepts rather than abstract principles may be more effective with less cognitively advanced children (Stallard 2002).

Case Example Karen is an 11-year-old girl referred for treatment because of her inability to sit still in the classroom, lack of motivation in school, difficulty concentrating, sleep problems, restlessness, and overall bad mood. At her intake appointment, Karen presents as a well-spoken, socially skilled girl. Indeed, assessment of Karen’s social skills indicates that she is appropriately socially competent. However, the cognitive assessment reveals that Karen has difficulties reflecting on her own thoughts and emotions, as well as problems with abstract and hypothetical reasoning. Therefore, the therapist decides to draw on Karen’s interpersonal strengths by using more concrete role-play examples based on actual situations from Karen’s life (e.g., interactions with her teacher) rather than using abstract, hypothetical (e.g., “what if ”) and future-oriented scenarios. Thus, by matching therapeutic techniques to Karen’s actual cognitive level, the therapist is able to induce greater behavioral change over time.

Although most clinicians recognize the importance of considering children’s levels of competence in different domains (e.g., cognitive, social, emotional) when conducting therapy, they lack information about how particular developmental limitations affect children’s ability to acquire and implement the various strategies taught in treatment (Shirk 1999; Weisz and Hawley 2002). Moreover, as children develop, they may use skills differently depending on context. That is, although children may demonstrate mastery of a developmental skill in one context, they may not be able to apply this skill in other situations (Sauter et al. 2009). Clinicians also should be cognizant of the zone of proximal development (i.e., the difference between what children can learn when they have support or not [Vygotsky 1978]) when considering children’s ability to implement clinical skills with and without help from others (e.g., therapist or parents).

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Although the terms age and development are often used interchangeably, they are not synonymous (Durlak et al. 1991; Holmbeck and Kendall 1991). Development is significantly more complex than the linear progression of chronological age. As such, clinicians cannot assume that older children will always benefit more than younger children from CBT approaches. For example, some studies have shown greater improvements in adolescents than in children receiving CBT for anxiety, whereas others have found that children benefit more than adolescents (e.g., Sauter et al. 2009; Weisz et al. 1995). The unique developmental characteristics associated with adolescence may impact adolescents’ willingness to participate in therapy as well as their ability to apply therapeutic skills (Weisz and Hawley 2002). Additionally, given the heterogeneity of development, not all adolescents (or even adults) will possess the developmental competencies necessary to grasp some of the abstract and hypothetical constructs involved in CBT. Clinicians also need to be mindful of the link between clinical symptoms and development, as well as the relations among the individual areas of development (e.g., cognitive, social, and emotional). Because clinical symptoms may disrupt normal developmental pathways, one treatment goal should be to return children to a more normative trajectory (Shirk 1999). In addition, attention should be paid to the ways in which delays in one area of development may be associated with difficulties in other developmental domains. Given the importance of incorporating development into treatment design and planning, why is it that developmental approaches are not already an empirically validated and universally implemented standard of care? The translation of developmental principles into practice is neither simple nor direct, and as such the integration of clinical and developmental psychology continues to be a challenge (Holmbeck et al. 2006; Ollendick et al. 2001). In the next section, we describe what has been attempted already to tailor CBT, and we provide recommendations for additional ways to developmentally modify treatments for youth.

What Has Been Done to Developmentally Tailor CBT? Researchers and clinicians have begun paying more attention to contextual factors related to development when implementing treatments. For example, the changing interpersonal relationships that occur as children mature (e.g., increased importance of peers, formation of cliques, individuation from parents) have been addressed in some treatment planning (Holmbeck et al.


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2006). One complicated clinical issue affected by the child’s level of social development is the amount and type of parental involvement in treatment. Whereas family-based interventions have been found to be more effective for younger children, individual treatment has been shown to be more effective with older children (Ruma et al. 1996). Given the emergence of autonomy during adolescence, having parents play a directive or even “coaching” role during this developmental stage may be contraindicated, though this may depend on other factors such as the youth’s temperament and the quality of the parent-child relationship. Adolescents who are given appropriate control and input into how parents can be helpful in supporting their new skills may particularly benefit from parental involvement.

Case Example Kevin, a 14-year-old adolescent boy, was an average student and socially engaged with his friends. Six months ago, Kevin became more irritable, easily frustrated with others, and disinterested in school and social activities. He was diagnosed with a major depressive episode and oppositional defiant disorder. The therapist began individual CBT with Kevin to try to elicit more behavioral activation and work on his disengaged social interaction style. Although Kevin and his mother had always had a good relationship, it was clearly worsening as a result of greater conflict between them, particularly about Kevin’s recent misguided expressions of autonomy (e.g., breaking curfew). With Kevin’s permission, the therapist added sessions with the mother to help her understand his growing need for independence. A family problem-solving exercise was initiated where Kevin came up with the solution that he would try to talk with his mother calmly and less disrespectfully, and in turn, his mother gradually would grant him greater freedom as long as he was safe and legal. Kevin began trying out more of the CBT skills he was learning in therapy at home in order to improve his relationship with his mother and steadily obtain more age-appropriate privileges.

Some developmentally based treatment manuals do exist, mostly for treating child anxiety disorders (Sauter et al. 2009). For example, Chorpita’s (2007) CBT manual for children with anxiety consists of several modules, each containing CBT techniques to be selected according to the child’s cognitive abilities. Other CBT manuals for anxiety disorders designed specifically for children ages 7 years and older are The Coping Cat (Kendall 1990) and How I Ran OCD Off My Land (March and Mulle 1998). Kendall and colleagues (2002) modified the child anxiety manual for use with adolescents at different developmental levels. These developmentally sensitive manuals, however, are exceptions rather than a widely used and available standard. The most common adaptation of CBT for children has been to use ageappropriate activities to convey therapeutic skills. One common alteration

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has been to include more child-friendly materials, simplified language, and cartoons. For example, thought bubbles have been used to help children identify what they are thinking (Kendall 1990). With younger children, therapists can use more concrete pictorial or narrative formats, behaviorally active strategies, and activities that stimulate the imagination (Grave and Blissett 2004). Some programs have suggested representing cognitive distortions as coming from a “bad thought monster” (Leahy 1988) or “muck monster” (Stark et al. 2007). Children are then instructed either to fight the monster (e.g., with the help of a Zen warrior) or to talk back to the monster with the help of the group and therapist. Using less complex behavioral techniques with younger children and more complex cognitive techniques with older children also has been recommended (Doherr et al. 2005; Eyberg et al. 1998). Systematic desensitization also has been modified for young children (Ollendick et al. 2001). Shorter attention span and limited abstract thinking in young children may hinder the use of traditional progressive muscle relaxation scripts and guided imagery. Using concrete imagery for muscle relaxation (e.g., tensing and relaxing hands by “squeezing lemons” [Christophersen and Mortweet 2002]) and replacing imagination-based desensitization with in vivo experiences may be more effective with younger children. An age-appropriate desensitization strategy could include imagining confronting the feared situation with the help of a favorite superhero (Lazarus and Abramovitz 1962). When typical relaxation techniques (e.g., muscle relaxation, guided imagery) are not effective with a young child, then other counterconditioning methods (e.g., play, music, food) should be considered (Ollendick et al. 2001). Also recommended is the use of simple, situation-specific coping statements with young children, progressing toward more general self-instructions and eventually using generalized statements during adolescence. CBT techniques such as identifying thinking errors, examining underlying beliefs, and using Socratic questioning are recommended only for more cognitively advanced youth (Stallard 2002). When presented with information that contradicts a belief, children have more difficulty than adults in revising their thoughts accordingly (Shirk 1999). Some CBT programs for children have simplified the cognitive restructuring process to solely replacing negative thoughts with more positive thoughts. Although this “replacement” strategy allows less cognitively advanced children to engage in a form of cognitive restructuring, its efficacy as compared to teaching children to examine their beliefs and distortions and to generate accurate and realistic counter-thoughts has not been demonstrated. Merrell (2001) provided a compendium of developmentally appropriate cognitive-behavioral methods for use with depressed and anxious children and


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adolescents, in which strategies were separated by age. For example, to help children recognize degrees of emotional intensity, Merrell recommended that the therapist draw an “emotional thermometer” with different levels that the child can use to identify the emotional intensity of different experiences. This exercise can be used with individuals of all ages, but Merrell recommended keeping emotional gradations simple for young children. For identifying automatic thoughts, Merrell recommended using thought forecasting, in which individuals generate hypothetical scenarios and predict possible thoughts and feelings they might have in those situations. In contrast to the emotional thermometer, thought forecasting is only recommended for older children and adolescents because “younger children may find this exercise too abstract and may not be able to generate realistic future situations” (p. 89). In general, Merrell suggested that for younger children, clinicians should use more concrete and simplified examples and questions while also providing more support, structure, and feedback. Merrell’s (2001) book provides useful examples of techniques clinicians can use to teach skills to children of different ages, although it has some limitations. All the recommended activities are either for children of all ages or for “older” or “cognitively mature” children and adolescents. Few activities specifically designed for younger children are presented. Moreover, information is not provided regarding how clinicians can assess children’s specific levels of cognitive maturity. Age is only a crude and imprecise estimate of a child’s developmental level at any point in time. In a handbook of clinical strategies for teaching rational emotive behavior therapy techniques to youth, Vernon (2009) separated strategies by their appropriateness for children versus adolescents and provided a developmental rationale for most activities. For example, for “So Long, Sadness,” an activity designed to help children generate ideas for coping with depressed feelings, Vernon stated, “Most children feel sad from time to time, but given that their sense of time is immediate, it is easy for them to get discouraged if they aren’t able to deal with their feelings effectively. This concrete strategy involves them generating things they can do to feel better” (p. 122). Similarly, for “Don’t Stay Depressed,” an activity in which adolescents detail what they can think and do and who they can turn to for support when feeling depressed, Vernon wrote, “Given that adolescents live in the ‘here and now,’ it is easy for them to become overwhelmed and feel hopeless when they are depressed. Consequently, it is important to empower them so that they have many different strategies for coping more effectively because it is difficult for them to generate ideas when they are down” (p. 125). In addition, Vernon included a section titled “Interventions for Typical Developmental Problems,” in which she detailed activities for enhancing self-acceptance, relationships, and

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healthy transitions. Thus, Vernon’s book presents activities that incorporate age-based developmental considerations. Attention to developmental factors in CBT has increased since the 1990s. The percentage of empirical articles mentioning developmental issues in treatment has increased from 26% between 1990 and 1998 to 70% between 1999 and 2004 (Holmbeck et al. 2006). However, the construction of developmentally sensitive treatment strategies generally has been an informal process not always driven by empirical evidence. Further research is needed on how to individualize treatment techniques according to a child’s specific developmental level rather than age. Until more precise guidelines are constructed for tailoring treatments developmentally, clinicians will need to modify the therapy on the basis of their assessment of a child’s level of development in relevant domains.

What Is Needed for Clinicians to Developmentally Tailor CBT More Effectively? To effectively adapt CBT to children’s developmental levels, clinicians need to 1) recognize the connections between developmental skills and clinical techniques, 2) understand the normative trajectory of the relevant developmental skills, 3) use appropriate assessment tools to determine children’s developmental abilities, and 4) incorporate all of this knowledge into an individualized treatment plan. In the following sections, we elaborate on each of these recommendations; outline some specific clinical skills involved in CBT; and discuss how cognitive, social, and emotional development can impact treatment. 1. Recognize the connections between developmental skills and clinical techniques. Cognitive therapy is based on the assumption that irrational or maladaptive cognitive schemata (attitudes and beliefs), cognitive products (thoughts and images), and operations (processing) influence problematic behavior. The aim of therapy is to help the child to identify possible cognitive deficits and distortions, to reality-test them, and then, either to teach new thinking skills or to challenge irrational thoughts and beliefs and replace them with more rational thinking. (Grave and Blissett 2004, pp. 401–402)


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A variety of cognitive, social, and emotional developmental skills (e.g., metacognition, perspective taking, and emotion understanding, respectively) may be necessary to learn and apply the clinical tasks described by Grave and Blissett (2004). Identifying exactly which developmental skills are linked to which specific clinical tasks, however, is neither simple nor intuitive, in part because of the heterogeneity of the skills that incorporate CBT (Grave and Blissett 2004). Durlak and colleagues (1991) reviewed CBT programs for children and identified 8 core components: task-oriented problem-solving, social problem-solving, self-instructions, roleplaying, rewards, social cognition training, social skills training, and other CBT elements. Within the 64 studies reviewed, there were 42 different permutations of these 8 skills. As such, the term cognitive-behavior therapy is really an umbrella for a wide and divergent amalgamation of therapeutic techniques (Durlak et al. 1991; Stallard 2002). We cataloged the specific skills described in 14 different CBT manuals for the treatment of child and adolescent depression. Table 2–1 presents the 19 main clinical skills identified and the number of treatment programs that explicitly include each skill. In addition to the many different combinations of core skills labeled “cognitive-behavior therapy,” each of these skills was taught in a variety of ways. For example, “understanding the cognitive model” was broken down into different components in each manual, with children being asked to make different connections depending on the treatment program (see Table 2–2). 2. Understand the normative trajectory of the relevant developmental skills. At the foundation of effectively tailoring treatment to developmental level is an understanding of the normative trajectory of the relevant skills. Familiarity with the typical course of skill acquisition can help clinicians determine if a particular child is more advanced, on track, or delayed. Knowledge of developmental norms is needed to improve the quality of interventions with children, guide expectations, and decrease faulty assumptions (Spritz and Sandberg 2010; Weisz and Weersing 1999). For example, all-or-none thinking, overgeneralizing, and negative filtering are types of cognitive distortions described in the adult CBT literature (Beck et al. 1979; Grave and Blissett 2004), but these distortions actually may be developmentally normative ways of thinking in young adolescents (Spritz and Sandberg 2010). In addition to knowledge of cognitive development, knowledge of social and emotional development also is needed to provide comprehensive and effective care (Eyberg et al. 1998; Masten and Braswell 1991).

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TABLE 2–1.

Frequency of core clinical skills in 14 cognitivebehavior therapy manuals for youth depression

Core clinical skill

Number of manuals

Understanding the cognitive model

14

Using skills outside of session/practice/homework

14

Cognitive restructuring

13

Goal setting

12

Behavior activation

12

Developing/maintaining/seeking social support

12

Motivation to engage in therapy

12

Identity formation

11

Types of thoughts

11

Other coping skills/emotion regulation

11

Meeting new people/conversation skills

10

Relapse prevention planning

10

Social problem-solving/conflict resolution

9

Relaxation training

8

Controllable vs. uncontrollable stressors

8

Problem solving

7

Assertive behavior training

6

Understanding depression

6

Mindfulness

5

3. Use appropriate assessment tools to evaluate a child’s developmental abilities. For treatments to be tailored to a child’s particular developmental level, a thorough developmental assessment is required. Because chronological age is not necessarily an accurate indicator of a particular child’s developmental level, a comprehensive evaluation of a child’s actual abilities across relevant domains is needed to match clinical strategies to the child’s specific skills (Durlak et al. 1991; Holmbeck and Kendall 1991). Although the importance of conducting this type of assessment has been emphasized (Holmbeck et al. 2006; Sauter et al. 2009; Shirk 1999), it is rarely done in practice. Clinical assessments generally focus on evaluating children’s symptoms and diagnoses rather than on creating a developmental profile to guide treatment plans.


TABLE 2–2.

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Frequency of components for the core clinical skill “understanding the cognitive model” in 14 treatment manuals

Subskills

Number of manuals

Rate mood

10

Identify thoughts

13

Identify situations

7

Identify feelings

7

Identify behaviors

3

Connect situations and thoughts

7

Connect situations and feelings

8

Connect thoughts and feelings

11

Connect thoughts and behaviors

3

Connect feelings and behaviors

10

Connect situations, thoughts, feelings

8

Connect thoughts, feelings, behavior

8

Connect situations, thoughts, feelings, behavior

4

Assessment measures can over- or underestimate children’s abilities depending on the context and format of the evaluation (e.g., language used, support provided [Grave and Blissett 2004]). Therefore, in selecting an assessment battery for developmentally tailoring treatment, clinicians should choose ecologically valid measures that capture abilities in both the therapeutic setting and the more challenging realworld environment. The few studies that have attempted to assess development separate from age have used measures of intellectual ability or achievement. Intelligence tests, however, do not examine all CBTrelevant cognitive subdomains or assess social or emotional competencies (Sauter et al. 2009). 4. Incorporate knowledge about development into treatment planning. How can knowledge of clinical skills, typical development, and assessment data be incorporated into treatment planning? At least two methods are possible: a) modify the treatment to fit the developmental level of either the individual child or a certain developmental profile (Weisz and Weersing 1999), and b) enhance the child’s developmental competencies to prepare him or her for more advanced therapeutic

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techniques (Holmbeck and Kendall 1991). Examples of treatment modifications include altering activities to be more or less complex, concrete, behavioral, cognitive, or visual (Sauter et al. 2009; Stallard 2002). Additionally, different versions of treatment protocols can be designed for children at various levels of developmental maturation (Holmbeck et al. 2006). Such modifications should be made on the basis of a systematic evaluation of developmental level rather than age. The other frequently mentioned method for developmentally tailoring interventions involves clinicians beginning treatment by priming developmental skills, with the expectation that providing scaffolding and tapping into the zone of proximal development (Vygotsky 1978) will facilitate the later mastery of CBT techniques (Holmbeck et al. 2006; Sauter et al. 2009; Shirk 1999). Some empirical evidence indicates that development can be primed in this way (Keating 1990). For example, Doherr and colleagues (2005) found that children taught with a curriculum designed to improve thinking skills performed better on CBT tasks than did children in a more typical curriculum. Thus, a child’s developmental level in multiple domains should inform all aspects of treatment planning, from case conceptualization and goal setting to intervention selection and outcome assessment. In summary, multiple steps are needed to appropriately tailor therapeutic techniques to children’s developmental level. Figure 2–1 outlines the empirical work that needs to be done to map out the specific links between the clinical techniques being used with children and the developmental demands of these techniques. First, we need to catalog the clinical procedures described in the various CBT manuals for youth and then specify the developmental abilities necessary for a child to learn and use each of these therapeutic techniques. Once the developmental requirements are identified, we next need to construct a reliable and valid assessment battery of these abilities from which a developmental profile can be created. Finally, with these empirically derived guidelines, clinicians will be ready to administer an assessment battery that measures a child’s developmental abilities, create an individualized profile across multiple domains, and formulate a developmentally sensitive treatment plan.

Developmental Domains Cognitive Development The complex cognitive strategies taught in CBT place demands on children’s information processing and presuppose a certain level of cognitive function-


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Empirical research needed Catalog the therapeutic techniques described in different CBT manuals for youth

Identify the specific developmental abilities necessary for children to learn and use each of these therapeutic techniques

Construct an assessment battery of these abilities from which a developmental profile can be created

Practical clinical implications Use this assessment battery to evaluate a child’s developmental abilities

Create an individualized profile across multiple domains

Using this information, formulate a treatment plan that matches therapeutic techniques to the child’s level of development in each domain

FIGURE 2–1. Empirical steps needed to developmentally tailor cognitive-behavior therapy (CBT) for children and adolescents and practical implications for clinicians. ing in order to understand and apply the treatment techniques (Holmbeck et al. 2000; Shirk 1999). As such, an assessment of a child’s level of cognitive development can guide the selection of CBT techniques (Sauter et al. 2009). Although the specific cognitive capacities necessary for participating in CBT have not yet been explicitly determined empirically, metacognition, selfreflection, and reasoning are especially salient (Grave and Blissett 2004; Holmbeck et al. 2000; Sauter et al. 2009). Metacognition involves noticing one’s thoughts; self-reflection is the ability to reflect on one’s own beliefs, feelings, and actions; and reasoning is the ability to connect these reflections.

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Connection With CBT Techniques A central component of CBT involves reflecting on and causally linking thoughts, feelings, and behaviors, for which the developmental skills of reasoning, metacognition, and self-reflection are especially relevant (Grave and Blissett 2004; Harrington et al. 1998). Disputing cognitive distortions by generating alternative explanations requires the ability to reason hypothetically. Exploring maladaptive cognitions by examining evidence requires the ability to think logically and systematically. Other CBT techniques are multistep processes. Even when children have some of the requisite developmental skills to engage in certain activities, they may have difficulty enacting them simultaneously in a fluid process (Holmbeck et al. 2006; Weisz and Weersing 1999). That is, children may be able to engage in some of the individual components of a clinical skill (e.g., identifying situations, thoughts, feelings, and behaviors) but may struggle in putting all of the pieces together (e.g., connecting situations, thoughts, feelings, and behaviors; understanding that different thoughts can relate to different feelings in the same situation); such integration requires an even more sophisticated level of cognitive development (e.g., causal, hypothetical, systematic, logical, and abstract reasoning). An important part of most CBT treatments is the actual implementation of the new skills outside the therapeutic setting. To recognize appropriate times for enacting these skills, an individual needs abstract reasoning to generalize from a specific example to other real-life situations. Therapists sometimes ask clients to role-play scenarios and to imagine possible relevant future situations as a way to more concretely practice and prepare for using the techniques outside of the session. Such exercises, however, are largely hypothetical and involve future thinking. Simply concretizing exercises for children may not be sufficient. Having an understanding of normative cognitive development likely will facilitate a clinician’s ability to conceptualize a particular child’s abilities in a given context.

Normative Development of Cognitive Skills In clinical samples, where disrupted or advanced developmental pathways can be both a cause and consequence of psychopathology, age alone may not be an accurate marker of developmental level. Given the bidirectional relation between development and psychopathology, an understanding of how skills emerge and progress could be more useful to clinicians than a detailed outline of ages at which skills typically occur. Age frequently is used as a proxy for development because of its simplicity, but without having a more precise understanding of cognitive development, using age alone could slow or even undermine the efficacy of the intervention.


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Piaget (1964/2006) provided the early seminal work on children’s cognitive development, proposing that children progress through sensorimotor, preoperational, concrete operational, and formal operational stages, with thinking becoming more abstract, logical, complex, and systematic as development progresses. More recently, developmental psychologists have shifted away from Piaget’s stagelike model to conceptualizing development as a more continuous process. Indeed, some children in earlier phases of Piaget’s developmental model can engage in more complex thinking than he originally proposed (Grave and Blissett 2004). Nevertheless, Piaget provided an important foundation for understanding cognitive development. Various forms of reasoning, including abstract, causal, hypothetical, and logical, develop over time. Increased neural development leads to improvements in abstract reasoning (Sauter et al. 2009) and a decrease in concrete thinking (Vernon 2009). Causal reasoning changes throughout childhood and into adulthood—progressing from external, visible, and concrete connections to more internal and psychologically based associations (Grave and Blissett 2004)—underlie the ability to link thoughts, feelings, and situations. As development progresses, children become increasingly able to anticipate consequences (Keating 1990). Although less cognitively developed children can generate solutions, more advanced cognitive abilities are needed to evaluate these solutions using means-end thinking (Holmbeck and Kendall 1991). Maturation of hypothetical reasoning first results in an ability to imagine the outcome of future hypothetical ideas (e.g., “What might happen if you do this next time?”), followed by improved understanding of past hypothetical thinking (e.g., “What would have happened if you had done this?”) (Robinson and Beck 2000). These tasks are especially difficult for less cognitively developed children when the hypothetical outcome is inconsistent with their current beliefs. Similarly, the ability to logically test hypotheses by thinking about conflicting evidence simultaneously and differentiating theory from fact develops over time (Harrington et al. 1998; Holmbeck et al. 2006). With development, children become increasingly able to examine multiple aspects of a situation and engage in less biased reflection (Vernon 2009). A marker of a particularly sophisticated level of reasoning is the ability to think analogically (Grave and Blissett 2004)—that is, to see subtle relations between two things that are not based on overt similarities. Clinicians sometimes use analogies to help children understand new information by relating it to their existing knowledge. However, if a child lacks the reasoning ability to understand and apply analogies, then the child may end up even more confused.

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Another cognitive skill important for engaging in CBT is metacognition, which is the ability to think about thinking. Children first learn to monitor their own thoughts and to recognize that they have knowledge— that is, they know what they know, even if they are not yet able to reflect on the meaning of this knowledge. With development, children gain the capacity to report their thoughts to others (Grave and Blissett 2004) and to observe the consistency and accuracy of their thinking (Keating 1990). Specifically, children become increasingly able to identify thoughts and to distinguish thoughts from behaviors before they later develop the more nuanced capability of differentiating thinking from seeing and knowing (Doherr et al. 2005; Sauter et al. 2009). As children become more psychologically minded, they engage in more spontaneous reflections on their thinking (Grave and Blissett 2004; Sauter et al. 2009) and become aware of regulating their thoughts (Doherr et al. 2005). Finally, self-reflection is the individual’s ability to apply these reasoning and metacognitive skills to his or her own beliefs and actions. For example, the ability to think about multiple aspects of a situation and to examine contradictory evidence allows more cognitively developed children to understand there can be variation in their own strengths and weaknesses instead of viewing themselves as either “all good” or “all bad” (Grave and Blissett 2004). Over time, children develop an “inner monologue” that involves the ability to reflect on their own inner life (Sauter et al. 2009; Shirk 1999), leading to a developing sense of self that gradually solidifies and becomes less modifiable (Hoffman 2008). Unfortunately, with emergent cognitive maturity comes increased vulnerability to certain forms of psychopathology. For example, as children become better able to engage in self-evaluation, they also are more apt to be self-critical (Masten and Braswell 1991). As such, more developed children are increasingly able to identify their deficiencies and to believe them to be stable and unchangeable traits. Thus, clinicians need to be aware of the ways in which cognitive development may play a role in both decreasing and exacerbating symptoms.

Assessment Because cognitive skills are changing over time, it is important to assess children’s developmental level at any particular point in time. Some informal assessments have been used to gather information about metacognition, systematic thinking, recognizing consequences, and generating alternatives (Holmbeck et al. 2006). Example questions include “What went through your mind when...” and “What is going through your mind now?” Measures of intellectual ability also have been used to assess cognitive development; for


45

example, the Wechsler Intelligence Scale for Children, 4th Edition (WISCIV), similarities subtest measures abstract reasoning skills (Sauter et al. 2009). Subscales of intelligence measures might not be sufficiently comprehensive, however, to serve as indicators of how children think (Spritz and Sandberg 2010). Thus, although useful, more general intelligence measures may not provide a complete picture of a child’s level of cognitive development. A more formal assessment battery for evaluating relevant cognitive developmental skills would allow clinicians to gather more specific information needed to tailor treatment appropriately. A list of several existing measures of cognitive development is provided in Appendix 2–A. Although this is not a comprehensive catalog of all possible measures, it provides a resource of commonly used tools for assessing several important aspects of children’s cognitive development. Not every measure should be used for every child all of the time. Rather, measures can be selected on the basis of which will provide incremental knowledge to guide treatment planning for a particular child.

Practical Recommendations for Treatment Planning Although the need to assess developmental skills has long been suggested for treatment planning, such individualization is still in its infancy. The recommendations in Appendix 2–B are examples of the ways in which clinicians can integrate developmental and clinical knowledge to improve treatment planning and clinical outcomes.

Social Development Children’s level of social development also should be evaluated and used in treatment planning (Eyberg et al. 1998; Masten and Braswell 1991). Many forms of psychopathology both affect and are affected by interpersonal relationships. Consideration of the social context in which children’s psychiatric problems occur and how well children negotiate their interpersonal challenges is central to their treatment.

Connection With CBT Techniques Social skills have been defined as “learned behaviors which are socially acceptable and which permit an individual to initiate and maintain positive relationships with peers and adults” (Royer et al. 1999, p. 7). A considerable number of treatment manuals have been devoted to promoting children’s abilities to interact successfully with others (see Table 2–1). CBT

46


manuals emphasize such social development skills as meeting new people, conversation skills, social problem-solving, conflict resolution, assertive behavior, and seeking social support. For example, children with emotional and behavioral difficulties may have problems interacting with same-age peers and correctly appraising social situations (Quinn et al. 1999). Moreover, some children form friendships with similar others (e.g., those with the same type of symptoms), which could exacerbate their tendencies toward rumination or deviant behaviors (Crosnoe and Needham 2004). CBT involves various social-cognitive abilities, such as perspective taking, empathy, and prosocial behavior. In particular, children need social perspective-taking skills to anticipate the effects of their behavior on others (e.g., Grave and Blissett 2004; Holmbeck et al. 2006; Weisz and Hawley 2002). When children are asked to imagine hypothetical situations and the ways they and others might act, their perspective-taking ability likely will affect their responses (Weisz and Weersing 1999). Role-playing, a commonly used CBT strategy, also calls on children’s ability to see through another’s lens. Thus, perspective taking is a critical social developmental skill that should be assessed and considered when designing a treatment plan for a particular child.

Normative Development of Social Competence Bolstering children’s social competence is an important aim of CBT. Normatively, children learn and master social skills through navigating relationships over the course of development. The emergence and expression of social skills stems from multiple factors and is interrelated with other areas of development, including cognitive, emotional, and biological domains (Beauchamp and Anderson 2010). Perspective-taking abilities are part of normal social development. Selman (1980) defined perspective taking as understanding how “human points of view are related and coordinated with one another, that is, the core human ability to understand the thoughts, needs, and beliefs of individuals other than oneself ” (p. 22). This capability to stand in another’s shoes is foundational for successful interactions. Perspective taking presumably changes linearly from childhood to adulthood (Elfers et al. 2008). Less socially advanced children are limited in their ability to see another’s viewpoint beyond their own or to recognize that others’ perspectives even exist (Fireman and Kose 2010). As a result, children communicate in a seemingly “egocentric” way, such that they often omit vital information about what their listener needs to know. Over time, children learn that perspectives different from their own exist. Children also begin to


47

recognize that people have their own goals, intentions, and expectations, although they may not yet be able to conceive of what these might be. Perspective-taking ability is multifaceted and various components of this skill may emerge at different times. For example, children can comprehend that others have different views than their own, but they may think that the others’ perspectives are incorrect and that only their own view reflects reality. Thus, children’s “normal” processing of social information may appear to be distorted compared with that of adults (Grave and Blissett 2004). As children mature socially, they become better at reflecting on their own actions through the perspective of another person. This developing ability enables youth to take a more impartial position over time. The cognitive advances that develop in tandem with social development facilitate children’s understanding that perspectives are created by the mind and are not exact copies of reality but are instead interpretations and representations of the world. Such awareness leads to an understanding of the causes underlying multiple perspectives about the same situation and that external as well as internal factors contribute to personal perspectives and associated behaviors (Fireman and Kose 2010; Keating 1990). Another important aspect of the emergence of perspective taking is the increased motivation to take another’s perspective, which often is linked to a desire to engage in prosocial behavior (Eisenberg et al. 2009). Although motivation to engage in perspective taking typically is a marker of healthy social development, some youth try to anticipate what people are thinking and often assume that they are the focus of others’ thoughts; this belief is often referred to as the imaginary audience (Keating 1990). Such thinking is part of normative development but can be problematic when it takes the form of excessive self-consciousness or rumination. Achievement of social competence in children is cultivated through their encounters with different types of challenging social situations (Spence 2003). Adaptive social skills produce positive peer relationships and include expressing positive affect, attending to play partners, initiating nurturing behaviors (e.g., helping, sharing), being agreeable, and mastering reciprocal play (e.g., turn taking) (Bierman et al. 2010; La Greca and Prinstein 1999). Thus, good peer relationships are formed once children learn how to initiate and maintain positive social interactions. As children become more socially advanced, they develop the self-control that makes possible engaging in rule-based play and joining in prosocial behavior, thereby enhancing their peer acceptance and avoiding rejection (La Greca and Prinstein 1999). Social skills acquired early continue to be important (e.g., sharing, helping, cooperating). In addition, prosocial characteristics such as being kind and considerate contribute to being accepted by others.

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With regard to resolving interpersonal conflict, less socially developed children tend to use more physical aggression; over time, children use more indirect, relational aggression. Some children may be singled out for victimization, particularly those who are socially withdrawn or emotionally labile. In contrast, children who are socially adept demonstrate adaptive strategies for solving interpersonal conflicts and effectively inhibit and redirect impulsive and aggressive behaviors (Bierman et al. 2010). Gaining acceptance from others, particularly peers, is one of the salient social challenges that children face. Youth who are not accepted by their peers tend to have problems resolving conflict and less supportive friendships. Children with at least one reciprocal friendship fare much better emotionally than do those without a friend. The importance of friendships and the influence of peers increase with development (Crosnoe and Needham 2004). Intimacy characterizes the friendships of socially advanced youth, particularly for females whose friendships are marked by good communication, self-disclosure, and trust (La Greca and Harrison 2005). Intimacy emerges out of social perspective-taking skills, mature conversational skills, and developmentally advanced capacities for loyalty and empathy. Thus, children’s burgeoning ability to take others’ perspectives, generate multiple solutions to social problems, and think before acting aids in the formation of close dyadic friendships and the building of successful social relationships (Parker and Asher 1993). As children become more social and cognitively advanced, however, their abstract and reflective thinking also allows for new levels of social distress. For example, youth often evaluate themselves in comparison to their peers and judge their self-worth in terms of the social status of their friends. Finding their social niche, navigating social groups and cliques, and responding to peer influences are among the many social challenges youth must negotiate. Children who cope effectively with peer pressure tend to be more advanced socially and cognitively and are able to act assertively in challenging social situations (Bierman et al. 2010).

Assessment Assessing children’s social development, particularly regarding their peer relationships and friendships, is important for constructing an age-appropriate treatment plan (La Greca and Prinstein 1999). Children’s social competencies and skills have been assessed with role-play vignettes or questionnaires (Matson and Wilkins 2009). Multimethod, multi-informant approaches are likely to provide the most comprehensive assessment of children’s social aptitudes and deficiencies (Spence 2003), although this can be time-consuming and expensive.


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La Greca and Prinstein (1999) recommended four crucial areas to assess in children’s social functioning: 1. How is the child viewed by peers? 2. What are the child’s friends and friendships like? 3. How does the child feel about his or her peer interactions? Have any aversive occurrences happened with peers? 4. What are the child’s interpersonal skills? Addressing these four issues will aid clinicians in tailoring CBT to a particular child’s social level. Although several behavior rating scales (e.g., Child Behavior Checklist; Achenbach 1991) include some items about social competence, most do not provide a focused examination of social skills per se that would inform treatment planning. Some measures assess social skills that are particularly pertinent to CBT with youth (e.g., perspective taking, conversational skills). Appendix 2–A lists several measures that can be used to assess components of children’s social development. The distinction between acquisition versus performance of social skills and interpersonal problem-solving is germane to the assessment of social development (Gresham 1997; Spence 2003). For example, although a child may be capable of a certain social skill (e.g., initiating a conversation), actually implementing this knowledge in a real-world context may not necessarily follow. Deficits in performance may be due to factors such as intense affect, intrusive or anxious thoughts, and high levels of arousal (Gresham 1997). Thus, although questionnaires are the most common method for assessing knowledge about social skills, they may not capture this acquisition-performance disparity. Observation of a child’s skills deficits and strengths should be an adjunctive assessment of the child’s patterns of interactions with others.

Practical Recommendations for Treatment Planning Appendix 2–B provides examples of how knowledge about children’s social development can inform the choice of strategies to be used in therapy. Some of these recommendations are aimed at enhancing children’s social competence and specific social skills, whereas others are aimed at decreasing problematic interpersonal behaviors. Whether the clinician is applying a strengthbased or deficit-based approach, improving social interactions is a central focus of CBT with clinically referred youth (La Greca and Prinstein 1999). Tailoring the treatment to the developmental level of a particular child will increase the likelihood that the child will be able to grasp what is being taught, apply it to his or her own life, and show an improvement in symptoms.

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Emotional Development The set of emotional skills that allows individuals to effectively interact in their world has been conceptualized in several different ways. Salovey and Mayer (1990) defined emotional intelligence as “the ability to monitor one’s own and others’ feelings and emotions, to discriminate among them and to use this information to guide one’s thinking and action” (p. 189). These abilities include perceiving and identifying emotions, using emotions to facilitate thoughts, understanding emotions, and managing emotions. Bar-On (1997) offered a different definition of emotional intelligence, describing it as “an array of noncognitive capabilities, competencies, and skills that influence one’s ability to succeed in coping with environmental demands and pressures” (p. 14). He outlined five clusters of emotional intelligence skills: intrapersonal, interpersonal, stress management, adaptability, and general mood. Saarni (1999) described the development of emotional competence as consisting of a set of eight skills: an individual’s awareness of his or her own emotional state, discerning others’ emotions, using an emotion vocabulary, empathy and sympathy, recognizing the distinction between inner emotional state and outer emotional expression, adaptive coping, awareness of relationships, and emotional self-efficacy. Despite the different labels, there is considerable overlap in the skills considered to constitute emotional intelligence and competence and a consensus that these skills develop over time (Mayer et al. 2000; Saarni 1999).

Connection With CBT Techniques Emotional skills particularly relevant to CBT include the following: 1. Perceiving and identifying emotions, being aware of one’s own and others’ emotions, and having an emotion vocabulary. 2. Understanding emotions and the relations among emotions, using past emotions to predict future experiences, and recognizing the difference between inner emotional states and outer emotional expression. 3. Emotion management, including the use of self-regulation to decrease intensity or duration of emotions both for the self and for others. Understanding the connections within the cognitive model, participating in cognitive restructuring, and engaging in behavior activation require selffocused emotional competencies. For example, to understand how different thoughts lead to different feelings, the individual must be able to recognize, label, and differentiate among different emotions. In addition, awareness of intensity and duration of emotions is necessary to monitor emotional expe-


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riences outside of therapy; emotion recognition and an emotion vocabulary facilitate discussion of these emotional experiences in therapy. CBT also requires other-focused emotional intelligence. Learning to meet people and forming and maintaining social relationships require an understanding of others’ emotional experiences. To engage in social problem-solving or conflict resolution, individuals must be able to combine skills related to understanding their own and others’ emotions. The ability of children to manage their emotional experiences develops over time. The more developed their emotion management system is, the more readily children will be able to use the emotion regulation strategies taught in CBT (Suveg et al. 2009).

Normative Development of Emotional Skills The complexity of children’s emotions increases over time (Saarni 1999). Less emotionally mature children describe their emotional experiences in terms of physical complaints or behaviors, or they report feeling only one emotion at a time (Bajgar et al. 2005). Emotional awareness progresses from recognition of general feeling states (e.g., “I feel good”), to more specific emotions (e.g., “I feel happy”), to more complex emotions (e.g., “I feel embarrassed”; “I feel guilty”), to multiple simultaneous or conflicting emotions (e.g., “I feel love and anger”) (Ciarrochi et al. 2008). As children become able to provide more intricate explanations of their own emotional states, they also begin to recognize how their emotions impact other areas of their life (Bajgar et al. 2005). Additionally, children develop an understanding that emotions of different valences can affect one another (e.g., negative feelings get better with the experience of positive emotions [Donaldson and Westerman 1986]). Once children are cognizant of their own more complex emotional experiences, they become more aware of the emotions of others (Ciarrochi et al. 2008). Thus, children first incorporate a broader range of information into their understanding and description of their own emotions, and only later are they able to think about others’ reactions in the same way (Karniol and Koren 1987). As children begin to understand the connections between situations and emotions, as well as the multiplicity of emotional experiences, they become better able to engage in emotional reasoning (Grave and Blissett 2004). With increasing development, children can reflect on their past feelings to inform their understanding of their current experiences (Saarni 1999). Such skills are central to being able to engage in CBT. Children’s ability to regulate emotions develops throughout childhood and into adulthood. Emotion regulation strategies increase in complexity as children become better able to integrate information about others’ emo-

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tional experiences with management of their own feelings. Children also become increasingly able to talk about their emotions, a skill that typically develops faster in girls than in boys (Wintre and Vallance 1994). With increasing emotional competence, children become better at recognizing the difference between internal emotional experiences and external emotional expression. In turn, they learn to manage their emotional expressions in order to impact the emotional experience of others (e.g., to hide emotions to avoid hurting someone’s feelings) (Ciarrochi et al. 2001; Saarni 1999).

Assessment The number of assessment tools available to measure emotional intelligence in children is limited (Luebbers et al. 2007; Stough et al. 2009). Many of these measures either have been constructed recently or are still being developed. A review of measures for assessing emotional competence in children concluded that most existing measures focus on social rather than emotional competence and that few measures focus solely on emotional competence (Stewart-Brown and Edmunds 2003). Extant measures of emotional competence include parent or teacher observations, self-report questionnaires, and performance measures. These different measurement methods often are not correlated, however, and thus they likely are assessing different aspects of emotional intelligence, such as perceived versus actual awareness (Ciarrochi et al. 2001). Some performance measures assess a variety of emotional competencies (e.g., Mayer-Salovey-Caruso Emotional Intelligence Test; Mayer et al. 2002), whereas others assess one specific skill (e.g., ability to recognize emotional facial expressions; Nowicki and Duke 1994). Appendix 2–A presents some existing measures of emotional intelligence or competence for children and adolescents.

Practical Recommendations for Treatment Planning Examples of how knowledge about children’s emotional development can inform clinical practice are presented in Appendix 2–B. These recommendations emphasize helping children learn to identify their emotions, build an emotion vocabulary, manage their emotions, and recognize how their behaviors affect the emotions of others. Assessing a child’s strengths and deficits in emotional competence is a necessary precursor to formulating a plan for effectively implementing CBT with that child.


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Other Important Developmental Considerations 1. Language and vocabulary. Although modifying the language used in adult treatment manuals is insufficient to achieve developmental tailoring, such changes are nonetheless necessary. CBT with children should use clear, simple, and child-specific vocabulary (Sauter et al. 2009). Clinicians also should be aware of any discrepancies between receptive and expressive language that could impact children’s abilities to understand or respond to therapeutic demands. 2. Executive function. Developments in executive functions (e.g., attention, flexibility, planning) are occurring simultaneously with developments in cognitive, social, and emotional development to allow children’s effective engagement in treatment (Grave and Blissett 2004). Therefore, the link between children’s executive functions and the demands of CBT also needs to be explored. 3. Treatment modality. The context in which the therapy is implemented (e.g., family, individual, group) may be more or less appropriate and/ or effective depending on the child’s developmental level, particularly within the social domain. 4. Sex/race/socioeconomic status/culture. Developmental norms may not always incorporate sex, race, socioeconomic status, and other aspects of culture that could impact development (Ollendick et al. 2001). 5. Parameters of treatment. Developmental level also can affect the length of sessions, frequency of sessions (e.g., twice a week, weekly, biweekly, monthly), number of sessions, and overall duration of treatment (e.g., weeks, months). The child’s ability to sustain attention, remember what was discussed within sessions, and use the new skills outside the therapy session will affect decisions about these parameters of the treatment process.

Conclusions and Future Directions Tailoring treatment to the developmental level of the client is essential to increasing the efficacy of CBT interventions with children and adolescents. Existing strategies for modifying treatments include the following: 1. Changing parents’ role in therapy (e.g., more active “coaching” from parents of younger children). 2. Using treatment manuals designed for specific age groups.

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3. Altering specific therapeutic activities to be more or less concrete, complex, cognitive, behavioral, or visual. Typically these modifications have been made on the basis of children’s age, rather than according to a systematic evaluation of children’s developmental levels in multiple domains. Clinicians using CBT interventions with children and adolescents will benefit from recognizing the connections between each CBT technique and distinct developmental abilities, understanding the normative development of these abilities, and learning about methods for assessing these developmental abilities. We identified examples of cognitive, social, and emotional developmental abilities especially relevant to engaging in CBT; provided information about typical developmental trajectories of these abilities; and suggested several tools for assessing children’s developmental level. Finally, we provided suggestions for using this developmental assessment information to individualize treatment planning. Further research is needed to clarify the relations between specific clinical techniques and developmental abilities and to identify the most effective methods for tailoring treatment to a child’s specific developmental level in each domain (i.e., cognitive, social, emotional). When implementing CBT techniques with children and adolescents, clinicians should use a developmental framework to determine the intervention strategies likely to be most effective. Use of appropriate tools for assessing a child’s developmental level across multiple domains can allow the clinician to gather information about development when the client first presents for treatment, thus informing treatment planning at intake. Developmentally tailoring treatment in this way will impact how CBT interventions are delivered to children and adolescents and thereby reduce the time needed to ameliorate symptoms and improve functioning.

Key Clinical Points • Therapy likely will be more effective when matched to the child’s developmental abilities. • Age and developmental level are not synonymous. • Clinicians should acquire an understanding of normative cognitive, social, and emotional development and how such development impacts children’s ability to learn and implement therapeutic strategies. Clinicians should assess a child’s developmental level as a part of treatment planning.


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• CBT often is used as an umbrella term for a wide range of clinical skills, some of which are more developmentally appropriate than others. • Developmental skills particularly important for engaging in CBT involve multiple domains, including cognitive (e.g., reasoning, metacognition, self-reflection), social (e.g., perspective taking, empathy), and emotional (e.g., emotion perception, identification, understanding, and regulation).

Self-Assessment Questions 2.1. True or False: Adolescents are always better able to engage in cognitive-behavioral strategies than are young children. 2.2. Which of the following is NOT a reason to use a developmentally sensitive framework in treatment planning? A. Different treatment strategies require different developmental skills. B. Developmental level impacts children’s ability to both learn and apply therapeutic skills. C. Development level within a domain is uniform at each chronological age. D. Different areas of development (e.g., cognitive, social, and emotional) are interdependent. 2.3. Little Johnny is asked in therapy to recognize that when he thinks “I will fail this math test no matter what,” he feels discouraged and is less likely to study for the test. Which of the following developmental skills are necessary to understand this connection? A. B. C. D.

Metacognition and perspective taking. Causal reasoning and emotion identification. Self-reflection and social skills. Hypothetical thinking and emotion management.

2.4. True or False: Adapting adult language to be more age-appropriate is the primary way to developmentally tailor CBT for children.

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2.5. Clinicians should assess children’s developmental level A. Before starting treatment. B. Before introducing a new developmentally challenging technique. C. After implementing strategies designed to improve developmental skills. D. All of the above.

Suggested Readings Holmbeck GN, O’Mahar K, Abad M, et al: Cognitive-behavioral therapy with adolescents: guides from developmental psychology, in Child and Adolescent Therapy: Cognitive-Behavioral Procedures, 3rd Edition. Edited by Kendall PC. New York, Guilford, 2006, pp 419–464 Merrell K: Helping Students Overcome Depression and Anxiety: A Practical Guide. New York, Guilford, 2001 Shirk S: Developmental therapy, in Developmental Issues in the Clinical Treatment of Children. Edited by Silverman WK, Ollendick TH. Needham Heights, MA, Allyn & Bacon, 1999, pp 60–73 Vernon A: More of What Works When With Children and Adolescents: A Handbook of Individual Counseling Techniques. Champaign, IL, Research Press, 2009

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Tools for assessing developmental skills in cognitive, social, and emotional domains

Developmental skill

Assessment measure

Citation

Age

Decision making

Decision-making scenarios

Halpern-Felsher and Cauffman 2001

Grades 6–12 and young adults

Abstract, systematic, causal, and logical reasoning

Delis-Kaplan Executive Function System (DKEFS)

Delis et al. 2001

8–89 years

Conditional and logical reasoning

Conditional Syllogism Test

Artman et al. 2006

Grades 7–9

Hypothetical and causal reasoning

Generation of Alternatives Task

Janveau-Brennan and Markovits 1999 Grades 1–6

Conditional reasoning

Conditional Reasoning Task

Janveau-Brennan and Markovits 1999 Grades 1–6

Reasoning and problem solving

Cognitive Abilities Test, Form 6

Lohman and Hagen 2001

5–18 years

Systematic reasoning

Combinations Task (CT)

Goodnow 1962

10–11 years

Critical thinking

Ross Test of Higher Cognitive Processes

Ross and Ross 1976

Grades 4–6

Metacognition

Metacognitions Questionnaire for Children (MCQ-C)

Bacow et al. 2009

7–17 years

Metacognition

Metacognitions Questionnaire for Adolescents (MCQ-A)

Cartwright-Hatton et al. 2004

7–17 years

Metacognition

Think Task

Flavell et al. 2000

5 years to adult

Self-reflection and insight

Self-Reflection and Insight Scale for Youth

Sauter et al. 2010

9–18 years

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APPENDIX 2–A.

Cognitive development Cognitive-Behavior Therapy for Children and Adolescents

Tools for assessing developmental skills in cognitive, social, and emotional domains (continued)

Developmental skill

Assessment measure

Citation

Age

Social perspective-taking

Interpersonal Understanding Interview

Selman 1980

4.5–32 years

Social skills

Social Skills Rating System (SSRS)

Gresham and Elliot 1990

Grades K–6

Social skills

Matson Evaluation of Social Skills with Youngsters

Matson et al. 1983

4–18 years

Assertiveness; social problemsolving skills

Social Problem-Solving Inventory— D’Zurilla et al. 2004 Revised (SPSI-R)

13 years

Friendship quality

Friendship Quality Questionnaire

Parker and Asher 1993

7–12 years

Empathy

Bryant’s Index of Empathy for Children and Adolescents (BEI)

Bryant 1982

Grades 1, 4, and 7

Assertiveness; social skills

Behavioral Assertiveness Test for Children (BAT-C)

Bornstein et al. 1977

8–13 years

Social development

Appendix 2–A: Tools for Assessing Developmental Skills

APPENDIX 2–A.

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Tools for assessing developmental skills in cognitive, social, and emotional domains (continued)

Developmental skill

Assessment measure

Citation

Age

Emotion perception, emotion understanding, emotion management

Adolescent Swinburne University Emotional Intelligence Test (A-SUEIT)

Luebbers et al. 2007

11–18 years


Emotional Quotient Inventory: Youth Version (EQ-i:YV)

Bar-On and Parker 2000

7–18 years

Emotion perception, emotion identification, emotion management

Trait Emotional Intelligence Questionnaire—Child Form (TEIQue-CF)

Mavorveli et al. 2008

8–12 years

Emotion perception, emotion identification, emotion management

Trait Emotional Intelligence Questionnaire—Adolescent Form (TEIQue-AF)

Petrides et al. 2006

13–17 years

Emotion identification

Diagnostic Analysis of Nonverbal Accuracy Scale—Form 2 (DANVA2)

Nowicki and Duke 1994

6–10 years


Mayer-Salovey-Caruso Emotional Intelligence Test: Youth Version

Mayer et al. 2002

12–18 years

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APPENDIX 2–A.

Emotional development Cognitive-Behavior Therapy for Children and Adolescents

Practical recommendations for treatment planning based on cognitive, social, and emotional development

Therapeutic demands

Clinical recommendations

Problem solving a. Generate solutions b. Evaluate solutions

Hypothetical, systematic, logical, and causal reasoning

Children with less developed reasoning ability may need more teaching about how to examine each solution, more practice in evaluating possible solutions, and greater scaffolding from therapists and parents.

Connecting thoughts, feelings, and behaviors; using “if-then” statements (e.g., “If I think ____, then I will feel _____”)

Conditional and hypothetical reasoning

Avoid if-then language with children who do not display hypothetical reasoning abilities. Use in vivo strategies to induce mood and help children draw connections through experiences in the moment. Practice explicit labeling of the cause and effect. When explaining the connections among thoughts, feelings, and behaviors, check children’s understanding of each relation. Make sure that less cognitively developed children understand these associations before progressing.

Differentiating thoughts, feelings, and behaviors; recognizing the connections among them

Abstract and causal reasoning

Children with less developed abstract reasoning will benefit from more concrete and visual methods. In place of role-playing, use cartoons or puppets. Pictures (e.g., the body with thoughts in the head, feelings in the stomach or heart, and behaviors on the hand) or tangible illustrations (e.g., string connecting thoughts, feelings, and behaviors) can help show more complex concepts. These techniques are particularly relevant for children who grasp external constructs more readily than internal, psychological concepts.

Cognitive development

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Developmental skills

Appendix 2–B: Recommendations for Treatment Planning

APPENDIX 2–B.

Practical recommendations for treatment planning based on cognitive, social, and emotional development (continued)

Therapeutic demands


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APPENDIX 2–B.


Cognitive restructuring; examining evidence for and against child’s beliefs

Systematic and logical reasoning

Less cognitively advanced children may struggle with being impartial and may give more weight to evidence that supports their beliefs. Children may have difficulty separating facts from their beliefs, which is necessary for cognitive restructuring. Use other cognitive restructuring strategies with less cognitively advanced children (e.g., alternative explanations, helpful vs. unhelpful thoughts).

Thought monitoring and cognitive restructuring; reflecting on past and future patterns of thinking

Hypothetical reasoning about the past and future

Hypothetical reasoning about the past typically develops after reasoning about the future. For less cognitively mature children, first focus on the here and now rather than the past or future. Ask children “How do you feel when you think _____?” before moving on to the more advanced questions: “How will you feel the next time you think _____?” or “How might you have felt if you had thought _____?”

Using analogies and metaphors to convey information

Abstract and analogical reasoning

Keep it simple. Although analogies and metaphors can convey information in a more memorable and attainable way, children who have not yet developed this type of reasoning may find these strategies confusing.


Cognitive development (continued)


Therapeutic demands



Cognitive development (continued) Logical reasoning

Some “cognitive distortions” may be normative and not linked to psychopathology. Thinking errors that are “typical” but maladaptive may be especially intractable. Clinicians need to train children to think differently (e.g., to see the gray instead of black and white) before children can overcome these thinking errors.

Identifying own thoughts; recognizing negative thinking and cognitive distortions

Metacognition; self-reflection

Children first need to be able to identify their thoughts in general before they can recognize their negative thinking or cognitive distortions. For children who struggle with metacognition, first focus on identifying neutral and positive thoughts. Cartoons with thought bubbles can help explain thinking, although even this may be difficult for less cognitively advanced children. Ask children “What do you like?” and then help them see that their response was a thought (e.g., “Your brain/mind told you that you like _____”). Identify children’s thoughts in session, rather than asking them to remember a situation and identify past thoughts. Identifying thoughts in the present is less cognitively demanding than reflecting on past thoughts.

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Identifying and recognizing child’s cognitive distortions in order to modify them


APPENDIX 2–B.


Therapeutic demands



Introspection; understanding own identity; motivation to change

Self-reflection

Children in the midst of identity formation may become anxious when confronted with information that threatens their tenuous identity, which might then impede therapeutic progress. Motivational interviewing techniques may facilitate children’s decision making about change and likely will be more effective than the therapist directing children to change.

Generalizing new skills learned in therapy to the child’s everyday life

Self-reflection; metacognition

For less cognitively developed children who are unlikely to spontaneously reflect on their own thinking outside of therapy, caregivers will need to provide scaffolding. Parents can act as coaches at home to encourage children to think about their thinking. Clinicians can help children recognize physiological sensations or emotional reactions that may cue them to reflect on their thinking.

Social development For children who do not demonstrate advanced perspective-taking, Advanced perspectivetherapy may be more effective if less focus is placed on disputing taking; realizing the beliefs. Instead, therapists may prefer to rely on social-skills training validity of another’s view, to modify target behaviors. not just that other views exist


Cognitive development (continued)

Disputing negative thoughts; ability to step outside own perspective and take the viewpoint of another

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APPENDIX 2–B.


Therapeutic demands



Social development (continued) Learning social problem-solving

Evaluate child’s social competencies and deficits from multiple sources Ability to reflect on own (e.g., parents, teachers). behaviors in solving social Create a profile of the child’s strengths and weaknesses; design an problems; identifying intervention targeted at the child’s specific interpersonal skills what perpetuates deficits. maladaptive behaviors Build on the child’s existing skills through didactic instruction, modeling, role-playing, performance feedback, reinforcement, and practice in the natural environment.

Assertiveness training; understanding the impact of own statements and actions on others

Understanding cause-and- When teaching assertiveness, first have children achieve mastery of their own assertive behaviors before requiring that they recognize the effect sequences that full rationale for how their behaviors affect others. involve others; predicting Use simple role-play scenarios between the therapist and child to others’ social behaviors demonstrate the various possible consequences of the child’s actions.

Meeting new people; starting, maintaining, and ending conversations

Role-taking skills; ability to For less socially advanced children who have difficulty role-playing, first have them 1) learn the concrete behaviors involved with meeting new shift and assume multiple people (e.g., introducing self, being friendly, active listening); then perspectives 2) watch video clips of people meeting and identify others doing these specific behaviors successfully (or unsuccessfully) without yet having to role-play or take multiple perspectives.


APPENDIX 2–B.

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Therapeutic demands


Developing and maintaining relationships: understanding how moods, words, and behaviors impact relationships; focusing on others instead of the self

Empathy

Some children with self-regulation difficulties may have problems with empathy such that their empathic distress for another exacerbates their own distress, possibly leading to emotional overarousal, anxiety, and self-focus. They also might respond to their heightened distress over another’s hardship by disengaging and reducing their involvement with that person. Clinicians can assist children in recognizing how others’ emotions affect them and can teach children strategies for appropriately managing their empathic distress and maintaining emotional control.

Understanding how relationships affect mood

Self-reflection; perspective Although a child may report a healthy quantity of friends, the quality taking and consequences of their friendships also should be evaluated. Help children recognize the connection between their social relationships and their mood. Teach children to monitor their moods in the context of these relationships.

Seeking social support; strengthening social skills

Self-reflection; social skills For more socially competent youth without clear social difficulties, clinicians can enhance children’s interpersonal strengths and frame social support–seeking as a potentially healthy coping strategy for dealing with stress when done appropriately. For less socially adept children, help them identify when to seek support from others.

Social development (continued)



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APPENDIX 2–B.


Therapeutic demands



Improving and enhancing peer relationships

Social skills (e.g., conversational skills, generating questions)

Less socially advanced children will be less able to converse with adults and peers and unable to engage in more nuanced interpersonal strategies, such as asking questions to generate conversations or constructing positive statements about others. Some skills (e.g., making eye contact, smiling, engaging in friendly greetings) will be important for less socially competent children to master first.

Conflict resolution; interpersonal negotiation

Perspective taking; cooperation; reciprocity; appraising others’ intentions

Pair therapy involves two children matched for their perspective-taking abilities and interpersonal negotiation strategies to promote better coordination between them. Pair counseling involves children being paired to provide opportunities for aggressive, withdrawn, and socially immature children with contrasting relationship styles to practice social skills and learn from each other. Peer therapy involves a peer chosen by the child, parent, or clinician to attend one to two sessions. Identify and modify maladaptive interaction patterns in vivo (e.g., co-rumination).

Social development (continued)


APPENDIX 2–B.

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Therapeutic demands


Monitoring feelings; recognizing multiple, simultaneous feelings

Perception, identification, and awareness of emotional intensity; experiencing multiple simultaneous emotions

Children who do not have the ability to reflect on their own emotional experience in a more complex manner will be unable to engage in mood monitoring outside the therapy session. Help children label and describe emotional experiences in vivo. Teach parents to help children describe emotional experiences as they are happening outside of the therapy session. To increase awareness of simultaneous emotions, teach children to “scan” for multiple feelings when in an emotional situation.

Learning that changes in thoughts or behavior can impact emotions

Perception, identification, and understanding of emotions

Children who are not yet able to describe varying levels of emotional intensity will have difficulty noticing changes in their emotions following changes in their thinking or behaviors. Help children recognize indicators of emotional intensity (e.g., physiological sensations) using visual representations (e.g., emotion thermometer).

Describing emotional experiences

Emotion vocabulary

For children with a limited emotion vocabulary, focus on expanding their understanding of emotional experiences through feeling identification exercises that help them define emotions, talk about emotions, and recognize their experience of emotions in different situations. Games using pictures of people displaying different facial expressions can help children associate emotion labels with outer affective expressions (e.g., facial expression cards or facial zone puzzle).

Emotional development



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APPENDIX 2–B.


Therapeutic demands



Emotional development (continued) Awareness of emotions in others; emotion management

Assist less emotionally developed children to generalize their own emotional knowledge in order to better understand others. Use exercises describing the therapist’s or parents’ emotional experiences; encourage parents to talk about their emotions at home and to draw connections for the child among situations, emotional expressions, and emotional experiences in others. Use interpersonal vignettes (through narratives or use of puppets) to illustrate emotional experiences in others.

Social problem-solving; conflict resolution

Awareness of emotions in self and other; emotion management

Activities designed to improve understanding of others’ emotional experiences will help children engage in conflict resolution. In session, practice and role-plays using relaxation techniques to regulate emotional experience can help prepare children for real-life conflict situations. If a child’s emotional management skills are severely underdeveloped, increasing emotion-regulation skills should be the focus of intervention before expecting children to engage effectively in social problem-solving. Parents can model conflict resolution methods and can coach children to use effective emotion-regulation techniques both in preparation for and during conflicts.

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Developing and maintaining social relationships


APPENDIX 2–B.


3

Culturally Diverse Children and Adolescents Rebecca Ford-Paz, Ph.D. Gayle Y. Iwamasa, Ph.D.

IN an increasingly multicultural society, clinicians must learn to work effectively with people from a variety of backgrounds. Culture is defined by shared attributes of a particular group, including a common heritage, set of beliefs, norms, and values (U.S. Surgeon General 2001). A number of cultural influences may play an important role in shaping an individual’s identity, including membership in more than one cultural minority group. Race, ethnicity, nationality, religion, age, immigration status, gender, ability, sexual orientation, and income level are just some of the factors that may affect the therapeutic relationship, diagnosis, and treatment. In this chapter, we discuss the importance of addressing cultural issues, examine the pros and cons of using cognitive-behavior therapy (CBT) with individuals from a variety of different groups, and identify overarching themes relevant to providing treatment to youth of varying backgrounds. 75

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We also operationalize clinical recommendations for implementing culturally responsive CBT with children and adolescents. Because a sizable body of literature on cultural competence already exists (see Sue and Sue 2003; Sue et al. 2009 for excellent reviews), this chapter will not focus on the particulars of achieving cultural competence. In general, a good CBT clinician will develop a case formulation and treatment plan specific to each client; thus, individual diversity issues should be a central component of the treatment process. Regrettably, inadequate training in multicultural issues is a well-documented shortcoming of mental health training programs (Iwamasa 1996) and may impede the CBT clinician in achieving both clinical and cultural competence. Furthermore, the assumption that clinicians of color or from other minority groups are free from cultural biases and have some inherent diversity expertise is without merit because minority clinicians receive the same training as therapists from majority cultural groups (Iwamasa 1996). Thus, clinicians from any cultural group would benefit from training in cultural diversity. Because other chapters of this book outline disorder-specific strategies for cultural and ethnic minority groups, this chapter will focus on common themes to consider when working with diverse populations across disorders, rather than attempting to discuss specific interventions with every potential cultural group. Suggested readings are provided at the end of this chapter as resources for conducting CBT with particular populations.

Health Disparities and Evidence-Based Treatment Why is it important to consider cultural issues in the delivery of CBT? According to the U.S. Census Bureau (2008), racial and ethnic minorities currently constitute one-third of the U.S. population and are expected to become the majority in 2042. However, for minors, this demographic shift will come much sooner: racial and ethnic minorities will account for more than half of U.S. children by 2023 (U.S. Census Bureau 2008). In contrast to this population shift, in 2006, the American Psychological Association reported that 85% of psychologists were of European American descent. As a result, it is inevitable that these clinicians will need to work with culturally different clients (Pantalone et al. 2010). Thus, the movement toward increasing cultural competence in the delivery of evidence-based treatment (EBT) is a timely one. The Surgeon General’s report on mental health disparities for racial and ethnic minorities (U.S. Surgeon General 2001) brought a number of

Culturally Diverse Children and Adolescents

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issues to light. These groups have less access to mental health services, are less likely to receive mental health services when needed, are likely to receive poorer quality of mental health care when they do receive services, and are underrepresented in mental health research (U.S. Surgeon General 2001). Even when treated, ethnic minorities often terminate prematurely, improve more slowly, and have poorer outcomes (Cooper et al. 2003). Ethnic minorities experience disproportionately more psychosocial stressors than do non-Latino white Americans (Bernal and Scharrón-delRío 2001; U.S. Surgeon General 2001). These include social and environmental inequalities such as exposure to discrimination, violence, poverty, and limited access to education. A disproportionate number of children of color are referred for mental health services (Kazdin et al. 1995; Manoleas 1996), yet they continue to be underrepresented in randomized controlled trials of EBTs, resulting in a relative absence of treatments that may be deemed well established for ethnic minority youth (Huey and Polo 2008). To date, no EBT (including CBT) has been tested in at least two independent, high-quality, betweengroup trials (with random assignment and adequate sample size) that demonstrate that the treatment is superior to placebo or alternative treatment or is equivalent to an already established treatment with ethnic minority youth. Similarly, underrepresentation of gay, lesbian, bisexual, and transgender (GLBT); differently abled; religious minority; ethnic minority; and low-income populations in the research has led some investigators to pose the following question about empirically supported treatment: “Empirically supported treatments ...for whom?” (Pantalone et al. 2010, p. 452). More research is clearly needed to support the efficacy of CBT with ethnocultural minority youth.

Controversy About Adaptation of Evidence-Based Treatment Given documented mental health disparities, there has been a call for the adaptation or modification of EBTs to be more culturally sensitive (Bernal et al. 2009; U.S. Surgeon General 2001). Proponents of such adaptations highlight the differences among cultural groups and suggest that interventions should be tailored to the characteristics of specific groups and consider language, values, customs, child-rearing practices, expectations of child and parent behavior, and distinctive stressors associated with certain cultural groups (Lau 2006; Vera et al. 2003). Some investigators suggest that the failure to make cultural adaptations may lead to miscommunica-

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tion, value conflicts, low therapeutic engagement, and treatment failure (Huey and Polo 2008). Culturally adapted treatments can substantially improve engagement, perceived acceptability of the treatment, recruitment in clinical trials, and retention of ethnic minorities in treatment (Kumpfer et al. 2002). Suggested adaptations range from the creation of entirely new treatments for different ethnocultural groups to modifying treatment components of existing EBTs to address cultural factors (Whaley and Davis 2007). Many experts have expressed reservations about undertaking the cultural adaptation of all EBTs. The inherent assumption that cultural groups are homogeneous entities that remain unchanged over time actually lends more support to stereotypes of cultural groups and neglects the possibility of plural cultural identities (socioeconomic status [SES], gender, religion, sexual orientation, and so forth) (Vera et al. 2003). These experts also argue that rigorous testing of EBTs with ethnic minority youth is limited, that the first priority should be the dissemination and examination of treatment outcomes with cultural minority populations, and that cultural adaptations to EBTs are premature or unwarranted and compromise the fidelity of the interventions and their effectiveness (Lau 2006). Also of concern is the possibility that the active core treatment elements would somehow be diluted or delivered later in the protocol if modifications were made to the original manualized therapy (Kumpfer et al. 2002; Schulte 1996). Finally, opponents to cultural adaptation of EBT stress the impossibility of adapting treatments for every possible cultural group and equipping providers with adequate information about each group, again reinforcing stereotypes and making clinicians believe they do not need to provide services to groups they have not “studied” (Lau 2006; Vera et al. 2003). The limited existing literature on culturally adapted treatment protocols with ethnic minority youth does not indicate superiority of treatment outcomes beyond improvement in treatment engagement, and experts underline the methodological problems of these few studies, the dearth of randomized controlled trials of EBTs with cultural minorities, and the need for more research (Bernal et al. 2009; Huey and Polo 2008). For example, the lack of specific descriptions of cultural adaptations and wide variations in operational definitions of cultural adaptation make it difficult for researchers to replicate particular studies and make comparisons across trials. Some investigators suggest that EBT be maintained in its original form with all groups and that the intervention be culturally tailored to the individual client only when barriers or opportunities arise (Huey and Polo 2008). Lau (2006) suggested a model of selective adaptation of EBTs guided by empirical evidence. Adaptation should focus on the individual


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and the presenting problem that have demonstrated inequitable response to EBT by contextualizing content and enhancing engagement (Lau 2006). Contextualizing content requires that clinicians use novel treatment components to target risk factors and mobilize protective factors specific to the client’s cultural group or to respond to symptom presentation patterns that may require specialized intervention elements (e.g., somatic presentation of psychological distress). Enhancing engagement refers to adaptations that enhance the therapeutic alliance and retention of clients in therapy. Surface-level changes may include culturally relevant examples, translation into the preferred language of the client, and graphic material depicting ethnically similar families to improve perceived acceptability of the treatment. Structural changes may consist of provision of treatment in alternative settings and addressing logistical barriers and basic living needs to improve treatment engagement, but these changes also may require more substantial modifications to the intervention based on a more nuanced understanding of cultural, behavioral, and psychological attributes of a group (Lau 2006; Zayas 2010). A number of other cultural adaptation models have been proposed for specific ethnocultural groups (Bernal et al. 2009). Caught in the ongoing debate about the need for and the particulars of cultural adaptation, clinicians find themselves in a difficult position when trying to serve diverse youth. The benefit of these discussions is that there is more pressure on training programs to produce culturally competent clinicians and on researchers to diversify participants in CBT trials. Cultural adaptations may be a critical step toward integrating cultural competence and evidence-based practice (Whaley and Davis 2007). However, we share the discomfort voiced by some that the word adaptation implies that culture can be an add-on item, usually occurring at the beginning stages of treatment (Falicov 2009). It is our belief that there are some feasible and empirically informed strategies for infusing culture into assessment, case formulation, treatment planning, engagement, and implementation of CBT with diverse youth.

Pros and Cons of CBT for Children of Diverse Backgrounds To provide culturally competent CBT, it is essential to consider the advantages and limitations of using this type of intervention with youth who have been underrepresented in most randomized controlled trials. Despite the increasing popularity of multicultural therapy, there is a persistent dis-

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interest in cultural and ethnic minority groups in the EBT and CBT literature (Hays 2006; Whaley and Davis 2007). In theory, the clinician would expect that the basic tenets of CBT would be universal (Hays 1995; Pantalone et al. 2010)—that is, behavior is learned and can be unlearned; thoughts, feelings, and behaviors are interrelated; and social learning and operant conditioning are processes that fit with the human experience across diverse populations (Hansen et al. 2000; Pantalone et al. 2010). This belief that CBT is universally applicable, culture-free, value-neutral, or color-blind, however, has come about from practice-oriented research that historically has focused on people of middle class, heterosexual orientation, and European American descent (Balsam et al. 2006; Hays 2006; Organista 2006; Pantalone et al. 2010; Vera et al. 2003). The idea that cognitions affect emotions may, indeed, be relevant cross-culturally. However, CBT’s emphasis on cognition, logic, verbal skills, and rational thinking as therapeutic tools is influenced by American and European cultural values (Hays 2006; Hoffman 2006). Eastern cultures may attend more to context and relationships, rely on more experience-based knowledge instead of logic, and show more tolerance for contradiction (Hoffman 2006). In addition, CBT’s emphasis on rational thinking may overlook the importance of spirituality, which may be as central and equally important as rational thinking among many cultural groups (Abudabbeh and Hays 2006; Hays 2006; Iwamasa et al. 2006a; Kelly 2006) and may detract from the credibility of cognitive-behavioral strategies for coping (Falicov 2009). Consistent with collectivism, most ethnic minority groups value interdependence, family, harmony, and community (Nagayama Hall 2001). CBT’s focus on the individual client may clash with these values and result in missed opportunities to capitalize on a potential source of strength for many ethnic minority groups (Kelly 2006). The U.S. mainstream cultural value of individualism (i.e., personal independence, self-control, verbal ability) informs the promotion of assertiveness skills and direct expression of thoughts in CBT (Hays 1995; Pantalone et al. 2010). This value may directly conflict with collectivist cultures that may view direct communication as disrespectful and that prefer nonverbal and indirect behavioral communication (Nagayama Hall 2001). Relatedly, assertiveness training’s basis in egalitarian democratic principles runs counter to more traditional, hierarchical family structures (based on age and gender) in less acculturated ethnic minority families, where the person’s “right” to express himself or herself is not a priority (Abudabbeh and Hays 2006; Organista 2006). The use of “I statements” in assertiveness training would be especially challenging for Native Americans whose preferred language does not have a word for “I” (McDonald and Gonzalez 2006). Thus therapists wanting to implement CBT with diverse populations should carefully con-


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sider adherence to individualistic versus collectivist values for both the child and the parents. A strength of CBT is that it is relatively clear, straightforward, and understandable to clients new to psychotherapeutic interventions. CBT’s educational approach helps demystify psychotherapy and familiarizes clients with the roles of therapist and client (Organista 2006). Its focus on specific behaviors, thoughts, and emotions can be an important advantage for clients whose first language is not English (Vera et al. 2003). CBT’s emphasis on changing negative thoughts to affect feelings and behaviors aligns well with ethnocultural groups, such as Native Americans, whose spiritual beliefs about wellness emphasize harmony or balance among mind, body, and spirit (McDonald and Gonzalez 2006). However, a downside to the educational approach often used in CBT is the reliance on written assignments and bibliotherapy, which may not be appropriate when working with clients whose native language is not English or immigrant populations with little formal education (Iwamasa et al. 2006a). CBT’s short-term, problem-focused, present-oriented nature also may be appealing to cultural and ethnic minority groups for a variety of reasons. For one, CBT’s focus on current behavior, promotion of change (not underlying causes), directive nature, and goal-oriented and limited time frame are consistent with the expectations that many ethnic and religious minorities have for therapy (Abudabbeh and Hays 2006; Fudge 1996; Hansen et al. 2000; Huey and Polo 2008; Iwamasa et al. 2006a; Paradis et al. 2006; Rosselló and Bernal 1996). Likewise, these treatment aspects make CBT more appealing to those living in poverty, who have few resources and who may frequently be in crisis (Organista 2006). On the other hand, focusing exclusively on problem behaviors may neglect nonspecific factors important to the therapeutic alliance with diverse populations (Iwamasa et al. 2006a). Furthermore, a focus on the present and future may prematurely discount the client’s history, such as the experience of racism, and neglect useful information about culture-based life experiences (Hays 1995). Thus, the present and future focus of CBT may be both a disadvantage and an advantage when working with diverse youth, and it is incumbent on the clinician to use good clinical skills in navigating these pros and cons. CBT’s action-oriented approach and focus on empowering the individual appear to be distinct advantages for cultural groups exposed to various types of oppression and stressors related to minority status (Balsam et al. 2006; Hays 2006; Kelly 2006; Vera et al. 2003). CBT recognizes that people have the ability to control their thoughts and emotions and develop skills to deal with life situations. Additionally, behavioral experiments and activation may help ethnocultural minority youth build strengths, expand

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social supports, and acquire skills to meet goals more effectively (Kelly 2006). Despite the potential of CBT to address contextual factors, CBT proponents have not directly addressed the impact of racism and oppression on ethnic minority clients by creating explicit strategies to deal with these negative sociocultural influences. Critics suggest that CBT focuses too much on changing individual-level variables (thoughts and behaviors) in order to effect therapeutic change and adapt to current environmental conditions (Casas 1995; Organista and Muñoz 1996; Vera et al. 2003). This self-focus neglects unfair, discriminatory environmental factors that restrict an individual’s ability to effect change (Hays 2006). As a result, therapists of the majority cultural group often overlook diversity issues and are inconsistent in focusing on problem solving in relation to the client’s environment (Hays 1995). There are a few potential advantages of using CBT with diverse youth: 1. Directive and structured. One such strength is that the directive, structured nature of CBT likely fits with diverse clientele’s expectations of the nature of therapy. Because many ethnic minorities are accustomed to the traditional doctor-patient relationship in which the doctor (i.e., expert) recommends a course of action to improve health, they may have similar expectations of their therapist (Abudabbeh and Hays 2006; Organista 2006). Whereas other theoretical orientations’ intrapsychic focus implicitly locate psychopathology within the individual, CBT does not view behavior as good or bad, but rather as functional or not functional given the context (Balsam et al. 2006). Further, culturally effective CBT emphasizes assessment throughout the course of treatment by examining social-environmental conditions that might contribute to the problems that minorities face and tailoring the intervention to the individual and his or her unique context (Balsam et al. 2006; Hays 2006; Kelly 2006). Likewise, the consideration of clients’ perspectives on their progress demonstrates a respect for clients’ opinions, as well as for their financial and time constraints; such consideration may be especially beneficial to developing and/or maintaining therapeutic rapport (Vera et al. 2003). 2. Collaborative nature. Another strength of CBT is its collaborative nature and determination of mutually defined goals. Such collaboration demonstrates respect for the client’s values, abilities, and life circumstances and promotes a context in which cultural differences are recognized (Hays 1995; Vera et al. 2003). For clinicians working with children, such collaborative goal-setting often includes the parents. A collaborative relationship also implies that both the therapist and the client and parents possess valuable knowledge, which also may reduce


TABLE 3–1.

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Considerations in culturally responsive cognitivebehavior therapy

Intersection of development and culture Individualism vs. collectivism Oppression, -isms, and ethnic identity Acculturation and immigration issues Religion and spirituality Distinctive symptom presentation and somatic symptoms Contextual factors (e.g., socioeconomic status, environmental factors, school issues, access to services, and community involvement and solidarity)

the hierarchical distance between therapist and client (Abudabbeh and Hays 2006; Balsam et al. 2006; Fudge 1996; Kelly 2006). 3. Empirical support. Although there are no well-established treatments for ethnic minority children and adolescents, CBT has been found to be possibly (and probably, for some disorders) efficacious for such youth (Huey and Polo 2008). Compared to other types of therapies, cognitive-behavioral approaches have showed the strongest record of success with minority youth (Huey and Polo 2010). Furthermore, CBT has demonstrated effectiveness for a variety of problems in ethnic minority adults (Sue et al. 2009). Thus the use of CBT with ethnic minority youth has some preliminary support from the literature and appears to be a promising intervention for a variety of internalizing and externalizing disorders.

Overarching Themes Relevant to Culturally Responsive CBT Table 3–1 lists the considerations of culturally responsive CBT, which are discussed in further detail throughout this section.

Intersection of Development and Culture Culture influences many aspects of mental illness, including symptom manifestation, coping styles, family and community support, willingness

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to seek treatment, diagnosis, treatment, and service delivery (Bernal and Sáez-Santiago 2006). Clearly, culture also plays a role in the creation, shaping, and maintenance of cognitions (Dowd 2003). The concept of contextualism suggests that an individual must be understood in the context of his or her family, and the family needs to be understood in the context of the culture in which it is immersed (Bernal and Sáez-Santiago 2006). Compared to adults, children are relatively powerless, dependent on parents and caretakers, school personnel, and other community leaders to make important decisions on their behalf. With respect to treatment engagement, the clinician must engage the adult bringing the child into treatment if the clinician hopes to retain the child in treatment (Crawley et al. 2010). When a clinician works with children, the clinician is working with the family (Hansen et al. 2000). Because Chapter 2 focuses more directly on developmental issues in CBT with children, in this section we highlight how culture may intersect with developmental issues. Culture is strongly associated with child socialization. Harwood and colleagues (1996) demonstrated the centrality of familismo (strong identification with, and attachment to, family; importance of family solidarity, loyalty, and reciprocity) and respeto (respect and deference to authority figures and elders) to the socialization of Puerto Rican children by comparing non-Latino white and Puerto Rican mothers’ responses to open-ended questions on positive and negative child qualities. Puerto Rican mothers consistently emphasized the importance of proper demeanor, such as respectfulness and obedience. In contrast, non-Latino white mothers highlighted self-maximization (that the child be self-confident, be independent, and develop his or her talents (Harwood et al. 1996). In traditional Arab families, the structure tends to be patriarchal, and children are expected to obey parents and not question authority (Abudabbeh and Hays 2006). During middle childhood, ethnic minority youth become increasingly aware of their social milieu, discriminatory practices, inequities in the sociopolitical infrastructure, and (if applicable) limited economic resources for their cultural group (Ho 1992). These factors influence self-concept formation and may contribute to feelings of inferiority, frustrations, and resentment (Rivers and Morrow 1995). The issue of cultural identity is particularly relevant during adolescence, when the process of establishing an identity and a sense of autonomy while maintaining a positive relationship with parents are key experiences (Erikson 1968; Paniagua 1994). The Eurocentric expectation that adolescents separate from family during this stage, however, may conflict with collectivist cultures’ ideas of normative adolescent development. For example, in many Latino and Arab cultures, the period of dependence and cohabitation with parents is extended, and clinicians may risk a serious breach in the therapeutic relationship if they


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insist on adolescent autonomy (Abudabbeh and Hays 2006; Koss-Chioino and Vargas 1992; Rosselló and Bernal 1996). Other important developmental issues in adolescence are the onset of puberty and emergence of sexual behaviors. Youth development may be further complicated by coming to terms with their sexual orientation and sexual identity (Safren et al. 2001). Heterosexism (an ideological system that denigrates and stigmatizes any nonheterosexual behavior, identity, or relationship) is a form of oppression common to many societies (Herek 1990). As a result, GLBT youth face several stressors, including confusion and internalized heterosexism as they come to terms with their sexual identity. Additionally, they often are exposed to overt acts of abuse, harassment, and violence (Safren et al. 2001). Social isolation is a major issue with these youth, as they may lack access to appropriate social venues where they could meet, develop support networks, and date same-age GLBT peers (Safren et al. 2001). GLBT youth who reveal their sexual orientation (i.e., “come out”) are often met with punishment, rejection, criticism, and abuse (Balsam et al. 2006). In stark contrast to ethnic minority youth’s identity development, many GLBT youth navigate the issues of sexual orientation and coming out without GLBT role models or family members who could potentially be sources of support (Safren et al. 2001).

Individualism Versus Collectivism U.S. mainstream culture has been described as individualistic, valuing independence, self-confidence, self-reliance, competition, hard work, material success, and personal happiness (Dalton et al. 2001; Harwood et al. 1996). The collectivist worldview considers the well-being of others to supersede that of the individual and emphasizes respect (especially for elders), cooperation, obedience, self-control, politeness, family loyalty, dignity, and putting group interests first (Dalton et al. 2001; Pantalone et al. 2010; Paradis et al. 2006). Certainly all cultural groups value family, but ethnic and religious minority groups are more likely to give priority to the community’s or family’s needs over an individual’s needs. Collectivist cultures also have expanded definitions of who is family. In addition to blood relatives, Latino families often include compadres or padrinos (i.e., godparents) in the definition of family. In African American culture, “fictive kin” (e.g., close friends of the family, members of the church community) often play critical roles in the upbringing and racial socialization of children, acting as mediators, judges, networkers, and caregivers as needed (Kelly 2006). Thus, when conducting therapy with ethnic and religious minority children, the clinician must evaluate the role of immediate and extended family when planning interventions.

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Oppression, -Isms, and Ethnic Identity When working with diverse youth, consideration of the effects of social oppression (discrimination against and antagonism toward a particular minority group) on the life of the child is crucial, and regrettably, often overlooked because clinicians fail to ask about it. As visible minorities, girls, children with disabilities, Orthodox Jews (adhering to traditional garb), and devout Muslim girls (wearing a hijab) may endure sexism, ableism (prejudice against individuals with disabilities), anti-Semitism, or anti-Muslim sentiment, respectively. GLBT clients often seek psychological services related to stressors related to the pervasive heterosexism and subsequent social rejection and conflict with mainstream culture and religious beliefs (Balsam et al. 2006). The type of oppression that has received the most attention in the psychological literature is that of racism and discrimination. Ethnic minority youth are often targets of racism and discrimination at an early age (Harper and Iwamasa 2000). Racism and discrimination have been shown to be potent risk factors for psychological and physical health problems (Kelly 2006; Sáez-Santiago and Bernal 2003). Experiences such as these will certainly affect the relationship with a therapist whose cultural background is the same as the group that the child views as oppressors (Harper and Iwamasa 2000). One of the best predictors of resilience to the negative influences of racism and discrimination is the formation of a positive ethnic identity (Wong et al. 2003). Positive ethnic identity is associated with increases in self-esteem, coping, mastery, and optimism and is negatively correlated with loneliness, anxiety, and depression (Carter et al. 2001; Greene 1992). Ethnic minority children have to learn to be bicultural (i.e., able to negotiate the dominant culture successfully) in an often antagonistic environment. Children with underdeveloped cultural identities and long-term exposure to oppressive social environments often demonstrate signs of internalized oppression. Likewise, parents who themselves have internalized racist messages and beliefs in limited life options may pass these beliefs on to their children (Greene 1992). Greene (1992) described the importance of racial socialization in teaching African American children how to deflect and negotiate a hostile environment. African American parents often strive to warn their children about racism and disappointments without being overprotective. Greene discussed how cultural paranoia (sensitivity to potential for exploitation by whites) evolved as an adaptive defense mechanism to decrease psychological vulnerability to racism. Positive racial socialization often involves providing children with strategies to manage specific problems, acting as role


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models for handling discriminatory experiences, introducing African cultural values to increase cultural understanding and pride, having frank discussions with children about indirect and covert racism, and exposing children to accurate and positive messages about African American people and their history (Greene 1992). In short, racial socialization is an essential and underutilized parenting and therapeutic tool that promotes mental health in ethnic minority youth. In an innovative Afrocentric parent training protocol, Neal-Barnett and Smith (1996) summarized an approach to behavior therapy that incorporates racial socialization to assist African American parents in preparing their children for the experience of discrimination. The Afrocentric approach takes into account strengths embedded in African American culture (e.g., extended family and kinship networks, unity, spirituality, flexibility, and respect for elders) and uses elder role models for younger parents, African American group facilitators, and ethnically similar models in clinical vignettes, tying discipline with building high self-esteem in African American children (Neal-Barnett and Smith 1996). This racial socialization component is typically lacking in other parent training programs, which may contribute to the high attrition rate of ethnic minorities from these types of programs.

Acculturation and Immigration Issues The impact of immigration and acculturative stress on help seeking, treatment engagement, and family functioning for ethnic minority and immigrant youth cannot be overstated. Acculturation, the extent to which an individual adopts aspects of the dominant culture versus his or her indigenous culture, is a process pertinent to both immigrant and nonimmigrant ethnic minority populations (Klonoff and Landrine 2000). Nonimmigrant ethnic minority groups, such as Native Americans and African Americans, often struggle to maintain their indigenous cultural lifestyles and values while adopting the behaviors they need to function in the dominant culture (Kelly 2006; McDonald and Gonzalez 2006). Acculturation has been identified as a risk factor for depressive symptoms among ethnic minority groups (Sáez-Santiago and Bernal 2003), with some evidence indicating that more acculturated immigrants have worse mental health outcomes than less acculturated immigrants (Vega et al. 1998). Individuals who assimilate into the dominant culture (disregard their culture of origin’s values and adopt dominant cultural values) may undergo a loss of traditional support systems coupled with feelings of self-deprecation due to exposure

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to discrimination. Some investigators speculate that bicultural competency (balance between native cultural norms and those of the host culture) may lead to improved mental health outcomes (McDonald and Gonzalez 2006; Sáez-Santiago and Bernal 2003). Immigration is often associated with stressful life events that affect child development. Family members may experience lengthy separations, loss of social support, and feelings of loneliness (Interian and DíazMartínez 2007; Suárez-Orozco et al. 2002). The reason for immigration is important: Immigrants who come voluntarily for economic, political, health, or educational reasons are usually more prepared to migrate, may have a support network in the host country, and may know the language or be familiar with the host culture (Pantalone et al. 2010). Refugees, on the other hand, are forced to leave their country due to war, persecution, or disaster. They may have been economically or educationally deprived in their home country and have experienced trauma before or during migration (Pantalone et al. 2010). Refugees often have little exposure to the dominant language or culture of the host country, whereas English proficiency is a distinct advantage for immigrants and is associated with lower levels of depression (Sáez-Santiago and Bernal 2003). The legal status of both immigrants and refugees upon arrival to the new country will dictate the access they have to services and to educational and employment opportunities. Often legal status among family members may vary. For example, women who enter the United States illegally may give birth to children who are U.S. citizens and who receive corresponding services to which their parents are not entitled. These families are often in a constant state of anxiety about the possibility of deportation, and this undocumented status has been linked with increased vulnerability for socioemotional problems (Cavazos-Rehg et al. 2007). Despite high levels of psychological distress, these families often will not seek help for fear of deportation. In other cases, children are brought into the country without legal documentation by their caregivers and are limited after high school in accessing educational opportunities, employment, and medical care without a Social Security number. Upon reaching adolescence and gaining understanding of their predicament, these youth often experience poor mental health outcomes as a result of their severely restricted prospects (Mahoney 2008). Another complicating factor in the familial acculturation process is that children tend to acculturate faster than adults, in part due to ease of language acquisition for younger children and sometimes because adults have more difficulty adjusting to major life changes (Gil and Vega 1996; Suárez-Orozco et al. 2002). As a result, families often experience an intergenerational gap in cultural values. Traditional cultural values imposed by


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parents may contradict those of the dominant culture and cause identity confusion for ethnic minority youth (Ho 1992; Rivers and Morrow 1995) and conflict between parents and their children (Hansen et al. 2000). Also, traditional hierarchies in immigrant families can be disrupted by parents who must rely on children to translate and advocate for their families (Suárez-Orozco et al. 2002).

Religion and Spirituality Clinicians should appreciate the central role of religion and spirituality and consider how to integrate such beliefs into conceptualization of the problem and treatment planning when working with culturally diverse individuals and families. African Americans demonstrate higher levels of religious devotion and spirituality compared to other ethnic groups, and their religious institutions often are involved formally and informally in child care, educational programming, and community leadership (Bernal and Scharrón-del-Río 2001; Kelly 2006; Neal-Barnett and Smith 1996). Native American spiritual traditions maintain that all things possess a spirit and that wellness is constituted by harmony between the three facets of a person: mind, body, and spirit (McDonald and Gonzalez 2006). Additionally, religious minorities, such as Orthodox Jews, may strive to separate themselves from mainstream American society to maintain group solidarity and their adherence to cultural and religious practices (Paradis et al. 2006). A culturally competent CBT clinician should demonstrate sensitivity to these issues and attempt to utilize the strengths they may present in order to support treatment outcomes. By collaborating with clergy and spiritual leaders (e.g., curanderos) and becoming familiar with sacred writings, the CBT clinician may improve treatment engagement and perhaps also the success of interventions.

Distinctive Symptom Presentation and Somatic Symptoms Alternative manifestations of psychological distress have received increasing attention in the cross-cultural literature. The expression of psychological problems somatically is a common phenomenon in many ethnic minority groups. Arab and Latino clients often present with physical complaints, such as headaches, stomachaches, pain, and sleep disturbance (Abudabbeh and Hays 2006; Myers et al. 2002). It makes sense then that many ethnic minority individuals seek help from their primary care doctors instead of a mental health professional (Abudabbeh and Hays 2006;

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Interian and Díaz-Martínez 2007). CBT clinicians may need to consider assisting their young clients with connecting somatic symptoms with psychological distress in order to increase the likelihood that the youth will adequately understand the rationale behind CBT interventions.

Contextual Factors Ethnic and racial minority groups are often overrepresented in lower socioeconomic strata (U.S. Surgeon General 2001). Poverty and lack of resources often produce hopelessness and helplessness among ethnic minority clients and adversely affect their expectations for positive therapeutic outcomes (Bernal and Sáez-Santiago 2006; Koss-Chioino and Vargas 1992). Additionally, because of financial hardship, some parents need to work multiple jobs and, as a result, are less available to their children. While affluent, two-parent households may have the resources necessary to supervise children’s out-of-session practice and therapeutic homework, single parents struggling to provide for their families may not have the energy or time to devote to such endeavors (Greene 1992). For these reasons, these parents are less likely to provide positive racial socialization to the children who most need it. Low-income communities often are characterized by unsafe neighborhoods, gang activity, inadequate schools, poor housing conditions, limited access to quality health care and social services, and a number of other stressors. The ability of the family living in such conditions to follow through on therapy assignments (such as behavioral activation) may be significantly restricted due to these contextual factors. The limited literacy skills of many immigrant and some ethnic minority parents provide another potential barrier to compliance with written therapy homework and behavioral plans. The intersection of undocumented legal status and low SES creates another challenge for immigrant populations. Undocumented families may have difficulty regularly attending appointments scheduled during typical office hours because of the unpredictable nature of underthe-table day labor or repercussions of missing a day of work (e.g., no benefits and likely job loss for being absent). Despite these barriers to compliance and treatment, diverse populations present with a number of strengths that can enhance treatment outcomes. Social affiliation, common in many collectivist cultures, has been found to be inversely associated with depression (Sáez-Santiago and Bernal 2003). Resources such as strong connection to family, religious involvement, and voluntary associations may be powerful therapeutic assets in promoting positive change in ethnic minority clients.


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Clinical Recommendations Suggestions for Beginning CBT Therapist Self-Assessment The therapeutic process needs to start with the therapist’s own self-evaluation of his or her own cultural values, notions of acceptable behavior that may be culturally laden, personal experience with social oppression versus privilege, knowledge deficits, comfort in addressing and discussing issues of diversity and discrimination, and personal biases (Arredondo and Arciniega 2001; Hays 2006; Pantalone et al. 2010). To begin, therapists must be able to clearly identify their own cultural identity and the significance of belonging to that cultural group, including the relationship of individuals in that group with individuals from other groups institutionally, historically, and educationally (Arredondo et al. 1996). Therapists must examine differences between themselves and their clients and assess their level of comfort with working with culturally diverse clients who may have different values and beliefs. Such self-evaluation can make the therapist more attuned to social and environmental stressors that shape the client’s experience, such as exposure to oppression, and further help the clinician to identify areas in which he or she needs more education and training (Arredondo et al. 1996; Vera et al. 2003). Therapists must remember that they have a stimulus value (e.g., gender, race, dress) and that youth size them up the moment they meet regarding the therapist’s ability to help and to recognize differences between them. Culturally skilled therapists are aware of their social impact on others in the form of communication differences or interpersonal style (Arredondo and Arciniega 2001). Therapists who have thought critically about how they will be perceived by ethnocultural minority youth will better prepare thoughtful questions and ways to recognize and address potential cultural differences.

Assessment As discussed above, basic cultural competence calls for the therapist to find a balance between educating himself or herself about the sociocultural groups to which clients belong and recognizing that each client’s experiences are unique and not necessarily dictated by group membership (Pantalone et al. 2010). At the same time, clinicians who overestimate the role of these issues, inadequately assess individual differences, and neglect to

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consider other relevant factors affecting mental health will likely have poor treatment engagement and outcomes with diverse young populations (Sue et al. 2009). The Multidimensional Ecosystemic Comparative Approach (MECA; Falicov 1998) balances the universalist (assumption that Western psychotherapeutic concepts are universally applicable across cultures) and culture-specific positions to help clinicians appreciate human similarities, consider cultural differences, and recognize the uniqueness of each individual. MECA maintains that culture develops over time through membership in a variety of domains (e.g., language, race and ethnicity, sexual orientation, religion, SES) and experiences in different contexts (e.g., discrimination or isolation where the individual lives and attends school). By adopting a culturally responsive approach to assessment, clinicians will be informed of cultural factors at each step of the CBT process, including case formulation, diagnosis, treatment planning, and therapeutic intervention. Tanaka-Matsumi and colleagues (1996) outlined the Culturally Informed Functional Assessment to assist behavioral therapists who are culturally different from their clients in identifying the functional relationship between the client’s presenting problem and the sociocultural environment. The underlying assumption is that good behavioral therapists assume that each individual’s reinforcement history is unique (i.e., different from the therapist’s and other individuals’ from their cultural group). The two major tasks facing CBT therapists are 1) the need to evaluate the presenting problems using functional analysis and 2) the need to assess the larger context of the client’s social network with attention to cultural influences (e.g., cultural definitions of problem behavior, knowledge of accepted behavioral norms, cultural acceptability of behavior change strategies, and culturally approved behavior change agents) (Okazaki and Tanaka-Matsumi 2006). Recommendations include the use of an interpreter or cultural informant and acculturation measures to examine the cultural identity, cultural match or mismatch with the clinician, and acculturative stress. In addition to standard functional assessment with the client, the clinician should interview family members to explore how the presenting problem is viewed from the family’s and sociocultural group’s perspective (i.e., is this a culturally normative idiom of distress?), what the family perceives as the causes of the behavior, what characterizes traditional help-seeking in the cultural group, and how the family responds to the behavior in everyday situations (Tanaka-Matsumi et al. 1996). Assessment of cultural explanations for the individual’s behaviors will reveal pertinent cognitive schemas that may be targeted by interventions (e.g., it is inappropriate for a child to challenge the authority of an elder family member). The clinician needs to


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assess not only the quality of the child’s self-image but also the life experiences of the parent to understand the role of racial pride, shame, or confusion and how these factors influence the parent-child relationship (Greene 1992). Ensuring that these areas of inquiry are covered in the assessment process will allow the clinician to entertain hypotheses to explain client behavior with a consciousness of what is culturally normative for this individual and the sociocultural groups to which he or she belongs. The task of culturally responsive assessment may seem daunting because there are so many domains of diversity to consider and no clinician is bias-free. For this reason, a number of different models and tools have been developed to guide clinicians’ assessment of both risk and protective factors in the individual’s cultural environment. Hays (2008) proposed the ADDRESSING model to guide assessment and consideration of the various domains of diversity in case formulation: A—Age and generation D—Developmental and D—Acquired disabilities R—Religion or spiritual orientation E—Ethnicity S—Social status S—Sexual orientation I—Indigenous heritage N—National origin and G—Gender To avoid overgeneralizing, clinicians need to consider the individual’s level of acculturation compared with his or her level of involvement in the culture of origin (Balsam et al. 2006; Harper and Iwamasa 2000; Vera et al. 2003). Assessing cultural identity, language preference, English proficiency, acculturative stress, exposure to discrimination, and degree of internalized oppression is central to cultural case formulation (Bernal and Sáez-Santiago 2006; Vera et al. 2003). Despite the documented importance of assessing for these diversity issues, Harper and Iwamasa (2000) found that a majority of therapists talk with clients about ethnicity when the presenting problem is clearly related but otherwise do not often broach the subject. Many dominant-culture therapists fear being considered racist for bringing up the subject of race or ethnicity if the client does not do so. However, young clients’ fears of being dismissed or misunderstood may make it difficult for them to bring up such issues (Harper and Iwamasa 2000). By asking “What are aspects of your race or culture that are important for me to know about in working

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with you?” or “What are your spiritual or religious beliefs?” the therapist communicates a willingness to discuss these issues (Kelly 2006). Often clients are relieved when the therapist asks this type of question, or they themselves have not previously considered how race and ethnicity contribute to their presenting problem (Harper and Iwamasa 2000). Culturally competent therapists should “do their homework” to inform themselves about what questions to ask and potential influences that the diversity issues may have on the presenting problem. Alternatively, if the clinician does not touch on such issues, the youth may perceive that the therapist is uncomfortable discussing the client’s ethnic minority status, does not value the client’s ethnicity, or truly cannot understand him or her (Harper and Iwamasa 2000). Some investigators maintain that failure to address ethnicity and cultural values contributes to dropout and treatment failure (Fudge 1996; Harper and Iwamasa 2000). Considering that many individuals belong to more than one minority group, the clinician also should assess the degree to which the client’s selfidentity is tied to each of these diversity domains (Pantalone et al. 2010). For instance, in many cases, gay ethnic minority youth identify more with being a member of the GLBT community than with being an ethnic minority.

Case Example Avery, a 14-year-old biracial (African American and white) adolescent presented for treatment with the primary concern of conflict with her father. After having been raised by her white mother, Avery had to move in with her African American Baptist father at age 10 when her mother died unexpectedly. Her father perceived that Avery had internalized racist messages and that her conflicted relationship with him was rooted in her struggling with her biracial identity. With further assessment, Avery revealed that in her opinion, her bisexual orientation and conversion from Christianity to Buddhism were the primary issues of contention between herself and her father.

Another consideration is that the child’s identification will vary by context and level of exposure to oppressive and supportive social forces (e.g., school vs. home vs. religious events; Pantalone et al. 2010). A thorough understanding of contextual issues is crucial to being able to make clinical recommendations that are safe and have a good chance of being successful. For example, a clinician must be cognizant of the risks involved in a GLBT youth’s cultural environment before encouraging him or her to come out (Balsam et al. 2006). Culturally responsive assessment also involves inquiring about contextual risk and protective factors that will inform treatment. Conditions such as SES, educational level, safety of the neighborhood, adequacy of


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housing, adequacy of health care and social services, legal problems, and exposure to trauma need to be well understood in order to develop effective recommendations for intervention (Crawley et al. 2010; Hays 2006; Vera et al. 2003). Additionally, clinicians may find useful outlets to enhance treatment engagement and effectiveness by fully understanding a family’s cultural isolation versus access to a cultural community (e.g., availability of preferred foods or cultural art, music, and events), access to nature, participation in a religious community in their preferred language, interpersonal support (e.g., extended kinship, godparents, social networks), and involvement in political or social action groups (Hays 2006). Framing treatment in a culturally acceptable way is crucial in promoting treatment engagement, retention, and compliance. If the assessment process has been truly culturally responsive, the diagnosis and treatment planning stages should be consonant with the family’s perception of the problem and will reflect a collaborative effort between clinician, client, and the client’s family (Vera et al. 2003). Clients’ treatment goals may place less emphasis on cognitive and behavioral changes but rather may focus on having more involvement in a supportive faith community or having more balance in their lives (Pantalone et al. 2010).

Treatment Engagement and Orientation to Treatment The debate is ongoing about whether factors specific to theoretical orientation or nonspecific factors in therapy (e.g., being understood, receiving unconditional positive regard or respect, and being accepted) are responsible for clinical improvement. Arguably, attention to nonspecific factors in therapy is central to effective treatment engagement with ethnic minority youth (Harper and Iwamasa 2000; Sue et al. 2009). Engagement of ethnic minority families may be particularly challenging given the stigma associated with mental health treatment and a history of exploitation, abuse, and disparities in mental health care that has created a deep-seated suspicion of mental health professionals of the dominant culture (e.g., Tuskegee experiment, conversion therapy for GLBT individuals). It is incumbent upon clinicians to understand how previous experiences and/or misconceptions about mental health service providers may influence the client’s perception of them. As mentioned before, these misconceptions can be addressed by acknowledging cultural differences between clinician and client, thus signaling openness to further discuss the topic and sensitivity to the youth’s cultural context. Clinicians may need to be prepared to do home visits or to reach out by phone to persuade reluctant family

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members to join family sessions (Abudabbeh and Hays 2006). Attention to the therapeutic relationship cannot be overemphasized. For example, allowing time before and during sessions to engage the family in non-problem-related small talk and allocating additional time for standard rapport building may be necessary with culturally different clients (Falicov 2009). Matching therapist-client characteristics (e.g., ethnicity and gender), language proficiency, and modes of expression (the use of easily understood lay terminology and culturally appropriate metaphors) may enhance the ecological validity of therapy (Interian and Díaz-Martínez 2007; Rosselló and Bernal 1996). Other techniques such as telephone and letter prompts immediately before a scheduled session, engagement interviews to problem-solve barriers to treatment, family therapy techniques to reduce resistance and increase engagement, and interventions designed to increase patient participation in care have been shown to improve treatment attendance and retention of ethnic minority youth (Huey and Polo 2010). Additionally, provision of explanations about the limitations of the therapist role early in therapy will help to avoid misunderstandings among ethnocultural groups who value warm interpersonal relations and expect that the provider will provide constant support and assistance (Barona and Santos de Barona 2003; Bernal and Sáez-Santiago 2006). A willingness to selfdisclose often serves to relax the client, promote trust, and model how to discuss personal issues (Pantalone et al. 2010). For example, when working with Latino families, I (RFP) utilize the formal form of “you” (Usted) and formal titles (Señor/Señora, Don/Doña) instead of first names of parents to demonstrate the cultural value of respeto and to decrease the hierarchical distance between myself and adult family members. To respond to the Latino cultural value of personalismo (warm interpersonal relations and personalized attention), I avoid an exclusively task-oriented orientation to therapy sessions and allow time for small talk and appropriate self-disclosure. This often includes discussion of where the parents of the child were raised. Usually, my clients are curious about my background and how I came to speak Spanish, so I take this opportunity to model self-disclosure by explaining my cultural and family background to increase their comfort level in discussing cultural differences and personal information. Because of the stigma involved in pursuing mental health care among many ethnic minority and immigrant populations, psychoeducation during the treatment engagement phase is vital. Much of families’ anxiety can be relieved by learning about the etiology of the presenting problem and learning that they are not alone (Iwamasa et al. 2006a). Nonthreatening psychoeducation about the purpose, course, and process of treatment has been shown to improve therapeutic alliance with African Americans (Kelly 2006). Early on, the clinician should explain how the cognitive-behavioral


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clinician-client relationship differs from a traditional doctor-patient relationship to promote a collaborative treatment approach in which the client takes an active role in defining the problem, deciding on a plan, and negotiating homework (Hays 1995). A careful explanation of the CBT model and how it will specifically address the client’s problems is important to treatment retention for ethnic minorities less familiar with therapy (Iwamasa et al. 2006a). This explanation should avoid jargon, particularly when the clinician is presenting the model to children, and should use developmentally appropriate lay language (e.g., “thinking mistakes” or “stinkin’ thinkin’ ” instead of “cognitive distortions”). Pretherapy orientation videos for ethnic minority clients are available to enhance treatment engagement by depicting mock therapy sessions and including client testimonials by ethnically similar clients. These videos may be shown in waiting rooms or privately for individuals referred to therapy (Organista and Muñoz 1996). Before commencing therapy, the clinician should take time to address potential barriers to treatment compliance. During the culturally responsive assessment, the CBT clinician will have identified logistical barriers as well as potential sources of support (e.g., extended family that can help with child care, expenses, or transportation). Helping the family problemsolve these issues will demonstrate a respect for the context in which families live and a willingness to discuss basic family needs. Barriers may also be attitudinal in nature. For example, it is not uncommon for ethnic minority parents to state that they do not “believe in therapy,” that “therapy is for crazy people,” or that “therapy is for rich white people.” It will be necessary for the therapist to address these attitudinal barriers through psychoeducation and perhaps the use of the aforementioned therapy preparation videos. The willingness to discuss these issues nondefensively and the inclusion of important people, such as curanderos, extended family, clergy, and godparents, demonstrate a comfortable stance on cultural differences by the clinician and serve to build trust, improve attitudes toward treatment, and enhance compliance with homework for youth from ethnic and religious minority groups (Harper and Iwamasa 2000). Because premature termination is one of the major factors leading to poorer treatment outcomes among ethnic minority populations, attention to cultural factors in the treatment engagement phase is particularly crucial to building a therapeutic alliance and retaining the client in treatment.

Methods for Implementing CBT Consideration of cultural and contextual factors must extend from assessment throughout treatment when working with diverse youth. This means not only adding cultural elements but also using traditional CBT skills to

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address diversity issues. Creativity as a clinician is a great asset in flexibly implementing CBT with diverse youth. For example, the clinician may incorporate culturally appropriate metaphors and work cognitive restructuring into a child’s affinity for writing raps, to improve the likelihood that the child will accept CBT strategies (Harper and Iwamasa 2000). Therapists also should ensure that the new behaviors learned in therapy are positively reinforced by the social environmental contexts in which youth live (Harper and Iwamasa 2000). This requires an awareness that a particular behavior may be considered adaptive in one context and maladaptive in another.

Family-Focused Interventions Because of the emphasis on collectivism in many ethnic cultures, an emphasis on family-focused intervention may be most effective when working with ethnically and religiously diverse youth (Falicov 2009; Kumpfer et al. 2002; Organista 2006; Paradis et al. 2006). As part of culturally responsive assessment, the therapist should already understand family structures and backgrounds as well as how clients’ behaviors affect the family and vice versa (Pantalone et al. 2010). In a trial of CBT for depressed Latino adolescents that demonstrated treatment effectiveness, familismo was considered in the assessment and treatment engagement phases by assessing and addressing parent goals in the treatment process (Rosselló and Bernal 1996). Additionally, family can be integrated into CBT sessions post–treatment engagement. The Treatment for Adolescents with Depression Study demonstrated that involvement of extended family supported compliance among African American youth in CBT (Sweeney et al. 2005). With Latino adolescents, the module of family communication was emphasized to address intergenerational gaps in values. Therapists normalized cultural differences to alleviate family stress and facilitated discussion about the values and beliefs of the host culture and culture of origin with the following goals: 1) promoting understanding between parents and adolescents, 2) teaching the family positive communication and negotiation skills, and 3) teaching the adolescent how to cope with negative feelings and cognitions (Sweeney et al. 2005). Encouraging families to share migration narratives has been a helpful adaptation to family therapy to reduce misunderstandings and to decrease silent suffering (Falicov 2009). When there is a clash between personal and family obligations (individualism vs. collectivism), the therapist should be careful not to impose his or her values, pathologize, or criticize. It is the therapist’s role to help the youth anticipate the potential social consequences of certain decisions (Pantalone et al. 2010).


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Case Example Naomi, a 16-year-old Filipina girl raised in the United States, presented with conflict with her mother (a first-generation immigrant, single mother) about her mother’s traditional belief that girls should not date until after college (consistent with the mother’s upbringing). Due to the Filipino cultural taboo against discussing sexuality and intimate relationships and her mother’s vehemence about her not dating, Naomi was unable to engage her mother in open communication and started dating behind her mother’s back. Family therapy focused on allowing the mother to explain her values and express her concerns about dating while supporting Naomi to resist peer pressure. Parent-centered sessions provided psychoeducation about how difficult it is to bridge two cultures and the risks to Naomi if she did not have a parent to talk with about her challenges. These sessions included a discussion of the reality of the mother not being able to supervise her daughter 24 hours a day, the likelihood that Naomi might stop seeking her advice and would be more vulnerable to peer pressure if communication remained strained, the normalization that Naomi was likely attracted to the boy and he to her, and the possibility that Naomi might choose to defy her mother if she perceived the mother as being overly restrictive. Individual therapy helped Naomi weigh the pros and cons of continuing to deceive her mother versus choosing to be a nonconformist and not follow her peers’ examples, as well as learn to evaluate relationships with peers and with potential boyfriends.

Cognitive Restructuring As one of the core CBT skills, cognitive restructuring can be a powerful tool to use with youth to address diversity issues. A culturally competent CBT clinician will strive to integrate what is known about the child’s cultural values and environment into the teaching and implementation of this skill. In many cases, cognitive restructuring with diverse youth parallels its use in majority populations. For example, youth with disabilities often need assistance in decatastrophizing the impact of their disability (Mona et al. 2006). Cognitive restructuring can focus on personal strengths that were unaffected by the disability to dispute the belief that “Nothing will ever be the same.” For diverse youth, clinicians may want to simplify the A-B-C-D-E method (based on Albert Ellis’s work), which teaches the client to identify the Activating event, Beliefs about the activating event, Consequences (feelings and behaviors), Disputation of irrational beliefs, and Effects of disputation.

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Organista and Muñoz (1996) described how A-B-C-D-E can be difficult to master and as a result discarded by Latino clients. They suggested that instead of labeling cognitions as irrational or distorted, the “Yes, but...” technique may be presented as a way to challenge clients to consider more realistic alternatives, to see more positive situational elements that have been overlooked, and to make half-truths into whole truths (Organista and Muñoz 1996). For example, a first-generation immigrant adolescent from the Sudan struggling to learn English might say, “Yes, my English language skills are not so strong now, but I’m learning more every day. One day I might be fully bilingual, and this will give me an edge in getting a job!” A common misconception is that CBT is less helpful with diverse youth because of its emphasis on individual-level variables—that is, on challenging distorted cognitions about negative events in order to help the individual adapt to the environment (Casas 1995; Organista and Muñoz 1996; Vera et al. 2003). When ethnocultural minority youth experience injustice in an antagonistic environment (e.g., exposure to oppressive societal factors), adjusting their mind-set to fit the environment might be seen as maladaptive for their mental health. The challenge for the CBT clinician is to help the youth question whether a cognition is rational before engaging in cognitive restructuring. Culturally responsive CBT clinicians recognize the injustices facing diverse youth and acknowledge that distorted cognitions are not always the source of the problem; thus other skills, such as problem solving, might be more appropriate to alleviate distress. For example, a Latino student thinking “It’s not fair that the teacher gives me detention when I speak Spanish in school” is not experiencing a distorted cognition but rather is accurately labeling an experience of oppression. Even when there is no distorted cognition, however, cognitive restructuring can be used to assign responsibility and positively affect mood. A parallel can be drawn to youth exposed to trauma. By focusing on cognitions, the therapist is not laying blame on the child for the traumatic event but rather equipping the child with a coping skill that will allow him or her to react to the situation in the healthiest way possible (e.g., meaning making). In the case of youth who have experienced trauma or uncontrollable environmental circumstances (as is often the case for cultural minority populations), clinicians can use cognitive restructuring to reframe the impact of these undeniably negative events and help the youth generate more productive self-talk (e.g., “I am not responsible for the teacher being racist. Being bilingual is an ability I have that will be valuable to me in other settings.”). Cognitive restructuring is particularly useful for ethnocultural minorities because it can be used to challenge cognitions stemming from internalized oppression. Many GLBT youth and their families are troubled by heterosexist thinking, such as “Gays and lesbians are more promiscuous and are not ca-


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pable of having a stable, committed relationship with one partner.” GLBT youth may experience some relief through systematic analysis and correction of cognitive errors and adaptation of more constructive self-talk, including messages from a gay-affirmative therapy approach (e.g., homosexuality is not an illness, same-sex attractions are normal variants of sexual orientation, same-sex relationships can be fulfilling) (Balsam et al. 2006; Glassgold 2009; Safren et al. 2001). In the case of exposure to racial discrimination or harassment, African American youth are at risk of adopting beliefs such as “Being black means I’ll never be good enough”; “Being black means acting in a particular way”; and “Black men don’t do school; therefore, doing well in school means that I’m not a black man.” Clinicians can assist ethnic minority youth in challenging these beliefs and developing more realistic and positive selfstatements to combat the internalization of negative messages (Fudge 1996; Kelly 2006; Kuehlwein 1992). Knowing that religion and spirituality are central to the culture of many ethnocultural youth, the clinician can use scriptures and religious anecdotes to challenge maladaptive cognitions (Neal-Barnett and Smith 1996). Such religious disputation of disturbance-creating beliefs can be a potent catalyst for religious clients and is a strategy used by some clergy in the Christian, Jewish, and other faiths (Ellis 2000). Such disputation when carried out by clinicians working with young children, however, needs to be done in a respectful way so as not to alienate the young person or his or her family. Research has shown that devout individuals who believe in an angry, punitive God and perceive a lack of support from their religious community tend to suffer more psychological distress in contrast to those who believe in a loving God, who enjoy more positive mental health (Pargament 1997). Clinicians are encouraged to inquire what the youth’s and parents’ religious beliefs are in relation to the situation at hand, determining whether these beliefs are exacerbating or relieving the youth’s distress (Walker et al. 2010). Psychoeducation about the clinician’s role can highlight the intention to help the youth (and sometimes the family) feel better by adopting adaptive and hopefully religiously congruent thinking. This approach may require consultation with a clergy member to provide the family with the necessary reassurance that the treatment is acceptable (Walker et al. 2010). In the cases that young clients or the parents present with views that conflict with the clinicians’ beliefs, clinicians are encouraged to focus on the well-being of the youth as a way to guide therapeutic intervention.

Case Example José, a 17-year-old gay Catholic adolescent from Mexico, presented for individual therapy for depression. He was struggling to reconcile his Catholic identity with his sexual orientation. He had internalized negative messages,

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such as “Homosexuality is a sin,” and therefore felt as though he was a bad Catholic. Recognition that much of his distress emanated from this punitive belief that an integral part of identity was abhorrent to his God and religion guided my (RFP) decision to use scriptures to counteract this internalized oppression, common to Christian GLBT older adolescents. I engaged José in collaborative research into same-sex relationships in the Bible, alternative theories and interpretations of biblical passages, and contradictions in Scripture. Cognitive restructuring helped José adapt beliefs based on Scripture that emphasized his compliance with Christian ideals. Additionally, to help him cope with some of his family’s rejection as he disclosed his sexual orientation, José utilized religious readings, such as “When my father and my mother forsake me, then the Lord will take me up” (Psalm 27:10). He also was able to critically analyze and generate positive self-talk, such as “If nonheterosexual orientation is so completely unacceptable, then why is there not one mention of sexual orientation in the Ten Commandments or in all of Jesus’ teachings?”

Often cognitive restructuring with diverse youth is most effective in combating the effects of oppression when the therapist is able to access and enhance the client’s strengths (be they developing a positive ethnic identity or a belief in a loving God) and use them in therapy.

Behavioral Activation When designing behavioral activation for diverse youth, the clinician should attend to contextual factors such as income, safety of neighborhoods, gender roles, and other cultural norms. A clinician who recommends that a child living in the inner city exercise regularly by walking or running around the neighborhood, going to the park, or working out at the gym without thoroughly assessing such contextual factors may inadvertently put the child in danger of crossing gang lines and exposing himself or herself to violence, assumes access to parks, and presumes that the family has the resources to pay for private gym membership, respectively (all of which demonstrate the clinician’s lack of skill, knowledge, and understanding of the client). Clinicians need to help children identify activities that are congruent with their environment, do not require payment, or are readily available to low-income families (e.g., free admission days at museums, visiting friends, mall walks) (Organista 2006). Follow-through on behavioral activation may be highly dependent on how it is viewed by the family. For Latinos, focusing on themselves and improving their own moods may cause problems for more traditional families who value familismo. Therefore, activity schedules that include activities for the youth to do with and without family are more likely to be well received (Organista 2006). Additionally, traditional gender roles dictate that Latinas take on a caretaking role in the family by helping around the house


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with child care, cleaning, and chores. In these cases, behavioral activation might be more well received if instead of framing it as a way for the client to take care of herself, the clinician proposes the rationale that when the client takes care of herself, she is better able to care for her family (Organista 2006). For children who manifest psychological distress primarily in somatic symptoms, behavioral activation (e.g., physical exercise, distraction) in conjunction with relaxation techniques may be an intervention that is easily understood by the family (Interian and Díaz-Martínez 2007). Behavioral activation may also serve as a useful complement to cognitive restructuring to buffer youth from oppressive influences by connecting them to culturally specific networks and religious institutions (Hays 1995). For African American and Latino youth, clinicians can connect youth with church communities, local cultural organizations, English classes (for those whose first language is not English), and mentoring as part of their behavioral activation interventions (Interian and DíazMartínez 2007; Sweeney et al. 2005). GLBT youth, in particular, benefit from assistance in identifying appropriate agencies and organizations that will allow them to build social support networks and experience more positive events (Safren et al. 2001). Such culturally attuned behavioral activation interventions may decrease social isolation, enhance positive ethnic identity development, and improve overall mental health.

Case Example Ming is a 13-year-old girl who emigrated from China at age 11 and recently relocated to a new city in the United States. She feels isolated and different at her new school because most of the students are African American. She reported that the only other Asian students were “Gothic” (an offshoot of punk culture), a group with which she did not identify. In order to increase her social activity level, I (RFP) found a Chinese American agency near where Ming lived and suggested that she and her mother investigate some of the classes and recreational activities. We discussed how classes on Chinese cultural heritage might lead Ming to meet other youth with whom she would feel more connected. We also discussed that the youth group field trips could help her get to know her new city. To address her mother’s concern that Ming was not serious enough about academics, I explained that the agency also provided academic assistance such as tutoring and English-language classes, which might help Ming improve her writing for standardized testing.

Problem Solving Problem solving is another useful complement to cognitive restructuring when there is an environmentally based problem (Hays 2006). Problem solving is especially relevant to ethnocultural minority youth’s contextual

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experiences that may negatively influence their mood and behavior because of the focus on effecting change on the environment. Therapists can help youth (already disempowered because of their age) draw on community and family resources to address unjust treatment. For example, using family problem-solving to address discriminatory practices at the child’s school can empower parents to file complaints, request to speak to someone’s supervisor, seek out a new school, or consult an attorney. Helping ethnocultural minority children (and at times, their parents) successfully change their environment may serve to increase their self-efficacy and willingness to implement learned coping skills in subsequent situations. CBT with ethnic minority youth may require a higher level of intervention in the larger community than CBT with dominant cultural groups. Effecting change on the community level and healing a community of oppressive influences resonates with Afrocentric values of responsibility and self-determination, empowers clients to use more active coping styles, and strengthens positive ethnic identity (Kelly 2006). Problem solving can promote external change in the contingencies in the environment that may maintain child symptoms (Kelly 2006). This intervention may entail empowering the child or family to start an ethnocultural youth group at the school or in the community when one does not already exist (e.g., Latino Student Association, Gay-Straight Alliance).

Case Example Kadija is a 13-year-old African American girl who was having significant difficulty getting along with a particular teacher at school. She and her mother viewed this teacher as often discriminating against Kadija (e.g., blaming only her for something a group of students did). Her mother attempted to advocate for her daughter by talking to the teacher, but she had a strong emotional reaction to the teacher and would end up raising her voice, which only seemed to exacerbate the teacher’s discriminatory behavior. Through the use of problem solving and a review of communication skills in different cultural contexts during therapy, the family was able to enlist the help of an African American teacher who was willing to facilitate this discussion and identify assertive, rather than emotional, methods of opening discussion of the issue with school staff.

Exposure Therapy Traditional exposure therapies for anxiety and panic disorders have included interoceptive exposure to somatic symptoms evoked during a panic attack. Panic attacks brought on by stressors related to the client’s minority status, however, may need additional culturally relevant exposures coupled with relaxation training and problem solving to decrease chronic


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stress levels. For GLBT youth, coming out to specific individuals can be planned as clinicians would plan any other exposure—using a hierarchy of how difficult it would be to come out to particular individuals (Glassgold 2009). When engaging the client in exposure therapy, CBT clinicians need to be mindful of cultural factors that may alter effectiveness. For example, clinicians may need to address the role of shame with Asian American clients by weighing the pros and cons of the client experiencing short-term embarrassment while completing exposures versus the long-term consequences of not doing the exposures (Iwamasa et al. 2006a). For religious clients, the therapist needs to be careful not to engage the client in something that is specifically prohibited by religious law (Paradis et al. 2006).

Case Example Nicolas, an 8-year-old Dominican boy and observant Jehovah’s Witness, presented with obsessive-compulsive disorder (OCD). He was experiencing blasphemous obsessions about swearing at or hating God that were highly embarrassing and distressing to him and his family. I (RFP) worked with the family in psychoeducational sessions to help them understand the nature of OCD and how obsessions were often ego-dystonic and not stemming from a budding rebellion or defiance. We worked collaboratively to externalize OCD and separate it from Nicolas’ identity by making OCD the “bad guy” who bothered Nicolas with the most personally distressing thoughts it could generate. With a solid understanding of OCD and the rationale for exposure and response prevention, he and his mother were willing to proceed with exposures to acting out his obsessions (e.g., swearing at God).

Assertiveness Training Traditional assertiveness training stresses the rights of the individual, which may pose problems for youth from more collectivist cultural backgrounds. A breach in the therapeutic relationship may occur if the CBT clinician is perceived as trying to impose his or her cultural value system on a child or family by empowering the child to put his or her needs above those of the family or community. Organista and Muñoz (1996) suggested that instead, clinicians should frame assertiveness training as a way to help children develop bicultural competency. Assertiveness may be described as an effective communication skill in mainstream America that will serve the youth well in school and in pursuing a professional career. At the same time, the clinician may help youth recognize that assertive communication is inappropriate or may need to be used sensitively in other contexts, such as at home or in religious communities (Hays 1995; Koss-Chioino and Var-

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gas 1992). This approach to assertiveness training avoids devaluation of traditional communication patterns in particular cultural contexts (Organista and Muñoz 1996). By discussing cultural values, expectations, and family roles, the therapist may assist more acculturated adolescents in negotiating a looser attachment to the family without completely abandoning traditional cultural values (Koss-Chioino and Vargas 1992). For African American youth, assertiveness training can help them anticipate situations and generate and rehearse appropriate responses that focus on desired outcomes instead of the oppressive script of “acting black” (Fudge 1996). In combination with cognitive restructuring to challenge negative internalized messages, assertiveness training can present youth with alternatives to the extremes of either aggression and hostility or passivity and withdrawal. Through role-play and examples from role models, ethnic minority youth can strengthen assertiveness skills and effectively anticipate and manage problematic situations (Fudge 1996). A good deal of attention in the literature has been given to conducting assertiveness training with Latino populations. The therapist needs to be mindful of culture-based protocols of communication, respeto, and simpatía (i.e., warmth, kindness, emphasis on positive interactions and avoidance of conflict) in Latino cultures (Interian and Díaz-Martínez 2007; Organista 2006). Comas-Díaz and Duncan (1985) were the first to write about how Latinas could communicate assertively without seeming confrontational. Culturally sensitive framing of assertive communication may include prefacing statements, such as “With all due respect...,” and/or asking permission— for example, “Would you permit me to express how I feel about that?” (Comas-Díaz and Duncan 1985). When using assertiveness training in Latino family therapy, clinicians can ask the father’s permission to allow the wife and children to state their opinions or express feelings, which demonstrates respeto for his role as head of the family and to appeal to his machismo (i.e., male pride, man’s role as protector of the family) (Koss-Chioino and Vargas 1992; Organista 2006). When such cultural adaptations are made, assertiveness can be a useful tool for diverse youth.

Interventions to Promote Positive Ethnic and Cultural Identity Development Despite consistent findings that experiences of oppression and discrimination have adverse effects on mental health, there is a remarkable lack of emphasis in the CBT literature on techniques to develop self-efficacy and positive ethnic and cultural identity. Bandura (1982) discussed that central to the development of a sense of positive self-worth and effectiveness is


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the individual’s acquisition of skills necessary to master the environment. In the case of some ethnic minorities, internalization of racism contributes to difficulty accurately assessing personal competence and resisting negative behaviors that are reinforced by peers (Fudge 1996). Positive ethnic identity would alter expectations regarding personal competency and would give children the courage to engage in more adaptive behaviors even if not reinforced by some members of their peer group. Because of the emphasis on behavior change, behavior therapy is especially well suited to increasing youth’s sense of control and self-efficacy in disempowered young minority populations (Fudge 1996). Behavior change can result in empowerment and an increased ability to alter the environment. By exposing youth to positive role models of their own group through bibliotherapy (e.g., The Autobiography of Malcolm X), therapists can help youth learn vicariously about positive ethnic identity development (Fudge 1996). Through involvement in political activity or ethnoculturally based youth groups, youth can appreciate the interdependence between their own needs and those of the larger cultural community, gain a sense of belonging and solidarity, and strive collaboratively to modify systems-level problems and repair injustices, leading to increased self-confidence and self-esteem. Therapists can teach youth behavioral analysis to help them analyze antecedents and contingencies that are capable of being altered (Fudge 1996). For example, therapists can discuss with African American boys the negative behavior that is often reinforced by peers who have internalized racist messages. Therapists can appeal to these youth’s responsibilities as black men to help others with similar problems by changing the contingencies (e.g., label academic achievement as a positive, desirable quality) (Fudge 1996). Racial socialization has been identified as a therapeutic tool for clinicians to use when interested in promoting positive ethnic identity development in diverse young clients (Greene 1992). Although racial socialization is not a suitable treatment focus for all forms of psychopathology, Greene (1992) recommends that it be used proactively to promote self-esteem and not solely in response to discrimination. The first phase of racial socialization educates children to label racism accurately, identify when it occurs, and understand the experience. In the second phase, the parent is used as a role model to demonstrate to children how to handle certain situations (e.g., advocating for the child at school). The third phase of racial socialization is to provide emotional support for the expected angry emotional reaction to injustices. The final phase assists parents in not reinforcing negative racial stereotypes by showing them how to provide more positive racial images by sharing family folklore and other stories and symbols of racial pride (Greene 1992).

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Case Example Esmeralda is a 12-year-old Guatemalan girl exhibiting oppositional behavior at home, poor self-esteem, and academic decline. In addition to parent training and school consultation, I (RFP) engaged Esmeralda in a variety of activities meant to bolster positive ethnic identity development. Every week, I had Esmeralda read a printout from a Web site featuring successful, famous Latinas in the United States and answer questions about them to help her draw connections between their ethnic backgrounds and hers. I recommended seminars at the nearby university that were open to the community, focusing on Latino leadership and higher education, so that Esmeralda was exposed to role models, such as Latino politicians and college students. I also helped the family find ethnic minority college students at the local university who were willing to donate time to tutor Esmeralda after school to help increase her self-efficacy in her classes.

Hence, therapists may foster positive ethnic identity development in their young clients through a combination of CBT techniques, including cognitive restructuring, behavioral activation, and problem solving, as well as racial socialization.

Future Directions The topics covered in this chapter illustrate the need for a coherent approach to integrating cultural competence and CBT. To accomplish this goal, a number of changes must occur in the fields of mental health training, service provision, and research. Training programs for all types of mental health professionals need to improve preparation of clinicians to work with culturally diverse populations in addition to training them in EBTs (Vera et al. 2003). Diversity and cultural competence training has been demonstrated to increase knowledge about ethnocultural populations among trainees, improve client perceptions of therapist sensitivity, and enhance treatment outcomes (Yutrzenka 1995). Clinical CBT supervisors need to be willing to examine their own values, beliefs, attitudes, and worldviews to build the foundation of self-awareness (Iwamasa et al. 2006b). Likewise, cultural issues need to be raised in supervision to promote the competence of clinicians in training (Iwamasa et al. 2006b). Additionally, culturally responsive assessment in clinical practice is inconsistent in part because of the lack of training, but also because of the deemphasis of culture in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 2000) by relegating cultural formulation to an appendix as opposed to inclusion of such issues as an inherent part of multiaxial assessment (Hays 2008).


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Research must focus on culturally sensitive assessment and treatment response of minority populations to traditional CBT as well as culturally adapted protocols. Specifically, future research should integrate hypothesis-testing and discovery-oriented research and move away from cross-cultural comparisons, instead focusing on mediators and moderators of treatment outcomes for one specific ethnic group at a time (Bernal and Scharrón-del-Río 2001; Huey and Polo 2010). Discovery-oriented research on how to modify treatments with culturally diverse youth, including both quantitative and qualitative methods, would inform the development of culturally adapted protocols. Hypothesis-testing research with specific ethnocultural groups may then examine questions of efficacy and effectiveness of traditional CBT as well as culturally tailored protocols (Bernal and SáezSantiago 2006; Bernal and Scharrón-del-Río 2001). In addition to research that tests cultural adaptations of CBT strategies and manuals, there is a need for mainstream manuals to demonstrate applications of standard modules with diverse populations (Huey and Polo 2010). In the meantime, it is possible for CBT clinicians to provide culturally responsive interventions using the resources we have outlined in this chapter. CBT’s ongoing assessment and tailoring of the interventions to the individual make it particularly useful with clients from a wide variety of cultural backgrounds. CBT clinicians, however, should commit to incorporating cultural diversity issues into their treatment plans by educating themselves about the cultural groups to which their clients belong and using the tools and resources available to them.

Key Clinical Points Tips for Culturally Responsive Assessment • Conduct a cultural self-assessment and assess differences between yourself and your client. • Use a form of cultural assessment such as ADDRESSING (Hays 2008) or the Culturally Informed Functional Assessment (TanakaMatsumi et al. 1996) to avoid your own blind spots and incorrectly estimating the importance of diversity issues. • Assess the primary cultural identity of the client and consider how this might vary depending on context. • Focus on risk and protective factors in the cultural and contextual environment. • Arrive at treatment goals collaboratively and frame treatment goals in culturally congruent language.

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• Understand the complexities of expectations about relationships between the child and his or her family members. Tips for Culturally Responsive Treatment Engagement • Pay attention to nonspecific factors and work to reduce the hierarchical distance between you and the client to promote a collaborative therapeutic relationship. • Provide psychoeducation in easy-to-understand language to address common misconceptions, normalize help seeking, and make explicit how treatment will help. • Address logistical and attitudinal barriers to treatment engagement. • Recognize and address cultural differences between you and the client. • Communicate hope and willingness to assist the child and parents with addressing the presenting problem. CBT Interventions With Diverse Children and Adolescents • Develop interventions that are likely to be successful and culturally acceptable in the context in which the child lives. • When appropriate, inclusion of family in treatment may support treatment compliance and improve outcomes for ethnocultural minorities. • Directly address diversity issues using CBT tools such as cognitive restructuring, behavioral activation, problem solving, and exposure. • Be careful with competing cultural values when conducting assertiveness training and make sure that your client uses the skill in culturally appropriate ways and only in appropriate contexts. • Target somatic symptoms when they are the idiom of distress and explain how CBT strategies will impact physical well-being. • Support the development of positive cultural identity and racial socialization.

Self-Assessment Questions 3.1. Which of the following is NOT a strength of CBT when implemented with ethnocultural minority youth? A. B. C. D.

It is time limited and problem oriented. It is focused on the present and future. It is focused on intrapsychic, unconscious processes. It involves collaboration in defining treatment goals.


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3.2. Parent training protocols with ethnic minority youth may improve treatment retention and outcomes by including an emphasis on A. B. C. D.

Time-out. Physical discipline. Natural consequences. Racial socialization.

3.3. Antoine is a 9-year-old African American boy who is struggling in school. One of his core beliefs is that “only white kids do well in school.” This belief is an example of A. B. C. D.

Acculturation stress. Internalized oppression. Feelings as facts. Ableism.

3.4. CBT with an Iraqi (Muslim) 12-year-old girl with externalizing problems might be enhanced by A. B. C. D.

Family-focused sessions. Individual-focused sessions. Emphasis on assertiveness training in all contexts. Behavioral activation.

3.5. The clinician must be especially cautious in implementing which CBT skill because of its cultural acceptability in different settings (e.g., home vs. school)? A. B. C. D.

Behavioral activation. Problem solving. Assertiveness training. Cognitive restructuring.

Suggested Readings and Web Sites Population-Specific Information American Psychological Association: Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. August 2002. Available at: http://www.apa.org/pi/oema/resources/ policy/multicultural-guidelines.aspx. Accessed April 19, 2011.

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American Psychological Association: Practice guidelines for LGB clients: guidelines for psychological practice with lesbian, gay, and bisexual clients. February 2011. Available at: http://www.apa.org/pi/lgbt/resources/guidelines.aspx. Accessed April 19, 2011. American Psychological Association, Office of Ethnic Minority Affairs home page: www.apa.org/pi/oema/index.aspx Council of National Psychological Associations for the Advancement of Ethnic Minority Interests: Psychological treatment of ethnic minority populations. November 2003. Available at: http://www.apa.org/pi/ oema/resources/brochures/treatment-minority.pdf. Accessed April 19, 2011. Hays PA, Iwamasa GY: Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, and Supervision. Washington, DC, American Psychological Association, 2006 Additional resources such as peer-reviewed journals are also an excellent source of current literature on treatment with culturally diverse populations. Examples include Cultural Diversity and Ethnic Minority Psychology, Asian American Journal of Psychology, and Journal of Black Psychology.

Assessment Hays PA: Addressing Cultural Complexities in Practice: Assessment, Diagnosis, and Therapy, 2nd Edition. Washington, DC, American Psychological Association, 2008 Tanaka-Matsumi J, Seiden DY, Lam KN: The Culturally Informed Functional Assessment (CIFA) Interview: a strategy for cross-cultural behavioral practice. Cogn Behav Pract 3:215–233, 1996

Multicultural Training and Supervision to Promote Cultural Competence Ancis JR, Szymanski DM: Awareness of white privilege among white counseling trainees. Couns Psychol 29:548–569, 2001 Kiselica MS: Beyond multicultural training: mentoring stories from two white American doctoral students. Couns Psychol 26:5–21, 1998 Sue S, Zane N, Nagayama Hall GC, et al: The case for cultural competency in psychotherapeutic interventions. Annu Rev Psychol 60:525–548, 2009 Yutrzenka BA: Making a case for training in ethnic and cultural diversity in increasing treatment efficacy. J Consult Clin Psychol 62:197–206, 1995


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Research on Cultural Adaptations Bernal G, Jiménez-Chafey MI, Domenech Rodríguez MM: Cultural adaptation of treatments: a resource for considering culture in evidencebased practice. Prof Psychol Res Pr 40:361–368, 2009 Lau AS: Making the case for selective and directed cultural adaptations of evidence-based treatments: examples from parent training. Clin Psychol (New York) 13:295–310, 2006

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Combined CBT and Psychopharmacology Sarabjit Singh, M.D. Laurie Reider Lewis, Psy.D. Annie E. Rabinovitch, B.A. Angel Caraballo, M.D. Michael Ascher, M.D. Moira A. Rynn, M.D.

SINCE the 1990s, the field of mental health has significantly expanded its knowledge base on the treatment of pediatric psychiatric disorders through empirical research, which informs everyday clinical practice. This is most evident in the area of pediatric psychopharmacology. Pharmacotherapy has become an important treatment tool for clinicians treating children and adolescents with psychiatric disorders. Another effective treatment modality for many of these disorders is cognitive-behavior therapy (CBT), a well-established psychosocial intervention. Empirical evidence now exists to support the combination of both pharmacotherapy and CBT in the pediatric mental health sector for optimal outcome. Although the evidence supporting the efficacy of both interventions is rela119

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tively comparable for many psychiatric disorders, most parents and children prefer psychotherapy as a first-line intervention. For example, parents of anxious children with no prior treatment history have been found to prefer CBT to medication for the treatment of their child’s anxiety disorder. CBT is often perceived to be more acceptable, believable, and effective than medication (Brown et al. 2007). Medication is often used in conjunction with CBT when symptoms are in the moderate to severe range or when treatment with CBT has not provided symptom resolution. However, given the lack of treatment guidelines, clinicians face challenges regarding the use of combined treatment (CBT plus pharmacotherapy), such as the indications for use of the combination approach versus monotherapy treatment. In this chapter, we briefly review the psychopharmacological treatment evidence for the most common pediatric psychiatric disorders (depression, anxiety disorders, and attention-deficit/hyperactivity disorder [ADHD]); evidence for these treatments has increased our understanding of the effectiveness of psychopharmacological intervention in child and adolescent psychiatry. We subsequently present evidence for combined treatment with CBT. Finally, we substantively discuss clinical characteristics that might be useful in guiding the clinician to select the most appropriate treatment approach for a given patient.

Pharmacotherapy Treatment Depression The evidence-based literature supports the use of a class of antidepressants called the selective serotonin reuptake inhibitors (SSRIs) for children and adolescents. Although each of the SSRIs has individual pharmacological profiles, they all share the common property of effecting serotonin transporter inhibition. Abnormalities of serotonin function are believed to be critical in the etiology of depression and anxiety. In addition, serotonin is believed to affect sleep and appetite, and reduced serotonin functioning may cause insomnia and depression (Hamrin and Scahill 2005). When an SSRI is initiated, it generally takes 3–4 weeks to show evidence of an effect. Some of the better-known and common adverse effects associated with SSRIs include gastrointestinal upset, insomnia, restlessness, and sexual dysfunction. The clinician should carefully monitor the patient for the emergence of side effects during treatment, and the medication timing of dose and dosage may need to be adjusted to minimize adverse reactions.

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The only medications approved by the U.S. Food and Drug Administration (FDA) for the acute and maintenance treatment of major depressive disorder in children and adolescents are fluoxetine for ages 8–18 and escitalopram for ages 12–17. Currently fluoxetine is the only medication to yield three positive double-blind placebo-controlled trials to support its efficacy (Emslie et al. 1997, 2002b, 2008). Given its long half-life (i.e., the time it takes for the plasma concentration of a drug to reach half of its original concentration), there are fewer concerns about discontinuation syndrome. Discontinuation syndrome is a flu-like condition consisting of symptoms such as malaise, nausea, and headaches; the syndrome may occur after the patient stops taking the medication. Two studies have shown escitalopram to be more efficacious than placebo in adolescents (Emslie et al. 2009; Wagner et al. 2003). Escitalopram has the safest profile of all the SSRIs regarding interactions with other medications. This medication has an intermediate half-life; thus, discontinuation syndrome is possible and should be watched for. Despite positive studies indicating the effectiveness of other SSRIs in the treatment of pediatric depression, such agents are still considered offlabel treatments at this time. These medications include citalopram, sertraline, and paroxetine. The efficacy of citalopram over placebo is supported by one of two published studies (Wagner et al. 2004b; von Knorring et al. 2006). Two parallel placebo-controlled trials of sertraline showed statistically significant differences with sertraline compared with placebo when the data were pooled (Wagner et al. 2003). Paroxetine (Paxil) was shown to have antidepressant activity in adolescents on some primary and secondary measures Keller et al. 2001, whereas two other studies did not demonstrate efficacy versus placebo (Berard et al. 2006; Emslie et al. 2006). Results were mixed in studies of non-SSRI antidepressants in children and adolescents. Trials of nefazodone and mirtazapine resulted in unpublished negative double-blind, placebo-controlled depression trials (Emslie et al. 2002a). When venlafaxine ER was studied in the pediatric population, it was found to be effective only in depressed adolescents (Emslie et al. 2007). To date, no studies have been designed to assess the efficacy of bupropion for pediatric depression. A meta-analysis of tricyclic antidepressants (TCAs) for the treatment of pediatric depression found that they are not more efficacious than placebo (Ryan and Varma 1998); therefore, TCAs are not recommended at this time. They are considered inappropriate for children and adolescents because of their significant side effects, including anticholinergic effects (e.g., memory changes, constipation, confusion, blurred vision, dry mouth, sedation), and in overdose their cardiovascular effects and high lethality (Varley 2001).

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Although efficacy of some SSRI medications has been well established, in 2004, the FDA conducted a meta-analysis of 24 placebo-controlled trials of antidepressants in pediatric populations (both published and unpublished), and found that antidepressants pose a twofold (4% vs. 2%) increased risk for suicidal behavior or ideation (Hammad et al. 2006). Subsequently, the FDA issued a black box warning on all antidepressants, stating that these medications may increase the risk of suicidal thinking and behavior in children and adolescents. In the Treatment for Adolescents with Depression Study (TADS; Vitiello et al. 2009), acute interpersonal conflict greatly predicted suicidal events. Patients must be monitored and observed closely for long periods after an antidepressant has been started. The FDA developed a medication guide recommending that children treated with an SSRI be followed weekly during the first 4 weeks of treatment and biweekly from weeks 4 to 8. Patients should subsequently follow up with their physicians on a monthly basis beyond that time (U.S. Food and Drug Administration 2007).

Anxiety Disorders CBT and pharmacotherapy are the treatments with the broadest evidence of efficacy for pediatric anxiety disorders. When CBT and medication are used in combination, they are more efficacious than either treatment alone (Walkup et al. 2008). As with major depression, SSRIs are the first-line medication for the treatment of anxiety disorders. Three of the most rigorous randomized controlled trials (RCTs) investigated the efficacy of treating children diagnosed with one or several anxiety disorders (i.e., generalized anxiety disorder [GAD], separation anxiety disorder, and social phobia) with the following SSRIs: fluvoxamine (Research Unit on Pediatric Psychopharmacology Anxiety Study Group 2001), fluoxetine (Birmaher et al. 2003), or sertraline (Walkup et al. 2008). Each of these studies provides strong evidence for the efficacy of SSRIs in treating GAD, social phobia, and/or separation anxiety disorder. Studies have demonstrated the efficacy of sertraline and venlafaxine ER (Rynn et al. 2001, 2007) for the treatment of GAD. Paroxetine (Wagner et al. 2004a), fluoxetine (Beidel et al. 2007), and venlafaxine ER (March et al. 2007) have been found beneficial in the treatment of social anxiety. Alprazolam in a very small trial of avoidant adolescents demonstrated benefit but lacked statistical significance over placebo (Simeon et al. 1992). For panic disorder, daily use of paroxetine demonstrated significant improvement in subjects, with only transient and mild adverse effects associated with higher doses (Masi et al. 2001). In addition, an open case series


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documented the benefits of citalopram in school refusers with panic disorder (Lepola et al. 1996). Both fluvoxamine (Labellarte et al. 1999) and sertraline (March et al. 1998) have FDA approval for the treatment of obsessive-compulsive disorder (OCD) in patients ages 8–17 and 6–17, respectively. Fluoxetine has been found to be effective and is currently FDA approved for the treatment of pediatric OCD in patients ages 7–17 (Rossi et al. 2004). As compared with other anxiety disorders, OCD symptoms often need to be treated with higher dosing.

Attention-Deficit/ Hyperactivity Disorder Hundreds of studies conducted since the 1960s have consistently shown the efficacy of stimulant medication in improving symptoms associated with ADHD in children and adolescents. The recommended initial psychopharmacological treatment of ADHD is a trial with one of the medications currently approved by the FDA (Pliszka 2007). The FDA-approved stimulant medications for the treatment of ADHD include dextroamphetamine, D- and D,L-methylphenidate, mixed amphetamine salts, and lisdexamfetamine. The two nonstimulant medications that are currently FDA approved for ADHD are atomoxetine and guanfacine XR. It is believed that inattention and/or hyperactivity may be the result of insufficient dopamine and norepinephrine activity. Stimulant medication primarily increases synaptic concentrations of dopamine whereas nonstimulant medications, such as atomoxetine, increase norepinephrine synaptic concentrations (Solanto 1998). Evidence reflecting the benefits of stimulant medication was demonstrated by the Multimodal Treatment Study of Children With ADHD (MTA), which is detailed in the section “Review of Combination Treatment,” in “Attention-Deficit/Hyperactivity Disorder” later in this chapter. Some of the better-known adverse effects associated with stimulant use are suppression of appetite, weight loss, insomnia, and headache. Children with a preexisting heart condition should receive a consultation with a cardiologist before initiation of treatment with a stimulant medication (Pliszka 2007). According to Mosholder et al. (2009), symptomatology consistent with psychosis or mania may arise during treatment with stimulants and represents adverse effects. It is controversial whether or not tics occur more often in children and adolescents treated with stimulant medication. Some researchers have found that most tics that emerge during treatment are transient, and chronic tics are rather rare (Gadow et al. 1999). In children and adolescents with comorbid Tourette’s syndrome

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and ADHD, 30% of patients experienced an exacerbation of tics while on stimulant medication (Castellanos et al. 1997). Further investigation is needed to make definitive statements concerning the relationship between tics and stimulant medication. Adverse effects, which must be monitored when a patient is taking the norepinephrine reuptake inhibitor atomoxetine, include gastrointestinal distress, sedation, and decreased appetite. The FDA has issued black box warnings for atomoxetine, because of risks of hepatotoxicity and suicidality. The literature also supports the use of alpha-adrenergic agonists such as clonidine and guanfacine (both FDA approved) as second-line treatments (Newcorn et al. 1998). Other agents such as bupropion, desipramine, and modafinil have shown efficacy and are currently recommended as second-line treatments for ADHD (Banaschewski et al. 2004). When patients do not respond to either stimulant medication or atomoxetine, the two medications can be combined with good effect; however, more research is needed in this area to establish the safety of this combination (Brown 2004).

Review of Combination Treatment Since 2000, numerous trials have demonstrated the efficacy of CBT for various psychiatric disorders; Chapters 1 and 2 present the studies supporting this evidence-based treatment for children and adolescents. A common approach used by clinicians is the combination of medication and CBT for residual symptoms. There is growing evidence for the efficacy of combination treatment for childhood psychiatric disorders. This section reviews the evidence, issues to consider, and approaches to the childhood psychiatric disorders of depression, anxiety disorders, and ADHD. Appendix 4–A at the end of this chapter summarizes the evidence for these approaches in children and adolescents.

Depression There has been empirical support for the combination of CBT and pharmacotherapy for depressive disorders. TADS (March et al. 2004) was a large, multisite study designed to compare four different interventions: CBT alone, fluoxetine alone, CBT plus fluoxetine, and CBT plus placebo. The trial showed that combination treatments held an advantage over CBT or pharmacotherapy, specifically for adolescents with moderate to severe depression. The combination (fluoxetine plus CBT) was superior to placebo plus CBT, to fluoxetine alone, and to CBT alone. Additionally, fluoxetine alone was superior to CBT alone.


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Because only about 60% of adolescents with depression show an adequate clinical response to initial treatment trial with an SSRI, the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA; Brent et al. 2008) RCT studied the relative efficacy of four treatment strategies in adolescents who continued to exhibit depression despite an adequate medication trial. The interventions included switching to a different SSRI, switching to a different SSRI plus CBT, switching to venlafaxine, or switching to venlafaxine plus CBT. The authors concluded that for adolescents with depression who had not responded to an adequate initial treatment with an SSRI, the combination of CBT with a switch to another antidepressant resulted in a higher rate of clinical response than did a medication switch alone. Of note, a switch to another SSRI was just as efficacious as a switch to venlafaxine and resulted in fewer adverse effects. Predictors of better response to pharmacological management include less severe depression, less family conflict, and the absence of nonsuicidal self-injurious behavior. Clarke et al. (2005) tested a collaborative care CBT program adjunctive to SSRI treatment in a primary care setting (treatment as usual). They detected a weak CBT effect and small, incremental improvements compared with monotherapy. Goodyer et al. (2007) concluded that for adolescents with major depression, there is no evidence that the combination of CBT plus an SSRI in the presence of routine clinical care contributes to an improved outcome compared with the provision of routine clinical care plus an SSRI alone. Melvin et al. (2006) compared CBT alone, sertraline alone, and their combination in treatment of adolescents with depression. The authors concluded that while all treatments led to a reduction in symptoms of depression, the advantages of a combined approach were not evident. In summary, studies of combined treatment for major depressive disorder have shown conflicting results but overall support consideration, especially if monotherapy fails (e.g., Melvin et al. 2006). However, further research is needed to help identify patient clinical characteristics that might direct a clinician to consider initiating a combination approach first.

Anxiety Disorders In the treatment of anxiety disorders, both CBT and pharmacotherapy are considered efficacious as monotherapies; however, often symptom resolution is not complete, and many patients remain symptomatic. Additionally, predictors and moderators have been difficult to identify from these studies (Compton et al. 2004). Until recently, only a scarcity of research demonstrated the relative or combined efficacy of these interventions. Over the past several years, the field of mental health has focused on studying

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the effectiveness of combination versus monotherapy treatment of a variety of disorders. The Child/Adolescent Anxiety Multimodal Study (CAMS; Walkup et al. 2008) was a multisite RCT of 488 children (ages 7–17 years) with a primary diagnosis of an anxiety disorder (separation anxiety disorder, GAD, social phobia). Subjects were assigned to one of the four treatment arms: CBT only, pharmacotherapy only (sertraline 25– 200 mg), combination of CBT and sertraline, or placebo only. Monotherapy with either CBT or pharmacotherapy reduced the severity of anxiety, but the combination of the two therapies showed a superior response rate. All treatments were found to be safe and well tolerated. The Pediatric OCD Study (POTS) was designed to look at the combined efficacy of CBT and pharmacotherapy. Patients treated with CBT either alone or in combination with medication showed more improvement, with a slightly superior response rate seen for combination therapy as opposed to CBT alone (Pediatric OCD Treatment Study (POTS) Team 2004). Sertraline was shown to be more effective than placebo, but the effect size of improvement was smaller than that of CBT alone. Thus, the authors concluded that children and adolescents with OCD should be treated with CBT alone or CBT plus an SSRI. There has been considerably less work studying the efficacy of combined treatments for posttraumatic stress disorder (PTSD). Cohen et al. (2007) examined the potential benefits of adding an SSRI (sertraline) to trauma-focused CBT for improving PTSD and related psychological symptoms in children who experienced sexual abuse. Only minimal benefit was noted in adding sertraline to trauma-focused CBT. The authors concluded that an initial trial of trauma-focused CBT or other evidence-supported psychotherapy should be started for most children with PTSD symptoms before adding medication (Cohen et al. 2007). Overall, there is support for the use of combined CBT and pharmacotherapy for maximum benefit in the short-term treatment of anxiety disorders. Future studies will need to assess the long-term efficacy and safety of this combined approach.

Attention-Deficit/ Hyperactivity Disorder The largest clinical trial conducted to evaluate the efficacy of different treatment modalities for ADHD is the MTA. The study found that at 14-month follow-up, the combined treatment arm (stimulant and behavioral treatment) and stimulant treatment alone provided greater symptom improvement for core symptoms of ADHD than did the behavioral treat-


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ment arm (MTA Cooperative Group 1999). At 24-month and 8-year follow-ups, the greatest predictors of outcome were initial severity of symptoms and continued medication compliance (Molina et al. 2009). Interestingly, when areas of functioning were reviewed—such as oppositional or aggressive symptoms, internalizing symptoms, teacher-rated social skills, parent-child relations, and reading achievement—combination treatment was consistently more effective than routine community care, whereas medication alone and behavioral treatment alone were not as effective (MTA Cooperative Group 1999). However, these longitudinal findings need to be interpreted with caution because no random assignment was in effect, and children in all the “conditions” were receiving assorted treatments and a variety of self-selected combinations.

Clinical Implication and Application In the preceding sections, we have outlined the evidence for use of pharmacotherapy and for combined treatment with pharmacotherapy and CBT. Evidence for such interventions is seen across various disorders, with the most compelling evidence existing for depression and anxiety. Despite emerging evidence in recent years for combined treatments, a clinician often still faces a dilemma in making a careful determination as to which intervention approach will provide the best result and the needed relief of symptoms. Although evidence to date suggests that for some disorders, beginning with a combined treatment strategy is most effective, careful consideration should be taken when deciding to initiate pharmacotherapy, especially if psychotherapy alone could result in a significant reduction of symptoms. Lacking specific guidelines to determine the appropriate modes of treatment for particular disorders, clinicians commonly use their best clinical judgment on the basis of their sum total of clinical experiences. This variability in approach among clinicians leads to suboptimal treatment response. Although no one strategy will fit all cases, a careful assessment should help clinicians identify factors that could guide them in making their clinical decisions. Such an approach by no means guarantees success, but it can help clinicians more confidently select an approach that might lead to greater treatment success for the patient.

Clinical Characteristics In selecting an individualized treatment strategy, we recommend a detailed assessment, with particular attention to the factors discussed in the

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remaining sections of this chapter. With attention to these factors, clinicians can make informed decisions regarding which intervention to choose first and if unsuccessful, when a given intervention should be changed or augmented with another treatment. These factors may have value in informing the treatment selection process. We have provided three main categories, and discussion of the various factors within these categories follows. 1. Patient factors 2. System factors 3. Practitioner factors For example, since 2000, most of the studies investigating combination treatment recruited adolescent populations, with the majority in the age range of 12–18 years (TADS, March et al. 2004; TASA, Brent et al. 2009; TORDIA, Brent et al. 2008). The mean age for many of the trials is approximately 15 years. In a clinic population, it is not uncommon to see children ages 7–12 years or even younger presenting with anxiety or depressive disorders. Therefore, even if medications are considered, families and most practitioners typically prefer CBT for the younger age group. Thus, the age of the child at presentation becomes an important factor in determining which intervention to choose first.

Patient Factors Patient Perspective Patients may envision themselves playing an important role in their treatment. They may want to be an active participant in the treatment process. Such individuals readily agree to a CBT approach. Other patients, however, may want their treatment driven by the clinician only. These patients may not be strong candidates for CBT, and pharmacotherapy may be more acceptable to them. Prior experience of treatment. A patient’s prior experience with an intervention has a significant impact on his or her current choice for treatment. Individuals who have had a positive experience with psychotherapy in the past are more likely to reengage in psychotherapy. Similarly, a positive experience with medications (for medical or psychiatric reasons) makes the patient more willing to agree to a medication trial. It is essential that clinicians build on the positive transference for a successful outcome. It is also important for the clinician to explore the meaning of medication


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and taking medication, as patients’ perspectives on their treatment may have a major influence over outcomes. Patient preference. As noted above, a patient’s preference is generally guided by his or her prior experience. However, at times it could be informed by other factors, such as information regarding treatments obtained from the Internet, social networking Web sites, health educators at school, peer opinions, and most importantly, family members. It is important for clinicians to educate the patient and family about all potential treatment options and assist them in making an informed treatment decision after discussing the pros and cons of each intervention. Clinicians should be respectful of the patient’s preference in choosing an intervention; this will lead to an improved therapeutic alliance and increased treatment success. Psychoeducation regarding the biological basis of many disorders and the role of medications, discussion regarding stigma of being on medications, and alleviating fears pertaining to side effects are essential components of psychopharmacological interventions and should be used to help the patient make an informed decision. Understanding of illness. Patients who conceptualize their illness on the basis of a medical model are more likely to agree to a medication trial or a combined approach. If depression is understood as a disorder that has resulted from a “chemical imbalance” or “dysregulated neurotransmitters,” then the patient may view it as a fixable problem, correctable with medication. On the other hand, if patients believe that their illness has been caused by their being “weak” (psychologically), or that their illness results from stress or being overwhelmed by external factors such as school, then they may feel more comfortable with CBT so that they can learn skills to cope with their problems. Irrespective of the intervention chosen, psychoeducation is a key component of treatment. Clinicians should help patients understand the diathesis-stress model: the complex interaction of biological and genetic factors (predisposition) with the environment and life stressors (Morley 1983). This concept promotes the use of a combined approach, and patients will see the benefit of each intervention. CBT helps patients learn ways to mitigate stress, solve problems, and develop coping skills, whereas medications tend to address the physiological and biological aspects of the illness. Psychological mindedness. Patients with cognitive limitations may not be able to engage with CBT. These patients may be concrete and inflexible in their thinking, making the process of rendering CBT difficult. However, this is not necessarily an excluding factor. Clinicians need to

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modify their techniques and treat patients according to their intellectual and emotional age rather than their chronological age. Clinicians also could emphasize more of the behavioral aspects of the treatment over the cognitive components. Patients with cognitive limitations may more often receive treatment with medications in combination with supportive therapy. In contrast, patients who have greater strengths verbally and who are psychologically minded have the potential to be strong candidates for CBT. These patients can implement newer skill sets. However, for a variety of patients, CBT principles can assist with pharmacological management (e.g., monitoring of progress and adherence).

Symptom Severity It is essential to assess the severity of symptoms before determining which intervention should be initiated first (CBT, pharmacotherapy, or combined). Clinical wisdom supports the recommendation that the more severe the symptoms, the more strongly medication should be considered. Some clinicians might consider pharmacotherapy as the only intervention. This is more likely to be the case for disorders such as ADHD, for which the evidence of medication as the main intervention is very strong. For depressive and anxiety disorders, if the severity is mild, then the recommendation is to initiate CBT first. Continuous monitoring is needed and a switch to a combined approach should be made if symptoms worsen. For moderate to severe symptoms, medications (alone or combined with CBT) are recommended. Data from TADS (March et al. 2004) indicates that adolescents with moderate to severe depression have the best chance of clinically significant improvement at 12 weeks if they start with a combination of medication and CBT. Similarly, for moderate to severe anxiety disorders, recent research supports the use of combined treatment (Walkup et al. 2008). With medication treatment, symptom reduction is seen as early as week 3 or 4; and with CBT, symptom reduction occurs later in treatment (Keeton and Ginsburg 2008). Furthermore, early improvement also leads to overall successful treatment (Westra et al. 2007). Although previous studies recommended CBT for mild to moderate pediatric anxiety cases only (James et al. 2005), more recent evidence from CAMS (Walkup et al. 2008) shows that CBT is an effective intervention for patients with moderate to severe symptoms and is a relatively riskfree intervention compared to pharmacotherapy. However, patients might not be able to participate in CBT if they have significant symptoms. Severe symptoms could become a hindrance to compliance with psychotherapy appointments and could also lead to a general feeling of hopelessness and a pessimistic outlook (e.g., “I am feeling terrible, and it is too hard to do


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the things I need to feel better”). Therefore, in severe cases, the combined approach should be considered as first-line treatment. Notwithstanding, a combined approach can have its challenges. For example, symptom reduction with medication could make implementing CBT difficult: in a patient who no longer has anxiety arousal or symptoms, it is difficult to teach the skills necessary to cope effectively with those triggers. Severity of symptoms is an important factor in determining which intervention to choose first, and a combined approach of CBT and pharmacotherapy is recommended if symptoms are severe. Symptom type. Clinicians recognize that symptoms often vary among patients with the same diagnosis. There could be a predominance of a subset of symptoms, or a particular symptom (e.g., insomnia) could be the cause of most impairment for the individual. Therefore, the clinician should note the key symptoms that constitute the illness. Patients with depression and/or anxiety can present with a vast array of symptoms that can be classified as 1) physiological symptoms or 2) cognitive symptoms or maladaptive behaviors. Physiological or neurovegetative symptoms of depression, such as insomnia, decreased or increased appetite, weight loss or weight gain, decreased energy, and poor concentration, generally respond well to medications. If any of the aforementioned symptoms are a significant part of the patient’s presentation, medications should be strongly considered. Similarly, physiological symptoms of anxiety disorders, such as insomnia, palpitations, sweating, and increased heart rate, do also respond to medications such as SSRIs or benzodiazepines. Regulation of physiological symptoms leads to quick reduction in distress and impairment and therefore increases compliance with the intensive work of CBT, both in session (e.g., exposures) and outside session (e.g., homework assignments). If the patient’s symptom pattern is overwhelmingly that of hopelessness, distorted thinking, guilt, and avoidance behaviors, then a trial of CBT is warranted. CBT techniques focus on identifying triggers for automatic thoughts, reframing and replacing maladaptive patterns of thinking (cognitive distortions), problems solving, self-regulation, relaxation training, social skills, anger management, and contingency management. CBT also helps in providing a framework to understand the role of medication and so helps in improving medication adherence. The patient’s symptoms can guide the clinician in choosing which intervention to start with (CBT vs. pharmacotherapy), although in many cases a combined approach might be the best, especially if the profile reflects a combination of symptoms. A combined approach is likely to yield better results as evident from faster improvement, greater symptom reso-

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lution, and increased sustainability of improvement (March et al. 2004; Walkup et al. 2008). Because the different approaches are not necessarily isolated entities, synergistic effects are often seen when the same symptom is targeted using a combined approach. For example, insomnia is quickly and effectively treated with both CBT and medication: pharmacotherapy can treat the immediate symptoms, and CBT techniques can provide a basis for preventing future psychopathology when the patient learns, for example, stress management skills.

Case Example Feliciana is a 10-year-old Latino girl with no formal psychiatric history who was referred by her pediatrician to the emergency room secondary to impairing symptoms of anxiety over the past 2 months. At presentation, Feliciana reported daily symptoms of nausea, vomiting, trembling, feeling nervous, and school refusal. Other symptoms included initial insomnia >3 hours (as a result of worrying about school), appetite disturbance (not eating anything during school time and nighttime overeating), and having occasional feelings of dizziness. She also reported feeling sad, frustrated, and overwhelmed. The mood symptoms were in the context of her getting “tired” of her anxiety. Onset of symptoms was described as “sudden,” and a recent change in school with subsequent difficulty in adjusting to the new environment was the main stressor. She reported a long-standing history of excessive worries. The worries were about her school performance, the health of her mother, the relationship between her parents, earthquakes, and someone breaking into their house. She reported symptoms suggestive of a panic attack (heart beating too fast and breathing rapidly). She was medically discharged from the emergency room and given a provisional diagnosis of GAD; separation anxiety disorder and panic disorder were ruled out. Although CBT was the preferred intervention by the parent, considering the severity of symptoms (progressive worsening of anxiety leading to school refusal) and symptom profile (severe insomnia and other physiological symptoms), a combined approach (CBT and fluoxetine) was recommended and agreed on. Fluoxetine was started at 10 mg for 2 weeks and then increased to 20 mg. Psychoeducation was provided to the parent by discussing the disorder, its course, and the role of medications in addressing target symptoms of anxiety and insomnia. By week 3, Feliciana reported some improvement in her anxiety symptoms, especially with respect to her insomnia and feeling less overwhelmed. The CBT therapist focused on psychoeducation, identification of triggers, relaxation breathing, cognitive restructuring, problem solving, and behavior modification. Feliciana was maintained at that dose for the next 5 months. She was able to successfully start attending school on a regular basis after week 6 of treatment. By week 12, Feliciana reported significant improvement in symptoms, with resolution of most of her symptoms. CBT was tapered to once every 2 weeks and then monthly sessions. Feliciana has been attending school regularly and has been symptom-free for the past 4 months.


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This case highlights the effectiveness of a combined approach. Participation in psychotherapy was assessed to be difficult because of the severity of symptoms. A clinician could argue that CBT alone on a trial basis could have been employed first, but given the symptom severity, presentation to the emergency room, and a concern that the patient may have struggled initially with the CBT work, a combined approach was deemed appropriate. The synergistic effects of medication and CBT were seen in this case. Comorbidity. Comorbidities are extremely common and are viewed by many clinicians as a rule rather than an exception for pediatric psychiatric disorders. For example, oppositional defiant disorder (ODD) is commonly seen as a comorbid disorder in children with ADHD. Other common comorbidities with ADHD include learning disorders, depression, and anxiety disorders. Although medications are considered the first-line intervention for children with ADHD, a combined approach is recommended if there are significant comorbid disorders. Parent training for ADHD and ODD and behavioral modification therapy for ODD are effective interventions to implement in such cases. Additional measures such as appropriate classroom placement are helpful to address comorbid learning disorders if present. As shown by the MTA, behavioral therapy can address non–core symptoms of ADHD, such as poor social skills and low selfesteem (MTA Cooperative Group 1999). For patients with primary depressive and anxiety disorders, pharmacotherapy or CBT might be the only intervention indicated in the absence of comorbidities. However, for significant complex comorbidities, such as social phobia with ADHD and mood disorders, combined treatment may be warranted. Of note, with comorbid substance use, medication management may be challenging and risky for patients who are actively abusing substances. Specialized CBT for this patient population would provide an important treatment component. Comorbidities generally indicate the need for a combined approach for better outcomes.

Treatment Response In patients who started with monotherapy (CBT or pharmacotherapy alone), lack of improvement or suboptimal improvement after 6–8 weeks of treatment typically becomes an indication for a combined approach (Keeton and Ginsburg 2008). Provided that the lack of improvement is not due to noncompliance with recommendations (therapy or medications), it is reflective of the severity of illness and lack of response to one intervention. An alternative to a combined approach would be to intensify the same intervention; for example, the therapist could increase CBT ses-

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sions to twice weekly or the psychiatrist could increase the dose of medication or add other agents.

Case Example Jonna, a 14-year-old Jewish adolescent girl in ninth-grade regular education at a coed Jewish private school, presented to the outpatient clinic with symptoms of inattention, distractibility, and poor organization. Other symptoms included losing items (like her debit card), impulsivity related to speaking out of turn, and poor concentration. Symptoms of inattention and impulsivity were negatively impacting her academics regarding time needed to complete her assignments, ability to focus in school, and her peer relationships. Regarding her symptoms of inattention, Jonna and her parents noted that she frequently made careless mistakes in her homework and exams, often appeared dazed (as reported by teachers and peers), had difficulty organizing tasks, forgot to hand in homework assignments that were completed, and was easily distracted. Hyperactive and impulsive symptoms that were currently noted included fidgeting, appearing as if she was driven by a motor, talking excessively, blurting out answers in class before being called on, and often interrupting others in conversation. Jonna was previously diagnosed with ADHD, combined type, at age 7 and was successfully treated with Adderall XR, 30 mg, until age 13. About 1 year ago, medication had been discontinued by her parents. Jonna met criteria for ADHD and was willing to restart medications. Additional areas of clinical concern included Jonna’s anxiety related to succeeding at school and being a competitive candidate for college. In light of her strong desire to apply to a number of competitive universities, Jonna had signed up for a plethora of extracurricular activities at school, including the environmental and drama clubs, debate and soccer teams, and art group. Jonna did not meet criteria for a specific anxiety disorder but had worries and anxiety related to school pressure, measuring up to her peers and older sibling, and meeting her future goals. Family history was relevant for anxiety disorder (mother, successful remission of symptoms following psychotherapy), bipolar disorder (father), and suicide (paternal uncle with unknown psychiatric diagnosis). Jonna was restarted on medication, and immediate improvement in symptoms of ADHD was noted. Benefits far outweighed the side effects (mild loss of appetite). However, over the next several months, her anxiety symptoms worsened, which resulted in more impairment and academic decline. This led to negativistic thinking (“I will never get better”), sad mood, low self-esteem, and hopelessness. Jonna recognized the need to seek treatment for her anxiety and depressive symptoms to achieve overall better outcome. The possibility of stimulants worsening her anxiety was considered, but this seemed unlikely because Jonna was persistently anxious even during times of an extended drug holiday. The need for medications to address ADHD was clear, but the question was, “Should we treat comorbidities with an SSRI, CBT, or a combined approach?” Owing to successful remission of core symptoms of ADHD on medications, Jonna initially expressed willingness for a medication trial of an SSRI to target symptoms of anxiety as well. We conducted a detailed as-


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sessment of all factors to decide the next intervention. Her symptoms of anxiety and depression were mild to moderate in severity. Her symptom profile was suggestive of symptoms being primarily “cognitive” as opposed to “physiological.” Jonna’s mother had had a positive experience in psychotherapy to achieve remission of anxiety symptoms. Other factors we considered included Jonna’s high IQ, her being articulate and psychologically minded, and her understanding of anxiety disorder (in her own words, “it is an excess of normal anxiety, which gets exacerbated by stress”). Jonna was available to commit to weekly therapy sessions, and she expressed eagerness to learn a new skill set to address her symptoms. She also felt that although core symptoms of ADHD were in good control, she still needed to learn to be less forgetful and more organized, and she wanted to augment positive effects of medication treatments. All of the above led us to recommend CBT along with continuation of stimulants for ADHD. Six weeks after initiation of CBT treatment, Jonna reported symptoms being less intense. Seeing early improvement and excellent participation and compliance, we decided to continue with CBT as the monotherapy to address symptoms of anxiety and depression. However, 1 week after this decision was made, Jonna reported worsening of symptoms (new stressors had emerged). Lack of improvement was evident at subsequent sessions. At week 10, a medication consult was done and an SSRI recommended along with continuation of CBT (combined approach). After 4 months of CBT and medications, Jonna’s symptoms completely resolved. She discontinued the SSRI after 6 months of treatment and continued with CBT and Adderall XR for her ADHD. Jonna went on to do exceedingly well in school.

This case highlights several important steps in determining which intervention to choose. Following a careful assessment of a variety of factors, we initially considered only CBT to be a reasonable choice. However, owing to lack of significant improvement at week 8, a combined approach was chosen, to which the patient responded well.

System Factors In addition to patient factors that may influence clinical decision-making regarding the use of a specific treatment approach, system factors also mediate treatment choices. These system factors are especially critical to consider when working with youth, because these patients are heavily dependent on and influenced by the family, social, school, and cultural systems in which they are embedded.

Parental Attitudes Treatment choice. In most cases, parents are the ultimate arbiters of the type of treatment in which their child will engage. The way parents conceptualize the nature of their child’s psychiatric condition and associ-

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ated treatment needs following the assessment and recommendations of a mental health professional is often linked to their own personal preferences, understanding, and experiences. One issue that Moses (2011) highlighted is the extent to which parents believe a diagnosis to be credible or accurate. Generally speaking, a strong treatment alliance between clinician and parent is widely acknowledged in the literature as a significant variable in promoting adherence to treatment (American Academy of Child and Adolescent Psychiatry 1998). Strengthening the alliance between parents and the clinicians treating their children is an especially important goal, because if a parent trusts the integrity of the diagnostic process as well as that of the clinician, he or she is more likely to trust the verity of a diagnosis and to accept and ultimately follow through with a given treatment recommendation for the child, be it in favor of a single or combined approach. Parental attitudes about psychiatric treatment for their child can also be shaped by their own psychiatric history and/or experiences with mental health professionals (Moses 2011), as illustrated in the following case examples.

Case Examples Mariela is the 50-year-old mother of a 16-year-old girl with major depression. At the age of 45, Mariela was prescribed an SSRI for symptoms associated with a debilitating major depressive episode; she reported not liking “the way it made me feel” and stopped taking her medication against medical advice. She explained that her negative experience was exacerbated by the fact that “my doctor didn’t listen to me.” Consequently, she was extremely reluctant to even consider employing psychotropic medication when the recommendation was made by her daughter’s clinician after a trial of CBT failed to address some unremitting neurovegetative symptoms of the illness. Paula is the 40-year-old mother of a 10-year-old girl with impairing symptoms of social anxiety. During the first appointment of her daughter’s psychiatric evaluation, Paula detailed her own experience with severe anxiety and outlined a family history significant for anxiety disorders and depression. She immediately advocated for the use of psychotropic medication to address her daughter’s symptoms because she had found them helpful in the treatment of her own anxiety disorder. She expressed this preference, as well as an understanding of the role of genetic factors involved in psychiatric disorders, in the following statement to the intake clinician: “Why make Rebecca wait for longer than she should to feel some relief? I did the whole psychotherapy stuff first, and yeah, I learned some things—but at the end of the day, my body was my body and my genes were my genes, and the feelings were often too difficult to bear. Unfortunately, Rebecca is blessed with the same curse.”


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The latter case example (Paula) illustrates the position of Moses (2011) that those parents who have participated in their own mental health treatment in the past may be ultimately more inclined to conceptualize their children’s psychiatric issues in a manner consistent with mental health professionals’ diagnostic and treatment paradigms, and they are perhaps more sensitized to a medical conceptualization of their children’s psychiatric condition. On some occasions, a parent’s mental illness may negatively impact the parent’s effectiveness in accessing mental health treatment for the child, as in the case of maternal depression (Ryan 2003). A parent’s distress about the prospect of, for example, the child taking psychotropic medications on a long-term basis for the treatment and prevention of major depressive episodes will influence treatment plan implementation (Ryan 2003). How parents comprehend the scope and context of their child’s problems and the attitudes they possess about treatment are important variables to consider when deciding on and recommending a treatment approach. Demographics. A number of demographic variables are likely to influence parental attitudes about mental health treatment and parents’ styles of managing their children’s mental health issues. One variable is a parent’s level of educational attainment. Less-educated parents are less likely to use psychiatric terms to explain their child’s problems (Moses 2011), which may result in negative attitudes about a medical conceptualization of their child’s mental health problems and the use of psychotropic medication, for example. In general, higher rates of noncompliance with both medication and psychotherapy were discovered among families of children from lower socioeconomic backgrounds (Brown et al. 1987). Demographic variables were also examined in a study of the use of psychostimulant drugs in children across the United States, which found a positive correlation between the use of psychostimulants and a higher level of affluence, geographic regions with greater population density, and higher rates of health care access (Bokhari et al. 2005). Race, culture, and ethnicity also contribute greatly to parental attitudes about mental health conceptualization and treatment. For example, African American families tend to be skeptical of more medicalized, potentially pathologizing ways of understanding, talking about, and treating their children’s mental health issues (Carpenter-Song 2009; Moses 2011), whereas European Americans are more inclined to consider neurobiological explanations for behavioral and emotional problems and are therefore more open to the use of psychotropic medication in the treatment of their children (Carpenter-Song 2009). Ultimately, these findings illustrate the need for clinicians to assess the sociocultural lens through which patients

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view different mental health treatment approaches, as covered in more detail in Chapter 3. Treatment compliance. Parental or familial attitudes about the child’s mental health treatment impact the extent to which a family may be willing and/or able to adhere to treatment recommendations. In general, consistent parental involvement in the mental health treatment of the child, whether in the case of a singular psychotherapy or pharmacotherapy approach or a combined approach, is critical—and assessing and acknowledging whatever attitudes about treatment a parent or caregiver may hold can enhance treatment outcomes. CBT treatments for youth, such as the Coping Cat (Kendall 1990) and C.A.T. Project (Kendall et al. 2002) for the treatment of anxiety disorders in children and adolescents, actively incorporate parent sessions into protocols, thus highlighting the need for family involvement in psychotherapy in order to enhance positive treatment effects. Regarding the role of parents and family in a combined treatment context, Diamond and Josephson (2005) advocated for a combined approach to treating ADHD that integrates pharmacotherapy and a psychosocial family intervention in order to address parental concerns about medication side effects, nurture parental competency, and target overall family functioning in the support of better treatment engagement, retention, compliance, and achievement of treatment goals. A combined treatment approach integrating individual and family-based psychosocial interventions with pharmacotherapy was also favored in the treatment of bipolar disorder in youth for similar reasons (Schenkel et al. 2008).

Logistical Concerns and Availability of Resources The level of parental impairment and logistical concerns (such as a parent’s ability to get a child to treatment and the parent’s ability to afford treatment) also influence treatment compliance and should be evaluated by the treating clinician to help determine the treatment of choice. For Mona, a young single mother of three, the likelihood of being able to get her 10-year-old daughter to psychotherapy on a weekly basis was limited; for her, a once-monthly medication management appointment with a psychopharmacologist was much more feasible. In the case of Horacio, a single father, his own mental illness limited his ability to competently administer psychotropic medication to his 12-year-old son, Michael, who had moderate symptoms of anxiety and depression. Consequently, the clinician thought it more appropriate to focus on supporting attendance at weekly individual psychotherapy sessions to address


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Michael’s socioemotional concerns through CBT, and whenever and wherever possible, to intervene at the family level to support an improvement in Michael’s and the family’s overall level of functioning. Health insurance. Access to mental health care is another system factor that impacts clinical decision-making. Health insurance companies have become a major influence in this regard; for example, many favor cheaper drug therapy over more expensive counseling alternatives (Bokhari et al. 2005). This reality may increase access to psychotropic medication and may ultimately strengthen a clinician’s recommendation for a combined treatment when accompanied by data about the potency of such an approach in treating certain types of psychiatric disorders in youth. Unfortunately, increasingly higher rates of uninsured patients have resulted in a higher unmet need for care (Bruce et al. 2002). Geography. Geography also plays a role in clinical decision-making. Proximity to practitioners is one concern. In some communities, access to a mental health practitioner qualified to provide psychotherapy or pharmacotherapy to a child or adolescent may be limited. Bruce et al. (2002) pointed out how, in rural communities, the greater the distance to health care providers, the lower the rates of access to care and treatment for affective disorders in youth. Given the larger number of children going to school with unmet mental health needs, school-based mental health programs are important systems-level interventions that can help bridge the gap between mental health providers and children with mental health needs (Nemeroff et al. 2008). Location of treatment is another consideration in clinical decisionmaking. For instance, if a youth is being seen in a hospital-based clinic, then greater access to psychopharmacologists may support a recommendation for pharmacotherapy.

Societal Factors The larger social, intellectual, and political zeitgeist by which a child and his or her family is influenced is another system factor that can inform the clinician’s attitudes about treatment and associated treatment choices. Stigma. In many societies, negative assumptions exist about mental health issues and treatment. Mukolo et al. (2010) noted that children with mental health concerns are particularly vulnerable to stigmatizing contexts, given how dependent they are on others within their extended family and social system to gain access to care. In recent years, the media attention paid to the possible negative side effects of psychotropic medications in youth and the

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consequent application of black box warnings on certain classes of medications have furthered the stigma about pharmacotherapy. In these instances, the stigma associated with taking psychotropic medication is an example of a barrier to effectively treating affective disorders in children (Bruce et al. 2002). In the case of Martina, a 15-year-old depressed adolescent, this stigma was influenced by cultural factors. Her parents readily agreed to psychotherapy but were resistant to pharmacotherapy because of the “bad things we have heard lately”; their pessimistic view of allopathic approaches to health care was prevalent in the close-knit South American community from which the family had recently emigrated. This case highlights how geographical proximity to others with similar perspectives serves to influence and normalize individual attitudes about a certain issue. Popular culture. A number of societal factors may contribute to more positive, socially acceptable views of mental health treatment. In the United States, for example, the high frequency of advertisements and information about psychotropic medications evident in a wide variety of outlets such as television, radio, the Internet, and print media has led to more widespread knowledge and acceptance of pharmacotherapy as a viable treatment option, which may influence parents to advocate more forcefully for a psychopharmacological approach to treating their child’s mental illness, in spite of the negative press (mentioned in the above paragraph) (Sparks and Duncan 2004). This shift is generally consistent with a movement in modern American culture to popularize psychology and mental health treatment in general, and interacts with demographic and geographical factors that were mentioned above to influence treatment decisions. These ideas are reflected in the statement of a 42-year-old mother of an 8-year-old son participating in weekly individual CBT sessions for separation anxiety: “Everyone I know has a kid who is either in therapy or is on meds for something or other if they are not in therapy or on meds themselves. It is almost like ‘the thing to do’— check that off the list along with extracurriculars and tutoring.”

Practitioner Factors Both patient and system factors that inform decision-making practices for the selection of a single or combined treatment are mediated by a third variable: practitioner factors. The clinician should consider the influence of his or her own specific characteristics when making treatment recommendations and/or assisting youth and families with the treatment decision-making process. The following factors should be considered: • Qualifications of the practitioner can influence the treatment choice made. Is the practitioner who is considering a single or combined treat-


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ment a psychologist or psychiatrist? Clearly, the educational background, knowledge of the research base demonstrating efficacy and effectiveness of various treatment approaches to treating youth, awareness of practice recommendations about treating youth with mental health needs (Winters and Pumariga 2007), and expertise and comfort level of a practitioner in the areas of CBT and pharmacotherapy are related to other important practitioner characteristics, such as practitioner preferences, attitudes, and biases, that dictate treatment decision-making practices (American Academy of Child and Adolescent Psychiatry 1998). • Age of the practitioner has been cited in the literature as relevant to clinical decisions. It seems that there is a higher ratio of younger physicians to older practitioners willing to prescribe psychotropic medications, a more recent statistic possibly linked to changes in medical training—namely, a greater emphasis on the role of psychotropic medication in treating mental health conditions. • Insurance company influence impacts practitioners’ choices, as it does families and consumers of health care services in general. In the current health care climate, practitioners are pressured by a need to be held accountable to both consumers and third-party payers for the effectiveness and efficacy of interventions, increasing the amount of pressure they face to balance issues such as service, cost, and treatment outcome in a managed care context (Burlingame et al. 2001). How a practitioner balances these issues directly affects treatment decision-making practices.

Conclusion CBT and pharmacotherapy have been shown to be efficacious interventions to treat many psychiatric disorders in children and adolescents. It is not uncommon for clinicians to use a combined treatment approach (CBT plus medication) to improve outcomes when the use of a single intervention is suboptimal and/or symptom remission is incomplete. In recent years, empirical support for use of the combination treatment approach has grown; however, there is still the need for developing guidelines to direct when to use these treatments alone or in combination, as well as guidelines for sequencing approaches. We suggest that a detailed assessment with special attention to child and parent factors and system factors would assist a clinician in making treatment decisions. In addition, there are certain practitioner factors that could influence the choice of the treatment approach. Consideration of all these factors and creation of an inventory of the patient’s clinical characteristics will help clinicians in providing individualized care and achieve the desired outcome.

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With the encouraging results of major studies conducted since 2000, which indicate a promising outcome for a combined treatment approach, future research is needed to help understand the moderators and mediators of an optimal treatment response.

Key Clinical Points • There are times when the primary diagnosis necessitates a combined treatment approach of CBT and pharmacotherapy (e.g., mood and anxiety disorders, attention-deficit disorder or ADHD). • Efficacy of the combined treatment approach to treat a variety of psychiatric disorders in youth (e.g., anxiety, depression, ADHD) is supported by research findings from major studies such as the Treatment for Adolescents with Depression Study, Treatment of SSRI-Resistant Depression in Adolescents, Pediatric OCD Study, Children/Adolescent Anxiety Multimodal Study, and Multimodal Treatment Study of Children With ADHD. • Many factors guide clinical decision-making in the recommendation of a specific treatment approach; it is important to consider these factors in the context of a thorough case evaluation and assessment before making treatment decisions. • Assessment will result in an inventory of clinical characteristics that reflect the child and parent factors, the context of the system factors, and the role of the practitioner making the recommendation. • The available evidence suggests that the use of combination treatment (CBT plus medication) is a safe and effective treatment approach, especially for pediatric mood and anxiety disorders. Many factors need to be considered before recommending this treatment approach.

Self-Assessment Questions 4.1. The only other medication besides fluoxetine that the U.S. Food and Drug Administration has approved for the treatment of major depressive disorder in adolescents (12–17 years) is A. B. C. D. E.

Sertraline. Escitalopram. Paroxetine. Fluvoxamine. Imipramine.


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4.2. On the basis of the results of the Children/Adolescent Anxiety Multimodal Study (CAMS), the following statement is true: A. CBT is the most effective intervention for children and adolescents. B. Pharmacotherapy is the most effective intervention for children and adolescents. C. Combined treatments (CBT and pharmacotherapy) showed a superior response rate compared to CBT or pharmacotherapy alone. D. No intervention was shown to be better than placebo. E. The results were inconclusive. 4.3. Which of the following statements is true regarding evidence for combined treatments (CBT plus pharmacotherapy) for depression? A. Combined treatments (CBT and pharmacotherapy) are always better than either treatment alone. B. CBT is consistently better than pharmacotherapy and thus should be the first line of treatment. C. Pharmacotherapy is consistently better than CBT and thus should be the first line of treatment. D. The results are mixed, with some studies showing efficacy of combined treatments and others the advantages of a combined approach. E. None of the above statements is true. 4.4. For a 13-year-old patient presenting with a first episode of major depression, the clinician should A. Always start with CBT first and switch to medications if CBT does not work. B. Take a detailed history and make a decision on treatment interventions on the basis of the inventory of factors, such as symptom severity and patient and parent preferences. C. Always start with pharmacotherapy first and then add CBT if symptom resolution has not been achieved by pharmacotherapy alone. D. Take a detailed history, assess for various factors, and then always start with a combined approach (CBT plus pharmacotherapy) because it has been shown to be the most efficacious. E. Let the patient decide.

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4.5. Which of the following are important factors to consider when deciding which intervention to choose from? A. B. C. D. E.

Severity of symptoms. Prior experience with treatment. Comorbidities. Availability of resources. All of the above.

Suggested Readings and Web Sites Leahy RL (ed): Contemporary Cognitive Therapy: Theory, Research, and Practice. New York, Guilford, 2004 Morris TL, March JS (eds): Anxiety Disorders in Children and Adolescents, 2nd Edition. New York, Guilford, 2004 American Academy of Child and Adolescent Psychiatry, www.aacap.org American Psychiatric Association, www.psych.org Anxiety Disorders Association of America, www.adaa.org Attention-Deficit Disorders Association, www.add.org Family Guide to Keeping Youth Mentally Healthy and Drug Free, Substance Abuse and Mental Health Services Administration, www.family.samhsa.gov MindZone, Annenberg Foundation Trust at Sunnylands with the Annenberg Public Policy Center of the University of Pennsylvania, www.fhidc.com/annenberg/copecaredeal National Alliance for the Mentally Ill, www.nami.org National Institute of Mental Health, www.nimh.nih.gov National Institutes of Health, U.S. National Library of Medicine, Medline Plus: Child mental health. Available at: http://www.nlm.nih.gov/ medlineplus/childmentalhealth.html. Accessed April 19, 2011. TeensHealth, Nemours Foundation, www.teenshealth.org

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Medication, dose, duration of treatment

N, age, diagnostic qualifications, comorbidities

FLX, 10–40 mg/day 12 weeks Participants were randomly assigned to one of four conditions: PBO FLX alone CBT alone CBT+ FLX Double-blind assignment: FLX alone, PBO alone Unblinded assignment: CBT alone, CBT+FLX

N=439; multisite Ages 12–17 years (mean age=14.6 years) MDD Comorbidities: anxiety disorder, disruptive behavior disorder, OCD/tic disorder Exclusions: bipolar disorder, severe CD, substance abuse or dependence, PDD, thought disorder, receiving concurrent psychotropic or psychotherapeutic treatment, failed two SSRI trials, or had poor response to treatment that included CBT

Primary and secondary outcome results

Comments, limitations, adverse events

FLX+CBT>PBO FLX+CBT >FLX alone and CBT alone FLX>CBT aCGI: 71% FLX+ CBT 60.6% FLX 43.2% CBT alone 34.8% PBO

Results suggest that CBT +FLX in the treatment of adolescents with MDD has best benefit-risk trade-off. Of note, clinically significant suicidal thinking decreased from baseline in all treatment groups.

Depression TADS (March et al. 2004)


Study

Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents

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Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued)





Depression (continued) Clarke et al. 2005

Participants who had been prescribed SSRIs by their TAU pediatric provider before study enrollment were randomly assigned to CBT+SSRI or TAU+ SSRI (control condition). Participants who were randomly assigned to CBT +SSRI received five to nine individual CBT sessions.

Primary outcome results: N= 152 aCES-D results showed a Ages 12–18 years (mean age= 15.3 years, TAU; nearly significant trend mean age=15.29 years, (P=.07) supporting CBT) CBT+ SSRI>TAU + MDD SSRI. Comorbidities: schizophrenia No advantage of CBT +SSRI Exclusions: significant over TAU +SSRI on other developmental or intellectual primary outcome measure, disability; suicidal risk MDD recovery. Secondary outcome results: Significant CBT advantage was found on Youth Self Report—Externalizing (P=.07) and Short Form-12 Mental Component Scale (P=.04).

Weak CBT effect was detected, possibly because of 1) small sample and 2) unexpected reduction in SSRI pharmacotherapy in CBT condition. High attrition posttreatment and at follow-up among adolescents.

Appendix 4–A: Combination Treatment

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Depression (continued) Melvin et al. 2006

SERT, 12.5–100 mg 12 weeks Participants were randomly assigned to one of three conditions: CBT SERT alone CBT+ SERT

aDepressive diagnosis N= 73; multisite Ages 12–18 years (remission=8 weeks (mean age=15.3 years) asymptomatic) MDD, dysthymic disorder, All treatments had DDNOS significant improvements Comorbidities: adjustment or at the end of acute phase; anxiety disorder, enuresis, however, for partial reading disorder, cannabisremission: related disorder NOS, CD/ 71.4% CBT ODD, BDD 46.7% CBT+ SERT Exclusions: bipolar disorder, 33.3% SERT psychotic disorder, substance abuse, active suicidality, other severe psychiatric disturbance requiring acute hospital admission

COMB showed greater response in MDD postacute treatment, but relatively low dose of SERT was prescribed. Few participants with severe depression were included. PBO condition was not included. AEs: fatigue, concentration, insomnia, drowsiness, restlessness, suicidal ideation, headache, yawning, increased appetite, nausea


Study


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No benefit of SSRI+CBT over SSRI alone across aHealth of the Nation Outcome Scales for Children and Adolescents and secondary outcome measures (participantrated mood and feelings questionnaire, CDRS-R, CGI-I).

Results suggest that for adolescents with moderate to severe depression, combination CBT +SSRI in the context of routine care contributes to improved outcome at 28-week follow-up compared with SSRI and routine care alone. Participants with previous optimal trial with SSRI+CBT were excluded. Neither severity nor comorbidity influenced results of COMB. Most common AEs: headaches, nausea, tiredness, dry mouth, and reduced appetite. Of note, symptoms of suicidality for both treatment groups for most outcomes reduced over time.

Depression (continued) Goodyer et al. 2007

Participants were randomly assigned to SSRI alone or SSRI+CBT (28 weeks) SSRI treatment: FLX, 10 mg/day for 1 week, increasing to 20 mg/day for 5 weeks. If no response, increase was considered at 6 weeks (to 40 mg on alternative days for 1 week followed by 40 mg/day for 5 weeks) and again at 12 weeks (60 mg on alternative days for 1 week followed by 60 mg daily for 5 weeks). 30 mg/day on average; 60 mg/day maximally.

N= 208; multisite Ages 11–17 years Moderate-severe major or probable major depression Comorbidities: suicidality, depressive psychosis, CD, anxiety disorders, alcohol abuse, tic disorder, eating disorders Exclusions: schizophrenia, bipolar disorder, global learning disability

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Depression (continued) TORDIA (Brent et al. 2008)

Paroxetine, 20–40 mg Citalopram, 20–40 mg Fluoxetine, 20–40 mg Venlafaxine (VLX), 150–225 mg 12 weeks Treatment arms: Switch to new SSRI alone Switch to new SSRI+CBT Switch to VLX alone Switch to VLX+CBT

CBT+ MED > MED switch N= 334 (231 completed alone protocol through week 12); VLX switch=SSRI switch multisite aAdequate clinical response: Ages 12–18 years (mean age= 15.9 years; mean CGI score ≤2 +CDRS-R of treatment-arm averages) score reduction by 50% MDD 54.8% CBT +MED 40.5% MED switch alone

Adolescents with treatmentrefractory depression may benefit from a switch to a new SSRI or VLX, in addition to CBT. Participants were nonresponders to initial treatment with SSRI for depression. Attrition: 30.8% withdrew due to AEs. AEs: sleep difficulties, irritability, flu-like aches, accident/injury, gastrointestinal issues, skin problems, musculoskeletal issues


Study


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Depression (continued) TASA (Brent Participants were allowed et al. 2009) to choose to be randomly assigned or to select their treatment. Three treatment conditions were available: Psychotherapy (TASA CBT) MED management TASA CBT +MED management 6 months

155

aSuicidal event: rate of Although differences in suicidal N= 124; multisite outcome were not detected Ages 12–18 years suicidal events was higher among treatment arms, risks for MDD, dysthymic disorder, in COMB group than either suicide events and for reattempts DDNOS, MDD +dysthymic MED alone or CBT alone, were lower in the current study disorder likely due to than in comparable samples, Significant qualification: made disproportionate treatment perhaps warranting further suicide attempt 90 days assignment (MED alone, examination of this intervention. before intake n= 15; MED+TASA CBT, Given that 40% of suicidal events Exclusions: bipolar disorder, n= 93; TASA CBT alone, occurred 4 weeks from intake, psychosis, developmental n= 18). increased safety planning and disorder, substance Significant group therapeutic contact early in dependence differences: monotherapy treatment may be useful. groups had higher interviewer- and selfreported rates of depression, greater hopelessness, higher number of previous suicide attempts, more hospitalizations 6 months before study, and lower levels of functioning.


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Depression (continued) When group differences were controlled, no differential effect of treatment type on suicidal outcomes was found among CBT+ MED, MED alone, and CBT alone.

TASA (Brent et al. 2009) (continued)

Anxiety disorders Bernstein et al. 2000

IMI Dosage monitored via blood levels (150 µg/L–300 µg/L) 8 weeks Participants were randomly assigned to one of two conditions: CBT+ IMI PBO+ IMI

N= 63 School refusal Ages 12–18 years (mean age=13.9 years) Comorbidities: One or more anxiety disorder, MDD Exclusions: ADHD, CD, bipolar disorder, eating disorder, drug and/or alcohol abuse, mental retardation, bipolar or affective disorder in first-degree relative

aOutcome

measures = weekly school attendance: IMI>PBO ARC-R: IMI>PBO RCMAS: IMI>PBO CDRS-R: IMI>PBO BDI: IMI=PBO

Results support multimodal approach to treating school refusal in adolescents (MED +CBT). COMB (CBT +IMI) was more effective than PBO on most outcomes. Attrition rate: 25.4% (n= 16)


Study


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Anxiety disorders (continued) POTS (Pediatric OCD Treatment Study [POTS] Team 2004)

SERT, 25–200 mg/day 12 weeks Participants were randomly assigned to one of four conditions: PBO SERT alone CBT alone CBT+SERT

aCOMB> CBT alone= N= 112 Ages 7–17 years SERT alone>PBO (mean age= 11.8 years; mean For remission of treatment-arm averages) (CY-BOCS≤ 10): COMB OCD and CBT >SERT alone=PBO

Both CBT alone and CBT + SSRI may be effective in treating childhood OCD. Treatment-emergent AEs in MEDtreated patients: decreased appetite, diarrhea, enuresis, motor overactivity, nausea, stomachache


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Anxiety disorders (continued) Asbahr et al. 2005

SERT, 25–200 mg/day 12 weeks Participants were randomly assigned to one of two treatment conditions: Group CBT alone SERT alone

aCY-BOCS N= 40 OCD 12 weeks’ acute treatment: Ages 9–17 years group CBT =SERT (mean age= 13.1 years; mean 9-month follow-up: of treatment-arm averages) group CBT >SERT Comorbidities: MDD (only if secondary to OCD) and other major Axis I disorders Exclusions: MDD (if primary diagnosis), bipolar disorder, ADHD (if primary diagnosis and/or if psychostimulants were required), PDD, PTSD, borderline personality disorder, psychosis, neurological disorders other than Tourette’s syndrome or any organic brain disorder

Significantly higher compliance rates in SERT group Psychotherapy (group CBT) may have more lasting effects in the treatment of pediatric OCD than MED (SERT) alone. AEs: SERT>group CBT: increased weight loss Group CBT> SERT: increased nausea, abdominal pain SERT=group CBT: irritability, headaches, dry mouth, trembling, diarrhea, sweating, increased appetite, weight gain


Study


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TF-CBT +SERT= TF-CBT +PBO Clinically meaningful improvement occurred on several measures, including the following: PTSD diagnosis: At posttreatment, 14 of 20 participants with PTSD no longer met criteria for diagnosis (8 TF-CBT + SERT; 6 TF-CBT+PBO). Global impairment status: At posttreatment, 15 of 22 participants who were in the “clearly impaired” range at pretreatment (CGAS< 60) had moved into the “not clearly” range on the CGAS: 9 TF-CBT+ SERT; 6 TF-CBT+PBO.

No significant group × time differences between the two groups. Cohort was not representative of sexually abused children requesting clinical treatment. Treating childhood PTSD with psychotherapy first, then following with MED, might be most effective. AEs were defined as suicide attempts, reportable child abuse episodes, drug overdoses, or psychiatric hospitalization Only one AE occurred over course of study between groups (one psychiatric hospitalization for ODD).

Anxiety disorders (continued) Cohen et al. 2007

SERT, 50–200 mg/day 12 weeks Participants were randomly assigned to receive one of two treatments: TF-CBT +SERT TF-CBT +PBO

N= 22 Sexual abuse–related PTSD Ages 10–17 years, females only Demographic information (% total participants): Ages 10–11, n= 5 (22.7%); Ages 12–14, n=10 (45.5%); Ages 15–17, n= 7 (31.8%) Comorbidities: MDD, GAD, substance abuse NOS (but not use), ODD, anorexia nervosa, panic disorder Exclusions: schizophrenia, other active psychotic disorder, mental retardation, PDD

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Anxiety disorders (continued) Cohen et al. 2007 (continued)

SERT, 25–200 mg/day CAMS (Walkup et 12 weeks Participants were al. 2008) randomly assigned to one of four conditions: PBO SERT alone CBT alone CBT+SERT Double-blind assignment: SERT and PBO groups Unblinded assignment: SERT +CBT group

Significant result: Most symptom improvement for TF-CBT+ SERT group occurred between weeks 3–5 (to be expected in a trial using SERT). aCGI-I score= 1 or 2: N= 488; multisite Ages 7–17 years 80.7% SERT+ CBT* (mean age=10.7 years) 59.7% CBT* GAD, SAD, and/or social 54.9% SERT* phobia 23.7% PBO Comorbidities: ADHD, OCD, *(P < .001) PTSD, ODD, CD SERT+ CBT> CBT =SERT Exclusions: MDD, substance >PBO use disorders, bipolar disorder, psychotic disorders, PDD, nonresponders to two trials of SSRI or prior CBT trial

Dropout rates: 23 (17.3%) on SERT and 15 (19.7%) on PBO 6-month open-label continuation phase for responders AEs: SERT vs. PBO: ns SERT vs. CBT: insomnia, fatigue, sedation, restlessness, and fidgeting more common in SERT (P<.05) Serious AEs: SERT+CBT: one psychiatric hospitalization SERT: one psychiatric hospitalization; one medical hospitalization


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ADHD MTA (MTA Cooperative Group 1999)

AEs: Most severe was depression, Results on 19 primary N= 579; multisite worrying, or irritability and could outcome measures show ADHD (combined type) have been due to nonmedication COMB and MED Ages 7–9.9 years factors. management>intensive Comorbidities: ODD, CD, For ADHD symptoms, MED behavioral therapy or internalizing disorder, special management was superior to community care learning disability behavioral treatment and to Exclusions: <80 on all WISC- COMB=MED management routine community care that for treatment of core III scales and on SIB; bipolar included MED. ADHD symptoms disorder, psychosis, or COMB did not yield significantly personality disorder; chronic greater benefits than MED serious tics or Tourette’s management for core ADHD syndrome; OCD serious symptoms, but it may have enough to require separate provided modest advantages for treatment; neuroleptic MED non-ADHD symptom and in previous 6 months; major positive functioning outcomes. neurological or medical illness; history of intolerance to MTA MEDs; ongoing or previously unreported abuse; suicidal or homicidal ideation

161

Methylphenidate hydrochloride 28-day titration period 5–20 mg (or higher if patient’s weight >25 kg) If inadequate response was achieved, patients were given alternative. MED: Dextroamphetamine (1.4%) Pemoline (1.0%) IMI (0.3%) Bupropion (0.3%) Haloperidol (3%) 13-month follow-up period after initial titration phase


APPENDIX 4–A



Note. AE=adverse event; ARC-R=Anxiety Rating Scale for Children—Revised; BDD =body dysmorphic disorder; BDI=Beck Depression Inventory; CAMS=Child/Adolescent Anxiety Multimodal Study; CBCL=Child Behavior Checklist; CD=conduct disorder; CDRS-R=Children’s Depression Rating Scale—Revised; CES-D=Center for Epidemiologic Studies—Depression Scale; CGAS=Child Global Assessment Scale; CGI-I=Clinical Global Impression—Improvement scale; COMB=combination treatment; CY-BOCS=Yale-Brown Obsessive Compulsive Scale, Child Version; DDNOS=depressive disorder not otherwise specified; FLX=fluoxetine; GAD=generalized anxiety disorder; IMI=imipramine; MDD=major depressive disorder; MED= medication; MFQ=Mood and Feelings Questionnaire; MTA=Multimodal Treatment Study of Children With ADHD; NOS=not otherwise specified; ns=not significant; OCD=obsessive-compulsive disorder; ODD=oppositional defiant disorder; PARS=Pediatric Anxiety Rating Scale; PBO=placebo; PDD=pervasive developmental disorder; POTS=Pediatric OCD Treatment Study; PTSD=posttraumatic stress disorder; RCMAS=Revised Children’s Manifest Anxiety Scale; SAD=separation anxiety disorder; SCARED=Screen for Child Anxiety Related Emotional Disorders; SERT=sertraline; SIB=Scales of Independent Behavior; SSRI=selective serotonin reuptake inhibitor; TADS=Treatment for Adolescents with Depression Study; TASA=Treatment of Adolescent Suicide Attempters; TAU=treatment as usual; TF-CBT=trauma-focused cognitive-behavior therapy; TORDIA=Treatment of SSRI-Resistant Depression in Adolescents; WISC-III=Wechsler Intelligence Scale for Children—3rd Edition. a Primary outcome measure.

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Depression and Suicidal Behavior Fadi T. Maalouf, M.D. David A. Brent, M.D.

CBT for Depression Empirical Evidence Depressive disorders in children and adolescents are common, recurrent, and impairing. Depression is prevalent in 1%–2% of children and 3%–8% of adolescents (Lewinsohn et al. 1998). These conditions are a leading cause of morbidity and mortality in the pediatric age group (Brent 1987; Bridge et al. 2006) and are associated with significant functional impairment in school and work, frequent legal involvement, and increased risks for substance abuse and completed suicide (Birmaher et al. 1996; Kandel and Davies 1986).

S This chapter has a video case example on the DVD (“Depression and Suicide”) demonstrating CBT for a depressed and suicidal adolescent.

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Clinical guidelines for the acute management of child and adolescent depression recommend the prescribing of antidepressant medications, psychotherapy, or both, with the best-studied psychotherapy being cognitive-behavior therapy (CBT) (Birmaher et al. 2007). CBT has the strongest evidence base to support its efficacy in the treatment of pediatric depression compared with other therapies. Clinical trials and meta-analyses have shown that CBT monotherapy is effective for the treatment of depression (Birmaher et al. 2000; Brent et al. 1998; Harrington et al. 1998; Weisz et al. 2006, 2009; Wood et al. 1996). However, in the Treatment for Adolescents with Depression Study (TADS), CBT monotherapy did not perform better than pill placebo and was inferior to medication monotherapy for acute treatment (March et al. 2004). The reasons why CBT was not more effective are not clear. The content of the psychotherapy was very dense, and it is possible that too many skills were offered, at too low a dose. After 18 weeks of treatment, however, the CBT-only treatment “caught up” with combination and medication-only treatments (Kennard et al. 2009b). The Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT), which compared the efficacy of medication alone to that of CBT plus medication in depressed adolescents, found no difference between medication monotherapy and combination treatment (Goodyer et al. 2007). Although these findings may seem to be at variance with TADS, in fact, the difference in acute phase response rate between medication alone and combination was not statistically significant in TADS, and this was especially true in those with more severe depression. Consequently, these results are actually consistent with the results from the ADAPT sample, which had more severe depression, was younger, and had to fail to respond to a brief psychosocial intervention—all factors that mitigate against CBT being effective (Curry et al. 2006; Renaud et al. 1998). In a more recent study that randomly assigned depressed youth to CBT versus usual care, CBT showed advantages over usual care in engaging parents, shortening time to remission, and requiring less additional medication. In this study, however, CBT and usual care had similar remission rates of 75% at the end of treatment (Weisz et al. 2009). One other study has compared CBT plus usual care, consisting of antidepressant medication provided in primary care, to usual care alone (Clarke et al. 2005). There were nonsignificant trends favoring the combination treatment, which also resulted in fewer outpatient visits for usual care and a lower adherence rate to antidepressant treatment. In the Treatment of SSRI-Resistant Depression in Adolescents (TORDIA) study, 334 depressed adolescents who had not responded to an adequate trial with an SSRI antidepressant were randomly assigned to a

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medication switch with or without CBT. There was a higher response rate with those who received both the medication switch and CBT, compared to those who received a medication switch alone (Brent et al. 2008). Interestingly, CBT appears to perform particularly well in depressed adolescents with comorbidity, especially anxiety (Brent et al. 1998). In the TORDIA study, the greater the number of comorbid conditions, the stronger the performance of CBT plus medication compared with medication alone (Asarnow et al. 2009). Studies have found that adolescents with higher levels of cognitive distortion are less likely to respond to CBT (Brent et al. 1998; Ginsburg et al. 2009). Marital and parent-child discord also militate against CBT efficacy (Birmaher et al. 2000; Feeny et al. 2009). CBT appears to be more effective in those youths from more advantaged socioeconomic backgrounds (Asarnow et al. 2009; Curry et al. 2006). CBT is also less efficacious compared with other treatments in patients who have a history of abuse and in those whose parents are currently depressed (Asarnow et al. 2009; Barbe et al. 2004; Brent et al. 1998; Lewis et al. 2010). In general, CBT is a treatment whose results are robust in patients with comorbidity, suicidal ideation, and hopelessness, but it performs less well in patients with a history of maltreatment or current parental depression. CBT has also been shown to be effective in preventing the onset of depression in adolescents who are at high risk because of subsyndromal depression, a previous history of depression, and/or a parent with a history of depression (Clarke et al. 2001; Garber et al. 2009). However, in the presence of current parental depression, CBT is not more effective than usual care in preventing depression in offspring of parents with a history of depression (Garber et al. 2009).

The CBT Model According to the cognitive diathesis-stress model (Beck 1967), depression is the result of an interaction between cognitive vulnerabilities and stressful life events. These cognitive vulnerabilities, referred to as schemas, are formed early in life and are shaped by life experiences. Depressogenic schemas are cognitive structures based on a negative internal representation of the self and the environment (including others). Vulnerable individuals, when experiencing life stressors, engage in negative thinking as a result of these schemas. Their automatic negative thoughts lead to depressive feelings that are associated with maladaptive behaviors (e.g., social withdrawal). Depressed children and adolescents have been shown to have the same cognitive distortions and bias to negative events as depressed adults. Depressed youths have negative thoughts about themselves and the

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world around them, and they selectively attend to negative stimuli in their environment (Maalouf and Munnell 2009). In addition to cognitive models, there are behavioral models of depression, of which social learning theory has been the most prominent (Lewinsohn et al. 1998). This behavioral model posits that life stressors cause a disruption in normal adaptive behavior, and this disruption leads to and tends to perpetuate depression. This disruption causes individuals to use maladaptive skills to control their depressive feelings when these skills can only lead to worsening of these feelings (e.g., a girl who isolates herself in her room and declines an offer to go out with her friends because of depression would most likely feel more depressed secondary to social isolation). CBT for youths with depression aims to target the above-mentioned maladaptive cognitive processes and behavioral patterns that contribute to low mood. In order to achieve this goal, a repertoire of techniques is used in CBT.

Application CBT treatment is not a long-term treatment but rather is time limited. Acute treatment typically consists of 12 weekly sessions of 60–90 minutes each. Most of these sessions are individual sessions, but family sessions can take place as needed (typically 3–6 sessions during the treatment course). In addition, at the beginning of each individual session, the therapist typically checks in with the parent for 5–10 minutes. Although specific CBT manuals vary in the extent to which they emphasize one technique over the other (Brent and Poling 1997; Clarke et al. 2003; Curry et al. 2000), we will focus here on techniques that in our clinical experience, have been relevant to most depressed youths: psychoeducation, mood monitoring, problem solving, cognitive restructuring, emotion regulation, behavioral activation, and social skills training. At times, other specific intervention strategies are selected on the basis of an assessment of the cognitive, behavioral, and environmental variables contributing to the depressive symptoms; these strategies may include family interventions and relaxation techniques. The different CBT components are summarized in Table 5–1.

Session Format Start by setting the agenda for the session together with the youth. Review his or her current mood symptoms and assess the youth’s suicide risk. Then review events that took place since the last session and the CBT skills that were practiced. If the youth did not practice the CBT skills, it is important to explore the reasons and whether anything can be done to make the skills more easily and readily usable. Next, review the material covered


TABLE 5–1.

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Cognitive-behavior therapy (CBT) with depressed youth: main components

Component

Content

Psychoeducation

Defining depression, identifying its causes and treatments, and setting treatment goals. Typically done over one to two sessions with family and youth.

Mood monitoring

Making the youth aware of different emotions and asking him or her to keep a mood diary.

Problem solving

Training the youth to solve problems by identifying what the problem is, generating different solutions, and evaluating the consequences of each.

Cognitive restructuring

Guiding the youth to recognize distortions in his or her thought process and helping the youth to come to a more adaptive way of thinking.

Emotion regulation

Introducing the concept of intensity of emotions using a feelings thermometer and making the youth aware of physiological and psychological cues associated with the different intensities. Teaching emotion regulation strategies such as opposite action.

Behavioral activation

Asking the youth to increase time spent in pleasurable activities on a daily basis and educating him or her that mood does not need to improve before engaging in these activities.

Social skills training

Teaching effective communication skills such as greeting, active listening, and maintaining eye contact through role-playing.

Family interventions

Educating family members about depression and treatment, introducing the different CBT concepts to them, and addressing high expectations by setting clear goals for treatment.

Relaxation

Teaching diaphragmatic breathing, progressive muscle relaxation, and guided imagery as a means to cope with stressful situations.

Relapse prevention

Providing booster sessions to help reinforce the CBT model, monitoring for recurrence of depression, and preparing for future stressors.

in the previous session, including the homework given. Devote the rest of the session to teaching a new set of skills. Rehearse the skills with the youth using role-play. Elicit feedback from the youth as you go along in the session and then agree with the youth on a homework assignment.

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Specific CBT Components Psychoeducation. Psychoeducation is the first component of a successful CBT intervention. It is typically done in one to two sessions conducted with both the youth and the parents. Children and parents are often confused about the nature of the disease and the type of treatment. Use these sessions to explain to the family that depression is a condition that affects thoughts and feelings, review the fact that depression can be caused by many factors, and explain that there are successful interventions that include medications and therapy. This step helps reassure the child and family that what they are experiencing is a known condition that many people go through. Psychoeducation can be a powerful intervention tool, and multiple family therapy groups that feature this component have been shown to improve the outcome of children with mood disorders (Fristad et al. 2009). Next, review the rationale behind CBT by explaining to the family the triad of thoughts, behaviors, and emotions and how they are interrelated. Introduce the family to the basic principles and goals of CBT, which include targeting maladaptive behaviors and thoughts with the goal of alleviating negative emotions associated with depression. Hearing from the child and the family a summary of the presenting problem helps you personalize subsequent components of CBT during the treatment course. Ask the child about his or her goals for treatment and elicit from the parents support of these goals. There is a tendency for youths to come up initially with a vague and nonspecific goal for treatment, such as “I want to feel better.” You may want to help the youth identify more concrete goals by asking him or her questions, such as “If you were not depressed, what would you be doing differently?” and here the youth may state, “Doing better in school,” “Going out more with friends,” and so forth. Mood monitoring. Mood monitoring is an important component of CBT that helps increase the youth’s awareness of emotions. Use the illustration of a feelings thermometer and have the youth rate his or her mood on a scale of 0 to 10, in which 0 corresponds to feeling “very bad” and 10 to feeling “very good.” Ask the youth to keep a mood diary by recording his or her mood at least three times a day along with the event associated with the specific mood. This technique serves more than one purpose: 1) it helps you highlight to the child that he or she does not feel bad at all times (this is especially helpful in children who tend to dismiss positive emotions and report in the session that they “never feel good”); and 2) it helps the youth identify activities that make him or her “feel good” and that can be built on for use later in therapy in the behavioral activation module.


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Problem solving. Depressed teens often struggle with impaired problem-solving skills. They often find it difficult to generate solutions to problems they encounter in their daily lives mainly because of the cognitive deficits associated with depression, namely difficulty concentrating, difficulty planning, and psychomotor slowing. The problem-solving module teaches depressed teens to systematically work through problems that would typically cause them to feel down and hopeless. Start first with introducing the youth to the concept of learning problem-solving skills by explaining that everybody faces daily problems and that these can be more helpfully solved when not feeling down or hopeless. Next, train the youth to brainstorm solutions to problems that youths typically encounter (e.g., conflict with peers or parents). Encourage the youth to bring in problems of his or her own and teach how to solve these problems using the following problem-solving steps: 1. 2. 3. 4. 5. 6.

Relax when faced with a problematic situation. Identify what the problem is. Elicit different possible solutions. Evaluate them by predicting the consequences of each. Choose the best solution. Encourage yourself to implement the solution.

If, for instance, a depressed girl talks about a verbal altercation with her parents every time she doesn’t abide by curfew hours, coach her to identify the problem as such and then to brainstorm solutions, which may include negotiating other hours with her parents, having friends over after hours, or not doing anything differently. Next, guide her to evaluate the options by identifying the consequences of each and to choose the most suitable solution that doesn’t leave her depressed or hopeless. Generalizing these skills may involve some challenges. Youths may give up on this technique if they attempt to apply it to complex problems prematurely. Help them practice this strategy to solve problems with increasing difficulty to help them gain mastery of the skills. Depressed youths need to experience success with this strategy in order to believe in it and use it more generally. Cognitive restructuring. One key aspect of CBT is identifying and remediating automatic thoughts and beliefs. These automatic thoughts 1) are rapid and reflexive, 2) are accepted as valid, 3) may be triggered by internal or external events, and 4) negatively influence emotions and behaviors. An example of an automatic thought is “I am not going to have a date for the prom.” Automatic thoughts are based on assumptions that are the product of schemas.

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Start by teaching the youth about the most common cognitive distortions (e.g., dichotomous thinking, overgeneralization, dismissing the positive) that a person with depression may have. Then elicit automatic thoughts from the youth by asking, “What images and thoughts go through your mind when a specific event occurs?” Introduce the paradigm of antecedent, belief, and consequence while trying with the youth to understand the context in which automatic thoughts occur. By asking a series of gentle questions, the clinician can guide the youth to recognize distortions in his or her thought process and help him or her come to a new, more adaptive way of thinking. To generalize this skill outside the therapy session, ask the youth to record automatic thoughts on a four-column dysfunctional thoughts record, as shown in Figure 5–1. In general, the following questions are useful for the youth to ask himself or herself (Brent and Poling 1997): 1. 2. 3. 4. 5. 6.

What is the evidence? What are the errors in my thinking? What is the best and worst thing that could happen? What is the most realistic concern? What are the effects of my thinking this? What are some alternative thoughts?

Emotion regulation. Because the problem of emotion dysregulation is so central to the depressed adolescent’s problems, it must be made an explicit part of the information shared in teaching emotion regulation skills. It is helpful to be familiar with Linehan’s definition of the three components that constitute vulnerability to emotion dysregulation (Linehan et al. 1993): high sensitivity to emotion stimuli, high reactivity, and slow return to baseline. Start by translating these three components into everyday language for the youth; for example, the following statements may be helpful (Bonner 2002): • “A very FAST emotional response: it does not take much to get the ball rolling, and the ball gets rolling very rapidly down the hill to the land of emotion dysregulation.” • “A very BIG emotional response: emotions are felt and expressed with much intensity, making it difficult to think clearly; when the ball gets rolling down the hill, it quickly becomes a BIG ball.” • “A very SLOW return to being calm or relaxed: it takes a long time to roll the ball back up the hill; there may have been damage done by the


Distressing situation

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Negative automatic thoughts associated with the situation

Feelings resulting from the thought or situation

Evidence for and against the thought

1.

1.

Evidence for

2.

2.

1.

3.

3.

2.

4.

4.

3. 4. Evidence against 1. 2. 3. 4.

FIGURE 5–1.

Thought record.

ball as it sped down the hill, so extra distress may have been added to whatever got the ball rolling in the first place.” Next, use the HEAR ME acronym to educate the youth about other vulnerabilities that can make emotion regulation more difficult (Bonner 2002): H =Health (take care of your physical illness) E = Exercise regularly A =Avoid mood-altering drugs R=Rest (balanced sleep) M=Master one rewarding activity daily E = Eat a balanced diet The clinician can illustrate one way to regulate emotions by using the picture of a blank feelings thermometer. Ask the youth to identify different feelings corresponding to different temperature readings on the thermometer before the strength of his or her feelings would reach the top of the thermometer, which corresponds to an irreversible point of losing control. Then help the youth identify the physical and psychological cues as-

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sociated with these feelings (e.g., muscle tension, rapid breathing). Finally, ask the youth to identify the point where he or she needs to take action before getting to the irreversible point of dyscontrol, and identify what the adolescent can do (e.g., walking away from the situation, calling a friend, taking a warm bath). Another important emotion regulation skill is opposite action. Introduce this term by telling the youth that this method is based on the fact that bodily posture, facial expressions, and actions strongly influence how people experience their emotions. Thus, it is sometimes possible to change how someone experiences an emotion by altering the posture, behavior, and facial expressions that go with the emotion. The clinician may want to illustrate this concept by focusing on one emotion, such as anger. Explain that most people find that if they make an angry face and also make their body language consistent with this feeling, they actually find themselves experiencing anger. Tell the youth that the opposite is also true—that is, if he or she feels angry and at the same time tries to smile, take some deep breaths, and relax his or her posture, then he or she will less likely act impulsively on the angry feeling. Generalizing these skills to apply them outside the therapy session can be challenging for youths. For this reason, rehearsing situations that are very likely to happen in the near future and reenacting situations that happened in the recent past are key factors that help youths master these skills and make it more likely that they will use them when faced with emotionally charged situations. Behavioral activation. Clinicians should give behavioral technique priority over cognitive interventions in severely depressed adolescents. It is important to get severely depressed adolescents moving and motivated in order for them to engage in cognitive therapy. Work with the youth—and here the clinician may want to elicit the help of the family—to schedule activities that give the youth a sense of pleasure or accomplishment. Increasing pleasurable activities can also be used with less depressed adolescents. Begin by asking the youth to make a list of up to 10 activities that he or she enjoys doing. These activities must be safe, inexpensive, and legal. Then ask the youth to increase the amount of time during the day that he or she spends engaging in these activities and to note the mood associated with the activity. If the youth is reluctant to engage in the brainstorming because “I do not enjoy anything,” remind him or her about activities that were mentioned in previous sessions and that he or she appeared to have enjoyed. Adolescents may also state that they “often do not feel like doing anything.” The clinician can then educate them that they do not have to


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wait for their mood to improve in order to engage in pleasurable activities. On the contrary, increasing the time they spend engaging in these activities may by itself lead to improvement in their mood. If the youth’s schedule is fully booked with school and other activities that the adolescent doesn’t necessarily consider pleasurable (e.g., music classes, home chores), work with the parent on freeing up some of the youth’s time to make room for those activities that the youth considers pleasurable. Social skills training. Social skills training is another important treatment focus for depressed youths. Many of these children struggle with making and maintaining friendships. They lack appropriate social skills and are overly sensitive to criticism, which leads to further social isolation and reinforces their depressed mood. In this module, the clinician teaches the child the basics of initiating and maintaining a conversation—including greeting others, making appropriate eye contact, and active listening through role-playing—and models effective communication skills. Relapse prevention. CBT continuation treatment has been shown to be effective in preventing relapse in youths whose major depressive episode has remitted over a 6-month period (Kennard et al. 2008; Kroll et al. 1996). Hence, after 12 weeks of acute treatment, a 6-month CBT continuation treatment phase is recommended. This phase typically consists of 8–11 sessions, in which sessions occur weekly for 4 weeks and biweekly for 2 months, followed by monthly booster sessions for 3 months. Include family sessions as part of this treatment phase, with a minimum of 3 family sessions. During this treatment phase, review the skills learned during acute treatment and monitor for any recurrence of symptoms.

Case Example Jessica is a 15-year-old white adolescent girl referred by her pediatrician due to concerns regarding her mood. Jessica presents in session wearing overly baggy clothes and with disheveled hair. She slumps in her chair, maintains a flat affect, and yawns throughout the initial session. She is soft-spoken and allows her mother to speak for her unless she is specifically addressed. Jessica’s mother reports that she is extremely concerned about her daughter. She reports that Jessica is “always irritable” and has rarely interacted with family members or even friends for the past month. She explains that Jessica has been slowly dropping out of all her extracurricular activities, even theater, which Jessica has always loved. Initially, her parents wondered whether Jessica was ill given how much she was sleeping, her lack of appetite and sudden weight loss, and her low energy level. However, medical concerns were ruled out after they met with the pediatrician.

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During intake, Jessica reported that she was very hard on herself and never felt she was as good as her friends in all areas of her life, including schoolwork, her appearance, and even theater. Her grades have been dropping recently, and she reported that she has been having a difficult time focusing in class, even though this has never been an issue for her in the past. Jessica became emotional when admitting that at times she feels hopeless, as if nothing will ever turn out right for her. Jessica held her mother’s hand, and she explained that she has not experienced any thoughts about suicide and that she would never do this to her family. During the first therapy session, Jessica’s therapist informed her that she was reporting clinically significant symptoms of major depressive disorder. The clinician then provided Jessica and her mother with education regarding depression. Once Jessica and her mother were able to clearly understand depression, the therapist then explained how CBT could be beneficial. The therapist explained the relationship of thoughts, feelings, and behaviors and explained that CBT helps individuals change the way they think and behave to help them decrease negative feelings. The therapist was able to link this information with the symptoms Jessica reported during the initial session. Jessica was able to understand that when she thinks “No one ever calls me anymore,” she feels sad—and that when she is sad, she tends to isolate herself by going to her room and falling asleep. Once asleep, Jessica has little chance of changing her mood, and thus when she wakes, she continues to experience negative thoughts. By the end of the session, Jessica was able to form some goals, including becoming more active with friends and theater, as well as improving school performance. In the following session, Jessica was taught how to monitor her mood using a feelings thermometer. She was then assigned to begin monitoring her mood three times daily and to note the situation when she also noted her mood. Jessica mentioned that she had been feeling lonely and felt that her friends were leaving her out. Her mother gently pointed out that Jessica had not been returning phone calls or text messages lately. The clinician then met individually with Jessica to teach a problem-solving skill. With the help of this skill, Jessica was able to calmly brainstorm some solutions for her current peer difficulties and to weigh the pros and cons of each solution. Jessica decided to try calling her friends more frequently and asking them to take part in activities. At the next session, Jessica brought in completed feelings thermometers, which supported the idea that when she took part in social or pleasurable activities, her mood was improved—and that her mood was low when she isolated herself. The clinician then taught Jessica about how thoughts affect feelings and provided common examples of maladaptive thoughts. Jessica admitted that she frequently views situations as “all or nothing” and that this can cause her to feel sad and blue. She also recognized that she can become overly focused on negative events that occurred throughout the day and ignore positive events. Jessica was then taught how to challenge these negative thoughts and was assigned thought records to complete. The next few sessions focused on Jessica’s thought records and cognitive challenges. She gradually became better at recognizing and challenging


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her cognitive distortions, and her mood ratings were improving. At the same time, Jessica’s solution for improving her relationships with friends was beginning to work, and she was reporting improved social relationships. Jessica still reported a tendency to react quickly to any social cues she perceived as negative, and the next few sessions focused on emotional dysregulation. Jessica was taught the HEAR ME tips for self-care and was assigned to work on applying these to her daily life. In particular, Jessica focused on forming a more balanced sleep routine and meal patterns. Jessica’s mood ratings continued to improve, and she was feeling very pleased with her progress. The next few sessions focused on behavioral activation, and Jessica began to increase her time spent in pleasurable activities, including theater. At this point, Jessica’s mother reported feeling relieved and felt that the “old Jessica is back.” Jessica continued to monitor her mood and use her skills taught in previous sessions. Eventually, Jessica was feeling confident about her ability to manage her mood on her own. She and the therapist agreed that she would come back to review skills monthly for the next 3 months. All of Jessica’s followup sessions were positive and focused on refreshing any skills that were needed. Overall, Jessica left therapy feeling proud of her ability to cope with her emotions and improve her mood.

CBT for Suicide Empirical Evidence Although suicide is the third leading cause of death among adolescents in the United States (Bridge et al. 2006), no individual psychotherapies have been shown effective in randomized controlled trials (RCTs) in reducing suicidal behavior in youths. Generalizing evidence-based therapies used with depressed adolescents to suicidal adolescents may not be adequate because many of the trials that established efficacy of these therapies excluded suicidal adolescents. The importance of suicide prevention interventions lies in their efficacy to prevent future suicide attempts in recent attempters, because repetition of these behaviors among adolescents is common 3–6 months after the first suicide attempt. Family, group-oriented, and brief adjunctive psychosocial intervention models have had mixed success in reducing self-injury in adolescents (Huey et al. 2004; Wood et al. 2001). Empirical evidence on individual psychotherapies such as dialectical behavior therapy (DBT) has not yet been supported in RCTs, despite such treatment showing efficacy in a quasi-experimental study (Rathus and Miller 2002). Although the TADS group reported CBT and CBT-plus-medication treatments as more effec-

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tive in reducing suicidal ideation and events compared with medication alone, this result has not been replicated in other studies (Brent et al. 2008; Goodyer et al. 2007; March et al. 2004).

Suicide Prevention The Treatment of Adolescent Suicide Attempters (TASA) study developed a cognitive-behavior therapy for suicide prevention (CBT-SP; Stanley et al. 2009) that is feasible and accepted by adolescent suicide attempters. The efficacy of CBT-SP is worth testing in the future. CBT-SP draws from the principles of CBT and DBT. This treatment was piloted in a mostly open study of 124 depressed adolescent suicide attempters and resulted in a 6-month hazard of recurrence of suicidal behavior that was less than has been reported in similar samples (hazard ratio = 0.12; Brent et al. 2009). CBT-SP aims primarily to reduce suicide risk factors among adolescents who are recent attempters, to help them develop more adaptive coping skills—and ultimately, to refrain from suicidal behavior. CBT-SP involves the parents and the adolescent in treatment, which lasts about 24 weeks. CBT-SP consists of two treatment phases: 1. An acute treatment phase, which is divided into a) initial, b) middle, and c) end phases. The acute treatment phase typically lasts for 12 weekly sessions in total. 2. A continuation phase, which consists of up to 6 sessions tapered in frequency and lasts for an average of 12 weeks. We here summarize the different components of CBT-SP.

Acute Treatment Phase Initial phase (4 sessions). This phase involves 5 components: chain analysis, safety planning, psychoeducation, identifying reasons for living, and case conceptualization. • Chain analysis: In this component, the clinician helps the youth identify the series of events that led to the recent suicidal crisis; the work in this component aims to reveal concurrently the youth’s precipitating thoughts, feelings, and actions. • Safety planning: Here, the clinician helps the youth identify internal (distracting activities) and external (family, friends, psychiatry emergency contact numbers) resources to use as coping strategies when


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faced with suicidal urges. This technique aims to help youths stay safe by not engaging in suicidal behavior at least until the next session. • Psychoeducation: The clinician educates the youth and family about suicide risk factors and behaviors and about the goals of therapy. • Identifying reasons for living: In this component, the clinician helps the youth identify reasons to live and sources of hope that he or she can hold on to when having a suicide crisis. • Case conceptualization: The clinician and patient determine target problems and deficits revealed in the chain analysis and identify the personalized strategies that are needed to reduce suicide risk in the adolescent. Middle phase (5 sessions). The clinician introduces cognitive, behavioral, and family interventions in the form of skills training via modules chosen on the basis of the particular needs of each youth as determined during the case conceptualization phase. End phase (3 sessions). The clinician aims to test the efficacy of skills learned thus far by having the youth review the recent attempt during the session, following these recommended steps: • Prepare the youth by providing the rationale of this task. • Have him or her review the indexed attempt or suicidal crisis. • Have the youth review the event of the attempt or suicidal crisis using skills acquired so far and highlight what he or she could have done differently. • Discuss a future high-risk scenario and debrief.

Continuation Phase In this 12-week treatment phase, the clinician and patient review the skills learned in the acute treatment phase, go over the course of treatment, and identify accomplishments. The clinician prepares the youth to deal with any future fluctuations or episodes and assesses the need for ongoing treatment. The following case example on DVD illustrates CBT techniques to assess (e.g., chain analysis) and treat depression and suicidal ideation in Jane, an adolescent who recently attempted suicide.

S Case Example Jane, a 17-year-old adolescent girl, was referred to the clinician by an emergency room physician at the local children’s hospital after she was treated for a suicide attempt, in which she swallowed a bottle of her mother’s sleeping pills. Jane presented in session as sad and tearful. She did not

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make eye contact and was soft-spoken. She cried at times throughout the session, especially when her parents began to cry. Jane reported that she hated high school and that she attempted suicide because she was extremely hopeless that anything would ever get better. During the first session, the clinician discussed with Jane what led up to her suicide attempt. Initially, Jane could only say, “I hate school.” However, the therapist provided a series of open-ended questions about what was happening in Jane’s life before the event, what Jane was thinking about, and how she was feeling. Jane recalled that she was having a particularly bad week in school because her best friend was out sick and she did not have anyone to sit with at lunch. She found herself feeling embarrassed and lonely and told herself that she was a “loser” and that “no one would notice” if she didn’t exist. In addition, Jane said that her ex-boyfriend had spread a rumor about her, and this was causing her unwanted negative attention from others. When she went home one day from school, Jane said that she decided she could no longer deal with the stress and took the bottle of pills quickly. After discussing this event, Jane reported that she “did not think” and that she never considered how this would affect her family. The therapist then discussed the idea of forming a safety plan so that Jane could be sure to keep herself safe in between sessions. Jane reported that she was willing to do this and felt bad about how she had upset her family. She admitted that she continues to have suicidal thoughts and would like a plan for managing these thoughts. Jane agreed to a plan where she would initially try to get her mind off the thought by listening to music. If her thoughts continued or she began to experience a suicidal urge, she agreed to tell a parent or call the local crisis center. In addition, the therapist provided Jane and her family with education about suicide and risk factors. One risk factor in particular was discussed with Jane’s family: leaving prescription medications lying around the home, because Jane’s attempt and suicidal thoughts generally focused on ingestion. Jane and her family added reducing risk factors to the safety plan. During the next few sessions, Jane and her family agreed that she did well following through with her safety plan. These sessions focused primarily on establishing rapport with Jane and helping her to begin to think about why her life was in fact worth living. This list began to grow, and Jane became more motivated for treatment. In addition, the therapist began to form a case conceptualization regarding Jane’s suicidal behavior. This focused on Jane’s difficulties with social skills. Throughout sessions it became apparent that Jane had difficulties making new friends. She had one group of peers that she had made friends with in elementary school, and through the years, these peers had made new friends and gradually drifted off except for her best friend. Jane was aware of her social difficulties and embarrassed by her lack of popularity. This led to low self-esteem, and Jane began to overly focus on her difficulties with peers. Once Jane became depressed, her level of energy and ability to concentrate decreased, and she began to have difficulties problem solving. When faced with a social problem at school after the breakup with her boyfriend, she was unable to think of an adequate solution and became hopeless. This conceptualization of Jane’s suicidal behavior helped the therapist to then form a treatment plan for the middle phase of Jane’s acute treatment.


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During the middle phase of Jane’s acute treatment, the therapist spent about five sessions focusing on continuing to assess for safety, as well as teaching skills focused on improving mood. The therapist focused on social skills training for making new friends, cognitive challenging for decreasing Jane’s tendency of focusing on the negative, HEAR ME skills for improving her energy level and decreasing emotional lability, and problem-solving skills for helping Jane to cope in an effective manner with life stressors. Jane participated actively in learning these techniques and reported improvements in her mood at each session. The last three sessions focused on summarizing these skills to ensure that Jane would be able to apply them in the future. The clinician asked Jane to think about her previous suicide attempt and to discuss what skills she could have used to prevent herself from getting to that point. Jane was able to effectively apply the problem-solving skill in session to find solutions both for feeling lonely at lunch and handling the made-up rumor. In addition, she was able to discuss how she was focusing on the negative and putting herself down and to challenge these negative thoughts in session. Lastly, Jane was able to discuss some active coping skills, such as going for a jog or playing a video game, that she had learned generally worked for her when she needed to distract herself. Jane was also able to discuss which skills she felt would work best for her in future stressful situations. By the end of treatment, Jane reported that she no longer experienced either suicidal ideation or depressive symptoms.

Caveats and Conclusion Despite the evidence supporting the role of CBT in treating depression in adolescents, CBT is often unavailable in many settings and may increase the financial costs of treatment. Therefore, identifying and disseminating the most effective components of these therapeutic techniques is needed in order to better tailor them into a personalized approach for depressed and/or suicidal adolescents and to make treatment as beneficial and cost-effective as possible. In the TORDIA study, for instance, participants who received more than nine CBT sessions and those who received the problem-solving and social skills treatment modules were more likely to have a good treatment response (Kennard et al. 2009a). This evidence suggests that problemsolving and social skills training modules may be more cost-effective to disseminate for use in the community than other CBT modules. In addition, while delivering CBT, therapists are reminded to keep a cultural perspective. Maladaptive beliefs and behaviors are learned and perpetuate in a social context; hence, being cognizant of the relevant cultural and ethnic factors of the youth’s presenting problems is essential for every therapist in building a therapeutic alliance with youths and their families and for treatment to succeed.

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Key Clinical Points • CBT is effective in preventing depressive disorders in at-risk youths and when combined with medications in treating pediatric depression. • CBT for youths with depression aims to target maladaptive cognitive processes and behavioral patterns that contribute to low mood through a repertoire of techniques. • CBT components, such as psychoeducation, mood monitoring, cognitive restructuring, problem solving, behavioral activation, emotion regulation, and social skills training, need to be individualized to the particular youth. • Continuation CBT treatment is effective in preventing relapse after depression remission over a 6-month period. • CBT for suicide prevention aims to reduce suicide risk factors among adolescents who recently attempted suicide by helping them develop more adaptive coping skills and ultimately refrain from suicidal behavior.

Self-Assessment Questions 5.1. A 14-year-old Hispanic boy diagnosed with a major depressive disorder has not responded to a trial of a selective serotonin reuptake inhibitor (SSRI). The next management step that the youth would most likely respond to is to A. B. C. D.

Switch to another SSRI. Switch to venlafaxine. Switch to another SSRI and add CBT. Treat with the same SSRI for a period longer than 12 weeks.

5.2. A 13-year-old girl with a history of depression gets easily irritable at school and becomes aggressive with teachers and friends. The most helpful CBT technique to include in her treatment plan is A. B. C. D.

Exposure and response prevention. Cognitive restructuring. Emotion regulation Safety planning.


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5.3. You tell your depressed adolescent youth that it is important to schedule activities that he or she finds pleasurable and to engage in these activities on a regular basis. This is an example of A. B. C. D.

Cognitive restructuring. Emotion regulation. Behavioral activation. Social skills training.

5.4. A feasible and acceptable therapeutic intervention with a depressed adolescent who recently attempted suicide is A. B. C. D.

Interpersonal therapy. CBT used with depressed youths. Relaxation techniques. Cognitive-behavior therapy for suicide prevention.

5.5. You see an adolescent youth with depression who is having difficulty initiating and maintaining relationships with peers. The most helpful CBT technique to include in the treatment plan of this youth is A. B. C. D.


References Asarnow JR, Emslie G, Clarke G, et al: Treatment of selective serotonin reuptake inhibitor-resistant depression in adolescents: predictors and moderators of treatment response. J Am Acad Child Adolesc Psychiatry 48:330–339, 2009 Barbe RP, Bridge JA, Birmaher B, et al: Lifetime history of sexual abuse, clinical presentation, and outcome in a clinical trial for adolescent depression. J Clin Psychiatry 65:77–83, 2004 Beck AT: Depression: Clinical, Experimental, and Theoretical Aspects. New York, Hoeber, 1967 (Republished as Beck AT: Depression: Causes and Treatment. Philadelphia, University of Pennsylvania Press, 1970) Birmaher B, Ryan ND, Williamson DE, et al: Childhood and adolescent depression: a review of the past 10 years. Part I. J Am Acad Child Adolesc Psychiatry 35:1427–1439, 1996 Birmaher B, Brent DA, Kolko D, et al: Clinical outcome after short-term psychotherapy for adolescents with major depressive disorder. Arch Gen Psychiatry 57:29–36, 2000

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Birmaher B, Brent D; AACAP Work Group on Quality Issues, et al: Practice parameter for the assessment and treatment of children and adolescents with depressive disorders. J Am Acad Child Adolesc Psychiatry 46:1503–1526, 2007 Bonner C: Emotion Regulation, Interpersonal Effectiveness, and Distress Tolerance Skills for Adolescents: A Treatment Manual. 2002. Available at: http:// www.box.net/shared/jbbu7c4xc7. Accessed April 19, 2011. Brent DA: Correlates of the medical lethality of suicide attempts in children and adolescents. J Am Acad Child Adolesc Psychiatry 26:87–91, 1987 Brent DA, Poling K: Cognitive Therapy Treatment Manual for Depressed and Suicidal Youth. Pittsburgh, PA, Star Center Publications, 1997 Brent DA, Kolko DJ, Birmaher B, et al: Predictors of treatment efficacy in a clinical trial of three psychosocial treatments for adolescent depression. J Am Acad Child Adolesc Psychiatry 37:906–914, 1998 Brent D, Emslie G, Clarke G: Switching to another SSRI or to venlafaxine with or without cognitive behavioral therapy for adolescents with SSRI-resistant depression: the TORDIA randomized controlled trial. JAMA 299:901–913, 2008 Brent DA, Greenhill LL, Compton S, et al: The Treatment of Adolescent Suicide Attempters study (TASA): predictors of suicidal events in an open treatment trial. J Am Acad Child Adolesc Psychiatry 48:987–996, 2009 Bridge JA, Goldstein TR, Brent DA: Adolescent suicide and suicidal behavior. J Child Psychol Psychiatry 47:372–394, 2006 Clarke GN, Hornbrook M, Lynch F, et al: A randomized trial of a group cognitive intervention for preventing depression in adolescent offspring of depressed parents. Arch Gen Psychiatry 58:1127–1134, 2001 Clarke GN, DeBar LL, Lewinsohn PM: Cognitive-behavioral group treatment for adolescent depression, in Evidence-Based Psychotherapies for Children and Adolescents. Edited by Kazdin AE, Weisz JR. New York, Guilford, 2003, pp 120–134 Clarke G[N], DeBar L, Lynch F, et al: A randomized effectiveness trial of brief cognitive-behavioral therapy for depressed adolescents receiving antidepressant medication. J Am Acad Child Adolesc Psychiatry 44:888–898, 2005 Curry J, Wells K, Brent D, et al: Cognitive Behavior Therapy Manual for TADS. Durham, NC, Duke University, 2000 Curry J, Rohde P, Simons A, et al: Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry 45:1427–1439, 2006 Feeny NC, Silva SG, Reinecke MA, et al: An exploratory analysis of the impact of family functioning on treatment for depression in adolescents. J Clin Child Adolesc Psychol 38:814–825, 2009 Fristad MA, Verducci JS, Walters K, et al: Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Arch Gen Psychiatry 66:1013–1021, 2009 Garber J, Clarke GN, Weersing VR, et al: Prevention of depression in at-risk adolescents: a randomized controlled trial. JAMA 301:2215–2224, 2009 Ginsburg GS, Silva SG, Jacobs RH, et al: Cognitive measures of adolescent depression: unique or unitary constructs? J Clin Child Adolesc Psychol 38:790–802, 2009


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Goodyer I, Dubicka B, Wilkinson P, et al: Selective serotonin reuptake inhibitors (SSRIs) and routine specialist care with and without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial. BMJ 335:142, 2007 Harrington R, Campbell F, Shoebridge P, et al: Meta-analysis of CBT for depression in adolescents. J Am Acad Child Adolesc Psychiatry 37:1005–1007, 1998 Huey SJ Jr, Henggeler SW, Rowland MD, et al: Multisystemic therapy effects on attempted suicide by youths presenting psychiatric emergencies. J Am Acad Child Adolesc Psychiatry 43:183–190, 2004 Kandel DB, Davies M: Adult sequelae of adolescent depressive symptoms. Arch Gen Psychiatry 43:255–262, 1986 Kennard BD, Emslie GJ, Mayes TL, et al: Cognitive-behavioral therapy to prevent relapse in pediatric responders to pharmacotherapy for major depressive disorder. J Am Acad Child Adolesc Psychiatry 47:1395–1404, 2008 Kennard BD, Clarke GN, Weersing VR, et al: Effective components of TORDIA cognitive-behavioral therapy for adolescent depression: preliminary findings. J Consult Clin Psychol 77:1033–1041, 2009a Kennard BD, Silva SG, Tonev S, et al: Remission and recovery in the Treatment for Adolescents with Depression Study (TADS): acute and long-term outcomes. J Am Acad Child Adolesc Psychiatry 48:186–195, 2009b Kroll L, Harrington R, Jayson D, et al: Pilot study of continuation cognitive-behavioral therapy for major depression in adolescent psychiatric youths. J Am Acad Child Adolesc Psychiatry 35:1156–1161, 1996 Lewinsohn PM, Rohde P, Steelev JR: Major depressive disorder in older adolescents: prevalence, risk factors, and clinical implications. Clin Psychol Rev 18:765–794, 1998 Lewis CC, Simons AD, Nguyen LJ, et al: Impact of childhood trauma on treatment outcome in the Treatment for Adolescents with Depression Study (TADS). J Am Acad Child Adolesc Psychiatry 49:132–140, 2010 Linehan MM, Heard HL, Armstrong HE: Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline youths. Arch Gen Psychiatry 50:971–974, 1993 Maalouf F, Munnell R: Cognitive control and emotion processing impairments in adolescent depression: state vs. trait? Presented at the 56th annual meeting of the American Academy of Child and Adolescent Psychiatry, Honolulu, HI, October 27–November 1, 2009 March J, Silva S, Petrycki S, et al: Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. JAMA 292:807– 820, 2004 Rathus JH, Miller AL: Dialectical behavior therapy adapted for suicidal adolescents. Suicide Life Threat Behav 32:146–157, 2002 Renaud J, Brent DA, Baugher M, et al: Rapid response to psychosocial treatment for adolescent depression: a two-year follow-up. J Am Acad Child Adolesc Psychiatry 37:1184–1190, 1998 Stanley B, Brown G, Brent DA, et al: Cognitive-behavioral therapy for suicide prevention (CBT-SP): treatment model, feasibility, and acceptability. J Am Acad Child Adolesc Psychiatry 48:1005–1013, 2009

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6

Bipolar Disorder Benjamin W. Fields, Ph.D., M.Ed. Mary A. Fristad, Ph.D., ABPP

PHARMACOLOGICAL treatment (mood stabilizers or atypical antipsychotics) is considered the first-line approach to manage pediatric bipolar disorder (McClellan et al. 2007). However, childhood-onset and early adolescent–onset bipolar disorder appear phenotypically similar to adult mixed manic, chronically cycling, and frequently treatment-resistant bipolar disorder; thus, these youth, even when medicated, are likely to relapse (Geller et al. 2002). The refractory nature of pediatric bipolar disorder underscores the important, albeit adjunctive, role of psychotherapy in treating the disorder, especially from the standpoint of illness management (e.g., mitigating symptom exacerbation, preventing or delaying the onset of future mood episodes, promoting healthy and affectively moderating lifestyle choices, and addressing psychosocial stressors that may impact the course of disorder).

Empirical Support A small but growing literature base supports the use of cognitive-behavior therapy (CBT) in the treatment of pediatric bipolar disorder (Table 6–1). 185

Intervention

Study design

Citation(s)

Significant findings

Null findings

Open trial, no control

Pavuluri et al. 2004 Improvement in child symptoms (mania, depression, aggression, psychosis, sleep disturbance, attention-deficit/hyperactivity disorder (ADHD), and overall symptoms) and global functioning

CFF-CBT maintenance program plus medication management


West et al. 2007

Improvement in child symptoms (mania, depression, aggression, psychosis, sleep disturbance, ADHD, and overall symptoms) and global functioning found in Pavuluri et al. 2004 maintained over 3-year follow-up

CFF-CBT adaptation for group treatment plus medication management


West et al. 2009

Improvement in child manic symptoms and psychosocial functioning (parent rated)

Decrease in child depressive symptoms; improved child psychosocial functioning (child rated); decrease in parenting stress; increase in parent knowledge of and perceived self-efficacy in dealing with child’s disorder


Child- and family-focused cognitive-behavior therapy (CFF-CBT) or RAINBOW program for pediatric bipolar disorder CFF-CBT plus medication management

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TABLE 6–1. Studies of CBT-based interventions for the treatment of pediatric bipolar disorder

Intervention

Study design

Citation(s)


Null findings

Family-focused treatment for adolescents with bipolar disorder (FFT-A) FFT-A plus medication management


Miklowitz et al. 2004, 2006

Improvement in child depressive and manic symptoms and overall behavior problems; gains maintained or increased 15 months posttreatment with continued medication management and trimonthly FFT-A booster sessions

FFT-A plus medication management

Randomized controlled trial (control= “Enhanced Care” plus medication management)

Miklowitz et al. 2008

Reduction in time to recovery Treatment group as compared from any mood episode or with control group: More mania; increase in time to favorable and rapid recovery recurrence of any mood from depressive symptoms; less episode or mania, weeks free time spent in depressive of all mood disorder episodes; more weeks without symptoms, and time depressive symptoms; greater remitted from mania; more overall reduction in mood favorable trajectory of mania severity; more favorable or hypomania trajectory of depression

Bipolar Disorder

TABLE 6–1. Studies of CBT-based interventions for the treatment of pediatric bipolar disorder (continued)

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Intervention

Study design

Citation(s)


Null findings


Goldstein et al. 2007

Decreased affective lability, depressive symptoms, and suicidality

Decrease in manic symptoms; improved interpersonal functioning

Interpersonal and social rhythm therapy for adolescents with bipolar disorder (IPSRT-A) IPSRT-A plus medication management


Hlastala et al. 2010 Decreases in manic, depressive and general psychiatric symptoms; improvement in global functioning

Psychoeducational psychotherapy (PEP) Multifamily psychoeducational psychotherapy (MF-PEP) plus treatment as usual

Randomized controlled trial

Fristad et al. 2002, 2003

Treatment group as compared with control group: Improved parental knowledge of mood disorders; improved parental skills, support, and attitude toward treatment; increase in child-perceived social support from parents; increase in positive family interactions; improved service utilization

Decrease in child mood severity; increase in childperceived social support from peers; decrease in negative family interactions


Dialectical behavior therapy (DBT) for adolescents with bipolar disorder DBT plus medication management

188


Intervention

Study design

Citation(s)


Null findings

Psychoeducational psychotherapy (PEP) (continued) MF-PEP plus treatment as usual


Fristad et al. 2009; Mendenhall et al. 2009

Treatment group as compared with control group: Decrease in overall mood severity; improved service utilization

Individual-family psychoeducational psychotherapy (IF-PEP) plus treatment as usual


Fristad 2006

Improvement in overall child mood severity and family climate

IF-PEP

Case studies

Leffler et al. 2010

Decreased manic and depressive symptom severity; improved family climate and global functioning

Bipolar Disorder


Improved treatment utilization

189

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Although only a minority of this research (with roots in the more sizable literature involving psychosocial treatment for adults with bipolar disorder) focuses on treatment nominally identified as CBT, interventions designed for youth with bipolar disorder are largely based on techniques traditionally associated with CBT and implement strategies consistent with it. Pavuluri et al. (2004) have developed child- and family-focused cognitive-behavior therapy (CFF-CBT; also referred to as the RAINBOW program) for children and adolescents with bipolar disorder. An adaptation of Miklowitz and Goldstein’s (1997) family-focused treatment for adults, CFF-CBT is delivered in conjunction with medication management and organized around seven general components, including the establishment and maintenance of healthy routines, regulating affect, building self-efficacy and coping skills, restructuring negative cognitions, social skills training, problem-solving techniques, and the identification of a useful and accessible social support system. The program is composed of 12 hourlong sessions implemented over 6 months. Meetings include combined family sessions, in which both parents and children participate, child-only and parent-only sessions, and a session for siblings to participate along with parents. Treatment feasibility has been found to be high; families attend most sessions; and they unexpectedly miss (“no showing”) an average of less than one session. Parents have indicated high satisfaction with the treatment protocol and efficacy. Participation in an open-label trial of CFF-CBT has been associated with improvement in mania, depression, aggression, psychosis, sleep disturbance, symptoms of attention-deficit/ hyperactivity disorder, and global functioning as rated by therapists, although the use of random assignment and independent evaluators in future trials will help to evaluate the true efficacy of the program. A maintenance model of CFF-CBT, in which the original treatment is followed by psychosocial booster sessions and continued medication management, has also been developed (West et al. 2007). Booster sessions focus on potential barriers to treatment. Preliminary results of the maintenance model—the addition of which has successfully maintained improvement in symptom severity and global functioning associated with CFF-CBT over a 3-year follow-up period—along with results of the original CFF-CBT trial, suggest the addition of a CBT-oriented adjunctive treatment may hold promise for effecting and maintaining therapeutic gains with a pediatric bipolar disorder population. Miklowitz and colleagues (2004, 2006, 2008) have developed familyfocused treatment for adolescents with bipolar disorder (FFT-A). FFT-A was designed to be implemented in twenty-one 50-minute sessions over a 9-month period, in combination with closely supervised medication man-

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agement. FFT-A is primarily composed of psychoeducation and skills training in the areas of communication and problem solving and allows for the involvement of the patient, parents, and siblings. Treatment aims to promote understanding of bipolar disorder, including its etiology and factors contributing to its course and outcome, as well as to equip patients and families with the skills to positively impact the course of the disorder (Miklowitz et al. 2004). FFT-A has been associated with substantial improvement in depressive and manic symptoms, as well as in behavioral problems, over the course of an open trial (Miklowitz et al. 2004). The addition of trimonthly maintenance therapy sessions and continued pharmacological management over the 15 months following initial treatment with FFT-A has resulted in overall maintenance of these treatment gains— although as might be expected given the cyclical nature of bipolar disorder, symptoms appear to wax and wane throughout the follow-up period (Miklowitz et al. 2006). FFT-A plus pharmacotherapy has also demonstrated superiority over an enhanced care intervention combined with pharmacotherapy (Miklowitz et al. 2008). Although neither treatment appreciably impacted manic symptoms in this study, patients receiving enhanced care (consisting of three psychoeducational family sessions focusing on relapse prevention, medication compliance, and maintaining low levels of conflict in the home) demonstrated a longer time to recovery from depressive episodes, more time spent in depressive episodes, and higher depression severity scores over time, as compared with patients receiving FFT-A. Goldstein et al. (2007) have piloted the use of dialectical behavior therapy (DBT) for adolescents with bipolar disorder. Based on adaptations of Miller et al.’s (2006) DBT manual for suicidal adolescents, the intervention utilizes both family skills training and individual therapy (36 total treatment hours) implemented over the course of 1 year and delivered as an adjunctive treatment to medication management. The primary aim of treatment is to improve affect regulation (the lack of which lies at the core of bipolar disorder), along with other features of bipolar disorder, including suicidality, interpersonal dysfunction, and treatment noncompliance. Modifications for adolescents with bipolar disorder include family involvement in treatment, the addition of psychoeducation, and skills training specifically applicable for bipolar disorder (e.g., identifying particular mood states, recognizing the signs that mood is becoming dysregulated, and taking action to modulate manic and depressive mood states). Treatment has demonstrated feasibility (i.e., high attendance and minimal dropout), and participants have reported satisfaction with both the psychotherapeutic approach and patient progress. Clinically significant improvements have been found in the areas of affective lability, depressive

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symptoms, and suicidality (in terms of both ideation and attempts). Whereas improvement in manic symptoms has been nonsignificant, manic symptoms at intake were generally mild, making a significant decrease difficult to achieve. Patients’ interpersonal functioning also did not demonstrate significant improvement. The authors have not yet investigated the mechanisms through which improvement was effected, calling into question whether treatment gains were due to the specific aims of therapy or related to other, nonspecific therapeutic factors (e.g., support). Interpersonal and social rhythm therapy (IPSRT), an empirically supported adjunctive treatment for adults with bipolar disorder, has recently been adapted for use with adolescents with the disorder (IPSRT-A; Hlastala et al. 2010). IPSRT-A, also based in part on interpersonal psychotherapy for adolescent depression, uses both individual therapy sessions and family psychoeducation (16–18 total sessions) delivered over the course of 20 weeks as an adjunctive treatment to medication management. The primary components of IPSRT-A include psychoeducation regarding bipolar disorder, addressing salient interpersonal difficulties, and the promotion of structure and routine in the areas of social activities and sleep. In an open trial (Hlastala et al. 2010), IPSRT-A was found to be feasible (i.e., high attendance and minimal dropout) and satisfactory to adolescent participants. Further, significant improvements were found in the areas of manic, depressive, and overall psychiatric symptomatology, as well as in global functioning, although randomized controlled trials are necessary. Finally, Fristad and colleagues have developed psychoeducational psychotherapy (PEP) treatment programs for use with children with bipolar disorder (Fristad 2006; Fristad et al. 2002, 2003, 2009). These programs, delivered alongside treatment as usual, employ family involvement, psychoeducation, and skill building in the areas of symptom management, affect regulation, problem solving, and effective communication, with the aim of increasing parent and child understanding of bipolar disorder and factors that may impact its course, ultimately leading to better management of the disorder through more adaptive family functioning and optimized utilization of available services. The multifamily format of PEP (MF-PEP) includes eight weekly 90-minute sessions, in which parents and children meet in a large group at the beginning and end of each session, but break into parent- and childonly groups for the majority of each meeting. Participation in a randomized controlled trial of MF-PEP has been associated with significant improvements in overall child mood severity, with children continuing to improve through 18-month follow-up (Fristad et al. 2009); an earlier version of MF-PEP consisting of six 75-minute sessions was also associated with positive clinical outcomes (Fristad et al. 2002, 2003). As intended, symptom

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improvement was mediated by better utilization of services, a phenomenon that, itself, was mediated by parents’ beliefs about treatment (i.e., knowledge of, and attitude toward, treatment) (Mendenhall et al. 2009). An individual-family version of PEP (IF-PEP), delivered over the course of sixteen 50-minute sessions, has also been associated with improvement in mood symptom severity through 12-month follow-up, as well as improved family climate and treatment utilization and high consumer satisfaction in a randomized controlled trial (Fristad 2006). This model has been extended to twenty 50-minute sessions with four optional “in the bank” sessions; initial case studies indicate it has good consumer evaluations and is associated with improved mood and family functioning (Leffler et al. 2010). Larger-scale trials are necessary, however, in order to evaluate the true significance of these findings.

Characteristics of CBT for Bipolar Disorder Although each of the above treatments has unique qualities, the similarities, particularly of CFF-CBT, FFT-A, and PEP, are striking. All involve psychoeducation, skill building in communication, problem solving, cognitive restructuring, and affect regulation, and are conceptualized to work in an adjunctive manner to medication management. All involve working with the family, primarily the parents, but also some attention is paid to sibling relationships. CFF-CBT and PEP also include specific units on working with schools. In addition to family involvement in the logistics of initiating and maintaining treatment, research indicates that families likely play a pivotal role in the ultimate success or failure of treatment, because of the impact of family dynamics on the course of bipolar disorder. High levels of expressed emotion, a term referring to family interactions characterized by criticism, hostility, and emotional overinvolvement, have been associated with poorer illness course in adults with both depressive and bipolar disorders (Hooley et al. 1986; Miklowitz et al. 1988). Although little research has examined the impact of expressed emotion on the course of pediatric bipolar disorder, preliminary data reported by Miklowitz et al. (2006) indicate that adolescents with bipolar disorder living in high–expressed emotion families evidence higher levels of mood symptoms than those in low–expressed emotion families, suggesting expressed emotion may exert a powerful effect on bipolar disorder in younger patients as well. Thus, several of the interventions used in the treatment of

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pediatric bipolar disorder (e.g., CFF-CBT, FFT-A, PEP) attempt to improve family interactions through promoting effective problem-solving and intrafamilial communication, as well as empathic responses toward the affected child. In addition to the role that negative family interactions may play in bipolar disorder, life stress has also been associated with a poorer course of illness. Kim et al. (2007), for example, found adolescents suffering from higher levels of chronic stress (including family-related stressors) demonstrated less improvement in both depressive and manic symptoms. Having thus established the importance of involving both families and patients in treatment, the issue becomes what materials to employ in the course of intervention. Psychoeducation, or teaching patients and their families about bipolar disorder, is a crucial first step in the provision of CBT. Psychoeducation involves much more than supplying informational handouts or recommended reading lists (though such materials may certainly be provided as part of the process) (Basco and Rush 1996). The rationale for including psychoeducation in treatment is that families and patients who are educated about this disorder—that is, provided with information that they are able to both process and utilize with the intent of becoming more active and competent members of the treatment team— are more likely and more able to make choices that are optimally beneficial to the patient and his or her mental health, as well as choices that are ultimately healthy for the patient’s family. Though the specific content of psychoeducation is necessarily fluid and subject to the growing research base regarding bipolar disorder, certain topics and themes are included in all CBT for bipolar disorder. These include the biological basis of bipolar disorder; symptoms of the disorder and methods for managing increases in these symptoms; information regarding comorbid diagnoses; the role of different treatment providers; and the importance of healthy routines in the management of bipolar disorder. As previously noted, CBT for bipolar disorder is not intended to serve as a stand-alone treatment. Instead, effective CBT is applied as an adjunctive intervention, to supplement and support first-line pharmacotherapy. Thus, another aim of psychoeducation, as implemented in the psychosocial interventions described earlier, is to foster an appreciation for the essential role medication plays in treatment, while simultaneously addressing the limitations of pharmacotherapy. Accomplishing this is no small task, given the high rates of medication noncompliance in children and adolescents who are prescribed medication for bipolar disorder (Kowatch et al. 2000); however, increased adherence allows for maximum benefit from psychopharmacological regimens (Strober et al. 1990) (i.e., better symptom management and fewer episodes of relapse) and for max-

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imally efficient medication adjustments, which are often necessary as individual responses to medication appear over time. Once parents and children have a working knowledge base regarding bipolar disorder, treatment progresses to increasingly skill-based content. Areas of skill building and skill refinement generally include effective problem-solving and communication techniques, cognitive restructuring, and methods to enhance affect regulation. Both the cognitive and behavioral components of CBT are well represented in the treatments reviewed above for youth with bipolar disorder. A description of these techniques— emphasizing the bidirectional relationship between emotions, thoughts, and behaviors on which CBT is based—is provided in the remainder of this chapter.

Application The initiation of CBT for a child or adolescent with bipolar disorder should occur after assessment and diagnosis by a mental health professional familiar with the disorder, and once the patient’s mood symptoms have been stabilized enough pharmacologically that retaining information and learning new skills are possible (Kowatch et al. 2005). Guidelines for identifying bipolar disorder in youth have been described elsewhere in considerable detail but generally include 1) obtaining a complete developmental history, a longitudinal examination of symptoms, a family history of mood and related disorders, data from multiple informants (i.e., parents, child, and school); 2) systematically ruling out alternative medical and psychiatric diagnoses; and 3) determining any comorbid diagnoses (Danner et al. 2009; Fields and Fristad 2009a). Refer parents or other family members for individual treatment, as needed, to reduce the overall level of dysfunction in the family (Kowatch et al. 2005). Although a multifamily group format for PEP has been developed (MF-PEP), the therapeutic protocol described herein is designed for use in an individual-family format (IF-PEP). The primary advantage of conducting treatment in a multifamily format is the social support parents and children often experience through interaction with individuals facing similar issues. In addition, participants may benefit from opportunities to learn from the successes and struggles of others. The individual-family format outlined here, however, is often more convenient for families, who may not wish to delay treatment until a new group can begin, and who may appreciate the more individualized consultation and privacy offered by such a format. Clinicians may also find an individual-family format desir-

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able, both because billing for services may be simplified and because many clinicians do not have access to a number of families appropriate for inclusion in multifamily group treatment. Below appears an outline of one version of CBT, IF-PEP. First, the general format of sessions is described, then key elements of each session are discussed. These elements share much in common with the other CBT treatments for bipolar disorder in youth reviewed above.

General Structure of Sessions Sessions alternate between child-focused and parent-only sessions, allowing you to maintain engagement and continuity with all participants while also offering opportunities for private consultation with children and parents. In child-focused sessions, you will spend the majority of time working individually with the child, but parents participate at the beginning and end of each session. Meeting with both parents and child at the outset of each child session allows for collaborative review of assignments from previous weeks and provides a chance to touch base with parents in terms of the child’s general progress and mood, and any particularly stressful or notable events that have occurred since the last visit and may impact the course of the child’s disorder (e.g., a death in the family or parent losing a job may increase the child’s vulnerability to depressive symptoms; a particularly large and involved school project may portend an increase in manic symptoms). Reconvening at the end of a child session allows the child to “teach” that week’s material to parents, reinforcing newly introduced concepts for the child and updating the parent in regard to the child’s session content. Parents familiar with what their children have been working on in treatment are better able to reference meaningful concepts between sessions and encourage their children to use recently acquired skills. Homework (which is best referred to as “projects,” as few children cherish additional homework assignments) is assigned at the end of each session to children, parents, and often both as a family exercise. Each week’s project is an extension of whatever lesson has been worked on in that session and typically involves recording/monitoring the newly learned skill. Child sessions begin with a review of mood states (the first session usually requires some teaching to establish the practice of rating one’s emotions). Younger children, in particular, may need additional assistance with this step, especially in distinguishing feelings (e.g., sad, mad, bored, happy) from thoughts (e.g., “I’m not sick enough to be here,” “My mom is mad at me,” “I’m a bad kid”). This distinction is critical, in light of CBT’s emphasis on understanding and effectively employing the interactional relationship between feelings, thoughts, and behaviors. Children also frequently

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begin therapy with a very limited vocabulary regarding emotions—sad, mad, and “normal” are often all they articulate. Helping children become aware of a broader range of mood states is a beginning step in learning to regulate their own affect. After labeling his or her current mood, the child then rates the intensity of that mood. Early in treatment, rely on a visual scale—a feelings thermometer—to illustrate how feelings can range in intensity from a healthy “middle” range to maladaptive and occasionally dangerous “highs” and “lows.” This routine encourages both accurate labeling and heightened awareness of the intensity of one’s emotions—fundamental skills needed before affect regulation will be successful. Child sessions end by teaching and reviewing, as needed, breathing exercises that children can use as a calming technique. Developmental adaptations are always important to keep in mind. In general, the younger the child, the more involved the parent will be in the session. As youth approach early, middle, then late adolescence, the need for autonomy grows. Expect up to twenty-four 50-minute sessions, with approximately 20 sessions (9 child-focused sessions, 8 parent-focused sessions, one session with parents and school personnel, one family session involving siblings, and one closing session involving parents and child) dedicated to covering specific psychoeducational matter and skill-building exercises and up to four sessions reserved for additional coverage of particularly challenging content or for crisis management, as needed. The sequence and number of sessions allotted to covering particular therapeutic content are suggested guidelines. They should be adapted to suit the needs of particular families, who may require varying levels of instruction and consultation. Material can be presented in fewer meetings, for example, for a family logistically unable to attend the full complement of sessions or for parents who begin treatment with considerable knowledge of the child’s condition. Similarly, a family encountering an especially vexing issue may benefit from prioritization of that concern, instead of waiting for the presentation of relevant material later in treatment. Excessive sibling conflict, for instance, might warrant the involvement of siblings earlier in treatment to best address the family’s needs. These types of alterations prevent treatment from being delivered in a cookie-cutter or impersonal fashion, and are intended to lead to higher therapist and family satisfaction. Though involving both parents in treatment is ideal, it may not be practical. If a child has only one parent, another significant adult caregiver (e.g., grandparent, aunt) may participate in treatment as well. In the not uncommon event that both parents have significant contact with the child but only one is able to attend treatment, the attending parent should communicate session content to the other and enlist this parent in utilizing the skills learned in treatment.

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Session 1 Child session 1: purpose of treatment; goal setting, rating feelings, and symptoms of bipolar disorder. Begin the introductory session together with the parents and child. Orient them to the purpose of treatment; emphasize that better understanding gained from this education along with skill building should improve treatment utilization and decrease family conflict, leading to a better outcome for the child. Successful management of the disorder, as opposed to a “cure,” is the ultimate goal. Share your expectations, which include the importance of regular attendance and practicing skills between sessions, the planned duration of treatment, and the potential for maintenance sessions after the initial course of intervention. Set the stage for establishing feasible treatment goals. Given the probable lifetime waxing and waning of symptoms, complete obliteration of any future symptoms is not realistic. However, improving family life through concrete actions, taking steps to build friendships, and developing a plan to address school concerns are all realistic and doable over the course of treatment. Finally, introduce both parents and child to the concept of bipolar disorder as a “no fault” disorder. Your motto for treatment is, “It’s not your fault, but it’s your challenge.” Although no one is to blame for the child’s diagnosis, it is a card the family has been dealt and a challenge the entire family can and must confront. Underscore this perspective in future sessions by providing information regarding the biological etiology of bipolar disorder and by helping to distinguish the child from his or her symptoms. Revisiting this message throughout the course of treatment serves to alleviate guilt and shame surrounding the disorder, while concurrently establishing a positive, proactive, and solution-focused approach to managing the disorder. After accomplishing the above, spend most of the remainder of the session with the child alone, inviting parents to rejoin at the end of the session to review progress and discuss activities to be completed before the next session. While with the child, you have three tasks to accomplish: 1) to help the child develop a basic understanding of his or her mood disorder as well as any comorbid conditions; 2) to help the child develop realistic treatment goals; and 3) to teach diaphragmatic breathing to use as a calming technique. Parent session 1: setting the proper tone; diagnosis and symptoms of bipolar disorder; mood charting. The first parent-only session includes presenting basic information about the diagnosis of bipolar disorder and information on tracking mood symptoms. The most important aim of

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the session, however, may be to set the tone for an empathic, hopeful, and solution-focused approach to treatment. Essential to establishing this tone is the presentation of bipolar disorder as a no-fault diagnosis (briefly touched on in the introductory session), beginning with a focus on the biological nature of the disorder, including its high genetic heritability. Helping parents view bipolar disorder as a brain disorder can assist them in approaching their child’s mood and associated behavioral issues with compassion, while also easing parents’ fears that they are responsible for their child’s problems. Youth with bipolar disorder can exhibit exceedingly aversive behaviors, occupy an inordinate amount of family resources, and be extremely difficult to manage. Parents, in turn, receive an unfortunate and often unfair share of the blame for these issues, often in the form of criticism from friends and family who attribute the child’s behavioral difficulties to nothing more than poor parenting. Without proper psychoeducation, parents can begin to view their affected child as selfish and willfully disruptive, leading to a decline in positive interactions within the family and an increase in expressed emotion (discussed earlier as a potentially significant factor in the course of bipolar disorder). Ironically, attempting to alleviate parental guilt over the child’s diagnosis by introducing information on the heritability of bipolar disorder can inadvertently lead to more self-blame by some parents, who feel guilty over passing down the disorder. No one, of course, selects his or her own genes; as the saying goes, you can pick your friends but not your relatives. Reminding parents of this can be useful in reframing unproductive and guilty cognitions regarding their child’s diagnosis. Providing information to parents regarding the neuroanatomy and neurochemistry putatively involved in bipolar disorder can also help place the disorder in a biological light, though the level of sophistication that will be useful to parents can vary significantly. In session, it is sufficient to explain that various structures of the brain appear different in bipolar disorder than in typical brains (e.g., different in size) and that these abnormalities, in conjunction with chemical irregularities in the brain that affect how messages are sent between brain structures, are thought to be involved in the symptoms of bipolar disorder. If parents express a deeper curiosity and would benefit from information regarding particular neuroanatomical and neurochemical abnormalities, refer them to additional up-to-date scientific findings (see References at the end of this chapter for suggestions). Provide parents with information on how bipolar disorder is diagnosed, including the symptoms, symptom duration, and impairment necessary to meet diagnostic criteria. This process requires helping parents develop familiarity with clinical nomenclature, so that terms such as mania, hypoma-

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nia, and major depressive episode can be used meaningfully in treatment, without fear of confusion. In addition, present a rationale for the child’s particular diagnosis (i.e., bipolar I, II, or not otherwise specified [NOS]; cyclothymia), as well as an explanation for how this diagnosis is subject to change, depending on the future course of symptoms (e.g., a current diagnosis of bipolar II disorder would progress to bipolar I disorder in the event of a manic or mixed episode). Just as children should be introduced to the differences between mood symptoms and symptoms of other disorders, so too should parents. In particular, address any other diagnoses the child may have been assigned, along with how these symptoms differ from those of bipolar disorder. Regardless of whether psychotic symptoms are present, describe psychotic symptoms that can occur in the course of pediatric bipolar disorder, as well as the potential for suicidality. Because youth with bipolar disorder are at elevated risk for suicidal behavior, parents need to be aware this is a potential complicating feature of the disorder. Mood charting, or the process of recording changes in a child’s mood, is an important tool in monitoring treatment progress in a child with bipolar disorder (Young and Fristad 2009). Not only can this process help parents give treatment providers useful information in guiding medication adjustments, but such charting can also aid parents’ understanding of how psychosocial and somatic stressors (e.g., interparent conflict, child getting less sleep than usual) can impact the course of their child’s disorder. Although it is often difficult for parents to retrospectively report on a child’s mood fluctuation and potential triggers for this variation when they come in to a session, parents who have spent even a couple of minutes each day detailing their child’s mood and the events of that day are typically much more able to provide useful information. A multitude of different formats have been proposed for charting mood, and the level of detail that is appropriate depends on the family. Remember, even a low level of information provided consistently is typically of greater value than a high level of information provided sporadically. Reviewing mood logs at the beginning of each session helps to reinforce their importance with parents.

Session 2 Child session 2: “Naming the Enemy”; medications. T h e p r i m a r y goals of this session are twofold: 1) to assist the child in differentiating symptoms of bipolar disorder from his or her “self,” and 2) to instill a firmer understanding of the use of medication in treatment for bipolar disorder, thereby enlisting the child as a more informed and active participant in treatment.

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The first goal can be addressed with the exercise Naming the Enemy (Fristad et al. 1999), inspired by the concept of “externalizing the symptom” (White and Epston 1990), in which patients are encouraged to objectify problematic symptoms as separate from the self. Over time, symptoms can come to be seen by the child and others as static and reflective of the child’s true self, as opposed to being surmountable and temporarily obscuring the child’s positive qualities. Identifying symptoms of bipolar disorder as an external “enemy” reconceptualizes the problem as a challenge to be overcome rather than a burden to be passively endured, while simultaneously encouraging more positive self-esteem in children often in need of just such a boost. To implement Naming the Enemy, write the child’s name at the top of a page, with two columns splitting the page below. In the left-hand column, labeled “Self,” have the child write positive qualities about himself or herself (e.g., “artistic,” “good sense of humor,” “helps Grandma”). In the right-hand column, have the child write his or her mood symptoms as the child understands them (e.g., “mean to brother,” “cries a lot,” “brags too much”). After the lists are complete, fold the right side of the paper over the left, covering the child’s positive qualities with the half of the paper listing symptoms. Explain how the symptoms of bipolar disorder can cover up the wonderful attributes the child has to offer. Then, refold the paper so the right side is behind the left side, and explain that treatment can help “uncover” the child’s positive qualities once more. The child will do this again at home with his or her parents; it can be very helpful in changing the language families use to describe symptoms (rather than negative attributes about the child). Raising the topic of treatment provides a segue into discussing the role medications play in managing bipolar disorder. All too often, children take medications with no knowledge of the names and dosages, let alone the purpose of these prescriptions. As medication adherence is essential to treating bipolar disorder, children should have an awareness of what they are taking, the reasons for doing so, how to manage the nearly inevitable side effects that occur with medications, and how to provide useful feedback to the provider on how the medicine is working. Children invested with this knowledge gain an additional stake in their treatment—a sense of ownership likely to be welcomed by parents, who often struggle to ensure daily medication adherence. To this end, review information with the child about the medications he or she is taking, including dosages, the symptoms each medication is intended to address, common side effects, and potential methods of mitigating these side effects (e.g., taking the medication with food for prescriptions causing stomach upset; keeping a bottle of water nearby for those causing dry mouth). Note that a discussion of why the medication has been prescribed may necessitate consultation with the

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child’s psychiatrist or pediatrician, as medications are often used off label or to counteract side effects of other medications. Parent session 2: medication and other treatments. Parents, too, benefit from information regarding the treatment their children are receiving. In particular, parents should be clear regarding their child’s current medication regimen and the purpose of medication in treating bipolar disorder—in short, management of symptoms rather than elimination of the disorder. Help parents understand the basic classes of medications, the target symptoms for which they are designed, and their common side effects, as well as how those side effects can be managed. Be prepared to review fundamentals of taking medication, such as what to do when a dose is missed (e.g., take as soon as possible or wait until the next scheduled dose), when and how medications are to be taken (e.g., in the morning or evening; with food or without), and necessary measures to ensure safety (e.g., blood draws for monitoring mood stabilizer levels). Polypharmacy may be necessary, but ensure that parents understand the reason for each medicine the child is taking. Despite the primary role of psychopharmacology in treating bipolar disorder, communicate to parents that medications are not a panacea and only part of managing what is typically considered a chronic illness. Familiarizing parents with the limitations of pharmacotherapy is necessary to foster realistic expectations of treatment and the prospective course of bipolar disorder. In addition to the necessity of using medication regularly and according to directions, parents need to be aware that somatic treatments may require some time to take maximum effect and that medication adjustments are a routine part of refining a bipolar disorder treatment regimen. Changes in dosage, administration time, and even type of medication are not uncommon or indicative of substandard treatment. On the contrary, competent medication providers should alter prescriptions in response to feedback from parents and the patient to optimize treatment response. Parents should also know that the best way to handle concerns regarding a perceived inadequate response to medication or impairing side effects is through a thoughtful analysis of the costs (side effects) and benefits (symptom relief) of continued administration, in combination with careful consultation with the prescribing physician. Effective communication, including a mood-medication log that records treatment response and side effects, enables the physician to proceed in the safest and most efficient manner. Although it is clearly parents’ prerogative to make important choices about their child’s health, decisions regarding alteration or discontinuation of somatic treatment should not be undertaken without proper medical supervision. This approach also applies once medications begin to relieve symptoms or even appear to resolve them completely, as

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it may be that medication is not only alleviating symptoms but preventing their return. Depending on the extent and nature of the child’s mood history (e.g., one acute antidepressant-induced manic episode versus multiple depressive and hypomanic episodes), pharmacotherapy may be recommended until mood symptoms have remained dormant for several months, or maintained indefinitely for prophylactic reasons. It is possible that children may be receiving other treatments (e.g., participating in a social skills group; receiving electroconvulsive therapy) for bipolar disorder or comorbid conditions while engaged in a CBT program, or other treatments may have been proposed. If so, this session is an opportunity to discuss these other treatment options and to provide basic information regarding the purpose of such therapies.

Case Example: The Medication Dilemma Emily is an 11-year-old girl who received a diagnosis of bipolar I disorder a year ago after a manic episode that resulted in hospitalization. Since then, she has undergone numerous medication trials. Upon beginning psychoeducational psychotherapy, Emily’s parents are vocal regarding their medication concerns. On the one hand, Emily’s father views medication as a crutch—moderately helpful in the short term, but ultimately undermining Emily’s ability to “really deal with her problems.” Her mother, on the other hand, has grown weary of Emily’s incomplete symptom remission, in spite of frequent medication adjustments. In response to these concerns, the therapist’s first step is to provide basic psychoeducation regarding the biological nature of bipolar disorder. After the therapist discusses the high heritability of the disorder, Emily’s parents are able to identify a familial pattern. Mom: My sister is also bipolar, and there was some talk about my grandmother having manic depression. It also seemed like my dad always had problems with depression. Dad: I struggle with depression, too, and it seems like half my cousins have been on antidepressants. Mom: Between mood problems and diabetes, seems like our family can’t catch a break. Therapist: Diabetes runs in your family? Mom: I actually have an insulin pump. My mom was diabetic, too, and so is my brother. The therapist uses this opportunity to address Emily’s father’s aversion to Emily taking medication. Therapist: So is there a difference between a diabetic who needs insulin and someone with bipolar disorder who needs medication?

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Dad: Well, sometimes diabetes can be controlled with diet and exercise. Mom: Not me. I’m really careful. Without my pump, though, I’m in trouble. Dad: But maybe Emily’s bipolar disorder isn’t that bad. Maybe she can manage without it if she just had the right—I don’t know—tools. Therapist: Research would suggest that learning coping skills may be enough to address depression, and they’re very important in managing bipolar disorder, too, but only if manic symptoms like Emily’s are stabilized first. That’s why the medication is essential. Dad: I don’t know. ... I just don’t like it. Therapist: I don’t think there are many parents who love the idea of their child needing medications, but let’s look at Emily’s history. How were her symptoms before she began the medication? Dad: She ended up in the hospital. It was awful. Therapist: Right. And has she needed to be hospitalized since starting her medications? Mom: No, but it’s not like she’s ever been ... better. Therapist: Let’s talk about what you mean by “better.” Mom: I hate to say it, but. . .normal. She still has rages sometimes, has nights where she’s up forever, sometimes talks about sexual things— it can be so embarrassing and frustrating. And that’s after who knows how many med changes. Therapist: OK, so when you say Emily’s not “better,” it sounds like you’re saying that she still has some symptoms, and really, we may never totally get rid of all those issues. It also sounds like, though, that her medications have helped reduce her symptoms. Mom: That’s true. But how can we be sure she’s on the right medications? Dad: Yeah, sometimes it seems like her psychiatrist is just throwing darts at a dartboard. This is an opportunity for the therapist to foster an appreciation for the active role Emily’s parents can play in the complex task of medication management of bipolar disorder. Therapist: Finding the best medication or even combination of medications can definitely be a long process. Dad: Maybe if we had a different doctor? Therapist: Maybe. But Emily’s doctor has a lot of experience working with kids like Emily, and it sounds like you feel comfortable with her. Mom: Oh, yes, she’s been really supportive, and I like that she takes time to explain what the medications are for. Therapist: Those are important qualities in a physician, so before making a big change like switching doctors, I think we should make sure we’re working with her in the most effective way. Dad: But we’re not doctors, and we can’t tell her what medications to prescribe. Therapist: And I’m not trained to prescribe medications either. We can make sure the doctor has the most complete information about Emily, though. (To the mother:) Managing your diabetes involves more than just taking insulin, right?

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Mom: Sure. I have to watch what I eat, watch my weight. Before I got my pump, I had to monitor my sugar levels regularly. Therapist: That monitoring is just as important with bipolar disorder. When you take Emily to see the psychiatrist, I bet she asks you lots of questions about her symptoms. Dad: Yes, but it’s so hard to keep track of everything. Her symptoms can change so much from week to week, even day to day. Therapist: That’s why the daily mood logs we will discuss are so important. The next time you go to the psychiatrist, you can actually take the log to her, and she can see details of how Emily’s symptoms have fluctuated without you having to recall them on the spot. As long as Emily is taking the medications as prescribed, the doctor can make the most informed decision about whether Emily’s medications should be changed, the dosage adjusted, or both.

Session 3 Child session 3: establishing healthy routines. Regulating sleep, nutrition, and exercise is an important aspect of regulating mood. In this first session devoted to healthy routines, provide an overview of these three topics, and have the child pick the topic he or she finds most troublesome to focus on first. Monitor the child’s progress with this first goal in each subsequent session; the child will pick a second goal from this list in his or her seventh session. Inadequate sleep can trigger mania (Malkoff-Schwartz et al. 1998, 2000) and is a frequent cause of increased irritability. Help the child identify any dysfunctional sleep practices, set goals for proper rest, and develop strategies for those goals to succeed. This involves structuring an environment conducive to sleep and may require relocating a television or video game system to another room and setting guidelines for hours of use. Many medications prescribed for youth with bipolar disorder lead to weight gain, which can lead to self-esteem concerns, not to mention very real health concerns of type 2 diabetes and hypertension. Thus, a focus on healthy food choices is often beneficial. Reviewing fundamentals of nutrition guidelines and troubleshooting how the child can make wiser food choices, often in the face of intense carbohydrate cravings, are important steps. The emphasis here should not be on dieting, but rather on establishing lifelong healthy eating habits. Much as sleep can play a role in mania, exercise has been found to decrease depressive symptoms (Pollock 2001). Increasing physical activity has several added benefits, including helping the child maintain a healthy weight, which also has physical and mental health benefits. Additionally, many ways in which a child can increase activity levels also increase social interaction, for example, through a team sport, playing in the park where other kids have gathered, or a martial arts class.

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This session will likely require more parental involvement, particularly for younger children. Changing patterns of sleep, exercise, and most of all, diet, is integrally tied to how the child’s family functions. Healthy behaviors that become normative for the family as a whole are more likely to be permanently adopted by the individual child. Parent session 3: understanding the mental health system and the school system. In this session, your task is to help parents understand the mental health system and the school system in relation to their child. By the end of the session, they should be able to construct a representation of their child’s mental health treatment team and their educational team. Children with bipolar disorder often require mental health treatment teams composed of a range of service providers, frequently operating out of different agencies or offices. Identifying these individuals, elucidating the role each can or should be playing, and conceptualizing the group as a team pursuing a common goal (i.e., successful management of the child’s disorder) are necessary for optimal treatment utilization. Parents need a fundamental understanding of the child’s current treatment providers, their role and training, and the service each team member typically provides. This exercise provides an opportunity to identify gaps in provided services and to address misconceptions parents may have about the responsibilities or capabilities of different treatment team members. When parents understand, for example, that their child’s psychiatrist may focus largely on medication management and depend on the child’s psychologist to provide behavioral intervention and any necessary psychoeducational testing, it can be easier to maintain a positive therapeutic relationship and can reduce frustration over the limited time a psychiatrist may have to engage in a discussion regarding effective problem-solving or the inability of a psychologist to arrange a medication refill. Further, parents familiar with the role of each service provider are better able to identify the most useful contact to consult with questions that arise over time. This discussion should emphasize the active role of parents and children on the treatment team. Whereas treatment providers may change over time depending on the child’s needs and logistical considerations (e.g., family moves, changes in insurance coverage), parents are constant members of the team and should feel empowered to serve as their child’s primary advocates. Both parents and children will learn skills in treatment to make them more effective contributing members to the treatment team. Children with bipolar disorder also frequently require school-based services. The professionals who provide these services work in collaboration with clinical treatment providers (e.g., rating school behavior, reporting

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suspected medication side effects to parents, implementing behavior plans constructed in conjunction with therapists). Additionally, school professionals also compose an educational team. Youth with bipolar disorder frequently evidence significant dysfunction in the school setting, requiring both academic and behavioral intervention to adapt successfully to the demands of school (Geller et al. 2002; Wozniak et al. 1995). In addition to neurocognitive deficits these students may exhibit, including impairment in memory, attention, and processing speed, fluctuating symptoms of mania and depression during the course of the disorder can also impact school performance (McCarthy et al. 2004; Pavuluri et al. 2006). Thus, parents need to understand what school services are potentially available. Review with parents the various types of school personnel who might be beneficial for their child, the different mechanisms of school-based support (i.e., a 504 plan vs. an Individualized Education Program, or IEP), and the myriad school labels and classification systems (e.g., other health impaired [OHI], severe behavior handicap [SBH]) so they can begin to determine how best to advocate for their child in the school setting. Encourage a cooperative, solution-focused relationship among parents, clinical treatment providers, and school service providers that will facilitate better utilization of available services (Fields and Fristad 2009b). Review with parents several concrete steps they can take to enhance their child’s school-based services. First, encourage parents to keep a binder containing all materials related to the child’s school services. This should include copies of all correspondence sent to or received from school, dates and brief descriptions of phone calls and voice mails, and notes taken at any meetings with school personnel. Second, coach parents on how to ask questions when they are unclear regarding any procedures or expectations. Competent school personnel will appreciate parents’ concern for their child and appreciate the opportunity to clarify information before miscommunication can sow conflict. Third, review information described above with parents, so they have a more comprehensive and realistic understanding of what schools can provide.

Session 4 Child session 4: triggers, physical cues, feelings and actions, coping tool kit. Perhaps the technique most identified with CBT is increasing patient awareness of how thoughts, feelings, and behaviors impact each other, then translating this knowledge into skills to relieve or prevent symptoms and impairment. Undertaking this practice with children requires a developmentally appropriate approach that organizes the process into manageable, routinized steps. Begin by helping the child to identify a

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recent trigger, an event that elicited negative feelings, and the somatic sensations that accompanied those feelings. Often children claim no awareness of physical indicators of mood states. If you provide examples (e.g., face flushing when angry, stomach tightening when afraid), children often begin to respond. Next, have the child identify actions he or she took in response to these negative feelings, along with the eventual consequences of these actions. A child could indicate, for example, that she became angry last week when her mother allowed a sibling to play the video game she was hoping to play (the “trigger”). She could tell she was becoming angry because her “forehead got wrinkled” and she began biting her lip (somatic sensations). In response to her anger, the child grabbed the video game controller from her brother and threw it against the wall (actions), breaking a button and rendering the game unplayable. As a result of these actions, she was unable to play the game at all and was yelled at by her mother (consequences). After identifying an example that illustrates how negative feelings can lead to negative choices and behaviors, the next step is to assist the child in developing a coping tool kit. This tool kit will contain reminders of effective strategies—identified by the child—to help the child regain control of his or her emotions and self-soothe. Younger children often enjoy constructing and decorating an actual shoebox or other container for this purpose, while adolescents may prefer to make a list that can be tucked into a school binder or posted on their bedroom wall. Regardless of the chosen format, the tool kit should include a range of coping strategies that can be implemented in a variety of situations and in response to a number of maladaptive or “hurtful” emotions. To help the child successfully identify an assortment of coping responses, break strategies down into four basic categories: creative, active, relaxation, and social (CARS becomes a useful acronym to remember these categories—just as a car can take someone places he or she wants to go, these coping CARS take a person to the mood state he or she prefers). Creative “tools” might include drawing or playing the piano; active tools might include shooting baskets or playing on the jungle gym; relaxation tools might include reading a book or listening to soothing music; and social tools might include calling a friend on the phone or playing with the family dog. Coping strategies need to match the child’s situation and mood. For example, riding a bike might be an excellent strategy for the child to use at home when feeling grumpy, but it won’t work when the child is at school. Talking to a trusted teacher or using one of the breathing techniques taught in therapy, on the other hand, would work in a school setting. Similarly, listening to dance music when feeling sad is a reasonable and adaptive strategy to use at home; however, using that strategy when thoughts are starting

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to race hypomanically could provide excess stimulation, potentially exacerbating symptoms and leading to poor decisions. Selecting a soothing activity instead (e.g., taking a bath) would be a more appropriate choice in this circumstance. The concept of choice is of considerable significance in this exercise and a theme to be emphasized throughout treatment. Children cannot control the feelings they experience, but they can take responsibility for their actions and choose to respond to feelings in a helpful manner. Parent session 4: negative family cycles, Thinking-Feeling-Doing. A child with bipolar disorder presents significant challenges for a family. Symptoms of a child’s mood disorder, along with those of commonly comorbid conditions such as behavioral and anxiety disorders, can make the child appear intolerant, wild, self-centered, lazy, and domineering, while at the same time extraordinarily needy and unsure of himself or herself. The use of the word appear is notable, in that it is likely more accurate (and certainly more helpful) to view the child’s aversive behavior as a manifestation of the disorder, rather than emblematic of core personality flaws considered largely beyond the reach of therapeutic intervention. Families with children who have bipolar disorder often inadvertently engage in negative interactional cycles characterized by a focus on negative behaviors, assigning blame for these behaviors (directed at both the affected child and parents), coercive behavior, frustration, and eventual feelings of rejection and isolation for parents and children. Addressing negative family cycles begins with first identifying negative cognitions (e.g., “My child doesn’t care about my feelings”; “My spouse never wants to help out when Joey is raging”) and then using the traditional CBT technique of reframing negative or hurtful thoughts in a more positive or helpful manner. The contrast between helpful and hurtful thoughts is quite salient, as it orients parents to the treatment’s emphasis on progress and serves as a reminder of the ultimate goal of CBT for bipolar disorder—helping the child (and the family as a whole) to function more effectively in the face of bipolar disorder, instead of identifying who is most at fault. Keeping in mind developmental needs, a cartoon version of the link among thoughts, feelings, and actions was developed, called “ThinkingFeeling-Doing” (TFD; Fristad et al. 2008). To enhance communication between parents and children, use the same cartoon version for both parents and children in their respective sessions. The cartoon has a light switch at the bottom of the page, accompanied by the text “Something Happens!” and an oval for the child to record the triggering event. The silhouette of a cartoon figure is connected to a thought bubble, feelings heart, and action box, each of which are divided in half, with space to record the “hurt-

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ful” or negative thought, feeling, and action in the lower half and the “helpful” or positive/desired thought, feeling, and action in the upper half. To explain TFD, begin by asking parents to identify a recent event that triggered negative feelings in themselves (e.g., sadness, anger, frustration, or fatigue) and that they didn’t feel they handled particularly well (e.g., “Makayla threw a tantrum just as we were leaving for a nice dinner—the babysitter refused to deal with her, and we had to cancel our night out”). Next, have parents recall the negative thoughts that accompanied these feelings (e.g., “Makayla is so selfish”; “We’ll never be a normal family”; “What’s the use of trying?”). Simply acknowledging these inevitable and understandable thoughts is a requisite step in this approach and provides an opportunity to validate the frustration and hurt experienced by parents struggling with a child with a mood disorder (e.g., “I can imagine how disappointing it was to anticipate a relaxing night out and to have that fall through at the last minute”). It’s not easy raising a child with bipolar disorder, and parents deserve to hear this from someone who understands the challenges they face on a daily basis and who is supportive of their desire to seek help. Once parents have identified the negative feelings and thoughts that arose in response to an event, have them specify the actions they took in response to these thoughts (e.g., “I yelled at Makayla, went to my room, and cried”). Ask parents to notice the negative cycle that occurs: negative feelings lead to negative thoughts, which lead to negative behaviors. Then help parents understand where they can intervene to break the cycle. Although it might seem easiest just to eliminate the frustrating event in the first place, this isn’t always under parental control, especially when the issue stems from a child experiencing mood symptoms. Further, negative feelings are part and parcel of raising a challenging child. Thus, the first area on which to focus is negative thinking. Encourage parents to brainstorm more positive, realistic, and helpful ways of thinking about the event. Instead of thinking “Makayla is so selfish,” they could reframe the event in a way that differentiates the child from the symptom (e.g., “Makayla’s really struggling with her manic symptoms this week; she’s been much more irritable and hasn’t been sleeping much”). Alternatively, parents could reframe the event in a way that emphasizes learning something from the experience (e.g., “This is an opportunity to help Makayla learn how to manage these emotions. Fortunately we were still here, because the babysitter might not have been able to help her through this as well as we can”). Next, help parents to generate ideas for actions that would have been more helpful in this situation, while also noting how much easier it is to act positively in response to problem-focused, helpful thoughts. For exam-

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ple, instead of yelling at the child and retreating to the bedroom to cry, parents could help the child choose a calming strategy from her tool kit and could make a plan to call her psychiatrist the next day to voice concerns that the child’s manic symptoms are increasing. They could take a long walk together after the situation at home calmed down sufficiently and order takeout from one of their favorite local restaurants. Generating these more adaptive thoughts and actions not only moves the family toward effectively managing the problem, but also positively impacts parents’ emotions. Whereas hurtful cognitions and responses beget more negative feelings, helpful thoughts and actions beget more positive feelings.

Sessions 5 and 6 Child session 5: Thinking-Feeling-Doing. This session introduces the TFD exercise to the child. As with the parents, help the child recall an upsetting event, identify and acknowledge the negative emotions associated with that event, discuss hurtful cognitions and actions arising in response to the negative feelings, and finally guide the child through the experience of restructuring thoughts and choosing more adaptive behaviors to alleviate emotional dysregulation. This session builds on the work from the previous session, in which the child focused on identifying triggers, accompanying somatic responses and negative affect, and hurtful actions. This new step adds in the role of cognition and links thoughts, feelings, and actions together. Parent session 5/child session 6: effective problem-solving. Parent session 5 and child session 6 both focus on developing an effective approach to problem solving. This approach employs hypothesis testing, a hallmark of CBT that encourages clients to predict (or hypothesize) the consequences of actions, then reevaluate their predictions in light of actual outcomes. Although parent and child sessions on problem solving are conducted separately, most of the techniques used will be described here only once, due to the similarity of material presented in each session. • First, identify the problem. Although selected “problems” can be incidents that the child finds upsetting (much as in TFD), it is also beneficial to frame symptoms of the child’s disorder as problems, reinforcing earlier content regarding depersonalization of symptoms as an external enemy. • After a problem has been identified (e.g., receiving detention, not getting enough sleep), have the child brainstorm ways in which he or she can regain control of his or her emotions in the face of a challenging sit-

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uation. Again, this session builds on the work of the previous sessions, as the child now has an understanding of how thoughts, feelings, and actions are integrated and affect each other. Because excessive emotional reactivity can compromise problem-solving skills (Pavuluri et al. 2004), a child needs to calm down affectively before he or she is likely to be successful in generating, selecting, and implementing sound decisions. • Next, have the child generate a list of possible solutions to the problem. Using a brainstorming approach, write down every suggestion made before weighing their merits. For example, a child dealing with anger over receiving a detention might generate suggestions that range from “Ask the teacher what I did wrong and try to avoid doing this in the future” to “Refuse to attend detention.” • Then, have the child think through the pros and cons of each action. After doing so, select an appropriate plan of action and encourage the child to implement the solution next time the situation arises. Most importantly, draw the child’s awareness to the results of his or her decision. If the child’s choice solves the problem, he or she should plan to use the strategy again in the future. If, on the other hand, the child’s choice fails to ameliorate the situation, a new strategy should be considered next time, taking into account what has proven previously unsuccessful.

Case Example: Making Responsible and Reasoned Choices Alejandro is a 9-year-old boy who was diagnosed with bipolar disorder NOS 2 years ago. Alejandro’s school behavior has improved with medication management and the implementation of special education services, including the identification of a “safe spot” where Alejandro can go when feeling overwhelmed, as well as an adjusted schedule that places his most demanding courses early in the day, when Alejandro tends to be at his best. However, his parents are concerned that Alejandro continues to blame others for his outbursts at home. When this occurs, Alejandro frequently says he can’t help it, and blames his actions on his “bipolar.” The therapist begins a discussion of effective problem-solving with Alejandro by bringing up an issue Alejandro identified earlier in treatment. Therapist: So, Alejandro, remember when we talked about some of your symptoms, and one thing you identified was hitting Paul when you get angry? Alejandro: That happened yesterday when Paul knocked over the Lego castle I was building. But that’s not the real me. That’s my bipolar. The real me is usually nice to Paul, like I show him how to build things.

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Therapist: Is it your fault that you have bipolar disorder? Alejandro: No. It’s not my fault. Therapist: Right. But even though having bipolar disorder is not your fault, it is still your.. .(pauses to let Alejandro answer).. .do you remember? Alejandro: Um, it’s not my fault? Therapist: Yes. But it is your challenge. That means it’s your responsibility to make good choices, even when you’re feeling angry. You can’t just say, “Oh well, I can’t help it; I have bipolar disorder.” Alejandro: Oh, yeah. Dad always says, “That’s no excuse.” Therapist: Right. So now we’re going to talk about how to make good choices, because that can seem hard sometimes. Alejandro: It’s really hard. Therapist: Is it harder to think of good choices when you’re very angry or when you’re more calm? Alejandro: When I’m angry. That’s what I tell my mom. I tell her I’m too mad. Therapist: OK, so the first step in making a good choice is calming down so you can think more clearly. We talked about ways to calm down earlier when you made your tool kit. What’s something in your tool kit you could use to calm down if you’re angry at Paul? Alejandro: I could squeeze my stress ball very hard. Oh, or I could talk to Mom and she could rub my shoulders. Therapist: You have a great memory! Now let’s think of another solution to your problem. What did you do yesterday when Paul knocked over your castle? Alejandro: I told you. I hit him. Therapist: OK. What are some other things you could have done, besides hitting Paul? Alejandro: I don’t know, tell Mom? Therapist: Good! Let’s look at those two choices and see what the good and bad things are about each one. Are there any good things about hitting Paul? Alejandro: No. I mean, yes. It made me feel better. Therapist: OK, it felt good. Did it feel good for a long time, or just for a little while? Alejandro: Just a second. Then Paul started to cry and Dad came and yelled at me and gave me a time-out. Therapist: So those were bad things about choosing to hit Paul, right? Alejandro: Yeah, and when I said that I still wanted to play with my Legos, Dad said that because I hit Paul, I couldn’t play with them anymore that day. Therapist: So the good thing about your choice was that you felt better for just a second, and the bad things were that you got yelled at and had to go to time-out. And in the end, your Legos got taken away and you couldn’t even rebuild your castle. Now what about your other choice— telling Mom? What are the good things about telling your mom? Alejandro: She would know that it was Paul who did something wrong and not me, and Dad wouldn’t have yelled at me.

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Therapist: And would you have been sent to time-out? Alejandro: No, they would make Paul go play with his own toys. Therapist: And are there any bad things about telling your mom? Alejandro: Maybe she would say I was being a tattletale. Therapist: Does she usually say that? Alejandro: No. Therapist: OK, then it doesn’t sound like that’s very likely. So in the end, what do you think would have happened if you had told your mom instead of hitting Paul? Alejandro: I would get to play with my Legos without Paul interrupting me. But it would be hard to make the exact same castle that I made before. Therapist: Maybe so. But maybe the next castle you made would have been even better. Alejandro: Yeah, I’m pretty good at making castles.

In this interaction, the therapist makes it clear that although Alejandro is not responsible for having bipolar disorder, he is responsible for the choices he makes. To this end, the therapist helps guide Alejandro through the process of making a good choice in a developmentally appropriate manner. For instance, the therapist poses questions by giving Alejandro choices (e.g., “Is it harder to think of good choices when you’re very angry or when you’re more calm?”), as opposed to posing completely openended questions that may be difficult for the child to answer. In addition, the therapist helps the child to deepen his analysis of the situation by asking follow-up questions (e.g., “OK, it felt good. Did it feel good for a long time, or just for a little while?”). Children are likely to require less such scaffolding as they become more experienced with analyzing problematic situations and their outcomes, although the rate of this progression is specific to each individual child. Structured practice, however, in which each step of the problemsolving process is explicitly addressed, is essential. Parent session 6: revisiting the mental health team and educational team. Often after learning more about how the mental health system and educational system can work on behalf of a child, parents will return to treatment with specific questions about how to implement effective change. Issues with schools are particularly common; use this session to plan for the pending school professional session (parent session 7). Assuming there are sufficient school issues to warrant direct communication with the school, use this session to plan the nuts-and-bolts of how, when, and where to accomplish this task. Examples include your going to a school meeting, video conferencing, conference calling, or inviting members of the school staff to attend a therapy session. Also, set a clear and realistic agenda with the parent at this

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session (i.e., What should be communicated? What questions need to be answered? What concerns does the parent have?).

Session 7 Child session 7: revisiting healthy routines. Given the importance of healthy routines in maintaining affective stability, revisiting these routines is in order. Progress on the child’s first goal should have been monitored at each session since the child began tracking sleep, nutrition, or exercise. At this session, have the child select the topic of second most importance, set reasonable goals around that behavior, and begin to track it. Suboptimal treatment adherence regarding healthy behaviors is common; because the child has now learned problem-solving skills, work with him or her to apply those skills to increase compliance. Often, the first step of identifying the problem is very important to successful problem-solving. For example, the problem “I need to lose 15 pounds before my senior pictures” may not lead to a successful outcome in a teenager 2 months before the event, but changing the problem to “I need to cut out most of the junk food in my diet” is more likely to lead to concrete but not extreme behaviors that can be maintained over a lifetime. Parent session 7: school treatment team. Use this session to problem-solve and share information directly with the previously identified member(s) of the child’s school. This might be the school psychologist, school social worker, school counselor, child’s IEP chair, intervention specialist or special education teacher, regular education teacher, resource room teacher, tutor, paraprofessional, school nurse, behavioral specialist, principal or vice principal, physical or occupational therapist, district special education coordinator, and other staff pertinent to the child’s school.

Session 8 Child session 8: nonverbal communication. Impaired communication, including the presence of expressed emotion, has been identified as a possible influence on the course of bipolar disorder. Thus, addressing maladaptive communication patterns between parents and children as well as every dyad in the family is important. Parents can usually absorb information, can typically practice using effective verbal and nonverbal communication in a single session (as will be discussed in parent session 8), and likely are at least somewhat familiar with the concepts. In contrast, children may benefit from separate presentations about verbal and nonverbal communication, with eventual integration of the two topics. Research indicates children with bipolar disorder tend to struggle with interpreting

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nonverbal cues, especially facial expressions; thus, devoting a session specifically to nonverbal communication is considered beneficial. Begin by discussing the communication cycle. That is, one individual sends a message, which is then received by another individual. This second individual then sends a message, which is received by the first individual. A problem in any step of this cycle has the potential to disrupt communication and understanding. In reality, of course, the process can be infinitely more complicated and involves issues such as how each member of a communication dyad interprets the other’s verbal and nonverbal cues. The intent here, however, is only to establish basic rules requisite to effective communication. Next, raise the child’s awareness of nonverbal communication cues and provide practice in accurately interpreting these signals. Though many children have some concept of helpful and hurtful language, they are often less aware of how nonverbal signals (i.e., posture, gestures, facial expressions, eye contact, level of personal space, and tone of voice) can influence interactions. After explicitly identifying and eliciting examples, introduce an activity in which the child and an adult take turns guessing the emotions displayed by the other. This activity, which can be framed as a game of charades, should be practiced by the child and parents before the next child session. Further, parents can employ this general technique (either asking the child to interpret the nonverbal cues of others to confirm comprehension or using the child’s own nonverbal cues to gauge his or her current emotional state) in the course of everyday interactions to increase the child’s facility with this often deficient skill and to enhance communication. Parent session 8: communication. Addressing how parents communicate, both verbally and nonverbally, also requires identification of the basic communication cycle that was discussed with the child in child session 7. Next, provide common examples of hurtful communication, including name-calling, blaming, denying, rehashing past or unrelated conflicts, interrupting, and lecturing. After drawing parents’ attention to these negative interactions, provide guidelines for more adaptive communication, including staying positive and calm, keeping instructions brief, taking turns speaking, paying attention to others’ verbal and nonverbal cues, listening to the child rather than lecturing, and being direct. Additionally, let parents know that asking questions and restating what the listener believes the other to be saying can be effective methods of eliminating confusion. Encourage practice of these communication strategies. In particular, ask parents to monitor their use of hurtful communication, then have them identify more helpful communication they could implement instead. Use of these strategies in interactions with all members of the family can significantly reduce the level of expressed emotion and confusion in the home.

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Session 9 Child session 9: verbal communication. As a follow-up to the session on nonverbal communication, begin this session with a quick review of the communication cycle. Then, focus on helping children to differentiate between helpful and hurtful words (e.g., “D’Shaun keeps coming in my room, and it’s making me angry” vs. “D’Shaun’s being a brat!”). Using helpful words involves standard training in assertive communication—i.e., describe the situation, express your feelings, state your desired outcome. Making the distinction between helpful and hurtful language increases children’s awareness of how they are speaking and how their words are impacting others. Parent session 9: managing symptoms of bipolar disorder. Being a good enough parent isn’t good enough to know how to manage the unique symptoms of bipolar disorder. Parents benefit from specific coaching on how to handle troublesome symptoms. An initial rule of thumb is to address symptoms before they escalate to levels where the child and parent are less able to use the tools and skills with which they have been equipped in treatment. A child who has progressed to full-blown mania, for example, is unlikely to successfully employ his or her coping tool kit or to engage in effective problem-solving. Likewise, when depressive symptoms appear, parents should encourage the child to use his or her tool kit, especially tools that involve physical activity and staying socially engaged. An adolescent experiencing an increase in depression may not feel like keeping plans to attend a movie with friends, but doing so (and engaging in other healthpromoting behavior) may help to mitigate symptoms and prevent eventual progression into a major depressive episode. With the onset or increase of the child’s manic symptoms, parents should limit stimulation such as loud music, bright lights, heavy physical exertion, large gatherings, overscheduling of events, and intake of caffeine or sugar. Routines should be kept consistent and healthy habits maintained, including attempts to keep the child’s sleep schedule as normal as possible. Encourage the child to use his or her tool kit, particularly coping techniques involving relaxation, because behavioral activation may exacerbate symptoms of mania. Even if suicidal behavior has not been an issue for the child, making prior arrangements for how to handle it in case it becomes a concern is preferable to attempting to design and implement appropriate measures in the midst of a crisis. Parents should have prearranged places to lock away guns, knives, medications (both prescription and over-the-counter), and toxic household cleansers. They should have easy access to essential information, including contact information for mental health care providers, a list of all medications the child is taking, and any relevant insurance information. A child who ex-

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presses an immediate intent to harm himself or herself and who may have the ability to do so should be immediately referred for emergency services, particularly if parents have any doubt about their ability to constantly monitor the child and ensure safety. Especially with children who have demonstrated significant physical aggression toward themselves and others, helping parents secure training in administering therapeutic holds may be advisable, as well as knowing when (and how) to call the police for assistance. Hospitalization, if necessary, should never be used punitively or as respite for overstressed parents. Stress that hospitalization is a setting for short-term stabilization of acute symptoms and a means of returning children to everyday routines as efficiently as possible. Managing the symptoms of a child with bipolar disorder also requires parents to manage the inherent stress of dealing with a chronically ill child. Use your knowledge of the family and its resources to help parents identify sources of emotional support and how to utilize them (e.g., family and friends who feel comfortable supervising the child for short periods; support groups for parents of children with mood disorders, including online forums; spiritual or religious groups, if consistent with the family’s beliefs). In addition, all family members, regardless of age or relationship to the child, should make time for themselves and for enjoyable activities with others. Parents are often so overwhelmed with the demands of managing their child’s disorder that they don’t realize the necessity of self-care. Those who do recognize the need often feel guilty about considering their own needs, out of understandable yet counterproductive concern for the child. Remind parents this is a marathon, not a sprint. They need to give self-preservation a high priority, and set aside time for exercise, meditation, other “refueling” activities, or therapy for themselves.

Family Session: Working With Siblings Easily lost in the wake of a child suffering from bipolar disorder are the needs of siblings. Including these children in the treatment process reminds parents that the impressive needs of the patient do not diminish those of their other children. In this session, which should be undertaken in the absence of the patient to encourage siblings to communicate openly, the clinician should validate siblings’ often conflicting emotions (e.g., concern for the patient and yet frustration over the disruption the disorder often causes). As parents are often unsure how much information to give siblings about the child’s condition, discuss with parents beforehand the level of information to impart on the basis of the relative sophistication of siblings. Additionally, the child with bipolar disorder should have an awareness of how information about the illness will be presented to siblings, in order to allay fear of embar-

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rassment. A key challenge in this session is balancing the need to involve siblings in helping to create an environment conducive to the health of all members of the family, while also maintaining appropriate boundaries that avoid placing excessive responsibility on these other children. Finally, as siblings have the same familial risk as the child with bipolar disorder, referral for an evaluation and treatment of one or more siblings may also be in order.

Closing Session: Summary and Graduation Up to four additional sessions to review necessary information and skills have been built into the treatment model that has been tested. Of course, clinically, you can follow a family as long as needed. An ideal model of care is one in which you as the family clinician are able to see the child intensively to begin treatment, then as needed over the course of his or her development. Often, this translates to additional sessions around times of transition—elementary school to middle school, middle school to high school, high school to college. When the end of the intensive initial treatment phase is reached, emphasize the importance of the family and child continuing to use skills learned during the intervention, in times of both symptom exacerbation and remission. Although symptoms will almost inevitably fluctuate to some degree, consistent application of these skills, sustained awareness that recurrence is possible, and medication adherence provide the best possible prognosis for the child in the future. This session should serve as a graduation ceremony. Children can be provided with a developmentally appropriate “diploma,” signifying successful completion of an intense course of treatment and recognition of their hard work. Parents, too, deserve praise for tackling their child’s disorder and their commitment to the well-being of their child and family—a proactive approach that if maintained should continue to pay dividends into the future.

Cultural Considerations Due to the relative infancy of research regarding psychosocial interventions for youth with bipolar disorder, evidence-based guidelines for making culturally specific adaptations to a CBT program of this type are not yet available. In lieu of such information, an emphasis on sensitivity to the specific needs of each family is likely the most optimal approach (see Chapter 3). A strength of the intervention described here is that it allows for therapists to adjust content to meet the family “where they are” as opposed to “where they should be.”

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Special Challenges to Treatment Distinguishing Mood From Behavioral Symptoms Given the extremely high levels of comorbidity between bipolar disorder and behavioral disorders, helping parents to differentiate mood from behavioral symptoms (i.e., the “can’ts” from the “won’ts”) is a particularly relevant exercise. On one hand, therapy urges compassion and tolerance for the maladaptive emotions these children often cannot control; on the other hand, treatment urges children (and parents) to take responsibility for their actions, regardless of their emotions. Striking an appropriate balance— knowing when to give way and when to push back—can be difficult for parents. Aside from educating parents about how the symptom presentation of bipolar disorder differs from behavioral disorders, identifying particular cues that indicate the source of a child’s inappropriate behavior can often benefit parents. Parents, for example, sometimes speak of a blank look in their child’s eyes or a feeling that the child is “gone” when in the midst of a moodinduced rage. In contrast, a child throwing a tantrum in the course of testing limits may be described as having a mischievous or petulant look, suggesting a purposeful quality to his or her actions. As parents become more adept at observing fluctuations in their child’s mood (perhaps through the use of mood logs), they are often able to identify the manner in which mood symptoms fluctuate in concert with other symptoms (e.g., a rise in mania may be indicated not just by increased irritability but by increased irritability accompanied by markedly agitated movements and increased speech). Heightened insight into how mood and behavioral symptoms tend to manifest in their particular child leads to more confidence in choosing when to give the child more leeway and when to stand firm.

Bringing Unspoken Negative Thoughts to the Forefront A good deal of CBT for bipolar disorder is directed at helping parents and children break the negative cycles that too often typify interactions within these families. Identifying overly negative and maladaptive thinking and helping individuals to reframe situations from a more helpful perspective can be exceptionally powerful and enlightening. The opportunity to finally express these negative thoughts (e.g., “Why can’t my child just be normal?” “He feeds off making me unhappy”; “The way my husband avoids interven-

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ing with our daughter, I’d be better off raising her alone”) is often uncomfortable for parents but can be ultimately cathartic and empowering, especially when the parents are interacting with an empathic therapist who responds to the presence of these thoughts with a sense of understanding (though without confirmation that the thoughts are accurate or helpful). Once negative cognitions have been brought to the forefront and stripped of the guilt that so often accompanies them, parents can begin to examine their thoughts from a fresh perspective more conducive to progress.

Conclusion While additional research is needed to further refine CBT-based, adjunctive treatments for pediatric bipolar disorder, the intervention described in this chapter (IF-PEP) has shown promise in helping patients and families to meet the challenges of this complex illness. Because bipolar disorder is typically believed to have a lifelong, chronic course, the intervention’s focus on providing families with a sound knowledge base and the development of essential skills (e.g., effective communication, problem-solving) should appeal to clinicians who wish to equip their patients with more than just a “band-aid” to address immediate concerns.

Key Clinical Points • CBT for child and adolescent bipolar disorder is adjunctive to medication management. Psychoeducational materials stress the need for close communication with the prescribing physician and consistent adherence to the prescribed medication regimen, even after symptoms have subsided. • Similarly, medication management in the absence of psychosocial intervention is likely to result in suboptimal outcome and is therefore best viewed as a necessary but not sufficient condition of effective treatment. • The involvement of families in treatment is essential. Parents who are more informed regarding the nature of bipolar disorder and effective management of symptoms are better equipped to serve as the eyes and ears of their child’s treatment team. Children with similar information are also more likely to take an active role in their own treatment. • Helping the family to create a home environment consistent with maintenance of the child’s long-term mood stability requires the develop-

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ment of a number of skills in both parents and child, including affect regulation, problem solving, communication training, and self-care. • Breaking maladaptive family cycles typified by negativity, criticism, and poor communication requires an understanding of the interrelatedness of emotions, cognitions, and behaviors.

Self-Assessment Questions 6.1. CBT would be considered an appropriate treatment strategy for a child with bipolar disorder A. Only when a strong family history of bipolar disorder is identified. B. In conjunction with mood stabilization with medication. C. If the child is of well above-average intelligence. D. As a stand-alone treatment. 6.2. Children with bipolar disorder are at increased risk for A. B. C. D.

Academic problems. Social problems. Suicidal ideation. All of the above.

6.3. A 14-year-old adolescent girl is diagnosed with bipolar I disorder. __________ is/are considered the first-line treatment(s). A. B. C. D.

CBT. Antidepressants. Mood stabilizers or atypical antipsychotics. Electroconvulsive therapy.

6.4. Although the etiology of bipolar disorder is thought to be largely ___________________, illness course is likely influenced by ___________________________. A. The result of trauma; biological factors. B. Biological; a combination of biological, psychological, and social factors. C. Due to impaired parenting; a combination of biological, psychological, and social factors. D. Medication induced; the child’s level of intelligence.

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6.5. _____________ is almost always recommended as a part of CBT for a child with bipolar disorder. A. B. C. D.

Family involvement. Use of a therapist of the same sex as the child. Residential treatment. Psychoeducational testing.

Suggested Readings and Web Sites For Families Books Andersen M, Kubisak JB, Field R, et al: Understanding and Educating Children and Adolescents With Bipolar Disorder: A Guide for Educators. Northfield, IL, The Josselyn Center, 2003—a book for parents to share with school professionals Child and Adolescent Bipolar Foundation: The Storm in My Brain. Evanston, IL, 2003. Available at: Child and Adolescent Bipolar Foundation (CABF): (800) 256–8525, www.bpkids.org—a book for children Fristad MA, Goldberg Arnold JS: Raising a Moody Child: How to Cope With Depression and Bipolar Disorder. New York, Guilford, 2004—a book for parents Jamieson PE, Rynn MA: Mind Race: A Firsthand Account of One Teenager’s Experience With Bipolar Disorder. New York, Oxford University Press, 2006—–a book for adolescents Miklowitz DJ, George EL: The Bipolar Teen: What You Can Do to Help Your Child and Your Family. New York, Guilford, 2007—a book for parents

Web Sites The Balanced Mind Foundation: www.thebalancedmind.org—for parents and adolescents BPChildren: www.bpchildren.com—for parents and children; features “BPChildren Newsletter”

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For Clinicians Books Fristad MA, Goldberg Arnold JS, Leffler J: Psychotherapy for Children With Bipolar and Depressive Disorders. New York, Guilford, 2011 Kowatch RA, Fristad MA, Findling RL, et al: A Clinical Manual for the Management of Bipolar Disorder in Children and Adolescents. Washington, DC, American Psychiatric Publishing, 2009

Web Sites Juvenile Bipolar Research Foundation (JBRF): www.bpchildresearch.org— includes a Listserv for therapists treating children with bipolar disorder MF-PEP and IF-PEP workbooks can be ordered directly from www.moodychildtherapy.com

References Basco MR, Rush AJ: Cognitive-Behavioral Therapy for Bipolar Disorder. New York, Guilford, 1996 Danner S, Fristad MA, Arnold LE, et al: Early onset bipolar spectrum disorders: diagnostic issues. Clin Child Fam Psychol Rev 12:271–293, 2009 Fields BW, Fristad MA: Assessment of childhood bipolar disorder. Clinical Psychology: Science and Practice 16:166–181, 2009a Fields BW, Fristad MA: The bipolar child and the educational system: working with schools, in A Clinical Manual for the Management of Bipolar Disorder in Children and Adolescents. Edited by Kowatch RA, Fristad MA, Findling RL, et al. Washington, DC, American Psychiatric Publishing, 2009b, pp 239–272 Fristad MA: Psychoeducational treatment for school-aged children with bipolar disorder. Dev Psychopathol 18:1289–1306, 2006 Fristad MA, Gavazzi SM, Soldano KW: Naming the enemy. J Fam Psychother 10:81–88, 1999 Fristad MA, Goldberg-Arnold JS, Gavazzi SM: Multifamily psychoeducation groups (MFPG) for families of children with bipolar disorder. Bipolar Disord 4:254–262, 2002 Fristad MA, Goldberg-Arnold JS, Gavazzi SM: Multi-family psychoeducation groups in the treatment of children with mood disorders. J Marital Fam Ther 29:491–504, 2003 Fristad MA, Davidson KH, Leffler JM: Thinking-feeling-doing. J Fam Psychother 18:81–103, 2008 Fristad MA, Verducci JS, Walters K, et al: Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorders. Arch Gen Psychiatry 66:1013–1021, 2009

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Geller B, Craney JL, Bolhofner K, et al: Two-year prospective follow-up of children with a prepubertal and early adolescent bipolar disorder phenotype. Am J Psychiatry 159:927–933, 2002 Goldstein TR, Axelson DA, Birmaher B, et al: Dialectical behavior therapy for adolescents with bipolar disorder: a 1-year open trial. J Am Acad Child Adolesc Psychiatry 46:820–830, 2007 Hlastala SA, Kotler JS, McClellan JM, et al: Interpersonal and social rhythm therapy for adolescents with bipolar disorder: treatment development and results from an open trial. Depress Anxiety 27:457–464, 2010 Hooley J, Orley J, Teasdale JD: Levels of expressed emotion and relapse in depressed patients. Br J Psychiatry 148:642–647, 1986 Kim EY, Miklowitz DJ, Biuckians A, et al: Life stress and the course of early-onset bipolar disorder. J Affect Disord 99:37–44, 2007 Kowatch RA, Suppes T, Carmody TJ, et al: Effect size of lithium, divalproex sodium, and carbamazepine in children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry 39:713–720, 2000 Kowatch RA, Fristad M, Birmaher B, et al: Treatment guidelines for children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry 44:213–235, 2005 Leffler JM, Fristad MA, Klaus NM: Psychoeducational psychotherapy (PEP) for children with bipolar disorder: two case studies. J Fam Psychother 21:269– 286, 2010 Malkoff-Schwartz S, Frank E, Anderson B, et al: Stressful life events and social rhythm disruption in the onset of manic and depressive bipolar episodes. Arch Gen Psychiatry 55:702–707, 1998 Malkoff-Schwartz S, Frank E, Anderson BP, et al: Social rhythm disruption and stressful life events in the onset of bipolar and unipolar episodes. Psychol Med 30:1005–1016, 2000 McCarthy J, Arrese D, McGlashan A, et al: Sustained attention and visual processing speed in children and adolescents with bipolar disorder and other psychiatric disorders. Psychol Rep 95:39–47, 2004 McClellan J, Kowatch R, Findling R: Practice parameter for the assessment and treatment of children and adolescents with bipolar disorder. J Am Acad Child Adolesc Psychiatry 46:107–125, 2007 Mendenhall AN, Fristad MA, Early T: Factors influencing service utilization and mood symptom severity in children with mood disorders: effects of multifamily psychoeducation groups (MFPGs). J Consult Clin Psychol 77:463– 473, 2009 Miklowitz D, Goldstein M: Bipolar Disorder: A Family Focused Treatment Approach. New York, Guilford, 1997 Miklowitz DJ, Goldstein MJ, Nuechterlein KH, et al: Family factors and the course of bipolar affective disorder. Arch Gen Psychiatry 45:225–231, 1988 Miklowitz DJ, George EL, Axelson DA, et al: Family focused treatment for adolescents with bipolar disorder. J Affect Disord 82 (suppl 1):S113–S128, 2004 Miklowitz DJ, Biuckians A, Richards JA: Early onset bipolar disorder: a family treatment perspective. Dev Psychopathol 18:1247–1265, 2006 Miklowitz DJ, Axelson DA, Birmaher B, et al: Family focused treatment for adolescents with bipolar disorder: results of a 2-year randomized trial. Arch Gen Psychiatry 65:1053–1061, 2008

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Miller AL, Rathus JH, Linehan MM: Dialectical Behavior Therapy With Suicidal Adolescents. New York, Guilford, 2006 Pavuluri MN, Graczyk PA, Henry DB, et al: Child- and family focused cognitivebehavioral therapy for pediatric bipolar disorder: development and preliminary results. J Am Acad Child Adolesc Psychiatry 43:528–537, 2004 Pavuluri MN, Schenkel LS, Subhash A, et al: Neurocognitive function in unmedicated manic and medicated euthymic pediatric bipolar patients. Am J Psychiatry 163:286–293, 2006 Pollock KM: Exercise in treating depression: Broadening the psychotherapist’s role. J Clin Psychol 57:1289–1300, 2001 Strober M, Morrell W, Lampert C, et al: Relapse following discontinuation of lithium maintenance therapy in adolescents with bipolar I illness: a naturalistic study. Am J Psychiatry 147:457–461, 1990 West AE, Henry DB, Pavuluri MN: Maintenance model of integrated psychosocial treatment in pediatric bipolar disorder: a pilot feasibility study. J Am Acad Child Adolesc Psychiatry 46:205–212, 2007 West AE, Jacobs RH, Westerholm R, et al: Child- and family-focused cognitivebehavioral therapy for pediatric bipolar disorder: pilot study of group treatment format. J Can Acad Child Adolesc Psychiatry 18:239–246, 2009 White M, Epston D: Narrative Means to Therapeutic Ends. New York, Norton, 1990 Wozniak J, Biederman J, Kiely K, et al: Mania-like symptoms suggestive of childhood-onset bipolar disorder in clinically referred children. J Am Acad Child Adolesc Psychiatry 34:867–876, 1995 Young ME, Fristad MA: Working with patients and their families, in A Clinical Manual for the Management of Bipolar Disorder in Children and Adolescents. Edited by Kowatch RA, Fristad MA, Findling RL, et al. Washington, DC, American Psychiatric Publishing, 2009, pp 217–238

7

Childhood Anxiety Disorders The Coping Cat Program Kelly A. O’Neil, M.A. Douglas M. Brodman, M.A. Jeremy S. Cohen, M.A. Julie M. Edmunds, M.A. Philip C. Kendall, Ph.D., ABPP

ANXIETY disorders are commonly experienced by youth, with reported rates of 10%–20% in the general population and primary care settings (Chavira et al. 2004; Costello et al. 2004). Anxiety disorders in youth include generalized anxiety disorder (GAD), social phobia, separation anxiety disorder (SAD), specific phobias, obsessive-compulsive disorder, and posttraumatic

S This chapter has a video case example on the DVD (“The Coping Cat Program”) demonstrating CBT for an anxious child. Preparation of this chapter was facilitated by research grants awarded to Philip C. Kendall (MH MH080788 and UO1MH63747).

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stress disorder (American Psychiatric Association 2000). In this chapter, we focus on a treatment for three youth anxiety disorders (GAD, social phobia, SAD) that have similar features and high rates of co-occurrence. Anxiety disorders do not remit with time, and most, if left untreated, are associated with impairments in adulthood. Anxiety disorders in children are also associated with difficulties in academic achievement (Ameringen et al. 2003), social and peer relations (Greco and Morris 2005), and future emotional health (Beidel et al. 1991). Anxiety in youth places children at increased risk for comorbidity (Verduin and Kendall 2003) and psychopathology in adulthood (e.g., anxiety, substance abuse, depression; Kendall et al. 2004). The consequences of untreated anxiety disorders in youth highlight the need for early intervention.

Empirical Evidence Cognitive-behavior therapy (CBT) for youth anxiety has been found to be effective in several randomized clinical trials conducted in the United States (e.g., Kendall 1994; Kendall et al. 1997, 2008b; Walkup et al. 2008). Additional studies with similar outcomes have been conducted in Australia (e.g., Barrett et al. 1996), Canada (e.g., Manassis et al. 2002), and the Netherlands (e.g., Nauta et al. 2003). Collectively, although not all participants are responders, the results of these trials indicate that between 50% and 72% of children with GAD, social phobia, and/or SAD who receive CBT do have a positive response—they no longer meet criteria for their presenting anxiety disorder following treatment. In contrast, such trials indicate that between 10% and 37% of youth who receive pill placebo, wait-list assignment, or active comparison treatment for their anxiety disorder have a positive response following treatment (Barrett et al. 1996; Kendall et al. 2008b; Nauta et al. 2003. The maintenance of therapeutic gains has been found up to 7 years posttreatment. In two follow-up studies of different samples of anxious youth (3.35 and 7.4 years after treatment), 80%–90% of successfully treated children continued to not meet criteria for their presenting anxiety disorder (Kendall and Southam-Gerow 1996; Kendall et al. 2004). To date, rates of long-term treatment maintenance following CBT have not been compared with a control group, because generally, the wait-listed youth in such trials were offered treatment following the initial wait-list period. It is pleasing to note that reviews of the evaluation literature support the utility of CBT for childhood anxiety disorders. Such reviews appearing earlier than 2008 and applying Chambless and Hollon’s (1998) criteria for evidence-based treatments conclude that CBT for youth with

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anxiety disorders is probably efficacious (Albano and Kendall 2002; Kazdin and Weisz 1998; Ollendick and King 1998; Silverman et al. 2008). Given studies published since these reviews (e.g., Walkup et al. 2008), it is reasonable to suggest that the treatment be considered efficacious.

CBT Approaches Consistent with a cognitive-behavioral model (Kendall 2010), CBT for childhood anxiety disorders targets the somatic, cognitive, and behavioral aspects of anxiety. For a discussion of the theoretical underpinnings of CBT for childhood anxiety disorders, see Gosch et al. 2006. Several CBT approaches to treating child anxiety have been developed and the majority have core treatment components in common: psychoeducation, recognition and management of somatic symptoms, cognitive restructuring, and exposure. The Coping Cat Program (Kendall and Hedtke 2006a, 2006b) is a manual-based individual CBT for youth with considerable empirical support when compared with a wait-list control condition, active comparison treatment, and pill placebo (Kendall 1994; Kendall et al. 1997, 2008b; Walkup et al. 2008). Other CBT approaches, such as Social Effectiveness Therapy for socially phobic youth (Beidel et al. 2000), may include a greater emphasis on social skills training. Individual CBT with an added parent component (e.g., Barrett et al. 1996), group CBT (e.g., Manassis et al. 2002), and family CBT (e.g., Wood et al. 2006) also have empirical support. In this chapter, we describe the CBT approach used at the Child and Adolescent Anxiety Disorders Clinic of Temple University, the Coping Cat Program. Although we describe the implementation of the Coping Cat Program to treat GAD, social phobia, and/or SAD specifically, the core principles of CBT for child anxiety are highlighted throughout the chapter.

Treatment Planning There are several important issues to consider when implementing CBT for childhood anxiety, such as assessment, the format and length of treatment, and the structure and content of sessions. We consider each of these issues below.

Assessment We recommend a multimethod, multi-informant approach to assessment. Clinical interviews, youth self-report measures, and parent- and teacher-

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reports provide useful information regarding the presenting symptoms and related impairment across settings. We use the Anxiety Disorders Interview Schedule for DSM-IV—Parent and Child Versions (ADIS-C/P; Silverman and Albano 1996), a semistructured diagnostic interview administered separately to parents and children. The ADIS-C/P has demonstrated favorable psychometric properties (Rapee et al. 1994; Silverman et al. 2001; Wood et al. 2002) and sensitivity to treatment-related changes (Kendall et al. 1997; Silverman et al. 1999). For child self-report, there are several options. One is the Multidimensional Anxiety Scale for Children (MASC; March et al. 1997). The MASC is a 39-item self-report measure of children’s anxiety symptoms over the past 2 weeks. The MASC has been found to have good psychometric properties (March et al. 1997). In addition to parent versions of self-report anxiety measures (e.g., MASC-P), parent and teacher measures of overall child symptomatology are informative. The Child Behavior Checklist (CBCL; Achenbach and Rescorla 2001) is a 118-item parent report of behavioral problems and social and academic competence, and the Teacher Report Form (TRF; Achenbach and Rescorla 2001) is a parallel teacher report. The CBCL and TRF do not alone diagnose anxiety disorders, but the CBCL and TRF effectively discriminate between externalizing and internalizing disorders (Seligman et al. 2004; see also Aschenbrand et al. 2005) and provide information on the child’s areas of disturbance, social activities, and peer interactions.

Format Typically, the Coping Cat Program involves child-focused therapy, with two specific parent sessions included in the program. In the Coping Cat Program, parents serve as consultants (i.e., provide the therapist with information about the child) and as collaborators (i.e., help with implementation of the program). Therapists who wish to work with parents in the sessions (family CBT) can consult the family therapy manual (Howard et al. 2000). Additionally, youth anxiety disorders have been treated within a group format.

Length of Treatment The Coping Cat Program is designed as a 16-session program. As operationalized in one study, treatment was 14 sessions provided within 12 weeks (Walkup et al. 2008). In accordance with the concept of “flexibility within fidelity” (e.g., Kendall et al. 2008a), some youth may require slightly more or fewer than 16 sessions.


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Structure of Sessions The Coping Cat Program is designed to be implemented in weekly childfocused sessions lasting 50–60 minutes. There are two parent sessions, and each may be scheduled for the same day as an adjacent child-focused session. Each child-focused session begins with a review of the weekly homework assignment (referred to as a STIC [Show That I Can] task). The majority of each session is devoted to psychoeducation (phase I) or exposure (phase II) content. Each session ends with an assignment of a STIC task (i.e., homework) and a fun activity or game.

Content of Sessions The Coping Cat Program combines behavioral strategies (e.g., modeling, relaxation training, in vivo exposure tasks, and contingent reinforcements) with cognitive strategies (e.g., problem solving, cognitive restructuring) to help youth identify and cope with anxiety. The content of the Coping Cat Program is described below. Therapists interested in using the Coping Cat Program with an anxious child should consult the therapist manual (Kendall and Hedtke 2006a) and the child’s workbook (Kendall and Hedtke 2006b). The therapist manual and the client workbook are designed to be used together: the manual guides the sessions of the treatment, whereas the workbook contains corresponding client tasks. A similar program is available for adolescents (Kendall et al. 2002a, 2002b), and a computerassisted version of the treatment (Camp Cope-A-Lot; Kendall and Khanna 2008) has been evaluated in research (Khanna and Kendall 2010).

Overview: The Coping Cat Program The overarching goal of the Coping Cat Program is to teach youth to recognize signs of anxiety and use these signs as cues for the use of anxiety management strategies. In addition to the core CBT components of psychoeducation, skills for managing somatic symptoms, cognitive restructuring (changing self-talk), and exposure, the Coping Cat Program also places emphasis on coping modeling and homework assignments to practice newly acquired skills. The program has two phases of eight sessions each. Phase I focuses on psychoeducation, whereas phase II emphasizes exposure to anxietyprovoking situations. Within the psychoeducation phase, the child learns to identify when she is feeling anxious and to use anxiety management strategies. The therapist presents these strategies to the child as a tool set that she may carry with her and draw from when she is feeling anxious.

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The strategies include identifying bodily arousal, engaging in relaxation, recognizing anxious thoughts (self-talk), using coping thoughts, and problem solving. Anxiety management strategies are taught in a sequence that allows the child to build skill upon skill. In the last eight sessions (phase II), the therapist provides exposure tasks for the child to approach anxiety-provoking situations and to use the skills learned in the first eight sessions. The exposure tasks are guided by a collaboratively determined hierarchy so that the child practices skills in increasingly anxiety-provoking situations. The therapist serves as a “coach,” teaching the child the necessary skills and guiding the child to practice the skills while in real anxietyprovoking situations.

Coping Modeling An important component of the Coping Cat Program is for the therapist to serve as a coping model for the child. A mastery model demonstrates success, whereas a coping model demonstrates encountering a problem, developing a strategy to deal with the problem, and then success. Therapists serve as a coping model by demonstrating their own anxiety, strategies that helped them cope with the anxiety, and then success. The therapist continues to serve as a coping model throughout treatment as each new skill is introduced. The therapist demonstrates the skill first, then asks the child to participate with him or her in role-playing. Finally, the therapist encourages the child to role-play scenes alone, practicing the newly acquired skills.

Weekly Homework Homework is an important component of the Coping Cat Program. Throughout treatment, ask the child to complete weekly homework assignments (STIC tasks). STIC tasks provide the child with an opportunity to test out and practice each of the skills learned in session. Consistent with behavioral theory, reward the child for STIC task completion.

Psychoeducation In phase I, the therapist presents four important concepts. 1. Recognition of bodily reactions to anxiety and management of these symptoms (e.g., using relaxation). 2. Recognition of anxious self-talk and expectations. 3. Modification of anxious self-talk using coping thoughts and the use of problem solving to develop a way to cope with anxiety more effectively.


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4. Self-reward for effort (partial or full success) in facing anxiety-provoking situations. To teach these concepts to the child, the therapist uses an acronym, referred to as the FEAR plan, to help the child learn, remember, and apply these four concepts. F = Feeling frightened? E = Expecting bad things to happen? A = Attitudes and actions that can help R = Results and rewards

Exposure Tasks In phase II, the therapist guides the child through exposure tasks—creating anxiety-provoking situations and helping the child practice the FEAR plan during anxious arousal. The purpose of exposure is prolonged, systematic, and repeated contact with the avoided stimuli or situation. The goal is to have the child remain in the situation until she has reached an acceptable level of comfort (i.e., habituation). Be sure to tailor the exposure tasks to each child according to the child’s specific anxieties and fears. For example, anxiety-provoking situations for a child with social phobia might include playing a game with a new person or peer, whereas anxietyprovoking situations for a child with separation anxiety might include waiting for a parent who is late. The exposure tasks increase in difficulty over the course of the second half of treatment; later exposure tasks are more anxiety provoking than earlier ones.

S Case Example:

The Coping Cat Program We illustrate the Coping Cat Program using the case of a youth named Zoe. (See the DVD for a demonstration of the FEAR strategy and STIC assignment.) Zoe, a 10-year-old girl, met criteria for a diagnosis of social phobia at the intake assessment. She is easily embarrassed, and afraid that others will laugh at her in social situations. Zoe’s feared situations include speaking to adults, reading aloud in class, giving presentations, and asking questions in class. Her parents report that Zoe’s distress is highly impairing and affects her academic performance. When Zoe is faced with a social situation, she “freezes up.” She has great difficulty maintaining eye contact.

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Session 1: Building Rapport and Treatment Orientation Because the child-therapist relationship is so vital, a main goal of the first session is to build rapport with the child. The therapist and child should spend the first part of the session getting to know one other by asking questions or playing an icebreaker game. Next, give the child a brief overview of the program and share logistics of the program with the child, such as how often and for how long the two of you will meet. After introducing the program, ask the child if she has any questions. This encourages the child’s participation in treatment and emphasizes that you and the child will be a collaborative team working together. At the end of the session, assign the child an easy STIC task (homework) from The Coping Cat Workbook and plan a reward for completing the task. Finally, end the session by playing a game or engaging in another fun activity. On the day of her first appointment, Zoe enters the therapy room without looking at the therapist. The therapist invites Zoe to make herself comfortable. The therapist asks Zoe to look around the room and see if there are any interesting games that she would like to play later in the session. Zoe finds the game Guess Who? and brings it to the therapist. The therapist lets Zoe know that they will save time at the end of the session to play the game together. The therapist gives Zoe an overview of what the session will involve. They play a get-to-know-you game (asking each other for personal facts, such as “What is your favorite TV show?”). During the game, Zoe’s eye contact improves slightly and the therapist notes that she seems more relaxed. After the get-to-know-you game, the therapist shares some of the logistics of the Coping Cat Program with Zoe. The therapist shares with Zoe that they will learn skills that can help kids when they are feeling worried or scared. She explains to Zoe that for the first half of the program, they will focus on recognizing and learning about anxiety, and in the second half, they will focus on knowing what to do about feeling anxious. The therapist points out to Zoe that they will work as a team, with the therapist as the coach. She encourages Zoe to ask questions and is enthusiastic when Zoe talks. The therapist introduces The Coping Cat Workbook and Zoe is assigned a STIC task from the book (e.g., “Write about a time you felt great”). The therapist and Zoe agree that she will earn stickers for each STIC task completed and can exchange those stickers for rewards every four sessions. As promised, the therapist and Zoe spend the last 10 minutes playing Guess Who?

Session 2: Identifying Anxious Feelings The aim of the second session is to help the child learn to distinguish anxious or worried feelings from other feelings. To begin, review the STIC task from session 1 and give an appropriate reward. If the child did not do the STIC


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task, complete it together. Next, discuss with the child how different feelings have different physical expressions. Collaborate with the child to list various feelings and their corresponding physical expressions. Once the child has a general understanding that different feelings correspond to different expressions, normalize the child’s own experience of fears and anxiety. To serve as a coping model, disclose a time when you felt anxious and how you handled it. Be a coping model rather than a mastery model—everything doesn’t always go well! Discuss the child’s own anxiety, including the types of situations that are difficult, and the child’s responses in the anxiety-provoking situation. Introduce the feelings thermometer, which is used to rate anxiety on a scale from 0 to 8 (see the therapist manual for details). With the child, begin to construct a hierarchy (or FEAR ladder; Figure 7–1) using the ratings from the feelings thermometer. Zoe and her therapist begin session 2 by reviewing her STIC task. Zoe wrote about feeling great during a recent soccer game. The therapist listens with interest to the account of Zoe’s soccer game. Together they pick out two stickers as Zoe’s reward. Next, the therapist introduces Zoe to the concept that different feelings have different physical expressions. Zoe and the therapist create a feelings dictionary by cutting out pictures of people with various expressions from magazines and labeling the pictures with the emotions depicted. During this project, Zoe and the therapist note that different facial or physical expressions (e.g., a smile, head hanging down) are linked to different emotions (e.g., feeling happy, feeling sad). The therapist and Zoe also play a brief feelings charades game. They take turns acting out various feelings and having the other person guess the feeling. The therapist shares with Zoe that everyone (including the therapist) feels anxious at times. The purpose of the program is to help Zoe learn to recognize when she is feeling anxious and then to use skills to help herself cope. Zoe and her therapist begin to develop a fear hierarchy of anxiety-provoking situations by categorizing the things Zoe is afraid of into easy, medium, and challenging categories. Zoe identifies talking to a new adult (e.g., store clerk) as a medium fear and giving an oral presentation as the most challenging fear. Zoe is assigned a STIC task: record one anxious experience and one nonanxious experience in her workbook. Zoe and her therapist play a game of Guess Who? before the session ends.

Session 3: Identifying Somatic Responses to Anxiety The main goal of this session is to teach the child to identify how her body responds to anxiety. First, discuss somatic symptoms that might occur when someone is feeling anxious, such as a racing heart or stomach butterflies. Ask the child to describe somatic responses that people have when anxious, and ask how she notices when she is in an anxiety-provoking sit-

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FIGURE 7–1.

FEAR ladder.

Source. Reprinted from Kendall PC, Hedtke K: Coping Cat Workbook, 2nd Edition. Ardmore, PA, Workbook Publishing, 2006. Used with permission.

uation. Next, practice identifying these responses (via coping modeling and role-playing), first in low anxiety–provoking situations and then in more stressful situations. After practice with identifying somatic responses, introduce the F step: Feeling frightened? In the F step, the child will ask herself, “How does my body feel?” and will monitor her somatic responses associated with anxiety. The therapist and Zoe start session 3 by reviewing Zoe’s STIC task and putting stickers in her bank. Next, the therapist introduces today’s topic: identifying the body’s reaction to anxiety. The therapist mentions several


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possible physical expressions of anxiety, such as sweating or a stomachache. The therapist asks Zoe to think about other ways that someone’s body might react when he or she is nervous. Zoe shares that when she has to answer a question at school aloud, her stomach starts to hurt. Together, the therapist and Zoe discuss what kinds of bodily reactions they have during anxiety-provoking situations of varying degrees (low, medium, high). The therapist acts as a coping model by sharing with Zoe that she blushes (gets red in her face) when she feels anxious. Zoe and her therapist create a body drawing depicting Zoe’s somatic reactions to anxiety, with Zoe permitted to be creative in her artwork. The therapist introduces this process of paying attention to what’s happening in Zoe’s body as a cue that Zoe is “Feeling frightened?” as the F step. At the end of session, the therapist reminds Zoe that she has the next week off as the next session will be with her parent(s). The therapist asks Zoe if she has any questions about the parent session and if there is anything specific the therapist should or shouldn’t say when meeting with the parent(s). Finally, the therapist assigns a STIC task from the workbook, and she and Zoe kick around a Nerf soccer ball for 5 minutes.

Session 4: First Parent Meeting Although parents have been involved already (providing information about the child), the goal of the first parent session is to encourage parental cooperation with the program and to answer the parents’ questions or concerns. Begin by providing an outline of the entire treatment program. Invite the parents to discuss any concerns that they may have, and ask for any input they feel will be helpful regarding their child’s anxiety. Finally, offer specific ways that the parents can be involved in the program. The therapist meets with Zoe’s mother and father. She shares with the parents that she has enjoyed meeting with Zoe and notes some of Zoe’s strengths. The therapist briefly outlines the treatment program, noting what Zoe has learned so far and what will happen in the remainder of treatment. The therapist explains that a parent can be involved in treatment by providing information about Zoe’s anxiety and by helping to carry out therapy tasks at home. The therapist talks with the parents to learn more about situations where Zoe becomes anxious. The parents describe Zoe’s reaction in several recent social situations, such as refusing to order for herself in a restaurant.

Session 5: Relaxation Training A main aim for the child in session 5 is learning to relax. Acknowledge the previous parent meeting, and be prepared to provide a very brief recap. Review the F step by suggesting to the child that when she is feeling anxious, her body has somatic responses that may serve as cues. These somatic re-

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actions may be associated with tension, which can be reduced by relaxation. Discuss the difference between feeling tense and feeling relaxed. Introduce useful ways to relax, including deep breathing, progressive muscle relaxation, and relaxation aids such as relaxation CDs. Practice relaxation with the child using coping modeling and role-play. The therapist begins Zoe’s session 5 by mentioning the parent session and inviting her to ask questions. Next, they review Zoe’s STIC task. Zoe has accumulated enough stickers to trade in for a small prize. The therapist introduces relaxation as a tool that Zoe can use when she is anxious. The therapist recalls that when Zoe has to answer a question in class, she gets a stomachache and feels tense. The therapist links this bodily response to the F step (Feeling frightened?) of the FEAR plan. The therapist explains that our bodies provide cues when we are feeling nervous, and these cues can be signals for us to relax. The therapist and Zoe engage in a robot–rag doll exercise (Kendall and Braswell 1993) and note the difference between feeling tense and feeling relaxed. Next, the therapist and Zoe practice deep breathing. The therapist suggests that Zoe sit comfortably on a beanbag chair. She asks Zoe to take a deep breath and then let it out slowly, focusing on how her body feels. The therapist asks Zoe how her body feels after a few deep breaths. Then, the therapist introduces relaxation. She gives Zoe a CD with the therapist’s voice guiding her through a progressive muscle relaxation exercise. The therapist and Zoe practice relaxation together with the therapist serving as a coping model. The therapist suggests that Zoe can use the CD to practice these skills at home. She also asks Zoe to consider times when relaxation may be useful. The therapist suggests that even when Zoe can’t complete an entire relaxation session, she may be able to take deep breaths Afterward, the therapist and Zoe invite Zoe’s parents into the session. Zoe “teaches” her parents relaxation and everyone follows along with the CD. Together, they discuss when and where Zoe will be able to practice her relaxation during the coming week (her STIC task). Zoe plans to practice each night in a comfortable chair in her bedroom.

Session 6: Identifying and Challenging Anxious Self-Talk The goal of this session is to learn to identify and challenge anxious selftalk. After introducing the concept of thoughts or self-talk, use exercises in The Coping Cat Workbook to help the child generate thoughts that might occur with various feelings. Discuss self-talk with the child and describe the connection between anxious thoughts and anxious feelings. Work together to discriminate anxious self-talk from coping self-talk. Next, introduce the E step of the FEAR plan: Expecting bad things to happen? In the E step, the child will ask herself, “What is my self-talk?” and monitor the thoughts associated with anxiety. Practice the use of various


TABLE 7–1.

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Questions the child can ask himself or herself to challenge anxious self-talk

Do I know for sure this is going to happen? What else might happen other than what I first thought? What has happened in the past? Has this happened to anyone I know? How many times has it happened before? After collecting evidence, how likely do I think this is going to happen? What is a coping thought I can have in this situation? What is the worst thing that could happen? What would be so bad about ____________________?

TABLE 7–2.

Coping thoughts

Trying is the most important thing. No one is perfect. Everyone makes mistakes sometimes. I will try my best. I can do it! I will be proud of myself if I try. What’s the worst that can happen? It’s probably not as scary as I think it is. I have done it before, so I can do it again.

types of coping self-talk using the first two steps in the FEAR plan (see Tables 7–1 and 7–2). Zoe and the therapist begin session 6 by reviewing the STIC task from last week. Zoe reports that she was able to relax while listening to her CD and that her mom joined in some nights. The therapist introduces Zoe to the idea that thoughts are connected to feelings. They work on a thought-bubble exercise in Zoe’s Coping Cat Workbook. They also look through magazines and give people in the pictures a thought bubble. The therapist helps Zoe differentiate between anxious self-talk and coping self-talk. The therapist introduces the E step (Expecting bad things to happen?) of the FEAR plan. She tells Zoe that in this step, she will ask herself, “What’s in my thought bubble? Am I expecting bad things to happen?” and that Zoe will start to pay attention to her

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thoughts when she is anxious. Together, Zoe and the therapist practice coping self-talk and review the F and E steps of the FEAR plan. At the end of the session, Zoe’s therapist assigns a STIC task from the workbook. They play a game on the clinic Wii for the final 5 minutes of the session.

Session 7: Attitudes and Actions: Developing Problem-Solving Skills The main goal of session 7 is to introduce problem solving as a strategy for coping with anxiety. First, review the F and E steps. Next, introduce the A step, “Attitudes and actions that can help.” In this step, the child learns that she may take action and change her reactions when feeling anxiety. Introduce problem solving as a tool to help the child deal with anxiety. Describe the four steps of problem solving (i.e., define the problem, explore potential solutions, evaluate the potential solutions, select the preferred solution). To begin, have the child practice using problem solving in a concrete, nonstressful situation. Slowly build to practicing problem solving in anxious situations. Zoe and the therapist review the STIC task and pick out stickers to place in the bank. Next, the therapist reviews the F and E steps with Zoe by asking her to describe what they stand for. Following Zoe’s explanations, the therapist presents the idea that now that Zoe knows how to check what’s going on in her body and her thoughts when she is nervous, it’s time to learn how to cope with that anxiety. The therapist introduces the A step in the FEAR plan: Attitudes and actions that can help. The therapist briefly describes the process of problem solving. She begins the discussion of problem solving with a concrete, nonstressful situation. The therapist gives the following example: “You can’t find your shoes. How would you try to find them?” The therapist and Zoe go through the steps of problem solving, having some fun along the way as they include silly solutions in their brainstorming. After they have practiced with a nonstressful situation, the therapist guides Zoe in using problem solving in low and high anxiety– provoking situations. To end the session, Zoe’s therapist assigns a STIC task from the workbook, and she and Zoe play a game of tic-tac-toe.

Session 8: Results and Rewards The aim of session 8 is to introduce the final step of the FEAR plan: Results and rewards (Figure 7–2). Introduce the concept of self-rating and self-rewarding for effort. Collaborate with the child to create a list of possible rewards that are both material and social. Serve as a coping model by describing a situation where you experienced some distress but were able to fully cope with the anxiety, rate your effort, and then give yourself a reward. Review the FEAR plan and then work with the child to identify a stressful situation and apply the FEAR plan together to get through it.


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Feeling frightened? Expecting bad things to happen? Attitudes and actions that can help Results and rewards

FIGURE 7–2.

FEAR steps.

Source. Reprinted from Kendall PC, Hedtke K: Coping Cat Workbook, 2nd Edition. Ardmore, PA, Workbook Publishing, 2006. Used with permission.

Inform the child that the next part of the program involves practicing the FEAR steps in anxiety-provoking situations. Remind the child that the practice will be gradual, starting with a situation that makes the child only a little anxious—an easy one. Let her know that the FEAR steps will need to be practiced in the same situations more than once. Zoe and her therapist begin by reviewing the STIC task. The therapist introduces the final step in the FEAR plan: Results and rewards. The therapist asks Zoe what she thinks about rewards, and they discuss the difference between a reward and an award. Together, Zoe and the therapist create a list of potential rewards (e.g., baking cookies with her mom, a high-five from the therapist, a new soccer ball) that she might be able to earn for completing challenging tasks in and out of session. Zoe and her therapist practice self-reward for effort through the exercises in the workbook and role-plays. They review the steps of the FEAR plan. Together they create a Coping Keychain with a personalized FEAR plan for Zoe to use as a keychain and when she is feeling anxious. Zoe and her therapist review Zoe’s fear hierarchy, which includes speaking to an adult she doesn’t know that well, reading in front of others, and answering questions in class. The therapist tells Zoe that the next part of treatment involves practicing the skills Zoe has learned in the program thus far. The therapist explains that Zoe may feel anxious during the practices but now she has the FEAR plan to help her cope. The therapist also reminds Zoe that she is going to meet with her parents again next time. The therapist assigns Zoe a STIC task from her workbook. They end the session by kicking around the Nerf soccer ball.

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Session 9: Second Parent Session The second parent session aims to provide an opportunity for the parents to learn more about the upcoming exposure tasks. Begin by describing the rationale behind exposure practice and the difference between avoidance and approach. Remind the parents that the goal of treatment is not to remove all of the child’s anxiety, but to reduce the amount of distress experienced and to help the child learn to manage it. This goal is accomplished through practicing the FEAR plan in anxiety-provoking situations, in and out of session. Inform the parents that it is expected that the child will feel some anxiety during the exposures. After this overview of exposure tasks, give the parents an opportunity to ask questions or discuss concerns. Finally, solicit the parents’ assistance in the planning of exposure tasks. Both of Zoe’s parents attend the second parent meeting. The therapist begins the session by giving them an overview of the remainder of treatment. She introduces the exposure tasks by explaining that Zoe has learned ways to cope with her anxiety in social situations and that now she will get to practice in real situations. As Zoe starts to face her fears, she will gain a sense of mastery and her anxiety will be reduced in future situations. The therapist notes that most children feel anxiety during the practices, and this is OK. Zoe’s mother expresses some concern about putting Zoe in upsetting situations. The therapist validates this concern and reminds Zoe’s parents that Zoe and the therapist will start with the least challenging practice and work their way up the hierarchy. Zoe now has the tools to cope with these upsetting situations. The therapist reminds the parents that the goal of treatment is not to get rid of all Zoe’s anxiety, but to “turn down the volume” on Zoe’s anxiety so she can cope in social situations. Finally, the therapist reviews Zoe’s fear hierarchy with her parents. Zoe’s mother emphasizes that Zoe needs practice presenting or reading in front of others, as this fear is currently causing interference in the school setting. The therapist agrees that this is an important situation for practice, and lets the parents know that she may ask for their help in planning some of the exposures.

Sessions 10 and 11: Practicing in Low Anxiety–Provoking Situations The goals of sessions 10 and 11 are similar: to practice the FEAR plan in a low anxiety–provoking situation, both imaginally and in vivo. Begin by reminding the child that the program shifts from learning skills to practicing using the skills in real situations (not unlike learning a sport and then playing a real game). Together, pick a low anxiety–provoking situation (see Table 7–3 for examples of exposure tasks). Practice using the FEAR plan

Description of exposure

Out of session

Disorder

In session

Give a speech or presentation or do show-and-tell: 1. Have people whispering during the speech or presentation 2. Have people ask questions during the speech or presentation

Social phobia

X

Buy something from a street vendor or at a store

Social phobia

X

Trip in front of a group of people

Social phobia

X

Wear strange makeup and make hair look messy in front of others

Social phobia

X

Call a friend on the phone

Social phobia

X

X

SAD

Go in the elevator to various floors Play a game where the rules keep changing Play a game with a new person Find the therapist in a different part of the building Therapist and child pop balloons

Others needed?a Yes

Money X

Yes Makeup

X

X

GAD (afraid of change)b

X

X

Social phobia

X

GAD

X

Social phobia

X

SAD, GAD

X

Yes

Yes Yes No

Game

No

Game

Yes No

Balloons X

No Yes

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Therapist arranges for the parent to pick up the child late from session

Props needed


TABLE 7–3. Examples of exposure tasks

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TABLE 7–3. Examples of exposure tasks (continued) Others needed?a

X

Toilet paper

No

Social phobia, GAD

X

Objects for treasure hunt

Yes

Pay a food vendor with the wrong amount of money (good for fear of embarrassment, perfectionism)

GAD, social phobia

X

Money

Yes

Surveys: the child goes around the building asking various people different questions (e.g., What’s your favorite ice cream flavor?)

Social phobia

X

Make a worry box and place worries in the box only to be looked at once a day for a designated amount of time

GAD

X

“Break the rules” or “get in trouble” (e.g., ask the child to go in part of the building where other staff are and have someone say, “No kids allowed here!”)

GAD

X

Look at pictures or watch videos of a feared stimulus (e.g., thunderstorms, insects, vomit)

Specific phobia

X

X

Pictures or videos

No

Sit in a room with the lights off (dark)

Specific phobia

X

X

Timer

No

Disorder

In session

The child walks around with toilet paper stuck to his or her shoe

Social phobia

Treasure hunt: the child receives a list of people and/or objects to find in the building and goes alone to find these people (the people then have to sign a paper to indicate the child found them)

Out of session

Yes

X

Shoebox, markers

No Yes


Props needed


Examples of exposure tasks (continued)


Props needed

Others needed?a

Fake test

No

X

Paper for script or tape recorder

No

X

X

Money for trip

No

Specific phobia, GAD

X

X

Social phobia, GAD

X

X

Specific phobia GAD (fear of uncertainty)b

Disorder

In session

Take a difficult “test” and receive a “poor grade”

GAD

X

Read or record an imaginal exposure script about the child’s worst fear (e.g., parents dying, world ending) and read or listen to the script repeatedly until anxiety decreases by 50%

GAD

X

GAD, specific phobia

Therapist and child take a ride on a bus, train, or other feared form of transportation Therapist and child go to the top of a tall building Call to order pizza or takeout on the phone (to make it more difficult, call back to change or cancel the order) Give the child or have someone else give the child a pretend injection Draw a “mystery challenge” or “mystery practice” out of a jar or hat

Out of session


TABLE 7–3.

No Money if actual order

Yes

X

Syringe

Yes

X

Jar or hat, paper

No

Note. GAD=generalized anxiety disorder; SAD=separation anxiety disorder. aIn addition to therapist. bSymptoms targeted are included in parentheses.

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through an imaginal exposure. With the child, prepare for the exposure task. Write out the FEAR plan for the specific situation in The Coping Cat Workbook. Serve as a coping model by thinking aloud about the situation. Then have the child walk through all the steps during the imaginal exposure task. Make the imagined situation as real as possible by using props or details. Ask for ratings on the feelings thermometer before, after, and every minute during the imaginal exposure. Next, it’s time for an in vivo exposure task. Develop a FEAR plan and negotiate a reward for completing the in vivo exposure. It is important to help the child prepare and think through any possible roadblocks or other outcomes to the task. A main goal of the exposure is to assist the child in approaching (not avoiding) until she feels an acceptable level of comfort in the anxiety-provoking situation. Ask for ratings on the feelings thermometer before, after, and at a regular time interval (every minute or two) during the in vivo exposure. A general guideline is to have the child stay in the situation until her ratings decrease by about 50%. After the exposure task, reward the child for effort. To end the session, plan an exposure task for the next session. At the beginning of Zoe’s session 10, the therapist reminds Zoe that they are going to start “doing challenges”—practicing the FEAR plan in real-life situations. They begin by agreeing on a situation that makes Zoe a little anxious, such as conducting a survey of several unfamiliar adults. Together, Zoe and the therapist develop a FEAR plan for coping with the challenge. Zoe plans to ask survey questions about favorite sports. She and her therapist decide to kick a soccer ball outside for 5–10 minutes as a reward for completing the challenge. First, Zoe and her therapist practice the FEAR plan by having Zoe imagine herself in the situation. The therapist has Zoe close her eyes and pretend that she is asking the survey questions. The therapist asks Zoe to talk through the FEAR plan. Zoe shares that she knows she is feeling frightened because her stomach hurts. She is having the anxious thought “What if I mess up one of the questions?” She shares the coping thought “It’s no big deal if I mess up. They probably won’t make a big deal of it, or even notice, and everyone makes mistakes.” She also practices taking deep breaths to help herself cope. Finally, she imagines herself doing a good job (not perfect) and receiving her reward. Zoe successfully completes the imaginal exposure task, providing ratings of her anxiety using the feelings thermometer. Next, Zoe and her therapist prepare for the in vivo exposure task. Zoe is able to ask her survey questions of five unfamiliar people. Throughout the exposure, the therapist asks for Zoe’s ratings of her anxiety and provides her own ratings as well. Zoe rates her anxiety at a 5 before asking the first person her survey questions, and the ratings decrease to a 2 by the fifth person. Afterward, the therapist asks, “What did you notice about your anxiety during the survey?” and Zoe responds that it went down, and


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the task became easier. As a reward, Zoe and the therapist play soccer outside the clinic. Finally, the therapist and Zoe plan a challenge for the upcoming session and complete a brief relaxation exercise together. For her STIC task, Zoe agrees that she will practice the FEAR plan in one low anxiety–provoking situation (an at-home challenge).

Sessions 12 and 13: Practicing in Moderately Anxiety-Provoking Situations The goal of sessions 12 and 13 is for the child to apply the FEAR plan in both imaginal and in vivo situations that are moderately anxiety-provoking. Zoe and her therapist begin session 12 by talking about Zoe’s at-home challenges from the prior week. Zoe is proud of how well she coped with them and excited about the rewards. Together, Zoe and her therapist develop the FEAR plan for today’s challenge—Zoe will read a passage from a book in front of two members of the clinic staff. Zoe shares that her stomach hurts already and that she is thinking, “What if I mess up? They will laugh at me!” Zoe and her therapist come up with the coping thought “It’s not likely that I will mess up because I’ve practiced. Even if I do, it’s OK because everyone makes mistakes.” Zoe is reminded of a TV star who made a few slips when interviewed, but it wasn’t a big deal. The therapist and Zoe agree to go get a special snack together as a reward. First, Zoe practices reading the passage to the therapist and talks through the FEAR plan. Zoe provides ratings of her anxiety on the feelings thermometer while she practices. Next, it’s time for the challenge. Zoe and the therapist invite two unfamiliar clinic staff members to join them in the therapy room. Zoe takes a deep breath, goes to the front of the room, and then reads a passage from her book. Afterward, Zoe and the therapist talk about the challenge. Zoe shares that her stomach hurt at first, but both her stomach and her anxiety felt better once she started. She “messed up” a few times, but she reminded herself that everyone makes mistakes. The therapist and Zoe note that the other audience members did not seem to notice the mistakes. Zoe is very proud of her effort and accomplishment today. Zoe and the therapist plan at-home challenges and next week’s exposure task before heading out for a treat.

Sessions 14 and 15: Practicing in High Anxiety–Provoking Situations The goal of sessions 14 and 15 is to apply the skills for coping with anxiety in high anxiety–provoking situations through both imaginal and in vivo exposure tasks. Zoe’s session 14 begins with a review of her STIC task and at-home challenges. Zoe and her therapist prepare for today’s high-level exposure by de-

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veloping a FEAR plan. Zoe’s challenge today is to order food for herself but purposely make a mistake and need to change the order. The therapist helps Zoe to identify aspects of the exposure task that may generate anxiety. Zoe describes how her body will feel (stomachache), what she is expecting (“They will laugh at me for the mistake”), and what she can do to help herself cope during the challenge (take deep breaths; use the coping thought “Everyone makes mistakes”). The therapist and Zoe plan for a reward of eating the snack that she orders. After practicing in the therapy room, Zoe and her therapist head out to the nearby fast-food restaurant for the challenge. Zoe provides ratings on the feelings thermometer before, during, and after the exposure task. Zoe is able to complete the task and enjoys her snack as a reward. Zoe, Zoe’s mother, and the therapist plan challenges for the remaining two sessions. The therapist reminds Zoe about the “commercial” that she can create in the final session. The therapist explains that the commercial is something to show off what she has learned and accomplished and to teach other kids about the FEAR plan. Zoe immediately decides she would like to create a collage and the therapist encourages her to keep thinking about what she would like to include in the collage.

Session 16: Final Practice, Commercial, and Termination The goal of the final session is to practice using the FEAR plan for a final time (in session) and to allow the child to “produce” a commercial to show off and celebrate her success. Prepare for and conduct a final exposure. Discuss the child’s performance, again noting effort and progress. Then, have some fun producing the commercial! The commercial should be a celebration of the child’s progress, efforts, and success in treatment. It is an opportunity for the child to teach others about how to manage anxiety (e.g., the Coping Cat Program). If the child chooses, invite the parents and/or others to watch the commercial. Review the child’s treatment gains with the family. Note that it is normal for there to be difficult times ahead in terms of coping with anxiety, but suggest that with continued practice there will be continued improvement. Provide the child with an official certificate (provided as the last page of The Coping Cat Workbook) to commemorate completion of the program. Invite the family to check in in approximately 1 month—to report progress and positive outcomes or additional concerns. Finally, give a final reward for participation, such as going out for ice cream or having a pizza party. During Zoe’s final session, Zoe and the therapist complete one final imaginal and in vivo exposure task: a personal speech in front of a group of clinic staff members. Zoe and the therapist put the finishing touches on Zoe’s commercial (a collage that includes the FEAR plan and pictures of some of Zoe’s at-home challenges). Zoe, the therapist, and Zoe’s parents review


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Zoe’s progress in treatment. They list ways that Zoe can keep practicing her skills at home. The therapist reminds the family about calling to check in next month. The therapist presents Zoe with a certificate of completion and a list of all the challenges she completed in the program with a little ceremony. To conclude, Zoe, her family, and the therapist have a pizza party to celebrate Zoe’s successful completion of the Coping Cat Program.

Cultural Considerations Given the rich cultural diversity in most countries, it is important for therapists to be aware of the cultural factors that can impact the perception, etiology, symptom expression, and treatment of anxiety in youth. Though limited, the available literature suggests some differences in symptom expression among anxious youth. For example, research shows that Latino youth tend to report higher rates of somatic symptoms compared with white youth (Canino 2004; Pina and Silverman 2004), Asian American youth tend to exhibit somatic symptoms as early signs of anxiety (Gee 2004), and African American youth tend to score higher than white youth on measures of anxiety sensitivity (Lambert et al. 2004). It is possible that therapists will find these same patterns when working with diverse youth. However, bear in mind that research on cultural differences is based on group averages; clinicians will likely encounter variations in symptom expression in youth from the same cultural background. In addition to informing therapist expectations for symptom expression, research on treatment outcomes has implications for how therapists treat diverse clientele. A majority of the participants in randomized controlled trials examining the efficacy of CBT for anxious youth have been white, limiting the examination of race and ethnicity as potential moderators of treatment outcome. However, available literature suggests that CBT is an appropriate treatment option for youth from various racial and ethnic groups. Treadwell et al. (1995) found comparable outcomes for white and African American youth who received the Coping Cat Program for their anxiety. Pina et al. (2003) found comparable outcomes for white and Latino youth who received exposure-based CBT for their anxiety. Although Asian American youth responded similarly to others in one study (Walkup et al. 2008), more research is needed regarding the responses of Asian American youth to CBT for anxiety. Nevertheless, on the basis of the available findings, therapists can have confidence in choosing CBT as a treatment choice for anxious youth from various cultural backgrounds. Although race and ethnicity have not been found to moderate treatment outcomes, they have been found to predict lower rates of treatment-seeking behavior and higher attrition rates among racial and ethnic minority groups

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(Hwang et al. 2006; Sood and Kendall 2006). Possible reasons for these findings include the presence of stressors (e.g., low socioeconomic status), lack of trust in psychology, unfamiliarity with treatment, and reliance on family or church for mental health needs. Given these findings, it is possible that therapists will encounter difficulty initially engaging and then maintaining in treatment some youth from minority racial and ethnic groups. If this occurs, we recommend spending additional time building rapport with these clients and their families, as well as seeking to identify and address the specific barriers inhibiting their involvement in treatment. With each client, regardless of his or her background, we and others (e.g., Hwang et al. 2006) encourage therapists to adopt an ecological approach to assessment and therapy practices. An ecological approach involves evaluating how a client’s affect, cognition, and behavior are influenced by contextual factors, including cultural background. An ecological approach is warranted at each stage of the therapeutic process: assessment, conceptualization, and treatment.

Assessment Before treatment begins, assess the client’s presenting problem with an eye for contextual factors. To accomplish this, use measures that have been validated for the cultural group of the child being assessed or choose culture-specific assessment instruments (when available). Supplement questionnaires with interviews to gather contextual information and to better understand the client’s and parents’ worldview (Gee 2004).

Conceptualization Develop treatment goals and tailor treatment for individual clients based on knowledge of cultural norms. For example, the normative age at which a child sleeps in her own bed may vary by cultural background.

Treatment Be flexible when delivering treatment. Given the variation found within cultural groups, it is important not to establish strict protocols for all members of a cultural group. Instead, we advocate adopting an open mind-set that seeks to understand and personalize treatment for each individual client. We do not advise eliminating the core components of CBT (i.e., psychoeducation and exposure). However, we do encourage therapists to flexibly adapt the treatment to meet the needs of diverse clients. For example, during the A step, the therapist might enlist various cultural and/


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or religious beliefs and practices as coping thoughts or actions to help the youth (Harmon et al. 2006). Overall, we encourage a collaborative dialogue among the therapist, client, and often the client’s parents regarding contextual factors. Be amenable to discussing such factors as culture, religion, and family practices. (For a more detailed discussion on cultural considerations when treating anxious youth, see Harmon et al. 2006.)

Potential Obstacles to Treatment As with any treatment, challenges exist when implementing CBT for the treatment of childhood anxiety disorders. Potential obstacles include comorbid psychopathology, varying cognitive abilities, noncompliance, and parental psychopathology. Each of these challenges is discussed, including two brief vignettes demonstrating strategies for addressing the potential obstacles.

Comorbidity Comorbidity is the rule, not the exception, among childhood anxiety disorders (Kendall et al. 2001). Although research indicates that the presence of comorbidity does not affect the efficacy of the Coping Cat Program (Kendall et al. 2001), making some flexible adjustments may be necessary in the implementation of the intervention nonetheless (while maintaining its fidelity). If, as is typical, a child presents with multiple anxiety disorders, assess which disorder is primary and causes the greatest interference. This information guides and prioritizes treatment goals. When constructing a list of graduated exposure tasks, for example, the therapist and the youth may decide to create multiple hierarchies addressing different sets of situations and then complete each hierarchy sequentially (e.g., first construct a hierarchy for social fears corresponding to the child’s social phobia and then complete a hierarchy for GAD fears). Alternatively, the therapist and the youth may opt to construct one hierarchy incorporating fears across various domains. Children with a primary anxiety disorder may also present with a comorbid externalizing disorder, such as attention-deficit/hyperactivity disorder (ADHD). First, check that the ADHD is adequately managed (e.g., through medication and/or behavioral intervention). Even when ADHD is controlled, it can still complicate intervention practices for treating anxiety. For instance, because youth with comorbid ADHD may benefit from very clearly structured sessions, consider providing the youth with a written agenda at each session and reinforcing on-task behavior with rewards.

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Developmental Level and Cognitive Abilities Throughout treatment, keep in mind the youth’s developmental level and cognitive abilities. The Coping Cat Program (Kendall and Hedtke 2006a) is for treating children ages 7–13 years. The Being Brave program (Hirshfeld-Becker et al. 2008), an adaptation of the Coping Cat, was developed for children ages 4–7 years and includes a greater emphasis on parent training. The C.A.T. Project Manual (Kendall et al. 2002a, 2002b) is for adolescents. Regarding overall cognitive functioning, the various programs are best matched for youth with an IQ>80. Younger children or children with cognitive limitations can benefit from the simplification of some of the cognitive-behavioral concepts. For example, it may be easier for them to rely on one or two general coping thoughts such as “I can do this!” or “I will be brave!” rather than 1) having to generate a wide range of novel responses to various situations or 2) having to self-reflect to identify what type of “thinking trap” they commonly fall into. Similarly, relaxation strategies can be simplified by demonstrating them in a fun, brief manner and by having children focus on just one or two steps. For example, children can choose their favorite part of progressive muscle relaxation (e.g., pretending to squeeze lemons in their hands) and use it to help relax when facing an anxietyprovoking situation. The therapist can provide visual and aural reminders of coping strategies to facilitate recall of session information. For example, youth may create index cards with brief statements or pictures reminding them of the FEAR plan or specific coping thoughts and actions. Parents may help cue children to follow the steps outside of therapy. To help solidify gains and foster a sense of accomplishment, particularly for children with cognitive limitations, incorporate the use of creative projects for children to take home. One such project that youth often find enjoyable and beneficial is creating a photo album documenting the exposure tasks completed during treatment.

Case Example Chloe is a 7-year-old who was diagnosed with SAD. She and her therapist begin today’s session by reviewing a STIC task that Chloe completed at home during the week. Because Chloe has difficulty reading and writing, her mother jotted down a few notes in Chloe’s workbook about Chloe staying in her bedroom by herself for the night. The therapist spoke to Chloe’s mom on the phone before the therapy session to find out how the exposure task went because Chloe sometimes has trouble accurately recalling and reporting her experiences. In session, Chloe shows the therapist a picture she drew of herself completing the exposure task. The therapist asks Chloe a few questions, such as “What were you feeling when you were first in your room all by yourself?” “What did you think might happen?”


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and “What did you tell yourself to help?” Sometimes the therapist has to prompt Chloe. For example, in response to the first question, Chloe states that she is not sure how she felt. The therapist provides her a few foils, such as “Were you feeling happy?” or “How about angry?” before Chloe endorses feeling “scared.” Chloe states that she used her coping card that she made with the therapist in the previous session to remind her to tell herself, “I can do this!” She notes that when she got really nervous, she colored a picture. Chloe and the therapist set up these activities with her mother before completing the exposure task. The therapist reinforces such effort by enthusiastically telling Chloe that she is proud of her for showing that she can be brave. Chloe receives two stickers of her choice, which she puts in her workbook. On the sticker chart is a picture of the prize that Chloe is working toward (a small stuffed animal).

Noncompliance With STIC Tasks or Exposure Tasks Youth may not complete the STIC tasks (homework assignments) for multiple reasons, and it is important to understand the problem and address it. For instance, youth with comorbid ADHD may have difficulty organizing material used in therapy, forget they have homework, and/or lose resources they need to complete it. For younger children, it is helpful to inform parents of the child’s homework task and request that they remind their child to complete it. For all youth, it may be helpful to have them keep their therapy materials (e.g., workbook) in one location at home where they know they can find them. The therapist can also take time to try to figure out when the youth is more likely to complete certain tasks during the week and provide appropriate reminders (e.g., hanging a schedule on the wall). Youth may avoid completing STIC (homework) tasks due to anxiety. Don’t judge youth for the quality of their work, but praise them for effort and trying their best. Highlight that there are typically no right or wrong answers—what you are interested in is their thinking and feelings. Be sure to reward youth for completion of STIC tasks either at home or at the start of the session. Although youth typically need to complete several tasks before earning enough points to obtain a tangible reward, noncompliant youth may benefit from a more frequent reward schedule (smaller, more frequent rewards). Immediate positive reinforcement at home, from their parents, can be taught and emphasized. Keep in mind that throughout treatment, avoidance of anxiety-provoking situations (e.g., STIC tasks) is not permitted. Accordingly, if a child fails to complete the STIC task at home, use time at the start of the session to complete the work. You can use this opportunity to practice the necessary coping skills.

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Reluctance or outright opposition to doing an exposure task can impede progress in treatment if not handled well. Not surprisingly, children with anxiety disorders have difficulty facing feared situations. In a sense, you are asking them to do the opposite of what they have been doing for some time. Establishing a strategy of approach to feared stimuli, as opposed to one of avoidance, can be fostered during the skill-building phase of treatment and reinforced when completing exposure tasks. Explain the rationale for completing exposure tasks, and allow the youth to help you construct their own hierarchy—a collaborative process that helps increase motivation and buy-in for the exposure tasks. If an exposure task is too difficult, it can be broken down into smaller steps. However, even when all the necessary preparations have been made, difficulties can still arise when completing an exposure task. We encourage youth to face the anxietyprovoking situation, but it is sometimes appropriate to scale back the task for the moment. For example, ask the youth to 1) complete a variation of the exposure task that may be less anxiety-provoking or 2) repeat a previous exposure task to increase a sense of mastery. Be supportive and reinforce efforts made by the youth. Ultimately, the youth still needs to attempt the difficult exposure task, but there may need to be smaller steps along the way. On occasion, a child may claim not to need to complete an exposure task because “it doesn’t make me anxious.” Don’t argue the point; just encourage the child to complete the exposure task anyway. (In this way, you do not permit the child’s verbal statement to serve as a way to avoid doing the task.) Occasionally, youth who deny experiencing anxiety—but who have parents who claim otherwise—can be persuaded to complete exposures to prove their parents wrong. And as usual, the use of meaningful rewards can facilitate cooperation. Chloe is about to complete a moderately anxiety-provoking exposure task. The exposure task is to go up to the tenth floor of the building by herself in the elevator. Chloe and the therapist reviewed her FEAR plan in the therapy room, and Chloe is now standing in front of the elevator, anxiously clutching her coping card that reminds her to be brave. Chloe refuses to push the button for the elevator, so the therapist does so for her while stating that Chloe can do this task. The elevator doors open, and Chloe refuses to go in. The elevator doors close without Chloe placing a foot inside. She is on the verge of tears, and the therapist senses that a meltdown is moments away. The therapist remains undeterred and calmly goes through the FEAR plan again. Chloe identifies that she is feeling nervous and states that she is worried that someone will kidnap her if she is alone in the elevator. She stares at her coping card, looking for inspiration, but she is still unwilling to complete the exposure task. Unflustered, the therapist tells Chloe, “I know you can be brave and do this.” She reminds Chloe of all her accomplishments so far. Chloe responds, “I know, but this challenge is different!”


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The therapist waits and then tells Chloe that this is a really difficult challenge—and maybe they should try other challenges first to get more practice. The therapist has Chloe repeat an exposure in which she goes up on the elevator one floor by herself with a walkie-talkie so she can talk to the therapist. Chloe receives a sticker for completing this exposure. Now that Chloe’s inertia has been overcome, the therapist suggests that Chloe go up one floor without the walkie-talkie. Chloe appears reticent, but she takes a peek at her sticker chart and notices she is one sticker away from that adorable teddy bear she has so longed for. The therapist praises Chloe again and acknowledges that she can earn her teddy bear today if she completes one more challenge (i.e., exposure task). Chloe musters the energy to complete the challenge, and with a big smile, high-fives the therapist when she gets back from her courageous, walkie-talkie-free journey. Although they have run out of time for the session, Chloe agrees to complete the tenth-floor challenge next week and to complete other exposure tasks at home during the week.

Parental Psychopathology Although the Coping Cat Program is largely a child-focused, individual treatment, parents play an important role in the intervention. As such, parental psychopathology is a potential obstacle to favorable outcomes. There are two specific parent sessions built into the program, but parents are involved even more as they help youth implement exposure tasks outside of the therapy setting. Parental anxiety is common when working with anxious youth, and although parental anxiety management is not a necessary part of treatment, the therapist can help parents manage their own anxiety using the same cognitive-behavioral strategies taught to the children. For example, parents may express anxiety about allowing their child to be in an anxiety-provoking situation. In these instances, the therapist can explore what is the worst that can happen, how likely is that scenario, what can the parents tell themselves to help, and what can they do to help. Note that parental anxiety management is not the focus of treatment and it is not a substitute for parents’ own treatment when necessary.

Conclusion CBT for child anxiety has been found to be effective in several randomized controlled trials. The Coping Cat Program is a manual-based CBT for anxious youth that comprises two phases of treatment: psychoeducation and exposure. Within the psychoeducation phase, the child learns to identify when he or she is feeling anxious and to use anxiety management strategies. The strategies include identifying bodily arousal, engaging in relaxation, recognizing

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anxious thoughts (self-talk) and using coping thoughts, and problem solving. In the second phase of treatment, the child practices the skills learned in the first phase through exposure tasks. The exposure tasks are guided by a collaboratively determined hierarchy so that the child practices skills in increasingly anxiety-provoking situations. Potential obstacles to implementing CBT for child anxiety may include comorbid psychopathology, varying cognitive abilities, noncompliance, and parental psychopathology. However, in order to address these potential barriers and individualize treatment, the Coping Cat Program should be implemented flexibly while maintaining fidelity.

Key Clinical Points • The core components of CBT for child anxiety are psychoeducation, recognition and management of somatic symptoms, cognitive restructuring (changing anxious self-talk), and importantly, multiple exposure tasks. • The Coping Cat Program uses the FEAR plan to describe the concepts learned in the psychoeducation phase of treatment: F=Feeling frightened? E= Expecting bad things to happen? A=Attitudes and actions that can help; R= Results and rewards. • Exposure tasks are a key component of the several versions of CBT for child anxiety. The main goal of exposure is to have the child approach (not avoid) anxiety-provoking situations and remain in the situations until she has reached an acceptable level of comfort. • We recommend that the Coping Cat Program be implemented flexibly while maintaining fidelity. Treatment can be individualized according to the child’s comorbidities, age, cognitive ability, and culture.

Self-Assessment Questions 7.1. Which of the following clients is an appropriate candidate for CBT for child anxiety? A. A 16-year-old white adolescent girl with primary social phobia, obesity, and a learning disability. B. A 6-year-old Hispanic girl with primary separation anxiety disorder and a specific phobia of blood. C. A 13-year-old African American adolescent boy with primary generalized anxiety disorder and comorbid attention-deficit/hyperactivity disorder (ADHD) managed with stimulant medication. D. All of the above.


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7.2. Which of the following is NOT a core component of CBT for child anxiety? A. B. C. D.

Cognitive restructuring. Exposure tasks. Psychoeducation. Behavioral activation.

7.3. A 7-year-old girl diagnosed with separation anxiety disorder presents for treatment. The best role for her parents in CBT treatment is A. No parental involvement in the child’s treatment. B. Parents as co-clients in treatment, with treatment for the child and treatment for the parents. C. Parents as collaborators in conducting exposure tasks involving the child’s separation from the parent(s). D. Parents as consultants regarding the child’s symptoms and impairment. 7.4. A 12-year-old boy with generalized anxiety disorder expresses worry about an upcoming test; he thinks, “I’m worried that I am going to fail, and then I’ll have to repeat seventh grade!” Which of the following is a reasonable coping thought in this situation? A. There’s no way I’ll fail. The teacher likes me.... I think. B. All I have to do is study every day before the test and then I won’t fail. C. Even if I fail seventh grade, I still have my friends ...so why bother studying? D. It’s unlikely that I will fail the test because I studied pretty hard. Even if I did fail this one test, I have plenty of time to bring up my grades before the end of seventh grade. 7.5. Which of the following is NOT an example of an appropriate flexible implementation of CBT for child anxiety (i.e., a flexible application that maintains treatment fidelity)? A. Simplifying cognitive restructuring to the use of a single coping thought (“I can do it!”) for a 7-year-old boy with primary separation anxiety disorder who didn’t fully grasp the concept of self-talk. B. Eliminating at-home exposure tasks for an 11-year-old girl with social phobia, because of parental concerns about causing the child too much stress.

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C. Using frequent breaks and additional rewards for an 8-year-old boy with primary generalized anxiety disorder and comorbid ADHD who is having difficulty staying on task in session. D. Downplaying “sleeping in own bed” as an exposure task for a 9year-old girl with primary social phobia, due to parental beliefs and preferences regarding a shared family bed.

Suggested Resources Treatment Manuals Kendall PC, Hedtke K: Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual, 3rd Edition. Ardmore, PA, Workbook Publishing, 2006a Kendall PC, Hedtke K: The Coping Cat Workbook, 2nd Edition. Ardmore, PA, Workbook Publishing, 2006b

Training DVD Kendall PC, Khanna M: CBT4CBT: Computer-Based Training to Be a Cognitive-Behavioral Therapist (for Child Anxiety). Ardmore, PA, Workbook Publishing, 2009

Further Reading Beidas RS, Benjamin CL, Puleo CM, et al: Flexible applications of the Coping Cat Program for anxious youth. Cogn Behav Pract 17:142–153, 2010 Kendall PC: Treating anxiety disorders in youth, in Child and Adolescent Therapy: Cognitive-Behavioral Procedures, 4th Edition. Edited by Kendall PC. New York, Guilford, 2010, pp 143–189 Kendall PC, Robin JA, Hedtke KA et al: Considering CBT with anxious youth? Think exposures. Cogn Behav Pract 12:136–150, 2005 Podell JL, Mychailyszyn M, Edmunds J, et al: The Coping Cat Program for anxious youth: the FEAR plan comes to life. Cogn Behav Pract 17: 132–141, 2010


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References Achenbach TM, Rescorla LA: Manual for School-Age Forms and Profiles. Burlington, University of Vermont, Research Center for Children, Youth, and Families, 2001 Albano AM, Kendall PC: Cognitive behavioral therapy for children and adolescents with anxiety disorders: clinical research advances. Int Rev Psychiatry 14:129– 134, 2002 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 Ameringen MV, Mancini C, Farvolden P: The impact of anxiety disorders on educational achievement. J Anxiety Disord 17:561–571, 2003 Aschenbrand SG, Angelosante AG, Kendall PC: Discriminant validity and clinical utility of the CBCL with anxiety disordered youth. J Clin Child Adolesc Psychol 34:735–746, 2005 Barrett P, Dadds M, Rapee R: Family treatment of child anxiety: a controlled trial. J Consult Clin Psychol 64:333–342, 1996 Beidel DC, Fink CM, Turner SM: Stability in anxious symptomatology in children. J Abnorm Child Psychol 24:257–269, 1991 Beidel DC, Turner SM, Morris TL: Behavioral treatment of childhood social phobia. J Consult Clin Psychol 68:1072–1080, 2000 Canino G: Are somatic symptoms and related distress more prevalent in Hispanic/ Latino youth? Some methodological considerations. J Clin Child Adolesc Psychol 33:272–275, 2004 Chambless DL, Hollon SD: Defining empirically supported treatments. J Consult Clin Psychol 66:5–17, 1998 Chavira D, Stein M, Bailey K, et al: Child anxiety in primary care: prevalent but untreated. Depress Anxiety 20:155–164, 2004 Costello E, Mustillo S, Keeler G, et al: Prevalence of psychiatric disorders in children and adolescents, in Mental Health Services: A Public Health Perspective. Edited by Levine B, Petrila J, Hennessey K. New York, Oxford University Press, 2004, pp 111–128 Gee CB: Assessment of anxiety and depression in Asian American youth. J Clin Child Adolesc Psychol 33:269–271, 2004 Gosch EA, Flannery-Schroeder E, Mauro CF, et al: Principles of cognitive-behavioral therapy for anxiety disorders in children. Journal of Cognitive Psychotherapy: An International Quarterly 20:247–262, 2006 Greco L, Morris T: Factors influencing the link between social anxiety and peer acceptance: contributions of social skills and close friendships during middle childhood. Behav Ther 36:197–205, 2005 Harmon H, Langle A, Ginsburg G: The role of gender and culture in treating youth with anxiety disorders. Journal of Cognitive Psychotherapy: An International Quarterly 20:301–310, 2006 Hirshfeld-Becker DR, Masek B, Henin A, et al: Cognitive-behavioral intervention with young anxious children. Harv Rev Psychiatry 16:113–125, 2008 Howard B, Chu B, Krain A, et al: Cognitive-Behavioral Family Therapy for Anxious Children: Therapist Manual. Ardmore, PA, Workbook Publishing, 2000

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Hwang WC, Wood JJ, Lin KH: Cognitive-behavioral therapy with Chinese Americans: research, theory, and clinical practice. Cogn Behav Pract 13:293–303, 2006 Kazdin AE, Weisz J: Identifying and developing empirically supported child and adolescent treatments. J Consult Clin Psychol 66:8–35, 1998 Kendall PC: Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol 62:100–110, 1994 Kendall PC: Guiding theory for therapy with children and adolescents, in Child and Adolescent Therapy: Cognitive-Behavioral Procedures, 4th Edition. Edited by Kendall PC. New York, Guilford, 2010, pp 3–24 Kendall PC, Braswell L: Cognitive Behavioral Therapy for Impulsive Children, 2nd Edition. New York, Guilford, 1993 Kendall PC, Hedtke K: Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual, 3rd Edition. Ardmore, PA, Workbook Publishing, 2006a Kendall PC, Hedtke K: The Coping Cat Workbook, 2nd Edition. Ardmore, PA, Workbook Publishing, 2006b Kendall PC, Khanna M: Camp Cope-A-Lot: The Coping Cat DVD. Ardmore, PA, Workbook Publishing, 2008 Kendall PC, Southam-Gerow M: Long-term follow-up of treatment for anxiety disordered youth. J Consult Clin Psychol 64:724–730, 1996 Kendall PC, Flannery-Schroeder E, Panichelli-Mindell SM, et al: Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol 65:366–380, 1997 Kendall PC, Brady EU, Verduin TL: Comorbidity in childhood anxiety disorders and treatment outcome. J Am Acad Child Adolesc Psychiatry 40:787–794, 2001 Kendall PC, Choudhury MS, Hudson JL, et al: The C.A.T. Project Manual: Manual for the Individual Cognitive-Behavioral Treatment of Adolescents With Anxiety Disorders. Ardmore, PA, Workbook Publishing, 2002a Kendall PC, Choudhury MS, Hudson JL, et al: “The C.A.T. Project” Workbook for the Cognitive Behavioral Treatment of Anxious Adolescents. Ardmore, PA, Workbook Publishing, 2002b Kendall PC, Safford S, Flannery-Schroeder E, et al: Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4-year follow-up. J Consult Clin Psychol 72:276–287, 2004 Kendall PC, Gosch E, Furr JM, et al: Flexibility within fidelity. J Am Acad Child Adolesc Psychiatry 47:987–993, 2008a Kendall PC, Hudson JL, Gosch E, et al: Cognitive-behavioral therapy for anxiety disordered youth: a randomized clinical trial evaluating child and family modalities. J Consult Clin Psychol 76:282–297, 2008b Khanna M, Kendall PC: Computer-assisted cognitive-behavioral therapy for child anxiety: results of a randomized clinical trial. J Consult Clin Psychol 78:737– 745, 2010 Lambert SF, Cooley MR, Campbell KD, et al: Assessing anxiety sensitivity in innercity African American children: psychometric properties of the Childhood Anxiety Sensitivity Index. J Clin Child Adolesc Psychol 33:248–259, 2004 Manassis K, Mendlowitz S, Scapillato D, et al: Group and individual cognitivebehavior therapy for childhood anxiety disorders: a randomized trial. J Am Acad Child Adolesc Psychiatry 41:1423–1430, 2002


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March JS, Parker J, Sullivan K, et al: The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry 36:554–565, 1997 Nauta M, Scholing A, Emmelkamp P, et al: Cognitive-behavioral therapy for children with anxiety disorders in a clinical setting: no additional effect of cognitive parent training. J Am Acad Child Adolesc Psychiatry 42:1270–1278, 2003 Ollendick TH, King NJ: Empirically supported treatments for children with phobic and anxiety disorders: current status. J Clin Child Psychol 27:156–167, 1998 Pina AA, Silverman WK: Clinical phenomenology, somatic symptoms, and distress in Hispanic/Latino and European American youths with anxiety disorders. J Clin Child Adolesc Psychol 33:227–236, 2004 Pina AA, Silverman WK, Weems CF, et al: A comparison of completers and noncompleters of exposure-based cognitive and behavior treatment for phobic and anxiety disorders in youth. J Consult Clin Psychol 71:701–705, 2003 Rapee RM, Barrett PM, Dadds MR, et al: Reliability of the DSM-III-R childhood anxiety disorders using structured interview: interrater and parent-child agreement. J Am Acad Child Adolesc Psychiatry 33:984–992, 1994 Seligman LD, Ollendick TH, Langley AK, et al: The utility of measures of child and adolescent anxiety: a meta-analytic review of the Revised Children’s Anxiety Scale, the State-Trait Anxiety Inventory for Children, and the Child Behavior Checklist. J Clin Child Adolesc Psychol 33:557–565, 2004 Silverman WK, Albano AM: Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. Boulder, CO, Graywind Publications, 1996 Silverman W, Kurtines W, Ginsburg G, et al: Treating anxiety disorders in children with group cognitive-behavioral therapy: a randomized clinical trial. J Consult Clin Psychol 67:995–1003, 1999 Silverman WK, Saavedra LM, Pina AA: Test-retest reliability of anxiety symptoms and diagnoses with the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. J Am Acad Child Adolesc Psychiatry 40:937–944, 2001 Silverman WK, Pina AA, Viswesvaran C: Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. J Clin Child Adolesc Psychol 37:105–130, 2008 Sood ED, Kendall PC: Ethnicity in relation to treatment utilization, referral source, diagnostic status and outcomes at a child anxiety clinic. Presented at the annual meeting of the Association for Behavioral and Cognitive Therapies, Chicago, IL, 2006 Treadwell KR, Flannery-Schroeder EC, Kendall PC: Ethnicity and gender in relation to adaptive functioning, diagnostic status, and treatment outcome in children from an anxiety clinic. J Anxiety Disord 9:373–384, 1995 Verduin TL, Kendall PC: Differential occurrence of comorbidity within childhood anxiety disorders. J Clin Child Adolesc Psychol 2:290–295, 2003 Walkup J, Albano AM, Piacentini J, et al: Cognitive-behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 359:2753–2766, 2008 Wood JJ, Piacentini JC, Bergman RL, et al: Concurrent validity of the anxiety disorders section of the Anxiety Disorders Interview Schedule for DSM-IV: child and parent versions. J Clin Child Adolesc Psychol 31:335–342, 2002 Wood JJ, Piacentini JC, Southam-Gerow M: Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Adolesc Psychiatry 45:314–321, 2006


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Pediatric Posttraumatic Stress Disorder Judith A. Cohen, M.D. Audra Langley, Ph.D.

MORE than two-thirds of children and adolescents (hereafter referred to as “children”) experience trauma, with half of these children experiencing multiple traumatic events (Copeland et al. 2002). Posttraumatic stress disorder (PTSD) symptoms are common in trauma-exposed children. However, many children with significant trauma symptoms and functional impairment do not meet full PTSD diagnostic criteria according to DSMIV-TR (American Psychiatric Association 2000) because of criteria that may be less developmentally appropriate for children, such as a sense of foreshortened future (Meiser-Stedman et al. 2008; Scheeringa et al. 2006). Several cognitive-behavior therapy (CBT) models have been found to be efficacious in addressing childhood PTSD and related problems following trauma exposure. CBT models have been tested for children who have experienced sexual abuse, domestic violence, terrorism, disaster and war, community violence, and multiple trauma exposures. 263

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This chapter will focus on two types of CBT trauma treatment models: 1) individual CBT, represented by trauma-focused cognitive-behavior therapy (TF-CBT); and 2) group (primarily school-based) CBT, represented by the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS; Stein et al. 2003). TF-CBT (Cohen et al. 2006) has been evaluated in eight randomized controlled treatment trials (RCTs) for sexual abuse, domestic violence, and multiple traumas among children ages 3–17 years (reviewed in Cohen et al. 2009). CBITS has been tested in two RCTs for children exposed to community violence (Kataoka et al. 2003; Stein et al. 2003). Other CBT models have been tested for single-episode traumas (Smith et al. 2007) and for war-exposed children and adolescents. Described later in this chapter, these models include largely overlapping components, which emphasizes the broad applicability of CBT interventions for traumatized children across different types of traumas and a broad developmental spectrum.

Cognitive-Behavioral Theory for PTSD PTSD was only officially recognized in the Diagnostic and Statistical Manual of Mental Disorders in 1980 (American Psychiatric Association 1980). Several complementary theories explain its complex symptoms. According to learning theory, PTSD results from overgeneralization and failure of extinction of fear and other negative emotions. Traumatic experiences are by definition accompanied by negative emotions such as horror, fear, helplessness, and anger (American Psychiatric Association 2000, p. 463); these emotions are often associated with physiological arousal in such forms as rapid heartbeat, elevated blood pressure, flushing, and sweating. Studies indicate that interpersonal violence such as child sexual or physical abuse, neglect, and domestic and community violence have a clearly negative impact on children; that early and/or multiple traumatic exposures lead to increasingly negative outcomes for children; and that if left untreated, impairment cuts across multiple domains of functioning as described in the case examples below (e.g., Felitti et al. 1998).

Case Examples Mariel, age 8 years, is referred for a mental health evaluation because of several recent episodes of getting into fights with boys at school. Her mother brings Mariel to you for an initial evaluation. According to the mother’s report, Mariel’s main problems are the fighting at school and fall-

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ing grades. Her mother also reports that recently Mariel has started going to the school nurse’s office with headaches. During the evaluation, you ask Mariel whether anything bad or scary has happened to her. She says, “People fighting.” You ask, “Do you mean the fights that have happened at school?” to which Mariel replies, “No, fighting at home.” You administer a brief interview to assess trauma exposure and symptoms of PTSD. Mariel endorses witnessing domestic violence between her parents and the following symptoms: Mariel loves her father but has scary thoughts about him hurting her mother. She tries to push these thoughts out of her head, but some boys at school remind her of this fear. They make her very mad sometimes. She can’t concentrate at school or sleep at night because she is always worried about what her father will do, and she is more jumpy and irritable than she used to be. She doesn’t want to spend time with her friends like she used to. Joaquin, a 14-year-old middle school student, is referred to the schoolbased social worker by his math teacher. His teacher explains that Joaquin is typically a conscientious student, especially in math, and socially popular. For the last couple of months, however, the teacher has noticed that Joaquin misses class frequently, that his grades are dropping, and that when he is in class, he has difficulty concentrating and appears sad and socially withdrawn. Joaquin often asks for a pass to the bathroom or to the nurse’s office, stating that he is sick to his stomach. The teacher explains that last week, he raised his voice to get the class’s attention, and Joaquin jumped visibly in his seat and became very upset, prompting him to walk out of class. When you meet with Joaquin, you ask if he has recently experienced any frightening, difficult, or very stressful events, and he replies that 3 months ago, he and his best friend witnessed a gang shooting in the park on their walk home. Since then, he hasn’t been able to stop thinking about what happened and worrying that it could happen to him or his family and feeling sick to his stomach. He feels upset each time he sees his best friend and feels sad and alienated from his peers in general. “How do they expect me to concentrate on my math test when I can’t stop thinking about the sound of that bullet and the look on that gangster’s face when he spotted us before we ran?”

Classical conditioning occurs when neutral cues that either were present at the time of the initial trauma or have enough resemblance to trauma reminders (i.e., sights, sounds, people, or places that were present at that time and remind the child of the original trauma) become associated with the negative emotions and physical responses the child had at that time and begin to elicit those same responses. For example, Mariel became angry around boys at school; the boys themselves were not dangerous or violent, but because they were loud males, they reminded her of her father and thus served as trauma reminders and elicited the same feelings she experienced during the traumatic event. Likewise, Joaquin became upset when he was around his best

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friend; although his friend was simply another witness to the traumatic event, he became a cue to the traumatic experience. Memories and thoughts about the trauma can also become conditioned trauma reminders and trigger highly negative physical and psychological responses in traumatized children. Operant conditioning may teach children to avoid such cues in order to reduce the likelihood of experiencing these negative emotions. As avoidance is reinforced (i.e., if it successfully keeps the child from feeling bad, even intermittently), the child will learn to avoid talking about or being around trauma reminders. For example, Mariel loved her father but was scared of him and tried to avoid him when he was “mad.” She also avoided talking or thinking about her family situation, which contributed to her avoidance of friends or social situations. As avoidance becomes more generalized, it is rarely successful, because most traumatized children have experienced multiple episodes of interpersonal violence and reminders of these experiences are so internally and externally ubiquitous that it is difficult to totally avoid them. Children with high levels of avoidance or emotional numbing may have trouble using optimal coping strategies such as implementing a safety plan or seeking help from supportive adults when violence occurs. In Joaquin’s case, he hadn’t even shared his traumatic experience with his mother and siblings, both because he didn’t want to think about it and because he didn’t want to burden his hardworking mother. Avoiding thinking and talking about the experience also meant avoiding his guilt and fear that not being able to stop the shooting meant that he was incompetent to protect his siblings and mother, something his father had implored of him as the oldest son when he was deported to their country of origin last year. Children, like adults, are prone to developing maladaptive cognitions about the cause and/or impact of having experienced trauma, such as being inherently defective or damaged (i.e., shame), being responsible for the trauma (i.e., self-blame), or being undeserving of love or care from others (i.e., low self-esteem). In addition, there can be cognitive developmental issues, particularly in younger children, such as magical thinking or causal misattributions. These cognitions may have been modeled for children (e.g., the perpetrator, a neglectful parent, or bullying peers may have told the child he or she was worthless or deserved to be maltreated), or children may come to these cognitions through faulty deductive reasoning (e.g., “Other children aren’t treated badly; therefore, I must be treated badly because of something bad about myself ”). Children who have experienced long-standing, severe, and/or interpersonal traumas such as child maltreatment, neglect, or domestic violence often lack skills such as affect expression, self-soothing, and affective and behavioral regulation. Therefore, these skills can be important components of a trauma treatment plan.


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Most CBT models for traumatized children integrate these various needs into their intervention components. CBT models for PTSD typically include 1) behavioral, 2) cognitive, and 3) parent-child relationship building components. Typically, but not always, they begin with skills-based interventions such as relaxation, labeling feelings, affective modulation, general cognitive coping skills, and problem solving. Exposure-based or trauma-specific interventions, such as developing a trauma narrative and undertaking in vivo exposure to generalized trauma cues, are usually provided after the earlier coping skills. Many models also include an active parent component that focuses on enhancing parenting and the parentchild relationship. CBT models that include all three components generally have more evidence for improving PTSD and related trauma problems than models that include only a single component. Including parents or other caregivers (hereafter referred to as “parents”) in CBT for traumatized children produces significant improvement in parents’ mental health (e.g., depression, emotional distress), parenting skills, and support of the child. Some evidence supports the use of brief skills in the absence of exposure components for the following groups of traumatized children: 1) younger children (4–11 years) who have relatively high levels of behavioral problems (e.g., Deblinger et al. 2001), and 2) children who have relatively mild levels of PTSD symptoms (UCLA PTSD Reaction Index levels <23 at the start of treatment) (CATS Consortium 2010).

Assessment A major challenge to effectively treating traumatized children is that child PTSD symptoms can be very difficult to accurately identify. How CBT is applied depends on this accurate assessment. Several self-report instruments, such as the UCLA PTSD Reaction Index for DSM-IV, assess PTSD symptoms. However, children often underreport PTSD symptoms due to trauma avoidance (not wanting to think or talk about the trauma or symptoms associated with it) or due to general child unreliability in reporting externalized symptoms such as anger or behavioral problems. Including parents in assessment is helpful in gaining additional information about children’s behaviors. However, parents may be unaware of the child’s internal trauma symptoms (e.g., having frightening recurrent thoughts about the trauma; being hypervigilant about the trauma recurring; avoiding trauma reminders or thoughts about the trauma; having maladaptive cognitions related to the trauma, such as self-blame, shame, or fear of trusting others), or parents may minimize these problems. For example, Mariel’s mother did not think Mariel was aware of the domestic violence occurring

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in the home and was shocked to learn that her daughter had serious PTSD symptoms related to these occurrences. Parents are typically more focused on children’s externalized trauma symptoms (e.g., irritability, sleep problems, anger, aggression). Mariel’s mother had made no connection between Mariel’s fighting in school and the father’s behavior at home. To optimally assess children for PTSD symptoms, consider the ABCs of trauma impact: • A—Affect: The classic feelings associated with PTSD are anxiety and fear, but clinicians should also ask about sadness, anger, or flat affect, as well as affective dysregulation (e.g., “going from 0 to 60,” not being able to soothe oneself after becoming upset) and dissociation. Mariel both loved and feared her father. It was not safe for her to show anger at home, but she was angry and experienced affective dysregulation at school. She also did not feel her usual happiness around her friends (flat affect). Joaquin exhibited sadness and anxiety in his classes and at home and had lost interest in what he used to find enjoyable, but he also would very quickly “fly off the handle” for what appeared to others as minor things, such as someone bumping into him or a teacher raising his or her voice to get the class’s attention.

• B—Behavior: Avoidance of trauma reminders and cues is a prominent behavior associated with PTSD. Joaquin avoided his best friend, who was with him during the shooting, as well as the park where the shooting occurred. His anxiety generalized to other outdoor settings, and he refused to let his younger siblings play outside when they were under his care in the afternoons and on weekends when his mother was working.

Traumatized children may also display problem behaviors learned or modeled during their traumatic experiences. Mariel was aggressive toward boys in part because they reminded her of her father’s aggression toward her mother. She was afraid of them but also angry because they reminded her of times when her father had hurt her mother.

Other trauma-associated behavior problems include self-injury; substance use and abuse; and irritable, aggressive, angry outbursts that are a manifestation of general behavioral dysregulation. • B—Biological changes: A variety of biological changes can be manifested as somatic symptoms or illness, including headaches, stomach-


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aches, muscle pains, trouble sleeping, hyperalertness and increased vigilance to danger, trouble relaxing, and hyperresponsiveness to sensory stimuli. Children who are biologically on alert may react in very negative ways to occurrences that they perceive as threatening and that lead these children to lash out in anger or to defend themselves. Joaquin was able to avoid going to school and walking near the park (on the route between school and home) by complaining of stomachaches. Likewise, when he felt anxious or overwhelmed at school, he frequently asked for a pass to go to the bathroom or to the nurse’s office with the same complaint. Mariel reported frequent headaches at school.

• C—Cognition: Ask about maladaptive cognitions, including self-blame, shame, feeling different, incompetence (“I can’t stop bad things from happening or protect myself or my family,” “I can’t do anything”), survivor guilt (“Why am I still alive when someone else died?”), generalized loss of trust in adults and supportive social systems, loss of faith in the social contract (i.e., that justice is served), the general notion that “the world is a dangerous place,” and other inaccurate or unhelpful thoughts. Mariel thought that her father’s “bad moods” and his subsequent abuse of her mother were in part her fault because they were sometimes preceded by her father yelling at her. Joaquin blamed himself for what happened because he came home later than usual that day, and he felt guilt and shame for not being able to stop the shooting and for potentially endangering his family by being a witness to gang-related violence.

• S—School interference: Difficulty in school may occur because of recurrent intrusive thoughts about the trauma; ongoing attempts to avoid thinking about the trauma; trying to numb oneself, which leads to generalized distance from cognitive tasks; and possible trauma reminders in the school setting. School problems may include difficulty with concentration and attention, difficulty learning, poor grades, and classroom behavior problems, among others. Because of intrusive thoughts, flashbacks, and hyperarousal, Joaquin exhibited difficulty concentrating, distractibility, jumpiness, poor attendance, and decreasing grades. Mariel experienced trauma reminders in school, leading to her trouble concentrating and declining grades.

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• S—Social and relationship problems: These problems may include new or increased fighting; social withdrawal; associating with deviant peers; and other social and relationship problems often resulting from loss or lack of trust in others, feeling that old friends don’t understand, and feeling different or alienated from others. Mariel felt alienated from her friends and became socially isolated. Likewise, Joaquin’s feelings of sadness and guilt and his isolation from his best friend left him feeling very different from his peers and made him withdraw from all social activity.

Application Reviews of individual (Cohen et al. 2009) and school-based (Jaycox et al. 2009) child CBT trauma treatments document that these treatments share many common treatment components (described later in this section). In addition to these core components, two general treatment concepts are critical when implementing CBT for traumatized children: 1) engaging families in treatment and 2) use of gradual exposure throughout the treatment process.

Treatment Concepts Treatment Engagement Treatment engagement is essential for effectively treating any family but is especially critical in addressing the needs of traumatized individuals, because trauma typically has a negative impact on trust. Children and parents may feel betrayed by a trusted person, community, educational system, criminal justice system, their faith, and/or society at large that allowed such an unfair thing to happen. When the trauma was perpetrated by a parent or other caregiver or over a long period of time, attachment is often negatively impacted. Because successfully engaging families in psychotherapy requires that they trust the clinician, this may be more challenging with traumatized children and their parents. The following strategies are effective for engaging even multiply traumatized children and their parents: • Ask what the family wants and expects from mental health treatment. • Ask about potential barriers to participation in mental health treatment, including differences between the family and yourself based on ethnicity, race, religion, socioeconomic status, or other factors that may


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lead the family to doubt your ability to understand their problems or needs. • Explain your understanding of the child’s problems and their relationship (if any) to the child’s trauma experiences, and see whether the family can accept this information. If the family doesn’t understand or accept this explanation, they are not agreeing to engage in traumafocused treatment, and another type of treatment should be offered (Cohen et al. 2010; McKay and Bannon 2004).

Gradual Exposure Gradual exposure refers to the process through which you gradually, purposefully, and incrementally increase the intensity, duration, and/or degree to which you introduce trauma-related material during each subsequent treatment session. As you implement subsequent CBT components, connect them to children’s trauma experiences by asking how children will implement these components when they are reminded of the traumatic events they experienced. It is important not to do anything that inadvertently models avoidance to children or parents. For example, you may avoid the topic of the trauma or do so indirectly by communicating that trauma is embarrassing or difficult for you to talk about. This may be the case when you start using trauma CBT models. Children who have experienced trauma are apt to blame themselves or feel ashamed about what happened. Either out of embarrassment or in an attempt to convey empathy, you may lower your voice, look away, use euphemisms, or say “I’m sorry” when talking directly about children’s trauma experiences. Children or parents may interpret these behaviors to mean that you think what happened was shameful. It is important to make a conscious effort not to do these things. Refer to traumatic events by their accurate descriptions (e.g., “sexual abuse,” “domestic violence,” “your father’s death,” “the car accident”). Do not use euphemisms such as “the scary thing,” “the upsetting situation,” “the events of September 11th,” or “passing away.” Do not use the term “down there” to refer to private parts (e.g., “vagina,” “penis,” “anus,” “breasts”). These behaviors may seem inconsequential, but they communicate to the child that you are not ready to hear or talk about the child’s trauma. Be conscious not to avoid talking about children’s trauma experiences (the opposite of gradual exposure). Gradual exposure is a critical part of trauma CBT models. Do not wait for children to give you a cue or otherwise show you that they are ready to talk about their traumatic experiences. Because avoidance is a core feature of PTSD, few children will

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spontaneously talk about traumatic experiences. It is up to the clinician to provide sufficient trauma-related exposure so that when children reach the part of treatment where they need to describe the details of their personal trauma experiences, this will not overwhelm them.

Core Components Parenting Component When feasible, include parents in CBT treatment of child PTSD in order to provide effective parenting skills, as well as to parallel other CBT components. This may be accomplished in parallel parent groups, in parallel individual child and parent sessions, in family sessions, or in a combination of these formats. Help parents understand the connection between the child’s behavior problems and past traumatic exposure, so that trauma-focused treatment makes sense. Behavioral parenting skills might include encouraging parents to use active praise; selective attention (i.e., to actively attend to and praise desired behaviors while attending less to undesired behaviors); and appropriate contingency reinforcement and other reward and punishment procedures that are tailored to the specific child behaviors. If parents can’t attend sessions regularly, provide them with written information about what the child is learning in treatment so that the parents can reinforce the skills their child is learning. In school-based trauma treatments, teachers may receive some instruction regarding how to support the implementation of CBT skills in the educational setting. This will enhance children’s optimal use of such skills in school and help teachers understand manifestations of trauma symptoms in the classroom.

Psychoeducation Many children and parents have inaccurate information about trauma because of societal stigma, family or cultural beliefs, or other reasons. They may also feel alone because they do not understand that trauma is a common experience that they share with many other children and families. Moreover, children and parents often do not make a connection between what the child has been through and the current difficulties they are having. Psychoeducation can reverse the negative impact of inaccurate information and normalize traumatic experiences. Educate children, parents, and/or teachers about the impact of trauma. Help them to understand the child’s current symptoms from a trauma perspective; normalize these problems as common reactions to traumatic events while providing hope for recovery. Also share information about how many children experience the type(s) of trauma the child has experi-


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enced. Information sheets about child trauma are available on the Web site of the National Child Traumatic Stress Network (www.nctsn.org).

Relaxation Skills Help children and parents understand and recognize the physiological impact of trauma (e.g., rushing pulse, pounding head, stomachache, increased muscle tension, “seeing red”), and ideally, help them to identify the early warning signs of these symptoms (i.e., recognize them when they first start to occur). Ask children what the earliest manifestations or antecedents of physical trauma-related symptoms are, and ask them to keep a record of when these early signs occur during the week. Their responses will assist you in developing tailored relaxation strategies for preempting, preventing, and/or “turning down the volume” (i.e., decreasing the intensity) of these symptoms when they occur in specific settings. Individualize different relaxation skills if the setting allows (e.g., individual therapy). Group settings may offer fewer opportunities for tailoring interventions to individual needs. Younger children may need ongoing assistance from parents or other adults to implement relaxation strategies. Teach parents these strategies so that they can encourage their children to use them.

Affect Expression and Regulation Skills It is very important to be aware of whether the children you treat are living with ongoing violence. Be cautious about encouraging children to express a range of feelings outside of therapy (e.g., with the perpetrator or other family members) unless you are sure that it is safe for children to do so. Use games or other engaging activities to encourage children to label and express new emotions that they may not be used to talking about. Help children gain skills to manage difficult emotions—for example, by seeking social support; problem solving; negotiating; learning skills in turning down the volume of their symptoms; using humor and faith; and learning optimism. Parents or other caregivers need to support children as they start to use these skills outside therapy.

Cognitive Coping Cognitive coping is a specialized skill for helping children to regulate upsetting emotions and negative behaviors. Help children recognize maladaptive (inaccurate and/or unhelpful) thoughts that are related to their negative emotions and how these in turn are connected to their behaviors. For example, if a child gets a bad grade on a test, he might think, “I’m stupid,”

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leading him to feel very upset and to not pay attention or to misbehave in school because he has given up any hope of success there. Examine with the child whether another thought besides “I’m stupid” could explain getting a bad grade (e.g., “I didn’t study enough”; “I didn’t study the right things to do well on this test”; “I didn’t understand the material on that test”; “The teacher picked really hard questions”; “I can do better if I ask for help”). Ask the child how he would feel if he focused on one of these thoughts instead of the thought “I’m stupid” and how this feeling (e.g., better, hopeful, OK) might lead to different behavior (e.g., studying harder, asking the teacher or a parent for help with studying, paying more attention in class, not giving up). Practice this for a variety of ordinary (non-trauma-related) situations and help the child generate alternative thoughts in order to feel better. Parents typically need to practice cognitive coping also. Provide cognitive coping skills to parents and help them to start processing their difficult feelings about the child’s trauma experiences. Typically, you will not start processing details of the traumatic experiences with the child until after he or she has developed a personal trauma narrative, described in the next section, “Trauma Narration and Processing.”

Trauma Narration and Processing Develop a narrative of the child’s trauma experiences, including all of the important types of trauma the child experienced. Allow the child to choose which trauma to start with, but plan at the beginning what to include in the narrative so that you leave enough time to include everything. Also be proportionate in timing so that the narrative component of therapy lasts no more than about a third of the total treatment duration. This will maintain the balance between present (skills), past (narrative), and planning for the future (final components). Through several sessions, help the child develop a trauma or life narrative. It may be helpful to start the narrative with paragraphs or chapters about “Who I am” and “My relationship with the perpetrator before the trauma started” (if appropriate) before proceeding to “What happened during the trauma episode I am describing.” Each trauma episode should include thoughts, feelings, and body sensations. Include as many episodes as needed to capture the important traumas the child has experienced. A final chapter about “How I have changed” is also important. Then return to what the child has already written (or produced in another format) and begin to cognitively process maladaptive trauma-related cognitions about core traumatic experiences using cognitive coping methods described above. As with other components, as the child is developing the narrative, you will be sharing this with the parent or caretaker in preparation for joint sessions.


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In Vivo Mastery of Trauma Reminders If the child has developed generalized fear of neutral cues, you may elect to use graduated exposure exercises to help the child master increasingly challenging trauma cues that are associated with generalized fear responses. This component should only be used 1) if the cue is safe (i.e., no real danger is associated with it); and 2) if the family and other adults are in full support of the exposure plan and committed to supporting graduated exposure, because stopping in the middle will worsen rather than improve the child’s avoidance symptoms.

Conjoint Child-Parent Sessions As treatment is nearing an end, have two to three conjoint sessions with the child and parent together. In order to prepare for these, meet with the child and parent separately for 10–20 minutes before bringing the child and parent together for the rest of the session. Typically use the joint sessions to help the child share the trauma narrative with the parent, enhance optimal child-parent communication about the child’s trauma experience, and move forward together toward treatment termination. Remember that although you have already shared the narrative with the parent, for the parent to hear it from the child’s own mouth is likely to be highly emotional for both the child and parent. Gauge the parent’s ability to cope with this and to support the child during this process. If the parent is not supportive (for example, if the parent still does not believe the child, calls the child a liar, is extremely angry or emotionally unstable), develop an alternative activity for the joint session or do not have a conjoint session.

Enhancing Safety and Future Developmental Trajectory Remember that after trauma, the most important thing many children and parents have lost is their belief that the world is a safe place or that others have benign intentions. Help the child and parent develop optimal ageappropriate safety skills for their life situations. Before terminating treatment, address treatment closure issues that may be particularly salient for children who experienced the traumatic death of a family member. Usually, address safety later in treatment so that children do not feel shame or embarrassment about safety strategies they may have failed to use to protect themselves previously. However, for children who have immediate safety concerns (e.g., they are living with a perpetrator of domestic vio-

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lence or with ongoing community violence), you will probably need to address safety issues early in treatment instead of later.

Case Management It may be important to collaborate with systems of care such as child welfare, juvenile justice, pediatric, educational, and other providers who are working with traumatized children.

Selecting an Optimal CBT Model and Logistics Several different child CBT trauma models have been empirically tested (Cohen et al. 2009; Jaycox et al. 2009). However, to select an optimal CBT treatment model for a specific traumatized child, you must know not only about alternative treatment approaches but also 1) which (if any) options are available at the child’s school and 2) which (if any) are acceptable to the child’s family. As more schools become proficient at providing trauma-focused CBT treatment, school-based group or individual CBT trauma treatment may become a feasible option (Jaycox et al. 2010); however, do not suggest this option unless you know that it is available at the child’s school. If the child’s school does not offer trauma treatment, it may be feasible to offer group therapy in outpatient settings that serve sufficient numbers of traumatized children. Individual treatment may be most appropriate for children who 1) have more severe symptoms (because individual therapy can be more easily tailored to individual needs) and/or 2) have experienced child abuse or domestic violence (parents often have concerns about their children talking about these experiences with other children). Group treatment may be most appropriate for children who 1) have somewhat less severe symptoms (i.e., because treatment cannot be tailored to the individual child’s needs to the same degree); 2) can only access treatment in school settings; and/or 3) might particularly benefit from peer support, social skills training, and other aspects of group therapy. However, these are only guidelines, and these considerations are less crucial than providing some form of effective treatment. For example, group therapy has helped many children with severe initial symptoms. Either group or individual CBT trauma therapy is likely to be helpful for most traumatized children. Although group or school-based treatment may be optimal for some children, if no group is available, offer individual therapy and vice versa. Be aware that many individual child treatments


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such as TF-CBT are also effective without parent involvement. Although inclusion of parents is always optimal, positive outcomes have been documented without parental involvement for TF-CBT and other individual child CBT models (e.g., Deblinger et al. 1996; Weiner et al. 2009). Thus, when deciding on a treatment plan, although you may consider factors such as symptom severity and the availability of group treatment (including in the child’s school), the most important consideration is to offer a form of treatment that the family will attend. Most CBT models are 10– 12 sessions, which is a reasonable duration of treatment for the clinician to suggest as a starting point, ensuring that families understand that some children may need fewer sessions, and some may need more.

Developmental Adaptations Child CBT trauma models (and TF-CBT in particular) have been used and tested for children ages 3–17 years with relatively minor adaptations on the basis of children’s developmental level. Adaptations for preschoolers and adolescents are briefly described.

Preschool (Ages 3–7 Years) Even very young children are able to use the core treatment components with positive outcomes if these components are provided appropriately for their developmental level (e.g., Cohen and Mannarino 1993; Deblinger et al. 2001). Because play is the primary activity of preschool children, play is the medium through which you will accomplish most effective therapy. It is important to develop engaging, fun activities for implementing all of the core components. Providing psychoeducational information, talking about feelings, learning about relaxation, and talking about “what your brain is telling you” (cognitive coping) can all be made into enjoyable, funny, soothing, or exciting guessing games, storytelling, or other activities for you to play with young children during therapy sessions. Providing small prizes (e.g., an M&M, a sticker, and most importantly, lavish praise such as “Oh my goodness, you are SO SMART!”) after children give each correct answer keeps young children engaged, excited, and involved in these activities.

Adolescents (Ages 13–17 Years) Traumatized adolescents are often challenging to engage in treatment for a variety of issues. Often they resent having to come to therapy, especially if they are coming because someone else (parent, teacher, judge) wanted them to. If they are coming because of trauma-related issues, you may hear com-

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plaints like “I didn’t do anything wrong”; “What happened was not my fault”; “Why should I be punished (by coming to therapy)?” “I’m not crazy”; or “I don’t want to talk to a shrink.” Start by validating these concerns as teenagers have a right to these feelings—they are not being brought to therapy because they were responsible for the trauma or because they are “crazy,” but almost always because of emotional or behavioral problems that often are related in some way to the traumatic experiences they have had. Addressing these concerns at the outset is a natural segue into psychoeducation about the impact of trauma and will also give you a chance to ask them what they are hoping to get out of coming to therapy, as well as any other concerns they may have about starting therapy. These are critical parts of engaging youth in psychotherapy (McKay and Bannon 2004) and have been used effectively to retain traumatized youth in TF-CBT.

Cultural Adaptations At least three child CBT trauma models have been culturally adapted and pilot-tested: • CBITS for Latino immigrant children (De Arellano et al. 2005) and American Indian children (Morsette et al. 2009) • TF-CBT for Latino immigrant (Kataoka et al. 2003), American Indian (Bigfoot and Schmidt, in press), and Zambian HIV-affected sexually abused children (Murray 2007) • KidNET for international war refugee immigrants to Germany (Ruf et al. 2010) In all cases, these adaptations recognized the importance of engaging local consumers in the adaptation process, both to assess cultural variations of how traumatized children presented clinically and in adapting the intervention itself. Interestingly, across the three models used in diverse settings (schools, clinics, and refugee camps and clinics), all of the models retained their core components, whereas language and examples were adapted to be culturally, developmentally, and contextually salient to the child or children being served. In each case, the models gained culturally sensitive engagement and implementation techniques that have achieved strong acceptability and positive initial outcomes among children cross-culturally.

Obstacles to Treatment You may encounter many obstacles when first starting to implement child CBT trauma treatment. These might include child-related challenges, such


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as children who are highly trauma avoidant; parents who have their own severe trauma history (and thus raise concerns about whether they can handle hearing the material this type of treatment might raise); children who have serious affective or behavioral dysregulation (whether or not related to trauma); and “crises of the week” (i.e., children and/or parents who come in each week with a new crisis, usually but not always caused by the child’s negative behaviors, that threatens your ability to follow the treatment plan). To help therapists who face these common problems, a new online resource has been developed through funding by the Annie E. Casey Foundation, TF-CBTConsult (www.musc.edu/tfcbtconsult).

Case Examples Mariel: Individual TF-CBT During the first session, you ask Mariel whether she would like to play a game or draw pictures. She chooses to play a game. You play What Do You Know? (CARES Institute 2006). You select cards that focus on domestic violence. Because there are immediate safety concerns, you also address safety during this first session instead of waiting until later in treatment, and provide psychoeducation about domestic violence and examples of children’s safety skills (e.g., don’t play with matches; only cross the street on a green light; don’t get between adults during a fight; how and when to call 911). You also provide information about PTSD: that having problems like hers has a name, that they are common after children experience really scary things like domestic violence, and that children can get better from PTSD. When talking about safety, Mariel says she is afraid that she cannot keep her family safe. You ask her whose job it is to do this, and she says that it is hers. You use the metaphor of children wearing a backpack and parents carrying suitcases. You draw a suitcase and a backpack, and then list a variety of jobs (e.g., paying the bills, doing your homework, going to school, going to work, buying food, brushing your teeth, keeping the family safe) on note cards and ask Mariel to put the cards in the correct container according to which jobs belong to parents and which jobs belong to children. Mariel puts all of the jobs in the correct containers until she comes to keeping the family safe. Then she says, “I know it’s supposed to be the parents’ job, but they don’t do it so I have to.” You say, “We’ve talked about things you can do to keep YOU safe. Keeping your family and your parents safe is a grown-up job, and it belongs in the grown-up suitcase, not the child’s backpack.” Mariel agrees to your talking about the family’s need for more safety with her mother. By the end of the session, Mariel seems relatively comfortable talking about these topics. When meeting with Mariel’s mother, Anita, at the first session, you tell her that one of the best predictors of children recovering from PTSD is

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“having a parent like you who believes and supports her child through therapy. Mariel already has that, so she is already on her way toward getting over this. She is so lucky to have you here.” Anita is visibly relieved to hear you say this. You then describe to Anita Mariel’s concerns about safety and her belief that she must keep the family safe. Anita becomes tearful, but says, “I understand why she feels that way; my husband has been angry a lot, and it must not feel safe to her sometimes.” You ask, “Help me understand what it is like at your house.” Anita gradually confirms more about what Mariel has told you, and additional information about the father’s controlling behavior. You provide Anita with written information about domestic violence that describes these behaviors as being part of a pattern of domestic violence. You also provide her with information about other resources for domestic violence, including a local domestic violence treatment center, and suggest that it might be helpful for her to look online and consider going to this center to seek counseling or other services. Anita denies that her husband would ever seriously hurt her. You tell her that you and Mariel are both very concerned about her safety, and you do not want anything to happen to her, not only because you care about her, but because Mariel loves her and needs her. You suggest that if Mariel could have a safety plan, this might help her to feel safer right now. Anita agrees to this idea but does not know what to include in the plan. You ask whether any of Anita’s friends or relatives know about how her husband treats her and Mariel and whom Mariel could call on the phone when she is afraid. Anita tearfully admits that she has been too ashamed to tell them. You encourage Anita to consider telling her sister, Carolina, who is the closest to Anita in her family. Anita also agrees to talk to Mariel about calling her aunt Carolina if she is afraid. During the next session, Mariel tells you that her mother talked to her about safety and said that she could call her aunt Carolina if she was scared about her parents’ fighting. Mariel says that she feels safer since her mother told her this. You teach Mariel progressive relaxation and focused breathing, and in collaboration with Mariel, her mother, and the school develop the following plan in order to address Mariel’s headaches in school: 1. When getting ready for school, Mariel will use visualization. She loves butterflies, so these will be her focus during visualization. She will keep this vision in her head when she is walking to school and will use deep breathing and progressive muscle relaxation on the way to school. If she is not relaxed, she will tell her mother, who will practice these relaxation strategies with her before she leaves for school. 2. Once in school, she will go to her first classroom. In her backpack, she will have a picture of butterflies. She will arrive 5 minutes early so that she has time to look at the butterfly picture before class begins. She will sing her favorite song in her head (a lullaby her mother used to sing to her), which makes her feel safe. 3. If she starts getting a headache, she will have a special signal (putting her hair in a ponytail) that her teacher recognizes as her help signal. Her teacher will come to her desk if she puts her hair in a


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ponytail and will ask her to do her deep breathing and butterfly visualization exercise. Mariel has a second visualization exercise to use as well. She can do this at her desk quietly without attracting the attention of other children in the class. If this doesn’t work, she will be allowed to go to the nurse’s office to get some aspirin, after which she will return to class. You meet alone with Anita, who tells you that she told her sister Carolina about the domestic violence. Carolina was very upset when she heard this but was supportive of Anita and quickly agreed to Mariel calling her anytime, day or night, if she was worried or scared. Anita explained that she and Mariel were getting help for the problem, and Carolina was relieved and told Anita that she was proud of her for telling someone about it and getting help. Anita says, “I was surprised that Carolina said this; I thought she would put me down for staying with him, but she actually said she was proud of me for coming to therapy. I feel so much better now that someone knows about this. I wasn’t sure it was the right thing to do, but I’m really relieved that I told her.” Anita agrees to practice the above relaxation strategies with Mariel. During the following session, you begin working on affective expression and modulation skills. Mariel reports that she called her aunt Carolina twice this week. Once she called when she was upset, and this helped her feel safer. She says, “Once I just called her to talk—I just liked knowing I could talk to her.” She has also been using the relaxation strategies in school and has had fewer headaches. You and Mariel play Emotional Bingo, and she is able to name times when she has felt happy (when her mother is happy), sad (when her parents fight), anxious (when her father comes home in a bad mood), angry (when the boys at school are loud), confused (when she doesn’t understand what her teacher says in school), and excited (when she gets a present). When she can’t think of a time she has felt hopeful, you ask, “When would another child feel hopeful?” Mariel says, “When her family gets along and is happy.” You then ask what kids can do to feel better when they have upsetting feelings like being sad or angry. Mariel is not sure at first, but you say, “Some kids go to their rooms and read a book, other kids talk to their moms or a friend, other kids like to get active, and other kids have a hobby or something else they like to do. Is there anything you can do to help yourself feel better when you’re upset?” Mariel says, “I try not to think about things that upset me.” You ask, “Does that help you feel better?” Mariel says, “Sometimes.” You say, “I bet sometimes it’s really hard not to think about your parents fighting. Let’s see if we can figure out some other ways to help you feel better.” Mariel thinks for a minute and says, “I call Aunt Carolina.” You say, “Has that been helping you to feel better?” Mariel says, “Yes, that helps me feel less scared.” You say, “So that’s another way to feel better—reaching out to adults who can help you feel safe is called asking for support. Are there other grown-ups you can ask to help you feel better? How about at home—are there other adults you can ask for help?” Mariel says, “Mommy, if Daddy isn’t fighting with her.” You say, “So Mommy is someone you can ask for help when you’re feeling sad or scared. Anyone at school you can ask for help?” Mariel

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says, “Mrs. Jones, my teacher, is really nice. She’s been helping me do my breathing at school this week. And the school nurse, Mrs. Tomas, is nice too.” You say, “So those are two other people you can talk to if you are feeling upset.” You then work with Mariel to identify the early signs of getting mad at school and to recognize these early warning signs before she loses her temper and starts fighting with boys at school. She agrees to try to talk to one of the helping grown-ups at school before she loses her temper. You also introduce the use of thought stopping (e.g., using the visual image of a red light when Mariel has intrusive scary thoughts at school when she is trying to do schoolwork). She likes the idea that she can be in charge of her thoughts and draws a stoplight to practice thought stopping. After practicing this, she agrees to bring the drawing to school and practice thought stopping when she has intrusive thoughts about her father at school. You meet with Anita to address affect regulation skills. Anita tells you that her husband found out that she is bringing Mariel to therapy. He has demanded that she stop coming, but Anita is determined to get Mariel the help that she needs. Her husband has beaten her up severely twice this week. She shows you several bruises on her body. However, she is worried about leaving him because she has read that perpetrators can become deadly when their wives try to leave. She asks you if you think she and Mariel are in danger. You tell her that she is already in danger and that she needs to get help immediately. You emphasize that you are very concerned about her because no one should be beaten and mistreated the way she is. You offer to help Anita call the local domestic violence program from your office and arrange for her and Mariel to go directly to this program from your office. Anita agrees to this plan. You meet together with Anita and Mariel to explain to Mariel that her mother is taking her to a special place that helps mothers and children to deal with domestic violence. Mariel hugs her mother and asks whether she can call her aunt Carolina. Anita says OK, and you praise Mariel for using the coping skills you just discussed. You say that maybe sometimes Aunt Carolina could even go with Mariel and her mom to the domestic violence program. Mariel calls her aunt, who says she will meet them as soon as she can catch the bus to the domestic violence center. Anita and Mariel are very reassured and leave for the center. The following week, you start by meeting briefly with Anita to follow up on what has happened since the last session. Anita reports that she is still living with her husband but has gone to her first session of a women’s support group at the domestic violence center, and she has met with a legal advocate there. She has heard a lot of frightening stories, and these have made her both more scared to stay and more scared to leave. She is not sure what to do. On the positive side, Mariel is doing better in school. When you meet with Mariel, she tells you that her headaches have decreased significantly at school. She has talked to her teacher about “feeling mad,” and to her surprise, Mrs. Jones thanked her for “using your words” instead of fighting. This comment was very reinforcing to Mariel, and she felt very pleased with her new skills. She is continuing to talk to her mother, her aunt, and her teacher when she is feeling scared or upset and has not had any new episodes of fighting. You introduce cognitive coping by asking whether Mariel has had any upsetting feelings during the past


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week. She says, “Yes, for the first time in a while I felt like playing with some of my friends during lunch, but none of them asked me to play with them. I felt really sad.” You say, “That’s a perfect example. When you felt sad, what were you thinking? What was your brain saying to you?” Mariel says, “I don’t know, I guess it was saying that I feel sad.” You say, “Sad is what you were feeling. Usually we can say our feelings in one word, like sad, mad, or happy, like we talked about last week. So I’m really glad that you are so good at recognizing your feelings. Thoughts are connected to feelings, but they are a little different. When we have a feeling, we often have a more complicated thought that is connected to it, like something we are telling ourselves in our head that is more than a one-word feeling, like a sentence. So when you felt sad, what sentence were you telling yourself in your head about your friends?” Mariel says, “Um... maybe they didn’t like me anymore.” You say, “Great job, Mariel, that’s exactly what I mean by a thought. So when you thought, maybe my friends don’t like me anymore, this was the thought that made you feel sad. Of course it did; I would feel sad, too, if I thought my friends didn’t like me anymore. When you felt sad, what did you do?” Mariel says, “I went back inside and sat in the bathroom by myself.” You say, “So, this is how we would write this down to show the connection between what you thought, what you felt, and how you acted” (Figure 8–1). You say, “What if you had a different thought instead of that they didn’t like you? Can you think of any other thought a child could possibly have in this situation?” Mariel thinks for a minute and shakes her head no. You say, “What about this thought: Maybe they thought that you didn’t want to play with them anymore because it’s been so long since you’ve wanted to spend time with them. You didn’t ask them to play either, did you? So maybe your friends thought you still wanted to stay by yourself? If you thought that, how would you feel?” Mariel says, “I never thought of that. I guess I wouldn’t feel so bad.” You say, “And if you didn’t feel so bad, what might you have done?” Mariel says, “I might have asked them if I could play with them.” You say, “That’s right. So this is how we would write this down” (Figure 8–2). You encourage Mariel to use cognitive coping during the coming week when she is upset and to replace maladaptive thoughts with more accurate and/or more helpful ones. You meet again with Anita to introduce her to cognitive coping and to encourage Mariel to use this in the coming week. During the next three sessions, Mariel writes the following trauma narrative. As she is writing it, you share it with Anita during her individual sessions.

Chapter 1: All About Me Hi, my name is Mariel. I am 8 years old. I live with my mother and father in Oakland. I go to school at St. Christopher’s School, and my best friend is Barbara. We both have black hair and brown eyes. My favorite food is pizza. I don’t like to eat peas. I like to play with dolls, sing and dance, and read. I want to be a teacher when I grow up.

Chapter 2: My Family I have a very big family that includes lots of aunts, uncles, cousins, and three grandparents, but my family in my house is just three peo-

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ple: Mommy, Daddy, and me. When I was little, things were better. Daddy played with me and said he loved me. That was when we had a happy family.

Chapter 3: Fighting My parents started to not be happy when I was little, like about when I was 5, in preschool. My parents were not happy like before. My father had trouble with working, and his anger was bad. He and Mommy were fighting, and it was bad a lot at home. One time I remember was when Daddy came home, and he was really mad. He yelled at me to get in my room right now. He yelled, “What is wrong with you?” I ran to my room crying. I thought, “Daddy is mad at me. He does not love me anymore. I am not a good child.” My stomach hurt. I had to go to the bathroom, but I was afraid it would make him madder, so I did not go and it made my stomach hurt more and more. What will happen if he doesn’t love me and Mommy anymore? I felt sad and scared about what he would do to Mommy. I heard the door slamming and Mommy crying. I tried not to hear, but I know Daddy was hitting Mommy, and I heard her head hit the wall. I heard Daddy call her bad names; he said really bad things to her over and over so that I held my hands over my ears so I couldn’t hear. It was so bad, I can’t even stand to think about it. I was afraid he would hurt her or kill her and who will love me then? I am sick when I think about this. I wish I had hit him. I felt really mad, but I was too sick and too scared, and I cried to sleep at night. And Mommy cried all night and so did I, and I was praying and please let it stop, but all night long he was hitting and yelling and kicking and she was crying, and I just wanted to stop him and hit him, but I was so afraid that he would kill her. The next day she had a black eye and her face was swollen up, and she said she fell down but I knew it was because of Daddy. I was scared to tell her what I heard, so I just hugged her and went to school. When you read this to Anita, she is shocked. She is sobbing and says she had no idea that Mariel knew about this episode. She says, “I thought I had hid it from her, but she’s known all along. This makes him look like a monster. She is growing up with these horrible things, and I’ve let it happen.” You say, “You have both been the victims in this story, and until now you didn’t understand what Mariel’s trauma experiences have been like. How does hearing about her experiences change this for you as her mother?” Anita says, “I—I just, I can’t believe it. I can’t believe I let my own child live through this. I have to get her out of here. I can’t let her live through this one more minute. I can hardly live with myself knowing that I let. ..” Anita sobs at this point, saying, “How could I not see—how could I think she wouldn’t know?” You validate Anita’s pain and support her use of cognitive processing to replace these maladaptive thoughts with more accurate and helpful ones (e.g., “My husband perpetrated the violence, not me”; “Now that I understand what Mariel has gone through, I can protect her”; “If I hadn’t brought her to therapy, she might not have talked about this and


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Situation: My friends didn’t play with me.

Thought: They don’t like me anymore.

Feeling: Sad.

FIGURE 8–1.

Behavior: I went in the bathroom and stayed by myself.

Mariel’s initial cognitive triangle.

Situation: My friends didn’t play with me.

New thought: They didn’t know I wanted to play with them.

New feeling: Not so bad.

FIGURE 8–2.

New behavior: Ask them if I can play with them.

Mariel’s new cognitive triangle.

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gotten better”; “Mariel is getting better, and this is largely because I’ve been a good mother to her”). During the following week, Anita calls to tell you that she and Mariel have moved to the shelter, but they will attend their appointment as scheduled. At the next session, you ask Mariel how she has been, and she says that she is relieved, mad, and sad. She is relieved that her mother is safe but mad at both of her parents for “making it be like this. Why can’t they love each other like they did before? Why does he have to be so mean, and why can’t she make him be nicer? I never want to get married.” You validate Mariel’s sadness and anger at losing the family she had. You take out three cans of Play-Doh and use the metaphor of Mariel (blue Play-Doh), Mommy (red Play-Doh), and Daddy (yellow Play-Doh). At the start of their family, there was just red and yellow; then there was red, yellow, and blue. You ask Mariel to put them into a shape that shows the family in Chapter 2 of her story. Mariel makes a circle with red, blue, and yellow together. Then you explain that the family changed in Chapter 3; they were not the same as in Chapter 2: red and yellow were fighting, and blue was hiding from yellow sometimes, so their shapes were very different from in Chapter 2 when they were all happy together. You ask Mariel to show what shape the family looked like in Chapter 3. Mariel makes a configuration with blue away from red and yellow, which are mashed together with her fists. Now you explain that there will be a Chapter 4, when blue and red live in one place and yellow lives somewhere else. But all three people are still part of a family even if they live in different places. So how will their shapes change in this chapter? You ask Mariel to show what their shapes will look like in this next chapter. Mariel thinks and makes a circle of blue and red, with yellow on the outside. You ask what the feeling is, and she says, “Sad, but not scary. It’s quieter than fighting.” Mariel completes her narrative with Chapter 4.

Chapter 4: How I Have Changed Since I have come to therapy, I have learned a lot about domestic violence. I have learned that grown-ups have to keep kids safe. The police came to my house and brought us to the shelter. I miss Daddy but not the fighting. I worry about Daddy living alone and if he is okay without us. It makes me sad to think that he is alone but then I remember all the fighting, and I don’t want to go back to the way it was. I don’t want my mother to get hurt again. That was worse than anything else. I call Aunt Carolina or Mommy or talk to my teacher when I feel sad or worried. I met other kids who had domestic violence. It happens to lots of kids; I am not the only one. I feel sad that our family is not together. I didn’t make Daddy get mad. He needs to get help for doing domestic violence. I would tell other kids it’s not their fault. Tell a grown-up if you are scared. Don’t get in the middle of grown-ups when they fight. You might make it worse. It will get better someday. You are not alone. Anita and Mariel meet together with you for Mariel to read her narrative to her mother (until now you have been reading it to Anita in her in-


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dividual sessions) and to fine-tune safety plans. Mariel and her mother have just moved to a small apartment near Carolina and her family, and Mariel’s symptoms have significantly improved. She has started to visit with her father at her paternal grandmother’s house; this has decreased her worry about her father. At the end of treatment, she is doing well and her UCLA PTSD Reaction Index has fallen to within the normal range.

Joaquin: Group CBITS During your initial meeting with Joaquin, you assess his PTSD symptom level (which is in the moderate to severe range), and after you have provided him with some information, the two of you agree that he could benefit from a group you are offering at school. You get permission from Joaquin’s mother to include him in a 10-week CBT group at school for students who have been exposed to very stressful or traumatic events. Although his mother is not aware of the shooting, she knows that they live in a dangerous neighborhood, that the kids see fights at school, and that their father was deported last year. She recognizes that Joaquin has become sad, tired, and sick to his stomach over the last few months, that he does not have any patience with his siblings, and that he does not like to go to school. She agrees that she would like Joaquin to receive support and learn coping skills so he can feel better. His mother works two jobs and has three younger children, making it feel impossible for her to accompany Joaquin or provide transportation for services, so she is grateful that he can attend a group at school. While you have her on the phone, you provide his mother with some brief information about the skills that Joaquin will be learning and let her know he will be given the opportunity to talk about the experiences he has been through. She agrees to do her best to get time off to attend parent sessions at the school when possible. You give her your contact information and ask her to provide you with any alternative contact information for her and best times to contact her if needed. During the first group session, you facilitate a game with the students so they can get to know one another and feel comfortable talking in the group. Joaquin smiles when he realizes that two other students name similar interests to his and that there is another youth who is the eldest in his family and whose father does not live with them. You talk about the prevalence of violence and trauma among youth and what those words mean. When you ask each of the six participants to briefly state why he or she is in the group, Joaquin says that he “saw a kid get shot on the way home from school.” You discuss confidentiality, and the group arrives at a set of “group rules”; you also introduce the reinforcement chart so that the students see how they will be rewarded for participation and practice. Next, you create a triangle with thoughts, feelings, and behaviors for each point and discuss that scary or traumatic events affect everything about us—all three of these things—and provide an example of how they are linked and affect each other. After others talk, Joaquin joins in and says that he sees how what happened to him makes him think that if he goes to the park again or lets his siblings play outside, he thinks they could get shot. These fears make him feel “crazy nervous,” and so he yells at them not to go outside

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and doesn’t hang out with his friends anymore near the park. The group supports him by saying that those thoughts, feelings, and behaviors make sense given what he went through. You talk about how this CBITS group can help him and the others learn to think, feel, and act in a way that makes them feel better so that each person can get back to doing what he or she likes and needs to do that is safe. At the end of the first group session, you ask students to fill out a goals worksheet to give you information to better understand what each student hopes to get out of the group and for you to begin to individualize their treatment plans. They are sent home with a similar form for parents to write in goals they have for their child. The week after the first session, you have scheduled an early morning parent session, which Joaquin’s mother attends along with a couple of other parents from the group. After some introductions and brief sharing at the meeting, you review common reactions to stress and trauma; have the parents engage in the same relaxation training exercises you will do with the students; discuss the link among thoughts, feelings, and behaviors; explain the rationale for the group; and answer any questions. You highlight the issue of avoidance and why it is important for youth to be able to process and digest their experiences by telling their stories. You emphasize that students will be practicing skills between sessions at home and that they may need support in doing so, especially as they work toward getting back to doing things that they may have been avoiding. You explain that the next parent group will be in 3 weeks and that you will further discuss avoidance and exposure along with problem solving. You provide handouts for the content of both sessions in case some parents do not return for the second session. You notice that some parents exchange contact information, and you have provided time in the room in case anyone wants to speak to you afterward. In the second group session, you facilitate a discussion with the students about common reactions to stress and trauma, and as each is discussed, you are able to normalize why that symptom would occur and provide hope for how the group may help it improve. For example, Joaquin offers that one reaction may be to not want to go places or see people that remind you of what happened. You reinforce him for participating and state, “Avoidance is common and makes sense because you may feel better for the moment, but just like not wanting to talk or think about the trauma, avoiding situations or people that remind you of the shooting can keep you from doing normal things that are an important part of your life, right? In this group, we’ll be learning about how to cope with some of these bad feelings so you can get back to doing those things. Can anyone else relate to what Joaquin just said about avoidance?” Following the discussion of common reactions, where many symptoms that come up are related to physiological arousal, you transition into teaching different forms of relaxation training, including deep breathing, progressive muscle relaxation, and positive imagery. You explain the idea of a feelings thermometer (i.e., rating how you feel on a scale of 0–10, where 0 is feeling OK and 10 is feeling very, very upset, anxious, or scared) and ask for ratings before and after the relaxation exercises. You give students a “Common Reactions to Stress or Trauma” handout to take to their parents, and ask them if they are com-


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fortable doing so, to share with their parents which reactions they may be experiencing. In addition, you ask them to practice some form of relaxation two times during the next week and report back. You spend the next two group sessions reviewing and practicing cognitive coping (similar to the description in “Mariel: Individual CBT”), allowing each student to practice how to replace negative thoughts with more helpful and accurate thoughts. Between sessions, you monitor each student’s practice with relaxation and cognitive coping. Joaquin reports that he finds taking deep breaths before his tests in class useful, and when another group member mentions that she is trying to do deep breathing and positive imagery when she gets headaches, Joaquin decides this could be something for him to try when his stomach is bothering him and when teachers or kids are loud. When he has thoughts about the shooting, Joaquin uses positive imagery of his “safe and happy place” (his grandmother’s kitchen in El Salvador) and imagines the feeling of warmth and calm and the good smells of his favorite foods there that comfort him. He later reports that he has been able to find privacy in the bathroom at home to do muscle relaxation and that helps him feel “less angry” when his siblings frustrate him. When you ask group members to write down a couple of helpful thoughts on a small card to carry with them, it reminds Joaquin of his brother’s Yu-Gi-Oh! Power (Japanese video animation) cards, so he begins to carry the power card in his pocket to remind him to check his thoughts and to use helpful and accurate thinking when negative thinking gets in his way. In addition to the group sessions, during weeks 3 and 4 you meet individually with Joaquin twice to work on his trauma narrative (and with each student one to three times). During the initial discussion, you find out that Joaquin has experienced other traumatic events, including his family being robbed and temporarily separated while crossing the border into the United States 7 years ago, a home invasion 5 years ago, and his father being deported during a raid at his workplace last year. However, Joaquin reports that it is the recent shooting that is causing him the most distress currently. You ask Joaquin to tell you the story of what happened the day of the shooting and to add information so you can imagine what is happening as if it is projected onto a movie screen in front of you. You let him know that you are going to jot down parts of the story as he tells it. Joaquin shares the following: “My best friend, Carlos, and I stayed after school for a while that day because some kids were playing basketball and we watched. I started thinking that I should get home so my brothers and sister wouldn’t be alone, because I’m supposed to take care of them after school. So finally, Carlos and I took off for home. When we got to the park on 3rd Street, it was starting to get dark, and we cut through by the rec [recreational center] like we always did on the way home. When we got past the corner of the building, we saw two guys from a gang pointing a gun at a high school kid in a big jacket near the other corner of the rec. They were cursing and yelling back and forth, and I felt frozen, like I was just stuck in time and didn’t know what to do. The next thing I knew there was the gunshot—loud in my ears—and the other gangster looked right in my eyes. Carlos pushed me, and we both started running through the park.

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We were so scared, we didn’t even shout out or warn anyone there. We didn’t even know if the boy was killed or nothing. We just ran until it burned too much to run, and we were home by then. Carlos went straight to his house, and I went to mine. I just went to the bathroom at home and sat on the ground, and I was shaking and just told the kids to leave me alone. When my mom came home from work that night, I was still shaking and had a stomachache. My mom looked so tired and worried that I was sick. She works all the time since they sent my dad back to El Salvador, and I just couldn’t tell her what I saw. I couldn’t say it. My dad told me to take care of her and my brothers and sister until he could figure out how to get back.” You work with Joaquin to retell his story several times over the two sessions, providing support and assistance in reframing some of his maladaptive thoughts about what happened and his role in it. By the second session, it is much easier for Joaquin to talk about what he went through. You then help him plan for later group sessions, which will provide continued practice at processing his trauma memory. You ask if there are parts of his story he would like to continue working on in the group, some of which he may want to keep private and some of which he may be willing to share with the group. You make a note of these things for him. You also prepare Joaquin to be supportive in the group by first asking what he may need from the group in order to feel supported and comfortable. He states that he would “like others to be paying attention and not be messing around” and that “others will also have a turn so I am not the only one sharing.” You then use that information to ask Joaquin for ideas about how he can be respectful and show support for other group members. Joaquin agrees to do the same for the others and also to look at them while they are talking, but in a “nice way, not straight at their eyes.” At the conclusion of the second individual session, Joaquin thinks that he is ready to talk to his mom about what happened. You help him think through and plan a good time to talk to her and role-play how it might go. You also offer to invite his mother to join you for a third individual session next week in case he doesn’t find a time to do it himself during the week, or after he has shared the information, either way. You encourage Joaquin to do something fun this week to take care of himself because he has been working through difficult stuff. He agrees that he will play basketball or video games at his cousin’s house, something he used to do frequently and hasn’t done in a while, on his mom’s day off from work. Following individual sessions with each group member, you refer back to the individual treatment plans you have started and add new information gleaned from these sessions, including symptoms, family structure, and so forth, and note particular skills that will be important for each individual based on his or her presentation. For example, because of Joaquin’s somatic complaints and jumpiness, you want to ensure he finds a relaxation technique that really works for him. Likewise, because Joaquin’s anxiety since the shooting has generalized to his friend and is interfering with his home life in that he is refusing to let his siblings play outside, you want to be sure that these issues are addressed with in vivo exposure and/or problem solving. You also note that Joaquin would like to share his story with


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his mother and that the family may benefit from a referral to some community and social resources given the father’s deportation. Some time before session 5, you also try to make phone contact with each parent, letting him or her know that beginning in session 5, youth will begin working on concrete steps toward things that may be anxiety provoking or that they have been avoiding that they want or need to be able to do. You assess the extent to which parents, other caregivers, or extended family may be available to provide support and /or transportation if needed during that practice. You invite parents to the second parent session and briefly review the information you will be providing in case they do not attend. In your phone conversation with Joaquin’s mother, you realize she will not be able to attend the parent session, so you provide her with information on the remaining sessions over the phone. She shares with you that Joaquin told her about the shooting and that he is starting to talk with her about other things when he is upset. She tells you that things are very difficult for her now that she is supporting her family alone and that she sometimes does not know how they will survive financially. You validate her concerns and reinforce all she is doing for the well-being of her children and family. You refer Joaquin’s mother to a community agency that provides resources and services for recent immigrants and to a nonprofit legal aid group that may be able to provide her with information regarding her husband’s status and any options the family may have for reuniting. You praise her again for being involved with Joaquin’s program even though she is so terribly busy. During group session 5, you focus on things that students may have been avoiding since their traumatic event. Each child makes a list of things he or she has been avoiding but would like to be able to do again. You circulate to each student, helping each one refine his or her hierarchy of gradual approach steps, getting feelings thermometer ratings for each of the steps, and having each student choose one to two things that can feasibly be practiced over the next week that are rated at 3–4 or under on his or her feelings thermometer. Joaquin lists that he has been avoiding Carlos, his best friend, and that he has stopped letting his siblings play outside when he cares for them. After assessing for the safety of having siblings play outside (“Do other children in the neighborhood play outside?” “Did your siblings used to be able to play outside safely?” “Is there a place it is safest to be while playing outside?” “Is it safe to do so during the day, evening, or weekends?”), you help Joaquin list steps for allowing the kids to play outside, and he accords each step with a rating of how anxious it will make him feel to do so (at present), as shown in Figure 8–3. You also help him create a hierarchy of gradual steps for getting back in touch with Carlos. He constructs the steps and ratings shown in Figure 8–4. Joaquin decides that this week, he will practice letting his siblings play outside at his cousin’s house, where he has started hanging out again on weekends. He will also text message Carlos after school one day. You begin group session 6 by checking in with group members about their progress with in vivo exposures and how they used their coping strategies to manage their anxiety during exposure practice. Joaquin reports that he let his siblings play outside two times at their cousin’s house and

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that it got easier for him by the second time. He even went in the house to play video games while they played outside at one point. He also sent a text message to Carlos, but as soon as he sent the text, he felt much more anxious than he anticipated (he had written an 8 on his practice sheet for his feelings thermometer rating at the time). On the same form, Joaquin had logged his automatic thoughts and alternative helpful thoughts for why Carlos didn’t get right back to him and noted that he took some deep breaths to reduce his anxiety. You ask how it all worked out, and Joaquin says that Carlos was surprised and happy to hear from him. They texted back and forth a few times, joked, and ended with “See ya at school.” You use the opportunity to remind the group that the next time they feel upset or anxious, they can reflect back on how they have felt that way before and what coping strategies helped them get through it, and remember that things may even turn out well. You then help each group member decide on which in vivo steps he or she is ready to progress to in the coming week. In group sessions 6 and 7, you focus on allowing students to continue processing their trauma memory. First, by passing each student the notes you took during his or her individual sessions, you remind each student of the parts of the story that he or she wanted to continue digesting in group. You then guide the group through an imaginal exposure. The students imagine a particular point in their story as you slowly ask questions to guide them to think about what they are picturing—engaging their senses around what is happening, who is there, how they are feeling, what they are thinking, and so forth (they do not answer, but use your guidance to create an individual exposure experience even though they are in a group setting). You pause intermittently and ask for students to show you their feelings thermometer ratings on their fingers so that you have a sense for when ratings have gone down across the group and you can move forward. Next, you provide art supplies and paper and ask each student to draw a picture of part of his or her story. You allow students to draw without instructions or asking questions about what they are doing, being respectful that each may do something very different. Joaquin draws a picture of him and Carlos near the corner of the recreational center and the two boys holding another one at gunpoint on the other side of the building. You check in with students to see how they are feeling as they finish their drawings. You decide to do a relaxation exercise with the group, and afterward you help to focus everyone back to the present by asking about what classes they have next and who is doing what after school that day. In group session 7, you review in vivo exposure practice and progress. Joaquin describes that he played outside at home with his siblings over the weekend and that he has been eating lunch with Carlos and his old group of friends again. You again help each student decide what his or her next in vivo steps will be and then distribute the students’ drawings from the previous week and allow some time for them to finish their drawings. Next, you lead the group in a verbal sharing of part of each student’s story, explaining that students can show their drawing to the group and talk about what is happening in the picture if they like, or they can tell about a different part of their story. You let them know that if someone does not feel like sharing verbally that day, he or she can take a few minutes to write out the story instead—and either keep it private or read it to you at the end of the


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Siblings outside in yard while Joaquin is inside (weekdays). 8 Siblings outside in yard with Joaquin (weekdays).

6

Siblings outside in yard while Joaquin is inside (weekends). 5 Siblings outside in yard with Joaquin (weekends).

4

Siblings play outside at cousin’s house.

3

Imagine siblings playing outside with Joaquin supervising.

2

FIGURE 8–3.

Joaquin’s anxiety ratings.

Hang out with Carlos at Carlos’s house.

7

Hang out with Carlos at Joaquin’s house.

5

Hang out with Carlos at lunch with a group of other kids.

5

Say hello to Carlos during two passing periods.

4

Text message him a “Hey, what’s up” message.

2

FIGURE 8–4. ratings.

Joaquin’s hierarchy of exposure tasks with anxiety

group session. Joaquin shares his drawing, describing what he saw at the park to the group. You then lead the group through another drawing or imaginal exposure and end the group in a similar fashion to group session 6. At the outset of group session 8, you review students’ progress with in vivo practice and plan for continued movement up their hierarchy. Group sessions 8 and 9 focus on problem solving to enable group members to look at options for managing their real-life problems. You illustrate the link between thoughts and actions by working through an example with the group, listing potential actions someone could take and making links to the underlying thoughts. You ask the group for ideas of problems they encoun-

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ter in daily life. The situations include someone writing something bad about you on the bathroom wall, a teacher yelling at you, and parents fighting with each other. You engage the group via games and teamwork in brainstorming and in rating and selecting potential actions for these situations. You emphasize that there are many things a person cannot control in situations like these, but someone can always control how he or she thinks about the situation and what he or she decides to do. Toward the end of group session 9, you engage the students in a trivia game, CBT Jeopardy, which reviews the skills they have learned thus far. You discuss plans for celebrating their success in the final session. You reassess student PTSD symptom levels and find that Joaquin’s PTSD scores have significantly decreased. You also note that he has reconnected with Carlos, even having him over to his house; is spending time with extended family on the weekends; has been allowing his siblings to play outside before dark; and is attending class on a more regular basis. Group session 10 includes a celebration of each student’s progress, marked by your verbal acknowledgment of each child; the handing out of certificates of accomplishment; and a piece of paper for each student, with his or her name on it, passed around for each student to write something positive and to be taken home afterward. Most of the students exchange contact information with one another, and you let them know that although the group is ending, you will still be at school each week and how to contact you if they need anything. You ask the group if they would like to check in before the semester ends and have a booster session, and the group agrees this is a great idea. You hand out a small bag or folder with reminders of their CBT skills and ways to take care of themselves, including small cards for them to write helpful thoughts on; steps they want to continue to make with their hierarchy; relaxation scripts or reminders, such as a worry stone to rub; and lists of things that make them happy, the people they can go to when they feel upset or need advice, and pros and cons for problem-solving issues that come up. You contact parents of group members to let them know that the group has ended and how to contact you if any concerns arise. You remind parents of the skills their children have learned and how to reinforce them at home. Joaquin’s mother is very grateful for the changes she sees in Joaquin. She also reports that she has followed up with the community referral you have given her and has an appointment with a legal advocate to discuss immigration options and community and social services her family may be eligible for. You also get information about students’ classroom functioning from their teachers. Joaquin’s math teacher reports that he is coming to class more settled down, that his concentration and participation level have improved, and that he is no longer asking for passes out of class.

Conclusion Individual (TF-CBT) and group (CBITS) trauma-focused CBT have been extensively tested and found to be effective for traumatized children, in-


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cluding those with multiple traumatic exposure and comorbid difficulties. Other CBT treatments for traumatized children have also shown efficacy for improving PTSD symptoms. Child trauma-focused CBT interventions have been successfully disseminated to large numbers of providers in the United States and internationally. Future research will examine to what extent these dissemination efforts have changed outcomes for traumatized children.

Key Clinical Points • CBT treatment is appropriate for children who have significant trauma symptoms even if they do not meet full PTSD diagnostic criteria. • Gradual exposure is a core feature of most CBT trauma treatments for children. • Skills-based components of child CBT trauma treatments include psychoeducation, parenting skills, relaxation skills, affective modulation skills, and cognitive coping skills. • Trauma-specific components of child CBT treatments include developing a trauma narrative, in vivo mastery of trauma reminders, and safety planning. Some models also include conjoint child-parent sessions. • Individual and group CBT models are both effective; selecting the optimal treatment is primarily a matter of feasibility and accessibility.

Self-Assessment Questions 8.1. Which of the following is a characteristic of gradual exposure? A. Incrementally increasing the duration and intensity of traumatic material in each sequential treatment component. B. Therapists being mindful not to model avoidance. C. Connecting each component, including the skills-based components, to the child’s trauma in some way. D. Instructing children to think about their trauma experiences for at least an hour every day. E. A, B, and C only. F. All of the above.

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8.2. Connections among which of the following three components form the basis of cognitive coping? A. B. C. D.

Thoughts, feelings, behaviors. Thoughts, antecedents, consequences. Antecedents, behaviors, consequences. Thoughts, behaviors, beliefs.

8.3. Which of the following factors may be considered in choosing between individual and group CBT trauma treatments? A. B. C. D.

Severity of symptoms. Accessibility of school-based treatment. What treatment parents will accept. All of the above.

8.4. Which of the following may inadvertently communicate trauma avoidance to children during therapy? A. Using euphemisms for traumatic experiences. B. Attempting to show empathy by changing voice tone or volume when talking about trauma. C. Change in body language. D. Preparatory statements when introducing traumatic themes. E. A, B, and C only. F. All of the above. 8.5. Cultural adaptations of CBT trauma treatments have A. Found some core components to be ineffective with certain populations. B. Retained all core components of the efficacious treatments. C. Found that manuals cannot be properly translated into other languages. D. Created new models for different ethnic groups.

Suggested Readings and Web Sites Cohen JA, Mannarino AP, Deblinger E: Treating Trauma and Traumatic Grief in Children and Adolescents. New York, Guilford, 2006 Jaycox L: Cognitive Behavioral Interventions for Trauma in Schools. Longmont, CO, Sopris Educational Press, 2003


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CTGWeb: A free online training course for applying TF-CBT for childhood traumatic grief that provides 6 free continuing education credits upon completion. http://ctg.musc.edu The National Child Traumatic Stress Network: Provides information sheets about child trauma, as well as a host of other resources for clinicians and families. www.nctsn.org TF-CBTConsult: An online consultation tool for therapists maintained by the National Crime Victims Research and Treatment Center. www.musc.edu/tfcbtconsult TF-CBTWeb: An online training course that offers 10 free continuing education credits upon completion. http://tfcbt.musc.edu

References American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition. Washington, DC, American Psychiatric Association, 1980 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 Bigfoot DS, Schmidt S: Applications for Native American and Alaskan Native children: honoring children—mending the circle, in Applications of TraumaFocused Cognitive-Behavioral Therapy. Edited by Cohen JA, Mannarino AP, Deblinger E. New York, Guilford, in press CARES Institute: What Do You Know? A therapeutic card game about child sexual and physical abuse and domestic violence. 2006 CATS Consortium: Implementation of CBT for youth affected by the World Trade Center disaster: matching need to treatment intensity and reducing trauma symptoms. J Trauma Stress 23:699–707, 2010 Cohen JA, Mannarino AP: A treatment model for sexually abused preschoolers. J Interpers Violence 8:115–131, 1993 Cohen JA, Mannarino AP, Deblinger E: Treating Trauma and Traumatic Grief in Children and Adolescents. New York, Guilford, 2006 Cohen JA, Mannarino AP, Deblinger E, et al: Cognitive-behavioral therapy for children, in Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies, 2nd Edition. Edited by Foa EB, Keane TM, Friedman MJ, et al. New York, Guilford, 2009, pp 223–244 Cohen JA, Berliner L, Mannarino AP: Trauma-focused CBT for children with trauma and behavior problems. Child Abuse Negl 34:215–224, 2010 Copeland WE, Keeler G, Angold A, et al: Traumatic events and posttraumatic stress in childhood. Arch Gen Psychiatry 64:577–584, 2002 De Arellano MA, Waldrop AE, Deblinger E, et al: Community outreach program for child victims of traumatic events: a community-based project for underserved populations. Behav Modif 29:130–155, 2005

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Deblinger E, Lippmann J, Steer R: Sexually abused children suffering posttraumatic stress symptoms: initial treatment outcome findings. Child Maltreatment 1:310–321, 1996 Deblinger E, Stauffer LB, Steer R: Comparative efficacies of supportive and cognitive-behavioral group therapies for young children who have been sexually abused and their nonoffending mothers. Child Maltreat 6:332–343, 2001 Felitti VJ, Anda RF, Nordenberg D, et al: Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 14:245–258, 1998 Jaycox LH, Stein DB, Amaya-Jackson L: School-based treatment for children and adolescents, in Effective Treatments for PTSD: Practice Guidelines From the International Society for Traumatic Stress Studies. Edited by Foa EB, Keane TM, Friedman MJ, et al. New York, Guilford, 2009, pp 327–345 Jaycox LH, Cohen JA, Mannarino AP, et al: Children's mental health care following Hurricane Katrina: a field trial of trauma-focused psychotherapies. J Trauma Stress 23:223–231, 2010 Kataoka S, Stein BD, Jaycox LH, et al: A school-based mental health program for traumatized Latino immigrant children. J Am Acad Child Adolesc Psychiatry 42:311–318, 2003 McKay MM, Bannon WM: Engaging families in child mental health services. Child Adolesc Psychiatr Clin N Am 13:905–921, 2004 Meiser-Stedman R, Smith P, Glucksman E, et al: The PTSD diagnosis in preschooland elementary school-age children exposed to motor vehicle accidents. Am J Psychiatry 165:1326–1337, 2008 Morsette A, Swaney G, Stolle D, et al: Cognitive Behavioral Intervention for Trauma in Schools (CBITS): school-based treatment on a rural American Indian reservation. J Behav Ther Exp Psychiatry 40:169–178, 2009 Murray LA: HIV and child sexual abuse in Zambia: an intervention feasibility study (NIMH Grant No K23 MH77532). Baltimore, MD, Johns Hopkins University, 2007 Ruf M, Schauer M, Neuner F, et al: Narrative exposure therapy for 7- to 16-yearolds: a randomized controlled trial with traumatized refugee children. J Trauma Stress 23:437–445, 2010 Scheeringa MS, Wright MJ, Hunt JP, et al: Factors affecting the diagnosis and prediction of PTSD symptomatology in children and adolescents. Am J Psychiatry 163:644–651, 2006 Smith P, Yule W, Perrin S, et al: Cognitive behavior therapy for PTSD in children and adolescents: a preliminary randomized controlled trial. J Am Acad Child Adolesc Psychiatry 46:1051–1061, 2007 Stein BD, Jaycox LH, Kataoka SH, et al: A mental health intervention for schoolchildren exposed to violence: a randomized controlled trial. JAMA 290:603– 611, 2003 Weiner DA, Schneider A, Lyons JS: Evidence-based treatments for trauma among culturally diverse foster care youth: treatment retention and outcomes. Children and Youth Services Review 31:1199–1205, 2009

9

Obsessive-Compulsive Disorder Jeffrey J. Sapyta, Ph.D. Jennifer Freeman, Ph.D. Martin E. Franklin, Ph.D. John S. March, M.D., M.P.H.

OBSESSIVE-COMPULSIVE disorder (OCD) is a serious mental health condition with a prevalence rate of 1%–3% across various epidemiological studies (Flament et al. 1988; Sasson et al. 2001; Valleni-Basile et al. 1996). Among adults with OCD, approximately one-half began struggling with symptoms during childhood or adolescence (Rasmussen and Eisen 1990). Considering that both a long duration of illness and early onset are strongly associated with OCD persistence (Stewart et al. 2004), youth with OCD need to be aggressively treated with empirically supported approaches

S This chapter has a video case example on the DVD (“Obsessive-Compulsive Disorder”) demonstrating education and exposure and response prevention methods of CBT for an adolescent with obsessive-compulsive disorder.

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as soon as the disorder is identified. Since the mid-1990s, there have been tremendous advances in the treatment of pediatric OCD, and cognitivebehavior therapy (CBT) has consistently been shown to be the monotherapy of choice for OCD in youth (Abramowitz et al. 2006). Although the superiority of CBT as a monotherapy or in combination with serotonin reuptake inhibitor (SRI) treatment is clear, there remains a need to disseminate this efficacious approach from treatment laboratories to frontline clinicians. From our years of experience in successfully treating youth, including treatment-resistant patients referred from seasoned CBT therapists, we have developed a CBT approach that facilitates treatment compliance and avoids common pitfalls that may lead to ineffective implementation of CBT principles. For clinicians seeking to better serve patients with OCD, this chapter is geared toward improving implementation of an exposure and response prevention (E/RP) approach. This chapter begins with a general review of the CBT treatment outcome literature and then illustrates our particular CBT approach for pediatric OCD. First, we present the empirical evidence for cognitive-behavioral approaches in pediatric OCD in both clinical and research settings. Second, we describe the various theoretical models within the CBT framework used to treat OCD and how elements of these various models are typically implemented within pediatric OCD protocols. Next, we explain in detail our clinical assessment, treatment planning, and treatment approach for pediatric OCD. Finally, we discuss common issues that arise in special populations, particularly for children with OCD content related to scrupulosity or sexual obsessions.

Empirical Support Since the mid-1990s, there has been significant work developing CBT interventions for pediatric populations with OCD. Initially, these interventions began with age-downward extensions of protocols found efficacious with adults, which led eventually to open clinical trials involving these protocols (Franklin et al. 1998, 2001; March 1998). Collectively, the published uncontrolled evaluations led to randomized studies evaluating the efficacy of CBT (e.g., Barrett et al. 2004; Bolton and Perrin 2008; de Haan et al. 1998; Franklin et al., in press; Pediatric OCD Treatment Study Team 2004; Storch et al. 2007). Our research group did a quantitative review of the child and adolescent CBT literature. Efficacy studies in youth have consistently demonstrated large effect sizes for CBT interventions, particularly for individual and family-based formats (Freeman et al. 2007).

Obsessive-Compulsive Disorder

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The effects of CBT interventions in these populations are durable after treatment, observably sustained as long as 9 months after treatment termination (Bolton and Perrin 2008; Franklin et al. 1998; March et al. 1994; Wever and Rey 1997). CBT has proved to be effective even when applied flexibly outside of efficacy trials. For example, large CBT effect sizes have been demonstrated in community-based effectiveness trials with fewer methodological controls than efficacy trials (Nakatani et al. 2009). In Norway, an open trial involving community therapists and their supervisors showed that having access to OCD experts periodically (every 3–4 weeks) led to treatment effects comparable to those of efficacy trials (Valderhaug et al. 2007). This “supervision of supervisors” model indicates that the quality of care by frontline clinicians in areas without extensive OCD expertise can be significantly enhanced with only periodic contact with expert supervisors. A final interesting development in pediatric OCD involves the equitable effects demonstrated from outpatient versus intensive approaches. Although most CBT treatment for pediatric OCD is delivered weekly, there is evidence indicating that CBT can be applied more intensely (e.g., one session per day), demonstrating remarkably similar improvement in outcome to a weekly CBT approach (Franklin et al. 1998; Storch et al. 2007). This suggests that the specific, skill-based CBT work occurring in session is the main driver for improvements in functioning and symptom reduction, regardless of the treatment session schedule. The evidence to date suggests that OCD can effectively be treated with CBT, notwithstanding the various CBT protocols in use. Both the American Academy of Child and Adolescent Psychiatry (1998) and the American Psychological Association (Task Force on Promotion and Dissemination of Psychological Procedures 1995) have concluded that CBT including E/RP elements is the treatment of choice for both children and adults with OCD. E/RP, simply stated, is a collection of behavioral techniques that provide a systematic way of both approaching fear-inducing triggers (exposure) and avoiding fear-neutralizing rituals or other safety behaviors simultaneously. CBT for OCD may also include cognitive therapy elements such as cognitive restructuring. Although a meta-analysis comparing the relative effectiveness of E/RP and pure cognitive treatment suggests superiority of E/RP (Abramowitz et al. 2002), the authors acknowledge it is difficult to compare pure behavioral and pure cognitive therapy approaches, given their overlap in treatment implementation. Although we will discuss later how an overemphasis on cognitive techniques can attenuate the impact of E/RP, the judicious use of cognitive therapy during psychoeducation and initial exposure planning can be helpful for patients beginning a CBT program.

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Theoretical Models Behavioral Learning Most protocols used today are based on principles derived from conditioning models or belief and appraisal models applied to the development and maintenance of OCD symptoms (Taylor et al. 2007). The theoretical models closely tied to E/RP have their start in early learning models. The two-factor model of fear describes a process in which unconditioned behavioral responses (e.g., unlearned escape responses) occur in situations where physiologically mediated anxiety is experienced (Mowrer 1960). If an individual performs a behavior that succeeds in reducing anxiety, the behavior will be negatively reinforced; and subsequent situations where similar anxiety-provoking stimuli occur will more likely reproduce this learned anxiety-reducing behavior. In addition, behaviors related to avoiding situations that evoke physiological fear will also be reinforced. From this initial work, operant conditioning models were described specifically for OCD (e.g., Rachman and Hodgson 1980). When escape behaviors involve learned, compulsive rituals, an individual could be considered to have OCD. Using this descriptive framework, E/RP is thought to work because it makes those learned connections between safety behaviors and the physiological experience of anxiety more ambiguous (see Foa and Kozak 1986). In a typical successful E/RP exercise, a patient begins by exposing himself or herself to an OCD-related trigger that elicits a moderate level of fearful arousal. If the patient then refrains from performing the ritual, the patient will experience a gradual decline of the physiological arousal. With successive E/RP trials, the physiological response to the exposed trigger will gradually reduce (i.e., habituation). As a patient habituates to the OCD trigger, the extinction of OCD behaviors typically follows.

Cognitive Belief and Appraisal Cognition-based theoretical models expanded on earlier efforts to explain the etiology of OCD. Cognitive researchers argue that most forms of psychopathology stem from individuals having and overvaluing dysfunctional beliefs (e.g., Beck 1976). Cognitive theorists for OCD (e.g., Salkovskis 1989, 1996) explain that ephemeral, intrusive thoughts, which occur routinely in most people, may become obsessions when these thoughts are interpreted as having serious consequences for which the individual is personally responsible. Compulsions are reinforced by negative reinforcement, as described in earlier learning models, because they serve to immediately reduce an individual’s dis-


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tress. Cognitive theorists also advance the argument that compulsions persist because they prevent individuals from having opportunities to test whether obsessions lead to their unrealistic predictions of harm (Salkovskis 1989). An enduring legacy of the early cognitive theorists includes articulating the various themes of dysfunctional beliefs found in OCD obsessions. Although it has been shown that using pure cognitive therapy techniques (e.g., Socratic questioning) in isolation is not effective over and above applying E/RP techniques (Abramowitz et al. 2002), the nomenclature of cognitive content is quite useful in setting up exposures that directly target the core fears of an individual. Advancing on Salkovskis’s seminal ideas, a collaborative group of OCD treatment experts outlined additional cognitive domains involved in obsessive content (Obsessive Compulsive Cognitions Working Group 1997). Combining the expert consensus of its members, the Obsessive Compulsive Cognitions Working Group outlined the most common cognitive domains involved in OCD. The final cognitive domains included inflated responsibility, overestimation of threat, thought-action fusion (e.g., a belief that a thought is morally equivalent to performing the action), superstitious or magical thinking, intolerance of uncertainty or doubt, perfectionism, and concerns for controlling thoughts. Although these cognitive constructs were not necessarily specified for child and adolescent OCD, many of these cognitions have been observed as ways to differentiate children with OCD from control subjects and those with other anxiety disorders (Barrett and Healy 2003). Despite the distinctions in theoretical explanations of OCD, it should be emphasized that there is no evidence that any one of these can uniquely account for the symptom variability observed in OCD patients (Himle and Franklin 2009). Our treatment approach emphasizes a neurobehavioral framework, which combines biological, developmental, learning, and family dynamic models (Freeman et al. 2003; March and Mulle 1998). However, techniques used in other treatment approaches (e.g., motivational interviewing, mindfulness-based treatments) can also be useful in the flexible implementation of this program, particularly to promote sustained practice in E/RP activities and remove family involvement in escape and avoidance behaviors that reinforce OCD. Next, we describe our CBT approach in more detail.

Application Assessment A thorough clinical assessment is necessary to determine whether OCD is present and if it should be considered primary over other comorbidities. If

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other comorbid conditions are identified, the clinician must consider carefully whether E/RP should be the primary focus of treatment for the patient. For example, if OCD-appearing behavior could be better described in terms of other disorders with intrusive thoughts or repetitive behaviors (e.g., impulse-control disorders or tic disorder, respectively), then the best approach would not normally involve E/RP. Furthermore, if the severity of OCD symptoms would make E/RP hard to tolerate, SRI medication treatment should be considered. In children, it is also important to determine whether observed behaviors are clinically significant or fall within the range of normal development (Evans et al. 1997). Finally, identifying family factors such as family dynamics related to OCD behaviors (e.g., family accommodation) and history of OCD members is also of tremendous importance. The assessment process that occurs in our treatment clinic is described in detail below. Table 9–1 describes the assessment battery that is used in our collaborative treatment studies and respective clinics. In general, we use the Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS; Scahill et al. 1997) and Anxiety Disorders Interview for Children (ADIS; Silverman and Albano 1996) for most children and adolescents. However, at times due to a patient’s age or comorbidity rule-outs, we also use sections of the Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-P/L; Kaufman et al. 1997), Yale Global Tic Severity Scale (YGTSS; Leckman et al. 1989), or Childhood Autism Rating Scale—High Functioning, 2nd Edition (CARS2; Schopler et al. 2010) as appropriate. We also routinely use the Multidimensional Anxiety Scale for Children (MASC; March et al. 1997), Child Obsessive-Compulsive Impact Scale—Revised (COIS-R; Piacentini et al. 2007), and Children’s Depression Inventory (CDI; Kovacs 1981) to screen for comorbidities and improve treatment planning. Next, we describe a few key assessment considerations for every potential CBT candidate. These clinical considerations are important to determine whether a CBT approach is appropriate for a given family.

OCD Versus Developmentally Appropriate Behavior Differentiating between OCD-related obsessions and rituals and developmentally appropriate behaviors is important. A normally developing child can get deeply immersed in specific interests, become rigidly rule bound, or have behaviors that are stereotypic in nature. For children with OCD, these behaviors are either not developmentally appropriate or are extreme


TABLE 9–1.

Measure

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Typical obsessive-compulsive disorder (OCD) assessment battery Age (years) Target

Notes

Interviews ADIS

8–17

DSM-IV criteria for anxiety disorders; ratings on severity and impairment

Preferred for ruling out anxiety comorbidities

CARS2-HF

6–17

High-functioning autism spectrum behaviors

Best when ruling out autism spectrum– related stereotypies and rigidity

CY-BOCS

5–17

OCD symptoms and severity

Score of 16 indicates clinically significant OCD

K-SADS-P/L

5–17

Full range of DSM-IV criteria

Preferred for ages <8 years and children with wider range of comorbidities

YGTSS

5–17

Motor and vocal tics and severity

7–17

Depression symptoms

Includes parent- and child-rated scales

OCD-related functional impairment

Includes parent- and child-rated scales

Child-rated anxiety symptoms

Includes normed severity and validity ratings

Self-report CDI COIS-R

7+

MASC

8–19

Note. ADIS=Anxiety Disorders Interview for Children; CARS2-HF=Childhood Autism Rating Scale—High Functioning, 2nd Edition; CDI=Children’s Depression Inventory; COIS-R=Child Obsessive-Compulsive Impact Scale—Revised; CY-BOCS=Children’s Yale-Brown Obsessive Compulsive Scale; DSM-IV=Diagnostic and Statistical Manual of Mental Disorders, 4th Edition; K-SADS-P/L=Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version; MASC=Multidimensional Anxiety Scale for Children; YGTSS=Yale Global Tic Severity Scale.

in their manifestation when compared with same-age peers. In either OCD or nonclinical individuals, these behaviors can become more profound during transitions or times of stress. However, for children with

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OCD, these behaviors are typically more acute, pervasive, and hard to resist even with parental encouragement. Repetitive behaviors that children approach because they are considered fun or enjoyable are never considered OCD. Some examples of developmentally appropriate behavioral routines are listed in Table 9–2.

OCD Versus Differential Diagnoses Several childhood disorders involve behaviors that resemble OCD symptoms. Furthermore, children with significant OCD symptoms often have comorbid disorders, particularly tic disorders, attention-deficit/hyperactivity disorder, and oppositional defiant disorder. For these reasons, a careful assessment should differentiate OCD symptoms from these other conditions, because many of these differential diagnoses will not benefit primarily from E/RP. A few classes of disorders have behaviors that resemble obsessions or compulsions but are clearly not OCD. A cardinal characteristic of OCD obsessions is that they are both intrusive and ego-dystonic, which means that the child experiences only fear, discomfort, or guilt when contemplating their content. Furthermore, in the presence of these obsessions, a behavior is considered a compulsion if it only serves to reduce or neutralize the negative affect associated with obsessions. Therefore, children who are “obsessed” with topics that interest them or who exhibit functional rigid or repetitive behaviors cannot be considered to have OCD without evidence of ego-dystonic content. With this pure OCD context in mind, some disorders with similar behaviors can be differentiated more clearly. For example, stereotypies found in autism (e.g., hand flapping, pacing, swaying) can at times be self-stimulating or enjoyable, and they do not appear to be preceded by an ego-dystonic obsession. Motor tics functionally are like OCD compulsions because they reduce uncomfortable physical urges, but they are not reflective of OCD because the urge does not contain thoughts (i.e., feared consequences of not completing tic, save for immediate relief of uncomfortable urge). Children who attempt to exhibit rigid control of parent behavior (e.g., resisting family routines, demanding play activities be always dictated by the child, receiving special treats or favors) may be differentially diagnosed with oppositional defiant disorder, particularly if no clear obsession-related fear is apparent and other defiant behaviors are similarly observed with other adults.

Importance of Identifying the Child’s Core Fears One common pitfall for clinicians using CBT for OCD is not having an adequate understanding of the child’s core fears. Granted, this task may be dif-


TABLE 9–2. Age (years)

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Developmentally appropriate rigidity found in children Normal behavioral rigidity and rituals

1–2

Strong preference for rigid routines around home rituals (e.g., bedtime goodnight). Very aware and can get upset about imperfections in toys and/or clothes.

3–5

Repeat same play activity over and over again.

5–6

Keenly aware of the rules of games and other activities (e.g., rules in classroom settings) and may get upset if rules are altered or broken.

6–11

Engage in superstitious behavior to prevent bad things from happening and may show increased interest in acquiring a collection of objects (e.g., Pokémon cards).

12+

Become easily absorbed in particular activities enjoyed (e.g., video games) or with particular people (e.g., pop stars); may also show superstitious behavior in relation to making good things happen (e.g., performance in sports).

Source. Adapted from Evans et al. 1997; Freeman and Garcia 2009.

ficult especially with younger children, who may not be articulate or have complete insight into their obsessions. But from the start of the assessment and continuing into treatment, the clinician should at every opportunity attempt to understand the specific characteristics of OCD triggers and the feared consequences of not completing OCD rituals. For example, a child may avoid things that are “germy,” but why? Does the child fear getting sick himself or dread getting loved ones sick? If the child gets sick, does she fear she might die or just experience acute illness (headaches, sore throat, vomiting)? For a girl with scrupulosity obsessions, if she doesn’t confess to her mom, does she fear only that her mom will be mad at her or that there is a chance she will go to hell for the offense? These crucial details will assist the therapist in developing a well-targeted fear hierarchy for E/RP activities later in the program. Some typical obsession and compulsion themes we see in children are described in Table 9–3. Note that in particular cases, the specific fears may be a blend of two or more of these themes.

Overview of Treatment Program The treatment protocol is typically 12–14 sessions delivered weekly, but this format can be tailored to the specific needs and motivation of the family. As discussed in the earlier section “Empirical Support,” the clinician can apply this protocol efficaciously in either weekly or intensive (e.g., one ses-

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sion per weekday) outpatient formats with similar results. Regardless of the chosen session schedule, the general structure of the program is the same: 1) psychoeducation, 2) externalization from OCD, 3) mapping the hierarchy and identifiying family involvement in OCD, 4) engagement in “bossing back” strategies, and 5) graded E/RP and family disengagement from OCD. However, because of developmental considerations for insight and maturation, we do adjust our protocol emphasis on the basis of the child’s age. For an older child or adolescent, the treatment focus can be primarily with the child. In this format, parental check-ins will be only at the beginning and end of sessions, with periodic family sessions scheduled when needed (see March and Mulle 1998). For younger children or in families with extensive family involvement in rituals and avoidance of OCD triggers, parents should be involved in most sessions, with a focus on differential attention, appropriate modeling of CBT skills, and scaffolding assistance to the child in ways that do not reinforce OCD symptoms (Freeman and Garcia 2009). Contingency management should also be developmentally appropriate for the child. The clinician should help parents provide appropriate rewards and privileges for the child completing assigned homework and using CBT skills spontaneously in unplanned situations. The clinician must also be explicit that the plan will reward behaviors reflecting good effort toward CBT practice, not necessarily results.

Psychoeducation The first task of the protocol is to ground the family in the neurobehavioral model for OCD and highlight elements of the treatment program. By the time a family comes to treatment, they have likely experienced excessive distress, conflict between family members, fears of stigma, and feelings of hopelessness. Therefore, the clinician’s initial focus should involve presenting OCD as a neurobehavioral condition that is no one’s fault, as well as providing hope that there are now proven tools to manage OCD’s influence on the child and the larger family. Depending on the clinician’s comfort level with describing recent advances in the understanding of OCD, it may be helpful to briefly emphasize the point that OCD is a condition in the brain, albeit influenced by how the individual and family interact with OCD behaviors. Metaphors involving descriptions of “brain hiccups,” ineffective “circuits,” or broken “alarms” have been used effectively. An example of a typical explanation to the family is given below. In recent years, we have learned a lot about what OCD is and how it can be treated in families. The first thing to understand is that OCD is no different from other medical conditions found in childhood, like asthma or di-


TABLE 9–3.

309

Common obsessive-compulsive disorder (OCD) themes found in children and adolescents

OCD theme

Related obsessions

Related compulsions

Contamination

Getting sick or dying from germs, dirt, chemicals, or other contaminants Getting others ill from own germs or fluids Feeling uncomfortable when in contact with surfaces that are sticky, wet, and so forth

Washing or cleaning Reassurance seeking Actively avoiding contact with feared targets (e.g., “surgeon hands”)

Harm

Harm or death coming to child or family Child “losing control” and causing harm to others

Reassurance seeking Checking Superstitious behaviors

Loss of essence

Fear of losing or doubt about retaining own vitality, personality, or humor Essence can be lost or tainted when personal objects are misplaced or when one is in contact with individuals with undesirable traits (e.g., nerds)

Hoarding Superstitious behaviors Checking

Ordering/ arranging

Need to have things just right, equitable, or symmetrical

Counting Repeating Ordering and arranging

Scrupulosity

Feelings of moral or religious doubt Intrusive “bad words” Ego-dystonic sexual thoughts

Confessing Praying Reassurance seeking

abetes. Where asthma is a problem in your lungs affecting your breathing, OCD is a problem in your brain that affects how you can control thoughts, feelings, and behavior. As you might know, our brain is like a powerful computer. It has places to store information we need to remember, places that handle new information coming in from our senses, and electrical wires or “circuits” that connect each part of the brain to every other part of the brain. Some circuits even help us stay safe by sounding an alarm to our bodies when we might be in danger. Every animal you know has circuits like this, and when danger is around, these circuits help the body get ready for action. Now for kids with OCD, these danger circuits do not work as they should. For some kids, these alarm circuits go off much too loud when compared to the real danger. So when they (describe a fear trigger similar

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to the child’s obsessions), their brain alarm goes off loudly even if there is no real danger. These kids might even know that they are not in that much danger, but that alarm circuit sounds off anyway! For other kids, the circuits might not be too loud, but once they go off it’s very hard for those alarms to shut off. For example, when the alarm goes off for (insert obsession) and (describe a relevant repetitive compulsive behavior), they either don’t feel better for long or spend a lot of time trying to do it “just right.” Again, they might know that they are safe by (doing the compulsion), yet their alarm circuit does not remain quiet for long.

During the above psychoeducation portion, it is helpful to make the neurobehavioral portion tailored to the families’ interest and clinical needs. Some families are quite interested in a brief, focused discussion of the role neural circuits play. As a clinician, it is good to dwell a little more here if there are concerns that the child is “just being manipulative” or a particular parent is being labeled as merely coddling the child. For example, describing hypothetical situations that parents and children can relate to with a touch of humor (walking in a park, tripping, and accidentally putting your hand in dog poop) can be an excellent way to describe how the cortical-thalamic-striatal-cortical circuit is activated for everyone and to make the point that excessive hand washing can have some adaptive merit in specific situations! The heritability of OCD can be described as having a “birthmark” near these circuits, which leads to OCD behaviors. After the biological components of OCD have been explained adequately, it is then important to discuss how CBT and other behavior changes can influence these “loud and leaky” circuits. This explanation should be tailored carefully to the amount of insight the child has. So as I have been discussing, OCD is primarily a brain thing. A lot of people with OCD know that these alarms don’t make sense and the behaviors they do to feel better don’t work for long—yet they continue to do them because the circuits in their brain will otherwise make them feel extremely uncomfortable. But the fact that these feelings come from a birthmark on your brain is actually good news. Your brain is an incredibly flexible organ and can rewire itself slightly when it learns how to do something new. Think about how your brain works. Every time you learn something new, the brain slightly rewires itself, some circuit connections get stronger, and some get weaker. This is wonderful when we’re dealing with brain birthmarks and leaky circuits! If you had a similar problem in your kidney, you might have to have surgery in order to fix it. But because we are dealing with the brain, we can help make the brain healthier simply by learning new things and practicing new skills. The new things I’m going to teach you come from a program called cognitive-behavior therapy, or CBT. There has been a lot of research already showing that CBT works for kids just like you. Not only can kids feel better


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after doing this program, but their brains look different. It’s true! Researchers have taken pictures of people’s brains with OCD before this treatment and then taken pictures of those people’s brains after the people worked with this program for 3 months. Amazingly, after a relatively short time, their brains actually don’t look as much like OCD brains anymore. And the only thing these kids have changed in those 3 months was how to think and act toward their OCD in a different way. So what do you think, do you want to learn more?

At this point, the clinician should check in about any questions the family has about OCD as a neurobehavioral disorder and assess the overall treatment engagement of each participant. After these issues have been addressed, the clinician can continue by describing the nuts and bolts of OCD and how CBT can help. At this point, we should probably talk a little more about what OCD is. As you know, OCD involves things called obsessions and compulsions. Do you know what exactly makes something an obsession or compulsion? First, let me say that having obsessions or compulsions is actually quite normal. (Looking at parents) If you ever had an annoying song stuck in your head for awhile, you had a brief obsession. Similarly, if you ever found yourself checking and double-checking something very important, you were having compulsions. But when these behaviors are happening every day, becoming increasingly distressful, and they are getting in the way of life, that’s when someone is considered to have OCD. Obsessions are persistent ideas, thoughts, pictures, or sounds that get stuck in someone’s head even though the person doesn’t want to think about them. These thoughts that get stuck are either stressful or gross, and the person would do anything to not think about them. Now, compulsions are things people do, either in their head or where others can see them, to try to feel better about the obsessions they are thinking about. Typical compulsions include hand washing, checking things, counting, arranging, and doing things just right; they may even involve other people by causing the person with OCD to repeatedly ask for reassurance from someone. Let me stress that although someone with OCD spends a great deal of time doing these compulsions, they would rather not be doing them. They only do them to “change the subject” or feel less bad about an obsession they are having; these compulsions are never fun.

After the initial introduction of obsessions and compulsions, it’s often helpful to illustrate how a typical OCD pattern works (Figure 9–1). OCD episodes typically involve a sawtooth pattern that begins with the child at low distress. Once a child encounters an OCD-relevant trigger, anxiety increases to the point where a compulsion is performed, which then leads to a repetitive pattern of repetitive compulsions and oscillating anxiety. (This pattern is explained to a parent in a dialogue example in the section “Mapping the OCD Hierarchy and Identifying Family Involvement” later in this chapter.)

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Externalization From OCD The transition from psychoeducation to the start of active treatment usually begins with introducing externalization from OCD. The therapist should save enough time in the first session with the child to adequately address this concept. As we discuss in our previous treatment manuals on this topic, externalization cumulates into giving OCD processes a nickname for younger children or calling it simply “OCD” for older children. Even before the clinician brings up externalization explicitly, his or her language about the child’s issues should be consistent with externalization from the first meeting onward. For example, with a young child worried that germs might kill her mother, the therapist might say, “[OCD/nickname] makes you worry that your mom will likely die if she gets sick from germs.” The initial introduction of externalization, particularly for kids with less insight about their OCD, should be conducted carefully. The clinician should focus on validating the child’s specific values that OCD is preying on, while drawing the distinction between these values and the avoidant and ineffective processes OCD forces families to do. On the basis of how the family is describing the child’s OCD, the therapist should use active listening to then reflect back their frustration with OCD as “tricky” or “annoying” but also validate the underlying value tied to the core fear; this approach helps to highlight externalization and build rapport. Therapist: The last thing for today is how we can start bossing back these worries you are having. We have discussed already how OCD involves a part of your brain hiccupping or not acting like it should, and that part of the brain may be making you feel bad in a way that is not as strong or loud as in other kids. Child: But I don’t want to get sick ... and I definitely don’t want Mom to get sick either. Therapist: You absolutely don’t want to get sick, and you also care about your mom so much that you don’t want her to get sick either. Child: That’s right. Therapist: And most people, myself included, don’t like getting sick, not at all. Child: The thought of getting sick from germs is just so gross. Therapist: Absolutely—when you think about germs, OCD seems to be yelling in your ears so loud that you just have to avoid germs and wash whenever you think you’re germy. Child: That’s right. Therapist: And that must be so annoying. Child: Yeah. Therapist: I wonder what other kids your age feel when they think about germs? Do you think they need to wash their hands as much? Do you think their brains are screaming at them as loud?


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10

Worry/anxiety rating

9

C

8 7 6

O

5 4 3

T

2 1

E/RP

0

Time FIGURE 9–1. Example of drawing used in psychoeducation session to explain typical obsessive-compulsive disorder pattern. T= trigger; O=obsession; C= compulsion; E/RP= exposure and response prevention. Child: Maybe not. Therapist: So I wonder if that might be something we work on together: you can still care for your mom and do things that are good for your health, but we are also going to boss back OCD so he’s not as annoying and yelling at you so loudly. Child: Sounds good.

Mapping the OCD Hierarchy and Identifying Family Involvement Before the process of skill building and E/RP can begin, the family must learn about how OCD is working in the family and the specific hierarchy of their child’s symptoms. Some of these objectives might already be accomplished through the assessment and initial psychoeducation portion of the program. However, as the clinician begins to understand—through the functional analysis of the child’s triggers—the child’s particular obsessive content, subsequent compulsions, and family accommodation of OCD,

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the clinician should begin to conceptualize the best way to structure the graded E/RP that will be implemented later in the program. The use of an OCD fear thermometer to build the fear hierarchy will help the child and family get a little insight into the relative distress each OCD symptom causes. When the clinician reviews the hierarchy, it is important to carefully verify the feelings thermometer ratings that the child has given, making sure that the ratings correspond to the level of difficulty or fear the child anticipates when trying to alter or eliminate the ritual. This task has the potential to be confusing if not done correctly, because it is possible that the level of general distress or fear associated with a certain symptom is not the same as the distress or fear associated with trying to resist that ritual. For example, a child may rate the distress or fear associated with doing his or her handwashing ritual as a 4 but may rate the distress or fear associated with not doing (or resisting) this ritual as an 8. Finally, there are often examples where a child may resist OCD differently outside the presence of family members. For example, sometime children may be better at resisting rituals, even if they feel general distress, at school or around peers than they are at home. Identified instances where the child can resist for a time, due to fear of peer rejection or other motivation, could be a good place to start building E/RP tasks that can tried later on.

Case Example Crystal is a 7-year-old white girl who has become increasingly concerned about germs in the past few months. At school, she has been learning that there are very dangerous germs out there that can get people very sick, and she must be careful not to touch germy things without washing her hands thoroughly. At home, she has been increasingly checking in with her mom about whether certain places are completely clean from germs. If something has not just been washed, she will ask her mom if it’s clean enough and the chances she will get sick if something is mostly clean. Crystal’s parents, at first, were very patient with her concern about cleanliness, explaining in detail how she’s safe from most germs. They even thought it was nice that she was becoming aware of germs and taking an active role in washing her hands, but lately things have become increasingly concerning. Crystal is beginning to avoid touching anything that she thinks could have germs. She even has begun avoiding her little brother, a toddler who is still in diapers and puts his hands in his mouth and touches things all over the house. Crystal’s hands are getting pink with the amount of washing she is doing, and she checks with her mom almost constantly about things related to germs. Therapist: So I want to understand better how Germy makes you feel bad. Child: OK.


Therapist: So we talked a little bit about how Germy makes you feel bad before. But I have here a way you can tell me a little better, with what is called a fear thermometer. As you can see, it has some faces next to numbers that go from 0 to 10. You can see that next to the 0, there is a smiley face—meaning Germy is not talking to you and you are not feeling bad. Next to 10 is a frown face—meaning Germy is talking to you a lot and it can be like one of the worst times Germy was messing with you. Child: OK. Therapist: Now before we go into how Germy is at home, I want to check in on how you are feeling now. What do you think your number is right now, from 0 to 10? Child: About a 2. Therapist: Oh, about a 2. You don’t feel completely relaxed, but you don’t feel very bad either? Child: Yes. Therapist: OK, now when you are home, what’s a typical thing Germy can talk to you about that makes you feel bad? Child: Germy says I might get sick because I touched something my brother touched. He sticks his hands in his mouth all the time. It’s gross. Therapist: That can be gross. So if you were close to touching something, like a toy, that you just saw Jack touch after his hands were in his mouth, what number would that be? Child: A 10, maybe a 12. Therapist: Wow.. .so even if you didn’t actually touch it, Germy would make you feel that your thermometer was as high as it could go? Child: Well, if I did touch it, that would be the highest. If I didn’t touch it, but it was close to me, probably a 9. Therapist: 9/10. (Near the 10 on fear thermometer, the therapist writes, “Touch toy Jack’s wet hands just touched.” At 9: “Close to wet toy, no touching.”) Most kids might think that stuff that their kid brother drools on might be gross. ... Does Germy have you also worry about stuff that Jack might not have touched for a while? Child: Well, anything that is Jack’s might have germs on it, I guess. Therapist: So, if you were to touch something that is Jack’s, like his high chair, what would that number be? Child: 10. Therapist: What if he hadn’t been in it in a while? Like after lunch, Mom had washed his high chair tray and put it back on the high chair. What would be your number if you touched that? Child: If Mom cleaned it and he hadn’t touched it? Probably a 9... . He eats there and gets his food everywhere. Therapist: So for places that Jack touches, even if they have been cleaned, Germy can get loud, yelling at you about germs? Child: Yes. Therapist: What if it’s a part of the high chair he can’t touch? What about the back of the high chair seat that is too tall for him to reach? Child: Probably a 5.

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Therapist: (Writes near 5: “Back of Jack’s seat—where he can never reach.”) Now, what if instead of you touching the back of the seat directly, we have something else touch it first, like a new pencil— and then you touch the pencil? Child: Hmmm. ..not very high, maybe a 3. Therapist: So if something clean touches something dirty, and you touch the clean thing, Germy doesn’t yell at you as loudly. Child: Yes. Therapist: So let’s take another clean pencil. But instead of touching the back of his seat, it would touch Jack’s high-chair tray that Mom just cleaned. What would your number be if you touched the pencil that touched the tray Mom just cleaned? Child: Well, if it was a 9, probably about a 7.

After summarizing and validating Crystal’s anxiety about touching anything she normally sees (toys with toddler drool can be gross), the therapist then curiously asks about things that could be safer. Notice that when this line of questioning led to most objects receiving a high fear rating, even if they were washed and not touched by Crystal’s brother, the therapist switched gears to things Crystal’s brother never touches. Typically, children will lower their fear ratings for these hypothetical targets they have not thought about. Finally, once some targets are determined, even if they are only hypothetical ones in the middle range of the thermometer, the therapist should inquire about elements that might be manipulated in a future E/RP exercise (touching something clean that briefly touched a “dirty” item). If some gradients can be found in these milder targets, the clinician can then go back and reassess these same gradients at the higher numbers. It’s likely that the clinician will be more successful in finding anxiety gradients at the higher ranges if they can first be fleshed out in the lower ranges. S Next, the case of Ashley, a 14-year-old white adolescent girl, is featured on the DVD accompanying this book. Ashley’s case is identical to that of Crystal, except for her age. The video illustrates an educational component about OCD followed by E/RP work, demonstrating an appropriate developmental approach with an adolescent. The text example of a younger child and video example of an adolescent allow for the illustration of similar points in a developmentally appropriate manner. In both examples, several things are occurring that accumulate information about the child’s OCD as well as set the stage for future exposures. First, the therapist is discussing OCD content with the child in an open way, which for kids who spend a great deal of time avoiding thinking about OCD is a minor exposure in itself. Second, the therapist’s stance about OCD in this phase of treatment should be nonplussed about the content but curious about how the child’s OCD works. It is important for cli-


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nicians not to get ahead of themselves by challenging the child’s inaccurate OCD-inspired beliefs. Simply gather information to set up future E/RP work. Third, especially for children who rate most OCD triggers as very high, it is important to start introducing degrees of separation from the usual OCD triggers. Identifying family involvement in OCD symptoms should be approached with the same sensitivity used in introducing externalization of OCD, with an acknowledgment of the child’s and family’s underlying values. This task will be particularly important for families with a history of OCD, as well as for families with a parent who has been accused of facilitating OCD behaviors. At every opportunity, validate the parents’ desire to reduce their child’s suffering and be effective parents. Proper psychoeducation and mapping of OCD processes at home can allow the parents to view OCD as something that interferes with these two values. Using externalization language (e.g., “OCD has the whole family running in circles”) and painting OCD as tricky, an enemy, or inconsistent with the family’s values can all be useful in building rapport and getting everyone united against OCD processes. The following communication between the therapist and Crystal’s mother demonstrates psychoeducation with an adult and parental coaching. Therapist: Now, from all the research that has been done in OCD, we understand pretty well how OCD works in families. Let me describe for you how OCD works and see if it makes sense to you (see Figure 9–1). So if we draw here (the y-axis) how stressed Crystal can feel on a scale of 0 to 10 and this line (the x-axis) is just time, let’s draw out how OCD might work at home. So let’s say she’s having a normal day (draws a horizontal line near the 2 on the fear axis), but then she accidentally touches her baby brother’s high chair as she walks past it (writes a “T”). Now on a typical day, what happens next? Mother: Crystal gets extremely upset. Therapist: OK, so she starts feeling really anxious (draws line at a 45-degree angle), and then what happens? Mother: She will walk up to me and start saying, “Mom, I just touched Jack’s high chair. Am I going to be OK? Am I going to get sick?” Therapist: And then what happens? Mother: Well, of course, I tell her that she’s OK and there’s nothing to worry about, just like I always do. Therapist: And does that help? Mother: Yes, she typically is not as upset with a little reassurance. Therapist: (Stops upward line at about 8/10; now draws the line turning downward at a 45-degree angle from the apex; writes “C” at the apex of the first sawtooth) OK, so her anxiety starts coming down. And is that all it takes? Does it go all the way down to 0, and she’s good for the rest of the day?

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Mother: No, it might help for a few minutes, but then she’s touched something else and is coming back to ask me if she’s dirty. Therapist: Oh, so after a few minutes she’s getting increasingly anxious again (draws line moving up again at a 45-degree angle), and then what happens? Mother: I’m again explaining to her that she’s OK, which reassures her, but then this goes on all day when we’re home together... . Therapist: So she comes to you upset, you again explain the facts and reassure her that she’s safe and nothing will happen... . (draws downward, completing the second sawtooth) Mother: Explaining things to her all the time is not helping, is it? Therapist: Well, I don’t know, what do you think? How will the pattern go as you go through the day? Mother: It just keeps going up and down through the day, and my reassurance never satisfies her. (Therapist draws a repeating sawtooth pattern.) Therapist: So let me summarize how it seems OCD is working with Crystal. Crystal is fine until she becomes confronted with some sort of OCD trigger, or the T here. Then, those OCD alarm circuits begin going off and making Crystal feel very anxious (draws an “O” near first upward line). When that happens, all she wants to do is to make those thoughts and feelings stop, so sometimes she will go wash her hands and other times she will check in with you about whether she’s safe, or the O here. That washing or cleaning works very well in the short term; she gets nearly immediate relief. But the relief is short-lived and starts the pattern we have been talking about. Mother: So what should we do? I feel in the moment I’m helping her feel better, but I am afraid I’m part of these rituals. I just don’t see any other way to help her! Therapist: You are not expected to. No parent gets a manual on how to help their kid in every situation. And for most kids, a little bit of reassurance, perhaps with some facts about how germs work and how our bodies are equipped to fight them off, actually makes them feel better. But for a child with OCD, where those leaky circuits are never quite satisfied with Mom and Dad’s reassurance, we see this sawtooth pattern over and over again. And as you guys know from trying to help Crystal, this response can actually set up a pattern that a kid will go through for hours and hours. Mother: So what should I do instead? Therapist: What we’ll do here is teach you a different strategy. It will take a few weeks to teach you and several more weeks to practice. As we get in the program, we’ll be able to teach everyone in the family how to approach this differently so OCD doesn’t win. We may have certain situations where Crystal’s OCD is triggered and it goes up, but instead of Crystal falling into the trap of a compulsion, we will teach you and Crystal other things you can do instead. What we know by seeing lots of kids with OCD is that when the family does these other skills they learn in CBT, the anxiety does not go down immediately (uses a different colored marker to draw gradual habituation


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line), but it goes gradually yet steadily down to where it was before the trigger happened. The general approach looks like this. We will first teach you and Crystal, when OCD shows up, what to do instead of the compulsion that begins that sawtooth pattern. Second, we also will teach Crystal how to proactively boss back OCD on her own, by helping her approach the triggers she’s currently avoiding or trying to neutralize with compulsions. We do this by teaching her an approach called exposure and response prevention, or E/RP. When we use E/RP, we will help her actively practice feeling what OCD makes her anxious about in small doses (draws an upward line at about 4/10) and using those skills to show her that she doesn’t have to do any compulsions. Simply put, her body will get calm all by itself. To get her to do this, we will be teaching you how to encourage or reward her when she does her E/RP practice. What we know from working with lots of kids with OCD is that the more a kid practices E/RP, the less her body reacts to those triggers. And these peaks will become less extreme over time, and the time it takes for her body to recover will decrease.

Bossing-Back Strategies For active treatment components, our program is separated into two major categories: 1) E/RP and 2) elements that facilitate engaging in E/RP. As discussed earlier, our clinical experience and meta-analytic reviews show that E/RP is the primary active component for symptom reduction in OCD. Although this may suggest that clinicians should rush to do E/RP, an early misplaced E/RP exercise can sabotage treatment irrecoverably, which is why we carefully establish the CBT model, introduce symptom monitoring, and add other bossing-back skills that will facilitate future E/RP adherence. Within bossing-back strategies (i.e., cognitive resistance), the two major categories are 1) externalization from OCD and 2) cognitive therapy elements such as cognitive restructuring and constructive self-talk. The bossing-back strategies we have found to be the most helpful for treatment success are those consistent with externalizing OCD. Identifying OCD thoughts and feelings as external to the child and subsequently interacting with these thoughts and feelings with a level of detachment is at the heart of E/RP and the process leading to habituation. In contrast, we have found cognitive restructuring strategies helpful only in very specific situations. Although cognitive restructuring activities can be important to a family before a given E/RP exercise (e.g., What is the likelihood we will contract swine flu if we touch this table?), it is important not to emphasize these activities too strongly as a means to reduce stress beyond the first few sessions. We have found that for some kids, an overemphasis on talking back to OCD with coping thoughts during acute stress (e.g., reminding

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themselves that “I’m safe” or “These germs can’t really kill me”) can elicit OCD-reinforcing mental safety behaviors at times when an emphasis on habituating to the stress without additional efforts to promote safety would be more effective. We recommend that clinicians use only enough cognitive training to make the child’s engagement in E/RP effective and to facilitate approaching activities the child was otherwise avoiding due to OCD-related triggers. For the most part, cognitive strategies should only be used before and never during E/RP to maximize effectiveness. The therapist must be vigilant to deemphasize anything that could potentially become an emerging mental ritual.

Graded Exposure and Response Prevention and Family Disengagement Only after rapport building, establishing OCD externalization with the child, mapping common OCD processes in the child and greater family, and setting up enough cognitive training to portray OCD compulsions as ineffective can E/RP training be initiated. The therapist’s primary goal is to make those initial E/RP sessions relevant to the child’s core fears but not so distressing that the child engages in safety behaviors. As discussed earlier in the section “Mapping the OCD Hierarchy and Identifying Family Involvement,” we recommend having a thorough discussion of areas where the child already has some success resisting rituals. It is much easier to convert partial to full success than it is to willy-nilly identify an E/RP task that “sounds good.” The first E/RP activities should focus on targets that are well fleshedout on the child’s hierarchy, including targets on the low (1–3), medium (4–6), and high (7–10) ranges on the child’s fear thermometer. Although the clinician will have a good understanding of the child’s hierarchy, it’s important not to begin exposures too high on the hierarchy. Once the clinician can observe how well the child participates in targets exclusively in the low range, the clinician can adjust the targets accordingly. Once an E/RP begins, the clinician should encourage the child to maintain awareness or contact with the feared trigger until he or she feels at least a 50% reduction in the initial stated stress, but absolutely try for 90%–100% reduction if habituation is occurring quickly. The clinician may check in on the child’s fear level about every 30–60 seconds. As the child is doing the exposure, the clinician can reflect the number the child reports with “OK, going down a little bit” or “OK, about the same,” but should not try to reduce distress by reminding the child of coping thoughts or other things that can take away from feeling the distress. We find that children can


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usually report significant reduction in distress between 30 seconds and 10 minutes. If the clinician finds that a child’s anxiety begins to plateau or go down and then begins to go up again, the clinician might want to explore later (not then) what was happening at that moment. The clinician will typically find behaviors ranging from losing focus (e.g., “This is taking too long”) to overt experiential avoidance, such as mental rituals. Subsequent E/RP targets should generally hit in the low to moderate range of the fear thermometer at the child’s pace. Often targets that were initially identified as moderate will be considered lower by the child after some E/RP success. In these cases, the therapist may never need to get out of the low to lower midrange of exposure difficulty. If after some E/RP successes the only remaining targets are in the high range, take some time to flesh out some gradients of separation (e.g., touch something clean that first touched something appearing very dirty) from the very high targets (e.g., touch something dirty). Once a child is successfully habituating to the initial targets, continue E/RP by moving up the hierarchy on that particular fear until the child achieves habituation to the core fear, perhaps over several weeks. Only then should the clinician switch to the next OCD fear. Imaginal exposure can be useful for obsessional content that cannot be done in vivo (e.g., fears involving going to hell, hurting others, going to prison). Before an imaginal exposure is proposed, the family should already have some E/RP success in the fear target area and the rationale for doing the exposure should be carefully explained and understood. It is important that the clinician flesh out the plot of the imaginal exposure collaboratively with the patient first. The arc of the story should begin with a typical trigger that elicits obsessions related to the feared consequence, eventually leading to an imagined catastrophic conclusion. As the clinician tells the story, including as much of the child’s language as possible will give it the maximum benefit. Like any well-conducted guided imagery exercise, the story should also bring in details that will involve as many sensory descriptors as possible. The imaginal exposure should then be taped in session and the tape provided to the child to replay at home. These re-exposures should be done at home in a quiet place without other distractions. The therapist should adhere to several key principles that will facilitate effective E/RP in session. First, the therapist should always demonstrate first and join the child in exposures as much as possible. There is nothing that the therapist shouldn’t do that is reasonably safe in the service of the patient. Granted, there are some non-zero risks to doing things like touching dirty surfaces or eating off the floor, but children do respond to these ways to fight their OCD, particularly if the task is first demonstrated by a supportive therapist willing to do it with them. To do this seamlessly before an exposure, the therapist can talk about the plan for the child while dem-

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onstrating the task concurrently (e.g., “So the first thing we can do against OCD is take our finger like this, touch the table, and then quickly touch it on our tongue”). Second, when planning in-session E/RP, the therapist should discuss any proposed exposure matter-of-factly in front of the child. Third, unless the family has demonstrated several successes with E/RP that they did independently at home, it’s best to first initiate any increase in exposure intensity in a treatment session. Allow the family to practice these new exposures at home without escalating them, unless the child is no longer getting anxious at home when these E/RPs are attempted. Finally, do not disengage from an E/RP until the child habituates or has experienced at least a 50% reduction. For this reason, budget enough time at the end of sessions if a new E/RP exercise is to be attempted. In conjunction with E/RP work for the child, the clinician must also be mindful of helping the family disengage from OCD accommodation and related behaviors. A recent text from one of our clinics describes in steps how to systematically put this program into place for the parents while concurrently working with the child (Freeman and Garcia 2009). Most of the skills taught are consistent with other parent training approaches involving differential attention and scaffolding more responsibility to the child regarding distress management. Allowing parents to see how the therapist conducts symptom monitoring, OCD mapping, and E/RP exercises will also provide them a model on how to do similar behaviors at home instead of accommodating OCD.

Relapse Prevention Once E/RP activities have been introduced and successfully implemented in session and during in-home practice, subsequent sessions will be devoted to going ever higher up the hierarchy as the child habituates to previous triggers. Once the child begins demonstrating little distress while doing E/RP on his or her hierarchy and otherwise not exhibiting distress or interference from OCD in home, school, transitions, or social situations, session frequency can be scaled back and relapse prevention strategies can be introduced. Effective relapse prevention involves anticipating when OCD might likely try to return and using CBT skills proactively to boss back symptoms as they occur. Therefore, the family should be educated about the potential for OCD to return at some point, particularly in times of developmental changes (e.g., advancing to middle or high school) or any acute stressful time. It’s important to normalize the fact that OCD can try to come back, but also to stress that the family and child now have the tools to boss it back effectively when it is identified for what it is. OCD can look different when children age because of developmental changes in concerns and val-


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ues (see Table 9–2); however, the sawtooth pattern typically demonstrated in OCD (see Figure 9–1) rarely changes. Parents should be encouraged to be vigilant for signs of OCD but not to overprotect their child from stress or triggers related to it. Rather, the child should be provided significant support and encouragement to use his or her CBT skills using praise and/ or other rewards that work for the family in other areas. Families should also be encouraged to seek a phone chat or booster session with their therapist if symptoms do reappear and initial attempts of addressing it independently from treatment appear not to be working.

Cultural Considerations CBT may need to be altered in order to be sensitive to the context of specific cultural backgrounds. Although reviews in the pediatric OCD literature find little support for race or ethnicity moderating treatment effects, the reality is that OCD symptoms are often misdiagnosed or underdiagnosed in minority populations (Hatch al. 1996). More research is required in tailoring CBT interventions to minority populations before we can comment further on how to tailor our treatment to better serve them. One particular cultural consideration that routinely comes up in our clinic is treating children with scrupulosity, harm, or sexual obsessions in families who are deeply religious. These families may pose some unique challenges (e.g., being overly concerned about sinning) to clinicians trying to treat OCD symptoms through exposure, yet continuing to be supportive and validating of the family’s spiritual values. Some families could even be skeptical of the therapist’s motives, particularly if the therapist doesn’t share the family’s particular religious tradition. Huppert and Siev (2010) recently discussed some excellent approaches to treating religious individuals with scrupulosity obsessions that we have used with success in treating children. The therapist’s stance should be at all times respectful and supportive of the child’s wish to have a more fulfilling religious life, regardless of the therapist’s personal beliefs. Once OCD has been established as the main presenting problem, the therapist must clearly explain to the family that the child’s OCD is not a result of their religious beliefs. Rather, OCD typically preys on the core values of the individual, leading to scrupulosity in children who are religious. The therapist can explore this concept in detail during psychoeducation and the initial effort of externalization of OCD from the family’s religious tradition. If the therapist can paint OCD as opportunistically messing with their faith, the therapist may be able to discuss some distinctions between the religious practices of devout peers and how OCD might be distorting

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the child’s sincere attempts to live a religious life. Most older children can articulate a perceived distinction between the true joy or awe of being spiritually connected versus the emptiness felt when doing compulsive rituals. Exposures for scrupulosity need to be handled sensitively and explicitly discussed ahead of time with both the child and family. The therapist should provide sufficient time to discuss the rationale for engaging in exposures and collaboratively discuss how these can be done in a manner with which the family is comfortable. The family must provide the therapist with guidance on the boundaries about what their faith considers intentionally sinning (e.g., worshipping the devil) versus doing things that elicit anxiety because they increase the person’s risk of sinning (e.g., saying out loud the word devil). For example, one mother once said it was OK to do exposures regarding sinful images because “OCD puts these in his head all day anyway.” In some cases, collaborative discussions with the family’s clergy could also be useful.

Conclusion Since focused empirical attention began in the mid-1990s, CBT for pediatric OCD has blossomed into an empirically supported treatment for an often severe and disabling condition. As is the case in treatment studies for adults with OCD, the effects of CBT for children and adolescents appear to be both robust and durable. When used in combination with serotonin reuptake inhibitors, weekly treatment as described above for approximately 12–14 weeks appears to be sufficient, although as noted earlier, the format of sessions can be accelerated with little impact on overall efficacy. Therefore, the primary challenge moving forward is less about improving the techniques, but rather how to disseminate this approach to a wider variety of trainees and community clinicians, particularly in geographical areas that do not have medical centers that routinely treat children with OCD. This will remain a pressing challenge to the field, but recent studies suggesting that a “supervision of supervisors” community model can yield comparable results to efficacy studies involving academic medical settings is encouraging and should be a focus of replication.

Key Clinical Points • OCD is a neurobehavioral condition that can be treated effectively. It is critical for families to understand that it is not their fault and that these behaviors are not the child’s fault. Families must first buy into individual and family externalization of OCD if subsequent CBT


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techniques are to be successful. Discuss the literature about how CBT can treat OCD effectively, including changes in brain activity. • Successful treatment requires teaching families how OCD operates for them and dispelling myths about OCD (e.g., family accommodation makes the child less anxious over time). In a developmentally appropriate fashion, each family member participating should understand that OCD is negatively reinforced through the child’s compulsions and any corresponding family accommodation of OCD. • To facilitate OCD externalization, the clinician should emphasize that OCD’s game is to prey upon what each family member cares about most. This depiction of OCD as clever and opportunistic can be effective in framing OCD content and family accommodation in a nonblaming and validating fashion. It also can be useful in drawing a clearer distinction between what each person cares about and what is being distorted by OCD. This work will also assist the clinician in developing a plan on what to target in E/RP and at what pace. • Habituation is the therapist’s primary ally, and E/RP should be the therapist’s primary tool; other techniques can be useful if they facilitate progress toward E/RP targets. Remember to be vigilant for signs that the therapeutic work is being exploited by OCD. For example, note whether a patient is using coping thoughts during exposures or is allowing anxiety to continue unabated. De-emphasize anything that could become an emerging ritual. • E/RP targets should be chosen very carefully, particularly in the initial exercises. Initial targets should be in areas where the child is already successful at times, and these E/RP tasks should not be terminated until the child feels a 50% reduction in distress. Finish up an E/RP target completely before moving up the fear hierarchy. E/RP work should be approached collaboratively with the family, but the child has the final say in pacing, as long as the child is moving forward on OCD targets. • Until the clinician feels that the family is proficient in doing E/RP at home, the clinician should initiate any new or more difficult E/RP exercises in session first. That being said, the child is best served doing some form of E/RP every day; therefore, assign slightly less difficult exposures to be done at home. • Effective relapse prevention involves anticipating when OCD might likely try to return and using CBT skills proactively to boss back symptoms as they occur. Educate the family that OCD might look different when it returns (due to developmental changes or shifts in

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the child’s interests/values), but the process of OCD reinforcement (i.e., the sawtooth pattern) rarely changes. When OCD attempts to make a comeback, the child should not be overprotected from stress but rather be encouraged to use CBT skills to cope.

Self-Assessment Questions 9.1. CBT treatment research has indicated that the most efficacious component for decreasing obsessive-compulsive disorder (OCD) symptoms is A. B. C. D.

Prolonged exposure. Socratic questioning. Progressive muscle relaxation. Exposure and response prevention.

9.2. Research by Storch and colleagues has indicated that CBT with exposure and response prevention (E/RP) is A. B. C. D.

Most effective when delivered in a weekly outpatient format. Most effective when delivered in a daily outpatient format. Equally effective in either a weekly or daily outpatient format. Equally effective in either an outpatient or inpatient format.

9.3. What is considered to be the threshold for clinically significant OCD on the Children’s Yale-Brown Obsessive-Compulsive Scale (CYBOCS)? A. B. C. D. E.

10. 12. 16. 20. 30.

9.4. Which of the following is not considered relevant to at least some OCD cognitions? A. B. C. D.

Feared consequence of not relieving urges. Thought-action fusion. Overestimation of threat. Intolerance of uncertainty or doubt.


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9.5. When is an E/RP exercise typically considered to be successfully completed? A. When the child and parent experience a 30% reduction in initial distress. B. When the child experiences a 50% reduction in initial distress. C. When the child experiences a 90% reduction in initial distress. D. When the child and parent experience a 90% reduction in initial distress. E. Either B or D. F. Either B or C.

Selected Readings For Clinicians Freeman J, Garcia A: Family Based Treatment for Young Children With OCD: Therapist Guide. New York, Oxford University Press, 2008 March J, Mulle K: OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. New York, Guilford, 1998 Piacentini J, Langley A, Roblek T: Cognitive-Behavioral Treatment of Childhood OCD: It’s Only a False Alarm: Therapist Guide. New York, Oxford University Press, 2007

For Children and Families Chansky T: Freeing Your Child From Obsessive-Compulsive Disorder: A Powerful, Practical Program for Parents of Children and Adolescents. New York, Crown Publishing, 2001 Huebner D: What to Do When Your Brain Gets Stuck: A Kid’s Guide to Overcoming OCD. Washington, DC, Magination Press, 2007 March J, Benton C: Talking Back to OCD: The Program That Helps Kids and Teens Say “No Way”—and Parents Say “Way to Go.” New York, Guilford, 2006 Wagner AP: Up and Down the Worry Hill: A Children’s Book About Obsessive-Compulsive Disorder and Its Treatment. Mobile, AL, Lighthouse Press, 2000

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References Abramowitz JS, Franklin ME, Foa EB: Empirical status of cognitive-behavioral therapy for obsessive-compulsive disorder: a meta-analytic review. Romanian Journal of Cognitive and Behavioral Psychotherapies 2:89–104, 2002 Abramowitz J, Whiteside S, Deacon B: The effectiveness of treatment for pediatric obsessive-compulsive disorder: a meta-analysis. Behav Ther 36:55–63, 2006 American Academy of Child and Adolescent Psychiatry: Practice parameters for the assessment and treatment of children and adolescents with obsessivecompulsive disorder. J Am Acad Child Adolesc Psychiatry 37(suppl):27S– 45S, 1998 Barrett PM, Healy LJ: An examination of the cognitive processes involved in childhood obsessive-compulsive disorder. Behav Res Ther 41:285–299, 2003 Barrett P, Healy Farrell L, March JS: Cognitive-behavioral family treatment of childhood obsessive-compulsive disorder: a controlled trial. J Am Acad Child Adolesc Psychiatry 43:46–62, 2004 Beck A: Cognitive Therapy and the Emotional Disorders. New York, International Universities Press, 1976 Bolton D, Perrin S: Evaluation of exposure with response-prevention for obsessive compulsive disorder in childhood and adolescence. J Behav Ther Exp Psychiatry 39:11–22, 2008 de Haan E, Hoogduin KA, Buitelaar JK, et al: Behavior therapy versus clomipramine for the treatment of obsessive-compulsive disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 37:1022–1029, 1998 Evans DW, Leckman JF, Carter A, et al: Ritual, habit, and perfectionism: the prevalence and development of compulsive-like behavior in normal young children. Child Dev 68:58–68, 1997 Flament M, Whitaker A, Rapoport J, et al: Obsessive compulsive disorder in adolescence: an epidemiological study. J Am Acad Child Adolesc Psychiatry 27:764–771, 1988 Foa EB, Kozak MJ: Emotional processing of fear: exposure to corrective information. Psychol Bull 99:20–35, 1986 Franklin ME, Kozak MJ, Cashman LA, et al: Cognitive-behavioral treatment of pediatric obsessive-compulsive disorder: an open clinical trial. J Am Acad Child Adolesc Psychiatry 37:412–419, 1998 Franklin ME, Tolin DF, March JS, et al: Treatment of pediatric obsessive-compulsive disorder: a case example of intensive cognitive-behavioral therapy involving exposure and ritual prevention. Cogn Behav Pract 8:297–304, 2001 Franklin ME, Sapyta J, Freeman J, et al: Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: the Pediatric OCD Treatment Study II (POTS II) Randomized Controlled Trial. JAMA (in press) Freeman J, Garcia A: Family Based Treatment for Young Children With OCD: Therapist Guide. New York, Oxford University Press, 2009 Freeman JB, Garcia AM, Fucci C, et al: Family based treatment of early onset obsessive-compulsive disorder. J Child Adolesc Psychopharmacol 13 (suppl 1):S71–S80, 2003


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Freeman JB, Choate-Summers ML, Moore PS, et al: Cognitive behavioral treatment for young children with obsessive-compulsive disorder. Biol Psychiatry 61:337–343, 2007 Hatch M, Friedman S, Paradis C: Behavioral treatment of obsessive-compulsive disorder in African Americans. Cogn Behav Pract 3:303–315, 1996 Himle M, Franklin M: The more you do it, the easier it gets: exposure and response prevention for OCD. Cogn Behav Pract 16:29–39, 2009 Huppert JD, Siev J: Treating scrupulosity in religious individuals using cognitivebehavioral therapy. Cogn Behav Pract 17:382–392, 2010 Kovacs M: Rating scales to assess depression in school-aged children. Acta Paedopsychiatr 46:305–315, 1981 Leckman JF, Riddle MA, Hardin MT, et al: The Yale Global Tic Severity Scale: initial testing of a clinician-rated scale of tic severity. J Am Acad Child Adolesc Psychiatry 28:566–573, 1989 Kaufman J, Birmaher B, Brent D, et al: Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-PL): initial reliability and validity data. J Am Acad Child Adolesc Psychiatry 36:980–988, 1997 March J: Cognitive behavioral psychotherapy for pediatric OCD, in ObsessiveCompulsive Disorders: Practical Management, 3rd Edition. Edited by Jenike M, Baer L, Minichello WE. Philadelphia, PA, Mosby, 1998, pp 400–420 March J, Mulle K: OCD in Children and Adolescents: A Cognitive-Behavioral Treatment Manual. New York, Guilford, 1998 March JS, Mulle K, Herbel B: Behavioral psychotherapy for children and adolescents with obsessive-compulsive disorder: an open trial of a new protocoldriven treatment package. J Am Acad Child Adolesc Psychiatry 33:333–341, 1994 March JS, Parker JD, Sullivan K, et al: The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry 36:554–565, 1997 Mowrer OH: Learning Theory and Behavior. New York, Wiley, 1960 Nakatani E, Mataix-Cols D, Micali N, et al: Outcomes of cognitive behaviour therapy for obsessive compulsive disorder in a clinical setting: a 10-year experience from a specialist OCD service for children and adolescents. Child Adolesc Ment Health 14:133–139, 2009 Obsessive Compulsive Cognitions Working Group: Cognitive assessment of obsessive-compulsive disorder. Behav Res Ther 35:667–681, 1997 Pediatric OCD Treatment Study Team: Cognitive-behavioral therapy, sertraline, and their combination for children and adolescents with obsessive-compulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 292:1969–1976, 2004 Piacentini J, Peris TS, Bergman RL, et al: Functional impairment in childhood OCD: development and psychometrics properties of the Child ObsessiveCompulsive Impact Scale—Revised (COIS-R). J Clin Child Adolesc Psychol 36:645–653, 2007 Rachman S, Hodgson RJ: Obsessions and Compulsions. Englewood Cliffs, NJ, Prentice Hall, 1980 Rasmussen S, Eisen J: Epidemiology of obsessive compulsive disorder. J Clin Psychiatry 51 (suppl 2):10–13, 1990

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Salkovskis PM: Cognitive-behavioral factors and the persistence of intrusive thoughts in obsessional problems. Behav Res Ther 27:677–682, 1989 Salkovskis PM: Cognitive-behavioral approaches to the understanding of obsessional problems, in Current Controversies in the Anxiety Disorders. Edited by Rapee RM. New York, Guilford, 1996, pp 103–134 Sasson Y, Chopra M, Amiaz R, et al: Obsessive-compulsive disorder: diagnostic considerations and an epidemiological update, in Anxiety Disorders: An Introduction to Clinical Management and Research. Edited by Griez EJL, Faravelli C, Nutt D, et al. New York, Wiley, 2001, pp 157–168 Scahill L, Riddle MA, McSwiggin-Hardin M, et al: Children’s Yale-Brown Obsessive Compulsive Scale: reliability and validity. J Am Acad Child Adolesc Psychiatry 36:844–852, 1997 Schopler E, Van Bourgondien ME, Wellman GJ, et al: The Childhood Autism Rating Scale, 2nd Edition (CARS2). Los Angeles, CA, Western Psychological Services, 2010 Silverman W, Albano AM: Anxiety Disorders Interview Schedule for DSM-IV: Parent Version. San Antonio, TX, Graywing, 1996 Stewart SE, Geller DA, Jenike M, et al: Long-term outcome of pediatric obsessivecompulsive disorder: a meta-analysis and qualitative review of the literature. Acta Psychiatr Scand 110:4–13, 2004 Storch EA, Geffken GR, Merlo LJ, et al: Family-based cognitive-behavioral therapy for pediatric obsessive-compulsive disorder: comparison of intensive and weekly approaches. J Am Acad Child Adolesc Psychiatry 46:469–478, 2007 Task Force on Promotion and Dissemination of Psychological Procedures: Training and dissemination of empirically validated psychosocial treatments: report and recommendations. Clin Psychol 48:3–23, 1995 Taylor S, Abramowitz JS, McKay D: Cognitive-behavioral models of obsessivecompulsive disorder, in Psychological Treatment of OCD: Fundamentals and Beyond. Edited by Antony MM, Purdon C, Summerfeldt L. Washington, DC, American Psychological Association, 2007, pp 9–29 Valderhaug R, Larsson B, Götestam KG, et al: An open clinical trial of cognitivebehaviour therapy in children and adolescents with obsessive-compulsive disorder administered in regular outpatient clinics. Behav Res Ther 45:577–589, 2007 Valleni-Basile L, Garrison C, Waller J, et al: Incidence of obsessive-compulsive disorder in a community sample of young adolescents. J Am Acad Child Adolesc Psychiatry 35:898–906, 1996 Wever C, Rey JM: Juvenile obsessive compulsive disorder. Aust N Z J Psychiatry 31:105–113, 1997

10

Chronic Physical Illness Inflammatory Bowel Disease as a Prototype Eva Szigethy, M.D., Ph.D. Rachel D. Thompson, M.A. Susan Turner, Psy.D. Patty Delaney, L.C.S.W. William Beardslee, M.D. John R. Weisz, Ph.D., ABPP

THERE is increased evidence for a relationship between psychological and physical processes, particularly in youth with chronic physical illness. For example, physiological processes in the body can impact brain functioning (e.g., inflammation, infection, or metabolic dysregulation), which in turn can influence emotional regulation and cognitions. Such disease-related neurobiological manifestations may adversely impact illness-related attitudes (e.g., low contingency related to control over the disease leading to helplessness and pessimism) and coping behaviors (e.g., medical nonadherence). In addition, psychiatric comorbidities and functional physical symptoms not

This work was supported by grant nos. K23 MH064604, R01MH077770, and 1DP2OD001210 from the National Institutes of Health.

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caused by an underlying medical condition have been reported in pediatric physically ill populations (Burke and Elliott 1999). Because psychopathology in adolescents with physical illness has been associated with higher health care utilization, functional impairment, decreased quality of life, poorer medical outcome, and increased mortality (Karwowski et al. 2009; Lernmark et al. 1999; Strunk 1987), it is often necessary to provide psychological treatment alongside standard medical care in order to promote treatment adherence, medical prognosis, and emotional well-being. One of the most empirically supported treatment approaches for psychological aspects of medical illness is cognitive-behavior therapy (CBT). In the pediatric medical population, the goal of CBT is to help youth attribute realistic meanings to illness-related life events and challenge dysfunctional thoughts and behavior patterns (e.g., pessimism, damaged sense of self, denial that interferes with medical compliance, and sick-role behavior). Left untreated, such negative cognitive schemas and maladaptive coping strategies can interfere with optimal development in youth with lifelong physical conditions. CBT can also help youth with physical illness deal with symptoms of pain and fatigue. We will first summarize the empirical findings on CBT as applied to general medical conditions. For the remainder of the chapter, we will then illustrate the theory and application of one empirically supported CBT approach that combines individual and family sessions to target depression and physical illness–related problems using pediatric inflammatory bowel disease (IBD) as a model illness. More specifically, Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI; Szigethy et al. 2007), which was modified to help depressed youth with IBD cope with malaise, gastrointestinal symptoms, abdominal pain, pessimistic illness perceptions, and medical nonadherence, will be described in detail with a case example to illustrate effective implementation. For further guidance on using CBT with chronic physical illness, readers are directed to Chapter 11, which focuses on the application of another CBT model to address obesity and depression among female adolescents with polycystic ovary syndrome and associated binge eating.

Empirical Evidence on CBT for General Medical Conditions Randomized controlled trials testing the effectiveness of CBT compared with alternative forms of treatment in physically ill pediatric populations are limited. Studies to date (Table 10–1) have focused on both specific illness-

Chronic Physical Illness

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related factors (e.g., social isolation, adjustment to illness, damaged self, family conflict, and health-related quality of life) and psychiatric comorbidities, such as anxiety and depression. The existing literature, however, is difficult to integrate and interpret given the wide diversity of presenting medical conditions, specific subpopulations of youth sampled, variations in CBT approach and dose, and different outcomes assessed. Moreover, various components of CBT have been studied, including cognitive restructuring, contingency contracts, relaxation, systematic desensitization, social role-play, problem solving, and conflict resolution, making it challenging to determine which elements comprise the most “active ingredients” in CBT. Treatment modality has also varied, with individual, group, and family-based interventions having some empirical support (see Table 10–1).

PASCET Theory The original PASCET program is a structured CBT approach developed by John Weisz and his team (2009) for the treatment of depression in youth. The PASCET program is based on the Skills-and-Thoughts (SAT) depression model, which focuses specifically on skill deficits and habits of thought that underlie and prolong depression in youth. Skill deficits often include poor activity selection, poor self-soothing skills, disengagement or avoidant social style, and inferior performance in academic or extracurricular domains (Hammen and Rudolph 1996; Weisz et al. 1992). Habits of thought include 1) negative cognitions (e.g., inappropriate self-blaming, catastrophizing, failure to find the “silver lining”); 2) rumination over depressogenic events and cognitions; and 3) perceived helplessness, hopelessness, and/or lack of control leading to low-level persistence in coping with stress and challenges (Gladstone and Kaslow 1995; Weisz et al. 1992, 2001). Youth with chronic physical illness are likely to be even more predisposed to such skill deficits (from loss of social practice time due to physical disease flares) and cognitive habits (from having to deal with a medical stressor out of their control). The SAT perspective holds that these skill deficits and cognitive habits can generate sad affect and make youth vulnerable to overt depressive symptoms in response to adverse, stressful, or ambiguous life events. Furthermore, these deficits and habits may actually generate their own stressful cascade (e.g., unsuccessful interactions and social rejection), which then stimulate further depression, in a cyclical fashion (Hammen and Goodman-Brown 1990). Not only can this cycle disrupt psychological functioning, but learned helplessness can also compromise immune system functioning, thus leading to a worsened illness course in physically ill populations (Sieber et al. 1992). A central task

Study

Type of intervention

Design

Findings

77


Individual 1. CBT 2. Control

CBT group associated with greater treatment adherence in asthma self-monitoring.

Liossi and Hatira 1999

30


Individual 1. Coping skills 2. Hypnosis 3. Standard care

Participants receiving brief hypnosis and coping skills treatment before bone marrow aspirations reported less pain and pain-related anxiety postprocedure than control subjects.

Poggi et al. 2009

40

Nonrandomized controlled trial


CBT group showed greater improvement in internalizing symptoms, overall problems, somatic complaints, attention, and social skills.

Knoop et al. 2008; Stulemeijer et al. 2005

71



CBT group showed greater improvement in fatigue severity, functional impairment, and school attendance. Positive effects were maintained at long-term follow-up.

Chalder et al. 2010

63


Family 1. CBT 2. Education

No difference found between treatment conditions on school attendance, fatigue, and social adjustment.

Asthma Burkhart et al. 2007

Cancer

Chronic fatigue syndrome


N

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TABLE 10–1. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population

Study


N

Design

Findings

41


Individual 1. PASCET-PI 2. Standard care

PASCET-PI associated with greater improvement in depression, global functioning, and perceived control.

12

Open trial

Individual 1. PASCET-PI

Decrease in weight and depressive symptoms.

69


Family 1. CBT 2. Standard care

CBT group reported less abdominal pain and fewer school absences at short-term and long-term follow-up. No differences in functional disability and somatization.

Grey et al. 2000

77


Group 1. Coping skills 2. Standard care

Coping skills group showed improved glycosylated hemoglobin (A1C) levels, diabetes, and medical selfefficacy and less impact of diabetes on quality of life at long-term follow-up.

Ellis et al. 2005c

31


Family 1. Multisystemic 2. Standard care

Multisystemic treatment group had a decreasing number of inpatient admissions and lower medical costs.

Inflammatory bowel disease Szigethy et al. 2006, 2007


TABLE 10–1. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population (continued)

Polycystic ovary syndrome Rofey et al. 2009 Recurrent abdominal pain Robins et al. 2005

Type 1 diabetes

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Study


Design

Findings

Ellis et al. 2005a, 2005b, 2007

127


Family 1. Multisystemic 2. Standard care

Wysocki et al. 2006, 2007, 2008

104


Behavioral systems treatment associated with improved A1C Family 1. Behavioral systems levels, treatment adherence, and decreased family 2. Education conflict. Treatment adherence and relational outcomes 3. Standard care were variable and not maintained at long-term follow-up.

Grey et al. 2009

82


Group 1. Coping skills 2. Education

Type 1 diabetes (continued)

Note.

Multisystemic therapy associated with short-term improvements in metabolic control, frequency of blood glucose testing, inpatient admissions (decreased), and diabetes-related stress. Some improvements in treatment adherence lost at long-term follow-up.

Coping skills group did not fare better statistically than education group on measures of distress, medical outcome, quality of life, or familial functioning.

PASCET-PI=Primary and Secondary Control Enhancement Training for Physical Illness.


N

336

TABLE 10–1. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population (continued)


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in treatment is to break this cycle of reciprocal influence and self-generated stress by providing clients with a collection of solution-relevant tools in the hopes of helping these youth counter depressive symptoms and boost their immune functioning. The change model that drives the PASCET program grows out of the two-process model of perceived control and coping (Rothbaum et al. 1982; Weisz and Stipek 1982; Weisz et al. 1994). Perceived control assumes a contingency between action and outcome (Weisz et al. 1982). In the PASCET model, primary control involves an individual’s efforts to cope by making objective conditions (e.g., the activities the individual engages in) conform to his or her wishes. In contrast, secondary control (Weisz et al. 1984a, 1984b, 1997) involves an individual’s efforts to cope by adjusting himself or herself (e.g., his or her beliefs or interpretations of events) to fit objective conditions so as to influence their subjective impact without altering the events themselves. The model holds that depression may be addressed, in part, by learning to apply primary control to distressing conditions that are modifiable and appropriate secondary control to those conditions that are not modifiable. Taken together, both skills help individuals to realistically assess situations they cannot control and to derive adaptive meaning in order to facilitate acceptance. This change model aligns with the SAT depression model previously described. In general, the skill deficits are addressed by primary control coping strategies that are taught in the PASCET program, and the habits of thought described in the SAT model are addressed by secondary control coping strategies. Reduction in depression is seen as coming about gradually, through a growing working knowledge of various primary and secondary coping strategies that may be used to combat depressive symptoms and the conditions that trigger them. This working knowledge is enhanced through structured exercises with a therapist and through in vivo practice activities that the youth engages in outside the treatment context. The PASCET model recognizes that not all youth exhibit the same skill and cognitive-habit deficits predisposing to depression. Thus, a flexible toolbox approach is utilized to choose those skills that will be most applicable to each youth’s specific problems and situations. Accordingly, the therapist collaboratively assists in the youth’s selection of coping skills that are most relevant and most likely to be helpful. The primary control skills (i.e., how youth can ACT to change their environment) are covered in the first half of the sessions, whereas the secondary control skills (i.e., how youth can THINK differently to change expectations and adjust to objective conditions) are covered in the latter half of the treatment. ACT is an acronym for skills involving primary control techniques, and THINK is an acronym for skills involving secondary control techniques (Appendix 10–

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A). It is hypothesized that the ACT skills help the youth reverse behavioral inhibition and passivity by inducing positive or reinforcing appetitive behaviors. The resulting mood improvement likely makes the youth more receptive to the THINK skills aimed at reversing erroneous cognitive processing (i.e., negative distortions and attributional style). Using the principles of learning theory, these early changes are reinforced with repetitive practice of the skills, with the eventual goal of establishing automatic and more stable behavioral repertoires to counter the negative mood and thought-inducing effects of depression. The developmental plasticity of the brain during childhood provides a critical window in which to stamp in such cognitive and behavioral changes, which is particularly relevant for youth who must deal with lifelong physical diseases. The original PASCET program involved 10 structured sessions with the individual youth, focused on learning the ACT and THINK skills, followed by 1–4 individually tailored sessions involving 1) applications of the most relevant PASCET coping skills to important situations or problems in the youth’s life and 2) planning for future applications of the PASCET skills after the treatment has ended. The 10 structured sessions included in-session exercises and take-home practice assignments, guided by a workbook that each youth used throughout the program and kept afterward. The individual sessions were supplemented by three parent sessions designed to help parents support the practice of the new coping skills in their children.

PASCET-PI: Inflammatory Bowel Disease as a Model Illness Pediatric IBD, which includes Crohn’s disease and ulcerative colitis, is a chronic and debilitating autoimmune disease consisting of abdominal pain, bloody diarrhea, and weight loss, as well as long-term sequelae (e.g., pubertal and growth retardation). The onset of pediatric IBD is most often between ages 10 and 20, with an unpredictable course requiring frequent medical procedures, surgeries, or medications (e.g., corticosteroids) with negative side effects. Pediatric patients with IBD have shown increased rates of anxiety and depression, functional abdominal pain, and fatigue even when the disease is in remission; and there is a growing literature showing that stress can lead to exacerbations of IBD course (Tang et al. 2009). Youth with IBD often miss a significant amount of school, extracurricular activities, and social time with friends. For these reasons, IBD was chosen as a model physical illness on which to base modifications of PASCET to address problems related to a medical disease. Not only is


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there support in adults with IBD that CBT can improve emotional disturbances, improve quality of life, and decrease patient suffering, but our studies show a positive impact of PASCET-based CBT in terms of reduced depression and improved functioning (Szigethy et al. 2006, 2007). Other investigators have shown that a modified CBT approach using the Coping Cat Program (see Chapter 7) for IBD-related anxiety in children has a positive impact on patient outcomes (Reigada et al. 2010).

Empirical Evidence Our PASCET-PI model was empirically tested in both an open trial (Szigethy et al. 2004) and randomized trial compared with a medical treatment-as-usual condition (Szigethy et al. 2007, 2009). Not only did the PASCET-PI group show improved depressive severity and global functioning posttreatment, but these positive effects were maintained 1 year posttreatment compared to the standard care group (Szigethy et al. 2006). In addition, IBD severity (as measured by validated disease activity measures as well as circulating inflammatory markers) was reduced at 6-month follow-up in youth receiving PASCET-PI. Although other factors could account for these positive changes in the CBT group, collectively these results are consistent with PASCET-PI having a positive effect on both emotional and physical aspects of IBD. Moreover, youth who had more pessimistic illness narratives and received PASCET-PI showed significantly more optimistic attitudes toward having IBD and more positive contingency and active coping post–CBT treatment (McLafferty et al. 2010). There are several potential mechanisms to explain the impact of PASCETPI on IBD activity, including improved medical compliance, integration of a more positive attitude toward and active coping with IBD, and a brainmediated effect on the peripheral immune system. Recent data from our laboratory suggest that depressed youth with IBD receiving CBT have increased metabolism in the dorsolateral prefrontal cortex, which is linked to emotional regulation relative to healthy matched controls (Szigethy et al. 2010).

Domains In addition to the traditional focus of PASCET-based CBT on altering maladaptive skills and cognitions, PASCET-PI integrated three components into the program. 1. Emphasis on the physical illness narrative of the youth, especially negative illness perceptions or cognitive misconceptions about his or her IBD.

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2. Enhanced coping strategies targeting disease-specific problems, such as medication adherence and disability from pain. 3. More intensive family work using a cognitive psychoeducational model developed by Beardslee and colleagues (1996). The Beardslee model is helpful in facilitating parents’ developmentally appropriate support of their child and helps eliminate environmental influences that may be preventing the youth from letting go of sick-role behavior. The modifications in PASCET-PI were drawn from examples in the adult literature that suggest a beneficial impact of such interventions on coping with physical illness—highlighting the importance of increasing patients’ knowledge of disease process and understanding of illness perception (Barlow et al. 2010; Bernstein et al. 2011), learning self-management skills, and encouraging active coping strategies over passive ones (Gil et al. 1989).

Physical Illness Narrative Narrative-based treatments emphasize the construction of meaning as a central concept and goal (Grinyer 2009; Hörnsten et al. 2004), and using narrative approaches has been linked to improved coping with illness (Pennebaker 1997). In PASCET-PI, youth write about their illness experience, including perceived causes and fears of their physical illness and its effects on everyday life, positive and negative aspects of having a physical illness, and their thoughts about how they can affect the course of their disease (Appendix 10–A). For example, in youth with IBD, feelings of loss of control, poor body image, fear of disease relapse, fear of not reaching full physical or functional potential, rejection by peers, and embarrassment are common and may predispose youth to depression (McLafferty et al. 2009, 2010). Parents also are asked about their experiences, including the effect of IBD on family life and how they cope with having a child with a physical illness. Therapists can assist youth and their parents in the reconstruction of narratives that have become too negative (or restrictive) by formulating alternative narratives that more fully incorporate life events into a coherent and positive story using PASCET skills. Studies have shown that such self-understanding and shared understanding with a therapist are important components of resiliency (Focht and Beardslee 1996).

Physical Illness–Related Problems In addition to addressing the youth’s illness perceptions, it is important to target maladaptive behaviors associated with IBD. These commonly in-


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clude social withdrawal, inactivity, excessive preoccupation with eating or bathroom access, traumatization, and avoidance of unpleasant external factors (e.g., medical visits, invasive procedures, or medication side effects). Several strategies have been incorporated into PASCET-PI to help with these types of problems. 1. Educating the family and youth about IBD in consultation with the appropriate medical specialist is important to correct any misperceptions about IBD and its treatment. For example, explaining depressive symptoms as extra-intestinal manifestations of IBD instead of as an additional and stigma-inducing psychiatric diagnosis is helpful and recommended. 2. Teaching strategies to reduce abdominal pain, including relaxation, hypnosis, biofeedback, distraction, and cognitive coping strategies, provides valuable education to the youth and his or her family. Daily practice of relaxation and calming techniques alone with minimal therapist contact has been shown to yield increased functionality in daily activities and decreased health care utilization (Gil et al. 2001). In adults with IBD, hypnosis not only improved quality of life, but also decreased IBD-related inflammatory markers (Mawdsley et al. 2008; Miller and Whorwell 2008). 3. Enhancing social skills through focused social problem-solving (e.g., how to share aspects of having a chronic physical illness with peers to increase support), utilizing in-session role-plays that target cognitive distortions and related feelings in settings with peers (e.g., perceived social rejection due to physical illness), and facilitating problem solving around social limitations related to physical illness (e.g., how to choose and maintain fun activities during IBD disease flares) address an important facet of the youth’s life and enhance coping skills. The development of such coping strategies not only can help the youth overcome depressive symptoms but also may serve to buffer the effects of stress on IBD flares and improve daily functioning. 4. Medication nonadherence is an important issue to address and often can be effectively targeted through cognitive restructuring and active problem-solving.

Family Involvement Living with a chronic physical illness often involves a host of psychosocial stressors in addition to the demands of addressing illness symptoms and medical treatment, including negotiating academic and occupational limitations, financial burden and medical coverage, communication difficul-

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ties, and lack of adequate leisure-work balance (Barakat and Kazak 1999). Parents can experience difficulties related to the impact of the youth’s physical illness on the family system, and how parents respond to these difficulties directly influences how the rest of the family copes. Parents often focus most of their attention on the ill child and struggle to balance their jobs, personal needs, and the needs of their other children effectively. Although the normal developmental push during this critical period is toward separation and individuation from the nuclear family, increased dependence on parents because of physical illness–related issues and altered parenting styles (overprotection or excessive lenience) can make the transition through adolescence particularly tumultuous. In addition, there is evidence that families of children with comorbid depression and physical illness deserve special attention. Families of children who have physical illness have increased rates of psychological distress and poor communication (Engstrom 1999). Depressed children are more likely to have parents who are depressed, and parental depression may interfere with compliance with both medical and psychological treatments (Beardslee et al. 1993; Cohen and Brook 1987). Cognitive approaches have been shown to be quite effective in educating families about childhood depression, increasing family understanding and communication, and decreasing risk factors for future depression (Beardslee et al. 1997; Brent et al. 1993). To meet the special needs of this population, family psychoeducational sessions modeled after the clinician-facilitated family preventive intervention of Beardslee (1990) are provided. Beardslee’s Family Talk Intervention has been tested in a long-term randomized trial and has received very high ranks in the National Registry of Effective Programs. It has been adapted for use with low-income African American and Latino families and used in country-wide programs in Scandinavia and Costa Rica. We have chosen those core components most relevant to PASCET adaptation and integrated them with treatment of the child. In PASCET-PI, adolescents and their families participate in three family psychoeducational sessions corresponding to the beginning, middle, and end of the individual CBT protocol. Content areas that are covered during these separate family sessions help parents reinforce the child’s ability to use PASCET-PI skills to cope, deliver education about depression and resiliency in adolescents, address salient parental concerns about their adolescent and family, and help families develop more effective communication. Beardslee’s work has shown the critical importance of linking cognitive material to an individual’s narrative life experiences (Beardslee and Podorefsky 1988; Focht and Beardslee 1996). This approach can help families identify affect, deal with stigmatization, and decrease noncompliance, psychosocial deficits, and resistance to the concept of illness. Training parents to become CBT


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coaches for their children not only provides an active and constructive focus of parental energy, but the role may also help them to avoid maladaptive parental coping practices such as distancing, denial, and overprotection of the sick child. Furthermore, there is a preventive tone to these family sessions, in that parents are building strengths that will help promote long-term resilience in the family. Just as in the original PASCET, both the youth and parents work from a PASCET-PI workbook. The youth receives 9 individual sessions and up to 3 flexible sessions to stamp in the skills most useful to the child. Parents participate in 3 sessions during the approximately 3-month intervention. In addition to modifications in content to incorporate physical illness– related realms, structural changes include the choice of phone sessions for up to 60% of the total sessions and coupling face-to-face sessions with medical appointments to improve compliance with therapy. We have found the phone sessions most helpful and effective when the initial session is conducted face-to-face with the ongoing therapist. On the part of the therapist, the key to making the phone sessions productive is ensuring that youth have their PASCET-PI workbook at hand and that their environment is private and free from distractions.

Application The following section will outline the application of the PASCET-PI intervention for youth with IBD and comorbid depression, with emphasis on the case formulation and content of both the individual and family sessions.

Case Formulation The successful application of the PASCET-PI skills is dependent on the formulation of the case and the integration of psychological and physical illness–related information. In addition to a thorough psychiatric and medical history, it is also important to consider potential obstacles to treatment progress, as well as personal and familial strengths so that these factors can be used as building blocks to target more maladaptive areas of coping. Additionally, an evaluation of precipitating events or situations, assessment of how the youth shows depressed feelings, and a thorough exploration of the youth’s social functioning can facilitate the development of a comprehensive case formulation. Collectively, this type of reformulation of the classic psychiatric evaluation into a CBT-based assessment can help the therapist hypothesize a priori regarding which ACT and THINK skills will be most applicable to the youth. The following is an example of a case history and formulation for PASCET-PI.

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Case History Kyle is a 13-year-old Hispanic adolescent boy in the eighth grade. He was diagnosed with Crohn’s disease 4 years ago. He presented for a psychiatric evaluation with a 6-month history of feeling sad and frustrated, decreased motivation and energy, intermittent hopelessness, insomnia, and low selfesteem. He also had increased complaints of stomach pain that were out of proportion to the degree of Crohn’s disease activity (as determined by inflammatory markers from his blood and endoscopy). He missed more than 40 days of school during the past 6 months due to the abdominal pain, resulting in a downward drift in his usually above-average grades. He has been on intermittent steroid therapy for the past 4 years and identified that he sometimes feels down when his steroid dose is high. Kyle reported being good about taking his morning medications but has variable compliance with the evening doses. Family history is positive for colitis, depression, posttraumatic stress disorder, alcohol dependence, and hypothyroidism on the paternal side. Kyle identified stressors as feeling isolated from his friends, being restricted in physical activities because of his physical illness, and the constant tension between his parents, who were frequently arguing and contemplating divorce. When he did spend time with his friends, he reported difficulty in negotiating conflicts between his school and neighborhood friends. Kyle’s parents are concerned about his depressive symptoms and stomach pain, his anxiety about falling behind in school, how their parental conflicts may be affecting Kyle, the problems he has been having with his classmates (e.g., he received his first suspension from school for fighting with a peer in the cafeteria), and how Kyle is coping with having Crohn’s disease. His father is often unemployed, and he stays home with Kyle during missed school days. Kyle’s mother works as a high school teacher, often withdrawing from conflicts at home and burying herself in her work. Kyle’s strengths include being bright and future oriented, having a good sense of humor, being sensitive to the feelings of others, having a variety of interests, and displaying skill at video games, soccer, and biking. PASCET-PI formulation: A 13-year-old white adolescent boy with long-standing Crohn’s disease presents with worsening depressive symptoms over the past 6 months, increased abdominal pain (in the absence of objective evidence of Crohn’s flare), decreased school attendance with resulting failing grades, increased social isolation and peer conflict, and decreased physical activity. IBD and steroid use in addition to family history of depression, anxiety, and hypothyroidism could predispose Kyle to depression. Stressors include decreased academic performance, marital conflict between parents, interpersonal difficulties with peers, and coping with a chronic physical illness. In addition, modeling of sick-role behavior and possibly learned helplessness by his father may also be a contributing factor to Kyle’s maladaptive coping. Skill deficits and cognitive habits: Kyle’s skill deficits include difficulty negotiating social conflicts with peers; difficulty eliciting positive social reinforcement from adults in his life; difficulty self-soothing, with increased focus on pain; and difficulty setting goals in different life do-


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mains. Cognitive habits include lack of perceived control over his environment with resulting helplessness, negative cognitive distortions (e.g., “I can’t do anything fun because of my Crohn’s”; “My friends will think I’m weird if they know I am diseased”), and hopelessness. Together these negative behaviors and thoughts make him even more vulnerable to feeling depressed. Using the following skills (i.e., ACT and THINK for relaxation, STEPS problem-solving skills, and POWER skills) along with family sessions aimed to increase parental communication and Kyle’s sense of primary control. (STEPS and POWER skills are discussed further in the following section “Individual Sessions,” in “Session 2: Problem Solving” and “Session 6: Talents,” respectively.)

This initial formulation is refined through information gathered during individual and parent or family sessions. As the treatment reaches the flexible final sessions 10–12, there is an increasing emphasis on identifying the particular lessons and coping skills of the PASCET-PI program that seem most likely to help the youth’s depressive symptoms and address the cross-section between mental and physical well-being. In this process of tailoring and fitting treatment to the patient, the therapist should rely on an evolving formulation, information on how the youth has responded to the various components of the PASCET-PI program (i.e., which parts the youth seemed to like and use effectively), and input from the youth to determine the best-fit coping skills. Continual reformulation of the case is essential to achieving the best-fit coping skills for the youth, incorporating both developmental growth and changes related to the course of the depression and/or the youth’s environment (e.g., parental divorce, physical illness flare). A carefully developed formulation is especially critical to the success of the maintenance sessions. The maintenance sessions are designed to be highly flexible, but their central aim is the application of the PASCET-PI skills that will best fit the youth’s life.

Individual Sessions The following section will provide an overview of the individual youth sessions according to the PASCET-PI intervention. Table 10–2 provides an outline of each session following the ACT and THINK skill format. Session 1: mood monitoring. The key components of session 1 are to explain the purpose and process of the sessions, deliver psychoeducation about depression and IBD, introduce the ACT and THINK chart (see Appendix 10–A), and explain mood monitoring. As in other CBT protocols, explain that this therapy will involve learning different ways of doing things and of thinking about things to help improve mood. This aim will be achieved over 9–12 weekly sessions, with the most important steps in suc-

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cess being regular attendance to learn new skills and consistent practice of the skills between sessions. Next, explain the two types of skills: ACT skills to learn new behaviors and THINK skills to change thinking about what distresses the patient but that are not in his power to change. These two types of skills will be used to target problems related to IBD and other life problems. Next, deliver psychoeducation about how depression can be caused by chemicals released in the gut during IBD flare-ups, affecting the brain and causing depressed mood, fatigue, changes in sleep and appetite, and increased sensitivity to pain. For youth who do not have a current IBD flare-up, depression may be a response to the realization that they have a lifelong chronic illness, or perhaps it can be linked to other life stressors that are not directly related to IBD. Irrespective of the root cause, the important take-home message for patients is that applying ACT and THINK coping skills can help facilitate positive changes in mood in either of these causes. Finally, introduce the new skill for this session: learning to be aware of mood and how it relates to what the patient is doing (or not doing). For each day of the week, have the youth rate his overall mood on a scale of 1 to 10 (1=very bad and 10=very good). Next, have the youth choose a word or phrase that best describes his mood for the day and also list good things and bad things that happened that day. Session 2: problem solving. The key components of this session are completing the illness narrative questions and teaching STEPS problemsolving (Appendix 10–A). For this session and each subsequent session, start by assessing the youth’s weekly ratings of mood, IBD symptoms, and medication compliance. Review the assignment from the previous week and process any difficulties with the youth. After the youth completes the illness narrative (see Appendix 10–A), discuss any negative or pessimistic answers in an empathic, open-ended manner. Younger children may prefer drawing their “illness stories.” Listen with the intent of making an inventory of illness-related problems that can be used to apply the STEPS problem-solving technique. Together with the youth, generate a list of both general and IBD-related problems, having the youth prioritize the list from smallest to largest problems. The STEPS approach teaches a type of decision matrix to produce a range of solutions, highlighting the importance of examining potential outcomes and providing a way for the youth to decide the order in which to try each solution. After the therapist and youth complete the STEPS worksheet in session, the practice assignment will be for the youth to complete the worksheet during the week with another problem—trying out the solutions for each problem and examining the impact each solution may have on his mood. Appendix 10–A provides mood thermometers for this activity.


TABLE 10–2.

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Outline of individual sessions for Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI)

Session

Goals

Session 1

Introduce PASCET-PI, ACT and THINK skills (see Appendix 10–A), and education about inflammatory bowel disease (IBD).

Session 2

Initiate completion of physical illness narrative and apply problem-solving techniques for IBD.

Session 3

Establish which activities the youth enjoys. Find agreement on importance of physical activity and exercise.

Session 4

Apply relaxation techniques and hypnotherapy for pain and immune system.

Session 5

Teach about showing positive self and improving social skills.

Session 6

Focus on developing the youth’s talents and skills.

Sessions 7–8

Address negative cognitive distortions about physical illness.

Sessions 9–12

Review skills learned and personalize skills.

Maintenance sessions 1–6

Reinforce use of coping skills.

This is also a good session to work on problem solving if medication nonadherence is an issue. The more the youth is involved with generating solutions, the more likely that compliance will improve. Session 3: activities. The main purpose of this session is to teach a variety of behavioral activation options. Several types of activities are covered, including activities that can be completed alone and are feasible in terms of access and cost, activities that can be completed with others, and activities that involve a group or club (e.g., extracurricular school activities, community class or activity, job pursuits for older teens). This behavioral activation is meant to help the youth socialize and expand his horizons, especially if having IBD has prevented him from participating in his usual activities. In addition, other activities discussed include helping others as a way to distract from the youth’s own problems and engaging in moderate exercise. Creating a list of physical activities that are tolerable and available for the youth is important, because exercise has been shown to help keep IBD in remission among adults (e.g., walking, yoga, more

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structured sports). For youth who have active IBD, the amount and type of physical activity should be determined in consultation with their gastroenterologist. Session 4: calm. The aim of this session is to teach calming techniques to help the youth relax. These techniques involve muscle relaxation, diaphragmatic breathing, and visual imagery in which the youth imagines a happy or calm place using all his senses (e.g., seeing the beach, hearing the waves, feeling the warmth of the sun, smelling the seabreeze, and so forth). Hypnotic scripts are provided in Appendix 10–B for youth experiencing either abdominal pain or active IBD inflammation. The purpose of these scripts is to help the youth facilitate attentional control, ignore pain, and boost immune system functioning. As in all hypnotic sessions, proper trance induction and deepening techniques (e.g., counting from 1 to 10) should be used before providing the hypnotic suggestions in the scripts and to reorient the youth back to full conscious alertness (e.g., counting back from 10 to 1). In addition to the words used during hypnosis, the more closely the therapist’s voice cadence matches the youth’s changing physiology (e.g., slowed breathing rate) during the trance, the better the results will be. The youth’s mood should be monitored before and after the relaxation sessions, with any improvements noted. In addition, biodots (which change color based on skin temperature, similar to mood rings) can also be used to make practice more fun and to give biofeedback to the youth that he can change his bodily functions. The following is an example of how the biodots can be introduced to provide a type of ramification for the relaxation experience. One way to measure the amount of stress we are holding in our body is to measure the temperature in our hands. Hand temperature is caused, in large part, by the distribution of blood in our body. When too much blood is in our head, less blood is in our body, including our hands; and thus, our hands are colder. This fact is useful to know because it is also the case that too much blood in one area can cause pressure, which causes pain. So, for example, tension headaches are often caused by too much blood in the brain. Today we will work on learning to relax and use the power of our mind to help shift the blood from the head to the hands. We will use biodots to test how well our attempts are working. Here’s a biodot to place on the back of your hand or another area of skin. Notice the color of the biodot as we go through some relaxation training.

The practice tool for this session will consist of making a CD of the relaxation exercises completed during the session so that the youth can practice these techniques at home. Listening to music is another way in which


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youth can relax. Incorporating soothing music or the youth’s favorite songs into the recording can be helpful in creating a calming experience. Session 5: confidence. The primary aim of this session is to help the youth understand the meaning of confidence as believing in himself, even if the youth feels down about having IBD. Feeling confident involves being optimistic about interactions with others, a skill that can require practice like any other skill that is learned. This skill is taught through the following exercises. First, introduce the concept of showing a negative and positive self, and identify specific behaviors that go with the specific features of the youth’s negative and positive self (e.g., how the youth looks and acts, what the youth says). Second, make a videotape during which the youth acts gloomy, negative, and sad, to explore with the youth how IBD influences his negative self. Next, make another videotape during which the youth, after coaching and practice, does his best to present a positive self. Finally, have the youth compare the negative- and positive-self videos, judging which of the two shows a self that he and others will like better. It is helpful to use real-life experiences as anchoring points for how a youth shows these attributes. Reviewing the illness experience and problem list generated in session 2 may also give clues of specific events or experiences to use with the youth. For the video, it is useful to use a role-play, particularly if it is relevant to the youth’s life. In the case of Kyle, one scenario may be with a peer with whom he had a conflict. The therapist could role-play the peer while Kyle would be himself, first as his negative self, then as his positive self. The practice assignment for this session is to have the youth practice his positive-self skills with others and write about the experience, including the reactions of others. There are certain pitfalls to avoid during this session. Avoid criticizing the youth’s depressed self. Instead, the exercises should be presented in the context of exploration and curiosity. That is, the therapist really does want to know what the youth thinks about these two different videos, and what the youth thinks the consequences of positive and gloomy behavior may be for how he feels and how others feel about him. A second pitfall to avoid is implying in any way that showing a positive self is the same thing as “faking it.” Instead, the key idea to emphasize is that all individuals have the capacity within themselves to behave in different ways; the positive ways seem to make a person feel better and to make others feel better about being with that person. As the therapist and the youth work on identifying positive-self behaviors, a final issue to remember is to be aware of the impact of new behaviors on both peers and adults. Avoid creating a positive-self profile that might seem arrogant or obnoxious to adults, even if it is likely to evoke a positive reaction from peers. Likewise, avoid coach-

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ing the client to behave in a way that adults might like but that his peers may find “nerdy” or socially undesirable. Use therapeutic judgment liberally in coaching the youth to come up with his positive-self skills. Session 6: talents. The goals of this session are to work with the youth to further develop existing talents, develop new skills, and learn social problem-solving to improve social skills. This session is particularly important when illness symptoms are preventing youth from doing their usual activities or from developing opportunities for socialization. The main concept is that developing a skill takes three steps: goal setting, planning realistic steps, and practicing until the youth masters each of the small steps and reaches his desired goal. Ask the youth to identify a goal involving some talent or skill he wants to develop, and collaboratively identify some of the small steps that would need to be mastered on the way to that goal. For the weekly practice assignment, have the youth begin practicing one of the steps. The second part of this session focuses on teaching the youth social problem-solving skills using the POWER steps (Problem with a relationship, Outline the positive and negative parts of the relationship, Which negative parts do I have the power to change? Explore the good and bad aspects of making a change, Relationship improvement takes action; Appendix 10–A) to improve relationships with others. Introduce the idea that everyone has had someone with whom they have had difficulty getting along in a particular situation. The therapist can give common examples from other youth or from his or her own life (e.g., arguments, breakups, disagreements with a parent). Tell the youth that just like there are STEPS to solving other problems, there are concrete things someone can do to improve a relationship with another person. Further, improving relationships with others can help the youth feel good. For the practice assignment, have the youth pick one person to focus on to complete the POWER worksheet on his own and to try out one of the solutions to improve the relationship with this person. When going through the POWER steps with the youth, make sure to hit on the following basic ideas, which are organized according to the steps associated with each letter in the POWER acronym. • Problem with a relationship. This step involves identifying a specific problem the youth is having with another person. Having the youth pick a relatively specific problem (e.g., an argument with a specific friend in the cafeteria yesterday) versus a more general one (e.g., I fight with my friends) will make the subsequent steps of the problem solving easier.


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• Outline the positive and negative parts of the relationship. This step is the most difficult and germane to the process of improving a relationship. Sometimes when a person is having difficulty with another person, it is difficult to think about things that are going well in the relationship or that he does like about the other person. A big step in improving a relationship is to overcome this tendency and recognize that there are both good and bad things about the relationship. Explore with the youth whether the positive aspects of the relationship outweigh the negative ones. Oftentimes, even though it is clear that the positives outweigh the negatives, people can forget about the positives when they become focused on the negatives. • Which negative parts do I have the power to change? Looking at each of the negative parts of the relationship that the youth has listed, help him decide which parts he has control over or has the power to change. Explain that often the things that are not within a person’s control are the characteristics or qualities of the other person. It may be a good idea to illustrate this point using an example of someone the youth knows or a hypothetical person who is caught up in trying to change another person. Often it is much easier to see from an outside perspective how frustrating and futile it is to have a mission of changing another person. This step is a specific application of one of the main tenets of the PASCET model: deciding when to have primary control (changing the environment) versus secondary control (changing one’s own thinking) of a situation and changing personal actions or thinking accordingly. • Explore the good and bad aspects of making a change. In this step, help the youth examine the potential outcomes of each of the proposed solutions for changing something about the relationship. • Relationship improvement takes action. This step simply involves the youth actually trying out one of the listed solutions and seeing how it works. Encourage him to make a commitment about when he will attempt to make the change.

Case Example Kyle initially presented as quiet and lethargic. He yawned several times throughout the session and did not display consistent eye contact. During the first few sessions, the clinician focused not only on psychoeducation and introducing ACT skills, but also on establishing rapport. The main way rapport was established with Kyle was by linking ACT skills with the concerns he reported during the illness narrative. With time, Kyle became more invested in treatment. He was receptive to learning about the ACT and THINK skills and began to complete his mood monitoring assign-

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ments. Kyle openly discussed how his mood was lower on days when he stayed at home and did not spend time with friends. His mood tended to be better on days when he was busier. This pattern was discussed, and Kyle agreed that he was happier when he was doing something social than when he was home alone. This discussion naturally led to introducing the ACT activities skill by reminding Kyle that his mood ratings were better when he did fun activities and lower when he isolated himself. With the help of the clinician, Kyle formed a list of pleasurable, social, active, and helpful activities in which he could participate. He was assigned to take part in at least one of these per day and to rate his mood both before and after taking part in the activity. Kyle followed through with this assignment, and his mood ratings began to gradually improve. He also noted that the more time he spent with peers, the closer he became with them and the less conflict he experienced with them. Kyle explained that when he was not hanging out with friends a lot, he began to assume that others thought he was “weird” and therefore he needed to prove he was cool by fighting with others. However, as he increased spending fun times with friends, he became less defensive and no longer felt the need to appear tough; therefore, his fighting behavior decreased. Another ACT skill that proved beneficial for Kyle was the set of STEPS problem-solving techniques. Kyle rated his academic problems as most upsetting to him currently. The STEPS problem-solving skills were then introduced to Kyle, and together with the clinician, each step was applied to Kyle’s concerns regarding his dropping grades and poor attendance. Eventually, Kyle was able to pick the solution of speaking with his teachers and parents about 1) getting a tutor to help him to catch up on the work he had missed and 2) starting to return to regular school attendance. He was excited when the clinician explained that given his illness, the school would likely agree to a specialized plan focused on providing him with extra time and support to catch up academically, as well as support him while he gradually increased his time in school until attending full-time again. Kyle’s parents joined in at the end of one session to sign a release for the clinician to contact the school guidance counselor in order to begin the process of obtaining accommodations in the school setting for Kyle because of his health condition. Kyle was pleased with how problem solving worked for him and therefore was also quite receptive to the POWER skill introduced during session 6, focusing on talents. Kyle reported that one of the most concerning things about his illness currently was that he was not able to tell his friends what was going on for fear of being teased. This fear had caused him to feel isolated from his friends, especially his best friend. Kyle realized that it was his choice whether to open up to his friends, but that choosing not to tell them caused him to feel more isolated from them. He formed the solution of telling his best friend about his IBD diagnosis and seeing how he would react. The clinician helped Kyle by role-playing how he would bring this subject up with his friend, as well as how to deal with his friend’s possible reactions. After sharing this information with his friend, Kyle was surprised when his friend was “really cool” about it. Kyle said that


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this made a big difference for him. Even though he wasn’t as close to his friend as he was before the IBD diagnosis, he felt a lot better once his illness wasn’t a big secret. Although Kyle’s mood ratings were gradually improving with the use of ACT skills, his IBD ratings did not initially improve because Kyle was reporting high amounts of pain, especially in the mornings before school. Kyle was open to the idea that some of his pain might be related to anxiety regarding school rather than IBD symptoms alone. He was taught calming skills, including breathing techniques, visualization, and hypnosis. Kyle especially benefited from the hypnosis skills and found that he could reduce his level of pain when he practiced this technique regularly. After learning and practicing these techniques, Kyle began to experience less pain and also felt a higher amount of control over his symptoms. His IBD weekly ratings began to decrease.

Session 7: think positive. This session represents the transition from the ACT to the THINK skills. The primary skill to be delivered focuses on the T (“Think positive”) in THINK and marks the beginning of the cognitive portion of this cognitive-behavioral treatment. As is true for all cognitive therapies, the rationale of this session is based on the idea that how individuals think about events or situations will affect how they feel. Therefore, one way that people can control their feelings in situations that they cannot change (e.g., having a physical illness) is by changing their thoughts about those situations. This is a defining feature of secondary control coping. BLUE thoughts are loosely based on Beck’s model (1967) of cognitive errors: B “Blaming myself ” refers to Beck’s concept of excessive responsibility, or personalizing, and is defined as taking personal responsibility for negative events. L “Looking for the bad news” is related to Beck’s concept of selective abstraction and refers to selectively attending to negative aspects of experiences. U “Unhappy guessing” refers to jumping to conclusions—basically, making negative predictions on the basis of scanty evidence (e.g., assuming that someone who did not say “hi” to you dislikes you). E “Exaggerating—imagining a disaster” refers to Beck’s concept of catastrophizing (i.e., imagining that the outcome of an event will be catastrophic or that the event itself is catastrophic). The practice assignment involves the youth logging his negative thoughts each day with an associated mood rating on a scale from 1 to 10. Next, the youth categorizes each of these thoughts according to the BLUE

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letters. Finally, the youth will identify a less negative (or more neutral) way of thinking and rate his associated mood. For example, instead of saying, “I hate having IBD,” which may be an example of looking for the negative, the youth might think, “It could be worse—I could be so sick that I would need to be in the hospital, but I’m not.” Session 8: help from a friend, identify the silver lining, and no replaying bad thoughts. The focus of this session is to develop and use alternative methods to reverse negative thinking. First, introduce how seeking feedback from a trusted other person can be helpful in catching negative thinking. Have the youth identify three people he could turn to for help in identifying and altering negative or pessimistic thoughts. Second, explain the proverb “Every cloud has a silver lining,” and link it to the idea that even in bad or negative situations, there is something good that he can focus on instead. Alternatively, some youth understand this concept better by imagining how their situation could be worse. When they juxtapose the current situation and a potentially worse situation, the current situation will not seem as bad. Finally, it can be developmentally challenging to work purely in the cognitive realm for some youth. For example, younger children can often identify negative thoughts but have difficulty with the idea that these can be replaced with positive thoughts. In these situations, help the child come up with a list of activities he can utilize to distract himself from negative thoughts as a way of feeling better. For the practice assignment, the child is asked to try out all three of these skills during the week and to rate his mood before and after each attempt.

Case Example Once Kyle’s symptoms were beginning to lessen due to the ACT skills, the clinician moved on to teaching the THINK skills in later sessions. At this point in the treatment, Kyle was functioning at a much higher level. However, he continued to maintain some hopeless and negative cognition regarding his illness. The therapist explained to Kyle the relationship between thoughts and feelings and introduced the concept of BLUE thoughts. Kyle was able to recognize his pattern of “looking for the bad” by overly focusing on how IBD negatively affected him. In addition, his pattern of exaggerating the negative impact of IBD on his life was also discussed. Kyle practiced countering these thoughts and replacing them with more helpful thoughts. He also began regularly practicing “finding the silver lining” because this helped him to challenge his tendency to focus on the negative. Kyle’s illness narrative slowly began to change. Although initially his thoughts about his illness caused him to feel sad, by the end of treatment, his thoughts had become much more realistic. Most of the time, Kyle was able to recognize when his thoughts were making him feel worse and then work to challenge these thoughts.


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Sessions 9–12: keep trying. In the final structured session (session 9), the overarching goal is to introduce the idea that often one skill alone is not enough to optimally improve the youth’s mood. In fact, it is often the combination of different skills that can lead to the best outcome. In session 9, the ACT and THINK chart is reviewed, and the youth identifies a list of current life and IBD-related problems. For each problem, encourage the youth to think of three ACT and THINK skills that would be most helpful in the given situation in an effort to develop plans for future action (Appendix 10–A). To solidify this concept of having several plans, it can be useful for the youth and therapist to switch roles, with the therapist as the depressed youth and the youth as the therapist who helps the “client” to develop Plan A, Plan B, and Plan C for specific problems. This role reversal not only allows the youth to experience mastery, but it also helps symbolize a transition in the sessions, with the youth taking a more active role in problem solving and generating solutions. For the remaining sessions 10–12, the focus is on the application of the most personally relevant PASCET-PI skills for the youth’s current problems, as well as the introduction of some skills that might be needed in the future. These additional sessions may be most helpful for youth experiencing only partial remission of depressive symptoms, youth with comorbid anxiety problems, youth from more chaotic or less supportive families, youth experiencing IBD flare-ups during the course of therapy, and youth who are struggling to learn PASCET-PI coping skills or having trouble implementing the skills into their daily routines. The session content will consist of focused discussions, role-plays, brainstorming, and other exercises aimed at practicing and reinforcing the application of specific PASCET-PI skills to potentially depressogenic events and conditions that are present in the youth’s daily life. Thus, a considerable part of each of these later sessions will be devoted to collaboratively designing and troubleshooting the practice assignments for the following week. Maintenance sessions. After completion of the acute phase of treatment, six monthly booster sessions can be provided. These sessions follow the format of the flexible sessions in terms of reinforcing coping skills to address current problems and to anticipate future problems, particularly in social, functional, or physical illness domains. To achieve these objectives, it is essential to obtain a thorough interval history of the following information since the preceding session: • Depressive symptoms and mitigating circumstances • Physical illness course • Environmental stressors (family, school, peers)

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• Problems encountered in implementing PASCET-PI skills • Positive outcomes resulting from PASCET-PI skill use

Family Sessions Individual youth sessions are complemented by contact with parents in two forms. At the end of each individual youth session, a parent (or both, if available) joins the therapist and youth for a 5-minute summary conference to discuss the main points of the session (excluding information the youth does not want to share) and the youth’s practice assignment for the upcoming week, which the parent is encouraged to assist the youth with. Individual family sessions are held at the beginning, middle, and end of the youth’s treatment. The goals of these family sessions are threefold, including explaining the treatment program and soliciting the parent’s perspective on the youth’s depression and coping with IBD, educating the family about depression and comorbid physical illness, and helping the family reinforce the youth’s ability to cope with depression and physical illness by using PASCET-PI skills. Incorporate parents in a developmentally appropriate manner. For example, discuss confidentiality of the specific topics brought up by the adolescent, but encourage the adolescent to share the CBT coping skills learned with the parent at the end of the session. Help the parents adopt a more appropriate perspective on the adolescent’s behavior, balancing firm control with warmth and granting autonomy. The format of the family portion of the overall PASCET-PI protocol is a short-term, intensive, psychoeducational, family-based intervention. Just as the crux of the individual PASCET-PI is to help the adolescent develop primary and secondary control, the central tool in the family sessions is to apply a modified version of the STEPS skills for family problem-solving. To help families increase their behavioral problem-solving repertoire, a variety of strategies are employed, including teaching about depression and the interface of depression and physical illness, helping to develop a sense of hope about the future, and linking cognitive information to both the individual and family perspectives on affective illness and the unique life experience of the family, including dealing with the physical illness. Each family session is outlined below. Ideally, the first session involves only the parents or parental figures in the youth’s life, and the subsequent two sessions involve first the parents alone and then include the youth so the therapist can help develop more constructive interactions between the parents and the child. However, given differences in family structure and degree of impairment, the therapist can decide on a case-by-case basis how these family sessions will best assist the youth in the family’s ultimate goal of learning more adaptive ways to cope with having IBD.


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Family session 1: parents as partners. The main goal of this session is to socialize the family to the cognitive-behavioral model, develop an understanding of the parents’ perspectives on the youth and family situations, and to deliver brief psychoeducation and apply skill building at the familial level. First, gently ask for the parents’ perspectives about the youth’s problems and the IBD-related illness experience of both the youth and the family. Next, provide an overview of PASCET-PI structure and the ACT and THINK chart, providing a rationale for how these skills apply to their current situation and their child’s difficulties. Educate the family about the relationship between IBD and depression, as well as provide helpful tips for modifying school plans and improving medication adherence (see information worksheets in Appendix 10–C). Finally, introduce the family STEPS problem-solving exercise. This activity uses the same STEPS worksheet completed by the youth in individual session 2; however, each family member contributes to the generation of solutions and gives input examining what is good and bad about each solution. This exercise teaches families how to problem-solve in a respectful way, in which everyone’s opinions are valued and communication is open. Family session 2: parents as facilitators. The goals of this session are to gather information, review ACT and THINK skills, and highlight the importance of positive communication. First, ask for feedback from the parents about their child’s progress and ongoing problems. Next, educate parents about how improving family communication can help their child cope better. Explain how decreased communication or negatively expressed emotions toward the youth can maintain a youth’s depressive or pessimistic stance (Figure 10–1). Help the parents develop goals for how they might change their communication style with their child (e.g., stop nagging and praise the youth for going to school every day). Review the ACT and THINK skills that have been covered with the youth to date and how parents can reinforce these skills. If the youth is present for the session, have him participate and possibly even lead this part of the family session. Finally, introduce the family de-stressing game described below, which aims to reduce stress at home by building more positive interactions between family members. Family de-stressing game: Each family member gets five popsicle sticks in a certain color (red, orange, yellow, green, blue, or purple) or other unique token identifiers. The idea of the game is for each player to get as many popsicle sticks in colors other than his or her own from family members by the end of the game. Players earn the sticks by saying something nice or doing something nice for someone else in the family. For example, if the youth says, “Dad, I really appreciate you spending time with me yesterday,” the youth would get a stick from his father. If the youth’s mother baked him

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cookies, he would give one of his sticks to her. The family decides as a unit when they will begin and end the game, but ideally each game should be played for 5–7 days. Negative comments or interactions are ignored.

Family session 3: parents as coaches. The main goal of this session is to have the parent-child dyad determine the best way that parents can become CBT coaches, facilitating the youth’s long-term maintenance of treatment gains. As in previous sessions, the parents are encouraged to give their perspectives about their child’s progress and ongoing problems. In this session, these perspectives are provided in the presence of the youth so that there can be in vivo STEPS problem-solving completed with the family unit to address unresolved problems or issues. Next, the youth is encouraged to review the ACT and THINK skills and to communicate to the parents how they can be most helpful in reinforcing new skills. The therapist can act as a mediator for this interaction.

Case Example While Kyle’s individual sessions were greatly helpful for improving his mood and functioning, the family sessions also played a large role in his improvement. Kyle’s parents attended the first session without Kyle to learn about CBT and how they could support Kyle in his treatment. This education helped Kyle’s mother to realize that she herself was also depressed. She was referred for outside treatment and attended those sessions. Treating her own symptoms allowed her to more effectively support Kyle’s new healthy lifestyle. At the same time, Kyle’s father was also encouraged to support Kyle’s new healthy lifestyle by providing Kyle with praise and special attention when he was using coping skills and reducing attention when Kyle was not following through. In this way, the secondary gain of getting more special time with his father when he did not go to school dissipated, and this change also helped to improve Kyle’s attendance. Follow-up family sessions also focused on problem-solving some difficulties within the family unit. Kyle was able to explain that he often felt “put in the middle” of his parents arguing and that this made him feel like he “cannot win.” Therefore, the clinician helped Kyle’s parents to agree to discuss marital problems privately and to avoid including Kyle in these discussions. Although this intervention was not easy for the couple and at times they made mistakes, Kyle noticed great improvement in his interactions with his family, and his reported level of stress within the family was reduced.

Key Clinical Points Several general considerations can optimize the outcome of using CBT to treat depression, particularly in adolescents with physical illness.


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Downward spiral of youth’s depression Depressed mood

Negative thinking

Negative behavior

Family processes Negative expressed emotions Decreased communication

Upward spiral with CBT for youth Adaptive thinking

Education

FIGURE 10–1. pression.

Modified behavior

Improved mood

ACT and THINK skills Improved communication

Family communication and impact on youth’s de-

ACT= Activities, Calm and Confident, Talents; CBT= cognitive-behavior therapy; THINK= Think positive, Help from a friend, Identify the silver lining, No replaying bad thoughts, Keep trying—don’t give up.

• Balancing rapport and education. The key to success in using Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI) to enhance coping with physical illness is balancing rapport and didactic education in a manner that is fun and that allows the youth to take on a progressively more active role in problem solving throughout the course of therapy. Of course, what is fun and interesting for a 12-year-old boy may not be at all fun or interesting for a 16-year-old girl. As such, the fun and interesting aspect cannot be built into the manual very successfully. Instead, it becomes the therapist’s job to make the sessions enjoyable and engaging by designing clever, witty, and memorable ways to present and illustrate the main points of each session. • Flexibility. The therapist should also be flexible whenever possible in coordinating therapy sessions with medical appointments or visits for medication infusions. Sessions can also be completed bedside if the patient is medically hospitalized.

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• Review. After the initial session, each subsequent session begins with a review of the previous week’s material and practice assignment. This review is an important opportunity for the therapist to provide positive reinforcement for the youth’s work. Additionally, the practice assignment serves as an opportunity for the therapist to note consistencies and patterns in the youth’s approach, which may help in designing examples and setting up future assignments. Thus, spending time on the practice assignments is worthwhile, and the review should not be rushed to get to the remaining session content. Along these lines, the practice assignment will often lead quite naturally into the new session material, and efforts should be made to facilitate this transition. • Toolbox reminder. Remember that CBT is a skill-building treatment based on the toolbox concept. The ACT and THINK chart encompasses numerous different ways of coping with depression and a chronic physical illness. Not all of the tools will be useful for each youth. Thus, the therapist must not oversell a particular coping skill from the ACT and THINK list because of a sense that a youth rejects the idea or will not use it. Instead, the therapist should ascertain that the youth understands the notion and then move on. For those skills that a particular youth appears to find especially helpful, it may be beneficial to incorporate extra exercises to reinforce the lesson learned. Tap into the youth’s creativity and interests to help personalize the treatment tools for him (e.g., making a collage or drawing to illustrate a particular skill, or writing a story about the use of the skill). • Respect. The cognitive-behavioral therapist models treating each person in a respectful way and models appropriate listening behavior. He or she also helps parents and kids find their strengths. • Developmental considerations. The therapist should make sure that the process and content of the therapy is perceived and interpreted within a framework of the youth’s developing cognitive capacity (see Chapter 2). Age-calibrated adjustments in presenting issues, concepts, and skills are essential to make the CBT experience a positive one for the youth. Prepubertal youth (i.e., ages 9–12) may still have concrete thinking, and they often develop unusual beliefs about why they are sick or why they need to go to the hospital. They may have difficulty comprehending concepts like duration and quality (e.g., “It will only last a minute” and “This will only hurt a little bit”) and may manifest avoidant behaviors when faced with procedural stressors. Moreover, they may have limited awareness of feelings or believe that certain feelings are unacceptable. Youth may express feelings through activities like playing, drawing, painting, and roleplay (e.g., playing the role of the doctor); thus, it is important to use


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these modalities as vehicles to deliver PASCET-PI skills. In addition, continue to educate both the adolescent and the family about normal adolescent processes to normalize development (e.g., links between puberty and poor body image; parent’s role in helping the adolescent transition from a “child” status that involves adult monitoring to an “adult” status that requires more self-management). • Regression. Sometimes if extremely stressed or when sick with a flare-up, older youth can regress to coping styles used in earlier times of their lives. This can result in a return to magical thinking (such as attributing events in their lives to their own thoughts, feelings, and behaviors) and inferring causal links between events that occur in close physical or temporal proximity. Undergoing medical procedures can also regress some teens, especially those with anxious tendencies, resulting in misconceptions about the reasons for the procedure, misunderstandings about the nature of the illness or procedure, or a mistaken belief that the illness or procedure is “punishment.” • Autonomy and treatment nonadherence. The adolescent’s ambivalence about his sick role is a common source of treatment nonadherence. It is important to involve teens in treatment planning and to foster a developing sense of autonomy from family and close peer relationships. Developing a sense of identity and belonging are important adolescent tasks that are often interrupted by the presence of a chronic illness. Rapid physical changes associated with puberty produce heightened self-awareness and concern about appearance. Medical procedures can impinge on these tasks, especially when procedures involve loss of functioning (e.g., colostomy). The acceptance of authority and relinquishment of control needed to undergo medical procedures can be difficult for this age group and may foster feelings of helplessness and dependence. Adolescent patients may become resistant and nonadherent in an effort to regain a sense of control and independence in the medical context. Fortunately, their growing abilities for abstract thinking enable them to draw on a wider range of strategies for coping with anxiety and stress, including relaxation imagery and cognitive reframing. Address noncompliance with attendance or practice assignments immediately and directly by problem solving with the adolescent and examining mitigating environmental factors. Give consideration to flexible alternative solutions (e.g., phone sessions, reminder calls from the therapist about homework, addressing parental contributions to the problem). • Model of joint empiricism. Endorse a model of joint empiricism with the older adolescent from the onset of therapy by focusing on

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the problems raised by the adolescent and other jointly identified goals. For example, adolescents who have missed substantial amounts of school because of their illness need the problem-solving steps planned for school reentry to be realistic in scope and timing. Initial collaborative negotiation between the adolescent and therapist, and later with other resources (e.g., parents and school), can be instrumental in the development and execution of the plan. • Therapeutic alliance. Expect a more tentative therapeutic alliance and frequent comparison of the therapist to other adult figures. Empathy, warmth, patience, and a genuine respect for the adolescent’s strengths can help with rapport building and establish a strong working alliance. Use the structure that the CBT sessions provide and consider the use of phone sessions to help meet the adolescent’s needs. Another key component to forming an adequate therapeutic alliance is an assessment of the adolescent’s interpersonal skills (e.g., sophistication in verbal and nonverbal communication, capacity for perspective taking and empathy, degree of social judgment). • Social environment. Pay attention to the social environment at school and in the home. This is essential in adequately assessing which aspects of the environment the youth has control to change and which aspects need the help of the therapist to resolve (e.g., addressing parental criticism or shame-inducing comments, using school resources to provide more social or academic opportunities). Remember the school is a laboratory for developing not just academic competence, but social skills and personal coping strategies. • Therapist education about IBD. Although a detailed understanding about the etiology and treatment of pediatric physical illnesses is not essential in working with physically ill youth, some understanding of the physical and psychological manifestations of the physical illness involved will enhance the therapist’s ability to apply the coping skills taught to this comorbid population. • Etiology of depression does not preclude CBT. It is important for the therapist to keep in mind that physical illnesses can be both a physical and a psychological stressor, and that both aspects can lead to missed social and academic opportunities, family distress, and delayed physical growth and sexual maturation, all increasing the risk for depression. It is important to consider that cause and cure are not inextricably linked. Even a depressed state that is heavily influenced by biological factors may, in principle, be treated effectively by a psychosocial intervention such as PASCET-PI.


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Self-Assessment Questions 10.1. When CBT is used for the treatment of a youth with a chronic physical illness, which of the following treatment components will likely be most useful for improving mood and positive coping? A. Teaching the youth skills focused on changing negative thoughts regarding illness. B. Parent sessions focused on education regarding CBT and how parents can best support their child. C. Teaching the youth skills focused on how to behave differently when feeling upset, such as increasing pleasurable activities. D. All of the above. 10.2. Which of the following best describes the relationship between psychological and physical processes? A. Symptoms of physical illness, such as inflammation, can negatively impact brain chemistry, resulting in psychological disturbances. B. There is no relationship between physical illness and mental health concerns. C. The relationship is bidirectional. A preexisting mental health concern can negatively impact physical illness by decreasing healthy behaviors. Also, physical illness processes can contribute to increased psychological concerns by increasing both internal and external stressors. D. Psychological difficulties can negatively impact a youth’s perception of control over illness, leading to a hopeless view regarding health and a decreased participation in healthy behaviors. 10.3. A 14-year-old adolescent girl with comorbid Crohn’s disease and depression spends most of her time lying in bed in her bedroom, isolating herself. Which of the following coping skills is a primary control tool that will likely help her change this negative behavior? A. The tool of identifying the silver lining so that the youth begins to find the positive in her situation. B. Taking part in relaxation training techniques such as deep breathing and hypnosis. C. Recognizing negative thought patterns and challenging them with more helpful thoughts. D. Activity scheduling: being encouraged to take part in an increased variety of activities, including pleasurable, physically active, helpful, and social activities.

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10.4. Which of the following is not a focus of treatment according to the Skills-and-Thoughts (SAT) theory? A. Identifying negative thought patterns and learning to change them. B. Improving self-soothing skills. C. Using the therapeutic relationship as a model for outside relationships. D. Increasing participation in pleasurable or rewarding activities. 10.5. When working with a 17-year-old adolescent boy, the therapist notices that he appears bored when presented with the information. Which of the following developmental adaptations may be most useful for this situation? A. Leave out the ACT (i.e., Activities, Calm and Confident, Talents) skills when conducting treatment in order to focus more on the complex skill of cognitive challenging. B. Focus on making the sessions collaborative and fun by learning about the teen’s interests and linking skills with the teen’s illness narrative. C. Increase parent participation in the teen’s sessions to ensure that he participates actively. D. Do not make any adaptations, as this would decrease the overall efficacy of the treatment.

Suggested Readings and Web Sites American Society of Clinical Hypnosis, for hypnosis training and certification: www.asch.net Avery RR: Meet Thotso, Your Thought Maker. China, Smart Thot, 2008 Dudley CD: Treating Depressed Children. Oakland, CA, New Harbinger Publications, 1997 Thomson L: Harry the Hypno-Potamus: Metaphorical Tales for the Treatment of Children. Norwalk, CT, Crown House Publishing, 2005 Thomson L: Harry the Hypno-Potamus: More Metaphorical Tales for Children. Bethel, CT, Crown House Publishing, 2009 Wester WC, Sugarman LI: Therapeutic Hypnosis With Children and Adolescents. Bethel, CT, Crown House Publishing, 2007


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Szigethy EM, Jones NP, Silk J, et al: Brain processing of illness perception in depressed adolescents with inflammatory bowel disease. Poster presented at the 6th annual NIH Director’s Pioneer Award Symposium, Bethesda, MD, October 2010 Tang Y, Preuss F, Turek FW, et al: Sleep deprivation worsens inflammation and delays recovery in a mouse model of colitis. Sleep Med 10:597–603, 2009 Weisz JR, Stipek DJ: Competence, contingency, and the development of perceived control. Hum Dev 25:250–281, 1982 Weisz JR, Yeates KO, Robertson D, et al: Perceived contingency of skill and chance events: a developmental analysis. Dev Psychol 18:898–905, 1982 Weisz JR, Rothbaum FM, Blackburn TF: Standing out and standing in: the psychology of control in America and Japan. Am Psychol 39:955–969, 1984a Weisz JR, Rothbaum FM, Blackburn TF: Swapping recipes for control. Am Psychol 39:974–975, 1984b Weisz JR, Rudolph KD, Granger DA, et al: Cognition, competence, and coping in child and adolescent depression: research findings, developmental concerns, therapeutic implications. Dev Psychopathol 4:627–653, 1992 Weisz JR, McCabe MA, Denning MD: Primary and secondary control among children undergoing medical procedures: adjustment as a function of coping style. J Consult Clin Psychol 62:324–332, 1994 Weisz JR, Thurber CA, Sweeney L, et al: Brief treatment of mild-to-moderate child depression using primary and secondary control enhancement training. J Consult Clin Psychol 65:703–707, 1997 Weisz JR, Southam-Gerow MA, McCarty CA: Control-related beliefs and depressive symptoms in clinic-referred children and adolescents: developmental differences and model specificity. J Abnorm Psychol 110:97–109, 2001 Weisz JR, Southam-Gerow MA, Gordis EB, et al: Cognitive-behavioral therapy versus usual clinical care for youth depression: an initial test of transportability to community clinics and clinicians. J Consult Clin Psychol 77:383–396, 2009 Wysocki T, Harris MA, Buckloh LM, et al: Effects of behavioral family systems therapy for diabetes on adolescents’ family relationships, treatment adherence, and metabolic control. J Pediatr Psychol 31:928–938, 2006 Wysocki T, Harris MA, Buckloh LM, et al: Randomized trial of behavioral family systems therapy for diabetes. Diabetes Care 30:555–560, 2007 Wysocki T, Harris MA, Buckloh LM, et al: Randomized, controlled trial of Behavioral Family Systems Therapy for Diabetes: maintenance and generalization of effects on parent-adolescent communication. Behav Ther 39:33–46, 2008

Appendix 10–A: PASCET-PI Selected Skills and Tools

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Appendix 10–A PASCET-PI Selected Skills and Tools • • • • • • •

ACT and THINK skills STEPS problem-solving worksheet BLUE thoughts Physical illness narrative Mood thermometers for practice activities POWER relationship problem-solving Maintenance plan

ACT and THINK skills A:

Activities. Do activities that solve problems [use STEPS], activities that I enjoy, activities with someone I like, activities that keep me busy, and activities that help someone else.

C:

Calm and confident. Stay calm—make myself relax. Stay confident— show a positive self.

T:

Talents. Develop a special talent or skill. Set a goal, plan steps to reach the goal, then practice, practice, practice!

T:

Think positive. No negative thinking allowed. Change BLUE (negative), unrealistic thoughts into positive, realistic thoughts.

H:

Help from a friend. Think things over with someone I trust.

I:

Identify the silver lining. Figure out what’s good about my situation.

N:

No replaying bad thoughts. Stop thinking about things that make me feel bad. Get my mind on something else.

K:

Keep trying—don’t give up. Keep trying ideas from my ACT and THINK chart until I feel better.

Note.

The spelled-out terms for STEPS and BLUE are included next in this appendix.

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STEPS S

Stay calm and Say what the problem is: Solving problems creatively happens best if a person is calm and relaxed. Thus, the first step in problem solving is staying relaxed.

T

Think of solutions: Thinking of as many solutions as possible will increase the likelihood of coming up with the answer that will best solve the problem.

E

1.

3.

2.

4.

Examine each one: What good and bad things might happen if you did this? What is good, bad, easy, or difficult about each solution? 1.

Good:

Bad:

2.

Good:

Bad:

3.

Good:

Bad:

4.

Good:

Bad:

P

Pick one and try it out: Which one will you try?

S

See if it worked: If it worked, great! If it did not work, then go back to your list of solutions and try another one.

Active STEPS to problem solving.

BLUE thoughts B: Blaming myself L: Looking for the bad news U: Unhappy guessing E: Exaggerating—imagining a disaster


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Physical illness narrative About my physical illness 1a. What are your thoughts about what caused your inflammatory bowel disease? 1b. How do you think it works to cause your inflammatory bowel disease? 2a. Think about all of the problems you have had related to your inflammatory bowel disease. What are they? 2b. Think about all of the symptoms of inflammatory bowel disease that you’ve had in the past 2 weeks. What are they? 3a. How do you feel about having inflammatory bowel disease? 3b. How is the treatment of your inflammatory bowel disease going? 4a. How has your inflammatory bowel disease changed your life? 4b. How has having inflammatory bowel disease changed how you feel about your body? 4c. How has your inflammatory bowel disease made things different for your family? 5a. Is there anything good about having inflammatory bowel disease? What? 5b. Is there anything bad about having inflammatory bowel disease? What? 6.

How much control do you think you have over your inflammatory bowel disease and why?

7a. Can you change the course of your illness (make it better or make it worse)? 7b. What things can you do to make your inflammatory bowel disease better or worse? 8a. What do you do to make your inflammatory bowel disease better or worse? 8b. Rate how well you have been taking care of your illness over the past month using a scale of 1 to 10, in which 1= poor job and 10 =excellent job. 9.

When you are sick with your inflammatory bowel disease, how do you make yourself feel better?

10. What was happening in your life when your illness started?

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How I Felt Before Solution #1

Solution #2

Solution #3

Solution #4

Mood thermometers.

10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1

very good sort of good

so-so sort of bad very bad very good sort of good



so-so sort of bad very bad

How I Felt After 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1 10 9 8 7 6 5 4 3 2 1

very good sort of good




so-so sort of bad very bad


I have the POWER to improve relationships. P

Problem with a relationship: Name one. It can be with a friend, family member, romantic interest, teacher, etc.

O

Outline the positive and negative parts of the relationship: Positive

W

E

R

Negative

1.

1.

2.

2.

3.

3.

Which negative parts do I have the power to change? 1. Part:

How?

2. Part:

How?

3. Part:

How?

Explore each one: What good and bad things might happen if I try to change part of the relationship in this way? List the good and bad results for each “How?” listed above. 1.

Good:

Bad:

2.

Good:

Bad:

3.

Good:

Bad:

Relationship improvement takes action! Decide on one of the things I have the power to change about the relationship, and do it.

Relational problem-solving skill.

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Keep trying What happened when I felt bad: Use ideas from the ACT and THINK chart to come up with THREE PLANS for feeling better:

Plan A Letter from the ACT and THINK chart: What this client should do:

Plan B Letter from the ACT and THINK chart: What this client should do:

Plan C Letter from the ACT and THINK chart: What this client should do:

Maintenance plan.

Appendix 10–B: Guided Imagery

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Appendix 10–B Guided Imagery for Pain Management Before starting this exercise, it is important to have the youth describe the location of his pain, as well as the intensity and severity of his pain; the descriptions and words used by the youth are what the therapist will incorporate into the script. Although the youth will have his eyes closed during the exercise, the therapist will be asking him for verbal feedback to make sure that he is able to visualize the scene being described to him. Let the youth know that some children have mastered this skill so well that they have been able to call on it during surgery, thus avoiding the need for anesthesia or pain medications.

Induction Make yourself as comfortable as you can either sitting or lying down. Gently close your eyes, feeling comfortable and relaxed—let your body go. .. no need to tense any of your muscles ... all you need to do is listen to my voice. Now begin to focus in on the feelings in your right fingers and right hand and let go of whatever tension may be in those muscles—just relax— you will feel relaxation like a warmth or perhaps a pleasant tingling sensation—let it happen—naturally... let the feeling of relaxation spread gradually up your right hand . . . forearm . . . upper arm . . . and into your right shoulder—let go of the tension—relax, just relax... . Now do the same on your left side. .. begin with relaxing the muscles in your left fingers and hand. ..let it spread up your left arm and forearm... upper arm.. .and into your left shoulder. ..now both your left and right shoulders, arms, hands, and fingers are relaxed—keep feeling relaxed. ... That’s great—you’re doing well. ..now, let’s turn your attention to the muscles of your head and neck . . .smooth out the muscles in your forehead—above your eyebrows—down the muscles of your face—over your eyes, your cheeks; your jaw is loose and relaxed—feel the relaxation spreading around your ears—over your head—down the muscles of your neck.. .. You’re doing great—just keep relaxing like that.. .feel relaxation now spreading over your shoulders, down your back, and over your stomach—let it flow further down the muscles of your left and right legs—over your knees, feet, and toes... . Sometimes it is useful to imagine the relaxation as warm waves of water that begin at the top of your head and trickle gently over the muscles of your face, further down over your shoulders, arms, back, legs, and down to your feet—and with each gentle wave of water, feel the tension flushed from your body. ... Now focus on the muscles in your stomach—relax these

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muscles, releasing all the tension. Relax, just relax. In this way, you will be able to chase away any pain or discomfort, leaving you tension-free and calm. To help you relax even more, I’m going to count slowly from 1 to 10, and with each number I call out, you are going to feel even more comfortable and even more relaxed—even when you think it’s impossible to relax any further—there’s always more relaxation you can enjoy just by letting go. ... You may want to picture each number in your head as I call it out.. .. Let’s begin—1, you’re very relaxed... 2, more and more—further and further relaxed. . . 3, feel your whole body getting heavier and looser. . . 4, deeper and deeper relaxed... 5, more and more relaxed. ..6, you are feeling your whole body become totally relaxed.. .7, your body continues to become more and more deeply relaxed.. .8, deeper and deeper into a relaxed, comfortable state. ..9, no cares or concerns, just a carefree, gentle state of relaxation.. .and 10, completely and totally relaxed, feeling carefree, without worries or concerns. Now turn your attention to your breathing...this is the breathing of deep relaxation .. . rhythmic, smooth, effortless. . .listen to your breathing.. .. I would like you to try the following exercise—every time you let out a breath, think quietly to yourself of the word calm—this will help you to associate the word calm with the calm and relaxed state you’re now in—so that at any time in the future you can bring on this state of deep relaxation just by breathing rhythmically, slowly, and saying the word calm every time you let out a breath—do that for a few minutes until I return to talk to you once again (1–3 minutes). Now you are in a deep state of relaxation, and you are going to become even more relaxed...and still more relaxed as we continue. You will be able to shift your body to become more comfortable, and this will not disturb your relaxation or your concentration. You will stay in this relaxed state until I tell you to wake up.

In Trance Now focus on your body. Scan your body and notice the places that cause you pain. When you are asked, you will be able to verbally communicate these areas in your body to me without breaking your trance (pause). When you are ready, please tell me which areas of your body experience pain (pause and wait for the response). Thank you, you are doing a great job. Please imagine your (name a body part that the patient verbalized to you—e.g., stomach) and paint your (name the body part) with an imaginary paintbrush. Paint the entire area that causes you pain. On a scale from 1 to 10, 1 being hardly any pain and 10 being the most pain you have ever had, how much pain are you experiencing in your (name body part)? Focus your attention on your (name the body part), imagining the exact place you feel your pain and the type of pain you feel. Now, imagine a cable or wire connecting your (name the body part) to your brain, the control center for all your feelings, including pain. Can you see this cable? (Wait for a response.) Good. Now, imagine a room in your brain, called the thalamus. When you look inside this room, it is a bright room and you see four walls—each wall is covered by light switches from the ceiling to the floor.

Appendix 10–B: Guided Imagery

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As you look around at these switches, you see that each switch has a piece of tape under it with the name of a body part. You look around the room until you find the switch that has the word “(name the body part)” under it. Did you find this switch? Good. Now as you look closely at this switch, you see it is labeled from 1 to 10, with 10 being the most intense pain setting and 1 being almost no pain. Describe what setting the light switch you are imagining is at. (Wait for a response.) Now imagine the setting being cranked up to a 10, the most intense (name the body part) pain imaginable. Describe how your (name the body part) feels right now. Now visualize yourself turning the light switch down in the control room from 10, 9, 8, and with each number on the switch that you see, imagine the pain becoming less and less intense. Keep turning the switch lower and lower. What is the lowest number you can see the switch turned to?

Encourage the child to keep imagining this until he can visualize the switch being at least a 4 or 5, and continue reinforcing his control over the switch and the corresponding change in pain experienced. Finish the exercise on the lowest pain setting the child can achieve.

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Appendix 10–C Information Worksheets for Parents Helping Your Child Reintegrate Into School After Being Absent for Physical Illness Working With Schools You are your child’s helper in dealing with the school system. Inflammatory bowel disease (IBD) is uncommon, so the school may not understand it or may confuse it with less serious disorders. Your gastroenterologist can provide you with a letter as well as a pamphlet from the Crohn’s and Colitis Foundation of America explaining IBD, the ways it can affect school function, and the special needs that children with IBD may have. It will be important for you to get to know the contact people in the school, as well as school policies on absences and making up work. Should My Child’s Friends Be Told? Respect your child’s wishes—he or she should decide whether to tell friends about the illness. Your child may choose not to tell peers, especially in the beginning, but this may change. Should My Child’s Teacher Be Told? Yes, teachers should be told about your child’s illness and symptoms and what they can do to help: • Give your child permission to leave class to use the bathroom without asking each time, or provide a private bathroom or nurse’s facility. • Provide makeup work and extra help if your child is absent for long periods of time. • Facilitate administration of medications by the school nurse so that your child is not singled out at inappropriate times. • Communicate with you and your child’s medical team about possible flares or other difficulties noticed. Handling Academic Concern • Meet with your child’s principal and teacher to discuss a catch-up plan for long absences, tutoring options, and an individualized educational plan.

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• Set up a buddy system with one of your child’s friends who will keep track of homework assignments, bring over necessary books, and let your child know what went on in school that day. • Create a homework plan—set reasonable goals for completing homework, designate time in the day as homework time, and be available to assist your child. • Be clear on expectations for each class and the consequences of not keeping up with schoolwork. Section 504 of the Americans With Disabilities Act Prohibits Schools That Receive Federal Funds From Discriminating Against Children With Medical Disabilities A 504 plan is a map of needed assistance for students with medical disabilities, and having one in place can smooth reentry after absence for illness. IBD can be a medical disability. If you believe your child needs special supports or services to participate fully in school, you must write to your school district and explain the type of assistance you believe is needed. Accommodations that are commonly needed include the following: • When the child needs to miss school for medical reasons, the child should not be penalized for it. • The child should be given the assignments for missed work in writing. • The child should be allowed a reasonable time after he or she has recovered from the episode to complete missed schoolwork, including examinations. • It is medically necessary that the child be able to self-limit physical activity. • It is medically necessary that the child have unrestricted access to a bathroom. Your gastroenterologist can provide you with a letter stating that IBD is a medical disability and the types of accommodations frequently needed, but you will need to work with the school to get these accommodations implemented. Chronic Physical Illness in a Child or Adolescent Can Cause Parents to Become Overprotective: What Can You Do? • Foster independence by encouraging your child to take responsibility for some medical routines (taking medications and calling the doctor), so that you won’t have to constantly remind him or her. • Whenever possible, encourage your child to make decisions and to try new things and activities.

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• Praise small steps of independence in your child. • Encourage participation in fun activities with your child’s friends. This is especially important, because teens with physical illness can miss out on social opportunities due to sickness. Encourage Your Child to Find Practical Ways of Dealing With the Illness at School • Learn where the nearest bathrooms are. • Carry extra underclothing. • Visit the nurse’s office when necessary. Handling Curiosity and Questions About the Illness • Again, it is up to your child to determine whether he or she will tell classmates about the illness. • Let your child know that he or she can make casual responses without going into too much detail; for example, “I was sick and in the hospital, but I feel better now, so I can come back to school”; or “Yeah, I was feeling sick, but I don’t like to think or talk about that now that I’m feeling OK.” • If questions are about medication side effects (such as a puffy face), matter-of-fact statements like “That’s because I have to take strong medication, but it’ll go away when I stop taking it” may be helpful in diffusing curiosity. Even a shrug and an “I don’t know” can stop questions. Handling Teasing and Name Calling Depending on your child’s comfort level, a good strategy is often a nonchalant response such as those given above. If that is unsuccessful, ignoring is best. Reintegration Into Extracurricular Activities • Although prolonged high-dose steroid therapy may make contact sports such as football or wrestling ill-advised (ask your doctor), your child should be able to do anything he or she feels like doing. • Speak to the coach or activity supervisor about modifications that could be made to facilitate your child’s participation (e.g., fewer laps if easily fatigued in basketball, bathroom breaks in art class or music lessons). Initiating a Preventive Plan Before Illness • It may be helpful to begin creating a plan before a disease flare-up so that a system for your child to stay connected academically is already in place.

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• Familiarize yourself with the necessary contact persons and the school’s policies regarding absences. What About Homeschooling? • Consult with the medical team if there is any medically necessary reason for the child to be homeschooled (e.g., severe immune suppression). • Make sure to research computer-based school programs you are considering, for credentials, academic rigor, and statistics about how these students integrate back into school or college in the future. • With the lost socialization opportunity of school contact with peers, it is essential for children and adolescents who are homeschooled to have other social opportunities with peers.

Improving Medical Compliance of Your Teenager or Child Understanding How Developmental Factors Can Influence Compliance • Physical illness can interfere with adolescents’ ability to separate from their parents and create their own identity because they are more dependent on caretakers. • Adolescent omnipotence: the belief in invulnerability to harm. Many adolescents make statements such as “That will never happen to me” or “I could never get that.” The ideas adolescents have about being invincible may contribute to medical noncompliance. • Peer issues play an important part in medical compliance. Having a chronic illness is stigmatizing, and taking medications in front of peers may be embarrassing for adolescents. It is also important to keep in mind that some inflammatory bowel disease (IBD) medications have cosmetic side effects, making them particularly undesirable for teenagers. Understanding How Physical Illness Issues May Influence Compliance As noted above, the side effects of some IBD medications (e.g., weight gain, irritability, puffiness) may keep adolescents from complying with their course of treatment, as they are very sensitive to changes in body shape and size. Creating a Consistent Behavioral Plan With Input From Your Teenager • Consider the level of parental supervision needed to keep your child medically compliant. It is important to set firm yet empathic limits.

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• Try setting up a reward system with your child to reinforce medical compliance. You may remember creating a similar plan to reward your child for completing his or her practice assignments. You can use this as an example or come up with a new system that would work better for your family. • Although it is important to reinforce compliant behavior, it is also important to discuss ways in which medical noncompliance can be addressed. You and your child may want to think about certain privileges that can be taken away if medications or medical appointments are missed. • To make it easier for your child to remember his or her medications, use home-based visual cues or reminders (e.g., phone calls). In addition, organize all medications so that it is easy to figure out when each medication should be taken. Pillboxes are great investments. Below are some helpful hints for improving medical compliance. 1. Keep a medication calendar. 2. Have your child take medications at the same times every day. 3. Have your child take medications at the same time as another activity he or she does every day, like brushing his or her teeth or eating meals. • Use ACT and THINK coping skills to improve medical compliance. For example, the K stands for “Keep trying—don’t give up.” Apply this to the various plans you and your child come up with to improve medical compliance. If one system doesn’t work, think about ways to improve it and keep trying until it works. Improving Communication With the Medical Team • Always feel comfortable discussing any treatment concerns or communication issues with your doctor. It is crucial that you and your child feel supported and respected by the treatment team. If this is not true for your family, please discuss this with your doctor and therapist. • Keep track of symptoms and report them rapidly to your child’s doctor. Recording symptoms in a journal and dating each entry may help your child remember exactly how he or she was feeling when the doctor asks. Also, let the doctor know about any medical compliance issues and/or side effects your child may be experiencing from his or her IBD medications.

11

Obesity and Depression A Focus on Polycystic Ovary Syndrome Dana L. Rofey, Ph.D. Ronette Blake, M.S. Jennifer E. Phillips, M.S.

ACCORDING to U.S. Centers for Disease Control and Prevention data, approximately 17% of children and adolescents are obese, with significant medical sequelae into adulthood (Ogden et al. 2006). The myriad health risks associated with childhood and adolescent obesity include cardiovascular complications, insulin resistance, and chronic inflammation (Ford et al. 2001; Freedman et al. 1999). Obesity, along with cardiovascular disease, has been shown to track into adulthood (Fuentes et al. 2003;

S This chapter has a video case example on the DVD (“Polycystic Ovary Syndrome”) demonstrating CBT for a depressed adolescent with obesity. Supported by grants K12HD-043441; K23HD-HD061598.

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Hemmingsson and Lundberg 2005; Magarey et al. 2003). In contrast to the well-established physical health consequences, the psychological correlates of obesity in childhood are less clear (Friedman and Brownell 1995; Wardle and Cooke 2005). However, growing evidence suggests that obese youth often exhibit depressive symptoms and are often the targets of bias by peers (Kraig and Keel 2001; Latner and Stunkard 2003; NeumarkSztainer et al. 2002), teachers (Bauer et al. 2004; Neumark-Sztainer et al. 1999), and guardians (Davison and Birch 2004). Thus, similar to long-term physical consequences, the negative impact of obesity-related stigma may have lasting effects on emotional well-being (Phillips et al. 2010).

Polycystic Ovary Syndrome as a Model Physical Illness Polycystic ovary syndrome (PCOS) is the most common endocrine disorder among women of reproductive age, and rates have been exponentially increasing at 5%–10% prevalence each year (Arslanian and Witchel 2002; Azziz and Kashar-Miller 2000; Knochenhauer et al. 1998). Although the exact etiology of PCOS is unknown, two theories exist: 1) hypothalamic/pituitary dysregulation of luteinizing hormone and follicle-stimulating hormone leads to increased ovarian androgen production; and 2) hyperandrogenism occurs secondary to insulin resistance. According to criteria resulting from an expert conference sponsored by the National Institutes of Health in April 1990, a diagnosis of PCOS requires the following: 1) clinical or biochemical evidence of hyperandrogenism (i.e., excess production of male hormones by the ovaries); 2) infrequent, irregular ovulation; and 3) exclusion of other known disorders (Azziz et al. 2006). The spectrum of metabolic abnormalities for adolescents with PCOS is complicated, but typically includes insulin resistance and inflammation (Apter et al. 1995; Legro 2002; Lewy et al. 2001; Morin-Papunen et al. 2003; Palmert et al. 2002). The majority of adolescents with PCOS are overweight or obese. Obesity appears to be closely associated with PCOS; for example, in the United States, more than half of the patients with PCOS are either overweight or obese. It is well known that obesity influences the phenotypic expression of PCOS, and obesity might play a significant role in the pathophysiology of associated physical symptoms. Furthermore, obese patients with PCOS have more severe cardiometabolic risk factors compared to their lean counterparts (Yildiz et al. 2008). Moreover, symptoms of depression have been found to be common comorbidities of the PCOS diagnosis (Elsenbruch et al. 2003; Himelein and Thatcher 2006; Hollinrake et

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al. 2007; Rasgon et al. 2003; Weiner et al. 2004). To our knowledge, data that have been collected from 2008 through 20011 reveal a rate of depression in adolescents with PCOS with rates of approximately 50% (n=119) in a treatment-seeking sample. The intriguing aspect of the relationship between obesity and depression is that it is biochemical in nature. To date, only two studies have carefully explored the relationship among laboratory values, depression, and weight in adult women with PCOS. Preliminary findings reveal 1) testosterone levels that are slightly elevated and significantly related to depression after controlling for weight (Weiner et al. 2004), and 2) higher body mass index (BMI) and insulin resistance in depressed women (Rasgon et al. 2003). Therefore, adolescents with PCOS present as an ideal treatment-seeking pediatric population given the high comorbidity of obesity and depression. In this chapter, we review the psychological consequences associated with childhood obesity; provide empirical evidence for cognitive-behavior therapy (CBT) to treat obesity; and provide an overview of the theory and application of Healthy Bodies, Healthy Minds—a manualized CBT intervention created to address concomitant obesity and depression in female adolescents with PCOS.

Psychological Correlates of Pediatric Obesity In addition to the adverse physical health effects of pediatric obesity (BMI percentile ≥95), a growing body of evidence indicates damaging psychosocial consequences of severe overweight (BMI percentile ≥85). These include weight-based teasing (Eisenberg et al. 2003), social isolation and discrimination (Latner and Stunkard 2003), body dissatisfaction and low self-esteem (Eisenberg et al. 2003; Pierce and Wardle 1997), and depression and anxiety (Goodman and Whitaker 2002).

Teasing and Social Rejection Weight-based teasing encountered by obese youth may take several forms, including verbal remarks such as name calling; being the target of rumors; and being ignored, avoided, or otherwise socially excluded. More recent data reveal an alarming trend that may involve physical bullying as well (see review by Puhl and Latner [2007]). Obese children are rejected more often by peers and are more likely to be socially isolated than their nonoverweight counterparts (Pearce et al. 2002; Strauss and Pollack 2003).

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Body Dissatisfaction Reviews conclude that obese children, particularly girls, exhibit greater body dissatisfaction than their normal-weight peers (Ricciardelli and McCabe 2001; Wardle and Cooke 2005). Further, body dissatisfaction may have a negative impact on self-esteem in obese children. More recent data document a mediation effect for body dissatisfaction in the association between obesity and self-esteem in a sample of elementary school children (Shin and Shin 2008).

Low Self-Esteem The internalization of weight-based discrimination may have negative implications for self-esteem in obese youth. Weight-based teasing has been associated with poorer self-esteem and an increased likelihood of depression among adolescents (Eisenberg et al. 2003). Prospective data demonstrate that weight-based peer teasing, along with parental weight criticism, mediates the relationship between overweight and low self-concept in obese adolescents (Davison and Birch 2002). Further, weight-related teasing has been shown to account for associations between weight and body dissatisfaction in youth (Lunner et al. 2000; van den Berg et al. 2002). This result appears to extend into adulthood, as a retrospective study of adults reported an association between childhood weight-based teasing and adulthood body dissatisfaction (Grilo et al. 1994). Prospective studies examining the development of low self-esteem and obesity generally show that excess weight in children predicts future low self-esteem (Brown et al. 1998; Davison and Birch 2001, 2002; Hesketh et al. 2004; Strauss 2000; Tiggemann 2005). Epidemiological (French et al. 1996) and clinical (Zeller et al. 2004) data also demonstrate that body mass is inversely related to self-esteem in children, although comprehensive reviews of self-esteem and obesity reveal this relationship to be modest (French et al. 1995; Wardle and Cooke 2005). However, the relationship between self-esteem and obesity appears to be stronger when obese children are compared with their nonobese peers, specifically on measures of physical self-perception (Braet et al. 1997) rather than global self-esteem.

Anxiety and Depression To date, the evidence supporting an association between anxiety-related disorders and pediatric obesity is inconclusive. Some studies demonstrate no significant differences for anxiety symptoms between overweight and


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normal-weight children (Tanofsky-Kraff et al. 2004) and adolescents (Lamertz et al. 2002). In contrast, obese adolescents participating in an inpatient weight-loss program reported higher lifetime prevalence of anxiety disorders as compared with nonobese control subjects (Britz et al. 2000; Buddeburg-Fisher et al. 1999). A more recent longitudinal investigation of childhood psychopathology and body mass in youth ages 8–18 years showed a significant increase in anxiety for obese boys as compared to control subjects (Rofey et al. 2009a). Evidence of a relationship between obesity and depression in children is also mixed. Research generally shows that community-based samples of obese children do not differ in levels of depression compared to averageweight peers (Brewis 2003; Eisenberg et al. 2003; Wardle et al. 2006). However, in treatment-seeking clinical samples, obese children appear to display higher levels of depression than normal-weight controls (Britz et al. 2000; Erermis et al. 2004). As for cause-and-effect relationships, more research is needed. Two prospective studies did not show that obesity predicted depression in adolescent girls (Stice and Bearman 2001; Stice et al. 2000), whereas research among boys demonstrates a modest relationship between chronic obesity and higher levels of depression over time (Mustillo et al. 2003). In contrast, other evidence indicates that it is childhood depression that predicts the development of obesity in both children (Goodman and Whitaker 2002) and adults (Anderson et al. 2006; Richardson et al. 2003; Rofey et al. 2009a). Thus, no clear association between child psychopathology and obesity has been established, yet the possible long-term negative sequelae of these disorders reinforce the need for future research, particularly regarding the elucidation of any directional relationships. Regardless of the causal relationship, given the high rate of obese children presenting with depression, an empirically validated intervention to target both weight and mood is warranted. An extensive literature spanning several decades has addressed the importance of the relationship between weight and mood, specifically depression (Faith et al. 1997, 2002; Franko et al. 2005). Because mood disturbances commonly occur during childhood (Dahl and Spear 2004; Lewinsohn et al. 1993), recent studies have investigated whether depression experienced in childhood affects obesity in young adulthood. Pine et al. (1997) noted a positive predictive relationship between depressive symptoms at age 14 and both BMI and obesity at age 22. Franko et al. (2005) extended these data and traced depressive symptoms at ages 16 and 18 to an increased risk of obesity in adulthood. More recently, Rofey et al. (2009a) found that depression and anxiety (in girls) and anxiety (in boys) predict BMI percentile over time in a nonobese sample, which replicates previous work in obese samples (Goodman and Whitaker 2002).

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An efficacious (and effective) intervention is crucial given the long-standing relationship between these two variables and the high likelihood that patients present with constellations of both obesity and depressive symptoms. (See Chapter 5 for empirically supported treatments for childhood depression.)

Empirical Research in Behavioral Treatments for Pediatric Obesity Fortunately, a number of strategies have been shown to help prevent or reduce childhood obesity, and research demonstrates the positive health impacts of weight-loss interventions for pediatric populations (Becque et al. 1988; Epstein et al. 1995; Katch et al. 1988; Rocchini et al. 1988). Similarly, long-term improvements in psychological factors (e.g., depression) have been noted in children who have completed weight-loss programs (e.g., Levine et al. 2001). The increased prevalence of childhood obesity, although likely due to a combination of factors, has been largely attributed to the influence of environmental factors (i.e., nutrition and lifestyle) (Miller and Silverstein 2007), and evidence indicates that some combination of caloric restriction and exercise education has a greater impact on weight loss than one isolated component (Epstein et al. 1984, 1985; Rocchini et al. 1988). Thus, empirically supported treatments for pediatric obesity typically include nutritional education (Emes et al. 1990; Epstein et al. 1984, 1985) and the promotion of increased physical activity (Epstein and Goldfield 1999; Epstein et al. 1995). In addition, findings suggest that the involvement of both children and parents in treatment (Brownell et al. 1983; Kingsley and Shapiro 1977; Renjilian et al. 2001) contributes significantly to pediatric weight-loss efforts.

CBT One of the most empirically validated modalities for psychosocial aspects of obesity is CBT. In pediatric obesity, the goal of CBT is to assist youth in reducing self-defeating thoughts around wellness behaviors. It is important to assist the patient in identifying more adaptive coping strategies, such as less emotional eating, more assertiveness, and greater need sharing. When applied in this context, CBT helps patients gain insight into the connections among their thought processes, emotional responses, and eating behaviors. CBT strategies attempt to address issues that may have been overlooked in early behavioral programs, including cognitive distortions re-


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garding body image and eating; instruction in self-monitoring, problemsolving techniques, and motivational issues; and specific weight-loss goals and barriers to healthy behavior. Although some evidence suggests that a behavioral approach to pediatric obesity may be superior to cognitive strategies (Herrera et al. 2004), the inclusion of cognitive treatment components in laboratory-based investigations of childhood and adult weight loss has shown favorable results (Brownell et al. 1983; Coates and Thoresen 1981; Senediak and Spence 1985; Williams et al. 1993). Similar to behavioral programs, cognitive components are typically used in conjunction with dietary and physical activity education. One early cognitive-behavioral treatment program for children ages 9–13 years involved a 9-week program that included dietary and activity self-monitoring, cognitive strategies for managing negative self-statements, and assertiveness training (Kirschenbaum et al. 1984). Children in the cognitive treatment group lost significantly more weight than control subjects and retained their weight loss at 3-month follow-up. Duffy and Spence (1993) randomly assigned 27 overweight children (ages 7–13 years) to eight sessions of either behavioral management or combined behavioral-cognitive treatment. No differences between treatment groups were noted, and both groups of children demonstrated significant improvements in weight at 6- and 9-month follow-up. Thus, although additional research is needed to establish whether differences in outcome may exist between behavioral treatment and cognitively based strategies, it appears that the two approaches to pediatric weight loss may be equally valuable.

Motivational Interviewing Although CBT is considered to be the safest modality for weight loss in youth, compliance issues often lead the families of obese children and adolescents to seek alternative, though riskier, strategies (e.g., pharmacotherapy, bariatric surgery) (Miller and Silverstein 2007). Motivational interviewing techniques aimed toward enhancing adherence to dietary and exercise recommendations in children and families could play a key role in promoting safe and effective long-term weight management. Motivational interviewing is a therapeutic strategy aimed at helping individuals to explore ambivalence about making behavioral changes and has been suggested as a possible tool for helping achieve dietary and physical activity modifications (DiLillo et al. 2004). Using reflective listening and methods to elicit “change talk,” motivational interviewing seeks to resolve ambivalence and strengthen clients’ reasons for engaging in positive behavior change consistent with their goals and values (Miller and Rollnick 1991).

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Research on motivational interviewing for the treatment of obesity in pediatric populations is limited, yet promising. To date, little research has been done in the area of motivational interviewing and pediatric weight loss. Some data suggest that motivational interviewing assists in promoting more healthful eating habits, increasing physical activity, and improving weight status in adults, but these findings are not consistent (Berg-Smith et al. 1999; Dunn et al. 2001; Smith et al. 1997). Thus far, only two pediatric weight-loss interventions have employed motivational interviewing techniques, and these are the Healthy Lifestyles Pilot Study (Schwartz et al. 2007) and Go Girls (Resnicow et al. 2005). The Healthy Lifestyles Pilot Study, conducted from 2004 to 2005, was aimed at the prevention of overweight among children ages 3–7 years (Schwartz et al. 2007). Pediatric Research in Office Settings clinicians were trained to provide motivational interviewing to patients during office visits. Patients in the control group received usual care, whereas those in the minimal intervention group received one motivational interviewing session and those in the intensive intervention group received two motivational interviewing sessions during office visits. At 6-month follow-up, patients in the minimal intervention and intensive intervention groups showed a trend of decreasing BMI-for-age percentiles, although results were not statistically significant. Decreases in families’ eating-out behavior and high-calorie snacking were also noted. Thus, although children’s weight changes failed to reach significance, this study demonstrated the feasibility of implementing a physician office–based obesity prevention program using motivational interviewing. Go Girls was a church-based nutrition and physical activity program designed for overweight African American adolescent females. In one of the treatment conditions, girls received four to six motivational interviewing telephone counseling calls focused on participants’ progress. Unfortunately, both 6-month and 1-year follow-up assessments indicated no significant BMI differences between the motivational interviewing group and control subjects. Thus, at present, insufficient data exist to determine the efficacy of motivational interviewing for the prevention or treatment of pediatric obesity in children (Resnicow et al. 2006).

Key CBT Techniques Targeting Pediatric Obesity A variety of CBT techniques are used to target obesity (see Chapter 5 for how some of these same techniques assist with depression in children). Several techniques are broad-based CBT concepts that may overlap with tech-


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niques presented in other chapters throughout this book. These key ingredients can be broken down into behavioral and cognitive facets, linked by the fact that cognitive change is the primary aim of CBT. (Note that some data also support the efficacy of pharmacological and surgical interventions in the treatment of the most severe cases of pediatric obesity; see “Suggested Readings and Web Sites” at the end of this chapter for sources).

Behavioral Facets Dietary Guidelines The National Heart, Lung, and Blood Institute and The Obesity Society recommend low caloric intake that is intended to induce a caloric deficit greater than 500 kcal/day and thus assist children in losing approximately 0.5–1 pound per week. Moreover, specific guidelines are given for girls trying to lose excess body weight, with consideration given to medical factors (e.g., a certain percentage of calories should come from protein versus carbohydrates).

Physical Activity The American College of Sports Medicine recommends 60 minutes per day of physical activity for children. Physical activity refers to any movement that occurs throughout the course of the day. For obese patients, small, manageable changes typically lead to an increased heart rate and subsequent weight loss. Therefore, physical activity during a CBT obesity treatment should focus on activities targeted to the abilities of obese patients.

Self-Monitoring Self-monitoring, or recording food intake (time, amount, calories, relationship to mood) and physical activity (type, duration, steps taken), is the most important skill taught in standard behavioral programs. Being able to accurately measure caloric intake and energy expenditure assists patients and their families in reaching weight-loss goals.

Goal Setting Setting goals is important for achieving success and overcoming challenges. In a CBT obesity treatment, setting weekly reasonable goals for nutrition, physical activity, and general lifestyle (i.e., positive thinking) is a major component.

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Stimulus Control and Family Involvement Family-based involvement is a key CBT component in managing the participant’s environment. Research on adolescent obesity treatment indicates that family involvement is crucial for maximized success (Epstein et al. 1995). Family members are educated about the relationship between obesity and depression, as well as ways to help the participant engage in a healthier lifestyle. Moreover, the essence of stimulus control in pediatric obesity consists of removing the high-risk foods from the home. Given that some family members may feel as though “this is not fair,” we discuss the concept that everyone in the family can benefit from healthy lifestyle changes.

Relaxation Training Diaphragmatic breathing, progressive muscle relaxation, and guided imagery are also taught during the intervention, to help the participant cope with stressful situations. As more data show that aberrant eating patterns may be due to emotionally stimulating events, relaxation training becomes an even more salient component of obesity treatment.

Behavioral Activation The participant is reminded to increase time spent in pleasurable activities on a daily basis. Given the nature of obesity, small, manageable aspects of behavioral activation are discussed (e.g., putting tennis shoes on as a first step to being more active).

Homework and Between-Session Assignments Patients are encouraged to set their own goals, especially surrounding food intake and energy expenditure. Because CBT encourages practice between sessions, patients may be assigned “experiments” or to set their own goals.

Cognitive Skills Problem Solving This lifestyle skill is emphasized to address healthier food intake, more consistent and variable physical activity, and roadblocks to positive thinking. In the intervention, problem solving is encouraged by identifying what the problem is, generating different solutions, and evaluating the consequences of each solution.


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Cognitive Restructuring When using this critical component of CBT for obesity, the coach (i.e., therapist) encourages the participant to identify dysfunctional thinking and identify more adaptive, countering ways to reduce negative thinking. By the end of the intervention, participants should be able to provide countering alternatives to minimize stressors and maladaptive thinking surrounding the presenting problem.

Relapse Prevention This skill is used to help reinforce the CBT model and monitor for recurrence of weight gain and/or depression and to prepare for future stressors. Further, the distinction between lapses (“slip-ups”) and relapses is discussed with the patient to prevent lapses from becoming relapses.

Healthy Bodies, Healthy Minds: A Manualized Intervention Leonard Epstein and colleagues have shown that family-based lifestyle change—including the incorporation of exercise into daily living (Epstein et al. 1995), decreasing sedentary behaviors (Epstein et al. 2008), and dietary changes (Epstein et al. 2001)—promotes greater decreases in percentage overweight in children. In the creation of Healthy Bodies, Healthy Minds (HBHM), we have expanded on Epstein’s family-based weight management program (the Traffic Light Diet; Epstein and Squires 1988) to incorporate more client-centered tools for adolescents with PCOS (e.g., introducing a healthy plate that incorporates a starch, protein, and fruit or vegetable with appropriate portions for each meal; following a <5 g fat/>2 g fiber/<10 g sugar guideline; increasing pedometer steps per day), along with motivational interviewing concepts to elicit intrinsic motivation while decreasing resistant behaviors (Table 11–1 shows key components of Epstein’s program that have been integrated into HBHM). In addition, we incorporated depressive targets from the manual for Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI; Szigethy et al. 2007, 2009; see Chapter 10 for discussion of this model) to target depressive symptoms in these physically ill adolescents. The resulting intervention, HBHM, showed favorable initial results in a pilot trial (Rofey et al. 2009b), which has recently been extended to recruit adolescents with PCOS and depression, who are then randomly assigned to the HBHM manualized treatment versus treatment as usual.

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HBHM uses CBT and motivational interviewing to educate and motivate PCOS patients to make lifestyle changes through eight intensive oneon-one sessions with a behavior coach. Each session begins with the behavior coach going over the manualized treatment (i.e., the content of each session) for approximately 45 minutes. After the content is reviewed, the coach or an exercise physiologist completes 15–20 minutes of physical activity with the patient. The type of physical activity is provided on the basis of the participant’s interest (e.g., walking, video, resistance training, cardio) and depending on her level of existent physical movement. An emphasis is placed on healthy lifestyle goals, and secondarily, on the impact that positive thinking (i.e., decreasing depressive symptomatology) can have on the participant. Moreover, there is an attempt to reduce stigma and increase compliance by emphasizing the health focus and decreasing pathologizing the patient. The therapist is typically referred to as a coach; several focus groups were conducted that indicated the participant’s desire to “avoid psychotherapy.” The reasoning behind this term is not to undermine the utility of mental health counseling but instead to increase intrinsic motivation, because many adolescents with PCOS have failed therapy on numerous occasions. Following the intensive portion of the intervention, in which the participant meets on a weekly or biweekly basis with her coach, treatment continues with three booster sessions, in which the participant meets monthly with the coach to check in on her progress. During the entire intervention, family involvement is strongly encouraged as data show this to be one of the best predictors of obesity management and depression treatment.

Empirical Research and Results In HBHM, facets of PASCET (Szigethy et al. 2007; Weisz et al. 2009) were adapted to treat depression in a physically ill sample, and aspects of Epstein’s family-based pediatric weight management program (the Traffic Light Diet) and additional motivational interviewing–compliant goal setting were used to target improving nutrition, increasing physical activity, and decreasing sedentary behavior. Epstein’s weight management program has been empirically validated since the 1980s and in more than 25 randomized controlled trials (e.g., see Epstein and Goldfield 1999; Epstein et al. 1981, 1984, 1985, 1995, 2000, 2001, 2008). The PASCET model has been repeatedly validated in youth with obesity and depression and in youth with depression and physical illness (see Chapter 10 for extensive empirical evidence of this treatment). Two trials have been conducted testing this specific, combined treatment. First, an open trial (Rofey et al. 2009b) was conducted to evaluate the


TABLE 11–1.

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Key components of the Traffic Light Dieta incorporated into Healthy Bodies, Healthy Minds

Component

Description

Self-monitoring

Writing down food intake and steps taken in an effort to heighten selfawareness.

Stimulus control

Getting high-fat, high-calorie foods out of the house to decrease temptation.

Family-based components

Having a supportive person who assists the child in weight-loss endeavors and serves as a model or coach.

Traffic Light Guide (caloric restriction) Focusing on increasing foods with < 2 g of fat (i.e., GREEN foods), moderating foods with 2–5 g of fat (i.e., YELLOW foods), and decreasing foods with >5 g of fat (i.e., RED foods). Decreasing sedentary time and increasing physical movement

a Epstein

Limiting screen time per night (excluding schoolwork) and assisting the child to identify fun ways to move that incorporate everyday lifestyle activities (e.g., walking) and purposeful exercise (e.g., playing soccer).

and Squires 1988.

feasibility and effectiveness of an enhanced CBT, HBHM, for physical (obesity) and emotional (depression) disturbances in adolescents with PCOS. Twelve adolescents with PCOS, obesity, and depression underwent eight weekly sessions and three family-based sessions of CBT enhanced by lifestyle goals (nutrition and exercise), a physical illness narrative (meaning of having PCOS), and family psychoeducation (family functioning). Weight showed a significant decrease across the eight sessions, from an average of 104 kg (SD±26) to an average of 93 kg (SD±18). Depressive symptoms on the Children’s Depression Inventory (CDI) significantly decreased, from a mean of 17 (SD±3) to a mean of 9.6 (SD±2). This open trial revealed that a manual-based CBT approach to treat depression in adolescents with PCOS and obesity appears to be promising. Subsequently, a comparative treatment trial has been under way for approximately 2 years. Changes to enhance the weight management portion of the current HBHM manual include the following: more nutritional compo-

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nents addressing eating healthy with PCOS; extension of treatment from 8 sessions to 11 sessions through a combination of 4 weekly sessions, 4 biweekly sessions, and 3 monthly booster sessions; and incorporation of more motivational interviewing. Fifty participants (thus far) have participated in this comparative treatment trial. By the end of the trial, 63 participants will have received HBHM and approximately 50 participants will have received treatment as usual. Currently, 50 patients receiving HBHM have experienced significant decreases in weight, from an average of 105.82 kg (SD=25.94) to an average of 104.10 kg (SD=26.20), and a decreased score on the CDI, from a mean of 13.85 (SD=8.48) to a mean of 10.05 (SD=8.92). A similar trend was seen between session 1 and session 11 (the last booster session), with weight significantly decreasing, from an average of 103.63 kg (SD=21.42) to an average of 99.30 kg (SD=23.10), and decreased CDI scores, from an average score of 12.11 (SD=6.24) at session 1 to 7.36 (SD=6.45) at session 11. Although recruitment for the treatmentas-usual group (i.e., standard endocrine management of PCOS) has not been completed, data from 39 participants with PCOS who received treatment as usual showed that they gained approximately 2 pounds (starting weight = 99.8 kg [SD = 20.6] and posttreatment weight = 101.2 kg [SD=23.6]) over the same time frame as young women receiving HBHM, who lost, on average, approximately 2 pounds. These data will continue to be collected, with an end goal of a randomized controlled trial that incorporates other sites across the country to recruit the number of adolescents with PCOS needed to exhibit findings that can be generalized.

Treatment Overview Table 11–2 provides an overview of the behaviors targeted in HBHM. This 11-session “dose” is an initial active-phase treatment for adolescents with obesity and co-occurring mood disturbance presenting within a clinical setting. Because 8–12 sessions have been empirically validated for adolescents with major depression and 4–12 sessions have been associated with significant initial weight loss for adolescents presenting to outpatient obesity centers, an 11-session intervention is implemented. However, the acknowledgment needs to be made that longer, more intensive HBHM treatments may be more efficacious.

Family-Based Sessions Incorporating the family into the treatment plan is crucial for success. Often, parents and other family members dictate what food choices the adolescent has at home. Additionally, the lifestyle habits of adolescents tend


TABLE 11–2.

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Overview of behaviors targeted by session in Healthy Bodies, Healthy Minds

Session Behaviors 1

Overview of the program, description of healthy eating and physical activity, and difference between dieting and lifestyle change

2

Logging food and movement, reading food labels, and avoiding food traps

3

Managing emotions, avoiding sneak eating, and psychological versus physiological hunger

4

Using the Traffic Light Guide and other self-selected tools to increase health and wellness

5

Staying motivated, increasing physical activity, everyday lifestyle movement, and decreasing sedentary behavior

6

Changing self-talk to be more positive, developing a healthy body image and self-esteem

7

Being more self-aware with regard to eating, being active, and staying positive

8

Overcoming barriers; planning ahead for healthy meals, special occasions, and eating out Monthly booster sessionsa

1

Coping with polycystic ovary syndrome

2

Adjusting to the Healthy Bodies, Healthy Minds plan

3

Reflecting on the intervention

a Subsequent

to eight sessions above.

to be heavily influenced by parents’ habits; therefore, targeting and working with parents is important. Through three parent sessions, HBHM strives to motivate parents to make changes to the home environment and to serve as coaches for their child. (For clarity in further discussion, “coach” will refer to the therapist or behavior coach, and not to the parent as coach, unless otherwise indicated.) The first parent session focuses on creating a home environment that encourages healthy eating habits. During this session, the behavior coach discusses ways that the parents can create this environment through their grocery store purchases and cooking habits (e.g., baking instead of frying foods). Additionally, parents are encouraged to create an eating environment that encourages healthy food consumption habits (e.g., eating meals as a family).

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Many parents cannot easily cook every meal at home due to time constraints, so the coach also addresses ways that parents can encourage healthy food choices when dining out, complete with calorie charts from many restaurants. The second parent session focuses on parenting strategies that the parent can use to encourage healthy behaviors and discourage less healthy habits. The coach will discuss the difference between reinforcement and punishment, describing in detail the difference between positive reinforcement (giving something to encourage a behavior) and negative reinforcement (taking something away to discourage a behavior). During this session, the coach guides and encourages parents to use positive reinforcement (such as praise) by describing the utility of this strategy. The coach also provides brief assertiveness training and techniques for setting limits and rules within the home. The third parent session focuses on preparing parents to serve as coaches at home by providing an overview of the content that the behavior coach has covered with the participant during the intervention. Here, the behavior coach describes all of the tools that the participant has been educated to use so that parents can encourage use within the home environment.

Motivational Interviewing Components While CBT serves as the empirically validated therapeutic approach in HBHM and teaches adolescents how to reduce their physical and emotional disturbances, motivational interviewing techniques elicit health behavior change by enhancing intrinsic motivation (Resnicow et al. 2006). An engagement session that transpires at the first meeting with each participant uses the key principles of motivational interviewing (Miller and Rollnick 2002): suspension of the clinician’s assumptions, use of open-ended questions, expression of empathy and reflective listening, rolling with patients’ resistance, working with change and adherence talk, and supporting the patients’ selfefficacy. HBHM draws on motivational interviewing components to enhance the likelihood that adolescents with PCOS who are struggling with weight and mood disturbances will enter, attend, and participate actively in the CBT protocol. In this modified therapy, CBT and motivational interviewing serve as complementary approaches. Asking open-ended questions, encouraging the patient to tell her own story, seeking elaboration on important or unclear points, and identifying and affirming strengths are common themes throughout the HBHM intervention. Motivational interviewing emphasizes the potential for participants’ own goals, preferences, values, and ideas about what is healthy or adaptive. The work of motivational interviewing is to place the patient’s personal perspective at the center of the discussion and not to have the be-


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havior coach express his or her own desires (i.e., for the coach to avoid the impulse of “righting the wrong”). Suspension of behavior coach’s biases. Most coaches inevitably bring a set of values and beliefs about what constitutes healthy or adaptive behaviors, especially in the case of pediatric obesity, where health is of utmost concern. Although these values and beliefs cannot (and should not) be eliminated, the coach must work to suspend them during the encounter with the patient. Moreover, although the coach may have significant experience reading about therapeutic intervention strategies, the patient is the only expert on her own life. At specific points during the interview, the clinician does take on an expert role, providing psychoeducation about depression and overweight and about the nature of CBT. However, even at these moments, the coach does not insist on his or her own perspective in the face of patient resistance, but the clinician either defers to the patient’s expertise on her own life or offers his or her own views as alternatives for the patient to consider if the patient is willing to do so. Open-ended questions. The coach employs open-ended questions throughout HBHM. Unlike closed questions, open-ended questions cannot be answered with a “yes” or “no” and do not pull for specific information; rather, they draw the patient out and encourage her to express her thoughts, feelings, and concerns. Open-ended questions can be used both to gently guide the direction of the session and to encourage the patient to elaborate on something the clinician believes is important. There will be times when the clinician will be talking more; however, in general, the patient should talk for two-thirds of each session. Empathy and interpretations using reflections. Empathy is defined as an accurate understanding of the patient’s communications and experience, as if from inside the patient’s world. The clinician expresses empathy through the technique of reflective listening, in which the patient’s words, meanings, and/or feelings are communicated back to the patient in the form of a statement. These statements are made with humility, given that clinicians can never be certain that their understanding is correct, and presented in a warm, accepting, nonjudgmental manner. Although clinicians may go beyond the explicit statements the patient makes and convey their understanding of the underlying meanings or feelings that the patient is expressing, clinicians do not make interpretations of the patient’s hidden motives or of the presumptive causes of the patient’s behavior. Affirmations. Just as in CBT, the clinician is not neutral, but is a supportive advocate for the patient’s well-being. Affirmation—or expression of

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sincere appreciation by the clinician of the patient’s efforts and strengths in coping with life challenges or the patient’s participation in the treatment process—is an effective way of communicating this support. Summarizing. Bringing together several of the patient’s previously expressed thoughts, feelings, or concerns, often including the coach’s understanding of how these fit together, has several important functions. Summarizing can help the coach ensure correct understanding of the patient’s situation, help the patient see connections between things she has been saying (linking summaries), and prepare the way for the coach to shift focus or move on to the next part of the session (transitional summaries). Patients are almost always more willing to follow the coach once they feel confident that their own agenda has been understood. Working with resistance talk. Patients are expected to be ambivalent about whether they are really depressed, need to lose weight, or want to be working more intensively with a coach. From this perspective, resistance simply reflects the negative side of ambivalence, and rather than challenging or confronting it, the clinician seeks to understand and work with it (i.e., rolling with resistance). Techniques for working with resistance include the following: • Working with change and adherence talk: Change talk and adherence talk are the “positive” side of ambivalence—indications that the patient desires to work at overcoming her eating habits, physical activity behavior, or depression. A patient’s change and adherence talk also indicate that she would like to receive help, sees a need for treatment and/or change, has reasons for committing to treatment and/or change, or believes she has the ability to succeed at changing or sustaining a commitment to treatment. • Supporting self-efficacy: Self-efficacy refers to a patient’s beliefs about how likely she is to succeed at something she tries to do. Self-efficacy plays a key role in engaging patients in treatment. No matter how much the patient comes to believe she needs support, a patient who doesn’t believe that she can succeed at treatment is unlikely to try very hard to stick with it.

S Case Example Mary, a 16-year-old, overweight, depressed adolescent girl diagnosed with PCOS, was referred by her family doctor. Mary currently lives at home with her parents, who are also overweight, and her older brother, who is athletic and is not overweight. Mary is currently in the eleventh grade and attends a local public high school.


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Mary has been overweight for most of her life, and she currently has a BMI of 32. In addition to struggling with weight-loss issues, most recently, Mary has found herself struggling academically and socially: her grades have plummeted from As and Bs to Cs and Ds, and she is brutally teased by her classmates because of her weight. Mary states that she has stopped doing her homework because she won’t do well on it anyway, and she recently failed a science test. Mary has started to eat her school lunch by herself because she is teased when she eats with classmates. Mary finds herself feeling depressed 4 out of 7 days of the week and often isolates herself during these periods, preferring to spend time alone in her bedroom watching television or sleeping. Mary’s mother states that during these episodes, Mary is irritable and argumentative and usually ends up crying when confronted. Lately, Mary has been truant from school, refusing to attend school at least once a week because she “feels sick.” Mary often finds herself feeling out of control when she is eating, and these bingeing episodes usually occur during her postschool snack. In the past, Mary has tried a national weight loss program, a popular fad diet, and diet pills. She lost weight with all three approaches but gained it all back within a few months. Mary states that she eats fast food weekly and knows that she “shouldn’t” because it is “bad.” Mary is frustrated and believes that she is incapable of losing weight permanently and believes that nothing will ever work, so why should she try? At the beginning of the therapeutic intervention, Mary, a straight talker, quickly admitted that she is not happy to be seeing a counselor and feels that her mother is forcing her to be involved. Mary states that she doesn’t care to be told what to do by someone who doesn’t understand her personal situation. However, by Mary’s second session with her new counselor, she has admitted that she does not dread attending sessions anymore. She has started to consistently complete her in-between session assignments but always prefaces her discussion about them by saying that she’s sure that she “didn’t do it right.”

Application Session 1: Introduction to the Program During this session, the behavior coach will introduce the purpose of The PCOS Lifestyle Program. The coach will discuss the definition of lifestyle change and how this differs from a diet. There will be ongoing conversations about all-or-nothing thinking and how it may be more helpful to the patient to engage in behaviors that are sustainable. The concept of weight maintenance, gain, and loss will be elucidated using calorie-in/calorie-out scales with an emphasis on caloric intake and energy expenditure. Also, it may be helpful to discuss the patient’s previous successes or failures, which may serve as building blocks for future goals. The next objective of this session is to discuss the link between PCOS and depression and to assess how the participant is personally affected by

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depression. The coach will help the participant to connect sadness through emotions, thoughts, and behaviors (Appendix 11–A, Worksheet 1). Note that some patients may have depressive symptoms but not depression per se. Coaches should be cognizant of how they phrase “depression” and allow the adolescent to claim or disclaim the symptoms. Assist the adolescent in making a connection between family history, stressful life events, PCOS, and focusing on negative experiences. Following this discussion, a general overview of CBT and how it can help with weight loss and mood is provided. The coach also introduces the general concepts for the ACT and THINK acronyms: that people can control their feelings by 1) how they act and/or 2) how they think (see Chapter 10, Appendix 10–A, for the ACT and THINK chart). The session includes a get-acquainted exercise designed to build rapport, in which the participant talks about three of her strengths. This exercise not only allows the coach to get to know the participant but also serves to emphasize positive thinking over negative self-thoughts. Note that some participants may be so depressed that they cannot think of three strengths. If this happens and the coach has given the participant plenty of silence, the coach should help the patient in order to reduce any discomfort in the first session. For example, the coach can say, “Would it be OK if I shared something with you that I noticed from our work today that I think is one of your strengths?” Additionally, depending on rapport, the coach can then highlight the fact that the participant had difficulty coming up with three strengths. This observation can serve as a building block to emphasize empowering the participant to think positively, both generally and about herself. Following this exercise, the participant sets three specific lifestyle goals to accomplish over the course of the program (Appendix 11–A, Worksheet 2). Note that if the participant sets a specific weightloss goal, direct her to break it down into behaviors that are realistic (not idealistic) and that could lead to weight loss. Toward the end of the session, the coach should also start the weight tracker (Appendix 11–A, Worksheet 3) that will be used at the beginning of each session when the participant gets weighed. Discuss what it feels like for the participant to get weighed. In very rare exceptions, weights are not shared with the participant; otherwise, explain that actual weight is important as a concrete measure of behavioral changes that the participant is making throughout the program. The session concludes with an explanation of the first practice assignments: 1. Having the participant monitor her mood using the Mood Monitoring sheet (Appendix 11–A, Worksheet 4).


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2. Setting goals for the next week (Appendix 11–A, Worksheet 2). 3. Using the ACT and THINK chart before the next session (Chapter 10, Appendix 10–A).

Session 2: Eating Well With PCOS There are four main goals for session 2: 1. 2. 3. 4.

Discuss lifestyle goals and wellness accomplishments over the past week. Review the ACT and THINK chart. Introduce the PCOS food pyramid. Establish food and activity logging.

To begin the session, thermometer ratings are used to gauge the participant’s perception of her current levels of eating healthy, being active, feeling good, and feeling bad (Appendix 11–A, Worksheet 5). Research has shown that in adolescents with depression, feeling “good” and “bad” are actually two distinct facets of emotion. In other words, on separate mood thermometers for feeling good and feeling bad, an adolescent can feel mildly good but still feel really bad (i.e., depressed kids ruminate about bad things but have difficulty savoring good events). After the participant states a number, ask what that number means to her. The coach can also use motivational interviewing to better understand why the number is a 5 and not a 4. The coach will also discuss the worksheet “What It’s Like When I Feel Good” (Appendix 11–A, Worksheet 6) with the participant. At this point, focus on helping the patient to identify that feeling good isn’t just a feeling, but that it makes other people feel a certain way toward her and that it has somatic and behavioral consequences as well. Proper nutrition plays a large role in the management of PCOS, and this session focuses on how to eat healthy with PCOS. For the next several pages of the manual (not provided here), allow the patient to read the information about a healthy diet, if she would like to. We don’t want this activity to get too monotonous, especially if the patient already knows the material. Instead, focus on the fact that even very minimal weight loss has a long-standing impact on health. Also emphasize that the participant is not going on a diet, but instead making lifestyle changes that will become part of her life. The coach then discusses different weight management tools (the PCOS Pyramid, 5/2/10 Guideline, Healthy Plate [Appendix 11–A, Worksheets 7–9, respectively], and the Traffic Light Diet) but encourages the participant to select only those tools that work best for her. This session concludes with a discussion about the role that self-monitoring plays in weight loss with a focus on 1) tracking weight, 2) monitor-

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ing food and physical activity, and 3) making conclusions about the relationship between weight and mood. Lifestyle and mood goals are set for the following week.

Session 3: Managing Your Emotions There are five objectives for session 3: 1. 2. 3. 4. 5.

Discuss goals and accomplishments over the past week. Review the lifestyle log and how it was to wear the armband.1 Learn about emotional eating versus overeating. Introduce the concept of craving and how to pay attention to hunger. Explore self-talk and common cognitive errors.

The coach will start this session by reviewing the concept of emotional eating versus overeating and explore whether these are challenges for the patient. The coach will discuss these concepts by normalizing both types of eating and attempting to elicit intrinsic motivation to identify these situations. The participant may have a lot of shame surrounding these concepts, and at times, her self-disclosure may also be warranted. If nothing is disclosed, the coach can say something like “Other young women with PCOS share with me that after school is their high-risk time. And I guess carbs are the hardest to resist.” The coach will also address how negative thinking can lead to emotional eating by reviewing different cognitive distortions (e.g., “I’ve always failed when I’ve tried to lose weight, so I’ll never be able to”); revealing what negative self-talk (e.g., “I didn’t go to the gym today so my weight loss efforts are a total failure”) can lead to, with a focus on eating and wellness (e.g., concession of weight loss goals); and discussing how to overcome overeating. The coach will want to return to the ACT and THINK chart to illustrate that some of the skills used for addressing negative mood can also help with overeating and emotional eating. Next, the session focuses on overcoming overeating by discussing food cravings and PCOS. Many women with PCOS experience food cravings,

1As

part of the HBHM research protocol, participants wear a BodyMedia SenseWear armband that measures physical activity and sleep. Participants are given a watch that records the number of steps they take each day. The armband not only provides data for the research protocol, but it also serves to provide insight to the participants. Summaries are provided to each participant the session after she wears the armband.


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especially for starchy foods. The coach will discuss that these cravings can sometimes lead to overeating, but more importantly, will focus on pointers for combating food cravings cognitively. When cravings won’t stop, the coach also provides pointers for how to cope with them behaviorally. There are worksheets to complete after review of the session. One of the most important worksheets for this program is the cognitive restructuring worksheet, Cognitive Self-Monitoring (Appendix 11–A, Worksheet 10). Generally, the coach completes the first example provided and asks for the patient to provide another example to elucidate the concept. Emphasize that the “Countering (alternatives, evidence)” column may be the most challenging. Stress the importance of using material from this session in the patient’s daily life after she leaves the session meeting place. Because the coach and patient exercise at the end of each session, coaches periodically meet participants outside the clinical setting. Relaxation training is also incorporated. Typically, coaches allow the patient to pick one of three relaxation methods (deep breathing, imagery, or progressive muscle relaxation), but some patients may want to try each one. Feel free to be creative and let the patient guide the activity (e.g., yoga with deep breathing). Encourage the patient to practice these skills (e.g., turning negative thoughts into positive thoughts, relaxation training).

Session 4: The Traffic Light Guide There are three objectives for session 4: 1. Educate about nutrition labels. 2. Introduce the Traffic Light Guide (Epstein and Squires 1988). 3. Discuss portion sizes. The coach will discuss nutrition labels with the participant; typically, the patient may know what the nutrition label shows but may feel confused about exactly what to concentrate on changing. Go back to the 5/2/10 guideline and ask if the patient has used this tool. Explain that the Traffic Light Guide is yet another tool that she may find helpful. Emphasize that some people like it, whereas others find it too elementary. Overall, >5 g fat=RED food, 2–5 g fat=YELLOW food, and <2 g fat=GREEN food. Although reducing red foods to one or two per day is a goal, ask the participant what would seem reasonable for her. Encourage the patient to record the red foods as an in-between session assignment and to reduce those foods by one or two items the subsequent days until she reaches the goal that was agreed on. Explain that the Traffic Light Guide fits well with the PCOS Eating Plan. The PCOS Eating Plan contains primarily green and yellow foods, and the coach can use the PCOS Pyramid (see Appendix 11–A, Worksheet

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7) to help guide appropriate serving sizes. Focus on portion sizes and portion distortion. Be aware that most adolescents know this information but that implementing the knowledge is a challenge. Remember to set goals with the patient: logging food intake, physical activity, and mood; labeling red foods consumed; and any other goals.

Session 5: Having Fun While Moving There are three objectives for session 5: 1. Discuss physical activity. 2. Discuss My Activity Pyramid. 3. Set physical activity goals. The coach will begin this session by eliciting from the participant what she thinks the difference is between physical activity and exercise and discussing her response. Physical activity is any activity that causes the body to work harder than normal and can involve a number of daily tasks, whereas exercise is a planned, structured, and repetitive movement done to improve or maintain physical fitness. Additional ways in which physical activity can be increased should be discussed. The coach will also discuss the different types of physical activity with the participant: aerobic exercise—activity that increases breathing and heart rate; resistance exercise—exercise that increases the ability to exert or resist force and makes the muscles stronger; and stretching— activity that improves flexibility by warming up and lengthening the muscles. After showing the participant the activity pyramid (Appendix 11–A, Worksheet 11), probe for understanding. Ask about anything that stands out or that she finds surprising. Clarify any confusion. At the end of the session, help the participant set realistic physical activity and exercise goals to complete before session 6. Although working out every day is ideal, emphasize realistic goals. Share with the participant that setting idealistic goals sometimes leads to failure and an exacerbation of negative mood symptoms. Set physical activity goals and encourage the participant to use her pedometer to increase the number of steps taken.

Session 6: A Focus on Body Image There are three objectives for session 6: 1. Introduce and define body image. 2. Discuss myths that impact body image. 3. Introduce eight steps for building a better body image.


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Body image is a concept that most participants have explored in the past. The coach should discuss how the patient defines body image and how her thoughts about her body affect her behavior using the worksheet provided for the session (not included here). This session also includes a list of myths about body image. Going through each myth and discussing whether the participant has heard it before and whether she believes it can be helpful. Then discuss why it is not true, referring to the facts section underneath each myth. Last, the coach shares with the participant a list for developing a healthier body image, Eight Steps for Building a Better Body Image (Appendix 11–A, Worksheet 12). Read through this list with the participant, or have the participant look through the list, and discuss the steps that she would find most helpful or that stand out for her. Goals for this session include identifying lifestyle goals (see Appendix 11–A, Worksheet 2) and completing the body image worksheet, Helpsheet for Change: My Desire for Change (Cash Body Image Workbook 1997).

Session 7: Being More Self-Aware There are four objectives for session 7: 1. Introduce and define self-awareness. 2. Discuss challenges to maintaining a healthy lifestyle. 3. Introduce the STEPS problem-solving worksheet (see Chapter 10, Appendix 10–A). 4. Discuss in-between session assignments. First, assess the patient’s level of familiarity with the term self-awareness, asking what she thinks it might mean. Many participants have never heard this term used before in this context, so it is important to discuss its meaning. Once the general definition is discussed and understood, discuss what it means to be aware when eating. This type of self-awareness involves focusing on what she is eating and drinking and noticing all of the physical and mental sensations that occur before, while, and after the item is consumed. Next, the coach should discuss awareness of physical activity. Start by assessing what the participant thinks this could mean and discussing her experience with physical activity awareness. Awareness of physical activity generally means noticing how her body feels when in motion: breathing, heart rate, muscle movements, posture, coordination, and flow (or being “in the zone”). Discuss with the participant whether she has experienced any of these things during physical activity. Last, discuss the participant’s awareness of her mood. This means paying attention to her emotions, knowing how she is feeling, and recognizing ways that she can

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change her emotions. The coach can then practice the mood awareness activity with the patient by focusing on the patient’s ability to control her emotions (Appendix 11–A, Worksheet 13). Note that more succinct distinctions for the concepts of mood, emotion, and affect are given in other manualized treatments but that HBHM focuses on overall emotion, and at times, depressive symptoms. During this session, the coach will also discuss challenges to maintaining a healthy lifestyle. The coach will talk about food temptations that seem to be everywhere, inappropriate portion sizes that have become common practice, and environmental cues that can signal overeating. Allow the participant to openly talk about challenges that she may face. Given that most people encounter problems and challenges throughout life, it is important to learn how to effectively manage them. During this session, the coach will introduce the STEPS worksheet, allowing the participant to apply this method of problem solving to an example that she has faced recently. This week, the participant should complete the STEPS worksheet for one challenge she faces between now and the next session. Talk about journaling and how this relates to self-awareness, and set a goal with the participant for her to journal a certain number of days. Set any additional wellness goals that the participant would like to achieve.

Session 8: Planning Ahead for Continued Success There are two objectives for session 8: 1. Review wellness goals from previous sessions, the STEPS problemsolving worksheet, and any journaling. 2. Discuss strategies for planning to make healthy choices. The coach should make sure that the participant understands how to use the problem-solving worksheet when faced with a challenge; see if the participant can state the challenge, brainstorm possible solutions, weigh pros and cons of each solution, try one out, and assess whether that solution worked. Planning ahead for the future is important to ensure future success when challenges are faced. During this session, the coach will discuss with the participant ways to plan ahead for daily meals, snacks, physical activity, special occasions, and challenges to positive thinking. An entire packet is available highlighting healthier choices while dining out, with a special emphasis on meals and foods that fall within the 5/2/10


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guideline. Because this is the last session in the intensive intervention (before the monthly booster sessions), goals are set that highlight continued change. Encourage the patient to call to move the appointment to an earlier date if challenges arise. Commend the participant for completing the intensive part of the intervention and make sure to set wellness goals.

Booster Sessions After the intensive part of the intervention, participants are encouraged to attend three monthly booster sessions. For some young women, these are maintenance sessions where they check in on their weight and mood. For others (and contrary to the outcome in some pediatric obesity treatments), young women begin to use the skills that they have learned and begin to lose more weight and feel more positive. Booster session 1 concentrates on the patient’s physical illness narrative (see Chapter 10, Appendix 10–A). This serves to assist the coach and patient in better understanding what it means for the patient to have PCOS. Booster session 2 focuses on living with PCOS and attaining support from the patient’s environment. Topics that may be discussed consist of support networks and feeling uncomfortable talking with peers about having PCOS. Booster session 3 centers on reflecting not only about the program but also about having PCOS (Appendix 11–A, Worksheet 14). Although some participants decide that this session is the end of their HBHM journey, we offer participants follow-up sessions in our clinical PCOS program.

Conclusion and Caveats Obesity in pediatric and adolescent populations has reached epidemic proportions in the United States. Depressive disorders in children are common, recurrent, and impairing. Depression is prevalent in 1%–2% of children and 3%–8% of adolescents (Lewinsohn et al. 1998). Existent interventions for obese adolescents have excluded patients experiencing comorbid conditions. Given the long-standing link between obesity and depression and the questions many providers have expressed about which disorder to treat first, HBHM provides an infrastructure with a model physical illness (PCOS) in which adolescents present frequently with both obesity (~70%) and depression (~50%). Fortunately, several evidencebased pediatric obesity and depression treatments have been successful in promoting weight loss and in improving mood in adolescents. As reviewed

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here, the inclusion of complementary therapeutic strategies has been shown to be effective in enhancing standard pediatric weight management programs. As can be seen in Chapter 5, similar strategies have been shown to be efficacious in childhood depression. Both behavioral (Aragona et al. 1975; Brownell et al. 1983; Coates et al. 1982; Epstein and Wing 1980; Epstein et al. 1995; Flodmark et al. 1993) and cognitive (Brownell et al. 1983; Coates and Thoresen 1981; Senediak and Spence 1985; Williams et al. 1993) techniques, used in conjunction with dietary and activity change strategies, have demonstrated favorable results for weight loss and depression remittance in adolescents. By targeting dietary, activity, and other behavioral skills in both adolescents and parents, family-based behavioral programs have been shown to be more effective than targeting children alone (Epstein et al. 1981; Epstein et al. 2008) and benefit all family members by encouraging reciprocal weight loss and a positive home environment between parent and child (Wrotniak et al. 2004). Although data supporting the efficacy of motivational interviewing techniques in weight-loss interventions are sparse, these strategies may provide additional safe, cost-effective methods for enhancing motivation for behavior change, especially in psychiatrically ill adolescents who have repeatedly failed at weight loss or mood improvement. Even in more severe cases of obesity, when practitioners may consider additional approaches such as pharmacotherapy or bariatric surgery, these therapies can make a significant contribution to enhancing patients’ quality of life and compliance with the weight-loss intervention (Kalarchian and Marcus 2003). Moreover, careful consideration of which patients may benefit from this combined intervention is crucial. For example, providers should think of excluding patients from HBHM who have a family history of major depressive disorder, have been hospitalized for psychiatric reasons in the past, or have active suicidal ideation. In these cases, a more direct CBT approach to treat only the depressive disorder, possibly along with antidepressants, should be considered.

Key Clinical Points • Many facets that underlie maladaptive eating and a lack of physical activity also relate to problematic mood symptoms. • Before the introduction of Healthy Bodies, Healthy Minds (HBHM), most pediatric obesity interventions excluded adolescents with comorbid mood symptoms. A manualized treatment, HBHM aims to provide more broad-based CBT techniques that will assist an adolescent struggling with both weight management concerns and mood symptomatology.


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• Although CBT serves as the content for HBHM treatment, motivational interviewing components assist in working with adolescents who may exhibit resistant behaviors. However, the motivational interviewing components of HBHM are not be appropriate for adolescents with depression who need more intensive treatment (see Chapter 5 for their treatment). • HBHM was validated for adolescents with PCOS who exhibit difficulties abiding by healthy lifestyle goals, as well as managing their depressive symptoms. Carefully selecting patients who may benefit from HBHM is crucial in optimizing the likelihood of its utility. For example, if a patient presents with long-standing, recurrent, severe major depressive disorder, more intensive treatment that targets solely mood symptoms may be warranted. Conversely, patients who have depressive thinking secondary to body image concerns and compromised self-esteem may greatly benefit from HBHM. • Although CBT and motivational interviewing skills are summarized as a blueprint, this intervention may need to be individualized on the basis of each patient’s needs. Many adolescents with PCOS and/or obesity may have difficulty with cognitive skills required for CBT. Moreover, cultural and age-specific aspects from the patient’s perspective need to be addressed to optimize treatment outcome. • Although the sessions are numbered sequentially, patients will cycle back to previous sessions on an as-needed basis. Frequently, adolescents will learn a skill and then regress due to either a lapse or environmental circumstances. • Continuation of CBT treatment is effective in preventing relapse once weight maintenance and positive thinking are achieved.

Self-Assessment Questions 11.1. Which is not typically a psychological correlate of adolescent obesity? A. B. C. D.

Low self-esteem. Compromised body image. Depression. Obsessive-compulsive traits.

11.2. Why is polycystic ovary syndrome an appropriate physical illness for a CBT approach? A. CBT helps adolescents restructure their psychosomatic complaints. B. CBT assists adolescents in better understanding why they are obese.

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C. CBT can target both the obesity and depression that these adolescents may experience. D. CBT can activate adolescents to exercise more frequently. 11.3. Which comorbid condition may CBT assist in the treatment of adolescents with obesity and depression? A. B. C. D.

Obsessive-compulsive disorder. Posttraumatic stress disorder. Eating disorder not otherwise specified. Alcohol dependence.

11.4. Which of the following is not a key strategy used during motivational interviewing as a complementary approach to CBT? A. B. C. D.

Open-ended questions. Nondirective empathy. Affirmations. Reflective listening.

11.5. An 8-year-old boy comes into the clinic with a body mass index percentile of 99.9. He complains that his family has a lot of high-fat, high-calorie food in the home. Both parents are obese, and they question why they should have to change their habits for their child. Which of the following CBT techniques is most logical to employ with this child and his family? A. B. C. D.

Behavioral activation. Self-monitoring. Stimulus control. Cognitive restructuring.

Suggested Readings and Web Sites Belle SH, Berk PD, Courcoulas AP, et al: Safety and efficacy of bariatric surgery: longitudinal assessment of bariatric surgery. Surg Obes Relat Dis 3:116–126, 2007 Dunican KC, Desilets AR, Montalbano JK: Pharmacotherapeutic options for overweight adolescents. Ann Pharmacother 41:1445–1455, 2007


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Kalarchian MA, Marcus MD, Levine MD, et al: Psychiatric disorders among bariatric surgery candidates: relationship to obesity and functional health status. Am J Psychiatry 164:328–334, 2007 Kushner RF: Anti-obesity drugs. Expert Opin Pharmacother 9:1339– 1350, 2008 Rofey DL, Kolko RP, Iosif A, et al: A longitudinal study of childhood depression and anxiety in relation to weight gain. Child Psychiatry Hum Dev 40:517–526, 2009 Rofey DL, Szigethy EM, Noll RB, et al: Cognitive-behavioral therapy for physical and emotional disturbances in adolescents with polycystic ovary syndrome: a pilot study. J Pediatr Psychol 34:156–163, 2009 Stunkard AJ, Faith MS, Allison KC: Depression and obesity. Biol Psychiatry 54:330–337, 2003 Wadden TA, Stunkard AJ: Handbook of Obesity Treatment, 2nd Edition. New York, Guilford, 2004 Motivational Interviewing: Provides materials designed to facilitate the dissemination, adoption, and implementation of motivational interviewing among clinicians, supervisors, program managers, and trainers. www.motivationalinterview.org Motivational Interviewing Network of Trainers: Provides resources for information on motivational interviewing; includes general information about the approach, as well as links, training resources, and information on reprints and recent research. www.motivationalinterviewing.org

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Appendix 11–A Healthy Bodies, Healthy Minds: Selected Patient Worksheets Session 1: Introduction to the Program Worksheet 1

The Guiding Principles of Wellness

Thoughts Emotions

Behaviors

How our emotions, thoughts, and behaviors are connected: Negatives Bring Us Down. Negative thought Negative behavior I look terrible. I’m not going out tonight. Negative thought I’ll never pass the test anyway.

Negative behavior I’m not studying.

Negative emotion Sadness Negative emotion Hopelessness

Positives Bring Us Up. Positive thought Positive behavior My friends like me. Going out will help me.

Positive emotion Happiness

Positive thought Positive behavior I can do well if I try. I’m going to study for the test.

Positive emotion Confidence

Appendix 11–A: HBHM Selected Patient Worksheets

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Session 1: Introduction to the Program Worksheet 2

Healthy Lifestyle Goals Now, take some time to think about three specific lifestyle goals that you would like to begin to work toward. It is important to be as specific as possible and to write down the steps that you will take to achieve these goals. We also will ask you to think of barriers (that is, things that may get in the way of success) and ways that you can overcome these challenges. Make sure to be realistic, not idealistic, so that your goals can be achieved.

Goal 1:

To achieve this goal, I/we will:

Goal 2:


Goal 3:


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Healthy Bodies, Healthy Minds Weight Tracker

Initials: Gender: Birth date:

Session

1 2 3 4 5 6 7 8 9 10 11 12

Height

Weight

BMI

Percentile


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Mood Monitoring Practice assignment: During the next week, write down what your mood was for most of each day (e.g., bored, happy, sad, angry, irritable, grumpy). Rate your mood for the day on a scale of 1–10 (1 being worse mood/more bored than ever, 10 being best mood ever/rarely bored). Then write down what good and bad things happened that day.

Describe mood Day

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

Mood rating (1–10)

Good things that happened today

Bad things that happened today

Changes in my eating (e.g., felt like eating more or less than usual)

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Session 2: Eating Well With PCOS Worksheet 5

Ratings Eating Healthy

Being Active

10 Wonderful

10 Wonderful

5 Better than Nothing

5 Better than Nothing

1 Not so Well

1 Not so Well

Feeling Good

Feeling Bad

10 Great

10 Worst Ever

5 OK

5 OK

1 Not so Well

1 Not so Bad



What It’s Like When I Feel Good Things I do or things that happen to me that make me feel good:

How my body feels when I feel good:

How I look when I feel good:

What thoughts I have when I feel good:

How I act when I feel good:

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Tool 1: The PCOS Pyramid The PCOS Pyramid reflects current nutrition recommendations for girls and women who have PCOS. To be sure you’re getting the nutrients you need, we recommend you make choices according to the pyramid. At the end of this session, we have provided copies of this pyramid, which you can use daily to help guide your food choices.

Sweets Lower sugar varieties 1 serving Fats & ils (healthy O fats) Olive and cano nuts, flaxseeladoils, 3-4 servings Dairy Low-fat milk, yogurt, cheese 3 servings

Meat Fatty fis lean meat/ph, ou 3 servings ltry

Whole Gra Pasta, bread, ric ins e, cere 4-6 servings als Fr Fresh and frozeuits n whole fruits 3 servings

Vegetables Non-starchy ve geta 5 servings bles



Tool 2: Reading Nutrition Labels & the 5/2/10 Guideline The Nutrition Facts label can be used to help you choose healthier items. To choose healthy items, it is important to look at the fat, fiber, and sugar content of the food. Too much fat or sugar may cause weight gain and too little fiber may leave you feeling hungry. Healthier items will have less than 5 grams of total fat per serving, more than 2 grams of fiber per serving, and less than 10 grams of sugar per serving. Start by looking at the labels of items you have at home and decide if the foods are healthy items to keep around the house.

Nutrition Facts Serving Size 1 cup (30g) Amount Per Serving

Calories 111

Calories from Fat 16

Total Fat 2g Saturated Fat 0g Trans Fat Cholesterol 0mg Sod ium 213mg Total Carbohydrate 22g Dietary Fiber 4g Sugars 1g Protein 4g Vitamin A Calcium

10% 12%

This is the recommended serving size. The amounts of TOTAL FAT, FIBER, and SUGAR in this item are for this serving of the food. If you eat two servings, you will be getting two times the amount of fat, fiber, and sugar.

• •

% Daily Value* 3% 2% 0% 9% 7% 14%

Limit TOTAL FAT to less than 5 grams per serving.

Increase FIBER to at least 2 grams per serving. Limit SUGAR to less than 10 grams per serving.

Vitamin C 10% Iron 57%

*Percent Daily Values are based on a 2,000 calorie diet. Your daily values may be higher or lower depending on your calorie needs:

Calories Total Fat Less than Sat Fat Less than Cholesterol Less than Sodium Less than Total Carbohydrate Fiber

2,000 65g 20g 300mg 2,400mg 300g 25g

Calories per gram: Fat 9 • Carbohydrate 4

•

2,500 80g 25g 300mg 2,400mg 375g 30g

Protein 4

NutritionData.com

By choosing items that fit the guidelines for fat, fiber, and sugar, you will have healthier foods at home to put together for meals and snacks.

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Tool 3: Healthy Plate (HP): HP is a model of how meals should typically look. Attempt to follow the HP at each meal to eat a nutritious, balanced diet. It is important to follow the serving sizes listed on the HP as well. See the Portion cheat sheet.

FRUIT SALAD VEGGIES 2 cups total

STARCH: Rice, pasta, potatoes Corn, bread, cereal 1/2 to 1 cup

LOW-FAT MILK OR YOGURT 1 cup

PROTEIN: Meat (3-4 oz = size of palm) Beans (1 cup) Milk or yogurt (1 cup) Cheese (1 oz =1 slice) Peanut Butter (2 tbsp) Egg (1)

Now it is time to put what you have learned into action. LOGGING your eating habits and physical activity plays a very important role in weight management and lifestyle change.

Benefits of Logging: Shows eating and physical activity patterns so that you can see your habits Helps you to plan physical activity into your daily routine Assists you in identifying benefits and challenges Helps you set realistic goals to make lifestyle changes

Tracking your weight every week when you meet with us also is useful when trying to make healthy changes to lose weight.


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Session 3: Managing Your Emotions Worksheet 10

Cognitive Self-Monitoring Trigger/Event

Automatic thought

I don’t have a date for the prom.

It’s because of my looks; no one likes me.

Anxiety (0–8)

6

Problem (0–100%)

75%

Countering (alternatives, evidence)

Many girls weren’t asked yet. There are more important things in life. I have lots of good friends and family.

Realistic problem (0–100%)

10%

Anxiety (0–8)

3

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Session 5: Having Fun While Moving Worksheet 11

My Activity Pyramid*

Inactivity: Cut down < 2 hrs per day (TV, computer, videogames)

Flexibility & Stre 2-3 times a we ngth: ek (stretching, yoga , rope climbing, push-ups)

Active Aero bic & Recrea tional Activ ities: 3-5 (basketball, so times a week ccer, swimming , rollerblading)

Everyday Ac tivities: As of (cleaning your room, taking th ten as possible e stairs, playing outside, going shopping)

* Adapted from the USDA’s MyPyramid by the University of Missouri Extension

These levels correspond to how many calories you are burning. “Inactivity” burns the least number of calories, whereas “Active Aerobic & Recreational Activities” burn the most, in a short period of time. You’ll be surprised how many calories you can burn by increasing your “Everyday Activities.” Your armband and pedometer/watch will help tell you how many calories you are burning on the weekends that you wear it. METs are an estimate of the intensity of a particular activity and are based on your resting metabolic rate (or the amount of energy your body uses while at rest). The higher the MET, the more calories you burn while doing the activity. Sedentary activities require less than 2.0 METs and will not help you lose weight. Moderate activities require between 2.0 and 2.9 METs. They are better than sedentary activities but not as healthy as vigorous activities. Vigorous activities require MET levels of 3.0 or higher. They make your body work hard and will help you to lose weight.


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Session 6: A Focus on Body Image Worksheet 12

Eight Steps for Building a Better Body Image Step 1: Discover your body image strengths and weaknesses. You have your own distinctive appearance and your own experience of how you look. Even though someone else may see it differently, how you see yourself will be our focus. Step 2: Why do you have a negative body image? We know that body image stems from your developmental past as well as from the current forces in your life. We will focus on where your beliefs about your body image originate. Step 3: A negative body image is emotionally draining. Feeling self-conscious or even ashamed about your looks impairs your ability to feel in charge of your life. Step 4: Typically, you feel what you think. How you feel about your looks is influenced by the beliefs you have about yourself. Most people have assumptions about the importance of looks— this can sometimes lead to trouble. We discussed these assumptions or myths and their opposing facts.

Step 5: In this step, we will talk about the negative ways of thinking from Session 2 and learn how to identify these mental mishaps. Identifying the times when you are thinking negatively is a huge first step to feeling better about yourself.

Step 6: A negative body image may lead you to act in ways that protect you from uncomfortable feelings (for example, not going out with friends because you don’t like the way you look). Avoidance can sometimes make your body image worse—after all, it only prevents you from having fun. Learning that these behaviors are self-defeating will be an important step for change.

Step 7: Creating a positive body image is important. At times (and sometimes frequently), the negative thoughts will come back, but it is important to recognize these thoughts and challenge yourself to come up with countering and healthier ones.

Step 8: Planning ahead for possible challenges is an important step for staying healthy. It will be important to continually check in with yourself to make sure you are staying on track.

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Session 7: Being More Self-Aware Worksheet 13

Activity: Pretend you are in a room all by yourself and the door is closed. There are a set of knobs on the wall, and each one has a different label: angry, sad, happy, jealous, selfish, greedy, and humorous. As you turn each knob, you begin to feel that emotion. You can choose to turn any or all of the knobs. You can also decide how much you want to turn each knob. What knobs would you choose? Would you turn them all the way? Let’s assume you step out of the room and are back to your normal self. Can you be more aware of your mood? Can you choose to keep some of those emotions after leaving the room?

Create Awareness The first step to making changes in your food choices, physical activity, and mood begins with increasing your awareness of your current habits. You have already been doing this by keeping a journal. You may have found from your own experience with logging that this has been an important tool for raising your awareness in many areas, such as which foods give you lasting energy and more satisfaction, what types of physical activity you enjoy, and when you feel most positive. You are encouraged to continue keeping a journal to help you increase your awareness of your own unique needs. Keeping a journal will also show you that you don’t have to “go on a diet” and “exercise all of the time” to lose weight, but a balanced approach to healthy living will support you in feeling your best—physically and emotionally.


Booster Session 3: Reflection Activity Worksheet 14

Reflection Activity: You have come a long way. We would like to hear your reflections about this process. What helped you make positive changes?

How could this process have been better?

Compared to the beginning of these sessions, how are you different?

Is there anyone in particular who you would like to thank for his or her support throughout this process? If so, who and why?

For our purposes, can you please provide feedback on the intervention delivered? • Are there any changes you would recommend? • How was it to work with your coach? • Would you recommend this intervention to someone else?

Anything else you would like to tell us about this process?

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12

Disruptive Behavior Disorders John E. Lochman, Ph.D., ABPP Nicole P. Powell, Ph.D. Caroline L. Boxmeyer, Ph.D. Rachel E. Baden, M.A.

THE focus of this chapter, disruptive behavior disorders (DBD) in children and adolescents, includes the diagnosable disorders of oppositional defiant disorder (ODD) and conduct disorder (American Psychiatric Association 2000), as well as behavioral patterns of aggressive, noncompliant, and delinquent behavior. Children with these recurrent patterns of hostile, disobedient, and rule-breaking behaviors typically have poor abilities to self-regulate and inhibit their prepotent impulsive and antisocial behaviors. These externalizing behaviors lead to external social reinforcement, sometimes in unwitting ways from the adults and peers around these chil-

S This chapter has a video case example on the DVD (“Disruptive Behavior”) demonstrating CBT for an adolescent with oppositional defiant disorder.

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dren, and can be maintained by children’s social-cognitive processes (Matthys and Lochman 2010).

Empirical Research Several reviews have examined the efficacy of psychosocial treatments for conduct problems in children and adolescents in comparison to no treatment or wait-list control conditions (Kazdin 2005; Lochman and Pardini 2008). These reviews indicate that a vast majority of the empirically supported treatments for conduct problems in youth are based on behavioral or cognitive-behavioral theoretical frameworks (Brestan and Eyberg 1998; Farmer et al. 2002; Kazdin and Weisz 1998; Nock 2003). Many traditional behavioral programs have cognitive-behavioral elements (e.g., stress management sessions during behavioral parent training), and most cognitivebehavioral programs have substantial operant reinforcement elements, so that there are few strictly behavioral or strictly cognitive programs in this area of psychopathology. Meta-analytic reviews suggest a range of medium to large effect sizes (0.47–0.90) for cognitive-behavioral interventions targeting conduct problems (for review, see Nock 2003). In addition, research suggests that cognitive-behavioral interventions that include a child component focusing on social problem-solving and social skills development together with a parent-management training component produce broader positive effects and better maintenance of behavioral improvements over time than interventions with either component in isolation (Kazdin et al. 1992; Nock 2003; Webster-Stratton and Hammond 1997). However, the parenting component of these interventions has been shown to produce particularly robust reductions in conduct problems and delinquent behaviors (Beauchaine et al. 2005; Lochman and Wells 2004). Research on cognitive-behavior therapy (CBT) programs has examined CBT interventions that have both parent and child components and CBT interventions that focus only on parents or only on children. Parent-only interventions are more likely to be delivered to families with younger children with DBD. In the sections below, we will first briefly summarize the results of intervention research with the Coping Power Program, a CBT program for preadolescent children with disruptive behaviors. We will also provide an overview of results of several other examples of treatment and prevention programs with substantial cognitive-behavioral elements for children with DBD. These other programs target many of the same cognitive, emotional, and behavioral processes that are the focus of the Coping Power Program, and as a group, these programs cover three different developmental peri-

Disruptive Behavior Disorders

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ods (Matthys and Lochman 2010). Later in the chapter, discussion of the Coping Power Program components will provide the structure for the discussion of CBT techniques for children with DBD.

Coping Power Program The Coping Power Program was derived from earlier research on the Anger Coping Program (Lochman 1992). Coping Power has cognitive-behavioral child and parent components (Lochman et al. 2008; Wells et al. 2008). Coping Power was originally designed to be implemented with fourth- to sixth-grade children in school or clinic settings, but has been successfully adapted for younger and older children. In comparison to randomly assigned control groups in two separate samples (one sample with only boys, the other with both boys and girls), the Coping Power Program produced decreases in self-reported delinquency, substance use, and aggressive behavior at school at follow-up assessments 1 year after the end of intervention (Lochman and Wells 2003, 2004). Results indicated that the Coping Power intervention effects on lower rates of parent-rated substance use and of delinquent behavior at the 1-year follow-up, in comparison with the control group, were most apparent for the children and parents who received the full Coping Power Program with child and parent components (Lochman and Wells 2004). In contrast, boys’ teacher-rated behavioral improvements in school during the follow-up year appeared to be primarily influenced by the Coping Power Child Component. Mediation analyses, using path analytic techniques, indicate that the intervention effect for both intervention groups on outcomes at the 1-year follow-up were mediated by intervention-produced improvements in children’s internal locus of control, their perceptions of their parents’ consistency, children’s attributional biases, person perception, and children’s expectations that aggression would not work for them (Lochman and Wells 2002). In a dissemination study that used a clinical sample, Coping Power reduced the overt aggression of children with ODD or conduct disorder in Dutch outpatient clinics in comparison with care-as-usual children (van de Wiel et al. 2007). Long-term follow-up analyses of this sample 4 years after the end of intervention indicated that the Coping Power Program also had preventive effects by reducing adolescent marijuana and cigarette use in children who participated in the Coping Power Program in comparison with care-as-usual children (Zonnevylle-Bender et al. 2007). Other dissemination studies have found that Coping Power reduces externalizing behavior problems in comparison with control groups when implemented by regular school counselors in urban and suburban settings (Lochman et

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al. 2009); when used with aggressive children in a more abbreviated 24session format (Lochman et al. 2006a); when used with children with DBD in Puerto Rico (Cabiya et al. 2008); and when used with specialized populations, such as deaf children who have aggression problems in residential settings (Lochman et al. 2001). Coping Power in dissemination studies has also been found to reduce children’s disciplinary suspensions from schools (Cowell et al. 2008; Peterson et al. 2009).

Programs in the Preschool and Early Childhood Years Universal Prevention Programs The Promoting Alternative Thinking Strategies (PATHS) program is an example of a teacher-delivered universal prevention program that seeks to promote general social-emotional competencies and cognitive skill building in elementary school children (Greenberg and Kusché 2006). Results at 1- and 2-year follow-up indicated that children receiving the PATHS intervention were better at understanding emotions, were better at problem solving, and had reported decreases in self-reported and teacher-reported conduct problems and externalizing behavior compared with children in control groups (Greenberg and Kusché 2006; Greenberg et al. 2001).

Treatment and Targeted Prevention Programs The Incredible Years program includes parent training, a child training program (Dinosaur School), and a teacher component for young children with DBD (Webster-Stratton 2005). Research findings regarding the effectiveness of the Incredible Years parent, child, and teacher training interventions alone and in combination have been impressively replicated across multiple samples. The parent training component has repeatedly produced significant reductions in child conduct problems at home, in school with teachers, and with peers; decreases in negative parenting; and increases in positive parenting in comparison with wait-list control conditions (Webster-Stratton and Hammond 1997; Webster-Stratton et al. 2004). In addition, evidence suggests that overall improvements evident in reductions in children’s behavior problems as the result of the parenting intervention can still be seen at 3-year follow-up (Webster-Stratton 1990). The Incredible Years child intervention has also been shown to produce significant reductions in the amount of conduct problems children exhibit at home and school and to produce increases in social problem-


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solving skills in comparison with wait-list control conditions (WebsterStratton and Hammond 1997; Webster-Stratton et al. 2004). The inclusion of both child and parent components produced the most significant improvements in children’s behavior at 1-year follow-up (Webster-Stratton and Hammond 1997).

Programs in the Preadolescent Years Universal Prevention Programs The Seattle Social Development Project (SSDP) is a universal prevention program designed to reduce aggression by creating a positive school environment. The SSDP includes training for teachers to increase the use of nonpunitive classroom behavioral management strategies such as positive reinforcement, and more recent versions of the intervention have also included parent training and child problem-solving and social skills training (Hawkins et al. 1999). Longitudinal research conducted with the SSDP has found significant prevention or reductions of alcohol use (Hawkins et al. 1999; Lonczak et al. 2001), reductions in delinquency, a lower frequency of sexual intercourse and number of sexual partners, and decreased reports of pregnancy for females and causing pregnancy for males (Hawkins et al. 1999). In addition, students receiving the prevention program reported more positive feelings and stronger commitment to school compared with control groups, improved academic achievement, and less student-reported school misbehavior (Hawkins et al. 1999).

Treatment and Targeted Prevention Programs A program similar in structure to the Coping Power Program in the preadolescent age range is the Problem-Solving Skills Training Plus Parent Management Training (PSST+PMT) program. Similar to Coping Power, this program has a component addressing parent training and a component addressing prosocial problem-solving skills among children with DBD. This program is targeted for school-age children ages 7–13 years who have severe antisocial behavior. Although PSST has been found to do better than parent management training at increasing children’s social competence at school and reducing self-reports of aggression and delinquency, a combination of both treatments is optimal for most outcomes (Kazdin et al. 1992). The combination of PSST with a parent-focused intervention was found to produce the greatest improvements in statistical and clinical significance in reducing children’s aggressive and delinquent behaviors, as compared with PSST or parent-focused interventions alone (Kazdin et al. 1992).

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Programs in the Adolescent Years Universal Prevention Programs The Life Skills Training Program is an example of a universal prevention program designed to prevent substance abuse in adolescents (Botvin and Griffin 2004). The program was developed for middle school students. The program has been shown to be highly effective in reducing alcohol, tobacco, marijuana, and polydrug use in a series of randomized controlled efficacy trials and in two effectiveness studies.

Treatment Programs The Art of Self-Control is a cognitive and behaviorally oriented group (and individual) adolescent control program (Feindler and Ecton 1986). Outcome research for this program, with adolescents in in-school programs for multisuspended youth and in inpatient and incarcerated settings, has indicated reductions in aggressive and disruptive behavior and improvements in problem-solving abilities, social skills, cognitive reflectivity, and adultrated impulsivity and self-control (Feindler and Ecton 1986). Multisystemic therapy (MST) is an intensive family- and communitybased treatment program that has been implemented with chronic and violent juvenile offenders, substance-abusing juvenile offenders, adolescent sexual offenders, youth in psychiatric crisis (i.e., homicidal, suicidal, psychotic), and maltreating families (Henggeler and Lee 2003). MST is an individualized intervention that focuses on the interaction between adolescents and the multiple environmental systems that influence their antisocial behavior, including their peers, family, school, and community (Henggeler et al. 1992). Although the techniques used within these treatment strategies can vary, many of them are either behavioral or cognitive-behavioral in nature (e.g., contingency management, behavioral contracting). Evaluations of the effectiveness of MST with chronic and violent juvenile offenders have produced promising results. Several investigations have shown that families who receive MST report lower levels of adolescent behavior problems, improvements in family functioning at posttreatment, and lower recidivism in a 4-year follow-up in comparison with alternative treatment conditions (Borduin et al. 1995; Henggeler et al. 1992).

Conceptual Framework A contextual social-cognitive model serves as the basis for many CBT programs for children and adolescents with DBD and is based on empirically


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identified risk factors that predict children’s antisocial behavior (Lochman and Gresham 2008). As children develop, they can experience an accumulation of risk factors, increasing the probability that they will eventually display serious antisocial behavior (Loeber 1990). Malleable risk factors that are incorporated into CBT interventions include risks in the family context, in the peer context, and in social cognitive processes and emotional regulation.

Family Factors A wide array of factors in the family can affect child aggression, ranging from poverty to more general stress and discord within the family (Loeber and Stouthamer-Loeber 1998). Children’s aggression has been linked to general family background factors, such as parent criminality, substance use and depression, poverty, and stressful life events. All of these family risk factors interrelate with one another, build on one another, and in turn, can influence child behavior through their effect on parenting processes. Parenting processes linked to children’s aggression (Patterson et al. 1992) include 1) nonresponsive parenting at age 1, with the pacing and consistency of parent responses not meeting children’s needs; 2) coercive, escalating cycles of harsh parental demands to child noncompliance starting in the toddler years, especially for children with difficult temperaments; 3) harsh, inconsistent discipline; 4) unclear directions and commands; 5) lack of warmth and involvement; and 6) lack of parental supervision and monitoring as children approach adolescence. The relations between parenting factors and childhood aggression are bidirectional, as child temperament and behavior also affect parenting behavior (Fite et al. 2006).

Peer Factors Children with disruptive behaviors are at risk for being rejected by their peers. Aggressive children who are also socially rejected exhibit more severe antisocial behavior than children who are either aggressive only or rejected only (Lochman and Wayland 1994). The match between the race of students and their peers in a classroom influences the degree of social rejection that students experience (Jackson et al. 2006), and race and gender appear to moderate the relation between peer rejection and negative adolescent outcomes. For example, Lochman and Wayland (1994) found that peer rejection ratings of African American children within a mixedrace classroom did not predict subsequent externalizing problems in adolescence, whereas peer rejection ratings of white children were associated with future disruptive behaviors. Similarly, whereas peer rejection can pre-

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dict serious delinquency in boys, it can fail to do so with girls (MillerJohnson et al. 1999). As children with conduct problems enter adolescence, they tend to associate with deviant peers. Adolescents who have been continually rejected from more prosocial peer groups because they lack appropriate social skills turn to antisocial cliques for social support (Miller-Johnson et al. 1999). The tendency for aggressive children to associate with one another increases the probability that serious antisocial behavior will later occur (Fite et al. 2007).

Social Cognition On the basis of children’s temperament, biological dispositions, and contextual experiences with family, peers, and community, children begin to form stable patterns of processing social information and regulating their emotions. A contextual social-cognitive model (Lochman and Wells 2002), based on social information processing theory (Crick and Dodge 1994), stresses the reciprocal interactive relationships among children’s initial cognitive appraisal of problem situations, their efforts to think about solutions to the perceived problems, children’s physiological arousal, and their behavioral response. The level of physiological arousal will depend on the individual’s biological predisposition to become aroused and will vary depending on the interpretation of the event (Williams et al. 2003). The level of arousal will further influence social problem-solving, operate to intensify the fight-or-flight response, and interfere with the generation of solutions. Because of the ongoing and reciprocal nature of interactions, it may be difficult for children to extricate themselves from aggressive behavior patterns. Aggressive children have cognitive distortions at the appraisal phases of social-cognitive processing because of difficulties in encoding incoming social information and in accurately interpreting social events and others’ intentions. In the appraisal phases of information processing, aggressive children have been found to recall fewer relevant nonhostile cues about events (Lochman and Dodge 1994), and reactively aggressive children have a hostile attributional bias, as they excessively infer that others are acting toward them in a provocative and hostile manner (Dodge et al. 1997; Lochman and Dodge 1994). Aggressive children also have cognitive deficiencies at the problemsolution phases of social-cognitive processing. They tend to have dominance- and revenge-oriented social goals (Lochman et al. 1993), which guide the maladaptive action-oriented and nonverbal solutions they generate for perceived problems (Dunn et al. 1997; Lochman and Dodge 1994).


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Aggressive children frequently have low verbal skills, which contributes to their difficulty in accessing and using competent verbal assertion and compromise solutions. When aggressive children consider possible solutions to socially challenging situations, they evaluate aggressive behavior in a positive way at the next processing step (Crick and Werner 1998) and expect it will lead to positive outcomes for them (Lochman and Dodge 1994). Deficient beliefs at this stage of information processing are especially characteristic for children with proactive aggressive behavior patterns (Dodge et al. 1997) and for youth who have callous-unemotional traits consistent with early phases of psychopathy (Pardini et al. 2003). Indeed, children’s schematic beliefs and expectations affect each of these information processing steps (Lochman and Dodge 1998; Zelli et al. 1999).

Application Cognitive-behavioral interventions are frequently applied to the treatment of conduct problems in children and adolescents, and a number of CBT programs have been developed for this purpose. As noted earlier, CBT programs are available for preschool-age children, school-age children, and adolescents. Some CBT programs focus on prevention of conduct problems, whereas others are designed to treat youth with clinical diagnoses. Still other differences among CBT programs involve the inclusion of multiple components (e.g., parent training, teacher consultation) and program length. Nonetheless, most CBT programs for youth with conduct problems incorporate common elements such as goal setting, rewards, managing anger, and problem solving. In the following sections, cognitivebehavioral elements for treatment are described, using the Coping Power Program as an example.

Coping Power Child Component The Coping Power Child Component (Lochman et al. 2008) is a 34session manualized cognitive-behavioral intervention targeting aggression and other disruptive behaviors in fourth- through sixth-grade students. Originally designed for delivery to small groups of students in schools, the program has been successfully adapted for use with individual students and for implementation in clinical settings. With minor modifications, the program is also appropriate for younger elementary and middle school students. Coping Power groups typically include five to seven students and two coleaders, one of whom takes on the role of delivering the program content while the other coleader monitors and manages group behavior.

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Coping Power group leaders meet with students individually on a monthly basis to build rapport, assess and ensure comprehension of material, and individualize the program as needed. In the school setting, leaders also maintain regular communication with classroom teachers. The Coping Power Child Component curriculum comprises seven main foci: goal setting, organization and study skills, emotion awareness, anger management, perspective taking, social problem-solving, and handling peer pressure (examples of these activities are discussed later in this chapter in the section “Main Foci”). Sessions are highly structured, following a standard format of recurring opening and closing activities with topicbased, session-specific activities in between.

Group Behavior Management A group behavior management system is included in the program, incorporating rewards for appropriate behavior and consequences for disruptive behaviors. A token economy forms the basis of the behavior management system. Students earn points for following group rules, for appropriate participation in group activities, and for completion of program-related activities between sessions (e.g., working toward individual goals, as described later in the section “Goal Setting”). Leaders provide warnings or “strikes” for inappropriate behaviors, and students lose the opportunity to earn a point after three such warnings. When disruptive behaviors continue after this consequence is delivered, students may be excused from the remainder of the session. At the end of each session, students are given the opportunity to visit the program’s prize box. Small prizes worth only a few points are available, but students are encouraged to delay gratification and work toward accumulating points to purchase more desirable items.

Opening Activities At the beginning of each session, ask students to recall key points from the previous session, and conduct a brief review of the previous session’s content. Next, ask students to produce their weekly goal sheets for review. The goal sheets are an integral part of the Coping Power Program, serving as the main tool by which students practice target behaviors between sessions. Goal sheets also provide students and leaders with feedback about the students’ behavioral progress in the classroom. Each week, students and leaders work together to identify an individualized, operationally defined target behavior (e.g., “I will complete my math class work before going to the computer”). On a daily basis, teachers provide written and verbal feedback to the child. At the end of the week, students bring their


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goal sheets to the Coping Power meeting and are awarded one point for each day the goal was achieved.

Closing Activities At the end of each session, ask each student to provide positive feedback to another student in the group, commenting on the student’s prosocial behavior during the meeting or on a time the other child used appropriate coping between the previous and current meetings. Next, review points earned by each student during the meeting, announce point totals, and allow students to spend or save their points. Finally, award a brief free-play period to all students who have displayed appropriate behavior during the meeting. This activity serves as a reward for the students as well as an opportunity for leaders to observe peer interactions, providing coaching and support as needed. Students who fail to earn the free-play period use the time to discuss their difficulties with a leader and to problem-solve better choices for future meetings.

Main Foci Goal setting. The initial Coping Power Child Component sessions introduce the concept of goal setting, a theme that is continued for the duration of the program. Obtain input from teachers, then help students to identify personally meaningful long-term goals to work on for the current school year (e.g., to raise Cs to Bs, to be promoted to the next grade). Assist students in breaking down these long-term goals into manageable steps. For example, a student who strives to raise his or her grades might identify daily short-term goals such as accurately writing down homework assignments, bringing books home, and completing and turning in homework. Students can then use these short-term goals on the weekly goal sheets. Students may work on a short-term goal for 1 week or several weeks, until they have mastered the goal or until it is apparent that the goal requires modification for the student to achieve success. Other activities in the goal-setting component involve students interviewing or listening to an interview with an adult who set goals during his or her youth and later achieved them. Community leaders, local business owners, and college athletes can be effective role models for this task. Organization and study skills. Given the frequency with which externalizing problems co-occur with behavioral difficulties in the school setting, the Coping Power Child Component includes two sessions that directly address students’ study habits. Have students discuss the impor-

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tance of organization to academic success and participate in activities that highlight the effectiveness of good organization. For example, ask students to bring their backpacks to the meeting and direct them to find a common item (e.g., pencil, list of spelling words) as quickly as possible. Next, help students to organize their materials, then complete the activity again, noting the decreased time and effort required to locate items when the backpack has been organized. Other activities involve identification of helpful and unhelpful study habits and planning for completion of larger projects. Games and role-plays are used to bring the concepts to life for students. Emotion awareness. As a precursor to anger management training, students participate in several sessions designed to normalize the experience of various emotions and to help them accurately recognize and label their feelings. Help students to describe various emotions in terms of associated physiological sensations, behaviors, and cognitions. Next, have students use a thermometer analogy to help them recognize the range of intensity with which emotions occur. Labels are given to emotions at varying levels on the thermometer (e.g., “annoyed” at the bottom, “mad” in the middle, and “furious” at the top). These activities are helpful to students who might experience their feelings in an on-off manner, failing to recognize the range in intensity of their experience and resultantly missing early opportunities to manage their angry feelings. Subsequently, use the thermometer analogy to help students recognize that different events may evoke different levels of anger for them. For example, classroom noise may cause them to feel annoyed and a teacher’s reprimand may lead them to feel mad, whereas they may become furious when peers make disparaging comments about their family members. Anger management. Students learn several active strategies for selfcontrol in the anger management unit, including distraction, relaxation, and coping self-statements. Assuming they have learned to recognize their earliest signs of anger in the emotion awareness sessions, students can implement anger management skills before they become flooded with emotion and while their anger is still at a manageable level. To help them manage low levels of anger, have students participate in distraction exercises in which they practice directing their focus away from an annoying situation. For example, other group members can be directed to make noise and taunt a target student while he or she engages in a memorization task. By concentrating on the task, the student learns that he or she can keep his or her anger from escalating and that thinking about or doing other things can be an effective way to control angry feelings. Additionally, teach relaxation techniques, such as progressive muscle relaxation exercises and guided imagery.


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A sequence of progressively more challenging activities is built into the program to teach students to use coping self-statements (e.g., “I won’t let this get to me”) to manage their anger. In the initial activities, have students use puppets to practice using self-statements in response to peer teasing. Using puppets keeps the task fairly impersonal, allowing students to focus on learning the skill without eliciting strong feelings. When students demonstrate proficiency with the puppet task, make the task more challenging by having one student use coping statements in response to direct taunts by other group members. Closely monitor this activity, as it is designed to elicit mild to moderate levels of anger in students. Provide coaching or interrupt the activity if students demonstrate problems maintaining control. Although the activity can be challenging for leaders and students, the experience of appropriately managing anger in a real-to-life situation can be particularly salient and corrective for students. Perspective taking. The next set of sessions targets the problems with perspective taking commonly seen in children with disruptive behavior problems. The clinician can engage students in discussions and role-plays to illustrate individual differences in perspectives. For example, have students act out a situation and then interview each other about their perceptions of the events. The differing viewpoints highlight how the same event can be perceived differently by different people. Lead additional roleplays and games to foster awareness of how difficult it can be to accurately understand another person’s intentions. Because the tendency to make hostile inferences about others’ intentions is common among Coping Power participants, make sure to encourage students to consider more benign alternatives. Lead activities involving perspective taking in peer relationships and in interactions with teachers. For example, students can be asked to interview a teacher, asking questions that allow the teacher to correct common student misperceptions about disciplinary procedures and classroom management. Social problem-solving. Work with students to develop mastery in the use of a structured social problem-solving model, PICC, in problem situations. The PICC model comprises three steps: 1) Problem Identification, 2) Choices, and 3) Consequences. In the first step, help students learn to carefully assess the problem situation and to define the problem in objective, behavioral terms. In the second step, have students generate a list of possible choices that could be enacted in response to the problem. Encourage students to think broadly about choices, and accept even “bad” choices as discussion points for the next step. In the third and final step, ask students to discuss the likely consequences for each of the choices that have

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been proposed. Clarify the benefits of choosing prosocial options, as well as the negative outcomes associated with aggressive and antisocial solutions. Finally, have students rate the various choices and consequences and identify the solution with the highest likelihood of success. Use hypothetical problem situations as well as examples of problems from students’ own lives to illustrate the use of the PICC model. Include peer conflicts, problems with siblings, and teacher-student problems. As a final activity in the social problem-solving unit, work with students to create a video that explains and demonstrates the PICC model in action. Have students decide on a problem situation to portray, generate ideas for depicting several choices and consequences, write a script, and act out their ideas on video. The activity provides an engaging way for students to solidify their understanding and to gain additional practice using the PICC model. Handling peer pressure. The final sessions in the curriculum focus on peer relationships, and a main goal of this unit is for students to learn to identify and effectively manage peer-pressure situations. Discuss the meaning of peer pressure and reasons students might give in to it. Help students identify a variety of ways to resist peer pressure, such as making an excuse and finding other friends to hang around with. Lead students in role-plays to practice using the strategies. Also discuss peer pressure that may occur outside school (e.g., in students’ neighborhoods) and open the discussion to general neighborhood problems if relevant (e.g., violence and gang activity). Have students discuss their involvement in groups or cliques, and encourage them to consider the implications that associating with various groups might have for them. Ask students to self-identify personal strengths and leadership qualities and discuss how they can use their abilities to become involved with prosocial peer groups.

Coping Power Parent Component The Coping Power Parent Component includes sixteen 90-minute sessions that are held during the same 16- to 18-month time period as the child sessions. Parent groups are led by two coleaders and include up to 12 parents or parent dyads. Many elements of the Coping Power parent sessions derive from well-established parent training programs and focus on nurturing positive parenting skills. Parent sessions also include a focus on stress management, building family cohesion and communication, and family problem-solving. Moreover, an additional aim of the parent sessions is to teach parents how to reinforce the skills their children are learning in their groups. Although new content is introduced to parents in each session, all


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sessions include a review of previous session content and activities to facilitate the generalization of skills (e.g., interactive worksheets, role-plays, homework). Leaders deliver this intervention in a flexible manner, with an aim of adapting session activities to best address the specific problems and issues that group members present. The Coping Power Parent Components described below are typical of most programs for parents of youths with DBD.

Academic Support in the Home Leaders introduce the idea of a homework completion system that would allow for increased parent-teacher communication about homework and thereby promote children’s academic success. Brainstorm possible systems (e.g., an assignment notebook in which the teacher initials each homework assignment) and discuss how parent-teacher conferences might provide additional academic support for children. Provide parents with potential questions they might ask during these conferences, and role-play with parents. Emphasize that additional support structures are needed to increase children’s likelihood of homework completion. Strategize with parents about what support structures might be useful (e.g., a protected homework time, in which phone calls are not accepted and the television is off). Also discuss how parents might monitor their child’s progress. It is important to acknowledge parents’ concerns about the level of time and energy required to implement these strategies. Efforts should be made to help parents create a system that will work well for them given their particular demands. Encourage parents to establish a homework system with input from their child.

Stress Management Introduce the topic of stress management by defining stress and leading parents through a discussion of how stress can undermine their positive parenting behaviors. Ask parents for their ideas about how they might take care of themselves to reduce stress. Introduce the notion of active relaxation as a way to reduce stress. Practice in session, and ask parents to practice between sessions. In the second session, discuss time management as a way to reduce stress and introduce the cognitive model of stress and mood management, in which parents develop cognitive coping strategies for stressful events and learn to recognize the connection between cognitive perceptions and beliefs and related emotions. In reviewing this model, discuss how thoughts can contribute to feelings and subsequent behaviors in parenting situations. Role-play a stressful parent-child situation with

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parents and identify the thoughts and feelings that resulted in a behavioral overreaction by the parent.

Basic Social Learning Theory, Praise, and Improving the Parent-Child Relationship Present the basic social learning model using an ABC Chart to introduce the concepts of antecedents (A), behavior (B), and consequences (C). Discuss how parents might modify children’s behavior by rewarding good behavior with positive consequences. Work with parents to identify positive consequences (e.g., a favorite dessert, labeled praise) and introduce a tracking system whereby parents will become more aware of their child’s positive and negative behaviors. Also introduce the importance of parentchild “special time” and help parents set goals for special time (e.g., the number of times per week they will engage with their child in a certain activity) for the coming week.

Ignoring Minor Disruptive Behavior The focus here is on managing children’s minor disruptive behaviors through ignoring. First define minor disruptive behavior (e.g., changing the television channel repeatedly) and distinguish these behaviors from more serious transgressions that cannot be ignored (e.g., beating up a sibling). Then discuss how to appropriately ignore. Although these discussions lay important groundwork, the centerpiece of this work is role-play. Leaders should first model a parent-child interaction in which the parent ignores the child’s escalating behavior. Parents should then role-play a similar scenario. After these role-plays, engage parents in a debriefing discussion about what they think about ignoring and how they felt about the roleplays. Be prepared to address negative reactions parents might have to the concept of ignoring.

Antecedent Control: Giving Effective Instructions and Establishing Rules and Expectations Revisit the ABC Chart and point out the ways in which instructions can be the antecedents to compliant or noncompliant behaviors. Ineffective instructions often precede child noncompliance, whereas clear instructions often precede child compliance. Identify the qualities of “good” and “bad” instructions and work with parents to identify specific examples. “Bad” instructions include buried instruction (the instruction is buried in other un-


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related talk), chained instructions (too many instructions at one time), vague instructions, and indirect instructions (instruction is given as a question). Encourage parents to practice giving good instructions and monitoring whether their child subsequently complies. A distinction is made between rules and expectations. Behavior rules establish the behaviors that children should decrease (e.g., hitting), whereas behavior expectations establish the behaviors that children should increase (e.g., making the bed). In discussing rules and expectations with parents, emphasize the importance of labeling rule violations (e.g., “Tommy, you just hit your sister and that is against our behavior rules”) so that children are made more aware of the rules. Also emphasize the importance of keeping expectations age-appropriate. Coach parents in how to establish behavior rules and expectations at home and encourage them to track their child’s compliance, their positive reinforcement of compliance, and their labeling of noncompliance.

Discipline and Punishment Introduce the concept of punishment, provide a definition of punishment, and explain why physical punishment is often ineffective in curbing children’s misbehavior. Solicit parents’ ideas regarding punishments. Introduce the time-out procedure. Outline the steps for time-out, strategize with parents about how to handle child misbehavior on the way to timeout and while in time-out, and discuss parents’ reactions and attitudes toward the time-out procedure. Ask parents to identify the behaviors that will result in time-out and to name their time-out procedures (e.g., location, length). Introduce other discipline techniques, such as the removal of privileges and the assignment of chores. Incorporate role-plays of parents implementing these discipline techniques and children protesting. These role-plays will give parents additional practice and aid in the generalization of skills. Also engage parents in an open-ended conversation about punishment for major misbehavior, with an aim of helping parents find alternatives to physical punishment and lengthy, unspecified grounding.

Family Cohesion Building, Family ProblemSolving, and Family Communication Ask group members to invite their spouse, significant other, or other important caretakers in the child’s life to this session. Discuss parents’ concerns for their child as he or she matures. Emphasize that having a positive, healthy parent-child relationship will become increasingly important as

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the child grows older. Brainstorm strategies for how families might build their cohesion both in the home (e.g., family game nights) and outside of the home (e.g., going to a park). Parents are encouraged to follow through with family cohesion–building activities. Present the steps of the problem-solving PICC model. Describe (and show) how through worksheets and videotaped role-plays the children are coached in this problem-solving model—and encourage parents to use this model to resolve family conflicts. Lead parents through a discussion about their ongoing family communication patterns. Do family members have a way of talking with each other about their concerns? When someone wants to change a preestablished rule, how is that negotiated? Are family members satisfied with the way they communicate? Introduce the notion of a family meeting as one way to preserve positive parent involvement in children’s lives and to tackle potential problems before they arise. Guide parents through a discussion regarding how they might establish family meetings at home. Also present a communication system for helping parents monitor their child’s outings with peers.

Cultural Issues Culturally competent clinicians are those who can anticipate the culturally related appropriateness of, and obstacles to, the use of common assessment or intervention procedures for children and families. Ethnic and community factors can require some adaptations in the delivery of CBT for children and adolescents with DBD (Lochman et al. 2006b), especially among minority low-income individuals. Parents may model and promote the use of physically aggressive problem-solving strategies by their greater dependence on corporal punishment, as well as by actively teaching their children to retaliate when confronted with physically or verbally aggressive situations. These parents’ messages can result from their ongoing struggle to protect their children from danger in their impoverished neighborhoods and from their efforts to inculcate responsibility for safety and personal rights. Another factor that may interfere with easy dissemination of CBT techniques is that children may receive conflicting messages from parents and other authority figures (such as school personnel) about the use and value of aggression. Thus, when working with minority children and families, clinicians should attend to how contextual variables may have an effect on problem behaviors and on children’s and families’ abilities to generate a culturally relevant range of alternative solutions to their problems. These differences require


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discussion, and intervention can focus initially on the utility of less aggressive solutions in certain environments (e.g., the child’s school).

Case Examples The following two case examples illustrate key points and challenges of CBT for children with DBD addressed through the Coping Power Child Component and the Coping Power Parent Component.

S Coping Power Child Component Tim is a 15-year-old boy who has been diagnosed with ODD and attentiondeficit/hyperactivity disorder (ADHD). Tim has been seeing a psychiatrist for medication treatment for ADHD. His psychiatrist referred him to outpatient CBT when he continued to exhibit behavior problems while on stimulant medication. Clinical challenges: Blames others, has difficulty accepting responsibility for actions, angers easily. Cognitive techniques demonstrated: Reducing hostile attribution bias, increasing ability to see things from others’ perspectives, coping self-statements, monitoring emotional activation, generation of alternative solutions. Behavioral techniques demonstrated: Functional behavior assessment, behavioral rehearsal, skill acquisition, skill generalization. Clinician: Your mom said you got in some trouble at school yesterday. Tell me what happened. Tim: My teacher is so mean. She always gets on my case, way more than she does anyone else. Clinician: So, you feel like your teacher gets onto you a lot. What was it that she got onto you about yesterday that led to you getting suspended? Tim: I KNOW my teacher gets onto me a lot. All I did yesterday was get up to sharpen my pencil, and she put my name on the board. Clinician: So you got up to sharpen your pencil, and your teacher put your name on the board. Was that enough for you to get suspended? Your mom said you spent the rest of the day in the vice principal’s office. Tim: I got suspended for disrespecting the teacher. I got fed up with her getting onto me so much and not anybody else. Clinician: It sounds like you started feeling angry when your teacher put your name on the board and that you must have said something or done something that she thought was disrespectful enough to send you to in-school suspension. What happened after she put your name on the board? Tim: I threw my pencil down, and it accidentally bounced off my desk and hit the teacher. I called her a bad name, too. I wasn’t even saying it

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to her. I was just talking to myself. She wouldn’t have even heard me say it if she hadn’t been standing right in my space. She should just back off and leave me alone. Clinician: Is it safe to say that what happened after you got your name on the board—getting angry, hitting the teacher with your pencil, and calling her a name—caused you to get suspended? Tim: Yeah, but it’s all her fault. She lets other people sharpen their pencils all the time. If she hadn’t made such a big deal out of it, none of that would have happened. Clinician: Well, let’s take a look at that. Do you remember when you interviewed your teacher to get to know her better and find out where she is coming from? Tim: Yeah. Clinician: What do you remember learning about her during that interview? Tim: She didn’t like having a lot of homework when she was in elementary school, and she even got in trouble for talking too much in class sometimes. Clinician: That’s right. And what did she say about why she has rules for the classroom? Tim: So that we know what is expected of us and to help us learn. Clinician: That’s right. And what did she say about what she wants most for her students? Tim: She wants us to enjoy learning and do well so that we can get a good education and have a good life someday. Clinician: That sounds like what she said. So let’s think again about the situation that happened yesterday. Do you think she put your name on the board just to make you mad? Tim: No. Clinician: Do you think she put your name on the board just because she doesn’t like you? Tim: Maybe—it sure seems like she doesn’t like me a lot of the time. Clinician: Can you think of any other reason why she might have put your name on the board? Tim: Well, I guess maybe she could have just been trying to enforce her rule. She said that she wants us to get better about staying in our seats, especially because we’re getting close to testing time. She got on Jamal’s case for asking to go to the bathroom. Clinician: Oh, so you weren’t even the only one who got in trouble for getting out of your seat? Tim: No, I forgot about her getting on Jamal’s case until just now. Clinician: So do you think that maybe she’s just trying to get better at enforcing her rule about staying in your seat as testing gets closer, and you and Jamal happened to be the first ones who got in trouble now that she is enforcing the rule more strictly? Tim: Yeah, that could be it. Clinician: OK, so let’s think about how the situation might have gone differently if you had told yourself that instead. By the way, what did you say to yourself when your teacher put your name on the board?


Tim: I said, “She’s a [something I can’t repeat].. ..” I said, “She’s mean and she has it out for me.” Clinician: And what happened to your anger on your anger thermometer when you said that to yourself? Tim: I got real mad and that’s when I threw my pencil. Clinician: OK, so you’ve given a really good example about the way that our thoughts are related to our feelings. When you told yourself that your teacher is mean and has it out for you, you got really angry and threw your pencil and called her a name, which is what led you to get suspended. Now, what do you think might have happened if you had noticed yourself getting angry and said a coping statement to yourself instead? Tim: Like what? Clinician: Like, you could have said to yourself, “Mrs. Stephens seems like she is getting nervous for our standardized testing, and she really wants us to do a better job of staying in our seats for the next few days. I should just not make a big deal of it right now and go back to my seat and try to borrow a pencil from Terri instead.” Tim: That probably would have been a better thing to do. Clinician: That’s an example of a coping statement that you could have used in the situation with your teacher to control your anger and stay out of trouble. Now, it’s much easier to talk about using coping strategies to stay calm than it is to do in real life. So how about if we act out the situation from yesterday and see how it goes? I’ll pretend I’m Mrs. Stephens, and I’ll start to write your name on the board for getting out of your seat. How about if you start to respond like you did yesterday, but then try to catch yourself and use a coping statement instead? We’ll keep acting out the rest of the scene for a while and see how it goes. (The clinician and Tim conduct a role-play of the situation.) Clinician: What did you think of that? Tim: It went better. Clinician: What was it like for you to try to use a coping statement to control your anger when I wrote your name on the board? Tim: It was hard at first because I wanted to talk back to you, but when I remembered that Jamal had already gotten in trouble and that you were starting to get nervous about the testing coming up, it helped me calm down. Clinician: Good, so that was an example of how you can use your thoughts to help keep from getting so angry that you do something that causes you to get in trouble. As your teacher in the role-play, I noticed that you responded differently than you usually do, and I felt proud of you for not getting angry or making it a big deal. That seemed like a big improvement for you. Do you think it would help you to control your anger and act that way more often? Tim: Yeah, probably. Clinician: Well then, how can you use what we’ve been talking about today to help you have a better week?

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Tim: I can try to think of where the other person is coming from and try to use coping statements to stay calm instead of getting angry. Clinician: That sounds like a good idea. We’ll see how it goes. Would that be something you might want to pick as your goal on your goal sheet for the week? Then you could earn points for working on it, and it could help you get feedback from your parents and teacher to see how you do. Tim: Sure. Clinician: How would you feel about bringing your mom in and telling her what we’ve been talking about so she knows how to help you work on your goal this week? Tim: That’s fine. Clinician: OK, is there anything else we should talk about before she comes in?

Coping Power Parent Component Naomi is a 34-year-old single mother of three children. She has received prior mental health services to deal with her own mood disorder and a past abusive relationship. Naomi is currently seeking treatment for her youngest daughter, Anna (age 8), who has been getting into trouble for fighting and refusing to follow directions at school. Naomi hardly speaks with Anna at home because she is too tired when she gets off work to deal with Anna’s “attitude.” Anna currently spends most of her free time in her room. Anna’s father lives in a different state, and she sees him one to two times a year. Clinical challenges: Overextended mother with her own mental health and social support needs; poor parent-child bond as a result of frequent conflictual parent-child interactions; need for clearer behavioral contingencies to foster compliance at home; balancing parent and child involvement in therapy. Cognitive and behavioral techniques demonstrated: Parent-child special time, stress management, behavioral monitoring, behavioral contingencies, positive reinforcement, extinction and planned ignoring. Naomi (with Anna and clinician in the waiting room): Will you want to meet with me or Anna today? Clinician: I would like to meet with each of you individually for part of the time today and to spend some time with both of you together. Naomi: OK. Who would you like to see first? Clinician: Anna, do you have a preference about who I meet with first today? Anna: I don’t care. Clinician: All right then—because I met with you first last week, Anna, why don’t I go ahead and meet with your mom first today. There are some games you can play in the waiting room. Cathy should be at the front desk the whole time, so let her know if you need your mom or need anything else, OK? We’ll make sure to get you in about 25 minutes. Anna: OK. Clinician (to Naomi as they enter the therapy room): So, tell me how your week has been.


Naomi: It’s been pretty rough. I had to keep Anna home from school on Wednesday and Thursday because she got in a fight. The principal really let me have it when I went to check her back in on Friday. I had to go without pay those 2 days, so needless to say, I was pretty mad at Anna. Clinician: Gosh, I’m sorry to hear that. It does sound like you had a difficult week. Last week, we talked about helping you reconnect with Anna in two ways. We talked about having you try to set aside some special time to do an activity with Anna that you thought she would enjoy to help you two reestablish a positive bond. We also talked about having you use a tracking grid to catch her being good, to make sure you’re noticing the times she follows directions, puts effort into her schoolwork, and helps you out around the house. How did those things go for you this week? Naomi: Not very well. I was going to take her shopping on Wednesday night, but when she got in serious trouble at school that day, I did not think it was a good idea to reward her like that. Then I had to work overtime to make up for the days I missed at work, so we have not had a chance to do that yet. Clinician: Those do sound like real barriers to doing something special with Anna this week, like taking her shopping. It’s still important to not give up on the goal of you two having some positive time together though, so let’s think about how you might be able to do that this week. Do you have any ideas about what you could do? Naomi: Well, it might need to be something that doesn’t cost very much money, because money is tight right now. Clinician: That’s fine. The important thing is that you make it a priority and set the time aside and find something that you think you’ll both enjoy. Naomi: We both like watching the same singing competition on television, so I was thinking of asking her if she would like to watch it with me instead of watching it in her room. Clinician: That sounds like a nice thing for the two of you to do together. It would also be nice for you to find something the two of you can do that is interactive as well. I know you are probably exhausted at night when you get home from work. Are there any nights that you get home earlier or that are less hectic for you? Naomi: I’ve been trying to leave a little bit early on Friday afternoons. Clinician: Would that be a good day to try to do something with Anna? Naomi: Actually, it would because her brother and sister go to their aunt’s house for a few hours after school on Fridays. Clinician: OK, great. Now, what do you think might be a fun, inexpensive thing you and Anna could do on Friday? Naomi: Well, she has been begging me to let her get a pedicure. I don’t have the money to let her get one at the salon, but I have all of the stuff to give her one at home. Clinician: That sounds fun. Have you ever done that before? Do you think Anna would like it? Naomi: Well, I was going to do it a few weeks ago, but Anna blew up about something. I can’t even remember what it was. But the pedicure never happened.

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Clinician: So it sounds like to make it work, you’ll have to try to keep the mood pretty light with Anna beforehand so there aren’t any major blowups. Naomi: Yeah. ... How do I do that? Clinician: Well, sometimes in order to keep special time special, you’ll have to let things go with Anna that you wouldn’t ordinarily let go. For example, if you don’t approve of how she’s wearing her hair when you pick her up, don’t make a big deal of it. It might also help to be cautious about how you react to things she brings up. For example, if she tells you that she had a bad day at school, you might say, “I’m sorry to hear that, honey,” instead of jumping in with an inquiry such as “Why? Did you do something wrong?” It can help if you’re in the right frame of mind to interact calmly with her. We talked a few weeks ago about how parenting is stressful and about how our own feelings of stress affect our mood and our interactions with our children. It is easier to be more patient with them when we’ve had some time to rejuvenate ourselves. Any chance you’ll get some time to yourself before you spend time with Anna on Friday? Naomi: Well, I have a coworker who is always asking me to walk with her for exercise on our lunch break. I would really like to do it but never make time for it. Maybe I could do that on Friday so I’ll be more relaxed when I hang out with Anna. Clinician: That sounds like a great idea. What will it take to make sure you have the time to do that? Naomi: I just need to write it in on my calendar like any other appointment. Clinician: Do you want to take out your calendar and do that right now? Naomi: There, I just did it. Clinician: Great. I’ll check back next time and see how it goes, both the walking and the special time with Anna. The other thing we were going to follow up on was whether you were able to pay attention to how often Anna exhibited some of the target behaviors we’ve set for her, such as following your directions, putting more effort into her schoolwork, and helping you around the house. Tell me how that went this week. Naomi: Well, I have to confess, I forgot all about the sheet you gave me until right before we came here. Sorry, it was just that kind of a week. Clinician: Even though you didn’t fill out the sheet, did you pay any more attention to Anna’s behavior? Naomi: I did pay more attention to her behavior early in the week, before she got in trouble at school. I did notice that there are quite a few things that she does around the house that I tend to overlook. Clinician: Like what? Naomi: Well, she pretty much takes care of herself a lot of the time, because I’m gone for work. She gets herself dressed for school in the morning and fixes herself breakfast. I think she helps her brother and sister with the dinner dishes some before I get home from work and she does keep her room pretty clean.


Clinician: It sounds like you noticed quite a few things that she’s doing already to help out around the house that you weren’t very aware of before. Did you say anything to Anna about that? Naomi: Not really, because those are all things I think she should be doing because she’s part of the family and we all have to do our part. Clinician: It’s appropriate to have expectations for your children to help out around the house. The difference is that in trying to improve Anna’s compliance at home, it’s important to recognize where she is already showing effort in this area and to provide her with some positive reinforcement. Quick labeled praise, such as telling Anna that you appreciate her effort in getting herself ready in the morning and cleaning up the kitchen at night, lets her know that you notice and appreciate these things and can help her feel very encouraged. Naomi: Yeah, I’ll try to do more of that this week. Clinician: What I would like you to do is to make an effort to praise her for her effort around the house several times this week and then to pay attention to what effect it has on her willingness to help out around the house and also on your relationship. We’ll follow up next time to see if it made any difference. The other side of the equation that we talked about last time is that it can also be helpful to ignore small annoyances that could lead to a big blowup and might be better left alone. Tell me about how that went this week. Naomi: I did try that a few times this week. Clinician: Great, can you give me an example? Naomi: Yeah, it drives me crazy when Anna tracks water in the hallway after she takes a bath and then she leaves the sink messy and sticky after she brushes her teeth. In the past, when I’ve tried to make her come back and clean these things up, it has led to a big blowup right before bedtime. I decided to let it go a few times this week. It went better than I expected. We were able to have some nice time together before bedtime several nights this week, and I guess that’s what should be more important than having a perfectly clean bathroom. Anna even cleaned out the sink on her own at one point. Clinician: That’s terrific. What did you learn from that? Naomi: I learned that it helps to pick my battles, especially with Anna, where even the littlest thing could lead to a big rift between us. Clinician: That seems like an important lesson for you to draw on in the future. It’s almost time for us to bring Anna back in. Would you like to use the time to tell her that you appreciate what she does to help out around the house and also to talk about what you might do together on Friday? Naomi: That sounds good. We will still need to talk about what happened at school on Wednesday. Clinician: Yes, we’ll talk about that, too. Perhaps we can use it as an opportunity for Anna to show you the approach she’s learning to stop and think about the best way to solve problems when she is angry, so that you can help her use it at home. Naomi: That sounds good. I’ll go get Anna... .

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Conclusion This chapter summarizes research-supported prevention and treatment programs for DBD. The Coping Power Program, used in targeted prevention and treatment interventions for aggressive children, is described in detail. Coping Power is based on a contextual social-cognitive model and has been tested in a series of efficacy and effectiveness studies. The major foci of the Coping Power Child and Parent Components are described and are illustrated with case examples.

Key Clinical Points • Problematic parenting practices that are especially associated with children’s aggressive behavior include harsh punishment, inconsistent discipline, lack of warmth and positive attention, and poor monitoring. • Peer factors that can contribute to the development and maintenance of children’s aggressive behavior are high levels of peer rejection and involvement in deviant peer groups. • Numerous deficits in social information processing and problem solving have been found. Children with aggressive behavior and DBD attend to fewer nonhostile cues in social situations than their peers do, and they then have a bias in attributing hostile intentions to others. When compared with their peers, they generate fewer verbal assertion and compromise solutions to their social problems. When evaluating their responses, they consider aggressive solutions acceptable and expect that aggressive solutions will lead to positive outcomes for them. • Key elements of most CBT programs include a focus on children’s behavioral goals, emotional awareness and self-regulation, perspective taking and attribution retraining, social problem-solving skill training, and avoidance of deviant peer processes. • Social problem-solving is an especially common element of most evidence-based CBT programs for children with conduct problems and can be delivered through discussion, role-play, homework exercises, and creation of therapeutic products such as videos. • Positive reinforcement is effective not only for increasing the amount of appropriate behaviors but also for decreasing the amount of inappropriate behaviors. The clinician and parents may reinforce appropriate behaviors that are “positive opposites” of inappropriate behaviors.


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Self-Assessment Questions 12.1. A 10-year-old boy with a history of aggressive, disruptive behavior at home and at school is referred for psychological treatment. The most effective treatment for his referral problems is which of the following? A. Parent training alone. B. Cognitive-behavioral interventions with the child alone. C. Cognitive-behavioral interventions with parent and child components. D. Relationship therapy with the child. 12.2. David is a 10-year-old boy who attends individual therapy to address his diagnosis of oppositional defiant disorder. When his therapist asks about his feelings, his responses are limited to “happy” and “mad.” In seeking to broaden his recognition of various feeling states, his therapist should work on helping him recognize which of the following? A. B. C. D.

Physiological sensations. Behaviors. Cognitions. All of the above.

12.3. Amanda, age 11, has been referred for therapy because of her frequent angry outbursts. When she is calm, she can articulate appropriate responses to problems such as peer teasing, but she tends to act out aggressively when confronted with real-life problems. Which of the following areas should Amanda’s therapist focus on first? A. B. C. D.

Social problem-solving. Perspective taking. Anger management strategies. Identifying consequences for aggressive behaviors.

12.4. In one of the clinical vignettes in this chapter, 15-year-old Tim assumes that his teacher “has it out for him” when she puts his name on the board for getting out of his seat to sharpen his pencil. Tim’s CBT-oriented clinician seeks to help him see the situation from his teacher’s perspective to modify his initial A. B. C. D.

Intermittent explosive disorder. Hostile attribution bias. Reactive attachment. Relational aggression.

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12.5. In another clinical vignette in this chapter, Naomi has sought mental health services to reduce her daughter Anna’s disruptive behavior. The family’s CBT-oriented clinician has asked Naomi to praise Anna’s prosocial behaviors (such as following directions and helping out around the house) and to ignore minor disruptive behavior (such as whining or not cleaning out the sink thoroughly). The clinician is likely trying to help Naomi use which of the following? A. B. C. D.

Behavioral rules and expectations. Mood management. Discipline. Contingency management.

Suggested Readings Eyberg SM, Nelson MM, Boggs SR: Evidence-based psychosocial treatments for children and adolescents with disruptive behavior. J Clin Child Adolesc Psychol 37:215–237, 2008 Farmer EM, Compton SN, Burns BJ, et al: Review of the evidence base for treatment of childhood psychopathology: externalizing disorders. J Consult Clin Psychol 70:1267–1302, 2002 Matthys W, Lochman JE: Oppositional Defiant Disorder and Conduct Disorder in Childhood. Oxford, UK, Wiley-Blackwell, 2010 Nelson WM III, Finch AJ, Hart KJ (eds): Comparative Treatment of Conduct Disorder. New York, Springer, 2006

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Enuresis and Encopresis Patrick C. Friman, Ph.D. Thomas M. Reimers, Ph.D. John Paul Legerski, Ph.D.

ALTHOUGH incontinence continues to be one of the leading causes of child abuse in this country, children with urinary or fecal accidents today fare much better than children of antiquity. The methods then used to attain continence seem freakishly harsh given the benign nature of the problem. Penile binding, buttock and sacrum burning, and forced urinesoaked pajama wearing are among the many aversive treatments reported in a review of ancient approaches to incontinence (Glicklich 1951). But perhaps the question of whether incontinence was a bigger threat to health in antiquity than it is now could at least partly explain why treatments were so harsh. The health-based consequences of prolonged incontinence during that time could be severe due to the limited means for cleaning bedding, beds, and clothing coupled with ineffective methods for managing infection. Another concern may have been the unpleasant olfactory sensations resulting from close contact with soiled bedding and clothing in homes where air circulation may have been poor. Fortunately for many in467

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continent children (unfortunately not all), practitioners and parents have mostly abandoned physically harsh treatments for incontinence and now use methods that are much more humane from a physical perspective and much more effective from an outcomes perspective. Although many forces contributed to the shift in the treatment of children with incontinence, the most potent force was the advent of behavioral theory and the conditioning-type treatments derived from it. Behavioral theory and treatment inaugurated a veritable paradigmatic shift in the approach to and management of enuresis, and to a lesser but still significant extent, encopresis. For example, behavioral theory eschewed historical tendencies to interpret incontinence in moral, characterological, or psychopathological terms in favor of a biobehavioral view emphasizing genetic predispositions coupled with environmental circumstances. The biobehavioral view has proven superior in at least two important ways. First, it does not disparage afflicted children to the degree that the moral, characterological, and psychopathological views do. Second, it leads much more directly to treatment options. Clinicians do not have direct access to the mechanics of a child’s soul, character, or psyche, but they do have direct access to the circumstances that initiate and/or perpetuate incontinence. This is a book devoted to cognitive-behavior therapy (CBT), and CBT for incontinence involves the strategic manipulation of circumstances to establish continence. Although the cognitive dimension of CBT is minimal in CBT treatment of incontinence, it does play a role, and therefore we refer to treatments for enuresis and encopresis as CBT throughout the chapter. The chapter is divided into two sections, one for enuresis and one for encopresis, and each section includes brief descriptions of the conditions (i.e., diagnosis), a brief review of empirical support, theoretical perspectives on treatment, the assembly of an optimal treatment, the implications of diversity, and challenges to treatment.

Enuresis Diagnosis and Prevalence Enuresis is the collective term for chronic urinary accidents occurring after the conventional age of completed toilet training. The diagnostic criteria in the Diagnostic and Statistical Manual for Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR; American Psychiatric Association 2000) include repeated urination into beds or clothing at least twice a week for at least 3 months after the age of 5 years or the attainment of a 5-year level of development if the child has a developmental disability. Additionally, the ac-

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cidents must not be directly due to the physiological effects of a substance (e.g., diuretics) or a general medical condition. DSM classifies enuresis into primary (in which the child has never achieved urinary continence) and secondary (in which incontinence develops after a period of continence) cases and subdivides it into three subtypes: nocturnal, diurnal, and combined nocturnal and diurnal. This chapter will focus almost solely on primary nocturnal enuresis for three reasons: 1) because it is, by a very wide margin, the most frequently presenting type; 2) because empirically supported treatment is the same for primary and secondary cases, just as it is for the nocturnal type and the nocturnal portion of the combined type; and 3) because there is very little published research on treatment of diurnal enuresis. Prevalence estimates range as high as 25% for 6-year-old boys and 15% for 6-year-old girls (Gross and Dornbusch 1983), and although enuresis is much less prevalent by the teenage years, it is not rare. For example, as many as 8% of boys and 4% of girls are still enuretic at age 12 (Byrd et al. 1996; Friman 2007, 2008).

Empirical Support The primary active component in all empirically supported CBT treatments for enuresis is the urine alarm. Reviews of the literature show that the success rate of the alarm is higher and its relapse rate lower than any other method, including drug treatment and empirically supported nondrug treatments, such as retention-control training. Outcomes from alarmbased treatment range as high as 80% for success and as low as 17% for relapse (Christophersen and Friman 2010; Friman 2007, 2008; Mellon and McGrath 2000). One problem with interpreting the review literature on alarm treatment is that adjunctive components are often added to improve effectiveness, resulting in treatment “packages.” Following the section on theoretical perspectives below, we will describe the treatment components and the treatment packages that have the most empirical support. However, because the effectiveness of the urine alarm when used alone ranges as high as 70% and because it is the central component of the major treatment packages, it should be considered the most empirically supported treatment for all types of enuresis—nocturnal, mixed, and diurnal.

Theoretical Perspectives Early psychological theory attributed the cause of enuresis to defective intrapsychic variables (Sperling 1994); however, the forward march of science has significantly reduced the relevance of the psychopathological perspective on enuresis (Christophersen and Friman 2010; Friman 2007, 2008). Among the

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many contributors to this turn of events are the absence of scientifically secured outcomes of treatment based on that perspective, the abundance of scientifically secured outcomes of CBT (especially but not only alarm based), and research showing the significant role a family history of enuresis plays in the genesis of enuresis, regardless of whether afflicted children live with afflicted blood relatives. For a brief time in the 1990s, a cognitive perspective on enuresis emerged following a report of cognitive therapy competing favorably with conditioning treatment in a comparative trial (Ronen et al. 1992). Two other papers describing successful cognitive therapy were published by the same group (Ronen and Wozner 1995; Ronen et al. 1995), but they essentially report the same findings. The relevance of cognitive theory that emerged following the initial study has diminished to almost nil, however, for at least four reasons. First, after more than 15 years, the findings still have not been independently replicated, despite the ease of their application. Second, the findings are dramatically inconsistent, with over 50 years of research showing the routine success of behavioral approaches and the routine failure of purely psychological (e.g., cognitive) approaches to treatment of enuresis (Christophersen and Friman 2010; Friman 2007, 2008; Houts 1991, 2000; Mellon and McGrath 2000). Third, the authors made no attempt to explain how a purely cognitive approach could so powerfully influence a problem that has such a fundamentally biological basis. Fourth and finally, the original study is flawed methodologically in several ways (see Houts 2000 for a thorough critique). At present, the dominant theoretical perspective on enuresis is the biobehavioral model, which assumes that enuresis results from a combination of genetic predisposition and manipulable environmental events (Christophersen and Friman 2010; Friman 2007, 2008). Those manipulable events provide the behavioral source material for CBT for successful treatment. However, there is a role for cognition in the treatment of enuresis, albeit a supportive rather than a directly active one. Specifically, the incontinent child is typically included in all discussions of treatment—and the child’s understanding of the condition, its likely course, the benefits of treatment, and the value of full compliance is important for treatment progress. It is extremely important that the child be made aware that the condition is not due to any psychological or characterological deficiency on his or her part, and this too is a cognitive rather than a behavioral matter.

Treatment Components Urine Alarm Bed devices. The urine alarm uses a moisture-sensitive switching system that when closed by contact with urine-seeped bedding, completes a


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small-voltage electrical circuit and activates a stimulus that is theoretically strong enough to cause waking (e.g., buzzer, bell, light, vibrator). The bed device typically involves two aluminum foil pads, one of which is perforated, with a cloth pad between them. The bed pads are placed under the sheets of the target enuretic child’s bed, with the perforated pad on top. A urinary accident results in urine seeping through perforations in the top pad, collecting in the cloth pad, and causing contact with the bottom sufficient to complete an electrical circuit and activate a sound-based alarm mechanism. In principle, the awakened child turns off the alarm and completes a series of treatment steps. In practice, initially at least, the alarm often alerts parents first, who then waken the child and guide him or her through the training steps. Pajama devices. Pajama devices are similar in function, yet simpler in design than bed devices. The alarm itself is either placed into a pocket sewn into the child’s pajamas or pinned to the pajamas. Two wire leads extending from the alarm are attached (e.g., by small alligator clamps) on or near the pajama bottoms. When the child wets during the night, absorption of urine by the pajamas completes an electrical circuit between the two wire leads and activates the alarm. A range of stimuli are available for use with the pajama devices and include buzzing, ringing, vibrating, and lighting. Child- and parent-focused methods. Actual alarm use can be divided into different methods, depending on the primary roles of the child and parent. In the child-focused method, the alarm awakens the child, who independently completes treatment steps. In the parent-focused method, the alarm awakens or alerts the parent, who awakens the child and guides him or her through treatment steps. The treatment steps vary across published accounts and guides but generally include full arousal, going to the bathroom to complete (or attempt) urination, changing bedding and pajamas, resetting the alarm, and going back to bed. Parent-focused methods are obviously dependent on the saliency of the alarm stimulus, and with the bed-device wire leads, can be extended to the parents’ auditory range (e.g., in their bedroom). For the pajama device, either a very loud alarm or periodic checking is necessary to allow parents to readily attend to accidents. Our clinical experience suggests that optimal treatment compliance is attained only with parent-focused practice.

Retention-Control Training Retention-control training (RCT) was developed following the observation that many enuretic children had reduced functional bladder capacity, the primary characteristic of which is frequent small volume urinations

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(Muellner 1960, 1961; Starfield 1967). RCT expands functional bladder capacity by having children drink extra fluids (e.g., 16 oz of water or juice) and delaying urination as long as possible, thereby increasing the volume of their diurnal urinations and expanding the interval between nocturnal urges to urinate (Muellner 1960, 1961; Starfield and Mellits 1968). To use RCT, establish a regular time to begin training each day and ensure that it is concluded at least a few hours before bedtime. Encourage enuretic children to drink as much of their favorite beverage as they can and forestall urination as long as they can. When they reach their limit, have them urinate in a washable receptacle that is designed to measure volumes of fluid. Explain that the goal for each target urination is to produce more urine than was produced with the previous target urination. Use a reward system (discussed in the section “Reward Systems” later in this chapter) to maintain motivation. Rewards can be delivered for increasing the amount of fluid drunk, increasing the time between urinations, and/or exceeding the previous amount of urine produced.

Kegel and Stream-Interruption Exercises Kegel exercises involve purposeful manipulation of the muscles necessary to prematurely terminate urination or to contract the muscles of the pelvic floor (Kegel 1951; Muellner 1960). These exercises were originally developed for stress incontinence in women, and a version of Kegel exercises, called stream-interruption exercises, has been used in enuresis treatment packages for years. Clinicians train children to conduct Kegel exercises by having them start and stop their urine flow multiple times during active urinations at least once a day. When they have mastered “wet practice,” teach them “dry practice” by telling them to employ the same urogenital contractions they use with wet practice. Teach children to hold the contraction for 5–10 seconds, followed by a 5-second rest, 10 times on three separate occasions a day.

Waking Schedule This treatment component involves waking enuretic children and guiding them to the bathroom for urination. There are multiple potential benefits, including changes in arousal, increased access to the reinforcing properties of dry nights, managing urinary urge in lighter stages of sleep, and reduction in the length of time children must hold their urine. The early use of waking schedules typically required full awakening, often with sessions that occurred in the middle of the night, but subsequent modifications to the procedure involved only partial awakening and conducting waking ses-


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sions just before the parent’s normal bedtime, with no loss of effectiveness. To use the waking schedule, have the parent who goes to bed latest wake the incontinent child and take him or her to the bathroom for urination. If the bed is already wet, wake the child 15 minutes earlier the next night. After one week of accident-free nights, have the parent awaken the child one half-hour earlier. Continue making the wake times earlier until the child’s original bedtime is reached.

Overlearning Overlearning is a nocturnal version of RCT. Like the RCT procedure, this method requires that children drink extra fluids—but just before bedtime rather than during the day. Overlearning is an adjunctive strategy only, and is used primarily to enhance the maintenance of treatment effects established by alarm-based means. Thus, it should not be initiated until a dryness criterion has been reached (e.g., 7 dry nights; Houts and Liebert 1985).

Cleanliness Training Some form of consequential effort directed toward returning soiled beds, bed clothing, and pajamas to a presoiled state is a standard part of empirically supported treatment packages for enuresis. It has not been evaluated independently of other components, and thus, the extent of its contribution to outcome is unknown. However, its contribution to the logic of treatment is obvious, as is its relevance to the training of responsibility in childhood, and thus we recommend its inclusion in all treatment for enuresis.

Reward Systems Although contingent rewards alone are unlikely to cure enuresis, they are a component of multiple empirically supported programs, and they are routinely recommended in papers describing effective treatment (Christophersen and Friman 2010; Friman 2007, 2008). With the current state of the literature, it is impossible to determine their independent role in treatment. A plausible possibility is that they sustain the enuretic child’s motivation to participate in treatment, especially when the system reinforces success in small steps. If dry nights are initially infrequent and motivation begins to wane, decreases in the size of the urine stain can be used as the criterion for earning a reward. To measure these decreases, merely place tracing paper over the urine spot and trace it and then compare it with previous tracings.

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An example of a reward system we often use in enuresis treatment programs involves a dot-to-dot drawing. The child or parent draws a dotted picture of an item the child would like and the parents are willing to buy. To determine the number of dots, determine the amount of money parents would be willing to let their child have on a daily basis and divide that amount into the cost of the item. Each time the child reaches a specified criterion (e.g., accidentfree night, smaller urine spot), have him or her connect one dot; when all the dots are connected, have the parent buy the item and give it to the child. Using this method allows parents to reward their incontinent child for small amounts of progress made on the way to continence, and thus potentially increases motivation (this system can also be used for accident-free days or successful defecations in encopresis treatment programs).

Fluid Restriction Listing fluid restriction among treatment components with well-established contributions to effective treatment presents an anomaly. Specifically, no research of any kind has ever shown fluid restriction to contribute to the success of an enuresis treatment program. We mention fluid restriction here because despite the complete absence of supportive evidence, it continues to be an integral part of most treatments. We base our position on the absence of evidence for several compelling reasons. First, fluid restriction is probably the most widely used intervention for enuresis in the world. Second, it is probably the easiest form of treatment to conduct. Third, its effects, if there were to be any, would be relatively easy to measure. Despite these characteristics of fluid restriction, it still has absolutely no empirical support. Thus, we assert that it should not be part of any treatment plan, with one exception. Specifically, if an enuretic child drinks fluids to excess before bedtime, then his or her fluid intake should be reduced—not because of the enuresis, but because of the excess.

Medication There are two primary drugs used for treatment of enuresis: imipramine (Tofranil) and desmopressin (DDAVP). The former is a tricyclic antidepressant whose mechanism for reducing bed-wetting is not clear; it appears to make the bladder less sensitive to filling, thus allowing it to hold more urine before urinary urge. Desmopressin is a synthetic antidiuretic that concentrates urine, thus decreasing urine volume and intrabladder pressure. Because of alarming reports of the potential cardiotoxic effects of imipramine overdose (Herson et al. 1979) and other side effects of imipramine, desmopressin briefly emerged as the most preferable medication for enuresis


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treatment (Christophersen and Friman 2010; Friman 2007, 2008). However, reports by the U.S. Food and Drug Administration (FDA) in 2007 alerted the public to potential dangers posed by desmopressin, especially when delivered in its most popular form—intranasal spray. Specifically, some persons taking desmopressin are at risk for developing a sodium deficiency in their blood—a condition called hyponatremia—that can result in seizures and death. Children treated for enuresis with the intranasal form of desmopressin are particularly susceptible to severe hyponatremia and seizures. Therefore, the FDA has ruled that the intranasal form of desmopressin not be used for treatment of enuresis and has recommended only very cautious use of the tablet form (U.S. Food and Drug Administration 2007). These rulings are likely to have a notable impact on interventions for enuresis, given the pervasiveness of the problem and the popularity of desmopressin as a treatment. Psychologists may be able to successfully capitalize on the resulting gap in treatment options available to medical providers by offering evidence-based CBT alternatives such as those offered here.

Empirically Supported Treatment Packages The oldest, best-known, empirically supported treatment package is dry-bed training (Azrin et al. 1974). Initially evaluated for use with a group of adults with profound mental retardation, it has been systematically replicated numerous times across child populations. In addition to the bed alarm, its initial composition included overlearning, intensive cleanliness training, intensive positive practice (of alternatives to wetting), hourly awakenings, close monitoring, and rewards for success. In subsequent iterations, the stringency of the waking schedule and the cleanliness training was reduced, positive practice was eliminated, and RCT was added. Other similar programs have also been developed, the best known and most empirically supported of which is full-spectrum home training (FSHT; Houts and Liebert 1985). FSHT includes use of the alarm, cleanliness training, RCT, and overlearning. Multiple variations are now available (Christophersen and Friman 2010; Friman 2007, 2008). Component analyses have been conducted on both dry-bed training and FSHT programs, and the findings show that the alarm is the critical element and that the probability of success increases as additional components are added (Bollard and Nettelbeck 1982; Houts et al. 1986).

Optimal Treatment Planning An optimal treatment plan is presented in Table 13–1. During the assessment phase (steps 1–4), the clinician’s initial concern should be to obtain

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TABLE 13–1.

Sample enuresis treatment plan

Assessment 1. Refer child for physical exam. 2. One to two weeks before treatment, initiate collection of data on wet and dry nights or documentation of size of urine spot (using tracing paper to draw outline of the spot). 3. Assess developmental and motivational readiness and tailor treatment according to findings. 4. Discuss the elimination of punishment with parents and child.

Initial treatment 5. Establish a trial treatment period. 6. Help parent and child select and purchase the type of alarm to be used (see Table 13–2). 7. Negotiate for inclusion of as many treatment components as child and parents are willing and able to perform.

Monitoring progress and planning for termination 8. When initial dryness goal is achieved (e.g., 1 week), add an overlearning component. 9. When 14 consecutive days of dryness have been achieved, discontinue alarm, retention-control training, and overlearning. 10. Address relapses by resuming use of treatment components that have been discontinued.

a history of wetting episodes. There is some evidence that children who wet less frequently and children who wet only at night have a better prognosis (Houts et al. 1994), although the type of enuresis (primary or secondary) does not appear to moderate treatment outcomes. Next, the clinician provides information about enuresis, including the most effective parental response to accidents. For example, the child and parents should be informed that numerous other children, many probably in the child’s neighborhood and school, are also afflicted with enuresis. With the child in attendance, firmly instruct the parents to avoid blaming, shaming, and/ or punishing their child for wetting. Then obtain the child’s cooperation in treatment and work with the child and family on a treatment plan. However, do not proceed with direct treatment until a medical examination is completed and pathophysiological variables are ruled out. During the initial treatment phase (steps 5–7 of Table 13–1), base the number and selection of treatment components on child readiness, child


TABLE 13–2.

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Sample urine alarms

Device

Type

Manufacturer

Cost

Wet-Stop

Pajama, buzzer

PottyMD Knoxville, TN (877) 768-8963 http://wetstop.com/ index.php

$50.00

Potty Pager

Pajama, buzzer

Ideas For Living Boulder, CO (800) 497-6573 www.pottypager.com

$75.00

SleepDry

Pajama, buzzer

Star Child Labs Santa Barbara, CA (800) 346-7823 http://sleepdryalarm.com

$53.95

Malem Bedwetting Alarm

Pajama, various combinations of sounds and light

Bedwetting Store Ashton, MD (800) 214-9605 www.bedwettingstore.com

$84.95

Wet Call

Bed pad, buzzer

Bedwetting Store Ashton, MD (800) 214-9605 www.bedwettingstore.com

$84.95

Vibrating Enuresis Alarm

$65.95 Pajama, vibrating Enabling Devices Hawthorne, NY (800) 832-8697 http://enablingdevices.com

Note. Manufacturer and pricing information subject to change; verified at time of writing.

and parent willingness, and family resources (see Table 13–2 and Suggested Readings and Web Sites at the end of this chapter for information on obtaining necessary materials, such as the alarm). Strive to include the waking schedule, reward system, and responsibility training with the alarm. “Titrate” the components in the plan over time in accord with family resources and motivation until a cure is obtained. For example, a twoparent, one-wage earner, middle-income family with a motivated 10-yearold bed-wetting child whose parents are also motivated could start with all treatment components at once (i.e., alarm, waking schedule, Kegel exercises, overlearning, RCT, cleanliness training, rewards). When families have fewer resources or less motivation to conduct treatment, prescribe fewer components but strive to ensure the alarm is one of

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them. If the home situation changes in a way that heightens motivation or frees up more resources, renegotiate treatment to include more components (remember that the alarm is effective, but its effects increase even further with addition of other treatment components). In the rare case in which the child is motivated but the parents are much less invested, prescribe only components that can be independently completed by the child. Unfortunately, this may preclude use of the alarm, either because the parents will not purchase one or because the child is not capable of using it without assistance. If an alarm can be obtained, however, older children or sophisticated younger children may be able to use it independently with training provided by the clinician or the clinical team. If not, prescribe the treatment components that can readily be performed independently (e.g., Kegel exercises, self-monitoring, RCT, possibly a waking schedule activated by the child’s alarm clock). The chances for cure are less likely when fewer components are used (especially if the alarm is not used) but still higher than if no treatment were used. Furthermore, the active involvement of the child may lead to increased involvement by the parents, at which point more components can be added. The final steps of treatment involve progress monitoring and planning for termination (steps 8–10 in Table 13–1). If progress is limited, add adjunctive components with primary emphasis on RCT and stream interruption. When 14 consecutive days of dryness have been achieved, discontinue the alarm. As with most enuretic treatments, the potential for relapse is a serious concern, so schedule follow-up contact as a routine element of treatment.

Implications of Diversity The major diversity issue in studies of enuresis involves gender. Enuretic boys outnumber enuretic girls by as much as 3 to 1. On the basis of the abundance of evidence indicating this disparity, one group of epidemiological researchers has recommended changing the diagnostic criteria for boys from age 5 to age 8 because the proportion of enuretic girls at age 5 is about the same as the proportion of boys at age 8. The implication of this position is our recommendation that clinicians consider delaying treatment for boys who at age 5 meet criteria for enuresis but who clearly lack the motivation to participate in treatment or the maturity to benefit from it. Cross-cultural research also indicates that although enuresis is more prevalent in the United States than in Europe and other developed countries such as Thailand and China, it may be more prevalent in some developing countries, such as Nigeria. Enuresis is also more prevalent in populations that have lower socioeconomic status or that exhibit significant psychosocial deviancy, such as children in institutionalized settings (for reviews covering this material, see Friman 1986, 2007).


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Challenges to Treatment One critical challenge to treatment is the rare but real possibility of a physiopathic cause of enuresis (e.g., diabetes, urinary tract infection). Although fewer than 10% of cases are attributed to these causes, alarm treatment in these cases may be contraindicated. For this reason, it is paramount to refer all enuretic children to a physician for a physical examination before beginning CBT in earnest. When physiopathic causes are ruled out, age, developmental level, and motivation levels are cardinal concerns. For example, we recommend that CBT be forestalled until enuretic boys are at least 7 years old or until girls are at least 5 years old (unless either younger boys or girls are highly motivated). The difference in ages is due to the lower incidence of enuresis, higher motivation, and advanced maturation in enuretic girls versus boys. If the enuretic child is not motivated, suspend treatment for 3–6 months and schedule a follow-up with the child and family at that point. Another challenge to treatment involves punishment. As mentioned earlier, incontinence is a major cause of child abuse. With no access to effective treatment, parents faced with their child’s chronic incontinence are at risk for directing punishing responses to their child’s accidents, ranging from direct and indirect expressions of frustration to harsh physical discipline. Prescribing effective treatment can reduce the risk, but to eliminate it altogether, we recommend that clinicians assess for a history of punishment and obtain a verbal commitment from parents (with the enuretic child present) to never again punish or even criticize the child for having accidents. A final challenge involves nonadherence to treatment, in the child, parents, or both. To limit child nonadherence, assess for motivation and capacity to perform prescribed treatment steps and refrain from prescribing steps that children are unwilling or unable to perform. To increase motivation, use a system that rewards progress in small increments—for example, for dry nights, decreases in the size of the urine spot, or even compliance with components of treatment. To limit parental nonadherence, follow similar steps: assess for motivation and capacity and prescribe only steps that parents are willing and able to perform. Help parents identify signs of progress, which range from multiple dry nights for some children to mere performance of treatment steps for others. More generally, describe continence as a skill that can be attained readily with diligent practice of treatment steps; disclose that dry nights could be slow in coming, especially for children with multiple nightly accidents; and schedule periodic booster clinic visits and/or telephone calls to monitor progress.

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Case Example Tommy is a white 8-year-old boy who lives at home with his natural parents and two younger siblings, a girl age 5 and a boy age 3. His medical, psychiatric, developmental, and educational histories are unremarkable. He is in the second grade and works a little below his potential, but routinely earns grades in the B range. He is well liked in school and has at least two good friends. At home, beyond some moderate resistance to bedtime, he does not pose any behavior problems. His relationship with his siblings is described as positive. The referral concern involved primary nocturnal enuresis. According to the parents, Tommy has been nocturnally incontinent since birth and to the best of their memory, has never had a dry night. In fact, they complained that he sometimes has more than one accident at night. Although approached by grandparents, aunts and uncles, and his parents about working harder to stay dry, he exhibited little interest in continence until a recent episode involving an accident while on a camping trip. He had a friend along for the trip and was embarrassed by the friend’s discovery of his accident, and from that point forward, he has been very concerned about learning how to have dry nights. His parents brought him to his primary care physician, who did a routine physical examination including a urinalysis, and ruled out all organic causes for nocturnal enuresis. During the history, it was revealed that Tommy’s father had a history of nocturnal enuresis that ended at about age 9. Following the physical examination, the physician referred Tommy and his parents to a psychologist specializing in CBT, and that person began treatment by conducting a joint interview with Tommy and his parents. The psychologist explained the role of family history in the cause of enuresis and that it was unlikely that any form of psychopathology played a significant determining role. However, he explained that the parental, family, and social response to accidents could cause psychological problems if it was aversive and perpetuated. Following that, he solicited Tommy’s participation in treatment and reviewed all of the available treatment options he had at his disposal, which included the urine alarm, RCT, waking schedule, responsibility training, a reward system, and Kegel exercises. Also, in the presence of the parents, he explained to Tommy that children who wet their bed should never be punished for wetting. Additionally, he also communicated that it would be fine for Tommy to have water before bed as long as he didn’t drink an excessive amount. He explained to the parents that fluid restriction had never shown a significant role in reducing nocturnal accidents unless incontinent children were shown to be drinking excessively before bed. Finally, he drew a picture of the bladder and explained how the process of urination worked and how the alarm system, along with the other treatment components, would influence Tommy’s system and help him learn how to have dry nights. Jointly, Tommy and his parents selected all of the treatment components that were described. For the reward system, the parents selected the dot-to-dot program, and Tommy selected a new video game as his reward. While in the doctor’s office, Tommy and his mother drew a picture of the video game using dots and the psychologist provided a handout describing


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the reward system for the parents to bring home. The psychologist also asked that the parents monitor progress along with Tommy using a calendar to be attached to the refrigerator that could be easily inspected by them and by Tommy. The parents also asked to include one other component in the treatment program, one that has not been shown to play a role in the treatment of enuresis, but that very well could play a role in the social acceptability of treatment. Specifically, the parents asked whether it might be helpful if when Tommy said his prayers at night, he could ask for God to help him have a dry night, and the psychologist agreed that it would be a good idea. The parents obtained the urine alarm by consulting the Bedwetting Store online, and the brand they selected was the Nytone, which attached to the pajamas. The outcome of the case was successful, although Tommy did not have a dry night for the first month or so. In fact, the parents initially complained that he slept through the alarm and that its sound awakened one or the other of them, and they then would wake him and take him to the bathroom. However, as the program progressed, the alarm began to awaken Tommy, at which point he would take himself to the bathroom, but he would also alert one of his parents to help him. As the program progressed further, the alarm would quickly awaken Tommy, at which point he would turn it off, and his accident would be so small that it didn’t require that he do anything about the accident until his typical wake-up time. And finally, he began sleeping through the night without the alarm going off, eventually one or two times a week, and ultimately ending with only one or two accidents per month. At that point, the psychologist terminated care and recommended that the parents stay in touch if questions arose. Although the amount of clinical contact varies, for this case, the psychologist saw Tommy and his parents for the initial session and then Tommy with one parent for two subsequent sessions, and the rest was done by telephone follow-up.

Conclusion: Enuresis Enuresis is the third most distressing experience reported by children, exceeded only by divorce and parental fights (Van Tijen et al. 1998). Left untreated, enuresis will likely persist for years, and in some cases, into young adulthood, with considerable negative social consequences and disruption of family life. Urine alarm treatment is an easily used, highly effective method for treating one of the most prevalent and chronic of all childhood problems. It represents an enormous breakthrough for enuretic children because 1) it does not involve the physically aversive experiences typical of ancient treatments; 2) its effectiveness undermines the historical psychopathological characterization of enuresis; and 3) it eliminates much of the expense, high relapse, and potential side effects of medication treatment. Furthermore, the effectiveness of urine alarm treatment when used alone is high and can be raised even higher when combined with any or all

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of a variety of adjunctive treatment components (Houts et al. 1994). At this point in the evolution of alarm-based treatment, it seems safe to assert that this method should be part of the armamentarium of every child therapist seeing children with enuresis, and if it is not, it seems appropriate to pointedly ask why.

Encopresis Diagnosis and Prevalence The diagnostic criteria for encopresis outlined in DSM-IV-TR (American Psychiatric Association 2000) include 1) repeated passage of feces into inappropriate places (e.g., clothing or floor), whether voluntary or unintentional; 2) at least one such event a month for at least 3 months; 3) chronological age of at least 4 years (or equivalent developmental level); and 4) the determination that the behavior is not exclusively due to a physiological effect of a substance (e.g., laxatives) or a general medical condition, except through a mechanism involving constipation. Similar criteria are outlined in the International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10; World Health Organization 2007). Two subtypes are identified with the DSM-IV-TR criteria for encopresis: with constipation and overflow incontinence (787.6) and without constipation and overflow incontinence (307.7). For the subtype with constipation, there should be evidence of constipation from a physical examination by a physician or a history of having a bowel movement on no more than three occasions during a week. Individuals with this subtype typically have stools that are poorly formed, with continuous leakage during the day and in rare cases at night. Only small amounts of feces are passed in the toilet and successful treatment usually involves intervention components aimed at relieving the constipation (i.e., enemas, laxatives). In cases of encopresis without constipation, stools are generally well formed, with soiling intermittent and deposited in a toilet. Children with encopresis without constipation typically present with comorbid emotional and behavioral problems; thus, treatment efforts for this subtype focus on the remediation of psychological and behavioral problems (Friman 2008). Prevalence rates in the United States are estimated to be around 1%– 3%, with boys three to six times more often affected than girls (Schonwald and Rappaport 2008). Rates of fecal incontinence have shown to be 4.4% in primary care pediatric settings (Loening-Bauck 2007). A Dutch popula-


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tion-based study found that 4.1% of children ages 5–6 years and 1.6% of children ages 11–12 years experienced soiling incidents once a month (van der Wal et al. 2005), and comparable rates were found in the United Kingdom (Joinson et al. 2007).

Empirical Support An obstacle to supportive research for CBT treatment of encopresis involves the transdisciplinary, biobehavioral approaches to the disorder that are most frequently used. It is virtually impossible to tease out the unique cognitive, behavioral, or biomedical components, because successful treatment almost always involves all three (Christophersen and Friman 2010). Biofeedback represents a fourth, less commonly used biomedical-CBT approach that appears to have no greater level of effectiveness than behavioral-medical interventions (Brooks et al. 2000). Medical interventions have traditionally focused on three areas: 1) cleansing the bowels, 2) encouraging regular bowel movements with the use of facilitative medications, and 3) regulating dietary intake (Christophersen and Friman 2010). In their most basic forms, CBT approaches emphasize the use of positive reinforcement to motivate the child’s adherence and success in using appropriate toileting practices. Mildly aversive components are also sometimes used, in the form of overcorrection practices in which the child participates in cleaning himself or herself and the soiled clothing after a bout of encopresis (Reimers 1996). Many CBT treatment programs also incorporate stimulus-control procedures, enhanced scheduling, enhanced health education, and various types of monitoring. These CBT approaches are often administered alone or used to supplement biomedical interventions put into place. A number of studies have examined the effectiveness of these different treatment modalities. In their meta-analysis, McGrath et al. (2000) found that no published study at the time met criteria frequently used by psychologists to determine which interventions can be declared empirically well established (Chambless and Ollendick 2001). Two studies using a combination of medical plus behavioral interventions were shown to be probably efficacious. Two extensive behavioral interventions plus medical interventions also were shown to meet the efficacy criteria for the treatment of constipation plus incontinence. Another study published at the same time (Brooks et al. 2000) included a review of randomized controlled published studies involving medical, behavioral, psychological, and biofeedback treatments for encopresis, functional constipation, and stool-toileting refusal in preschool-age and school-age children. This review found that anal sphincter biofeed-

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back in the treatment of pediatric fecal elimination dysfunctions was no more effective in treating encopresis or functional constipation than comprehensive medical-behavioral intervention. Furthermore, the paradoxical constriction of the external anal sphincter did not appear to influence the treatment outcome of either biofeedback or medical-behavioral interventions. Despite the similarities in outcomes across these two approaches, medical-behavioral interventions may have certain advantages given that these approaches are generally less intrusive than procedures used in biofeedback interventions. Another randomized controlled trial compared treatment outcomes of CBT and the conventional approaches involving the use of laxatives, a bowel diary, and education (van Dijk et al. 2008). These researchers found that the outcomes for the CBT approach and conventional treatments were comparable. The authors of this study noted that in some circumstances, CBT or a referral to mental health services should be considered, particularly when a child presents with behavioral problems. Below, we describe the CBT techniques that can be used to successfully assess and treat encopresis.

Theoretical Perspectives There have been multiple theoretical perspectives on encopresis throughout history, but the current dominant viewpoint involves a combination of biological, learning/behavioral, and cognitive components; and consistent with the theme of this book, we will refer to it as the CBT perspective. Historically, early unpleasant toileting experiences were thought to determine personality and behavior (Freud 1905/1953). Although no actual research confirmed or even supported this perspective, vestiges of this position remain operative to this day (Friman 2002); this viewpoint is so deeply rooted in antiquated theory and so resistant to the influence of abundant contrary scientific evidence that it can be discarded as nonsense with impunity (Sperling 1994). The problem with this position involves its association with psychodynamic theory. The predicate for the initial position involved infant sexuality (Freud 1905/1953), and as the position evolved, a sexualized perspective on toilet training and incontinence remained (Aruffo et al. 2000; Sperling 1994). As a blatant and disturbingly mainstream example, the description of encopresis without constipation in DSM-IV-TR (American Psychiatric Association 2000) includes an association with anal masturbation, despite there being no supportive scientific evidence. In early attempts to sketch an account of encopresis consistent with the CBT theoretical perspective, Levine (1982) and colleagues described


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a developmental trajectory resulting from disordered defecation dynamics (rather than disordered psychodynamics) and their subsequent influence on toileting behaviors. Not surprisingly, the cardinal variable in this account is constipation, which increases the difficulty and discomfort that accompany bowel movements. Avoidance of discomfort associated with bowel movements negatively reinforces toileting resistance. In turn, successful toileting resistance leads to stool withholding, which has the same effects on bowel movements as constipation itself—and thus, it is possible that the resistance rather than the constipation is the more important consideration. Research on this question, however, has suggested that constipation usually precedes toileting refusal, and thus it is more likely to be the primary influence. Other research has shown that children who resist toilet training often have histories of painful bowel movements and/or constipation (Luxem et al. 1997). In sum, the theoretical perspective with the most empirical support and that which leads most directly to effective treatment is the CBT model that emphasizes defecation dynamics, disordered fecal toileting, and toileting resistance (Christophersen and Friman 2010; Friman 2007, 2008).

Assessment Obviously assessment is an important dimension of CBT treatment for any disorder, but it is particularly important to conduct a thorough assessment of the child’s behavioral, family, and bowel-training history before developing a treatment plan. Additionally and most importantly, it is critical with encopresis to refer all cases to the primary care physician for a physical examination before initiating treatment (as with enuresis). It is not necessary to refer affected children to a gastroenterologist; doing so prematurely could lead to unnecessarily invasive and expensive biomedical evaluations. We recommend that clinicians surrender the decision of whether to involve specialists to the primary care physician. As for the clinician’s own assessment, we recommend that it be conducted separately with the parents and then with the child (age 4 and above). This approach allows both parties to be less inhibited when sharing sensitive information (e.g., family mental health history, negative behaviors or attributes of the child).

Parent Intake Below, we will highlight a few general questions that are likely to be included in the standard clinical assessment, highlighting those issues that are relevant to the assessment and treatment of encopresis. Although it will often be helpful to gain the child’s perspective on these issues, the cli-

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nician may choose to reserve some of these questions for the parent intake when considering the age of the child and the sensitivity of the questions. Is there a history of developmental delays or ongoing difficulties? It is important that the child possess developmental skills that allow for effective management of toilet training. In general, the child needs to be ambulatory to the point that he or she is able to independently remove his or her clothing and is able to walk (or run) to the bathroom when he or she feels the urge to defecate. All developmental skills need to be at least at a 2-year age level. If motor skills are significantly delayed or if cognitive and speech/language skills are below a 2-year level, consideration should be given toward delaying intervention. Are there any relevant medical problems? A variety of medical conditions can significantly contribute to a child’s constipation and/or bowelrelated difficulties. Relevant medical diagnoses or histories such as Hirschsprung’s disease, celiac disease, Crohn’s disease, or other similar conditions do not rule out behavioral treatment for encopresis, but certainly have significant medical implications, and working closely with the medical professional is imperative. Additionally, children with a history of distended colon or megacolon, or who have a chronic history of stool impaction and constipation, warrant close monitoring and periodic follow-up with their primary care physician. Is there a history of constipation? If the child is constipated, the condition must be managed before behavioral treatment is initiated. Children with a history of constipation or fecal impaction often also present with a history of a distended colon, and in some cases, megacolon. Children with this history can experience limited or poor feedback regarding the volume of fecal matter in the rectal vault. Some children with constipation also experience a solid fecal mass in their colon, but they continue to have bowel movements because fecal matter moves around the fecal impaction, allowing the child to pass what are typically loose or soft stools. The presence of loose or soft stool in this scenario can lead parents to wrongly assume that the child is not constipated. Having parents monitor and document their child’s stooling pattern (see Figure 13–1) will help the clinician to monitor the frequency of stools and will provide valuable information to the child’s primary care physician. Children with a recent or past history of constipation will likely be on some type of stool softener. Miralax is currently the most common stool softener prescribed for children with constipation. If a client is using Miralax or some other type of stool softener, ask the parents to document the amount of stool softener provided to their child and the time of day


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Name: Date of birth: Stool Assessment Date Number of stools in toilet Number of soiling episodes Consistency of stools a Difficulty ratingb Medicine taking Medicine amount a

Enter number from Stool Consistency Continuum. See Difficulty With Stool Passage Scale.

b

Difficulty With Stool Passage Scale Was passing a stool a problem? 0

1

No problem

Some problem

2

Severe problem

Stool Consistency Continuum 1. Watery

2. Water ring with formed particles

4. Loose, soft

6. Normal, formed

FIGURE 13–1.

3. Liquid, creamy

5. Soft, formed

7. Hard, formed

8. Hard and dry

Stool assessment chart.

that it is taken. The timing of stool softener can sometimes have an effect on the pattern of the child’s bowel movements. What are the quality of the child’s diet and quantity of daily exercise? The child’s dietary habits and level of exercise can impact both the frequency and consistency of his or her bowel movements. In general, learn-

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ing that a child has a “typical” diet and level of physical activity is probably sufficient. In some cases, it is helpful to have the parents provide a description or log of a typical day regarding their child’s diet and physical activity. This description will allow an assessment of whether a child has a diet that is high in fat or low in fiber. Both fat and fiber intake can impact the bowel habits of some children. Although high-fat diets are often blamed for fecal impaction or infrequent stools in some children, the effect of high-fat diets is idiosyncratic. However, if a child presents with a dietary history that is atypical—that is, in which the balance is tilted in one direction or another—then it may be necessary to have a discussion with the parents about balancing their child’s diet and possibly increasing their child’s level of physical activity. Are there any behavioral or emotional difficulties? Some studies (Cox et al. 2002) have suggested that children with encopresis have a higher percentage of related or comorbid behavioral difficulties that can interfere with treatment planning. The use of any number of standardized behavior checklists (e.g., Child Behavior Checklist; Achenbach and Edelbrock 1983) will provide a good, age-based behavioral profile to identify relevant behavioral difficulties. Children who are not under good instructional control or who present with high levels of hyperactivity or oppositional defiant–type behavior present with additional challenges when managing encopresis. For clinicians working with children with encopresis and these comorbid behavioral problems, it may be necessary to prioritize working with the parents and child to help improve instructional control and to reduce levels of noncompliance or oppositional behavior before behaviorally managing the child’s encopretic symptoms. On the other hand, if the behavioral concerns are specific to the encopresis, then moving forward with a treatment plan for managing the encopresis is warranted. What was the child’s experience with toilet training? Ascertain at what age the parents started toilet training; whether the parents focused on urine training, bowel training, or both; and the level of success achieved. Question the parents about the type of approach that they have used and the use of both positive reinforcement and punishment, as well as the length of time spent during the training process. Determine the child’s response to the parents’ training efforts, and focus on how the parents manage resistance on the part of their child, soiling accidents, and other setbacks. It is especially important to determine to what level, if any, punishment techniques have been used. Finally, it is important to determine if the child has ever experienced partial or complete success with either urine or bowel training. Many children present with no experience with


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complete success in the area of bowel training, while others have experienced months or even years of success before the onset of the encopresis. How frequently does the child have soiling incidents? Assess what percentage of the child’s bowel movements result in some type of soiling episode. Some children with encopresis will have occasional successful bowel movements in the toilet, whereas other children experience a soiling episode of some type with each bowel movement. Other children appear to have what can be considered an “accident” when they pass fecal matter into their clothing because of the loose consistency of their stool or because they did not respond quickly enough to the physical urge to have a bowel movement. For some children, the soiling episode clearly involves some volitional control. This includes children who hide in their room or in a quiet part of the house while they intentionally have a bowel movement, or children who have a bowel movement in their clothing regardless of where they are, with no interest or intention of attempting to void in the toilet. What is the routine for managing the child’s toileting? The toileting routine used by parents of encopretic children will likely vary from the approach that they used when they were initially toilet training their children. The frustration caused by the child’s lack of success or the onset of soiling accidents will cause parents to develop a variety of approaches and routines to manage their child’s toileting habits. Ask parents to describe their general routine for managing their child’s toileting habits and include questions pertaining to scheduled sit times on the toilet, the parents’ response when they see their child gesturing that he or she is about to have a bowel movement, and the length of time that the child is expected to sit on the toilet. Has the child developed a resistance to approaching the bathroom and toilet? It will also be important to assess the child’s resistance to the bathroom or the toilet itself. Children resist going into the bathroom and/ or sitting on the toilet for a variety of reasons. Some children exhibit significant levels of resistance toward having a bowel movement because of a history of painful bowel movements or discomfort associated with the use of enemas or suppositories. This avoidance can lead to a reciprocally devolving process composed of toileting resistance, constipation, and painful stools (Borowitz et al. 2003; Levine 1982). How do the parents respond to their child’s resistance to toileting? The manner in which parents respond to their child’s resistance toward sitting on the toilet and toward having bowel movements is an integral com-

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ponent of the treatment plan. Parents’ responses to their child’s resistance will range from pleading to corporal punishment. Parent who are frustrated with managing their child’s soiling episodes often rely on verbal reprimands, corporal punishment, and time-out. Therefore, it is important to identify the frequency, length, and severity of the parents’ use of punishment during their attempts to manage their child’s encopresis, because children who have experienced significant levels of punishment are likely to engage in stool holding or experience increased soiling episodes, regardless of the management approach used. Therefore, obtaining details about parents’ responses to their child’s resistance can often shed some light on the severity of the avoidance behavior as well as the contingencies that are contributing to the child’s negative behavior. How do the parents respond to successful bowel movements? Make a note as to whether the parents have used verbal praise, sticker charts, edible or tangible rewards, or some type of activity reward. Also, determine the schedule and intensity of rewards used by parents. For example, some parents will establish unreasonable goals (e.g., no accidents for 1 month) that must be met to earn small rewards, whereas other parents will offer large rewards for small goals (e.g., each successful bowel movement). In general, determine which behaviors parents have targeted for change (e.g., sitting, voiding), the types of rewards that they have offered, and the frequency with which these have been distributed. What type of underclothing does the child usually wear? The type of underclothing that children wear can have an important effect on their success with managing encopresis. Allowing children to wear diapers and Pull-Ups beyond the developmentally appropriate age inhibits motivation to use the toilet and is an obstacle to success. Some children insist on putting on a Pull-Up when they need to have a bowel movement, only to be accommodated by their parents. Ask parents about their child’s history with the use of diapers, Pull-Ups, training pants, and regular underwear and their current use of all of these throughout the day.

Child Intake Conducting the child intake assessment separately will allow the clinician to obtain more accurate information and perceptions from the child without him or her being influenced by the parents’ presence. Learn the terminology parents and child use to describe bowel movements and the toileting practices that are in place. Obtaining the child’s perception of the physical cues to which he or she attends when the toileting urge occurs is


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important. This will allow discussion with the child about how he or she responds to those physical cues. For example, does the child ignore them, seek the parents’ assistance, or make an effort to have a bowel movement independently? Review with the child his or her understanding of any scheduled sit times that have been put in place, his or her perception of personal responsibilities regarding toileting practices, what consequences are in place for soiling accidents, and any rewards that may be available to him or her for successfully voiding in the toilet. Finally, meeting with the child separately will provide an opportunity to discuss, at the child’s level, the treatment goals that involve helping him or her to learn to successfully and reliably have all bowel movements in the toilet. This should be reiterated with the parents as well.

Treatment The treatment of encopresis does not follow the same course as that of other disorders. For example, the treatment of disorders such as anxiety, depression, and attention-deficit/hyperactivity disorder (ADHD) involves the assessment and treatment of a constellation of symptoms that constitute the disorder, whereas encopresis can be assessed and defined in a much more concrete manner—that is, the child is either successfully voiding in the toilet 100% of the time or he or she is not. Some children with encopresis have never successfully voided in the toilet, whereas other children have had good success with toilet training and are having only occasional accidents. Thus, children vary regarding where they fall in the appropriate bowel movement continuum. Because of that, it is perhaps more prudent to develop a treatment plan based on the point in the toileting process where children are struggling. Thus, we have developed a simple task analysis to allow clinicians to determine where in the toileting process their client is having success and where he or she needs intervention. The steps below compose the task analysis that we typically use. 1. 2. 3. 4. 5.

Attend to anticipatory physical cues. Enter the bathroom, remove clothing, and sit on the toilet. Have a successful bowel movement. Use toilet paper and clean self adequately. Replace clothes, flush, wash hands, and leave the bathroom.

Children who are being evaluated for encopresis are experiencing problems with one of the above steps. Thus, the treatment approach and the nature of the initial treatment session(s) will be dependent on where each child falls on the task analysis continuum. Accordingly, we have outlined below a

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number of treatment approaches that focus on educational, proactive, and corrective approaches that can be used on their own or in combination.

Educational Approach The gastrointestinal system. Most parents, understandably, do not have a thorough or full understanding of how the gastrointestinal (GI) system works. A diagram (e.g., Levine 1982) or some other visual aid can be beneficial when educating parents about the mechanics of the GI system in general and about how fecal impaction and constipation affect the colon in particular. It is important to help parents understand that when their child’s colon becomes stretched from impaction, he or she is likely to lose colonic sensation, thus adversely affecting the normal bowel movement cycle. This explanation will also help parents understand that in most cases, their child’s encopresis is not intentional and that there are clear physical factors that need to be addressed, along with the behavioral intervention. Parents’ increased understanding of the mechanics of the colon, along with the importance of keeping their child’s stools soft, will hopefully help parents establish and maintain good compliance with their child’s daily regimen of stool softeners as well as the behavioral recommendations that are offered to them. Mechanics. Young or physically small children will often sit on the toilet with their feet dangling. This positioning makes it difficult for them to adequately relax or to use proper musculature when attempting to have a bowel movement. To avoid this problem, ensure that there is solid support for the child’s feet when he or she is seated on the toilet and attempting a bowel movement. A small stepstool can make a large difference in the mechanics needed for a child to have a successful bowel movement. Diet and exercise. If the child has a diet that is inadequate in fluid intake and/or low in fiber, or if the child does not get an adequate amount of exercise, then it will be important to educate parents about the benefits of balancing the child’s diet, increasing fluids, and encouraging more physical activity. All of these factors will help promote normal bowel activity (Dwyer 1995). The role of stool softeners, diet, and exercise is a critical part of the treatment approach, and it is important for parents to know the importance of any needed changes in these areas. Parental demeanor. By the time that parents bring their child for management of encopresis, they are likely to be frustrated and to have yelled or screamed at, or even spanked, their child for having accidents. Punitive


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or severely negative responses to a child’s soiling episodes hinder the treatment process or cause secondary negative behaviors, such as stool holding, hiding soiled underwear, or general defiance with the toileting regimen. Help parents understand that maintaining a neutral and matter-of-fact demeanor will help to place the emphasis on their child’s behavior and choices regarding the toileting process. Caregivers outside the home. If the child is in day care or is school age, then it will be important to provide appropriate education to teachers, day care providers, and so forth regarding the child’s encopresis and toileting regimen. Explain to teachers that the child may need to take more frequent toileting breaks and/or that making use of the nurse’s bathroom (if one is available) may be necessary. Also, keeping an extra set of clothing at the school or day care will be helpful for many children.

Positive or Proactive Approaches Responding to physical cues. Children with encopresis often respond inconsistently to physical cues to have a bowel movement. Some children have limited sensation, and others have normal sensation yet ignore physical cues for a variety of reasons. Regardless of the reasons, it is important for children to respond consistently and in a timely manner to physical cues and urges to have a bowel movement. Treatment success is not possible without this response. It will be important for the clinician to reinforce the importance of the child’s response to these cues and urges. Before having a bowel movement, many children will posture themselves in a certain way or will quietly remove themselves to another room. When parents observe these behaviors, encourage them to prompt their child to sit on the toilet or to offer to escort the child to the bathroom. Parents should not physically guide or place their child on the toilet if the child is being resistant. This will only serve to create or exacerbate negative associations either with sitting on the toilet or with the toileting regimen. One alternative contingency is to teach the child that sitting on the toilet at the assigned times has more positive than negative consequences. Some sample contingencies will be described later in the section “Successful Bowel Movements.” Shaping and scheduling sit times. It is important to promote a routine of having the child sit on the toilet on a regular basis and at scheduled times. The treatment goals should focus on having the child sit anywhere from 15 to 20 minutes after each meal for a period of 5 to 10 minutes. To accomplish this goal, it will be important to help the child feel comfortable

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with sitting on the toilet and reaching a level of relaxation that will facilitate a successful bowel movement. For young children, have parents “practice” having their child sit on the toilet for very brief (30–60 seconds) periods of time. This can be done multiple times throughout the day, with the parent verbally praising or rewarding the child in some small way for participating. The use of a timer can help facilitate the child’s cooperation, because the child will know that the time that he or she spends sitting on the toilet is limited. As the child’s level of cooperation increases, the amount of time can be increased until the child is sitting on a regular basis for 5–10 minutes. Once children are cooperatively sitting on the toilet for 5–10 minutes, help parents establish a routine for regular sit times. As mentioned above, an ideal time for children to sit on a regular basis is 15–20 minutes after a meal, with the child sitting for 5–10 minutes. Having the child sit after meals is designed to coordinate with the increased activity of the GI system following meals. This will hopefully increase the probability for the child passing stool in the toilet. As treatment progresses, work toward fading out scheduled sit times and promoting and reinforcing independence. However, initially, scheduled sit times will be important. For young children, the use of small, tangible rewards can help to promote cooperation. Continued use of a timer to regulate the time spent sitting will also continue to be important. These and other shaping techniques should be used to promote teaching the child to sit cooperatively for a length of time that will provide him or her with the opportunity to relax and have a bowel movement. Once sitting cooperatively has been accomplished, efforts can be made toward promoting successful bowel movements. Successful bowel movements. Once children are sitting cooperatively, or better yet, sitting on the toilet independently after responding to a physical urge to have a bowel movement, the opportunity to promote and reinforce successful bowel movements increases dramatically. Because encopretic children naturally resist sitting on the toilet, and in particular voiding in the toilet, the use of some type of tangible reward seems to be important toward promoting successful bowel movements. Until the natural contingencies associated with sitting and successfully voiding in the toilet become evident to the child, it is important to make use of some type of reward system to promote both sitting on and voiding in the toilet (van Dijk et al. 2008). Below are several types of tangible rewards that can be used to promote both sitting on and voiding in the toilet. Candy dispensers. This tends to be particularly effective for young children. The advantage of some type of candy or food reward is that it is immediate, meaningful, and relatively inexpensive. The small size of the food


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reward also does not tend to be problematic for most parents, who are understandably concerned about their child’s nutrition. We recommend placing the dispenser on a bathroom counter or in a location that is visible to the child but not easily accessible. These types of rewards could be used to promote both sitting on and voiding in the toilet. For example, the child could receive one Skittle (or other similar small candy) for sitting and several for passing stool into the toilet. The main point here is that for young children especially, the visual and immediate benefits of having this type of reward evident for sitting and/or voiding are often necessary. Sticker charts. Depending on the child’s level of motivation and the value that he or she attributes to earning stickers, the use of a sticker chart can be very motivating toward reinforcing both sitting and voiding. For children who can count to a particular number or who understand quantity, consideration should be given toward providing an additional reward for earning a set number of stickers. For example, the clinician might ask a 4-year-old child to draw four circles on a piece of paper and decorate it to signify its use for documenting sitting and voiding. Each time that the child voids in the toilet, a sticker would be placed on one of the circles. Once the child has earned four stickers, he or she would earn an additional (not easily accessible) reward. This type of strategy will provide immediate feedback to the child for his or her successfully sitting and voiding, and at the same time, provide some intermediate reward for cumulative progress. Wrapped rewards. These types of rewards are often useful for children ages 3–6. Have the parents purchase small, inexpensive trinkets at a local novelty store and wrap them using aluminum foil or some other wrap. The reward should be placed in a basket that is visible to the child but not easily accessible. The child should be told that each time that he or she voids in the toilet, he or she will earn one of the rewards and will be allowed to unwrap it. Many children are motivated to put forth additional effort to void in the toilet in order to earn the “mystery reward.” Reward jar. The use of a reward jar is likely more appropriate for older children (age 5 and older) and should be combined with immediate, tangible rewards. To implement this strategy, the parents select a jar in which some type of token will be placed. The parent should discuss with the child the different types of activities or rewards that the child would like to earn, starting with small rewards and working up toward something larger. Once a series of four or five rewards has been identified, the parent and child should work together to rank the items from least expensive and motivating to most expensive and motivating. The parent then writes the names of the

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items on pieces of masking tape and places them on the jar in order, beginning with the least expensive–motivating reward on the bottom and ending with the most expensive–motivating reward at the top of the jar. The child will earn one token each time that he or she sits on the toilet cooperatively and two tokens each time that he or she voids in the toilet. The tokens could include things such as pennies, marbles, poker chips, cotton balls, and so forth. The size of the token will depend on the size of the jar and how quickly the parent wants the child to earn the rewards. The child will continue to receive immediate, tangible rewards for sitting on or voiding in the toilet but will also add tokens to the reward jar. The tokens should be in a visible place, ideally in the bathroom. Parents should review with their child his or her progress and how closely the child is getting toward earning the next reward. Once the child has filled the reward jar, the process can start over, with the child selecting new rewards, if he or she so chooses. Access to a special activity or item. This technique is probably most suitable for older children (age 5 and above), but it can certainly be used with younger children. Have parents identify an activity or item to which the child will have access, but only for a limited amount of time, once the child has successfully had a bowel movement in the toilet. This might include a special book, video game, movie, or some other activity that can be set aside and only provided to the child once he or she has voided in the toilet. The parents should put a limit on how much time that the child has access to it, to maintain its value. For example, if the parent purchases a special book, then the parent and child might sit and read the book for 15 or 20 minutes after the child has successfully had a bowel movement, with the book then being put away until the next time that the child has a bowel movement in the toilet. A variety of other activities and toys can be used in this manner. Fading rewards. Reward systems should be put in place to initiate and shape behavior, as well as to maintain positive toileting and bowel habit routines. Once the behavior has been established, it will be important to work with parents to help reduce these interventions. This is best accomplished by increasing the demands on the child (e.g., more sit times or bowel movements) to earn the same reward, or by eventually fading the use of specific rewards for less critical behaviors (e.g., sitting). If a reward jar is used, then either the child can earn fewer tokens for previously targeted behaviors or the number of tokens needed to gain access to a reward can be increased. Cleaning technique. Many children with encopresis will continue to have minor soiling episodes (e.g., “skid marks”). These are often caused mostly by a child’s poor wiping technique. It may be necessary for parents


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to check the technique that their young children (under age 5) are using to make sure that they are wiping appropriately. Older children should be reminded to wipe and clean themselves appropriately. Parents can check the child’s underwear periodically to monitor this. Instruct the parents to provide some type of reinforcement to their child when his or her underwear is found clean (e.g., a treat, points, verbal praise) to enhance compliance with the monitoring procedure. If possible, help the parent understand the difference between mild soiling due to poor hygiene and unintentional minor soiling that can be associated with the use of stool softeners. Some children will occasionally pass small amounts of stool with the addition of fiber and Miralax (or other laxatives) to their daily regimen. The parents should be educated that these types of minor soiling episodes may occur until the amount of stool softener needed to promote regular bowel movements is reduced.

Corrective Approach Parents need an effective way to respond to their child’s soiling episodes (Reimers 1996). Whether soiling occurs intentionally or unintentionally, an effective response to soiling episodes is an important component of successful treatment (also see the section “Challenges to Treatment” later in this chapter). An overcorrection technique is usually an effective consequence that is naturally associated with the child’s soiling accident. Use of this type of approach will remove the need for parents to use other, less effective punishment techniques such as time-out, corporal punishment, and verbal reprimands. In general, have parents follow the steps below after a soiling episode: 1. Have parents check their child’s underwear periodically to make sure that the child has not soiled himself or herself. 2. If a soiling episode has occurred, the parents should bring this to the child’s attention and inform the child that he or she will need to change and assist with the cleanup. 3. Emphasize to parents that it is important that they maintain a neutral, matter-of-fact demeanor to the best of their ability. Maintaining a neutral, matter-of-fact demeanor is important to reducing avoidant behavior on the part of the child and keeping the focus of the consequences on the child’s behavior. 4. Children should be expected to help clean themselves and their clothing to the best of their ability, based on their age and developmental ability. The rationale behind an overcorrection procedure is to place the responsibility for the soiling episode on the child while also apply-

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ing a mild to moderate negative consequence for the soiling episode. Because the consequence is logically connected to the child’s soiling episode and behavior, it avoids the pitfalls associated with using punitive consequences (e.g., time-out, losing privileges) that are not directly connected to the child’s soiling episode. 5. Emphasize to the parents that they should make every effort to make the overcorrection procedure “inconvenient.” In other words, the parents should not make the cleanup process easy and time efficient. The parents should focus on taking 10–20 minutes for the cleanup process to be completed. This will reinforce for the child that sitting on the toilet and having a bowel movement is much more efficient and less time-consuming than taking the time to clean himself or herself and his or her clothing. One way of extending the overcorrection procedure is to have the child sit in a few inches of bathwater (with no toys, bubbles, bubble bath, etc.). The purpose for such soaking is for the child to avoid developing a rash. Some children who have been wearing soiled clothing for an extended period of time or who are chronically soiled may need the benefit of a sitz bath to help prevent a rash. This activity also enhances the effect of the overcorrection procedure. 6. Once the child has adequately cleaned himself or herself and appropriately placed the soiled clothing in its proper place, he or she should return to the bathroom and sit on the toilet for a brief period of time to practice appropriate toileting. It is unlikely that the child will defecate, but it is important for the parent to reinforce what is expected of the child. The child should then put on clean clothing and be redirected to his or her normal activities.

Implications of Diversity There is much less epidemiological research on encopresis than there is on enuresis. As with enuresis, the prevalence rate of encopresis is much higher for boys. In terms of cultural variation in encopresis, very little is found in the peer-reviewed literature on the subject, beyond the occasional suggestion that encopresis is more likely to be found in families with lower incomes (van der Wal et al. 2005). Although this suggestion is consistent with our own experience, it has been questioned by others, who have suggested it is merely a reflection of biased population sampling (Fritz and Armbrust 1982). At least some early research on prevalence indicates encopresis is much more frequent in boys than girls, with the ratios ranging from 3:1 to 6:1 (Fritz and Armbrust 1982; Wright et al. 1978). Some of the relevant research was conducted in foreign countries (Bellman 1966), but the samples were primarily whites from industrialized cul-


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tures and thus not substantially different from the populations studied in the United States. In sum, on the basis of extant empirical literature, there are no significant implications of diversity to highlight here.

Challenges to Treatment The most frequent and difficult challenge to treatment involves resistance and noncompliance. Some children are resistant toward sitting on the toilet or entering the bathroom because of their painful bowel movement history or their negative experience with the training process that has been used. For children who avoid entering a bathroom at all, some type of shaping approach can be helpful by first establishing positive associations with the bathroom itself. This could include reading, listening to music, playing a game, or other fun activities to help eliminate the negative associations of being in the bathroom. Once the child is able to engage in other activities that are pleasurable in the bathroom, efforts can be made toward shaping him or her to sit on the toilet. This may involve starting with the child sitting on the toilet fully clothed while parents engage in some simple activity, such as reading a book, listening to music, and so forth. For older children, it might involve having them play some portable video game or read a magazine while sitting. Gradually increase the expectations for the child, such as having him or her go from being fully clothed to sitting in his or her underwear to finally sitting unclothed on the toilet. For younger children, the use of some type of simple, tangible reward (e.g., stickers, small food items) may be helpful toward motivating them to follow the directions. Any resistance by the child to participate should result in him or her having no access to other preferred activities, with the parent reminding the child of his or her choice to either play while sitting on the toilet or not play at all. For many children, the use of some simple contingency management (described earlier) will be effective enough to promote compliance with sitting on the toilet. We recommend avoiding time-out when possible, because it further creates negative associations with the toileting regimen and increases conflict between the parent and child. Additionally, many children would rather sit in time-out than sit on the toilet. Most children will acquiesce to sitting on the toilet for a few minutes in order to gain access to their preferred activities. Once this occurs, it will create an opportunity to shape more cooperative sitting for longer periods of time, until the child is able to sit long enough to relax. For children who are highly resistant toward sitting on the toilet or entering the bathroom, it may be necessary to spend some time working with the parents on developing more effective parenting skills and focusing on improved levels of instructional

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control across a number of domains. Once these goals have been accomplished, it would likely be prudent to return to the management of the encopresis.

Case Example Sam was a 5-year-old boy who was referred because of recurring soiling episodes. He had never been successfully toilet trained. Sam’s medical history was unremarkable. He took no medication other than Miralax for periodic constipation. He met all developmental milestones as expected. Outside of the encopresis, the parents noted no significant behavioral concerns. Sam was otherwise compliant with demands made of him, outside of toileting requests. His parents had begun toilet training him when he was about 2½ years of age. In time, he had begun engaging in some stool-holding behavior, which led to constipation and large, painful bowel movements. Sam had been placed on a regimen of Miralax for management of the constipation. He continued to be resistant to his parents’ attempts to toilet train him. His parents had reinstituted various toilet-training attempts approximately every 6 months up to the current time. The parents had used a variety of positive reinforcement programs, as well as some forms of punishment to address Sam’s soiling episodes and resistance to sitting on the toilet. The punishment strategies included time-out, spanking, and loss of privileges. The parents noted that their efforts had not caused any significant improvements in Sam’s voiding in the toilet. Sam would urinate in the toilet but was not having bowel movements in the toilet. Despite taking Miralax, Sam would frequently attempt to hold his stool for as long as possible. This would often lead to him having a large bowel movement every 2–3 days, with some apparent overflow incontinence multiple times each day. Sam would also hide when having a bowel movement, and at times, hide his soiled underwear. This increased his parents’ frustration and led to additional forms of punishment. Most recently, he had seen a gastroenterologist, who admitted Sam to the hospital for a fecal impaction clean-out. Sam’s pediatrician continued to monitor his constipation and toileting difficulties. Given the long-standing soiling episodes and toileting difficulties, Sam and his parents were referred to a CBT psychologist. (It is important to note here that we did not refer Sam for a physical examination because he was referred to us by his primary care physician.)

CBT Evaluation During the intake assessment, the psychologist reviewed with Sam’s parents his past medical history and their efforts to toilet train Sam. The therapist obtained a thorough description of the toilet-training strategies the parents had used as well as their use of different punishment techniques. The parents had used a variety of sticker charts and other tangible reward systems to motivate Sam to void in the toilet. The psychologist also learned


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that the parents used time-out, corporal punishment, and restricting access to preferred activities each time that Sam refused to sit on the toilet or any time that he had a soiling episode in his clothing. The punishment techniques had been used for the past 6–12 months. The parents indicated that as their efforts met with limited success, their level of frustration increased. The psychologist met separately with Sam. It was learned during the intake with Sam that he was afraid to sit on the toilet because he said that it “hurt” when he had bowel movements while sitting on the toilet. Sam also commented that he did not want his parents to know when he had a soiling episode because he “didn’t want to get in trouble.” Sam was also questioned about his awareness of physical cues and urges to have a bowel movement. Sam indicated that his “tummy hurt” when he needed to “go poop.” When asked if he tried to sit on the toilet and have a bowel movement when his tummy hurt, Sam responded, “No, it will hurt.” Following the intake assessment, the psychologist met with the parents and asked them to collect data on Sam’s soiling episodes and their toilet-training practices.

Data Collection Sam’s parents were provided with a data form that allowed them, on a daily basis, to record the number of bowel movements that Sam had in the toilet, the number of soiling episodes, the consistency of Sam’s stools (a chart was provided to the parents to help them record stool consistency), a rating of the difficulty that Sam had with passing a stool, any medicine that he was taking, and the amount of medicine taken. Additionally, the parents were asked to record the number of times that Sam hid his soiled underwear. They were also asked to journal their efforts toward prompting Sam to have a bowel movement, as well as how they responded to Sam’s successful bowel movements and accidents.

Treatment Sessions Session 1. During the first treatment session, it was learned that Sam was having a large bowel movement approximately every 2 days. None of his bowel movements occurred in the toilet; all were soiling episodes. Sam also had approximately five small liquid soiling accidents each day. Sam sat on the toilet only on two occasions during the first week. Based on these data and Sam’s history, the following treatment recommendations were put in place: 1. Sam was expected to sit on the toilet for a period of 5 minutes after each meal. A timer was set to help Sam know how much time he needed to remain seated. Sam’s parents agreed to read a book to Sam or allow him to play a video game on a portable video game console while he was sitting. Sam was to be rewarded in some small way for sitting cooperatively on the toilet. Sam’s par-

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ents rarely provided any candy or sweets to him at home. The parents agreed to provide Sam with a piece of candy for sitting cooperatively. They purchased a small candy dispenser, and Sam earned one Skittle for successfully sitting on the toilet for 5 minutes (Sam seemed excited about the opportunity to earn the Skittles). 2. The parents agreed to purchase small toys and other items, such as action figures, that were meaningful to Sam in order to reinforce his use of the toilet. They wrapped the toys in aluminum foil and placed them in a basket that was placed on a shelf out of Sam’s reach, but visible to him. Sam was told that he would be able to unwrap one of the items any time that he had a bowel movement in the toilet. The parents were instructed to provide one of the items to Sam no matter how small the stool was that he passed in the toilet. 3. The parents were asked to provide no verbal reprimands or any form of punishment to Sam for having a soiling episode. Rather, they were instructed on how to engage Sam in assisting them with cleaning himself and his soiled clothing and placing new clothing on himself to the best of his ability. The parents were encouraged to make the cleanup process mildly aversive while maintaining a neutral, matter-of-fact demeanor. If Sam had multiple soiling accidents and the parents were concerned about a possible rash, then Sam was expected to soak in a bathtub for 5–10 minutes to reduce the possibility of rash. Sam was to be provided with no bathtub toys. Session 2. At the next follow-up treatment session 1 week later, Sam’s cooperation with sitting had improved. He was now sitting fairly cooperatively on the toilet 70% of the time. The parents noted that his resistance toward sitting had decreased. Sam continued to have frequent minor soiling accidents and became increasingly agitated when he was required to help his parents with cleaning his clothing and himself. On two occasions, he had hidden his underwear after a minor soiling episode. Sam lost the opportunity to play outside for the remainder of the day after his parents discovered the hidden, soiled underwear. He had thus far not voided in the toilet but was now having approximately one bowel movement per day in his clothing. Session 3. Sam continued to sit cooperatively and was now sitting on the toilet approximately 90% of the time requested. His parents also noted that there were no instances in which Sam had hidden his soiled underwear. The parents were very excited because Sam had had two successful bowel movements in the toilet (one small, one large) during the past week. Sam also seemed more excited about having bowel movements in the toilet than about the tangible rewards that he had received for them. The parents continued to have Sam assist with the cleanup associated with any soiling episodes. The frequency of his soiling episodes had decreased to approximately two times per day.


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Session 4. Two weeks later, the parents reported significant improvement in Sam’s level of cooperation and the frequency of his bowel movements in the toilet. The parents noted no instances in which Sam either hid to have a bowel movement in his clothing or hid his soiled underwear. Sam had had only two minor soiling episodes during the past 2 weeks, both of which occurred while he was busy playing outside. Sam was much more cooperative and clearly expressed his satisfaction with the progress that he had made, telling the psychologist how many times that he had gone “poop” in the toilet. He also shared with the psychologist the action figures that he had earned over the past 2 weeks. The components of the treatment protocol were reviewed with the parents and Sam, and they were asked to return in 1 month. Session 5. Sam’s parents reported that the soiling episodes had almost completely ceased. Sam occasionally would have very small amounts of liquid stool in his underwear, but the parents attributed these to the loose consistency of his stools. Sam was now having all bowel movements in the toilet. Sam was also able to tell the psychologist that each time that he felt his “tummy hurt,” he would go to the bathroom and attempt to have a bowel movement. Sam was now voiding independently the majority of the time. The parents were instructed to discontinue regular sit times after meals, and instead to reward Sam only if he had a bowel movement in the toilet independently. They were to continue to have Sam assist with any cleanup for minor soiling episodes. It was also suggested that they consult with Sam’s pediatrician to receive recommendations on possibly titrating his Miralax dosage. Sam was praised for his progress, and it was evident that he was very proud of his accomplishment. Final session. Sam was seen 8 weeks later, and his encopresis had resolved fully. Sam was now voiding completely independently in the toilet and was having no soiling episodes. Sam’s parents were working with the pediatrician to reduce and eventually eliminate the Miralax dosage, which helped to reduce the minor soiling episodes. The treatment components were again reviewed with the parents, and final recommendations were offered. The parents were encouraged to contact the psychologist with any questions that arose in the future.

Conclusion: Encopresis Although enuresis is one of the most distressing experiences reported by children (Van Tijen et al. 1998), unfortunately no similar type of research has been conducted on how distressing encopresis is for affected children. Our clinical experience suggests that encopresis is even more distressing for afflicted children than enuresis. Furthermore, the psychological, emotional, social, and medical complications that result from chronic untreated cases of encopresis are greater than the complications that arise from untreated enuresis. Although effective treatment for encopresis is

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more invasive and potentially embarrassing for affected children and their families than treatment for enuresis, it can actually involve less effort. For example, all of the parental treatment efforts occur during the day, whereas with enuresis, important treatment efforts are needed at night. Presently, physicians are the major first line of defense against encopresis, but their approach typically is mostly biomedical, and as we hope we have clearly demonstrated, there is a substantial cognitive-behavioral dimension to the condition. As with CBT for enuresis, CBT for encopresis is not an obvious example of CBT. Classic examples of CBT application include treatment for anxiety, depression, or habit disorders. Those conditions are more dominantly psychological, and thus with the exception of cases involving drug treatments, the emphasis in CBT treatment for these disorders is mostly on the cognitive and emotional behavior of those affected. With encopresis, however, the condition is quite obviously dominantly biomedical and so too is its most significant cause, constipation. Nonetheless, effective treatment always involves cognitive and motoric behavior changes, and therefore encopresis is an appropriate target for CBT-trained therapists, with the caveat that they be highly familiar with the physiology of defecation.

Conclusion Enuretic and encopretic children have been misunderstood, misinterpreted, and mistreated for centuries. Fortunately for them, scientists and practitioners working in the latter half of the twentieth century supplied a more accurate, humane, and treatment-relevant characterization of these conditions. These characterizations have led to empirically supported treatments, and the best known of these have been described in this chapter. Although in this chapter we refer to the general category for these treatments as CBT, this form of treatment is also characterized as biobehavioral in other work (Christophersen and Friman 2010; Friman 2007, 2008). The CBT understanding and approach to enuresis and encopresis is substantially superior to the historically psychogenic understanding and approach, and even more so to the moral and characterological understanding and approach of antiquity. The CBT approach incorporates the physiology of elimination, and although it also incorporates the psychological state of the child, it does not view psychological variables as necessarily causal. Rather, psychological variables are viewed as critical to active participation in treatment, and CBT provides methods for using or modifying these variables to promote participation. When psychological abnormali-


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ties are present, they are more likely to be viewed as a consequence rather than a cause of either condition. The psychogenic approach virtually ignores the physiology of elimination and views psychological variables as dominantly causal. Although the psychogenic approach views psychological variables as relevant to participation in treatment, it provides no methods for using these same variables to promote participation. From the CBT perspective, the evaluation and treatment of enuresis and encopresis always require the direct involvement of a physician, but ideal management results from a partnership with the child, family, cognitive-behavioral therapist, and physician. This unified approach, when accompanied by empirically supported CBT, can alleviate incontinence completely—and eliminate or dramatically minimize the possibility of the harmful overinterpretation and unhealthful forms of treatment that have tarnished the health care approach to incontinence in children throughout history.

Key Clinical Points Enuresis • A physical exam of the child that includes a urine analysis should be included in the assessment phase. • All forms of punishment for urinary accidents should be abolished. • The child and parents should be educated about enuresis with emphasis on definition, causes, prevalence, and treatment options. • The most empirically supported treatment by a wide margin is alarmbased treatment. • Because of the health risks associated with medications used for treatment of enuresis, medication should not be used as a primary treatment agent. Encopresis • A physical exam to rule out fecal impaction and gastrointestinal diseases (e.g., Crohn’s disease) should be conducted before behavioral consultation is sought. • The child and parents should be educated about encopresis with emphasis on definition, causes, prevalence, and treatment options. • Punishing the child for having soiling accidents should be avoided because of the risk for stool holding and a reduction in cooperation with the behavior plan.

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• Shaping the child’s cooperation for sitting on and voiding in the toilet through positive behavioral strategies should be the center of any intervention plan. • The child’s stool consistency, successful bowel movements, and soiling accidents should be monitored closely throughout treatment.

Self-Assessment Questions Enuresis 13.1. Which of the following statements best characterizes enuresis? A. It is a benign condition. B. It is a psychopathological condition. C. It is a psychopathological condition medically but not psychologically. D. It is a psychopathological condition psychologically but not medically. 13.2. Regarding physician involvement in the initial assessment of enuresis, which of the following is most accurate? A. Because enuresis is a psychological condition, there is no need to involve a physician. B. Because enuresis is a medical condition, physicians are solely responsible for assessment and diagnosis. C. Involvement of the physician is best left to the psychologist’s discretion. D. All cases of enuresis should be referred to a physician for an initial evaluation so that potential medical causes can be detected and treated or ruled out. 13.3. Which of the following does not have strong evidence supporting its role as a cause of enuresis? A. Family history. B. Reduced functional bladder capacity. C. Difficulty arousing from sleep. D. Psychopathology. 13.4. Which of the following is true of drug-based treatment for nocturnal enuresis?


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A. Drugs are highly effective as treatment for enuresis and should always be considered as primary treatment. B. Drugs are highly ineffective for treatment of enuresis and should never be considered in a treatment plan. C. Both drugs and biobehavioral treatment methods are effective as primary treatment for enuresis, and the therapist should choose between them. D. Because of unhealthy side effects and temporary results, drugs should be considered only as adjuncts to treatment. 13.5. Which of the following treatments for diurnal enuresis has the most empirical support? A. Scheduled toilet visits. B. Retention-control training. C. Alarm-based treatment. D. Fluid restriction.

Encopresis 13.6. Compared to enuresis, the prevalence rate for encopresis is A. Lower. B. Higher. C. About the same. D. Not available for the general population. 13.7. Which of the following factors is not known to contribute to the development of encopresis? A. Fiber intake. B. History of painful bowel movements. C. Volitional stool-holding. D. Sodium intake. 13.8. From a treatment standpoint, the research suggests that which treatment modality is most efficacious when treating encopresis? A. Medical treatment only. B. Behavioral treatment only. C. Collaborative medical and behavioral treatment. D. Dietary modifications, with consultation by a psychologist.

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13.9. Regarding physician involvement in the management of encopresis, which of the following is most accurate? A. All cases of encopresis should be referred to a primary care physician to rule out potential medical causes. B. All cases of encopresis should be referred to a pediatric gastroenterologist. C. Psychologists should decide, at their discretion, whether involvement by a physician is needed. D. Because there is a strong behavioral component to encopresis, further involvement by a physician is not needed. 13.10. Which of the following best characterizes encopresis? A. It is a condition that has many contributing factors, including medical, behavioral, and nutritional. B. Encopresis is primarily a medical condition. C. Encopresis is primarily a behavioral disorder. D. The contributing factors for encopresis are not well known. 13.11. Which of the following is true about the role of biofeedback treatment for encopresis? A. It has demonstrated superior long-term effects over traditional medical interventions. B. Biofeedback does not increase treatment rates above those achieved with conventional treatment alone. C. There is no support for the use of biofeedback, and it should generally be avoided. D. Biofeedback has been shown to be a critical and essential treatment component, especially when combined with medical and behavioral interventions.

Suggested Readings and Web Sites Christophersen ER, Mortweet SL: Treatments That Work With Children: Empirically Supported Strategies for Managing Childhood Problems. Washington, DC, American Psychological Association, 2001


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The Journal of the American Academy of Child and Adolescent Psychiatry October 2001 issue provides an extensive review of the research literature on enuresis and encopresis. McGrath ML, Mellon MW, Murphy L: Empirically supported treatments in pediatric psychology: constipation and encopresis. J Pediatr Psychol 25:225–254, 2000 (a comprehensive review of the empirically supported treatments for constipation and encopresis) Schonwald AD, Sheldon GG: The Pocket Idiot’s Guide to Potty Training Problems. Indianapolis, IN, Penguin, 2006 Vemulakonda VM, Jones EA: Primer: Diagnosis and Management of Uncomplicated Daytime Wetting in Children. Nat Clin Pract Urol 3:551–559, 2006. Available at: http://www.medscape.com/viewarticle/546017. Accessed July 28, 2011. For a variety of toilet training accessories: www.pottytrainingconcepts.com For more information on toilet training and the Toilet School at Children’s Hospital Boston (Massachusetts): http://www.childrenshospital.org/ az/Site1755/mainpageS1755P0.html The Web site for the University of Virginia Health Sciences Center features a tutorial for patients and families, “Chronic Constipation and Enuresis”: http://www.medicine.virginia.edu/clinical/departments/ pediatrics/clinical-services/tutorials/constipation/home The Bedwetting Store: www.bedwettingstore.com Bedwetting facts: www.aacap.org/cs/root/facts_for_families/bedwetting Bedwetting general information: http://en.wikipedia.org/wiki/Bedwetting Bedwetting and soiling information and treatment: www.soilingsolutions.com Diurnal enuresis: http://en.wikipedia.org/wiki/Diurnal_enuresis General information and products for all aspects of child incontinence: www.pottymd.com FamilyDoctor.org: “Stool Soiling and Constipation in Children”: http:// familydoctor.org/online/famdocen/home/children/parents/toilet/ 166.html

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Houts AC, Liebert RM: Bedwetting: A Guide for Parents. Springfield, IL, Thomas, 1985 Houts AC, Peterson JK, Whelan JP: Prevention of relapse in full spectrum home training for primary enuresis: a components analysis. Behav Ther 17:462–469, 1986 Houts AC, Berman JS, Abramson H: Effectiveness of psychological and pharmacological treatments for nocturnal enuresis. J Consult Clin Psychol 62:737– 745, 1994 Joinson C, Heron J, Butler R, et al: A United Kingdom population-based study of intellectual capacities in children with and without soiling, daytime wetting, and bed-wetting. Pediatrics 120:E308–E316, 2007 Kegel AH: Physiological therapy for urinary stress incontinence. JAMA 146:915– 917, 1951 Levine MD: Encopresis: its potentiation, evaluation, and alleviation. Pediatr Clin North Am 29:315–330, 1982 Luxem MC, Christophersen ER, Purvis PC, et al: Behavioral-medical treatment of pediatric toileting refusal. J Dev Behav Pediatr 18:34–41, 1997 Loening-Baucke V: Prevalence rates for constipation and fecal and urinary incontinence. Arch Dis Child 92:486–489, 2007 McGrath ML, Mellon MW, Murphy L: Empirically supported treatments in pediatric psychology: constipation and encopresis. J Pediatr Psychol 25:225–254, 2000 Mellon MW, McGrath ML: Empirically supported treatments in pediatric psychology: nocturnal enuresis. J Pediatr Psychol 25:193–214, 2000 Muellner SR: Development of urinary control in children: some aspects of the cause and treatment of primary enuresis. JAMA 172:1256–1261, 1960 Muellner SR: Obstacles to the successful treatment of primary enuresis. JAMA 178:843–844, 1961 Reimers TM: A biobehavioral approach toward managing encopresis. Behav Modif 20:469–479, 1996 Ronen T, Wozner Y: A self-control intervention package for the treatment of primary nocturnal enuresis. Child Fam Behav Ther 17:1–20, 1995 Ronen T, Wozner Y, Rahav G: Cognitive interventions for enuresis. Child Fam Behav Ther 14:1–14, 1992 Ronen T, Rahav G, Wozner Y: Self-control and enuresis. J Cogn Psychother 9:249– 258, 1995 Schonwald AD, Rappaport LA: Elimination conditions, in Developmental-Behavioral Pediatrics. Edited by Wolraich ML, Drotar DD, Dworkin PH. Philadelphia, PA, Mosby, 2008, pp 791–804 Sperling M: The Major Neuroses and Behavior Disorders in Children. Northvale, NJ, Jason Aronson, 1994 Starfield B: Functional bladder capacity in enuretic and nonenuretic children. J Pediatr 70:777–781, 1967 Starfield B, Mellits ED: Increase in functional bladder capacity and improvements in enuresis. J Pediatr 72:483–487, 1968 U.S. Food and Drug Administration: Desmopressin acetate (marketed as DDAVP Nasal Spray, DDAVP Rhinal Tube, DDAVP, DDVP, Minirin, and Stimate Nasal Spray). FDA Alert, December 4, 2007. Available at: http://www.fda.gov/Drugs/ DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ ucm107924.htm. Accessed April 26, 2011.

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van der Wal MF, Benninga MA, Hirasing RA: The prevalence of encopresis in a multicultural population. J Pediatr Gastroenterol Nutr 40:345–348, 2005 van Dijk M, Bongers ME, de Vries GJ, et al: Behavioral therapy for childhood constipation: a randomized, controlled trial. Pediatrics 121:E1334–E1341, 2008 Van Tijen NM, Messer AP, Namdar Z: Perceived stress of nocturnal enuresis in childhood. Br J Urol 81 (suppl 3):98–99, 1998 World Health Organization: International Statistical Classification of Diseases and Related Health Problems, 10th Revision. Version for 2007. Available at: http:// apps.who.int/classifications/apps/icd/icd10online. Accessed April 26, 2011. Wright L, Schaefer AB, Solomons G: Encyclopedia of Pediatric Psychology. Baltimore, MD, University Park Press, 1978

APPENDIX 1

Self-Assessment Questions and Answers

Chapter 1: Cognitive-Behavior Therapy: An Introduction 1.1.

What is the most readily available form of core beliefs called? Answer: Automatic thoughts are the most readily available form of core beliefs.

1.2.

What is a negative schema? Answer: A negative schema is an information processing “lens,” informed by early life experiences and negative life events, through which an individual views the world and makes sense of new information. This schema is activated in situations that remind the individual of the original learning experiences, leading to maladaptive negative beliefs about the self, the world, and the future. 513

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1.3.


Define collaborative empiricism. Answer: Collaborative empiricism is a process by which the therapist and client carefully consider all available evidence and identify “clues” that support the maladaptive cognition and those that do not support the thought or belief.

1.4.

How are behaviors reinforced? How are they extinguished? Answer: Behaviors are reinforced when an event, privilege, material item or behavior that follows a behavior is rewarding. Extinction refers to the reduction in frequency or total elimination of a behavior by use of nonrewarding occurrences.

Chapter 2: Developmental Considerations Across Childhood 2.1.

True or False: Adolescents are always better able to engage in cognitive-behavioral strategies than are young children. Answer: False.

2.2.

Which of the following is NOT a reason to use a developmentally sensitive framework in treatment planning? A. Different treatment strategies require different developmental skills. B. Developmental level impacts children’s ability to both learn and apply therapeutic skills. C. Development level within a domain is uniform at each chronological age. D. Different areas of development (e.g., cognitive, social, and emotional) are interdependent. Answer: C.

2.3.

Little Johnny is asked in therapy to recognize that when he thinks “I will fail this math test no matter what,” he feels discouraged and is less likely to study for the test. Which of the following developmental skills are necessary to understand this connection? A. Metacognition and perspective taking. B. Causal reasoning and emotion identification.

Appendix 1: Self-Assessment Questions and Answers

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C. Self-reflection and social skills. D. Hypothetical thinking and emotion management. Answer: B. 2.4.

True or False: Adapting adult language to be more age-appropriate is the primary way to developmentally tailor CBT for children. Answer: False.

2.5.

Clinicians should assess children’s developmental level A. Before starting treatment. B. Before introducing a new developmentally challenging technique. C. After implementing strategies designed to improve developmental skills. D. All of the above. Answer: D.

Chapter 3: Culturally Diverse Children and Adolescents 3.1.

Which of the following is NOT a strength of CBT when implemented with ethnocultural minority youth? A. B. C. D.

It is time limited and problem oriented. It is focused on the present and future. It is focused on intrapsychic, unconscious processes. It involves collaboration in defining treatment goals.

Answer: C. 3.2.

Parent training protocols with ethnic minority youth may improve treatment retention and outcomes by including an emphasis on A. B. C. D.

Time-out. Physical discipline. Natural consequences. Racial socialization.

Answer: D.

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3.3.

Antoine is a 9-year-old African American boy who is struggling in school. One of his core beliefs is that “only white kids do well in school.” This belief is an example of A. B. C. D.

Acculturation stress. Internalized oppression. Feelings as facts. Ableism.

Answer: B. 3.4.

CBT with an Iraqi (Muslim) 12-year-old girl with externalizing problems might be enhanced by A. B. C. D.

Family-focused sessions. Individual-focused sessions. Emphasis on assertiveness training in all contexts. Behavioral activation.

Answer: A. 3.5.

The clinician must be especially cautious in implementing which CBT skill because of its cultural acceptability in different settings (e.g., home vs. school)? A. B. C. D.

Behavioral activation. Problem solving. Assertiveness training. Cognitive restructuring.

Answer: C.

Chapter 4: Combined CBT and Psychopharmacology 4.1.

The only other medication besides fluoxetine that the U.S. Food and Drug Administration has approved for the treatment of major depressive disorder in adolescents (12–17 years) is A. Sertraline. B. Escitalopram. C. Paroxetine.


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D. Fluvoxamine. E. Imipramine. Answer: B. 4.2.

On the basis of the results of the Children/Adolescent Anxiety Multimodal Study (CAMS), the following statement is true: A. CBT is the most effective intervention for children and adolescents. B. Pharmacotherapy is the most effective intervention for children and adolescents. C. Combined treatments (CBT and pharmacotherapy) showed a superior response rate compared to CBT or pharmacotherapy alone. D. No intervention was shown to be better than placebo. E. The results were inconclusive. Answer: C.

4.3.

Which of the following statements is true regarding evidence for combined treatments (CBT plus pharmacotherapy) for depression? A. Combined treatments (CBT and pharmacotherapy) are always better than either treatment alone. B. CBT is consistently better than pharmacotherapy and thus should be the first line of treatment. C. Pharmacotherapy is consistently better than CBT and thus should be the first line of treatment. D. The results are mixed, with some studies showing efficacy of combined treatments and others the advantages of a combined approach. E. None of the above statements is true. Answer: D.

4.4.

For a 13-year-old patient presenting with a first episode of major depression, the clinician should A. Always start with CBT first and switch to medications if CBT does not work. B. Take a detailed history and make a decision on treatment interventions on the basis of the inventory of factors, such as symptom severity and patient and parent preferences.

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C. Always start with pharmacotherapy first and then add CBT if symptom resolution has not been achieved by pharmacotherapy alone. D. Take a detailed history, assess for various factors, and then always start with a combined approach (CBT plus pharmacotherapy) because it has been shown to be the most efficacious. E. Let the patient decide. Answer: B. 4.5.

Which of the following are important factors to consider when deciding which intervention to choose from? A. B. C. D. E.

Severity of symptoms. Prior experience with treatment. Comorbidities. Availability of resources. All of the above.

Answer: E.

Chapter 5: Depression and Suicidal Behavior 5.1.

A 14-year-old Hispanic boy diagnosed with a major depressive disorder has not responded to a trial of a selective serotonin reuptake inhibitor (SSRI). The next management step that the youth would most likely respond to is to A. B. C. D.

Switch to another SSRI. Switch to venlafaxine. Switch to another SSRI and add CBT. Treat with the same SSRI for a period longer than 12 weeks.

Answer: C. 5.2.

A 13-year-old girl with a history of depression gets easily irritable at school and becomes aggressive with teachers and friends. The most helpful CBT technique to include in her treatment plan is A. Exposure and response prevention.


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B. Cognitive restructuring. C. Emotion regulation D. Safety planning. Answer: C. 5.3.

You tell your depressed adolescent youth that it is important to schedule activities that he or she finds pleasurable and to engage in these activities on a regular basis. This is an example of A. B. C. D.


Answer: C. 5.4.

A feasible and acceptable therapeutic intervention with a depressed adolescent who recently attempted suicide is A. B. C. D.

Interpersonal therapy. CBT used with depressed youths. Relaxation techniques. Cognitive-behavior therapy for suicide prevention.

Answer: D. 5.5.

You see an adolescent youth with depression who is having difficulty initiating and maintaining relationships with peers. The most helpful CBT technique to include in the treatment plan of this youth is A. B. C. D.


Answer: D.

Chapter 6: Bipolar Disorder 6.1.

CBT would be considered an appropriate treatment strategy for a child with bipolar disorder

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A. Only when a strong family history of bipolar disorder is identified. B. In conjunction with mood stabilization with medication. C. If the child is of well above-average intelligence. D. As a stand-alone treatment. Answer: B. 6.2.

Children with bipolar disorder are at increased risk for A. B. C. D.

Academic problems. Social problems. Suicidal ideation. All of the above.

Answer: D. 6.3.

A 14-year-old adolescent girl is diagnosed with bipolar I disorder. __________ is/are considered the first-line treatment(s). A. B. C. D.

CBT. Antidepressants. Mood stabilizers or atypical antipsychotics. Electroconvulsive therapy.

Answer: C. 6.4.

Although the etiology of bipolar disorder is thought to be largely ___________________, illness course is likely influenced by ___________________________. A. The result of trauma; biological factors. B. Biological; a combination of biological, psychological, and social factors. C. Due to impaired parenting; a combination of biological, psychological, and social factors. D. Medication induced; the child’s level of intelligence. Answer: B.

6.5.

_____________ is almost always recommended as a part of CBT for a child with bipolar disorder.


A. B. C. D.

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Family involvement. Use of a therapist of the same sex as the child. Residential treatment. Psychoeducational testing.

Answer: A.

Chapter 7: Childhood Anxiety Disorders 7.1.

Which of the following clients is an appropriate candidate for CBT for child anxiety? A. A 16-year-old white adolescent girl with primary social phobia, obesity, and a learning disability. B. A 6-year-old Hispanic girl with primary separation anxiety disorder and a specific phobia of blood. C. A 13-year-old African American adolescent boy with primary generalized anxiety disorder and comorbid attention-deficit/hyperactivity disorder (ADHD) managed with stimulant medication. D. All of the above. Answer: D. The clients described in A, B, and C are all appropriate candidates for CBT for child anxiety. Treatment manuals exist for CBT for child anxiety for youth ages 4–17, and CBT for child anxiety can be implemented with flexibility for youth with learning differences and comorbid conditions.

7.2.

Which of the following is NOT a core component of CBT for child anxiety? A. B. C. D.

Cognitive restructuring. Exposure tasks. Psychoeducation. Behavioral activation.

Answer: D. Although behavioral activation is a component of some CBT protocols for child depression, it is not a common core component of CBT approaches to child anxiety. 7.3.

A 7-year-old girl diagnosed with separation anxiety disorder presents for treatment. The best role for her parents in CBT treatment is

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A. No parental involvement in the child’s treatment. B. Parents as co-clients in treatment, with treatment for the child and treatment for the parents. C. Parents as collaborators in conducting exposure tasks involving the child’s separation from the parent(s). D. Parents as consultants regarding the child’s symptoms and impairment. Answer: C. Though it might seem tempting to include parents as co-clients, the core component of treatment will be graduated exposure to the feared situation—specifically, separation from parents. Parents can be involved as collaborators in planning and carrying out the exposure tasks. Parents can and do serve as consultants, but the best role for them in this case is as collaborators. 7.4.

A 12-year-old boy with generalized anxiety disorder expresses worry about an upcoming test; he thinks, “I’m worried that I am going to fail, and then I’ll have to repeat seventh grade!” Which of the following is a reasonable coping thought in this situation? A. There’s no way I’ll fail. The teacher likes me.... I think. B. All I have to do is study every day before the test and then I won’t fail. C. Even if I fail seventh grade, I still have my friends...so why bother studying? D. It’s unlikely that I will fail the test because I studied pretty hard. Even if I did fail this one test, I have plenty of time to bring up my grades before the end of seventh grade. Answer: D. This coping thought is realistic about the probabilities of the various feared outcomes.

7.5.

Which of the following is NOT an example of an appropriate flexible implementation of CBT for child anxiety (i.e., a flexible application that maintains treatment fidelity)? A. Simplifying cognitive restructuring to the use of a single coping thought (“I can do it!”) for a 7-year-old boy with primary separation anxiety disorder who didn’t fully grasp the concept of self-talk. B. Eliminating at-home exposure tasks for an 11-year-old girl with social phobia, because of parental concerns about causing the child too much stress.


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C. Using frequent breaks and additional rewards for an 8year-old boy with primary generalized anxiety disorder and comorbid ADHD who is having difficulty staying on task in session. D. Downplaying “sleeping in own bed” as an exposure task for a 9-year-old girl with primary social phobia, due to parental beliefs and preferences regarding a shared family bed. Answer: B. This application would not be an example of “flexibility within fidelity” because the child will not face her fears in settings other than the therapy clinic. The therapist should review the rationale behind exposure tasks with the parents and the importance of allowing the child to learn to cope with the distress. A, C, and D are all appropriate ways to individualize CBT for child anxiety according to age, comorbidities, and culture, while maintaining treatment fidelity.

Chapter 8: Pediatric Posttraumatic Stress Disorder 8.1.

Which of the following is a characteristic of gradual exposure? A. Incrementally increasing the duration and intensity of traumatic material in each sequential treatment component. B. Therapists being mindful not to model avoidance. C. Connecting each component, including the skills-based components, to the child’s trauma in some way. D. Instructing children to think about their trauma experiences for at least an hour every day. E. A, B, and C only. F. All of the above. Answer: E.

8.2.

Connections among which of the following three components form the basis of cognitive coping? A. B. C. D.

Thoughts, feelings, behaviors. Thoughts, antecedents, consequences. Antecedents, behaviors, consequences. Thoughts, behaviors, beliefs.

Answer: A.

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8.3.

Which of the following factors may be considered in choosing between individual and group CBT trauma treatments? A. B. C. D.

Severity of symptoms. Accessibility of school-based treatment. What treatment parents will accept. All of the above.

Answer: D. 8.4.

Which of the following may inadvertently communicate trauma avoidance to children during therapy? A. Using euphemisms for traumatic experiences. B. Attempting to show empathy by changing voice tone or volume when talking about trauma. C. Change in body language. D. Preparatory statements when introducing traumatic themes. E. A, B, and C only. F. All of the above. Answer: F.

8.5.

Cultural adaptations of CBT trauma treatments have A. Found some core components to be ineffective with certain populations. B. Retained all core components of the efficacious treatments. C. Found that manuals cannot be properly translated into other languages. D. Created new models for different ethnic groups. Answer: B.

Chapter 9: Obsessive-Compulsive Disorder 9.1.

CBT treatment research has indicated that the most efficacious component for decreasing obsessive-compulsive disorder (OCD) symptoms is A. Prolonged exposure. B. Socratic questioning.


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C. Progressive muscle relaxation. D. Exposure and response prevention. Answer: D. 9.2.

Research by Storch and colleagues has indicated that CBT with exposure and response prevention (E/RP) is A. Most effective when delivered in a weekly outpatient format. B. Most effective when delivered in a daily outpatient format. C. Equally effective in either a weekly or daily outpatient format. D. Equally effective in either an outpatient or inpatient format. Answer: C.

9.3.

What is considered to be the threshold for clinically significant OCD on the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS)? A. B. C. D. E.

10. 12. 16. 20. 30.

Answer: C. 9.4.

Which of the following is not considered relevant to at least some OCD cognitions? A. B. C. D.

Feared consequence of not relieving urges. Thought-action fusion. Overestimation of threat. Intolerance of uncertainty or doubt.

Answer: A. 9.5.

When is an E/RP exercise typically considered to be successfully completed?

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A. When the child and parent experience a 30% reduction in initial distress. B. When the child experiences a 50% reduction in initial distress. C. When the child experiences a 90% reduction in initial distress. D. When the child and parent experience a 90% reduction in initial distress. E. Either B or D. F. Either B or C. Answer: F.

Chapter 10: Chronic Physical Illness 10.1. When CBT is used for the treatment of a youth with a chronic physical illness, which of the following treatment components will likely be most useful for improving mood and positive coping? A. Teaching the youth skills focused on changing negative thoughts regarding illness. B. Parent sessions focused on education regarding CBT and how parents can best support their child. C. Teaching the youth skills focused on how to behave differently when feeling upset, such as increasing pleasurable activities. D. All of the above. Answer: D. When using CBT, the behavioral, cognitive, and family skills introduced are all equally important to the overall outcome of improving mood and positive coping for youth. Ultimately, CBT is a toolbox approach, and the best treatments provide youth with several options for coping with negative situations they may encounter in the future. 10.2. Which of the following best describes the relationship between psychological and physical processes? A. Symptoms of physical illness, such as inflammation, can negatively impact brain chemistry, resulting in psychological disturbances. B. There is no relationship between physical illness and mental health concerns.


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C. The relationship is bidirectional. A preexisting mental health concern can negatively impact physical illness by decreasing healthy behaviors. Also, physical illness processes can contribute to increased psychological concerns by increasing both internal and external stressors. D. Psychological difficulties can negatively impact a youth’s perception of control over illness, leading to a hopeless view regarding health and a decreased participation in healthy behaviors. Answer: C. The relationship between physical illness and psychological processes is bidirectional. This supports providing mental health treatment alongside medical treatments in order to promote medical adherence and to increase quality of life and feelings of well-being. 10.3. A 14-year-old adolescent girl with comorbid Crohn’s disease and depression spends most of her time lying in bed in her bedroom, isolating herself. Which of the following coping skills is a primary control tool that will likely help her change this negative behavior? A. The tool of identifying the silver lining so that the youth begins to find the positive in her situation. B. Taking part in relaxation training techniques such as deep breathing and hypnosis. C. Recognizing negative thought patterns and challenging them with more helpful thoughts. D. Activity scheduling: being encouraged to take part in an increased variety of activities, including pleasurable, physically active, helpful, and social activities. Answer: D. Choices A and C are secondary control techniques; they focus on changing the youth’s perception in order to improve mood. Choice B is a primary control tool; however, relaxation training would not be the most helpful skill for decreasing the youth’s isolative behavior. Activity scheduling is a primary control tool because it encourages the youth to behave in a different way to change the negative situation. 10.4. Which of the following is not a focus of treatment according to the Skills-and-Thoughts (SAT) theory? A. Identifying negative thought patterns and learning to change them.

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B. Improving self-soothing skills. C. Using the therapeutic relationship as a model for outside relationships. D. Increasing participation in pleasurable or rewarding activities. Answer: C. Choices A, B, and D all describe components of the SAT theory, which focuses on improving negative cognitions as well as behavior patterns. Choice C describes the interpersonal therapy approach. 10.5. When working with a 17-year-old adolescent boy, the therapist notices that he appears bored when presented with the information. Which of the following developmental adaptations may be most useful for this situation? A. Leave out the ACT (i.e., Activities, Calm and Confident, Talents) skills when conducting treatment in order to focus more on the complex skill of cognitive challenging. B. Focus on making the sessions collaborative and fun by learning about the teen’s interests and linking skills with the teen’s illness narrative. C. Increase parent participation in the teen’s sessions to ensure that he participates actively. D. Do not make any adaptations, as this would decrease the overall efficacy of the treatment. Answer: B. When working with teens, it is especially important to create a collaborative relationship and to link the skills presented with the reported concerns in the illness narrative. Making these adaptations will likely strengthen the efficacy of the treatment. Because teens are often seeking independence, increasing parental participation in individual sessions would likely not increase the therapist’s rapport with the teen. It is important for therapists to present both ACT and THINK (i.e., Think positive, Help from a friend, Identify the silver lining, No replaying bad thoughts, Keep trying—don’t give up) skills to patients of all ages with whom they are working; these are the key components of the treatment.


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Chapter 11: Obesity and Depression 11.1. Which is not typically a psychological correlate of adolescent obesity? A. B. C. D.

Low self-esteem. Compromised body image. Depression. Obsessive-compulsive traits.

Answer: D. 11.2. Why is polycystic ovary syndrome an appropriate physical illness for a CBT approach? A. CBT helps adolescents restructure their psychosomatic complaints. B. CBT assists adolescents in better understanding why they are obese. C. CBT can target both the obesity and depression that these adolescents may experience. D. CBT can activate adolescents to exercise more frequently. Answer: C. 11.3. Which comorbid condition may CBT assist in the treatment of adolescents with obesity and depression? A. B. C. D.

Obsessive-compulsive disorder. Posttraumatic stress disorder. Eating disorder not otherwise specified. Alcohol dependence.

Answer: C. 11.4. Which of the following is not a key strategy used during motivational interviewing as a complementary approach to CBT? A. B. C. D.

Open-ended questions. Nondirective empathy. Affirmations. Reflective listening.

Answer: B.

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11.5. An 8-year-old boy comes into the clinic with a body mass index percentile of 99.9. He complains that his family has a lot of highfat, high-calorie food in the home. Both parents are obese, and they question why they should have to change their habits for their child. Which of the following CBT techniques is most logical to employ with this child and his family? A. B. C. D.

Behavioral activation. Self-monitoring. Stimulus control. Cognitive restructuring.

Answer: C.

Chapter 12: Disruptive Behavior Disorders 12.1. A 10-year-old boy with a history of aggressive, disruptive behavior at home and at school is referred for psychological treatment. The most effective treatment for his referral problems is which of the following? A. Parent training alone. B. Cognitive-behavioral interventions with the child alone. C. Cognitive-behavioral interventions with parent and child components. D. Relationship therapy with the child. Answer: C. 12.2. David is a 10-year-old boy who attends individual therapy to address his diagnosis of oppositional defiant disorder. When his therapist asks about his feelings, his responses are limited to “happy” and “mad.” In seeking to broaden his recognition of various feeling states, his therapist should work on helping him recognize which of the following? A. B. C. D.

Physiological sensations. Behaviors. Cognitions. All of the above.

Answer: D.


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12.3. Amanda, age 11, has been referred for therapy because of her frequent angry outbursts. When she is calm, she can articulate appropriate responses to problems such as peer teasing, but she tends to act out aggressively when confronted with real-life problems. Which of the following areas should Amanda’s therapist focus on first? A. B. C. D.

Social problem-solving. Perspective taking. Anger management strategies. Identifying consequences for aggressive behaviors.

Answer: C. 12.4. In one of the clinical vignettes in this chapter, 15-year-old Tim assumes that his teacher “has it out for him” when she puts his name on the board for getting out of his seat to sharpen his pencil. Tim’s CBT-oriented clinician seeks to help him see the situation from his teacher’s perspective to modify his initial A. B. C. D.

Intermittent explosive disorder. Hostile attribution bias. Reactive attachment. Relational aggression.

Answer: B. 12.5. In another clinical vignette in this chapter, Naomi has sought mental health services to reduce her daughter Anna’s disruptive behavior. The family’s CBT-oriented clinician has asked Naomi to praise Anna’s prosocial behaviors (such as following directions and helping out around the house) and to ignore minor disruptive behavior (such as whining or not cleaning out the sink thoroughly). The clinician is likely trying to help Naomi use which of the following? A. B. C. D.

Behavioral rules and expectations. Mood management. Discipline. Contingency management.

Answer: D.

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Chapter 13: Enuresis and Encopresis Enuresis 13.1. Which of the following statements best characterizes enuresis? A. It is a benign condition. B. It is a psychopathological condition. C. It is a psychopathological condition medically but not psychologically. D. It is a psychopathological condition psychologically but not medically. Answer: A. 13.2. Regarding physician involvement in the initial assessment of enuresis, which of the following is most accurate? A. Because enuresis is a psychological condition, there is no need to involve a physician. B. Because enuresis is a medical condition, physicians are solely responsible for assessment and diagnosis. C. Involvement of the physician is best left to the psychologist’s discretion. D. All cases of enuresis should be referred to a physician for an initial evaluation so that potential medical causes can be detected and treated or ruled out. Answer: D. 13.3. Which of the following does not have strong evidence supporting its role as a cause of enuresis? A. B. C. D.

Family history. Reduced functional bladder capacity. Difficulty arousing from sleep. Psychopathology.

Answer: D. 13.4. Which of the following is true of drug-based treatment for nocturnal enuresis? A. Drugs are highly effective as treatment for enuresis and should always be considered as primary treatment.


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B. Drugs are highly ineffective for treatment of enuresis and should never be considered in a treatment plan. C. Both drugs and biobehavioral treatment methods are effective as primary treatment for enuresis, and the therapist should choose between them. D. Because of unhealthy side effects and temporary results, drugs should be considered only as adjuncts to treatment. Answer: D. 13.5. Which of the following treatments for diurnal enuresis has the most empirical support? A. B. C. D.

Scheduled toilet visits. Retention-control training. Alarm-based treatment. Fluid restriction.

Answer: C.

Encopresis 13.6. Compared to enuresis, the prevalence rate for encopresis is A. B. C. D.

Lower. Higher. About the same. Not available for the general population.

Answer: A. 13.7. Which of the following factors is not known to contribute to the development of encopresis? A. B. C. D.

Fiber intake. History of painful bowel movements. Volitional stool-holding. Sodium intake.

Answer: D. 13.8. From a treatment standpoint, the research suggests that which treatment modality is most efficacious when treating encopresis? A. Medical treatment only. B. Behavioral treatment only.

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C. Collaborative medical and behavioral treatment. D. Dietary modifications, with consultation by a psychologist. Answer: C. 13.9. Regarding physician involvement in the management of encopresis, which of the following is most accurate? A. All cases of encopresis should be referred to a primary care physician to rule out potential medical causes. B. All cases of encopresis should be referred to a pediatric gastroenterologist. C. Psychologists should decide, at their discretion, whether involvement by a physician is needed. D. Because there is a strong behavioral component to encopresis, further involvement by a physician is not needed. Answer: A. 13.10. Which of the following best characterizes encopresis? A. It is a condition that has many contributing factors, including medical, behavioral, and nutritional. B. Encopresis is primarily a medical condition. C. Encopresis is primarily a behavioral disorder. D. The contributing factors for encopresis are not well known. Answer: A. 13.11. Which of the following is true about the role of biofeedback treatment for encopresis? A. It has demonstrated superior long-term effects over traditional medical interventions. B. Biofeedback does not increase treatment rates above those achieved with conventional treatment alone. C. There is no support for the use of biofeedback, and it should generally be avoided. D. Biofeedback has been shown to be a critical and essential treatment component, especially when combined with medical and behavioral interventions. Answer: B.

Index Page numbers printed in boldface type refer to tables or figures. ABC Chart, 450 ABCs of trauma impact, 268–270 A-B-C-D-E sequence, 4–5, 99–100 Abstract reasoning, 43, 66 Acceptance, and peer relationships, 48 Acceptance and commitment therapy, 25 Acculturation, and cultural issues, 87– 89 ACT (acronym) chronic physical illness and, 337– 338, 346, 353–354, 355, 357, 359, 369, 382 obesity and, 402 Active stance, of therapist in CBT, 14– 15 Activities, and chronic physical illness, 347–348, 380. See also Exercise; Physical activity ADAPT (Adolescent Depression Antidepressants and Psychotherapy Trial), 164 Adaptation, and cultural issues in CBT trials, 79 ADDRESSING model, for assessment, 93 ADHD. See Attention deficit/ hyperactivity disorder Adherence, to treatment for enuresis, 479. See also Compliance Adherence talk, and motivational interviewing, 400

ADIS (Anxiety Disorders Interview for Children), 304, 305 ADIS-C/P (Anxiety Disorders Interview Schedule for DSMIV—Parent and Child Versions), 230 Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT), 164 Adolescents and adolescence. See also Age behavioral plan and chronic physical illness in, 381–382 Coping Cat Program for anxiety disorders in, 252 cultural identity and, 84 developmental adaptations of CBT for PTSD in, 277–278 developmental characteristics and efficacy of CBT for, 32, 33 obesity and prevalence of anxiety, 387 prevalence of depression, 409 Adolescent Swinburne University Emotional Intelligence Test (A-SUEIT), 64 Aerobic exercise, 406 Affect, and PTSD, 268, 273. See also Emotion(s); Mood Affirmations, and motivational interviewing, 399–400

535

536


African Americans anxiety disorders and, 249 combined therapy and, 137 cultural issues and, 85, 86–87, 89, 96, 98, 101, 103, 106, 107 peer rejection and disruptive behavior disorders in, 441 Age. See also Adolescents and adolescence; Preschool children adaptation of CBT for children and, 33–34 behavioral rigidity in OCD and, 307 challenges to treatment of enuresis and, 479 desensitization strategy and, 34 diagnosis of encopresis and, 482 efficacy of CBT as function of, 30 of therapist, 141 use of term development and, 32 Agenda, and organization of CBT sessions, 12, 166 Aggression bipolar disorder and, 218 disruptive behavior disorders and, 437, 438, 441, 442–443 American Academy of Child and Adolescent Psychiatry, 301 American College of Sports Medicine, 391 American Psychological Association, 76, 301 American With Disabilities Act, and Section 504, 379 Analogies, and cognitive development, 43, 66 Anger management, and disruptive behavior disorders, 446–447 Annie E. Casey Foundation, 279 Antecedent control, and disruptive behavior disorders, 450–451 Antidepressants, and suicidal behavior or ideation, 122. See also Selective serotonin reuptake inhibitors; Tricyclic antidepressants Anti-Semitism, 86

Antisocial behavior, and disruptive behavior disorders, 441 Anxiety, and childhood obesity, 386– 388 Anxiety disorders approaches in CBT for, 229 assessment of, 229–230, 250 combined therapy for, 125–126, 130, 131, 133, 156–160 Coping Cat Program and, 230–256 cultural issues in, 249–251 efficacy of CBT for, 228–229 pediatric psychopharmacology and, 122–123 potential obstacles to treatment of, 251–255 prevalence of, 227 psychopathology in parents and, 255 treatment planning and, 229–231 Anxiety Disorders Interview for Children (ADIS), 304, 305 Anxiety Disorders Interview Schedule for DSM-IV—Parent and Child Versions (ADIS-C/P), 230 Arab Americans, and cultural issues, 84, 89 Arousal, and disruptive behavior disorders, 442 Art of Self-Control program, 440 Asian Americans, and cultural issues, 105, 249 Assertiveness training, 69, 80, 105–106 Assessment. See also Case formulation; Diagnosis of anxiety disorders, 229–230, 250 cultural issues and, 91–95 developmental considerations in, 38–39, 44–45, 48–49, 52, 62– 64 of encopresis, 485–491 of enuresis, 476 of OCD, 303–307 of PTSD, 267–270 Asthma, 334. See also Chronic physical illness

Index

A-SUEIT (Adolescent Swinburne University Emotional Intelligence Test), 64 Atomoxetine, 123, 124 Attention deficit/hyperactivity disorder (ADHD) cognitive-behavior therapy formulation and, 9 combined therapy for, 126–127, 133, 161 comorbidity and, 133, 251 differential diagnosis of OCD and, 306 pharmacotherapy for, 123–124 Autism, 306 Automatic thoughts, 17, 35, 169–170 Avoidance, and PTSD, 266, 271 Barriers, to treatment. See also Logistical concerns anxiety disorders and, 251–255 cultural issues and, 97 PTSD and, 278–279 BAT-C (Behavioral Assertiveness Test for Children), 63 Beck, A.T., 3–4, 5, 17, 353 Behavior. See also Aggression; Behavioral activation; Behavior therapy; Disruptive behavior disorder conceptualization of problems in terms of cognition and, 7–8 encopresis and, 488 inflammatory bowel disease and maladaptive, 340–341 mood symptoms of bipolar disorder and, 220 OCD and developmentally appropriate, 304–306, 307 PTSD and, 268 weight loss programs and, 391 Behavioral activation chronic physical illness and, 347– 348 cultural issues and, 102–103

537 depression and, 167, 172–173 obesity treatment and, 392 reinforcement principles and, 21 Behavioral Assertiveness Test for Children (BAT-C), 63 Behavioral learning, and theoretical models of OCD, 302. See also Learning theory Behavioral model, of depression, 166 Behavioral theory, of incontinence, 468 Behavior therapy for ADHD, 133 Coping Cat Program for anxiety disorders and, 231 cultural identity and, 107 for pediatric obesity, 388–390 BEI (Bryant’s Index of Empathy for Children and Adolescents), 63 Being Brave program, 252 Beliefs development and, 34 OCD and dysfunctional, 303 role of in CBT, 17–20 Bibliotherapy, 107 Biobehavioral view, of encopresis and enuresis, 468 Biodots, 348 Biofeedback, and encopresis, 483–484 Biological changes, in PTSD, 268– 269. See also Biobehavioral view; Neurobiology Bipolar disorder characteristics of CBT for, 193– 195 clinical applications of CBT for, 195–219 cultural issues in, 219 efficacy of CBT for, 185–193 refractory nature of pediatric, 185 special challenges to treatment of, 220–221 BLUE thoughts, 353–354, 370 BMI (body mass index), 385, 387, 390

538


Body image, and obesity, 386, 406– 407, 431 Body mass index (BMI), 385, 387, 390 Booster sessions, and obesity treatment, 409 Bossing-back strategies, and OCD, 319–320 Brainstorming approach to bipolar disorder, 212 to disruptive behavior disorders, 452 Bryant’s Index of Empathy for Children and Adolescents (BEI), 63 Bullying, and childhood obesity, 385 Bupropion, 124, 161 Calming techniques, and chronic physical illness, 348–349 Camp Cope-A-Lot, 231 CAMS (Child/Adolescent Anxiety Multimodal Study), 126, 130, 160 Cancer, 334. See also Chronic physical illness Candy dispensers, and encopresis, 494–495 Caregivers bipolar disorder and, 197 encopresis and, 493 CARS (acronym), and bipolar disorder, 208 CARS2 (Childhood Autism Rating Scale—High Functioning, 2nd Edition), 304, 305 Case conceptualization, and suicide prevention, 177 Case examples of bipolar disorder, 203–205, 212– 214 of chronic physical illness, 344– 345, 351–353, 354, 358 of combined therapy, 132, 134– 135, 136 of common principles of CBT, 6–16

of Coping Cat Program for anxiety disorders, 233–234, 235, 236– 237, 238, 239–240, 241, 242, 246–249, 252–253, 254–255 of cultural issues, 94, 99, 101–102, 103, 108 of depression, 173–175 of development, 31, 33 of disruptive behavior disorders, 453–459 of encopresis, 500–503 of enuresis, 470–481 of obesity, 400–401 of OCD, 105, 314–319 of PTSD, 264–265, 279–287, 287– 294 of suicidal ideation, 177–179 Case formulation, and chronic physical illness, 343–345 C.A.T. Project, 138, 252 Causal reasoning, 43 CBCL (Child Behavior Checklist), 49, 230, 488 CBITS (Cognitive-Behavioral Intervention for Trauma in Schools), 264, 278, 287–294 CBT. See Cognitive-behavioral therapy CBT-SP (cognitive-behavioral therapy for suicide prevention), 176 CDI (Children’s Depression Inventory), 304, 305, 395, 396 Centers for Disease Control and Prevention, 383 CFF-CBT (child- and family-focused cognitive-behavior therapy), 186, 190, 193 Chain analysis, and suicidal ideation, 176 Change talk, and motivational interviewing, 400 Child abuse, and incontinence, 467, 479. See also Sexual abuse Child/Adolescent Anxiety Multimodal Study (CAMS), 126, 130, 160

Index

Child Behavior Checklist (CBCL), 49, 230, 488 Child- and family-focused cognitivebehavior therapy (CFF-CBT), 186, 190, 193 Childhood Autism Rating Scale— High Functioning, 2nd Edition (CARS2), 304, 305 Child Obsessive-Compulsive Impact Scale—Revised (COIS-R), 304, 305 Children. See Adolescents and adolescence; Age; Child abuse; Chronic physical illness; Development; Encopresis; Enuresis; Obesity; Patients; Preschool children; specific disorders Children’s Depression Inventory (CDI), 304, 305, 395, 396 Children’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS), 304, 305 Choice, as theme in CBT for bipolar disorder, 209, 212 Chronic fatigue syndrome, 334 Chronic physical illness. See also Polycystic ovary syndrome; Primary and Secondary Control Enhancement Training for Physical Illness efficacy of CBT for, 332–333, 334–336 encopresis and, 486 guided imagery for pain management and, 375–377 inflammatory bowel disease as model illness in studies of CBT for, 338–358 information worksheets for parents and, 378–382 relationship between psychological and physical processes in, 331–332 Citalopram, 121, 123, 154

539 Cleanliness training, and enuresis, 473 Clinical applications, of CBT for bipolar disorder, 195–219 combined therapy and, 127–141 cultural issues and, 91–108 for depression, 166–175 for disruptive behavior disorders, 443–452 for obesity, 390–393 for OCD, 303–323 for PTSD, 270–278 Coaches, and obesity, 399 Cognition-based theoretical models, of OCD, 302–303 Cognition and cognitive skills. See also Cognitive restructuring; Metacognition anxiety disorders and, 252 conceptualization of problems in terms of behavior and, 7–8 developmental issues in, 34, 40– 44, 65–68 obesity and lifestyle changes, 392– 393 PTSD and, 266, 269 role of in treatment of enuresis, 468, 470 Cognitive Abilities Test, Form 6, 62 Cognitive-Behavioral Intervention for Trauma in Schools (CBITS), 264, 278, 287–294 Cognitive-behavioral therapy (CBT). See also Assessment; Behavioral therapy; Chronic physical illness; Clinical applications; Cognitive therapy; Combined therapy; Culture; Development; Efficacy; Obesity; Treatment planning; specific disorders common myths and misperceptions in, 22–24 common principles of, 6–16 evidence-based treatments and, 1–2 history of, 2–6

540


Cognitive-behavioral therapy (CBT) (continued) new challenges for, 24–25 role of beliefs in, 17–20 role of reinforcement principles in, 20–22 Cognitive-behavioral therapy for suicide prevention (CBT-SP), 176 Cognitive restructuring cultural issues and, 99–102, 103 depression and, 167, 169–170 obesity and, 393 treatment planning and, 66 Cognitive theory, of enuresis, 470 Cognitive therapy, and history of CBT, 3–4 Cognitive triad, 3 Cognitive triangle, 285 Cohesion building, and disruptive behavior disorders, 451–452 COIS-R (Child ObsessiveCompulsive Impact Scale— Revised), 304, 305 Collaboration, between therapist and patient common principles of CBT and, 10–12, 22 cultural issues and, 82–83 Collaborative empiricism, 19 Collectivism, as cultural issue, 80–81, 85, 98 Combinations Task (CT), 62 Combined therapy ADHD and, 126–127 anxiety disorders and, 125–126, 130, 131, 133, 156–160 clinical implications and application of, 127–141 depression and, 124–125, 130, 131, 133, 150–156 Communication bipolar disorder and, 215–217 chronic physical illness and, 359, 382

disruptive behavior disorders and, 451–452 Comorbidity, of psychiatric disorders anxiety disorders and, 251 bipolar disorder and, 220 combined therapy and, 133, 151, 152, 153, 156, 158, 159, 160, 161 Competence, and social skills, 46–48 Compliance. See also Adherence anxiety disorders and, 253–255 bipolar disorder and, 194–195 chronic physical illness and, 381– 382 combined therapy and, 138 culture and potential barriers to, 97 importance of in treatment of enuresis, 470 Concrete thinking, 43 Conditional Reasoning Task, 62 Conditional Syllogism Test, 62 Conduct disorder. See Disruptive behavior disorder Confidence, and chronic physical illness, 349–350 Conflict resolution bipolar disorder and, 197 treatment planning recommendations and, 71, 73 Constipation, and encopresis, 482, 485, 486–487, 504 Contamination, and themes in OCD, 309 Contextualism, and cultural issues, 79, 84, 90 Contextual social-cognitive model, for disruptive behavior disorders, 440–443 Contingency management, for OCD, 308 Contingency reinforcement encopresis and, 499 PTSD and, 272 Control, and chronic physical illness, 337

Index

Coping Cat, The (Kendall 1990), 33, 138 Coping Cat Program, for anxiety disorders, 230–256 Coping Power Program, for disruptive behavior disorders, 436, 437–438, 443–459 Coping skills chronic physical illness and, 337 coping tool kit for bipolar disorder, 208–209, 217 PTSD and, 273–274 Core beliefs, 17 Core clinical skills, in cognitivebehavior therapy manuals, 38, 39 Corrective approach, to treatment of encopresis, 497–498 Crohn’s disease, 338. See also Chronic physical illness CT (Combinations Task), 62 Culturally Informed Functional Assessment, 92 Culture. See also Popular culture anxiety disorders and, 249–251 bipolar disorder and, 219 clinical recommendations and, 91– 108 combined therapy and, 137–138 definition of, 75 developmental considerations and, 53, 83–85 disruptive behavior disorders and, 452–453 encopresis and, 498–499 enuresis and, 478 evidence-based treatment and, 76, 77–79 mental health disparities and, 76–77 OCD and, 323–324 pros and cons of CBT for children of diverse backgrounds, 79–83 PTSD and, 278 CY-BOCS (Children’s Yale-Brown Obsessive Compulsive Scale), 304, 305

541 DANVA2 (Diagnostic Analysis of Nonverbal Accuracy Scale—Form 2), 64 Day care, and encopresis, 493 DBD. See Disruptive behavior disorder DBT. See Dialectical behavior therapy DDAVP (Desmopressin), 474–475 Deafness, and aggression in residential settings, 438 Delinquent behavior, and disruptive behavior disorders, 437 Delis-Kaplan Executive Function System (DKEFS), 62 Depression. See also Major depressive episode chronic physical illness and, 359 clinical applications of CBT for, 166–175 combined therapy for, 124–125, 130, 131, 133, 150–156 efficacy of CBT for, 163–165 exercise and, 205 obesity and, 384–385, 386–388, 409 pediatric psychopharmacotherapy for, 120–122 Desipramine, 124 Desmopressin (DDAVP), 474–475 Development anxiety disorders and, 252 assessment and assessment tools, 38–39, 44–45, 48–49, 52, 62– 64 compliance issues in chronic physical illness and, 381 cultural issues and, 53, 83–85 diagnosis and treatment of encopresis and, 486 domains of, 40–45 emotions and, 50–52, 64, 72–73 future directions in, 53–54 impact of on efficacy of CBT, 29– 30 information needed to adapt CBT to stages of, 36–40

542


Development (continued) OCD and, 304–306, 307 PTSD and, 266, 275–276, 277–278 social skills and, 45–49, 63, 68–71 treatment of enuresis and level of, 479 treatment planning and considerations of, 30–36, 39– 40, 49, 52, 65–73 use of term age and, 32 Dextroamphetamine, 123, 161 Diabetes, 335–336 Diagnosis. See also Assessment; Case Formulation; Differential diagnosis of bipolar disorder, 195, 199–200 of encopresis, 482 of enuresis, 468–469 Diagnostic Analysis of Nonverbal Accuracy Scale—Form 2 (DANVA2), 64 Diagnostic and Statistical Manual of Mental Disorders (DSM), 108, 263, 264, 468, 482, 484 Dialectical behavior therapy (DBT) bipolar disorder and, 188, 191–192 newer forms of CBT and, 25 suicidal ideation and, 175 Diathesis-stress model, of CBT, 129, 165–166 Diet bipolar disorder and, 205, 206, 215 encopresis and, 487–488, 492 obesity and, 391, 393, 397–398, 403, 405–406, 426–427 Differential diagnosis, of OCD, 306 Directive nature, of CBT as cultural issue, 82 Discipline, and disruptive behavior disorders, 451 Discontinuation syndrome, 121 Discovery-oriented research, 109 Disruptive behavior disorder (DBD) clinical applications of CBT for, 443–452

conceptual framework for, 440–443 Coping Power Program for, 436, 437–438, 443–459 cultural issues in, 452–453 efficacy of CBT for, 436–440 DKEFS (Delis-Kaplan Executive Function System), 62 Dot-to-dot drawing, and reward systems, 474 Downward arrow technique, 18 Dry-bed training, and enuresis, 475 DSM. See Diagnostic and Statistical Manual of Mental Disorders Dysthymic disorder, 152, 155 Duration of treatment anxiety disorders and, 230 depression and, 166 developmental considerations and, 53 PTSD and, 277 time-limited structure of CBT and, 12–13 Eating environment, and weight loss, 397–398 EBT. See Evidence-based treatment Ecological approach, to anxiety disorders, 250 Education. See also Psychoeducation common principles of CBT and, 11 cultural issues in CBT and, 81 encopresis and, 492–493 inflammatory bowel disease and, 341 Efficacy, of CBT anxiety disorders and, 228–229 bipolar disorder and, 185–193 chronic physical illness and, 332– 333, 334–335 depression and, 163–165 disruptive behavior disorders and, 436–440 effectiveness as focus of research on CBT and, 24–25 encopresis and, 483–484

Index

impact of development on, 29–30 OCD and, 300–301 psychosocial aspects of obesity and, 388–389 suicidal ideation and, 175–176 Ego-dystonic character, of OCD obsessions, 306 Ellis, A., 4, 5, 17 Emotion(s). See also Affect; Expressed emotion; Feelings thermometer; Mood concepts of emotional competence and emotional intelligence, 50, 51 depression and regulation of, 167, 170–172 development and, 50–52, 64, 72– 73 disruptive behavior disorders and awareness of, 446 encopresis and, 488 obesity and, 404–405 PTSD and numbing of, 266 Emotional Quotient Inventory: Youth Version (EQ-i:YV), 64 Empathy, and treatment planning recommendations, 70, 399 Encopresis assessment and treatment of, 485– 491, 500–501 challenges to treatment of, 499–500 cultural issues and, 498–499 diagnosis of, 482 efficacy of CBT for, 483–484, 503 prevalence of, 482–483 theoretical perspectives on, 484– 485 treatment planning for, 491–498, 502 Enhancing engagement, and evidencebased treatment, 79 Enuresis challenges to treatment of, 479 components of treatment for, 470– 475

543 cultural issues in studies of, 478 diagnosis of, 468–469 prevalence of, 469 theoretical perspectives on, 469– 470 urine alarms and, 469, 470–471, 477, 481–482 EQ-i:YV (Emotional Quotient Inventory: Youth Version), 64 E/RP (exposure and response prevention), and OCD, 301, 302, 304, 307–308, 316, 317, 319– 323. See also Exposure therapy Escitalopram, 121 Ethnicity. See also Culture; Race combined therapy and, 137 experience of oppression and, 82, 86–87 mental health disparities and, 76– 77 treatment engagement and, 270 Evidence-based treatment (EBT) CBT protocols and, 1–2 cultural issues in, 76, 77–79 Executive functions, and development, 53 Exercise. See also Physical activity bipolar disorder and, 205, 206, 215 chronic physical illness and, 347– 348 encopresis and, 487–488, 492 obesity and, 391, 406 Expectations, and behavior rules in disruptive behavior disorders, 451 Experiences, and regulation of emotions, 52 Exposure therapy. See also E/RP Coping Cat Program for anxiety disorders and, 233, 243–245, 246, 253–255 cultural issues and, 104–105 PTSD and, 271–272, 293 Expressed emotion, and bipolar disorder, 193–194

544


Expression, and regulation of emotions, 52 Externalization, and OCD, 312–313 Extinction, and reinforcement, 20 Eysenck, H.J., 3 Family. See also Family history; Family therapy; Parents; Siblings bipolar disorder and negative cycles in, 209, 220–221 chronic physical illness and, 341– 343, 356–358, 359 combined therapy and, 138 cultural issues and, 80, 88–89, 92– 93, 98 disruptive behavior disorders and, 441 obesity and, 392, 395, 396–398 OCD and, 313–314, 320–322 success or failure of treatment for bipolar disorder and, 193 Family-focused treatment for adolescents with bipolar disorder (FFT-A), 187, 190–191, 193 Family history, of enuresis, 470. See also Genetics Family therapy, and depression, 167 FDA (U.S. Food and Drug Administration), 121, 122, 475 FEAR plan, and Coping Cat Program, 233, 236, 238–241, 242, 246– 248, 252 Fears, and OCD, 306–307 Feelings thermometer, 35, 167, 168, 171, 197, 235, 246, 288, 291– 292, 314–316, 320–321, 372, 403, 424, 446 FFT-A. See Family-focused treatment for adolescents with bipolar disorder Fluid restriction, and enuresis, 474 Fluoxetine, 121, 122, 124, 150, 154 Fluvoxamine, 122, 123 Food cravings, and diet, 404–405 Friendship Quality Questionnaire, 63

Friendships, importance of, 48. See also Peer relationships Full-spectrum home training, and enuresis, 475 GAD. See Generalized anxiety disorder Gastrointestinal system, and encopresis, 492 Gay, lesbian, bisexual, and transsexual (GLBT) youth behavioral interaction and, 103 cognitive restructuring and, 100– 101 exposure therapy and, 105 social oppression and, 86 Gender culture and roles of, 93, 102–103 encopresis and, 482, 498 enuresis and, 478 Generalized anxiety disorder (GAD), 160, 228, 243–245 Generation of Alternatives Task, 62 Genetics. See also Family history bipolar disorder and, 199 OCD and, 310 Geography, and clinical decisionmaking, 139 Germany, and KidNET for refugees, 278 Get-acquainted exercise, and treatment for obesity, 402 GLBT. See Gay, lesbian, bisexual, and transsexual youth Goals and goal-setting behavioral facets of obesity and, 391 bipolar disorder and, 198 disruptive behavior disorders and, 445 focus of CBT on specific, clearly defined, 10 Go Girls program, 390 Gradual exposure, and PTSD, 271– 272

Index Graduation ceremony, and termination of treatment, 219 Group therapy for disruptive behavior disorders, 444 for PTSD, 276, 287–294 Guanfacine, 123 Guided discovery, 18 Guided imagery, for pain management, 375–377 Guidelines, for healthy diet, 391 Haloperidol, 161 Harm, and themes in OCD, 309 HBHM. See Healthy Bodies, Healthy Minds Health care. See Chronic physical illness; Mental health care system; Physical examination Health insurance, and combined therapy, 139, 141 Healthy Bodies, Healthy Minds (HBHM), 385, 393–409, 395, 397, 420–433 Healthy Lifestyles Pilot Study, 390 Healthy routines, and bipolar disorder, 205–206, 215 HEAR ME (acronym), 171 Hispanic Americans. See Latino/ Latina Homeschooling, and chronic physical illness, 381 Homework. See also STIC tasks; Workbooks bipolar disorder and, 196 Coping Cat Program for anxiety disorders and, 231, 232 disruptive behavior disorders and, 449 obesity and, 392 Hospitalization, and bipolar disorder, 218 How I Ran OCD Off My Land (March and Mulle 1998), 33 Hyperandrogenism, 384

545 Hypnotic scripts, 348 Hypomania, use of term, 199–200 Hyponatremia, 475 Hypothesis testing, 109, 211 Hypothetical reasoning, 43, 66 ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision), 482 Identification, of thoughts and beliefs, 17–19 Identity, and cultural issues, 84, 86– 87, 106–108 IEP (Individualized Education Program), 207 IF-PEP (individual-family version of PEP), 193, 195–196 Imaginal exposure, 321 Imaginary audience, 47 Imipramine, 156, 161, 474 Immigration, and cultural issues, 87– 89 Incontinence, and child abuse, 467, 479. See also Encopresis; Enuresis Incredible Years program, 438–439 Individual-family version of PEP (IF-PEP), 193, 195–196 Individualism, and cultural issues, 80, 85 Individualized Education Program (IEP), 207 Induction, and guided imagery for pain management, 375–376 Inflammatory bowel disease, 335, 338–358, 371. See also Chronic physical illness Insomnia, and combined therapy, 132 Insulin resistance, and polycystic ovary syndrome, 385 Intermediate beliefs, 17 International Statistical Classification of Diseases and Related Health Problems, 10th Revision (ICD-10), 482

546


Interpersonal conflict, and social skills, 48, 71 Interpersonal and social rhythm therapy for adolescents with bipolar disorder (IPSRT-A), 188, 192 Interpersonal Understanding Interview, 63 Introductory sessions bipolar disorder and, 198 Coping Cat Program for anxiety disorders and, 234 Coping Power Program for disruptive behavior disorders and, 444–445 In vivo mastery, of trauma reminders, 275 IPSRT-A (interpersonal and social rhythm therapy for adolescents with bipolar disorder), 188, 192 Joint expertise, and therapist/patient collaboration in CBT, 10–12 Jones, M.C., 2 K-SADS-P/L (Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version), 304, 305 Kegel exercises, and enuresis, 472 KidNET, 278 Language. See also Analogies; Metaphors cultural issues and, 81, 97 description of traumatic events and, 271 development and, 53, 72 Latino/Latina, and cultural issues, 84– 85, 89, 96, 98, 100, 102, 103, 106, 249, 278 Laxatives, and encopresis, 482, 484, 497. See also Miralax Lazarus, A.A., 2

Learned helplessness, and chronic physical illness, 333 Learning, of maladaptive behaviors and cognitions, 8–10 Learning theory, and history of CBT, 2. See also Behavioral learning; Social learning theory Legal status, of immigrants and refugees, 88, 90 Life Skills Training Program, 440 Literacy, and cultural issues, 90 Logistical concerns. See also Barriers combined therapy and, 138–139 optimal model of CBT for PTSD and, 276–277 London, P., 2 Loss of essence, and themes in OCD, 309 Maintenance sessions chronic physical illness and, 355– 356, 374 obesity and, 409 Major depressive episode, and bipolar disorder, 200, 217 Mania management of symptoms, 217 sleep patterns and, 205, 206 use of term, 199–200 MASC (Multidimensional Anxiety Scale for Children), 230, 304, 305 Mastery model, of coping, 232 Matson Evaluation of Social Skills with Youngsters, 63 Mayer-Salovey-Caruso Emotional Intelligence Test, 52, 64 MCQ-A (Metacognitions Questionnaire for Adolescents), 62 MCQ-C (Metacognitions Questionnaire for Children), 62 Means-end thinking, 43 Medication. See also Psychopharmacology

Index

for chronic physical illness, 341 for enuresis, 474 Meditative traditions, and new approaches in CBT, 25 Megacolon, and encopresis, 486 Meichenbaum, Donald, 5–6 Mental health care system, and bipolar disorder, 206, 214–215. See also Comorbidity; Hospitalization; Logistical concerns; specific disorders Metacognition cognitive development and, 41, 44, 67 definition of, 17 Metacognitions Questionnaire for Adolescents (MCQ-A), 62 Metacognitions Questionnaire for Children (MCQ-C), 62 Metaphors cognitive development and, 66 OCD and, 308–310 Methylphenidate, 123, 161 MF-PEP (multifamily format of PEP), 192–193, 195 Minor disruptive behaviors, 450 Miralax, 486, 497. See also Laxatives Mirtazapine, 121 Modafinil, 124 Monitoring, of enuresis, 476. See also Mood monitoring; Self-monitoring Mood. See also Emotion(s); Mood monitoring bipolar disorder and, 196–197, 200, 220–221 relationship between weight and, 387 Mood charting, and bipolar disorder, 200 Mood disorders, and combined therapy, 133 Mood-medication log, and bipolar disorder, 202

547 Mood monitoring chronic physical illness and, 345– 346 depression and, 167, 168 obesity and, 402, 423 Motivation, and treatment planning for enuresis, 477–478, 479 Motivational interviewing, and obesity, 389–390, 394, 398–400, 403 MST (multisystemic therapy), 440 MTA. See Multimodal Treatment Study of Children With ADHD Multidimensional Anxiety Scale for Children (MASC), 230, 304, 305 Multidimensional Ecosystemic Comparative Approach (Falicov 1998), 92 Multifamily format of PEP (MF-PEP), 192–193, 195 Multimodal Treatment Study of Children With ADHD (MTA), 123, 126–127, 133, 161 Multisystemic therapy (MST), for disruptive behavior disorders, 440 Music, and relaxation exercises, 348– 349 Naming the Enemy, and bipolar disorder, 201 Narratives chronic physical illness and, 339– 340, 371 PTSD and descriptions of trauma, 274 National Heart, Lung, and Blood Institute, 391 National Institutes of Health, 384 National Registry of Effective Programs, 342 Native Americans, and cultural issues, 80, 81, 89, 278 Nefazodone, 121

548


Negative reinforcement, 20, 398 Netherlands Coping Power Program for disruptive behavior disorders and, 437 study of age and encopresis in, 482–483 Neurobiology, and bipolar disorder, 199. See also Biological changes “New Wave,” and recent treatment approaches in CBT, 25 “No fault” disorder, bipolar disorder as, 198 Nonspecific therapy elements, 22 Nonverbal communication, and bipolar disorder, 215–216 Norway, and trial of CBT for OCD, 301 Number, of sessions bipolar disorder and, 197 developmental considerations and, 53 time-limited structure of CBT and, 13 Nutrition labels, 405, 427 Obesity behavioral therapy for, 388–390 depression and, 384–385, 386– 388, 409 Healthy Bodies, Healthy Minds intervention for, 385, 393– 409 key CBT techniques for, 390– 393 polycystic ovary syndrome and, 384–385 prevalence of, 383 psychological correlates of in childhood, 384, 385–388 Obesity Society, The, 391 Obsessive Compulsive Cognitions Working Group, 303 Obsessive-compulsive disorder (OCD) assessment of, 303–307

clinical applications of CBT for, 303–323 combined therapy for, 126, 157, 158 cultural issues in, 323–324 efficacy of CBT for, 300–301 pharmacotherapy for, 123 prevalence of, 299 theoretical models of, 302–303 OCD. See Obsessive-compulsive disorder ODD. See Oppositional defiant disorder Open-ended questions, and motivational interviewing, 398, 399. See also Socratic questioning Operant conditioning, and PTSD, 266 Opposite action, and emotion regulation, 172 Oppositional defiant disorder (ODD), 133, 306, 488. See also Disruptive behavior disorder Oppression, ethnic minorities and experience of, 82, 86–87, 100, 102 Ordering/arranging, and themes in OCD, 309 Orientation, cultural issues in videotapes for, 97. See also Introductory sessions Outcome, and client-therapist relationship, 22–23. See also Efficacy Overcorrection, and encopresis, 497– 498 Overlearning, and enuresis, 473 Overprotectiveness, and parents of children with chronic physical illness, 379–380 Pain management, and guided imagery, 375–377 Pajama devices, and enuresis, 471, 477 Panic disorder, and psychopharmacology, 122–123

Index

Parents. See also Family Afrocentric model of training for, 87 bipolar disorder and, 196, 197, 198–199, 202–203, 206–207, 209–212, 214, 216, 217 chronic physical illness and, 357, 378–382 combined therapy and, 135–136, 138 Coping Cat Program for anxiety disorders and, 237, 242, 255 Coping Power Program for disruptive behavior disorders and, 448–452, 456–459 cultural issues in assessment and, 93 developmental level of child and involvement of in treatment, 33 encopresis and, 485–490 enuresis and, 471, 479 prevention of depression in children of parents with history of, 165 PTSD and, 272, 275 Paroxetine, 121, 122–123, 154 PASCET-PI. See Primary and Secondary Control Enhancement Training for Physical Illness Past, and focus on present in CBT, 8 PATHS (Promoting Alternative Thinking Strategies), 438 Patients collaboration with therapist in CBT, 10–12, 22 combined therapy and, 128–132 needs of as focus of CBT, 13–14 Pavlov, I.P., 2 PCOS. See Polycystic ovary syndrome PCOS Lifestyle Program, The, 401– 409 Pediatric OCD Study (POTS), 126, 157

549 Peer relationships achievement of social competence and, 47 disruptive behavior disorders and, 441, 448 PTSD and, 270 treatment planning recommendations and, 71 Pemoline, 161 PEP (psychoeducational psychotherapy), 188–189, 192, 193 Performance, of social skills, 49 Perspective taking, and social skills, 46–47, 68, 70, 447 Photo album, and Coping Cat Program, 252 Physical activity. See also Exercise encopresis and, 488 obesity and, 391, 394, 395, 406, 430 Physical cues, and encopresis, 493 Physical examination encopresis and, 485 enuresis and, 479 Piaget, J., 43 Planning, for continued success in obesity treatment, 408–409. See also Treatment planning Play, and Coping Power Program for disruptive behavior disorders, 445 Polycystic ovary syndrome (PCOS), 335, 384–385, 393–409. See also Chronic physical illness Popular culture, and societal factors in mental health care, 140 Positive reinforcement. See also Reinforcement principles encopresis and, 483–484 obesity and, 398 Posttraumatic stress disorder (PTSD) assessment of, 267–270 clinical applications of CBT for, 270–278

550


Posttraumatic stress disorder (PTSD) (continued) cognitive-behavioral theory of, 264–267 combined therapy for, 126, 159 cultural issues and, 278 obstacles to treatment of, 278–279 POTS (Pediatric OCD Study), 126, 157 Poverty. See also Socioeconomic status cultural issues and, 90 risk factors for disruptive behavior disorders and, 441 POWER steps program, 350–351 Preschool children, and developmental adaptations of CBT for PTSD, 277 Present focus, of CBT, 8, 81 Prevalence of anxiety disorders, 227 of anxiety in obese adolescents, 387 of depression in obese children and adolescents, 409 of encopresis, 482–483 of enuresis, 469 of obesity, 383 of OCD, 299 Prevention, of suicide, 176–179. See also E/RP; Relapse prevention Primary control, and chronic physical illness, 337 Primary and Secondary Control Enhancement Training for Physical Illness (PASCET-PI), 332, 333, 337–358, 347, 369– 374, 393, 394 Proactive approaches, to treatment of encopresis, 493–497 Problem solving bipolar disorder and, 211–212 chronic physical illness and, 346– 347, 350, 370, 373 cognitive development and treatment planning, 65, 69, 73

Coping Cat Program for anxiety disorders and, 240 cultural issues and, 103–104 depression and, 167, 169 disruptive behavior disorders and, 447–448, 451–452 obesity and, 392 Problem-Solving Skills Training Plus Parent Management Training (PSST+PMT), 439 Promoting Alternative Thinking Strategies (PATHS), 438 Prosocial behavior, and peer relationships, 47 PSST+PMT (Problem-Solving Skills Training Plus Parent Management Training), 439 Psychodynamic theory, and encopresis, 484 Psychoeducation. See also Education bipolar disorder and, 194, 198–199 chronic physical illness and, 342 combined therapy and, 129 Coping Cat Program for anxiety disorders and, 232–233 cultural issues in, 96–97 depression and, 167, 168 OCD and, 308–313, 317–319 PTSD and, 272–273 suicidal ideation and, 177 Psychoeducational psychotherapy (PEP), 188–189, 192, 193 Psychological correlates, of obesity, 384, 385–388 Psychological mindedness, and combined therapy, 129–130 Psychopharmacology. See also Combined therapy; Medication ADHD and, 123–124 anxiety disorders and, 122–123 bipolar disorder and, 185, 201–203 depression and, 120–122 PTSD. See Posttraumatic stress disorder

Index

Puerto Rico Coping Power Program for disruptive behavior disorders and, 438 cultural issues for mental health care in, 84 Punishment definition of reinforcement and, 20 disruptive behavior disorders and, 451 encopresis and, 490 enuresis and, 479 Puppets, and Coping Power Program for disruptive behavior disorders, 447 Race. See also African Americans; Culture; Ethnicity; Native Americans; Racism combined therapy and, 137 mental health disparities and, 76– 77 treatment engagement and, 270 Racism, and cultural identity, 82, 86– 87, 107. See also Oppression RAINBOW program, 186, 190. See also Child- and family-focused cognitive-behavior therapy Rational emotive therapy (RET), 3, 4– 5, 35–36 RCT (retention-control training), for enuresis, 471–472, 473, 478 Real world, implementation of CBT in, 15–16 Reappraisal, of thoughts or beliefs, 19–20 Reasoning, and cognitive development, 41, 43, 66, 67 Reasons for living, and suicide prevention, 177 Recurrent abdominal pain, 335 Refugees, and cultural issues, 88, 278 Regulation, of emotions, 51–52, 73, 167, 170–172

551 Reinforcement principles, role of in CBT, 20–22 Relapse and relapse prevention depression and, 167, 173 enuresis and potential for, 478 obesity and, 393 OCD and, 322–323 Relaxation techniques chronic physical illness and, 341, 348–349 Coping Cat Program for anxiety disorders and, 237–238, 252 cultural issues and, 103 depression and, 167 modification of for age levels, 34 obesity and, 392, 405 PTSD and, 273 Religion cultural issues and, 83, 89, 94, 101–102, 251, 481 OCD and, 105, 323–324 stress management with bipolar disorder and, 218 treatment engagement and, 270 Resilience, and negative influences of racism and discrimination, 86 Resistance encopresis and, 489–490 motivational interviewing for obesity and, 400 Resistance exercise, 406 Responsibility training, and enuresis, 477 Restaurants, and calorie charts, 398 RET (rational emotive therapy), 3, 4– 5, 35–36 Retention-control training (RCT), for enuresis, 471–472, 473, 478 Rewards. See also Positive reinforcement; Token economy Coping Cat Program for anxiety disorders, 240–241, 248 Coping Power Program for disruptive behavior disorders and, 445

552


Rewards (continued) encopresis and systems of, 490, 494–496 enuresis and systems of, 472, 473– 474, 477 Risk factors for disruptive behavior disorders, 441 for suicide, 176 Role-playing, and disruptive behavior disorders, 447, 449–450 Ross Test of Higher Cognitive Processes, 62 Rules, and behavior expectations in disruptive behavior disorders, 451 Safety PTSD and enhancement of, 275– 276 suicide prevention and planning for, 176–177 SAT (Skills-and-Thoughts depression model), 333, 337 Schedule for Affective Disorders and Schizophrenia for School-Age Children—Present and Lifetime Version (K-SADS-P/L), 304, 305 Scheduling, and encopresis, 493–494. See also Waking schedule Schemas, and cognitive diathesisstress model, 165 Schizophrenia, 151 Schools and school systems bipolar disorder and, 206–207, 214–215 chronic physical illness and, 378– 381 disruptive behavior disorders and, 449 encopresis and, 493 PTSD and, 269, 276 refusal to attend, 14, 156 Scrupulosity, and themes in OCD, 309, 323–324

Seattle Social Development Project (SSDP), 439 Secondary control, and chronic physical illness, 337 Section 504, of Americans With Disabilities Act, 207, 379 Selective attention, and PTSD, 272 Selective serotonin reuptake inhibitors (SSRIs), and depression 120, 121, 122, 125, 151, 153 Self-awareness, and obesity, 407–408, 432 Self-control, and social skills, 47 Self-disclosure, and cultural issues, 96 Self-efficacy, and motivational interviewing, 400 Self-esteem, and obesity, 386 Self-instructional training (SIT), 5–6 Self-monitoring, and obesity, 391, 395, 403–404, 429. See also Monitoring; Mood monitoring Self-reflection, and cognitive development, 41, 44, 67, 68, 70 Self-Reflection and Insight Scale for Youth, 62 Self-talk, and Coping Cat Program, 238–240 Sertraline anxiety disorders and, 122, 123, 126, 157, 158, 159, 160 depression and, 121, 125, 152 SES. See Socioeconomic status Sexual abuse, and PTSD, 159, 278 Sexual behavior, and cultural issues, 85 Shaping approach, to treatment of encopresis, 499 Show That I Can (STIC) tasks, 231, 232, 234–235, 253–255 Siblings, and bipolar disorder, 197, 218–219 SIT (self-instructional training), 5–6 Skills-and-Thoughts (SAT) depression model, 333, 337 Skinner, B.F., 2

Index

Sleep, and bipolar disorder, 205, 206, 215. See also Insomnia; Waking schedule Social anxiety disorder, 160, 228, 243–245 Social cognition, and disruptive behavior disorders, 442–443 Social information processing theory, and disruptive behavior disorders, 442 Socialization, and cultural issues, 84, 86–87, 107 Social learning theory, and disruptive behavior disorders, 450 Social phobia, 133, 160, 228, 243– 245 Social Problem-Solving Inventory— Revised (SPSI-R), 63 Social rejection childhood obesity and, 385 disruptive behavior disorders and, 441–442 Social skills. See also Conflict resolution; Peer relationships chronic physical illness and, 341, 350 definition of, 45 depression and, 167, 173 development and, 45–49, 63, 68– 71 disruptive behavior disorders and, 447–448 Social Skills Rating System (SSRS), 63 Social support networks, and GLBT youth, 103 Socioeconomic status (SES) assessment and, 92, 93 combined therapy and, 137 enuresis and, 478 immigrant populations and, 90 treatment engagement and, 270 Socratic questioning, 11–12, 34. See also Open-ended questions Solution-focused approach, to bipolar disorder, 198, 199

553 Somatic symptoms anxiety disorders and, 235–237, 249 cultural issues and, 89–90, 103 Special time, of parents with child, 450 Spirituality, and cultural issues, 80, 83, 89. See also Religion SPSI-R (Social Problem-Solving Inventory—Revised), 63 SSDP (Seattle Social Development Project), 439 SSRIs. See Selective serotonin reuptake inhibitors SSRS (Social Skills Rating System), 63 STEPS problem-solving skills, 356, 357, 370 STIC (Show That I Can) tasks, 231, 232, 234–235, 253–255 Stigma, and combined therapy, 139– 140 Stimulant medication, for ADHD, 123–124 Stimulus control, and obesity, 392, 395 Stool assessment chart, 487 Stream-interruption exercises, and enuresis, 472, 478 Stress and stress management bipolar disorder and, 194, 218 chronic physical illness and family de-stressing game, 357–358 disruptive behavior disorders and, 441, 449–450 Stretching, and exercise, 406 Sticker charts, and rewards, 495 Study skills, and disruptive behavior disorders, 445–446 Substance abuse, and disruptive behavior disorders, 437 Subtypes, of encopresis, 482 Suicide and suicidal ideation bipolar disorder and, 200, 217–218 black box warning on antidepressants and, 122, 124 CBT for, 175–179 combined therapy and, 155

554


“Supervision of supervisors” model, of CBT for OCD, 301 Symptoms bipolar disorder and management of, 217–218, 220–221 combined therapy and severity of, 130–131 and type of, 131–132 culture and expression or presentation of, 89–90, 249 misperceptions of CBT and, 23– 24 Symptom substitution, 23–24 Systematic desensitization, 34 System factors, and combined therapy, 135–140 TADS. See Treatment for Adolescents with Depression Study Talents, chronic physical illness and development of, 350–351 TASA (Treatment of Adolescent Suicide Attempters), 128, 155– 156, 176 Task analysis, and treatment of encopresis, 491 TCAs. See Tricyclic antidepressants Teacher Report Form (TRF), 230 Teamwork, and therapist/patient collaboration in CBT, 11 Teasing, and childhood obesity, 385, 386 TEIQue-AF (Trait Emotional Intelligence Questionnaire— Adolescent Form), 64 TEIQue-CF (Trait Emotional Intelligence Questionnaire— Child Form), 64 Termination, of treatment bipolar disorder and, 219 Coping Cat Program for anxiety disorders and, 248 Testosterone, 385 TF-CBT. See Trauma-focused cognitive-behavioral therapy

TFD (Thinking-Feeling-Doing), and bipolar disorder, 209–211 Therapeutic relationship cultural issues in, 96 importance of in CBT, 22–23 Therapists active stance of in CBT, 14–15 collaboration with patient in CBT, 10–12, 22 combined therapy and, 140–141 culture and self-assessment of, 91 misperceptions about CBT and creativity and flexibility of, 24 Thermometer. See Feelings thermometer THINK (acronym) chronic physical illness and, 337– 338, 346, 353–354, 355, 357, 359, 369, 382 obesity and, 402 Thinking-Feeling-Doing (TFD), and bipolar disorder, 209–211 Think Task, 62 Third wave, of CBT, 25 Thought forecasting, 35 Thought record, 170, 171 Thoughts and thinking chronic physical illness and, 353 cognitive development and monitoring of, 66 Coping Cat Program for anxiety disorders and, 239 identification of, 17–19 reappraisal of, 19–20 Tic disorders, 306 Time. See Duration; Past; Present Time-outs, and encopresis, 499 Toilet training, and encopresis, 484, 485, 488–489, 491 Token economy, and disruptive behavior disorders, 444. See also Rewards TORDIA. See Treatment of SSRIResistant Depression in Adolescents

Index

Tourette’s syndrome, 123–124 Traffic Light Diet, 393, 394, 395, 403, 405–406 Trait Emotional Intelligence Questionnaire—Adolescent Form (TEIQue-AF), 64 Trait Emotional Intelligence Questionnaire—Child Form (TEIQue-CF), 64 Trance, and guided imagery for pain management, 376–377 Trauma. See also Posttraumatic stress disorder cultural issues and, 100 language and description of events, 271 narratives of, 274 reminders of, 265–266, 275 Trauma-focused cognitive-behavioral therapy (TF-CBT), 126, 264, 277, 278, 279–287 Treatment. See Barriers; Behavior therapy; Cognitive-behavioral therapy; Combined therapy; Compliance; Efficacy; Outcome; Psychopharmacology; Termination; Treatment engagement; Treatment planning Treatment for Adolescents with Depression Study (TADS), 98, 122, 124, 128, 130, 150, 164, 175–176 Treatment of Adolescent Suicide Attempters (TASA), 128, 155– 156, 176 Treatment engagement cultural issues in, 95–97 PTSD and, 270–271 Treatment modality, and developmental considerations, 53 Treatment planning. See also Planning adaptation of CBT for developmental stages, 32–36, 39–40, 49, 52, 65–73 anxiety disorders and, 229–231

555 encopresis and, 491–498 enuresis and, 475–478 Treatment of SSRI-Resistant Depression in Adolescents (TORDIA), 125, 128, 154, 164– 165, 179 TRF (Teacher Report Form), 230 Tricyclic antidepressants (TCAs), 121. See also Imipramine Triggers, and bipolar disorder, 208 UCLA PTSD Reaction Index for DSM-IV, 267 Ulcerative colitis, 338 United Kingdom, and study of age and encopresis, 483 Urine alarms, for enuresis, 469, 470– 471, 477, 481–482 U.S. Census Bureau, 76 U.S. Food and Drug Administration (FDA), 121, 122, 475 Values, and cultural issues, 80, 88–89 Venlafaxine, 122, 125, 154 Videotapes chronic physical illness and, 349 for orientation, 97 Visual imagery, 348 Waking schedule, and enuresis, 472– 473, 477 Watson, J. B., 2 Wechsler Intelligence Scale for Children, 4th Edition (WISC-IV), 45 Weight gain, and pharmacotherapy for bipolar disorder, 205. See also Obesity Weight tracker, 402, 422 WISC-IV (Wechsler Intelligence Scale for Children, 4th Edition), 45 Wolpe, J., 2 Workbooks. See also Homework chronic physical illness and, 343 Coping Cat Program and, 231

556


Working hypothesis, 7, 15 Worksheets, and obesity, 402, 403, 405, 407, 408, 420–433 Wrapped rewards, 495 Yale Global Tic Severity Scale (YGTSS), 304, 305 Yates, A. J., 2

YGTSS (Yale Global Tic Severity Scale), 304, 305 Zambia, and TF-CBT for HIVaffected sexually abused children, 278 Zone of proximal development, 31, 40

Cognitive-Behavior Therapy for Children and Adolescents

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