Transcript Cognitive Behavioral Therapy (CBT) for children

Cognitive Behavioral
Therapy (CBT) for children
Carolyn R. Fallahi, Ph. D.
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CBT proven effective for adults
• CBT effective for:
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Depression
Generalized anxiety disorder
Social phobia
Obsessive compulsive disorder
Substance abuse & dependence
Agoraphobia
Panic disorder
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Can we use this treatment for
children?
• Theory: we can apply the principles of CBT to
children with developmental modifications.
• Why?
– Children make systematic errors in thinking
(cognitive distortions).
– Children have skill deficits that maintain the
problem.
– Theory behind CBT: person’s thinking influences
his/her mood & thus, modifications to thinking will
result in changes in mood & behavior (Beck).
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Example: Separation Anxiety
Disorder
• Main clinical features of SAD.
• The anxiety must be beyond what is expected
developmentally*.
• Prevalence of SAD = 4% in children & young
adolescents.
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Conceptualization
• SAD
– Phobic avoidance (e.g. child
tries to avoid separation from
parents)
– Catastrophic interpretations
(e.g. I will not be able to handle
it).
– Panic symptoms (e.g.
autonomic arousal,
palpitations, perspiration,
hyperventilation, shaking, fear).
• Panic Disorder with
Agoraphobia
– Phobic avoidance
– Catastrophic interpretations
– Panic symptoms
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The Process for SAD
Makes catastrophic
Interpretations about
Being separated from
Parents
This activates child’s
ANS = anxiety.
Reinforcement of
Catastrophic Interpretations.
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Treatment of Panic Disorder with
Agoraphobia versus SAD
• Panic Disorder
– Explanation of the nature
of anxiety & panic
– Anxiety-management
strategies, e.g. Barlow’s
work.
– Barlow’s prescriptive
treatment – integration of
a spouse or partner in
exposure-based treatment.
• SAD
– Historically, focus on
medication,
psychodynamic therapy,
family therapy, or
behavior interventions.
– Might the approach we
take with PD with
agoraphobia be helpful
for children?
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Theoretical Reasoning
• If we only focus on behavioral therapy, then we
are tied to environmental contingencies.
• This does not take care of the cognitive
distortions also seen in children.
• What about working with the parents? We need
a model.
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Case History
• 6-year-old boy, 1st grade.
• History of panic attacks in relation to SAD.
• Symptomotology includes:
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Clinging
1 panic attack / day, at least
“really scared”
ANS symptoms: shake, weak legs, sweat, cry,
scream.
– Worries: parents will die; I might get kidnapped.
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Applying CBT to this case
• Phase I: Psychoeducation for the parents &
patient about the nature of anxiety & the model
for CBT.
• Phase II: Development of CBT coping
strategies.
• Phase III. Graded exposures & family work.
• Phase IV. Booster Session.
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Phase I
• Psychoeducation
– Parents informed of treatments
– Child told stories to help him understand the
treatment, e.g. the purpose of exposure.
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Phase II
• Developing the skills to cope with exposure.
– Patient not forced to do anything doesn’t feel ready for.
– Graded exposures, e.g. choose an exposure where the child
has a high chance of succeeding, e.g. parents standing outside
of the office door for progressively longer periods. Patient
earns chips for initiating & completing exposures.
– Contingency management, e.g. chip system, plastic poker
chips turned in for prizes or treats.
– Distraction techniques
– Coping self-statements, e.g. “I can be brave”; “I can do this”;
“My parents will not leave me”; “I am not in danger”
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Phase III
• Usually by the 3rd session, we can begin Phase
III.
– Develop a stimulus hierarchy, starting with
exposures that provoked little anxiety, e.g. parents
sitting in a nearby office.
– Increase exposures that create strong feelings of
anxiety, e.g. parents taking a walk outside the office
building.
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Phase III
• Distraction strategies taught.
– Counting game, A-B-C game.
– Counting game: counting backward from 10, stating
“blast off ” & taking a deep breath.
– A-B-C game: generate words that begin with A, B,
& C. Repeat the chain with new words.
– Exposures paired with pleasurable activities, e.g.
playing with blocks or toy cars.
– Patient states positive self-coping statements before
each exposure.
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Phase III
• Patient questioned before each exposure about
his fear or threat prediction.
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After each session, he was asked:
What happened?
How accurate was your prediction?
What did this experience teach you?
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Family Work
• Parents = co-therapists.
– Homework assignments that occur in patient’s
home.
– Sessions are 20-25 minutes per night at home.
– This important = increases likelihood of
generalizability & allows the patient to practice in the
settings where panic occurs (state-dependent
learning).
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Family Work
• Assess for problems with parents
– Overprotectiveness
– Excessive reassurance
– Aversive parent-child interactions, e.g. belief that the
child should just “pull himself up by his bootstraps.”
This negative set could lead to yelling or teasing
which increases anxiety in the child.
– Education for parents on behavioral principles, e.g.
positive reinforcement, shaping.
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Phase IV
• Booster session: review strategies & attribute
the child’s success to his use of coping
strategies.
– This increases sense of self-efficacy (patient’s
capability to produce an effect).
– Scheduled 4 weeks after last session.
– Issues of relapse addressed.
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