APPROACHES TO TREATMENT

Cognitivebehavioural therapy for children and adolescents

Thomas G OConnor Cathy Creswell

Examples of key cognitions associated with childhood psychopathology

Characteristics of clinically anxious children3 Vigilant to threat Interpret ambiguity as more threatening Come to faster conclusions about threat Underestimate personal coping ability Anticipate distress (often exaggerated) in the face of threat Characteristics of clinically aggressive children4 Attend to less social cues Direct attention towards hostile social cues Interpret stimuli in a hostile manner Generate fewer solutions to social problems Positively appraise aggressive responses Positively appraise own ability to perform aggressive response Characteristics of children with low mood5 Selectively attend to negative features of events Report negative attributions, i.e. internal, stable explanations for positive events and external, unstable explanations for negative events 1

Cognitivebehavioural therapy (CBT) is a treatment approach based on the general notion that a psychological disorder is caused or maintained by dysfunctional thought patterns and lack of positively reinforced adaptive behavioural coping strategies. CBT is a class of treatment; all cognitivebehavioural treatments aim to identify and reduce cognitive biases or distortions and build effective coping and problem-solving skills. After decades of extensive research on CBT in adult populations1 and expanding the treatment beyond depression and anxiety disorders,2 CBT is now being applied to child and adolescent populations, and with good success.

Basic premises of the CBT approach

The basic CBT model hardly differs when applied to adults or to children and adolescents. That is, the disorder is conceptualized as resulting, at least in part, from the individuals cognitive distortions (such as false attributions or expectations of the self or other) that then undermine positive coping and problem-solving behaviour. Research over the past decade or so has shown robust differences in how depressed, anxious, and conduct-problem youth construct events and anticipate outcomes (Figure 1).35 These studies also show how cognitive distortions or biases may be evoked. Clinical and developmental research outlines processes by which distorted cognitions influence and underlie behavioural/ emotional problems. An example is the social information processing model.4 Although developed in the context of conduct disorder, this model generalizes to other childhood disorders, including depression and anxiety. The model focuses on the following: the childs attending to, encoding, and interpreting social cues (e.g. why did that child step on my foot?) developing goals for ones own behaviour (e.g. what do I want to do now?)

generating potential solutions and evaluating their effects (e.g. what would happen if I hit back at him?). Interventions based on this model target each step in that process, seeking to break the cascade of maladaptive thoughts and feelings that lie between the initial misattribution and the destructive behaviour. Developmental considerations We now know that depressed, anxious, or conduct problem-related cognitions are evident at an early age. In an elegant study of 5-yearolds, Murray and colleagues found that higher rates of negative cognitions, defined as spontaneous expressions of hopelessness or low self-worth during an experimentally manipulated card game with a friend, were observed in children whose mothers were, or had been, depressed.6 Significantly, differences between the children of depressed and non-depressed mothers were apparent only when the children were losing. Evidence that cognitive distortions do not operate in a trait-like manner, even in 5-year-olds, is an important clinical and developmental lesson. Other studies also suggest that early emerging cognitive biases may be learned from parentchild interactions. For example, one report indicated that 3-year-olds with an insecure (non-optimal) attachment relationship were more likely than securely attached children to recall negative emotions in a recall test paradigm, a method that is comparable to what is used in adult studies.7 Problems in social cognitions may be found not only in selective attention and recall, but also in basic understanding of emotions and how they influence feelings and behaviour. Thus, a study of 26-year-olds found that insecurely attached children showed poorer understanding of negative emotions compared to securely attached children; that is, they had more difficulty explaining or

Thomas G OConnor is Associate Professor of Psychology and Psychiatry and Director of the Laboratory for Mental Disorders at the University of Rochester Medical Center, NY, USA. His research interests include attachment, genetics, family process and the mechanisms by which early experiences may have long-term impact on human development. Cathy Creswell is a Clinical Psychologist and Research Fellow at the University of Reading, UK. She graduated from Oxford University and trained in Clinical Psychology at University College London, where she also obtained a PhD in the development of anxious cognitions in children. Her primary research interests are the development and treatment of childhood anxiety disorders.

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Sample responses to ambiguous scenarios

You arrange to have a party at 4pm and by 4.30 no one has arrived Cognitive bias What do you think is most likely to have happened? Anxious: Nobody wants to come to the party Aggressive: Nobody wants to come to the party Non-clinical controls: They might be late because there is bad traffic Behaviour What will you do about it? Anxious: Nothing Aggressive: Get cross and when I see them at school I will tell them I dont want to be friends with them Non-clinical controls: Phone around and see where they are and when they will arrive You are playing inside and your dog starts barking and growling outside. Cognitive bias What do you think is most likely to have happened? Anxious: There is someone I dont know trying to get into my house Aggressive: Someone is stealing my bike from outside Non-clinical controls: Another dog is walking past outside Behaviour What will you do about it? Anxious: Hide! Aggressive: Find the thief and hit them! Non-clinical controls: Look out of the window and tell my dog to be quiet
Adapted from Barrett P M, Rapee P M, Dadds M R, Ryan S M. Family enhancement of cognitive style in anxious and aggressive children. J Abnorm Child Psychol 1996; 24: 187203.

making sense of negative emotions.8 Detecting distortions or biases in expectations, attributions, and other cognitive processes at an early age does not mean that these processes cause the disturbance, or even that they derive from wholly environmental factors. On the other hand, they do illustrate the richness of young childrens mental states and may suggest strategies for clinical assessment and treatment monitoring (Figure 2). Surprisingly, we lack strong evidence that the childs developmental stage predicts treatment outcome in CBT. This may be because the predictors so far considered (e.g. age) are weak indicators of the cognitive and social processes that are required for successful CBT. It is interesting to note that the theory and implementation of CBT has not been especially developmentally informed. So, for example, the traditional CBT model is not explicit about why the approach might work with a 12-year-old but not with a 5-year-old. Further developmentalclinical investigation of this type may yield important insights into development and psychopathology.

The programmes have several features in common, and progress through these stages in a logical, stepped manner, usually lasting 1216 weeks (Figure 3). First, detailed information is collected about the settings that lead to the child feeling anxious and incompetent in dealing with a situation. At this early stage, and throughout, emphasis is placed on developing rapport with the child/adolescent. CBT programmes value rapport, but unlike psychoanalytically oriented approaches, do not construct the treatment as working through the relationship with the therapist (e.g. involving transference). Instead, the CBT therapist guides the child/adolescent to reshape attributions and expectations in order to change behaviour. A second step is to help the child/adolescent to identify and differentiate feelings and somatic reactions. This is followed by the clear articulation of anxious cognitions in anxiety-provoking situations and the development of a hierarchy of these situations. This leads to the focus on self-talk, helping the child to recognize how certain kinds of self-talk can be destructive (Ill look silly) and promoting positive self-talk (I have done this OK before). Relaxation is often included to improve the childs coping strategies and expand his/her coping repertoire. The next stage is to help the child evaluate newly developed coping skills in real-life settings, and reward where appropriate. This last stage can continue for several sessions, as the child learns to test new strategies and, through trial and error, to find strategies that work and to diagnose why other strategies do not. Homework throughout the treatment process fosters understanding of why feelings of anxiety or depression develop and how they might be managed effectively. Family-based treatment models the above model is oriented to the individual child/adolescent, although inevitably there is some degree of contact with parents to explain the treatment approach and engage the parents in reinforcing the message of treatment. Treatment models that require family or at least the parents involvement in the treatment have also been developed. These programmes carry all the CBT messages as above, but also focus on the parents or parents own anxiety and how that may influence the child. These approaches build on and address the finding that parental anxiety has been found to be a significant predictor of treatment failure of individual treatment of the child, through such processes as modelling poor coping, communicating expectations to the child that she/he cannot cope with effectively, and parenting in an overprotective manner. Other variations have been tried with some success, including group-based approaches and treatments in alternative settings, but the empirical support for individual and family CBT for anxiety

Core steps in CBT for childhood anxiety

Recognize feelings and physical reactions Identify associated thoughts (e.g. interpretations, attributions and expectations) Cognitive restructuring/coping self-talk Progressive muscle relaxation Imaginary/in vivo (graded) exposure Self-evaluation and reward 3

Model CBT programmes for children and adolescents

Anxiety: several model programmes exist for treating child anxiety that have a proven track record and a manualized programme.
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have received by far the most attention. We briefly review some of the key findings in the next section.

Empirical findings
Several research groups have demonstrated that CBT is an effective treatment for depression and anxiety in children from around 8 years of age. Several short-term treatment studies have been reported, but there are also data showing that these gains persist. Kendall and Southam-Gerow found that individual CBT was effective in treating children/adolescents with anxiety disorders, and that approximately 90% were diagnosis-free more than 3 years after treatment ended.9 Barrett and colleagues reported that 42 out of 49 participants who had been diagnosed with an anxiety disorder were diagnosisfree 57 years after receiving individual CBT, also indicating that the benefits of treatment persist long after treatment ends.10 In that study, no additional long-term benefit was found for those who received individual plus family treatment. In the above studies a wait-list design was used, with the consequence that no long-term follow-up data are available for the non-treated individuals. Nevertheless, the continuity of anxiety disorders is known to be high, so a drop of the magnitude reported in the above studies is clinically highly significant. To date, much of the research shows efficacy, that is, the treatment works under relatively controlled conditions concerning, for example, who is included. Several years of work in this area have shown that efficacy trials yield consistently stronger treatment effects than trials conducted under typical non-controlled outpatient conditions. This means that it is not known whether the remarkable success rates noted above generalize to a typical child and adolescent mental health service setting. Nevertheless, the consistency of the findings from these trials certainly supports the use of CBT and should encourage services to offer this treatment modality. It is apparent that CBT has made it in to the child/adolescent treatment literature because it is now being set alongside drug treatments. In a large-scale study (n=439) of depressed 1217-year-olds, those receiving fluoxetine plus CBT showed the strongest treatment benefits, with those receiving monotherapy falling between the combined and placebo conditions.11 The sideeffect profile is also of note when making clinical decisions, so it is significant that the number of psychiatric adverse events was substantially greater in the groups receiving fluoxetine (20 out of 109 patients receiving fluoxetine only). Outcome was available only immediately after treatment. Therefore, further work is needed to show if, as in other studies, a key benefit of CBT (especially compared with drug treatment) is that the treatment effects persist long after treatment ends. To date, the child/adolescent treatment literature lacks the headto-head comparisons of CBT with other psychological treatments, such as interpersonal therapy, that we have with adults.1 Given that other treatments have been shown to be effective (especially for depression), perhaps this is a ripe area for further research.

consequential reductions in psychiatric symptoms. Results from many clinical trials have shown that CBT reliably improves child outcomes, and the list of targeted disorders is increasing. These findings are important for telling us how to improve the psychological wellbeing of children and how to understand the complex, developing mental life of young people.

REFERENCES 1 Elkin I, Gibbons R D, Shea M T et al. Initial severity and differential treatment outcome in the National Institute of Mental Health Treatment of Depression Collaborative Research Program. J Consult Clin Psychol 1995; 63: 8417. 2 Tarrier N, Kinney C, McCarthy E, Humphreys L, Wittkowski A, Morris J. Two-year follow-up of cognitive-behavioral therapy and supportive counselling in the treatment of persistent symptoms in chronic schizophrenia. J Consult Clin Psychol 2000; 68: 91722. 3 Muris P, Merckelbach H, Damsma E. Threat perception bias in nonreferred, socially anxious children. J Clin Child Psychol 2000; 29: 34859. 4 Crick N, Dodge K A. A review and reformulation of social information processing mechanisms in childrens social adjustment. Psychol Bull 1994; 115: 74101. 5 Abela J R Z, Brozina K, Haigh E P. An examination of the response styles theory of depression in third- and seventh-grade children: A short-term longitudinal study. J Abnormal Child Psychol 2002; 30: 51527. 6 Murray L, Woolgar M, Cooper P, Hipwell A. Cognitive vulnerability to depression in 5-year-old children of depressed mothers. J Child Psychol Psychiatry 2001; 42: 8919. 7 Belsky J, Spritz B, Crnic K. Infant attachment security and affectivecognitive information processing at age 3. Psychol Sci 1996; 7: 11114. 8 Laible D J, Thompson R A. Attachment and emotional understanding in preschool children. Dev Psychol 1998; 34: 103845. 9 Kendall P C, Southam-Gerow M A. Long-term follow-up of a cognitivebehavioral therapy for anxiety-disordered youth. J Consult Clin Psychol 1996; 64: 72430. 10 Barrett P M, Duffy A L, Dadds M R, Rapee R M. Cognitive-behavioral treatment of anxiety disorders in children: long-term (6-year) followup. J Consult Clin Psychol 2001; 69: 13541. 11 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 2004; 292: 80720. FURTHER READING OConnor T G, Creswell C. Cognitive behavioural therapy (CBT) in developmental perspective. In Graham P, ed. Cognitive-behaviour therapy for children and families. 2nd ed. Cambridge, UK: Cambridge University Press, 2005. Shortt A L, Barrett P M, Fox T L. Evaluating the FRIENDS program: a cognitive-behavioral group treatment for anxious children and their parents. J Clin Child Psychol 2001; 30: 52535.

Conclusion
Childrens cognitions about their social world reflect developmental histories that shape behaviour. CBT is concerned with how these cognitive processes may be altered and, when altered, if there are
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