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

3

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

11

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

12

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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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

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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

Contributors

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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

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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

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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.

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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

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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

Cognitive-Behavior Therapy: An Introduction

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

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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.

Developmental Considerations Across Childhood

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

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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

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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

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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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Bierman KL, Torres MM, Schofield HL: Developmental factors related to the assessment of social skills, in Practitioner’s Guide to Empirically Based Measures of Social Skills (ABCT Clinical Assessment Series). Edited by Nangle DW. New York, Springer, 2010, pp 119–134 Bornstein MR, Bellack AS, Hersen M: Social-skills training for unassertive children: a multiple-baseline analysis. J Appl Behav Anal 10:183–195, 1977 Bryant BK: An index of empathy for children and adolescents. Child Dev 53:413– 425, 1982 Cartwright-Hatton S, Mather A, Illingworth V, et al: Development and preliminary validation of the Meta-Cognitions Questionnaire—Adolescent Version. J Anxiety Disord 18:411–422, 2004 Chorpita BF: Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders. New York, Guilford, 2007 Christophersen ER, Mortweet SL: Treatments That Work With Children: Empirically Supported Strategies for Managing Childhood Problems. Washington, DC, American Psychological Association, 2002 Ciarrochi J, Chan AY, Bajgar J: Measuring emotional intelligence in adolescents. Pers Individ Dif 31:1105–1119, 2001 Ciarrochi J, Heaven PC, Supavadeeprasit S: The link between emotion identification skills and socio-emotional functioning in early adolescence: a 1-year longitudinal study. J Adolesc 31:565–582, 2008 Crosnoe R, Needham B: Holism, contextual variability, and the study of friendships in adolescent development. Child Dev 75:264–279, 2004 Delis DC, Kaplan E, Kramer JH: The Delis-Kaplan Executive Function System. San Antonio, TX, The Psychological Corporation, 2001 Doherr L, Reynolds S, Wetherly J, et al: Young children’s ability to engage in cognitive therapy tasks: associations with age and educational experience. Behav Cogn Psychother 33:201–215, 2005 Donaldson SK, Westerman MA: Development of children’s understanding of ambivalence and causal theories of emotions. Dev Psychol 22:655–662, 1986 Durlak JA, Furhman T, Lampman C: Effectiveness of cognitive-behavior therapy for maladapting children: a meta-analysis. Psychol Bull 110:204–214, 1991 D’Zurilla TJ, Nezu AM, Maydeu-Olivares A: Social problem solving: theory and assessment, in Social Problem Solving: Theory, Research, and Training. Edited by Chang EC, D’Zurilla TJ, Sanna LJ. Washington, DC, American Psychological Association, 2004, pp 11–27 Eisenberg N, Morris AS, McDaniel B, et al: Moral cognitions and prosocial responding in adolescence, in Handbook of Adolescent Psychology, Vol 4: Individual Bases of Adolescent Development, 3rd Edition. Edited by Lerner RM, Steinberg L. Hoboken, NJ, Wiley, 2009, pp 229–265 Elfers T, Martin J, Sokol B: Perspective taking: a review of research and theory extending Selman’s developmental model of perspective taking. Adv Psychol Res 54:229–262, 2008 Eyberg SM, Schuhmann EM, Rey J: Child and adolescent psychotherapy research: developmental issues. J Abnorm Child Psychol 26:71–82, 1998 Fireman GD, Kose G: Perspective taking, in A Clinician’s Guide to Normal Cognitive Development in Childhood. Edited by Sandberg EH, Spritz BL. New York, Routledge/Taylor & Francis, 2010, pp 85–100

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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

Emotion perception, emotion understanding, emotion management

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

Emotion perception, emotion understanding, emotion management

Mayer-Salovey-Caruso Emotional Intelligence Test: Youth Version

Mayer et al. 2002

12–18 years

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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

Developmental skills

66

APPENDIX 2–B.

Clinical recommendations

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-Behavior Therapy for Children and Adolescents

Cognitive development (continued)

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

Therapeutic demands

Developmental skills

Clinical recommendations

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: Recommendations for Treatment Planning

APPENDIX 2–B.

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

Therapeutic demands

Developmental skills

Clinical recommendations

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-Behavior Therapy for Children and Adolescents

Cognitive development (continued)

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

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

Therapeutic demands

Developmental skills

Clinical recommendations

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: Recommendations for Treatment Planning

APPENDIX 2–B.

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

Therapeutic demands

Clinical recommendations

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)

Cognitive-Behavior Therapy for Children and Adolescents

Developmental skills

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APPENDIX 2–B.

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

Therapeutic demands

Developmental skills

Clinical recommendations

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: Recommendations for Treatment Planning

APPENDIX 2–B.

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

Therapeutic demands

Clinical recommendations

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

Cognitive-Behavior Therapy for Children and Adolescents

Developmental skills

72

APPENDIX 2–B.

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

Therapeutic demands

Developmental skills

Clinical recommendations

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: Recommendations for Treatment Planning

APPENDIX 2–B.

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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

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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

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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

References Abudabbeh N, Hays PA: Cognitive-behavioral therapy with people of Arab heritage, in Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, and Supervision. Edited by Hays PA, Iwamasa GY. Washington, DC, American Psychological Association, 2006, pp 141–159 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC, American Psychiatric Association, 2000 Arredondo PT, Arciniega GM: Strategies and techniques for counselor training based on the multicultural counseling competencies. J Multicult Couns Devel 29:263–273, 2001 Arredondo PT, Toporek R, Brown SP, et al: Operationalization of the multicultural counseling competencies. J Multicult Couns Devel 24:42–78, 1996 Balsam KF, Martell CR, Safren SA: Affirmative cognitive-behavioral therapy with lesbian, gay, and bisexual people, in Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, and Supervision. Edited by Hays PA, Iwamasa GY. Washington, DC, American Psychological Association, 2006, pp 223–243 Bandura A: Self-efficacy mechanism in human agency. Am Psychol 37:122–147, 1982 Barona A, Santos de Barona M: Recommendations for the Psychological Treatment of Latino/Hispanic Populations. Washington, DC, Association of Black Psychologists, 2003 Bernal G, Sáez-Santiago E: Culturally centered psychosocial interventions. J Community Psychol 34:121–132, 2006 Bernal G, Scharrón-del-Río MR: Are empirically supported treatments valid for ethnic minorities? Toward an alternative approach for treatment research. Cultur Divers Ethnic Minor Psychol 7:328–342, 2001 Bernal G, Jiménez-Chafey MI, Domenech Rodríguez MM: Cultural adaptation of treatments: a resource for considering culture in evidence-based practice. Prof Psychol Res Pr 40:361–368, 2009 Carter MM, Sbrocco T, Lewis EL, et al: Parental bonding and anxiety: differences between African American and European American college students. J Anxiety Disord 15:555–569, 2001

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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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Labellarte MJ, Ginsburg GS, Walkup JT, et al: The treatment of anxiety disorders in children and adolescents. Biol Psychiatry 46:1567–1578, 1999 Lepola U, Leinonen E, Koponen H: Citalopram in the treatment of early-onset panic disorder and school phobia. Pharmacopsychiatry 29:30–32, 1996 March JS, Biederman J, Wolkow R, et al: Sertraline in children and adolescents with obsessive-compulsive disorder: a multicenter randomized controlled trial. JAMA 280:1752–1756, 1998 March J[S], 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 March JS, Entusah AR, Rynn M, et al: A randomized controlled trial of venlafaxine ER versus placebo in pediatric social anxiety disorder. Biol Psychiatry 62:1149–1154, 2007 Masi G, Toni C, Mucci M, et al: Paroxetine in child and adolescent outpatients with panic disorder. J Child Adolesc Psychopharmacol 11:151–157, 2001 Melvin GA, Tonge BJ, King NJ, et al: A comparison of cognitive-behavioral therapy, sertraline, and their combination for adolescent depression. J Am Acad Child Adolesc Psychiatry 45:1151–1161, 2006 Molina BS, Hinshaw SP, Swanson JM, et al: The MTA at 8 years: prospective follow-up of children treated for combined-type ADHD in a multisite study. J Am Acad Child Adolesc Psychiatry 48:484–500, 2009 Morley S: The stress-diathesis model of illness. J Psychosom Res 27:86–87, 1983 Moses T: Parents’ conceptualization of adolescents’ mental health problems: who adopts a psychiatric perspective and does it make a difference? Community Ment Health J 47:67–81, 2011 Mosholder AD, Gelperin K, Hammad TA, et al: Hallucinations and other psychotic symptoms associated with the use of attention-deficit/hyperactivity disorder drugs in children. Pediatrics 123:611–616, 2009 MTA Cooperative Group: A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. The MTA Cooperative Group. Multimodal Treatment Study of Children with ADHD. Arch Gen Psychiatry 56:1073–1086, 1999 Mukolo A, Heflinger CA, Wallston KA: The stigma of childhood mental disorders: a conceptual framework. J Am Acad Child Adolesc Psychiatry 49:92–103; quiz 198, 2010 Nemeroff R, Levitt JM, Faul L, et al: Establishing ongoing, early identification programs for mental health problems in our schools: a feasibility study. J Am Acad Child Adolesc Psychiatry 47:328–338, 2008 Newcorn JH, Schulz K, Harrison M, et al: Alpha 2 adrenergic agonists. Neurochemistry, efficacy, and clinical guidelines for use in children. Pediatr Clin North Am 45:1099–1122, viii, 1998 Pediatric OCD Treatment Study (POTS) Team: Cognitive-behavior therapy, sertraline, and their combination for children and adolescents with obsessivecompulsive disorder: the Pediatric OCD Treatment Study (POTS) randomized controlled trial. JAMA 292:1969–1976, 2004 Pliszka S: Practice parameter for the assessment and treatment of children and adolescents with attention-deficit/hyperactivity disorder. J Am Acad Child Adolesc Psychiatry 46:894–921, 2007

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Research Unit on Pediatric Psychopharmacology Anxiety Study Group: Fluvoxamine for the treatment of anxiety disorders in children and adolescents. N Engl J Med 344:1279–1285, 2001 Rossi A, Barraco A, Donda P: Fluoxetine: a review on evidence based medicine. Ann Gen Hosp Psychiatry 3:2, 2004 Ryan ND: Child and adolescent depression: short-term treatment effectiveness and long-term opportunities. Int J Methods Psychiatr Res 12:44–53, 2003 Ryan ND, Varma D: Child and adolescent mood disorders—experience with serotonin-based therapies. Biol Psychiatry 44:336–340, 1998 Rynn MA, Siqueland L, Rickels K: Placebo-controlled trial of sertraline in the treatment of children with generalized anxiety disorder. Am J Psychiatry 158:2008– 2014, 2001 Rynn MA, Riddle MA, Yeung PP, et al: Efficacy and safety of extended-release venlafaxine in the treatment of generalized anxiety disorder in children and adolescents: two placebo-controlled trials. Am J Psychiatry 164:290–300, 2007 Schenkel LS, West AE, Harral EM, et al: Parent-child interactions in pediatric bipolar disorder. J Clin Psychol 64:422–437, 2008 Simeon JG, Ferguson HB, Knott V, et al: Clinical, cognitive, and neurophysiological effects of alprazolam in children and adolescents with overanxious and avoidant disorders. J Am Acad Child Adolesc Psychiatry 31:29–33, 1992 Solanto MV: Neuropsychopharmacological mechanisms of stimulant drug action in attention-deficit hyperactivity disorder: a review and integration. Behav Brain Res 94:127–152, 1998 Sparks JA, Duncan BL: The ethics and science of medicating children. Ethical Hum Psychol Psychiatry 6:25–39, 2004 U.S. Food and Drug Administration: Medication guide: antidepressant medicines, depression and other serious mental illnesses, and suicidal thoughts or actions. 2007. Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/ ucm088660.pdf. Accessed April 19, 2011. Varley CK: Sudden death related to selected tricyclic antidepressants in children: epidemiology, mechanisms and clinical implications. Paediatr Drugs 3:613– 627, 2001 Vitiello B, Silva SG, Rohde P, et al: Suicidal events in the Treatment for Adolescents with Depression Study (TADS). J Clin Psychiatry 70:741–747, 2009 von Knorring AL, Olsson GI, Thomsen PH, et al: A randomized, double-blind, placebo-controlled study of citalopram in adolescents with major depressive disorder. J Clin Psychopharmacol 26:311–315, 2006 Wagner KD, Ambrosini P, Rynn M, et al: Efficacy of sertraline in the treatment of children and adolescents with major depressive disorder: two randomized controlled trials. JAMA 290:1033–1041, 2003 Wagner KD, Berard R, Stein MB, et al: A multicenter, randomized, double-blind, placebo-controlled trial of paroxetine in children and adolescents with social anxiety disorder. Arch Gen Psychiatry 61:1153–1162, 2004a Wagner KD, Robb AS, Findling RL, et al: A randomized, placebo-controlled trial of citalopram for the treatment of major depression in children and adolescents. Am J Psychiatry 161:1079–1083, 2004b Walkup JT, Albano AM, Piacentini J, et al: Cognitive-behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 359:2753–2766, 2008

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Westra HA, Dozois DJ, Marcus M: Expectancy, homework compliance, and initial change in cognitive-behavioral therapy for anxiety. J Consult Clin Psychol 75:363–373, 2007 Winters NC, Pumariga A: Practice parameter on child and adolescent mental health care in community systems of care. J Am Acad Child Adolesc Psychiatry 46:284–299, 2007

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)

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Comments, limitations, adverse events

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.

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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

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Comments, limitations, adverse events

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

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Comments, limitations, adverse events

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)

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Comments, limitations, adverse events

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

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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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Primary and secondary outcome results

Comments, limitations, adverse events

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 (Pintensive 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: 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: Combination Treatment

APPENDIX 4–A

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

Cognitive-Behavior Therapy for Children and Adolescents

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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5

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

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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

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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.

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

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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Weisz JR, McCarty CA, Valeri SM: Effects of psychotherapy for depression in children and adolescents: a meta-analysis. Psychol Bull 132:132–149, 2006 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 Wood A, Harrington R, Moore A: Controlled trial of a brief cognitive-behavioural intervention in adolescent youths with depressive disorders. J Child Psychol Psychiatry 37:737–746, 1996 Wood A, Trainor G, Rothwell J, et al: Randomized trial of group therapy for repeated deliberate self-harm in adolescents. J Am Acad Child Adolesc Psychiatry 40:1246–1253, 2001

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

Open trial, no control

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

Open trial, no control

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

Cognitive-Behavior Therapy for Children and Adolescents

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

186

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

Intervention

Study design

Citation(s)

Significant findings

Null findings

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

Open trial, no control

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)

187

Intervention

Study design

Citation(s)

Significant findings

Null findings

Open trial, no control

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

Open trial, no control

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

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

188

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

Intervention

Study design

Citation(s)

Significant findings

Null findings

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

Randomized controlled trial

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

Randomized controlled trial

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

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

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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Yo u

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FIGURE 7–1.

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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

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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

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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

Cognitive-Behavior Therapy for Children and Adolescents

Props needed

Description of exposure

Examples of exposure tasks (continued)

Description of exposure

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

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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