WELCOME TO CBT ESSENTIALS FOR
CHILDREN & ADOLESCENTS!!
LECTURE 4
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Check in
Comments/questions from last week?
 Quiz 3
 Homework take up
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Cognitive Behavioural Interventions Within the
Family
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Influences of the family on the individual
Optimal levels of parental involvement
Dysfunctional Family Roles
Family Functions
Case examples of programs that work
HOMEWORK - CASE STUDY
Brian is described as having externalizing behaviours
during transition times at school (beginning of the day,
nutrition and lunch breaks, end of the day). These
behaviours include: not following the steps of getting
ready (back pack and coat where supposed to be, proper
shoes on, inside voice); yelling and shoving peers at
times, and not listening to school staff. What behaviour
modification strategies can you plan using the following
techniques? Shaping, chaining, token reinforcement,
replacement behaviour training, differential
reinforcement of alternative or incompatible behaviour,
self reinforcement. What would your plans look like?
COGNITIVE BEHAVIOURAL INTERVENTIONS
WITHIN THE FAMILY – WHY?
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Psychological disorders run in families (Beck 1999) and
environmental factors appear to have a major role in the development
of mental health disorders (Gregory & Ely 2007).
Strong associations are found between parental mental health,
parental behaviours and child and adolescent emotional and
behavioural problems (Connell & Goodman 2002)
THERE ARE PROBLEMS WITH ENGAGEMENT AND
THESE CAN BE ATTRIBUTED PARTIALLY TO FAMILY
FACTORS
Approximately 50% of all adolescents and their
families who receive mental health services
disengage prematurely (Nock et al., 2005)
 Of adolescents seen in an emergency room 5077% are non adherent to outpatient treatment
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(Groholt et al 2009)
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25-50% of adolescents presenting for emergency
are are likely not to attend any follow up sessions
(Granboulan et al 2001; Taylor & Stansfield 1984)
POOR ENGAGEMENT WITH ADOLESCENTS
CORRELATES TO:
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Older age (Piacentini et al 1995)
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Male gender (Piacentini et al 1995)
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Belonging to an ethnic minority (Goldston et al 2003, Wilder et al 1977)
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Low socioeconomic status (Armbruster et al 1994, Goldston et al 2003, Wilder et al 1997)
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Parental low socioeconomic status (Brookeman-Frazee et al 2008)
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Poor insurance coverage (Armbruster et al 1994)
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High stress (Kazdin & Mazurick 1994)
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Low expectations for treatment outcome (Castro-Blanco & Karver 2010)
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If parents have low expectations for adolescent change
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If parents have low confidence in their ability to effect change
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If Parents perceive treatment to be low relevance to adolescent
presenting problem or think the problem is too demanding (Kazdin &
Mazurick 1994, Staudt 2007)
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Adolescents feeling incompetent in session (if too much psychoed or too
intellectual could lose the client) – Oetzel & Scherer 2003)
PARENTS INFLUENCE CHILDREN’S
COGNITIONS AND BEHAVIOURS
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Parents influence the development of maladaptive
cognitive styles such as threat interpretation,
attributional style, and dysfunctional attitudes (Creswell
2005, Alloy 2001, Gifford 2008, Halligan 2008)
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Parents significantly influence development of anxiety
and conduct problems which is thought to happen by
parent’s expectations regarding their children’s
behaviour and parents subsequent behaviours (Alloy
2001).
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With anxiety parental beliefs about threat and
vulnerability in a dangerous world lead to parenting
behaviours that promote development of anxiety in the
child (Rubin 2001).
PARENTS INFLUENCE DEVELOPMENT AND
MAINTENANCE OF CHILDREN’S BEHAVIOURS
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Studies have shown parents can promote negative
behaviours such as avoidance and aggression (Barrett et al
1996)
Increases of avoidance present after parental
modelling of fear (de Rosnay 2006, Gerull & Rapee 2002)
 Studies show aggressive behaviours increase:
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following children’s observation of aggressive models
(Cummings 1981)
When problematic behaviour is negatively reinforced
(removal of something unpleasant to create a more
favourable environment for the person) Patterson 1982
 With inconsistent and harsh discipline (Dodge 1994)
 Lack of warmth shown toward the child (Pettit & bates 1989)
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CBT FAMILY MAINTENANCE CYCLES
CBT FAMILY MAINTENANCE CYCLES
PARENTS CAN HELP
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Treatments that train parents to alter maladaptive parent-child
interactions are considered the most promising available
treatments for behavioural problems (Kazdin 1997)
Combination of parent behaviour modification training and social
problem solving has produced the greatest changes in child
behaviour treatment (Webster-Stratton & Hammond 1997)
Anxiety related school refusal treatment for ages 7-14 years old
showed significant outcomes for treatment involving parents
(Heyne 2002)
In one study of 7-10 year olds with anxiety disorders, 100% were
free of their primary anxiety diagnosis following FCBT treatment
Outcome studies of working solely with parents for anxiety within
children 5-12 show significant results – 79% of those whose parents
were provided psychoed and tools for intervention completely
recovered, 61% in another study (Lyneham & Raepp 2006, Creswell
2010)
Remission of parental mental health problems is associated with
reduction in children’s mood and behaviour concerns (Weissman
2006)
WHAT’S THE BEST LEVEL OF FAMILY
INVOLVEMENT?
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Studies have compared outcomes from
individual child focused CBT (aka CCBT)
and family based CBT (FCBT) and
concluded complete family involvement
isn’t always what is optimal for best
treatment outcome (Creswell & Cartwright-Harton 2007; Albon
& Schneider 2007).
Through assessment of stage of development,
presenting problem, and family risk and
protective factors it is up to the clinician to
determine the optimal level of parental and
family involvement for the client.
CHOOSING THE BEST LEVEL OF PARENTAL
INVOLVEMENT
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Parents can be involved in varied ways across CBT
based interventions (Stallard 2005):
Co-clinician role – parents participate in the treatment in
order to promote children’s application of CBT skills in
their day to day environment
 Facilitator role – parents are responsible for ensuring
their children attend sessions and may attend sessions to
inform about the rationale and principles of treatment
 Co-client or client role – parental factors become a direct
target of treatment
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CASE STUDY
Mike presents to your agency for ‘counselling’. When doing intake
with his parents you find out the presenting problem is that Mike
is being aggressive at school near the swings – chasing kids,
pushing them so they don’t get on, or pushing kids off when they
are on the swings. You determine through the session that Mike’s
older brother Zack used to ‘rough house’ with Mike at the park,
which once resulted in Mike falling off the swing and hurting
himself ‘really bad’ as mom tells. Mike’s dad says he was not hurt
at all and he has encouraged Zack and Mike to continue acting the
same as always. Mom presents as very anxious about Mike even
being around swings, an argument ensues between parents as you
meet with them.
Which family member behaviours are contributing, reinforcing or
maintaining Mike’s behaviour?
What role/level of involvement would you engage parents within?
What would your intervention look like?
OTHER FAMILY POTENTIAL RISK FACTORS
WHAT BEHAVIOURS MAY THE CHILD OR ADOLESCENT
BE EXPOSED TO IN THESE CIRCUMSTANCES WHICH
MIGHT BE UNHEALTHY?
History of family violence, mental illness, addictions,
unstable family finances or residences/locations
 Important to consider family stage of development:
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Joining families through marriage
 Families with young children
 Families with adolescents
 Launching children
 Families in late middle age
 Families nearing end of life
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Marital problems/affairs
 Single parent stress
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HOW MIGHT THESE INFLUENCES APPEAR
IN SESSION?
Disclosures of abuse
 Patterns in play/externalizing of:
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Secret keeping and avoidance of
telling/communicating behaviours
High conflict
Modeling age inappropriate
behaviours (ie adolescent
behaviours in childhood)
Strong negative feelings towards
other siblings (younger/older)
Aggression – verbal, emotional
FAMILY RISKS: UNHEALTHY ROLES WITHIN
THE FAMILY
In groups of 2-3 review the handout
Dysfuntional Family Roles
What:
Cognitions, Behaviours or Patterns might
emerge in sessions if a child identified with
any of these roles?
Which mental health disorders might these roles
contribute to the development of?
FAMILY RISKS: UNHEALTHY ROLES WITHIN
THE FAMILY
In groups of 2-3 review the handout
Family Functions
What:
Cognitions, Behaviours or Patterns might
emerge in sessions if a child is immersed in
unhealthy family functions?
Which mental health disorders might these roles
contribute to the development of?
ASSESSING THE FAMILY SYSTEM.
DIRECTIVES FOR PLAY, SAND TRAY, PUPPET PLAYING, ROLE
PLAYING, COLLAGES, DRAWING ETC.
Show me what it looks like when:
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Parent’s aren’t getting along.
You need to make a choice when one parent is disagreeing with
another.
When your family is happy/sad/angry/worried (etc)
When caregivers are in agreement. United. Calm. Relaxed.
Helping each other. Getting help. Being supported.
You are doing chores.
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You are having fun with your family.
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When the family is following a daily routine.
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When you feel connected to your family member(s)
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When you are spending too much time with your family members
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All your family members are in their roles. Show me the:
caregiver, income earner, protector, plumber, cook, chef, baker,
dishwasher, commentator, joker, actor/actress, story teller,
intellect, hero
ASSESSING THE FAMILY SYSTEM.
DIRECTIVES FOR PLAY, SAND TRAY, PUPPET PLAYING, ROLE
PLAYING, COLLAGES, DRAWING ETC.
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Boundaries are being respected in your family
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Boundaries are not being respected
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Boundaries are too loose, rigid
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You are communicating within your safe topics
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You are getting along with your brother(s)/sister (s). When you aren’t getting
along with him/her/them.
You are communicating. What spoken or unspoken rules of communication
look like.
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When topics are safe.
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You are being assertive/passive/aggressive
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The family leaders emerge and/or speak
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Everyone listens and who is there? How are they showing they are listening?
How are you showing you are listening
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Who everyone looks up to.
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People’s needs are being met.
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There’s love/affection at home.
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Your family tackles a problem
INTERVENTIONS:
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Helping the client process, explore, identify and balance
beliefs about their family and situation
Becoming a detective yourself and being an advocate
within the family system if you need to be/evidence
suggests unhealthy family dynamics
Developing action plans and solutions to implement for
family problems
CCBT - Focusing on the clients behaviours and cognitions
Behavioural interventions focusing on the clients
behaviours (ie assertiveness, interaction changes) to
improve communication/problem resolution/boundaries etc
FCBT – treating the family
Parental counselling
CASE EXAMPLE: COMBINED PARENT CHILD
CBT TO EMPOWER FAMILIES AT RISK FOR
CHILD PHYSICAL ABUSE
Studies show positive outcomes for children and
parents and especially an improvement in
children’s PTSD symptoms following this
treatment
 Significant results for: reductions in use of
physical punishment, reductions in parental
anger toward children, reduced behaviour
problems in children and increased consistency in
parenting
 Significant results for parents: experienced a
reduction in symptoms of depression
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(Kjellgren 2013; Runyon 2009; Runyon, Deblinger & Schroeder 2010,
Runyon Deblinger & Steer 2010)
CASE EXAMPLE: COMBINED PARENT CHILD
CBT TO EMPOWER FAMILIES AT RISK FOR
CHILD PHYSICAL ABUSE
CPC – CBT Protocol
Psychoeducation
Consequence review
Disclosure of referral incident
Contract for family safety
How children learn to behave
Praise
Psychoed of physical punishment
Weekly parenting practices record
Gaining your children’s cooperation
with more effective instructions
Cool downs
Praise plus active ignoring
Top 10 Ways to Gain Control
Anger Monitoring Form
Taking care of yourself
Time Out guidelines
Family Safety Plan Worksheet
Helping Children Express their
Feelings
Using Positive and Negative
Consequences to influence behaviour
Establishing house rules
Behaviour contract
The five minute work chore
CASE EXAMPLE: PARENT CHILD
INTERACTION THERAPY (PCIT)
Based on operant and play interventions
 Designed for children 2-8 years old
 Aimed at modifying children’s behaviours through
modification of parental behaviours
 Studies show efficacy of PCIT in:
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Reducing child behaviour problems
Maintaining positive effects 6 years later
School settings
Untreated siblings
High risk families and those with abuse and violence in the home
Kinship and foster care givers
Aboriginal, Chinese and Hispanic populations
Autism Spectrum Disorder clients
HOMEWORK 
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Play with a child or adult this week, using the
PRIDE principles of Parent Child Interaction
Therapy. With a partner, practice also giving
direction to an adult of how to use the PRIDE
principles.