WELCOME TO CBT ESSENTIALS
FOR CHILDREN & ADOLESCENTS!!
LECTURE 1: ADAPTING CBT TO CHILDREN &
ADOLESCENTS – KEY CONSIDERATIONS
TODAY’S AGENDA
Goals for today:
 Get acquainted as a class
 Remind ourselves of the benefits of CBT for
Children & Adolescents
 Understand the sociocultural context and history
of CBT for Children & Adolescents
 Identify basic considerations when adapting CBT
to children and adolescents
CLASS RULES
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We run a token economy:
Each time you participate/share/contribute to the
class you get a point
 3 points earns you a treat at break
 6 points earns you no homework needing to be
submitted
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WELCOME & INTRODUCTIONS
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Welcome to the course!!!
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Introductions –
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You can include:
Where you grew up
 Your education and work history
 Your interest in taking this course
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Please definitely include:
 Your favourite colour
 Your favourite zen/vacation spot
 A child or adolescent you care a lot about and why
WHY ARE WE HERE?
Why is adapting CBT for children and adolescents
important?
• 1 in 5 children in Canada
experience mental illness
• Only 20% receive the mental
health help they need
• 4000 adolescents die
prematurely each year by suicide
• Mental health problems account
for half of disability in ages 10-24
Figure 1. Age-specific annual prevalence (%) of the use of health services for mental illness
among people aged 1 to 19 years, Canada 1996/97 to 2009/10
• In 2009/10, 5 million (or 14.4%) Canadians aged 1+ received services for a
mental illness
• In 14 years there was a large increase in children and adolescents receiving
services. The largest increase was observed among youth 10 to 14 years old
(43.8%), followed closely by children five to nine years old (34.5%)
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70% of mental health
problems have their
onset during
childhood or
adolescence
Once depression is
recognized, help can
make a difference for
80% of people who
are affected, allowing
them to get back to
their regular
activities
Almost one half
(49%) of those who
feel they have
suffered from
depression or anxiety
have never gone to
see a doctor about
this problem.
HOW IS MENTAL ILLNESS EXPERIENCED
BY A CHILD OR ADOLESCENT ?
In groups of 3 discuss the cases of Natalie and Nathaniel .
What is their experience of mental illness?
How does this effect them?
How would their life improve with alleviation of their symptoms?
It is therefore imperative to remember that:
Treating child & adolescent mental health not only treats
and alleviates symptoms children and adolescents suffer
from, but can also prevent the chronic nature of mental
illness from interfering in that child or adolescents
future.
FOCUSING ON THE BEST TREATMENT
INTERVENTIONS
Cognitive Behavioural Therapy has been
scientifically demonstrated in hundreds of clinical
studies to be an effective treatment for a variety of
mental and behavioral health disorders for adults,
older adults, children, and adolescents.
~ Academy of Cognitive Therapy
The BIG Question which this entire course is
centered upon:
HOW do we best adapt and tailor the life changing
techniques from Cognitive Behavioural Therapy
to utilize with children and adolescents?
WHAT ARE SOME ESSENTIAL CONSIDERATIONS FOR
ADAPTING CBT TO THE CHILD & ADOLESCENT
POPULATION?
We need to participate in a critical discussion of
evidence-based practice, but one that is
informed by the complex philosophical issues
that permeate all our socio-cultural and
linguistic practices”
(Lines, 2001, p 174).
What are the socio-cultural and linguistic
factors we need to consider when working
with children and adolescents?
FOR CHILDREN A PRIMARY MEANS OF
UNDERSTANDING, INTERPRETING, PROCESSING
AND EXPRESSING THEMSELVES IS PLAY
429-354 BC
INSIDE OUT EXCERPT
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When does Riley feel joy? What is happening for
her during play?
Play provides a child:
A sense of self control
 A place to solve problems
 A means to master new experiences , ideas and concerns
 An opportunity to build feelings of accomplishment and confidence
 A method to communicate verbally, non verbally, symbolically, action oriented
way
 A medium of exchange
 A way to form a therapeutic alliance and relationship
 Allows a different way for children, adolescents and any non verbal adults to
express emotion and feelings in a safe and gradual manner
 Permission to be a child
 Narratives which enable children to organize their fragmented memories and
experiences into cohesive meaningful stories (Pennebaker 2002)
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The use of fantasy, symbolic play and make believe is a
developmentally natural activity in children’s play (Russ 2007).
Play is central and critical to child development (Roopnarine &
Johnson 1994)
The intense sensory and physical stimulation that comes with
playing helps to form the brains circuits and prevents loss of
neurons (Perry 1997)
Play is the most developmentally appropriate and powerful medium
for young children to build adult-child relationships, develop causeeffect thinking critical to impulse control, process stressful life
experiences and learn social skills (Chaloner, 2001).
What is the socio-cultural context of our current
learning? Where does CBT for children and
adolescents fit : within history? the mental
health movement ? evidence based practice?
HISTORY OF CBT FOR
CHILDREN
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Freud (1909) published Analysis of a Phobia in a Five-year-old Boy.
Anna Freud – 1923 opened her own psychoanalytic practice and later
(1928) incorporated play for development of therapeutic alliance. She
saw a child’s behaviours as defence mechanisms in action. She was
the first proponent of parent and school consultations. Considered the
Mother of Play Therapy
Melanie Klein (1932) felt that play was a direct substitution for
verbalizations, and play was a primary means of emotional
communication for children. She used play as a way for free
associations. Mother of a school of psychoanalysis called Kleinian
psychoanalysis.
HISTORY CONT’D.....
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David Levy (1938) developed a technique he called release therapy. His technique
emphasized a structured approach. A child, who had experienced a specific stressful
situation, would be allowed to engage in free play. Subsequently, the therapist
would introduce play materials related to the stress-evoking situation allowing the
child to reenact the traumatic event and release the associated emotions. He worked
with children mostly with night terrors and fears.
1945 American Psychological Association Division 7 created which focused
specifically on child research
Carl Rogers (1942) expanded the work of the relationship therapist and developed
non-directive therapy, later called client-centered therapy (Rogers, 1951). Virginia
Axline (1950) expanded on her mentor's concepts. In her article entitled ‘Entering
the child’s world via play experiences’ Axline summarized her concept of play
therapy stating, “A play experience is therapeutic because it provides a secure
relationship between the child and the adult, so that the child has the freedom and
room to state himself in his own terms, exactly as he is at that moment in his own
way and in his own time” (Progressive Education, 27, p. 68).Virginia Axline (1947)
published child centered play therapy transcripts, paying attention to play themes
and behaviours.
ROGERIAN PLAY THERAPY EXCERPT
How might CBPT differ from this?
HISTORY CONT’D....
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Erikson (1950) – play served the role that dreams do for adults as a “road to the
unconscious” and “the infantile form of the human ability to deal with experience by
creating model situations and to master reality by experimenting and planning”
Hambridge (1955) very directive play therapy where conflicts spoken of in assessment
recreated in play and child guided to respond.
Aaron T Beck Develops Cognitive Therapy !!!! 1964
Gardner (1971) developed Mutual Storytelling – child tells a story, then the therapist tells
another story with the characters of the child’s story but with a healthier response/coping
outcome.
Woltman (1972) introduced Puppets into play therapy stressing child to related to, identify
with and work through feelings with puppets
Behavioural Interventions (Forehand, McMahon 1981) – supports the use of parents to
effect change in child behaviours, like noncompliance at school
National Association for Play Therapy founded 1982
Cognitive Therapy emerges for younger populations 1983 & 1985. Emery et al (1983)
research cognitive therapies for children and adolescents with depression. Many believe
that CT cannot be adapted to use with children.
HISTORY CONT’D.....
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1990 Knell & Moore publish a case report on the use of CBPT with an
encopretic 5 year old, the FIRST published case report of the integration
of cognitive interventions and play therapy with a preschool aged child.
Susan Knell (1993, 1994, 1997, 1998) began to argue that CT could be
modified for use with young children if presented in a way that is highly
accessible for children (ie puppets, stuffed animals, books and other toys
that can model cognitive strategies).
Freeman et al (2008) - 69% of participants who were aged 5-8 years old
achieved clinical remission of symptoms of OCD after completing a 12
week CBPT program
Hirshfeld-Becker et al (2010) - found significant post treatment decreases
in anxiety disorders in participants (aged 4-7 years old) after completing
parent-child CBT
Scheeringa et al (2011) - largely significant post treatment and 6 month
effect size for reduction of PTSD symptoms following trauma focused
CBPT intervention for participants (aged 3-6 years old)
Cartwright-Hatton et al (2011) - 57% of participants (aged 2-9 years old)
no longer classified as having an anxiety disorder after CBPT intervention
Game based CBT interventions successfully treat trauma 2011
What does it mean that it has only been within the
last 20 years that CBT has been adapted and
studied for use with children?
CBT FOR CHILDREN AND ADOLESCENTS IS
STILL IN ITS INFANCY
Researchers have reported that a widespread
developmental-clinical child interface has
yet to be realized
(Drewes, A. 2009)
TO CLARIFY: WHAT IS CBPT?
Cognitive behavioural play therapy (CBPT) is a
developmentally appropriate treatment, designed
specifically for young children (3-8 years old). It
is based on cognitive and behavioural theories of
emotional development and psychopathology and
on interventions derived from these theories.
CBPT is an offspring of Cognitive Therapy as
conceptualized by Aaron T Beck (1964, 1976).
WHO IS CBPT FOR?
CHARITY’S DEFINITION:
Cognitive Behavioural Play Therapy incorporates
aspects of play to improve methods of
engagement, intervention and creative
motivation. Benefits of play may include
improved: brain/cognitive functioning, memory of
interventions and mood. (Magnuson, D. 2011).
“Playfulness in later life improves cognitive,
emotional, social, and psychological functioning
and healthy aging overall.” (Yarnal, Careen;
Qian, Xinyi, 2011). Play can especially help with
non verbal or less expressive populations, but can
be used effectively in all age groups.
THE PRINCIPLES OF CBPT:
Knell (1993, 1994) stated the principles of CBPT as being:
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Based on the cognitive model of emotional disorders - with
developmental considerations. Behaviour and activity may precede children’s
thoughts. Thinking is often not adaptive and the child just does not have the
life history/experience to be able to think of alternatives or other choices. CBPT
then will focus the correction of the absence of adaptive thoughts rather than
cognitive distortions per se.
Brief and time limited – keeping treatment brief and time limited is often the
treatment of choice for children and adolescents. This allows treatment to be
focused on immediate relief of difficulties, providing problem solving strategies
and coping skills, and quickly returning a child to prior optimal developmental
level of functioning.
A sound therapeutic relationship - is a necessary condition for effective
child and adolescent treatment. A positive therapeutic relationship is the best
predictor of treatment outcome (Brady et al). Therapy needs to be seen as a
safe, accepting place where communicating about oneself is permissible.
THE PRINCIPLES OF CBPT CONT’D. ...
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Structured and directive – sessions should follow a structured, directive format
which allows agenda setting and focusing on specific goals. Sessions should also be
balanced with spontaneous play and client led activity and conversation
Problem oriented – it is just as essential to focus on problem resolution with
children as it is with adults, however it is critical to ensure problem identification
and clarification happens (ie. The presenting problem is often seen as symptoms of a
different problem once clarified)
Based on the educational model – teaching essential skills to children is also at
the heart of CBPT as is teaching to adults is for CT
Collaborative – not only with the child is a balance needed between direct and non
direct interaction and learning, but sessions are also often a collaborative with
caregivers
Socratic & Inductive in nature – children do not have the cognitive development
and verbal skills to deduce outcomes and knowledge the same as adults, but they
can learn the process of choosing a best outcome and their own cognitive emotional
ways to do this. They may also need to be supplied choices for answers rather then
being expected to know the best response, for example by the process of informed
decision making with adolescents
Homework – homework is not assigned for children in terms of worksheets but
instead homework assignments of play and modeling by caregivers may be assigned
COMPARING & CONTRASTING CBPT
WHY MIGHT CBPT BE IMPORTANT KNOWLEDGE
TO HAVE FOR WORKING WITH OLDER CHILDREN
& ADOLESCENTS?
What are the benefits of client happiness within
sessions?
LEARNING
& RETRIEVAL IS COORDINATED
WITH MOOD
HAPPINESS INFLUENCES:
Beliefs about life being desirable and rewarding
 Improves an individuals experience of their
quality of life
 Friendliness, cooperation
 Health
 Evaluation of their life satisfaction
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Diener, E & Tay, L 2012
DOES HAPPINESS MAKE YOU SMARTER?
POSITIVE PEOPLE ARE BETTER AT SOLVING
PROBLEMS THAN THEIR UNHAPPY
COUNTERPARTS
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The study by the Free University of Bozen-Bolzano in Italy
found that happy computer developers write better code
than unhappy workers
Researchers investigated how mood affected students'
programming abilities to find that quirky offices with fun
distractions are worthwhile
Having a positive mood boosted problem solving
By Sarah Griffiths, Published: 17:08 GMT, 13 March 2016
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Marty is a 11 year old
boy with selective
mutism. Why might
you choose or not
choose to incorporate
play into sessions
with him? What might
that look like and
what can expectations
be for improved
communication?