Topic 1: Cognitive-Behavioral Formulation and Treatment for Children {by 6/5}
There are three readings due this week: Friedberg & McClure Ch. 1 – Case Conceptualization, Mash & Barkley Ch. 1 – Cognitive-Behavioral Systems Perspective, and Case Example – Terry. This first discussion blog has two rather broad discussion points: (1) After reading the two text chapters, what are your initial thoughts about CBT conceptualization and treatment for youth? Include in your answer any significant strengths or weaknesses using this approach (based on the reading/research/your own experiences); (2) The Terry case provides a CBT example for conceptualization and treatment. Simply share your thoughts on Terry’s case conceptualization and how you would implement such an approach with one of your clients (in general – i.e., broad thoughts and impressions). You may also feel free to pose a question to the class. Your original post should be posted by the beginning of class 6/5. Have your two replies no later than 6/7. *Please remember to click the “reply” button when posting a reply. This makes it easier for the reader to follow the blog postings.
Dr. Adam M Volungis 
Jun 01, 2014 @ 12:18:11
1) After reading the chapters it is clear that CBT for children includes many aspects. Originally CBT was implemented on adults and thus that framework has been adapted for the use of children. Many considerations come into play when treating children over adults including cognitive abilities, attention span and ability to complete CBT tasks such as labeling emotions and completing homework. Despite the lack of research with children, CBT has demonstrated that 79% of those children/adolescents treated are better adjusted than those who are not treated. A downfall to working with children is the number of factors that contributes to disorders and needs to be addressed throughout the course of therapy. For instance, some guardians are do not agree with the course of treatment or that treatment is needed. This would make therapeutic change more difficult. It is also difficult to work on positive change when you have to send the child/adolescent back to the enviroment that is fostering this negative behavior or cognitions. However, many strengths exist when using CBT. CBT works to incorporate many facets of children/adolescents lives. Therapeutic mentors, guardians, schools and DCF all work to ensure the best possible outcome for the child. CBT provides the support of increased self-esteem, offers ways to learn self-support techniques while addressing negative beliefs and behaviors. This provides many frameworks for a positive therapeutic change.
2) Overall I think Terry’s CBT case conceptualization is a good start to her treatment plan. Depression and anxiety should be the main focus of treatment (in the beginning) to insure that Terry begins to develop more positive coping skills and social skills. Working with the guardian of Terry would be key as well. Although it is explicitly stated that the mother finds Terry to be difficult with the right support and training she can be aught how to handle Terry’s negative affect and implementation new routines and strategies to change it. This approach could be used with other clients with similar behaviors. although they treatment would need to be tailored to a new client, it is evident that play therapy and role-play would be beneficial for children/adolescents to learn how to perceive and handle social situations both negative and positive without negative self-talk. the inclusion of all facets of a child’s life should be always be included (school, home, community) to help improve treatment and treatment outcomes.
Jun 03, 2014 @ 11:57:06
Ashley, the downfalls of using CBT with youth that you included are definitely ones in which I feel strongly with. Throughout my internship, I cannot tell you how many times I had felt productive in leaving a session, but felt a slight twinge inside me knowing that my youth client would have to go back into an environment in which such tools I had implemented would essentially be nullified. For example, I had a five year old client who presented as slightly oppositional, however only in the home environment. It turned out that her and her mother’s relationship was less than satisfactory. Therefore, in session, I would work on building self-esteem and providing positive experiences for my client, whereas I knew once she would arrive back home, none of those messages would be conveyed to her since her mom perceived her as all around difficult. With that being said, although this is a downfall throughout the therapy process, I guess it shows that we are doing our jobs as therapists by providing our clients with a safe environment in which we can validate them and provide positive experiences so that they can collaborate with us in helping them with their presenting problems.
Jun 07, 2014 @ 08:29:27
“For instance, some guardians are do not agree with the course of treatment or that treatment is needed. This would make therapeutic change more difficult. It is also difficult to work on positive change when you have to send the child/adolescent back to the enviroment that is fostering this negative behavior or cognitions.”
I definitely agree with this as well Ashley. I have not yet had a chance to work with children, but this is definitely one of my biggest concerns. Parents or other guardians are often the most influential people in a child’s life, so how can we expect them to make meaningful changes if their caregivers are not on board and active in their treatment? This is something I hope we discuss in class this semester and hopefully we can learn tactics to combat this issue.
Jun 08, 2014 @ 08:05:08
Ashley, I like that you brought up the aspect that parents can impact treatment. Having worked previously with parents who disagree with treatment, I know first hand that treating children can be especially difficult when the parents do not agree with the treatment. It is also difficult if they don’t cooperate with treatment as well and do work themselves to improve the child’s environment.
Jun 01, 2014 @ 15:33:26
1) My initial thoughts about CBT conceptualization and treatment for youth were mostly geared towards how important a multidisciplinary approach is (i.e. including the child’s family, the school, and any other outside activities and/or services). The Mash and Barkley text made it a strong point to say that CBT with youth is not just about the child, but rather the child and his or her subsystems. The social environment is a very important aspect to consider in working with children because that is how the child is shaped in terms of how he or she thinks, feels, and behaves. By incorporating the components of the child’s social environment (i.e. home, school, etc.), we as therapists will be better able to understand the child’s presenting problem(s) in such contexts and therefore gear treatment goals that will reduce any impairments in functioning and foster long-term optimal functioning. Weaknesses that I could see in regards to CBT with youth would be in regards to working with children who suffer from a learning disability or those who are lower functioning, cognitively speaking. I see this as a challenge in modifying CBT for such children because it may be difficult to monitor progress if the child is unable to process therapeutic interventions (i.e. cognitive restructuring) that essentially lead to positive emotional and behavioral change.
2) I thought that the Terry case was a very well formulated case conceptualization. Upon studying her case, I had the same impressions as the author. What most caught my attention was in regards to the family system. I believe that Terry’s mother’s parenting style had a significant influence on Terry’s current presenting problem(s). The sibling relationship then came into play, as well, with Lilly and how Terry’s mother interacted with her in difference to her interactions with Terry. Favoritism can have a pivotal influence on a child’s perception of self-worth which can have serious implications on a secure attachment. An insecure attachment, as we know, is a risk factor and can lead to a great deal of internalizing issues. I have always been interested in parenting styles and attachment patterns since beginning work in this field and it is always something I take into consideration when working with children. One very important thing that I would do implementing this approach with a client would be in regards to improving the parent-child relationship. I would include Terry’s mother in a number of sessions and offer a bit of parent education in regards to how certain interactions may have influenced why Terry is functioning in the current way that she is.
Jun 02, 2014 @ 19:54:13
Taylor, I agree with your comment regarding the importance of incorporating the child’s whole environment into the treatment considerations. Because a child’s life is impacted so significantly by factors around them, treatment would most likely be ineffective if elements other than the child weren’t considered as strengths and weaknesses of the case.
Jun 01, 2014 @ 16:44:29
1) The importance of CBT case conceptualization for youth is made clear by Friedberg and McClure (2002). The case conceptualization provides the information needed to understand the youth’s specific situation and state it in a consistent and useful way. Based on this, the therapist can identify precise areas to focus on and develop an individualized treatment plan for the young person. My initial thoughts about the case conceptualization is that it is necessary and useful in clarifying what is going on with the child and how to address it. I especially appreciate it as an objective, scientific way through which to operationalize the target symptoms and behaviors, and then evaluate the effectiveness of the treatment over time. The standardized approach makes sense to me as opposed to a touchy-feely anecdotal judgment about the child’s progress, which could be inaccurate and not in the child’s best interest.
2) The Terry case reinforces the efficacy of using a straightforward, methodic approach to formulating a case. While we need to be intuitive, flexible, and personable while doing therapy, behind the scenes it is helpful to have a structured model to follow when formulating the client profile. The three questions listed with the stages of formulation; What is the problem? What caused the problem? and Why is the problem persisting? (Wilmshurst, 2011) are easy to remember and are really helpful when we write case formulation. This is an approach I would readily use as a template to guide questions I ask clients, help me develop case formulations and treatment plans, and to keep in mind as I evaluate how the treatment is going.
Jun 03, 2014 @ 08:48:55
Jane, your interpretation of the article on Terry. You present a great idea about being flexible yet structured behind scenes which made me feel more comfortable about my work in internship. I agree that even when we have structured treatment plans each therapist needs to be flexible in their work.
Jun 03, 2014 @ 11:58:54
Jane, I like your approach of finding an equal balance between being flexible and personable, as well as being structured when formulating client profile. I generally follow a structured intake form with parents and/or clients, but will then take the semi-structured route and ask other questions that come to me in regards to the presenting problem, how it emerged, and what is maintaining it. Even in session, particularly with children, I attempt to make each session as fun as I can, but with still incorporating structure (e.g. first, we will complete my activity or talk about certain things that are warranted to talk about, then we will color or play a board game). The three questions listed when formulizing a case are crucial and always something that we should consider when completing intakes.
Jun 04, 2014 @ 08:58:26
Taylor,
You make a great point about not only the value in structure and the need for flexibility within it, but also the power of being creative and having lots of “tools” in the toolbox to interject when an opening presents itself. There is real talent involved in being able to follow a structured session, but also know when to ask questions that are outside that structure that might help to really get at the heart of a problem. I think this really points to the need to always consider individual differences among our clients.
Jun 06, 2014 @ 13:08:08
Jane, I agree with your statement that a strength of CBT is the evaluation of effectiveness over time. CBT uses concrete and measurable goals and interventions in order to help clinicians recognize whether treatment is effective and goals are being met, or whether the treatment plan needs to be evaluated in order to make progress. It is very helpful for the client to be able to see these meaurable and concrete advances they are making in their general functioning in order to help motivate and continue progress in treatment. Clinicians that do not use clear, measureable goals assess effectiveness of treatment very subjectively, which leaves room for repeated errors and ineffective treatment methods.
Jun 01, 2014 @ 20:55:25
After reading the chapters, I think that CBT conceptualization for youth is a comprehensive method of assessing the individual as a whole. The case conceptualization then drives the development of a treatment plan that is unique to the individual’s case. I liked the way that Friedberg & McClure described a case conceptualization as a personalized psychological portrait. Instead of relying solely upon a diagnostic classification which does not allow for questioning of the “how, why, when, where, what etc.” that should be explored in order to gain a full understanding of the individual; a case conceptualization provides the method not only to answer these questions, but also to apply a diagnostic classification, and an anticipated treatment plan.
Mash & Barkley discussed the expansive number of components applied within the methods of cognitive-behavioral treatment, but also emphasized throughout the chapter that the growing tendency of researchers and clinicians is to use a systems approach to CBT. In other words, the assessment and conceptualization of the child should be a dynamic, always changing unique framework that is not limited to the individual, but also includes the child’s micro and mesosystems. Mash & Barkley also note that the concepts of multifinality and equifinality are applied to the systems approach in that one individual’s life and therapeutic situation may begin and end significantly differently than another individual who may have a similar situation. I think that this highlights the value of a unique CBT case conceptualization, which takes the individual’s whole situation into context, and allows for a complete assessment of the problem prior to treatment planning.
With regards to any weaknesses with the CBT case conceptualization approach, I think that the overall extensiveness with which CBT assesses the individual is a double edged sword of sorts. On one hand, in order to gain the most complete understanding, the individual is assessed in a multitude of ways, which is excellent. On the other hand, the time spent doing so must be considerable, and may prove futile if the individual’s environment is unresponsive to the assessment. Essentially it seems like if the process to gain the assessment information works, it should yield a conceptualization and treatment plan that is comprehensive and therapeutically effective. If not, it seems like it would be a lot of time spent with no therapeutic gain.
Terry – I liked the contrasts between Terry’s initial case summary, the large amount of additional information provided during the follow-up assessment, the various theoretical formulations provided, and the final summation at the end. In addition, the information provided within the initial case summary in contrast with the follow-up assessment causes the reader to change their initial assumptions of Terry significantly. It’s always interesting how much more information can be determined during follow-up assessments with the individual and others in their environment. As mentioned in the text chapters, the methods of assessment in which the additional information was gathered (how, why, when, where, what, etc.) allows for the case conceptualization and treatment to be formulated.
Jun 03, 2014 @ 09:02:21
Becca, I enjoyed reading your idea of the “double edged sword.” I think its an interesting idea to consider when entering into our internships. I had the pleasure of sitting in on my first intake yesterday with a young individual who has ODD and I found that, although the intake took 3 hours to complete, the information turned out to be very important. Collecting information on his enviroment (school, home, family, etc.) although we cannot change those things showed to be valuable knowledge. This young individual displays ODD when dealing with women only. We could not have known this information without spending the 3 hours completing the CANS and other such tools. Before stepping into the intake I had the same thought you did was, is this all really necessary? When I left my thoughts had changed completely.
Jun 06, 2014 @ 05:54:50
Ashley I’m so glad that you were able to experience your first intake on Wednesday. It must have been a really great experience to apply the knowledge that we have learned towards a disorder that we have heard so much about. Im glad that you shared this side of the double edged sword with me, so I can get the full perspective of what it looks like 🙂
Jun 04, 2014 @ 09:05:55
Becca,
Your thoughts about the usefulness or futileness of the assessment really struck a cord with me. It really speaks to the fact that the quality of the assessment and formulation can either make or break the effectiveness of the treatment. I also agree that the only accurate way to assess a child is within context and from a holistic viewpoint. Kids kind of “are” what they are based in large part on reactions to the environments they are stuck in. I think that is one of the areas that makes working with them so unique, and probably extra challenging.
Jun 04, 2014 @ 17:15:58
Friedberg and McClure (2002) and Mash and Barkley (2006) provide comprehensive models for creating individualized case conceptualizations for children. For the most part, it seems the case formulation for children follows a similar structure as for adults (e.g., defining the presenting problems, administering a range of assessments, obtaining information about multiple factors affecting the children, and functional analysis, etc.). However, one important difference between the case formulation for children versus adults is the need for even broader understanding of, and reliance on, the child’s environment (e.g., parents, school, etc.) in order to most accurately conceptualize the child’s issues. Specifically, obtaining a comprehensive history for the child relies on accurate and thorough reports from the child’s parents, guardians, teachers, etc. in addition to the child. Being that self-report can be inaccurate, though, conceptualizing a child’s case can be even more difficult than an adult’s in some instances. For example, if the caretaker is depressed, has difficulty recalling information from the child’s early history, or is experiencing marital issues, for instance, the reported information may be accidently or purposely skewed. Though inaccurate reports from the caretakers or children is a potential weakness to the CBT approach, the benefits of obtaining information about a variety of the domains from numerous sources far outweigh the costs overall. Gathering this broad range of information will help the therapist most accurately conceptualize each particular case and consequently create the most effective treatment plan.
The formulation of Terry’s case appears to be quite comprehensive given the information provided. The formulation was systematic and covered a broad range of factors which led into a strong hypotheses and a comprehensive understanding of Terry’s presenting problems from a CBT perspective. I found it to be particularly useful that the author not only focused on a wide variety of potential factors that could have caused and maintained Terry’s issues, but provided a thoughtful explanation of the factors’ potential interaction with one another and how those interaction could have evolved over time. For example, the author described the relationship between Terry and her mother beginning with Terry’s difficult temperament and Mrs. Hogan’s potentially inconsistent parenting styles when Terry was an infant. The author then continued to describe the ongoing interaction and patterns of reinforcement and punishment between Terry and her mother that could explain Terry’s present-day behavior.
This style of case formulation that considers a broad range of interconnected factors and influences on the child’s presenting problems would be very useful with my clients. I work in a setting with adolescents where I have limited interaction with parents. Being that parents are a significant factor that influence children’s behavior both positively and negatively, it is extremely useful to use this multifaceted approach to case conceptualization where I can learn about all aspects of the client’s life in order to formulate the case appropriately and implement the most effective interventions.
Jun 04, 2014 @ 23:54:54
Juliana, you bring up a very valid point about the potential difficulty for obtaining thorough and accurate information during a child’s assessment. I agree with you and think it is important for clinicians to also privately evaluate the condition/characteristics of the parents so that they can understand the best they can whether or not the information the parent is providing is accurate.
Jun 06, 2014 @ 06:07:14
Julianna, I hadn’t considered the possibility that a child’s “psychological portrait” my be inaccurate despite the overarching comprehensive approach to gathering information in child conceptualization. Your point regarding a depressed parent who has inaccurate thoughts/memories about the child is certainly valid. In addition, the point made in class last night regarding a family that moves frequently may result in poor/inaccurate school testing/treatment data for the child, and difficultly obtaining police/community/medical records. I think you made a really great point, and it is definitely a large obstacle to consider when determining formulations/goals/treatments.
Jun 06, 2014 @ 23:35:48
Julianna,
I completely understand and agree with your statement relative to the importance of the environment for accurate conceptualization of children. It also makes me wonder however, if the number of factors that contribute to a disorder and need to be addressed can also exist as a weakness in certain circumstances. You also bring up a considerable challenge when it comes to attaining accurate information; despite the broad scope of factors that CBT includes when it comes to conceptualization and treatment, I also can’t help but consider how often one will get insufficient and inaccurate information in many important areas. I like the way CBT acknowledges so many possible contributions to the development of a problem, and I truly believe this is why CBT is so effective with children; however I also feel that misinformation can be a major issue. Consider the way marital discord can contribute to the development and maintenance of oppositional defiant disorder: What if the parents themselves don’t consider their behavior/interactions as qualifying as ‘marital discord’ and as such no interventions to promote changing this factor are taken? It may be the case that working well with the parents is more of a challenge than working with the child in some circumstances.
Jun 07, 2014 @ 14:08:16
Juliana,
You bring up a good point about gathering information from multiple sources. I agree that, although it is essential, it can be difficult in cases when the parents are not a reliable source. This is unfortunate because parents are usually very important for assessment and treatment. In these cases, I think it is best to remember that the information recieved from these sources is not the best, and, if possible, talk to other important people in the child’s live.
Jun 04, 2014 @ 21:10:41
1) I thought of CBT conceptualization and treatment for youth as taking more of an individualized focus, but as Mash and Barkley (2006) point out, it is increasingly and best characterized by a systems approach. A CBT systems approach conceptualizes childhood disorders as “representing exaggerations, insufficiencies, handicapping combination, situationally inappropriate behaviors, or developmentally atypical expressions of behavior that are common to all children at certain ages” (Mash & Barkley, 2006, 34). Childhood problems tend to be viewed as constellations of behaviors, cognitions, and emotions, not just as isolated incidents. And when possible, the CBT model utilizes an empirical perspective, though the key difficulty here is being able to apply empirical knowledge to an individual case that may differ considerably from rather homogenous groups of research participants. A depressed adolescent may experience some atypical symptoms and other comorbid diagnoses that may lessen the effectiveness of how applicable research findings are to the case based on group norms of depressed patients. This discrepancy between research and clinical practice leaves some room for personal experience and clinical judgment as scientific knowledge cannot guide all of a therapist’s actions.
2) The CBT conceptualization of Terry’s case appears to provide an avenue to challenge her feelings of negative self-worth and avoidant behaviors as well as address her parents’ negative attributions, emotion regulation and increase strategies for positive communication. Activity scheduling, play therapy, role-play, individual and group therapy could all be beneficial for Terry and for clients her age. Like Terry, it would be recommended that all environments in that the child demonstrates their problematic behaviors are addressed to maximize the effectiveness of their treatment.
Jun 05, 2014 @ 10:31:09
Robert, I like how you pointed out the importance of drawing from empirical support and actual clinical practice when working with the child. It is crucial to stay informed about up-to-date empirical support in order to learn about changes in the field and the most effective interventions for the client. However, as you pointed out, each individual case is unique and may not “fit” with a certain client’s presentation. If that is the case, relying solely on empirical evidence and not taking the time to consider the unique case may actually be harmful to the client. Overall, your point highlights the importance of treating the client themselves rather than treating their diagnosis in order to ensure that he or she is receiving the best care.
Jun 04, 2014 @ 22:56:42
When conceptualizing and treating a youth through CBT five components are considered: presenting problems, history/developmental milestones, cultural context, cognitive structures, and behavioral antecedents and consequences. All of these variables provide valuable data that can be helpful in treating the client. As children’s cognitive abilities are limited, information on their cognitive processes may be sparce depending on the age and functioning of the child; this could potentially be a weakness to this apporach, however looking at behavior antecedants and consequences is a definite strength and can provide much insight. Another weakness would be that family dynamics seem to be downplayed as they are not included as a major variable. Family dynamics are very important, especially for children; one may argue that family dynamics can be included within cultural contexts however they go beyond that as well and deserve more of a focus. It is also important to note that information comes from a variety of sources when treating children. Adults can advocate for themselves and provide the necessary information, but this is not the case for children as therapists need to seek data from other sources as well (i.e. parents, teachers) in order to get an accurate picture of what is going on with the child. As such, cooperation of the parents and other adults in a child’s life are crucial to the child’s treatment.
The case of Terry outlines many different models that can be used to conceptualize the case including biological, behavioral, cognitive, psychodynamic, and attachment, parenting, and family systems modalities. All of these models bring different pieces of the puzzle together to determine how Terry’s problems came about and how to treat her. Not one of models, however, gives a complete conceptualization on it’s own, instead different pieces from each are needed. Bringing together many different pieces is what Bronfenbrenner’s bioecological model does very well, showing interactions between biology, the child’s personality, and the environment. This model conceptualizes the case similarly to how I would have done it, pulling in pieces from CBT, familiy systems, and biology. In treating Terry, CBT could certainly provide her with some necessary coping skills and implementing cognitive resructuring and behavioral activation would be useful too. However, there also seems to be a deeper problem with the family system that ideally, I would like to address as well.
Jun 06, 2014 @ 13:30:35
Angela, I like the points you make about a need to put more focus into family systems and family dynamics. Particularly in the case of Terry, whose family clearly has some dysfunction that requires intervention. The CBT model did address the possibility of parent training as a supplement to Terry receiving therapy in order to provide psychoeducation to her parents on positive communication and more affirmative parenting skills. However, it may be more appropriate and effective for the family to partake in family therapy sessions all together also in order to practice more positive parenting skills. Perhaps CBT has not included family dynamics as much as other treatment modalities because it has generally been used more with the adult populations until more recently. This makes it all the more important to consider the role that family plays in a child’s life when doing an intake in order to utilize this information to involve the family with interventions when it is necessary.
Jun 06, 2014 @ 23:36:30
Angela,
I like your mention of how crucial the cooperation of the parents/family and other adults in a child’s life are. As you also stated, this is one way in which CBT with children differs greatly from CBT with adults and makes conceptualization and treatment more difficult. I also believe that this is one reason why acknowledging any barriers or hesitance families have to become involved in therapy is important. Family members are often the one’s who are able to advocate on behalf of the child, so if a parent is hesitant to engage in CBT because of a previous bad experience with mental health services for example, this should be noticed early in the process so that the treatment plan can be revised appropriately and support parental engagement in therapy.
Jun 07, 2014 @ 16:52:58
Angela,
I like your mention of the limited cognitive abilities of children. I see this as one of the main weaknesses of CBT with youth. It seems that as children grow and develop they are able to better think about their thinking, and move toward cognitive interventions.
Jun 04, 2014 @ 23:45:02
After reading the assigned chapters from this week, I feel confident that CBT conceptualization and treatment is an effective theoretical approach for most children and adolescents. One point from the readings is that CBT can be tailored to meet a client’s specific needs. Comprehensive assessments, though long and redundant as they can feel, are important for clinicians to understand a client’s “psychological portrait.” As a result, a CBT treatment plan can be developed in regards to each client’s individual needs. For instance, more behavioral techniques can be used for younger children because the lack critical and abstract cognitive skills that older children have developed.
Another advantage to CBT is that client’s can feel involved in making decisions and feeling control over their own treatment. This is particularly important for children and adolescents who are forced into therapy by their parents or by the recommendation of their teacher/school. Using a collaborative approach to develop treatment goals and what topics are discussed during sessions may increase a client’s willingness to attend and investment in his/her treatment.
A disadvantage to CBT is that it is not a perfect match for all clients, specifically clients with a lower IQ/cognitive disability because these clients may not have the cognitive or behavioral skills CBT requires for change to occur. Another disadvantage to CBT is that if parents are not involved in treatment, children are less likely to gain anything from therapy. Working with a young client and then sending them back into an unchanged social environment undermines all the work that is done in therapy. This is why I found the Barkley & Mash chapter particularly interesting. Even before starting this graduate program, my mindset was very CBT-based, and this only increased after CBT was drilled into us in the initial core classes. But the cognitive-behavioral systems approach chapter made me realize that it is most important for children, more than any other population, to have strong, involved, and cooperative support from parents. Integrating a systems approach into CBT makes sense because of the extent of which children are influenced by their parents.
Overall, I think Terry’s cast conceptualization and CBT treatment plan was very detailed and comprehensive. I think her depression and anxiety should be the key focus of her treatment. This would also hopefully improve her academic performance because through treatment for depression, Terry’s self-esteem and self-efficacy would increase, which would hopefully lead to the improvement of her grades. As mentioned in the treatment plan, Terry’s mom should also receive parent training to deal and cope with Terry’s behavior. Based on the assessment, Terry’s mother is facing many stressors: not having a stable place to live, struggling financially, and doing much of the parenting on her own without her husband. Learning how to balance these stressors can improve communication and the relationship she has with Terry.
I think this case is something that could be modeled and referenced at practicum. I would use a similar approach with a child who is depressed and/or anxious and who is struggling to maintain a positive relationship with his/her parent.
Jun 05, 2014 @ 11:28:38
Melissa, I like how you pointed out the importance of CBT’s collaborative approach. I definitely agree that collaborating with the child or adolescent will play an important role in establishing rapport and encouraging them to be active participants in therapy, particularly in this population where the clients are likely to not have voluntarily chosen to be in therapy to begin to with. On the other hand, I also wonder, depending the age and development of the client, how it could be difficult to collaborate with the child alone. I was thinking about the particular scenario we discussed in class that often, especially if the child is young, therapy may be equally or more effective with the parents alone. In those cases, collaborating with the parents will be just as advantageous as collaborating with the clients as well.
Jun 07, 2014 @ 04:27:14
Melissa, I agree with your comment that CBT is hard to use with certain populations, particularly those with limited cognitive capacities and children who have not developed those cognitive capacities yet. In these cases using more behavioral techniques and simple cognitive techniques would be the most useful. Also, as you mentioned having children’s parents involved in treatment is very important as with children it is often the system/environment that is contributing to or maintaining the child’s problems.
Jun 05, 2014 @ 08:03:59
After reading the two chapters on CBT conceptualization and treatment for children it, again, mentioned the ideas of mulitfinality and equifinality which is important to remember that children and adolescents could start from very different points and could end up with similar behavior results or the opposite where children can come from the same background and can end up with very different behaviors. This is important because when coming up with a conceptualization and treatment the ideas of mulitfinality and equifinality have to be kept in mind because one strategy for treatment may work for one child and not for another. One of the many strengths of CBT is the fact that, for children especially, a very intense history should be taken in order to really find out what factors are contributing to the child’s problems or helping the child with their problems. This is beneficial because as the chapters pointed out there are many different systems or interactions that children have with the different people in their lives. One of the most significant weaknesses of CBT would be the fact that there is such a disconnect between the empirical research that find effectiveness of treatments that are being utilized in controlled settings and how those treatments can really be used in the real world by clinicians who cannot control the setting. This disconnect is something that both researchers and practicing clinicians need to work together on so that way the treatments that are being researched and put into place are effective in both settings so more people and children can benefit from these treatments.
The Terry case was very interesting because when you first read it there was very little information to go on. The CBT conceptualization and treatment made a lot of sense; Terry shows signs of helplessness, hopelessness, and worthlessness that could have begun with negative treatment from her mother who also could be depressed. Terry then had expectations of what the world was like and has applied that to her schoolwork and other areas. From this formulation it would explain how being considered a failure and the negative communication style that her mother has would lead her to begin to feel even worse after the bicycle accident and begin the downward spiral that lead her teacher to be concerned. CBT as treatment would also be beneficial because it is something that could be done in the school setting which would be most beneficial so for Terry. I would be able to implement the case conceptualization to one of my current clients that I have just started working with because this type of negative thinking makes the most sense from what I currently know. Once I build some more rapport with my client I will be able to start using CBT treatments to change negative thoughts and get my client to participate in more activities that they like.
Jun 05, 2014 @ 08:49:12
1) What is interesting about CBT with youth, according to Mash and Barkley, is that CBT is focused less so on just the youth, and moreso on the entire family dynamic. The system views the disorder the child has as “constellations of interrelated response systems and subsystems (2006 p. 10). What this means is that they are just factors i the entire family dynamic, and through treatment, the entire family dynamic can change. They also emphasize the point of equifinality, in that similar behaviors can result from different sets of factors, and that different behaviors can result from similar sets of initiating factors,known as multifinality.This is important for treatment with CBT, as it shows that not every method of treatment will work for every client with similiar disorders. Conversely, a certain treatment may be effective on two very different case, leading to the same desired goal. One weakness of CBT I have found personally with children is the aspect of homework and thought journaling. To children, the word homework has a very negative connotation due to school. Even if the work is being done to benefit the child, they may not necessarily seem this way. It is important to process with the child on various aspects if they are not willing to do the homework, or have the parent sit at home and process with them in an attempt to encourage the child.
2) Terry’s case formulation was very thorough. I found it very interesting how little information was given at first about Terry’s case, but how it grew so quickly from the followup assessments and such. The formulation also did an excellent job of covering every factor that could have led to Terry’s current state. What I also liked is that the formulation not only focused on Terry, but also on Terry’s mother and how she played a part in Terry’s diagnosis. For example, linking her parenting style to how Terry feels about herself and the possibility that Terry’s mother uses Terry to avoid her problems in her marriage by giving her a scapegoat. For my own personal formulations in the future, I hope to be as thorough in assessing every aspect of the a child’s disorder and work with both the parents/guardians and the child to best assess the child’s needs.As for implementing the case formulation, it would seem most beneficial to tackle CBT with both Terry and her mother in a hopes to curb Terry’s depression and anxiety, as well as help her mother understand why she acts the way she does and how it is affecting Terry.
Jun 05, 2014 @ 09:34:53
1. The assigned chapters highlight the importance of a comprehensive, multidisciplinary approach when applying CBT to children. Multiple sources (family, school) should be involved in order to best treat each child’s specific situation. It makes sense that looking at all contexts would be necessary in order to best increase functioning. Furthermore, children present their symptoms in a variety of different ways, making it crucial to treat each case as unique. Strengths I see for CBT with youth are that it allows for therapists to look at the many factors that go into disorders, making each case different. It also has prevention programs. Treating disorders as early as possible can be effective, and results in lower costs for services. Lastly, CBT, unlike other approaches to treatment, is based off of objective data and has been shown to be effective. As for weaknesses, younger children, or those with low cognitive functioning, might have difficult putting emotions into words and working on adjusting their thinking.
2. The case of Terry shows the importance of getting information from multiple sources and using those sources to aid in treatment. Each source gave important information on Terry to create a comprehensive understanding of her. The reading also looked at the case from several different theoretical orientations. It was interesting to see how one’s formulation of a case can influence treatment.
Jun 05, 2014 @ 09:56:58
1. The assigned chapters highlight the importance of a comprehensive, multidisciplinary approach when applying CBT to children. Multiple sources should be involved in assessment and treatment in order to best treat each child’s specific situation. It makes sense that looking at all contexts, such as home and school, would be necessary in order to best increase functioning. Furthermore, children can present their symptoms in a variety of ways, making it crucial to treat each case as unique. Strengths I see in CBT for youth are that it looks at many factors that go into disorders, allowing for clinicians to fully understand the child they are treating. Additionally, there are prevention programs. Often it is most effective to treat individuals as early as possible, which also lowers the costs for services. Lastly, I like the fact that CBT is based off of objective data. Unlike other approaches, it has been shown to be an effective form of treatment.
2. The case of Terry shows the importance of a comprehensive approach when it comes to treating youth. Many relevant factors were taken into consideration, including development, the family, thoughts, and behaviors. The article looked at the case from several different theoretical orientations. It was interesting to read how formulation influences treatment. I found the CBT formulation/ treatment to make the most sense. I believe that treating her depressive and anxious thoughts would result in a positive change in Terry’s home and school behaviors.
Jun 05, 2014 @ 11:25:49
1) From these reading it is clear that a case conceptualization is highly important especially when creating a treatment plan that is specific to each child. Each child’s situation (internally and externally) is complex and unique. I found it interesting that Friedburg & McClure described case conceptualization as a “hard sell” to new trainees as they often see it as a more abstract exercise. At least in this program we have already been taught how important case conceptualization is, particularly because every case is different and every client has different needs. The reading shows this is especially true with children as well.
Children are complex and because they are involved in and influenced by so many different factors and systems, I think the cognitive-behavioral systems perspective that Mash & Barkley describe sounds like an appropriate approach to take with children. The collaborative problem-solving approach is of course a necessary component when working with the parents of these children, even though it may be difficult to do so at times. I was surprised where Mash & Barkley noted that on study found that 63% of parent-child pairs did not agree on even a single problem at the outset of treatment. This could certainly pose a challenge for a collaborative approach in which the goal is for parents, children, and professional to mostly agree and work together.
2) With Terry’s case I agree with the author particularly in terms of the poor fit between terry’s difficult temperament and her mother’s impatient, negative, and hostile approach to parenting. I wondering if when she was injured, her mother was more nurturing and cared for her more while she was injured. This would have been a nice change in their dynamics for Terry and so I wonder if she feels that if she complains of being sick, she will get to stay home and her mother will care for her. And she may have fallen behind a bit in school while she was injured, so like the author said, she has learned that this is a way to avoid a stressful academic environment. My inclination would be to follow a course of treatment similar to the family systems approach described by the author, where the focus would be on improving family interactions and balancing power dynamics. Interactions to focus on would include how her mother handles Terry’s avoidance attempts, as well as increasing the positive interactions between Terry and her mother. In a case like this I would focus on communication, love and affection, and understanding between the parent and the child to improve the relationship.
Jun 07, 2014 @ 04:34:08
Juliana, that is an interesting point you raise about how it is possible that Terry’s mother may have been more nurturing during her injury which has led to her increase in somatic complaints in order to receive that treatment from her mother again. I had never considered that possibility before, but it would make sense. I do agree that in her treatment focusing on family interactions and communication, especially between Terry and her mother would be very important.
Jun 07, 2014 @ 21:09:36
Children are complex and because they are involved in and influenced by so many different factors and systems, I think the cognitive-behavioral systems perspective that Mash & Barkley describe sounds like an appropriate approach to take with children. The collaborative problem-solving approach is of course a necessary component when working with the parents of these children, even though it may be difficult to do so at times. I was surprised where Mash & Barkley noted that on study found that 63% of parent-child pairs did not agree on even a single problem at the outset of treatment. This could certainly pose a challenge for a collaborative approach in which the goal is for parents, children, and professional to mostly agree and work together.
Juliana, I agree with you that the collaborative systems and CBT approach sounds the most beneficial with this population, whether it be with older children or with the parents of younger children. I think children are a unique population because they are influenced, more than other populations, by their parents and their families. Therefore, including the parents when treating children and working with them to come up with a treatment plan is important. I think it is sad that so many parents disagree with the therapist about the needs of their child, as you pointed out with the study you mentioned. I find that 63% is an alarming statistic, so that makes me curious about whether or not similar studies have arrived at the same findings.
Jun 05, 2014 @ 12:31:27
CBT conceptualization and treatment for adults has been proven to be effective and likewise can be modified and used for children and adolescents. I believe it is a very crucial core component of CBT that can aid us as potential therapists as well as our clients to understand the factors that predisposed them to their current problems, factors that caused the maintenance of their issues, and the perpetuating factors. As was stated in Friedberg and Mcclure’s book, a case conceptualization guides therapist’s interventions based on the child’s situation. My initial thoughts were that CBT conceptualization and treatment for youth is a great approach because it brings together all the factors and systems that are affecting the child to create a clearer picture of things that maybe not have been explicit and the best interventions. One of the strengths of the approach is that it is not set in stone but rather is flexible and constantly incorporating new information as it emerges. And finally, it is not looked at as one size fits all but it’s tailored to the child’s cultural background, cognitive level, developmental stage etc.
Terry’s case conceptualization provided a vast variety of information that took into account the factors that influenced her presenting problems, practices or behaviors that caused the maintenance of her problems, as well as the continuation. In moving forward, a major focus of treatment would taking into account Terry’s anxiety and depression using CBT techniques, as well as focusing on the family as a system.
Jun 06, 2014 @ 20:08:56
Larrisa, I liked how you mentioned that CBT isn’t a concrete thing and it can be flexible and change to fit the needs of the child and then adapt to the different changes that the child is going through. This is also helpful for making the treatments culturally sensitive as well as changing the developmental and cognitive levels as the child matures.
Jun 05, 2014 @ 12:38:18
Incorporation of the family and school are very important to understanding and treating the presenting problems of youth. This leads me to the belief that for effective treatment of youth, formulating a view of said youth that encompasses both a systemic perspective and a cognitive model is extremely important. CBT places an emphasis not only on the individual youth, but also on other elements such as family and school and the way these elements all exist interwoven to impact the presenting problem. Utilization of a CBT conceptualization allows us to focus on both internal and external factors that may be contributing to the development and maintenance of the youth’s problem. One significant weakness I see with a CBT approach however, is the very same broad inclusion of elements in treatment: controlling or altering a child’s environment is not always easy. What if a major factor contributing to the problem is a parent’s temperament or parenting style? Or consider the possibility that effective treatment for a specific child requires the active involvement of various family members, teachers, or other community members: Some individuals may refuse to cooperate and become involved in the child’s treatment. Still, the strengths of CBT with youth are far more significant than the weaknesses. A CBT conceptualization allows us to continually revise and refine our ‘picture’ of the child and formulate the most optimal treatment plan. For instance, consider the above weakness: if a parent expresses significant hesitancy to engage with mental health care, CBT allows us to reformulate the treatment plan to hopefully overcome such an issue. Of the many strengths found within CBT conceptualization and treatment, one of my favorite aspects is the strength-basis it operates with. Consider an adolescent who is using substances as a way to cope with stress in the family: Rather than maintaining focus on the substance use as inherently wrong, CBT allows us to focus on the underlying problem of family stress and acknowledge that while the substance use is problematic, it is understandable given the circumstances. We can work with the adolescent to give him/her greater awareness into his/her thoughts/behavior and offer guidance that emphasizes his/her strengths to further motivate him/her to change.
Formulation of the case of Terry provides us with an organized framework of Terry from multiple perspectives and emphasizes the way in which each of the different theoretical perspectives contribute to the most comprehensive understanding of Terry’s presenting problem. This systemic and multifaceted formulation led to well-defined speculations as to why she could have developed her symptoms on various different levels and offers areas of focus in treatment specific to Terry. I found this formulation to be particularly useful as we are able to see the development and maintenance of Terry’s presenting problems through the individual factors and how said factors all exist in a web to form the whole picture of the presenting problem. The author emphasized Terry individually and the impact her environment (e.g. family and peer relationships) has on her symptoms to gain a broad, yet very specific view of Terry. I feel this would be an extremely useful approach to implement with young clients. The broad consideration of factors that may contribute to a presenting problem is exactly what I believe needs to be employed for children as much of our information will come from environmental sources. Parents and teachers especially, need to be included when formulating a view of child clients and this approach allows us to gain an appropriately broad view of the youth in all domains.
Jun 07, 2014 @ 13:02:56
You made a good point, Rebekah, about one of the main difficulties inherent in working with children: it’s one thing if the child is not cooperative, but it’s another if their family members or others who support them are uncooperative or are the main contributors to the child’s problems. The younger the child, the more critical it is to have these main players in the child’s life supportive of therapy process and its goals. Like you mentioned, CBT conceptualization is supposed to address such concerns and be revised as the child’s situation changes. Acknowledging the effect of reciprocal determinism, CBT conceptualization includes addressing possible obstacles to successful treatment, including noncompliance from the child and/ or the people supporting them. Focusing on the child’s strengths is also more likely to reduce noncompliance in the short-term as well as ensure a successful, lasting treatment.
Jun 05, 2014 @ 13:20:02
After reading the two chapters, I found that CBT conceptualization and treatment for youth to be an effective method. Friedberg & McClure emphasize the importance of case conceptualization, as it allows the therapist to tailor the techniques that will be used to the particular youth’s situation and circumstances. It is important to address all aspects of a youth’s situation within the case conceptualization, including the five symptom clusters of physiological, mood, behavioral, cognitive, and interpersonal. Understanding how the variables of the youth’s history, cultural context, cognitive structures, as well as behavioral antecedents and consequences are intertwined is a significant aspect of case conceptualization. A potential weakness of the CBT approach when working with youth may be the use of homework. It may be difficult to have the youth complete homework for their treatment, as it may not sound appealing or the youth may forget to complete it.
After reading Terry’s case, I thought that her conceptualization was well formulated as it draws upon biological, behavioral, cognitive, psychodynamic, attachment, parenting, and family systems perspectives. Reading Terry’s case through a variety of perspectives helps to understand her presenting problem fully, as well as potential causes for her problem. I believe that her mother will need to play a significant role within her treatment as it appears that her mother’s parenting style and interactions with Terry may be largely responsible for her presenting problem.
Jun 06, 2014 @ 18:49:14
Paige, I agree with you about the homework aspect of CBT depending on the developmental level of the youth. This is something that as clinicians will need to be kept in mind when formulating a treatment plan, objectives, and interventions. Youth of the same age may vary in capability cognitively and mentally. It is important to pay attention to these potential barriers when completing the initial assessment or in the initial interview. Clinicians may first attempt to tailor the treatment and simplify it to the youth, but if the core principles of the treatment model cannot be executed then a different approach will need to be explored.
Jun 06, 2014 @ 19:24:24
Paige, I agree that homework is a weakness for CBT. It is important to have children and adolescents do homework so that way concepts that are being worked on can be practiced outside of therapy but many times it hard to have kids do their regular school homework let alone homework from therapy. I also agree that Terry’s mother will need to participate in therapy so that way she can get psychoeducation about the issue and hopefully work on her parenting style.
Jun 07, 2014 @ 08:42:48
Paige, I agree that the homework in CBT may be difficult with children. I feel like th aspect of calling it “homework” may automatically make them not want to do it because it sounds just like homework from school (which we all know kids generally dislike). I wonder if a good way to help combat this obstacle would be to come up with another name for homework such as “action plan”, or just something that sounds more fun for younger kids.
Jun 08, 2014 @ 08:08:46
Paige, I agree about the homework aspect of CBT. Having worked with CBT with children before, I have found one of the hardest parts is having the children do the homework. Sometimes, it is about making the homework into in session work. For example, with thought records, it can help that for a few sessions, you spend the time processing the child’s week with them, having their “homework” be to just think about what happened over the week so u can process in session.
Jun 05, 2014 @ 13:44:07
My observations from the readings include observing that when a therapist is developing a CBT conceptualization and treatment for children, there is a much greater emphasis on talking to the parents. Therapists must learn not only the child’s history and current living situation, but also parenting style and background history of the parents. Using CBT case conceptualization seems to be a great approach for starting the therapeutic process with a child (I have no formal, clinical experience with children), and I can see how the collection of relevant information regarding the child would be helpful in order to begin developing a comprehensive treatment plan. For example, cultural and/or biological factors could be placing pressure on psychological issues and the therapist may never know if the right questions are not being asked. The only experience I have with counseling children is observing adjustment counselors with elementary school aged children and groups are based on common concerns such as self-esteem or anxiety.
The Terry case was first interesting to me because the question about gender got me right away. I re-read the case and realized I had read it the first time incorrectly assuming that Terry was a boy. I also recognized interesting points from each of the different perspectives, especially attachment and the biological perspectives, when thinking specifically about case conceptualizations of children. Depending on the age of the child, biological concerns may be more prominent because of their dependence on their parents. Children are typically optimistic about life, so when a child shows signs of depression it can hint at a more pronounced biological influence. Each perspective has its own priorities and areas of focus that can cause valid and real problems in a child’s life. I would probably use these approaches to begin to conceptualize the questions I would need to ask to cover the different areas of functioning with the parents/ guardians and the family situation. Having as complete a picture as possible of the child in their present state is necessary to ascertain the ultimate problem(s).
Jun 06, 2014 @ 10:44:32
Robin,
You discuss a great point about using CBT with children, involving the large role that parents play in their treatment. Parents help to provide information regarding developmental history of the child, the child’s current living situation, the child’s school performance, as well as the child’s peer group. Engaging with the child’s parents allows us as clinician’s to gain extensive information that will be pertinent to treatment that we wouldn’t otherwise gain from the child themselves.
Jun 06, 2014 @ 17:05:11
Hello Robin,
I agree with you on the fact that a great deal of emphasis should be placed on parents in order for treatment to be effective. I have been working in a residential program for a while now and I have seen where children who have made significant progress in their treatment regressed after going home for a visit. Often times it’s because their parents are not invested in their treatment, and their environment remains the same. So I believe it is important to collaboratively work with children and their parents not only to gain background information but also to put together measureable goals and interventions.
Jun 05, 2014 @ 14:53:49
1. Based on the knowledge I have acquired thus far in regards to cognitive-behavioral conceptualization and treatment for youth, I feel that this theoretical framework can be highly effective when used appropriately. It is important to keep in mind a child’s developmental abilities when selecting an intervention. Children who have lower cognitive functioning are likely to have a lot of difficulty with CBT. For some younger children CBT may be appropriate if worksheets and language are used with consideration of the child’s age, while other children or adolescents may be able understand and utilize more complex ideas. Homework is a key component to CBT, and can be very useful in a child and adolescent population. This gives the client the opportunity to practice interventions in the real world and generalize knowledge into their home, school and/or social lives. As long as the clinician has the ability to make the interventions fun and age/developmentally appropriate, CBT can help to restructure negative thought patterns, schemata and core beliefs rather than allowing these negative patterns to continue on for years and become increasingly stable by continual negative experiences.
2. When applying the case of Terry to the cognitive-behavioral model, it is clear that Terry is exhibiting some errors in thinking. Generally, Terry tends to focus more on negative events and possible negative outcomes than she does on positive events and outcomes. Terry seems to have developed learned helplessness when it comes to social relationships and academic performance. She has been taught from a young age through her mother’s negativity and criticism to expect rejection and failure. The cognitive-behavioral case conceptualization in the reading sets a good foundation for a treatment plan. The focus in therapy with Terry would include decreasing her depression, anxiety and somatic symptoms by identifying her negative schemata, poor self-image and avoidant behaviors in order to reconstruct them into more positive beliefs. Interventions such as role-play are suggested to aid Terry in developing stronger social skills. Cognitive-behavioral parent training should also be presented to Terry’s family in order to help them increase positive communication. In a perfect world, Terry’s family would be on board with all the interventions and openly participate in the therapeutic process. However, the interview with Terry’s mom suggests this is not likely to be the case. If Terry’s family is uncooperative with services and family interventions, alternative interventions can be used to help Terry with the negativity her family directs towards her, such as role play to build on perspective taking skills. If Terry were a client that I was working with, I would begin treatment with some very basic thought records that would be age-appropriate, role play to develop social skills and self-esteem building activities that focus on positive self-attributes.
Jun 06, 2014 @ 10:37:27
Melysa,
I like how you mentioned the importance of considering the child’s developmental ability when treating a child with CBT. This is definitely an important aspect to consider, as the therapist should tailor the treatment to meet the child’s specific needs. I also like how you mentioned that the therapist should be sure to use interventions that are fun, in order to keep the child engaged within treatment.
Jun 06, 2014 @ 18:24:30
Hey Melysa,
I agree with you that children who are lower functioning are likely to have difficulties processing the cognitive aspect of CBT and as potential therapists we should be cognizant of this and plan effectively. As Dr. V mentioned in class, in such situations it may be helpful to focus more on the behavioral aspect of CBT.
Jun 06, 2014 @ 18:40:27
Just as with treating adults, case conceptualizations present hypotheses for treating individuals. The case conceptualization also forms a basis for developing a treatment plan and tailoring the course of treatment to the youth. Although proven effective for treating adults, when working with children, CBT may need to be adjusted to fit the client. Tasks such as homework assignments or psychoeducation may need to be included differently. This may be viewed as a weakness with using this approach as some themes can only be simplified so much. Therefore, working with children with a learning disability or cognitive impairment may be challenging. Nonetheless, CBT serves to promote a positive change and incorporate all varying supports in the child’s life. This is important as treatment may not be as successful if the child is not receiving the necessary support outside of therapy. As with treating adults, some behaviors maybe maintained outside of treatment if reinforced. By assessing all areas of the child’s life and incorporating each system, the therapist will obtain a better understanding of the presenting problem and the precipitating factors.
The case of Terry presented how straightforward a case formulation should be. When formulating a case conceptualization the authors present to consider, what is the problem, what caused the problem, and the why the problem is persisting. These are questions that may serve as a guide and as mentioned some information gathered in forming answers to these questions may come from assessing the child’s overall system of interactions. Implementing this approach with clients would assist in gaining a better understanding of the child and not just the illness which he/she may be suffering. Effective case conceptualizing will contribute to fostering a therapeutic environment of growth.
Jun 07, 2014 @ 12:36:27
I agree with your assessment, Nafi, of the strengths and weaknesses of CBT for children. Its application for children is less straightforward than treatment with most adults, especially children on the spectrum, with learning disabilities or cognitive impairment. As been stated by our peers, it can be difficult for children and families to translate what they learn in therapy towards their lives outside the office or their homes. There are so many confounding factors at play in the environment, especially for children that CBT, even from a systemic approach, may be limited in addressing so many factors that lead to instability in a child’s life. Because of these realities and other factors, the differences between child/family counselors and social workers is increasingly blurring. It is hoped that children with multiple risk factors and chronic stressors may benefit from CBT by applying what they learn in therapy towards situations that they have at least some control over and apply those positive cognitions and skill sets to other facets of their lives largely beyond their control.