Topic 4: CBT Strategies with Children and Adolescents {by 6/26}

There are three readings due this week: Friedberg & McClure Chapters 8 & 9 and Friedberg et al. (2000).  Address the following two discussion points:  (1) Identify at least two concerns that you have about effectively implementing CBT strategies with children and adolescents.  (2) What are your thoughts about the use of modified thought records (or other modified CBT techniques) with children (e.g., PANDY 3-column thought diary)?  Your original post should be posted by the beginning of class 6/26.  Have your two replies no later than 6/28.  *Please remember to click the “reply” button when posting a reply.  This makes it easier for the reader to follow the blog postings.

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51 Comments (+add yours?)

  1. Taylor Tagg
    Jun 23, 2014 @ 13:47:54

    1) Throughout the readings assigned for this week, I came across a couple of, what I would consider, concerns that I would have about effectively implementing CBT strategies with children and adolescents. The first concern I have is in regards to systematic desensitization and exposure therapy. I feel as though I would not only have to encompass the necessary skills and techniques needed, but I would also have to feel very competent in myself and in my ability to tolerate any discomfort of seeing the child experiencing a great deal of unpleasant emotions. I would need to know that there would be no way that implementing SD and exposure techniques would lead to potential harm to my client. Since children and adolescents are shaped by negative experiences, I would not want to have that kind of impact on my clients. Another concern I had in regards to CBT strategies with youth was the “TOE” method discussed in chapter 8 and also the implementation of workbooks in therapy. These two strategies may be limited with children and adolescents who do not have the cognitive/intellectual ability to understand and carry out techniques that are introduced. It may be very difficult for a child and/or adolescent to not only attempt to confirm/disconfirm thoughts, but also to try and think of alternate ways of thinking, feeling, and behaving. Age, developmental level, and maturity are factors that I would take into consideration when implementing certain CBT strategies with youth. A third concern that came up was when reading the Friedberg article in regards to using the “My Thought Feeling Organizer Book”. I simply did not see this as being an activity that would hold a child and/or adolescent’s attention, nor would it be something that they would likely want to complete as a homework assignment.

    2) I liked the components of the modified thought records that were incorporated in the PANDY program. I think that the modified thought records are very engaging for young children, particularly with the coloring and drawing components. I think that it is a very efficient way of having the child identify how he or she feels, how intense the feeling is, and what he or she is thinking based on that feeling. From there, the therapist can ask why the child feels/thinks in such a way, what can be done to resolve the thought/feeling, etc. I can see the simplified three-column thought record being effective with young children in channeling their inner workings, and doing so in a fun and developmentally appropriate manner. I also really liked how the PANDY program used metaphors to explain CBT components, such as the “thought digger” and also how a child character is used via videotapes to describe such components. That way, children and adolescents who watch the video will acquire a sense of relatedness that will hopefully facilitate therapeutic change.

    Reply

    • Ashley
      Jun 24, 2014 @ 11:13:08

      Taylor- I never thought of SD and exposure in that manner. It was very enlightening to hear your thoughts on it. When I originally read it I thought that it was a necessary component that probably couldnt be avoided since it has such therapeutic value, however I can see your concerns to OUR own thoughts and feelings when needing to put a child in such a place. Now I am reconsidering it! I also thought your comments on the Organizer Book were insightful and probably very true as well. Keeping a child on one task especially one they are not interested in can pose to be a huge challenge. I wonder if we have learned some other techniques or maybe the others in the class have some ideas has to how to use the “Thought, Feeling Organizer Book” in a manner that would keep the attention of the client??

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    • Robin Horsefield
      Jun 28, 2014 @ 15:04:52

      Taylor, I completely agree with you about the exposure therapy with children and adolescents. One of our previous readings brought up the issue of being able to sett aside our own “discomfort” for the better of the child. I have thought about what that first experience with trying to administer this type of therapy with a child; it would certainly take me a while to fully conceptualize that the techniques will make them better.

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    • Rebekah Kiely
      Jun 28, 2014 @ 17:51:06

      Taylor,
      Your mention of exposure therapy is interesting. It hadn’t occurred to me the downside to such techniques relative to the therapists well-being. But the idea that I may have to cause a child significant distress in such a way is something that I find very problematic personally. Although I also wonder, for the younger children especially, if the use of such techniques could have a negative impact on the therapeutic bond: A young child will not be able to gather the same comprehension of why we are putting him/her into such distressing situations, I can’t help but wonder if this could lead to issues in trust between the child and therapist.

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  2. Ashley
    Jun 24, 2014 @ 11:08:20

    1) So I have to admit, out of all of the techniques suggested for children I was uncomfortable with the progressive muscle relaxation. Not because I don’t think it would be useful but because I think it takes a particular mind to be able to actually implement it into ones life. For instance, (and this is not a dig at all!!) those who do yoga are very good at finding a “zen” – have this capability to relax their body and clear their mind. Thats the idea I get when you do progressive muscle relaxation. I have actually done this with clients when I was assisting on a doctorate level Ph.D dissertation and even as I was implementing it I couldn’t see myself or any of the adults sitting in front of me doing this outside of the controlled area. Thus with that small rant, I cant imagine it would work with children. To get them to sit still, relax their body and focus on each muscle seems like a stretch. I think its a great technique especially those who suffer from severe anxiety I just find it hard to believe it can be used with children, effectively. Second, I thought the TOE would be hard to implement with children. I think the idea of it is great and useful I just also think that it needs to be age appropriate/cognitive ability all need to be considered. Even for adults, we hold onto the negative and find every reason to dismiss the evidence against our thoughts. Children/adolescents who do not see a problem with their behavior, feels and thoughts would have a difficult time completing this task.
    2) Thus far in my internship I have been worried that I would not have the ability to implement all of these great CBT techniques with children. After the readings this week I have had a moment of relief wash over me! I think the PANDY 3-column thought record could be very useful and easily implemented into therapy with children and adolescents. At one point when the authors talked about coloring in the stop light I wanted to fill out this form over the adult version!! Although I can see the challenges with just starting to implement this technique and how it might be difficult I think this version is a good start to using the thought record in an age appropriate way. I thought the PANDY design was a good shortened, age appropriate version of a thought record for children that has great potential for use in the therapeutic session.

    Reply

    • Rebecca Boisvert
      Jun 24, 2014 @ 11:34:44

      Ashley, I have read so many texts, journal articles, etc. about progressive muscle relaxation with children, and it never occurred to me that it might not work because they are kids, and they probably couldn’t handle it/hold still for long enough to focus. Now that you have brought it to my attention, it makes perfect sense 🙂 I would think that children with anxiety, or those with ADHD most likely wouldnt do well with prolonged muscle relaxation techniques. I have used a few really brief “tricks” with some of the kids that I have worked with that seem to work well…One of my favorites was “Smell the flowers, and blow the bubbles” (breathe in through the nose and out through the mouth). Although this isnt technically a muscle relaxation technique, it still calmed them when they were in a stressful situation, and then we could discuss it afterwards.

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      • Ashley
        Jun 24, 2014 @ 14:09:48

        That is funny you say you used that “Smell the Flowers and Blow the Bubble” technique Becca because I use that one all the time too but never considered it as anything more than that. Maybe I was wrong and with a modified (shortened) version of Progressive Muscle Relaxation it could be very useful for children. I know when I used it, it was a long, slow process. Maybe children can use it just in a quicker fashion.

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    • Jane Jenkins
      Jun 25, 2014 @ 17:06:10

      Along the lines of smell the flowers and blow out the bubbles, which is a FANTASTIC idea for deep breathing technique for little ones (thank you), I wanted to add that I have seen the progressive muscle relaxation shown and termed as “Gumby Body”. Maybe that will have to be updated as I’m sure many of today’s kids have no idea who Gumby is, but it examples another way to modify CBT techniques to kid-friendly terms.

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  3. Rebecca Boisvert
    Jun 24, 2014 @ 11:15:01

    After reading chapter 8 & 9 in Friedberg and McClure’s text, I have a few concerns about effectively implementing CBT strategies with children and adolescents. First, I think the implementation of a hierarchical ranking scale (for anxiety stimuli or otherwise) may be difficult because unless at the polar extremes (I am extremely stressed or not stressed at all), children may have difficulty ranking where in the scale the stimuli may fall. I know that as an adult I would most likely have difficulty establishing this scale, so for children and adolescents who are still learning about their feelings, this may be a challenging task to complete. I would agree that identifying the stimuli/stressors may be less difficult, but accurately placing them on the scale may be the tricky part. For example, when working with children on the spectrum, we have used something called The Incredible 5-Point Scale which is a simple visual tool that shows the numbers 1-5 and allows the child to assess their stress/emotion level at any given point during the day (1 is feeling great, 5 is angry and ready to explode). After having used it for years, I think that it is a great tool, but I don’t necessarily think that the kids can accurately assess their feelings, especially when they are not upset. I would regularly make a point to present the scale to them even if they weren’t upset (happy and having a great day), so I could see where their self assessment was, and rarely would it coincide with their presentation of mood. I don’t think they were deliberately misrepresenting their feelings, it just seems like they didn’t know exactly what they were feeling, or how to express it. Although this is not what a hierarchy scale is/does, it seemed like a similar example.
    Also, Lazarus’s time projection method of problem solving seems like something that both a child and adolescent would have difficulty grasping, but for different reasons. For a child, I think that to assume their ability to effectively apply a situation to a time frame that is as far into the future as 5 years is not reasonable. Children certainly worry about the future, but I don’t think that they can visualize this concept in a therapeutic way. When considering adolescents, I would think that this method would be even less effective because so much of their lives is in the here-and-now. Time projection seems like it would be an effective adult method of therapy because adults are more able to see what lies ahead of them in their future.
    Finally, I’m not sure that I like the use of masks in problem solving with children because it may encourage the child to think like the person on the mask, rather than like themselves. In the example, Kyle chose Harry Potter. Although the dialogue is not provided, Kyle may have determined that the solution to the problem was to conjure up a magical spell and fly around, which is of course not a rational solution, and may create a new challenge if the child has fantasy issues. In the end, I think there are methods of not putting the child on the spot that don’t involve asking the child to problem solve like a fictional character.
    I think that the modified CBT tools used in the PANDY program are an excellent representation of the traditional CBT techniques, but definitely more appropriate for the level of a child client. I agree with the rationale that traditional methods of CBT would be too complex and too tedious for the typical child client. However the modified methods that are used in the PANDY program simplify the fundamental components of the CBT tools, and make them engaging for children. I especially liked the 3-column thought diary because it encourages the connection between feelings and thoughts in a developmentally appropriate and engaging way.

    Reply

    • Angela Vizzo
      Jun 26, 2014 @ 09:27:35

      Becca, I agree with your thoughts about the ranking. Like you had said the rating on a scale of 1 to 5 seems more tangible for children and like it would work better. That is also a really good point you brought up about the masks!

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    • Sarah Chelio
      Jun 28, 2014 @ 09:43:26

      Becca, I found your concerns on the time projection method of problem solving to be interesting and valid. Children do not have the same capacity as children to think about the future, and, although adolescents have the understanding, they are focused on themselves in the present. I also think this would be a difficult thing to work on with both age groups.

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    • Melysa Faria
      Jun 28, 2014 @ 21:06:55

      Becca,
      I agree with your point that The Incredible 5-Point Scale would be a difficult task for children and adolescents because it would be hard to rank different events in association with different intensity levels of emotions.
      However, in regards to Lazarus’ projection of method of problem solving, I agree that it would be very difficult to conceptualize for children and early teens. On the other hand, I feel like this type of activity could be really useful with older teens who are starting to reach the developmental level in which they are able to consider the future and see what lies ahead of them.
      I think the use of creating masks in problem solving could be effective when used with an appropriate age group. I think with younger children that engage in pretend play, having a mask represent a hero figure and learning to think to themselves about what their role model would do in a situation, it has the potential to help children learn to think before acting and regulate emotions. It’s a similar activity to the PANDY modified thought records for young kids because it uses fun activities and characters that kids can relate to in order to teach new skills in a developmentally sensitive manner.

      Reply

  4. Ashley
    Jun 24, 2014 @ 14:14:05

    Becca, I had not thought of the ranking in such a manner. Originally I thought it would be a simple and useful task but now that you brought it up I can see why it would be difficult. I think even I would have trouble indicating my rankings. Very good point you brought up there. Maybe it can still be used on a smaller scale just as you have described with your 5-point scale. Can that be a starting point to help children learn than build it up to a hierarchical rating?

    Reply

    • Rebecca Boisvert
      Jun 25, 2014 @ 10:24:58

      I would definitely think so. I would probably start at the most and least extreme, and then work in from there. The best part of the ranking in my opinion is it helps to teach the child to recognize what they are feeling/thinking/doing that is causing the issue. As they get better at it, they can begin to assess it on their own.

      Reply

  5. Sara Grzejszczak
    Jun 24, 2014 @ 22:11:32

    One concern that I have about effectively implementing CBT strategies with children and adolescents is that while many children really like doing activities and work sheets some children will be very resistant to them as well as some adolescents. Even now, there are some students that I have worked with that will tell me that they will not do the activity because it is “stupid.” I am not really sure what I would do or how I would respond to a situation like this one. I would definitely make sure that everything that I would present to my clients would be developmentally appropriate but even then some clients will not do the activity and work sheet because they feel it is childish. I would hopefully have other things planned as a backup just in case this came up. If I try a couple of ideas for activities and nothing was working I am not sure what to do besides talk with the child about what he or she is not keen on. Another concern that I have about implementing CBT strategies with children and adolescents is the “responsibility pie chart.” I really like the concept of having clients split a tangible item in to pieces, either with clay or by cutting a circle or even by drawing a pie chart, but I am concerned about what I would do if my client that I am with makes the biggest piece about them in a negative way. It is one thing when reading the book chapter and the vignettes show clients making small pieces about them but in session it might not happen and I am not sure how to turn it around so that way the child gets the right message from the exercise while allowing them to really decide how much of the situation is their fault versus other faults.

    I think the modified versions of the CBT techniques are a good thing for children. Many times they are so concrete and so they need to have things like thought records broken down into smaller parts so that they can make the connections between thoughts and feelings. I also like how the PANDY program is coming up with a set of videos that help therapists with the psychoeducation part of therapy. By using the videos, the child can see a young actor playing different roles to explain different scenarios. Children are also hooked on screens, be it television or videogames, and so this is a better way to engage them in therapy on their level because having the therapist talk using a lot of technical terms would make the child zone out and not want to pay attention to what is going on.

    Reply

    • Rebecca Boisvert
      Jun 25, 2014 @ 10:21:40

      Sara, I also share your concerns about children and (definitely) adolescents thinking that activities that I present to them are stupid or childish, and then now knowing how to proceed. Because I have worked with little kids for so long, my transition to high school aged students is a move where this concern definitely comes into play. After posting my comment yesterday about “smelling the flowers and blowing the bubbles” I started thinking about how that would go over if I said it to a 17 year old, and decided that I should probably rethink my strategies 🙂 I guess in the end, it is more trial and error than anything. We learn the skills, but application of the skills is a different thing entirely, and certain age, developmental, diagnostic groups may or may not respond in the way that we hope.
      My best idea at this point is to ask the individual what they would do to improve the activity if they reject it as being stupid or childish. That way you get ideas from their point of view, you are validating their feelings of not wanting to participate, and you are showing them that their ideas matter.

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    • Sarah Chelio
      Jun 28, 2014 @ 09:51:21

      Sara, I share your concern regarding what to do when children do not want to do activities because they find them “stupid”. What further complicates this issue is that every child is different, so they will respond to different things. What works to motivate one child may not work on another. Even if they agree to try an activity, if they are not completely engaged it is not going to be fully effective. At my internship, what I have seen the clinicians do is split their sessions with the kids. The clinician chooses the activity for the first part (worksheets, therapeutic games, etc) and, gives the child a little time at the end to pick something they want to do. It seems like this is a good way to handle this problem.

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    • Rebekah Kiely
      Jun 28, 2014 @ 17:51:34

      Sara,
      I agree with your statements about the difficulties of employing certain activities with adolescents especially. I also believe this is why engaging the adolescent by using a topic on something he/she likes or enjoys doing can be very important. Adolescents who are resistant to therapy can definitely cause problems, but I feel this is an obstacle that can also be overcome by individualizing the therapy to the specific client and including the clients personal interests/activities into therapeutic activities in anyway possible.

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  6. Robert Jarrard
    Jun 25, 2014 @ 11:46:00

    1) Two of the main concerns I have for implementing CBT strategies with children and adolescents are a test of evidence (TOE) and Lazarus’ time projection. Utilizing the TOE successfully may depend more on the child’s age and cognitive ability compared to other CBT strategies. It requires a level of insight that may prove rather difficult for some children. It may not be the most appropriate intervention for children on the spectrum, for example. Time projection also requires some insight and appreciation of consequences that may not be effective for some children and adolescents. While children are capable of thinking about their future, they may struggle to accurately connect their actions to long-term consequences. Adolescents may realize the possible long-term consequences of their actions but do those actions anyway because they think it won’t happen to them.
    2) Modified thought records like the PANDY 3 appears to be helpful to children with anxiety, depression, and anger issues to better express their feelings, and to realize the interaction between their thoughts, feelings, and situations. Since even adults can have trouble with completing thought records whether based on ability or motivation, it is all the more important to present simpler and more interesting thought records to children. PANDY 3 with its use of pictures and symbols seems to be rather child-friendly and invites them to actively explore their thoughts and feelings rather than view it as a tedious worksheet. Despite the accompanying videos that help in this task, some children may not readily take to thought records. They may be too depressed or defiant to accomplish them or may lack the cognitive abilities to effectively complete them. However, a PANDY 3 thought record may be useful for many children to therapeutically express their thoughts and emotions without it feeling like it is extra work.

    Reply

    • Jane Jenkins
      Jun 25, 2014 @ 17:01:50

      Robert, I really like your insight about the problems with time projection. With ADHD being so prevalent, it seems like a bit of a stretch to ask them to cognizant of time out very far from right now. However, it might be useful for kids who have suicidal ideations by encouraging them to think about future events in their lives and getting them away from the “in the moment” thinking they may be dwelling on.

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    • Angela Vizzo
      Jun 26, 2014 @ 09:59:26

      Robert, I agree with your thoughts on the TOE and Lazarus techniques. Both of these require more advanced cognitive skills that some children have not developed yet. With children it’s usually better to be more concrete as this is how their thinking works.

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    • Robin Horsefield
      Jun 28, 2014 @ 15:09:40

      Robert, I quite agree with your evaluation of the PANDY 3 column thought record. I think that it is presented in a format that is more approachable for children. Children tend to shy away from anything that even appears like homework so the authors, I thought, did a great job of simplifying a thought record but retaining the basic concepts.

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    • nafi
      Jun 30, 2014 @ 01:19:31

      Robert, I like how you described the CBT strategies and the concerns that you had I agree with you that depending on the developmental level of the child, these strategies may be difficult. Children only possess the mental capacity to do so much and while some may be more advanced than others, the work required from these two strategies may present difficulty for some if not most. Using techniques are appropriate and specific to that child is important for fostering more long-term outcomes.

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  7. Juliana Eells
    Jun 25, 2014 @ 14:30:03

    1) Through the reading one concern that came up was about how children acquire skills and how they need in vivo experiences to practice the new skills. With adults you can usually have the imagine situations and how they would use their new skills for practice, but children may not be able to do this. They need to be able to practice skills in a real-life difficult situation. I can imagine that it may be hard to allow such situations to occur or to create them when needed, so it may be more difficult for kids to practice in therapy. Another concern that came up for me was about family involvement and commitment. Friedberg & McClure discussed techniques such as contingency management and activity scheduling, and how these would require the child’s family to commit and follow through with the interventions. As we’ve discussed in class, parents may not always be cooperative with the therapist or skilled in implementing the interventions for many reasons. If the family is not committed and does not follow through with the interventions, it will be much more difficult for the child to make changes.

    2) As Freidberg (2000) discussed, there are many reasons that children may have difficulty with traditional CBT techniques such as finding the task boring, unengaging, or too difficult, so I think that using modified CBT techniques necessary for therapy to be effective. As long as the technique is still based on the same CBT concepts, I think modified techniques such as the PANDY thought record would be useful. I did like the PANDY thought record as it still contained the same concept for identifying feelings and thoughts associated with a situation, but made it into an activity that would be engaging and doable for children.

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    • Sara Grzejszczak
      Jun 25, 2014 @ 18:57:08

      Juliana, I also think it would be difficult to do in vivo exposure with children when they cannot necessarily imagine the situation. Sometimes time restraints or even parents wishes will not let us therapists meet the child out in public to work on real life situations. Because of this we need to do a lot to make sure that we come up with similar real life situations for the children to work through. Children who are very good at coming up with imaginative play may, on the other hand, do very well with imagining the situation in therapy sessions so they can practice, but this may not work for every child, especially those who are concrete thinkers.

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      • Juliana Eells
        Jun 28, 2014 @ 08:53:33

        I definitely agree that some kids may be better than others when using imaginal techniques. I’m doing my internship in a therapeutic day school for kids with social and emotional problems, and they’ve already been telling me that many of the kids have a hard time with imagining things when it applies to themselves (they may even be good at imagining how someone else might feel/think/act, but have more trouble when applying things personally), so that would pose a challenge.

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    • Melysa Faria
      Jun 28, 2014 @ 21:15:12

      Juliana,
      I understand your concern for activities with children in therapy that require the family to commit and follow through with interventions. When you are working with a family that often doesn’t follow through, teaching activities like active ignoring, time outs and behavior contingencies often backfire. Their child or teen’s behaviors can become worse because parents will start to use the skills from sessions without consistently following through with consequences. In cases like these, doing interventions like this could cause more harm than good if families don’t follow through.

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    • nafi
      Jun 30, 2014 @ 01:23:52

      Juliana, I agree with you completely in that techniques such as exposure may be difficult with children. I also discussed this in my post and the idea that sometimes with adult, one exposure session can be beneficial and a phobia, for example may be managed. On the other hand, with children, I suppose that therapy will need to take place for a longer period of time in order to ensure that the child is competent in the skills that are being taught. Moreover, family involvement is one aspect that will be difficult to predict and/or control. I do not plan to work with children but I imagine working with a difficult or uncooperative family would have an impact on the child’s motivation to engage. The environment which the child engages outside of therapy is just as influential as the work being done within the clinic.

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  8. Jane Jenkins
    Jun 25, 2014 @ 16:57:59

    1) Two concerns that I have about effectively implementing CBT strategies with children and adolescents are that I will feel an urge to be too directive, and that I may miss an opportunity to identify a distortion that could be explored and challenged.
    Many of the interventions described in the Friedberg and McClure chapters remind the therapist not to “preempt the brainstorming”, such as in basic problem-solving, allowing the child to come up with the alternative solutions. Because I am a direct person, I find that part of the process challenging and something I am already seeing as an area that I need to keep in check.
    In the Friedberg and McClure book, they offer very smooth interactions where the therapist neatly interjects input at just the right time to help the individual think about and evaluate something they just said. When I am listening to an adolescent speak about things that are bothering him or her, I feel that I should say something about what they just said, but I feel as though I’m interrupting, rather than providing an opportunity for them to question their automatic thoughts. I worry about getting proficient at knowing when to interrupt and when to let them continue speaking. I hope this “feel” will be more natural as time progresses.
    2) I like the idea of modifying thought records, as long as they are still applicable as they were meant to be. Boredom is probably a therapist’s worst nightmare when it comes to trying to do interventions with kids, so the focus on keeping them engaged and participating is great. By the example in the Friedberg et al article it appears that the modified interventions are effective and fairly interesting. The only one I have trouble supporting is the Thought Shop. It feels a little too abstract to generalize to the child’s life.

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    • Sara Grzejszczak
      Jun 25, 2014 @ 19:07:50

      Jane, I feel that way too. Sometimes the client is talking so much because they have so much to say and I am worried because I cannot get a word in edge wise. I then question myself and wonder if I am even doing anything helpful because I do not want to interrupt but at the same time I know I should interject and provide opportunities for the client to then think about what they are saying. I also have to stop and check myself because I want to jump in and start work right away when I know that the first session are spent building rapport and letting the client decide what they want to work on during that session.

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  9. Paige Hartmann
    Jun 25, 2014 @ 22:22:45

    Two concerns I have about effectively implementing CBT strategies with children and adolescents include the use of the test of evidence (TOE) and the pleasant event scheduling/activity scheduling. The use of TOE involves the child evaluating facts that both support and disconfirm their beliefs. This procedure requires the child you are treating to have advanced cognitive skills in order to think critically and challenge their own overgeneralizations. Some children that you may work with in the future may not possess these skills necessary for a procedure like TOE to be effective. I also found that the pleasant event scheduling/activity scheduling in theory sounds like it would be useful in increasing a child’s level of positive reinforcement. I think it would be easy to develop the pleasant event scheduling with the child within the session, however, it would require the family to help facilitate this. Some parents may be committed to engaging and participating in their child’s treatment, while others may not be involved. This would pose difficulty in implementing the pleasant event scheduling with the child if the parents were not following through with it.

    After reading the article by Friedberg et al. (2000), I believe that modifications of CBT techniques for children would be beneficial. The authors discuss how CBT may be too structured/directive and often exceed the child’s capacities, which demonstrates how modifications are necessary. The therapist should adjust the typical CBT techniques into manners that are creative and engaging for the child. For instance, the use of the PANDY 3-column thought record is interactive by having the child draw a “feeling face” on the PANDY cartoon. This allows the child to express feelings in a fun manner rather than the more complicated approach of the automatic thought record for adults.

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  10. Melissa Symolon
    Jun 26, 2014 @ 00:47:15

    1. One concern I have is about implementing play therapy. Play therapy should be child-directed and the therapist should pay careful attention to the roles, dialogue, and behaviors of the characters/toys. However, I think it can be easy for therapists to over-analyze the nature of play. Of course, some play can be obvious, like a 6-year-old mimicking sexual behaviors of the characters, but other times counselors may over-analyze a young boy acting out a violent war scene or something similar that is normal for young children.
    Another concern I have is about implementing the suggested “thought-feeling bookmark.” I know that this was merely a suggested activity and counselors do not HAVE to use this activity, but it did not sit well with me after I read it. I found the activity to be a stretch of a metaphor. I think that young children would not even understand the metaphor and some-most older children would not appreciate the metaphor. Personally, I just found this activity as one I would probably not use in practice. I was wondering what other people thought about this activity—if they found it useful and if they would use it or not?

    2. I like the idea of using of the modified automatic record, and I would actually consider using it with my current client. I think it’s extremely beneficial that it is so simple and broken down for children to use and understand. It also reminded me of when little kids say their imaginary friend is upset or sad, when in fact the child himself/herself is the one who is upset. The PANDY example reminded me of that because the illustration is of the mouse instead of having the child draw a picture of himself. Young children also have a hard time identifying feelings, so I think breaking them down by intense, moderately intense, and low is a great idea. Using regular thought records are a lot of writing and deep thinking for young children, so the modified thought record puts labeling their feelings in a context they can understand.

    Reply

    • Paige Hartmann
      Jun 26, 2014 @ 18:46:17

      Melissa, you point out a valid concern regarding implementing play therapy with children. Therapists need to be careful when analyzing the nature of play during a session to prevent overanalyzing in certain situations. It is important to ensure that play therapy is child-directed, but the therapist should be cautious in their analysis.

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    • Taylor Tagg
      Jun 27, 2014 @ 14:05:16

      Melissa, I found your outlook on play therapy very interesting and also something that I am sure a lot of other beginning therapists take into consideration. I have a four and a half year old male client who is in therapy for anger issues coinciding with emotion regulation, and he is extremely interested in superheroes and villains. When playing with action figures he portrays them as being “bad guys” and when he colors he mostly draws monsters, resembling “bad guys”. It is interesting for me to observe and note this theme, and sometimes it is hard for me to distinguish between him simply finding villains interesting, or identifying with “bad” guys and developing a fixation with them.

      Reply

  11. Julianna Aguilar
    Jun 26, 2014 @ 07:41:43

    I have two main broad concerns I have about implementing CBT with children. First, applying therapeutic techniques in a way that is effective for the client’s specific age may be a challenge. I have no doubt that CBT is an effective form of therapy for a child and do believe that a wide range of CBT techniques can be used, many of which were listed in Friedberg and McClure (2002) and Friedberg et al. (200) (e.g., responsibility pie, role play, story telling, games, modified thought records, and thought-feeling exercises, to name a few). What I worry about with children is being able to modify those techniques in such a way that it matches their specific developmental level. For example, addressing cognitive distortion is a key feature of CBT. I know that there are modified techniques and worksheets available for addressing these thoughts, but I still worry that it may be too complex depending on the nature of the maladaptive thought and cognitive skills of the child. Second, as I read about these interventions, I found myself thinking about possible issues with the parents again. Again, I have no doubt that many of these techniques will be effective during therapy sessions. However, it seems that there is potential for parents to have difficulty implementing certain techniques at home, or for reminding the child or adolescent to do his or her homework. For example, Friedberg and McClure note that contingency management can be an effective intervention for children, but that children lose confidence in those who break the management system that they created. In this sense, it seems that if the parents are not very careful to implement certain techniques at home consistently, that it could actually be somewhat harmful to the parent-child relationship. Overall, I do believe that parents can help their children be successful, though I would want to be careful to assess the parent’s ability to help their child with certain interventions and follow-up with parents regularly about their understanding of the CBT interventions being implemented.

    Using modified thought records for children seems to be a great way to match an important CBT intervention to the appropriate developmental age. It seems that it would be particularly useful that the thought record is broken down into more manageable chunks for the children to complete (i.e., event, feeling, feeling signal, and thought). Within these different steps to complete, I like how there are both written and visual components for the child (e.g., write PANDY’s feeling and draw the feeling on PANDY’s face). Using these different modalities for expressing feelings and thoughts would be beneficial for all children, specifically those who express themselves more comfortably in a particular way (e.g., it is easy for them to draw the feeling “sad”, but difficult for them to describe it). Having both written and creative elements may also alert the therapists to possible discrepancies in the child’s understanding of different thoughts and emotions (e.g., the child writes “sad”, but draws what appears to be an angry face). Altogether, it seems that using a modified thought record such as PANDY would add fun and creativity to addressing cognitive distortions that would help the child become active participants in therapy.

    Reply

    • Robert Jarrard
      Jun 27, 2014 @ 19:41:40

      I agree with you, Julianna, in the difficulty that these modified CBT techniques present in their application to real life cases. One exercise may work well with one 8 year old, but may fail with another 8 year old for a variety of possible reasons. While certain activities are designed for specific groups of children, it is up to our clinical judgement to tell if the activity will benefit a child who fits within that group. This application of techniques to an individual case may involve some trial-and-error and presents a challenge to hone our skills as counselors.

      Reply

  12. Angela Vizzo
    Jun 26, 2014 @ 09:49:41

    I really enjoyed the readings about using CBT with children and thought they gave a lot of useful techniques. However, there are still concerns that I have. One concern I have is parental involvement and homework compliance, these go hand in hand. When working with children parental compliance is key and parental follow through with given tasks can greatly affect how effective the treatment is. With that activity scheduling needs that parental follow through in order to be effective. On the same lines parents may need to remind children to do their therapy homework which can be a battle with children and some parents may give up, especially considering they may already battle with the children to do their school homework. Another concern I have is a child getting stuck on one task and not wanting to move on to anything else. Children like their routines and they may get stuck on one type if game or activity and associate that with coming to therapy. As such getting them motivated to move on to the next task may present a challenge.

    I really like the modifications made to CBT for use with children! In particular, the PANDY thought record will prove to be very useful. I like that it is broken down into smaller, more manageable parts and involves a visual/creative component which will be both more engaging for children and help them understand it better. Also the way it is presented is that it looks more like a fun activity to a child rather than work.

    Reply

    • Paige Hartmann
      Jun 26, 2014 @ 18:52:04

      Angela, I have similar concerns about the involvement of parents within their child’s treatment, particularly with ensuring the child completes their “therapy homework”. I liked how you pointed out the potential for a child to get “stuck” on a certain task which would make it difficult to transition on to something new within therapy. I hadn’t considered this, but this is an issue a therapist should be aware of in order to have a plan in place to work through such barriers.

      Reply

  13. Robin Horsefield
    Jun 26, 2014 @ 11:33:35

    Many of my concerns regarding implementing CBT strategies have to do with first impressions and effecting change. I have concerns with a child who has trouble engaging in therapy, either by stubbornness or preoccupation experiences. I worry that I will not be able to connect with a child or adolescent (or their parents) and therefore not solidify a firm foundation for therapy. Trust is an essential part of therapy and is difficult to cultivate, especially with adolescents. If trust is not solidified early, the course of therapy will be difficult. My second concern regards finding the right technique. The “treatment considerations” section of the Friedburg article brought up concerns such as reading level and maturity that must always be considered when choosing interventions. Attention disorders, family environment, personal interests are just a few other considerations that must be recognized when implementing CBT strategies.
    CBT for children may need to be modified at times for children who are slow to engage in the process. These children would benefit from such modified technique as the PANDY 3-column thought diary. Traditional thought records look like dull forms that are tedious to fill out, while the simplistic and colorful nature of the PANY thought record may engage young children. The sample worksheet looks like a page out of a coloring book, something most children are familiar with. I think these modified techniques are a step in the right direction towards being able to reach children otherwise unresponsive to traditional CBT for children, but as the article mentioned, there are quite a few treatment considerations to keep in mind. The PANDY thought record is ideal for a slim age range and this includes a slim maturity range as well. While the simplistic nature might help some children, it may be too simplistic for a more mature child.

    Reply

  14. Rebekah Kiely
    Jun 26, 2014 @ 11:54:45

    One of my primary concerns relative to implementing CBT strategies with children and adolescents is more specific to older children or adolescents: For individuals in this age bracket, consider the possibility that they are not attending therapy because of their own wish to but rather because their family is making them; I am concerned about how to effectively implement CBT on such children/adolescents who are not wanting to be here at all and refusing to engage with therapy. Collaborative empiricism in CBT is essential, especially for youth who have so little control of their lives, but I remain concerned about how to go about engaging them if they are adamant on not doing so. Another concern I have is about the use of homework and how we can effectively support the child completing said homework. If a child automatically associates the word homework with a negative context, and refuses to do it how can we appropriately encourage him/her to complete it? I imagine it may be possible for younger children to involve the parent in integrating a reward of some sort for completing it such as can be done with homework assignments from school; but ways in which we can effectively get children to complete such assignments and take them seriously instead of just thinking of them in the same way as school assignments they may greatly dislike I remain troubled about.
    Modifying thought records is definitely a good approach to adapting CBT to children appropriately and I believe for many young clients can be very effective. It actually brings to mind a similar activity I was shown at a trauma training (for child clients) I attended recently in which children would be asked to draw a person and then pick 4 feelings and pick a different color to represent each feeling. The child would then be asked to color [with each different color] on the person where in their body they would feel each feeling. Activities such as this or PANDY I believe are very beneficial in helping children identifying thoughts and feelings and to help them to understand the connection between them (as well as other symptoms such as somatic that the activity I learned at my trauma training demonstrated).

    Reply

    • Julianna Aguilar
      Jun 26, 2014 @ 14:39:28

      Rebekah, you bring up a good point about possible issues with homework. Because of homework always being associated with additional assignments that interfere with free time, children and adolescents are likely to be resistant to any additional homework on top of their school homework. Friedberg and McClure (2002) suggest that the best way to handle this issue is to not refer to any assignments outside of therapy as homework. In the Coping Cat manual and other treatments, homework is referred to as “Show That I Can” (STIC) assignments. For PANDY specifically, the homework is called “mousework.” I can certainly see how those names would make it more digestible for younger children, though I imagine older children and adolescents will easily figure out that these assignments are simply homework in disguise. Nonetheless, it seems that the most important way to address this issue in the very beginning is to determine a different name for homework and encourage the child to be involved in the homework-making process so he or she can take greater ownership of their work.

      Reply

    • Larrisa Palmer
      Jun 28, 2014 @ 01:51:23

      Rebekah, I am also concern that CBT techniques maybe difficult to implement with older children and adolescents who are sent to therapy against their own wishes and as a result do not want to be in therapy. As counselors our goals are to empower our clients and to facilitate change and if they are not willing to engage full in therapy, I feel like we are basically at a dead end. One particular case was shared with me by one of the therapists at my practicum site that eased my concern a bit. The therapist mentioned that she had been seeing a teenage girl for a few weeks and she was very upset that she was there and as a result she would just sit and stare at the wall. Just as the therapist was about to give up on her, she told the therapist that she appreciated her being there despite the fact that she was withdrawn and disrespectful to her. Every client will be different, some will take a longer time to warm up and other will probably be motivated by our persistent effort to engage with them

      Reply

      • Juliana Eells
        Jun 28, 2014 @ 08:52:46

        Most kids and adolescents are brought in to therapy by their parents, so I definitely agree that resistance could be a big issue at these ages. A clinician at my practicum site also described her experience with one of the clients I will be taking over who shows a lot of resistance to therapy. He is an eleven year old boy and at first he really would not even talk to her. She said that it took quite a while, but she decided to focus more on building rapport and just did activities with him that he enjoyed (like sports and other games) and eventually he started to open up. My practicum class professor has also mentioned that focusing more on building rapport is a good strategy to use when a client is resistant at first, especially with children and adolescents.

        Reply

  15. Sarah Chelio
    Jun 26, 2014 @ 12:30:26

    1. I have two concerns when it comes to doing CBT with children and youth. First, I worry that, even with modification, some strategies may be too complex and therefore hard to use with younger children in particular. Children are at various levels of development and functioning, so what works for an eight year old would be completely different from what works for a thirteen year old. It seems that it would be difficult to constantly adjust approaches to meet the needs of specific developmental ages. This is especially true when it comes to psychoeducation, which is a large part of CBT. I believe it is difficult to develop an understanding in the youth of the concepts being used. Friedberg (2002) mentions how difficult it can be for children to separate thoughts, feelings, and situations. My second, more specific, concern is with some of the more complex cognitive interventions. The Friedberg and McClure readings, for example, discuss evaluating advantages and disadvantages and testing evidence. I think that these would be difficult to teach children and adolescents to do. It would take time for them to be able to apply these techniques, because thinking before doing is an unfamiliar concept to many children.

    2. My thought on using modified thought records with children is that it can be useful in connecting their thoughts and behaviors, in a way that is developmentally appropriate. I have learned that if children are not interested in doing something, it is not going to be effective. Modifying this common CBT technique seems to make it interesting for the child so they want to engage. I think that, once thoroughly explained, it could a useful tool for counselors working with youth.

    Reply

    • Julianna Aguilar
      Jun 26, 2014 @ 14:48:16

      Sarah, I like that you pointed out possible difficulties in providing psychoeducation to children. With adolescents, it seems that, aside from those with lower developmental levels, psychoeducation would be fairly similar to adults depending on the specific topic. However, the therapist must have to be quite creative and knowledgeable of the child’s capabilities in order to make sure that the child understands the information. A similar issue I wonder is about is that some children and adolescents will “yes” you for various reasons even if they do not understand what you are saying (e.g., do not want to talk about the subject anymore, do not want you to think less of them for not understanding, think they really do understand the material but they have understood it incorrectly). For that reason, it seems that the therapist would have to be careful both to provide psychoeducation in an age-appropriate way as well as take extra caution to ensure that the child has understood the material.

      Reply

    • Larrisa Palmer
      Jun 28, 2014 @ 02:11:00

      Sarah, you made an important point that some strategies though they were already modified may still be too complex for many children. While I had this understanding I never really focused too much on the fact that I may have to go back and modify the information several times to cater for my clients. It can be extremely burdensome for a therapist who works with children predominantly and who has a large case load implement CBT strategies.

      Reply

  16. nafi
    Jun 26, 2014 @ 12:43:46

    The discussion for this week taps into a topic that I have mentioned in some of my previous posts in regards to doing CBT with children. A widely used intervention for treating multiple disorders, CBT can be used with children but there may come a point where implementing strategies may be difficult. One strategy that may be difficult may be exposure or systematic desensitization. Research has shown these techniques being implemented in one session with adults but with children I don’t see that being possible. I would think when working with children there would need to be several sessions of training and practice before getting to this stage. The concepts will need to be broken down more and vividly explained to the child. I assume that imaginary exposure may be a better approach to take for a couple of sessions before trying in vivo exposure. With adolescents, depending on the developmental of the child this maybe different. Moreover, depending on the developmental level of the child, another technique that maybe difficult to implement is homework assignments. Although not always used, homework assignments are interventions that give clients a chance to explore their own abilities in managing symptoms outside of therapy. Some children may not have the capacity to complete assignments outside of therapy and this is where other interventions may need to be implemented to tailor to the child.

    The modifications made to the thought records appeared to be well thought out and created for varying age levels of children. The form appeared more children specific just by the way it was set up and if I was a child I would get excited upon seeing this sheet. Sometimes I get so comfortable with doing things or hearing things one way that my mind hesitates to explore other options. This form presents how you can explore the same themes just by changing the appearance of a form. When working with children, there will need to be more room for creativity and expanding on interventions.

    Reply

    • Robert Jarrard
      Jun 27, 2014 @ 20:03:03

      Exposure therapy does seem to be a little more tricky when it applies to children compared to adults. I would think providing in vivo exposure would require parental consent or the involvement of the parents so that is an extra step that wouldn’t have to be done with most adults. I agree that to get children prepared for exposure is slower compared to adults and they may need to get more exposures to effectively desensitize them. If children’s initial exposure experiences is negative, it is probably harder to convince them to continue with the exposures compared to adults. Although exposure therapy with children may pose more difficulties, it may also be more effective for children if done correctly. A child who’s been successfully exposed several times to threatening situations or stimuli may experience more a meaningful boost self-efficacy and more readily apply the lessons learned to other aspects of their lives than an adult would.

      Reply

  17. Larrisa Palmer
    Jun 26, 2014 @ 14:29:30

    The two main concerns I have about effectively implementing CBT strategies with children and adolescents include: not being competent enough and overanalyzing and misinterpreting the behaviors exhibited in play therapy. My first concern is in regards to systematic desensitization and similar procedures used to decrease fears and anxiety. I’m concern about how to use such technique appropriately without running the risk of re-traumatizing my clients and my ability to use sound clinical judgment and intuition in selecting clients who are appropriate for such technique.
    Secondly, it’s very challenging at times to understand a child’s world. This is so because children often lack the capacity to verbalize their thoughts and feelings as adults do because they do not have abstract reasoning skills. Play therapy is useful because it gives children the opportunity to place their stories into fantasy play, and particular themes that will allow us to get a clearer understanding of what is going on in their world. I am concern because I don’t think I am able to interpret what the child is unable to communicate verbally as well as making the connection between the play actions and metaphors that a child uses. I think that in conducting play therapy, I will be so focus on identifying distortions and effects of stressful life events that I might overanalyze and misinterpret their innocent play.
    I think the use of modified CBT techniques is a great way to cater for the cognitive and developmental levels of children and adolescents in therapy. The therapist should be flexible and creative enough to use techniques that are high in energy, interactive, colorful and tangible to get the full attention of their clients. The modified thought record used by the Pandy program is a good way of keeping children and adolescents engage in therapy

    Reply

    • Taylor Tagg
      Jun 27, 2014 @ 14:19:13

      Larissa, I think that your concerns regarding systematic desensitization and how one perceives certain actions and metaphors of play therapy are two normal concerns to have when working with children! I had similar views in regards to systematic desensitization and how I feel as though it would be anxiety-provoking for me to implement. Play therapy can be somewhat misleading for us therapists. We are so caught up in analyzing a child’s alleged psychopathology that sometimes we look for anything that may coincide with it. We must take a step back and rationalize what could be developmentally-appropriate play verbalizations and behaviors, and what could be warranted as therapy-related issues and concerns.

      Reply

  18. Melysa Faria
    Jun 26, 2014 @ 14:54:09

    1) One concern that I have with implementing CBT strategies with youth is how the child or adolescent’s developmental and cognitive abilities may affect his or her ability to understand the intervention. It is important to consider the youth’s cognitive abilities prior to beginning any intervention, however as a beginning clinician this is something that will likely be easier to do with more experience. It would be very ineffective to start working with a child or teen on an intervention that he or she just cannot seem to grasp. This may become frustrating for them and damage self-esteem and the therapeutic relationship. It would certainly be possible to process through this frustration and use it as a learning experience for both the client and the therapist, however it is definitely important to be aware of the client’s cognitive abilities while planning therapeutic interventions to avoid overwhelming or confusing a client.
    Another concern that I have with implementing CBT strategies with youth is the potential that younger clients may refuse to partake in some of the activities either because they are boring or because the client has difficulty with such direct discussion about feelings and thoughts. What should a clinician do if a child or adolescent client refuses to complete any of the therapeutic interventions, however the parent insists that their child continues with therapy? Building rapport with the child and beginning with very light, fun interventions can be helpful, but what do you do if those strategies don’t work and the youth still refuses to participate?

    2) I think the use of modified CBT techniques with children can be very useful and have effective results with some children. Having a basic understanding of the connection between thoughts, feelings, behaviors, and the environment at an early age can help to prevent the further development of mental health difficulties in the future because it gives children the ability to practice the use of coping skills and emotion regulation as they grow up. Interventions like these may not be appropriate for all populations; some children may not have the cognitive ability to complete tasks like thought diaries and may find other interventions more effective. Other populations may have a diagnosis in which a thought diary would not be an appropriate intervention and other techniques would be more appropriate and effective.
    The modification of CBT techniques also allows the use of creativity, which will spark the child’s interest. The use of pictures, toys, and games can allow children to learn the skills they need, while having a fun, positive experience with practicing new thoughts and behaviors and coping with feelings. Modified interventions can be a naturally reinforcing activity because it is enjoyable for the child and it will encourage them to generalize the new skills learned in therapy to other areas of their lives. It is important to remember that tailoring an intervention to be more easily understood and exciting can ensure that children will grasp the techniques learned in sessions and utilize them in other settings and in the future.

    Reply

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Adam M. Volungis, PhD, LMHC

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