Cognitive Therapy with Children and Adolescents

Robert D. Friedberg, Ph.D., ABPP, ACT and Aimal Khan, M.D.
Penn State Milton Hershey Medical Center/College of Medicine

Introduction

Similarly to Cognitive Therapy (CT) with adults, CT with children is defined by its theoretical and conceptual premises rather than by any circumscribed set of techniques. Therefore, practitioners from other orientations will recognize some familiar techniques (e.g., play therapy). CT with children is guided by the robust conceptual paradigm pioneered by A.T. Beck. Accordingly, clinical practice is informed by the cognitive model of psychopathology, the hierarchical structural organizational model, and the content-specificity hypothesis. Cultural, developmental, and systemic issues are integrated into case formulations.

CT with children makes use of collaborative empiricism and guided discovery in clinical practice (A.T. Beck et al., 1979). Additionally, the characteristic session structure including mood check-ins, homework review, agenda setting, session content, homework assignment, and feedback/summaries is also applied with children and families. CT with children includes psychoeducational, self-monitoring, cognitive restructuring, rational analysis, and behavioral exposure techniques.

What is cognitive therapy with children like?

In CT with children, special emphasis is placed on the experiential tradition in CT. Accordingly, playfulness, metaphors, child-friendly procedures, and making psychotherapy real and relevant are all pivotal. Children rarely initiate psychotherapy. Rather, they are brought to treatment by powerful others (parents, teachers, etc.) and institutions (juvenile justice, schools). Moreover, the notion of “psychotherapy” is a foreign one to children. Talking about thoughts and feelings, tolerating distress in order to overcome it, written therapy homework where coping skills are practiced, and behavioral experiments where these skills are enacted are not part of children’s ecology.

Therefore, games, stories, puppet play, fun exercises, interesting “therapeutic adventures,” and experiments are essential part of treatment. The youngster’s emotional arousal propels cognitive behavioral therapy (CBT). Procedures lay lifeless when they are delivered in an emotionally sterile environment. Effective CBT reveals and deals with the tragedies of young patients’ lives (Leahy, 2007). When therapists elicit and gracefully deal with deeply felt emotional issues, treatment takes off. The challenge and excitement of CBT with young people is to make use of intensely charged emotional moments in present tense and real time (Friedberg & Gorman, 2007). Thus, CBT with children is not an abstract intellectual exercise. Instead, cognitive behavioral therapists honor the experiential tradition by guiding young patients’ heads and hearts toward consensus (Padesky, 2004).

Since CT is so flexible, it may be applied in a variety of formats including individual, family, and group psychotherapies. Family based CT is an especially welcome development (Dattilio, 2001; Ginsburg et al., 2004; Woods et al., 2006). Family CT addresses problematic beliefs, behaviors, and emotions in a systemic context. Group CT also is a new and promising application where children apply techniques in an interpersonal and social context (Christner, Menutti & Stewart, 2007).

Research on CBT with children

CBT with children and adolescents has been the subject of randomized clinical trials, empirical studies, and clinical reports (Weisz, 2004). Overall, the results from multiple studies show very favorable outcomes. CBT spectrum approaches demonstrate treatment success with anxiety spectrum disorders (Barrett, Dadds & Rapee, 1996; Cohen, Deblinger, Mannarino & Steer, 2004 Kendall et al., 1992; March & Franklin, 2006; March & Mulle, 1998; Piacentini & Langley, 2004).

CBT is shown to be successful with childhood and adolescent depression. Stark and his colleagues demonstrated CBT to be an effective school-based intervention (Stark et al., 1960. Lewinsohn’s Coping with Depression Course for adolescents also yields favorable outcomes (Clarke et al., 1999). The Treatment of Depression Study (TADS 2004) yielded somewhat disappointing results for CBT. However, the use of a potent control condition, multiple therapists from multiple sites, and a particularly severe clinical population may have attenuated the results from end of treatment analyses (McCarty & Weisz, 2007). Weisz, McCarthy, and Valeri (2006) remarked that the performance of CBT in TADS may not representative of CBT effects. For instance, they found that 20 of 23 studies reviewed in their meta-analysis showed effect sizes larger than those found in TADS. Moreover, McCarthy and Weisz noted that the effect of CBT may grow over time as follow up results are analyzed. Finally, Brent (2006) asserted it is relatively unclear whether the relatively weak showing of CBT in TADS was due to the way CBT was delivered, research design issues, or both.

Disruptive behavioral disorders are also managed with CBT. The Anger Control Program (Lochman & Wells, 2004; Boxmeyer et al., 2007) is a very successful approach to treating angry youth. CBT is also being applied to eating disorders with promising results (Lock & Fitzpatrick, 2007; Lock, LeGrange, Agras & Dare, 2001). In a recent development, CBT is being used with children experiencing pervasive developmental disorders (Attwood, 2004; Sze & Wood, 2007).

Medications

In addition to cognitive behavior treatment for Depressive Disorders, Anxiety Spectrum Disorders, and Attention Deficit/Hyperactivity Disorder, there are a multitude of pharmacotherapeutic approaches for the treatment of these conditions in the child and adolescent population. CT allows for the seamless integration of pharmacological and psychotherapeutic approaches.

The condition which causes the most morbidity in the child and adolescent population is Major Depression. The first line of pharmacotherapy for child and adolescent depression is the Selective Serotonin Reuptake Inhibitor (SSRI) class of medications. To this date, the only FDA approved medication for the treatment of child and adolescent depression is fluoxetine (Prozac). It is the most studied antidepressant with the greatest number of controlled clinical trials to support its efficacy in the treatment of this disorder. Other SSRIs that have successfully been used under the "umbrella" of a similar mechanism of action as Prozac and heralding from its FDA approval status include sertraline (Zoloft), citalopram (Celexa), and escitalopram (Lexapro). Furthermore, selective Noreadrenergic Reuptake Inhibitors (NRIs), such as bupropion (Wellbutrin), and dual Serotonin and Noreadrenergic Reuptake Inhibitors (SNRIs), such as venlafaxine (Effexor) and mirtazapine (Remeron), have also successfully been used. The Tricyclic Antidepressants (TCAs) have been utilized less frequently than SSRIs due to their higher incidence of side effects and increased lethality in overdose. One medication which is absolutely contraindicated in the child and adolescent population is the SSRI paroxetine (Paxil). However, other SSRIs have also been shown to cause new onset suicidal ideation and/or self-injurious thoughts and behavior, which are usually ego-dystonic, in the child and adolescent population. Arising from the suicidality associated with SSRI use in children and adolescents, all antidepressants that are administered within the child and adolescent population carry with them the FDA “Black Box” warning that suicidal ideation may arise as a result of their use.

The treatment for the Anxiety Spectrum Disorders is quite similar to that of Depressive Disorders in children and adolescents. There are no medications specifically approved by the FDA for the treatment of the following Anxiety Spectrum Disorders in the child and adolescent population: Generalized Anxiety Disorder, Separation Anxiety Disorder, phobias, and Post Traumatic Stress Disorder. However there are three FDA approved medications for the treatment of Obsessive Compulsive Disorder in children and adolescents: fluoxetine, sertraline, and fluvoxamine. Due to the general acceptance by clinicians of the neuronal serotonin depletion hypothesis as the underlying mechanism in Depressive Disorders and Anxiety Spectrum Disorders, SSRIs are also used in treatment of the above mentioned Anxiety Spectrum Disorders in children and adolescents. However, there are other options for the treatment of these conditions. These include the TCAs and the medication buspirone (Buspar). As above, the FDA warning concerning the incidence of new onset suicidal thinking and self-injurious behavior in children and adolescents treated with SSRIs is also applicable during their use in treatment of the Anxiety Spectrum Disorders.

The most prominent condition in the child and adolescent population which almost always requires pharmacotherapeutic intervention is Attention Deficit/Hyperactivity Disorder. The primary medications for the treatment of ADHD are methylphenidate (Ritalin) or amphetamine mixed salts (Adderall). These medications are taken at 4-6 hour intervals throughout the day due to their short half-lives. Due to the heterogeneous metabolism of these medications in the population and with compliance difficulties that can arise from multiple administrations throughout the day, extended release versions with specialized delivery mechanisms have been developed which include Concerta (methylphenidate) and Adderall XR (amphetamine mixed salts). Other forms of methylphenidate and amphetamine mixed salts are available which are typically used in cases which call for variability in length and timing of effect. In addition, a patch form of methylphenidate has recently become available which offers the advantage of a higher rate of compliance. Furthermore, a non-stimulant medication which is now being used in the child and adolescent population is the Norepinephrine Reuptake Inhibitor atomoxetine (Strattera). Strattera also carries the same FDA warning as the antidepressants of the need for careful monitoring for new-onset suicidal thinking and self-injurious behavior when used in children and adolescents. Finally, for those patients displaying more severe hyperactivity and impulsivity, the medications of choice, which can be used adjunctively with the stimulants, are the direct-acting alpha-2 adrenergic agonists guanfacine (Tenex) and clonidine (Catapres).

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