Child Cognitive Behavioral Therapy (CBT) Program
Off-site service delivery also includes consultation with school programs and IEP teams, where the focus is on developing a comprehensive and consistent behavior management program that can be implemented across settings. Children will also be assessed for commonly co-occurring problems, such as anxiety, depression, or social skills deficits. Social skills allow children to develop and maintain positive social relationships with peers, teachers, and community members. When children struggle with communication, problem-solving, decision making, self-management, and perspective taking, it can interfere with social and academic development and functioning.
The group will address the content of the skills, as well as barriers that interfere with implementation of the skills. Additionally, participants will have individualized goals for which they will receive ongoing skills coaching and feedback. Being a parent is a multifaceted job and can be challenging with children of any age. We offer parents the opportunity to learn skills to manage their own emotions in response to parenting as well as to manage difficult behavior in children of any age. We emphasize increasing mindfulness in parenting to allow for more enjoyable and rewarding parenting moments.
Learn more about our parenting services here. Children Coping with Divorce is a CBT-oriented, group therapy program for children who have experienced parental separation or divorce. The group format provides children with a sense of safety and support. This includes robust examination of research but also takes into account other forms of evidence where no randomised control trials are available.
The Institute makes recommendations and sets clinical standards. The NICE evaluation of treatments for depression in young people concluded that CBT and other individual therapies are likely to reduce the length of a depressive episode a reflection that controls improve over time. Two studies were considered where CBT showed no difference in outcome from waiting list or treatment as usual and three studies where CBT performed better than a control comparison, although the advantage was lost by follow-up. For group therapy, CBT showed consistently better outcomes than wait list or no treatment control.
Mixed results were described when comparing CBT to other treatments. NICE defines the UK national standards and the recommendations were, in summary, that it is important to train front line professionals working with young people in detection and awareness of depression, and that within CAMHS we need to ensure that clinicians involved in assessment adequately consider the presence of depression. For treatment of moderate to severe depression in specialist CAMHS, psychological therapy should be first line. Psychological therapy should be conducted for at least a 3-month trial.
Antidepressants may be considered, but should be closely monitored and used in combination with psychological treatments. Treating depressed young people successfully is difficult. The evidence base gives us little reassurance that we are effective. Clinical populations are often harder to reach than research populations and working with multiple problems is the norm.
There is higher prevalence of high risk behaviour, particularly suicidality, and persisting adversity in clinical as opposed to research populations. Patterns of relapse and recovery in depression in adolescence can make engagement and sustaining therapy difficult. In clinical work the challenges include engaging depressed young people into therapy. There can be problems in ensuring attendance at sessions and for young people in being optimistic about help; this takes time.
In addition, there can be difficulty in maintaining the pace of therapy, particularly if there are attendance issues. Sometimes drop out can relate to rapid improvement but then there can be a subsequent deterioration following a negative experience. There are challenges in working cognitively with some young people who find it difficult to access their thoughts. When considering comparison with adult populations, NICE states:. In clinical practice, CBT for depression has tended to focus more on one-to-one work than CBT for other childhood disorders, probably because of the personal nature of the experience of depression.
There are several useful approaches to successful engagement. Motivational interviewing see Schmidt, , developed from work with substance abusing adults, can give a framework for supporting the start of the change process. It is crucial that interventions address the problems defined by a formulation. Work needs to be supported by appropriate supervision. The evidence suggests that both cognitive and behavioural elements are effective. There tends to be an emphasis from CBT practitioners on purely cognitive approaches.
CBT can be delivered not only one-to-one and face-to-face but with supplementary systems such as texting, e-mail and telephone. CAMHS professionals bring skills in creative work with young people, particularly in non-verbal and action techniques and these can be implemented within the CBT model. There needs to be flexibility in treatment duration, including creating an expectation of sustained intervention from the outset. Booster sessions can be used, with longer follow-up, possibly in groups see Clarke et al.
In clinical practice techniques have developed for working with multiple problems. They include having a goal focus and identifying the difficulties that are most distressing to the young person. Problems that are easiest to change are addressed first in order to enhance motivation.
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There is a negotiation of goals on behalf of the young person with parents and others. A structured approach can help the young person to cope with seemingly overwhelming problems in a range of different areas. Young people with depression will be at high risk of suicidality and self harming behaviour. Even though effective engagement in CBT reduces this risk, it is important that a non-judgemental and supportive approach is taken by the clinician and that appropriate goals are set by the young person in managing these problems.
Self harming behaviours commonly encountered include self cutting, burning, hitting, excessive use of drugs and alcohol, risk and promiscuity. Chaotic eating patterns including bingeing and vomiting are also common. Suicidal thinking and urges needs to be identified and incorporated into a risk management structure. If the initial presentation to mental health services has been an act of self harm, following assessment it will be important to determine key problems as the young person sees them.
Risk assessments will continue to play a part in sessions and it will be important to agree reviews of treatment and progress and contingencies for deterioration in the clinical situation. For many young people self harm is seen as a coping mechanism and they can be interested and engaged in therapy on the basis of developing alternative strategies for dealing with the feelings that lead to self harm. Suicidal behaviour clearly needs to be managed within a safe environment with close working with parents or carers. The formulation will include other depressive symptoms and an analysis of the underlying beliefs and assumptions and negative automatic thoughts and styles of thinking that maintain them.
Strategies used commonly in CBT in the management of suicidality and deliberate self harm include distraction from thoughts of self harm and developing alternative ways of managing overwhelming emotion. Suicidal content may emerge in challenging negative automatic thoughts, cognitive distortions and core beliefs.
Much systemically driven work is compatible with CBT, particularly some elements of solution focused approaches. It is important to maintain a balance of work with families and individual work. Issues of confidentiality within the individual work will continue to be important.
Differing goals between young people and their families may need to be considered. It is likely that other members of the family will have experienced symptoms of depression. In working with families it may be possible to address these issues or elicit further information that informs the nature of early challenges. The active parental role in therapy, including the evaluation of progress, should not be under-estimated. Placing individual therapy within a conceptualisation that includes family work has implications for services and in some cases more than one therapist may be deemed appropriate.
The following case vignettes are provided in order to exemplify the diverse presentations of depression in young people referred to services and to demonstrate a range of ways in which CBT can be applied. Britta was described as always having been a bright sensitive girl, generally a competent coper in the face of new experiences. At the initial assessment key features were anxiety and depression.
She was only able to sleep with the light on in her room, she was over-eating and had gained weight. Her mood was irritable and tearful although she was not usually badly behaved. Her father had a history of alcohol abuse but contact with him had been maintained. Britta and her mother had moved house and she had had to change school. Subsequently a friend had moved out of the country, the family dog had died and Britta experienced bullying in her new school.
As is usual with children of this age the therapeutic intervention included some individual work with Britta in identifying goals, thoughts and feelings. She had been afraid at the time but was also fearful that her contact with him would be stopped. The majority of the following sessions involved work with mother and child together to help Britta improve communication about her feelings, to increase shared positive activities and then boost self esteem by encouraging age appropriate independence in activities and routines.
The matter of contact was managed after discussion with Britta. Her mother was able to intervene effectively to reassure Britta that contact would continue safely, with the help of paternal grandmother. Adam was referred with a 6 month history of depression following the death of his paternal grandfather. His father was also depressed.
Adam was able to talk about feeling that he had always to succeed and that he should not admit to difficulties. Following this, work with Adam and his father together on core beliefs helped Adam to understand that his father had felt similarly in relation to his own father. His father emphasised the importance that he placed on understanding how Adam felt and that he valued being able to help Adam if he could so needed to know of any problems.
Erica had experienced sexual abuse when age 9 from an adolescent male babysitter. A sexual assault in adolescence led to the onset of depression. Since starting High School Erica had experienced learning and peer problems in school which were exacerbated by recent school absences. Her mother worked full time. She had an older sister and a younger brother both of whom were outgoing and successful at school.
Erica had symptoms of low mood but also frequent headaches and abdominal pain. Individual CBT involved activity scheduling and a typical programme of cognitive work. Erica had no symptoms of trauma but her unwanted sexual experiences had directly affected her self esteem and sense of self worth. Work with Erica and her family focused on reducing conflict and supporting a successful school intervention in obtaining additional help with difficult lessons.
In recent years there has been a significant increase in research activity in the area of depression in children and young people. The focus of research has moved away from establishing the nature of depression in young people to the task of delivering effective treatments.
Child and Adolescent Services
The earliest intervention studies generally involved comparing CBT to no intervention in mild to moderately depressed young people, usually not those accessing clinical services. More recently the emphasis has been on moderately to severely clinically depressed young people and includes use of medication as well as psychological intervention.
This has led to challenges to increase efficacy for the most troubled populations. Thus the current state of research evidence would suggest that CBT for depression has modest effects. There is a need for the further developments taking place in clinical practice to be reflected in research. Practice is evolutionary and interactive, and pragmatic outcome trials play a relatively minor part in this development. This needs integrating both theoretically and clinically in order to be able to be evaluated in research trials.
This may include wider consideration of models for delivery of CBT including group work and computer and new technology applications. Abeles, P. Behavioural and Cognitive Psychotherapy, 37 , — Ackerson, J.
Psychotherapy for Children and Adolescents: Different Types
Cognitive bibliotherapy for mild and moderate adolescent depressive symptomatology. Journal of Consulting and Clinical Psychology, 66 , — Angold, A. The epidemiology of depression in children and adolescents. In Goodyer I. Beck, A. Cognitive therapy of depression. New York: Guilford Press. Birmaher, B. Course and outcome of child and adolescent major depressive disorder. Bogels, S. Family cognitive behavioural therapy for children and adolescents with clinical anxiety disorders. Brent, D. A clinical psychotherapy trial for adolescent depression comparing cognitive, family and supportive therapy.
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Journal of Child Psychology and Psychiatry, 50 , — Clarke, G. Cognitive-behavioural treatment of adolescent depression: Efficacy of acute group treatment and booster sessions. Costello, E. Prevalence and development of psychiatric disorders in childhood and adolescence. Archives of General Psychiatry, 60 , — Delaney, M. A critical evaluation of the role of cognitive behaviour therapy in children and adolescents with depression.
http://mail.maier.de/libraries/fairfield/lease-pull-ahead-deals-ford.php The Cognitive Behaviour Therapist, 2 , 83— Dummett, N. Processes for systemic cognitive behavioural therapy with children, young people and families. Behavioural and Cognitive Psychotherapy, 34 , — Fergusson, D. Archives of General Psychiatry, 62 , 66— Goodyer, I. A community study of depression in adolescent girls: II The clinical features of identified disorder. British Journal of Psychiatry, , — Selective Serotonin Reuptake Inhibitors SSRIs and routine specialist care with or without cognitive behaviour therapy in adolescents with major depression: randomised controlled trial.
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