How is cognitive behavioural therapy (CBT) provided to children and young adults? - Chapter 3

What is cognitive behavioural therapy (CBT)?

Cognitive behavioural therapy (CBT) is a collective term for all therapies that use cognitive, behavioural and problem-solving approaches. There are many CBT techniques that can be used – in different combinations. Anyway, a CBT session always starts with psycho-education regarding the problem (diagnosis), explanation of the cognitive model and a discussion about expectations of the therapy.

In terms of cognition, dysfunctional (biased) cognitions are identified, examined and then objectively evaluated – the latter often done using behavioural experiments in which an assumption is systematically tested, or challenged with the help of a Socratic dialogue. This helps to create a good basis to achieve functional and balanced thoughts and beliefs. The child is also assisted in developing functional skills (such as adequate coping strategies) and monitoring their own emotion in stressful situations in order to learn to control the intense emotion, for example with the help of relaxation training. Finally, CBT also makes use of behavioural techniques, such as role-playing which can be used to optimize skills and learn to apply them  in everyday life.

CBT therapy is not only based on specific techniques: the therapeutic relationship between a therapist and a child is also an important part of the treatment. Important factors can be remembered by the acronym PRECISE:

• Partnership: therapy is a collaboration between child, family and therapist.
• Right developmental level: the therapy must fit in with the level of development.
• Empathic: the cooperation relationship must be warm and familiar.
• Creative: in a creative, flexible way, CBT is applied to the child.
• Investigative: the therapy is based on guided discovery.
• Self-efficacy: self-efficiency is promoted by building on skills.
• Enjoyable: in order to maintain motivation, the therapy must be liked.

How is CBT provided to young children (<7 years)?

CBT is often considered to be an unsuitable form of therapy for young children (< 7 years), as they are thought to be cognitively insufficiently developed. However, in the first years of life, a child already develops inner speech. At the age of three, they can already distinguish between thoughts and actions, recognize that people can have different thoughts about the same event and already learn that a thought does not have to be an accurate representation of an event.

More and more studies conclude that young children (including children suffering from PTSD or OCD) may benefit from CBT, as long as the therapy fits carefully within the level of development. In order for this to be achieved, a lot of creativity is required from the therapist. For example, using visuals can help children in understanding something. Thus, explaining something purely in verbal terms without using any visuals should be avoided as much as possible. Specific, concrete and well-known examples should also be used as much as possible. Games and dolls or other game characters can also be helpful.

The parents will also be present in the majority of therapy sessions. They are not only there to support the child, but also to learn CBT techniques themselves. In addition, parenting skills are improved (such as encouraging adequate coping strategies). Thus, parents are given tools with which they can help to improve their child's development as much as possible.

How is CBT provided to children between the ages of 7 and 11?

Many RCTs confirm the effectiveness of CBT for children (7 to 11 years), as long as the methods and techniques are in line with the child's level of development at that time. This means that a mix of verbal and non-verbal techniques should be used. With guidance, children can learn to verbalize their own cognitions. In a concrete (situation-specific) way, children are stimulated to convert their 'red thoughts' into 'green thoughts' (red thoughts are ineffective thoughts – green thoughts are effective thoughts). "Catch it, track it, change it" is the specific three-step process that can help a child to identify, evaluate and change a thought. Metaphors are used to turn complex or abstract concepts into concrete situations that are easy to understand. Additional material and visuals are always good to use. Also games, a quiz and/or the use of cartoons (with thought bubbles) can be beneficial for the therapy.

The result of the therapy is not necessarily better when the parents are (routinely, and intensively) involved in the therapy: the same results are also achieved with individual (child-therapist) therapy! However, this does not apply when the parenting style plays a large role in the cause of the child's problems.

How is CBT provided to young adults (between 12 and 17)?

Although it is often assumed that all types of techniques can be used from adolescence (12 years), it is always necessary to take a critical look at the individual level of development. Abstract concepts can be clarified with terms such as 'dark glasses' (in case of depression) or 'pop-ups' on the computer (to make automatic thoughts understandable). Also for adolescents, non-verbal materials (such as diagrams) can be helpful.

At the moment, a lot of attention is paid to the use of technologies in the transmission of CBT. Certain computerised CBT programs (cCBT) are being developed.

By not intensively involving parents in the therapy, the autonomy and self-efficiency of young adults is recognised and emphasized as much as possible. Of course, as noted, this decision is based on a case-by-case basis. Therapy in young adults can be difficult in terms of engagement and motivation. A genuine and cooperative therapeutic relationship is therefore very important. Two aspects of the therapeutic relationship that deserve extra attention are:

• Objective empiricism – being open to critical evaluation of beliefs, assumptions and cognitions – is something that is not standard. The "adolescent" is often convinced of his/her own truth, which could result in a struggle with the therapist when the therapist tries to convince the child that other opinions exist. The therapist should adopt an open and curious attitude in which he/she will critically talk about the child's own vision (Socratic dialogue).
• The cooperation relationship must be established clearly and repeatedly: cooperation is the key word, the therapist is not a "know-it-all"! What works for one doesn't work for the other, and you're going to find out about this together.

What can be concluded?

In summary, this chapter states that the therapist must at all times tailor the treatment (the techniques) to the level of development of the child. Methods and concepts will have to be adapted to different dimensions (simple vs complex, abstract vs concrete) and will be presented using both verbal and non-verbal methods.

Cognitive behavioural therapy (CBT) is a collective term for all therapies that use cognitive, behavioural and problem-solving approaches. There are many CBT techniques that can be used – in different combinations. Anyway, a CBT session always starts with psycho-education regarding the problem (diagnosis), explanation of the cognitive model and a discussion about expectations of the therapy.