Summary of Cognitive Behaviour Therapy for Children and Families by Graham and Reynolds - 3rd edition - Exclusive

What is this chapter about?

Young adults (adolescents: 12 to 17 years) have more anxiety and/or depression problems compared to children. In 50% of adults with anxiety disorders, symptoms begin before the age of 12 – and for 75% of them symptoms are visible before their 21st birthday! Although there has been a lot of research conducted on individual risk factors for mental disorders, there has been little research conducted on development of mental disorders. Therefore, this chapter looks at the biological, cognitive and social changes during adolescence that may be related to the onset of such problems. In other words, the question is: why do so many of the persistent, long-term anxiety and mood disorders start so early in development?

Which environmental factors play a role in anxiety and depression?

Twin studies have shown that environmental factors play a major role in the rise (or rather the absence) of anxious and depressive feelings. Unfortunately, such studies cannot identify exactly what environmental factors are responsible for this. Some of the social factors that are often involved are:

• A single profound, stressful event (such as a divorce).
• Daily stressors within domestic circles (such as a parent-child relationship in which the overprotective, strict mother raises an anxious child).
• Negative interpersonal experiences outdoors (e.g. being bullied at school or at their sports club).

Such factors have a predictive value, but this does not mean that they are always a cause. In addition, anxiety and depression are both associated with a lack of social support that normally acts as a buffer against negative experiences. One drawback of these studies is that these results are only based on children and young adults in the Western world.

More complex twin studies (which unfortunately are also still only focused on Western society) suggest that new individual and environmental factors play a greater role in adolescents (for example, the transition to high school). Adolescents show a greater stress response to performance-oriented stressors during this developmental period compared to younger children. Also, adolescents are spending more and more time with their peers than with their families, which may lead to increasing parent-child conflicts. In general, young adults experience more stressful events, more daily hinderances and new stressors (such as ambiguous social situations).

Which genetic factors play a role during adolescence?

It is not (yet) possible to identify specific genes that affect anxiety symptoms or depression symptoms. Although in adults with anxiety and mood problems it has been implied that they often have a short form of the serotonin transporter gene, this is less implied in children and young adults. But, how could genes have more influence during a certain developmental phase (since DNA is stable over time)?! The answer according to  Gesell's (1932) “Maturationist” theory is that genes that contribute to anxiety and depression can be "turned on"(maturing) by certain experiences throughout development! There are multiple genetic factors and many environmental factors that can (influence) each other to varying degrees: thus there is an interaction between the environment and DNA.

Which changes take place in the emotional and social brain?

The "emotional brain" refers mainly to four brain circuits: the amygdala, the striatum (caudate, putamen and nucleus  accumbens – have to do with detecting emotions, especially fear), areas that become active when anticipating and experiencing rewards, and areas of the prefrontal cortex (PFC) that regulate emotional responses through complex processes (such as decision-making). The "social brain" refers to a circuit that partially overlaps with these areas, including the amygdala, because there is also an emotional component of social activities. Other – typically "social" areas – are associated with social cognition, such as understanding other people's perspective or recognizing faces. During adolescence, compared to younger children and adults, there is increased subcortical activity, both in the amygdala and the striatum. In particular, the amygdala is more active in adolescents with anxiety and mood problems. Although the subcortical structures mature early, the PFC is not yet fully matured (thus there is less white matter compared to adults). The PFC could normally regulate this strong/increased reaction of the amygdala. Both the function (such as the strong activation of the amygdala and  striatum) and the structure of brain regions (such as the immature PFC areas) are therefore partly responsible for the way emotional and social information is processed in adolescence.

Is there a bias in information processing?

Anxiety and depression are often associated with biases in cognition. Children and young adults with anxiety symptoms have an automatic bias and thus more attention for threatening information (attention-orientation bias), which also leads them to have more difficulty turning away from such information (attention-checking  bias). Although it is a little more complicated for depressed children and young people, in both types of disorders individuals tend to quickly label information as "threatening". Mood symptoms are also associated with a memory bias for negative information. Other cognitive biases include a negative/dysfunctional attribution style (success is due to external factors; failure is due to the person's own (internal) factors), dysfunctional attitudes, and negative interpersonal  cognitions. As children age (and enter adolescence), the interaction between life events and a negative attribution style plays an increasingly important role in the development of depressive symptoms. Other cognitive biases also become more stable and cohesive as children enter adolescence.

What can be concluded?

There are multiple age-related  changes during adolescence that occur when anxious and/or depressive symptoms first emerge. Recent studies use  cognitive bias modification (CBM) techniques that try to correct cognitive biases: this is how patients learn to shift their attention away from negative things and to assign positive interpretations to (ambiguous) information.

Young adults (adolescents: 12 to 17 years) have more anxiety and/or depression problems compared to children. In 50% of adults with anxiety disorders, symptoms begin before the age of 12 – and for 75% of them symptoms are visible before their 21st birthday! Although there has been a lot of research conducted on individual risk factors for mental disorders, there has been little research conducted on development of mental disorders. Therefore, this chapter looks at the biological, cognitive and social changes during adolescence that may be related to the onset of such problems. In other words, the question is: why do so many of the persistent, long-term anxiety and mood disorders start so early in development?

What is this chapter about?

What works for whom, and why? In particular, a lot of research has been conducted into the question: what is the impact of a particular treatment compared to a) no treatment, and b) other types of treatments?

What makes a treatment effective?

It is difficult to pinpoint the factors that make treatments effective, due to the following factors:

• When a child's mental health improves after treatment (correlation), it does not mean that the treatment is the cause ("correlation ≠ causation").
• After all, it is also possible that the improvement is due to a third (confound) variable, through psychosocial development and/or by spontaneous recovery.
• Regression to the mean: it is very likely that someone who initially reports many problems will automatically mention fewer problems later on. This also applies to questionnaires taken shortly after each other.
• Selection bias of individuals who are treated or not treated, as opposed to those who stop treatment halfway through, can lead to an incorrect and misleading high proportions of "effective" treatments.
• Specific and nonspecific effects of treatments are sometimes difficult to distinguish.

Currently, two approaches are used to assess the outcomes of a treatment: RCTs, and to analyse routinely collected results (using data from databases).

What are RCTs and how is data analysed from big databases?

RCTs are seen as the most powerful source of evidence ("the gold standard"), because the researchers here also take into account other influential factors besides treatment. This allows them to assign the differences found to the treatment and therefore be able to equate treatment with causation, thus resolving the first factor. By randomly dividing the subjects into groups, any unknown third variables are distributed fairly. A common criticism about RCTs is that the people who participate in such studies are not necessarily representative of clinical practice: they often have less serious problems than participants that really suffer from mental disorders.

An additional method to evaluate treatments is through the use of routinely collected results from large databases. Symptom scores obtained before and after treatment are compared. If someone would use this method only, the absence of random assignment of participants is a big problem. This problem can be solved by using data from RCTs or from studies that use a naturalistic control group.

A major advantage of analysing outcome data compared to an RCT design is that it also gives the possibility of analysing processes that cannot be easily and ethically manipulated or randomly classified, such as engagement and therapeutic alliance.

How can we decide if an outcome is clinically significant?

Whether the data comes from RCT or from naturalistic studies, it is always difficult to determine what is sufficient as a meaningful (clinically significant) outcome. After all, a statistically significant outcome is not always clinically significant. Some researchers have developed indices to address this. The two most commonly used methods are:

• Look at recovery: This means that symptom scores from before treatment were (too) high, and the scores are lower/average after treatment.
• Assessing reliable change: analysing the amount of change that can be attributed to the treatment.

Which criticism is there on the evaluation of treatments?

Although, on the one hand, there is a lot of interest in making the routine evaluation of a treatment a standard part of clinical practice, there is also a lot of criticism. Many therapists do not want to use standardized questionnaires to evaluate the impact of treatment. There are several reasons for this, for example 1) because they feel that this method of evaluation cannot capture complexity, 2) because this is an administrative burden which limits the time for personal contact with the client, 3) because the data can be used for purposes that are not in the client's interest (where any reported improvement can lead to dismissal of care and refusal of (further) services).

What about outcomes?

Previously, routine evaluations of treatments were obtained from one or more questionnaires completed by the therapist. However, this is not very helpful, since therapists have their own styles. Therefore, the focus is now more on PROMS (patient-reported outcomes) or PREMS (patient-reported experiences). Teacher reports can also be useful, as teachers can accurately observe externalizing symptoms (such as aggression). However, they cannot properly assess the internalizing symptoms (such as anxiety). Parent reports can also be useful. Although there is a bias (because they are also unable to properly assess the internalising problems and/or assess their child from their point of view), it can be helpful when the children are too young to complete reports on their own.

It is recommended that therapists collect data from multiple persons (at least from the child him/herself, the parent/caregiver and the therapist) with the greatest value attached to the reporting of the child. What is annoying is that in general (in less than 75% of cases) there is no agreement between the perspectives of the child, the parent or the practitioner in terms of the problems for which help was initially sought.

When determining the outcome, it is necessary to carefully determine the domains that are evaluated (e.g. symptom reduction, improved functioning at school or at home), since improvement in one domain does not guarantee improvement in another domain.

The first measurement of a domain takes place when the child first enters the therapy. The second measurement takes place at a time that is predetermined, for example at the end of treatment, or six months after treatment. The problem here is the low response rate of people at the second time of measurement: the data that is missing from the second measurement is not random and therefore implies a systematic difference between two groups. According to Clark and colleagues (2008), people who do not submit data to the second measurement have often not been involved (enough) in the treatment or are somehow dissatisfied with the treatment, which will result in conclusions of these unfair dates resulting in an overestimation of the "effectiveness" of the treatment.

How is information obtained from outcome analyses used for practice?

What can we do for practice, with the information obtained from outcome analyses? In principle, there are three possibilities:

1. For example, if therapists looked at the data qualitatively, they could find out which techniques are generally related to a better outcome (for example, when patients feel that they are being listened to).
2. Follow an individual's trajectory: during each session, the progress is mapped and feedback is given about the session. If there is no change after, say, five meetings, according to Miller and colleagues (2006) it makes sense for another therapist to be deployed to prevent a bad outcome and drop-out.
3. Use a bundle of outcome data for benchmarking: results can also be compared (e.g. annually) between institutions.

How are academics and practitioners brought together?

According to the authors of the book, there are three promising ways to better analyse therapies for children and young adults:

1. Analysing individuality in terms of change trajectories. When evaluating psychotherapies, the average changes of groups are often looked at. As a result, actual effects on certain subgroups may be over- or underestimated. In addition, there is also often a lot of variation within (sub)groups in terms of, among other things, reported improvement. Thus, instead of a top-down approach (group), a bottom-up approach (individual) might be a better way to determine the actual effects of a therapy.
2. Analysing more nuanced models of processes and outcomes. Due to the enormous focus on (wanting to develop) causal models for specific diagnoses, there is little attention on more nuanced models about change processes and outcomes. In such a nuanced model, the focus is on networks of symptoms that are determined by multiple factors and also influence multiple factors. By mapping such networks (links and interactions with symptoms) – at an individual or group level – more insight can be obtained into the areas in which change is possible. An example of this story is the development of personalised methodology: although pen-and-paper questionnaires are still the norm, there is increasing attention to online questionnaires. A major advantage of online questionnaires is that the questions can be extracted from an item bank, and that the selected question depends on a previously given answer.
3. The further development of the links between academics and practitioners. Practitioners should be more aware of the results found by academics, and vice versa.

What works for whom, and why? In particular, a lot of research has been conducted into the question: what is the impact of a particular treatment compared to a) no treatment, and b) other types of treatments?

What is this chapter about?

CBT is by definition a very dynamic collaborative process in which the therapist and the client jointly create insight into how the current problems have arisen and how they are maintained. This insight – the wording – is often written down, but can also be conveyed verbally. It explicitly mentions the links between the "four response systems" (cognitive, emotional, behavioural and physical) in the current problem situation and it explains how these responses are related to the underlying beliefs about the self, about others and about the world. Every stressful situation elicits a response in each of the domains. This formulation is gradually built up by Socratic dialogues to promote a guided discovery in which the therapist only accompanies the client. The client thus finds out not only the vicious circles in his or her life that cause or sustain the problems, but also thinks about his or her own strengths and resources. When CBT is used for children (under 18) it is essential to also include the developmental, attachment and family, contextual and cultural factors in order to meet the unique needs of each child. Pragmatically, primary physical and emotional safety must also be met before trying to address the "higher processes".

What is the traditional structure of individual CBT treatments?

Clients learn to understand how a response in one system may affect elements in other systems, leading to a disproportionate magnification of symptoms. In the treatment, the client is as actively involved as possible.

Which CBT treatment structures suit children, families and the wider system?

Many psychologists try to simplify the model of the “four response systems” of CBT when they want to use it in children. However, it is essential that, after simplification, all four systems are still involved! When using CBT in children, a systematic approach should also be employed. In other words, the child's system (parents, siblings and the wider system such as school, hobbies and boyfriends, girlfriends) should also be considered. The child is central to this (see an example of such a systematic CBT treatment structure in the figure in the book). The direct complaints, wishes, thoughts, emotions and behaviours of the most involved persons in the immediate proximity of the child (usually the parents) and any major life event, which may have helped to shape the child's underlying beliefs, are therefore also incorporated into the formulation of the problem. Thus, the child and the parents are asked to formulate a problem list: what do you think are problems and how serious do you think they are? They are also asked: What are the changes you're hoping for? This explicitly highlights the differences in problem perception and reveals the motivation for change. This structure is never presented to the child in all its complexity at once. Nevertheless, this is the starting point of the treatment. This is always a gradual process and proceeds in accordance with the child's level of development.

Processing development, insights from other psychotherapies and adhesion processes in the formulation

Developmental problems and biologically intrinsic difficulties are also included in the formulation. Here it is always important to emphasize and encourage the strengths and attempts of the child to improve something. In the case of a child with ADHD, the primary defect, in child A, for example, is the impulsive behavior, can be identified together with other perpetuating or strengthening factors such as parental cognitions or behaviors. Unrealistic expectations and the consequences of this can therefore also be mapped. Due to the dynamic and empirical nature of the formulation, this is by definition an integrative approach, incorporating insights from other psychotherapies. Attachment-related factors can also be reflected in the formulation, through observation of attachment-related behaviors and affect – which are mediated  by cognitions – on each of the four systems and from there, among other things, address selective perceptions, unrealistic expectations, assumptions and the standards of the parents.

What is meant by four systems?

To this day, there is little scientific evidence that can tell us for which populations and clinical patients systematic CBT interventions are effective. Therefore, the practitioner has to assess this on a case-by-case basis.

Systematic CBT is always based on the four systems. Self-reflection and guided discovery are both strongly stimulated by the use of Socratic dialogues and empirical research (including recent event analysis). There are four possible applications of the systematic CBT:

1. Only with the child (individual): In the case of such individual sessions it is important to help the child change their focus, because they often enter the room with a very internal focus (e.g. guilt). Many systematic factors can be well mapped by the child himself, which can then serve as the basis for family sessions.
2. With the child and the parents/carers: Parents can be involved in therapy as mediators, co-therapists or as clients (see Chapter 7). Pragmatic factors and the formulation determines which role is appropriate.
3. With the whole family: Socratic recent events analysis of both recent problems and recent positive events form the basis of a systematic CBT treatment in which the whole family works together. To ensure that the family members drop their natural defence mechanisms, there must be a trusted and safe therapeutic relationship. In this way, all perspectives and problems can be discussed, with which constructive work can be done. Everyone is asked to reflect on their own and other people's experiences and reactions. It must be remembered that the emphasis is not only on person who should change!
4. With the broader system: This helps to when multiple organizations are involved. Involving all of these organizations can help to improve the child’s outcomes.

Integrating developmental factors, attachment factors and family and wider system factors into CBT treatment for children, young people and families has many advantages, as it helps children and families to (better) understand things and discover the possibilities for change.

CBT is by definition a very dynamic collaborative process in which the therapist and the client jointly create insight into how the current problems have arisen and how they are maintained. This insight – the wording – is often written down, but can also be conveyed verbally. It explicitly mentions the links between the "four response systems" (cognitive, emotional, behavioural and physical) in the current problem situation and it explains how these responses are related to the underlying beliefs about the self, about others and about the world. Every stressful situation elicits a response in each of the domains.

What is this chapter about?

In the sequel, the abbreviation BME will refer to people with a "black and minority ethnic" background. Most psychotherapeutic interventions are developed for and applied to (white) people with a Western culture: are such interventions equally suitable for, and effective in, people from different cultural backgrounds? In terms of accessibility and appropriateness of the services provided, many assistive institutions are well suited to Western culture, but not to the needs of BME populations.

What is cultural competence?

Cultural competence of the therapist refers to the therapist's ability to successfully involve BME children and their families in interventions. The diversity within a BME group must of course always be recognised.

What is the effectiveness of CBT in BME children and families?

CBT is often routinely used in adults from BME groups, sometimes in a culturally adapted form. These include ethnically matching the therapist with the client, transferring the therapy into the client's mother tongue, translating material and taking into account the client's cultural norms and values. Custom forms of CBT are at least as effective, sometimes more effective, than the unadjusted form. They are especially more effective with clients who have not made the (Western) culture their own and when the language of the therapist and client do not match. Certain specifically developed programs for parents from BME groups can provide benefits in terms of increased engagement and a higher percentage of people completing treatment.

How can the involvement and effectiveness of the intervention be increased?

The variations in identities and cultures within populations (based on social class, sexuality, and the like) emphasize the heterogeneity in cultural experiences. Therefore, the authors of the book argue not for a culture-specific approach of the therapist, but for a process-specific approach. Two examples of process-specific models are the model of Hays (2009) and the work of Falicov  (1995). Such models provide a  framework for the therapist to work with ethnically different target groups. For example, Hays's model (2009) called "Ten Steps to Cultural Competence" emphasizes that the therapist should know about culturally determined "respectful behavior", that he/she should use culture-related strengths, have examined the cultural environmental factors and cognitive factors, and that he/she emphasizes that the treatment is about cooperation, and not about confrontation.

Within the cultural competence, the overall competence in forming a therapeutic relationship with the client is to be able to analyse and formulate the experienced problems and the ability to convey the intervention. In addition to essential qualities such as empathy, warmth and sincerity, the importance of a respectful, non-judgmental and collaborative attitude in working with clients of BME populations cannot be overstated. Also consider the "little things", such as appropriate forms of greetings (first name or last name, handshake, eye contact?). In terms of analysing and formulating the experienced problems, the client's perspective should be the main focus and the focus should be on the current problems which are decided on together. However, the client's standards and values may differ significantly from those of the therapist, and the therapist should not try to "convince" the client to apply other standards and values. After all, everyone is unique. According to Rathod and colleagues (2010), it is therefore important to jointly determine what is functional for the client within his/her culture, given his/her standards and values.

A common problem in BME populations is that the (younger) child (through schooling and dealing with peers) adapts much more quickly to the (Western) culture than the parents. Especially during adolescence, in which Western children emphasize independence, this can clash violently. It is important that the therapist does not align himself with the adolescent (since his values are closer to the therapist's own norms and values) and thus reject the parents. Try to find safe middle  ground – make compromises, which are in the interest of the child's psychosocial development.

In a thorough analysis and formulation of the problems of children and families of BME populations, it should not be forgotten to also address protective factors. Adapting to a new culture obviously takes a lot of stress, but there are also related factors that reduce this stress:

• BME clients often have a broader and deeper social network for support.
• Bi-cultural competence is beneficial for the child: many people are afraid of a "culture clash", but it is often true that children who grow up in two worlds are better at seeing different perspectives and beliefs.
• A strong and secure ethnic identity, like certain religious beliefs, is related to a great psychosocial adaptability.

Outside the therapy room

Therapists tend to focus on interactions and events within the therapy room and not on the whole system/context. It is important to think about the structure of our health services and the obstacles in terms of engagement, effectiveness and accessibility of children and families with BME backgrounds. The Building Bridges project was set up to increase the involvement and accessibility of support for BME groups. For example, it was discovered that a non-pathologizing and solution-oriented therapy was preferred, with an emphasis on the client's own vision of the problem, his/her strengths and the way he/she thinks that change can take place. The Fathers and Sons project was set up to meet the needs of a specific group, namely the Somali, Yemeni and Black British fathers and sons whose relationship suffered greatly from the generational differences and the experiences of migration, discrimination and bi-cultural life.  

What can be concluded?

It is clear that cultural values and beliefs are an essential component of working with children and families with a BME background. In addition to working according to a process model, it is also important for therapists to think about specific approaches for specific BME groups. The following questions are important: who determines which intervention is used and how therapists are trained? What are goals? In order to arrive at answers, it is essential that this group of service users and the wider community is involved.

In the sequel, the abbreviation BME will refer to people with a "black and minority ethnic" background. Most psychotherapeutic interventions are developed for and applied to (white) people with a Western culture: are such interventions equally suitable for, and effective in, people from different cultural backgrounds? In terms of accessibility and appropriateness of the services provided, many assistive institutions are well suited to Western culture, but not to the needs of BME populations.

What is this chapter about?

Sexual abuse in children is defined as the use of power (emotional, physical or psychological power) to engage a child or adolescent in behaviors in which he or she must touch or look at sexual body parts, when it is inappropriate for age, uncomfortable, or against the child's will. 1 in 4 women and 1 in 6 men experience sexual abuse before the age of 18.

What is the impact of sexual abuse?

The long-term impact of sexual abuse includes a greater risk on post-traumatic stress disorder (PTSD), depression, substance abuse, suicide, multiple medical problems, interpersonal problems, and premature death. In the short term, PTSD and affective, behavioural, cognitive and social or school problems may also arise. While each case is unique, there are some shared factors:

• Generalized triggers for flashbacks. Example: being abused in the private bathroom leads to fear and panic in every bathroom/toilet room. Abused children relive the trauma, leading to evasive behavior.
• Abusers often train children to accept the sexual abuse. Example: by slowly getting the child to get used to an uncomfortable feeling, the perpetrator always goes one step further (buying presents, watching TV, cuddling, sex). This reduces the likelihood that the child will resist, and will give the child the idea that he/she was partly responsible.
• Developing dysfunctional cognitions: there are always cognitions regarding guilt and responsibility in relation to the abuse.
• Teaching inappropriate behavior: abused children receive positive feedback from the perpetrator for their behavior, leading to sexualized behavior.

What are predictive symptoms of sexually abused children?

Some moderating factors – factors that already exist before sexual abuse took place and cannot be changed (such as age) – predict the degree of symptoms after the abuse. Mediating factors – factors from the time of sexual abuse – also determine the symptoms. Examples of mediating factors are the trauma-related  cognitions, feelings of guilt, parental stress caused by the abuse and the support of the parents. Trauma-focused CBT (2) is designed to identify 1) various symptoms of sexually abused children, 2) identify mediating factors, and 3) develop effective treatments.

What does TF-CBT mean?

Before the therapist decides to start treatment, there is a careful analysis: is the sexual abuse a relevant focus for treatment? Are there other traumas? There should be at least one standardized assessment to assess the initial trauma symptoms and evaluate the impact of treatment. TF-CBT is suitable for children from three years of age with (at least) one traumatic experience. They should also be experiencing significant trauma-related problems. Parental involvement is not required in treatment, but the best results are achieved if a parent also participates (if of course he or she has not been involved in the trauma). It is suitable for children from all kinds of cultural backgrounds and for children with intellectual disabilities. Involvement of the child in the treatments is crucial. The trauma is obviously the focus of the treatment (not the externalizing problems), and this is something that should be explained mainly to the parents. Often parents/children are afraid of treatment. Going to therapy then feels like going to the dentist: it seems scary and painful, but is ultimately the best treatment for a particular problem.

Gradual exposure is an important part of treatment. For example, during the TF-CBT, the child and parent are gradually becoming more and more exposed to things that remind the child of the trauma and the child is trained in achieving better coping skills to the point that he or she can tell the trauma as a story (narrative trauma). Each component of the TF-CBT must be gradually built up/transferred.

What are the PRACTICE components of TF-CBT?

• Psycho-education and parental component: During the whole treatment, the therapist should give realistic information about the trauma, in this case sexual abuse. After the abuse, parents should not drastically change their parenting style, but provide appropriate structure and rules.
• Relaxation techniques such as concentrated breathing and progressive muscle relaxation, are taught to apply in situations where the child experiences physical sensations by thinking about the trauma. Other forms of relaxation are determined by the child (sports, reading, crafting, listening to music).
• Affect-modulating (emotion-regulation) skills can be applied after the child is able to experience feelings, rather than suppress them. Some of these skills include: seeking social support, finding distractions, doing self-reassuring exercises, and learning problem-solving skills.
• Coping mechanisms: as a therapist, try to guide the child in discovering other possibilities, for example "what do you think might be another reason your friend didn't want you to come over? And how would you make that feel or behave if that were true?" Learning adequate coping behavior is the only component that does not directly address the memory of the trauma!
• Trauma as narrative and its processing: the child is encouraged to tell a story of the experienced abuse. This can be stimulated by reading from such a book after which the child is asked to tell his/her story. Chapter 1 is about the child himself (what are the hobbies, what are the name of the school, what about the family in each other, etc.). Chapter 2 deals with the relationship between the offender and the child before the abuse. Chapter 3 discusses the specific trauma, in which the child is encouraged to give details about his or her thoughts, feelings and physical sensations. This story is shared with the parent(s) in a parallel individual session.
• Learning to control things that remind the child of trauma is a process that should not be stopped halfway through, otherwise it reinforces the trauma!
• Involving parents takes place in the last 2 to 3 sessions in which at least one of the four things take place:

1. the child tells about his or her story
2. the child talks about trauma-related  aspects
3. parents and the child talk about healthy sexuality (appropriate to age), and/or
4. planning how to proceed in the future

• Improving safety and the future development is encouraged by talking about general safety and safety for the child specifically. Sex education or (preventive) information about bullying can be part of this. The safety plan must be appropriate for the age and for the living environment of the child.

What empirical support for TF-CBT exists?

There is a lot of empirical support for the short- and long-term benefits of TF-CBT in terms of alleviating PTSD, depression, anxiety, feelings of guilt and behavioural problems. It is suitable for all kinds of traumas, in children from three years of age and of all kinds of cultures. Internationally, it is especially recommended for children with PTSD, and especially for those who have experienced sexual abuse.

Sexual abuse in children is defined as the use of power (emotional, physical or psychological power) to engage a child or adolescent in behaviors in which he or she must touch or look at sexual body parts, when it is inappropriate for age, uncomfortable, or against the child's will. 1 in 4 women and 1 in 6 men experience sexual abuse before the age of 18.

What is this chapter about?

Children suffering from chronic pain experience continuous pain or recurrent pain for at least 3 months, which can fluctuate in severity, quality, regularity and predictability. Often they have had many consultations with other professionals. Many chronic pain syndromes involve back pain, abdominal pain and headaches. This chapter focuses on the last two. Chronic pain is a complex problem which, and according to the biopsychosocial model, it consists of three components that cause and maintain the pain experience: a biological component (the physical, the genes, the age, the sex, the temperament), a psychological component (anxiety, former pain experiences, learned pain behavior) and a social component (cultural influences, pain behaviors of others around you, reactions of parents and/or peers).

What does the psychological analysis of chronic pain mean?

In analysing chronic pain, many things need to be mapped:

• Symptom description (where, how long, how intense, how frequent?).
• The triggers (what exacerbates the pain?).
• Its course (when did it start, and how did it go from that point?).
• Behavioural aspects (learning factors?).
• Pain processing (what are the cognitions, emotions and behaviours in pain situations?).
• The role of stress and personality (how does the pain relate to these two factors?).
• Clinical trials and diagnoses (medical background, medication?).
• "Self-therapy" (what has already been tried to treat the pain?).
• Pain in family members (are there other family members with chronic pain?).
• Environment (what is the role and perspective of people in the environment?).

Keeping a pain diary is essential. Other self-report tools (such as assessment scales) can also provide insight into the subjective pain experience. In addition, there are also self-reporting tools for the child that are used for analysing the psychopathological symptoms, the impact on their social life, and the quality of their life. Since sleep disorders are also often part of chronic pain syndromes (Palermo et al., 2011), this should also be mapped. Therapists should focus not only on the child's pain experience, but also on the perspectives of the parents by looking at their assessments. The therapist should also determine what the behaviour of the parents is, so how do they behave when their child is in pain? What does this mean for ‘operant learning’? Operant learning means that if a child is sick and gets a lot of attention when he or she is sick compared to when he or she is happy, he or she might start to feel like that its good to be sick.

How does CBT work for children and adolescents with chronic pain?

Common CBT intervention techniques used to treat chronic pain are relaxation techniques or hypnosis, cognitive or behavioural interventions, biofeedback, acquiring pain management techniques in a situation with acute pain (e.g. in case of a migraine attack), and cognitive-behavioural strategies.

These techniques focus on self-management skills and the development of active coping strategies. The age of the child also determines the specific intervention and the degree of parental involvement. If there is parental involvement, their behaviour (in pain situations) also needs to be determined. The purpose of CBT is:

• To identify and then modify factors that trigger, aggravate and maintain the pain (in both the child and the parent).
• To develop adequate pain management techniques.
• To increase the child's self-efficacy.

In addition, each intervention contains psycho-education about chronic pain and a unique model of the specific pain syndrome is developed from a biopsychosocial perspective.

How is CBT used to manage chronic headaches and abdominal pain?

The prevalence of chronic headaches increases with age, and more girls than boys suffer from it. The most frequent types of (primary) headaches in children and adolescents are migraines (with and without aura, i.e.: focal neurological symptoms) and tension headaches. A typical feature of migraine (besides vomiting) is the pulsating quality of the medium to severe headache on only one side of the head. A migraine attack lasts between 4 and 72 hours. Tension headache is mild to moderate, lasts from minutes to days and is just bilateral (and without vomiting). It is important to pay attention to preventive pain management techniques and pain management techniques in situations of acute pain, as the negative consequences of headaches on the quality of life and the healthy psyche are often underestimated. There are also gender differences in chronic abdominal pain as more girls than boys suffer from this, especially between the ages of 13 and 15. If there is no underlying cause (which is often the case), this is called functional abdominal pain (this includes irritable bowel syndrome). Sometimes children and parents are very frustrated because no organic cause can be found. This frustration needs to be taken into account for further treatment. There is empirical support (based on three meta-analyses) for the effectiveness of CBT in treating chronic headaches and abdominal pains.

What is the role of computer-based CBT for chronic pain?

There is increasing attention to self-help programs for effective and preventive CBT. While this is an innovative, efficient and cost-effective alternative to face-to-face sessions (especially in rural areas), it also has drawbacks.

For example, it is more difficult for the therapist to notice alarming symptoms (such as indications of suicidal behavior), and technical defects can make communication more difficult. Since parental involvement may be necessary, they must also be willing and able to use such technologies.

Children suffering from chronic pain experience continuous pain or recurrent pain for at least 3 months, which can fluctuate in severity, quality, regularity and predictability. Often they have had many consultations with other professionals. Many chronic pain syndromes involve back pain, abdominal pain and headaches. This chapter focuses on the last two. Chronic pain is a complex problem which, and according to the biopsychosocial model, it consists of three components that cause and maintain the pain experience: a biological component (the physical, the genes, the age, the sex, the temperament), a psychological component (anxiety, former pain experiences, learned pain behavior) and a social component (cultural influences, pain behaviors of others around you, reactions of parents and/or peers).

What is this chapter about?

Although the majority of eating disorders – anorexia nervosa (AN) and bulimia nervosa (BN) – begin in adolescence and persist during adulthood, surprisingly little research has been conducted on the effectiveness of interventions for adolescents with eating disorders. In particular older adolescents suffer from eating disorders. Bryant-Waugh and Lask (1995) state that 10% of the children they refer to are under the age of 14.

People suffering from AN show extreme weight loss, refuse to maintain healthy body weight, and have abnormal cognitions that lead to huge overestimations of the importance of body shape and body weight. These cognitions express themselves in a huge fear of gaining weight and a continuous preoccupation and dissatisfaction with their own shape and weight. Food intake is limited, laxatives are abused and excessive exercise are typical behaviours. Although amenorrhea (the absence of menstruation) is a diagnostic criterion of AN, the relevance to the diagnosis is questionable. Children with AN also often have difficulty staying hydrated.

BN is characterized by recurring periods in which a lot is eaten (loss of control), which is then "compensated" by activities that prevent gaining weight (such as vomiting yourself, using laxatives, or fasting). As in AN, there is a huge overestimation of (and preoccupation with) the importance of body shape and weight. People with BN often feel guilty and ashamed. Unlike AN, BN is sometimes difficult to diagnose, because the people who suffer from it are often at average body weight.

What scientific support for the effectiveness of CBT exists for adolescents with eating disorders?

There is some evidence that individual CBT treatments are effective for adolescents with BN, but there is no evidence yet for the effectiveness of CBT for adolescents with AN. In the latter case, CBT did not seem to be more effective than any other therapy (such as dietary therapy or parental counselling). Theoretically, CBT should be effective, as there are abnormal cognitions that lead to abnormal behaviors. Thus, more research is needed as to why it does not seem to be effective.

What does cognitive behaviour theory mean?

There are many cognitive behavioural models made of AN. In summary, predisposing factors – including individual vulnerabilities, general environmental influences and environmental influences related to diets, body weight and body shape – lead to the development of core beliefs and assumptions. These beliefs and assumptions, when activated by a so-called "critical incident", result in the development of thoughts and behaviors as we see them in people with eating disorders. See the figure in the book for an example of this process. This figure shows that in young people, these thoughts and behaviors are perpetuated by a number of factors, including behavioural factors, factors related to self-starvation, avoidance-related factors, family factors, social factors and emotional factors.

What is an analysis and formulation of eating disorders?

In any case, the initial analysis should map the following things: the current symptoms of the eating disorder, the history and course of the eating disorder, comorbid disorders and associated problems, physical health, information about their family, the individual’s development, their career, their social functioning, and positive characteristics. When developing the formulation, the therapist should not discuss too complicated matters, and present ideas/hypotheses (and not claim that these would be the "absolute truth").

Some additional considerations that the therapist should take into account are the physical (starving) condition and associated risks, the ability to maintain a curious attitude (without exerting pressure) and  boosting of the adolescent's involvement and motivation (as it is often the parents who want the child to get better; not the child him/herself). Thus, parents should sometimes be highly involved in the treatment.

What does the treatment of eating disorders consist of?

It is important to be transparent about the therapy, and to explain when and why confidentiality will be violated. The child/adolescents also needs to be told that some parts of the treatment cannot be changed, such as weighing. As a therapist, you need to stay interested in the person and want to understand his/her experience. At the beginning of treatment, the child should first be stimulated to regain a normal diet, and in the case of AN, to regain weight. The extent to which the family is involved depends on the diagnosis and severity of the disorder. In addition, it is important to set common goals as early as possible in the treatment. Explain to your client why you as a therapist can't help to achieve unhealthy goals, such as losing weight. Often, the person can often name targets they want to change that are not directly related to the disorder. Furthermore, it makes a lot of sense to schedule an "information meeting" at the beginning of the treatment in which psycho-education about eating disorders is provided. Finally, the client's motivation is very important. Motivation consists of two parts: the desire to change and confidence in that you can change. Motivational interviewing (MI) can be very useful in boosting the intrinsic motivation to change, by detecting and addressing ambivalence (contradictions). Since the level of motivation (the need and the confidence) can fluctuate very much, this is something that needs to be determined. It is advisable to let the client indicate on a scale of 0 to 10 how motivated she is at the beginning of each session. This allows the therapist to determine whether too little motivation is something he/she needs to deal with. Some motivation-related techniques are as follows:

1. The child creates a list of the pros and cons of changing the eating disorder. They will see that most of the benefits they cite ‘not changing the eating disorder’ are beneficial only on the short term.
2. Let the child write two letters to the eating disorder: one as a friend of the eating disorder, and one as an enemy. This provides insight into how the eating disorder hinders them in their lives and strengthens the bond with the therapist.
3. Ask the child about long-term plans: where do you want your life to be in one year (given school, friendships, relationships, family life, health, self-esteem, leisure and hobbies)? And what will it be like if you still have an eating disorder then?

Self-monitoring helps the child to identify thoughts, feelings and behaviors that cause stress and that sustain the behavior. This can be done by keeping a journal or a diary.

But, how can a therapist deal with compensatory behavior, such as vomiting and the use of laxatives? In this case, information should be given about the negative physical consequences and it should be explained that this is not an effective way to lose weight (this changes their motivation). Both behaviors lead to weight loss in the very short term, but the body recovers once it is sufficiently hydrated again. Excessive sporting, on the other hand, is more difficult to change. It is maintained by 5 factors: compulsion, behavioural rigidity, psychological dependence on sports for the mood, perfectionism, and of course the concerns about weight and body shape. The assumptions and beliefs associated with sports should be carefully addressed. Behavioural experiments are often very useful in testing predictions of assumptions and beliefs. Both planned and unplanned behavioural experiments can bring about more cognitive, behavioural and emotional change than just verbal cognitive techniques. Questionnaires can be used to test what the client thinks other people think is important (for example, to test the assumption "boys only find skinny girls handsome"). Another experiment is a discovery experiment: do something you never normally do, and see what happens. A hypothesis-testing experiment tests the validity of a specific belief. A therapist should think about the most appropriate behavioural experiment for each client.

Food, body weight and body shape determine to a large extent how the person thinks about themselves. Normally, things like sports, school, family and friends also play a big role, but in patients with an eating disorder this is completely out of balance. Together with the client, create a pie chart of the factors that contribute to self-esteem (see page 216 and 217). Then explain to the client that she does put all her money on one horse (all attention on one domain), which puts her under a lot of pressure and if something goes wrong within that domain, the person feels bad. Their goals are often unattainable, with a high likelihood failing. Then create a second pie chart that represents the ideals of the young person: what would be their best type of life? Then build bridges between these two diagrams.

People often say they feel "fat." However, "feeling fat" is not an emotion, so learn together to correctly identify the feelings in order to get to the heart of the feeling. Perfectionism is a huge factor in eating disorders. In this case, delve deeper into the advantages and disadvantages of perfectionism, address the sustained behaviors, tackle their beliefs and cognitive styles, and look at the history of this perfectionist behavior. In the context of relapse prevention, it is useful to identify what has been effective during treatment. Based on this, a plan can be made about how the client can deal with future risky situations.

Although the majority of eating disorders – anorexia nervosa (AN) and bulimia nervosa (BN) – begin in adolescence and persist during adulthood, surprisingly little research has been conducted on the effectiveness of interventions for adolescents with eating disorders. In particular older adolescents suffer from eating disorders. Bryant-Waugh and Lask (1995) state that 10% of the children they refer to are under the age of 14.

What is this chapter about?

Experiencing a traumatic event can lead to several psychological problems, such as anxiety, depression, behavioural problems, substance abuse or post-traumatic stress disorder (PTSD). According to the DSM-IV-TR, one can be diagnosed with post-traumatic stress disorder (PTSD) if, as a result of such an event, there are persistent symptoms for at least one month (because most people spontaneously recover within about a month). For example:

• Re-experiencing the traumatic event (for example through flashbacks or nightmares).
• Avoiding the things that remind the child of the trauma or emotional dulling, in which the child generalizes the triggers.
• Increased physiological arousal (difficulty falling asleep or staying asleep, getting angry very fast, difficulty concentrating, being extra alert).

Young children often experience less of symptoms 1 and 2 as described above. That is why there are special criteria for young children. These criteria focus more on observing and reporting behavioural symptoms by people who regularly interact with the child.

82% of young people suffering from PTSD have a comorbid disorder. There are three possible causes that explain this high comorbidity:

1. Some factors – such as poor family function or unsafe attachment style – are risk factors for developing both PTSD and other psychological problems.
2. Comorbid psychological problems can be secondary to PTSD (for example: being depressed due to PTSD). This is supported by the fact that the comorbid disorder often improves through the PTSD treatment.
3. The comorbid disorder can sustain the PTSD.

What does the cognitive model of PTSD mean?

Meiser-Stedman's cognitive model of PTSD in children and adolescents (2002) shows how PTSD develops, how it is sustained, and how interventions can help. Problems associated with PTSD are often persistent because of the nature of the traumatic memory, or because of the significance attributed to the event, or by both.

Brain and colleagues (1996) introduced the term VAMs – verbally accessible memories, to refer to memories of normal autobiographical events. VAMs are coherent reminders and can be called up on purpose, can be updated (or manipulated) with new information and involve concepts of time and place. In a situation of extreme stress, the balance shifts from a conceptual to a perceptual processing, making the memory qualitatively different from a VAM. Such memories are called SAMs – situationally accessible memories, and are stored in terms of incoherent images, sounds, smells, tastes and physical sensations. SAMs are easily triggered and brought to consciousness when the person does not want these SAMs. Memories are often deliberately suppressed. SAMs don't involve the concepts of time and place that makes it feel like it's happening right now (so it feels more like a memory). The development of PTSD is associated with a vicious circle in which the memory imposes itself, followed by stress and a deliberate suppression of the memory, while this suppression of the memory naturally leads to the memory being more frequently imposed.

There is also an ‘adopted world’ in which there are assumptions or beliefs about three things: the world (how it's supposed to work), about other people and about yourself. These assumptions are often unconscious, unspoken and are often automatic. Through these glasses, events are observed and given meaning. After a trauma, many people revise their "adopted world", so that there is a good fit between this and the traumatic event: something Horowitz (1986) calls the ‘completion tendency’. In this way, previous, helpful assumptions are replaced by negative beliefs. For example, in the case of an attacked teenager:

• The world is safe, except at night -- the world is unsafe.
• Most people are good at heart, only some are not -- others are bad.
• I'm strong and safe -- I'm vulnerable.

This can also be incorporated into a cognitive behavioural formulation, in which the four systems: thoughts ("when I go out, I am attacked), feelings (anxiety), physical reaction (arousal) and behavior (staying indoors) interact, and – can be strengthened by the family that encourages him/her to stay indoors – lead to the three beliefs as above (the world is unsafe, others are bad, I am vulnerable).

The vicious circle regarding "vicarious avoidance" is as follows: the parents think that talking about the trauma will make the situation worse, so they do not bring it up. The result is that the child will think that no one wants to talk about it, and therefore does not bring it up himself. While the parents assume that everything is okay because the child does not bring it up, the SAM remains unprocessed. This avoidance limits the child's ability to process the memory properly and to re-evaluate trauma-based beliefs.

How does the analysis of PTSD symptoms take place?

If a child has experienced interpersonal trauma, it is difficult for the child to trust others (such as the therapist). A careful formulation should be made so that 1) the child and the parents learn to understand the stress and problems, 2) the comorbid problems are mapped, and 3) there is a guide to the intervention. If a comorbid depression maintains the avoidant symptoms of PTSD, then the depression may need to be treated first. If symptoms of depression are the result of PTSD, then the PTSD must first be treated.

Sometimes there is a court case: it can make the situation more complex, but does not have to rule out treatment!

Questionnaires and structured interviews are useful additional sources of information in order to evaluate certain areas in a systematic and quantitative way.

How can PTSD be treated?

Because of its high comorbidity, PTSD cases are often very complex. Developing, revising and implementing a formulation and intervention plan is necessary for effective CBT treatment. This formulation is a "story" in which the different sources of information about the person, his/her experiences and the problem (how did it arise and what sustains it) connect. It's not just a list of factors, but it explains how these factors affect the problem. The wording also reveals specific targets for the intervention, resulting in a direct intervention plan arising from this formulation. According to Persons (1989), sharing the wording with the client and the parents has a number of positive effects and purposes: making sure that it is a good fit with the client's experience, communicating that the therapist has listened carefully, declaring that their reactions to the traumatic event are natural and that there is not something "fundamentally wrong" with them, and explaining the rationale for the intervention that will increase motivation. The wording can be explained verbally, but often help diagrams. See p. 1. 244 for a template for a formulation. When someone close to the child has died and this is part of the experienced trauma, the trauma of death and other PTSD symptoms can hinder the grieving process. In this case, children must first be guided in processing the experience of death, before they can process their loss.

An effective intervention contains a combination of three components (Ehlers & Clark, 2000): reducing avoidant strategies, changing the traumatic event (reviving) to form a coherent narrative of the event (narrative exposure), and developing a meaning that is both true and useful (cognitive restructuring). It is important that the child and the parents are well prepared for this, given the intensity of the treatment. First of all, there must be stability and security, and systematic work must be done. Both of these have an impact on each other and serve together as the basis for a healthy therapeutic context/relationship in which the therapist is calm, confident, clear and collaborative. Finally, the therapeutic relationship serves as a platform for the development of individual sources. Individual sources include learning to regulate emotions using emotional recognition, self-talk, relaxation techniques and problem-solving skills. Only then one can progress to the other three components:

1. Reduce avoidant (coping) behavior. Avoidant behavior is the most important perpetuating factor in most anxiety disorders, including PTSD. This avoidance often generalizes enormously. Spending one or more sessions on the child gradually in vivo – in the flesh – exposing a dreaded situation (therapist and child or therapist, child and parents) is often the best remedy.
2. Narrative exposure. The purpose of this component is to create a coherent, verbal reminder of the experience, by evoking the memory in a safe therapeutic context. To process a traumatic memory, it must be properly and consciously revived and thought through, as a story with a beginning and an end. This is not a popular part of the treatment, but by explaining why this works, motivation can increase. There are several metaphors that you can use for this. An example of this is the chocolate factory metaphor: a chocolate factory uses different ingredients to make a chocolate bar, after which the ingredients are listed on the outside. This can only be done if all ingredients are in balance and ready to be processed. We know what each bar (memory) means because of the words on the outside (the story about all feelings, thoughts, touches etc.): we experience it from a distance. Two other metaphors are the wardrobe metaphor and the paper waste bin metaphor (see page 248 and 249). There are several methods to use: drawings or dolls, but also writing are good ways to revive the child's memory. You can also share an A4 in four quadrants: "my life before the event", "the worst part of it", "my life since the event" and "my wishes for the future". All in all, the sensory elements should become less clear than the words, and the story prevails.
3. Cognitive restructuring: the same cognitive restructuring methods used in other disorders can also be used for PTSD.

As for its effectiveness, this extract has already stated that there is a lot of empirical support for the effectiveness of TF-CBT.

Experiencing a traumatic event can lead to several psychological problems, such as anxiety, depression, behavioural problems, substance abuse or post-traumatic stress disorder (PTSD). According to the DSM-IV-TR, one can be diagnosed with post-traumatic stress disorder (PTSD) if, as a result of such an event, there are persistent symptoms for at least one month (because most people spontaneously recover within about a month).

What is this chapter about?

Obsessive compulsive disorder (OCD) is characterized by at least one irrational obsession (intrusive thoughts, images associated with a lot of stress) or compulsion (routine behaviours or mental acts that a person has to perform to feel good again), but often both are present. The first symptoms are often visible in childhood. Between 1% and 3% of children and adolescents suffer from OCD. Clinical interviews, questionnaires, mapping of the overall psychosocial functioning and functioning of the family are all part of the diagnostic process.

Both CBT and drug treatments based on SSRIs (selective serotine reuptake inhibitors) are effective in treating OCD in young people. CBT is the first choice of treatment. In children and adolescents, the obsessions are often aggressive, and obsessions are more likely to be sexual and religious in adults. Depending on the level of development, each child will experience and describe symptoms differently. Since children are more oriented in the present, they are often less motivated to perform difficult tasks that will be beneficial on the long term. The extent to which the family adapts to their child's disorder (participating in rituals, promoting or tolerating difficult situations) is associated with the severity of symptoms and the degree of clinical restrictions. Because often one parent is more involved in the disorder than the other and deals with it in a different way, this is often a source of a lot of relational stress.

How does OCD develop in young children?

There are several factors that contribute to the development of OCD in young people:

• Genetic vulnerability: In childhood OCD, the genetic factor (primary family) plays a greater role than in adulthood.
• Negative life events can trigger OCD.
• Parenting style: at least one parent of a child with OCD often has difficulty expressing warmth/affection, is overprotective, and/or demanding. Parents have less confidence in their child's skills, use less positive problem solving techniques and very little promote their child's independence. The stress experienced by the parents through the OCD is associated with the intensity of the symptoms and the degree of internalizing and externalizing problems.
• Psychopathology in the parents: it is difficult to determine whether this is the result of having a child with OCD, or whether this is partly a cause of the OCD in the child. In any case, this will maintain the OCD in the child and should be included in the formulation. These parents clearly use more cognitive and behavioural avoidance strategies than healthy parents, which automatically promotes such strategies in the child.
• The family often plays a major role in tolerating their child's OCD and excessive involvement in the expression of symptoms. It is therefore not uncommon for parents to have their own OCD symptoms which they can model to their child.

What is comorbidity?

As many as 80% of all children with OCD have a comorbid disorder, another disorder than the OCD. This often involves a comorbid anxiety disorder, usually a GAD, a social phobia or a SAD. When there is comorbidity, there are also conflicts within the family than if a child only suffers from OCD. In addition, depression is also a common comorbid disorder: up to 45% of children with OCD suffer from depression (leading to more severe OCD symptoms and more social problems). Thus, this means that these disorders do not exist in parallel, and that there is interaction between the disorders.

What is CBT with ERP?

CBT, which works with "exposure and response prevention" (ERP) has proven effective in children and adolescents. It is not only symptom reduction, but also about improving functioning in the social domain, at school and within the family.

ERP is based on the learning theory that states that OCD is maintained by: avoiding feared situations, or by "neutralizing" any perceived hazard. In other words, the child will try to avoid the situation, and if this fails or cannot be done, then the child will deal with the fear by exhibiting certain behaviors which reduces the chance of something terrible happening (such as repeatedly washing their hands) or neutralizing the fear (for example, by counting up to 100). These behaviors lead to a direct reduction of anxiety, which promotes repetition of these behaviors. However, such avoidant or neutralising behaviours do not teach the child that the fear is not so bad in reality. ERP guides the child in confronting the feared situation, without being allowed to neutralize the fear. This requires a lot of motivation/perseverance from the child. ERP is therefore associated with a high level of drop-out. Therefore, behavioural aspects of ERP are implemented in the CBT treatment, and ERP is not a treatment on its own.

What are models of OCD?

According to several CBT models, OCD is mainly triggered and maintained by the child's conviction about their obsession, and their consequent response.

1. Inflated responsibility – Salkovski's model of OCD (1999). They state that the child feels overly responsible for preventing harm to himself and/or others.
2. Thought-Action-Fusion or TAF – Rachman's model of OCD (1993). Rachman argues that there are two types of TAFs underlying OCD: TAF Morality (having the intrusive thought about unacceptable behavior is morally equivalent to expressing that behavior), and TAF-Probability (thinking about a bad situation will increase the likelihood that it will happen).
3. Meta-cognitive beliefs – Well's and Papegeorgiou's model of OCD (1998). They say that obsessive thoughts are interpreted negatively because of the metacognitive beliefs about their meaning or its terrible consequences.

These models were initially developed to apply to adults with OCD, but are also all applicable to children with OCD. All models state that misinterpreting cognition is the most important perpetuating factor. In children, however, it is often the emotion and physical sensations that they misinterpret as being harmful or unacceptable.

Derisley and colleagues (2008) developed an OCD model called the "OCD staircase". This vicious circle shows how OCD is maintained and is very useful to use in practice, because it is easy to understand for children (and parents). The circle originally consists of four aspects: the obsession (and the meaning), the resulting fear, the successive compulsion and the resulting relieved feeling in the short term. For example: the door may not be locked so someone can enter (obsession) and I am responsible for their safety (meaning of the obsession). That this leads to fear, the coercive act and a feeling of relief speaks for itself. The relieved feeling reinforces the feeling that the child is responsible for safety. Derisley and colleagues assume that fear is the primary emotion, but children often indicate that it is an uncomfortable feeling, or some kind of irritation, frustration or anger, rather than fear. The vicious circle including the meaning of the emotion then consists of five aspects:

• The obsession (the chair is not straight).
• The emotion (an uncomfortable feeling, frustration).
• The meaning of the emotion (this feeling never goes away, I cannot sleep).
• Coercive act (straightening the chair).
• Feeling relieved in the short term.

This vicious circle can be extended with a semi-overlapping second vicious circle when there is a comorbid disorder (see page 283, Figure 18.4).

What are the challenges of working with young people with OCD?

According to Canavera and colleagues (2009), parents often report more severe OCD symptoms than their child (who sees the symptoms themselves as less severe). Therefore, it is often the parents who seek help for their child. If this decision is not made in accordance with the child, it will of course not benefit the involvement and motivation of the child in the treatment. Especially with the CBT for OCD symptoms it is important that the child is highly motivated, because he or she will have to do things that are very stressful and the thoughts discussed in sessions are often private and shameful for the child to discuss. To increase the child's involvement, the child may be asked to keep a diary so that he/she can see how much time the OCD is swallowing. Psycho-education can help to normalize the child's experience, so as to show that they are not unique or bad because they have annoying thoughts. This also teaches them that the intrusions are just thoughts, and so the therapist can create a healthy distance between the child and his/her thoughts. Furthermore, it teaches the parents that their behavior is likely to sustain the OCD. However, older adolescents who are more likely to experience sexual or shameful obsessions keep this as private as possible, leaving parents to not notice much of the OCD. In this case, the child and the therapist must carefully decide whether the CBT takes place on an individual basis or whether the parents are involved.

Parental involvement in the CBT has proven to be effective in adults with OCD, however, only a handful of studies have been conducted onto the effectiveness of this combination in children. The authors of the book argue that the formulation of the treatment should be drawn based on family factors.

Despite the obvious successes of CBT in the treatment of OCD, there remains a significant group of young people who do not respond to treatment. This subgroup probably developed OCD at a very young age, has a significantly deteriorated level of functioning, more severe symptoms and more comorbid problems. Their OCD is likely to become chronic. New theoretical models and associated treatments for this group should be at the top of the list for researchers in this area.

Obsessive compulsive disorder (OCD) is characterized by at least one irrational obsession (intrusive thoughts, images associated with a lot of stress) or compulsion (routine behaviours or mental acts that a person has to perform to feel good again), but often both are present. The first symptoms are often visible in childhood. Between 1% and 3% of children and adolescents suffer from OCD. Clinical interviews, questionnaires, mapping of the overall psychosocial functioning and functioning of the family are all part of the diagnostic process.

What is this chapter about?

Behavioural disorders are characterized by persistent antisocial behaviour in children and adolescents and occur regularly, in 5% of the population. In the DSM-IV-TR, ODD (oppositional defiant disorder) is a separate disorder; in the ICD-10, ODD is a subtype of behavioural disorders. A behavioural disorder often persists into adulthood and is related to crime, drug and alcohol abuse, and unemployment, among other things.

Since behavioural disorders are accompanied by a huge cost to the government, it is important to take preventive action. For this, a disorder 1) should be noticed early, 2) be preventable or can be quickly reduced with the help of interventions, and 3) in most cases develop further into a more severe disorder.

In addition to the cost, it is also important to tackle behavioural disorders preventively, because the current approach does not produce the desired result. This is due to the following five facts:

1. Only a quarter of people who meet the ODD/behavioural disorder criteria receive specialized help.
2. Most current treatments are not proven effective.
3. The treatments that have been proven effective are effective in the "lab" and not in practice.
4. Many children and families receive treatment only later in childhood or adolescence, when the chance of a positive outcome is less.
5. Most children-health centres are only meant for children who have been referred: there are few routinely delivered prevention programs.

In order to make a prevention program more than a theoretical concept, there must be recognition of the problem at government level (national level) and for possible solutions. The American Institute of Medicines (1994) has developed a classification on prevention levels:

• Universal prevention is for the entire population of a specific area.
• Targeted prevention is provided for specific groups.
• Targeted selective prevention is aimed at children with a general risk factor, such as poverty, or being a (single) teenage mother.
• Targeted indicated prevention is aimed at children who are already showing the first signs/symptoms, such as aggressive behaviour at school.

Prevention can also be classified in other ways, such as timing. This refers to the development period in which the intervention takes place: prenatal, childhood, infancy, infancy, primary school age or adolescence.

There are many factors associated with the onset of behavioural disorders. According to Moffitt and Scott (2008) there are no less than 24! This includes intra-individual factors (genetics, temperament, insecure attachment pattern, reading difficulties), family functioning (lack of warmth, inconsistent discipline, violence between parents), and social factors (being bullied, poor school, unsafe neighbourhood). Treatment (preventive or curative) should focus on as many factors as possible that are known to have influence.

Some current treatment programs offered at group level are not only ineffective, but can also backfire! It is therefore important that there is sufficient supervision in group treatments to prevent the promotion of anti-social attitudes and behaviours.

What are examples of effective programs?

Programs aimed directly at the child

Anger management is a treatment program that can be offered at the individual or group level. It is base on the assumption that aggressive children cannot properly recognize their emotions, that these children hold false beliefs about the effectiveness of aggression, and quickly become emotionally aroused when they find themselves in a situation they see as threatening. The best known preventive anger management program was developed by Lochman (2011) and is called Coping Power. This consists of five steps:

1. Identify the problems and the emotional responses.
2. Analyse the possible intentions of the other party.
3. Come up with possible solutions to the conflict.
4. Analyse the short- and long-term consequences of each solution.
5. Make a plan and execute it.
6. Evaluate the effectiveness of the plan and learn from it.

Limitations of anger management programs are as follows: some children simply do not want to do this, in addition there are few therapists who have the necessary set of skills, and some children do fine in the therapy room but cannot yet control their anger when they are actually faced with a difficult situation out of the therapy room.

Programs aimed at parents

The parenting style plays a huge role in behavioural disorders, which is why many parenting programs have been developed. These parenting programs are very effective in the prevention of behavioural disorders. The programs based on social learning theory are the most effective. The best-known targeted selective prevention program is that of Olds and colleagues (2007) and is called Nurse-Family Partnership. Expectant mothers who are at risk (because they are poor, or a teenager) are visited at home by a sister before the child is born, and then regularly for two years. Three goals are:

1. To promote maximum prenatal health, for example by helping the mother to quit smoking;
2. To stimulate the health and development of the child by making parents more competent in their care for the child;
3. To improve the life course of the parent(s) by making future plans (with regards to education, future pregnancies, etc.).

The most commonly used targeted prevention program was developed by Webster-Stratton and Reid (2010) and is called Incredible Years. See p. 1. 316, Table 20.2 for all components that contain an effective program. Webster-Stratton and Reid's program (2010) consists of four parts:

1. Make it a child-focused treatment: play!
2. Reinforce the desired behavior of the child: provide compliments and rewards!
3. Provide clear punishments/rules: be the boss in a calm, clear way.
4. Reduce unwanted behavior of the child: be consistent in punishing. The consequences of the unwanted behaviour must be appropriate and only in the short term (not: a month no TV)! Ignoring the child is an effective technique! Also a time out works very well (1 minute for each year of life).

Programs for teachers and schools

On a universal level, Social and Emotional Learning (SEL) programs are aimed at developing five competencies (all of which consist of a cognitive, affective and behavioural component): self-awareness, self-management, social awareness, skills for entering into and maintaining relationships, and making responsible decisions. When the child has the SEL competencies, a shift takes place: instead of being controlled by external factors, the child learns to act in accordance with the internalized beliefs and values. The most widely used SEL program was developed by Domitrovich and colleagues (2007) and is called Promoting Alternative Thinking Strategies (PATHS). In weekly sessions at school, children are stimulated with the help of stories and role-playing games to identify their emotions and to learn how to deal with difficult situations in a problem-solving way.

Programs that combine multiple approaches

Combinations of certain approaches, such as combining a training for the parents with a social skill training for the child, can be very effective.

What problems arise in practice during the implementation of prevention programmes?

According to Nation and colleagues (2003), there are nine qualities of prevention programs that actually make these programs effective in practice:

1. Completeness: use combinations of interventions, partly to stimulate the skills optimally. Focus on the individual, the family and also the school. Address risk factors and increase or stimulate protective factors. All in all: ensure a treatment that is complete in the broadest sense of the word.
2. Variation in learning methods: Use multiple learning methods with an emphasis on building skills.
3. Adequate dosage: do the interventions last long enough and are they intensive enough?
4. Base the treatment on explicit theoretical models.
5. Foster positive relationships with others.
6. Note the right timing: 1) the problem may not yet be fully developed, so the trajectory can still be affected, 2) pay attention to the child's level of development.
7. Ensure sociocultural relevance.
8. Evaluate the outcome of the treatment.
9. Provide training and support for the employees.

Behavioural disorders are characterized by persistent antisocial behaviour in children and adolescents and occur regularly, in 5% of the population. In the DSM-IV-TR, ODD (oppositional defiant disorder) is a separate disorder; in the ICD-10, ODD is a subtype of behavioural disorders. A behavioural disorder often persists into adulthood and is related to crime, drug and alcohol abuse, and unemployment, among other things.

What is this chapter about?

While there are several factors that hinder young people's access to CBT (such as misdiagnoses and stigmas), the biggest problem is that the demand for CBT for children is much greater than the availability of therapists. As a result, only a small proportion of needy children receive the necessary help. Low-intensity treatment methods could increase accessibility.

Why should we use low-intensity CBT treatment methods?

Low-intensity CBT treatment methods increase accessibility by improving cost-effectiveness, reducing geographic barriers, and/or reducing the treatment burden for patients. Thus, so-called "low intensity CBT", as opposed to "high intensity CBT" – contains at least one of the following characteristics: less input from the therapist per patient, integrating communicative technologies into CBT treatment, and/or transferring the CBT by therapists trained in low-intensity therapies.

Which low-intensity CBT treatment methods exist?

Four low-intensity CBT treatment methods will now be briefly discussed: self-help interventions, group-based CBT, telephone-based CBT and video calls.

Self-help interventions

Self-help interventions are treatments that can be performed independently, or with minimal support from a therapist. These can include books and manuals, audio recordings, DVDs or computerised therapies. The following can be created with regard to self-help interventions: pure self-help (PSH) or guided self-help (GSH). In PSH, there is no involvement of the therapist at all. In GSH, the therapist can offer support or guidance during face-to-face sessions, but also through phone or e-mail. Most of self-help treatments are based on the CBT. More and more studies argue that such treatments are clinically effective and also cost effective. In general, studies on the effectiveness of such programs in children and adolescents can be broken down into programmes that 1) are directly aimed at the child, and 2) programmes to help the child but directed at the parents.

Although little research has been done on the effectiveness of GSH, studies suggest that this is a promising method for adolescents with mental health problems. According to Schmidt's and colleagues’ RCT study(2007), GSH is one step ahead in terms of accessibility, treatment costs and outcome compared to family therapy. According to other studies, GSH is effective in managing mental health problems, with a medium effect size. Young people often have a very positive attitude towards such self-help methods.

Significantly more research has been conducted onto the self-help methods in which parents are the group that are focused on when the child exhibits disruptive behavior. Both GSH and PSH can then be effective to reduce disruptive behaviours of the child. Behavioural parenting programs are the most powerful interventions for families, especially when the child is under 9 years of age. Positive interactions between parent and child are stimulated, and inconsistent or compulsive parenting styles are addressed.

In the context of anxiety disorders, PSH does show potential for families with anxious children. What is more definitive is the effectiveness of GSH in treating an anxiety disorder in the child (Creswell and colleagues, 2010).

Group-oriented CBT

Over the last ten years, a lot of research has been conducted to evaluate group-oriented CBT. Group-oriented CBT is promising, especially in the treatment of anxiety disorders. According to Manassis and colleagues (2012), group-oriented CBT is even as effective as individual CBT in treating anxiety disorders, but more research is needed to really say something about this relative effectiveness. A side note is the subgroup of children with social anxiety: this can be a problem within the context of group-oriented CBT. This can be solved by dedicating sessions specifically to social anxiety, and not to a heterogeneous group of anxiety symptoms. These studies do involve the parents to some extent in the treatment, since group-oriented CBT works better for anxious children when the parents are involved.

Parenting programmes are very effective in preventing behavioural disorders (see Chapter T) but also in treating them, even when offered in a group. Some studies even say that it works better if they are offered in groups (for example, Cunningham and colleagues, 1995).

Telephones and video-calls in CBT

CBT sessions over the phone, or telephone CBT, have the same structure as traditional (face-to-face) sessions. In the context of telephone CBT in parents of children with various disorders (such as ADHD, ODD and anxiety disorders) telephone CBT has been shown to be effective, and it is expected to be as effective as personal CBT! Video-calls are also effective in treating depression or anxiety disorder, according to two recent studies, including that of Storch and colleagues (2011).

What can be concluded?

There are some things that can be concluded in terms of low-intensity CBT. First of all, the amount of evidence on the efficiency, effectiveness and cost-effectiveness of parent-based interventions (interventions aimed at parents) for the treatment of behavioural disorders in their child is particularly high, as it is a relatively new area. In addition, a great deal of effort is made to develop new methods to transfer such low-intensity CBT. Finally, the therapeutic experiences of patients are still positive, especially the experiences of young people, as self-help and the new modern ways in which this can be conveyed (by telephone, videoconferencing) are easy and flexible. According to Bennett-Levy and colleagues (2010), there is a "revolution in health care" because of the emergence of these low-intensity CBT interventions.

While there are several factors that hinder young people's access to CBT (such as misdiagnoses and stigmas), the biggest problem is that the demand for CBT for children is much greater than the availability of therapists. As a result, only a small proportion of needy children receive the necessary help. Low-intensity treatment methods could increase accessibility.

What is this chapter about?

Mindfulness-based interventions, or mindfulness training, are referred to as MFT. MFT is an umbrella term for all forms of such interventions, such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). MFT for children and adolescents with psychopathology is growing rapidly and worldwide. For adults, there is a medium effect size of MFT on psychological health and stronger effect sizes for MBCT for anxiety disorders and depression. The research on (the effectiveness of) MFT for children and adolescents is still in its infancy. The studies were carried out within three psychopathologies: autism spectrum disorders (ASD), internalizing disorders (anxiety and mood) and externalizing disorders (ADHD, ODD and [other] behavioural disorders).

How does MFT work for children and adolescents with an ASD?

According to the ToM hypothesis (Theory of Mind hypothesis), people with an ASD have difficulty in understanding others’ mental states, which may explain the flaws in social interactions (such as little empathy). MFT improves the ability to express empathy. Very little research has been done on the effectiveness of such an intervention – only one study conducted by Singh and colleagues (2006) (in which only three children were included) shows modest but promising results.

How does MFT work for children and adolescents with internalizing disorders?

In most anxiety disorders, attention problems play a (major) role. Think of the attention bias for threatening stimuli, the self-focused attention, the low concentration as a symptom of GAD, and the avoidance of social cues in a social anxiety disorder. According to Semple and colleagues (2005), mindfulness-based techniques can already be taught to children from the age of 7. According to an RCT by Semple and colleagues (2010), MFT leads to a reduction in attention problems, behavioural problems and anxiety symptoms. According to another study (no RCT) by Biegel and colleagues (2009), MFT is a promising addition to outpatient health care for adolescents with mood disorders, to reduce levels of anxiety, depression and somatic symptoms and to improve self-esteem and quality of sleep!

How does MFT work for children and adolescents with externalizing disorders?

Externalizing disorders such as ADHD, ODD and behavioural disorders all have the characteristics that there are problems in attention and impulsivity. MFT can help to fix these attention problems.

An important challenge is that studies on the effectiveness of MFT for children and adolescents with psychopathology have many methodological flaws, such as very small samples, few objective outcome measurements (they mainly use self-reports), a lack of measurements that can really notice changes in the underlying mechanisms of the disorders, and also a lack of RCTs! Almost all supporting evidence now comes from pilot studies or uncontrolled studies.

How does MFT work for children with ADHD?

It is clear from the following that new treatments for ADHD are needed. Currently, there are two evidence-based treatments for children with ADHD: medications, and behavioural treatments. The long-term effect of medications is still unclear, there are often side effects, and treatment loyalty is often low. The most commonly used behavioural treatment is to train the parents in their parenting style. However, part of ADHD is hereditary and the training does not affect this. CBT treatments for ADHD are not empirically proven: coping skills and other skills learned are often not permanent in the long term and generalization of the learned skill of the therapy setting to other settings is often low. Mindfulness training is promising: it focuses on the core problems of ADHD, namely the prolonged focus of attention is addressed directly (by focusing attention on breathing, or the body), and an impulsive response is inhibited (by seeing thoughts as thoughts, and not as the beginning of an action).

The program of the authors of the book is Mindfulness Training (MFT) for children with ADHD and parallel mindful parenting (MP) for their parents. The program consists of eight group sessions of one and a half hours with 4 to 6 children (between 9-12 years) or 6 to 8 adolescents (between 13-17 years) diagnosed with ADHD, and eight parallel group sessions for the parents (presence of both parents is best), with one follow-up session 8 weeks after the training.

What are the eight sessions of MFT for the child?

• Session 1: The Martian male. In the first half hour the children, parents and trainers are in one room and do the "weather forecast" for 2 minutes, i.e., meditating while sitting and focusing on how they feel (and talk about this in one or two words afterwards). Then the "raisin exercise" in which everyone talks about what they see, hear, feel, smell, and taste during meditation. The third half hour is used to increase motivation. Then parents and children split up and the session for the children involves stretching, breath-focused meditation, setting group rules and providing psycho-education.
• Session 2: At home in our bodies. The general structure of sessions 2 through 7 is as follows: a short sedentary meditation, repeat the theme of the previous session and what has been learned, introduce and learn the new theme, discuss the homework done and provide new homework. The theme of this session is to learn to listen to one's own body so that the child becomes aware of restless moments (the body is an alarm clock), but also how this awareness can help him or her to concentrate.
• Session 3: Breathing. The theme "breathing" teaches children what happens to their breathing in case of hyperactivity or intense emotions, and how this can be controlled so to calm down.
• Session 4: Distractors. This theme revolves around both external distractors (such as noise) and internal distractors (e.g. tired), and how meditation can help to stay focused.
• Session 5: Highway, sidewalk. The first 20 minutes involve the parents and the children together, so they perform the sedentary meditation together. Everyone is given a moment to talk what they have learned so far. "Highway" refers to the times when the child feels uncontrollable, "sidewalk" refers to the way focused breathing can lead the child off the highway and into quieter lanes.
• Session 6: What we learned. All central concepts are reflected in a quiz. In this session, the ‘seeing-meditation’ is also introduced (follow a soap bubble) as well as the ‘hearing-meditation’ (listen to the meditation bell).
• Session 7: Practice with difficult situations. In these sessions, meditation is practiced when all kinds of difficult situation occur (such as, when there is a mountain of candy in front of the meditating child).
• Session 8: And now alone. Most of the sessions involve both the parents and the children. Six meditation sessions are performed together, in which the child learns the meditation together with the parent. Also, each child will learn what the parent has learned, and the parent will learn what the child has learned. Each family also creates a plan for meditation exercises for the next eight weeks (until the follow up session).

Does the parallel session of mindful parenting exist for parents?

In mindful parenting (MP) parents learn the following things:

1. To be fully aware of the here-and-now with your child, in a non-judgmental way.
2. Take good care of yourself, as this is the basis for a good upbringing.
3. Accept your child's problems.
4. Be careful to deal with difficult behaviour, rather than reacting impulsively/automatically in difficult situations.

What can be concluded?

Mindfulness trainings combined with MP are promising. A warning is in place in the case of MFT in children with anxiety disorders. CBT programs for anxious children are often twice as effective as CBT treatments for adults, so it's not clear whether MFT is as effective within this context as a CBT treatment. CBT treatments for depression in children are less impressive, and given the success of MFT for treating depression in adults, it is a good idea to develop such programs for children with depression.

Mindfulness-based interventions, or mindfulness training, are referred to as MFT. MFT is an umbrella term for all forms of such interventions, such as mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT). MFT for children and adolescents with psychopathology is growing rapidly and worldwide. For adults, there is a medium effect size of MFT on psychological health and stronger effect sizes for MBCT for anxiety disorders and depression. The research on (the effectiveness of) MFT for children and adolescents is still in its infancy. The studies were carried out within three psychopathologies: autism spectrum disorders (ASD), internalizing disorders (anxiety and mood) and externalizing disorders (ADHD, ODD and [other] behavioural disorders).