Why is it important to involve parents/caregivers in CBT? - Chapter 7

What is this chapter about?

Parental factors are often associated with the development of emotional and behavioural problems in the child. Therefore, it is essential that there is parental involvement in the (CBT) treatment of children. However, the way and the extent to which parents are involved is not always that clear. Two factors should always be taken into account: 1) The associations between parental factors and mental health problems in the child are often only modest, and 2) Studies comparing the outcomes of individual child-based CBT to family-based  CBT are not always superiority of the latter. While these findings are subject to methodological limitations, it is important to be aware of the role of parental engagement in CBT.

What are ways to involve parents in the treatment?

Volges Stallard (2005) distinguished four roles of parents during treatment:

1. Mediator: make sure that their child is present and completes the homework assignments, and also attend sessions.
2. Co-therapist: stimulating the use of the skills that are obtained in the treatment in daily life.
3. Co-client: changing parental factors (such as parental behaviours, parenting styles) can also be the focus of treatment.
4. Client: this is when only the parental factors are the focus of the treatment.

In practice, parents often take on different roles at different times during treatment.

What are possible parental influences on the cognitions and behaviors of the child?

There are significant correlations between the cognitive biases of the parents and that of the child, including the (maladaptive) attribution style, dysfunctional attitudes and the tendency to interpret something as threatening. Parents' expectations also play a big role: believing that your child is vulnerable in a dangerous world leads to parental behaviors that promote the development of anxiety in the child. One of the routes on which parents can achieve inappropriate behaviour in the child is through the verbal route (discussing). In addition, the behaviour of the parents also counts as an example for the child. Also the roles of negative reinforcement of aversive behavior (punishment), an inconsistent and strict method of discipline and a lack of warmth towards the child are behaviors that are detrimental to healthy development. Finally, it is important that parents do not stop the child from socializing: socializing is an important part of development.

What common (cognitive-behavioural) vicious circles exist in the family?

An example of a common cognitive-behavioural vicious cycle regarding a child with anxious feelings is as follows:

How are parents involved in the treatment?

If children are willing to be treated and the parents respond well to the child's progress, then it is enough if the parent takes on the role of a mediator. If the child does not want to participate in the treatment due to the problems he/she has, considerably more parental involvement is needed. Parents should also be more involved in treatment if parental factors play an important role in maintaining the problems. For example, sometimes the parent is convinced that the child is still very anxious, while the child has made considerable progress. As a result, the parent can stand in the way of further development.

The nature of the child's problems

When children exhibit difficult behavior and refuse to go to school, parental involvement in treatment is crucial. It is not clear what the influence of the mother is compared to the father (or vice versa). However, it is clear that the child's behaviour improves more when parents are involved and the changed parenting style has a greater beneficial effect when the father is also involved in the treatment (and not just the mother).

Child age

Compared to adolescents, younger children are more dependent on their parents in terms of social support and ratification, which makes parental involvement even more important. Adolescents, on the other hand, are more likely to have conflicts in their relationships with their parents compared to younger children. In general, there is not enough evidence for that family-based CBT is more effective at treating anxiety disorders than individual (child-based) CBT. Remarkably, recent studies have highlighted the positive outcomes of children under the age of 10 with anxiety disorders when only their parents are treated!

The presence of parents with mental health problems

When parents are struggling with mental health problems, the chances of successful CBT treatment are lower. When they are in remission, this reduces the problematic behavior of the child. However, more research is needed to find out exactly what factors need to be addressed in order to achieve a successful treatment when parents also deal with mental problems.

Obstacles regarding parental involvement

Although the degree of parental involvement varies on a case-by-case basis, it is always important that parents understand the rationale behind the treatment, that they are involved in assessing their child's progress and that they encourage the creation of homework assignments.

It is important that there is a partnership between the therapist and the parents. In order to prevent failure, it is important, among other things, that possible obstacles to treatment are explicitly identified and discussed, as well as the expectations of treatment, in order to prevent failure.

What are overarching processes?

There are some overarching processes that make a treatment successful. First, successful CBT requires cooperation. Second, the use of humour can be very useful in reducing tension and conveying difficult messages. Third, the use of metaphors helps to convey a complex or threatening message to parents. For example, a common metaphor is "the Botox face" in which parents have to keep their own emotion hidden from the child so that they learn to control what emotion they want their children to see. Fourthly, supervision during treatment is crucial.

Initial obstacles (prior to their decision to be involved)

Sometimes it comes as a complete surprise to the parent that the therapist expects an active role from him or her. Here are some of the reactions you can get as a therapist:

"I'm not the one with the problem." In this situation, it helps to explain that we do not blame the parent for the problem, but that he/she is the right person to help the child. Their involvement also provides an opportunity for them to learn more about their child's problems and an opportunity to learn how to deal with their child’s problems.

"I'm too busy." The life of parents is often busy and sometimes a therapy should be offered more flexibly, such as in the form of evening sessions or therapy at home. Other times, "I'm too busy" is just an excuse to cover up the fact that the parent feels that he/she is not ready to get involved. This is something the therapist needs to carefully examine.

"I'm not a psychiatrist." Sometimes parents are expected to conduct exposure or behavioural experiments at home. Prior to each "experiment", they should be asked if they think it is OK to do so, and they should be reassured that 1) nothing will be asked of them that could harm the child, and 2) it is not a bad thing if something does not work out.

Subsequent obstacles (after deciding to be actively involved)

Some of the later obstacles that can arise in the course of treatment: changes in mental health of the parents, life events, and a lack of support from the partner.

Other practical obstacles

Due to the existing problems, there is often already a difficult parent-child relationship. This relationship needs to be improved before the parents can be involved. Also, every therapy has ups and downs and the parent needs to be prepared for this. After all, it is not always easy for the parent to trust the therapist. Finally, at the end of therapy, it is necessary to ensure that the therapist does not get all the credits: the parents should be praised for their part and be reassured that they can continue from this point on without the guidance of the therapist. Realistic expectations must be achieved with regard to the development of the child in the coming months/years.

Parental factors are often associated with the development of emotional and behavioural problems in the child. Therefore, it is essential that there is parental involvement in the (CBT) treatment of children. However, the way and the extent to which parents are involved is not always that clear. Two factors should always be taken into account: 1) The associations between parental factors and mental health problems in the child are often only modest, and 2) Studies comparing the outcomes of individual child-based CBT to family-based  CBT are not always superiority of the latter. While these findings are subject to methodological limitations, it is important to be aware of the role of parental engagement in CBT.