What is a developmental approach?

Cognitive behavioural therapy in developmental perspective

Thomas O’Connor and Cathy Creswell

Institute of Psychiatry, London, UK

Studies showing the effectiveness of cognitive behavioural therapy (CBT) for children have proliferated in recent years. Findings from these investigations provide clear evidence that CBT is an effective clinical tool for treating some of the more common psychological disorders in children and adolescence, principally anxiety and depression (Kendall,1985; Harrington et al.,1998). Given that this first essential hurdle has been cleared, attention can now be directed towards two follow-on questions: what are the mechanisms underlying effective treatment and how do we understand the inevitable variation in treatment response? This chapter addresses these latter questions by appealing to developmental theory and research relevant to social cognitions and psychological disorders in children and adolescence.

The aims of the chapter are to outline why a developmental model of CBT is needed and how one might be constructed; to review illustrative findings from research on children’s social cognitions and the extent to which CBT with children is informed by this research; to identify some of the obstacles blocking greater synthesis of developmental and clinical research relevant to CBT with children; and to draw implications for assessment and interventions.

3.1 What is a developmental approach?

Before considering what a development perspective can add to the practice of CBT with children, we first need to assess what it is. A developmental approach as applied to CBT with children can be characterized by several distinct features.

A core consideration is the carrying forward of effects and the mechanisms involved, or, in other words, the nature of continuities and discontinuities in development. More broadly considered, psychopathology has been defined in

Cognitive Behaviour Therapy for Children and Families, ed. Philip J. Graham.

Published by Cambridge University Press.
^C Cambridge University Press 2004.

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terms of the individual’s development trajectory and whether it has veered off a normative developmental course (e.g. Bowlby,1988). In other words, rather than (or perhaps in addition to) viewing psychopathology as a constellation of symptoms, it can be assessed according to the ability of the individual to meet the developmental challenges, such as the formation of positive peer relations in middle childhood. In terms of assessment, the focus should be not only on symptom expression but also on the individual’s developmental course and pro-jection of likely further disturbance. There are also implications of this approach for conceptualizing treatment. So, for example, prevention and intervention studies showing sustained or even continued improvements in children’s adjust-ment after treatadjust-ment (Barrett et al.,1996; Silverman et al.,1999) may be seen as the intervention altering the child’s developmental trajectory and not simply reducing particular symptoms.

A second feature of a developmental approach as applied to CBT is to identify what it is about the children’s developmental phase that might moderate treat-ment response or the way in which the intervention is delivered. The alternative (i.e. ‘adevelopmental’) position is that there is nothing specific about the child’s cognitive, linguistic or social development that is pertinent to the delivery of the intervention or to understanding its effects. Few would accept this latter notion, although it is a hypothesis that is often not considered directly and rejected. So, for example, does the same kind of CBT intervention have different effects when delivered to children in different phases of development? If so, what accounts for these differences? Compared with mid-adolescents, do younger children need a form of CBT that makes less use of cognitive structuring? This would be the case if, for example, anxiety in younger children were not mediated by cognition/

language (e.g. Prins,2000).

More broadly, we might ask a parallel set of questions concerning the expres-sion of psychopathology in children. For example, what does the finding that generalized anxiety has a later onset than separation anxiety tell us about the cognitive sophistication underlying the phenomenology of these disorders? Is it the case that generalized anxiety requires more sophisticated cognitive processes, i.e. those necessary for the child to generalize? Answering questions of this sort is complicated, but there are some illustrative findings. Thus, children’s ability to generalize across contexts or show an understanding of constancy is evident in early childhood. However, whereas constancy of concrete and observable physi-cal characteristics emerges in early childhood and constancy of gender and exter-nally observable characteristics appears slightly later (Gouze and Nadelman, 1980), it is not until late childhood that children appreciate constancy of internal

(psychological) characteristics (e.g. 8–9 years for self-identity in Guardo and Bonan,1971). Accordingly, prior to middle childhood, children infrequently use trait terms to describe themselves and explain their own behaviour (Rotenberg, 1982). In a similar vein, compared with younger anxious children, older anxious children (adolescents) exhibit more trait anxiety and more worry (Strauss et al., 1988). Finally, does the early onset of certain fears and phobias suggest a weaker cognitive basis than later emerging symptoms of anxiety (e.g. worry), and does this have any implications for the effectiveness of cognitive approaches?

Research into developmental changes in symptom expression has yet to elu-cidate what the clinical applications may be, but there are signs of progress. For instance, clinical wisdom and, increasingly, empirical research raise doubts about the position that depression should be defined similarly in children and adults (Garber,2000). Progress towards a developmental understanding of treatment delivery has proceeded more slowly.

A third component of a developmental model seeks to place the child in his/her social context and to examine how the multiple social contexts in which the child is embedded (family, school, neighbourhood and subculture) influence his/her affect, cognition and behaviour. This is in contrast to the more ‘insular’

or individual focus in CBT. Applied to the clinic setting, a consideration of the child’s social context may help explain why the child’s cognitions and behaviour are resistant to change despite the application of sound clinical technique. Given the likely importance of social context, especially family processes, in working with children, this topic is developed further in a subsequent section.

A fourth component to a developmental model emphasizes the need to consider continuities between normal and abnormal behaviour rather than to assume a disjunction between the two. A corollary is that understanding nor-mal variation may inform our understanding of abnornor-mal behaviour and vice versa (Cicchetti and Cohen,1995). It is well known that core ‘symptoms’ of the anxiety disorders, including fears and phobias, separation anxiety and obsessive-compulsive behaviour, all show strong age-based trends; furthermore, the age trends differ for each behaviour (Bolton,1996; Evans et al.,1997; Garber,2000;

Rapee,2001). Thus, a fear of dogs would be considered within the boundaries of normal in early childhood, but the same fear (and accompanying behavioural avoidance) may have clinical significance in the older child or adolescent. A developmental hypothesis is that there may be similar mechanisms involved and that normative fear in childhood may be linked with non-normative fear in later childhood. To date, however, surprisingly few studies directly test this hypothesis.

3.1.1 How is development integrated in current practice and research on CBT?

The ‘adevelopmental’ model underlying CBT is illustrated in several ways. Thus, there is nothing about the theory (as generally defined) that predicts that younger children would be less responsive to CBT than older children or, more generally, how variation in treatment response might reflect the child’s context or devel-opmental phase. Additionally, the focus has traditionally been on the process of changing cognitions and behaviour in the ‘here and now’ and less on under-standing their origins (although a possible exception to this may be more recent

‘scheme-based’ work for patients with complex problems).

Notwithstanding the lack of developmental emphasis in CBT, it cannot escape the treating clinician’s attention that the child’s development is relevant for the treatment. This clinical impression is reinforced by a number of recent concep-tual articles and chapters discussing developmental issues in child CBT. However, writings on this topic typically appeal to vague notions about development that do not point to particular mechanisms or carry any particular clinical applica-tions. As a result, what it is about development that is pertinent to applying CBT or understanding its (in)effectiveness is unclear; that is, whereas there is broad agreement that a developmentally informed model for CBT is needed, there is no consensus on what it is about development that is critical and how practice should be altered.

The ambiguous manner in which development is included in child CBT is illustrated in the case of age. As regards clinical practice, some consideration of the child’s age is encouraged and there appears to be general agreement that older children may be more responsive to cognitive approaches whereas younger children may require more behaviourally oriented treatment techniques. How-ever, there is as yet no clear formulation of why the child’s age may moderate treatment response or shape the delivery of the treatment. This conceptual uncertainty is reflected in empirical findings. One meta-analysis of treatment response suggested age may be an important predictor, with larger effect sizes for adolescents and early adolescents than pre-adolescents (Durlak et al.,1991).

In contrast, more recent studies reported that younger age (e.g. pre-adolescent versus adolescent) predicted a more positive response to treatment that involved a cognitive component (e.g. Southam-Gerow et al.,2001). In this case, older age may be associated with less positive results because the cognitive biases may have been more entrenched and more difficult to change (although the effects of age controlling for duration and severity of disturbance are often not reported;

see also Cowen and Durlak,2000); still other studies find no effect of age on treat-ment outcome. In short, the effect of age on treattreat-ment response is not robust and may differ across childhood disorders (Hudson et al.,2002).

The reason why age is not likely to move research on in any substantive way is that age is a proxy for a range of developmental processes, only some of which may be relevant to cognitively mediated therapy. We need to ask what it is indexed by age that explains variation in treatment response. In addition, a focus on age will obscure individual differences in social cognitive skills that may be only modestly associated with age, a topic discussed in more detail below.

Consequently, we should not be too surprised to find that age is at best an inconsistent predictor of treatment response, and neither should we invest too much in findings that demonstrate that there is (or is not) a connection between age and treatment response. Importantly, the mixed findings concerning age as a predictor of treatment response do not mean that there may not be important developmental constraints on CBT, but simply that age is not a sensitive index of what these moderating factors are.

The remainder of this chapter will examine alternatives to age that may provide a developmental model to explain mechanisms of treatment and variation in treatment response.