The role of the parent in CBT with prepubertal children

When undertaking CBT with prepubertal children, it is important to consider the role of parents in treatment and in the development and maintenance of their child’s psychological problems. Viewing the child in isolation without rec-ognizing or involving significant systemic influences, particularly the role of the family and peers, is inappropriate. In clinical practice, parents are often involved in CBT programmes, although developmentally appropriate theoret-ical models that inform the nature of this involvement are currently lacking.

A notable exception is the work of Rapee (2001) who has described a model for generalized anxiety disorder that highlights the effect of parental cognitions and behaviour on the development and maintenance of the child’s problems.

In particular, parental overcontrol, overprotection, overly critical behaviour and reinforcement of avoidant behaviour have been identified as important factors that are associated with the development of anxiety disorders in children.

It is surprising that, despite their potential importance, the role of parents in CBT programmes, particularly with prepubertal children, has received such little attention. Programmes have involved parents in different ways, such as facilitators, co-therapists or as clients in their own right (Kendall,1994; Barrett et al.,1996; Toren et al., 2000). The parent facilitator is the more limited role and is highlighted in the ‘Coping Cat’ programme (Kendall,1994). The predom-inant focus of the intervention is on individual CBT with the child, with parents receiving one or two educational sessions designed to encourage their cooper-ation with treatment. As co-therapists, parents are more extensively involved in therapy sessions and are encouraged to monitor, prompt and reinforce their child’s use of cognitive skills outside of treatment sessions (Mendlowitz et al., 1999; Toren et al.,2000). With the facilitator and co-therapist models, the child continues to remain the focus of the intervention, with the parents working towards reducing their child’s psychological distress.

An alternative model is where both the child and parents are the subject of direct intervention. Children may, for example, engage in parallel child-focused CBT and participate in family sessions during which the family learns alterna-tive ways of managing anxiety or problem-solving skills. Barrett (1998) describes such a model in which parents and children are empowered to form an ‘expert team’ to tackle anxiety. Therapy sessions involve parents and children, the open sharing of information is promoted and the content and process of therapy is jointly determined, with emphasis placed on identifying and reinforcing exist-ing skills of family members. Cobham et al. (1998) described a similar model.

The authors report an intervention that incorporates both child-focused CBT to

treat child anxiety and a programme designed to reduce parental anxiety. Chil-dren received ten therapy sessions while their parents received four specifically designed sessions to help them recognize the effect of their own behaviour on the development and maintenance of their child’s problems and how to address their own anxiety.

The final model, which has received less attention, is where child-focused concerns are indirectly addressed by cognitive work with parents. Parental attri-butions about the child’s behaviour, beliefs about parenting or perceptions of parenting efficacy can be identified and reappraised via direct cognitive work with the parents. This model may be useful for working with preschool children or in preventive approaches. A recent example was described by Bugental et al.

(2002) who found that parents of newly born infants who were encouraged to identify non-blaming causal attributions to explain their child’s behaviour were less likely to engage in harsh or abusive parenting.

The focus, content and nature of these interventions are very different, thereby raising the question of what is the most effective way of involving parents in CBT with children. A number of researchers have suggested that parental involvement may enhance the effectiveness of CBT (King et al., 1998; Mendlowitz et al., 1999; Toren et al.,2000). More systematic attempts to evaluate the additional contribution of parental involvement have been undertaken in a series of studies with children with generalized anxiety disorders. Barrett et al. (1996) compared child-focused CBT with child-focused CBT plus family anxiety management and found that involving parents resulted in additional benefits, particularly for younger children. These improvements were maintained at 12 months, although, contrary to predictions, the addition of family anxiety management did not result in any additional gains when assessed at 6 years (Barrett et al.,2001). Similarly, Cobham et al. (1998) found that child-focused CBT was enhanced by the inclusion of parental anxiety management, but only for children with at least one anxious parent. These gains, however, became less evident at 6- and 12-month follow-up. The results are not, however, consistent with the findings of Spence et al.

(2000) who failed to find any significant effects of parental participation in a CBT programme with children with social phobia at 12-month follow-up.

8.9 Conclusion

This chapter has attempted to highlight some of the many issues involved in undertaking CBT with young children. There is a general consensus that chil-dren of 7 years and above are able to participate in CBT. Younger chilchil-dren may be able to engage in some CBT programmes if the cognitive demands of the

intervention are matched to the child’s cognitive development. Although aware-ness of the need to adapt and modify CBT for use with prepubertal children is growing, comparatively few studies describe how this has been achieved. Pro-grammes currently span a comparatively wide age range and there are few reports of the use of CBT with children under the age of 7. Comparatively few randomized controlled trials have yet been reported and the issue of whether or not CBT is more or less effective with younger children has received little attention. Research evaluating the active treatment components and the bal-ance between the cognitive and behavioural elements has seldom been investi-gated. As highlighted by Bailey (2001), CBT with younger children will probably involve a higher proportion of behavioural to cognitive strategies; this raises the important definitional question of when behaviour therapy becomes CBT.

In terms of theoretical development, cognitive models to explain the onset and maintenance of psychological problems in children are notably absent. The unique developmental context of the child has rarely been considered as CBT models derived from research with adults have been downloaded and applied to children (Barrett et al.,2000). Developmentally appropriate models that consider the child’s age and the role of the family are not widely developed. Similarly, while parental involvement in CBT programmes, particularly with younger children, appears to be inherently logical, there is, as yet, no consistent evidence that effectiveness is enhanced by such involvement. Further work is required to develop theoretically sound models to explain the development and mainten-ance of dysfunctional cognitive processing in children that, in turn, will inform the most effective way of involving parents in CBT programmes with their children.

8.10 R E F E R E N C E S

Bailey, V. (2001). Cognitive-behavioural therapies for children and adolescents. Advances in Psychi-atric Treatment, 7, 224–32.

Barrett, P. M. (1998). Evaluation of cognitive-behavioural group treatments for childhood anxiety disorders. Journal of Clinical Child Psychology, 27, 459–68.

(2000). Treatment of childhood anxiety: developmental aspects. Clinical Psychology Review, 20, 479–94.

Barrett, P. M., Dadds, M. R. and Rapee, R. M. (1996). Family treatment of childhood anxiety: a controlled trial. Journal of Consulting and Clinical Psychology, 64, 333–42.

Barrett, P. M., Duffy, A. L., Dadds, M. R. and Rapee, R. M. (2001). Cognitive-behavioural treatment of anxiety disorders in children: long-term (6 year) follow-up. Journal of Consulting and Clinical Psychology, 69, 135–41.

Barrett, P., Webster, H. and Turner, C. (2000). The FRIENDS Group Leader’s Manual for Children, edn 111. Australian Academic Press.

Berliner, L. and Saunders, B. E. (1996). Treating fear and anxiety in sexually abused children.

Results of a controlled 2-year follow-up study. Child Maltreatment, 1, 294–309.

Bugental, D. P., Ellerson, P. C., Lin, E. K., Rainey, B., Kokotovic, A. and O’Hara, N. (2002). A cognitive approach to child abuse prevention. Journal of Family Psychology, 16, 243–58.

Cobham, V. E., Dadds, M. R. and Spence, S. H. (1998). The role of parental anxiety in the treatment of childhood anxiety. Journal of Consulting and Clinical Psychology, 66, 893–905.

Cohen, J. A. and Mannarino, A. P. (1996). A treatment outcome study for sexually abused preschool children: initial findings. Journal of the American Academy of Child and Adolescent Psychiatry, 35, 42–50.

Cornwall, E., Spence, S. H. and Schotte, D. (1996). The effectiveness of emotive imagery in the treatment of darkness phobia in children. Behaviour Change, 13, 223–9.

Dadds, M. R., Spence, S. H., Holland, D. E., Barrett, P. M. and Laurens, K. R. (1997). Prevention and early intervention for anxiety disorders: a controlled trial. Journal of Consulting and Clinical Psychology, 65, 627–35.

Durlak, J. A., Furnham, T. and Lampman, C. (1991). Effectiveness of cognitive-behaviour therapy for maladapting children: a meta-analysis. Psychological Bulletin, 110, 204–14.

Durlak, J. A., Wells, A. M., Cotton, J. K. and Johnson, S. (1995). Analysis of selected methodological issues in child psychotherapy research. Journal of Clinical Child Psychology, 24, 141–8.

Ehlers, A. and Clark, D. M. (2000). A cognitive model of posttraumatic stress disorder. Behaviour Research and Therapy, 38, 319–45.

Feehan, C. J. and Vostanis, P. (1996). Cognitive-behavioural therapy for depressed children: chil-dren’s and therapists’ impressions. Behavioural and Cognitive Psychotherapy, 24, 171–83.

Flavell, J. H., Flavell, E. R. and Green, F. L. (2001). Developments of children’s understanding of connections between thinking and feeling. Psychological Science, 12, 430–2.

Friedberg, R. D. and McClure, J. A. (2002). Clinical Practice of Cognitive Therapy with Children and Adolescents: The Nuts and Bolts. New York: Guilford Press.

Harrington, R., Wood, A. and Verduyn, C. (1998). Clinically depressed adolescents. In P. Graham (ed.). Cognitive Behaviour Therapy for Children and Families, 1st edn. Cambridge: Cambridge University Press.

Jackson, H. J. and King, N. J. (1981). The emotive imagery treatment of a child’s trauma-induced phobia. Journal of Behaviour Therapy and Experimental Psychiatry, 12, 325–8.

Jayson, D., Wood, A., Kroll, L., Fraser, J. and Harrington, R. (1998). Which depressed patients respond to cognitive-behavioural treatment? Journal of the American Academy of Child and Adolescent Psychiatry, 37, 35–9.

Kane, M. T. and Kendall, P. C. (1989). Anxiety disorders in children: a multiple baseline evaluation of a cognitive behavioural treatment. Behaviour Therapy, 20, 499–508.

Kendall, P. C. (1994), Treating anxiety disorders in children: results of a randomised clinical trial.

Journal of Consulting and Clinical Psychology, 62, 100–10.

Kendall, P. C. and Hollon, S. D. (eds.) (1979). Cognitive-Behavioural Interventions: Theory, Research and Procedures. New York: Academic Press.

Kendall, P. C., Flannery-Schroeder, E., Panichelli-Mindel, S. M., Sotham-Gerow, M., Henin, A.

and Warman, M. (1997). Therapy with youths with anxiety disorders: a second randomized clinical trial. Journal of Consulting and Clinical Psychology, 65, 366–80.

King, N. J., Tonge, B. J., Heyne, D. et al. (1998). Cognitive behavioral treatment of school-refusing children: a controlled evaluation. Journal of the American Academy of Child and Adolescent Psychiatry, 37, 395–403.

Last, C. J., Hansen, C. and Franco, N. (1998). Cognitive-behavioural treatment of school phobia.

Journal of the American Academy of Child and Adolescent Psychiatry, 37, 404–11.

March, J. S., Mulle, K. and Herbel, B. (1994). Behavioral psychotherapy for children and adolescents with obsessive-compulsive disorder: an open clinical trial of a new protocol-driven treatment package. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 333–41.

Mendlowitz, S. L., Manassis, M. D., Bradley, S., Scapillato, D., Miezitis, S. and Shaw, B. F. (1999).

Cognitive behavior group treatments in childhood anxiety disorders: the role of parental involvement. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 1223–9.

Rapee, R. M. (2001). The development of generalised anxiety disorder. In M. W. Vasey and M. R.

Dadds (eds.), The Development of Psychopathology in Anxiety. New York: Oxford University Press.

Ronen, T. (1993). Intervention package for treating encopresis in a 6 year old boy: a case study.

Behavioral Psychotherapy, 21, 127–35.

Ronen, T., Rahav, G. and Wozner, Y. (1995). Self-control and enuresis. Journal of Cognitive Psychotherapy, 9, 249–58.

Salkovskis, P. (1999). Understanding and treating obsessive-compulsive disorder. Behaviour Research and Therapy, 37, 29–52.

Salmon, K. and Bryant, R. A. (2002). Posttraumatic stress disorder in children: the influence of developmental factors. Clinical Psychology Review, 22, 163–88.

Sanders, M. R., Cleghorn, G., Shepherd, R. W. and Patrick, M. (1996). Predictors of clinical improve-ment in children with recurrent abdominal pain. Behavioural and Cognitive Psychotherapy, 24, 27–38.

Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Lumpkin, P. W. and Carmichael, D. H. (1999a). Treating anxiety disorders in children with group cognitive behavioral therapy:

a randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, 995–1003.

Silverman, W. K., Kurtines, W. M., Ginsburg, G. S., Weems, C. F., Rabian, B. and Setafini, L. T.

(1999b). Contingency management, self control and education support in the treatment of childhood phobic disorders a randomized clinical trial. Journal of Consulting and Clinical Psychology, 67, 675–87.

Spence, S. H. (1995). Social Skills Training: Enhancing Social Competence with Children and Adolescents.

Windsor: NFER.

Spence, S. H., Donovan, C. and Brechman-Toussaint, M. (2000). The treatment of childhood social phobia: the effectiveness of a social skills training-based cognitive behavioural intervention with and without parental involvement. Journal of Child Psychology and Psychiatry, 41, 713–26.

Stallard, P. (2002). Think Good Feel Good: A Cognitive Behaviour Therapy Workbook for Children and Young People. Winchester: John Wiley.

Thornton, S. (2002). Growing Minds: An Introduction to Cognitive Development. Hampshire: Palgrave Macmillan.

Toren, P., Wolmer, L., Rosental, B. et al. (2000). Case series: brief parent-child group therapy for childhood anxiety disorders using a manual based cognitive-behavioral technique. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 1309–12.

Turk, J. (1998). Children with learning difficulties and their parents. In P. Graham (ed.), Cognitive Behaviour Therapy for Children and Families, 1st edn. Cambridge: Cambridge University Press.

Vostanis, P., Feehan, C., Grattan, E. and Bickerton, W. (1996). Treatment for children and adoles-cents with depression: lessons from a controlled trial. Clinical Child Psychology and Psychiatry, 1, 199–212.

Wellman, H. M., Hollander, M. and Schult, C. A. (1996). Young children’s understanding of thought bubbles and thoughts. Child Development, 67, 768–88.

Williams, T. I., Salkovskis, P. M., Forrester, E. A. and Allsopp, M. A. (2002). Changes in symptoms of OCD and appraisal of responsibility during cognitive behavioural treatment: a pilot study.

Behavioural and Cognitive Psychotherapy, 30, 69–78.

Wood, A., Harrington, R. and Moore, A. (1996). Controlled trial of a brief cognitive-behavioural intervention in adolescent patients with depressive disorders. Journal of Child Psychology and Psychiatry, 37, 736–46.

9

Cognitive behaviour therapy in