Suggestions for improving the integration of developmental theory, research and practice

This section takes as a starting point the poor fit between research into children’s cognitions and the practice of CBT with children. This is an inevitable conclusion, evident in a more indirect form from publications in this area and in a more direct form from discussions with clinical colleagues and students. This section aims to consider how a better fit between research and practice might be accomplished.

3.4.1 Methods and meaning of research

One of the reasons for the tenuous links between research evidence and clinical practice of CBT with children is the complication of measuring social cognitive processes. For example, an important methodological lesson from research is that children’s capacities to demonstrate social cognitive abilities are influenced by how they are assessed. A good illustration is in the area of measuring children’s understanding of mixed emotions. Understanding mixed emotions, the notion that an event may provoke both positive and negative emotional reactions, is an important developmental landmark in children’s understanding of emotion and

the causes of emotions, and has wider implications for children’s psychological development. The establishment of the point in development when children can be said to understand that events may provoke positive and negative emotions might seem to be a straightforward task. However, children’s success at labelling mixed emotions in response to a particular event depends on how the task is presented. This is illustrated in a study of 50 6-year-olds by Brown and Dunn (1996). They found that, if the child was told that a character in a story felt both positively and negatively about a particular event, most (42 of the 50) children could give a plausible rationale for the positive and negative feeling; however, if children were not told how the character felt and were instead asked to tell the experimenter how the story protagonist may have felt, only 16 children sponta-neously mentioned both a positive and negative feeling. An even smaller number of children (11 of 50) were able to give a spontaneous personal example of an event that made them feel both positively and negatively. So, as for the ques-tion ‘when can a child understand mixed emoques-tions?’, we might well suppose the answer is around 6 or so years of age. However, that must be tied to the way in which we operationalize understanding of ambivalent emotions. If the question is instead posed as, ‘when is the understanding of ambivalent feelings likely to have import into the clinical context?’, it might be that the answer is not age 6 years but instead at the later assessments when children spontaneously report ambivalent feelings about events in their own lives (which may corre-spond more with how previous research suggested children understand mixed emotions).

A further potential limitation of extending current research into social cogni-tive processes to the clinic context is that many of the experimental assessments are affectively neutral (e.g. as in the case of Piagetian tasks) or, if there is affect involved, it is within a hypothetical context unrelated to the child (e.g. as in the case of emotional understanding tasks in which the child is asked to predict the emotion of a protagonist in a vignette). The applicability of commonly used methods and the findings from such methods to the clinical setting is likely to be compromised as a result of the ‘impersonal’ quality of the assessment. The fact that cognitive processes concerning neutral or hypothetical events may not translate to the individual psychology of the adult or child is to be expected.

After all, it has been appreciated for some time that the cognitive vulnerabilities to depression (e.g. attributions of negative events to internal, stable qualities of the self ) may not be continuously active but may emerge only in response to negative events or in the context of negative mood (e.g. Teasdale,1988). Recent evidence suggests that children’s cognitions, including those characteristic of

possible clinical disturbance, may be best accessed in the context of nega-tive mood. For example, in their study of 5-year-olds, Murray and colleagues (Murray et al.,2001) found that negative cognitions (expressions of hopelessness or low self-worth) were spontaneously expressed only when negative mood was induced, in this case by a card game with a friend in which their winning or losing was experimentally manipulated. Negative cognitions were not observed while the child was winning but were observed when the child was losing.

Furthermore, an association between exposure to maternal depression and neg-ative cognitions was evident only in the setting in which the child was losing the card game. The findings of Murray et al. (2001) are significant in demon-strating that spontaneously expressed negative (depressogenic) cognitions are observed in children as young as 5 years, that these cognitions are more com-monly observed among those at risk for depression and that these cognitions are emitted in the context of negative but not positive (non-negative) mood.

A third illustration concerns a distinction between competence and perfor-mance in assessments of social cognitive skills, and the role of context. Good illustrations are provided by the fact that children show wide intra-individual vari-ation in their display of social cognitive sophisticvari-ation, as seen in preschoolers’

discussions with parents, peers and siblings (Brown et al.,1996; see also Cole et al.,1997), as do early adolescents in their use of emotional understanding and mentalizing ability when talking about positive versus conflicted relationships (O’Connor and Hirsch,1999). The implication is that, for research on social cognitive processes to be more clinically useful, greater emphasis needs to be placed on the social, relationship or affective context in which they occur.

The general divide between developmental theory and clinical practice is as unnecessary as it is counterintuitive. This state of affairs is probably explained by a host of factors other than how research is conducted. For instance, there is a general lack of cross-fertilization of developmental and clinical findings in academic and applied journals, a tendency for clinicians not to read research reports and the counterpoint that ‘basic’ researchers have difficulty elucidating the clinical significance of their findings and disseminating their results outside the academic setting. In any event, efforts to redress this are much needed. This may take several forms, such as those implied above. Additionally, including a component on developmental theory in CBT training courses is a good start, as is including a focused discussion of developmental theory in applied and prac-titioner orientated texts (as exemplified in the current volume). What benefits these efforts will realize remain to be seen. Will knowledge of developmental theory make more effective cognitive behavioural therapists? Will knowledge of developmental research enable clinicians to identify those individuals who are

most likely to respond to a course of CBT? Perhaps. At present, the strongest argument for adopting a developmental perspective is merely the promise of more effective clinical treatment.