PARTICULARITIES OF COGNITIVE BEHAVIOURAL PSYCHOTHERAPY WITH CHILDREN AND ADOLESCENTS

ABSTRACT:

Cognitive therapy with children is an extension of the fundamentals of behaviour therapy based on the classical theory of learning merged with modelling, being useful in the treatment of externalized (hyperactivity, aggression, disruptive behaviours) or internalized disorders (depression, anxiety). Behavioural therapists adapted techniques to the specific level of development of each child.

Operational methods include: using positive and negative reinforcements, overcorrection, therapeutic contracts, extinction and punishments. Nonverbal and nondirective methods (therapy through play and art therapy) are the most notorious while cognitive forms and hypnosis are rarer. There are 230 psychotherapeutic techniques that can be applied to children and adolescences.

We have to make a precise evaluation and an adaptation of the verbal and nonverbal methods and strategies to the level of the children. The best results are obtained with adolescents (between 13-18 years) and preadolescents (between 11 and 13 years) but any child may benefit from cognitive-behavioural therapy.

Through re-evaluation and correction of the way of thinking, children and adolescents learn: to control their problems; to observe their negative automatic thoughts (cognitions); to recognise he connection between cognition, emotion and behaviour; to examine evidences for and against automatic thoughts; to substitute interpretations based on reality in the place of negative ones; to learn to identify dysfunctional beliefs which predispose to those kinds of experiences.

Motto: H. Ey: “If psychotherapy is not always sufficient, it is always necessary.”

The cognitive behavioural psychotherapy term has a lot of meanings. In a restricted sense, the term covers classic cognitive and behavioural therapy, and in a larger sense it refers to a cognitive perspective on the entire psychotherapy insofar as it aims at modifying the behaviour, the way in which the information is processed and the way a traumatic situation is lived.

Some psychoanalytical and experiential dynamic techniques of orientation are reevaluated from a cognitive- behavioural perspective.

The beginnings of child and adolescent cognitive behavioural psychotherapy

Cognitive therapy in children is an extension of the basic behaviour therapy based on classic learning theory which is operational through modelling, too which can be useful in the treatment of psychiatric diseases. (Eysenck, 1959). Many of the cognitive techniques used with children and adults resemble those that are used in the behaviour therapy. For example, the training of social abilities is considered at present a cognitive strategy, but the roots are deep in the behaviour therapy, by making use of models, role-play and repetition. Also, the relaxation is an important technique in cognitive therapy, although it was initially defined by Jacobson (1938, after Ronen, 1997) and then developed by Wolpe (1982), being further used as a part of the classical desensitization in behaviour therapy. Marks (1987) developed the exposure therapy, as part of operational conditioning, which was then introduced into the cognitive therapy, helping to centre on one’s exposure, as a necessary condition in the images of difficulties (especially in learning to accept one’s own emotions). Behaviour therapists did not create special techniques for children, they just adjusted these techniques to suit their particularities.

The most popular technique used with children arise from operational and pattern making learning, which can be applied to externalization disorders such as aggressiveness. The application of operational methods in clude: the usage of positive and negative reinforcement, over-castigation, therapeutic contracts, extinction, and punishment. When it is applied to children, this technique, which is also applied to adults, must be clear, concrete, facile, and easy to explain to the child. The children are ordinarily exposed to pattern making techniques as part of a maturing process (for example: the role of the sex, gaining social skills by social interaction).

Beside models based therapy, other techniques are used too, like “self-talk” or reinforcements which proved to de useful in anxieties, stress and learning to think before acting. The techniques based on classical conditioning such as relaxation and desensitization (Wolpe, 1982), are difficult to be applied with children, requiring special adjustments like self- instruction image, concision of instructions, parents help, playing, painting, lollipops and toys which can be offered as a reward, all of these leading to increased child motivation and training of relaxation abilities.

Psychotherapeutic techni ques applicable to children and adolescents

Most of the psychotherapeutic forms applicable to children and adolescents are based on non-verbal and non-directive methods, like the playing therapy or art therapy, cognitive forms or hypnosis being less used for the moment but they are in a continuous development by adjusting adult techniques to children. Now there are almost 230 psychotherapeutic techniques that can be applied to children and adolescents (Kazdin, 1988). One must select from current practice those forms of psychotherapy which are appropriate to the cases that are treated.

Conditions for the success of psychotherapy

A precise evaluation of the child’s situation is necessary in order to guarantee the complete success of any psychotherapy method that is applied. This evaluation must take into consideration the following aspects:

• Obtaining information about the child’s situation from varied sources:

• parents (for problems like “ acting-out”- disobedience, aggressiveness, negativism, hyperactivity, rashness);
• pedagogue, teacher, schoolmaster-information regarding the way that child is related to the norms of the chronological age ( intellectual and school efficaciousness, social and communication abilities);
• directly from the child- to understand his emotions, evaluate self-esteem, depression;
• direct observation.

• The comparison of the present problems/disorders with behaviours that are considered normal for the child’s age.
• Evaluating if the child needs treatment or if there are chances that the problems will be solved without any intervention. (table 1)
• Choosing the most appropriate therapeutic frame. (table 2)
• Choosing the best technique for the child’s problems. (table 3 and table 4) (Ronen, 1997).

Other important factors involved in the success of psychotherapy

1. Age: children and adolescents are the most susceptible to psychotherapy, including hypnosis, in comparison to 40-50 year old people, who are reluctant;
2. Cognitive level – the extremes: the very gifted and the least gifted do not respond to psychotherapy – it is necessary to have an ascendant over the client;
3. Cultural level: the co-operation is difficult if the child is primitive;
4. A precise diagnosis is necessary, because there are precise indications and contraindications for different types of therapy;

Generally speaking, the method is chosen based on three criteria:

1. therapist valences;
2. the client ( diagnosis, personality);
3. the time available for therapy.

Child and adolescent particularities

Child and adolescent psychotherapy is different from adult psychotherapy, for many reasons. One of those differences is the nature of childhood, since the child is compared with a “ moving target”, and he is in a process of continuous change. His actions and his behaviour are the result of the stage of development he is in, his family situation, the influences of the environment and the individual characteristics.

Psychotherapists that handle this age group must become familiar with childhood sociology, developmental psychology, conduct norms and family processes, before they begin their struggle with child psychopathology and start learning the therapeutic techniques. Child psychotherapy is compared with the ability to combine a lot of pieces from a giant puzzle, which is at the same time science and art and requires natural talent, availability and creativity on the part of the therapist in communication with children.

The psychotherapist must learn certain strategies both verbal and non-verbal methods that must be adjusted to the understanding level of the suffering children.

Infor mative questions for the psychotherapist

In order to apply any form of individual psychotherapy to a child, the therapist can take the following questions as a guide:

• Is the child with problems in a developmental stage where the verbal therapy can be applied?
• Is the child able to sit, listen and concentrate?
• Is the child motivated to do therapy or a playing therapy must be applied in order to gain his attention and his motivation?
• Has the child verbal abilities or has he got better performances in art, music or play?

Child and adolescent cognitive psychotherapy

Child cognitive therapy has a big part of its origin in Bandura ‘s (1997) theory, which refers to the role of learning expectations and the expectation abilities that facilitate a successful therapy. Also, there have been other theorists who influenced this form of therapy with children, such as Ellis (1962) (rationalemotive therapy), Beck (1979), Meichenbaum (1985), D’Zurilla (1986) (solving problems training).

Child cognitive treatment must be based on learning the most appropriate abilities and on the application of the most adequate techniques. Theoretical considerations led to the hypothesis that the most important factor involved in cognitive therapy efficacy in children is their cognitive development level.

Child and adolescent cognitive therapy – results

Best results are obtained with adolescents (between 13- 18 years old) and preadolescents (11-13 years old) and modest results are noted with young children (5-11 years old). (Durlak, 1991). Despite these findings, at present it is considered that despite the child’s age, any child can benefit from cognitive-behavioural therapy, if the therapist adjusts the therapy to the child’s personal cognitive style (Ronen, 1992; Knele, 1993). Older children can develop independent cognitive strategies, while the younger need the therapist to help them develop these strategies.

The high cognitive level children can achieve general and abstract strategies while modest level children need concrete strategies. Cognitive therapy addresses both the externalization troubles (hyperactivity, aggressiveness, a disruptive behaviour) and the internalization troubles (depression, anxiety).

Children with externalization disorder and lack of self-control, have difficulties with their blight tolerance, with their gratuities, maintaining attention over the objects or using their abilities of solving direct problems.

Children with internalization disorders or over control have the necessary abilities but they are not used properly. They misunderstand social situations and they benefit the most from non-verbal therapeutic strategies, especially the exposure and experiential ones.

Kendall (1993) suggests that, while introverted children are limited by the distortion thinking, extroverted ones act without thinking or planning their actions and they do not process data in the situations where thinking can be favourable.

Cognitive therapists assert that any child who can learn is a good candidate for the cognitive therapy.

Applying cognitive – behavioural techni ques with children and adolescents

There is a large variety of cognitive-behaviour techniques for children that assume behaviour response handling, such as: modelling, sequential repetition and abilities training. The therapy purpose is to modify cognitive distortion and deficiency that influence the behaviour.

All the cognitive techniques have as intervention purpose to influence the thinking. They identify, test the reality and correct distortion views and schemes (dysfunctional beliefs) that accompany those cognitions.

By thinking reevaluation and correction, clients learn how to overrule their problems and situations.

Children are taught how to:

• handle their automatic negative thoughts (cognitions);
• recognize the connection between cognition, feelings and behaviour;
• observe affirmative and negative evidence of the automatic thoughts;
• substitute basic negative interpretations with reality based interpretations;
• learn to identify dysfunctional thoughts which predispose them to those kinds of experiences.

An interventional programme may include various types of procedures and methods of combination. There is no general formula like: method X for problem Y.

The planning of therapeutic intervention is based on individual considerations. One of the intervention decision criteria is the nature of the problem: behavioural deficit or excess. If there is a deficit behaviour problem, the therapist’s obligation is to increase the power of the particular behaviour (answer increasing procedures), or to add acquisitions or new behaviour patterns (answer acquisition procedures). If there is a behaviour excess the therapist’s obligation is to eliminate or reduce the power of the behaviour (answer decrease procedures).

Often, the parents ask themselves: “How can I that to him?” “How can I make him continue the desirable behaviour?” “How can I stop him?”

If a child does not sleep enough he may become irritable and impolite. A good sleep can solve the problem.

Direct demands for the change can be enough sometimes. Environment changes, changes of routines or responsibilities can be useful in certain situations.

The therapeutic method will be established by the target of the problem. The desensitization technique will not be used with those who do not go to school because they say they are bored in class.

The problem does not appear only at action level but also at the thinking and emotional level. There are two basic learning tasks in child therapy:

1. acquisition, learning the wanted, desirable behaviour (self-control, verbal fluency, social and academic skills) or the deficit behaviour;
2. decreasing the unwanted answer in the child behaviour (aggression, theft, facial twitch, anxiety, phobia, bulimia) or changing one answer with another (timidity with assertion).

All of those tasks can be achieved by combining the four major learning types:

• classical conditioning;
• operational conditioning;
• learning by observing;
• cognitive learning.

The decision about the therapeutic approach depends not only on the nature of the target behaviour or on the stimulus that maintain this behaviour, but also on age, child’s maturity, the circumstances of the behaviour manifestations and on some environment aspects (Herbert Martin, 1981).

Success of cognitive-behaviour therapy, is conditioned by an appropriate evaluation of the case and a correct conceptualization and the applicability of those techniques that had been validated scientifically through randomized studies (Lupu, 2009).

Conclusions

1. At the moment it is considered that no matter the age, any child can benefit from the cognitivebehavioural therapy, on condition of adjusting the therapy to the child’s personal cognitive style. Older children can develop independent cognitive strategies, while the younger need the therapist to help them develop these strategies.
2. Success of cognitive-behaviour therapy, is conditioned by an appropriate evaluation of the case and a correct conceptualization and the applicability of those techniques that had been validated scientifically through randomized studies.

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