In my clinical work with children & adolescents, I often employ a form of psychotherapy called Cognitive Behavioral Therapy (CBT), which focuses on the interaction between thoughts, feelings, and behaviors. Children with anxiety or depression tend to have faulty thinking, exaggerated feelings, and maladaptive behaviors. CBT strategies help to challenge and change these 3 domains to reduce symptoms and improve functioning.
Effective CBT with children begins with a thorough assessment. Since children can’t tell us what is wrong, they need to be interviewed and observed with a trained eye. Any changes in mood, behavior, grades, or relationships Stress in the home? Parent’s input? Teacher’s input? How do they transition from their parents to session? How do they relate to me in session? What is the underlying function of the child’s behavior? Answers to these questions provide clues about contributing and maintenance factors, which can then be integrated into a comprehensive treatment plan.
Once the core issues have been identified, the next step is to form a trusting relationship with the child. Each child thinks and communicates differently, so finding my way into their world requires patience, flexibility, and creativity. I do this by playing games, listening without judgment, asking non-threatening questions, and using humor. I give unconditional attention and provide the child with a unique emotional experience, from which they feel cared for and base our working relationship. But most of all, I try to make sure we’re having fun or the child will not want to return to therapy.
Once the child begins to show trust and a willingness to participate, I begin to address the negative behaviors, irrational thoughts, and/or emotional distress. Many professionals mistakenly over-focus on children’s behavior by implementing elaborate behavioral plans. The problem is that negative behaviors are just the tip of the iceberg; the bulk of what drives negative behavior in children (and adults) is faulty thinking and emotional distress. For example, symptoms of ADHD, (e.g., distractibility, lack of focus, hyperactivity, arguing with teachers/peers, etc…), can occur as the result of depression.
Many children form faulty or irrational thoughts after a trauma or stressful event. For example, a child whose father has recently left the home (due to marital discord, being arrested, or death) might believe that he is at fault and a bad son. These thoughts reinforce feelings of anger, sadness, and/or hurt, which can then negatively affect the child’s vegetative functions (i.e., sleeping, eating, going to the bathroom), academic performance (i.e., concentration, motivation), and overt behaviors (e.g., tantrums, arguing, isolation). Depending on the child’s age, treatment might include a combination of talk, play, and behavioral techniques, such as exploring the possible meanings of the father’s departure; using action-figures to re-enact the child’s stress at home; and teaching relaxation techniques to reduce anger.
Finally, individual treatment with children almost always includes working with the parents and family to help them understand the child’s behavior and how they can be most helpful. I might also include group therapy if there are significant socialization problems and consult with the teacher if there are school issues. Overall, effective CBT with children requires skill, experience, intuition, and a flexible and playful personality style, as well as an integrated approach (child, parents, family, school) that targets the emotional, cognitive, and behavioral aspects of the child’s functioning.
Written by Joshua Rosenthal, PsyD