Cognitive therapy is actually most often used in conjunction with behavioural therapy when used with children and most often is aimed at trying to break the circle of emotion – thought – behaviour that is thought to cause most of the symptomology that the therapy is intended to ameliorate. The idea is that a person feels an emotion which leads to a thought that is uncomfortable which in turn leads to a behaviour that makes the feeling better, but the feeling is then affected by the behaviour so that it leads to another uncomfortable thought which leads to another and possibly even more inappropriate behaviour which leads to another feeling and so on. Cognitive therapy is an attempt to change the thought into a more realistic and helpful one thus breaking the circle.

In treating children there are stressors that are not usually present for adults generally related to education. A child might have unrealistic goals that are reinforced by adults in his or her life: perfection as the only acceptable outcome is a primary one. When perfection is the only goal then failure will be the most usual experience for a child and failure is a very unhappy thing indeed. In order to avoid the bad feelings and thought engendered by failure the child acts out by being bad in some way and sometimes finds that he or she can be perfectly bad which feels like a success, and success leads to further acting out. Breaking the cycle by making trial and error an acceptable outcome, a success, takes the onus of failure away and can lead to a change in behaviour by the redefinition of success.

What is COGNITIVE BEHAVIOURAL THERAPY for Childhood Anxiety?

Cognitive-behavioural therapy (CBT) for anxiety is an integrative approach founded on the assumption that both cognitive and behavioural processes can cause and maintain anxiety (Brewin, 1996). Although variations in these interventions exist depending on the specific disorder to be treated (e.g., Separation Anxiety, Social Anxiety, Generalised Anxiety Disorder), most CBT protocols aim to teach the child or adolescent new approach behaviours, concrete problem-solving skills, and strategies for challenging maladaptive or unrealistic anxious thoughts and beliefs.

Cognitive distortions are considered to play a key role in the maintenance of youth anxiety as they lead to misinterpretations of environmental threats and undermine the child’s coping abilities. Behavioural avoidance is also a primary maintaining factor in anxiety. Avoidant behaviour is triggered by a distressing event and then is reinforced by the reduction in distress that follows escape. Continued avoidance perpetuates a cycle of fear, withdrawal, and catastrophic beliefs. CBT aims to alter maladaptive thought processes by highlighting the link between thoughts, feelings, and behaviours and then cultivates new problem-solving and coping skills. CBT uses direct reinforcement, modelling, and in vivo exposures to facilitate safe and adaptive approach behaviours during which children can challenge dysfunctional beliefs. Multiple treatment formats have received empirical support, including single session treatments for specific phobias, week-long intensive formats for Obsessive Compulsive Disorders (OCD) and phobic disorders, and traditional short-term therapy protocols (typically 12-20 weeks). Parents are also frequently involved in treatment to facilitate behavioural practice and help generalize skills to home and school life.

Core Components of the CBT Model for Anxious Youth

CBT uses a variety of strategies to help a child reduce anxiety, challenge anxious thinking, and counter long-standing avoidance behaviour, including affective education, behavioural relaxation, cognitive restructuring, imaginal and in-vivo exposure, modelling and rewards, and behavioural parent training. Several of these techniques are outlined as follows:

Emotions Education and Relaxation. Parents and child are taught about the interrelated physiological, cognitive, and behavioural components of anxiety. Activities help demonstrate different emotions, body postures, and cognitive and physiological correlates. Progressive relaxation training helps anxious children develop awareness and control over their own physiological and muscular responses to anxiety.

Cognitive restructuring. Cognitive restructuring helps children identify and replace distorted cognitions with more adaptive beliefs. Basic cognitive strategies include identifying and reducing negative self-talk, generating positive self-statements, thought stopping, thought challenging (weighing evidence for and against), testing both dysfunctional and adaptive beliefs, and creating a coping plan for feared situations.

Imaginal and in-vivo exposure. The goals of exposures are to encourage approach behaviour by positioning the child in a previously feared or challenging situation. The child attempts to complete tasks in a graded “fear hierarchy” such that the child experiences early success before attempting greater challenges. During individual exposures, a child is encouraged to use any number of coping skills, including relaxation exercises, coping thoughts (challenging anxious thoughts with more positive, realistic thoughts), concrete problem-solving, or rehearsal of desirable skills.

Parent Interventions. Parents may have their own preconceptions about the threatening nature of anxiety and they may not know how best to encourage a child to cope with anxiety. CBT provides parents education about the risks of continued avoidance and guidance in managing their own anxiety. CBT may also impart basic parenting strategies (e.g., positive/negative reinforcement, planned ignoring, modelling, reward planning) to facilitate the practice of therapy skills in the home.

Exposure and Response Prevention (ERP) for Obsessive Compulsive Disorder. ERP is a variant of traditional exposures wherein exposures target specific obsessions and repetitive compulsions. The child is exposed to a stimulus that triggers anxiety and intrusive thoughts and is helped to resist performing the compulsions meant to relieve the anxiety. Exposures often proceed in a progressive hierarchical gradient but a range of exposure durations and intensities can be successful.

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