Cognitive Behavioral Therapy with Children

A Guide for the Community Practitioner

Katharina Manassis

• Publisher: Routledge
• Year: 2016
• Print ISBN:
  9781138850293
• eBook ISBN:
  9781317531920
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

This new edition of Cognitive Behavioral Therapy with Children links together the methods of cognitive behavioral therapy (CBT) practiced in academic centers as well as the community. This book addresses the challenges community practitioners face when pressured to use CBT with youth who live with mental health disorders, but whose circumstances differ from those in research settings. Practitioners will learn how to overcome therapeutic obstacles. This new edition contains an expanded discussion on cultural considerations relevant to assessment and treatment, as well as a new chapter on training others in CBT for children.

Chapter One
Narrowing the Gap between Efficacy and Effectiveness

Efficacy refers to how well a treatment works under ideal conditions, usually in a research setting. Effectiveness, by contrast, refers to how well a treatment works under “real-world” conditions, usually outside academic centers. Another way of thinking about these ideas is in terms of advantages and disadvantages faced by clients seen in different settings. Thus, your CBT clients may be at a relative disadvantage compared to those seen in academic centers, even if you are just as skilled as the therapists there are. Understanding this disadvantage can improve the chances of success with your clients.

What is Known

Recent meta-analyses attest to the efficacy of CBT for children and adolescents with anxiety or depression (James, James, Cowdrey, Soler, & Choke, 2013; Klein, Jacobs, & Reinecke, 2007), although results are generally more impressive when CBT is compared with waitlist or other inactive control conditions than when it is compared with other psychological treatments. Large multi-site trials have found enhanced benefits when serotonin-specific medications are added to CBT in both anxious and depressed youth (Domino et al., 2008; Ginsburg et al., 2011).

Studies of effectiveness of CBT in non-academic settings have largely focused on sub-clinical populations in schools (Miller et al., 2011), who show symptomatic improvement relative to waitlist controls. Some studies have examined clinical populations in community treatment, but most are open trials. Among comparative trials, Weersing and Weisz (2002) found worse outcomes for community-treated depressed youth than those treated in academic settings. Weisz and others (2009) found that CBT did not outperform usual care for depressed youth in community settings, and Southam-Gerow and colleagues (2010) reported the same finding for anxious youth.

Relative to clients in academic settings, CBT clients in the community typically have higher rates of ethnic minority status, attend fewer sessions, and have higher rates of comorbid diagnoses. All of these factors have been linked to poor treatment outcome (Crawley, Beidas, Benjamin, Martin, & Kendall, 2008; Weersing & Weisz, 2002). Client differences between academic and community settings underscore the need for thorough assessment, which is detailed in the next chapter. However, therapist and organizational differences may also contribute to outcome differences, and addressing these is discussed further in this chapter. Possible client, therapist, and organizational differences are summarized in Table 1.1.

Table 1.1 Child CBT in Community Settings Relative to Academic Settings

Typical Clients in Community Settings	More comorbid psychiatric illness
	More comorbid medical illness
	More suicidal thoughts or other critical issues
	More needing psychotropic medication
	More intellectual delay or learning disability
	More with first language other than English
	More family instability
	Lower family treatment motivation
	Lower child awareness of symptoms
Typical Therapists in Community Settings	Less intensive training
	Less ongoing supervision
	Fewer adherence checks used
	Face more competing demands
	Lower client/therapist optimism
Community Mental Health Organizations	Different mandates
	Different organizational structure
	Different funding mechanisms
	More community perceptions/stigma

In view of these apparent discrepancies between academic and community practice, my research group developed a group supervision program for community practitioners. We wanted to evaluate our ability to train them in CBT, and to better understand the problems community practitioners encounter when they try to do CBT in their settings. We had previously offered workshops in child CBT, but found that most community practitioners were no longer using CBT techniques six months later because they lacked the confidence to do so independently (Barankin & Manassis, 2003).

The response to our program was overwhelmingly positive, with 85% of participants indicating that they planned to do further child CBT in their settings, even at six-month follow-up (Manassis et al., 2009). Participants’ knowledge of child CBT improved on a short test given before and after the program, confidence using CBT increased, and participants were very satisfied with the supervision. Older participants and participants working in settings that used a diagnostic screen at client intake showed the greatest benefit. This finding was consistent with the adult CBT literature, where prior therapy experience and careful case selection have been linked to training success (James, Blackburn, Milne, & Reichfelt, 2001). We subsequently replicated this study with ten rural mental health agencies using tele-health. This program was positively evaluated by training therapists and, more importantly, was associated with significant symptom reduction in participating children (Jones et al., 2015).

In these studies, concerns were raised about difficulty finding suitable cases for supervision, the need for more background information about CBT and its evidence base, and a desire for more observational opportunities of “expert” clinicians. Therapists also identified difficulty adapting CBT to their clientele, their role in their organizations, the time commitment needed to do CBT, and low organizational support of CBT as potential barriers to doing further child CBT. These concerns were very helpful to improve our understanding of obstacles to CBT in the community, and provided some of the ideas for this book.

Putting what we Know to Work

To begin narrowing the gap between efficacy and effectiveness, each of the differences between academic and community settings listed in Table 1.1 must be addressed. Many client-related differences can be addressed when a thorough assessment is done, as detailed in Chapter 2. Specific client- and family-related challenges are discussed further in Chapters 7 and 8. In this chapter, therapist and organizational differences are considered.

Therapist Factors

In research settings, most therapy is provided by psychology graduate students who receive intensive training and are under close supervision by experienced practitioners. Many must audiotape or videotape their sessions for subsequent review to ensure their work is consistent with the CBT model being studied. Checklists to ensure treatment adherence are part of most protocols (Compton et al., 2004). Supervisors provide guidance not only about specific CBT techniques but also about engaging clients in treatment, when to deviate from treatment manuals, dealing with impasses in treatment, and other important aspects of the therapeutic process. Therapists often have few competing demands, allowing them to focus almost exclusively on their CBT cases. Collegial support and the reputation of the research center often create optimism in both therapist and client, further increasing the chances of treatment success.

These ideal therapeutic conditions may be reproducible, to some degree, in the community. Doing so is one step towards narrowing the efficacy/effectiveness gap. For example, doing one’s first few CBT cases with regular meetings or supervision with a more experienced CBT therapist or with a peer supervision group may be helpful. By using first names only, one can avoid compromising client confidentiality in these meetings. Honestly sharing one’s difficulties in therapy is also important, as we all learn more when we discuss our therapeutic problems and mistakes as well as our successes. Adherence checklists are not time-consuming, and often very helpful in ensuring that one doesn’t deviate from the CBT model. Audiotaping sessions for review in supervision (with client consent, of course) can also provide a valuable learning opportunity. Starting with an easy case (i.e., one that is close to ideal) is advisable. Advocating for some screening for CBT-suitability at intake is also worthwhile, though not all settings are receptive to this practice. In centers where CBT is a new treatment modality, be honest with clients and families about this fact. Then, emphasize CBT’s considerable evidence base and the benefits of ongoing supervision to allay any concerns about therapist inexperience and to support therapeutic optimism. Try to limit competing demands by, for example, not scheduling meetings to conflict with supervision times and having an ‘on call’ roster for unforeseen emergencies so these do not repeatedly disrupt therapy. Ensure that at least one person in a leadership position considers CBT important. Having a local ‘CBT champion’ is one of the best ways of ensuring optimal therapeutic conditions.

Organizational Factors

Community mental health settings vary widely in their mandates, organizational structures, funding mechanisms, and perception by the community. All of these factors can influence the success of CBT in such settings, particularly when it is newly introduced. For example, if the mandate of the organization is to “take all comers” and offer treatment strictly in order of arrival at the clinic, it may be impossible to collect enough suitable children for a CBT group for many months or even a year. Oppositionality, family conflicts, and ADHD are common primary presenting problems in the community, and although CBT may be a useful treatment component at some point in these cases, it is rarely the initial or “first line” treatment of choice. By the time six to eight CBT-suitable children are collected (about the number needed for a group), families referred at the beginning of the waiting period would probably have lost interest. When forming CBT groups, it is desirable to be able to pull at least some children ahead on the waitlist in order to get the group started, but of course this is perceived as unfair in settings where the mandate dictates “first come first serve.”

Similarly, organizational structures may be more or less conducive to CBT. The ideal structure, in my opinion, is one that includes a helpful, diagnostically oriented intake screen to improve the odds of finding CBT-suitable cases (Manassis et al., 2009) and conveys the message that therapists are valued professionals, not just service-providers. The latter does not mean that therapists necessarily need to be at the top of the pecking order, but they do need to have some input as to whom they treat, for how long, and how their treatment fits with the client’s overall management plan. For example, mental health assessment does not always include assessment for CBT-suitability (see next chapter), so therapists usually need the opportunity to do this piece in the first session or two. In settings where therapists are not allowed to decline cases or offer alternative forms of therapy, this can be problematic.

Organizations that promote regular communication between case managers, physicians, therapists, and other members of the treatment team are also more likely to successfully adopt CBT. In complex cases (and most community cases are complex), CBT may need to be carefully timed in relation to other treatments, and this requires teamwork. For example, a child who is frequently suspended from school for aggressive behavior that is attributed to “underlying anxiety” is unlikely to learn coping skills through CBT until the behavior is contained. A child who is engaged in individual psychodynamic therapy and participating in a CBT group may be overburdened with therapies, and therefore not benefit optimally from either. Family work may need to precede CBT or vice versa, depending on the case. Concurrent medication may help or hinder CBT. There is a subsequent chapter on treatment combinations, but all require teamwork.

Funding for psychotherapy varies by setting, by agency, and by jurisdiction. Lack of funding can reduce the therapist’s flexibility in relation to the number of sessions provided, the length of sessions, and (especially relevant to CBT) the location of sessions. Exposure to feared stimuli in anxious children, for example, often works best when the therapist accompanies the child into the anxiety-provoking setting initially, and then gradually encourages independent coping (Bouchard, Mendlowitz, Coles, & Franklin, 2004). When therapists are only paid for work done in the office, however, this may not be possible without significant finan...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• Preface
• Acknowledgments
• Author
• 1 Narrowing the Gap between Efficacy and Effectiveness
• 2 Assessing Children for CBT
• 3 Priorities and Timing of Therapy
• 4 Treatment Expectations
• 5 Using Manuals Appropriately
• 6 How Child CBT Differs from Adult CBT
• 7 Working with Diverse Children
• 8 Working with Diverse Families
• 9 Group-Based and School-Based Child CBT
• 10 Overcoming Therapeutic Obstacles
• 11 Concluding Therapy
• 12 Training Others in Child CBT
• Appendix I Possible Answers to Clinical Challenges
• Appendix II Fear-Masters Modules
• Glossary
• Index