CBT with Children, Young People and Families

Peter Fuggle, Sandra Dunsmuir, Vicki Curry, SAGE Publications Ltd

• Publisher: SAGE Publications Ltd
• Year: 2012
• Print ISBN: 9780857027283, 9780857027276
• eBook ISBN: 9781446290491
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Psychology & Cognition
• Index: Psychology

This timely book uniquely addresses the application of CBT to children and young people within health, school and community contexts.

With the recent expansion of increasing access to psychological therapies (IAPT) CBT is increasingly applied to work with children outside the traditional therapy clinic. This book provides accessible knowledge and practice skills for professional staff working with troubled children and young people in real-world settings. Taking into consideration complex difficulties that do not always fit fixed length treatments, the authors take a much-needed realistic approach to applying CBT to childhood problems.

This is relevant and accessible reading for a wide range of specialist child trainees and practitioners, including new IAPT therapists, counsellors, nurses, teachers and social workers.

Peter Fuggle, Sandra Dunsmuir & Vicki Curry are co-Directors of the UCL accredited Certificate, Diploma & Masters course on Cognitive Behaviour Therapy and other outcomes based interventions (CBTOBI) delivered at the Anna Freud Centre in London.

PART 1

KNOWLEDGE OF CHILDREN AND THEIR CONTEXT

CBT practitioners working with children and young people require basic knowledge about child development and the context of childhood. Therapeutic practice needs to be connected to the wider knowledge base of developmental science. In Part 1 we will select specific aspects of developmental, educational and clinical psychology that are essential for an understanding of core CBT practice. This is not comprehensive but the intention is to demonstrate that a connection to this knowledge base is essential to guide effective practice. Without it, there is a risk that techniques may be used ineffectively without an understanding of the child’s experience and context.

Part 1 is divided into three chapters. Chapter 1 deals with child development and parenting. Chapter 2 will focus on contextual aspects of childhood such as the family, schools, culture and child protection. Chapter 3 deals with childhood distress and how this relates to childhood cognition and behaviour.

The impact of developmental considerations is generally more pronounced for younger children than for adolescents, so that many of the examples and specific practice issues focus on younger children. Some themes, such as about culture or social identity, may be more prominent for adolescents. Where there are differences between adolescents and children these will be highlighted. We will also follow the case examples of Mia (7 years), Ryan (11 years) and Rehana (15 years) and describe their therapy throughout the book. This will provide an additional perspective on differences between children and adolescents.

THREE CASE EXAMPLES: THE PRESENTING PROBLEM

Mia

Mia was a 7-year-old white British child. Her mother’s main concern was that Mia was hardly attending school at all. She had started feeling sick in the mornings, saying she did not want to go to school, and was often crying and protesting on the journey there. Her mother found this very upsetting, and there were many days when she let Mia stay at home. Mia was also distressed when left with her maternal grandmother, and did not want to go to her contact visits with her father. Additionally, Mia was shouting a lot and getting into arguments at home, mainly triggered by situations where she needed to separate from her mother.

Ryan

Ryan was an 11-year-old white British boy in his final year at primary school. Ryan’s teacher reported incidents where he suddenly lost his temper and become non-compliant. These had become increasingly frequent in school and there was a significant risk of exclusion. Ryan’s mother, Sharon, reported fewer behavioural problems at home, but Ryan was having difficulty sleeping and occasionally had nightmares. Ryan believed that other children should stop picking on him and that the teachers were unfair.

Rehana

Rehana was a 15-year-old British Asian girl showing increasingly withdrawn behaviour at home and at school. Her mother described her as irritable, not sleeping well, and finding it hard to concentrate on her schoolwork. She did not see her friends, and spent increasing amounts of time either in her room or in the bathroom at home. Rehana was bright but had lost interest in her schoolwork. She acknowledged some anxiety that she could not concentrate well, and was worried that she was going to fail her exams. She was not suicidal but described times when she felt very hopeless and had experimented with cutting her arms.

1

Parents and Child Development

CHILDREN, THEIR PARENTS AND ATTACHMENT

What does the CBT practitioner need to know?

CBT with children and young people needs to be provided so that it is sensitive and supportive to the role of parents in caring for their children. It should aim to harness the positive resources of parent and carer relationships to support the child’s progress and development. Such aspects of therapy are not always easily achieved, and the CBT therapist needs to have a working model of the way parents typically support a child’s development to guide this aspect of the work.

The knowledge base

Children are cared for in families, and the vast majority of emotional and psychological help for children is primarily (and usually successfully) provided by parents. Childhood itself could be characterised as a developmental obstacle course through which the majority of children successfully navigate by being cared for by parents and receiving help from teachers, other significant adults and peers. It is only when obstacles become too difficult (or when caring systems become ineffective) that problems emerge that may require therapeutic input of some kind.

Attachment theory has provided a useful model for making sense of the variability of the quality of parent–child relationships in navigating a child’s developmental journey. Early work into the study of attachment theory was initiated by John Bowlby (1988) and has been taken forward both empirically and theoretically by the work of Ainsworth (1991), Fonagy, Gergely and Target (2008) and many others. The core aspect of the theory is that attachment is a process by which a child maintains a sense of safety, initially by maintaining proximity to the parent. As children begin to explore the world, they increasingly move away from the object of safety (the attachment figure) only to seek proximity if they experience threat, fear or need (hunger or warmth). This mechanism has obvious survival functions. With maturation, the process of seeking and maintaining proximity to the attachment figure becomes increasingly symbolic, mediated through self-regulation of responses to fear and threat and satisfaction of needs. Although proximity to parents as a method of safety diminishes with age, residual aspects of this may persist into adulthood, so that in times of personal difficulty or crisis offspring may return to parents for periods of recuperation and recovery.

From this basic framework, attachment theory has evolved a complex assessment methodology and typography for mapping out the degree to which a parent–child dyad successfully (or not) navigates this attachment process. For parent–child dyads for whom this attachment process works well, the relationship may be described as ‘secure’. Within a ‘secure’ relationship, the child will engage in exploratory behaviour in an age-appropriate way while being able to show distress and seek proximity whenever they experience threat or fear. A wide range of studies (e.g. Steele, Steele, & Fonagy, 1996) have shown that approximately 65 per cent of children fall into this attachment pattern. A second group making up approximately 25 to 30 per cent of the population have an attachment pattern which is described as ‘insecure’. Although this attachment pattern is less overtly adaptive than the secure pattern, the overall association between insecure attachment and psychological difficulties in children is not strong, and many children with insecure patterns of attachment function well and have typical normative developmental trajectories to adulthood (Goldberg, 1997). A third attachment category (formally a subtype of insecure attachment) is described as ‘disorganised’ and characterised by highly unpredictable attachment behaviour. This occurs for a small minority of children (less than 5%) and has a much higher association with child mental health difficulties in later childhood than children rated as insecure in general (Goldberg, 1997; Atkinson & Goldberg, 2004). A fuller description of both secure and insecure patterns of parent–child dyads can be found in Ainsworth (1991).

Attachment and the three case examples

Mia

Sally (Mia’s mother) described how a series of previous miscarriages had led to high levels of anxiety during her pregnancy with Mia. This worry about her daughter was exacerbated by Mia’s temperamental tendency towards shyness, and she had difficulty settling at the school nursery. Mia’s temperament and problems with early separation led Sally to be hypersensitive to anxiety in her daughter and led to her experiencing her own anxiety both before and during separations. She often assumed that Mia experienced the same feelings as she did. In attachment terms, the relationship between Sally and Mia could be characterised as being insecure and anxious.

Ryan

Ryan had a very difficult early life with his mother experiencing post-natal depression when he was a baby, and later in infancy he witnessed violence directed at her by his father. His relationship with his mother was characterised by a combination of anger and feeling protective towards her. His mother sometimes accused him of making her ill and depressed and he hated this. In attachment terms, his relationship with his mother could be summarised as being insecure with an avoidant style of dealing with his anxiety. His positive relationship with his stepfather mitigated his anger and resentment to a certain extent.

Rehana

Rehana had been an easy baby to care for. During the first two years of her life her mother, Sana, had enjoyed being a mother and was supported by her own mother, who shared much of Rehana’s care. When Rehana was about two, her grandmother returned to her home country and Rehana missed her grandmother a lot. Rehana’s distress at her grandmother’s departure made Sana feel guilty, and she worried that this had caused Rehana not to be as confident as she would like. Rehana felt very distant from her father and believed that he did not really know her. In attachment terms, Rehana appeared to have been securely attached to both her mother and her grandmother and her loss of her grandmother had been very significant for her. Her relationship with her father was distant and difficult to characterise in attachment terms.

Implications for CBT practice

1. The immediate challenge for the CBT therapist is to ensure that the offer of professional help does not unintentionally undermine or disempower the parent’s capacity to provide effective help for the presenting problem.
2. The value of attachment theory is that it invites curiosity in the CBT therapist about the nature of the parent–child relationship and the degree to which it is characterised by confidence, warmth and predictability or by anxiety, distance or even resentment or hostility.
3. For CBT with children it is not required for the therapist to assess the attachment status of the child using formal measures, but it may be very helpful to consider whether the parent–child relationship has created a degree of vulnerability to the presenting problem (e.g. anxiety or anger) or may be unintentionally supporting it.

ATTACHMENT AND SOCIAL COGNITION

What does the CBT practitioner need to know?

One of the central tenets of CBT is to understand the way a person’s ideas, attitudes, beliefs and assumptions may contribute to maintaining specific difficulties which negatively impact on the person’s life. With children and young people, the CBT therapist needs to have a model of how such a child’s cognitions about themselves, others and the world have come about. This process is far from completely understood so that there are different perspectives on this process. However, it is essential to have a broad understanding of what is currently known about this process.

The knowledge base

The starting point of social cognition (Sharp, Fonagy, & Goodyer, 2008) is that key cognitive processes develop through a complex process of social interaction, primarily with attachment figures. Social cognition contributes to our understanding of some of the central problems for CBT, namely processes of emotional regulation (controlling one’s feelings), the co-construction of cognitions (developing ideas about oneself, others and the world) and mentalisation (the capacity to make sense of one’s own state of mind and others). We shall briefly look at each of these in turn.

Emotional regulation

Attachment theory suggests that early processes of seeking emotional help and relief from fear are central to early human survival, and so the early processes of emotional regulation are fundamentally social in their origin. When distressed, the child seeks comfort from their parent, and this regulates and reduces their distress. Within normal development, children learn how to understand and control feelings through their interactions with others, initially and importantly with their parents. Although this process is most apparent in younger children, the way that a parent of an older child responds to the child’s feelings remains a key aspect of much therapeutic practice. If an anxious child experiences her own anxiety as making her mother feel anxious or cross, then this is likely to exacerbate her own feeling state and reduce her capacity to manage her own feelings. Similarly, such interactive patterns may apply to the relationship between the child and the therapist if the child experiences the therapist as anxious or disapproving.

Co-construction of cognitions

Attachment theory emphasises the way that core childhood cognitions about the nature of the self, others and the world are constructed in the child’s mind during countless interactions between the child and parent. These ‘internal working models’ (Bowlby, 1988) are not formal, logical thoughts but general expectations and assumptions about the world that are more likely to be implicit than explicit or conscious. Developing an understanding of the interpersonal process of co-construction of meaning is fundamental to CBT. A crucial component is the central interest by the therapist in the states of mind (thoughts and feelings) of the child, but also from a social cognitive perspective, how a child’s cognitions about self, others and the world are constructed in partnership with others, particularly parents/carers.

This suggests that the therapist may get assistance from the parent in learning about the child’s cognitions simply by listening to what the parent says to and about the child. This observation was made by Bolton (2005), who hypothesised that the future core beliefs of the child were often articulated somewhat transparently in the consulting room by the parents. Statements by parents such as ‘He’s a terrible child’, ‘It’s all his fault’ or ‘He’s just like his Dad’ may well become internalised by the child as part of his implicit self-schema or internal working model. Bolton’s suggestion is that the therapist may not need to go digging around for these core beliefs within the child as they are often presented to him rather more transparently by the parent.

Mentalisation

Attachment theori...

Table of contents

• Cover Page
• Title
• Copyright
• Contents
• About the Authors
• Acknowledgements
• Introduction
• PART 1: KNOWLEDGE OF CHILDREN AND THEIR CONTEXT
• PART 2: CORE CBT PRACTICE
• PART 3: CBT IN CONTEXT
• Appendix 1: Session Competency Framework
• Appendix 2: Assessment Forms
• References
• Index