Rebecca Laptook, Ph.D., is an assistant professor (clinical) of psychiatry and human behavior at the Warren Alpert Medical School of Brown University as well as a staff psychologist in the Hasbro Children’s Partial Hospital Program and Child & Family Psychiatry Outpatient Department at Rhode Island Hospital.

Ally follows her mother wherever she goes. Lately, Ally’s been more tearful around leaving for school in the morning and keeps complaining that her stomach hurts. Ally always thinks she’s getting sick and worries every time she is around anyone who coughs or sneezes.

Sam has a hard time following directions. His room is a mess, his homework is incomplete, and it’s a struggle to get him to do daily things like brushing his teeth. Sam frequently argues with his younger brother, and his mother feels like she has to yell in order to get anyone to do anything.

Parents are often concerned by certain behaviors they observe in their kids, such as crying, tantrums, difficulty following directions, shyness, difficulty separating, troubles with transitioning, and so on. But when do these behaviors warrant intervention? All of the above can be considered within the realm of normal childhood development. It is when these behaviors co-occur with other patterns of symptoms, have a negative impact on functioning, and cause distress in either the child or those around him/her that therapeutic intervention may be helpful and warranted. For example, with Ally, her parents may want to seek help if distress in the mornings continues to the point where it’s difficult getting to school or if she becomes so clingy to her mother that it’s hard for her mother to be able to work, run errands, or do things at home. With Sam, his parents may want to seek help if he starts doing poorly in school or if the level of conflict and overall stress at home remains high.

What’s the next step?

The first step to effectively addressing concerning behaviors in kids is to do a thorough evaluation of the symptoms, circumstances, and functions in order to fully understand the nature of behaviors. For example, in children specifically, it is common for acting-out behaviors, such as arguing, temper tantrums, or anger, to be in reality driven by anxiety. Once the nature of symptoms is more fully understood, appropriate intervention can take place.

Cognitive behavioral therapy (CBT) is one of the most commonly evaluated treatments for a range of psychological problems in children and adolescents. CBT is a therapy framework that emphasizes the role and link between thoughts, feelings, and behaviors in order to improve functioning. While some youngsters may not be able to fully take part in the entirety of a CBT model of treatment due to their cognitive/developmental levels, tailoring components of CBT for a specific child and treatment focus can be helpful.

Components of CBT treatment

There are different components of CBT depending on the specific treatment model, but for the purposes of describing a general overview, they are conceptualized here by three overarching components: psychoeducation, coping skills, and behavior practice/management.

  1. Psychoeducation. This consists of helping to better understand emotions and normalizing the fact that people experience a range of them, which are sometimes advantageous (e.g., having some anxiety before a test so that you are alert and concentrating) and sometimes impairing (e.g., having so much anxiety before a test that you can’t focus on the questions). Psychoeducation also involves understanding similarities/differences between emotions and helping children learn to identify the cues in their thinking and in their body in order to correctly label the emotional experience. It’s also important to be able to differentiate between varying levels of emotions. If a child thinks of everything that makes him nervous/scared and sees it all as the same intensity of that feeling, it would be very overwhelming. In CBT, children learn to view their emotions as a thermometer where they can tease apart situations/stimuli that would create a “10” on their meter versus a “5” or a “1” so that tackling these experiences starts to seem more manageable.
  2. Psychoeducation also focuses on learning to identify the thoughts, feelings, and actions that occur in a situation so that kids can start to see how modifying one part can affect another. For example, if Ally thinks that the person next to her is sick because he sneezed, she will start to feel anxious that she will get sick too. But if Ally is able to come up with other thoughts, this could alter how she feels. How anxious would she be if she thought that the person next to her sneezed not because he was sick but because something just tickled his nose? In exploring thoughts, children start to recognize when they fall into thinking traps by identifying cognitive distortions and labeling them as such. Cognitive distortions can include thinking the worst will happen (catastrophizing), thinking you know what others are thinking (mind-reading), and believing something without any proof (jumping to conclusions), among others. By learning to recognize thinking traps, youngsters can start to challenge them and become more flexible in their thinking, which may then alter how they feel and act.

  3. Coping skills. After psychoeducation about thoughts/feelings/actions and the relationship between them, patients start to build a “toolbox” of skills to help them effectively manage emotional/physical distress. This component helps empower children to feel that they have the tools they need to conquer problems. Furthermore, in order to face stress-inducing situations, they may need to first learn to lessen their arousal level to the point where they can tolerate facing a stressful situation. The coping skills that are added to their toolbox may include things such as relaxation techniques (e.g., diaphragmatic breathing, progressive muscle relaxation, imagery) to help calm their bodies and minds enough to participate in treatment. Skills also include learning scripts to challenge cognitive distortions (e.g., “Do I know 100% that I will get sick?”, “Could there be other explanations why my brother threw the ball at me?”) so that ultimately children may become more flexible in their thinking instead of solely believing the automatic thought that comes to mind. Other distress-tolerance skills include proactive activities (e.g., taking a walk, listening to music, squeezing a stress ball) and positive thoughts to keep in mind in order to help manage distress.
  4. Behavior practice/management. The third component of CBT is where individuals get a chance to practice the skills that they have learned. It includes skill rehearsal, role-playing situations, and ultimately experiencing the situations. For some disorders, such as anxiety, the experiencing of a feared situation and habituating to it (i.e., anxiety lessening by remaining in the situation over time) is the key ingredient of treatment. However, some will need to use the psychoeducation and skills described above in order to even get to the point of being able to face a fear in any form. Another key aspect of this component of CBT is the idea of reinforcing a desired behavior, whether it’s facing a fear, complying with a direction, or reacting in a calm and appropriate way. Some children may respond to encouragement from adults and a feeling of self-efficacy, but most need external reinforcement in order to push through cognitive/emotional barriers to their goals. This typically involves parents setting up a reinforcement system in which kids can earn rewards for reaching certain goals. Rewards can be immediate or in the form of tokens that can be traded in for bigger rewards or privileges after earning a certain amount. It is essential that parents are always aware of what effect their response has on their child’s behavior so that they are not inadvertently increasing the likelihood of the problem behavior rather than the desired behavior. For example, if Sam argues around limits on videogame time, and his mother lets him keep playing so that he stops yelling, Sam has learned that the more he yells, the longer he gets to play. If Sam’s mother gives him a check mark for every time he turns off the game when prompted, Sam learns that by following directions, he earns tokens that he can then trade in for bigger rewards. Likewise, if Ally’s mother lets her stay home when she is crying, instead of fighting the anxiety, this will increase the likelihood that this pattern will continue. However, if Ally earns rewards for getting to school by a certain time, this may reinforce leaving home rather than staying home.

Summary

While childhood behaviors such as fears, tantrums, noncompliance, and the like may be part of normal development, patterns of behaviors may become distressing and start to impair functioning. When this happens, it’s important to seek help from a professional who can perform a thorough evaluation and determine appropriate intervention. CBT is an evidence-based treatment that can be applied to a variety of childhood problems. Developmental considerations, such as age and cognitive level, may determine whether treatment is more cognitive or behaviorally focused. CBT can be thought of as a skill set that children and parents both develop and improve over time with practice.

References

Christophersen ER, Mortweet SL. Treatments that work with children: Empirically-supported strategies for managing childhood problems. Washington, DC: American Psychological Association; 2001.

Creswell C, Waite P, Cooper P. Assessment and management of anxiety disorders in children and adolescents. Archives of Disease in Childhood 2014; 99(7):674–678.