**2. Application of CBT in children**

under childhood internalizing disorders include anxiety disorder (specific phobia, social phobia, generalized anxiety disorder, panic disorder, and separation anxiety disorder),

Anxiety disorder ranks first among the most common mental disorders seen in childhood, and has a prevalence rate varying between 8.6 and 17.7% [3–6]. Prevalence of childhood major depressive disorder before the age of 13 is reported as 2–3% [7–9]. Apart from the similarities of symptoms, etiologic descriptions and developmental characteristics of two disorders, another reason for grouping them together is the high comorbidity rates observed in clinical practice [2]. Accordingly, 69% of the children primarily diagnosed with anxiety disorder meet the depression criteria, and 75% of the depressive children are also diagnosed with anxiety disorder [10–12]. In prospective and retrospective studies performed on adults, it has been found that internalizing problems that start in childhood become permanent at the beginning

Both research data and clinical practices show that cognitive behavioral therapy (CBT) has become a quite strong option in the treatment of childhood internalizing disorders. CBT is a therapy method that was firstly designed to fight cognitive distortion of depressive adults [17]. Then its field of application has extended significantly, and it has become a psycho-social therapy method that is primarily used in treatment of anxiety disorders, eating disorders, anger management problems, chronic pain disorders, marriage conflicts, psychotic disorders, and even personality disorders [18]. However, use of CBT in psycho-social treatment of children started almost in 1990s. The main reason of such a delay lasting about 20 years was the question whether the basic concepts of cognitive therapy, and rational analysis techniques that query thoughts were suitable for children. However, studies conducted over years showed that children were capable of understanding many abstract concepts when described in a concrete language by using metaphors and practical examples from daily life, and performing the tasks with "cognitive" content assigned to them during therapy without any difficulty. It has been proven that especially children that are eight or above can distinguish emotions, thoughts, and behaviors from each other in line with the basic mechanism of CBT, talk about their thoughts, capture their self-talks, and fulfill the self-monitoring tasks

During the last 30 years, CBT has been the most accepted therapy model in the treatment of childhood internalizing disorders [20]. Use of CBT in the treatment of childhood anxiety disorders started with the "Coping Cat" program designed by Kendall in 1990. Effectiveness of this program translated to many languages ("Coping Kuala"—see [21, 22]; "Coping Bear" see [23]), and similar therapy programs based on Coping Cat has been supported with several

"FRIENDS" program developed by Barrett, Lowry-Webster and Turner for the treatment of childhood internalizing disorders in 2000 is another structured CBT program that was firstly created in group format followed by the individual format (for its effectiveness, see [36, 37]). The most significant feature of this program distinguishing it from Coping Cat is that it has

of adolescence and continue the same way in adulthood [13–16].

study findings that have different research designs [24–35].

been developed to treat not only anxiety disorders but also depression.

and major depressive disorder.

2 Cognitive Behavioral Therapy and Clinical Applications

[19, 20].

Children are quite different than adults both cognitively, emotionally, and behaviorally. Therefore, adaption of adult therapy techniques to children has always been a difficult and quite sensitive issue. Even though the rationale of therapy and main frame of the techniques used do not change, issues such as adaptability of them to children in developmental terms, structure or duration of sessions are quite important.

CBT affects the results of treatment more positively [51–53]. Maintenance of such co-operation throughout the therapy and regular family meetings are critical in terms of checking if the nonfunctional behaviors of the child are reinforced or adaptive behaviors are not punished. It is a known negative factor that parents play a role in continuity of anxiety by reinforcing the

Cognitive Behavioral Therapy Principles in Children: Treatment of Internalizing Disorders

http://dx.doi.org/10.5772/intechopen.71932

5

Additionally, it has been shown by many researchers that certain parent attitudes cause internalizing problems in children such as anxiety or depression. Protective and neglectful attitudes are the main parent attitudes that are associated with internalizing symptoms

Protective parenting is the most striking attitude in the studies. In these type of families, parents do not let the child to face any problem, and continuously and actively intervene in child's life. The child cannot learn how to cope with a real life stress that will emerge in the future and thinks that he/she does not have the strength and skills to cope with such challenging living conditions, since he/she has never directly faced with life problems as a result of such intervening parenting behaviors. Consequently, anxiety or depressive disorder will

Neglectful attitude of parent is also thought to be associated with child's anxiety. As a result of neglectfulness, the child will continuously face with every day challenges, make mistakes during the solution of such challenges since he/she lacks both physical and cognitive skills due to the developmental period, and experience repetitive failures without guidance. These failure and disappointment experiences will surely lead to internalizing symptoms in the child after some point. Moreover, because of the neglectful parenting style, the child may feel herself/himself as undesirable, loveless, alone, and insignificant. Considering the relationship between parenting behaviors and internalizing in children, another significant issue is the

Psychopathology history of parents is commonly researched issue in childhood psychopathology. Many studies have emphasized the presence of a considerable number of people diagnosed with internalizing disorder among the parents of children diagnosed with internalizing disorder [61, 62]. Similarly, studies have shown that the risk of anxiety or depressive disorder is significantly higher in children with anxious parents as compared to those with non-anxious parents [60, 63–67]. Therefore, even though the applied therapy program is child-oriented CBT, being in a close relationship and co-operation with the parents, and referral of the parent with psychopathology to the necessary services as well as facilitation of his/her access to treatment will increase the effectiveness of treatment. By this way, the parent with decreased symptoms will be able to establish a healthier communication with the child

Family sessions can be involved in the therapy program in various ways during CBT of internalizing disorders. In some programs, the last 5 min of each session with the child can be allocated to parents, whereas some may require parent meetings in addition to this arrangement. Family meetings should mainly include the following: psychoeducation on the nature of childhood internalizing disorders, debriefing about the main rationale of CBT, a short

escape/avoidance behaviors of the child [22, 54].

critical approach level of parents [59, 60].

and serve as a positive model.

[52, 55–58].

emerge inevitably.
