**3. Main CBT techniques used in internalizing disorders and application examples**

The main target of CBT is to change the bias and distortion in information processing processes that are thought to trigger internalizing symptoms, and prevent the non-functional coping patterns created by such cognitive impairment. Therefore, combination of behavioral techniques and cognitive techniques is used in the treatment of childhood internalizing disorders with CBT [73].

When CBT programs designed for the treatment of internalizing disorders are examined, it is observed that similar technique sets are used both in anxiety and depression. In a study conducted by Chorpita and Daleiden [74], effectiveness-proven programs that are applied in a total of 322 randomized clinical studies were examined, and the techniques used were grouped by diagnosis, age, and gender. As a result, although the programs generally incorporate many different techniques, they have determined the techniques that constitute the framework of therapy manuals which are found to be effective for depression and anxiety. Accordingly, they have suggested that exposure, relaxation exercises, cognitive reconstruction, modeling, and psycho-education are used mostly in the treatment of childhood anxiety disorder. Manuals prepared for the treatment of depressive disorder mostly include psycho-education, cognitive restructuring, activity scheduling, problem solving, social skills training, and self-monitoring techniques. This structuring does not vary with age or gender, and these techniques are rather sorted similarly in all children CBT programs [74].

**3.2. Relaxation techniques**

muscle relaxation.

and regular [73].

Application of relaxation techniques in the therapy for childhood internalizing disorders improves coping skills of the child, and increases the self-efficacy by enabling the child to see

Cognitive Behavioral Therapy Principles in Children: Treatment of Internalizing Disorders

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

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In the treatment of internalizing disorders, relaxation techniques are used to reduce the psychophysiologic arousal level in the presence of stimuli that trigger emotions such as fear, anxiety, anger, and despair. Therefore, main target of relaxation exercises is the child's recognition of his/her subjective muscle and body reactions against stress, and learning to control such physiological reactions [73, 76]. Relaxation techniques used in children can be applied in two different ways; deep breathing exercise and progressive

Children with anxiety or depressive disorder report that they feel shortness of breath when they are faced with a situation that causes negative affect, or they get out of breath since their inhalation time shortens. In such a case, the air panted fills only the upper part of lungs, oxygen that goes into the brain decreases, physical stress emerges, and the autonomic nervous system gets activated. Therefore, the breath inhaled deeply using diaphragm relaxes the alarmed nervous system to some degree, since it makes respiration rhythmic

In deep breathing exercise, the child is asked to close his/her eyes and take a deep breath from his/her nose, then exhale this breath slowly. The fact that inhaled breath fills the abdomen rather than the rib cage by pushing down the diaphragm is the most important part to be considered in education [77]. Teaching the diaphragmatic breathing may be quite difficult, especially if the target group is children. Therefore, laying the child on a mat and placing a weight on his/her belly such as a book, and making sure that his/her belly moves up and

Aim of the muscle relaxation technique, which is the second stage, is to decrease the muscle tightness related to anxiety, and prevent such tightness from further aggravating the internalizing symptoms. With this technique, activity of the parasympathetic nervous system increases, and a regression is enabled in the activity level of the triggered sympathetic system [78]. In the progressive muscle relaxation training, the main muscle groups of the body are introduced to the child, and then the child is taught to tense up and release them progressively. At this tense up-release stage, child learns about the changes in his/her body while his/her muscles are tensed. Besides, while the child learns about the muscle groups, he/she can recognize which parts of own body are affected during anxiety or stress, constitute an "early alarm system" of his/her own, and start to apply the relaxation techniques when he/ she faces with a situation that causes a negative affect. As a result of this awareness, the child can adapt the muscle relaxation technique which might take long to himself/herself, and achieve a shorter and effective relaxation during anxiety by focusing only on the problematic muscle groups [73, 76]. For instance, if the child states that she feels tenseness on her shoulders, head, mouth, and hands among the muscle groups in the body under stress, she

himself/herself more strong against situations that create stress [49].

down would be a practical method that can be used.

The most frequently used techniques in internalization disorders are described below.

### **3.1. Psycho-education**

Psycho-education is considered as the first component of CBT in internalization disorders, and programs generally start with this technique. The main purpose of psycho-education is that child is informed about many different aspects (for instance, its nature, components, symptoms, and etiology) of anxiety or depressive disorder throughout the therapy [71]. While working with children, it is a common practice to nickname the disorder for externalization of the symptoms of disorder by the child [75].

After the informing stage, two main focus points of internalization disorders are examined; emotions and physical symptoms. Considering the developmental characteristics, realizing, naming, and expressing the emotions are quite complex for a child. At the same time, it will not be easy for a child with internalizing problems to talk about his/her own emotions. Therefore, hypothetical examples, emotion-oriented entertaining exercises and games should be used while working with children about emotions. Thus, the child feels comfortable, and a suitable environment is created to talk about emotions. Creating a list of emotions, creating situation cards and making guesses about what a person might feel against these situations, playing facial expression games about emotions, giving homework for the child to investigate emotions of the people around him/her like a detective and keep records of them, and teaching the child to rate his/her emotions with metaphors such as emotion thermometer are some examples of activities. As a result of psycho-education, the child can distinguish the emotional processes of himself/herself and others, and can express them accurately.

Physiological symptoms such as stomachache, shortness of breath, headache, and somatic complaints are often observed in internalizing disorders. Therefore, in order to cope with these, it is a prerequisite for the children to know about the nature of physiological symptoms, how and where they emerge, and how the anxiety or depressive mood is triggered or alleviated. As a result, the main rationale of psycho-education is that the child that can identify his/ her own emotions and physical symptoms well and distinguish from other situations will be able to effectively cope with this intense mood [73, 76].
