**2.1. Main characteristics of childhood CBT**

One of the main points to take into consideration when dealing with CBT in children is a candid, understanding, and accepting communication. Such communication is emphasized as an essential factor of CBT in children regardless of the psychopathology. Additionally, it is important to maintain the structured and guiding nature of CBT in all sessions. However, a strict, forceful, or ignoring manner should always be avoided. On the contrary, it is required to present both the session structure and the techniques within the therapy in a quite flexible, playful, and co-operative manner to the child, and play an active and directive role as a therapist. Maintenance of such a gentle and accepting attitude, especially while working with techniques that would trigger anxiety and fears of the child such as exposure or problem solving is ultimately important for the course of therapy and motivation of child. At this point, therapist has a critical role for behaving in a creative and spontaneous manner [18, 49].

Apart from the quality of relationship between the child and therapist, considering the developmental characteristics of childhood, identification of therapy targets that would increase child's functionality and satisfaction with life in the most concrete and understandable way possible, but at the same time, inclusion of the child into the process are among other key points. This stage of the therapy is quite sensitive and significant, since especially depressive children have serious difficulties in determining accessible and positive life targets. Besides, more time should be allocated and examples should be used for identification and discrimination of emotions in childhood CBT as compared to adult therapy. Use of a scale up to a maximum of 10 when the child is asked to rate his/her emotions, and making use of visual templates such as "emotion thermometer" or "wheel of emotions" will enable the child to learn this technique more easily.

Considering the cognitive characteristics of children specific to the age periods, another element that is as much difficult as emotions to understand and express is thoughts or self-talks. Therefore, diversely the adult CBT, it will be useful to do more exercises on capturing and expressing thoughts as well as to make use of hypothetical examples while working with children. Another must-have therapy element while working with children is naturally games. Inclusion of games that will relax the child into sessions will make the therapy setup more appealing for the child, extend the short concentration time of child, and enable him/her to move away from incidents that are quite difficult for the child to talk about [18, 49].

CBT is a structured therapy technique; therefore, the order of skills and tasks to be worked on is certain. Use of acrostics for the child to remember that order will both make the therapy more fun, and cause the order to stay at the back of child's mind more easily [50].

#### **2.2. Importance of family involvement**

In line with both the results of controlled studies and clinical observations, today many clinicians and researchers agree on the fact that active involvement of family in child-oriented 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 escape/avoidance behaviors of the child [22, 54].

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,

One of the main points to take into consideration when dealing with CBT in children is a candid, understanding, and accepting communication. Such communication is emphasized as an essential factor of CBT in children regardless of the psychopathology. Additionally, it is important to maintain the structured and guiding nature of CBT in all sessions. However, a strict, forceful, or ignoring manner should always be avoided. On the contrary, it is required to present both the session structure and the techniques within the therapy in a quite flexible, playful, and co-operative manner to the child, and play an active and directive role as a therapist. Maintenance of such a gentle and accepting attitude, especially while working with techniques that would trigger anxiety and fears of the child such as exposure or problem solving is ultimately important for the course of therapy and motivation of child. At this point, therapist has a critical role for behaving in a creative and spontaneous manner [18, 49].

Apart from the quality of relationship between the child and therapist, considering the developmental characteristics of childhood, identification of therapy targets that would increase child's functionality and satisfaction with life in the most concrete and understandable way possible, but at the same time, inclusion of the child into the process are among other key points. This stage of the therapy is quite sensitive and significant, since especially depressive children have serious difficulties in determining accessible and positive life targets. Besides, more time should be allocated and examples should be used for identification and discrimination of emotions in childhood CBT as compared to adult therapy. Use of a scale up to a maximum of 10 when the child is asked to rate his/her emotions, and making use of visual templates such as "emotion thermometer" or "wheel of emotions" will enable the child to learn this technique more easily. Considering the cognitive characteristics of children specific to the age periods, another element that is as much difficult as emotions to understand and express is thoughts or self-talks. Therefore, diversely the adult CBT, it will be useful to do more exercises on capturing and expressing thoughts as well as to make use of hypothetical examples while working with children. Another must-have therapy element while working with children is naturally games. Inclusion of games that will relax the child into sessions will make the therapy setup more appealing for the child, extend the short concentration time of child, and enable him/her to

move away from incidents that are quite difficult for the child to talk about [18, 49].

more fun, and cause the order to stay at the back of child's mind more easily [50].

**2.2. Importance of family involvement**

CBT is a structured therapy technique; therefore, the order of skills and tasks to be worked on is certain. Use of acrostics for the child to remember that order will both make the therapy

In line with both the results of controlled studies and clinical observations, today many clinicians and researchers agree on the fact that active involvement of family in child-oriented

structure or duration of sessions are quite important.

**2.1. Main characteristics of childhood CBT**

4 Cognitive Behavioral Therapy and Clinical Applications

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 [52, 55–58].

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 emerge inevitably.

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 critical approach level of parents [59, 60].

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 and serve as a positive model.

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 introduction of the therapy program to be used, discussion on parenting attitudes that trigger or alleviate internalizing symptoms, a short training on effective parenting methods, debriefing on effective reinforcement and punishment techniques, conversation on intrafamily communication skills and ways to strengthen them, debriefing about how should the parents help their children during the process of doing homework given through the therapy, and practice of techniques in daily life [50, 68].

problem solving exercises, and exposure exercises. Typical homework types observed in children with depression focus on activity scheduling, social skills training, problem solving

Cognitive Behavioral Therapy Principles in Children: Treatment of Internalizing Disorders

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

7

In treatment of all the mental disorders seen in childhood, rewarding that is based on operant conditioning is one of the essential therapy components of CBT. Unlike other techniques, the focus in rewarding is not reducing the internalizing symptoms; the primary aim of rewards is to enable the child to maintain the motivation and attendance to sessions, encourage him/ her to do the homework given, as well as to create a factor that facilitates application of techniques such as exposure or social skills training. Behavior shaping, positive reinforcement, fading, and negative reinforcement are the most commonly used rewarding techniques in the

There are some points that must be taken into consideration while using rewarding techniques in children. Firstly, it is quite important to create a reward pool that suits the needs and interests of each child. Besides, it should be known that social reinforcers are effective on children as much as the physical reinforcers. Therefore, the role of social reinforcers in the treatment must be noted; they should be used frequently during or between sessions, and the family must be informed about the matter [20]. Secondary reinforcement such as collection of coupons or points are considered as a main rewarding technique just as the spontaneous and short-term rewards [73]. Therefore, it is quite important to establish a rewarding system to be maintained throughout the program in childhood CBT, and integrate this planned system

Teaching the child to reward himself/herself will increase the motivation of child about techniques and change in the long-term as much as being rewarded by the therapist or family. For this reason, if the child learns self-reinforcement during the sessions, symptoms of children with internalizing disorder such as negative mood, low self-esteem, and social withdrawal

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 dis-

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

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

skills, self-monitoring of mood and thought records [72].

**2.4. Importance of rewarding**

into structured therapy.

will be affected positively.

**application examples**

orders with CBT [73].

treatment of internalizing disorders [20, 73].

Another issue to be covered during parent meetings is the expectations. Some parents have great expectations from the treatment, such as CBT will change all the behaviors of child; there will not be any problems while he/she is doing his/her homework; there will be less conflicts with the siblings; or his/her room will always be tidy. At this point, it is quite important to underline which behaviors this therapy program will specifically focus on while informing the family about the content of program. Similarly, some parents who cannot observe the improvement, they have expected during the first few sessions may not bring the child to sessions at the very important point of therapy. While talking about contents of sessions during family meetings, emphasizing that the child will mostly learn about techniques developed to effectively cope with the symptoms in the first sessions, so they will be more theoretical, and the change will occur when the child starts to use these acquired skills in his/her own life will positively affect the rate of attendance to sessions.
