**1. Introduction**

In recent years, there has been a tendency toward gathering disorders under two main groups in order for the nature of mental disorders in childhood to be understood more easily, and to develop common therapy techniques. Externalizing disorders refer to mental disorders that include characteristics such as mainly opposition and aggressive behaviors, hyperactivity, and impulsivity [1]. Internalizing disorders are characterized by mood symptoms such as anxiety, fear, hopelessness, unhappiness, as well as social withdrawal, reduced self-esteem, loss of self-confidence [2]. The main disorders grouped

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

Another CBT-based treatment program developed by Beidel, Turner, and Morris in 1998 to be used in the treatment of social phobia is "Social Effectiveness Therapy for Children (SET-C)." This program is designed for children between the ages of 8 and 12 and composed of 12 individual and 12 group sessions conduced simultaneously on the same weeks (for its effectiveness, see [38]). "Stand Up, Speak Out" is another effectiveness-proven therapy program designed for social phobia [39]. A structured therapy program also designed to be used in childhood anxiety disorder is the individual CBT program called "Thinking + Doing = Daring (TDD)" which was developed by Bögels in Holland in 2008. This manual which was prepared based on effectiveness-proven programs such as Coping Cat and Friends has a structure that consists of 20 sessions and includes basic CBT techniques (for its effectiveness, see [40]). Another therapy manual used in the treatment of childhood anxiety disorders is the CBT program called "Fear Hunter" which was designed by Sorias and her colleagues in 2009. This program consists of 13 child sessions and 3 family sessions and respectively, covers the basic CBT techniques (for its effectiveness, see [41]). Though they are not as diverse as the manuals created for anxiety disorders, there are also effectiveness-proven CBT programs that have been developed for childhood major depressive disorder. In 1990, "Coping With Depression (CWD)" program was developed under the leadership of Clarke and Lewinsohn, and effectiveness of the program has been proven (for its effectiveness, see [42]). Program consists of 16 sessions including basic CBT techniques such as relaxation, cognitive restructuring, problem solving, and social skills training, and

Cognitive Behavioral Therapy Principles in Children: Treatment of Internalizing Disorders

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

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In the following years, Brent and Poling [44] developed a therapy program for depressive and suicidal children. They compared it with behavioral family therapy (SBFT) and non-directive supportive therapy (NST) to test its effectiveness, and emphasized in the findings that program was significantly more effective as compared to two conditions [45]. In 1996, Stark and Kendall developed the program called "Taking Action" that could be applied both in groups or with individuals, and generally targeted girls with depressive disorder [46]. In the program consisting of 18 children and 11 family sessions, individual workbooks were prepared for parents and children separately. Program mainly covered emotion training, coping skills, problem solving technique, and cognitive restructuring. After that, in 2006, Stark and his team published a new workbook and therapist manual, and developed a program called "ACTION" [47, 48]. Designed for girls aged between 9 and 13, the program consisted of 20 sessions.

In the following sections of the chapter, main points to take into consideration while adapting CBT which was firstly designed for adults to children with reference to both the mentioned therapy manuals and research findings will be covered, as well as the main CBT techniques

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

whose effectiveness has been proven in the treatment of internalizing disorders.

was designed in group format [43].

**2. Application of CBT in children**

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

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 [19, 20].

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

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

Another CBT-based treatment program developed by Beidel, Turner, and Morris in 1998 to be used in the treatment of social phobia is "Social Effectiveness Therapy for Children (SET-C)." This program is designed for children between the ages of 8 and 12 and composed of 12 individual and 12 group sessions conduced simultaneously on the same weeks (for its effectiveness, see [38]). "Stand Up, Speak Out" is another effectiveness-proven therapy program designed for social phobia [39].

A structured therapy program also designed to be used in childhood anxiety disorder is the individual CBT program called "Thinking + Doing = Daring (TDD)" which was developed by Bögels in Holland in 2008. This manual which was prepared based on effectiveness-proven programs such as Coping Cat and Friends has a structure that consists of 20 sessions and includes basic CBT techniques (for its effectiveness, see [40]). Another therapy manual used in the treatment of childhood anxiety disorders is the CBT program called "Fear Hunter" which was designed by Sorias and her colleagues in 2009. This program consists of 13 child sessions and 3 family sessions and respectively, covers the basic CBT techniques (for its effectiveness, see [41]).

Though they are not as diverse as the manuals created for anxiety disorders, there are also effectiveness-proven CBT programs that have been developed for childhood major depressive disorder. In 1990, "Coping With Depression (CWD)" program was developed under the leadership of Clarke and Lewinsohn, and effectiveness of the program has been proven (for its effectiveness, see [42]). Program consists of 16 sessions including basic CBT techniques such as relaxation, cognitive restructuring, problem solving, and social skills training, and was designed in group format [43].

In the following years, Brent and Poling [44] developed a therapy program for depressive and suicidal children. They compared it with behavioral family therapy (SBFT) and non-directive supportive therapy (NST) to test its effectiveness, and emphasized in the findings that program was significantly more effective as compared to two conditions [45]. In 1996, Stark and Kendall developed the program called "Taking Action" that could be applied both in groups or with individuals, and generally targeted girls with depressive disorder [46]. In the program consisting of 18 children and 11 family sessions, individual workbooks were prepared for parents and children separately. Program mainly covered emotion training, coping skills, problem solving technique, and cognitive restructuring. After that, in 2006, Stark and his team published a new workbook and therapist manual, and developed a program called "ACTION" [47, 48]. Designed for girls aged between 9 and 13, the program consisted of 20 sessions.

In the following sections of the chapter, main points to take into consideration while adapting CBT which was firstly designed for adults to children with reference to both the mentioned therapy manuals and research findings will be covered, as well as the main CBT techniques whose effectiveness has been proven in the treatment of internalizing disorders.
