**3.2. Relaxation techniques**

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 pro-

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

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

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

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

grams [74].

accurately.

**3.1. Psycho-education**

the symptoms of disorder by the child [75].

8 Cognitive Behavioral Therapy and Clinical Applications

able to effectively cope with this intense mood [73, 76].

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

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 muscle relaxation.

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 and regular [73].

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 down would be a practical method that can be used.

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 can constitute a personal relaxation program that is focused on these areas only rather than a long relaxation exercise involving all muscles, and can be applied more practically since it is short.

It is assumed that the more detailed the scene pictured in the mind is, the quicker and easier the child will relax. Accordingly, it will be quite useful to work on this imagination during

Cognitive Behavioral Therapy Principles in Children: Treatment of Internalizing Disorders

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

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The key component of all CBT manuals developed for the treatment of internalizing disorders is cognitive restructuring. In the cognitive behavioral theory, cognition, emotion, and behavior are conceptualized as inseparable elements; therefore, it is assumed that impairments in emotions and behaviors will improve by means of identification and restructuring of distorted or unreal cognition. Restructuring refers to replacement of nonfunctional thoughts with more constructive thinking styles, and in a sense, revision of

Main targets of cognitive restructuring are recognizing, testing, and decreasing the mistakes made while interpreting what goes around and unrealistic/negative self-talks that emerge accordingly, then producing positive self-talks based on reason that can replace the negative ones, and coping with the unrealistic negative cognitive distortions. Frequently used techniques during cognitive structuring include Socratic questioning, evidence search, giving instructions to yourself, in-session behavior rehearsal and role-playing, thought record, and

Negative self-talks that are not adaptive (or automatic thoughts) are an expression of child's cognitive distortions. Cognitive distortion is a concept that is created as a result of incomplete or inaccurate information processing process, results in misinterpretation of the environment and/or others and/or oneself, and has a significant place in the etiology of childhood internalizing problems. Thereby, it is an important step of CBT for the child to get training on cognitive distortions and evaluate his/her negative self-talks within the scope of cognitive mistakes by using the Socratic questioning method during the cognitive restructuring stage. Once the negative self-talks are captured, the child tries to break this loop by using various motivating sentences or slogans to replace the non-adaptive self-talks via "giving instructions to yourself" technique [81]. Studies show that the most frequently seen cognitive distortions in children with internalizing disorder include catastrophizing, black and white thinking, overgeneralization, should statement, mind reading, magnifying/minimizing, and labeling [20].

Children need time to distinguish between emotion-thought-behavior due to their developmental characteristics; therefore, they need to do enough exercises to gain this skill. It is important to cope with overly negative/unrealistic thoughts more effectively and focus on the behavior and emotions that will emerge as a result of the positive/realistic thoughts, by working on exemplary situations [82]. Since talking directly on examples of their anxieties will discomfort the children, this exercise period is generally covered with hypothetical examples, and then child's own anxieties are addressed [73, 76]. Limiting the homework related to thought record to a maximum of four columns (situation-thought-emotion-behavior) will be

session, and help the child to elaborate it [73, 76].

**3.4. Cognitive restructuring**

in-session rewarding system [73, 76].

suitable for the child's developmental period.

thoughts [80].

While teaching progressive muscle relaxation technique, practicing the moves in the tense up-release exercise by using entertaining concrete examples both increases the child's willingness to apply the exercise and strengthens the memorability of moves [73, 76]. For instance, while working with hand muscles, the child might be asked to imagine a lemon in his/her hand and squeeze it to extract its juice, or while working with abdominal muscles, the child might be guided to pull his belly in by saying that a baby elephant is about to step on his/her belly, or while working with foot muscles, the child might be asked to imagine that he/she has stepped in a huge mud puddle and is trying to leave his/her feet marks [79].

Another method used in progressive muscle relaxation technique is called "cue-controlled relaxation." The aim of this method is to enable the children that do not want to attract attention of others when he/she needs to relax in social environments to move to relaxed mode without performing the exercise. For this purpose, at the end of the progressive muscle relaxation exercise performed during session, when the child is completely relaxed, a word that will remind him/her this relaxation mood is called out loudly. Therefore, the called out word is linked with the relaxation mood, and the child that cannot apply the technique due to an inappropriate environment can say this word to himself/herself and relax in any anxiety or anger situation to occur in the future [73, 76].

Effectiveness of the progressive muscle relaxation technique is realized when applied regularly. Therefore, this technique is given to the child as homework during therapy, and he/ she is asked to practice this acquired skill throughout the whole therapy program. It would be a good idea to ask for the help of parents at this point. Doing the relaxation exercise with the child, if possible, or allowing the child to teach this technique to the parents will not only enable the exercise to be more reinforced but also make the exercise more entertaining and strengthen the parent-child interaction.
