**3.4. Cognitive restructuring**

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

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

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

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

Most of the children with anxiety disorder focus totally on the negative thoughts when a thought causing anxiety comes to their mind, and selective attention works up the anxiety further. Similarly, depressive children focus on the negative situations/incidents rather than experiences or memories that makes their valuable in life or feel good, and fill their mind with such thoughts continuously. Therefore, a technique is used to distract attention from the thought causing negative emotions to a neutral or relaxing mental activity, and help the child

These mental activities might include neutral reasoning such as counting or finding names starting with the last letter, or thinking activities such as imagining to be somewhere that the child feels very happy and comfortable or thinking of the lyrics of a song that he/she likes.

it is short.

10 Cognitive Behavioral Therapy and Clinical Applications

marks [79].

anger situation to occur in the future [73, 76].

strengthen the parent-child interaction.

**3.3. Attention shifting technique**

to feel himself/herself much better.

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 thoughts [80].

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 in-session rewarding system [73, 76].

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 suitable for the child's developmental period.

Use of evidence search method during Socratic questioning, and performance of this by the therapist loudly while working on hypothetical examples is a good opportunity to serve as a model. Some questions that might be asked during Socratic questioning are as follows: "Do you really think that it will happen?," "What evidence do you have to think like this?," "May there be another alternative?," "What is the worst scenario, and how you can cope with it?," "What is the best scenario in this situation?," "What would you advice if this happened to someone else?," "Has it happened before, and if so what happened?," etc. [81].

consists of five steps in total, therapist encourages the child to see and accept problems as a part of daily life, and replace the avoidance reactions against these problems with more active coping behaviors. In the second step, operational definition of the problem is made with the child, and problem is formulated in detail. In the third step of technique, "brainstorming" is made regarding the alternative ways of solution, and a list is created for possible solutions. Each solution on the list is evaluated in detail with its pros and cons, the best way is selected for the solution of problem, and action is taken, in the fourth step. The last step is the evaluation stage; results of the way used for the solution of problem are evaluated

Cognitive Behavioral Therapy Principles in Children: Treatment of Internalizing Disorders

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Firstly, problem-solving technique is theoretically explained to the child during therapy, then exercises are made using hypothetical examples in order for the child to externalize the problem and talk more comfortably, and lastly, real life events and problems in child's life are addressed. At this stage, the existing life problems of the child can be listed, and exercises can be started with the one selected by the child. Therapist undertakes an active role in the whole process, and shows how to address a problem by serving as a model. Rewarding the child in each problem that he/she solves successfully and achieves his/her target will increase motiva-

Modeling is a concept based on social learning theory [90]. Its rationale is based on the assumption that people learn by observing many things rather than directly performing or directly being exposed to them [87]. Behavior that is desired to be taught to the child might be a behavior that is known but not performed by the observer for various reasons or an action that is lacking in the behavior repertoire of the child. For instance, if the child is depressed with lacks social skills or social phobic, communicating with others in the environment comfortably by using the appropriate words is mostly a social skill that is not in the repertoire of

Rationale of the technique for anxiety disorder is described as follows; when a model that gives suitable reactions to the feared situation exists, the child will not show a fear reaction when faced with the situation that creates fear, and prefer the behavior that he/she takes as a model, and is more functional. With such perspective, therapist is able to be a good model in terms of anxiety reactions. Especially during the role-plays performed in the session, therapist offers the child reasonable examples of more functional reactions [73, 76]. In depressive children, modeling is rather focused on social skills training or problem solving skill, and used to show the adaptive behavior patterns by means of role-playing

Modeling can be carried out as implicit (imagination of someone that effectively copes with the situation that creates anxiety), symbolic (watching a film including someone that effectively copes with the situation that creates anxiety), live (the situation where model is present before the anxious child and the child directly observes the behaviors), or participatory

(model is in interaction with the child and provides feedback) [20].

[73, 76].

tion [50, 81, 89].

**3.7. Modeling**

the child.

[91, 92].
