**3.7. Modeling**

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?,"

Self-monitoring is one of the cognitive elements of therapy, and generally used to facilitate the cognitive restructuring. The aim of the self-monitoring technique is to enable the child gain a self-awareness to identify his/her emotions and thoughts. Therefore, self-monitoring differs from other CBT techniques in that child monitors and evaluates his/her own behaviors

While gaining the self-monitoring skill, the child must firstly gain awareness on whether the target reaction exists. Besides, keeping records on target behaviors is an important part of this technique. Thus, child can observe how often and when he/she performs such behaviors out of session, and notice the recurring patterns related to possible triggers on paper [83]. Focus of self-monitoring can also be emotions as well as behaviors. The target is to enable the child to observe his/her mood during the day, and realize which emotions are felt when and during which situations [50, 84]. Depressive children can be timid and shy for working on his/ her emotions and thoughts. At this point, therapist should undertake a more active role and

For a depressive child, problem solving is a serious difficulty; the main reason of difficulty consists of decision-making difficulty, depressed mood, absence of energy, and intense despair emotions seen in depression [85]. A similar situation applies to the anxious child. The child that faces with a problematic situation experiences serious problems in analyzing the problem and thinking of solutions due to anxiety and panic [86]. As a result, the child with internalizing disorder tends to perceive the problems as a trouble, unsolvable, or a serious threat. Such a distorted perception prevents the child from acting, negative emotions appear

Another purpose of CBT is teaching the child necessary practical skills to cope with problems that he/she may encounter every day, exist in real life, cause trouble, and must be actively addressed and solved. Problem solving technique enables the child to think of more than one solution, consider the possible results of every solution, and be able to gain decision-making

The problem-solving technique learned in childhood CBT involves similar techniques with the technique used in adults [88]. In the first step of the problem-solving technique, which

as a result of such avoidance, and problem becomes more insolvable [87].

etc. [81].

by oneself.

**3.5. Self-monitoring**

12 Cognitive Behavioral Therapy and Clinical Applications

encourage the child.

**3.6. Problem solving technique**

skills on which solution to be selected [87, 88].

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 the child.

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 [91, 92].

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].

#### **3.8. Exposure technique**

The most important factor that feeds the continuous and resistant nature of childhood anxiety disorders is the avoidance behavior that the child has developed against the situation causing anxiety. Therefore, prevention of the avoidance behavior in anxiety disorders constitutes one of the most important targets of CBT in terms of treatment [49, 93]. Exposure can also be used in childhood depression even though it cannot be involved as the primary technique. Especially in the current conceptualization of activity scheduling technique, the importance of avoiding on "depresso-typic" behavior has been emphasized [94]. From such perspective, avoidance behavior feeds the continuous nature of childhood depressive behavior just as in anxiety disorders. Avoidance behavior is triggered by situations creating stress, and reinforced by the relaxation feeling afterward. Along with the avoidance, immobility, withdrawal, and inertia symptoms increase more and a vicious circle is created; as a result of such vicious circle, the child lacks the surrounding reward resources that might reduce depressive symptoms [95]. Consequently, especially if the child has started to avoid situations or activities that trigger cognitive distortions, or depression is accompanied with anxiety symptoms, exposure must be involved in the childhood depression treatment program [82].

apply the technique more comfortably in real life. Coping techniques such as relaxation and distraction exercises as well as modeling and reinforcement methods are also added to

Cognitive Behavioral Therapy Principles in Children: Treatment of Internalizing Disorders

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Even though most of the tasks in exposure steps are quite simple situations to face with, these encounters might not be easy at all for children with intense anxiety. Therefore, supporting, encouraging, not forcing, and never reinforcing avoidance of the child in all steps are the main tasks of both the therapist and family. Another important point to be noted in systematic exposure technique is that it is required not to move on to the situation on the upper step before the child has exactly managed to cope with a situation on

In flooding, the child is directly faced with the situation causing anxiety in an imaginary or experiential manner without any hierarchy. This recurring and long-continued confrontation continues until the child states that his/her anxiety drops down to a certain level. Flooding technique must be used with response prevention; therefore, any avoidance behavior is prevented until the end of child's exposure process. However, since flooding causes a quite intense anxiety in the person as compared to systematic exposure technique, its use is very limited in children in practice. And when it is going to be applied, it must be ensured that child understands the rationale of technique well and knows the procedure in detail; such detailed information is quite important in terms of effectiveness

Social withdrawal is observed in most of the depressive and anxious children (especially, social phobia and generalized anxiety disorder) [97]. For instance, a child with social phobia might feel intense anxiety to communicate with others, and not know how to start communication either. Similarly, a depressive child might feel withdrawn due to maladaptive cognition and self-talks, and miss the social support and reinforcers that he/she might receive from

In social skills training, verbal and motor behaviors that are necessary to improve the suitable communication ways in interpersonal relationships are taught. Before starting the training, it is important to identify the lacking verbal or motor behaviors well, and establish co-operation between the child and family in the meantime. If the child has performance anxiety, main factors preventing the performance must be identified, and additional techniques must be included in the social skills training, if necessary. Social skills training is applied in children generally through techniques such as modeling, role-playing and homework. While applying these techniques, therapist must be quite active, and awareness of the child must be increased

Main focus topics of social skills training in children are weak peer relationships and conflicting parent relationships. For this reason, apart from modeling of therapist and performance of role-playing activities, exemplary behavior videos concerning the topic might be watched

the exposure sessions [81].

any step [96].

of the treatment [20].

**3.9. Social skills training**

the environment due to lack of social skills.

by constantly providing feedback [85].

Exposure faces the child with a situation that evokes fear in an imaginary or in vivo manner, and offers the opportunity to apply and test the skills learned during the therapy in order to cope with situations creating anxiety. This technique can be applied in systematic exposure or flooding forms, and adapted according to the developmental period of child or characteristics of the feared object/situation [73, 76]. For instance, it is not possible to carry out an exposure activity the same way with a child that is afraid of insects, a child that is afraid of sleeping alone, and a child that is afraid of the death of his/her parents. While it is possible to use *in vivo* exposure for some anxiety sources, imaginary exposure is the best choice in others.

In systematic exposure technique, first therapist and child make a list of events or situations that trigger anxiety. However, it is quite important to arrange a hierarchical order between events on the list starting from the one that creates least anxiety and ending with the one that creates most anxiety [20]. For this purpose, it will be useful to work carefully on the hierarchy, and ask for the help of parents in this process. Then, child starts to face the events on the list one by one. Mostly, the child is exposed to an imaginary situation during the session under the guidance and control of therapist before facing with it in real life. Therefore, he/she will have rehearsed the challenges that might be experienced in real life, and how he/she will cope with them in a safe environment [73, 76]. For instance, a child with social phobia might be asked to make a presentation in front of the therapist before making a presentation in the class. Thus, child starts the technique with a task that is similar to the situation where he/she will experience anxiety intensely but creates less trouble. In another instance, the child might be afraid of sleeping alone and might state in the session that he/she is frightened by the tree branches seen from the window across his/her bed during the imaginary exposure. Taking precautions about this might enable the child apply the technique more comfortably in real life. Coping techniques such as relaxation and distraction exercises as well as modeling and reinforcement methods are also added to the exposure sessions [81].

Even though most of the tasks in exposure steps are quite simple situations to face with, these encounters might not be easy at all for children with intense anxiety. Therefore, supporting, encouraging, not forcing, and never reinforcing avoidance of the child in all steps are the main tasks of both the therapist and family. Another important point to be noted in systematic exposure technique is that it is required not to move on to the situation on the upper step before the child has exactly managed to cope with a situation on any step [96].

In flooding, the child is directly faced with the situation causing anxiety in an imaginary or experiential manner without any hierarchy. This recurring and long-continued confrontation continues until the child states that his/her anxiety drops down to a certain level. Flooding technique must be used with response prevention; therefore, any avoidance behavior is prevented until the end of child's exposure process. However, since flooding causes a quite intense anxiety in the person as compared to systematic exposure technique, its use is very limited in children in practice. And when it is going to be applied, it must be ensured that child understands the rationale of technique well and knows the procedure in detail; such detailed information is quite important in terms of effectiveness of the treatment [20].
