I have thoroughly enjoyed creating my blog about Cognitive Behavioural Therapy with Children. After further research on this topic I have gained a stronger understanding of how Cognitive Behavioural Therapy can benefit children who experience different mental health issues; anxiety, depression and ADHD.
Throughout my blog I have explained what CBT is, the different children that it is used with, why and how it is used with these children with an example of group sessions that I was involved with on a fieldwork placement.
Symptoms of mental health issues, e.g. anxiety and stress, can have a big impact on a child's quality of life. Occupational Therapists play an important role within CBT as they aim to enable people to achieve as much as they can for themselves in order to get the most out of life. Cognitive Behavioural Therapy helps the child to identify and correct faulty thinking patterns, which can therefore improve the psychological and behavioural problems of the children and improve their well-being and quality of life.
After researching and creating this blog I believe that there could be more research done on the effectiveness of using Cognitive Behavioural Therapy in children with mental health issues, as when I was researching there were very limited specific studies on this topic.
I hope you have enjoyed reading my blog. I would love to hear of your experiences with Cognitive Behavioural Therapy or any opinions you have with this approach. I welcome any questions or comments that you may have.
Thank you =)
Sunday, September 4, 2011
Examples of CBT based group sessions
Fieldwork Experience
My experience using Cognitive Behavioural Therapy with children was on a fieldwork placement in a Child Mental Health clinic. While on this placement I had the opportunity to co-facilitate some anxiety management group sessions. On my first day of placement, I was involved in a last group session on 'Social Skills and Anxiety'. There were approximately 5-7 children in this group. The children were between the ages of 5-7 who were involved in the clinic and having key difficulties with anxiety and social skills. Children within the unit had mental health issues including; anxiety, ADHD, depression and psychosis.
The group was run by two Occupational Therapists and was 60minutes long.
There were three children within the group that were needing extra sessions to work on anxiety management, therefore the occupational therapist's ran three more sessions with these children. These are the groups that I was involved in.
Here is an example of some group sessions using CBT;
Group One
Introduction
Warm up- cards, board game etc
Review what was covered in the previous groups the children were involved in. re anxiety.
Main Activity
Fears and worries list- children were given a worksheet where they wrote down all their fears and worries.
The children then picked an individual anxiety goal to work on.
Step ladder worksheet- The children wrote down on a piece of paper all the things they would like to do and then arranged them on the ladder. The things that feel the easiest were put at the bottom of the ladder and the most difficult ones at the top. The therapist then discussed with the children that they should start at the bottom and work their way up each step and the key was to take small steps at a time to help climb the ladder.
-Set homework tasks for the child. E.g. working on their step ladder, recording down any fears or worries that may arise between sessions.
Conclusion
Relaxation Activity- breathing exercise (child friendly)
1. Get the child to hold their left hand in a fist and imagine that they are holding their favourite pretty flower.
2. Hold their right hand in a fist, imagine it is a candle.
3. Ask the child to inhale as much as they can, sniffing the flower!
4. Then ask the child to exhale/breath out and blow their candle out.
Repeat this a few times with the child. Talk about when they might use this deep breathing activity and why it is important.
At the end of the session the parents join and the children and therapist feedback to parents and let them know what they need to work on between sessions. E.g Homework tasks.
Group Two
Introduction
Review the goal/step ladder from the previous session. See how the children are going with it.
Main Activity
-Self-talk- discussions about negative and positive self-talk, and teaching the children how negative thoughts can be disputed and changed to more positive thoughts.
-A self-talk work sheet- children write down negative self-talk and then change the statement in a positive self-talk.
-Coping Cards-these are palm-sized cards, that have positive "self-statements" that children can read these at anytime. These are a great tool for boosting confidence and 'coping' with stress and anxiety.
Conclusion
Relaxation Activity- Progressive muscle relaxation. There are different scripts that can be used for this. Here is one section of a script that I used that the children engaged in really well;
"Pretend you have a whole lemon in your hand. Now squeeze it hard. Try to squeeze all of the juice out. Feel the tightness in your hand & arm as you squeeze. Now drop the lemon. Notice how your muscles feel when relaxed. Take another lemon & squeeze. Try to squeeze harder than the first one..."
Again, at the end of the session the parents join and children and therapist feedback what happened in the session and what the homework will be in between sessions.
Group Three
Introduction
Review the step ladder and how the children's week has been since the last session.
Talk about the generalising the skills learnt over the sessions.
Main Activity
Snakes and Ladders- when child lands on a ladder they have to write down a positive self-talk statement and stick it on the board and when they land on a snake they wrote down a negative self-talk statement.
Talk to children about confidence;
- what builds it
- what makes you feel you can cope
- achievements
Conclusion
Another relaxation activity with children.
Go over everything from the last three sessions with the children and parents. Give out any worksheets for the child to use in the future.
My experience using Cognitive Behavioural Therapy with children was on a fieldwork placement in a Child Mental Health clinic. While on this placement I had the opportunity to co-facilitate some anxiety management group sessions. On my first day of placement, I was involved in a last group session on 'Social Skills and Anxiety'. There were approximately 5-7 children in this group. The children were between the ages of 5-7 who were involved in the clinic and having key difficulties with anxiety and social skills. Children within the unit had mental health issues including; anxiety, ADHD, depression and psychosis.
The group was run by two Occupational Therapists and was 60minutes long.
There were three children within the group that were needing extra sessions to work on anxiety management, therefore the occupational therapist's ran three more sessions with these children. These are the groups that I was involved in.
Here is an example of some group sessions using CBT;
Group One
Introduction
Warm up- cards, board game etc
Review what was covered in the previous groups the children were involved in. re anxiety.
Main Activity
Fears and worries list- children were given a worksheet where they wrote down all their fears and worries.
The children then picked an individual anxiety goal to work on.
Step ladder worksheet- The children wrote down on a piece of paper all the things they would like to do and then arranged them on the ladder. The things that feel the easiest were put at the bottom of the ladder and the most difficult ones at the top. The therapist then discussed with the children that they should start at the bottom and work their way up each step and the key was to take small steps at a time to help climb the ladder.
-Set homework tasks for the child. E.g. working on their step ladder, recording down any fears or worries that may arise between sessions.
Conclusion
Relaxation Activity- breathing exercise (child friendly)
1. Get the child to hold their left hand in a fist and imagine that they are holding their favourite pretty flower.
2. Hold their right hand in a fist, imagine it is a candle.
3. Ask the child to inhale as much as they can, sniffing the flower!
4. Then ask the child to exhale/breath out and blow their candle out.
Repeat this a few times with the child. Talk about when they might use this deep breathing activity and why it is important.
At the end of the session the parents join and the children and therapist feedback to parents and let them know what they need to work on between sessions. E.g Homework tasks.
Group Two
Introduction
Review the goal/step ladder from the previous session. See how the children are going with it.
Main Activity
-Self-talk- discussions about negative and positive self-talk, and teaching the children how negative thoughts can be disputed and changed to more positive thoughts.
-A self-talk work sheet- children write down negative self-talk and then change the statement in a positive self-talk.
-Coping Cards-these are palm-sized cards, that have positive "self-statements" that children can read these at anytime. These are a great tool for boosting confidence and 'coping' with stress and anxiety.
Conclusion
Relaxation Activity- Progressive muscle relaxation. There are different scripts that can be used for this. Here is one section of a script that I used that the children engaged in really well;
"Pretend you have a whole lemon in your hand. Now squeeze it hard. Try to squeeze all of the juice out. Feel the tightness in your hand & arm as you squeeze. Now drop the lemon. Notice how your muscles feel when relaxed. Take another lemon & squeeze. Try to squeeze harder than the first one..."
Again, at the end of the session the parents join and children and therapist feedback what happened in the session and what the homework will be in between sessions.
Group Three
Introduction
Review the step ladder and how the children's week has been since the last session.
Talk about the generalising the skills learnt over the sessions.
Main Activity
Snakes and Ladders- when child lands on a ladder they have to write down a positive self-talk statement and stick it on the board and when they land on a snake they wrote down a negative self-talk statement.
Talk to children about confidence;
- what builds it
- what makes you feel you can cope
- achievements
Conclusion
Another relaxation activity with children.
Go over everything from the last three sessions with the children and parents. Give out any worksheets for the child to use in the future.
Friday, September 2, 2011
CBT Sessions
Witihn sessions it can be beneficial to adapt and match the techniques and concepts of Cognitive Behavioural Therapy to the developmental age of the child, as it may help to overcome some of the pervcieved developmental issues of the child. Material used within CBT should be pitched at the appropraite level so children can understand and engage in intervetion. Instructions should be clear and simple to comprehend. (Stallard, 2002)
CBT should be fun!! Children are more likely to engage and learn if the work that they are doing is enjoyable and intersting for them.
Accessing and communicating thoughts
Different ways to get children to start thinking about there thoughts. (Stallard, 2002)
- Direct questioning, to gain information about their thoughts and self-talk. Asking the children what they are thinking. Some children may not respond well to this style of gathering information. It doesn't mean that they are unable to access their thoughts, the therapsit may need to try another style.
- Ask the children to think of difficult situations that they have been in. The therapist can help the child to describe it, draw a picture about it and while doing so may be able to describe the situation. E.g thoughts about event. Children may need prompted throughout session.
- Some young children may have difficultly describing their own cognitions, but may be able to talk about what someone else may be thinking. The therapist may be able to use puppets to role play the child's difficult situation, and then the child can be asked what the puppets might be thinking, which will highlight the child's thoughts witihn the situation. The therapist could also write down different options of cognitions that the child could choose from.
- Thought bubbles. Another idea would be to use the child's favourite cartoon charater or others and put thought bubbles out of the side, for the child to fill in what the characters might be thinking.
Activities
Therapists can engage child in activities so they are able to monitor the child's thought processes throughout the activity, and challenging any unhelpful automatic thoughts that may arise while involved in the activity. (Everett, Donaghy & Feaver, 2003)
Meaningful Occupation
An activity that is meaningful for the child, carried out by both the therpist and client can create a safe environement in which the client is able to discuss experiences that they are finding unhelpful or distressing. (Evertt, Donaghy & Feaver, 2003)
Length of sessions
CBT sessions are intitially held weekly until the end of the aggreed sessions, when the therapist may meet less frequently, depending on the child's needs. The duration of each session is usually 45 to 60 minutes.
Structure of sessions
CBT sessions are well structured so that the children know what to expect when they come to treatment. (Boyes, 2011)
Beginning of the session- the therapist will do a brief overview of the last session and what has happended in the time since the last session. i.e at home, school etc.
- Feedback from homework, chid will show homework sheets and therpist will discuss these with the child, finding out what was helpful and unhelpful.
- Set an agenda for the main part of the session. The child can add anything that they want to talk about witihn session. There is usually one main focus of session. eg working on thoughts emotions or behaviour. ( Boyes, 2011)
- Towards the end of the session, the therapist will set homeowrk for the child- a self-help task for them to do at home. The idea of homework is for the client to put what they have learnt in the session into practice.
- Some sessions will include a relaxation activities or another warm down task at the end of the session.
Both homework, reading and relaxation are both important strategies used within the Cognitive Behavioural Approach, with homework being the most important. Therapy sessions can be seen as 'training sessions' where clients can try and out and practice what they have learnt in between sessions with their 'homework'. Relaxation activities are important for the client to learn in order to help manage stress and anxiety.
Boyes, A. (2008-2011). Cognitive Behavioural Therapy. Retrieved September 2nd, 2011, from http://www.aliceboyes.com/cbt/Everett, T., Donaghy, M., & Feaver, S. (2003). Interventions for Mental Health: An Evidence-based Approach for Physiotherapists and Occupational Therapists. New York: Elsevier Science.
Froggatt, W. (2006). A Brief Introduction to Cognitive- Behaviour Therapy. New Zealand.
Stallard, P. (2002). Think Good- Feel Good. A Cognitive Behaviour Therapy Workbook for Children and Young People. Chichester: John Wiley & Sons Ltd.
Helping people to change
Within Cognitive Behavioural Therapy there are steps taken for "helping people change". These are broken down into 4 steps.
1. Help the client to understands that their emotions and behaviours are effected by beliefs and thinking.
2. Show how the believes may be changed. Using the ABC Model.
3. Teach the client how to dispute and change irrational thoughts.Here the ABC model can be extended to include- D, E & F. D= disputing irrational beliefs. E=the new effects the client wishes to achieve. i.e new ways of feeling and behaving. F= Further action for the client to take.
4. Help the client to get into action. Acting against irrational beliefs.
The ABC Model A= Activating event. E.g A child not being invited into a game of soccer.
B=Beliefs about the event E.g.Nobody likes me, I'm useless.
C=Consequence. E.g. emotions-hurt, behaviours- avoiding soccer all together.
(A causes B, and B then triggers off C.)
1. Help the client to understands that their emotions and behaviours are effected by beliefs and thinking.
2. Show how the believes may be changed. Using the ABC Model.
3. Teach the client how to dispute and change irrational thoughts.Here the ABC model can be extended to include- D, E & F. D= disputing irrational beliefs. E=the new effects the client wishes to achieve. i.e new ways of feeling and behaving. F= Further action for the client to take.
4. Help the client to get into action. Acting against irrational beliefs.
The ABC Model A= Activating event. E.g A child not being invited into a game of soccer.
B=Beliefs about the event E.g.Nobody likes me, I'm useless.
C=Consequence. E.g. emotions-hurt, behaviours- avoiding soccer all together.
(A causes B, and B then triggers off C.)
Froggatt, W. (2006). A Brief Introduction to Cognitive- Behaviour Therapy. New Zealand.
Tuesday, August 30, 2011
Why CBT?
Children with anxiety disorders have been found to misperceive uncertain events and threatening and they tend to be overly self- focused and hypercritical and report increased levels of negative self talk and expectations. (Stallard, 2002)
Conner (2008) explains that once a fear or anxiety reaction has been created, the reaction tendency can be maintained a number of ways. One of these includes;
Self-talk or "automatic" thoughts. What the child believes can cause an emotional reaction and errors in thinking or catastophic conclusions, contribute significantly to anxiety reactions (e.g. I can't handle new situations alone. All dogs want to bite me.) This highlights how CBT would be benificial for a child experiencing differnet levels of anxiety, as it will aim to change the irrational thinking patterns that are contributing to their symptoms of anxiety.
"Deficits in cognitive processing, such as inability to engage in planning or problem solving have been found in children and young people with problems of self control such as ADHD and also in children with interpersonal difficulties.” (Stallard, 2002, p.5)
Cognitive Behavioural Therapy will teach children with ADHD new skills in order to be able to manage difficult symptoms they experience.
Depressed children have more negative attributions than non-depressed children and have distorted perceptions of their own performance, and selectively attend to the negative features of events. (Stallard, 2002)
Cognitive Behavioural Therapy will be beneficial for children with Anxiety Disorders, Depression, ADHD as there is evidence to support that they all experience cognitive and behavioural dysfunctions. CBT will be valuable because it has the overall purpose of increasing awareness, facilitating better self-understanding, improve self-control by developing more appropriate cognitive and behavioural skills for children.
Stallard, P. (2002). Think Good- Feel Good. A Cognitive Behaviour Therapy Workbook for Children and Young People. Chichester: John Wiley & Sons Ltd.
Conner, M. G. (2002-2008). Anxiety in Children. Retrieved August 31st, 2011, from http://www.crisiscounseling.com/Articles/AnxietyinChildren.htm
Conner (2008) explains that once a fear or anxiety reaction has been created, the reaction tendency can be maintained a number of ways. One of these includes;
Self-talk or "automatic" thoughts. What the child believes can cause an emotional reaction and errors in thinking or catastophic conclusions, contribute significantly to anxiety reactions (e.g. I can't handle new situations alone. All dogs want to bite me.) This highlights how CBT would be benificial for a child experiencing differnet levels of anxiety, as it will aim to change the irrational thinking patterns that are contributing to their symptoms of anxiety.
"Deficits in cognitive processing, such as inability to engage in planning or problem solving have been found in children and young people with problems of self control such as ADHD and also in children with interpersonal difficulties.” (Stallard, 2002, p.5)
Cognitive Behavioural Therapy will teach children with ADHD new skills in order to be able to manage difficult symptoms they experience.
Depressed children have more negative attributions than non-depressed children and have distorted perceptions of their own performance, and selectively attend to the negative features of events. (Stallard, 2002)
Cognitive Behavioural Therapy will be beneficial for children with Anxiety Disorders, Depression, ADHD as there is evidence to support that they all experience cognitive and behavioural dysfunctions. CBT will be valuable because it has the overall purpose of increasing awareness, facilitating better self-understanding, improve self-control by developing more appropriate cognitive and behavioural skills for children.
Stallard, P. (2002). Think Good- Feel Good. A Cognitive Behaviour Therapy Workbook for Children and Young People. Chichester: John Wiley & Sons Ltd.
Conner, M. G. (2002-2008). Anxiety in Children. Retrieved August 31st, 2011, from http://www.crisiscounseling.com/Articles/AnxietyinChildren.htm
Monday, August 29, 2011
Mental Health Issues in Children
Cognitive Behavioural Therapy is beneficial for children who experience different mental health issues including, Depression, Anxiety and ADHD. Below is some brief information on each.
Depression
Depression in children can be caused by a number of different factors. These include; physical health, life events, family history of depression, genetic vulnerability and the environment.
The presentation of a depressed child includes a sad and low self mood, lack of motivation, general low self-esteem and self-belief. (Florey, 2001)
Anxiety
There is no one cause for anxiety in children. Exposure to a stressfull environment can be a pathway to developing anxiety. Both geneitic and physiological make-up and exposure to specific trauma may also increase chances anxiety.
A child with anxiety may experience some of the following symptoms; a sense of apprehension or worry, low self- esteem and physical symptoms that may include headache, muscle tension, perspiration, restlessness, tension in the chest and mild stomach discomfort.
Attention Deficit Hyperactivity Disorder(ADHD)
ADHD fall in three main areas. These are hyperactivity, inattention and impulsivity.
A hyperactive child is often fidgety, has difficulty being quiet, always on the go and talks excessively. An inattentive will often have difficulty sustaining attention, struggles to listen to what is being sent, will not follow instructions or finish tasks, avoids tasks that require mental effort and is easily distracted. A child with impulsivity will often interrupt others and speak when not supposed to and is unable to wait their turn. (Rutherford, 2010)
Rutherford (2010) states that the combination of difficulties that a child with ADHD experiences is associated with increased rates of observed educational and social behaviour which therefore causes a decrease in self-esteem.
Link to more info on child anxiety
Link to more info on child depression
Link to more info on children with ADHD
Florey, L. (2001). Occupational Therapy for Child and Adolescent Mental Health. New York: Churchill Livingstone.
Rutherford, D. (2010, March 3rd). Symptoms of ADHD . Retrieved August 31st, 2011, from netdoctor: http://www.netdoctor.co.uk/adhd/indepthlookatsymptoms.htm
Depression
Depression in children can be caused by a number of different factors. These include; physical health, life events, family history of depression, genetic vulnerability and the environment.
The presentation of a depressed child includes a sad and low self mood, lack of motivation, general low self-esteem and self-belief. (Florey, 2001)
Anxiety
There is no one cause for anxiety in children. Exposure to a stressfull environment can be a pathway to developing anxiety. Both geneitic and physiological make-up and exposure to specific trauma may also increase chances anxiety.
A child with anxiety may experience some of the following symptoms; a sense of apprehension or worry, low self- esteem and physical symptoms that may include headache, muscle tension, perspiration, restlessness, tension in the chest and mild stomach discomfort.
Attention Deficit Hyperactivity Disorder(ADHD)
ADHD fall in three main areas. These are hyperactivity, inattention and impulsivity.
A hyperactive child is often fidgety, has difficulty being quiet, always on the go and talks excessively. An inattentive will often have difficulty sustaining attention, struggles to listen to what is being sent, will not follow instructions or finish tasks, avoids tasks that require mental effort and is easily distracted. A child with impulsivity will often interrupt others and speak when not supposed to and is unable to wait their turn. (Rutherford, 2010)
Rutherford (2010) states that the combination of difficulties that a child with ADHD experiences is associated with increased rates of observed educational and social behaviour which therefore causes a decrease in self-esteem.
Link to more info on child anxiety
Link to more info on child depression
Link to more info on children with ADHD
Florey, L. (2001). Occupational Therapy for Child and Adolescent Mental Health. New York: Churchill Livingstone.
Rutherford, D. (2010, March 3rd). Symptoms of ADHD . Retrieved August 31st, 2011, from netdoctor: http://www.netdoctor.co.uk/adhd/indepthlookatsymptoms.htm
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