Cognitive Behavior Therapy For Children and Adolescents

Cognitive-Behavior Therapy
for
CHILDREN AND ADOLESCENTS
This page intentionally left blank
Cognitive-Behavior Therapy
for
CHILDREN AND ADOLESCENTS
Edited by
Eva Szigethy, M.D., Ph.D.

John R. Weisz, Ph.D., ABPP
Robert L. Findling, M.D., M.B.A.
Washington, DC
London, England
Note: The authors have worked to ensure that all information in this book is accu-
rate at the time of publication and consistent with general psychiatric and medical
standards, and that information concerning drug dosages, schedules, and routes of
administration is accurate at the time of publication and consistent with standards
set by the U.S. Food and Drug Administration and the general medical community.
As medical research and practice continue to advance, however, therapeutic stan-
dards may change. Moreover, specific situations may require a specific therapeutic
response not included in this book. For these reasons and because human and me-
chanical errors sometimes occur, we recommend that readers follow the advice of
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Library of Congress Cataloging-in-Publication Data
Cognitive-behavior therapy for children and adolescents / edited by Eva Szigethy,
John R. Weisz, Robert L. Findling. — 1st ed.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-1-58562-406-5 (alk. paper)
I. Szigethy, Eva, 1962– II. Weisz, John R. III. Findling, Robert L. IV. American
Psychiatric Association.
[DNLM: 1. Cognitive Therapy. 2. Adolescent. 3. Child. 4. Mental Disorders—
psychology. 5. Mental Disorders—therapy. WS 350.6]
616.891425—dc23
2011039536
British Library Cataloguing in Publication Data
A CIP record is available from the British Library.
Contents
Contributors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix
Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xvii
Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xix
DVD Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . xxiii
1 Cognitive-Behavior Therapy:
An Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Sarah Kate Bearman, Ph.D.
2 Developmental Considerations
Across Childhood . . . . . . . . . . . . . . . . . . . . . . . 29
Sarah A. Frankel, M.S.
Catherine M. Gallerani, M.S.
Judy Garber, Ph.D.
Appendix 2–A: Tools for Assessing
Developmental Skills . . . . . . . . . . . . . . . . . . . . . . . . . .62
Appendix 2–B: Practical Recommendations
for Treatment Planning. . . . . . . . . . . . . . . . . . . . . . . . .65
3 Culturally Diverse Children

and Adolescents . . . . . . . . . . . . . . . . . . . . . . . . 75
Rebecca Ford-Paz, Ph.D.
Gayle Y. Iwamasa, Ph.D.
4 Combined CBT and Psychopharmacology . . .119
Sarabjit Singh, M.D.
Laurie Reider Lewis, Psy.D.
Annie E. Rabinovitch, B.A.
Angel Caraballo, M.D.
Michael Ascher, M.D.
Moira A. Rynn, M.D.
Appendix 4–A: Combination Treatment . . . . . . . . . . 150
5 Depression and Suicidal Behavior . . . . . . . . . .163

Fadi T. Maalouf, M.D.
David A. Brent, M.D.
6 Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . .185

Benjamin W. Fields, Ph.D., M.Ed.
Mary A. Fristad, Ph.D., ABPP
7 Childhood Anxiety Disorders:

The Coping Cat Program . . . . . . . . . . . . . . . . .227
Kelly A. O’Neil, M.A.
Douglas M. Brodman, M.A.
Jeremy S. Cohen, M.A.
Julie M. Edmunds, M.A.
Philip C. Kendall, Ph.D., ABPP
8 Pediatric Posttraumatic Stress Disorder. . . . . .263

Judith A. Cohen, M.D.
Audra Langley, Ph.D.
9 Obsessive-Compulsive Disorder . . . . . . . . . . .299

Jeffrey J. Sapyta, Ph.D.
Jennifer Freeman, Ph.D.
Martin E. Franklin, Ph.D.
John S. March, M.D., M.P.H.
10 Chronic Physical Illness: Inflammatory
Bowel Disease as a Prototype . . . . . . . . . . . . 331
Rachel D. Thompson, M.A.
Susan Turner, Psy.D.
Patty Delaney, L.C.S.W.
William Beardslee, M.D.
Appendix 10–A: PASCET-PI
Selected Skills and Tools . . . . . . . . . . . . . . . . . . . . . 369
Appendix 10–B: Guided Imagery for
Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . 375
Appendix 10–C: Information Worksheets
for Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 378
11 Obesity and Depression: A Focus on

Polycystic Ovary Syndrome . . . . . . . . . . . . . . 383
Dana L. Rofey, Ph.D.
Ronette Blake, M.S.
Jennifer E. Phillips, M.S.
Appendix 11–A: Healthy Bodies, Healthy Minds:
Selected Patient Worksheets. . . . . . . . . . . . . . . . . . . 420
12 Disruptive Behavior Disorders . . . . . . . . . . . . 435

John E. Lochman, Ph.D., ABPP
Nicole P. Powell, Ph.D.
Caroline L. Boxmeyer, Ph.D.
Rachel E. Baden, M.A.
13 Enuresis and Encopresis . . . . . . . . . . . . . . . . 467

Patrick C. Friman, Ph.D.
Thomas M. Reimers, Ph.D.
John Paul Legerski, Ph.D.
Appendix 1: Self-Assessment
Questions and Answers . . . . . . . . . . . . . . . . . .513
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535
Contributors
Resident in Psychiatry, Department of Psychiatry and Behavioral Sciences,
Beth Israel Medical Center, New York, New York

Graduate Student, The University of Alabama, Tuscaloosa, Alabama

Director, Baer Prevention Initiatives, Children’s Hospital of Boston; Gard-
ner/Monks Professor of Child Psychiatry, Harvard Medical School; Senior
Research Scientist, Judge Baker Children’s Center, Boston, Massachusetts

Assistant Professor of School-Child Clinical Psychology, Ferkauf Graduate
School of Psychology, Yeshiva University, Bronx, New York
Ronette Blake, M.S.

Project Coordinator, Weight Management Services, Children’s Hospital of
Pittsburgh, Pittsburgh, Pennsylvania

Research Psychologist, Department of Psychology, The University of Ala-
bama, Tuscaloosa, Alabama

Academic Chief, Child and Adolescent Psychiatry; Endowed Chair in Sui-
cide Studies; Professor of Psychiatry, Pediatrics, and Epidemiology, Uni-
versity of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

Child and Adolescent Anxiety Disorders Clinic, Temple University, Phila-
delphia, Pennsylvania

Assistant Clinical Professor of Psychiatry; Medical Director, School-Based
Mental Health Program, Columbia University Medical Center, New York,
New York
ix
x Cognitive-Behavior Therapy for Children and Adolescents


Professor of Psychiatry, Temple University School of Medicine, Philadel-
phia, Pennsylvania

Licensed Clinical Social Worker, Medical Coping Clinic, Children’s Hos-
pital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania


Postdoctoral Fellow in Clinical Child Psychology, Nationwide Children’s
Hospital, Columbus, Ohio
Robert L. Findling, M.D., M.B.A.

Rocco L. Motto, M.D., Professor of Child and Adolescent Psychiatry, Case
Western Reserve University School of Medicine; Director, Division of
Child & Adolescent Psychiatry, University Hospitals Case Medical Center,
Cleveland, Ohio

Assistant Professor of Psychiatry and Behavioral Sciences, Northwestern
University Feinberg School of Medicine, Chicago, Illinois

Graduate Student, Department of Psychology and Human Development,
Vanderbilt University, Nashville, Tennessee

Associate Professor of Clinical Psychology in Psychiatry at the Hospital of
the University of Pennsylvania; Director, Child/Adolescent OCD, Tics,
Trichotillomania and Anxiety Group (COTTAGe), University of Pennsyl-
vania School of Medicine, Philadelphia, Pennsylvania

Assistant Professor of Psychiatry and Human Behavior, Warren Alpert
Medical School of Brown University, Providence, Rhode Island
Contributors xi

Director, Boys Town Center for Behavioral Health; Clinical Professor of
Pediatrics, University of Nebraska School of Medicine, Omaha, Nebraska

Professor of Psychiatry, Psychology, and Nutrition, The Ohio State Univer-
sity, Columbus, Ohio

Graduate Student, Department of Psychology and Human Development,
Vanderbilt University, Nashville, Tennessee
Judy Garber, Ph.D.

Professor of Psychology and Human Development, Vanderbilt University,
Nashville, Tennessee

Department of Veterans Affairs, Central Office, Office of Mental Health
Operations, Washington, DC

Laura H. Carnell Professor of Psychology and Director of the Child and
Adolescent Anxiety Disorders Clinic, Temple University, Philadelphia,
Pennsylvania

Assistant Professor of Psychiatry and Biobehavioral Sciences, Semel Insti-
tute for Neuroscience and Human Behavior, University of California Los
Angeles, Los Angeles, CA

Assistant Professor of Psychology, University of North Dakota, Grand
Forks, North Dakota

Instructor in Clinical Psychiatry, Institute of Clinical Psychology (in Psy-
chiatry), Columbia University Medical Center, College of Physicians and
Surgeons, New York, New York

Professor and Doddridge Saxon Chairholder in Clinical Psychology, The
University of Alabama, Tuscaloosa, Alabama
xii Cognitive-Behavior Therapy for Children and Adolescents

Director, Division of Neurosciences Medicine, Duke Clinical Research In-
stitute, Durham, North Carolina


Assistant Professor of Psychiatry, Department of Child and Adolescent
Psychiatry, American University of Beirut Medical Center, Beirut, Leba-
non; Adjunct Assistant Professor of Psychiatry, Western Psychiatric Insti-
tute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh,
Pennsylvania

Predoctoral Psychology Fellow, University of Pittsburgh, Pittsburgh, Penn-
sylvania

Research Psychologist, Department of Psychology, The University of Ala-
bama, Tuscaloosa, Alabama

Research Assistant, New York State Psychiatric Institute, Columbia Uni-
versity, New York, New York

Director, Behavioral Health Clinic, Boys Town; Clinical Associate Profes-
sor, Department of Pediatrics, Creighton University School of Medicine,
Omaha, Nebraska

Assistant Professor of Pediatrics and Psychiatry, University of Pittsburgh
School of Medicine; Director of Behavioral Health, Weight Management
and Wellness Center, Children’s Hospital of Pittsburgh, Pittsburgh, Penn-
sylvania
Contributors xiii
Moira A. Rynn, M.D.

Associate Professor of Clinical Psychiatry, Columbia University; Unit Chief
of Children’s Research Day Unit; Deputy Director of Research, Division of
Child and Adolescent Psychiatry; Director of the Child and Adolescent Psy-
chiatric Evaluation Service, New York State Psychiatric Institute/Columbia
University; Medical Director of The Columbia University Clinic for Anxiety
and Related Disorders (CUCARD), New York, New York

Assistant Professor of Psychiatry and Behavioral Sciences, Duke Univer-
sity Medical Center, Durham, North Carolina

Assistant Professor of Clinical Psychiatry, Columbia University, New York
Presbyterian Hospital, Child and Adolescent Psychiatry, New York, New York

Associate Professor of Psychiatry, Pediatrics, and Medicine; Medical Di-
rector, Medical Coping Clinic, Division of Pediatric Gastroenterology,
University of Pittsburgh Medical Center, Children’s Hospital of Pitts-
burgh, Pennsylvania

Research Clinician, Medical Coping Clinic, Children’s Hospital of Pitts-
burgh of UPMC, Pittsburgh, Pennsylvania

Licensed Clinical Psychologist, Medical Coping Clinic, Children’s Hospi-
tal of Pittsburgh of UPMC, Pittsburgh, Pennsylvania

Professor of Psychology, Faculty of Arts and Sciences, Harvard University,
Cambridge, Massachusetts; Professor of Psychology, Harvard Medical
School, Boston, Massachusetts; President and Chief Executive Officer,
Judge Baker Children's Center, Harvard Medical School, Boston, Massa-
chusetts
xiv Cognitive-Behavior Therapy for Children and Adolescents
Disclosures of Interest
The following contributors to this book have indicated a financial interest in or other
affiliation with a commercial supporter, a manufacturer of a commercial product, a
provider of a commercial service, a nongovernmental organization, and/or a govern-
ment agency, as listed below:
David A. Brent, M.D. Works for the University of Pittsburgh School of Medicine
and University of Pittsburgh Medical Center, Western Psychiatric Institute
and Clinic; Research support: National Institute of Mental Health; Royalties:
Guilford Press; UpToDate psychiatry section editor; Honoraria: presentations
for continuing medical education events
Judith A. Cohen, M.D. Research support: Annie E. Casey Foundation, National
Institute of Mental Health, Substance Abuse and Mental Health Services Ad-
ministration; Royalties: Guilford Press (books); Training contracts (includes
funds for travel): California Institute for Mental Health; Pennsylvania Depart-
ment of Mental Health; New York State Office of Mental Health
Mina K. Dulcan, M.D. Royalties: Books published by American Psychiatric Pub-
lishing
Robert L. Findling, M.D., M.B.A. Receives or has received research support,
acted as a consultant, and/or served on a speaker’s bureau for Abbott, Ad-
drenex, AstraZeneca, Biovail, Bristol-Myers Squibb, Forest, GlaxoSmith-
Kline, Johnson & Johnson, KemPharm, Lilly, Lundbeck, Neuropharm,
Novartis, Noven, Organon, Otsuka, Pfizer, Rhodes Pharmaceuticals, Sanofi-
Aventis, Schering-Plough, Seaside Therapeutics, Sepracore, Shire, Solvay,
Sunovion, Supernus Pharmaceuticals, Validus, and Wyeth
Mary A. Fristad, Ph.D., ABPP Royalties: MF-PEP and IF-PEP workbooks
(www.moodychildtherapy.com) and Psychotherapy for Children With Bipolar
and Depressive Disorders (Guilford Press)
Philip C. Kendall, Ph.D., ABPP Royalties (income) from sales of books and
treatment materials for the treatment of anxiety in youth
Fadi T. Maalouf, M.D. Speaker’s bureau: Eli Lilly
John S. March, M.D., M.P.H. Equity: MedAvante; Scientific Consulting Fees:
Johnson & Johnson, Lilly, Pfizer; Scientific Advisor: Alkermes, Attention
Therapeutics, Avanir, Lilly, Pfizer, Scion, Translational Venture Partners, LLC,
Vivus; Royalties: Guilford Press, MultiHealth Systems, Oxford University
Press; Research support: Child/Adolescent Anxiety Multimodal Study
(CAMS); Child and Adolescent Psychiatry Trials Network (CAPTN); K24;
National Alliance for Research on Schizophrenia and Depression; Pfizer (prin-
cipal investigator); Pediatric OCD Study (POTS) I, II, Jr; Research Units on
Pediatric Psychopharmacology and Psychosocial Interventions (RUPP-PI);
Treatment for Adolescents with Depression Study (TADS)
Dana L. Rofey, Ph.D. Research support: National Institutes of Health
Moira A. Rynn, M.D. Research support: Boehringer Ingelheim Pharmaceuticals,
National Institute of Mental Health, Neuropharm LTD, Pfizer; Royalties:
American Psychiatric Publishing
Eva Szigethy, M.D., Ph.D. Oakstone child psychiatry review video completed in
2010
Contributors xv
The following contributors to this book have indicated no competing interests to dis-
close during the year preceding manuscript submission:
Rachel E. Baden, M.A.; William Beardslee, M.D.; Sarah Kate Bearman, Ph.D.;
Ronette Blake, M.S.; Caroline L. Boxmeyer, Ph.D.; Douglas M. Brodman, M.A.;
Angel Caraballo, M.D.; Jeremy S. Cohen, M.A.; Patty Delaney, L.C.S.W.; Julie M.
Edmunds, M.A.; Benjamin W. Fields, Ph.D., M.Ed.; Rebecca Ford-Paz, Ph.D.;
Sarah A. Frankel, M.S.; Martin E. Franklin, Ph.D.; Jennifer Freeman, Ph.D.;
Patrick C. Friman, Ph.D.; Catherine M. Gallerani, M.S.; Gayle Y. Iwamasa, Ph.D.;
Audra Langley, Ph.D.; John Paul Legerski, Ph.D.; Laurie Reider Lewis, Psy.D.; John
E. Lochman, Ph.D., ABPP; Kelly A. O’Neil, M.A.; Jennifer E. Phillips, M.S.;
Nicole P. Powell, Ph.D.; Annie E. Rabinovitch, B.A.; Thomas M. Reimers, Ph.D.;
Jeffrey J. Sapyta, Ph.D.; Sarabjit Singh, M.D.; Rachel D. Thompson, M.A.; Susan
Turner, Psy.D.; John R. Weisz, Ph.D., ABPP
Foreword
THIS book, edited by three experts in developmental psychopathology,

is just what clinicians and trainees are waiting for! Eva Szigethy is a child
and adolescent psychiatrist with a B.A. in neuropsychology and a Ph.D. in
neuroanatomy. She had the good fortune to study Primary and Secondary
Control Enhancement Training (PASCET), a type of cognitive-behavior
therapy (CBT), with coeditor John Weisz, Ph.D., as she completed her fel-
lowship in child and adolescent psychiatry. This launched an unusual and
creative path for a physician, in which she methodically developed and
tested a model of CBT for youth with both a chronic medical illness (in-
flammatory bowel disease) and depression. John Weisz has been a pioneer
in the study of what works in child mental health treatment—in both uni-
versity research and community clinical settings. Bob Findling, M.D., the
third coeditor of this trio, is a child and adolescent psychiatrist and a pe-
diatrician, with a broad and deep portfolio of research in phenomenology
and pharmacological treatment of childhood psychopathology.
There are many excellent books on CBT, but the synergy between psy-
chiatry and psychology makes this one unique. The “complete” child and
adolescent psychiatrist uses therapeutic techniques, not only a prescrip-
tion pad.
Mental health professionals, especially psychiatrists, and clinical stu-
dents, residents, and fellows often find the strictly manualized approaches
to psychotherapy to be intimidating and difficult to implement in the real
world of patients and families with multiple biological, psychological, and
social problems. The chapters in this accessible text speak to those thera-
pists and their patients. Although each intervention has empirical support
and underpinnings in theory, extensive literature reviews are deliberately
avoided in favor of a practical how-to approach. Chapters include clinically
relevant pearls of wisdom, case examples, key clinical summary points,
suggested additional readings, and self-assessment questions and answers.
Each chapter contains practical advice on constructing a treatment plan for
the disorder or syndrome, incorporating CBT interventions—as specific as
xvii
xviii Cognitive-Behavior Therapy for Children and Adolescents
number, structure, format, and content of sessions and when and how to
include parents. Chapter authors also discuss how developmental and cul-
tural factors may require special attention or adaptation of techniques.
One of the most interesting and useful sections of each chapter is how to
identify and address challenges and obstacles to treatment. A unique fea-
ture of this book is a DVD containing video vignettes (presented by actors
and actual therapists) that bring to life selected CBT techniques described
in the text.
This 13-chapter therapy manual begins with an introduction to CBT
with children and adolescents. A novel part of this chapter is a section de-
bunking common myths and misperceptions about CBT. The next chapter,
on developmental considerations, is coauthored by Judy Garber, Ph.D.,
noted expert in developmental psychopathology. Following a chapter on
aspects of therapy with culturally diverse youth, there is a unique chapter
on integrating CBT with psychopharmacology—a topic too often ignored.
The following chapters cover the range of disorders, with contributions by
many leading lights: David Brent, M.D., on depression and suicidal behav-
ior; Mary Fristad, Ph.D., on bipolar disorder; Philip Kendall, Ph.D., on the
use of Coping Cat for anxiety disorders; Judy Cohen, M.D., on posttrau-
matic stress disorder; John March, M.D., on obsessive-compulsive disor-
der; and John Lochman, Ph.D., on disruptive behavior disorders. In
addition, there are chapters on problems with physical manifestations: pe-
diatric chronic physical illness, with inflammatory bowel disease as a pro-
totype; obesity and depression, with a focus on polycystic ovary syndrome;
and enuresis and encopresis—notoriously difficult disorders to treat once
children become too old for star charts and simple behavioral pediatric in-
terventions.
Not only would this book, with its illustrative DVD, be a top choice
for individual practitioners in any mental health discipline who wish to ap-
ply CBT to children and adolescents, it would also be ideal for classroom
or seminar use with clinical students, residents, and fellows, especially in
programs that may lack faculty expertise in these techniques.
Mina K. Dulcan, M.D.

Margaret C. Osterman Professor of Child Psychiatry;
Head, Department of Child and Adolescent Psychiatry, Children’s
Memorial Hospital; Director, Warren Wright Adolescent Program,
Northwestern Memorial Hospital; Professor of Psychiatry and Behavioral
Sciences and Pediatrics; Chief, Child and Adolescent Psychiatry,
Northwestern University Feinberg School of Medicine, Chicago, Illinois
Preface
AROUND the world, children are at risk. Rates of pediatric psychiat-

ric disorders are increasing worldwide, a phenomenon that has been linked
to elevated environmental stressors and their interactions with genetic and
epigenetic changes in our human species. Fortunately, advances in clinical
science are expanding our understanding of the environmental and neuro-
biological mechanisms involved, and advances in intervention science are
building an ever-richer armamentarium of treatments that can make a dif-
ference. Among these evidence-based treatments, cognitive-behavior ther-
apy (CBT) has shown particularly strong evidence of effectiveness with
children and adolescents, across diverse disorders and over decades of re-
search. CBT offers the hope of changing dysfunctional trajectories during
the critical developmental window of childhood and adolescence when
there is optimal plasticity in brain functioning and underlying circuitry.
CBT uses psychotherapy techniques to correct erroneous thinking and
alter maladaptive behaviors, ideally in the context of an empathic patient-
therapist relationship. Although CBT has growing empirical support for ef-
ficacy in treating a variety of psychiatric disorders, a common complaint
of practicing clinicians is that they have difficulty accessing the CBT pro-
tocols that have been tested and found to be effective, and thus they have
not been able to build their own proficiency in these potent interventions.
This appears to be particularly true for clinicians who are treating children
and adolescents across a variety of psychiatric disorders.
The challenge of making efficacious treatments accessible to clinical
practitioners is of special interest to each of us, the coeditors of this vol-
ume. As a psychotherapy researcher and Medical Director of the Medical
Coping Clinic at the Children’s Hospital of Pittsburgh, Eva Szigethy,
M.D., Ph.D., has had the unique opportunity to create a behavioral health
clinic embedded within the Gastroenterology Clinic to screen pediatric
patients for emotional distress and behavioral disturbances. In this setting,
Szigethy and her colleagues have found that CBT has a significant impact
on depression, abdominal pain, and health-related quality of life, as well as
xix
xx Cognitive-Behavior Therapy for Children and Adolescents
a fiscal impact in the form of decreased emergency room visits and hospi-
talizations. As a psychotherapy researcher, university professor, and Presi-
dent and Chief Executive Officer of the Judge Baker Children’s Center,
John Weisz, Ph.D., ABPP, has also seen the potency of CBT, both in ran-
domized effectiveness trials with clinicians in community clinics and in the
impact of CBT-enhanced school and outpatient programming at Judge
Baker. Robert Findling, M.D., M.B.A., a pediatrician, child psychiatrist,
medical school professor, and treatment researcher who directs a division
of child and adolescent psychiatry at an academic medical center, has re-
peatedly seen the practical obstacles to (as well as the feasible solutions
for) incorporating evidence-based treatments into routine clinical care.
This book was created to help fill the gap between clinical science and
clinical practice for children and adolescents by making CBT accessible
through the written word and companion videos. Our goal has been to pro-
vide a practical, easy-to-use guide to the theory and application of various
empirically supported CBT techniques for multiple disorders, written by
experts in CBT practice from around the world. These experts have pre-
sented core principles and procedures, clinical vignettes, source material
from their various workbooks, and video demonstrations of some of the
more challenging applications of CBT—including treatment of suicidality,
oppositional defiant disorder, obesity, and various anxiety disorders. An-
other unique feature of this book is the illustration of how CBT can be
used to treat psychological disorders in the context of chronic physical
conditions in children. The chapters are developmentally sensitive as well,
noting modifications needed to make the techniques applicable to differ-
ent age-groups and with differing levels of parental involvement. These
chapter features are complemented by introductory chapters on general
developmental consideration across CBT modalities, as well as cultural
and ethnic considerations. Finally, we have addressed the growing evidence
for the utility of CBT as a strategy for augmenting psychotropic medica-
tions, including some of the algorithms used to guide such augmentation.
The content has been designed to be user-friendly for clinicians across
different disciplines including pediatrics, psychiatry, psychology, and social
work. In addition, given the increased emphasis in graduate and profes-
sional training on achieving competence in psychotherapy during training,
the material was written to be accessible and useful to both trainees and
seasoned clinicians. We hope this resource will allow for the dissemination
of CBT-related expertise to clinicians in diverse treatment settings through-
out the world so that the children and adolescents with these disorders can
benefit from an approach to treatment that has such broad and growing
support from clinical scientists and practitioners.
Preface xxi
We want to offer special thanks to colleagues who have meant so much

to our professional life and in ways that have helped us to shape this book.
These valued colleagues include Dr. David DeMaso (Harvard University),
Dr. William Beardslee (Harvard University), Dr. John March (Duke Uni-
versity), Dr. David Kupfer (University of Pittsburgh), and Dr. David Bar-
low (Boston University). We also thank the authors of the various chapters,
who produced most of the book and whose writing skill helped us realize
the vision of a how-to guide that balances academic rigor with the art of
teaching. We appreciate the thoughtful Foreword prepared by Dr. Mina
Dulcan (Northwestern University), a career role model and a national
leader of child psychiatrists in this country. And we thank Debra Fox and
her staff at Fox Learning Systems, who made the production of the high-
quality DVD accompanying the book possible. We extend additional thanks
to the student actors from the top drama programs at universities in Pitts-
burgh, who performed their adolescent roles for the video with such talent
and believability, and the excellent faculty colleagues from University of
Pittsburgh, who agreed to demonstrate the various CBT applications on
video. Thanks to American Psychiatric Publishing Editor-in-Chief Dr. Rob-
ert Hales and Editorial Director John McDuffie for their patient guidance
through the editing process. We thank our staff, friends, and family (you
know who you are) for their support, editorial suggestions, and encourage-
ment in this adventure. And finally, and very importantly, we thank our pe-
diatric patients and their families for the privilege of working with them—
and through this process, learning about the curative power of CBT.
DVD Contents
Video titles and times by chapter
Patient name Time

Video title (corresponding chapter) (minutes)
Depression and Suicide Jane (Chapter 5) 14:07

The Coping Cat Program Zoe (Chapter 7) 10:18
Obsessive-Compulsive Disorder Ashley (Chapter 9) 11:31
Polycystic Ovary Syndrome Mary (Chapter 11) 17:47
Disruptive Behavior Tim (Chapter 12) 9:48
Total time: 63:31
xxiii
1
Cognitive-Behavior
Therapy
An Introduction
SINCE 2000, a great deal of attention and discussion in child psycho-

therapy has centered around the topic of evidence-based treatments—
psychosocial interventions that have been tested in scientific studies and
shown to benefit youths relative to some comparison condition. An update
on the status of evidence-based psychosocial treatments for children and
adolescents (Silverman and Hinshaw 2008) identified 46 separate treat-
ment protocols for child and adolescent mental health problems that meet
the criteria for “well established” or “probably efficacious” therapies set
forth by Chambless and Hollon (1998). The majority of the treatments
designated as “well established” fall under the broad umbrella of cognitive-
behavior therapy (CBT). These mental health problems span multiple di-
agnostic categories, including autism spectrum disorders, depressive disor-
ders, anxiety disorders, attention problems and disruptive behavior,
traumatic stress reactions, and substance abuse.
CBTs are known by many specific “brand names” (e.g., trauma-focused
cognitive-behavioral therapy, the Coping Cat Program, and the Adolescent
1
2 Cognitive-Behavior Therapy for Children and Adolescents
Coping With Depression Course); all are unified by the guiding belief that
an individual’s thoughts, behaviors, and emotions are inextricably linked
and that maladaptive cognitions and behaviors can produce psychosocial
dysfunction and impairment. Moreover, all CBTs approach cognitions and
behaviors as malleable agents of change through which client distress and
impairment may be alleviated. In this chapter, we will give a broad over-
view of key concepts shared across the various CBTs. Given that much of
CBT development has been focused on adults, the most influential theo-
ries and applications are reviewed by drawing from literature on both
adults and children, with some attention to animal studies as well.
Chapter 2 will review specific practical developmental considerations in
using CBT for children and adolescents.
A Brief History
Although the notion that individuals’ experience of the world is largely
shaped by their thoughts and behaviors predates the field of psychology, some
leaders in the field should be credited with laying the early foundation for
modern CBT. Particularly important theoretical precursors include Pavlov
(1927, 1928), whose experiments with animals using what is now known as
classical conditioning highlighted the relationship between prior experience
and involuntary responses, and Watson (1930), whose emphasis on the study
of observable behavior and the organism’s capacity to learn new behaviors
gave rise to learning theory. The more recent work of Skinner (1953) ex-
panded the scope of learning theory to encompass detailed analysis of rein-
forcement processes in operant conditioning. Learning theory arguably
established the ideological underpinnings of what would later be known as be-
havior therapy, with a number of notable contributors—among them Lazarus
(1971), London (1972), and Yates (1975)—and led to the understanding
that maladaptive behaviors are to a large degree acquired through learning. It
followed from this perspective that additional learning experiences might be
used to modify maladaptive behaviors and promote improved functioning.
An early adopter of this notion, Jones (1924) used the pairing of pleasant ex-
periences with feared stimuli to treat a child for a phobia.
The work of Wolpe (1958) is one of the best-known early comprehen-
sive approaches to the use of conditioning techniques in psychosocial in-
tervention. Building on his research with animals and counterconditioning,
Wolpe introduced the notion that anxiety in humans could be inhibited by
invoking an incompatible parasympathetic response, such as relaxation, as-
sertive responses, or sexual arousal. Likewise, the influential work of
Cognitive-Behavior Therapy: An Introduction 3
Negative beliefs
Situation Self World Future
Bad grade on a test “I am not very “This class is stupid “I will never do well
smart.” and a waste of in school.”
my time.”
FIGURE 1–1. Beck’s cognitive triad.
Eysenck (1959) paired graded contact with feared objects or situations

with training in relaxation to address phobic responses. These advances
can be traced forward to systematic desensitization, assertiveness training,
and related approaches to sex therapy, which continue to be in use today.
These early approaches to the use of behavioral techniques in psychother-
apy largely ignored the underlying cognitive processes involved in psycho-
logical dysfunction, focusing instead on shaping measurable behavior by
manipulating reinforcers and using repeated exposure to fearful stimuli to
uncouple the stimuli from the anxious response.
In the 1960s, two approaches emerged simultaneously that thrust cogni-
tion into the forefront of psychotherapy: cognitive therapy and rational emo-
tive therapy. Cognitive therapy, introduced by Beck (1963, 1964, 1967),
posited that the way individuals perceive events and attribute meaning in
their lives is a key to therapy. Specifically, Beck suggested that depressed in-
dividuals develop a negative schema, or a lens through which they view the
world and process information, often because of early life experiences and
negative life events—for example, the loss of a relationship or rejection by a
loved one. This schema is activated in situations that remind the individual of
the original learning experiences, leading to maladaptive negative beliefs
about the self, the world, and the future; the conglomeration of negative be-
liefs across these three entities is known as the cognitive triad. This cognitive
triad results in negative thinking errors in which the individual misinterprets
facts and experiences and makes assumptions about the self, the world, and
the future on the basis of this negative bias (Figure 1–1). Although his ap-
proach initially focused on depression, Beck extended the focus of cognitive
theory of mental illness to other disorders in the 1970s (e.g., Beck 1976).
Beck’s cognitive therapy in practice focused on educating the client
about the relationship between thoughts and feelings and on helping the
client to become more aware of the thoughts that preceded a change in af-
fect. Using a gentle questioning technique, the clinician would probe these
thoughts to better understand the underlying assumptions that led to the
thought. For example, a person who thinks “I failed a test” may have a
deeper belief that “Others will love me only if I am smart.” Once clients
became adept at noticing the occurrence of these rapid, involuntary, “au-
tomatic” thoughts, Beck encouraged them to question the validity and util-
ity of the cognition. Because these thoughts typically occur quickly and are
rarely examined for their veracity, much of the therapy involved helping
clients to consider how their thoughts may be inaccurate, unhelpful, or
distorted. In theory, once these thoughts were repeatedly challenged, a
gradual change in feelings and in behavior would result.
Simultaneous to the development of cognitive therapy, Ellis (1958,
1962) introduced rational emotive therapy (RET), later named rational
emotive behavior therapy. Much as in cognitive therapy, RET is predicated
on the belief that an individual’s feelings are largely determined not by the
objective conditions but by the way in which the individual views reality
through his or her language, evaluative beliefs, and philosophies about the
world, himself or herself, and others. Clients in RET learned to perceive
the relationship among thoughts, feelings, and behaviors using the A-B-C
model, in which activating events or antecedents (A) constitute the objec-
tive event that “triggers” the belief (B) about the meaning of the event.
When the beliefs are rigid, dysfunctional, and absolute, the consequence
(C) is likely to be self-defeating or destructive.
In contrast, beliefs about objective events that are flexible, reasonable, and
constructive are likely to lead to consequences that are helpful. Thus, in the
RET model, beliefs play a mediating role in the relation between events that
occur and the behavioral and emotional consequences. RET theory postulates
that most individuals have somewhat similar irrational beliefs and identifies
three major absolutes as particularly problematic: 1) “I must achieve well or
I am an inadequate person”; 2) “Other people must treat me fairly and well
or they are bad people”; and 3) “Conditions must be favorable or else my life
is rotten and I can’t stand it” (Ellis 1999). Although clients may not be com-
pletely aware of these beliefs in their totality, they are able to verbalize them
when queried and encouraged by the therapist—in other words, the beliefs
are not unconscious but may not have been examined or articulated fully.
In practice, clients in RET work with the therapist to identify the
A-B-C sequences in the client’s life that are leading to impairment and dis-
tress. The therapist then teaches the client to use a series of disputing
thoughts (D) to challenge or refute the dysfunctional belief. In particular,
RET emphasizes distinguishing between statements that are objectively
true and those that may be irrational. Once the belief has been refuted, a
Beliefs Consequences
Antecedents “I’m not very smart.” Sad feelings
Bad grade on test “I will never do well Decreased effort
in school.” in school
Effective thought Disputing thoughts

“The test was hard, “The test was difficult.”
but I can try to “Lots of kids did
do better.” poorly.”
FIGURE 1–2. The A-B-C-D-E model.
more flexible, effective thought (E) is generated and used to replace the
original belief. RET holds that clients have an existential choice about
transforming their hopes, expectations, and preferences to absolutistic,
rigid demands that will lead to emotional and behavioral disturbances—or
conversely, seeing their hopes, expectations, and preferences as flexible
and consequently to act in a healthy, self-helping manner. Figure 1–2 pro-
vides an example of the A-B-C-D-E sequence.
Although the original iterations of both cognitive therapy and RET ex-
plicitly mentioned cognitive processes, later work by both Beck and Ellis
noted that cognition is a facet of behavior and that behavioral components
have always been present in both therapies. Indeed, in cognitive therapy,
efforts are continually made to test the veracity of clients’ beliefs by using
behavioral experiments. A client who feels rejected by a loved one may be
encouraged to pursue activities and relationships in order to receive dis-
confirming information regarding the maladaptive belief (Beck et al.
1979). Likewise, RET has historically made use of behavioral activities,
such as encouraging a client to do something he or she is afraid of doing, in
order to demonstrate the irrationality of certain beliefs (Ellis 1962). Both
the Beck and Ellis cognitive models, however, were developed in adults.
Another central figure in the development of modern CBT, Donald
Meichenbaum, focused on children as well as adults. Meichenbaum noted
that people’s self-statements, or verbalized instructions to themselves, of-
ten appeared to guide their behavior. Much of Meichenbaum’s work fo-
cused on impulsive and aggressive children, who used fewer helpful
instructional self-statements than less impulsive children (Meichenbaum
and Goodman 1969, 1971). Self-instructional training (SIT) grew from
these observations. In SIT, the therapist works with the client to reduce
self-statements that produce maladaptive emotional and behavioral re-

sponses (such as frustration and aggression) and replace them with self-
statements that facilitate control of overt verbal and motor behavior.
In practice, SIT took the form of the therapist first modeling self-
instructions by performing a task in front of the child while engaging in au-
dible self-talk. Next, the child would perform the same task with instruc-
tion and encouragement from the therapist. The child would then repeat
the task stating the instructions aloud and then whispering the instructions
softly. Finally, the child would complete the task using only covert or in-
ternal self-instructions. Although initially used to help impulsive children
slow down during performance tasks and correct themselves without be-
coming distressed, the same techniques have been used to good effect
with anxious youngsters, who may engage in self-defeating and anxiety-
provoking self-statements (e.g., “I can’t do this”; “I’ll get hurt”; “Everyone
will laugh”). Nowadays, therapist modeling and helpful self-statements are
a staple of several modern CBT treatments for anxiety disorders.
Meichenbaum’s work is also notable for explicitly combining the cog-
nitive and behavioral traditions to form a unified approach and for applying
this unified approach in the treatment of children. Throughout the 1980s
and 1990s, cognitive and behavioral theories and techniques were further
merged and their application extended to include obsessive-compulsive
disorder (OCD), other anxiety disorders, disruptive behavior disorders,
depression, and other disorders, as discussed in subsequent chapters. Al-
though there undoubtedly remain some purists who defend the merits of
using either behavioral or cognitive strategies in isolation, most agree that
cognitive and behavioral theories and strategies complement one another,
and most use the label “CBT” to describe the pairing of these techniques.
Common Principles
As we have noted, CBT is a broad category that includes various therapies
to address a range of disorders and problems, and it may emphasize differ-
ent techniques, modalities, and target populations. Despite this variety,
some common principles of CBT can be identified. We illustrate some of
these common principles by focusing on the case of Ellen.
Case Example
A 9-year-old girl, Ellen, was diagnosed with major depression and attention-
deficit/hyperactivity disorder (ADHD), combined type. When Ellen was
age 5, her mother was diagnosed with a serious illness at the same time that
Ellen started a stimulant medication to address symptoms of ADHD. Ellen
had several side effects from the medication and became severely agitated
and aggressive at school when her mother was undergoing intensive treat-
ment and was largely unavailable; Ellen was briefly hospitalized. Following
the hospitalization, Ellen’s aggressive and agitated behavior subsided; how-
ever, because of her sensitivity to stimulant medication, she was not medi-
cated for ADHD symptoms. Ellen struggled in school, and although she was
bright, she did not achieve highly in academic situations and was moved to a
special education classroom to receive academic support. At the time that
Ellen came into treatment, she was experiencing an episode of major depres-
sion: she reported feeling sad and down more often than not, experienced
little pleasure from activities or events she once enjoyed, felt hopeless and
guilty, and had difficulty making decisions and concentrating. In the presence
of stressful situations, particularly in academic settings, Ellen would quickly
become tearful, stating “I can’t do this” or “No one will help me.” Behavior-
ally, she would often give up on the task, refuse to reattempt the task, and
withdraw. In the face of these behaviors, caregivers and teachers typically re-
acted with frustration, negative consequences, and finally resignation.
1. Clients and their problems are conceptualized in terms of cognition

and behavior. Although no one refutes the importance of early learning
and life experiences or the well-acknowledged role of biological processes
and vulnerabilities (these seem evident in Ellen’s case), clinical formulations
in CBT are largely focused on understanding the ways maladaptive thoughts
and behaviors are maintained and lead to client distress and impairment.
Whereas other factors are considered integral to development of a disorder,
the CBT therapist focuses largely on how a client’s current thinking and be-
haviors contribute to the current difficulties. The interplay of early life ex-
periences, situational stressors, biological or genetic factors, underlying
beliefs, and current thinking and behavior is considered in forming a “work-
ing hypothesis” for how the client’s disorder developed and is maintained.
This hypothesis is ever evolving and informs the treatment plan.
The CBT formulation of a case like Ellen’s would consider her biological and
medical vulnerabilities and earlier life experiences as contributing factors to
the development of a negative self-schema, through which Ellen now pro-
cesses new information and which becomes particularly activated during
times of stress. Experiences such as academic challenges remind Ellen of her
previous failures, confirm her beliefs that she is not capable of handling prob-
lems and that she cannot be helped, and lead to her acting-out and sullen be-
haviors. These behaviors are off-putting to adult figures and lead to negative
consequences, which further reinforce Ellen’s belief that she is helpless. Fig-
ure 1–3 provides an example of the form such a formulation might take.
In Ellen’s case, many factors are thought to be reciprocal: the maintain-

ing factors further confirm the schema even as they are caused by it; like-
wise, the depressive symptoms and academic stressors interact with one
another and with the maintaining factors. Although the CBT formulation
considers all of these components, the core elements of the client concep-
tualization are the cognitions and the behaviors. Changing these thoughts
and behaviors will be the focus of intervention.
2. CBT is largely present focused. Related to the first principle,

CBT is less focused than some other types of psychotherapy on the pre-
sumed “underlying causes” or precipitants of the maladaptive cognitions or
behavior. Although it is useful to understand a client’s history and to con-
sider how the past informs current functioning, the emphasis in CBT is on
what is happening for the client today. Clients beginning therapy often an-
ticipate that they will be asked to plumb the depths of their early childhood
experiences in great detail. Although the CBT therapist may consider for-
mative events in terms of how current thinking and behavior were shaped,
the approach does not subscribe to the notion that a client’s insight into and
processing of early events are curative.
There is little doubt that Ellen’s early experiences of behaving aggressively

in school and her subsequent hospitalization during a time when family re-
sources were limited played a role in the development of her belief that she
is helpless and inadequate. This belief, coupled with symptoms of inatten-
tion and hyperactivity, is activated in the face of academic challenges and
leads her to behave in a manner that often results in punishment and fur-
ther confirmation that she cannot be helped. However, it is impossible to
change what has happened to her in the past. Indeed, there is little evi-
dence to suggest that discussing these past events would do much to
change her current behavior. Currently, her negative view of herself, oth-
ers, and the future is maintained by the thoughts she has (“I can’t do this”;
“No one will help me”) and the behaviors that arise following these
thoughts (giving up, refusing to do her work, becoming withdrawn and an-
gry). These thoughts and behaviors directly lead to experiences that fur-
ther confirm her view of herself, others, and the world. Thus, the CBT
treatment would begin with an examination of the here-and-now circum-
stances that lead to the thoughts and behaviors that are problematic.
Of course, there are some important exceptions. The past may become
central in treatment when the content of current thoughts and beliefs di-
rectly involves past events, as is often the case in the treatment of post-
traumatic stress disorder. However, even in these instances, the focus is on
changing current thinking about the past, or current behavior in the pres-
ence of memories, rather than a focus on the past per se.
3. Maladaptive behaviors and cognitions are presumed to be learned.

Although few would argue that all impairing thoughts and behaviors are the
result of an unfortunate learning history, modern CBT stresses the impor-
Current stressors
Academic difficulties
Biological/genetic/
medical factors
ADHD and sensitivity to Symptoms of
stimulant medication
depression
Self-schema Sadness, anhedonia,
Life events “I am helpless.” guilt, indecision,
Mother’s illness; hopelessness, difficulty
hospitalization due to concentrating
medication side effects
Maintaining factors
Negative thoughts: “I can’t do this”; “No one will help me”
Maladaptive behavior: Withdrawal, defiance, sullen attitude
Others’ reaction: Adult withdrawal or punishment
FIGURE 1–3. Cognitive-behavior therapy formulation.

ADHD =attention-deficit/hyperactivity disorder.
tance of established learning principles (e.g., classical and operant condition-

ing) in the service of understanding how thoughts and behaviors are
maintained.
Certain factors may impact an individual’s predisposition to develop
maladaptive thoughts and behaviors. Genetic and biological predisposi-
tions play a role—for example, a child who is very sensitive to anxiety cues
may find it more difficult to tolerate physiological arousal, increasing the
likelihood that he or she will try to avoid that experience. A child with ex-
ecutive functioning deficits may have a more difficult time inhibiting an
impulsive behavior, increasing the likelihood that he or she may break a
rule. However, learning experiences nonetheless reinforce or extinguish
behaviors and cognitions, thereby transforming what is merely the in-
creased likelihood of a behavior into an enduring pattern that continues
and leads to impairment.
The symptoms of ADHD make it more difficult for Ellen to tolerate frus-
tration, and this certainly plays a large role in her propensity to give up
when faced with academic demands. At the same time, this behavior has
been reinforced by the consequences that have typically followed: teachers
have punished her (sent her from the room to time-out) or walked away
from her—in both instances, allowing her to escape from the aversive task.
These consequences also serve to underscore her belief that she can’t do
these tasks, increasing the likelihood that she will repeat this same thought
when faced with the next similar task. Similarly, the times when she is able
to complete a challenging task are largely ignored and unpraised, inadver-

tently decreasing the likelihood that successful completion of challenging
tasks will recur. Thus, although the biological predisposition contributes to
the difficulties, her behaviors and cognitions are also influenced by her en-
vironmental experiences.
4. CBT focuses on specific, clearly defined goals. Early in therapy, the

CBT therapist will set goals with the client and/or with the client’s care-
giver, and these goals are often described in objective, observable terms.
For example, a client’s goal to “feel better” may require further clarifica-
tion: How will he or she know when that goal is achieved? What will be
different in terms of behavior or thoughts? The goal or goals are frequently
reviewed throughout therapy, and maladaptive thoughts and behaviors are
reviewed regarding the obstacles they impose to achieving the goals that
have been set. Importantly, the goals in CBT are not only clearly defined
in terms of behavioral objectives, but they are also well known to client
and therapist alike. That is, they are transparent, and the interventions in
therapy are understood by the client and/or caregiver in terms of how they
will theoretically help move the client toward the therapeutic goals. CBT
does not assume, for example, that clients are controlled by unconscious
desires and impulses and therefore unable to truly know what is troubling
them. Rather, the client’s articulated concerns are considered to be the
“real” problem, and the intervention is designed to address these concerns.
When asked what she wanted to work on in therapy, Ellen initially stated
that she wanted to be in a regular education class rather than continue in
special education. Because this goal may not have been attainable, Ellen’s
therapist used a process of questioning to understand how Ellen’s life
might be different if she were no longer identified as needing extra aca-
demic help. Through these queries, Ellen revealed that she would like to
develop strategies that would allow her to remain in her classroom, com-
plete her coursework and homework, and do better in school. Additionally,
Ellen wanted to feel less anxious in academic settings and to make more
friends. Having clearly defined goals allowed Ellen and her therapist to
clearly measure her progress as therapy advanced, and these goals also pro-
vided a therapeutic rationale for the interventions that the therapist intro-
duced.
5. CBT is collaborative and emphasizes the client’s expertise. Transpar-

ency in CBT extends beyond setting goals and objectives; the CBT thera-
pist strives to engage the client in an active role in his or her own therapy.
To that end, CBT therapists emphasize that both the client and the thera-
pist have expertise: the therapist is an expert in strategies to change
thoughts, behaviors, and feelings, but the client (and the caregiver) is the
expert in the child. This “joint expertise” is necessary for successful treat-
ment, and the CBT therapist encourages the client to speak up about his
or her own unique experiences. Furthermore, the knowledge that the ther-
apist possesses regarding the client’s difficulties and treatment is not a
closely guarded secret—instead, the therapist hopes to educate the client
about his or her disorder and about the treatment strategies so that the cli-
ent eventually becomes an “expert” in his or her own treatment.
In other words, the CBT therapist’s goal is not only to help the client
set goals, identify and evaluate maladaptive thoughts and behaviors, and
modify those thoughts and behaviors, but also to teach the client how to do
these things so that the therapist is not necessary. In work with children,
CBT therapists may often use the analogy of a sports “coach” to explain
this role. A coach helps athletes hone their skills by teaching new strate-
gies, encouraging practice, and providing support. However, the athletes
must actively participate by practicing the skills and putting them into ac-
tion. In a similar way, CBT is viewed as a process of “teamwork” between
the client and therapist.
Part of the process of developing the client’s expertise is therefore ed-
ucation. CBT typically begins with education regarding the nature of the
disorder, including the symptoms, causes, course, and prevalence. It can
be tremendously comforting, for example, for a client to learn that the
scary feelings he or she has experienced have a name—panic attacks—and
that they are relatively common and are caused by the misinterpretation
of harmless bodily sensations. In addition to education about the disorder,
the therapist also provides education about the cognitive-behavioral for-
mulation of the disorder—the way in which the client’s thoughts, feelings,
and behaviors interact and lead to the distress or impairment he or she is
experiencing.
Client education also includes the therapeutic rationale for all pre-
scribed interventions. In CBT, the therapist is not using a technique that is
unknown to the client—the process of the therapy is explained to the cli-
ent in terms of how it relates to the symptoms or to the objective goals the
client has set. Thus, when a therapist begins asking a series of questions
about a client’s negative thought, the client knows that the purpose of
these questions is to test the evidence that supports the negative thought.
A client who is asked to repeatedly confront a feared situation in a slow,
graded manner understands that over time, he or she should begin to feel
less fearful.
Eventually, the CBT therapist will take a less central role in prescribing
and implementing such interventions, instead supporting the client’s own
use of these techniques. CBT teaches clients to identify, evaluate, and re-
appraise their own maladaptive thoughts and behaviors. Key to this pro-
cess is a technique called Socratic questioning, in which the therapist asks
a series of gentle questions regarding the utility of thoughts or behaviors.

The goal is twofold: by asking questions, rather than telling the client that
the thought or behavior is maladaptive or unwarranted, the therapist
heightens the client’s sense of expertise as he or she arrives at the conclu-
sion. Furthermore, asking questions also encourages a careful review of ob-
jective data as a means of determining the utility of the thought or behavior,
rather than relying on the therapist’s opinion or the client’s subjective
emotions.
An important component of Ellen’s therapy involved educating the client,

her family, and her teachers about the nature of ADHD and of major de-
pression. Ellen knew that she “had ADHD” but was unaware of its com-
mon occurrence in many youths. Introducing ADHD as a problem similar
to other medical problems such as allergies, which can cause difficulty but
are also amenable to environmental modifications, was useful for Ellen as
well as her parents. Additionally, it was important to provide the adults in
Ellen’s life with factual information about youth depression and how it
may manifest as irritability in addition to the sadness more commonly ad-
dressed. In turn, Ellen, her parents, and her teachers were able to provide
the therapist with examples of how these and other symptoms were ex-
pressed in Ellen’s day-to-day life—a perspective that was vital to personal-
izing the treatment for Ellen’s benefit.
6. CBT is structured and strives to be time limited. Regardless of the

diagnosis, CBT therapists attempt to organize each session using an
agenda. Continuing with the theme of transparency, the therapist informs
the client of the objectives of each therapy session, and because this is a
collaborative process, the client is asked to add topics or activities to the
agenda. As in other therapies, clients generally have issues they want to
discuss or concerns that have arisen over the prior week; these concerns do
not necessarily form the content of the therapy session, however. Rather
than abandon the agenda, the CBT therapist seeks to incorporate this issue
or concern into the agenda—either by linking it to an already planned topic
or by including it as an additional topic that need not replace those that
have been planned.
Sessions generally begin with a brief review of the previous week, in
terms of the client’s targeted problem area. Next, the agenda is reviewed
and modified collaboratively. If any therapeutic homework was assigned,
this is reviewed—and obstacles to completing homework or unanticipated
difficulties are discussed. Next, the agenda items are discussed, new
homework is assigned, and the client is asked to summarize the content of
the session. With children, sessions often end with some sort of engaging
activity, such as a game, and then by collaboratively teaching the caregiver
what was done in session. In fact, caregiver endorsement of the child’s
practice of new skills outside the therapy session is often key to achieving
therapeutic effect.
Many of Ellen’s sessions began with her or her parents wanting to discuss
a recent incident, such as a tantrum over homework completion or an emo-
tional outburst. In general, these topics would be added to the agenda but
would not require a change to the planned content. For example, for a ses-
sion in which the plan was to learn how relaxing muscles and taking calm-
ing breaths could result in less distorted thinking and disruptive behavior,
the therapist could skillfully use the client’s examples above as a way to
make this new skill salient to Ellen and her parents. Likewise, those spe-
cific examples introduce an opportunity to identify and evaluate negative
thoughts; examine the relationship of thoughts, behaviors, and emotions;
and perhaps modify those thoughts or behaviors. In this way, CBT ad-
dresses the client’s concerns but does so in a structured way.
Clients and caregivers are also given an overview of the course of treat-
ment from the beginning, and this topic is revisited as treatment progresses.
In an early session, for example, the client is informed that initially, the
therapist will be teaching the client about his or her disorder and about how
thoughts, behaviors, and feelings affect each other. Depending on the target
disorder, clients will be informed about the therapeutic interventions that
they can expect—that they will be learning how to test how true or helpful
their thoughts are, or learn to solve problems, or begin slowly facing situa-
tions that have caused them anxiety. They will be told that they will prac-
tice new skills until they can do them on their own and are moving toward
their goals. And they are told that the treatment will be time limited—that
it will not last forever.
Although many manualized CBT treatments have a specific prescribed
number of sessions, in practice CBT can vary widely in length. The severity
of some client’s problems requires treatment that greatly exceeds the 8 to
20 sessions so often described in efficacy trials. Despite variations in the
number of sessions, CBT is generally intended to be time limited, with a
focus on providing symptom relief, facilitating remission of the disorder,
increasing client functioning, training clients in skills to prevent future re-
lapse, and then ending treatment. CBT clients may return to therapy for
“booster” sessions when they experience a lapse, and CBT emphasizes
helping clients learn to recognize their symptoms so they can determine
when a return to therapy may be helpful. CBT does not, however, typically
“hold” clients in the therapeutic relationship once symptoms have remit-
ted and gains have been maintained for a reasonable length of time.
7. CBT is tailored to meet the particular needs of the client. CBT for-
mulates client difficulties using a cognitive-behavioral framework, places a
high premium on therapeutic interventions that have demonstrated scien-

tific support, and relies on principles of learning theory—but CBT is not a
one-size-fits-all treatment approach. To the contrary, specific techniques
used to address maladaptive behaviors and cognitions are based on the spe-
cific maintaining factors that prevent the client from achieving his or her
goals. Therefore, each treatment is specifically tailored to the needs of the
identified client.
Consider, for example, two children who both refuse to attend school.
Although the goal in treatment may be identical—increased attendance in
the classroom—the two children and their reasons for refusal are very dif-
ferent. One child has anxious beliefs about what will happen at school and
predicts that he will embarrass himself if called on in the classroom. Avoid-
ing school results in a decrease in anxious thoughts and feelings and is thus
rewarding to the child. The other child finds school aversive because he
lacks attention at home and has learned that avoiding school results in re-
warding attention from his caregiver and one-on-one instruction, as well as
plenty of time to watch television and play video games. Because the fac-
tors that maintain the school refusal are dramatically different in these two
cases, so too would the interventions differ. Thought reappraisal and grad-
uated exposure might be necessary for the former client, whereas the lat-
ter might require behavioral contingencies for school attendance.
Ellen’s treatment, for example, required interventions that addressed her

endogenous beliefs and volitional behaviors, but it also incorporated envi-
ronmental modifications to shape new behaviors and to phase out trouble-
some ones. Understanding the function of Ellen’s behavior was necessary
to know how to address the behavior in therapy. For example, being sent
from the classroom was an ineffective punishment in Ellen’s case because
the classroom when therapy began was a nonreinforcing environment—in
other words, being “punished” actually provided relief! A two-pronged ap-
proach was used to address this dilemma: 1) finding a more appropriate
consequence to address instances of Ellen’s misbehavior and 2) working to
improve Ellen’s perception of her classroom. The new approach required
actual changes (e.g., working with Ellen’s teachers to establish more fre-
quent praise for positive behaviors) and reappraisal of Ellen’s beliefs.
8. CBT requires an active stance on the part of the therapist. An ef-

fective coach does not simply sit on the sidelines observing the players, and
in much the same way, an effective CBT therapist takes an active, in-
volved, and directive role in treatment. Because learning is a key compo-
nent of CBT, the therapist has more characteristics of a “teacher” than in
some other orientations. To promote this learning, CBT emphasizes the
therapist’s expertise with the disorder or problem area as a means of in-
stilling hope and empowering the client to engage in treatment. CBT like-
wise highlights the collaboration between client and therapist, with each
committing time, energy, and effort to addressing the areas of concern.
CBT therapists approach each therapy session intent on structuring the
session to maximize the time, introduce and implement interventions that
may be helpful for the client, use client material to highlight the ways in
which cognitions and behavior are causally linked to emotions, and con-
firm or revise the ever-evolving “working hypothesis” of the client’s case
conceptualization. Over time, the client becomes increasingly involved in
the structure of sessions, but the CBT therapist remains highly involved in
planning the treatment in order to deliberately progress toward the behav-
ioral objectives or goals.
In contrast to therapies that advocate following the client’s lead, CBT
is initially quite directive. Clients whose current thinking and behavior are
self-defeating or cause difficulties are in need of new strategies. The ther-
apist considers which of these strategies will be most beneficial to the cli-
ent and works to introduce the intervention, ensures that the client
understands the intervention, and plans for implementation in the areas
where the client experiences difficulty. Because therapists are often asking
clients to try radically different ways of thinking or acting, the client would
not necessarily volunteer some of the strategies most useful to overcoming
the area of difficulty. Therefore, it is the CBT therapist’s job to suggest
new strategies and to provide a compelling therapeutic rationale.
Ellen’s treatment again provides an example of this active therapeutic stance.

On the basis of her prior experiences in therapy, Ellen’s expectations were
that treatment would consist largely of open discussion and play. The thera-
pist therefore needed to initially take a very directive role in establishing the
structure of each session, setting guidelines for how sessions would proceed,
and suggesting areas where skills might be useful. The therapist told Ellen
that therapy would first focus on learning new ways to handle sad, upset, or
angry feelings, and that Ellen would be learning “new tools” for her toolbox.
Thus, learning different strategies—for example, identifying and changing
negative thoughts, using relaxation strategies to manage anxious physical sen-
sations, or sequential problem-solving—was the aim of many early sessions.
Once Ellen became familiar with the strategies and accustomed to the struc-
ture of the sessions, she became more involved in planning each meeting,
providing suggestions of areas where additional attention was needed, and
identifying opportunities to practice her therapeutic skills.
9. CBT requires implementation in the real world, outside the

office. In contrast to therapies that focus mainly on the in-the-room
interactions, CBT therapists are largely concerned with making what hap-
pens in therapy relevant to what the client experiences in his or her day-
to-day life. This requires some consideration of how to make the interven-
tions salient and requires both flexibility and creativity on the part of the
therapist. Providing experiential in vivo opportunities wherein the client
actually uses a new strategy or has the chance to test his or her beliefs is
far more potent than discussing the strategy or belief in the abstract. Like-
wise, acting out what happens outside of therapy using role-plays can pro-
mote greater generalization of therapeutic gains. The therapist must
actively plan for these activities and be willing to perhaps go beyond the
boundaries of other types of therapies. For example, if a client is fearful of
crowds, the CBT therapist would try to find an opportunity to experience
crowds with the client. If the client’s caregiver has had difficulty creating
a home-rewards program to motivate behavior, the therapist should be
willing to spend time in session working out the logistics of this reward
program. The case of Ellen provides an example of this real-world inter-
vention.
Ellen had been practicing the skill of positive self-presentation in her inter-
personal interactions, particularly when she was upset. Typically, Ellen
practiced this skill in session, using role-plays with her therapist and even
videotaping herself in order to critique her verbal and nonverbal behaviors.
Ellen and her therapist agreed to work on positive self-presentation with a
teacher with whom Ellen found interactions especially challenging. The
therapist was able to go to the school in order to coach Ellen through an
interaction with this teacher, first discussing with the teacher the plan and
sharing the goals of the in vivo interaction. Although this intervention re-
quired planning on the part of the therapist, Ellen’s successful discussion
with this teacher disconfirmed many of her beliefs about what would hap-
pen if she approached him, in ways that merely discussing or role-playing
might not have achieved.
Another way in which CBT therapists press for real-world implemen-

tation is by encouraging clients to practice the strategies they learn in ses-
sion in the time between therapy meetings. CBT therapists generally
assign some version of homework each week. Because clients may struggle
with homework completion, CBT also addresses homework noncompli-
ance. Whereas some therapies interpret noncompliance as resistance or as
a behavior that is meaningful to the client-therapist relationship, it is more
consistent with CBT principles to first consider the ways in which princi-
ples of reinforcement may be at work. For example, is the practice aversive
and thus does noncompliance allow for escape? Is it possible to increase in-
centives for completion of therapeutic homework? Rather than assume the
position that the therapist cannot or should not work harder than the cli-
ent, CBT therapists work to understand, with the client, the potential bar-
riers to homework completion and devise an intervention to address the
noncompliance.
Role of Beliefs
As previously discussed, Beck and Ellis both postulated that individuals
hold certain beliefs or attitudes, constructed in part from early life expe-
riences and biological vulnerabilities, that are activated during times of
stress and form a lens through which new information is processed. At the
deepest level, these are known as core beliefs—beliefs so deeply ingrained
with a client’s fundamental sense of self, the world, and the future that
they may not be recognized or articulable. Core beliefs are not generally
examined in everyday life; instead, they are just accepted as “the way
things are.” Consider Ellen once again: she never stated a belief that she
was helpless; in her view, others withheld help from her. However, she en-
countered all new and potentially stressful situations with a deep-seated
belief that she could never succeed. Experiences that were inconsistent
with this belief were quickly forgotten or misattributed (for example, a
test she passed was deemed “easy”). By discounting or failing to notice the
experiences that disconfirm the core belief, the client maintains the belief,
despite its inaccuracy.
We have also discussed automatic thoughts, the actual thoughts or im-
ages that go through a client’s mind in response to a given situation. These
are the superficial expression of the core belief—the accessible thought
that flashes through the head for just an instant. Ellen thought, “No one will
help me,” or “I can’t do this,” when approaching demanding tasks. Between
these two levels of cognition (i.e., core beliefs and automatic thoughts) are
the rules, attitudes, and assumptions that link the core belief to the auto-
matic thoughts, known as intermediate beliefs. For example, Ellen may have
had several rules that governed the stressful situations: “If I don’t under-
stand something immediately, I’ll never understand it”; “If people don’t of-
fer help to me, it is because I can’t be helped”; and “If I don’t try, I won’t
have to fail.”
Identifying Thoughts and Beliefs

CBT typically begins by approaching the client’s automatic thoughts be-
cause these are the most available to the client. With children, even these
may be somewhat difficult to identify at first, because “thinking about
thinking,” or metacognition, is not routinely asked of children. It is some-
times helpful to reenact a triggering situation and then ask the child,
“What went through your head just then?” Using cartoons with thought
bubbles similar to those often used in comic books can also be helpful. Al-
though clients can be helped to evaluate the veracity of their automatic
thoughts, it is often the case that further questioning about the thought
will reveal a set of maladaptive assumptions or rules that are contributing
to the development of these more proximal ideas.
A technique called guided discovery is often used in CBT to help the
client move from automatic thoughts to intermediate beliefs, perhaps even
unveiling core beliefs. The therapist continues to ask the client questions
about the thought and its meaning in relation to the client, others, and the
world. This work is sometimes described as the downward arrow technique
(Burns 1980), beginning with a maladaptive automatic thought and win-
nowing downward to learn more about what it means to the client. At each
step, the therapist poses a question assuming that the automatic thought
is true. Below is an example of this technique.
Therapist: So you were working in your math group and you started to feel
really frustrated. What was going through your mind in that moment?
Client: I don’t know. I wasn’t paying attention—and then I did, and I felt
really annoyed.
Therapist: Let’s imagine I’m your teacher, and I’m talking about fractions,
and you suddenly start paying attention and you think ...
Client: I don’t get it.
Therapist: OK, so your thought was, “I don’t get it.” And then you felt
frustrated.
Client: And then I said, “You’re not making any sense!” and my teacher
told me to go to time-out.
Therapist: Ah, I see. So I wonder if there was anything else that connected
your thought “I don’t get it” to feeling frustrated and then saying
that to your teacher. I’d like to understand why that thought made
you feel so upset. Let’s assume for a moment that you didn’t under-
stand what the teacher was teaching. What would that mean?
Client: Then I won’t be able to do the exercise.
Therapist: Oh, OK. So if you couldn’t do the exercise, then what?
Client: Then the teacher will ask me why I didn’t do it.
Therapist: And if the teacher asks you why you didn’t do it. ..
Client: When I say I didn’t understand it, she says I didn’t pay attention.
She always says that!
Therapist: What would be the worst thing about that?
Client: She won’t help me; she never does! She always thinks I’m doing it
on purpose, and I’m not—I just don’t ever know how to do these
math problems. I just can’t do it, and I never will.
Therapist: What does that mean about you, do you think, if that’s true?
What does it mean that you can’t do these math problems?
Client: I can’t do anything right!
Whereas the thought “I don’t get it” was the most available to the cli-
ent, what made the thought so upsetting was the more fundamental belief
that failure to do the math problem was just another example that the cli-
ent “can’t do anything right.” Further exploration might have revealed that
the client’s self-perception is that of inadequacy. Regardless, the belief “I
can’t do anything right” is a clear distortion, and the therapist can work
with the client to examine how accurate or helpful that thought may be.
Reappraising Thoughts or Beliefs

Although different techniques are used for specific diagnoses or problem
areas, most CBT uses some form of collaborative empiricism to scrutinize
the veracity and utility of maladaptive thoughts and beliefs. This is a pro-
cess by which the therapist and client carefully consider all available evi-
dence and identify “clues” that support the maladaptive cognition and
those that do not support the thought or belief. Collaborative empiricism
can be done formally, using a list of all the evidence for and against the
thought, or through a series of questions. Sometimes behavioral experi-
ments are used to test beliefs—for example, trying out a behavior to see if
the outcome is what the client predicted, or having the client conduct an
informal poll by asking others about their own experiences.
Although some people erroneously believe that the goal of examining
a thought is to arrive at a positive thought, in actuality the goal is simply to
critique the overly critical, threatening, or otherwise distorted thought or
belief. Using the evidence that challenges the distortion, a more realistic
belief or thought can be constructed. It would be of little use to the client
above if she decided to think “I am always great at math!” the next time
she encountered a challenging exercise. For one thing, that would be un-
true! However, the current thinking—“I don’t get it, therefore I’ll never
get it, because I can’t do anything right”—is also inaccurate. A more help-
ful and accurate thought might be “This is challenging, but if I stay calm
and ask for help, maybe I will understand it better.”
When attempting to reappraise distorted cognition in children, it is
sometimes helpful to use the notion of being a detective searching for
clues. Other metaphors include presenting both sides of the case to the
“thought judge” (Stark et al. 2006) or looking at the situation first with
dark glasses and then removing the glasses to see if things look different.
Typically, children struggle at first to generate the evidence that counters
the distortion, so it is helpful to use a series of questions that they can ask
of themselves. Some examples of questions are listed below (Beck 1995).
1. What is the evidence that this thought is true? Not true?

2. Is there another explanation?
3. What is the worst that could happen? Could I live through it? What is
the best that could happen? What is the most realistic outcome?
4. What will happen if I believe this thought? What would happen if

I changed my thinking?
5. If my friend was in the same situation and had this thought, what
would I tell him or her?
It is important to remember that most clients have lived with their dis-
torted thoughts and beliefs for some time and are very familiar with these cog-
nitions. At first, more realistic cognitions may not “feel true.” This transition
from the familiar, maladaptive thought to a more realistic interpretation is a
bit like exchanging an old, worn-out shoe for a newer one: the new shoe works
better, but it takes time for it to feel right. Therefore, therapists should not be
discouraged when clients state that they still strongly believe the original, mal-
adaptive thought or belief. With continued practice, the client will find that
new beliefs begin to seem more accurate. Even when the client’s commitment
to the original thought changes very slightly, this slight change is still progress
toward more useful and accurate thinking.
Role of Reinforcement Principles

Just as maladaptive thoughts are important to identify, evaluate, and mod-
ify, the key aims of CBT are identifying the behaviors that are problematic
and considering how these behaviors are maintained. In the simplest terms,
whatever happens immediately after a behavior plays a part in whether that
behavior is repeated. Reinforcement refers to an event, behavior, privilege,
or material item that increases the chance that a behavior will recur. Nega-
tive reinforcement refers to reward in the form of withdrawal of an aversive
condition. Extinction refers to the reduction in frequency or total elimina-
tion of a behavior by use of nonreinforced occurrences, and punishment re-
fers to the contingent use of negative consequences for aversive behaviors.
All of these basic principles are used in the CBT conceptualization of the
client regarding how his or her thoughts and behaviors are maintained.
Previously we noted that Ellen showed a cognitive bias, or preference, for
remembering failure experiences—but her behavior was also maintained by
what happened following those times when she struggled with an academic
challenge. In the classroom, Ellen was usually sent to a time-out in response
to her negative statements and defiance around class work. Because this of-
fered her an escape from an aversive experience, being “punished” actually
made it more likely that Ellen would react similarly the next time she encoun-
tered frustration in the classroom. From a conditioning perspective, she had
“learned” that certain behaviors were paired with escape from an aversive ex-
perience, and these behaviors were therefore negatively reinforced.
On the other hand, on the occasions when Ellen was able to focus her
attention on the assigned task, approach the task with a positive attitude,
and put forth effort, she rarely received any attention at all. From the per-
spective of her teachers and other adults, these behaviors were not re-
markable—they simply exemplified what a student was expected to do.
However, because these desired behaviors were not reinforced when they
occurred, they were effectively extinguished.
Behavioral principles are important to CBT because they shed light on
how behaviors develop and are preserved. Behavioral principles also pro-
vide a road map for changing behaviors via interventions. Once the unde-
sirable behaviors are identified, the CBT therapist can work with the
client, or with the caregiver, to eliminate the reinforcement that keeps
these behaviors in place. Likewise, new behaviors can be identified, rein-
forced when they occur, and shaped to occur more frequently.
It is important to remember that thoughts and behaviors do not exist
in isolation from one another; rather, a central tenet of CBT is that the two
interact with one another and are inextricably linked to emotions. There-
fore, it is wise to consider both thoughts and behavior, even when the bulk
of the work in session may focus more on one or the other. Recall that for
some people, behavioral experiences are discounted because of a cognitive
processing error that causes them to give more weight to experiences that
confirm negative beliefs. Therefore, an awareness of negative cognitions is
important even when the emphasis in session may be on behavioral inter-
ventions. For example, suppose the client has a fear of spiders, but over
the course of a therapy session has repeatedly confronted a live spider in a
jar and has noted that the initial fear has decreased over time. It is very im-
portant to check in with such a client to ascertain what meaning he or she
may make of this experience. Perhaps there is a thought like “I can only
face this spider because my therapist is with me—I could never do this on
my own.” Attributing the success to an external force would, in this case,
somewhat decrease the potency of the exposure exercise.
In the same vein, behaviors can reinforce negative cognitions, and thus
it is most helpful to address behaviors that are related to maladaptive
thoughts in treatment. For example, depressed clients who think “I never
have any fun” may decide to decline social invitations and isolate them-
selves. In this way, the behavior actually leads to a verification of the belief.
Introducing some basic behavioral interventions—such as assigning pleas-
ant, reinforcing activities as homework—may result in the client’s receiv-
ing some disconfirming evidence about the belief. This technique, known
as behavioral activation, may also lead to an increase in energy and hope-
fulness. In short, although some CBTs may emphasize behavioral interven-
tions (for example, the treatment of disruptive behavior disorder in youths
via behavioral parent training), and some may focus more on cognitive pro-
cesses (as with cognitive therapy for depression), recognizing the ways in
which thoughts and behavior are mutually influential benefits both the
case formulation and the intervention.
Common Myths
and Misperceptions
Although many clinicians use CBT techniques, a number of “negative be-
liefs” remain about CBT practice and require some corrective attention.
1. The therapeutic relationship is not important in CBT. Although it is

true that CBT does not consider the therapeutic relationship to be the prin-
cipal agent of change as in some other therapies, it is nonetheless an impor-
tant element of a successful treatment. As with all good therapy, the CBT
therapist works to create a therapeutic environment that is warm, support-
ive, and genuine. The use of so-called nonspecific therapy elements, such as
empathy, validation, and positive regard, is important in CBT as well.
It is accurate, however, that CBT considers such nonspecific elements as
necessary but not sufficient for an effective course of treatment. In addition
to warmth, genuineness, and empathy, the CBT client-therapist relationship
is characterized by the collaborative spirit we have previously discussed. The
working alliance is based on the notion that both therapist and client have ex-
pertise about the focus of treatment and that by working as a team, they can
improve the client’s well-being. To establish this collaboration, the CBT ther-
apist is straightforward and well informed about the nature of the client’s
problems and is clear about the procedures that treatment will entail. At the
same time, to foster the client’s own engagement in treatment, the therapist
is inquisitive about the client’s goals, seeks examples from the client’s own life
that fit with the psychoeducative material, and checks in with the client re-
peatedly to assess the thoughts and concerns he or she has about treatment.
Research on the therapeutic relationship in many types of therapies sup-
ports the notion that the strength of the client-therapist relationship is asso-
ciated with treatment outcome (Shirk and Karver 2003). Measured in a
variety of ways, the client-therapist relationship has been found to predict
treatment outcome among clients receiving CBT for a variety of problem ar-
eas (Hughes and Kendall 2007; Karver et al. 2008; Keijsers et al. 2000). Al-
though some critics have suggested that the use of CBT treatments, and
particularly manualized treatment protocols, would undermine the thera-
peutic relationship, the few studies that have examined this empirically have
found the opposite. Indeed, one study found that therapists who engaged
youth clients in a collaborative manner formed the best therapeutic alliances
with their youth clients (Creed and Kendall 2005), and another study com-
paring the use of manualized CBT for youth depression to usual care services
noted that the early therapeutic alliance was stronger for those youths re-
ceiving CBT (Langer et al. 2011). In short, a strong therapeutic relationship
is a key component in CBT, and CBT’s emphasis on collaborative empiricism
in the service of changing thoughts and behaviors may actually bolster—not
weaken—the bond between client and therapist.
2. CBT addresses symptoms but not the root of the problem. Some
therapeutic orientations suggest that addressing a symptom while not at-
tending to the underlying cause of the problem will result in the later re-
currence of the symptom or in a phenomenon known as symptom
substitution, wherein the original symptom is merely replaced with an-
other. Within this model, treatment of symptoms is seen as insufficient,
and there is an emphasis among some schools of thought that therapists
must uncover the latent, and perhaps unconscious, cause of the disorder.
In CBT, the underlying cause of the disorder is very much a part of the
client formulation and intervention approach, but the cause is understood
as the processes that serve to reinforce and maintain the maladaptive cog-
nitions and behaviors. For example, consider the case of Ellen.
A previous therapist had suggested that Ellen’s acting-out behavior and de-
pression were caused by anger toward her mother, whom Ellen uncon-
sciously perceived as having “abandoned” her when she was young and her
mother was ill. The therapist posited that because Ellen was threatened by
this anger, she turned it against herself via her depression and against other
adult authority figures, such as teachers. Alternatively, in the cognitive-
behavioral approach, the acting-out behavior and the depression were seen
as the result of the interaction of Ellen’s negative beliefs (“I am helpless”)
and an environment that negatively reinforced her attempts to escape aver-
sive experiences and failed to reinforce her positive behaviors.
Although both models may be accurate, the latter formulation leads to a

testable hypothesis that can be explored via intervention, whereas the former
relies on a largely inaccessible construct that would be difficult to modify.
As for the notion of symptom substitution, follow-up studies of many
CBT interventions for youths do not support the notion that eliminated
symptoms merely return in another form. However, it is also important to
note that many disorders naturally wax and wane, and symptoms may
morph over time. For example, a youth with OCD may first present with
a hand-washing compulsion and later develop a different ritualized re-
sponse to anxiety. Successful CBT predicts such a process with the client
and plans for lapses in which symptoms may transiently return. In planning
for treatment termination, the therapist helps the client and the caregiver
to consider how problems may manifest in the future, how to manage
these recurrences, and how to differentiate between a lapse and a relapse.
3. CBT constrains the therapist’s creativity and flexibility. Perhaps the

biggest misperception among those new to CBT is that use of these tech-
niques will diminish the therapist’s ability to be spontaneous, creative, and au-
thentic in the session with the client. In fact, effective CBT is characterized
by the therapist’s ability to use session content in the moment to make the
principles of CBT come to life for the client. CBT is a lively, action-packed
therapy, where the therapist makes use of the client’s thoughts and behaviors
to illustrate the ways in which they contribute to the client’s difficulties.
For example, suppose the therapist intended to work with the client on
the ways in which nonverbal behaviors (e.g., slouching, avoiding eye contact,
rolling eyes, and sighing) serve to reinforce the client’s beliefs (“No one likes
me”) and also result in interpersonal conflict with others. As the therapist is
talking, the client appears to be disinterested and bored. This provides a per-
fect opportunity for the therapist to note the client’s nonverbal behaviors,
query about his or her thoughts, and suggest an experiment—for the next
5 minutes, the client will sit up straight, make eye contact, and nod as if in-
terested. How did that impact the client’s thoughts and feelings?
This is but one example of the ways in which CBT therapists have free
rein to use session content in a spontaneous and creative manner. Just as a
good teacher makes class interesting and fun by use of activities and met-
aphors that capitalize on the students’ experiences, a CBT therapist does
the same. Indeed, CBT emphasizes the use of creative approaches to in-
troducing new behaviors and changing thoughts.
New Inroads and Challenges

Currently, CBT is one of the most thoroughly researched psychosocial in-
terventions, with new studies emerging that examine its utility for a wide
range of problems. As it has become better established as a core resource
for mental health care, several new developments have emerged.
From Efficacy to Effectiveness

Although CBT has shown encouraging results when delivered in optimal set-
tings, such as in rigorously controlled research trials, the evidence suggests
that it may be somewhat less effective when treatment is delivered in the
“real world” of typical clinical care (Weisz et al. 2006). Although CBT still
does better, on average, than the comparison conditions of usual care ser-
vices, the clinical impact is lessened when treatments are moved from aca-
demic research into frontline services. Identifying the causes for these
weaker effects and increasing the focus on how CBT is implemented in the
real world are important topics that are beginning to be the focus of research-
ers and clinicians alike (Weisz and Gray 2008; Weisz and Kazdin 2010).
The “New Wave”

As CBT has developed, a number of recent treatment approaches have
emerged that blend CBT principles with concepts such as mindfulness,
acceptance, dialectics, and values. These skills have roots in Eastern med-
itative traditions and in practice include focusing attention on the experi-
ences occurring in the present moment (such as sensations, perceptions,
cognitions, and emotional states) with a nonjudgmental attitude of open-
ness, acceptance, and curiosity—without attempting to avoid or escape
these experiences, even if they are unwanted or unpleasant. This so-called
third wave of CBT (Hayes 2004) places less emphasis on changing the
form or content of thoughts and behaviors and instead emphasizes trans-
forming the relationships that clients have with their internal experiences.
For example, rather than challenging a negative thought, a client might be
encouraged to observe the thought, note that it is just an ephemeral
thought and not a reflection of reality, and continue to behave in a way that
is consistent with achieving the goals the client has for himself or herself.
These newer forms of CBT have begun to generate empirical tests,
some with significant support, and are expanding the array of techniques
available to CBT therapists. Although the focus of therapies such as accep-
tance and commitment therapy, dialectical behavior therapy, and others
may be less on changing thoughts and more on increasing a client’s distance
from those thoughts, the causal connection among thoughts, behaviors,
and emotions remains central.
Conclusion
CBT has evolved from two distinct traditions—cognitive therapy and be-
havioral learning principles—to form one of the most widely practiced and
thoroughly studied psychosocial treatments. CBT continues to evolve, in-
corporating new techniques for managing maladaptive cognitions and be-
haviors that are aimed at mitigating their impact on emotions, and it is
increasingly being transported from research settings into clinical practice
contexts such as hospitals, clinics, and schools. As the subsequent chapters

of this volume demonstrate, CBT offers a rich mix of techniques for ad-
dressing a myriad of disorders, reducing impairment and distress, and im-
proving adaptation and functioning in everyday life.
Key Clinical Points

• Cognitive-behavior therapies can be traced back to early animal re-
search and learning theory; these therapies emphasize the connec-
tion among thoughts, behaviors, and emotions.
• Thoughts and behaviors are seen as malleable agents of change for
client distress and impairment.
• Although there are numerous CBTs, most share a focus on cognition
and behavior, are present focused, and emphasize a collaborative,
active, and structured approach to achieving clearly operationalized
goals.
Self-Assessment Questions
1.1. What is the most readily available form of core beliefs called?
1.2. What is a negative schema?
1.3. Define collaborative empiricism.
1.4. How are behaviors reinforced? How are they extinguished?
Suggested Readings
and Web Sites
Beck JS: Cognitive Therapy: Basics and Beyond. New York, Guilford, 1995
Association for Behavioral and Cognitive Therapies: www.abct.org
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2
Developmental
Considerations
Across Childhood
Judy Garber, Ph.D.
COGNITIVE-BEHAVIOR therapy (CBT) is used with children

and adolescents to treat various forms of psychopathology, including de-
pression (Weisz et al. 2006), anxiety (Kendall et al. 2002), and conduct
disorder (Litschge et al. 2010). Effect sizes for CBT in children are mod-
est, typically ranging from 0.3 to 0.6 (e.g., Durlak et al. 1991; Litschge et
al. 2010; Weisz et al. 2006). One potential explanation for these medium
effects is that the developmental demands of CBT may exceed a child’s
capabilities. That is, CBT may be less effective for some children because
This work was supported in part by grants from the National Institute of Mental
Health (R01MH 64735; RC1 MH088329; T32 MH18921).
29
they are not cognitively, emotionally, or socially developed enough to un-

derstand and apply the clinical skills being taught in therapy.
Empirical evidence of differences in efficacy as a function of age has
been reported. For example, a meta-analysis of 150 studies of psychother-
apy with children and adolescents found that the mean effect size for ad-
olescents was larger than for children (Weisz et al. 1995). Similarly, an
earlier meta-analysis reported that children ages 11–13 benefited from
CBT more than did children ages 5–11 (Durlak et al. 1991). Few studies,
however, have explicitly assessed children’s developmental level or have
tested whether development moderates treatment effects (Grave and
Blissett 2004; Holmbeck et al. 2006).
The idea of incorporating developmental considerations into treatment
planning is not new (Eyberg et al. 1998; Ollendick et al. 2001; Shirk 1999;
Vernon 2009). Nevertheless, the actual translation of findings from basic
developmental research into clinical practice has been less common (Holm-
beck and Kendall 1991; Shirk 1999). Some developmental tailoring of inter-
ventions for children has been done informally and at a basically superficial
level (e.g., linguistic changes), but rarely has it been a systematic and empir-
ically driven pursuit (Masten and Braswell 1991; Ollendick et al. 2001).
Many CBT interventions for youth have been downward extensions of
adult treatment manuals (Eyberg et al. 1998; Stallard 2002). A few CBT
manuals have been designed specifically for children (e.g., Coping Cat for
anxiety; Kendall 1990) and have been extended upward for use with ado-
lescents (Kendall et al. 2002). As CBT for children and adolescents has
been derived, in part, from cognitive theory of therapy in adults, the extent
to which this model is appropriate for less developed age groups is unclear
(Grave and Blissett 2004). Both the downward and upward extension ap-
proach to designing treatments for children and adolescents serve to per-
petuate, however unintentionally, the developmental uniformity myth that
individuals with the same psychiatric diagnoses are homogeneous across de-
velopmental levels and therefore will respond similarly to treatment
(Holmbeck et al. 2006; Shirk 1999). Although most clinicians and re-
searchers would argue against this myth, they remain challenged in how to
translate a truly developmental perspective into practice.
Why Is It Important to Tailor

CBT Developmentally?
Incorporating developmental considerations into treatment design and
planning may increase treatment efficacy. Children likely will benefit
more when clinicians are aware of developmental norms and can match
Developmental Considerations Across Childhood 31
treatment strategies to children’s abilities (Holmbeck et al. 2006; Weisz

and Hawley 2002). The exact developmental requirements of the various
therapeutic strategies that incorporate CBT have not yet been precisely ar-
ticulated, however. Without a clearer understanding of these demands,
CBT with children may be less effective, and faulty assumptions may be
made about whether CBT should be used with children (Spritz and Sand-
berg 2010). Interventions may be too elementary or too advanced if de-
signed without consideration of developmental level. Given evidence that
some children do benefit from CBT, it is likely that certain CBT strategies
are appropriate for children, particularly if presented in a developmentally
sensitive manner. For example, a focus on concrete concepts rather than
abstract principles may be more effective with less cognitively advanced
children (Stallard 2002).
Case Example
Karen is an 11-year-old girl referred for treatment because of her inability
to sit still in the classroom, lack of motivation in school, difficulty concen-
trating, sleep problems, restlessness, and overall bad mood. At her intake
appointment, Karen presents as a well-spoken, socially skilled girl. Indeed,
assessment of Karen’s social skills indicates that she is appropriately so-
cially competent. However, the cognitive assessment reveals that Karen
has difficulties reflecting on her own thoughts and emotions, as well as
problems with abstract and hypothetical reasoning. Therefore, the thera-
pist decides to draw on Karen’s interpersonal strengths by using more con-
crete role-play examples based on actual situations from Karen’s life (e.g.,
interactions with her teacher) rather than using abstract, hypothetical
(e.g., “what if ”) and future-oriented scenarios. Thus, by matching thera-
peutic techniques to Karen’s actual cognitive level, the therapist is able to
induce greater behavioral change over time.
Although most clinicians recognize the importance of considering chil-

dren’s levels of competence in different domains (e.g., cognitive, social,
emotional) when conducting therapy, they lack information about how
particular developmental limitations affect children’s ability to acquire
and implement the various strategies taught in treatment (Shirk 1999;
Weisz and Hawley 2002). Moreover, as children develop, they may use
skills differently depending on context. That is, although children may
demonstrate mastery of a developmental skill in one context, they may not
be able to apply this skill in other situations (Sauter et al. 2009). Clinicians
also should be cognizant of the zone of proximal development (i.e., the dif-
ference between what children can learn when they have support or not
[Vygotsky 1978]) when considering children’s ability to implement clini-
cal skills with and without help from others (e.g., therapist or parents).
Although the terms age and development are often used interchangeably,
they are not synonymous (Durlak et al. 1991; Holmbeck and Kendall 1991).
Development is significantly more complex than the linear progression of
chronological age. As such, clinicians cannot assume that older children will
always benefit more than younger children from CBT approaches. For ex-
ample, some studies have shown greater improvements in adolescents than
in children receiving CBT for anxiety, whereas others have found that chil-
dren benefit more than adolescents (e.g., Sauter et al. 2009; Weisz et al.
1995). The unique developmental characteristics associated with adoles-
cence may impact adolescents’ willingness to participate in therapy as well
as their ability to apply therapeutic skills (Weisz and Hawley 2002). Addi-
tionally, given the heterogeneity of development, not all adolescents (or even
adults) will possess the developmental competencies necessary to grasp
some of the abstract and hypothetical constructs involved in CBT.
Clinicians also need to be mindful of the link between clinical symp-
toms and development, as well as the relations among the individual areas
of development (e.g., cognitive, social, and emotional). Because clinical
symptoms may disrupt normal developmental pathways, one treatment
goal should be to return children to a more normative trajectory (Shirk
1999). In addition, attention should be paid to the ways in which delays in
one area of development may be associated with difficulties in other de-
velopmental domains.
Given the importance of incorporating development into treatment
design and planning, why is it that developmental approaches are not al-
ready an empirically validated and universally implemented standard of
care? The translation of developmental principles into practice is neither
simple nor direct, and as such the integration of clinical and developmental
psychology continues to be a challenge (Holmbeck et al. 2006; Ollendick
et al. 2001). In the next section, we describe what has been attempted al-
ready to tailor CBT, and we provide recommendations for additional ways
to developmentally modify treatments for youth.
What Has Been Done to

Developmentally Tailor CBT?
Researchers and clinicians have begun paying more attention to contextual
factors related to development when implementing treatments. For example,
the changing interpersonal relationships that occur as children mature (e.g., in-
creased importance of peers, formation of cliques, individuation from par-
ents) have been addressed in some treatment planning (Holmbeck et al.
2006). One complicated clinical issue affected by the child’s level of social de-
velopment is the amount and type of parental involvement in treatment.
Whereas family-based interventions have been found to be more effective for
younger children, individual treatment has been shown to be more effective
with older children (Ruma et al. 1996). Given the emergence of autonomy
during adolescence, having parents play a directive or even “coaching” role
during this developmental stage may be contraindicated, though this may de-
pend on other factors such as the youth’s temperament and the quality of the
parent-child relationship. Adolescents who are given appropriate control and
input into how parents can be helpful in supporting their new skills may par-
ticularly benefit from parental involvement.
Case Example
Kevin, a 14-year-old adolescent boy, was an average student and socially en-
gaged with his friends. Six months ago, Kevin became more irritable, easily
frustrated with others, and disinterested in school and social activities. He
was diagnosed with a major depressive episode and oppositional defiant dis-
order. The therapist began individual CBT with Kevin to try to elicit more
behavioral activation and work on his disengaged social interaction style. Al-
though Kevin and his mother had always had a good relationship, it was
clearly worsening as a result of greater conflict between them, particularly
about Kevin’s recent misguided expressions of autonomy (e.g., breaking cur-
few). With Kevin’s permission, the therapist added sessions with the mother
to help her understand his growing need for independence. A family prob-
lem-solving exercise was initiated where Kevin came up with the solution
that he would try to talk with his mother calmly and less disrespectfully, and
in turn, his mother gradually would grant him greater freedom as long as he
was safe and legal. Kevin began trying out more of the CBT skills he was
learning in therapy at home in order to improve his relationship with his
mother and steadily obtain more age-appropriate privileges.
Some developmentally based treatment manuals do exist, mostly for

treating child anxiety disorders (Sauter et al. 2009). For example, Chor-
pita’s (2007) CBT manual for children with anxiety consists of several
modules, each containing CBT techniques to be selected according to the
child’s cognitive abilities. Other CBT manuals for anxiety disorders de-
signed specifically for children ages 7 years and older are The Coping Cat
(Kendall 1990) and How I Ran OCD Off My Land (March and Mulle
1998). Kendall and colleagues (2002) modified the child anxiety manual
for use with adolescents at different developmental levels. These develop-
mentally sensitive manuals, however, are exceptions rather than a widely
used and available standard.
The most common adaptation of CBT for children has been to use age-
appropriate activities to convey therapeutic skills. One common alteration
has been to include more child-friendly materials, simplified language, and

cartoons. For example, thought bubbles have been used to help children
identify what they are thinking (Kendall 1990). With younger children,
therapists can use more concrete pictorial or narrative formats, behavior-
ally active strategies, and activities that stimulate the imagination (Grave
and Blissett 2004). Some programs have suggested representing cognitive
distortions as coming from a “bad thought monster” (Leahy 1988) or
“muck monster” (Stark et al. 2007). Children are then instructed either
to fight the monster (e.g., with the help of a Zen warrior) or to talk back
to the monster with the help of the group and therapist. Using less com-
plex behavioral techniques with younger children and more complex cog-
nitive techniques with older children also has been recommended (Doherr
et al. 2005; Eyberg et al. 1998).
Systematic desensitization also has been modified for young children
(Ollendick et al. 2001). Shorter attention span and limited abstract think-
ing in young children may hinder the use of traditional progressive muscle
relaxation scripts and guided imagery. Using concrete imagery for muscle
relaxation (e.g., tensing and relaxing hands by “squeezing lemons” [Chris-
tophersen and Mortweet 2002]) and replacing imagination-based desensi-
tization with in vivo experiences may be more effective with younger
children. An age-appropriate desensitization strategy could include imag-
ining confronting the feared situation with the help of a favorite superhero
(Lazarus and Abramovitz 1962). When typical relaxation techniques (e.g.,
muscle relaxation, guided imagery) are not effective with a young child,
then other counterconditioning methods (e.g., play, music, food) should
be considered (Ollendick et al. 2001). Also recommended is the use of
simple, situation-specific coping statements with young children, pro-
gressing toward more general self-instructions and eventually using gener-
alized statements during adolescence.
CBT techniques such as identifying thinking errors, examining under-
lying beliefs, and using Socratic questioning are recommended only for
more cognitively advanced youth (Stallard 2002). When presented with
information that contradicts a belief, children have more difficulty than
adults in revising their thoughts accordingly (Shirk 1999). Some CBT pro-
grams for children have simplified the cognitive restructuring process to
solely replacing negative thoughts with more positive thoughts. Although
this “replacement” strategy allows less cognitively advanced children to
engage in a form of cognitive restructuring, its efficacy as compared to
teaching children to examine their beliefs and distortions and to generate
accurate and realistic counter-thoughts has not been demonstrated.
Merrell (2001) provided a compendium of developmentally appropriate
cognitive-behavioral methods for use with depressed and anxious children and
adolescents, in which strategies were separated by age. For example, to help

children recognize degrees of emotional intensity, Merrell recommended that
the therapist draw an “emotional thermometer” with different levels that the
child can use to identify the emotional intensity of different experiences. This
exercise can be used with individuals of all ages, but Merrell recommended
keeping emotional gradations simple for young children.
For identifying automatic thoughts, Merrell recommended using thought
forecasting, in which individuals generate hypothetical scenarios and predict
possible thoughts and feelings they might have in those situations. In contrast
to the emotional thermometer, thought forecasting is only recommended for
older children and adolescents because “younger children may find this exer-
cise too abstract and may not be able to generate realistic future situations”
(p. 89). In general, Merrell suggested that for younger children, clinicians
should use more concrete and simplified examples and questions while also
providing more support, structure, and feedback.
Merrell’s (2001) book provides useful examples of techniques clini-
cians can use to teach skills to children of different ages, although it has
some limitations. All the recommended activities are either for children of
all ages or for “older” or “cognitively mature” children and adolescents.
Few activities specifically designed for younger children are presented.
Moreover, information is not provided regarding how clinicians can assess
children’s specific levels of cognitive maturity. Age is only a crude and im-
precise estimate of a child’s developmental level at any point in time.
In a handbook of clinical strategies for teaching rational emotive behav-
ior therapy techniques to youth, Vernon (2009) separated strategies by
their appropriateness for children versus adolescents and provided a devel-
opmental rationale for most activities. For example, for “So Long, Sad-
ness,” an activity designed to help children generate ideas for coping with
depressed feelings, Vernon stated, “Most children feel sad from time to
time, but given that their sense of time is immediate, it is easy for them to
get discouraged if they aren’t able to deal with their feelings effectively.
This concrete strategy involves them generating things they can do to feel
better” (p. 122). Similarly, for “Don’t Stay Depressed,” an activity in
which adolescents detail what they can think and do and who they can
turn to for support when feeling depressed, Vernon wrote, “Given that ad-
olescents live in the ‘here and now,’ it is easy for them to become over-
whelmed and feel hopeless when they are depressed. Consequently, it is
important to empower them so that they have many different strategies
for coping more effectively because it is difficult for them to generate
ideas when they are down” (p. 125). In addition, Vernon included a sec-
tion titled “Interventions for Typical Developmental Problems,” in which
she detailed activities for enhancing self-acceptance, relationships, and
healthy transitions. Thus, Vernon’s book presents activities that incorpo-

rate age-based developmental considerations.
Attention to developmental factors in CBT has increased since the
1990s. The percentage of empirical articles mentioning developmental is-
sues in treatment has increased from 26% between 1990 and 1998 to 70%
between 1999 and 2004 (Holmbeck et al. 2006). However, the construc-
tion of developmentally sensitive treatment strategies generally has been
an informal process not always driven by empirical evidence. Further re-
search is needed on how to individualize treatment techniques according
to a child’s specific developmental level rather than age. Until more pre-
cise guidelines are constructed for tailoring treatments developmentally,
clinicians will need to modify the therapy on the basis of their assessment
of a child’s level of development in relevant domains.
What Is Needed for Clinicians

to Developmentally Tailor CBT
More Effectively?
To effectively adapt CBT to children’s developmental levels, clinicians
need to 1) recognize the connections between developmental skills and
clinical techniques, 2) understand the normative trajectory of the relevant
developmental skills, 3) use appropriate assessment tools to determine
children’s developmental abilities, and 4) incorporate all of this knowledge
into an individualized treatment plan. In the following sections, we elabo-
rate on each of these recommendations; outline some specific clinical skills
involved in CBT; and discuss how cognitive, social, and emotional develop-
ment can impact treatment.
1. Recognize the connections between developmental skills and clinical

techniques.
Cognitive therapy is based on the assumption that irrational or mal-

adaptive cognitive schemata (attitudes and beliefs), cognitive prod-
ucts (thoughts and images), and operations (processing) influence
problematic behavior. The aim of therapy is to help the child to iden-
tify possible cognitive deficits and distortions, to reality-test them,
and then, either to teach new thinking skills or to challenge irrational
thoughts and beliefs and replace them with more rational thinking.
(Grave and Blissett 2004, pp. 401–402)
A variety of cognitive, social, and emotional developmental skills (e.g.,

metacognition, perspective taking, and emotion understanding, respec-
tively) may be necessary to learn and apply the clinical tasks described by
Grave and Blissett (2004). Identifying exactly which developmental skills
are linked to which specific clinical tasks, however, is neither simple nor
intuitive, in part because of the heterogeneity of the skills that incorporate
CBT (Grave and Blissett 2004). Durlak and colleagues (1991) reviewed
CBT programs for children and identified 8 core components: task-ori-
ented problem-solving, social problem-solving, self-instructions, role-
playing, rewards, social cognition training, social skills training, and other
CBT elements. Within the 64 studies reviewed, there were 42 different
permutations of these 8 skills. As such, the term cognitive-behavior ther-
apy is really an umbrella for a wide and divergent amalgamation of thera-
peutic techniques (Durlak et al. 1991; Stallard 2002).
We cataloged the specific skills described in 14 different CBT manuals
for the treatment of child and adolescent depression. Table 2–1 presents
the 19 main clinical skills identified and the number of treatment pro-
grams that explicitly include each skill. In addition to the many different
combinations of core skills labeled “cognitive-behavior therapy,” each of
these skills was taught in a variety of ways. For example, “understanding
the cognitive model” was broken down into different components in
each manual, with children being asked to make different connections
depending on the treatment program (see Table 2–2).
2. Understand the normative trajectory of the relevant developmental

skills.
At the foundation of effectively tailoring treatment to developmen-
tal level is an understanding of the normative trajectory of the relevant
skills. Familiarity with the typical course of skill acquisition can help
clinicians determine if a particular child is more advanced, on track, or
delayed. Knowledge of developmental norms is needed to improve the
quality of interventions with children, guide expectations, and de-
crease faulty assumptions (Spritz and Sandberg 2010; Weisz and
Weersing 1999). For example, all-or-none thinking, overgeneralizing,
and negative filtering are types of cognitive distortions described in the
adult CBT literature (Beck et al. 1979; Grave and Blissett 2004), but
these distortions actually may be developmentally normative ways of
thinking in young adolescents (Spritz and Sandberg 2010). In addition
to knowledge of cognitive development, knowledge of social and emo-
tional development also is needed to provide comprehensive and ef-
fective care (Eyberg et al. 1998; Masten and Braswell 1991).
TABLE 2–1. Frequency of core clinical skills in 14 cognitive-

behavior therapy manuals for youth depression
Number of
Core clinical skill manuals
Understanding the cognitive model 14
Using skills outside of session/practice/homework 14
Cognitive restructuring 13
Goal setting 12
Behavior activation 12
Developing/maintaining/seeking social support 12
Motivation to engage in therapy 12
Identity formation 11
Types of thoughts 11
Other coping skills/emotion regulation 11
Meeting new people/conversation skills 10
Relapse prevention planning 10
Social problem-solving/conflict resolution 9
Relaxation training 8
Controllable vs. uncontrollable stressors 8
Problem solving 7
Assertive behavior training 6
Understanding depression 6
Mindfulness 5
3. Use appropriate assessment tools to evaluate a child’s developmental

abilities.
For treatments to be tailored to a child’s particular developmental
level, a thorough developmental assessment is required. Because chro-
nological age is not necessarily an accurate indicator of a particular
child’s developmental level, a comprehensive evaluation of a child’s ac-
tual abilities across relevant domains is needed to match clinical strate-
gies to the child’s specific skills (Durlak et al. 1991; Holmbeck and
Kendall 1991). Although the importance of conducting this type of as-
sessment has been emphasized (Holmbeck et al. 2006; Sauter et al.
2009; Shirk 1999), it is rarely done in practice. Clinical assessments gen-
erally focus on evaluating children’s symptoms and diagnoses rather
than on creating a developmental profile to guide treatment plans.
TABLE 2–2. Frequency of components for the core clinical skill

“understanding the cognitive model” in 14 treatment
manuals
Number of
Subskills manuals
Rate mood 10
Identify thoughts 13
Identify situations 7
Identify feelings 7
Identify behaviors 3
Connect situations and thoughts 7
Connect situations and feelings 8
Connect thoughts and feelings 11
Connect thoughts and behaviors 3
Connect feelings and behaviors 10
Connect situations, thoughts, feelings 8
Connect thoughts, feelings, behavior 8
Connect situations, thoughts, feelings, behavior 4
Assessment measures can over- or underestimate children’s abilities

depending on the context and format of the evaluation (e.g., language
used, support provided [Grave and Blissett 2004]). Therefore, in se-
lecting an assessment battery for developmentally tailoring treatment,
clinicians should choose ecologically valid measures that capture abili-
ties in both the therapeutic setting and the more challenging real-
world environment. The few studies that have attempted to assess de-
velopment separate from age have used measures of intellectual ability
or achievement. Intelligence tests, however, do not examine all CBT-
relevant cognitive subdomains or assess social or emotional competen-
cies (Sauter et al. 2009).
4. Incorporate knowledge about development into treatment planning.

How can knowledge of clinical skills, typical development, and as-
sessment data be incorporated into treatment planning? At least two
methods are possible: a) modify the treatment to fit the developmental
level of either the individual child or a certain developmental profile
(Weisz and Weersing 1999), and b) enhance the child’s developmental
competencies to prepare him or her for more advanced therapeutic
techniques (Holmbeck and Kendall 1991). Examples of treatment

modifications include altering activities to be more or less complex,
concrete, behavioral, cognitive, or visual (Sauter et al. 2009; Stallard
2002). Additionally, different versions of treatment protocols can be
designed for children at various levels of developmental maturation
(Holmbeck et al. 2006). Such modifications should be made on the ba-
sis of a systematic evaluation of developmental level rather than age.
The other frequently mentioned method for developmentally tai-
loring interventions involves clinicians beginning treatment by priming
developmental skills, with the expectation that providing scaffolding
and tapping into the zone of proximal development (Vygotsky 1978)
will facilitate the later mastery of CBT techniques (Holmbeck et al.
2006; Sauter et al. 2009; Shirk 1999). Some empirical evidence indi-
cates that development can be primed in this way (Keating 1990). For
example, Doherr and colleagues (2005) found that children taught
with a curriculum designed to improve thinking skills performed bet-
ter on CBT tasks than did children in a more typical curriculum. Thus,
a child’s developmental level in multiple domains should inform all as-
pects of treatment planning, from case conceptualization and goal set-
ting to intervention selection and outcome assessment.
In summary, multiple steps are needed to appropriately tailor thera-

peutic techniques to children’s developmental level. Figure 2–1 outlines
the empirical work that needs to be done to map out the specific links be-
tween the clinical techniques being used with children and the develop-
mental demands of these techniques. First, we need to catalog the clinical
procedures described in the various CBT manuals for youth and then spec-
ify the developmental abilities necessary for a child to learn and use each
of these therapeutic techniques. Once the developmental requirements
are identified, we next need to construct a reliable and valid assessment
battery of these abilities from which a developmental profile can be cre-
ated. Finally, with these empirically derived guidelines, clinicians will be
ready to administer an assessment battery that measures a child’s develop-
mental abilities, create an individualized profile across multiple domains,
and formulate a developmentally sensitive treatment plan.
Developmental Domains
Cognitive Development
The complex cognitive strategies taught in CBT place demands on children’s
information processing and presuppose a certain level of cognitive function-
Empirical research needed
Catalog the therapeutic

techniques described in different
CBT manuals for youth
Identify the specific developmental

abilities necessary for children to learn and
use each of these therapeutic techniques
Construct an assessment battery of these

abilities from which a developmental
profile can be created
Practical clinical implications
Use this assessment battery to evaluate a

child’s developmental abilities
Create an individualized profile across

multiple domains
Using this information, formulate a treatment plan

that matches therapeutic techniques to the child’s
level of development in each domain
FIGURE 2–1. Empirical steps needed to developmentally tailor cog-

nitive-behavior therapy (CBT) for children and adolescents and practi-
cal implications for clinicians.
ing in order to understand and apply the treatment techniques (Holmbeck et

al. 2000; Shirk 1999). As such, an assessment of a child’s level of cognitive
development can guide the selection of CBT techniques (Sauter et al. 2009).
Although the specific cognitive capacities necessary for participating in CBT
have not yet been explicitly determined empirically, metacognition, self-
reflection, and reasoning are especially salient (Grave and Blissett 2004;
Holmbeck et al. 2000; Sauter et al. 2009). Metacognition involves noticing
one’s thoughts; self-reflection is the ability to reflect on one’s own beliefs,
feelings, and actions; and reasoning is the ability to connect these reflections.
Connection With CBT Techniques

A central component of CBT involves reflecting on and causally linking
thoughts, feelings, and behaviors, for which the developmental skills of rea-
soning, metacognition, and self-reflection are especially relevant (Grave and
Blissett 2004; Harrington et al. 1998). Disputing cognitive distortions by
generating alternative explanations requires the ability to reason hypotheti-
cally. Exploring maladaptive cognitions by examining evidence requires the
ability to think logically and systematically. Other CBT techniques are mul-
tistep processes. Even when children have some of the requisite develop-
mental skills to engage in certain activities, they may have difficulty enacting
them simultaneously in a fluid process (Holmbeck et al. 2006; Weisz and
Weersing 1999). That is, children may be able to engage in some of the in-
dividual components of a clinical skill (e.g., identifying situations, thoughts,
feelings, and behaviors) but may struggle in putting all of the pieces together
(e.g., connecting situations, thoughts, feelings, and behaviors; understanding
that different thoughts can relate to different feelings in the same situation);
such integration requires an even more sophisticated level of cognitive de-
velopment (e.g., causal, hypothetical, systematic, logical, and abstract rea-
soning).
An important part of most CBT treatments is the actual implementa-
tion of the new skills outside the therapeutic setting. To recognize appro-
priate times for enacting these skills, an individual needs abstract reasoning
to generalize from a specific example to other real-life situations. Thera-
pists sometimes ask clients to role-play scenarios and to imagine possible
relevant future situations as a way to more concretely practice and prepare
for using the techniques outside of the session. Such exercises, however,
are largely hypothetical and involve future thinking. Simply concretizing
exercises for children may not be sufficient. Having an understanding of
normative cognitive development likely will facilitate a clinician’s ability to
conceptualize a particular child’s abilities in a given context.
Normative Development of Cognitive Skills

In clinical samples, where disrupted or advanced developmental pathways
can be both a cause and consequence of psychopathology, age alone may
not be an accurate marker of developmental level. Given the bidirectional
relation between development and psychopathology, an understanding of
how skills emerge and progress could be more useful to clinicians than a
detailed outline of ages at which skills typically occur. Age frequently is
used as a proxy for development because of its simplicity, but without hav-
ing a more precise understanding of cognitive development, using age
alone could slow or even undermine the efficacy of the intervention.
Piaget (1964/2006) provided the early seminal work on children’s cogni-

tive development, proposing that children progress through sensorimotor,
preoperational, concrete operational, and formal operational stages, with
thinking becoming more abstract, logical, complex, and systematic as develop-
ment progresses. More recently, developmental psychologists have shifted
away from Piaget’s stagelike model to conceptualizing development as a more
continuous process. Indeed, some children in earlier phases of Piaget’s devel-
opmental model can engage in more complex thinking than he originally pro-
posed (Grave and Blissett 2004). Nevertheless, Piaget provided an important
foundation for understanding cognitive development.
Various forms of reasoning, including abstract, causal, hypothetical,
and logical, develop over time. Increased neural development leads to im-
provements in abstract reasoning (Sauter et al. 2009) and a decrease in
concrete thinking (Vernon 2009). Causal reasoning changes throughout
childhood and into adulthood—progressing from external, visible, and
concrete connections to more internal and psychologically based associa-
tions (Grave and Blissett 2004)—underlie the ability to link thoughts,
feelings, and situations.
As development progresses, children become increasingly able to antic-
ipate consequences (Keating 1990). Although less cognitively developed
children can generate solutions, more advanced cognitive abilities are
needed to evaluate these solutions using means-end thinking (Holmbeck
and Kendall 1991). Maturation of hypothetical reasoning first results in an
ability to imagine the outcome of future hypothetical ideas (e.g., “What
might happen if you do this next time?”), followed by improved under-
standing of past hypothetical thinking (e.g., “What would have happened
if you had done this?”) (Robinson and Beck 2000). These tasks are espe-
cially difficult for less cognitively developed children when the hypothet-
ical outcome is inconsistent with their current beliefs. Similarly, the ability
to logically test hypotheses by thinking about conflicting evidence simul-
taneously and differentiating theory from fact develops over time (Har-
rington et al. 1998; Holmbeck et al. 2006). With development, children
become increasingly able to examine multiple aspects of a situation and
engage in less biased reflection (Vernon 2009).
A marker of a particularly sophisticated level of reasoning is the ability
to think analogically (Grave and Blissett 2004)—that is, to see subtle rela-
tions between two things that are not based on overt similarities. Clinicians
sometimes use analogies to help children understand new information by re-
lating it to their existing knowledge. However, if a child lacks the reasoning
ability to understand and apply analogies, then the child may end up even
more confused.
Another cognitive skill important for engaging in CBT is metacogni-

tion, which is the ability to think about thinking. Children first learn to
monitor their own thoughts and to recognize that they have knowledge—
that is, they know what they know, even if they are not yet able to reflect
on the meaning of this knowledge. With development, children gain the
capacity to report their thoughts to others (Grave and Blissett 2004) and
to observe the consistency and accuracy of their thinking (Keating 1990).
Specifically, children become increasingly able to identify thoughts and to
distinguish thoughts from behaviors before they later develop the more
nuanced capability of differentiating thinking from seeing and knowing
(Doherr et al. 2005; Sauter et al. 2009). As children become more psycho-
logically minded, they engage in more spontaneous reflections on their
thinking (Grave and Blissett 2004; Sauter et al. 2009) and become aware
of regulating their thoughts (Doherr et al. 2005).
Finally, self-reflection is the individual’s ability to apply these reasoning
and metacognitive skills to his or her own beliefs and actions. For example,
the ability to think about multiple aspects of a situation and to examine
contradictory evidence allows more cognitively developed children to un-
derstand there can be variation in their own strengths and weaknesses in-
stead of viewing themselves as either “all good” or “all bad” (Grave and
Blissett 2004). Over time, children develop an “inner monologue” that in-
volves the ability to reflect on their own inner life (Sauter et al. 2009;
Shirk 1999), leading to a developing sense of self that gradually solidifies
and becomes less modifiable (Hoffman 2008).
Unfortunately, with emergent cognitive maturity comes increased vul-
nerability to certain forms of psychopathology. For example, as children
become better able to engage in self-evaluation, they also are more apt to
be self-critical (Masten and Braswell 1991). As such, more developed chil-
dren are increasingly able to identify their deficiencies and to believe them
to be stable and unchangeable traits. Thus, clinicians need to be aware of
the ways in which cognitive development may play a role in both decreas-
ing and exacerbating symptoms.
Assessment
Because cognitive skills are changing over time, it is important to assess chil-
dren’s developmental level at any particular point in time. Some informal as-
sessments have been used to gather information about metacognition,
systematic thinking, recognizing consequences, and generating alternatives
(Holmbeck et al. 2006). Example questions include “What went through
your mind when...” and “What is going through your mind now?” Measures
of intellectual ability also have been used to assess cognitive development; for
example, the Wechsler Intelligence Scale for Children, 4th Edition (WISC-
IV), similarities subtest measures abstract reasoning skills (Sauter et al.
2009). Subscales of intelligence measures might not be sufficiently compre-
hensive, however, to serve as indicators of how children think (Spritz and
Sandberg 2010). Thus, although useful, more general intelligence measures
may not provide a complete picture of a child’s level of cognitive develop-
ment. A more formal assessment battery for evaluating relevant cognitive de-
velopmental skills would allow clinicians to gather more specific information
needed to tailor treatment appropriately.
A list of several existing measures of cognitive development is provided
in Appendix 2–A. Although this is not a comprehensive catalog of all pos-
sible measures, it provides a resource of commonly used tools for assessing
several important aspects of children’s cognitive development. Not every
measure should be used for every child all of the time. Rather, measures
can be selected on the basis of which will provide incremental knowledge
to guide treatment planning for a particular child.
Practical Recommendations for

Treatment Planning
Although the need to assess developmental skills has long been suggested
for treatment planning, such individualization is still in its infancy. The rec-
ommendations in Appendix 2–B are examples of the ways in which clini-
cians can integrate developmental and clinical knowledge to improve
treatment planning and clinical outcomes.
Social Development
Children’s level of social development also should be evaluated and used
in treatment planning (Eyberg et al. 1998; Masten and Braswell 1991).
Many forms of psychopathology both affect and are affected by interper-
sonal relationships. Consideration of the social context in which children’s
psychiatric problems occur and how well children negotiate their interper-
sonal challenges is central to their treatment.

Social skills have been defined as “learned behaviors which are socially ac-
ceptable and which permit an individual to initiate and maintain positive
relationships with peers and adults” (Royer et al. 1999, p. 7). A consider-
able number of treatment manuals have been devoted to promoting chil-
dren’s abilities to interact successfully with others (see Table 2–1). CBT
manuals emphasize such social development skills as meeting new people,

conversation skills, social problem-solving, conflict resolution, assertive
behavior, and seeking social support. For example, children with emotional
and behavioral difficulties may have problems interacting with same-age
peers and correctly appraising social situations (Quinn et al. 1999). More-
over, some children form friendships with similar others (e.g., those with
the same type of symptoms), which could exacerbate their tendencies to-
ward rumination or deviant behaviors (Crosnoe and Needham 2004).
CBT involves various social-cognitive abilities, such as perspective tak-
ing, empathy, and prosocial behavior. In particular, children need social
perspective-taking skills to anticipate the effects of their behavior on oth-
ers (e.g., Grave and Blissett 2004; Holmbeck et al. 2006; Weisz and Haw-
ley 2002). When children are asked to imagine hypothetical situations and
the ways they and others might act, their perspective-taking ability likely
will affect their responses (Weisz and Weersing 1999). Role-playing, a
commonly used CBT strategy, also calls on children’s ability to see through
another’s lens. Thus, perspective taking is a critical social developmental
skill that should be assessed and considered when designing a treatment
plan for a particular child.
Normative Development of Social Competence

Bolstering children’s social competence is an important aim of CBT. Nor-
matively, children learn and master social skills through navigating relation-
ships over the course of development. The emergence and expression of
social skills stems from multiple factors and is interrelated with other areas
of development, including cognitive, emotional, and biological domains
(Beauchamp and Anderson 2010).
Perspective-taking abilities are part of normal social development. Sel-
man (1980) defined perspective taking as understanding how “human
points of view are related and coordinated with one another, that is, the
core human ability to understand the thoughts, needs, and beliefs of indi-
viduals other than oneself ” (p. 22). This capability to stand in another’s
shoes is foundational for successful interactions.
Perspective taking presumably changes linearly from childhood to adult-
hood (Elfers et al. 2008). Less socially advanced children are limited in their
ability to see another’s viewpoint beyond their own or to recognize that oth-
ers’ perspectives even exist (Fireman and Kose 2010). As a result, children
communicate in a seemingly “egocentric” way, such that they often omit vital
information about what their listener needs to know. Over time, children
learn that perspectives different from their own exist. Children also begin to
recognize that people have their own goals, intentions, and expectations, al-
though they may not yet be able to conceive of what these might be.
Perspective-taking ability is multifaceted and various components of this
skill may emerge at different times. For example, children can comprehend
that others have different views than their own, but they may think that the
others’ perspectives are incorrect and that only their own view reflects real-
ity. Thus, children’s “normal” processing of social information may appear to
be distorted compared with that of adults (Grave and Blissett 2004). As chil-
dren mature socially, they become better at reflecting on their own actions
through the perspective of another person. This developing ability enables
youth to take a more impartial position over time.
The cognitive advances that develop in tandem with social develop-
ment facilitate children’s understanding that perspectives are created by
the mind and are not exact copies of reality but are instead interpretations
and representations of the world. Such awareness leads to an understand-
ing of the causes underlying multiple perspectives about the same situation
and that external as well as internal factors contribute to personal perspec-
tives and associated behaviors (Fireman and Kose 2010; Keating 1990).
Another important aspect of the emergence of perspective taking is the
increased motivation to take another’s perspective, which often is linked
to a desire to engage in prosocial behavior (Eisenberg et al. 2009). Al-
though motivation to engage in perspective taking typically is a marker of
healthy social development, some youth try to anticipate what people are
thinking and often assume that they are the focus of others’ thoughts; this
belief is often referred to as the imaginary audience (Keating 1990). Such
thinking is part of normative development but can be problematic when it
takes the form of excessive self-consciousness or rumination.
Achievement of social competence in children is cultivated through
their encounters with different types of challenging social situations
(Spence 2003). Adaptive social skills produce positive peer relationships
and include expressing positive affect, attending to play partners, initiating
nurturing behaviors (e.g., helping, sharing), being agreeable, and mastering
reciprocal play (e.g., turn taking) (Bierman et al. 2010; La Greca and Prin-
stein 1999). Thus, good peer relationships are formed once children learn
how to initiate and maintain positive social interactions.
As children become more socially advanced, they develop the self-control
that makes possible engaging in rule-based play and joining in prosocial behav-
ior, thereby enhancing their peer acceptance and avoiding rejection (La Greca
and Prinstein 1999). Social skills acquired early continue to be important (e.g.,
sharing, helping, cooperating). In addition, prosocial characteristics such as be-
ing kind and considerate contribute to being accepted by others.
With regard to resolving interpersonal conflict, less socially developed

children tend to use more physical aggression; over time, children use
more indirect, relational aggression. Some children may be singled out for
victimization, particularly those who are socially withdrawn or emotionally
labile. In contrast, children who are socially adept demonstrate adaptive
strategies for solving interpersonal conflicts and effectively inhibit and re-
direct impulsive and aggressive behaviors (Bierman et al. 2010).
Gaining acceptance from others, particularly peers, is one of the salient
social challenges that children face. Youth who are not accepted by their
peers tend to have problems resolving conflict and less supportive friend-
ships. Children with at least one reciprocal friendship fare much better
emotionally than do those without a friend. The importance of friendships
and the influence of peers increase with development (Crosnoe and
Needham 2004). Intimacy characterizes the friendships of socially ad-
vanced youth, particularly for females whose friendships are marked by
good communication, self-disclosure, and trust (La Greca and Harrison
2005). Intimacy emerges out of social perspective-taking skills, mature
conversational skills, and developmentally advanced capacities for loyalty
and empathy. Thus, children’s burgeoning ability to take others’ perspec-
tives, generate multiple solutions to social problems, and think before act-
ing aids in the formation of close dyadic friendships and the building of
successful social relationships (Parker and Asher 1993).
As children become more social and cognitively advanced, however,
their abstract and reflective thinking also allows for new levels of social dis-
tress. For example, youth often evaluate themselves in comparison to their
peers and judge their self-worth in terms of the social status of their
friends. Finding their social niche, navigating social groups and cliques, and
responding to peer influences are among the many social challenges youth
must negotiate. Children who cope effectively with peer pressure tend to
be more advanced socially and cognitively and are able to act assertively in
challenging social situations (Bierman et al. 2010).
Assessment
Assessing children’s social development, particularly regarding their peer
relationships and friendships, is important for constructing an age-appro-
priate treatment plan (La Greca and Prinstein 1999). Children’s social
competencies and skills have been assessed with role-play vignettes or
questionnaires (Matson and Wilkins 2009). Multimethod, multi-infor-
mant approaches are likely to provide the most comprehensive assessment
of children’s social aptitudes and deficiencies (Spence 2003), although
this can be time-consuming and expensive.
La Greca and Prinstein (1999) recommended four crucial areas to as-

sess in children’s social functioning:
1. How is the child viewed by peers?
2. What are the child’s friends and friendships like?
3. How does the child feel about his or her peer interactions? Have any
aversive occurrences happened with peers?
4. What are the child’s interpersonal skills?
Addressing these four issues will aid clinicians in tailoring CBT to a par-
ticular child’s social level. Although several behavior rating scales (e.g.,
Child Behavior Checklist; Achenbach 1991) include some items about so-
cial competence, most do not provide a focused examination of social skills
per se that would inform treatment planning. Some measures assess social
skills that are particularly pertinent to CBT with youth (e.g., perspective
taking, conversational skills). Appendix 2–A lists several measures that can
be used to assess components of children’s social development.
The distinction between acquisition versus performance of social skills
and interpersonal problem-solving is germane to the assessment of social
development (Gresham 1997; Spence 2003). For example, although a
child may be capable of a certain social skill (e.g., initiating a conversation),
actually implementing this knowledge in a real-world context may not
necessarily follow. Deficits in performance may be due to factors such as
intense affect, intrusive or anxious thoughts, and high levels of arousal
(Gresham 1997). Thus, although questionnaires are the most common
method for assessing knowledge about social skills, they may not capture
this acquisition-performance disparity. Observation of a child’s skills defi-
cits and strengths should be an adjunctive assessment of the child’s pat-
terns of interactions with others.

Treatment Planning
Appendix 2–B provides examples of how knowledge about children’s social
development can inform the choice of strategies to be used in therapy. Some
of these recommendations are aimed at enhancing children’s social compe-
tence and specific social skills, whereas others are aimed at decreasing prob-
lematic interpersonal behaviors. Whether the clinician is applying a strength-
based or deficit-based approach, improving social interactions is a central fo-
cus of CBT with clinically referred youth (La Greca and Prinstein 1999). Tai-
loring the treatment to the developmental level of a particular child will
increase the likelihood that the child will be able to grasp what is being taught,
apply it to his or her own life, and show an improvement in symptoms.
Emotional Development
The set of emotional skills that allows individuals to effectively interact in
their world has been conceptualized in several different ways. Salovey and
Mayer (1990) defined emotional intelligence as “the ability to monitor one’s
own and others’ feelings and emotions, to discriminate among them and to
use this information to guide one’s thinking and action” (p. 189). These abil-
ities include perceiving and identifying emotions, using emotions to facili-
tate thoughts, understanding emotions, and managing emotions. Bar-On
(1997) offered a different definition of emotional intelligence, describing it
as “an array of noncognitive capabilities, competencies, and skills that influ-
ence one’s ability to succeed in coping with environmental demands and
pressures” (p. 14). He outlined five clusters of emotional intelligence skills:
intrapersonal, interpersonal, stress management, adaptability, and general
mood. Saarni (1999) described the development of emotional competence
as consisting of a set of eight skills: an individual’s awareness of his or her
own emotional state, discerning others’ emotions, using an emotion vocabu-
lary, empathy and sympathy, recognizing the distinction between inner emo-
tional state and outer emotional expression, adaptive coping, awareness of
relationships, and emotional self-efficacy. Despite the different labels, there
is considerable overlap in the skills considered to constitute emotional intel-
ligence and competence and a consensus that these skills develop over time
(Mayer et al. 2000; Saarni 1999).

Emotional skills particularly relevant to CBT include the following:
1. Perceiving and identifying emotions, being aware of one’s own and

others’ emotions, and having an emotion vocabulary.
2. Understanding emotions and the relations among emotions, using past
emotions to predict future experiences, and recognizing the difference
between inner emotional states and outer emotional expression.
3. Emotion management, including the use of self-regulation to decrease
intensity or duration of emotions both for the self and for others.
Understanding the connections within the cognitive model, participating

in cognitive restructuring, and engaging in behavior activation require self-
focused emotional competencies. For example, to understand how different
thoughts lead to different feelings, the individual must be able to recognize,
label, and differentiate among different emotions. In addition, awareness of
intensity and duration of emotions is necessary to monitor emotional expe-
riences outside of therapy; emotion recognition and an emotion vocabulary

facilitate discussion of these emotional experiences in therapy.
CBT also requires other-focused emotional intelligence. Learning to
meet people and forming and maintaining social relationships require an
understanding of others’ emotional experiences. To engage in social prob-
lem-solving or conflict resolution, individuals must be able to combine
skills related to understanding their own and others’ emotions. The ability
of children to manage their emotional experiences develops over time. The
more developed their emotion management system is, the more readily
children will be able to use the emotion regulation strategies taught in CBT
(Suveg et al. 2009).
Normative Development of Emotional Skills

The complexity of children’s emotions increases over time (Saarni 1999).
Less emotionally mature children describe their emotional experiences in
terms of physical complaints or behaviors, or they report feeling only one
emotion at a time (Bajgar et al. 2005). Emotional awareness progresses
from recognition of general feeling states (e.g., “I feel good”), to more spe-
cific emotions (e.g., “I feel happy”), to more complex emotions (e.g., “I
feel embarrassed”; “I feel guilty”), to multiple simultaneous or conflicting
emotions (e.g., “I feel love and anger”) (Ciarrochi et al. 2008).
As children become able to provide more intricate explanations of
their own emotional states, they also begin to recognize how their emo-
tions impact other areas of their life (Bajgar et al. 2005). Additionally, chil-
dren develop an understanding that emotions of different valences can
affect one another (e.g., negative feelings get better with the experience
of positive emotions [Donaldson and Westerman 1986]). Once children
are cognizant of their own more complex emotional experiences, they be-
come more aware of the emotions of others (Ciarrochi et al. 2008). Thus,
children first incorporate a broader range of information into their under-
standing and description of their own emotions, and only later are they able
to think about others’ reactions in the same way (Karniol and Koren 1987).
As children begin to understand the connections between situations
and emotions, as well as the multiplicity of emotional experiences, they
become better able to engage in emotional reasoning (Grave and Blissett
2004). With increasing development, children can reflect on their past
feelings to inform their understanding of their current experiences (Saarni
1999). Such skills are central to being able to engage in CBT.
Children’s ability to regulate emotions develops throughout childhood
and into adulthood. Emotion regulation strategies increase in complexity
as children become better able to integrate information about others’ emo-
tional experiences with management of their own feelings. Children also

become increasingly able to talk about their emotions, a skill that typically
develops faster in girls than in boys (Wintre and Vallance 1994). With in-
creasing emotional competence, children become better at recognizing the
difference between internal emotional experiences and external emotional
expression. In turn, they learn to manage their emotional expressions in or-
der to impact the emotional experience of others (e.g., to hide emotions
to avoid hurting someone’s feelings) (Ciarrochi et al. 2001; Saarni 1999).
Assessment
The number of assessment tools available to measure emotional intelli-
gence in children is limited (Luebbers et al. 2007; Stough et al. 2009).
Many of these measures either have been constructed recently or are still
being developed. A review of measures for assessing emotional compe-
tence in children concluded that most existing measures focus on social
rather than emotional competence and that few measures focus solely on
emotional competence (Stewart-Brown and Edmunds 2003).
Extant measures of emotional competence include parent or teacher
observations, self-report questionnaires, and performance measures.
These different measurement methods often are not correlated, however,
and thus they likely are assessing different aspects of emotional intelli-
gence, such as perceived versus actual awareness (Ciarrochi et al. 2001).
Some performance measures assess a variety of emotional competencies
(e.g., Mayer-Salovey-Caruso Emotional Intelligence Test; Mayer et al.
2002), whereas others assess one specific skill (e.g., ability to recognize
emotional facial expressions; Nowicki and Duke 1994). Appendix 2–A
presents some existing measures of emotional intelligence or competence
for children and adolescents.

Treatment Planning
Examples of how knowledge about children’s emotional development can
inform clinical practice are presented in Appendix 2–B. These recommen-
dations emphasize helping children learn to identify their emotions, build
an emotion vocabulary, manage their emotions, and recognize how their
behaviors affect the emotions of others. Assessing a child’s strengths and
deficits in emotional competence is a necessary precursor to formulating a
plan for effectively implementing CBT with that child.
Other Important
Developmental Considerations
1. Language and vocabulary. Although modifying the language used in
adult treatment manuals is insufficient to achieve developmental tai-
loring, such changes are nonetheless necessary. CBT with children
should use clear, simple, and child-specific vocabulary (Sauter et al.
2009). Clinicians also should be aware of any discrepancies between
receptive and expressive language that could impact children’s abilities
to understand or respond to therapeutic demands.
2. Executive function. Developments in executive functions (e.g., atten-
tion, flexibility, planning) are occurring simultaneously with develop-
ments in cognitive, social, and emotional development to allow
children’s effective engagement in treatment (Grave and Blissett
2004). Therefore, the link between children’s executive functions and
the demands of CBT also needs to be explored.
3. Treatment modality. The context in which the therapy is implemented
(e.g., family, individual, group) may be more or less appropriate and/
or effective depending on the child’s developmental level, particularly
within the social domain.
4. Sex/race/socioeconomic status/culture. Developmental norms may not
always incorporate sex, race, socioeconomic status, and other aspects
of culture that could impact development (Ollendick et al. 2001).
5. Parameters of treatment. Developmental level also can affect the
length of sessions, frequency of sessions (e.g., twice a week, weekly,
biweekly, monthly), number of sessions, and overall duration of treat-
ment (e.g., weeks, months). The child’s ability to sustain attention, re-
member what was discussed within sessions, and use the new skills
outside the therapy session will affect decisions about these parame-
ters of the treatment process.
Conclusions and Future Directions

Tailoring treatment to the developmental level of the client is essential to
increasing the efficacy of CBT interventions with children and adoles-
cents. Existing strategies for modifying treatments include the following:
1. Changing parents’ role in therapy (e.g., more active “coaching” from

parents of younger children).
2. Using treatment manuals designed for specific age groups.
3. Altering specific therapeutic activities to be more or less concrete,

complex, cognitive, behavioral, or visual.
Typically these modifications have been made on the basis of children’s

age, rather than according to a systematic evaluation of children’s develop-
mental levels in multiple domains.
Clinicians using CBT interventions with children and adolescents will
benefit from recognizing the connections between each CBT technique
and distinct developmental abilities, understanding the normative devel-
opment of these abilities, and learning about methods for assessing these
developmental abilities. We identified examples of cognitive, social, and
emotional developmental abilities especially relevant to engaging in CBT;
provided information about typical developmental trajectories of these
abilities; and suggested several tools for assessing children’s developmental
level. Finally, we provided suggestions for using this developmental assess-
ment information to individualize treatment planning. Further research is
needed to clarify the relations between specific clinical techniques and de-
velopmental abilities and to identify the most effective methods for tailor-
ing treatment to a child’s specific developmental level in each domain (i.e.,
cognitive, social, emotional).
When implementing CBT techniques with children and adolescents,
clinicians should use a developmental framework to determine the inter-
vention strategies likely to be most effective. Use of appropriate tools for
assessing a child’s developmental level across multiple domains can allow
the clinician to gather information about development when the client
first presents for treatment, thus informing treatment planning at intake.
Developmentally tailoring treatment in this way will impact how CBT in-
terventions are delivered to children and adolescents and thereby reduce
the time needed to ameliorate symptoms and improve functioning.
Key Clinical Points

• Therapy likely will be more effective when matched to the child’s de-
velopmental abilities.
• Age and developmental level are not synonymous.
• Clinicians should acquire an understanding of normative cognitive,
social, and emotional development and how such development im-
pacts children’s ability to learn and implement therapeutic strate-
gies. Clinicians should assess a child’s developmental level as a
part of treatment planning.
• CBT often is used as an umbrella term for a wide range of clinical

skills, some of which are more developmentally appropriate than
others.
• Developmental skills particularly important for engaging in CBT in-
volve multiple domains, including cognitive (e.g., reasoning, meta-
cognition, self-reflection), social (e.g., perspective taking, empathy),
and emotional (e.g., emotion perception, identification, understand-
ing, and regulation).
2.1. True or False: Adolescents are always better able to engage in cogni-
tive-behavioral strategies than are young children.
2.2. Which of the following is NOT a reason to use a developmentally

sensitive framework in treatment planning?
A. Different treatment strategies require different developmental

skills.
B. Developmental level impacts children’s ability to both learn and
apply therapeutic skills.
C. Development level within a domain is uniform at each chronolog-
ical age.
D. Different areas of development (e.g., cognitive, social, and emo-
tional) are interdependent.
2.3. Little Johnny is asked in therapy to recognize that when he thinks “I

will fail this math test no matter what,” he feels discouraged and is
less likely to study for the test. Which of the following developmen-
tal skills are necessary to understand this connection?
A. Metacognition and perspective taking.

B. Causal reasoning and emotion identification.
C. Self-reflection and social skills.
D. Hypothetical thinking and emotion management.
2.4. True or False: Adapting adult language to be more age-appropriate is

the primary way to developmentally tailor CBT for children.
2.5. Clinicians should assess children’s developmental level
A. Before starting treatment.

B. Before introducing a new developmentally challenging technique.
C. After implementing strategies designed to improve developmen-
tal skills.
D. All of the above.
Suggested Readings
Holmbeck GN, O’Mahar K, Abad M, et al: Cognitive-behavioral therapy
with adolescents: guides from developmental psychology, in Child and
Adolescent Therapy: Cognitive-Behavioral Procedures, 3rd Edition.
Edited by Kendall PC. New York, Guilford, 2006, pp 419–464
Merrell K: Helping Students Overcome Depression and Anxiety: A Prac-
tical Guide. New York, Guilford, 2001
Shirk S: Developmental therapy, in Developmental Issues in the Clinical
Treatment of Children. Edited by Silverman WK, Ollendick TH.
Needham Heights, MA, Allyn & Bacon, 1999, pp 60–73
Vernon A: More of What Works When With Children and Adolescents: A
Handbook of Individual Counseling Techniques. Champaign, IL, Re-
search Press, 2009
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APPENDIX 2–A. Tools for assessing developmental skills in cognitive, social, and emotional domains
Developmental skill Assessment measure Citation Age
Cognitive development
Cognitive-Behavior Therapy for Children and Adolescents

Decision making Decision-making scenarios Halpern-Felsher and Cauffman 2001 Grades 6–12 and young
adults
Abstract, systematic, causal, and Delis-Kaplan Executive Function Delis et al. 2001 8–89 years
logical reasoning System (DKEFS)
Conditional and logical reasoning Conditional Syllogism Test Artman et al. 2006 Grades 7–9
Hypothetical and causal reasoning Generation of Alternatives Task Janveau-Brennan and Markovits 1999 Grades 1–6
Conditional reasoning Conditional Reasoning Task Janveau-Brennan and Markovits 1999 Grades 1–6
Reasoning and problem solving Cognitive Abilities Test, Form 6 Lohman and Hagen 2001 5–18 years
Systematic reasoning Combinations Task (CT) Goodnow 1962 10–11 years

Critical thinking Ross Test of Higher Cognitive Ross and Ross 1976 Grades 4–6
Processes
Metacognition Metacognitions Questionnaire for Bacow et al. 2009 7–17 years
Children (MCQ-C)
Metacognition Metacognitions Questionnaire for Cartwright-Hatton et al. 2004 7–17 years
Adolescents (MCQ-A)
Metacognition Think Task Flavell et al. 2000 5 years to adult
Self-reflection and insight Self-Reflection and Insight Scale for Sauter et al. 2010 9–18 years
Youth
Appendix 2–A: Tools for Assessing Developmental Skills
APPENDIX 2–A. Tools for assessing developmental skills in cognitive, social, and emotional domains (continued)
Social development
Social perspective-taking Interpersonal Understanding Selman 1980 4.5–32 years
Interview
Social skills Social Skills Rating System (SSRS) Gresham and Elliot 1990 Grades K–6
Social skills Matson Evaluation of Social Skills Matson et al. 1983 4–18 years
with Youngsters
Assertiveness; social problem- Social Problem-Solving Inventory— D’Zurilla et al. 2004 13 years
solving skills Revised (SPSI-R)
Friendship quality Friendship Quality Questionnaire Parker and Asher 1993 7–12 years
Empathy Bryant’s Index of Empathy for Bryant 1982 Grades 1, 4, and 7
Children and Adolescents (BEI)
Assertiveness; social skills Behavioral Assertiveness Test for Bornstein et al. 1977 8–13 years
Children (BAT-C)
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APPENDIX 2–A. Tools for assessing developmental skills in cognitive, social, and emotional domains (continued)
Emotional development

Emotion perception, emotion Adolescent Swinburne University Luebbers et al. 2007 11–18 years
understanding, emotion Emotional Intelligence Test
management (A-SUEIT)
Emotion perception, emotion Emotional Quotient Inventory: Bar-On and Parker 2000 7–18 years
understanding, emotion Youth Version (EQ-i:YV)
management
Emotion perception, emotion Trait Emotional Intelligence Mavorveli et al. 2008 8–12 years
identification, emotion Questionnaire—Child Form
management (TEIQue-CF)
Emotion perception, emotion Trait Emotional Intelligence Petrides et al. 2006 13–17 years
identification, emotion Questionnaire—Adolescent Form
management (TEIQue-AF)
Emotion identification Diagnostic Analysis of Nonverbal Nowicki and Duke 1994 6–10 years
Accuracy Scale—Form 2
(DANVA2)
Emotion perception, emotion Mayer-Salovey-Caruso Emotional Mayer et al. 2002 12–18 years
understanding, emotion Intelligence Test: Youth Version
management
APPENDIX 2–B. Practical recommendations for treatment planning based on cognitive, social, and emotional
Appendix 2–B: Recommendations for Treatment Planning

development
Therapeutic demands Developmental skills Clinical recommendations
Cognitive development
Problem solving Hypothetical, systematic, Children with less developed reasoning ability may need more teaching
a. Generate solutions logical, and causal about how to examine each solution, more practice in evaluating
b. Evaluate solutions reasoning possible solutions, and greater scaffolding from therapists and parents.
Connecting thoughts, feelings, and Conditional and Avoid if-then language with children who do not display hypothetical
behaviors; using “if-then” statements hypothetical reasoning reasoning abilities.
(e.g., “If I think ____, then I will feel Use in vivo strategies to induce mood and help children draw
_____”) connections through experiences in the moment.
Practice explicit labeling of the cause and effect.
When explaining the connections among thoughts, feelings, and
behaviors, check children’s understanding of each relation. Make sure
that less cognitively developed children understand these associations
before progressing.
Differentiating thoughts, feelings, and Abstract and causal Children with less developed abstract reasoning will benefit from more
behaviors; recognizing the reasoning concrete and visual methods.
connections among them In place of role-playing, use cartoons or puppets.
Pictures (e.g., the body with thoughts in the head, feelings in the
stomach or heart, and behaviors on the hand) or tangible illustrations
(e.g., string connecting thoughts, feelings, and behaviors) can help
show more complex concepts.
These techniques are particularly relevant for children who grasp
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external constructs more readily than internal, psychological concepts.
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development (continued)

Cognitive development (continued)
Cognitive restructuring; examining Systematic and logical Less cognitively advanced children may struggle with being impartial
evidence for and against child’s reasoning and may give more weight to evidence that supports their beliefs.
beliefs Children may have difficulty separating facts from their beliefs, which
is necessary for cognitive restructuring.
Use other cognitive restructuring strategies with less cognitively
advanced children (e.g., alternative explanations, helpful vs. unhelpful
thoughts).
Thought monitoring and cognitive Hypothetical reasoning Hypothetical reasoning about the past typically develops after reasoning
restructuring; reflecting on past and about the past and future about the future.
future patterns of thinking For less cognitively mature children, first focus on the here and now
rather than the past or future. Ask children “How do you feel when
you think _____?” before moving on to the more advanced questions:
“How will you feel the next time you think _____?” or “How might
you have felt if you had thought _____?”
Using analogies and metaphors to Abstract and analogical Keep it simple. Although analogies and metaphors can convey
convey information reasoning information in a more memorable and attainable way, children who
have not yet developed this type of reasoning may find these strategies
confusing.
Identifying and recognizing child’s Logical reasoning Some “cognitive distortions” may be normative and not linked to
cognitive distortions in order to psychopathology.
modify them Thinking errors that are “typical” but maladaptive may be especially
intractable.
Clinicians need to train children to think differently (e.g., to see the gray
instead of black and white) before children can overcome these thinking
errors.
Identifying own thoughts; recognizing Metacognition; Children first need to be able to identify their thoughts in general before
negative thinking and cognitive self-reflection they can recognize their negative thinking or cognitive distortions.
distortions For children who struggle with metacognition, first focus on identifying
neutral and positive thoughts.
Cartoons with thought bubbles can help explain thinking, although even
this may be difficult for less cognitively advanced children.
Ask children “What do you like?” and then help them see that their
response was a thought (e.g., “Your brain/mind told you that you like
_____”).
Identify children’s thoughts in session, rather than asking them to
remember a situation and identify past thoughts.
Identifying thoughts in the present is less cognitively demanding than
reflecting on past thoughts.
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Introspection; understanding own Self-reflection Children in the midst of identity formation may become anxious when
identity; motivation to change confronted with information that threatens their tenuous identity,
which might then impede therapeutic progress.
Motivational interviewing techniques may facilitate children’s decision
making about change and likely will be more effective than the
therapist directing children to change.
Generalizing new skills learned in Self-reflection; For less cognitively developed children who are unlikely to
therapy to the child’s everyday life metacognition spontaneously reflect on their own thinking outside of therapy,
caregivers will need to provide scaffolding. Parents can act as coaches
at home to encourage children to think about their thinking. Clinicians
can help children recognize physiological sensations or emotional
reactions that may cue them to reflect on their thinking.
Social development
Disputing negative thoughts; ability to Advanced perspective- For children who do not demonstrate advanced perspective-taking,
step outside own perspective and taking; realizing the therapy may be more effective if less focus is placed on disputing
take the viewpoint of another validity of another’s view, beliefs. Instead, therapists may prefer to rely on social-skills training
not just that other views to modify target behaviors.
exist
Social development (continued)
Learning social problem-solving Ability to reflect on own Evaluate child’s social competencies and deficits from multiple sources
behaviors in solving social (e.g., parents, teachers).
problems; identifying Create a profile of the child’s strengths and weaknesses; design an
what perpetuates intervention targeted at the child’s specific interpersonal skills
maladaptive behaviors deficits.
Build on the child’s existing skills through didactic instruction,
modeling, role-playing, performance feedback, reinforcement, and
practice in the natural environment.
Assertiveness training; understanding Understanding cause-and- When teaching assertiveness, first have children achieve mastery of
the impact of own statements and effect sequences that their own assertive behaviors before requiring that they recognize the
actions on others involve others; predicting full rationale for how their behaviors affect others.
others’ social behaviors Use simple role-play scenarios between the therapist and child to
demonstrate the various possible consequences of the child’s actions.
Meeting new people; starting, Role-taking skills; ability to For less socially advanced children who have difficulty role-playing, first
maintaining, and ending shift and assume multiple have them 1) learn the concrete behaviors involved with meeting new
conversations perspectives people (e.g., introducing self, being friendly, active listening); then
2) watch video clips of people meeting and identify others doing these
specific behaviors successfully (or unsuccessfully) without yet having
to role-play or take multiple perspectives.
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Developing and maintaining Empathy Some children with self-regulation difficulties may have problems with
relationships: understanding how empathy such that their empathic distress for another exacerbates
moods, words, and behaviors impact their own distress, possibly leading to emotional overarousal, anxiety,
relationships; focusing on others and self-focus. They also might respond to their heightened distress
instead of the self over another’s hardship by disengaging and reducing their involvement
with that person.
Clinicians can assist children in recognizing how others’ emotions affect
them and can teach children strategies for appropriately managing
their empathic distress and maintaining emotional control.
Understanding how relationships Self-reflection; perspective Although a child may report a healthy quantity of friends, the quality
affect mood taking and consequences of their friendships also should be evaluated.
Help children recognize the connection between their social
relationships and their mood.
Teach children to monitor their moods in the context of these
relationships.
Seeking social support; strengthening Self-reflection; social skills For more socially competent youth without clear social difficulties,
social skills clinicians can enhance children’s interpersonal strengths and frame
social support–seeking as a potentially healthy coping strategy for
dealing with stress when done appropriately.
For less socially adept children, help them identify when to seek
support from others.
Improving and enhancing peer Social skills (e.g., Less socially advanced children will be less able to converse with adults
relationships conversational skills, and peers and unable to engage in more nuanced interpersonal
generating questions) strategies, such as asking questions to generate conversations or
constructing positive statements about others.
Some skills (e.g., making eye contact, smiling, engaging in friendly
greetings) will be important for less socially competent children to
master first.
Conflict resolution; interpersonal Perspective taking; Pair therapy involves two children matched for their perspective-taking
negotiation cooperation; reciprocity; abilities and interpersonal negotiation strategies to promote better
appraising others’ coordination between them.
intentions Pair counseling involves children being paired to provide opportunities
for aggressive, withdrawn, and socially immature children with
contrasting relationship styles to practice social skills and learn from
each other.
Peer therapy involves a peer chosen by the child, parent, or clinician to
attend one to two sessions.
Identify and modify maladaptive interaction patterns in vivo (e.g.,
co-rumination).
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Emotional development
Monitoring feelings; recognizing Perception, identification, Children who do not have the ability to reflect on their own emotional
multiple, simultaneous feelings and awareness of experience in a more complex manner will be unable to engage in
emotional intensity; mood monitoring outside the therapy session.
experiencing multiple Help children label and describe emotional experiences in vivo.
simultaneous emotions Teach parents to help children describe emotional experiences as they
are happening outside of the therapy session.
To increase awareness of simultaneous emotions, teach children to
“scan” for multiple feelings when in an emotional situation.
Learning that changes in thoughts or Perception, identification, Children who are not yet able to describe varying levels of emotional
behavior can impact emotions and understanding of intensity will have difficulty noticing changes in their emotions
emotions following changes in their thinking or behaviors.
Help children recognize indicators of emotional intensity (e.g.,
physiological sensations) using visual representations (e.g., emotion
thermometer).
Describing emotional experiences Emotion vocabulary For children with a limited emotion vocabulary, focus on expanding
their understanding of emotional experiences through feeling
identification exercises that help them define emotions, talk about
emotions, and recognize their experience of emotions in different
situations.
Games using pictures of people displaying different facial expressions
can help children associate emotion labels with outer affective
expressions (e.g., facial expression cards or facial zone puzzle).
Emotional development (continued)
Developing and maintaining social Awareness of emotions in Assist less emotionally developed children to generalize their own
relationships others; emotion emotional knowledge in order to better understand others.
management Use exercises describing the therapist’s or parents’ emotional
experiences; encourage parents to talk about their emotions at home
and to draw connections for the child among situations, emotional
expressions, and emotional experiences in others.
Use interpersonal vignettes (through narratives or use of puppets) to
illustrate emotional experiences in others.
Social problem-solving; conflict Awareness of emotions in Activities designed to improve understanding of others’ emotional
resolution self and other; emotion experiences will help children engage in conflict resolution.
management In session, practice and role-plays using relaxation techniques to
regulate emotional experience can help prepare children for real-life
conflict situations.
If a child’s emotional management skills are severely underdeveloped,
increasing emotion-regulation skills should be the focus of
intervention before expecting children to engage effectively in social
problem-solving.
Parents can model conflict resolution methods and can coach children
to use effective emotion-regulation techniques both in preparation for
and during conflicts.
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3
Culturally Diverse
Children and
Adolescents
IN an increasingly multicultural society, clinicians must learn to work ef-

fectively with people from a variety of backgrounds. Culture is defined by
shared attributes of a particular group, including a common heritage, set
of beliefs, norms, and values (U.S. Surgeon General 2001). A number of
cultural influences may play an important role in shaping an individual’s
identity, including membership in more than one cultural minority group.
Race, ethnicity, nationality, religion, age, immigration status, gender, abil-
ity, sexual orientation, and income level are just some of the factors that
may affect the therapeutic relationship, diagnosis, and treatment.
In this chapter, we discuss the importance of addressing cultural issues,
examine the pros and cons of using cognitive-behavior therapy (CBT) with
individuals from a variety of different groups, and identify overarching
themes relevant to providing treatment to youth of varying backgrounds.
75
We also operationalize clinical recommendations for implementing cultur-

ally responsive CBT with children and adolescents.
Because a sizable body of literature on cultural competence already ex-
ists (see Sue and Sue 2003; Sue et al. 2009 for excellent reviews), this
chapter will not focus on the particulars of achieving cultural competence.
In general, a good CBT clinician will develop a case formulation and treat-
ment plan specific to each client; thus, individual diversity issues should
be a central component of the treatment process. Regrettably, inadequate
training in multicultural issues is a well-documented shortcoming of men-
tal health training programs (Iwamasa 1996) and may impede the CBT cli-
nician in achieving both clinical and cultural competence. Furthermore,
the assumption that clinicians of color or from other minority groups are
free from cultural biases and have some inherent diversity expertise is
without merit because minority clinicians receive the same training as
therapists from majority cultural groups (Iwamasa 1996). Thus, clinicians
from any cultural group would benefit from training in cultural diversity.
Because other chapters of this book outline disorder-specific strategies
for cultural and ethnic minority groups, this chapter will focus on common
themes to consider when working with diverse populations across disor-
ders, rather than attempting to discuss specific interventions with every
potential cultural group. Suggested readings are provided at the end of this
chapter as resources for conducting CBT with particular populations.
Health Disparities and

Evidence-Based Treatment
Why is it important to consider cultural issues in the delivery of CBT? Ac-
cording to the U.S. Census Bureau (2008), racial and ethnic minorities
currently constitute one-third of the U.S. population and are expected to
become the majority in 2042. However, for minors, this demographic shift
will come much sooner: racial and ethnic minorities will account for more
than half of U.S. children by 2023 (U.S. Census Bureau 2008). In contrast
to this population shift, in 2006, the American Psychological Association
reported that 85% of psychologists were of European American descent.
As a result, it is inevitable that these clinicians will need to work with cul-
turally different clients (Pantalone et al. 2010). Thus, the movement to-
ward increasing cultural competence in the delivery of evidence-based
treatment (EBT) is a timely one.
The Surgeon General’s report on mental health disparities for racial
and ethnic minorities (U.S. Surgeon General 2001) brought a number of
Culturally Diverse Children and Adolescents 77
issues to light. These groups have less access to mental health services, are
less likely to receive mental health services when needed, are likely to re-
ceive poorer quality of mental health care when they do receive services,
and are underrepresented in mental health research (U.S. Surgeon Gen-
eral 2001). Even when treated, ethnic minorities often terminate prema-
turely, improve more slowly, and have poorer outcomes (Cooper et al.
2003). Ethnic minorities experience disproportionately more psychosocial
stressors than do non-Latino white Americans (Bernal and Scharrón-del-
Río 2001; U.S. Surgeon General 2001). These include social and environ-
mental inequalities such as exposure to discrimination, violence, poverty,
and limited access to education.
A disproportionate number of children of color are referred for mental
health services (Kazdin et al. 1995; Manoleas 1996), yet they continue to
be underrepresented in randomized controlled trials of EBTs, resulting in
a relative absence of treatments that may be deemed well established for
ethnic minority youth (Huey and Polo 2008). To date, no EBT (including
CBT) has been tested in at least two independent, high-quality, between-
group trials (with random assignment and adequate sample size) that dem-
onstrate that the treatment is superior to placebo or alternative treatment
or is equivalent to an already established treatment with ethnic minority
youth. Similarly, underrepresentation of gay, lesbian, bisexual, and trans-
gender (GLBT); differently abled; religious minority; ethnic minority; and
low-income populations in the research has led some investigators to pose
the following question about empirically supported treatment: “Empiri-
cally supported treatments ...for whom?” (Pantalone et al. 2010, p. 452).
More research is clearly needed to support the efficacy of CBT with eth-
nocultural minority youth.
Controversy About Adaptation of

Evidence-Based Treatment
Given documented mental health disparities, there has been a call for the
adaptation or modification of EBTs to be more culturally sensitive (Bernal
et al. 2009; U.S. Surgeon General 2001). Proponents of such adaptations
highlight the differences among cultural groups and suggest that interven-
tions should be tailored to the characteristics of specific groups and con-
sider language, values, customs, child-rearing practices, expectations of
child and parent behavior, and distinctive stressors associated with certain
cultural groups (Lau 2006; Vera et al. 2003). Some investigators suggest
that the failure to make cultural adaptations may lead to miscommunica-
tion, value conflicts, low therapeutic engagement, and treatment failure

(Huey and Polo 2008). Culturally adapted treatments can substantially
improve engagement, perceived acceptability of the treatment, recruit-
ment in clinical trials, and retention of ethnic minorities in treatment
(Kumpfer et al. 2002). Suggested adaptations range from the creation of
entirely new treatments for different ethnocultural groups to modifying
treatment components of existing EBTs to address cultural factors (Wha-
ley and Davis 2007).
Many experts have expressed reservations about undertaking the cul-
tural adaptation of all EBTs. The inherent assumption that cultural groups
are homogeneous entities that remain unchanged over time actually lends
more support to stereotypes of cultural groups and neglects the possibility
of plural cultural identities (socioeconomic status [SES], gender, religion,
sexual orientation, and so forth) (Vera et al. 2003). These experts also ar-
gue that rigorous testing of EBTs with ethnic minority youth is limited,
that the first priority should be the dissemination and examination of
treatment outcomes with cultural minority populations, and that cultural
adaptations to EBTs are premature or unwarranted and compromise the fi-
delity of the interventions and their effectiveness (Lau 2006). Also of con-
cern is the possibility that the active core treatment elements would
somehow be diluted or delivered later in the protocol if modifications
were made to the original manualized therapy (Kumpfer et al. 2002;
Schulte 1996). Finally, opponents to cultural adaptation of EBT stress the
impossibility of adapting treatments for every possible cultural group and
equipping providers with adequate information about each group, again re-
inforcing stereotypes and making clinicians believe they do not need to
provide services to groups they have not “studied” (Lau 2006; Vera et al.
2003).
The limited existing literature on culturally adapted treatment proto-
cols with ethnic minority youth does not indicate superiority of treatment
outcomes beyond improvement in treatment engagement, and experts un-
derline the methodological problems of these few studies, the dearth of
randomized controlled trials of EBTs with cultural minorities, and the need
for more research (Bernal et al. 2009; Huey and Polo 2008). For example,
the lack of specific descriptions of cultural adaptations and wide variations
in operational definitions of cultural adaptation make it difficult for re-
searchers to replicate particular studies and make comparisons across tri-
als. Some investigators suggest that EBT be maintained in its original form
with all groups and that the intervention be culturally tailored to the indi-
vidual client only when barriers or opportunities arise (Huey and Polo
2008). Lau (2006) suggested a model of selective adaptation of EBTs
guided by empirical evidence. Adaptation should focus on the individual
and the presenting problem that have demonstrated inequitable response

to EBT by contextualizing content and enhancing engagement (Lau 2006).
Contextualizing content requires that clinicians use novel treatment com-
ponents to target risk factors and mobilize protective factors specific to
the client’s cultural group or to respond to symptom presentation patterns
that may require specialized intervention elements (e.g., somatic presen-
tation of psychological distress). Enhancing engagement refers to adapta-
tions that enhance the therapeutic alliance and retention of clients in
therapy. Surface-level changes may include culturally relevant examples,
translation into the preferred language of the client, and graphic material
depicting ethnically similar families to improve perceived acceptability of
the treatment. Structural changes may consist of provision of treatment in
alternative settings and addressing logistical barriers and basic living needs
to improve treatment engagement, but these changes also may require
more substantial modifications to the intervention based on a more nu-
anced understanding of cultural, behavioral, and psychological attributes
of a group (Lau 2006; Zayas 2010). A number of other cultural adaptation
models have been proposed for specific ethnocultural groups (Bernal et al.
2009).
Caught in the ongoing debate about the need for and the particulars of
cultural adaptation, clinicians find themselves in a difficult position when
trying to serve diverse youth. The benefit of these discussions is that there
is more pressure on training programs to produce culturally competent cli-
nicians and on researchers to diversify participants in CBT trials. Cultural
adaptations may be a critical step toward integrating cultural competence
and evidence-based practice (Whaley and Davis 2007). However, we share
the discomfort voiced by some that the word adaptation implies that cul-
ture can be an add-on item, usually occurring at the beginning stages of
treatment (Falicov 2009). It is our belief that there are some feasible and
empirically informed strategies for infusing culture into assessment, case
formulation, treatment planning, engagement, and implementation of
CBT with diverse youth.
Pros and Cons of CBT for

Children of Diverse Backgrounds
To provide culturally competent CBT, it is essential to consider the advan-
tages and limitations of using this type of intervention with youth who
have been underrepresented in most randomized controlled trials. Despite
the increasing popularity of multicultural therapy, there is a persistent dis-
interest in cultural and ethnic minority groups in the EBT and CBT litera-
ture (Hays 2006; Whaley and Davis 2007). In theory, the clinician would
expect that the basic tenets of CBT would be universal (Hays 1995; Pan-
talone et al. 2010)—that is, behavior is learned and can be unlearned;
thoughts, feelings, and behaviors are interrelated; and social learning and
operant conditioning are processes that fit with the human experience
across diverse populations (Hansen et al. 2000; Pantalone et al. 2010).
This belief that CBT is universally applicable, culture-free, value-neutral,
or color-blind, however, has come about from practice-oriented research
that historically has focused on people of middle class, heterosexual orien-
tation, and European American descent (Balsam et al. 2006; Hays 2006;
Organista 2006; Pantalone et al. 2010; Vera et al. 2003). The idea that
cognitions affect emotions may, indeed, be relevant cross-culturally. How-
ever, CBT’s emphasis on cognition, logic, verbal skills, and rational think-
ing as therapeutic tools is influenced by American and European cultural
values (Hays 2006; Hoffman 2006). Eastern cultures may attend more to
context and relationships, rely on more experience-based knowledge in-
stead of logic, and show more tolerance for contradiction (Hoffman
2006). In addition, CBT’s emphasis on rational thinking may overlook the
importance of spirituality, which may be as central and equally important
as rational thinking among many cultural groups (Abudabbeh and Hays
2006; Hays 2006; Iwamasa et al. 2006a; Kelly 2006) and may detract from
the credibility of cognitive-behavioral strategies for coping (Falicov 2009).
Consistent with collectivism, most ethnic minority groups value inter-
dependence, family, harmony, and community (Nagayama Hall 2001).
CBT’s focus on the individual client may clash with these values and result
in missed opportunities to capitalize on a potential source of strength for
many ethnic minority groups (Kelly 2006). The U.S. mainstream cultural
value of individualism (i.e., personal independence, self-control, verbal
ability) informs the promotion of assertiveness skills and direct expression
of thoughts in CBT (Hays 1995; Pantalone et al. 2010). This value may di-
rectly conflict with collectivist cultures that may view direct communica-
tion as disrespectful and that prefer nonverbal and indirect behavioral
communication (Nagayama Hall 2001). Relatedly, assertiveness training’s
basis in egalitarian democratic principles runs counter to more traditional,
hierarchical family structures (based on age and gender) in less accultur-
ated ethnic minority families, where the person’s “right” to express him-
self or herself is not a priority (Abudabbeh and Hays 2006; Organista
2006). The use of “I statements” in assertiveness training would be espe-
cially challenging for Native Americans whose preferred language does not
have a word for “I” (McDonald and Gonzalez 2006). Thus therapists
wanting to implement CBT with diverse populations should carefully con-
sider adherence to individualistic versus collectivist values for both the

child and the parents.
A strength of CBT is that it is relatively clear, straightforward, and un-
derstandable to clients new to psychotherapeutic interventions. CBT’s ed-
ucational approach helps demystify psychotherapy and familiarizes clients
with the roles of therapist and client (Organista 2006). Its focus on spe-
cific behaviors, thoughts, and emotions can be an important advantage for
clients whose first language is not English (Vera et al. 2003). CBT’s em-
phasis on changing negative thoughts to affect feelings and behaviors aligns
well with ethnocultural groups, such as Native Americans, whose spiritual
beliefs about wellness emphasize harmony or balance among mind, body,
and spirit (McDonald and Gonzalez 2006). However, a downside to the
educational approach often used in CBT is the reliance on written assign-
ments and bibliotherapy, which may not be appropriate when working
with clients whose native language is not English or immigrant populations
with little formal education (Iwamasa et al. 2006a).
CBT’s short-term, problem-focused, present-oriented nature also may
be appealing to cultural and ethnic minority groups for a variety of reasons.
For one, CBT’s focus on current behavior, promotion of change (not un-
derlying causes), directive nature, and goal-oriented and limited time
frame are consistent with the expectations that many ethnic and religious
minorities have for therapy (Abudabbeh and Hays 2006; Fudge 1996;
Hansen et al. 2000; Huey and Polo 2008; Iwamasa et al. 2006a; Paradis et
al. 2006; Rosselló and Bernal 1996). Likewise, these treatment aspects
make CBT more appealing to those living in poverty, who have few re-
sources and who may frequently be in crisis (Organista 2006). On the
other hand, focusing exclusively on problem behaviors may neglect non-
specific factors important to the therapeutic alliance with diverse popula-
tions (Iwamasa et al. 2006a). Furthermore, a focus on the present and
future may prematurely discount the client’s history, such as the experi-
ence of racism, and neglect useful information about culture-based life ex-
periences (Hays 1995). Thus, the present and future focus of CBT may be
both a disadvantage and an advantage when working with diverse youth,
and it is incumbent on the clinician to use good clinical skills in navigating
these pros and cons.
CBT’s action-oriented approach and focus on empowering the individ-
ual appear to be distinct advantages for cultural groups exposed to various
types of oppression and stressors related to minority status (Balsam et al.
2006; Hays 2006; Kelly 2006; Vera et al. 2003). CBT recognizes that peo-
ple have the ability to control their thoughts and emotions and develop
skills to deal with life situations. Additionally, behavioral experiments and
activation may help ethnocultural minority youth build strengths, expand
social supports, and acquire skills to meet goals more effectively (Kelly
2006). Despite the potential of CBT to address contextual factors, CBT
proponents have not directly addressed the impact of racism and oppres-
sion on ethnic minority clients by creating explicit strategies to deal with
these negative sociocultural influences. Critics suggest that CBT focuses
too much on changing individual-level variables (thoughts and behaviors)
in order to effect therapeutic change and adapt to current environmental
conditions (Casas 1995; Organista and Muñoz 1996; Vera et al. 2003).
This self-focus neglects unfair, discriminatory environmental factors that
restrict an individual’s ability to effect change (Hays 2006). As a result,
therapists of the majority cultural group often overlook diversity issues
and are inconsistent in focusing on problem solving in relation to the cli-
ent’s environment (Hays 1995).
There are a few potential advantages of using CBT with diverse youth:
1. Directive and structured. One such strength is that the directive,

structured nature of CBT likely fits with diverse clientele’s expecta-
tions of the nature of therapy. Because many ethnic minorities are ac-
customed to the traditional doctor-patient relationship in which the
doctor (i.e., expert) recommends a course of action to improve health,
they may have similar expectations of their therapist (Abudabbeh and
Hays 2006; Organista 2006). Whereas other theoretical orientations’
intrapsychic focus implicitly locate psychopathology within the indi-
vidual, CBT does not view behavior as good or bad, but rather as func-
tional or not functional given the context (Balsam et al. 2006).
Further, culturally effective CBT emphasizes assessment throughout
the course of treatment by examining social-environmental conditions
that might contribute to the problems that minorities face and tailor-
ing the intervention to the individual and his or her unique context
(Balsam et al. 2006; Hays 2006; Kelly 2006). Likewise, the consider-
ation of clients’ perspectives on their progress demonstrates a respect
for clients’ opinions, as well as for their financial and time constraints;
such consideration may be especially beneficial to developing and/or
maintaining therapeutic rapport (Vera et al. 2003).
2. Collaborative nature. Another strength of CBT is its collaborative
nature and determination of mutually defined goals. Such collabora-
tion demonstrates respect for the client’s values, abilities, and life cir-
cumstances and promotes a context in which cultural differences are
recognized (Hays 1995; Vera et al. 2003). For clinicians working with
children, such collaborative goal-setting often includes the parents. A
collaborative relationship also implies that both the therapist and the
client and parents possess valuable knowledge, which also may reduce
TABLE 3–1. Considerations in culturally responsive cognitive-

behavior therapy
Intersection of development and culture
Individualism vs. collectivism
Oppression, -isms, and ethnic identity
Acculturation and immigration issues
Religion and spirituality
Distinctive symptom presentation and somatic symptoms
Contextual factors (e.g., socioeconomic status, environmental factors, school
issues, access to services, and community involvement and solidarity)
the hierarchical distance between therapist and client (Abudabbeh

and Hays 2006; Balsam et al. 2006; Fudge 1996; Kelly 2006).
3. Empirical support. Although there are no well-established treat-
ments for ethnic minority children and adolescents, CBT has been
found to be possibly (and probably, for some disorders) efficacious for
such youth (Huey and Polo 2008). Compared to other types of ther-
apies, cognitive-behavioral approaches have showed the strongest
record of success with minority youth (Huey and Polo 2010). Further-
more, CBT has demonstrated effectiveness for a variety of problems
in ethnic minority adults (Sue et al. 2009). Thus the use of CBT with
ethnic minority youth has some preliminary support from the litera-
ture and appears to be a promising intervention for a variety of inter-
nalizing and externalizing disorders.
Overarching Themes Relevant to

Culturally Responsive CBT
Table 3–1 lists the considerations of culturally responsive CBT, which are
discussed in further detail throughout this section.
Intersection of
Development and Culture
Culture influences many aspects of mental illness, including symptom
manifestation, coping styles, family and community support, willingness
to seek treatment, diagnosis, treatment, and service delivery (Bernal and

Sáez-Santiago 2006). Clearly, culture also plays a role in the creation,
shaping, and maintenance of cognitions (Dowd 2003). The concept of
contextualism suggests that an individual must be understood in the con-
text of his or her family, and the family needs to be understood in the con-
text of the culture in which it is immersed (Bernal and Sáez-Santiago
2006). Compared to adults, children are relatively powerless, dependent
on parents and caretakers, school personnel, and other community leaders
to make important decisions on their behalf. With respect to treatment en-
gagement, the clinician must engage the adult bringing the child into treat-
ment if the clinician hopes to retain the child in treatment (Crawley et al.
2010). When a clinician works with children, the clinician is working with
the family (Hansen et al. 2000). Because Chapter 2 focuses more directly
on developmental issues in CBT with children, in this section we highlight
how culture may intersect with developmental issues.
Culture is strongly associated with child socialization. Harwood and col-
leagues (1996) demonstrated the centrality of familismo (strong identifica-
tion with, and attachment to, family; importance of family solidarity,
loyalty, and reciprocity) and respeto (respect and deference to authority fig-
ures and elders) to the socialization of Puerto Rican children by comparing
non-Latino white and Puerto Rican mothers’ responses to open-ended
questions on positive and negative child qualities. Puerto Rican mothers
consistently emphasized the importance of proper demeanor, such as re-
spectfulness and obedience. In contrast, non-Latino white mothers high-
lighted self-maximization (that the child be self-confident, be independent,
and develop his or her talents (Harwood et al. 1996). In traditional Arab
families, the structure tends to be patriarchal, and children are expected to
obey parents and not question authority (Abudabbeh and Hays 2006).
During middle childhood, ethnic minority youth become increasingly
aware of their social milieu, discriminatory practices, inequities in the so-
ciopolitical infrastructure, and (if applicable) limited economic resources
for their cultural group (Ho 1992). These factors influence self-concept
formation and may contribute to feelings of inferiority, frustrations, and
resentment (Rivers and Morrow 1995). The issue of cultural identity is
particularly relevant during adolescence, when the process of establishing
an identity and a sense of autonomy while maintaining a positive relation-
ship with parents are key experiences (Erikson 1968; Paniagua 1994). The
Eurocentric expectation that adolescents separate from family during this
stage, however, may conflict with collectivist cultures’ ideas of normative
adolescent development. For example, in many Latino and Arab cultures,
the period of dependence and cohabitation with parents is extended, and
clinicians may risk a serious breach in the therapeutic relationship if they
insist on adolescent autonomy (Abudabbeh and Hays 2006; Koss-Chioino

and Vargas 1992; Rosselló and Bernal 1996).
Other important developmental issues in adolescence are the onset of
puberty and emergence of sexual behaviors. Youth development may be
further complicated by coming to terms with their sexual orientation and
sexual identity (Safren et al. 2001). Heterosexism (an ideological system
that denigrates and stigmatizes any nonheterosexual behavior, identity, or
relationship) is a form of oppression common to many societies (Herek
1990). As a result, GLBT youth face several stressors, including confusion
and internalized heterosexism as they come to terms with their sexual
identity. Additionally, they often are exposed to overt acts of abuse, harass-
ment, and violence (Safren et al. 2001). Social isolation is a major issue
with these youth, as they may lack access to appropriate social venues
where they could meet, develop support networks, and date same-age
GLBT peers (Safren et al. 2001). GLBT youth who reveal their sexual ori-
entation (i.e., “come out”) are often met with punishment, rejection, crit-
icism, and abuse (Balsam et al. 2006). In stark contrast to ethnic minority
youth’s identity development, many GLBT youth navigate the issues of
sexual orientation and coming out without GLBT role models or family
members who could potentially be sources of support (Safren et al. 2001).
Individualism Versus Collectivism

U.S. mainstream culture has been described as individualistic, valuing in-
dependence, self-confidence, self-reliance, competition, hard work, mate-
rial success, and personal happiness (Dalton et al. 2001; Harwood et al.
1996). The collectivist worldview considers the well-being of others to su-
persede that of the individual and emphasizes respect (especially for el-
ders), cooperation, obedience, self-control, politeness, family loyalty,
dignity, and putting group interests first (Dalton et al. 2001; Pantalone et
al. 2010; Paradis et al. 2006). Certainly all cultural groups value family, but
ethnic and religious minority groups are more likely to give priority to the
community’s or family’s needs over an individual’s needs. Collectivist cul-
tures also have expanded definitions of who is family. In addition to blood
relatives, Latino families often include compadres or padrinos (i.e., godpar-
ents) in the definition of family. In African American culture, “fictive kin”
(e.g., close friends of the family, members of the church community) often
play critical roles in the upbringing and racial socialization of children, act-
ing as mediators, judges, networkers, and caregivers as needed (Kelly
2006). Thus, when conducting therapy with ethnic and religious minority
children, the clinician must evaluate the role of immediate and extended
family when planning interventions.
Oppression, -Isms, and

Ethnic Identity
When working with diverse youth, consideration of the effects of social op-
pression (discrimination against and antagonism toward a particular minor-
ity group) on the life of the child is crucial, and regrettably, often overlooked
because clinicians fail to ask about it. As visible minorities, girls, children
with disabilities, Orthodox Jews (adhering to traditional garb), and devout
Muslim girls (wearing a hijab) may endure sexism, ableism (prejudice
against individuals with disabilities), anti-Semitism, or anti-Muslim senti-
ment, respectively. GLBT clients often seek psychological services related to
stressors related to the pervasive heterosexism and subsequent social rejec-
tion and conflict with mainstream culture and religious beliefs (Balsam et al.
2006). The type of oppression that has received the most attention in the
psychological literature is that of racism and discrimination. Ethnic minority
youth are often targets of racism and discrimination at an early age (Harper
and Iwamasa 2000). Racism and discrimination have been shown to be po-
tent risk factors for psychological and physical health problems (Kelly 2006;
Sáez-Santiago and Bernal 2003). Experiences such as these will certainly af-
fect the relationship with a therapist whose cultural background is the same
as the group that the child views as oppressors (Harper and Iwamasa 2000).
One of the best predictors of resilience to the negative influences of
racism and discrimination is the formation of a positive ethnic identity
(Wong et al. 2003). Positive ethnic identity is associated with increases in
self-esteem, coping, mastery, and optimism and is negatively correlated
with loneliness, anxiety, and depression (Carter et al. 2001; Greene 1992).
Ethnic minority children have to learn to be bicultural (i.e., able to nego-
tiate the dominant culture successfully) in an often antagonistic environ-
ment. Children with underdeveloped cultural identities and long-term
exposure to oppressive social environments often demonstrate signs of in-
ternalized oppression. Likewise, parents who themselves have internalized
racist messages and beliefs in limited life options may pass these beliefs on
to their children (Greene 1992).
Greene (1992) described the importance of racial socialization in
teaching African American children how to deflect and negotiate a hostile
environment. African American parents often strive to warn their children
about racism and disappointments without being overprotective. Greene
discussed how cultural paranoia (sensitivity to potential for exploitation by
whites) evolved as an adaptive defense mechanism to decrease psycholog-
ical vulnerability to racism. Positive racial socialization often involves pro-
viding children with strategies to manage specific problems, acting as role
models for handling discriminatory experiences, introducing African cul-

tural values to increase cultural understanding and pride, having frank dis-
cussions with children about indirect and covert racism, and exposing
children to accurate and positive messages about African American people
and their history (Greene 1992). In short, racial socialization is an essential
and underutilized parenting and therapeutic tool that promotes mental
health in ethnic minority youth.
In an innovative Afrocentric parent training protocol, Neal-Barnett and
Smith (1996) summarized an approach to behavior therapy that incorpo-
rates racial socialization to assist African American parents in preparing
their children for the experience of discrimination. The Afrocentric ap-
proach takes into account strengths embedded in African American cul-
ture (e.g., extended family and kinship networks, unity, spirituality,
flexibility, and respect for elders) and uses elder role models for younger
parents, African American group facilitators, and ethnically similar models
in clinical vignettes, tying discipline with building high self-esteem in Af-
rican American children (Neal-Barnett and Smith 1996). This racial social-
ization component is typically lacking in other parent training programs,
which may contribute to the high attrition rate of ethnic minorities from
these types of programs.
Acculturation and
Immigration Issues
The impact of immigration and acculturative stress on help seeking, treat-
ment engagement, and family functioning for ethnic minority and immi-
grant youth cannot be overstated. Acculturation, the extent to which an
individual adopts aspects of the dominant culture versus his or her indige-
nous culture, is a process pertinent to both immigrant and nonimmigrant
ethnic minority populations (Klonoff and Landrine 2000). Nonimmigrant
ethnic minority groups, such as Native Americans and African Americans,
often struggle to maintain their indigenous cultural lifestyles and values
while adopting the behaviors they need to function in the dominant cul-
ture (Kelly 2006; McDonald and Gonzalez 2006). Acculturation has been
identified as a risk factor for depressive symptoms among ethnic minority
groups (Sáez-Santiago and Bernal 2003), with some evidence indicating
that more acculturated immigrants have worse mental health outcomes
than less acculturated immigrants (Vega et al. 1998). Individuals who as-
similate into the dominant culture (disregard their culture of origin’s val-
ues and adopt dominant cultural values) may undergo a loss of traditional
support systems coupled with feelings of self-deprecation due to exposure
to discrimination. Some investigators speculate that bicultural compe-

tency (balance between native cultural norms and those of the host cul-
ture) may lead to improved mental health outcomes (McDonald and
Gonzalez 2006; Sáez-Santiago and Bernal 2003).
Immigration is often associated with stressful life events that affect
child development. Family members may experience lengthy separations,
loss of social support, and feelings of loneliness (Interian and Díaz-
Martínez 2007; Suárez-Orozco et al. 2002). The reason for immigration is
important: Immigrants who come voluntarily for economic, political,
health, or educational reasons are usually more prepared to migrate, may
have a support network in the host country, and may know the language or
be familiar with the host culture (Pantalone et al. 2010). Refugees, on the
other hand, are forced to leave their country due to war, persecution, or
disaster. They may have been economically or educationally deprived in
their home country and have experienced trauma before or during migra-
tion (Pantalone et al. 2010). Refugees often have little exposure to the
dominant language or culture of the host country, whereas English profi-
ciency is a distinct advantage for immigrants and is associated with lower
levels of depression (Sáez-Santiago and Bernal 2003).
The legal status of both immigrants and refugees upon arrival to the
new country will dictate the access they have to services and to educa-
tional and employment opportunities. Often legal status among family
members may vary. For example, women who enter the United States il-
legally may give birth to children who are U.S. citizens and who receive
corresponding services to which their parents are not entitled. These fam-
ilies are often in a constant state of anxiety about the possibility of depor-
tation, and this undocumented status has been linked with increased
vulnerability for socioemotional problems (Cavazos-Rehg et al. 2007). De-
spite high levels of psychological distress, these families often will not seek
help for fear of deportation. In other cases, children are brought into the
country without legal documentation by their caregivers and are limited
after high school in accessing educational opportunities, employment, and
medical care without a Social Security number. Upon reaching adoles-
cence and gaining understanding of their predicament, these youth often
experience poor mental health outcomes as a result of their severely re-
stricted prospects (Mahoney 2008).
Another complicating factor in the familial acculturation process is
that children tend to acculturate faster than adults, in part due to ease of
language acquisition for younger children and sometimes because adults
have more difficulty adjusting to major life changes (Gil and Vega 1996;
Suárez-Orozco et al. 2002). As a result, families often experience an inter-
generational gap in cultural values. Traditional cultural values imposed by
parents may contradict those of the dominant culture and cause identity
confusion for ethnic minority youth (Ho 1992; Rivers and Morrow 1995)
and conflict between parents and their children (Hansen et al. 2000).
Also, traditional hierarchies in immigrant families can be disrupted by par-
ents who must rely on children to translate and advocate for their families
(Suárez-Orozco et al. 2002).
Religion and Spirituality

Clinicians should appreciate the central role of religion and spirituality and
consider how to integrate such beliefs into conceptualization of the prob-
lem and treatment planning when working with culturally diverse individ-
uals and families. African Americans demonstrate higher levels of religious
devotion and spirituality compared to other ethnic groups, and their reli-
gious institutions often are involved formally and informally in child care,
educational programming, and community leadership (Bernal and Schar-
rón-del-Río 2001; Kelly 2006; Neal-Barnett and Smith 1996). Native
American spiritual traditions maintain that all things possess a spirit and
that wellness is constituted by harmony between the three facets of a per-
son: mind, body, and spirit (McDonald and Gonzalez 2006). Additionally,
religious minorities, such as Orthodox Jews, may strive to separate them-
selves from mainstream American society to maintain group solidarity and
their adherence to cultural and religious practices (Paradis et al. 2006). A
culturally competent CBT clinician should demonstrate sensitivity to
these issues and attempt to utilize the strengths they may present in order
to support treatment outcomes. By collaborating with clergy and spiritual
leaders (e.g., curanderos) and becoming familiar with sacred writings, the
CBT clinician may improve treatment engagement and perhaps also the
success of interventions.
Distinctive Symptom Presentation

and Somatic Symptoms
Alternative manifestations of psychological distress have received increas-
ing attention in the cross-cultural literature. The expression of psycholog-
ical problems somatically is a common phenomenon in many ethnic
minority groups. Arab and Latino clients often present with physical com-
plaints, such as headaches, stomachaches, pain, and sleep disturbance
(Abudabbeh and Hays 2006; Myers et al. 2002). It makes sense then that
many ethnic minority individuals seek help from their primary care doc-
tors instead of a mental health professional (Abudabbeh and Hays 2006;
Interian and Díaz-Martínez 2007). CBT clinicians may need to consider

assisting their young clients with connecting somatic symptoms with psy-
chological distress in order to increase the likelihood that the youth will
adequately understand the rationale behind CBT interventions.
Contextual Factors
Ethnic and racial minority groups are often overrepresented in lower so-
cioeconomic strata (U.S. Surgeon General 2001). Poverty and lack of re-
sources often produce hopelessness and helplessness among ethnic
minority clients and adversely affect their expectations for positive thera-
peutic outcomes (Bernal and Sáez-Santiago 2006; Koss-Chioino and Var-
gas 1992). Additionally, because of financial hardship, some parents need
to work multiple jobs and, as a result, are less available to their children.
While affluent, two-parent households may have the resources necessary
to supervise children’s out-of-session practice and therapeutic homework,
single parents struggling to provide for their families may not have the en-
ergy or time to devote to such endeavors (Greene 1992). For these rea-
sons, these parents are less likely to provide positive racial socialization to
the children who most need it.
Low-income communities often are characterized by unsafe neighbor-
hoods, gang activity, inadequate schools, poor housing conditions, limited
access to quality health care and social services, and a number of other
stressors. The ability of the family living in such conditions to follow
through on therapy assignments (such as behavioral activation) may be sig-
nificantly restricted due to these contextual factors. The limited literacy
skills of many immigrant and some ethnic minority parents provide an-
other potential barrier to compliance with written therapy homework and
behavioral plans. The intersection of undocumented legal status and low
SES creates another challenge for immigrant populations. Undocumented
families may have difficulty regularly attending appointments scheduled
during typical office hours because of the unpredictable nature of under-
the-table day labor or repercussions of missing a day of work (e.g., no ben-
efits and likely job loss for being absent).
Despite these barriers to compliance and treatment, diverse popula-
tions present with a number of strengths that can enhance treatment out-
comes. Social affiliation, common in many collectivist cultures, has been
found to be inversely associated with depression (Sáez-Santiago and Ber-
nal 2003). Resources such as strong connection to family, religious involve-
ment, and voluntary associations may be powerful therapeutic assets in
promoting positive change in ethnic minority clients.
Clinical Recommendations
Suggestions for Beginning CBT
Therapist Self-Assessment
The therapeutic process needs to start with the therapist’s own self-eval-
uation of his or her own cultural values, notions of acceptable behavior that
may be culturally laden, personal experience with social oppression versus
privilege, knowledge deficits, comfort in addressing and discussing issues
of diversity and discrimination, and personal biases (Arredondo and Ar-
ciniega 2001; Hays 2006; Pantalone et al. 2010). To begin, therapists must
be able to clearly identify their own cultural identity and the significance
of belonging to that cultural group, including the relationship of individuals
in that group with individuals from other groups institutionally, histori-
cally, and educationally (Arredondo et al. 1996). Therapists must examine
differences between themselves and their clients and assess their level of
comfort with working with culturally diverse clients who may have differ-
ent values and beliefs. Such self-evaluation can make the therapist more
attuned to social and environmental stressors that shape the client’s expe-
rience, such as exposure to oppression, and further help the clinician to
identify areas in which he or she needs more education and training
(Arredondo et al. 1996; Vera et al. 2003).
Therapists must remember that they have a stimulus value (e.g., gen-
der, race, dress) and that youth size them up the moment they meet re-
garding the therapist’s ability to help and to recognize differences between
them. Culturally skilled therapists are aware of their social impact on oth-
ers in the form of communication differences or interpersonal style
(Arredondo and Arciniega 2001). Therapists who have thought critically
about how they will be perceived by ethnocultural minority youth will bet-
ter prepare thoughtful questions and ways to recognize and address poten-
tial cultural differences.
Assessment
As discussed above, basic cultural competence calls for the therapist to
find a balance between educating himself or herself about the sociocultural
groups to which clients belong and recognizing that each client’s experi-
ences are unique and not necessarily dictated by group membership (Pan-
talone et al. 2010). At the same time, clinicians who overestimate the role
of these issues, inadequately assess individual differences, and neglect to
consider other relevant factors affecting mental health will likely have
poor treatment engagement and outcomes with diverse young populations
(Sue et al. 2009).
The Multidimensional Ecosystemic Comparative Approach (MECA;
Falicov 1998) balances the universalist (assumption that Western psycho-
therapeutic concepts are universally applicable across cultures) and cul-
ture-specific positions to help clinicians appreciate human similarities,
consider cultural differences, and recognize the uniqueness of each individ-
ual. MECA maintains that culture develops over time through membership
in a variety of domains (e.g., language, race and ethnicity, sexual orienta-
tion, religion, SES) and experiences in different contexts (e.g., discrimina-
tion or isolation where the individual lives and attends school). By adopting
a culturally responsive approach to assessment, clinicians will be informed
of cultural factors at each step of the CBT process, including case formula-
tion, diagnosis, treatment planning, and therapeutic intervention.
Tanaka-Matsumi and colleagues (1996) outlined the Culturally In-
formed Functional Assessment to assist behavioral therapists who are
culturally different from their clients in identifying the functional relation-
ship between the client’s presenting problem and the sociocultural envi-
ronment. The underlying assumption is that good behavioral therapists
assume that each individual’s reinforcement history is unique (i.e., differ-
ent from the therapist’s and other individuals’ from their cultural group).
The two major tasks facing CBT therapists are 1) the need to evaluate the
presenting problems using functional analysis and 2) the need to assess the
larger context of the client’s social network with attention to cultural in-
fluences (e.g., cultural definitions of problem behavior, knowledge of
accepted behavioral norms, cultural acceptability of behavior change strat-
egies, and culturally approved behavior change agents) (Okazaki and
Tanaka-Matsumi 2006). Recommendations include the use of an inter-
preter or cultural informant and acculturation measures to examine the
cultural identity, cultural match or mismatch with the clinician, and accul-
turative stress.
In addition to standard functional assessment with the client, the clini-
cian should interview family members to explore how the presenting prob-
lem is viewed from the family’s and sociocultural group’s perspective (i.e.,
is this a culturally normative idiom of distress?), what the family perceives
as the causes of the behavior, what characterizes traditional help-seeking in
the cultural group, and how the family responds to the behavior in everyday
situations (Tanaka-Matsumi et al. 1996). Assessment of cultural explana-
tions for the individual’s behaviors will reveal pertinent cognitive schemas
that may be targeted by interventions (e.g., it is inappropriate for a child to
challenge the authority of an elder family member). The clinician needs to
assess not only the quality of the child’s self-image but also the life experi-
ences of the parent to understand the role of racial pride, shame, or confu-
sion and how these factors influence the parent-child relationship (Greene
1992). Ensuring that these areas of inquiry are covered in the assessment
process will allow the clinician to entertain hypotheses to explain client be-
havior with a consciousness of what is culturally normative for this individual
and the sociocultural groups to which he or she belongs.
The task of culturally responsive assessment may seem daunting be-
cause there are so many domains of diversity to consider and no clinician
is bias-free. For this reason, a number of different models and tools have
been developed to guide clinicians’ assessment of both risk and protective
factors in the individual’s cultural environment. Hays (2008) proposed the
ADDRESSING model to guide assessment and consideration of the vari-
ous domains of diversity in case formulation:
A—Age and generation

D—Developmental and
D—Acquired disabilities
R—Religion or spiritual orientation
E—Ethnicity
S—Social status
S—Sexual orientation
I—Indigenous heritage
N—National origin and
G—Gender
To avoid overgeneralizing, clinicians need to consider the individual’s

level of acculturation compared with his or her level of involvement in the
culture of origin (Balsam et al. 2006; Harper and Iwamasa 2000; Vera et
al. 2003). Assessing cultural identity, language preference, English profi-
ciency, acculturative stress, exposure to discrimination, and degree of in-
ternalized oppression is central to cultural case formulation (Bernal and
Sáez-Santiago 2006; Vera et al. 2003).
Despite the documented importance of assessing for these diversity is-
sues, Harper and Iwamasa (2000) found that a majority of therapists talk
with clients about ethnicity when the presenting problem is clearly related
but otherwise do not often broach the subject. Many dominant-culture
therapists fear being considered racist for bringing up the subject of race
or ethnicity if the client does not do so. However, young clients’ fears of
being dismissed or misunderstood may make it difficult for them to bring
up such issues (Harper and Iwamasa 2000). By asking “What are aspects
of your race or culture that are important for me to know about in working
with you?” or “What are your spiritual or religious beliefs?” the therapist
communicates a willingness to discuss these issues (Kelly 2006). Often cli-
ents are relieved when the therapist asks this type of question, or they
themselves have not previously considered how race and ethnicity contrib-
ute to their presenting problem (Harper and Iwamasa 2000). Culturally
competent therapists should “do their homework” to inform themselves
about what questions to ask and potential influences that the diversity is-
sues may have on the presenting problem. Alternatively, if the clinician
does not touch on such issues, the youth may perceive that the therapist
is uncomfortable discussing the client’s ethnic minority status, does not
value the client’s ethnicity, or truly cannot understand him or her (Harper
and Iwamasa 2000). Some investigators maintain that failure to address
ethnicity and cultural values contributes to dropout and treatment failure
(Fudge 1996; Harper and Iwamasa 2000).
Considering that many individuals belong to more than one minority
group, the clinician also should assess the degree to which the client’s self-
identity is tied to each of these diversity domains (Pantalone et al. 2010). For
instance, in many cases, gay ethnic minority youth identify more with being
a member of the GLBT community than with being an ethnic minority.
Case Example
Avery, a 14-year-old biracial (African American and white) adolescent pre-
sented for treatment with the primary concern of conflict with her father.
After having been raised by her white mother, Avery had to move in with her
African American Baptist father at age 10 when her mother died unexpect-
edly. Her father perceived that Avery had internalized racist messages and
that her conflicted relationship with him was rooted in her struggling with
her biracial identity. With further assessment, Avery revealed that in her
opinion, her bisexual orientation and conversion from Christianity to Bud-
dhism were the primary issues of contention between herself and her father.
Another consideration is that the child’s identification will vary by con-

text and level of exposure to oppressive and supportive social forces (e.g.,
school vs. home vs. religious events; Pantalone et al. 2010). A thorough un-
derstanding of contextual issues is crucial to being able to make clinical
recommendations that are safe and have a good chance of being successful.
For example, a clinician must be cognizant of the risks involved in a GLBT
youth’s cultural environment before encouraging him or her to come out
(Balsam et al. 2006).
Culturally responsive assessment also involves inquiring about contex-
tual risk and protective factors that will inform treatment. Conditions
such as SES, educational level, safety of the neighborhood, adequacy of
housing, adequacy of health care and social services, legal problems, and
exposure to trauma need to be well understood in order to develop effec-
tive recommendations for intervention (Crawley et al. 2010; Hays 2006;
Vera et al. 2003). Additionally, clinicians may find useful outlets to en-
hance treatment engagement and effectiveness by fully understanding a
family’s cultural isolation versus access to a cultural community (e.g.,
availability of preferred foods or cultural art, music, and events), access to
nature, participation in a religious community in their preferred language,
interpersonal support (e.g., extended kinship, godparents, social net-
works), and involvement in political or social action groups (Hays 2006).
Framing treatment in a culturally acceptable way is crucial in promot-
ing treatment engagement, retention, and compliance. If the assessment
process has been truly culturally responsive, the diagnosis and treatment
planning stages should be consonant with the family’s perception of the
problem and will reflect a collaborative effort between clinician, client,
and the client’s family (Vera et al. 2003). Clients’ treatment goals may
place less emphasis on cognitive and behavioral changes but rather may fo-
cus on having more involvement in a supportive faith community or having
more balance in their lives (Pantalone et al. 2010).
Treatment Engagement
and Orientation to Treatment
The debate is ongoing about whether factors specific to theoretical orien-
tation or nonspecific factors in therapy (e.g., being understood, receiving
unconditional positive regard or respect, and being accepted) are respon-
sible for clinical improvement. Arguably, attention to nonspecific factors
in therapy is central to effective treatment engagement with ethnic minor-
ity youth (Harper and Iwamasa 2000; Sue et al. 2009). Engagement of
ethnic minority families may be particularly challenging given the stigma
associated with mental health treatment and a history of exploitation,
abuse, and disparities in mental health care that has created a deep-seated
suspicion of mental health professionals of the dominant culture (e.g.,
Tuskegee experiment, conversion therapy for GLBT individuals). It is in-
cumbent upon clinicians to understand how previous experiences and/or
misconceptions about mental health service providers may influence the
client’s perception of them. As mentioned before, these misconceptions
can be addressed by acknowledging cultural differences between clinician
and client, thus signaling openness to further discuss the topic and sensi-
tivity to the youth’s cultural context. Clinicians may need to be prepared
to do home visits or to reach out by phone to persuade reluctant family
members to join family sessions (Abudabbeh and Hays 2006). Attention

to the therapeutic relationship cannot be overemphasized. For example,
allowing time before and during sessions to engage the family in non-prob-
lem-related small talk and allocating additional time for standard rapport
building may be necessary with culturally different clients (Falicov 2009).
Matching therapist-client characteristics (e.g., ethnicity and gender),
language proficiency, and modes of expression (the use of easily under-
stood lay terminology and culturally appropriate metaphors) may enhance
the ecological validity of therapy (Interian and Díaz-Martínez 2007; Ros-
selló and Bernal 1996). Other techniques such as telephone and letter
prompts immediately before a scheduled session, engagement interviews
to problem-solve barriers to treatment, family therapy techniques to re-
duce resistance and increase engagement, and interventions designed to in-
crease patient participation in care have been shown to improve treatment
attendance and retention of ethnic minority youth (Huey and Polo 2010).
Additionally, provision of explanations about the limitations of the thera-
pist role early in therapy will help to avoid misunderstandings among eth-
nocultural groups who value warm interpersonal relations and expect that
the provider will provide constant support and assistance (Barona and San-
tos de Barona 2003; Bernal and Sáez-Santiago 2006). A willingness to self-
disclose often serves to relax the client, promote trust, and model how to
discuss personal issues (Pantalone et al. 2010).
For example, when working with Latino families, I (RFP) utilize the for-
mal form of “you” (Usted) and formal titles (Señor/Señora, Don/Doña) in-
stead of first names of parents to demonstrate the cultural value of respeto and
to decrease the hierarchical distance between myself and adult family mem-
bers. To respond to the Latino cultural value of personalismo (warm interper-
sonal relations and personalized attention), I avoid an exclusively task-oriented
orientation to therapy sessions and allow time for small talk and appropriate
self-disclosure. This often includes discussion of where the parents of the
child were raised. Usually, my clients are curious about my background and
how I came to speak Spanish, so I take this opportunity to model self-disclo-
sure by explaining my cultural and family background to increase their com-
fort level in discussing cultural differences and personal information.
Because of the stigma involved in pursuing mental health care among
many ethnic minority and immigrant populations, psychoeducation during
the treatment engagement phase is vital. Much of families’ anxiety can be
relieved by learning about the etiology of the presenting problem and
learning that they are not alone (Iwamasa et al. 2006a). Nonthreatening
psychoeducation about the purpose, course, and process of treatment has
been shown to improve therapeutic alliance with African Americans (Kelly
2006). Early on, the clinician should explain how the cognitive-behavioral
clinician-client relationship differs from a traditional doctor-patient rela-

tionship to promote a collaborative treatment approach in which the client
takes an active role in defining the problem, deciding on a plan, and nego-
tiating homework (Hays 1995). A careful explanation of the CBT model
and how it will specifically address the client’s problems is important to
treatment retention for ethnic minorities less familiar with therapy (Iwa-
masa et al. 2006a). This explanation should avoid jargon, particularly when
the clinician is presenting the model to children, and should use develop-
mentally appropriate lay language (e.g., “thinking mistakes” or “stinkin’
thinkin’ ” instead of “cognitive distortions”). Pretherapy orientation videos
for ethnic minority clients are available to enhance treatment engagement
by depicting mock therapy sessions and including client testimonials by
ethnically similar clients. These videos may be shown in waiting rooms or
privately for individuals referred to therapy (Organista and Muñoz 1996).
Before commencing therapy, the clinician should take time to address
potential barriers to treatment compliance. During the culturally respon-
sive assessment, the CBT clinician will have identified logistical barriers as
well as potential sources of support (e.g., extended family that can help
with child care, expenses, or transportation). Helping the family problem-
solve these issues will demonstrate a respect for the context in which fam-
ilies live and a willingness to discuss basic family needs. Barriers may also
be attitudinal in nature. For example, it is not uncommon for ethnic mi-
nority parents to state that they do not “believe in therapy,” that “therapy
is for crazy people,” or that “therapy is for rich white people.” It will be
necessary for the therapist to address these attitudinal barriers through
psychoeducation and perhaps the use of the aforementioned therapy prep-
aration videos. The willingness to discuss these issues nondefensively and
the inclusion of important people, such as curanderos, extended family,
clergy, and godparents, demonstrate a comfortable stance on cultural dif-
ferences by the clinician and serve to build trust, improve attitudes toward
treatment, and enhance compliance with homework for youth from ethnic
and religious minority groups (Harper and Iwamasa 2000). Because pre-
mature termination is one of the major factors leading to poorer treatment
outcomes among ethnic minority populations, attention to cultural factors
in the treatment engagement phase is particularly crucial to building a
therapeutic alliance and retaining the client in treatment.
Methods for Implementing CBT

Consideration of cultural and contextual factors must extend from assess-
ment throughout treatment when working with diverse youth. This means
not only adding cultural elements but also using traditional CBT skills to
address diversity issues. Creativity as a clinician is a great asset in flexibly

implementing CBT with diverse youth. For example, the clinician may in-
corporate culturally appropriate metaphors and work cognitive restructur-
ing into a child’s affinity for writing raps, to improve the likelihood that
the child will accept CBT strategies (Harper and Iwamasa 2000). Thera-
pists also should ensure that the new behaviors learned in therapy are pos-
itively reinforced by the social environmental contexts in which youth live
(Harper and Iwamasa 2000). This requires an awareness that a particular
behavior may be considered adaptive in one context and maladaptive in an-
other.
Family-Focused Interventions
Because of the emphasis on collectivism in many ethnic cultures, an em-
phasis on family-focused intervention may be most effective when work-
ing with ethnically and religiously diverse youth (Falicov 2009; Kumpfer
et al. 2002; Organista 2006; Paradis et al. 2006). As part of culturally re-
sponsive assessment, the therapist should already understand family struc-
tures and backgrounds as well as how clients’ behaviors affect the family
and vice versa (Pantalone et al. 2010). In a trial of CBT for depressed La-
tino adolescents that demonstrated treatment effectiveness, familismo
was considered in the assessment and treatment engagement phases by as-
sessing and addressing parent goals in the treatment process (Rosselló and
Bernal 1996). Additionally, family can be integrated into CBT sessions
post–treatment engagement. The Treatment for Adolescents with Depres-
sion Study demonstrated that involvement of extended family supported
compliance among African American youth in CBT (Sweeney et al. 2005).
With Latino adolescents, the module of family communication was em-
phasized to address intergenerational gaps in values. Therapists normalized
cultural differences to alleviate family stress and facilitated discussion
about the values and beliefs of the host culture and culture of origin with
the following goals: 1) promoting understanding between parents and ad-
olescents, 2) teaching the family positive communication and negotiation
skills, and 3) teaching the adolescent how to cope with negative feelings
and cognitions (Sweeney et al. 2005). Encouraging families to share migra-
tion narratives has been a helpful adaptation to family therapy to reduce
misunderstandings and to decrease silent suffering (Falicov 2009). When
there is a clash between personal and family obligations (individualism vs.
collectivism), the therapist should be careful not to impose his or her val-
ues, pathologize, or criticize. It is the therapist’s role to help the youth an-
ticipate the potential social consequences of certain decisions (Pantalone
et al. 2010).
Case Example
Naomi, a 16-year-old Filipina girl raised in the United States, presented
with conflict with her mother (a first-generation immigrant, single
mother) about her mother’s traditional belief that girls should not date un-
til after college (consistent with the mother’s upbringing). Due to the Fil-
ipino cultural taboo against discussing sexuality and intimate relationships
and her mother’s vehemence about her not dating, Naomi was unable to
engage her mother in open communication and started dating behind her
mother’s back. Family therapy focused on allowing the mother to explain
her values and express her concerns about dating while supporting Naomi
to resist peer pressure. Parent-centered sessions provided psychoeducation
about how difficult it is to bridge two cultures and the risks to Naomi if
she did not have a parent to talk with about her challenges. These sessions
included a discussion of the reality of the mother not being able to super-
vise her daughter 24 hours a day, the likelihood that Naomi might stop
seeking her advice and would be more vulnerable to peer pressure if com-
munication remained strained, the normalization that Naomi was likely at-
tracted to the boy and he to her, and the possibility that Naomi might
choose to defy her mother if she perceived the mother as being overly re-
strictive. Individual therapy helped Naomi weigh the pros and cons of con-
tinuing to deceive her mother versus choosing to be a nonconformist and
not follow her peers’ examples, as well as learn to evaluate relationships
with peers and with potential boyfriends.
Cognitive Restructuring
As one of the core CBT skills, cognitive restructuring can be a powerful
tool to use with youth to address diversity issues. A culturally competent
CBT clinician will strive to integrate what is known about the child’s cul-
tural values and environment into the teaching and implementation of this
skill. In many cases, cognitive restructuring with diverse youth parallels its
use in majority populations. For example, youth with disabilities often
need assistance in decatastrophizing the impact of their disability (Mona
et al. 2006). Cognitive restructuring can focus on personal strengths that
were unaffected by the disability to dispute the belief that “Nothing will
ever be the same.”
For diverse youth, clinicians may want to simplify the A-B-C-D-E method
(based on Albert Ellis’s work), which teaches the client to identify the
Activating event,
Beliefs about the activating event,
Consequences (feelings and behaviors),
Disputation of irrational beliefs, and
Effects of disputation.
Organista and Muñoz (1996) described how A-B-C-D-E can be difficult

to master and as a result discarded by Latino clients. They suggested that in-
stead of labeling cognitions as irrational or distorted, the “Yes, but...” tech-
nique may be presented as a way to challenge clients to consider more
realistic alternatives, to see more positive situational elements that have been
overlooked, and to make half-truths into whole truths (Organista and Muñoz
1996). For example, a first-generation immigrant adolescent from the Sudan
struggling to learn English might say, “Yes, my English language skills are not
so strong now, but I’m learning more every day. One day I might be fully bi-
lingual, and this will give me an edge in getting a job!”
A common misconception is that CBT is less helpful with diverse
youth because of its emphasis on individual-level variables—that is, on
challenging distorted cognitions about negative events in order to help the
individual adapt to the environment (Casas 1995; Organista and Muñoz
1996; Vera et al. 2003). When ethnocultural minority youth experience
injustice in an antagonistic environment (e.g., exposure to oppressive soci-
etal factors), adjusting their mind-set to fit the environment might be seen
as maladaptive for their mental health. The challenge for the CBT clinician
is to help the youth question whether a cognition is rational before engag-
ing in cognitive restructuring. Culturally responsive CBT clinicians recog-
nize the injustices facing diverse youth and acknowledge that distorted
cognitions are not always the source of the problem; thus other skills, such
as problem solving, might be more appropriate to alleviate distress. For ex-
ample, a Latino student thinking “It’s not fair that the teacher gives me de-
tention when I speak Spanish in school” is not experiencing a distorted
cognition but rather is accurately labeling an experience of oppression.
Even when there is no distorted cognition, however, cognitive restructur-
ing can be used to assign responsibility and positively affect mood. A parallel
can be drawn to youth exposed to trauma. By focusing on cognitions, the ther-
apist is not laying blame on the child for the traumatic event but rather equip-
ping the child with a coping skill that will allow him or her to react to the
situation in the healthiest way possible (e.g., meaning making). In the case of
youth who have experienced trauma or uncontrollable environmental circum-
stances (as is often the case for cultural minority populations), clinicians can
use cognitive restructuring to reframe the impact of these undeniably negative
events and help the youth generate more productive self-talk (e.g., “I am not
responsible for the teacher being racist. Being bilingual is an ability I have that
will be valuable to me in other settings.”).
Cognitive restructuring is particularly useful for ethnocultural minorities
because it can be used to challenge cognitions stemming from internalized
oppression. Many GLBT youth and their families are troubled by heterosex-
ist thinking, such as “Gays and lesbians are more promiscuous and are not ca-
pable of having a stable, committed relationship with one partner.” GLBT

youth may experience some relief through systematic analysis and correction
of cognitive errors and adaptation of more constructive self-talk, including
messages from a gay-affirmative therapy approach (e.g., homosexuality is not
an illness, same-sex attractions are normal variants of sexual orientation,
same-sex relationships can be fulfilling) (Balsam et al. 2006; Glassgold 2009;
Safren et al. 2001). In the case of exposure to racial discrimination or harass-
ment, African American youth are at risk of adopting beliefs such as “Being
black means I’ll never be good enough”; “Being black means acting in a par-
ticular way”; and “Black men don’t do school; therefore, doing well in school
means that I’m not a black man.” Clinicians can assist ethnic minority youth
in challenging these beliefs and developing more realistic and positive self-
statements to combat the internalization of negative messages (Fudge 1996;
Kelly 2006; Kuehlwein 1992).
Knowing that religion and spirituality are central to the culture of many
ethnocultural youth, the clinician can use scriptures and religious anecdotes
to challenge maladaptive cognitions (Neal-Barnett and Smith 1996). Such
religious disputation of disturbance-creating beliefs can be a potent catalyst
for religious clients and is a strategy used by some clergy in the Christian,
Jewish, and other faiths (Ellis 2000). Such disputation when carried out by
clinicians working with young children, however, needs to be done in a re-
spectful way so as not to alienate the young person or his or her family. Re-
search has shown that devout individuals who believe in an angry, punitive
God and perceive a lack of support from their religious community tend to
suffer more psychological distress in contrast to those who believe in a loving
God, who enjoy more positive mental health (Pargament 1997). Clinicians
are encouraged to inquire what the youth’s and parents’ religious beliefs are
in relation to the situation at hand, determining whether these beliefs are ex-
acerbating or relieving the youth’s distress (Walker et al. 2010). Psychoedu-
cation about the clinician’s role can highlight the intention to help the youth
(and sometimes the family) feel better by adopting adaptive and hopefully
religiously congruent thinking. This approach may require consultation with
a clergy member to provide the family with the necessary reassurance that
the treatment is acceptable (Walker et al. 2010). In the cases that young cli-
ents or the parents present with views that conflict with the clinicians’ be-
liefs, clinicians are encouraged to focus on the well-being of the youth as a
way to guide therapeutic intervention.
Case Example
José, a 17-year-old gay Catholic adolescent from Mexico, presented for in-
dividual therapy for depression. He was struggling to reconcile his Catholic
identity with his sexual orientation. He had internalized negative messages,
such as “Homosexuality is a sin,” and therefore felt as though he was a bad

Catholic. Recognition that much of his distress emanated from this puni-
tive belief that an integral part of identity was abhorrent to his God and
religion guided my (RFP) decision to use scriptures to counteract this in-
ternalized oppression, common to Christian GLBT older adolescents.
I engaged José in collaborative research into same-sex relationships in the
Bible, alternative theories and interpretations of biblical passages, and con-
tradictions in Scripture. Cognitive restructuring helped José adapt beliefs
based on Scripture that emphasized his compliance with Christian ideals.
Additionally, to help him cope with some of his family’s rejection as he dis-
closed his sexual orientation, José utilized religious readings, such as
“When my father and my mother forsake me, then the Lord will take me
up” (Psalm 27:10). He also was able to critically analyze and generate pos-
itive self-talk, such as “If nonheterosexual orientation is so completely un-
acceptable, then why is there not one mention of sexual orientation in the
Ten Commandments or in all of Jesus’ teachings?”
Often cognitive restructuring with diverse youth is most effective in

combating the effects of oppression when the therapist is able to access
and enhance the client’s strengths (be they developing a positive ethnic
identity or a belief in a loving God) and use them in therapy.
Behavioral Activation
When designing behavioral activation for diverse youth, the clinician
should attend to contextual factors such as income, safety of neighbor-
hoods, gender roles, and other cultural norms. A clinician who recom-
mends that a child living in the inner city exercise regularly by walking or
running around the neighborhood, going to the park, or working out at the
gym without thoroughly assessing such contextual factors may inadvert-
ently put the child in danger of crossing gang lines and exposing himself or
herself to violence, assumes access to parks, and presumes that the family
has the resources to pay for private gym membership, respectively (all of
which demonstrate the clinician’s lack of skill, knowledge, and under-
standing of the client). Clinicians need to help children identify activities
that are congruent with their environment, do not require payment, or are
readily available to low-income families (e.g., free admission days at mu-
seums, visiting friends, mall walks) (Organista 2006).
Follow-through on behavioral activation may be highly dependent on
how it is viewed by the family. For Latinos, focusing on themselves and im-
proving their own moods may cause problems for more traditional families
who value familismo. Therefore, activity schedules that include activities
for the youth to do with and without family are more likely to be well re-
ceived (Organista 2006). Additionally, traditional gender roles dictate that
Latinas take on a caretaking role in the family by helping around the house
with child care, cleaning, and chores. In these cases, behavioral activation
might be more well received if instead of framing it as a way for the client
to take care of herself, the clinician proposes the rationale that when the
client takes care of herself, she is better able to care for her family (Organ-
ista 2006). For children who manifest psychological distress primarily in
somatic symptoms, behavioral activation (e.g., physical exercise, distrac-
tion) in conjunction with relaxation techniques may be an intervention
that is easily understood by the family (Interian and Díaz-Martínez 2007).
Behavioral activation may also serve as a useful complement to cogni-
tive restructuring to buffer youth from oppressive influences by connect-
ing them to culturally specific networks and religious institutions (Hays
1995). For African American and Latino youth, clinicians can connect
youth with church communities, local cultural organizations, English
classes (for those whose first language is not English), and mentoring as
part of their behavioral activation interventions (Interian and Díaz-
Martínez 2007; Sweeney et al. 2005). GLBT youth, in particular, benefit
from assistance in identifying appropriate agencies and organizations that
will allow them to build social support networks and experience more pos-
itive events (Safren et al. 2001). Such culturally attuned behavioral acti-
vation interventions may decrease social isolation, enhance positive ethnic
identity development, and improve overall mental health.
Case Example
Ming is a 13-year-old girl who emigrated from China at age 11 and recently
relocated to a new city in the United States. She feels isolated and differ-
ent at her new school because most of the students are African American.
She reported that the only other Asian students were “Gothic” (an off-
shoot of punk culture), a group with which she did not identify. In order
to increase her social activity level, I (RFP) found a Chinese American
agency near where Ming lived and suggested that she and her mother in-
vestigate some of the classes and recreational activities. We discussed how
classes on Chinese cultural heritage might lead Ming to meet other youth
with whom she would feel more connected. We also discussed that the
youth group field trips could help her get to know her new city. To address
her mother’s concern that Ming was not serious enough about academics,
I explained that the agency also provided academic assistance such as tu-
toring and English-language classes, which might help Ming improve her
writing for standardized testing.
Problem Solving
Problem solving is another useful complement to cognitive restructuring
when there is an environmentally based problem (Hays 2006). Problem
solving is especially relevant to ethnocultural minority youth’s contextual
experiences that may negatively influence their mood and behavior be-
cause of the focus on effecting change on the environment. Therapists can
help youth (already disempowered because of their age) draw on commu-
nity and family resources to address unjust treatment. For example, using
family problem-solving to address discriminatory practices at the child’s
school can empower parents to file complaints, request to speak to some-
one’s supervisor, seek out a new school, or consult an attorney. Helping
ethnocultural minority children (and at times, their parents) successfully
change their environment may serve to increase their self-efficacy and
willingness to implement learned coping skills in subsequent situations.
CBT with ethnic minority youth may require a higher level of interven-
tion in the larger community than CBT with dominant cultural groups. Ef-
fecting change on the community level and healing a community of
oppressive influences resonates with Afrocentric values of responsibility
and self-determination, empowers clients to use more active coping styles,
and strengthens positive ethnic identity (Kelly 2006). Problem solving can
promote external change in the contingencies in the environment that may
maintain child symptoms (Kelly 2006). This intervention may entail em-
powering the child or family to start an ethnocultural youth group at the
school or in the community when one does not already exist (e.g., Latino
Student Association, Gay-Straight Alliance).
Case Example
Kadija is a 13-year-old African American girl who was having significant
difficulty getting along with a particular teacher at school. She and her
mother viewed this teacher as often discriminating against Kadija (e.g.,
blaming only her for something a group of students did). Her mother at-
tempted to advocate for her daughter by talking to the teacher, but she had
a strong emotional reaction to the teacher and would end up raising her
voice, which only seemed to exacerbate the teacher’s discriminatory be-
havior. Through the use of problem solving and a review of communication
skills in different cultural contexts during therapy, the family was able to
enlist the help of an African American teacher who was willing to facilitate
this discussion and identify assertive, rather than emotional, methods of
opening discussion of the issue with school staff.
Exposure Therapy
Traditional exposure therapies for anxiety and panic disorders have in-
cluded interoceptive exposure to somatic symptoms evoked during a panic
attack. Panic attacks brought on by stressors related to the client’s minor-
ity status, however, may need additional culturally relevant exposures cou-
pled with relaxation training and problem solving to decrease chronic
stress levels. For GLBT youth, coming out to specific individuals can be
planned as clinicians would plan any other exposure—using a hierarchy of
how difficult it would be to come out to particular individuals (Glassgold
2009).
When engaging the client in exposure therapy, CBT clinicians need to
be mindful of cultural factors that may alter effectiveness. For example,
clinicians may need to address the role of shame with Asian American cli-
ents by weighing the pros and cons of the client experiencing short-term
embarrassment while completing exposures versus the long-term conse-
quences of not doing the exposures (Iwamasa et al. 2006a). For religious
clients, the therapist needs to be careful not to engage the client in some-
thing that is specifically prohibited by religious law (Paradis et al. 2006).
Case Example
Nicolas, an 8-year-old Dominican boy and observant Jehovah’s Witness,
presented with obsessive-compulsive disorder (OCD). He was experienc-
ing blasphemous obsessions about swearing at or hating God that were
highly embarrassing and distressing to him and his family. I (RFP) worked
with the family in psychoeducational sessions to help them understand the
nature of OCD and how obsessions were often ego-dystonic and not stem-
ming from a budding rebellion or defiance. We worked collaboratively to
externalize OCD and separate it from Nicolas’ identity by making OCD
the “bad guy” who bothered Nicolas with the most personally distressing
thoughts it could generate. With a solid understanding of OCD and the ra-
tionale for exposure and response prevention, he and his mother were will-
ing to proceed with exposures to acting out his obsessions (e.g., swearing
at God).
Assertiveness Training
Traditional assertiveness training stresses the rights of the individual,
which may pose problems for youth from more collectivist cultural back-
grounds. A breach in the therapeutic relationship may occur if the CBT cli-
nician is perceived as trying to impose his or her cultural value system on
a child or family by empowering the child to put his or her needs above
those of the family or community. Organista and Muñoz (1996) suggested
that instead, clinicians should frame assertiveness training as a way to help
children develop bicultural competency. Assertiveness may be described
as an effective communication skill in mainstream America that will serve
the youth well in school and in pursuing a professional career. At the same
time, the clinician may help youth recognize that assertive communication
is inappropriate or may need to be used sensitively in other contexts, such
as at home or in religious communities (Hays 1995; Koss-Chioino and Var-
gas 1992). This approach to assertiveness training avoids devaluation of

traditional communication patterns in particular cultural contexts (Orga-
nista and Muñoz 1996). By discussing cultural values, expectations, and
family roles, the therapist may assist more acculturated adolescents in ne-
gotiating a looser attachment to the family without completely abandoning
traditional cultural values (Koss-Chioino and Vargas 1992).
For African American youth, assertiveness training can help them an-
ticipate situations and generate and rehearse appropriate responses that
focus on desired outcomes instead of the oppressive script of “acting
black” (Fudge 1996). In combination with cognitive restructuring to chal-
lenge negative internalized messages, assertiveness training can present
youth with alternatives to the extremes of either aggression and hostility
or passivity and withdrawal. Through role-play and examples from role
models, ethnic minority youth can strengthen assertiveness skills and ef-
fectively anticipate and manage problematic situations (Fudge 1996).
A good deal of attention in the literature has been given to conducting
assertiveness training with Latino populations. The therapist needs to be
mindful of culture-based protocols of communication, respeto, and simpatía
(i.e., warmth, kindness, emphasis on positive interactions and avoidance of
conflict) in Latino cultures (Interian and Díaz-Martínez 2007; Organista
2006). Comas-Díaz and Duncan (1985) were the first to write about how
Latinas could communicate assertively without seeming confrontational.
Culturally sensitive framing of assertive communication may include prefac-
ing statements, such as “With all due respect...,” and/or asking permission—
for example, “Would you permit me to express how I feel about that?” (Co-
mas-Díaz and Duncan 1985). When using assertiveness training in Latino
family therapy, clinicians can ask the father’s permission to allow the wife
and children to state their opinions or express feelings, which demonstrates
respeto for his role as head of the family and to appeal to his machismo (i.e.,
male pride, man’s role as protector of the family) (Koss-Chioino and Vargas
1992; Organista 2006). When such cultural adaptations are made, assertive-
ness can be a useful tool for diverse youth.
Interventions to Promote Positive Ethnic

and Cultural Identity Development
Despite consistent findings that experiences of oppression and discrimina-
tion have adverse effects on mental health, there is a remarkable lack of
emphasis in the CBT literature on techniques to develop self-efficacy and
positive ethnic and cultural identity. Bandura (1982) discussed that central
to the development of a sense of positive self-worth and effectiveness is
the individual’s acquisition of skills necessary to master the environment.

In the case of some ethnic minorities, internalization of racism contributes
to difficulty accurately assessing personal competence and resisting nega-
tive behaviors that are reinforced by peers (Fudge 1996). Positive ethnic
identity would alter expectations regarding personal competency and
would give children the courage to engage in more adaptive behaviors even
if not reinforced by some members of their peer group.
Because of the emphasis on behavior change, behavior therapy is espe-
cially well suited to increasing youth’s sense of control and self-efficacy in
disempowered young minority populations (Fudge 1996). Behavior
change can result in empowerment and an increased ability to alter the en-
vironment. By exposing youth to positive role models of their own group
through bibliotherapy (e.g., The Autobiography of Malcolm X), therapists
can help youth learn vicariously about positive ethnic identity develop-
ment (Fudge 1996). Through involvement in political activity or ethno-
culturally based youth groups, youth can appreciate the interdependence
between their own needs and those of the larger cultural community, gain
a sense of belonging and solidarity, and strive collaboratively to modify sys-
tems-level problems and repair injustices, leading to increased self-confi-
dence and self-esteem. Therapists can teach youth behavioral analysis to
help them analyze antecedents and contingencies that are capable of being
altered (Fudge 1996). For example, therapists can discuss with African
American boys the negative behavior that is often reinforced by peers who
have internalized racist messages. Therapists can appeal to these youth’s
responsibilities as black men to help others with similar problems by
changing the contingencies (e.g., label academic achievement as a positive,
desirable quality) (Fudge 1996).
Racial socialization has been identified as a therapeutic tool for clini-
cians to use when interested in promoting positive ethnic identity develop-
ment in diverse young clients (Greene 1992). Although racial socialization
is not a suitable treatment focus for all forms of psychopathology, Greene
(1992) recommends that it be used proactively to promote self-esteem and
not solely in response to discrimination. The first phase of racial socializa-
tion educates children to label racism accurately, identify when it occurs,
and understand the experience. In the second phase, the parent is used as
a role model to demonstrate to children how to handle certain situations
(e.g., advocating for the child at school). The third phase of racial social-
ization is to provide emotional support for the expected angry emotional
reaction to injustices. The final phase assists parents in not reinforcing neg-
ative racial stereotypes by showing them how to provide more positive ra-
cial images by sharing family folklore and other stories and symbols of
racial pride (Greene 1992).
Case Example
Esmeralda is a 12-year-old Guatemalan girl exhibiting oppositional behav-
ior at home, poor self-esteem, and academic decline. In addition to parent
training and school consultation, I (RFP) engaged Esmeralda in a variety of
activities meant to bolster positive ethnic identity development. Every
week, I had Esmeralda read a printout from a Web site featuring successful,
famous Latinas in the United States and answer questions about them to
help her draw connections between their ethnic backgrounds and hers.
I recommended seminars at the nearby university that were open to the
community, focusing on Latino leadership and higher education, so that
Esmeralda was exposed to role models, such as Latino politicians and col-
lege students. I also helped the family find ethnic minority college students
at the local university who were willing to donate time to tutor Esmeralda
after school to help increase her self-efficacy in her classes.
Hence, therapists may foster positive ethnic identity development in

their young clients through a combination of CBT techniques, including
cognitive restructuring, behavioral activation, and problem solving, as well
as racial socialization.
Future Directions
The topics covered in this chapter illustrate the need for a coherent ap-
proach to integrating cultural competence and CBT. To accomplish this
goal, a number of changes must occur in the fields of mental health train-
ing, service provision, and research. Training programs for all types of men-
tal health professionals need to improve preparation of clinicians to work
with culturally diverse populations in addition to training them in EBTs
(Vera et al. 2003). Diversity and cultural competence training has been
demonstrated to increase knowledge about ethnocultural populations
among trainees, improve client perceptions of therapist sensitivity, and en-
hance treatment outcomes (Yutrzenka 1995). Clinical CBT supervisors
need to be willing to examine their own values, beliefs, attitudes, and
worldviews to build the foundation of self-awareness (Iwamasa et al.
2006b). Likewise, cultural issues need to be raised in supervision to pro-
mote the competence of clinicians in training (Iwamasa et al. 2006b).
Additionally, culturally responsive assessment in clinical practice is incon-
sistent in part because of the lack of training, but also because of the de-
emphasis of culture in the Diagnostic and Statistical Manual of Mental
Disorders (American Psychiatric Association 2000) by relegating cultural
formulation to an appendix as opposed to inclusion of such issues as an in-
herent part of multiaxial assessment (Hays 2008).
Research must focus on culturally sensitive assessment and treatment

response of minority populations to traditional CBT as well as culturally
adapted protocols. Specifically, future research should integrate hypothe-
sis-testing and discovery-oriented research and move away from cross-cul-
tural comparisons, instead focusing on mediators and moderators of
treatment outcomes for one specific ethnic group at a time (Bernal and
Scharrón-del-Río 2001; Huey and Polo 2010). Discovery-oriented research
on how to modify treatments with culturally diverse youth, including both
quantitative and qualitative methods, would inform the development of
culturally adapted protocols. Hypothesis-testing research with specific eth-
nocultural groups may then examine questions of efficacy and effectiveness
of traditional CBT as well as culturally tailored protocols (Bernal and Sáez-
Santiago 2006; Bernal and Scharrón-del-Río 2001). In addition to research
that tests cultural adaptations of CBT strategies and manuals, there is a
need for mainstream manuals to demonstrate applications of standard
modules with diverse populations (Huey and Polo 2010).
In the meantime, it is possible for CBT clinicians to provide culturally
responsive interventions using the resources we have outlined in this chap-
ter. CBT’s ongoing assessment and tailoring of the interventions to the in-
dividual make it particularly useful with clients from a wide variety of
cultural backgrounds. CBT clinicians, however, should commit to incorpo-
rating cultural diversity issues into their treatment plans by educating
themselves about the cultural groups to which their clients belong and us-
ing the tools and resources available to them.
Key Clinical Points

Tips for Culturally Responsive Assessment
• Conduct a cultural self-assessment and assess differences between
yourself and your client.
• Use a form of cultural assessment such as ADDRESSING (Hays
2008) or the Culturally Informed Functional Assessment (Tanaka-
Matsumi et al. 1996) to avoid your own blind spots and incorrectly
estimating the importance of diversity issues.
• Assess the primary cultural identity of the client and consider how
this might vary depending on context.
• Focus on risk and protective factors in the cultural and contextual
environment.
• Arrive at treatment goals collaboratively and frame treatment goals
in culturally congruent language.
• Understand the complexities of expectations about relationships

between the child and his or her family members.
Tips for Culturally Responsive Treatment Engagement
• Pay attention to nonspecific factors and work to reduce the hierar-
chical distance between you and the client to promote a collabora-
tive therapeutic relationship.
• Provide psychoeducation in easy-to-understand language to ad-
dress common misconceptions, normalize help seeking, and make
explicit how treatment will help.
• Address logistical and attitudinal barriers to treatment engagement.
• Recognize and address cultural differences between you and the
client.
• Communicate hope and willingness to assist the child and parents
with addressing the presenting problem.
CBT Interventions With Diverse Children and Adolescents
• Develop interventions that are likely to be successful and culturally
acceptable in the context in which the child lives.
• When appropriate, inclusion of family in treatment may support treat-
ment compliance and improve outcomes for ethnocultural minorities.
• Directly address diversity issues using CBT tools such as cognitive
restructuring, behavioral activation, problem solving, and exposure.
• Be careful with competing cultural values when conducting asser-
tiveness training and make sure that your client uses the skill in cul-
turally appropriate ways and only in appropriate contexts.
• Target somatic symptoms when they are the idiom of distress and
explain how CBT strategies will impact physical well-being.
• Support the development of positive cultural identity and racial so-
cialization.
3.1. Which of the following is NOT a strength of CBT when implemented
with ethnocultural minority youth?
A. It is time limited and problem oriented.

B. It is focused on the present and future.
C. It is focused on intrapsychic, unconscious processes.
D. It involves collaboration in defining treatment goals.
3.2. Parent training protocols with ethnic minority youth may improve
treatment retention and outcomes by including an emphasis on
A. Time-out.
B. Physical discipline.
C. Natural consequences.
D. Racial socialization.
3.3. Antoine is a 9-year-old African American boy who is struggling in

school. One of his core beliefs is that “only white kids do well in
school.” This belief is an example of
A. Acculturation stress.
B. Internalized oppression.
C. Feelings as facts.
D. Ableism.
3.4. CBT with an Iraqi (Muslim) 12-year-old girl with externalizing prob-
lems might be enhanced by
A. Family-focused sessions.
B. Individual-focused sessions.
C. Emphasis on assertiveness training in all contexts.
D. Behavioral activation.
3.5. The clinician must be especially cautious in implementing which

CBT skill because of its cultural acceptability in different settings
(e.g., home vs. school)?
A. Behavioral activation.
B. Problem solving.
C. Assertiveness training.
D. Cognitive restructuring.
Suggested Readings
and Web Sites
Population-Specific Information
American Psychological Association: Guidelines on multicultural education,
training, research, practice, and organizational change for psychologists.
August 2002. Available at: http://www.apa.org/pi/oema/resources/
policy/multicultural-guidelines.aspx. Accessed April 19, 2011.
American Psychological Association: Practice guidelines for LGB clients:

guidelines for psychological practice with lesbian, gay, and bisexual cli-
ents. February 2011. Available at: http://www.apa.org/pi/lgbt/re-
sources/guidelines.aspx. Accessed April 19, 2011.
American Psychological Association, Office of Ethnic Minority Affairs
home page: www.apa.org/pi/oema/index.aspx
Council of National Psychological Associations for the Advancement of
Ethnic Minority Interests: Psychological treatment of ethnic minority
populations. November 2003. Available at: http://www.apa.org/pi/
oema/resources/brochures/treatment-minority.pdf. Accessed April
19, 2011.
Hays PA, Iwamasa GY: Culturally Responsive Cognitive-Behavioral Ther-
apy: Assessment, Practice, and Supervision. Washington, DC, Ameri-
can Psychological Association, 2006
Additional resources such as peer-reviewed journals are also an excellent
source of current literature on treatment with culturally diverse pop-
ulations. Examples include Cultural Diversity and Ethnic Minority
Psychology, Asian American Journal of Psychology, and Journal of
Black Psychology.
Assessment
Hays PA: Addressing Cultural Complexities in Practice: Assessment, Di-
agnosis, and Therapy, 2nd Edition. Washington, DC, American Psy-
chological Association, 2008
Tanaka-Matsumi J, Seiden DY, Lam KN: The Culturally Informed Func-
tional Assessment (CIFA) Interview: a strategy for cross-cultural be-
havioral practice. Cogn Behav Pract 3:215–233, 1996
Multicultural Training and Supervision

to Promote Cultural Competence
Ancis JR, Szymanski DM: Awareness of white privilege among white
counseling trainees. Couns Psychol 29:548–569, 2001
Kiselica MS: Beyond multicultural training: mentoring stories from two
white American doctoral students. Couns Psychol 26:5–21, 1998
Sue S, Zane N, Nagayama Hall GC, et al: The case for cultural competency
in psychotherapeutic interventions. Annu Rev Psychol 60:525–548, 2009
Yutrzenka BA: Making a case for training in ethnic and cultural diversity in
increasing treatment efficacy. J Consult Clin Psychol 62:197–206, 1995
Research on Cultural Adaptations

Bernal G, Jiménez-Chafey MI, Domenech Rodríguez MM: Cultural adap-
tation of treatments: a resource for considering culture in evidence-
based practice. Prof Psychol Res Pr 40:361–368, 2009
Lau AS: Making the case for selective and directed cultural adaptations of
evidence-based treatments: examples from parent training. Clin Psy-
chol (New York) 13:295–310, 2006
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4
Combined CBT and

Psychopharmacology
Moira A. Rynn, M.D.
SINCE the 1990s, the field of mental health has significantly expanded
its knowledge base on the treatment of pediatric psychiatric disorders
through empirical research, which informs everyday clinical practice. This
is most evident in the area of pediatric psychopharmacology. Pharmaco-
therapy has become an important treatment tool for clinicians treating
children and adolescents with psychiatric disorders. Another effective
treatment modality for many of these disorders is cognitive-behavior ther-
apy (CBT), a well-established psychosocial intervention. Empirical evi-
dence now exists to support the combination of both pharmacotherapy
and CBT in the pediatric mental health sector for optimal outcome. Al-
though the evidence supporting the efficacy of both interventions is rela-
119
tively comparable for many psychiatric disorders, most parents and

children prefer psychotherapy as a first-line intervention. For example,
parents of anxious children with no prior treatment history have been
found to prefer CBT to medication for the treatment of their child’s anx-
iety disorder. CBT is often perceived to be more acceptable, believable,
and effective than medication (Brown et al. 2007). Medication is often
used in conjunction with CBT when symptoms are in the moderate to se-
vere range or when treatment with CBT has not provided symptom reso-
lution. However, given the lack of treatment guidelines, clinicians face
challenges regarding the use of combined treatment (CBT plus pharmaco-
therapy), such as the indications for use of the combination approach ver-
sus monotherapy treatment.
In this chapter, we briefly review the psychopharmacological treat-
ment evidence for the most common pediatric psychiatric disorders (de-
pression, anxiety disorders, and attention-deficit/hyperactivity disorder
[ADHD]); evidence for these treatments has increased our understanding
of the effectiveness of psychopharmacological intervention in child and ad-
olescent psychiatry. We subsequently present evidence for combined
treatment with CBT. Finally, we substantively discuss clinical characteris-
tics that might be useful in guiding the clinician to select the most appro-
priate treatment approach for a given patient.
Pharmacotherapy Treatment
Depression
The evidence-based literature supports the use of a class of antidepressants
called the selective serotonin reuptake inhibitors (SSRIs) for children and
adolescents. Although each of the SSRIs has individual pharmacological pro-
files, they all share the common property of effecting serotonin transporter
inhibition. Abnormalities of serotonin function are believed to be critical in
the etiology of depression and anxiety. In addition, serotonin is believed to
affect sleep and appetite, and reduced serotonin functioning may cause in-
somnia and depression (Hamrin and Scahill 2005). When an SSRI is initi-
ated, it generally takes 3–4 weeks to show evidence of an effect. Some of
the better-known and common adverse effects associated with SSRIs in-
clude gastrointestinal upset, insomnia, restlessness, and sexual dysfunction.
The clinician should carefully monitor the patient for the emergence of side
effects during treatment, and the medication timing of dose and dosage may
need to be adjusted to minimize adverse reactions.
Combined CBT and Psychopharmacology 121
The only medications approved by the U.S. Food and Drug Adminis-
tration (FDA) for the acute and maintenance treatment of major depres-
sive disorder in children and adolescents are fluoxetine for ages 8–18 and
escitalopram for ages 12–17. Currently fluoxetine is the only medication
to yield three positive double-blind placebo-controlled trials to support its
efficacy (Emslie et al. 1997, 2002b, 2008). Given its long half-life (i.e., the
time it takes for the plasma concentration of a drug to reach half of its orig-
inal concentration), there are fewer concerns about discontinuation syn-
drome. Discontinuation syndrome is a flu-like condition consisting of
symptoms such as malaise, nausea, and headaches; the syndrome may oc-
cur after the patient stops taking the medication. Two studies have shown
escitalopram to be more efficacious than placebo in adolescents (Emslie et
al. 2009; Wagner et al. 2003). Escitalopram has the safest profile of all the
SSRIs regarding interactions with other medications. This medication has
an intermediate half-life; thus, discontinuation syndrome is possible and
should be watched for.
Despite positive studies indicating the effectiveness of other SSRIs in
the treatment of pediatric depression, such agents are still considered off-
label treatments at this time. These medications include citalopram, ser-
traline, and paroxetine. The efficacy of citalopram over placebo is sup-
ported by one of two published studies (Wagner et al. 2004b; von Knorring
et al. 2006). Two parallel placebo-controlled trials of sertraline showed sta-
tistically significant differences with sertraline compared with placebo
when the data were pooled (Wagner et al. 2003). Paroxetine (Paxil) was
shown to have antidepressant activity in adolescents on some primary and
secondary measures Keller et al. 2001, whereas two other studies did not
demonstrate efficacy versus placebo (Berard et al. 2006; Emslie et al.
2006).
Results were mixed in studies of non-SSRI antidepressants in children
and adolescents. Trials of nefazodone and mirtazapine resulted in unpub-
lished negative double-blind, placebo-controlled depression trials (Emslie
et al. 2002a). When venlafaxine ER was studied in the pediatric popula-
tion, it was found to be effective only in depressed adolescents (Emslie et
al. 2007). To date, no studies have been designed to assess the efficacy of
bupropion for pediatric depression.
A meta-analysis of tricyclic antidepressants (TCAs) for the treatment of
pediatric depression found that they are not more efficacious than placebo
(Ryan and Varma 1998); therefore, TCAs are not recommended at this time.
They are considered inappropriate for children and adolescents because of
their significant side effects, including anticholinergic effects (e.g., memory
changes, constipation, confusion, blurred vision, dry mouth, sedation), and in
overdose their cardiovascular effects and high lethality (Varley 2001).
Although efficacy of some SSRI medications has been well established,

in 2004, the FDA conducted a meta-analysis of 24 placebo-controlled tri-
als of antidepressants in pediatric populations (both published and unpub-
lished), and found that antidepressants pose a twofold (4% vs. 2%)
increased risk for suicidal behavior or ideation (Hammad et al. 2006). Sub-
sequently, the FDA issued a black box warning on all antidepressants, stat-
ing that these medications may increase the risk of suicidal thinking and
behavior in children and adolescents. In the Treatment for Adolescents
with Depression Study (TADS; Vitiello et al. 2009), acute interpersonal
conflict greatly predicted suicidal events. Patients must be monitored and
observed closely for long periods after an antidepressant has been started.
The FDA developed a medication guide recommending that children
treated with an SSRI be followed weekly during the first 4 weeks of treat-
ment and biweekly from weeks 4 to 8. Patients should subsequently follow
up with their physicians on a monthly basis beyond that time (U.S. Food
and Drug Administration 2007).
Anxiety Disorders
CBT and pharmacotherapy are the treatments with the broadest evidence
of efficacy for pediatric anxiety disorders. When CBT and medication are
used in combination, they are more efficacious than either treatment alone
(Walkup et al. 2008). As with major depression, SSRIs are the first-line
medication for the treatment of anxiety disorders. Three of the most rig-
orous randomized controlled trials (RCTs) investigated the efficacy of
treating children diagnosed with one or several anxiety disorders (i.e., gen-
eralized anxiety disorder [GAD], separation anxiety disorder, and social
phobia) with the following SSRIs: fluvoxamine (Research Unit on Pediat-
ric Psychopharmacology Anxiety Study Group 2001), fluoxetine (Birma-
her et al. 2003), or sertraline (Walkup et al. 2008). Each of these studies
provides strong evidence for the efficacy of SSRIs in treating GAD, social
phobia, and/or separation anxiety disorder.
Studies have demonstrated the efficacy of sertraline and venlafaxine
ER (Rynn et al. 2001, 2007) for the treatment of GAD. Paroxetine (Wag-
ner et al. 2004a), fluoxetine (Beidel et al. 2007), and venlafaxine ER
(March et al. 2007) have been found beneficial in the treatment of social
anxiety. Alprazolam in a very small trial of avoidant adolescents demon-
strated benefit but lacked statistical significance over placebo (Simeon et
al. 1992).
For panic disorder, daily use of paroxetine demonstrated significant im-
provement in subjects, with only transient and mild adverse effects asso-
ciated with higher doses (Masi et al. 2001). In addition, an open case series
documented the benefits of citalopram in school refusers with panic dis-

order (Lepola et al. 1996).
Both fluvoxamine (Labellarte et al. 1999) and sertraline (March et al.
1998) have FDA approval for the treatment of obsessive-compulsive dis-
order (OCD) in patients ages 8–17 and 6–17, respectively. Fluoxetine has
been found to be effective and is currently FDA approved for the treat-
ment of pediatric OCD in patients ages 7–17 (Rossi et al. 2004). As com-
pared with other anxiety disorders, OCD symptoms often need to be
treated with higher dosing.
Attention-Deficit/
Hyperactivity Disorder
Hundreds of studies conducted since the 1960s have consistently shown the
efficacy of stimulant medication in improving symptoms associated with
ADHD in children and adolescents. The recommended initial psychophar-
macological treatment of ADHD is a trial with one of the medications cur-
rently approved by the FDA (Pliszka 2007). The FDA-approved stimulant
medications for the treatment of ADHD include dextroamphetamine,
D- and D,L-methylphenidate, mixed amphetamine salts, and lisdexamfet-
amine. The two nonstimulant medications that are currently FDA approved
for ADHD are atomoxetine and guanfacine XR. It is believed that inatten-
tion and/or hyperactivity may be the result of insufficient dopamine and
norepinephrine activity. Stimulant medication primarily increases synaptic
concentrations of dopamine whereas nonstimulant medications, such as ato-
moxetine, increase norepinephrine synaptic concentrations (Solanto 1998).
Evidence reflecting the benefits of stimulant medication was demonstrated
by the Multimodal Treatment Study of Children With ADHD (MTA),
which is detailed in the section “Review of Combination Treatment,” in
“Attention-Deficit/Hyperactivity Disorder” later in this chapter.
Some of the better-known adverse effects associated with stimulant
use are suppression of appetite, weight loss, insomnia, and headache. Chil-
dren with a preexisting heart condition should receive a consultation with
a cardiologist before initiation of treatment with a stimulant medication
(Pliszka 2007). According to Mosholder et al. (2009), symptomatology
consistent with psychosis or mania may arise during treatment with stim-
ulants and represents adverse effects. It is controversial whether or not tics
occur more often in children and adolescents treated with stimulant med-
ication. Some researchers have found that most tics that emerge during
treatment are transient, and chronic tics are rather rare (Gadow et al.
1999). In children and adolescents with comorbid Tourette’s syndrome
and ADHD, 30% of patients experienced an exacerbation of tics while on

stimulant medication (Castellanos et al. 1997). Further investigation is
needed to make definitive statements concerning the relationship between
tics and stimulant medication.
Adverse effects, which must be monitored when a patient is taking the
norepinephrine reuptake inhibitor atomoxetine, include gastrointestinal dis-
tress, sedation, and decreased appetite. The FDA has issued black box warn-
ings for atomoxetine, because of risks of hepatotoxicity and suicidality. The
literature also supports the use of alpha-adrenergic agonists such as clonidine
and guanfacine (both FDA approved) as second-line treatments (Newcorn
et al. 1998). Other agents such as bupropion, desipramine, and modafinil
have shown efficacy and are currently recommended as second-line treat-
ments for ADHD (Banaschewski et al. 2004). When patients do not re-
spond to either stimulant medication or atomoxetine, the two medications
can be combined with good effect; however, more research is needed in this
area to establish the safety of this combination (Brown 2004).
Review of Combination Treatment

Since 2000, numerous trials have demonstrated the efficacy of CBT for
various psychiatric disorders; Chapters 1 and 2 present the studies sup-
porting this evidence-based treatment for children and adolescents. A
common approach used by clinicians is the combination of medication and
CBT for residual symptoms. There is growing evidence for the efficacy of
combination treatment for childhood psychiatric disorders. This section
reviews the evidence, issues to consider, and approaches to the childhood
psychiatric disorders of depression, anxiety disorders, and ADHD. Appen-
dix 4–A at the end of this chapter summarizes the evidence for these ap-
proaches in children and adolescents.
Depression
There has been empirical support for the combination of CBT and phar-
macotherapy for depressive disorders.
TADS (March et al. 2004) was a large, multisite study designed to com-
pare four different interventions: CBT alone, fluoxetine alone, CBT plus
fluoxetine, and CBT plus placebo. The trial showed that combination treat-
ments held an advantage over CBT or pharmacotherapy, specifically for ad-
olescents with moderate to severe depression. The combination (fluoxetine
plus CBT) was superior to placebo plus CBT, to fluoxetine alone, and to
CBT alone. Additionally, fluoxetine alone was superior to CBT alone.
Because only about 60% of adolescents with depression show an ade-

quate clinical response to initial treatment trial with an SSRI, the Treatment
of SSRI-Resistant Depression in Adolescents (TORDIA; Brent et al. 2008)
RCT studied the relative efficacy of four treatment strategies in adolescents
who continued to exhibit depression despite an adequate medication trial.
The interventions included switching to a different SSRI, switching to a dif-
ferent SSRI plus CBT, switching to venlafaxine, or switching to venlafaxine
plus CBT. The authors concluded that for adolescents with depression who
had not responded to an adequate initial treatment with an SSRI, the com-
bination of CBT with a switch to another antidepressant resulted in a higher
rate of clinical response than did a medication switch alone. Of note, a switch
to another SSRI was just as efficacious as a switch to venlafaxine and resulted
in fewer adverse effects. Predictors of better response to pharmacological
management include less severe depression, less family conflict, and the ab-
sence of nonsuicidal self-injurious behavior.
Clarke et al. (2005) tested a collaborative care CBT program adjunc-
tive to SSRI treatment in a primary care setting (treatment as usual). They
detected a weak CBT effect and small, incremental improvements com-
pared with monotherapy.
Goodyer et al. (2007) concluded that for adolescents with major depres-
sion, there is no evidence that the combination of CBT plus an SSRI in the
presence of routine clinical care contributes to an improved outcome com-
pared with the provision of routine clinical care plus an SSRI alone.
Melvin et al. (2006) compared CBT alone, sertraline alone, and their
combination in treatment of adolescents with depression. The authors
concluded that while all treatments led to a reduction in symptoms of de-
pression, the advantages of a combined approach were not evident.
In summary, studies of combined treatment for major depressive dis-
order have shown conflicting results but overall support consideration, es-
pecially if monotherapy fails (e.g., Melvin et al. 2006). However, further
research is needed to help identify patient clinical characteristics that
might direct a clinician to consider initiating a combination approach first.
Anxiety Disorders
In the treatment of anxiety disorders, both CBT and pharmacotherapy are
considered efficacious as monotherapies; however, often symptom resolu-
tion is not complete, and many patients remain symptomatic. Additionally,
predictors and moderators have been difficult to identify from these stud-
ies (Compton et al. 2004). Until recently, only a scarcity of research dem-
onstrated the relative or combined efficacy of these interventions. Over
the past several years, the field of mental health has focused on studying
the effectiveness of combination versus monotherapy treatment of a vari-

ety of disorders. The Child/Adolescent Anxiety Multimodal Study
(CAMS; Walkup et al. 2008) was a multisite RCT of 488 children (ages
7–17 years) with a primary diagnosis of an anxiety disorder (separation
anxiety disorder, GAD, social phobia). Subjects were assigned to one of
the four treatment arms: CBT only, pharmacotherapy only (sertraline 25–
200 mg), combination of CBT and sertraline, or placebo only. Monother-
apy with either CBT or pharmacotherapy reduced the severity of anxiety,
but the combination of the two therapies showed a superior response rate.
All treatments were found to be safe and well tolerated.
The Pediatric OCD Study (POTS) was designed to look at the com-
bined efficacy of CBT and pharmacotherapy. Patients treated with CBT ei-
ther alone or in combination with medication showed more improvement,
with a slightly superior response rate seen for combination therapy as op-
posed to CBT alone (Pediatric OCD Treatment Study (POTS) Team
2004). Sertraline was shown to be more effective than placebo, but the ef-
fect size of improvement was smaller than that of CBT alone. Thus, the
authors concluded that children and adolescents with OCD should be
treated with CBT alone or CBT plus an SSRI.
There has been considerably less work studying the efficacy of com-
bined treatments for posttraumatic stress disorder (PTSD). Cohen et al.
(2007) examined the potential benefits of adding an SSRI (sertraline) to
trauma-focused CBT for improving PTSD and related psychological symp-
toms in children who experienced sexual abuse. Only minimal benefit was
noted in adding sertraline to trauma-focused CBT. The authors concluded
that an initial trial of trauma-focused CBT or other evidence-supported
psychotherapy should be started for most children with PTSD symptoms
before adding medication (Cohen et al. 2007).
Overall, there is support for the use of combined CBT and pharmaco-
therapy for maximum benefit in the short-term treatment of anxiety dis-
orders. Future studies will need to assess the long-term efficacy and safety
of this combined approach.
Attention-Deficit/
Hyperactivity Disorder
The largest clinical trial conducted to evaluate the efficacy of different
treatment modalities for ADHD is the MTA. The study found that at
14-month follow-up, the combined treatment arm (stimulant and behav-
ioral treatment) and stimulant treatment alone provided greater symptom
improvement for core symptoms of ADHD than did the behavioral treat-
ment arm (MTA Cooperative Group 1999). At 24-month and 8-year fol-
low-ups, the greatest predictors of outcome were initial severity of
symptoms and continued medication compliance (Molina et al. 2009). In-
terestingly, when areas of functioning were reviewed—such as opposi-
tional or aggressive symptoms, internalizing symptoms, teacher-rated
social skills, parent-child relations, and reading achievement—combina-
tion treatment was consistently more effective than routine community
care, whereas medication alone and behavioral treatment alone were not
as effective (MTA Cooperative Group 1999). However, these longitudinal
findings need to be interpreted with caution because no random assign-
ment was in effect, and children in all the “conditions” were receiving as-
sorted treatments and a variety of self-selected combinations.
Clinical Implication and Application

In the preceding sections, we have outlined the evidence for use of pharma-
cotherapy and for combined treatment with pharmacotherapy and CBT. Ev-
idence for such interventions is seen across various disorders, with the most
compelling evidence existing for depression and anxiety. Despite emerging
evidence in recent years for combined treatments, a clinician often still faces
a dilemma in making a careful determination as to which intervention ap-
proach will provide the best result and the needed relief of symptoms. Al-
though evidence to date suggests that for some disorders, beginning with a
combined treatment strategy is most effective, careful consideration should
be taken when deciding to initiate pharmacotherapy, especially if psychother-
apy alone could result in a significant reduction of symptoms. Lacking specific
guidelines to determine the appropriate modes of treatment for particular
disorders, clinicians commonly use their best clinical judgment on the basis of
their sum total of clinical experiences. This variability in approach among cli-
nicians leads to suboptimal treatment response.
Although no one strategy will fit all cases, a careful assessment should
help clinicians identify factors that could guide them in making their clin-
ical decisions. Such an approach by no means guarantees success, but it can
help clinicians more confidently select an approach that might lead to
greater treatment success for the patient.
Clinical Characteristics
In selecting an individualized treatment strategy, we recommend a de-
tailed assessment, with particular attention to the factors discussed in the
remaining sections of this chapter. With attention to these factors, clini-

cians can make informed decisions regarding which intervention to choose
first and if unsuccessful, when a given intervention should be changed or
augmented with another treatment. These factors may have value in in-
forming the treatment selection process. We have provided three main
categories, and discussion of the various factors within these categories fol-
lows.
1. Patient factors
2. System factors
3. Practitioner factors
For example, since 2000, most of the studies investigating combination

treatment recruited adolescent populations, with the majority in the age
range of 12–18 years (TADS, March et al. 2004; TASA, Brent et al. 2009;
TORDIA, Brent et al. 2008). The mean age for many of the trials is ap-
proximately 15 years. In a clinic population, it is not uncommon to see
children ages 7–12 years or even younger presenting with anxiety or de-
pressive disorders. Therefore, even if medications are considered, families
and most practitioners typically prefer CBT for the younger age group.
Thus, the age of the child at presentation becomes an important factor in
determining which intervention to choose first.
Patient Factors
Patient Perspective
Patients may envision themselves playing an important role in their treat-
ment. They may want to be an active participant in the treatment process.
Such individuals readily agree to a CBT approach. Other patients, how-
ever, may want their treatment driven by the clinician only. These patients
may not be strong candidates for CBT, and pharmacotherapy may be more
acceptable to them.
Prior experience of treatment. A patient’s prior experience with an in-

tervention has a significant impact on his or her current choice for treat-
ment. Individuals who have had a positive experience with psychotherapy
in the past are more likely to reengage in psychotherapy. Similarly, a posi-
tive experience with medications (for medical or psychiatric reasons)
makes the patient more willing to agree to a medication trial. It is essential
that clinicians build on the positive transference for a successful outcome.
It is also important for the clinician to explore the meaning of medication
and taking medication, as patients’ perspectives on their treatment may

have a major influence over outcomes.
Patient preference. As noted above, a patient’s preference is generally

guided by his or her prior experience. However, at times it could be in-
formed by other factors, such as information regarding treatments ob-
tained from the Internet, social networking Web sites, health educators at
school, peer opinions, and most importantly, family members. It is impor-
tant for clinicians to educate the patient and family about all potential
treatment options and assist them in making an informed treatment deci-
sion after discussing the pros and cons of each intervention. Clinicians
should be respectful of the patient’s preference in choosing an interven-
tion; this will lead to an improved therapeutic alliance and increased treat-
ment success. Psychoeducation regarding the biological basis of many
disorders and the role of medications, discussion regarding stigma of being
on medications, and alleviating fears pertaining to side effects are essential
components of psychopharmacological interventions and should be used
to help the patient make an informed decision.
Understanding of illness. Patients who conceptualize their illness on

the basis of a medical model are more likely to agree to a medication trial
or a combined approach. If depression is understood as a disorder that has
resulted from a “chemical imbalance” or “dysregulated neurotransmit-
ters,” then the patient may view it as a fixable problem, correctable with
medication. On the other hand, if patients believe that their illness has
been caused by their being “weak” (psychologically), or that their illness
results from stress or being overwhelmed by external factors such as
school, then they may feel more comfortable with CBT so that they can
learn skills to cope with their problems.
Irrespective of the intervention chosen, psychoeducation is a key com-
ponent of treatment. Clinicians should help patients understand the diathe-
sis-stress model: the complex interaction of biological and genetic factors
(predisposition) with the environment and life stressors (Morley 1983).
This concept promotes the use of a combined approach, and patients will
see the benefit of each intervention. CBT helps patients learn ways to miti-
gate stress, solve problems, and develop coping skills, whereas medications
tend to address the physiological and biological aspects of the illness.
Psychological mindedness. Patients with cognitive limitations may

not be able to engage with CBT. These patients may be concrete and in-
flexible in their thinking, making the process of rendering CBT difficult.
However, this is not necessarily an excluding factor. Clinicians need to
modify their techniques and treat patients according to their intellectual

and emotional age rather than their chronological age. Clinicians also could
emphasize more of the behavioral aspects of the treatment over the cogni-
tive components. Patients with cognitive limitations may more often re-
ceive treatment with medications in combination with supportive therapy.
In contrast, patients who have greater strengths verbally and who are psy-
chologically minded have the potential to be strong candidates for CBT.
These patients can implement newer skill sets. However, for a variety of
patients, CBT principles can assist with pharmacological management
(e.g., monitoring of progress and adherence).
Symptom Severity
It is essential to assess the severity of symptoms before determining which
intervention should be initiated first (CBT, pharmacotherapy, or com-
bined). Clinical wisdom supports the recommendation that the more se-
vere the symptoms, the more strongly medication should be considered.
Some clinicians might consider pharmacotherapy as the only intervention.
This is more likely to be the case for disorders such as ADHD, for which
the evidence of medication as the main intervention is very strong.
For depressive and anxiety disorders, if the severity is mild, then the
recommendation is to initiate CBT first. Continuous monitoring is needed
and a switch to a combined approach should be made if symptoms worsen.
For moderate to severe symptoms, medications (alone or combined with
CBT) are recommended. Data from TADS (March et al. 2004) indicates
that adolescents with moderate to severe depression have the best chance
of clinically significant improvement at 12 weeks if they start with a com-
bination of medication and CBT. Similarly, for moderate to severe anxiety
disorders, recent research supports the use of combined treatment
(Walkup et al. 2008). With medication treatment, symptom reduction is
seen as early as week 3 or 4; and with CBT, symptom reduction occurs
later in treatment (Keeton and Ginsburg 2008). Furthermore, early im-
provement also leads to overall successful treatment (Westra et al. 2007).
Although previous studies recommended CBT for mild to moderate
pediatric anxiety cases only (James et al. 2005), more recent evidence
from CAMS (Walkup et al. 2008) shows that CBT is an effective interven-
tion for patients with moderate to severe symptoms and is a relatively risk-
free intervention compared to pharmacotherapy. However, patients might
not be able to participate in CBT if they have significant symptoms. Severe
symptoms could become a hindrance to compliance with psychotherapy
appointments and could also lead to a general feeling of hopelessness and
a pessimistic outlook (e.g., “I am feeling terrible, and it is too hard to do
the things I need to feel better”). Therefore, in severe cases, the combined
approach should be considered as first-line treatment.
Notwithstanding, a combined approach can have its challenges. For ex-
ample, symptom reduction with medication could make implementing
CBT difficult: in a patient who no longer has anxiety arousal or symptoms,
it is difficult to teach the skills necessary to cope effectively with those
triggers. Severity of symptoms is an important factor in determining which
intervention to choose first, and a combined approach of CBT and phar-
macotherapy is recommended if symptoms are severe.
Symptom type. Clinicians recognize that symptoms often vary among

patients with the same diagnosis. There could be a predominance of a sub-
set of symptoms, or a particular symptom (e.g., insomnia) could be the
cause of most impairment for the individual. Therefore, the clinician
should note the key symptoms that constitute the illness. Patients with de-
pression and/or anxiety can present with a vast array of symptoms that can
be classified as 1) physiological symptoms or 2) cognitive symptoms or
maladaptive behaviors.
Physiological or neurovegetative symptoms of depression, such as insom-
nia, decreased or increased appetite, weight loss or weight gain, decreased
energy, and poor concentration, generally respond well to medications. If
any of the aforementioned symptoms are a significant part of the patient’s
presentation, medications should be strongly considered. Similarly, physio-
logical symptoms of anxiety disorders, such as insomnia, palpitations, sweat-
ing, and increased heart rate, do also respond to medications such as SSRIs
or benzodiazepines. Regulation of physiological symptoms leads to quick re-
duction in distress and impairment and therefore increases compliance with
the intensive work of CBT, both in session (e.g., exposures) and outside ses-
sion (e.g., homework assignments).
If the patient’s symptom pattern is overwhelmingly that of hopeless-
ness, distorted thinking, guilt, and avoidance behaviors, then a trial of CBT
is warranted. CBT techniques focus on identifying triggers for automatic
thoughts, reframing and replacing maladaptive patterns of thinking (cogni-
tive distortions), problems solving, self-regulation, relaxation training, so-
cial skills, anger management, and contingency management. CBT also
helps in providing a framework to understand the role of medication and
so helps in improving medication adherence.
The patient’s symptoms can guide the clinician in choosing which in-
tervention to start with (CBT vs. pharmacotherapy), although in many
cases a combined approach might be the best, especially if the profile re-
flects a combination of symptoms. A combined approach is likely to yield
better results as evident from faster improvement, greater symptom reso-
lution, and increased sustainability of improvement (March et al. 2004;

Walkup et al. 2008). Because the different approaches are not necessarily
isolated entities, synergistic effects are often seen when the same symp-
tom is targeted using a combined approach. For example, insomnia is
quickly and effectively treated with both CBT and medication: pharmaco-
therapy can treat the immediate symptoms, and CBT techniques can pro-
vide a basis for preventing future psychopathology when the patient
learns, for example, stress management skills.
Case Example
Feliciana is a 10-year-old Latino girl with no formal psychiatric history who
was referred by her pediatrician to the emergency room secondary to impair-
ing symptoms of anxiety over the past 2 months. At presentation, Feliciana
reported daily symptoms of nausea, vomiting, trembling, feeling nervous,
and school refusal. Other symptoms included initial insomnia >3 hours (as
a result of worrying about school), appetite disturbance (not eating anything
during school time and nighttime overeating), and having occasional feelings
of dizziness. She also reported feeling sad, frustrated, and overwhelmed. The
mood symptoms were in the context of her getting “tired” of her anxiety.
Onset of symptoms was described as “sudden,” and a recent change in school
with subsequent difficulty in adjusting to the new environment was the main
stressor. She reported a long-standing history of excessive worries. The wor-
ries were about her school performance, the health of her mother, the rela-
tionship between her parents, earthquakes, and someone breaking into their
house. She reported symptoms suggestive of a panic attack (heart beating
too fast and breathing rapidly). She was medically discharged from the
emergency room and given a provisional diagnosis of GAD; separation anxi-
ety disorder and panic disorder were ruled out.
Although CBT was the preferred intervention by the parent, consider-
ing the severity of symptoms (progressive worsening of anxiety leading to
school refusal) and symptom profile (severe insomnia and other physiolog-
ical symptoms), a combined approach (CBT and fluoxetine) was recom-
mended and agreed on. Fluoxetine was started at 10 mg for 2 weeks and
then increased to 20 mg. Psychoeducation was provided to the parent by
discussing the disorder, its course, and the role of medications in address-
ing target symptoms of anxiety and insomnia. By week 3, Feliciana re-
ported some improvement in her anxiety symptoms, especially with
respect to her insomnia and feeling less overwhelmed. The CBT therapist
focused on psychoeducation, identification of triggers, relaxation breath-
ing, cognitive restructuring, problem solving, and behavior modification.
Feliciana was maintained at that dose for the next 5 months. She was able
to successfully start attending school on a regular basis after week 6 of
treatment. By week 12, Feliciana reported significant improvement in
symptoms, with resolution of most of her symptoms. CBT was tapered to
once every 2 weeks and then monthly sessions. Feliciana has been attend-
ing school regularly and has been symptom-free for the past 4 months.
This case highlights the effectiveness of a combined approach. Partici-

pation in psychotherapy was assessed to be difficult because of the severity
of symptoms. A clinician could argue that CBT alone on a trial basis could
have been employed first, but given the symptom severity, presentation to
the emergency room, and a concern that the patient may have struggled
initially with the CBT work, a combined approach was deemed appropri-
ate. The synergistic effects of medication and CBT were seen in this case.
Comorbidity. Comorbidities are extremely common and are viewed by

many clinicians as a rule rather than an exception for pediatric psychiatric
disorders. For example, oppositional defiant disorder (ODD) is commonly
seen as a comorbid disorder in children with ADHD. Other common
comorbidities with ADHD include learning disorders, depression, and
anxiety disorders. Although medications are considered the first-line in-
tervention for children with ADHD, a combined approach is recom-
mended if there are significant comorbid disorders. Parent training for
ADHD and ODD and behavioral modification therapy for ODD are effec-
tive interventions to implement in such cases. Additional measures such as
appropriate classroom placement are helpful to address comorbid learning
disorders if present. As shown by the MTA, behavioral therapy can address
non–core symptoms of ADHD, such as poor social skills and low self-
esteem (MTA Cooperative Group 1999). For patients with primary de-
pressive and anxiety disorders, pharmacotherapy or CBT might be the
only intervention indicated in the absence of comorbidities. However, for
significant complex comorbidities, such as social phobia with ADHD and
mood disorders, combined treatment may be warranted. Of note, with co-
morbid substance use, medication management may be challenging and
risky for patients who are actively abusing substances. Specialized CBT for
this patient population would provide an important treatment component.
Comorbidities generally indicate the need for a combined approach for
better outcomes.
Treatment Response
In patients who started with monotherapy (CBT or pharmacotherapy
alone), lack of improvement or suboptimal improvement after 6–8 weeks
of treatment typically becomes an indication for a combined approach
(Keeton and Ginsburg 2008). Provided that the lack of improvement is
not due to noncompliance with recommendations (therapy or medica-
tions), it is reflective of the severity of illness and lack of response to one
intervention. An alternative to a combined approach would be to intensify
the same intervention; for example, the therapist could increase CBT ses-
sions to twice weekly or the psychiatrist could increase the dose of medi-
cation or add other agents.
Case Example
Jonna, a 14-year-old Jewish adolescent girl in ninth-grade regular education
at a coed Jewish private school, presented to the outpatient clinic with
symptoms of inattention, distractibility, and poor organization. Other
symptoms included losing items (like her debit card), impulsivity related
to speaking out of turn, and poor concentration. Symptoms of inattention
and impulsivity were negatively impacting her academics regarding time
needed to complete her assignments, ability to focus in school, and her
peer relationships. Regarding her symptoms of inattention, Jonna and her
parents noted that she frequently made careless mistakes in her homework
and exams, often appeared dazed (as reported by teachers and peers), had
difficulty organizing tasks, forgot to hand in homework assignments that
were completed, and was easily distracted. Hyperactive and impulsive
symptoms that were currently noted included fidgeting, appearing as if she
was driven by a motor, talking excessively, blurting out answers in class be-
fore being called on, and often interrupting others in conversation.
Jonna was previously diagnosed with ADHD, combined type, at age 7
and was successfully treated with Adderall XR, 30 mg, until age 13. About
1 year ago, medication had been discontinued by her parents.
Jonna met criteria for ADHD and was willing to restart medications. Ad-
ditional areas of clinical concern included Jonna’s anxiety related to succeeding
at school and being a competitive candidate for college. In light of her strong
desire to apply to a number of competitive universities, Jonna had signed up
for a plethora of extracurricular activities at school, including the environmen-
tal and drama clubs, debate and soccer teams, and art group. Jonna did not
meet criteria for a specific anxiety disorder but had worries and anxiety related
to school pressure, measuring up to her peers and older sibling, and meeting
her future goals. Family history was relevant for anxiety disorder (mother, suc-
cessful remission of symptoms following psychotherapy), bipolar disorder (fa-
ther), and suicide (paternal uncle with unknown psychiatric diagnosis).
Jonna was restarted on medication, and immediate improvement in
symptoms of ADHD was noted. Benefits far outweighed the side effects
(mild loss of appetite). However, over the next several months, her anxiety
symptoms worsened, which resulted in more impairment and academic
decline. This led to negativistic thinking (“I will never get better”), sad
mood, low self-esteem, and hopelessness. Jonna recognized the need to
seek treatment for her anxiety and depressive symptoms to achieve overall
better outcome. The possibility of stimulants worsening her anxiety was
considered, but this seemed unlikely because Jonna was persistently anx-
ious even during times of an extended drug holiday. The need for medica-
tions to address ADHD was clear, but the question was, “Should we treat
comorbidities with an SSRI, CBT, or a combined approach?”
Owing to successful remission of core symptoms of ADHD on medi-
cations, Jonna initially expressed willingness for a medication trial of an
SSRI to target symptoms of anxiety as well. We conducted a detailed as-
sessment of all factors to decide the next intervention. Her symptoms of

anxiety and depression were mild to moderate in severity. Her symptom
profile was suggestive of symptoms being primarily “cognitive” as opposed
to “physiological.” Jonna’s mother had had a positive experience in psycho-
therapy to achieve remission of anxiety symptoms. Other factors we con-
sidered included Jonna’s high IQ, her being articulate and psychologically
minded, and her understanding of anxiety disorder (in her own words, “it
is an excess of normal anxiety, which gets exacerbated by stress”). Jonna
was available to commit to weekly therapy sessions, and she expressed ea-
gerness to learn a new skill set to address her symptoms. She also felt that
although core symptoms of ADHD were in good control, she still needed
to learn to be less forgetful and more organized, and she wanted to aug-
ment positive effects of medication treatments. All of the above led us to
recommend CBT along with continuation of stimulants for ADHD.
Six weeks after initiation of CBT treatment, Jonna reported symptoms
being less intense. Seeing early improvement and excellent participation and
compliance, we decided to continue with CBT as the monotherapy to ad-
dress symptoms of anxiety and depression. However, 1 week after this deci-
sion was made, Jonna reported worsening of symptoms (new stressors had
emerged). Lack of improvement was evident at subsequent sessions. At
week 10, a medication consult was done and an SSRI recommended along
with continuation of CBT (combined approach). After 4 months of CBT and
medications, Jonna’s symptoms completely resolved. She discontinued the
SSRI after 6 months of treatment and continued with CBT and Adderall XR
for her ADHD. Jonna went on to do exceedingly well in school.
This case highlights several important steps in determining which in-

tervention to choose. Following a careful assessment of a variety of factors,
we initially considered only CBT to be a reasonable choice. However, ow-
ing to lack of significant improvement at week 8, a combined approach was
chosen, to which the patient responded well.
System Factors
In addition to patient factors that may influence clinical decision-making
regarding the use of a specific treatment approach, system factors also me-
diate treatment choices. These system factors are especially critical to con-
sider when working with youth, because these patients are heavily
dependent on and influenced by the family, social, school, and cultural sys-
tems in which they are embedded.
Parental Attitudes
Treatment choice. In most cases, parents are the ultimate arbiters of
the type of treatment in which their child will engage. The way parents
conceptualize the nature of their child’s psychiatric condition and associ-
ated treatment needs following the assessment and recommendations of a

mental health professional is often linked to their own personal prefer-
ences, understanding, and experiences. One issue that Moses (2011) high-
lighted is the extent to which parents believe a diagnosis to be credible or
accurate. Generally speaking, a strong treatment alliance between clinician
and parent is widely acknowledged in the literature as a significant variable
in promoting adherence to treatment (American Academy of Child and
Adolescent Psychiatry 1998). Strengthening the alliance between parents
and the clinicians treating their children is an especially important goal, be-
cause if a parent trusts the integrity of the diagnostic process as well as that
of the clinician, he or she is more likely to trust the verity of a diagnosis
and to accept and ultimately follow through with a given treatment rec-
ommendation for the child, be it in favor of a single or combined approach.
Parental attitudes about psychiatric treatment for their child can also
be shaped by their own psychiatric history and/or experiences with mental
health professionals (Moses 2011), as illustrated in the following case ex-
amples.
Case Examples
Mariela is the 50-year-old mother of a 16-year-old girl with major depres-
sion. At the age of 45, Mariela was prescribed an SSRI for symptoms asso-
ciated with a debilitating major depressive episode; she reported not liking
“the way it made me feel” and stopped taking her medication against med-
ical advice. She explained that her negative experience was exacerbated by
the fact that “my doctor didn’t listen to me.” Consequently, she was ex-
tremely reluctant to even consider employing psychotropic medication
when the recommendation was made by her daughter’s clinician after a
trial of CBT failed to address some unremitting neurovegetative symptoms
of the illness.
Paula is the 40-year-old mother of a 10-year-old girl with impairing symp-

toms of social anxiety. During the first appointment of her daughter’s psy-
chiatric evaluation, Paula detailed her own experience with severe anxiety
and outlined a family history significant for anxiety disorders and depres-
sion. She immediately advocated for the use of psychotropic medication to
address her daughter’s symptoms because she had found them helpful in
the treatment of her own anxiety disorder. She expressed this preference,
as well as an understanding of the role of genetic factors involved in psy-
chiatric disorders, in the following statement to the intake clinician: “Why
make Rebecca wait for longer than she should to feel some relief? I did the
whole psychotherapy stuff first, and yeah, I learned some things—but at
the end of the day, my body was my body and my genes were my genes,
and the feelings were often too difficult to bear. Unfortunately, Rebecca is
blessed with the same curse.”
The latter case example (Paula) illustrates the position of Moses

(2011) that those parents who have participated in their own mental
health treatment in the past may be ultimately more inclined to concep-
tualize their children’s psychiatric issues in a manner consistent with men-
tal health professionals’ diagnostic and treatment paradigms, and they are
perhaps more sensitized to a medical conceptualization of their children’s
psychiatric condition. On some occasions, a parent’s mental illness may
negatively impact the parent’s effectiveness in accessing mental health
treatment for the child, as in the case of maternal depression (Ryan 2003).
A parent’s distress about the prospect of, for example, the child taking
psychotropic medications on a long-term basis for the treatment and pre-
vention of major depressive episodes will influence treatment plan imple-
mentation (Ryan 2003). How parents comprehend the scope and context
of their child’s problems and the attitudes they possess about treatment
are important variables to consider when deciding on and recommending
a treatment approach.
Demographics. A number of demographic variables are likely to influ-

ence parental attitudes about mental health treatment and parents’ styles
of managing their children’s mental health issues. One variable is a parent’s
level of educational attainment. Less-educated parents are less likely to
use psychiatric terms to explain their child’s problems (Moses 2011),
which may result in negative attitudes about a medical conceptualization
of their child’s mental health problems and the use of psychotropic med-
ication, for example. In general, higher rates of noncompliance with both
medication and psychotherapy were discovered among families of children
from lower socioeconomic backgrounds (Brown et al. 1987). Demo-
graphic variables were also examined in a study of the use of psychostim-
ulant drugs in children across the United States, which found a positive
correlation between the use of psychostimulants and a higher level of af-
fluence, geographic regions with greater population density, and higher
rates of health care access (Bokhari et al. 2005).
Race, culture, and ethnicity also contribute greatly to parental atti-
tudes about mental health conceptualization and treatment. For example,
African American families tend to be skeptical of more medicalized, po-
tentially pathologizing ways of understanding, talking about, and treating
their children’s mental health issues (Carpenter-Song 2009; Moses 2011),
whereas European Americans are more inclined to consider neurobiologi-
cal explanations for behavioral and emotional problems and are therefore
more open to the use of psychotropic medication in the treatment of their
children (Carpenter-Song 2009). Ultimately, these findings illustrate the
need for clinicians to assess the sociocultural lens through which patients
view different mental health treatment approaches, as covered in more de-

tail in Chapter 3.
Treatment compliance. Parental or familial attitudes about the child’s

mental health treatment impact the extent to which a family may be will-
ing and/or able to adhere to treatment recommendations. In general, con-
sistent parental involvement in the mental health treatment of the child,
whether in the case of a singular psychotherapy or pharmacotherapy ap-
proach or a combined approach, is critical—and assessing and acknowledg-
ing whatever attitudes about treatment a parent or caregiver may hold can
enhance treatment outcomes. CBT treatments for youth, such as the Cop-
ing Cat (Kendall 1990) and C.A.T. Project (Kendall et al. 2002) for the
treatment of anxiety disorders in children and adolescents, actively incor-
porate parent sessions into protocols, thus highlighting the need for family
involvement in psychotherapy in order to enhance positive treatment ef-
fects. Regarding the role of parents and family in a combined treatment
context, Diamond and Josephson (2005) advocated for a combined ap-
proach to treating ADHD that integrates pharmacotherapy and a psycho-
social family intervention in order to address parental concerns about
medication side effects, nurture parental competency, and target overall
family functioning in the support of better treatment engagement, reten-
tion, compliance, and achievement of treatment goals. A combined treat-
ment approach integrating individual and family-based psychosocial
interventions with pharmacotherapy was also favored in the treatment of
bipolar disorder in youth for similar reasons (Schenkel et al. 2008).
Logistical Concerns and

Availability of Resources
The level of parental impairment and logistical concerns (such as a parent’s
ability to get a child to treatment and the parent’s ability to afford treatment)
also influence treatment compliance and should be evaluated by the treating
clinician to help determine the treatment of choice. For Mona, a young single
mother of three, the likelihood of being able to get her 10-year-old daughter
to psychotherapy on a weekly basis was limited; for her, a once-monthly med-
ication management appointment with a psychopharmacologist was much
more feasible. In the case of Horacio, a single father, his own mental illness
limited his ability to competently administer psychotropic medication to his
12-year-old son, Michael, who had moderate symptoms of anxiety and de-
pression. Consequently, the clinician thought it more appropriate to focus on
supporting attendance at weekly individual psychotherapy sessions to address
Michael’s socioemotional concerns through CBT, and whenever and wherever

possible, to intervene at the family level to support an improvement in
Michael’s and the family’s overall level of functioning.
Health insurance. Access to mental health care is another system factor

that impacts clinical decision-making. Health insurance companies have
become a major influence in this regard; for example, many favor cheaper
drug therapy over more expensive counseling alternatives (Bokhari et al.
2005). This reality may increase access to psychotropic medication and
may ultimately strengthen a clinician’s recommendation for a combined
treatment when accompanied by data about the potency of such an ap-
proach in treating certain types of psychiatric disorders in youth. Unfortu-
nately, increasingly higher rates of uninsured patients have resulted in a
higher unmet need for care (Bruce et al. 2002).
Geography. Geography also plays a role in clinical decision-making. Prox-

imity to practitioners is one concern. In some communities, access to a mental
health practitioner qualified to provide psychotherapy or pharmacotherapy to
a child or adolescent may be limited. Bruce et al. (2002) pointed out how, in
rural communities, the greater the distance to health care providers, the lower
the rates of access to care and treatment for affective disorders in youth.
Given the larger number of children going to school with unmet mental health
needs, school-based mental health programs are important systems-level in-
terventions that can help bridge the gap between mental health providers and
children with mental health needs (Nemeroff et al. 2008).
Location of treatment is another consideration in clinical decision-
making. For instance, if a youth is being seen in a hospital-based clinic,
then greater access to psychopharmacologists may support a recommenda-
tion for pharmacotherapy.
Societal Factors
The larger social, intellectual, and political zeitgeist by which a child and
his or her family is influenced is another system factor that can inform the
clinician’s attitudes about treatment and associated treatment choices.
Stigma. In many societies, negative assumptions exist about mental health

issues and treatment. Mukolo et al. (2010) noted that children with mental
health concerns are particularly vulnerable to stigmatizing contexts, given
how dependent they are on others within their extended family and social
system to gain access to care. In recent years, the media attention paid to the
possible negative side effects of psychotropic medications in youth and the
consequent application of black box warnings on certain classes of medica-

tions have furthered the stigma about pharmacotherapy. In these instances,
the stigma associated with taking psychotropic medication is an example of a
barrier to effectively treating affective disorders in children (Bruce et al.
2002). In the case of Martina, a 15-year-old depressed adolescent, this stigma
was influenced by cultural factors. Her parents readily agreed to psychother-
apy but were resistant to pharmacotherapy because of the “bad things we
have heard lately”; their pessimistic view of allopathic approaches to health
care was prevalent in the close-knit South American community from which
the family had recently emigrated. This case highlights how geographical
proximity to others with similar perspectives serves to influence and normal-
ize individual attitudes about a certain issue.
Popular culture. A number of societal factors may contribute to more

positive, socially acceptable views of mental health treatment. In the United
States, for example, the high frequency of advertisements and information
about psychotropic medications evident in a wide variety of outlets such as
television, radio, the Internet, and print media has led to more widespread
knowledge and acceptance of pharmacotherapy as a viable treatment option,
which may influence parents to advocate more forcefully for a psychophar-
macological approach to treating their child’s mental illness, in spite of the
negative press (mentioned in the above paragraph) (Sparks and Duncan
2004). This shift is generally consistent with a movement in modern Ameri-
can culture to popularize psychology and mental health treatment in general,
and interacts with demographic and geographical factors that were men-
tioned above to influence treatment decisions. These ideas are reflected in
the statement of a 42-year-old mother of an 8-year-old son participating in
weekly individual CBT sessions for separation anxiety: “Everyone I know has
a kid who is either in therapy or is on meds for something or other if they are
not in therapy or on meds themselves. It is almost like ‘the thing to do’—
check that off the list along with extracurriculars and tutoring.”
Practitioner Factors
Both patient and system factors that inform decision-making practices for
the selection of a single or combined treatment are mediated by a third
variable: practitioner factors. The clinician should consider the influence
of his or her own specific characteristics when making treatment recom-
mendations and/or assisting youth and families with the treatment deci-
sion-making process. The following factors should be considered:
• Qualifications of the practitioner can influence the treatment choice

made. Is the practitioner who is considering a single or combined treat-
ment a psychologist or psychiatrist? Clearly, the educational background,

knowledge of the research base demonstrating efficacy and effectiveness
of various treatment approaches to treating youth, awareness of practice
recommendations about treating youth with mental health needs (Win-
ters and Pumariga 2007), and expertise and comfort level of a practitioner
in the areas of CBT and pharmacotherapy are related to other important
practitioner characteristics, such as practitioner preferences, attitudes,
and biases, that dictate treatment decision-making practices (American
Academy of Child and Adolescent Psychiatry 1998).
• Age of the practitioner has been cited in the literature as relevant to
clinical decisions. It seems that there is a higher ratio of younger phy-
sicians to older practitioners willing to prescribe psychotropic medica-
tions, a more recent statistic possibly linked to changes in medical
training—namely, a greater emphasis on the role of psychotropic med-
ication in treating mental health conditions.
• Insurance company influence impacts practitioners’ choices, as it does
families and consumers of health care services in general. In the current
health care climate, practitioners are pressured by a need to be held ac-
countable to both consumers and third-party payers for the effectiveness
and efficacy of interventions, increasing the amount of pressure they face
to balance issues such as service, cost, and treatment outcome in a man-
aged care context (Burlingame et al. 2001). How a practitioner balances
these issues directly affects treatment decision-making practices.
Conclusion
CBT and pharmacotherapy have been shown to be efficacious interven-
tions to treat many psychiatric disorders in children and adolescents. It is
not uncommon for clinicians to use a combined treatment approach (CBT
plus medication) to improve outcomes when the use of a single interven-
tion is suboptimal and/or symptom remission is incomplete. In recent
years, empirical support for use of the combination treatment approach
has grown; however, there is still the need for developing guidelines to di-
rect when to use these treatments alone or in combination, as well as
guidelines for sequencing approaches.
We suggest that a detailed assessment with special attention to child and
parent factors and system factors would assist a clinician in making treatment
decisions. In addition, there are certain practitioner factors that could influ-
ence the choice of the treatment approach. Consideration of all these factors
and creation of an inventory of the patient’s clinical characteristics will help
clinicians in providing individualized care and achieve the desired outcome.
With the encouraging results of major studies conducted since 2000,

which indicate a promising outcome for a combined treatment approach,
future research is needed to help understand the moderators and media-
tors of an optimal treatment response.
Key Clinical Points

• There are times when the primary diagnosis necessitates a com-
bined treatment approach of CBT and pharmacotherapy (e.g.,
mood and anxiety disorders, attention-deficit disorder or ADHD).
• Efficacy of the combined treatment approach to treat a variety of

psychiatric disorders in youth (e.g., anxiety, depression, ADHD) is
supported by research findings from major studies such as the
Treatment for Adolescents with Depression Study, Treatment of
SSRI-Resistant Depression in Adolescents, Pediatric OCD Study,
Children/Adolescent Anxiety Multimodal Study, and Multimodal
Treatment Study of Children With ADHD.
• Many factors guide clinical decision-making in the recommendation
of a specific treatment approach; it is important to consider these
factors in the context of a thorough case evaluation and assessment
before making treatment decisions.
• Assessment will result in an inventory of clinical characteristics that
reflect the child and parent factors, the context of the system factors,
and the role of the practitioner making the recommendation.
• The available evidence suggests that the use of combination treatment
(CBT plus medication) is a safe and effective treatment approach, es-
pecially for pediatric mood and anxiety disorders. Many factors need to
be considered before recommending this treatment approach.
4.1. The only other medication besides fluoxetine that the U.S. Food and
Drug Administration has approved for the treatment of major de-
pressive disorder in adolescents (12–17 years) is
A. Sertraline.
B. Escitalopram.
C. Paroxetine.
D. Fluvoxamine.
E. Imipramine.
4.2. On the basis of the results of the Children/Adolescent Anxiety Mul-

timodal Study (CAMS), the following statement is true:
A. CBT is the most effective intervention for children and adolescents.

B. Pharmacotherapy is the most effective intervention for children
and adolescents.
C. Combined treatments (CBT and pharmacotherapy) showed a supe-
rior response rate compared to CBT or pharmacotherapy alone.
D. No intervention was shown to be better than placebo.
E. The results were inconclusive.
4.3. Which of the following statements is true regarding evidence for

combined treatments (CBT plus pharmacotherapy) for depression?
A. Combined treatments (CBT and pharmacotherapy) are always

better than either treatment alone.
B. CBT is consistently better than pharmacotherapy and thus
should be the first line of treatment.
C. Pharmacotherapy is consistently better than CBT and thus
should be the first line of treatment.
D. The results are mixed, with some studies showing efficacy of
combined treatments and others the advantages of a combined
approach.
E. None of the above statements is true.
4.4. For a 13-year-old patient presenting with a first episode of major de-
pression, the clinician should
A. Always start with CBT first and switch to medications if CBT

does not work.
B. Take a detailed history and make a decision on treatment inter-
ventions on the basis of the inventory of factors, such as symptom
severity and patient and parent preferences.
C. Always start with pharmacotherapy first and then add CBT if symp-
tom resolution has not been achieved by pharmacotherapy alone.
D. Take a detailed history, assess for various factors, and then always
start with a combined approach (CBT plus pharmacotherapy) be-
cause it has been shown to be the most efficacious.
E. Let the patient decide.
4.5. Which of the following are important factors to consider when de-
ciding which intervention to choose from?
A. Severity of symptoms.
B. Prior experience with treatment.
C. Comorbidities.
D. Availability of resources.
E. All of the above.
Suggested Readings
and Web Sites
Leahy RL (ed): Contemporary Cognitive Therapy: Theory, Research, and
Practice. New York, Guilford, 2004
Morris TL, March JS (eds): Anxiety Disorders in Children and Adoles-
cents, 2nd Edition. New York, Guilford, 2004
American Academy of Child and Adolescent Psychiatry, www.aacap.org
American Psychiatric Association, www.psych.org
Anxiety Disorders Association of America, www.adaa.org
Attention-Deficit Disorders Association, www.add.org
Family Guide to Keeping Youth Mentally Healthy and Drug Free,
Substance Abuse and Mental Health Services Administration,
www.family.samhsa.gov
MindZone, Annenberg Foundation Trust at Sunnylands with the Annen-
berg Public Policy Center of the University of Pennsylvania,
www.fhidc.com/annenberg/copecaredeal
National Alliance for the Mentally Ill, www.nami.org
National Institute of Mental Health, www.nimh.nih.gov
National Institutes of Health, U.S. National Library of Medicine, Medline
Plus: Child mental health. Available at: http://www.nlm.nih.gov/
medlineplus/childmentalhealth.html. Accessed April 19, 2011.
TeensHealth, Nemours Foundation, www.teenshealth.org
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150
APPENDIX 4–A Combination treatment of cognitive-behavior therapy (CBT) and pharmacotherapy for anxiety,
depression, and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents
Medication, dose, N, age, diagnostic
duration of qualifications, Primary and secondary Comments, limitations,

Study treatment comorbidities outcome results adverse events
Depression
TADS FLX, 10–40 mg/day N=439; multisite FLX+CBT>PBO Results suggest that CBT +FLX in
(March et 12 weeks Ages 12–17 years FLX+CBT >FLX alone and the treatment of adolescents
al. 2004) Participants were (mean age=14.6 years) CBT alone with MDD has best benefit-risk
randomly assigned to MDD FLX>CBT trade-off.
one of four conditions: Comorbidities: anxiety aCGI: Of note, clinically significant
PBO disorder, disruptive behavior 71% FLX+ CBT suicidal thinking decreased from
FLX alone disorder, OCD/tic disorder 60.6% FLX baseline in all treatment groups.
CBT alone Exclusions: bipolar disorder, 43.2% CBT alone
CBT+ FLX severe CD, substance abuse 34.8% PBO
Double-blind assignment: or dependence, PDD,
FLX alone, PBO alone thought disorder, receiving
Unblinded assignment: concurrent psychotropic or
CBT alone, CBT+FLX psychotherapeutic
treatment, failed two SSRI
trials, or had poor response
to treatment that included
CBT
Appendix 4–A: Combination Treatment
depression, and attention-deficit/hyperactivity disorder (ADHD) in children and adolescents (continued)
Depression (continued)
Clarke et al. Participants who had N= 152 Primary outcome results: Weak CBT effect was detected,
2005 been prescribed SSRIs Ages 12–18 years aCES-D results showed a possibly because of
by their TAU pediatric (mean age= 15.3 years, TAU; nearly significant trend 1) small sample and
provider before study mean age=15.29 years, (P=.07) supporting 2) unexpected reduction
enrollment were CBT) CBT+ SSRI>TAU + in SSRI pharmacotherapy
randomly assigned to MDD SSRI. in CBT condition.
CBT+SSRI or Comorbidities: schizophrenia No advantage of CBT +SSRI High attrition posttreatment and
TAU+ SSRI (control Exclusions: significant over TAU +SSRI on other at follow-up among adolescents.
condition). developmental or intellectual primary outcome measure,
Participants who were disability; suicidal risk MDD recovery.
randomly assigned to Secondary outcome results:
CBT +SSRI received Significant CBT advantage
five to nine individual was found on Youth Self
CBT sessions. Report—Externalizing
(P=.07) and Short
Form-12 Mental
Component Scale
(P=.04).
151
152

Melvin et al. SERT, 12.5–100 mg N= 73; multisite aDepressive diagnosis COMB showed greater response in
2006 12 weeks Ages 12–18 years (remission=8 weeks MDD postacute treatment, but
Participants were (mean age=15.3 years) asymptomatic) relatively low dose of SERT was
randomly assigned to MDD, dysthymic disorder, All treatments had prescribed.
one of three conditions: DDNOS significant improvements Few participants with severe
CBT Comorbidities: adjustment or at the end of acute phase; depression were included.
SERT alone anxiety disorder, enuresis, however, for partial PBO condition was not included.
CBT+ SERT reading disorder, cannabis- remission: AEs: fatigue, concentration,
related disorder NOS, CD/ 71.4% CBT insomnia, drowsiness,
ODD, BDD 46.7% CBT+ SERT restlessness, suicidal ideation,
Exclusions: bipolar disorder, 33.3% SERT headache, yawning, increased
psychotic disorder, substance appetite, nausea
abuse, active suicidality,
other severe psychiatric
disturbance requiring acute
hospital admission
Goodyer et Participants were N= 208; multisite No benefit of SSRI+CBT Results suggest that for
al. 2007 randomly assigned to Ages 11–17 years over SSRI alone across adolescents with moderate to
SSRI alone or Moderate-severe major or aHealth of the Nation severe depression, combination
SSRI+CBT (28 weeks) probable major depression Outcome Scales for CBT +SSRI in the context of
SSRI treatment: FLX, Comorbidities: suicidality, Children and Adolescents routine care contributes to
10 mg/day for 1 week, depressive psychosis, CD, and secondary outcome improved outcome at 28-week
increasing to 20 mg/day anxiety disorders, alcohol measures (participant- follow-up compared with SSRI
for 5 weeks. If no abuse, tic disorder, eating rated mood and feelings and routine care alone.
response, increase was disorders questionnaire, CDRS-R, Participants with previous optimal
considered at 6 weeks Exclusions: schizophrenia, CGI-I). trial with SSRI+CBT were
(to 40 mg on alternative bipolar disorder, global excluded.
days for 1 week learning disability Neither severity nor comorbidity
followed by 40 mg/day influenced results of COMB.
for 5 weeks) and again at Most common AEs: headaches,
12 weeks (60 mg nausea, tiredness, dry mouth,
on alternative days and reduced appetite.
for 1 week followed Of note, symptoms of suicidality
by 60 mg daily for for both treatment groups for
5 weeks). 30 mg/day on most outcomes reduced over
153
average; 60 mg/day time.
maximally.
154

TORDIA Paroxetine, 20–40 mg N= 334 (231 completed CBT+ MED > MED switch Adolescents with treatment-
(Brent et Citalopram, 20–40 mg protocol through week 12); alone refractory depression may
al. 2008) Fluoxetine, 20–40 mg multisite VLX switch=SSRI switch benefit from a switch to a new
Venlafaxine (VLX), Ages 12–18 years aAdequate clinical response: SSRI or VLX, in addition to CBT.
150–225 mg (mean age= 15.9 years; mean CGI score ≤2 +CDRS-R Participants were nonresponders
12 weeks of treatment-arm averages) score reduction by 50% to initial treatment with SSRI for
Treatment arms: MDD 54.8% CBT +MED depression.
Switch to new SSRI 40.5% MED switch alone Attrition: 30.8% withdrew due to
alone AEs.
Switch to new AEs: sleep difficulties, irritability,
SSRI+CBT flu-like aches, accident/injury,
Switch to VLX alone gastrointestinal issues, skin
Switch to VLX+CBT problems, musculoskeletal issues
TASA (Brent Participants were allowed N= 124; multisite aSuicidal event: rate of Although differences in suicidal
et al. 2009) to choose to be Ages 12–18 years suicidal events was higher outcome were not detected
randomly assigned or to MDD, dysthymic disorder, in COMB group than either among treatment arms, risks for
select their treatment. DDNOS, MDD +dysthymic MED alone or CBT alone, suicide events and for reattempts
Three treatment disorder likely due to were lower in the current study
conditions were Significant qualification: made disproportionate treatment than in comparable samples,
available: suicide attempt 90 days assignment (MED alone, perhaps warranting further
Psychotherapy (TASA before intake n= 15; MED+TASA CBT, examination of this intervention.
CBT) Exclusions: bipolar disorder, n= 93; TASA CBT alone, Given that 40% of suicidal events
MED management psychosis, developmental n= 18). occurred 4 weeks from intake,
TASA CBT +MED disorder, substance Significant group increased safety planning and
management dependence differences: monotherapy therapeutic contact early in
6 months groups had higher treatment may be useful.
interviewer- and self-
reported rates of
depression, greater
hopelessness, higher
number of previous
suicide attempts, more
155
hospitalizations 6 months
before study, and lower
levels of functioning.
156

TASA (Brent When group differences
et al. 2009) were controlled, no
(continued) differential effect of
treatment type on suicidal
outcomes was found among
CBT+ MED, MED alone,
and CBT alone.
Anxiety disorders
Bernstein et IMI N= 63 aOutcome measures = Results support multimodal
al. 2000 Dosage monitored via School refusal weekly school attendance: approach to treating school
blood levels Ages 12–18 years IMI>PBO refusal in adolescents
(150 µg/L–300 µg/L) (mean age=13.9 years) ARC-R: IMI>PBO (MED +CBT).
8 weeks Comorbidities: One or more RCMAS: IMI>PBO COMB (CBT +IMI) was more
Participants were anxiety disorder, MDD CDRS-R: IMI>PBO effective than PBO on most
randomly assigned to Exclusions: ADHD, CD, BDI: IMI=PBO outcomes.
one of two conditions: bipolar disorder, eating Attrition rate: 25.4% (n= 16)
CBT+ IMI disorder, drug and/or alcohol
PBO+ IMI abuse, mental retardation,
bipolar or affective disorder
in first-degree relative
Anxiety disorders (continued)
POTS SERT, 25–200 mg/day N= 112 aCOMB> CBT alone= Both CBT alone and CBT + SSRI
(Pediatric 12 weeks Ages 7–17 years SERT alone>PBO may be effective in treating
OCD Participants were (mean age= 11.8 years; mean For remission childhood OCD.
Treatment randomly assigned to of treatment-arm averages) (CY-BOCS≤ 10): COMB Treatment-emergent AEs in MED-
Study one of four conditions: OCD and CBT >SERT treated patients: decreased
[POTS] PBO alone=PBO appetite, diarrhea, enuresis,
Team SERT alone motor overactivity, nausea,
2004) CBT alone stomachache
CBT+SERT
157
158

Asbahr et al. SERT, 25–200 mg/day N= 40 aCY-BOCS Significantly higher compliance
2005 12 weeks OCD 12 weeks’ acute treatment: rates in SERT group
Participants were Ages 9–17 years group CBT =SERT Psychotherapy (group CBT) may
randomly assigned to (mean age= 13.1 years; mean 9-month follow-up: have more lasting effects in the
one of two treatment of treatment-arm averages) group CBT >SERT treatment of pediatric OCD
conditions: Comorbidities: MDD (only if than MED (SERT) alone.
Group CBT alone secondary to OCD) and AEs:
SERT alone other major Axis I disorders SERT>group CBT: increased
Exclusions: MDD (if primary weight loss
diagnosis), bipolar disorder, Group CBT> SERT: increased
ADHD (if primary diagnosis nausea, abdominal pain
and/or if psychostimulants SERT=group CBT: irritability,
were required), PDD, headaches, dry mouth,
PTSD, borderline trembling, diarrhea, sweating,
personality disorder, increased appetite, weight gain
psychosis, neurological
disorders other than
Tourette’s syndrome or any
organic brain disorder
Cohen et al. SERT, 50–200 mg/day N= 22 TF-CBT +SERT= No significant group × time
2007 12 weeks Sexual abuse–related PTSD TF-CBT +PBO differences between the two
Participants were Ages 10–17 years, females Clinically meaningful groups. Cohort was not
randomly assigned to only improvement occurred on representative of sexually abused
receive one of two Demographic information several measures, including children requesting clinical
treatments: (% total participants): the following: treatment.
TF-CBT +SERT Ages 10–11, n= 5 (22.7%); PTSD diagnosis: At Treating childhood PTSD with
TF-CBT +PBO Ages 12–14, n=10 (45.5%); posttreatment, 14 of 20 psychotherapy first, then
Ages 15–17, n= 7 (31.8%) participants with PTSD no following with MED, might be
Comorbidities: MDD, GAD, longer met criteria for most effective.
substance abuse NOS (but diagnosis (8 TF-CBT + AEs were defined as suicide
not use), ODD, anorexia SERT; 6 TF-CBT+PBO). attempts, reportable child abuse
nervosa, panic disorder Global impairment status: At episodes, drug overdoses, or
Exclusions: schizophrenia, posttreatment, 15 of 22 psychiatric hospitalization
other active psychotic participants who were in Only one AE occurred over course
disorder, mental retardation, the “clearly impaired” of study between groups (one
PDD range at pretreatment psychiatric hospitalization for
(CGAS< 60) had moved ODD).
into the “not clearly” range
159
on the CGAS: 9 TF-CBT+
SERT; 6 TF-CBT+PBO.
160
N, age, diagnostic
Medication, dose, qualifications, Primary and secondary Comments, limitations,

Study duration of treatment comorbidities outcome results adverse events
Cohen et al. Significant result: Most
2007 symptom improvement for
(continued) TF-CBT+ SERT group
occurred between weeks
3–5 (to be expected in a
trial using SERT).
CAMS SERT, 25–200 mg/day N= 488; multisite aCGI-I score= 1 or 2: Dropout rates: 23 (17.3%) on
(Walkup et 12 weeks Ages 7–17 years 80.7% SERT+ CBT* SERT and 15 (19.7%) on PBO
al. 2008) Participants were (mean age=10.7 years) 59.7% CBT* 6-month open-label continuation
randomly assigned to GAD, SAD, and/or social 54.9% SERT* phase for responders
one of four conditions: phobia 23.7% PBO AEs:
PBO Comorbidities: ADHD, OCD, *(P < .001) SERT vs. PBO: ns
SERT alone PTSD, ODD, CD SERT+ CBT> CBT =SERT SERT vs. CBT: insomnia,
CBT alone Exclusions: MDD, substance >PBO fatigue, sedation, restlessness,
CBT+SERT use disorders, bipolar and fidgeting more common in
Double-blind assignment: disorder, psychotic disorders, SERT (P<.05)
SERT and PBO groups PDD, nonresponders to two Serious AEs:
Unblinded assignment: trials of SSRI or prior CBT SERT+CBT: one psychiatric
SERT +CBT group trial hospitalization
SERT: one psychiatric hospitaliza-
tion; one medical hospitalization
N, age, diagnostic
Medication, dose, qualifications, Primary and secondary Comments, limitations,
Study duration of treatment comorbidities outcome results adverse events
ADHD
MTA (MTA Methylphenidate N= 579; multisite Results on 19 primary AEs: Most severe was depression,
Cooperative hydrochloride ADHD (combined type) outcome measures show worrying, or irritability and could
Group 28-day titration period Ages 7–9.9 years COMB and MED have been due to nonmedication
1999) 5–20 mg (or higher if Comorbidities: ODD, CD, management>intensive factors.
patient’s weight internalizing disorder, special behavioral therapy or For ADHD symptoms, MED
>25 kg) learning disability community care management was superior to
If inadequate response Exclusions: <80 on all WISC- COMB=MED management behavioral treatment and to
was achieved, patients III scales and on SIB; bipolar for treatment of core routine community care that
were given alternative. disorder, psychosis, or ADHD symptoms included MED.
MED: personality disorder; chronic COMB did not yield significantly
Dextroamphetamine serious tics or Tourette’s greater benefits than MED
(1.4%) syndrome; OCD serious management for core ADHD
Pemoline (1.0%) enough to require separate symptoms, but it may have
IMI (0.3%) treatment; neuroleptic MED provided modest advantages for
Bupropion (0.3%) in previous 6 months; major non-ADHD symptom and
Haloperidol (3%) neurological or medical positive functioning outcomes.
13-month follow-up illness; history of intolerance
period after initial to MTA MEDs; ongoing or
titration phase previously unreported abuse;
161
suicidal or homicidal ideation
162
Note. AE=adverse event; ARC-R=Anxiety Rating Scale for Children—Revised; BDD =body dysmorphic disorder; BDI=Beck Depression Inventory;
CAMS=Child/Adolescent Anxiety Multimodal Study; CBCL=Child Behavior Checklist; CD=conduct disorder; CDRS-R=Children’s Depression Rating
Scale—Revised; CES-D=Center for Epidemiologic Studies—Depression Scale; CGAS=Child Global Assessment Scale; CGI-I=Clinical Global Impres-

sion—Improvement scale; COMB=combination treatment; CY-BOCS=Yale-Brown Obsessive Compulsive Scale, Child Version; DDNOS=depressive dis-
order not otherwise specified; FLX=fluoxetine; GAD=generalized anxiety disorder; IMI=imipramine; MDD=major depressive disorder; MED=
medication; MFQ=Mood and Feelings Questionnaire; MTA=Multimodal Treatment Study of Children With ADHD; NOS=not otherwise specified; ns=not
significant; OCD=obsessive-compulsive disorder; ODD=oppositional defiant disorder; PARS=Pediatric Anxiety Rating Scale; PBO=placebo;
PDD=pervasive developmental disorder; POTS=Pediatric OCD Treatment Study; PTSD=posttraumatic stress disorder; RCMAS=Revised Children’s Man-
ifest Anxiety Scale; SAD=separation anxiety disorder; SCARED=Screen for Child Anxiety Related Emotional Disorders; SERT=sertraline; SIB=Scales of
Independent Behavior; SSRI=selective serotonin reuptake inhibitor; TADS=Treatment for Adolescents with Depression Study; TASA=Treatment of Ado-
lescent Suicide Attempters; TAU=treatment as usual; TF-CBT=trauma-focused cognitive-behavior therapy; TORDIA=Treatment of SSRI-Resistant De-
pression in Adolescents; WISC-III=Wechsler Intelligence Scale for Children—3rd Edition.
a Primary outcome measure.
5
Depression and
Suicidal Behavior
CBT for Depression

Empirical Evidence
Depressive disorders in children and adolescents are common, recurrent,
and impairing. Depression is prevalent in 1%–2% of children and 3%–8%
of adolescents (Lewinsohn et al. 1998). These conditions are a leading
cause of morbidity and mortality in the pediatric age group (Brent 1987;
Bridge et al. 2006) and are associated with significant functional impair-
ment in school and work, frequent legal involvement, and increased risks
for substance abuse and completed suicide (Birmaher et al. 1996; Kandel
and Davies 1986).
S This chapter has a video case example on the DVD (“Depression and Suicide”)
demonstrating CBT for a depressed and suicidal adolescent.
163
Clinical guidelines for the acute management of child and adolescent

depression recommend the prescribing of antidepressant medications,
psychotherapy, or both, with the best-studied psychotherapy being cogni-
tive-behavior therapy (CBT) (Birmaher et al. 2007). CBT has the stron-
gest evidence base to support its efficacy in the treatment of pediatric
depression compared with other therapies. Clinical trials and meta-analy-
ses have shown that CBT monotherapy is effective for the treatment of
depression (Birmaher et al. 2000; Brent et al. 1998; Harrington et al. 1998;
Weisz et al. 2006, 2009; Wood et al. 1996). However, in the Treatment
for Adolescents with Depression Study (TADS), CBT monotherapy did
not perform better than pill placebo and was inferior to medication mono-
therapy for acute treatment (March et al. 2004). The reasons why CBT
was not more effective are not clear. The content of the psychotherapy
was very dense, and it is possible that too many skills were offered, at too
low a dose. After 18 weeks of treatment, however, the CBT-only treat-
ment “caught up” with combination and medication-only treatments
(Kennard et al. 2009b). The Adolescent Depression Antidepressants and
Psychotherapy Trial (ADAPT), which compared the efficacy of medica-
tion alone to that of CBT plus medication in depressed adolescents, found
no difference between medication monotherapy and combination treat-
ment (Goodyer et al. 2007). Although these findings may seem to be at
variance with TADS, in fact, the difference in acute phase response rate
between medication alone and combination was not statistically significant
in TADS, and this was especially true in those with more severe depres-
sion. Consequently, these results are actually consistent with the results
from the ADAPT sample, which had more severe depression, was younger,
and had to fail to respond to a brief psychosocial intervention—all factors
that mitigate against CBT being effective (Curry et al. 2006; Renaud et al.
1998).
In a more recent study that randomly assigned depressed youth to CBT
versus usual care, CBT showed advantages over usual care in engaging par-
ents, shortening time to remission, and requiring less additional medica-
tion. In this study, however, CBT and usual care had similar remission rates
of 75% at the end of treatment (Weisz et al. 2009). One other study has
compared CBT plus usual care, consisting of antidepressant medication
provided in primary care, to usual care alone (Clarke et al. 2005). There
were nonsignificant trends favoring the combination treatment, which also
resulted in fewer outpatient visits for usual care and a lower adherence
rate to antidepressant treatment.
In the Treatment of SSRI-Resistant Depression in Adolescents (TOR-
DIA) study, 334 depressed adolescents who had not responded to an ade-
quate trial with an SSRI antidepressant were randomly assigned to a
Depression and Suicidal Behavior 165
medication switch with or without CBT. There was a higher response rate
with those who received both the medication switch and CBT, compared
to those who received a medication switch alone (Brent et al. 2008). In-
terestingly, CBT appears to perform particularly well in depressed adoles-
cents with comorbidity, especially anxiety (Brent et al. 1998). In the
TORDIA study, the greater the number of comorbid conditions, the stron-
ger the performance of CBT plus medication compared with medication
alone (Asarnow et al. 2009).
Studies have found that adolescents with higher levels of cognitive dis-
tortion are less likely to respond to CBT (Brent et al. 1998; Ginsburg et al.
2009). Marital and parent-child discord also militate against CBT efficacy
(Birmaher et al. 2000; Feeny et al. 2009). CBT appears to be more effec-
tive in those youths from more advantaged socioeconomic backgrounds
(Asarnow et al. 2009; Curry et al. 2006). CBT is also less efficacious com-
pared with other treatments in patients who have a history of abuse and in
those whose parents are currently depressed (Asarnow et al. 2009; Barbe
et al. 2004; Brent et al. 1998; Lewis et al. 2010). In general, CBT is a treat-
ment whose results are robust in patients with comorbidity, suicidal ide-
ation, and hopelessness, but it performs less well in patients with a history
of maltreatment or current parental depression.
CBT has also been shown to be effective in preventing the onset of de-
pression in adolescents who are at high risk because of subsyndromal de-
pression, a previous history of depression, and/or a parent with a history
of depression (Clarke et al. 2001; Garber et al. 2009). However, in the
presence of current parental depression, CBT is not more effective than
usual care in preventing depression in offspring of parents with a history of
depression (Garber et al. 2009).
The CBT Model

According to the cognitive diathesis-stress model (Beck 1967), depression
is the result of an interaction between cognitive vulnerabilities and stress-
ful life events. These cognitive vulnerabilities, referred to as schemas, are
formed early in life and are shaped by life experiences. Depressogenic
schemas are cognitive structures based on a negative internal representa-
tion of the self and the environment (including others). Vulnerable indi-
viduals, when experiencing life stressors, engage in negative thinking as a
result of these schemas. Their automatic negative thoughts lead to depres-
sive feelings that are associated with maladaptive behaviors (e.g., social
withdrawal). Depressed children and adolescents have been shown to have
the same cognitive distortions and bias to negative events as depressed
adults. Depressed youths have negative thoughts about themselves and the
world around them, and they selectively attend to negative stimuli in their
environment (Maalouf and Munnell 2009).
In addition to cognitive models, there are behavioral models of depres-
sion, of which social learning theory has been the most prominent (Lewin-
sohn et al. 1998). This behavioral model posits that life stressors cause a
disruption in normal adaptive behavior, and this disruption leads to and
tends to perpetuate depression. This disruption causes individuals to use
maladaptive skills to control their depressive feelings when these skills can
only lead to worsening of these feelings (e.g., a girl who isolates herself in her
room and declines an offer to go out with her friends because of depression
would most likely feel more depressed secondary to social isolation). CBT
for youths with depression aims to target the above-mentioned maladaptive
cognitive processes and behavioral patterns that contribute to low mood. In
order to achieve this goal, a repertoire of techniques is used in CBT.
Application
CBT treatment is not a long-term treatment but rather is time limited.
Acute treatment typically consists of 12 weekly sessions of 60–90 minutes
each. Most of these sessions are individual sessions, but family sessions can
take place as needed (typically 3–6 sessions during the treatment course).
In addition, at the beginning of each individual session, the therapist typi-
cally checks in with the parent for 5–10 minutes. Although specific CBT
manuals vary in the extent to which they emphasize one technique over
the other (Brent and Poling 1997; Clarke et al. 2003; Curry et al. 2000),
we will focus here on techniques that in our clinical experience, have been
relevant to most depressed youths: psychoeducation, mood monitoring,
problem solving, cognitive restructuring, emotion regulation, behavioral
activation, and social skills training. At times, other specific intervention
strategies are selected on the basis of an assessment of the cognitive, be-
havioral, and environmental variables contributing to the depressive symp-
toms; these strategies may include family interventions and relaxation
techniques. The different CBT components are summarized in Table 5–1.
Session Format
Start by setting the agenda for the session together with the youth. Review
his or her current mood symptoms and assess the youth’s suicide risk.
Then review events that took place since the last session and the CBT skills
that were practiced. If the youth did not practice the CBT skills, it is im-
portant to explore the reasons and whether anything can be done to make
the skills more easily and readily usable. Next, review the material covered
TABLE 5–1. Cognitive-behavior therapy (CBT) with depressed

youth: main components
Component Content
Psychoeducation Defining depression, identifying its causes and

treatments, and setting treatment goals. Typically done
over one to two sessions with family and youth.
Mood monitoring Making the youth aware of different emotions and asking
him or her to keep a mood diary.
Problem solving Training the youth to solve problems by identifying what
the problem is, generating different solutions, and
evaluating the consequences of each.
Cognitive Guiding the youth to recognize distortions in his or her
restructuring thought process and helping the youth to come to a
more adaptive way of thinking.
Emotion regulation Introducing the concept of intensity of emotions using a
feelings thermometer and making the youth aware of
physiological and psychological cues associated with
the different intensities. Teaching emotion regulation
strategies such as opposite action.
Behavioral activation Asking the youth to increase time spent in pleasurable
activities on a daily basis and educating him or her that
mood does not need to improve before engaging in
these activities.
Social skills training Teaching effective communication skills such as greeting,
active listening, and maintaining eye contact through
role-playing.
Family interventions Educating family members about depression and
treatment, introducing the different CBT concepts to
them, and addressing high expectations by setting clear
goals for treatment.
Relaxation Teaching diaphragmatic breathing, progressive muscle
relaxation, and guided imagery as a means to cope with
stressful situations.
Relapse prevention Providing booster sessions to help reinforce the CBT
model, monitoring for recurrence of depression, and
preparing for future stressors.
in the previous session, including the homework given. Devote the rest of
the session to teaching a new set of skills. Rehearse the skills with the
youth using role-play. Elicit feedback from the youth as you go along in the
session and then agree with the youth on a homework assignment.
Specific CBT Components

Psychoeducation. Psychoeducation is the first component of a success-
ful CBT intervention. It is typically done in one to two sessions conducted
with both the youth and the parents. Children and parents are often con-
fused about the nature of the disease and the type of treatment. Use these
sessions to explain to the family that depression is a condition that affects
thoughts and feelings, review the fact that depression can be caused by many
factors, and explain that there are successful interventions that include med-
ications and therapy. This step helps reassure the child and family that what
they are experiencing is a known condition that many people go through.
Psychoeducation can be a powerful intervention tool, and multiple family
therapy groups that feature this component have been shown to improve the
outcome of children with mood disorders (Fristad et al. 2009).
Next, review the rationale behind CBT by explaining to the family the
triad of thoughts, behaviors, and emotions and how they are interrelated.
Introduce the family to the basic principles and goals of CBT, which in-
clude targeting maladaptive behaviors and thoughts with the goal of allevi-
ating negative emotions associated with depression.
Hearing from the child and the family a summary of the presenting
problem helps you personalize subsequent components of CBT during the
treatment course. Ask the child about his or her goals for treatment and
elicit from the parents support of these goals.
There is a tendency for youths to come up initially with a vague and
nonspecific goal for treatment, such as “I want to feel better.” You may
want to help the youth identify more concrete goals by asking him or her
questions, such as “If you were not depressed, what would you be doing
differently?” and here the youth may state, “Doing better in school,” “Go-
ing out more with friends,” and so forth.
Mood monitoring. Mood monitoring is an important component of CBT

that helps increase the youth’s awareness of emotions. Use the illustration
of a feelings thermometer and have the youth rate his or her mood on a scale
of 0 to 10, in which 0 corresponds to feeling “very bad” and 10 to feeling
“very good.” Ask the youth to keep a mood diary by recording his or her
mood at least three times a day along with the event associated with the spe-
cific mood. This technique serves more than one purpose: 1) it helps you
highlight to the child that he or she does not feel bad at all times (this is es-
pecially helpful in children who tend to dismiss positive emotions and report
in the session that they “never feel good”); and 2) it helps the youth identify
activities that make him or her “feel good” and that can be built on for use
later in therapy in the behavioral activation module.
Problem solving. Depressed teens often struggle with impaired prob-

lem-solving skills. They often find it difficult to generate solutions to prob-
lems they encounter in their daily lives mainly because of the cognitive
deficits associated with depression, namely difficulty concentrating, diffi-
culty planning, and psychomotor slowing. The problem-solving module
teaches depressed teens to systematically work through problems that
would typically cause them to feel down and hopeless.
Start first with introducing the youth to the concept of learning prob-
lem-solving skills by explaining that everybody faces daily problems and
that these can be more helpfully solved when not feeling down or hope-
less. Next, train the youth to brainstorm solutions to problems that youths
typically encounter (e.g., conflict with peers or parents). Encourage the
youth to bring in problems of his or her own and teach how to solve these
problems using the following problem-solving steps:
1. Relax when faced with a problematic situation.

2. Identify what the problem is.
3. Elicit different possible solutions.
4. Evaluate them by predicting the consequences of each.
5. Choose the best solution.
6. Encourage yourself to implement the solution.
If, for instance, a depressed girl talks about a verbal altercation with her
parents every time she doesn’t abide by curfew hours, coach her to iden-
tify the problem as such and then to brainstorm solutions, which may in-
clude negotiating other hours with her parents, having friends over after
hours, or not doing anything differently. Next, guide her to evaluate the
options by identifying the consequences of each and to choose the most
suitable solution that doesn’t leave her depressed or hopeless.
Generalizing these skills may involve some challenges. Youths may give
up on this technique if they attempt to apply it to complex problems pre-
maturely. Help them practice this strategy to solve problems with increas-
ing difficulty to help them gain mastery of the skills. Depressed youths
need to experience success with this strategy in order to believe in it and
use it more generally.
Cognitive restructuring. One key aspect of CBT is identifying and re-

mediating automatic thoughts and beliefs. These automatic thoughts
1) are rapid and reflexive, 2) are accepted as valid, 3) may be triggered by
internal or external events, and 4) negatively influence emotions and be-
haviors. An example of an automatic thought is “I am not going to have a
date for the prom.” Automatic thoughts are based on assumptions that are
the product of schemas.
Start by teaching the youth about the most common cognitive distor-
tions (e.g., dichotomous thinking, overgeneralization, dismissing the posi-
tive) that a person with depression may have. Then elicit automatic
thoughts from the youth by asking, “What images and thoughts go through
your mind when a specific event occurs?” Introduce the paradigm of ante-
cedent, belief, and consequence while trying with the youth to understand
the context in which automatic thoughts occur. By asking a series of gentle
questions, the clinician can guide the youth to recognize distortions in his
or her thought process and help him or her come to a new, more adaptive
way of thinking.
To generalize this skill outside the therapy session, ask the youth to
record automatic thoughts on a four-column dysfunctional thoughts
record, as shown in Figure 5–1.
In general, the following questions are useful for the youth to ask him-
self or herself (Brent and Poling 1997):
1. What is the evidence?

2. What are the errors in my thinking?
3. What is the best and worst thing that could happen?
4. What is the most realistic concern?
5. What are the effects of my thinking this?
6. What are some alternative thoughts?
Emotion regulation. Because the problem of emotion dysregulation is

so central to the depressed adolescent’s problems, it must be made an ex-
plicit part of the information shared in teaching emotion regulation skills.
It is helpful to be familiar with Linehan’s definition of the three compo-
nents that constitute vulnerability to emotion dysregulation (Linehan et al.
1993): high sensitivity to emotion stimuli, high reactivity, and slow return
to baseline.
Start by translating these three components into everyday language for
the youth; for example, the following statements may be helpful (Bonner
2002):
• “A very FAST emotional response: it does not take much to get the ball
rolling, and the ball gets rolling very rapidly down the hill to the land
of emotion dysregulation.”
• “A very BIG emotional response: emotions are felt and expressed with
much intensity, making it difficult to think clearly; when the ball gets
rolling down the hill, it quickly becomes a BIG ball.”
• “A very SLOW return to being calm or relaxed: it takes a long time to
roll the ball back up the hill; there may have been damage done by the
Negative automatic Feelings resulting

Distressing thoughts associated from the thought Evidence for and
situation with the situation or situation against the thought
1. 1. Evidence for
2. 2. 1.
3. 3. 2.
4. 4. 3.
4.
Evidence against
1.
2.
3.
4.
FIGURE 5–1. Thought record.
ball as it sped down the hill, so extra distress may have been added to
whatever got the ball rolling in the first place.”
Next, use the HEAR ME acronym to educate the youth about other
vulnerabilities that can make emotion regulation more difficult (Bonner
2002):
H =Health (take care of your physical illness)

E = Exercise regularly
A =Avoid mood-altering drugs
R=Rest (balanced sleep)
M=Master one rewarding activity daily

E = Eat a balanced diet
The clinician can illustrate one way to regulate emotions by using the
picture of a blank feelings thermometer. Ask the youth to identify differ-
ent feelings corresponding to different temperature readings on the ther-
mometer before the strength of his or her feelings would reach the top of
the thermometer, which corresponds to an irreversible point of losing con-
trol. Then help the youth identify the physical and psychological cues as-
sociated with these feelings (e.g., muscle tension, rapid breathing). Finally,
ask the youth to identify the point where he or she needs to take action
before getting to the irreversible point of dyscontrol, and identify what the
adolescent can do (e.g., walking away from the situation, calling a friend,
taking a warm bath).
Another important emotion regulation skill is opposite action. Intro-
duce this term by telling the youth that this method is based on the fact
that bodily posture, facial expressions, and actions strongly influence how
people experience their emotions. Thus, it is sometimes possible to change
how someone experiences an emotion by altering the posture, behavior,
and facial expressions that go with the emotion. The clinician may want to
illustrate this concept by focusing on one emotion, such as anger. Explain
that most people find that if they make an angry face and also make their
body language consistent with this feeling, they actually find themselves
experiencing anger. Tell the youth that the opposite is also true—that is, if
he or she feels angry and at the same time tries to smile, take some deep
breaths, and relax his or her posture, then he or she will less likely act im-
pulsively on the angry feeling.
Generalizing these skills to apply them outside the therapy session can
be challenging for youths. For this reason, rehearsing situations that are very
likely to happen in the near future and reenacting situations that happened
in the recent past are key factors that help youths master these skills and
make it more likely that they will use them when faced with emotionally
charged situations.
Behavioral activation. Clinicians should give behavioral technique pri-

ority over cognitive interventions in severely depressed adolescents. It is
important to get severely depressed adolescents moving and motivated in
order for them to engage in cognitive therapy. Work with the youth—and
here the clinician may want to elicit the help of the family—to schedule
activities that give the youth a sense of pleasure or accomplishment. In-
creasing pleasurable activities can also be used with less depressed adoles-
cents.
Begin by asking the youth to make a list of up to 10 activities that he
or she enjoys doing. These activities must be safe, inexpensive, and legal.
Then ask the youth to increase the amount of time during the day that he
or she spends engaging in these activities and to note the mood associated
with the activity. If the youth is reluctant to engage in the brainstorming
because “I do not enjoy anything,” remind him or her about activities that
were mentioned in previous sessions and that he or she appeared to have
enjoyed. Adolescents may also state that they “often do not feel like doing
anything.” The clinician can then educate them that they do not have to
wait for their mood to improve in order to engage in pleasurable activities.

On the contrary, increasing the time they spend engaging in these activities
may by itself lead to improvement in their mood.
If the youth’s schedule is fully booked with school and other activities
that the adolescent doesn’t necessarily consider pleasurable (e.g., music
classes, home chores), work with the parent on freeing up some of the
youth’s time to make room for those activities that the youth considers
pleasurable.
Social skills training. Social skills training is another important treat-

ment focus for depressed youths. Many of these children struggle with
making and maintaining friendships. They lack appropriate social skills and
are overly sensitive to criticism, which leads to further social isolation and
reinforces their depressed mood. In this module, the clinician teaches the
child the basics of initiating and maintaining a conversation—including
greeting others, making appropriate eye contact, and active listening
through role-playing—and models effective communication skills.
Relapse prevention. CBT continuation treatment has been shown to be

effective in preventing relapse in youths whose major depressive episode
has remitted over a 6-month period (Kennard et al. 2008; Kroll et al.
1996). Hence, after 12 weeks of acute treatment, a 6-month CBT contin-
uation treatment phase is recommended. This phase typically consists of
8–11 sessions, in which sessions occur weekly for 4 weeks and biweekly
for 2 months, followed by monthly booster sessions for 3 months. Include
family sessions as part of this treatment phase, with a minimum of 3 family
sessions. During this treatment phase, review the skills learned during
acute treatment and monitor for any recurrence of symptoms.
Case Example
Jessica is a 15-year-old white adolescent girl referred by her pediatrician due
to concerns regarding her mood. Jessica presents in session wearing overly
baggy clothes and with disheveled hair. She slumps in her chair, maintains a
flat affect, and yawns throughout the initial session. She is soft-spoken and
allows her mother to speak for her unless she is specifically addressed.
Jessica’s mother reports that she is extremely concerned about her
daughter. She reports that Jessica is “always irritable” and has rarely inter-
acted with family members or even friends for the past month. She ex-
plains that Jessica has been slowly dropping out of all her extracurricular
activities, even theater, which Jessica has always loved. Initially, her parents
wondered whether Jessica was ill given how much she was sleeping, her
lack of appetite and sudden weight loss, and her low energy level. How-
ever, medical concerns were ruled out after they met with the pediatrician.
During intake, Jessica reported that she was very hard on herself and
never felt she was as good as her friends in all areas of her life, including
schoolwork, her appearance, and even theater. Her grades have been drop-
ping recently, and she reported that she has been having a difficult time fo-
cusing in class, even though this has never been an issue for her in the past.
Jessica became emotional when admitting that at times she feels hopeless,
as if nothing will ever turn out right for her. Jessica held her mother’s hand,
and she explained that she has not experienced any thoughts about suicide
and that she would never do this to her family.
During the first therapy session, Jessica’s therapist informed her that
she was reporting clinically significant symptoms of major depressive dis-
order. The clinician then provided Jessica and her mother with education
regarding depression. Once Jessica and her mother were able to clearly un-
derstand depression, the therapist then explained how CBT could be ben-
eficial. The therapist explained the relationship of thoughts, feelings, and
behaviors and explained that CBT helps individuals change the way they
think and behave to help them decrease negative feelings. The therapist
was able to link this information with the symptoms Jessica reported dur-
ing the initial session. Jessica was able to understand that when she thinks
“No one ever calls me anymore,” she feels sad—and that when she is sad,
she tends to isolate herself by going to her room and falling asleep. Once
asleep, Jessica has little chance of changing her mood, and thus when she
wakes, she continues to experience negative thoughts. By the end of the
session, Jessica was able to form some goals, including becoming more ac-
tive with friends and theater, as well as improving school performance.
In the following session, Jessica was taught how to monitor her mood
using a feelings thermometer. She was then assigned to begin monitoring
her mood three times daily and to note the situation when she also noted
her mood. Jessica mentioned that she had been feeling lonely and felt that
her friends were leaving her out. Her mother gently pointed out that Jes-
sica had not been returning phone calls or text messages lately. The clini-
cian then met individually with Jessica to teach a problem-solving skill.
With the help of this skill, Jessica was able to calmly brainstorm some so-
lutions for her current peer difficulties and to weigh the pros and cons of
each solution. Jessica decided to try calling her friends more frequently and
asking them to take part in activities.
At the next session, Jessica brought in completed feelings thermome-
ters, which supported the idea that when she took part in social or pleasur-
able activities, her mood was improved—and that her mood was low when
she isolated herself. The clinician then taught Jessica about how thoughts
affect feelings and provided common examples of maladaptive thoughts.
Jessica admitted that she frequently views situations as “all or nothing” and
that this can cause her to feel sad and blue. She also recognized that she
can become overly focused on negative events that occurred throughout
the day and ignore positive events. Jessica was then taught how to chal-
lenge these negative thoughts and was assigned thought records to com-
plete.
The next few sessions focused on Jessica’s thought records and cogni-
tive challenges. She gradually became better at recognizing and challenging
her cognitive distortions, and her mood ratings were improving. At the same
time, Jessica’s solution for improving her relationships with friends was be-
ginning to work, and she was reporting improved social relationships.
Jessica still reported a tendency to react quickly to any social cues she
perceived as negative, and the next few sessions focused on emotional dys-
regulation. Jessica was taught the HEAR ME tips for self-care and was as-
signed to work on applying these to her daily life. In particular, Jessica
focused on forming a more balanced sleep routine and meal patterns.
Jessica’s mood ratings continued to improve, and she was feeling very
pleased with her progress. The next few sessions focused on behavioral ac-
tivation, and Jessica began to increase her time spent in pleasurable activi-
ties, including theater. At this point, Jessica’s mother reported feeling
relieved and felt that the “old Jessica is back.” Jessica continued to monitor
her mood and use her skills taught in previous sessions.
Eventually, Jessica was feeling confident about her ability to manage
her mood on her own. She and the therapist agreed that she would come
back to review skills monthly for the next 3 months. All of Jessica’s follow-
up sessions were positive and focused on refreshing any skills that were
needed. Overall, Jessica left therapy feeling proud of her ability to cope
with her emotions and improve her mood.
CBT for Suicide

Empirical Evidence
Although suicide is the third leading cause of death among adolescents in
the United States (Bridge et al. 2006), no individual psychotherapies have
been shown effective in randomized controlled trials (RCTs) in reducing
suicidal behavior in youths. Generalizing evidence-based therapies used
with depressed adolescents to suicidal adolescents may not be adequate
because many of the trials that established efficacy of these therapies ex-
cluded suicidal adolescents. The importance of suicide prevention inter-
ventions lies in their efficacy to prevent future suicide attempts in recent
attempters, because repetition of these behaviors among adolescents is
common 3–6 months after the first suicide attempt.
Family, group-oriented, and brief adjunctive psychosocial intervention
models have had mixed success in reducing self-injury in adolescents
(Huey et al. 2004; Wood et al. 2001). Empirical evidence on individual
psychotherapies such as dialectical behavior therapy (DBT) has not yet
been supported in RCTs, despite such treatment showing efficacy in a
quasi-experimental study (Rathus and Miller 2002). Although the TADS
group reported CBT and CBT-plus-medication treatments as more effec-
tive in reducing suicidal ideation and events compared with medication

alone, this result has not been replicated in other studies (Brent et al.
2008; Goodyer et al. 2007; March et al. 2004).
Suicide Prevention
The Treatment of Adolescent Suicide Attempters (TASA) study devel-
oped a cognitive-behavior therapy for suicide prevention (CBT-SP; Stanley
et al. 2009) that is feasible and accepted by adolescent suicide attempters.
The efficacy of CBT-SP is worth testing in the future. CBT-SP draws from
the principles of CBT and DBT. This treatment was piloted in a mostly
open study of 124 depressed adolescent suicide attempters and resulted
in a 6-month hazard of recurrence of suicidal behavior that was less than
has been reported in similar samples (hazard ratio = 0.12; Brent et al.
2009).
CBT-SP aims primarily to reduce suicide risk factors among adolescents
who are recent attempters, to help them develop more adaptive coping
skills—and ultimately, to refrain from suicidal behavior. CBT-SP involves
the parents and the adolescent in treatment, which lasts about 24 weeks.
CBT-SP consists of two treatment phases:
1. An acute treatment phase, which is divided into a) initial, b) middle, and

c) end phases. The acute treatment phase typically lasts for 12 weekly
sessions in total.
2. A continuation phase, which consists of up to 6 sessions tapered in fre-
quency and lasts for an average of 12 weeks.
We here summarize the different components of CBT-SP.
Acute Treatment Phase

Initial phase (4 sessions). This phase involves 5 components: chain
analysis, safety planning, psychoeducation, identifying reasons for living,
and case conceptualization.
• Chain analysis: In this component, the clinician helps the youth iden-
tify the series of events that led to the recent suicidal crisis; the work
in this component aims to reveal concurrently the youth’s precipitating
thoughts, feelings, and actions.
• Safety planning: Here, the clinician helps the youth identify internal
(distracting activities) and external (family, friends, psychiatry emer-
gency contact numbers) resources to use as coping strategies when
faced with suicidal urges. This technique aims to help youths stay safe
by not engaging in suicidal behavior at least until the next session.
• Psychoeducation: The clinician educates the youth and family about
suicide risk factors and behaviors and about the goals of therapy.
• Identifying reasons for living: In this component, the clinician helps the
youth identify reasons to live and sources of hope that he or she can
hold on to when having a suicide crisis.
• Case conceptualization: The clinician and patient determine target prob-
lems and deficits revealed in the chain analysis and identify the personal-
ized strategies that are needed to reduce suicide risk in the adolescent.
Middle phase (5 sessions). The clinician introduces cognitive, behav-

ioral, and family interventions in the form of skills training via modules
chosen on the basis of the particular needs of each youth as determined
during the case conceptualization phase.
End phase (3 sessions). The clinician aims to test the efficacy of skills
learned thus far by having the youth review the recent attempt during the
session, following these recommended steps:
• Prepare the youth by providing the rationale of this task.

• Have him or her review the indexed attempt or suicidal crisis.
• Have the youth review the event of the attempt or suicidal crisis using
skills acquired so far and highlight what he or she could have done dif-
ferently.
• Discuss a future high-risk scenario and debrief.
Continuation Phase
In this 12-week treatment phase, the clinician and patient review the skills
learned in the acute treatment phase, go over the course of treatment, and
identify accomplishments. The clinician prepares the youth to deal with
any future fluctuations or episodes and assesses the need for ongoing treat-
ment. The following case example on DVD illustrates CBT techniques to
assess (e.g., chain analysis) and treat depression and suicidal ideation in
Jane, an adolescent who recently attempted suicide.
S Case Example
Jane, a 17-year-old adolescent girl, was referred to the clinician by an emer-
gency room physician at the local children’s hospital after she was treated
for a suicide attempt, in which she swallowed a bottle of her mother’s
sleeping pills. Jane presented in session as sad and tearful. She did not
make eye contact and was soft-spoken. She cried at times throughout the
session, especially when her parents began to cry. Jane reported that she
hated high school and that she attempted suicide because she was ex-
tremely hopeless that anything would ever get better.
During the first session, the clinician discussed with Jane what led up to
her suicide attempt. Initially, Jane could only say, “I hate school.” However, the
therapist provided a series of open-ended questions about what was happening
in Jane’s life before the event, what Jane was thinking about, and how she was
feeling. Jane recalled that she was having a particularly bad week in school be-
cause her best friend was out sick and she did not have anyone to sit with at
lunch. She found herself feeling embarrassed and lonely and told herself that
she was a “loser” and that “no one would notice” if she didn’t exist. In addition,
Jane said that her ex-boyfriend had spread a rumor about her, and this was
causing her unwanted negative attention from others. When she went home
one day from school, Jane said that she decided she could no longer deal with
the stress and took the bottle of pills quickly.
After discussing this event, Jane reported that she “did not think” and that
she never considered how this would affect her family. The therapist then dis-
cussed the idea of forming a safety plan so that Jane could be sure to keep her-
self safe in between sessions. Jane reported that she was willing to do this and
felt bad about how she had upset her family. She admitted that she continues
to have suicidal thoughts and would like a plan for managing these thoughts.
Jane agreed to a plan where she would initially try to get her mind off the
thought by listening to music. If her thoughts continued or she began to expe-
rience a suicidal urge, she agreed to tell a parent or call the local crisis center.
In addition, the therapist provided Jane and her family with education about
suicide and risk factors. One risk factor in particular was discussed with Jane’s
family: leaving prescription medications lying around the home, because Jane’s
attempt and suicidal thoughts generally focused on ingestion. Jane and her
family added reducing risk factors to the safety plan.
During the next few sessions, Jane and her family agreed that she did
well following through with her safety plan. These sessions focused prima-
rily on establishing rapport with Jane and helping her to begin to think
about why her life was in fact worth living. This list began to grow, and Jane
became more motivated for treatment.
In addition, the therapist began to form a case conceptualization regarding
Jane’s suicidal behavior. This focused on Jane’s difficulties with social skills.
Throughout sessions it became apparent that Jane had difficulties making new
friends. She had one group of peers that she had made friends with in elemen-
tary school, and through the years, these peers had made new friends and grad-
ually drifted off except for her best friend. Jane was aware of her social
difficulties and embarrassed by her lack of popularity. This led to low self-es-
teem, and Jane began to overly focus on her difficulties with peers. Once Jane
became depressed, her level of energy and ability to concentrate decreased,
and she began to have difficulties problem solving. When faced with a social
problem at school after the breakup with her boyfriend, she was unable to
think of an adequate solution and became hopeless. This conceptualization of
Jane’s suicidal behavior helped the therapist to then form a treatment plan for
the middle phase of Jane’s acute treatment.
During the middle phase of Jane’s acute treatment, the therapist spent
about five sessions focusing on continuing to assess for safety, as well as
teaching skills focused on improving mood. The therapist focused on social
skills training for making new friends, cognitive challenging for decreasing
Jane’s tendency of focusing on the negative, HEAR ME skills for improving
her energy level and decreasing emotional lability, and problem-solving
skills for helping Jane to cope in an effective manner with life stressors.
Jane participated actively in learning these techniques and reported im-
provements in her mood at each session.
The last three sessions focused on summarizing these skills to ensure that
Jane would be able to apply them in the future. The clinician asked Jane to
think about her previous suicide attempt and to discuss what skills she could
have used to prevent herself from getting to that point. Jane was able to effec-
tively apply the problem-solving skill in session to find solutions both for feel-
ing lonely at lunch and handling the made-up rumor. In addition, she was able
to discuss how she was focusing on the negative and putting herself down and
to challenge these negative thoughts in session. Lastly, Jane was able to discuss
some active coping skills, such as going for a jog or playing a video game, that
she had learned generally worked for her when she needed to distract herself.
Jane was also able to discuss which skills she felt would work best for her in
future stressful situations. By the end of treatment, Jane reported that she no
longer experienced either suicidal ideation or depressive symptoms.
Caveats and Conclusion

Despite the evidence supporting the role of CBT in treating depression in
adolescents, CBT is often unavailable in many settings and may increase the
financial costs of treatment. Therefore, identifying and disseminating the
most effective components of these therapeutic techniques is needed in or-
der to better tailor them into a personalized approach for depressed and/or
suicidal adolescents and to make treatment as beneficial and cost-effective
as possible. In the TORDIA study, for instance, participants who received
more than nine CBT sessions and those who received the problem-solving
and social skills treatment modules were more likely to have a good treat-
ment response (Kennard et al. 2009a). This evidence suggests that problem-
solving and social skills training modules may be more cost-effective to dis-
seminate for use in the community than other CBT modules.
In addition, while delivering CBT, therapists are reminded to keep a
cultural perspective. Maladaptive beliefs and behaviors are learned and
perpetuate in a social context; hence, being cognizant of the relevant cul-
tural and ethnic factors of the youth’s presenting problems is essential for
every therapist in building a therapeutic alliance with youths and their
families and for treatment to succeed.
Key Clinical Points

• CBT is effective in preventing depressive disorders in at-risk youths
and when combined with medications in treating pediatric depres-
sion.
• CBT for youths with depression aims to target maladaptive cognitive
processes and behavioral patterns that contribute to low mood
through a repertoire of techniques.
• CBT components, such as psychoeducation, mood monitoring,
cognitive restructuring, problem solving, behavioral activation,
emotion regulation, and social skills training, need to be individual-
ized to the particular youth.
• Continuation CBT treatment is effective in preventing relapse after
depression remission over a 6-month period.
• CBT for suicide prevention aims to reduce suicide risk factors
among adolescents who recently attempted suicide by helping
them develop more adaptive coping skills and ultimately refrain
from suicidal behavior.
5.1. A 14-year-old Hispanic boy diagnosed with a major depressive disor-
der has not responded to a trial of a selective serotonin reuptake in-
hibitor (SSRI). The next management step that the youth would
most likely respond to is to
A. Switch to another SSRI.

B. Switch to venlafaxine.
C. Switch to another SSRI and add CBT.
D. Treat with the same SSRI for a period longer than 12 weeks.
5.2. A 13-year-old girl with a history of depression gets easily irritable at

school and becomes aggressive with teachers and friends. The most
helpful CBT technique to include in her treatment plan is
A. Exposure and response prevention.

B. Cognitive restructuring.
C. Emotion regulation
D. Safety planning.
5.3. You tell your depressed adolescent youth that it is important to

schedule activities that he or she finds pleasurable and to engage in
these activities on a regular basis. This is an example of
A. Cognitive restructuring.
B. Emotion regulation.
C. Behavioral activation.
D. Social skills training.
5.4. A feasible and acceptable therapeutic intervention with a depressed

adolescent who recently attempted suicide is
A. Interpersonal therapy.
B. CBT used with depressed youths.
C. Relaxation techniques.
D. Cognitive-behavior therapy for suicide prevention.
5.5. You see an adolescent youth with depression who is having difficulty
initiating and maintaining relationships with peers. The most helpful
CBT technique to include in the treatment plan of this youth is
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6
Bipolar Disorder
PHARMACOLOGICAL treatment (mood stabilizers or atypical

antipsychotics) is considered the first-line approach to manage pediatric
bipolar disorder (McClellan et al. 2007). However, childhood-onset and
early adolescent–onset bipolar disorder appear phenotypically similar to
adult mixed manic, chronically cycling, and frequently treatment-resistant
bipolar disorder; thus, these youth, even when medicated, are likely to re-
lapse (Geller et al. 2002). The refractory nature of pediatric bipolar disor-
der underscores the important, albeit adjunctive, role of psychotherapy in
treating the disorder, especially from the standpoint of illness management
(e.g., mitigating symptom exacerbation, preventing or delaying the onset
of future mood episodes, promoting healthy and affectively moderating
lifestyle choices, and addressing psychosocial stressors that may impact
the course of disorder).
Empirical Support
A small but growing literature base supports the use of cognitive-behavior
therapy (CBT) in the treatment of pediatric bipolar disorder (Table 6–1).
185
186
TABLE 6–1. Studies of CBT-based interventions for the treatment of pediatric bipolar disorder
Intervention Study design Citation(s) Significant findings Null findings
Child- and family-focused cognitive-behavior therapy (CFF-CBT) or RAINBOW program for pediatric bipolar disorder

CFF-CBT plus medication Open trial, Pavuluri et al. 2004 Improvement in child symptoms
management no control (mania, depression, aggression,
psychosis, sleep disturbance,
attention-deficit/hyperactivity
disorder (ADHD), and overall
symptoms) and global
functioning
CFF-CBT maintenance Open trial, West et al. 2007 Improvement in child symptoms
program plus medication no control (mania, depression, aggression,
management psychosis, sleep disturbance,
ADHD, and overall symptoms)
and global functioning found in
Pavuluri et al. 2004 maintained
over 3-year follow-up
CFF-CBT adaptation for Open trial, West et al. 2009 Improvement in child manic Decrease in child depressive
group treatment plus no control symptoms and psychosocial symptoms; improved child
medication management functioning (parent rated) psychosocial functioning
(child rated); decrease in
parenting stress; increase in
parent knowledge of and
perceived self-efficacy in
dealing with child’s disorder
Bipolar Disorder
TABLE 6–1. Studies of CBT-based interventions for the treatment of pediatric bipolar disorder (continued)
Family-focused treatment for adolescents with bipolar disorder (FFT-A)

FFT-A plus medication Open trial, Miklowitz et al. Improvement in child depressive
management no control 2004, 2006 and manic symptoms and
overall behavior problems; gains
maintained or increased
15 months posttreatment with
continued medication
management and trimonthly
FFT-A booster sessions
FFT-A plus medication Randomized Miklowitz et al. Treatment group as compared Reduction in time to recovery
management controlled trial 2008 with control group: More from any mood episode or
(control= favorable and rapid recovery mania; increase in time to
“Enhanced Care” from depressive symptoms; less recurrence of any mood
plus medication time spent in depressive episode or mania, weeks free
management) episodes; more weeks without of all mood disorder
depressive symptoms; greater symptoms, and time
overall reduction in mood remitted from mania; more
severity; more favorable favorable trajectory of mania
trajectory of depression or hypomania
187
188
Dialectical behavior therapy (DBT) for adolescents with bipolar disorder

DBT plus medication Open trial, no Goldstein et al. Decreased affective lability, Decrease in manic symptoms;
management control 2007 depressive symptoms, and improved interpersonal
suicidality functioning
Interpersonal and social rhythm therapy for adolescents with bipolar disorder (IPSRT-A)
IPSRT-A plus medication Open trial, no Hlastala et al. 2010 Decreases in manic, depressive
management control and general psychiatric
symptoms; improvement in
global functioning
Psychoeducational psychotherapy (PEP)
Multifamily Randomized Fristad et al. 2002, Treatment group as compared Decrease in child mood
psychoeducational controlled trial 2003 with control group: Improved severity; increase in child-
psychotherapy (MF-PEP) parental knowledge of mood perceived social support
plus treatment as usual disorders; improved parental from peers; decrease in
skills, support, and attitude negative family interactions
toward treatment; increase in
child-perceived social support
from parents; increase in
positive family interactions;
improved service utilization
Bipolar Disorder
Psychoeducational psychotherapy (PEP) (continued)

MF-PEP plus treatment as Randomized Fristad et al. 2009; Treatment group as compared
usual controlled trial Mendenhall et al. with control group: Decrease in
2009 overall mood severity; improved
service utilization
Individual-family Randomized Fristad 2006 Improvement in overall child Improved treatment

psychoeducational controlled trial mood severity and family utilization
psychotherapy (IF-PEP) climate
plus treatment as usual
IF-PEP Case studies Leffler et al. 2010 Decreased manic and depressive
symptom severity; improved
family climate and global
functioning
189
Although only a minority of this research (with roots in the more sizable
literature involving psychosocial treatment for adults with bipolar disor-
der) focuses on treatment nominally identified as CBT, interventions de-
signed for youth with bipolar disorder are largely based on techniques
traditionally associated with CBT and implement strategies consistent
with it.
Pavuluri et al. (2004) have developed child- and family-focused cogni-
tive-behavior therapy (CFF-CBT; also referred to as the RAINBOW pro-
gram) for children and adolescents with bipolar disorder. An adaptation of
Miklowitz and Goldstein’s (1997) family-focused treatment for adults,
CFF-CBT is delivered in conjunction with medication management and
organized around seven general components, including the establishment
and maintenance of healthy routines, regulating affect, building self-effi-
cacy and coping skills, restructuring negative cognitions, social skills train-
ing, problem-solving techniques, and the identification of a useful and
accessible social support system. The program is composed of 12 hour-
long sessions implemented over 6 months. Meetings include combined
family sessions, in which both parents and children participate, child-only
and parent-only sessions, and a session for siblings to participate along with
parents. Treatment feasibility has been found to be high; families attend
most sessions; and they unexpectedly miss (“no showing”) an average of
less than one session. Parents have indicated high satisfaction with the
treatment protocol and efficacy. Participation in an open-label trial of
CFF-CBT has been associated with improvement in mania, depression, ag-
gression, psychosis, sleep disturbance, symptoms of attention-deficit/
hyperactivity disorder, and global functioning as rated by therapists, al-
though the use of random assignment and independent evaluators in fu-
ture trials will help to evaluate the true efficacy of the program.
A maintenance model of CFF-CBT, in which the original treatment is
followed by psychosocial booster sessions and continued medication man-
agement, has also been developed (West et al. 2007). Booster sessions
focus on potential barriers to treatment. Preliminary results of the main-
tenance model—the addition of which has successfully maintained im-
provement in symptom severity and global functioning associated with
CFF-CBT over a 3-year follow-up period—along with results of the origi-
nal CFF-CBT trial, suggest the addition of a CBT-oriented adjunctive
treatment may hold promise for effecting and maintaining therapeutic
gains with a pediatric bipolar disorder population.
Miklowitz and colleagues (2004, 2006, 2008) have developed family-
focused treatment for adolescents with bipolar disorder (FFT-A). FFT-A
was designed to be implemented in twenty-one 50-minute sessions over a
9-month period, in combination with closely supervised medication man-
Bipolar Disorder 191
agement. FFT-A is primarily composed of psychoeducation and skills

training in the areas of communication and problem solving and allows for
the involvement of the patient, parents, and siblings. Treatment aims to
promote understanding of bipolar disorder, including its etiology and fac-
tors contributing to its course and outcome, as well as to equip patients
and families with the skills to positively impact the course of the disorder
(Miklowitz et al. 2004). FFT-A has been associated with substantial im-
provement in depressive and manic symptoms, as well as in behavioral
problems, over the course of an open trial (Miklowitz et al. 2004). The ad-
dition of trimonthly maintenance therapy sessions and continued pharma-
cological management over the 15 months following initial treatment with
FFT-A has resulted in overall maintenance of these treatment gains—
although as might be expected given the cyclical nature of bipolar disorder,
symptoms appear to wax and wane throughout the follow-up period (Mik-
lowitz et al. 2006).
FFT-A plus pharmacotherapy has also demonstrated superiority over
an enhanced care intervention combined with pharmacotherapy (Miklo-
witz et al. 2008). Although neither treatment appreciably impacted manic
symptoms in this study, patients receiving enhanced care (consisting of
three psychoeducational family sessions focusing on relapse prevention,
medication compliance, and maintaining low levels of conflict in the
home) demonstrated a longer time to recovery from depressive episodes,
more time spent in depressive episodes, and higher depression severity
scores over time, as compared with patients receiving FFT-A.
Goldstein et al. (2007) have piloted the use of dialectical behavior
therapy (DBT) for adolescents with bipolar disorder. Based on adaptations
of Miller et al.’s (2006) DBT manual for suicidal adolescents, the interven-
tion utilizes both family skills training and individual therapy (36 total
treatment hours) implemented over the course of 1 year and delivered as
an adjunctive treatment to medication management. The primary aim of
treatment is to improve affect regulation (the lack of which lies at the core
of bipolar disorder), along with other features of bipolar disorder, includ-
ing suicidality, interpersonal dysfunction, and treatment noncompliance.
Modifications for adolescents with bipolar disorder include family involve-
ment in treatment, the addition of psychoeducation, and skills training
specifically applicable for bipolar disorder (e.g., identifying particular
mood states, recognizing the signs that mood is becoming dysregulated,
and taking action to modulate manic and depressive mood states). Treat-
ment has demonstrated feasibility (i.e., high attendance and minimal
dropout), and participants have reported satisfaction with both the psy-
chotherapeutic approach and patient progress. Clinically significant im-
provements have been found in the areas of affective lability, depressive
symptoms, and suicidality (in terms of both ideation and attempts).

Whereas improvement in manic symptoms has been nonsignificant, manic
symptoms at intake were generally mild, making a significant decrease dif-
ficult to achieve. Patients’ interpersonal functioning also did not demon-
strate significant improvement. The authors have not yet investigated the
mechanisms through which improvement was effected, calling into ques-
tion whether treatment gains were due to the specific aims of therapy or
related to other, nonspecific therapeutic factors (e.g., support).
Interpersonal and social rhythm therapy (IPSRT), an empirically sup-
ported adjunctive treatment for adults with bipolar disorder, has recently
been adapted for use with adolescents with the disorder (IPSRT-A;
Hlastala et al. 2010). IPSRT-A, also based in part on interpersonal psycho-
therapy for adolescent depression, uses both individual therapy sessions
and family psychoeducation (16–18 total sessions) delivered over the
course of 20 weeks as an adjunctive treatment to medication management.
The primary components of IPSRT-A include psychoeducation regarding
bipolar disorder, addressing salient interpersonal difficulties, and the pro-
motion of structure and routine in the areas of social activities and sleep.
In an open trial (Hlastala et al. 2010), IPSRT-A was found to be feasible
(i.e., high attendance and minimal dropout) and satisfactory to adolescent
participants. Further, significant improvements were found in the areas of
manic, depressive, and overall psychiatric symptomatology, as well as in glo-
bal functioning, although randomized controlled trials are necessary.
Finally, Fristad and colleagues have developed psychoeducational psy-
chotherapy (PEP) treatment programs for use with children with bipolar
disorder (Fristad 2006; Fristad et al. 2002, 2003, 2009). These programs,
delivered alongside treatment as usual, employ family involvement, psych-
oeducation, and skill building in the areas of symptom management, affect
regulation, problem solving, and effective communication, with the aim of
increasing parent and child understanding of bipolar disorder and factors
that may impact its course, ultimately leading to better management of
the disorder through more adaptive family functioning and optimized uti-
lization of available services.
The multifamily format of PEP (MF-PEP) includes eight weekly
90-minute sessions, in which parents and children meet in a large group at
the beginning and end of each session, but break into parent- and child-
only groups for the majority of each meeting. Participation in a randomized
controlled trial of MF-PEP has been associated with significant improve-
ments in overall child mood severity, with children continuing to improve
through 18-month follow-up (Fristad et al. 2009); an earlier version of
MF-PEP consisting of six 75-minute sessions was also associated with pos-
itive clinical outcomes (Fristad et al. 2002, 2003). As intended, symptom
improvement was mediated by better utilization of services, a phenome-

non that, itself, was mediated by parents’ beliefs about treatment (i.e.,
knowledge of, and attitude toward, treatment) (Mendenhall et al. 2009).
An individual-family version of PEP (IF-PEP), delivered over the
course of sixteen 50-minute sessions, has also been associated with im-
provement in mood symptom severity through 12-month follow-up, as
well as improved family climate and treatment utilization and high con-
sumer satisfaction in a randomized controlled trial (Fristad 2006). This
model has been extended to twenty 50-minute sessions with four optional
“in the bank” sessions; initial case studies indicate it has good consumer
evaluations and is associated with improved mood and family functioning
(Leffler et al. 2010). Larger-scale trials are necessary, however, in order to
evaluate the true significance of these findings.
Characteristics of CBT for

Bipolar Disorder
Although each of the above treatments has unique qualities, the similari-
ties, particularly of CFF-CBT, FFT-A, and PEP, are striking. All involve
psychoeducation, skill building in communication, problem solving, cogni-
tive restructuring, and affect regulation, and are conceptualized to work in
an adjunctive manner to medication management. All involve working
with the family, primarily the parents, but also some attention is paid to
sibling relationships. CFF-CBT and PEP also include specific units on
working with schools.
In addition to family involvement in the logistics of initiating and main-
taining treatment, research indicates that families likely play a pivotal role
in the ultimate success or failure of treatment, because of the impact of
family dynamics on the course of bipolar disorder. High levels of expressed
emotion, a term referring to family interactions characterized by criticism,
hostility, and emotional overinvolvement, have been associated with
poorer illness course in adults with both depressive and bipolar disorders
(Hooley et al. 1986; Miklowitz et al. 1988).
Although little research has examined the impact of expressed emotion
on the course of pediatric bipolar disorder, preliminary data reported by
Miklowitz et al. (2006) indicate that adolescents with bipolar disorder liv-
ing in high–expressed emotion families evidence higher levels of mood
symptoms than those in low–expressed emotion families, suggesting ex-
pressed emotion may exert a powerful effect on bipolar disorder in younger
patients as well. Thus, several of the interventions used in the treatment of
pediatric bipolar disorder (e.g., CFF-CBT, FFT-A, PEP) attempt to improve

family interactions through promoting effective problem-solving and in-
trafamilial communication, as well as empathic responses toward the af-
fected child.
In addition to the role that negative family interactions may play in bi-
polar disorder, life stress has also been associated with a poorer course of
illness. Kim et al. (2007), for example, found adolescents suffering from
higher levels of chronic stress (including family-related stressors) demon-
strated less improvement in both depressive and manic symptoms.
Having thus established the importance of involving both families and
patients in treatment, the issue becomes what materials to employ in the
course of intervention. Psychoeducation, or teaching patients and their
families about bipolar disorder, is a crucial first step in the provision of
CBT. Psychoeducation involves much more than supplying informational
handouts or recommended reading lists (though such materials may cer-
tainly be provided as part of the process) (Basco and Rush 1996). The ra-
tionale for including psychoeducation in treatment is that families and
patients who are educated about this disorder—that is, provided with in-
formation that they are able to both process and utilize with the intent of
becoming more active and competent members of the treatment team—
are more likely and more able to make choices that are optimally beneficial
to the patient and his or her mental health, as well as choices that are ul-
timately healthy for the patient’s family.
Though the specific content of psychoeducation is necessarily fluid and
subject to the growing research base regarding bipolar disorder, certain
topics and themes are included in all CBT for bipolar disorder. These in-
clude the biological basis of bipolar disorder; symptoms of the disorder and
methods for managing increases in these symptoms; information regarding
comorbid diagnoses; the role of different treatment providers; and the im-
portance of healthy routines in the management of bipolar disorder.
As previously noted, CBT for bipolar disorder is not intended to serve
as a stand-alone treatment. Instead, effective CBT is applied as an adjunc-
tive intervention, to supplement and support first-line pharmacotherapy.
Thus, another aim of psychoeducation, as implemented in the psycho-
social interventions described earlier, is to foster an appreciation for the
essential role medication plays in treatment, while simultaneously ad-
dressing the limitations of pharmacotherapy. Accomplishing this is no
small task, given the high rates of medication noncompliance in children
and adolescents who are prescribed medication for bipolar disorder (Ko-
watch et al. 2000); however, increased adherence allows for maximum
benefit from psychopharmacological regimens (Strober et al. 1990) (i.e.,
better symptom management and fewer episodes of relapse) and for max-
imally efficient medication adjustments, which are often necessary as in-

dividual responses to medication appear over time.
Once parents and children have a working knowledge base regarding
bipolar disorder, treatment progresses to increasingly skill-based content.
Areas of skill building and skill refinement generally include effective
problem-solving and communication techniques, cognitive restructuring,
and methods to enhance affect regulation. Both the cognitive and behav-
ioral components of CBT are well represented in the treatments reviewed
above for youth with bipolar disorder. A description of these techniques—
emphasizing the bidirectional relationship between emotions, thoughts,
and behaviors on which CBT is based—is provided in the remainder of this
chapter.
Application
The initiation of CBT for a child or adolescent with bipolar disorder should
occur after assessment and diagnosis by a mental health professional famil-
iar with the disorder, and once the patient’s mood symptoms have been sta-
bilized enough pharmacologically that retaining information and learning
new skills are possible (Kowatch et al. 2005). Guidelines for identifying bi-
polar disorder in youth have been described elsewhere in considerable de-
tail but generally include 1) obtaining a complete developmental history, a
longitudinal examination of symptoms, a family history of mood and re-
lated disorders, data from multiple informants (i.e., parents, child, and
school); 2) systematically ruling out alternative medical and psychiatric di-
agnoses; and 3) determining any comorbid diagnoses (Danner et al. 2009;
Fields and Fristad 2009a). Refer parents or other family members for indi-
vidual treatment, as needed, to reduce the overall level of dysfunction in
the family (Kowatch et al. 2005).
Although a multifamily group format for PEP has been developed
(MF-PEP), the therapeutic protocol described herein is designed for use
in an individual-family format (IF-PEP). The primary advantage of con-
ducting treatment in a multifamily format is the social support parents and
children often experience through interaction with individuals facing sim-
ilar issues. In addition, participants may benefit from opportunities to
learn from the successes and struggles of others. The individual-family for-
mat outlined here, however, is often more convenient for families, who
may not wish to delay treatment until a new group can begin, and who may
appreciate the more individualized consultation and privacy offered by
such a format. Clinicians may also find an individual-family format desir-
able, both because billing for services may be simplified and because many
clinicians do not have access to a number of families appropriate for inclu-
sion in multifamily group treatment.
Below appears an outline of one version of CBT, IF-PEP. First, the gen-
eral format of sessions is described, then key elements of each session are
discussed. These elements share much in common with the other CBT
treatments for bipolar disorder in youth reviewed above.
General Structure of Sessions

Sessions alternate between child-focused and parent-only sessions, allow-
ing you to maintain engagement and continuity with all participants while
also offering opportunities for private consultation with children and par-
ents. In child-focused sessions, you will spend the majority of time working
individually with the child, but parents participate at the beginning and end
of each session. Meeting with both parents and child at the outset of each
child session allows for collaborative review of assignments from previous
weeks and provides a chance to touch base with parents in terms of the
child’s general progress and mood, and any particularly stressful or notable
events that have occurred since the last visit and may impact the course of
the child’s disorder (e.g., a death in the family or parent losing a job may
increase the child’s vulnerability to depressive symptoms; a particularly
large and involved school project may portend an increase in manic symp-
toms). Reconvening at the end of a child session allows the child to “teach”
that week’s material to parents, reinforcing newly introduced concepts for
the child and updating the parent in regard to the child’s session content.
Parents familiar with what their children have been working on in treat-
ment are better able to reference meaningful concepts between sessions
and encourage their children to use recently acquired skills. Homework
(which is best referred to as “projects,” as few children cherish additional
homework assignments) is assigned at the end of each session to children,
parents, and often both as a family exercise. Each week’s project is an ex-
tension of whatever lesson has been worked on in that session and typically
involves recording/monitoring the newly learned skill.
Child sessions begin with a review of mood states (the first session usu-
ally requires some teaching to establish the practice of rating one’s emo-
tions). Younger children, in particular, may need additional assistance with
this step, especially in distinguishing feelings (e.g., sad, mad, bored, happy)
from thoughts (e.g., “I’m not sick enough to be here,” “My mom is mad at
me,” “I’m a bad kid”). This distinction is critical, in light of CBT’s empha-
sis on understanding and effectively employing the interactional relation-
ship between feelings, thoughts, and behaviors. Children also frequently
begin therapy with a very limited vocabulary regarding emotions—sad,

mad, and “normal” are often all they articulate. Helping children become
aware of a broader range of mood states is a beginning step in learning to
regulate their own affect. After labeling his or her current mood, the child
then rates the intensity of that mood. Early in treatment, rely on a visual
scale—a feelings thermometer—to illustrate how feelings can range in in-
tensity from a healthy “middle” range to maladaptive and occasionally dan-
gerous “highs” and “lows.” This routine encourages both accurate labeling
and heightened awareness of the intensity of one’s emotions—fundamen-
tal skills needed before affect regulation will be successful. Child sessions
end by teaching and reviewing, as needed, breathing exercises that chil-
dren can use as a calming technique. Developmental adaptations are al-
ways important to keep in mind. In general, the younger the child, the
more involved the parent will be in the session. As youth approach early,
middle, then late adolescence, the need for autonomy grows.
Expect up to twenty-four 50-minute sessions, with approximately 20
sessions (9 child-focused sessions, 8 parent-focused sessions, one session
with parents and school personnel, one family session involving siblings,
and one closing session involving parents and child) dedicated to covering
specific psychoeducational matter and skill-building exercises and up to
four sessions reserved for additional coverage of particularly challenging
content or for crisis management, as needed. The sequence and number of
sessions allotted to covering particular therapeutic content are suggested
guidelines. They should be adapted to suit the needs of particular families,
who may require varying levels of instruction and consultation. Material
can be presented in fewer meetings, for example, for a family logistically
unable to attend the full complement of sessions or for parents who begin
treatment with considerable knowledge of the child’s condition. Similarly,
a family encountering an especially vexing issue may benefit from prioriti-
zation of that concern, instead of waiting for the presentation of relevant
material later in treatment. Excessive sibling conflict, for instance, might
warrant the involvement of siblings earlier in treatment to best address the
family’s needs. These types of alterations prevent treatment from being
delivered in a cookie-cutter or impersonal fashion, and are intended to lead
to higher therapist and family satisfaction.
Though involving both parents in treatment is ideal, it may not be prac-
tical. If a child has only one parent, another significant adult caregiver (e.g.,
grandparent, aunt) may participate in treatment as well. In the not uncom-
mon event that both parents have significant contact with the child but
only one is able to attend treatment, the attending parent should commu-
nicate session content to the other and enlist this parent in utilizing the
skills learned in treatment.
Session 1
Child session 1: purpose of treatment; goal setting, rating feelings,
and symptoms of bipolar disorder. Begin the introductory session to-
gether with the parents and child. Orient them to the purpose of treat-
ment; emphasize that better understanding gained from this education
along with skill building should improve treatment utilization and decrease
family conflict, leading to a better outcome for the child. Successful man-
agement of the disorder, as opposed to a “cure,” is the ultimate goal. Share
your expectations, which include the importance of regular attendance
and practicing skills between sessions, the planned duration of treatment,
and the potential for maintenance sessions after the initial course of inter-
vention. Set the stage for establishing feasible treatment goals. Given the
probable lifetime waxing and waning of symptoms, complete obliteration
of any future symptoms is not realistic. However, improving family life
through concrete actions, taking steps to build friendships, and developing
a plan to address school concerns are all realistic and doable over the
course of treatment.
Finally, introduce both parents and child to the concept of bipolar dis-
order as a “no fault” disorder. Your motto for treatment is, “It’s not your
fault, but it’s your challenge.” Although no one is to blame for the child’s
diagnosis, it is a card the family has been dealt and a challenge the entire
family can and must confront. Underscore this perspective in future ses-
sions by providing information regarding the biological etiology of bipolar
disorder and by helping to distinguish the child from his or her symptoms.
Revisiting this message throughout the course of treatment serves to alle-
viate guilt and shame surrounding the disorder, while concurrently estab-
lishing a positive, proactive, and solution-focused approach to managing
the disorder.
After accomplishing the above, spend most of the remainder of the ses-
sion with the child alone, inviting parents to rejoin at the end of the session
to review progress and discuss activities to be completed before the next
session. While with the child, you have three tasks to accomplish: 1) to
help the child develop a basic understanding of his or her mood disorder
as well as any comorbid conditions; 2) to help the child develop realistic
treatment goals; and 3) to teach diaphragmatic breathing to use as a calm-
ing technique.
Parent session 1: setting the proper tone; diagnosis and symptoms

of bipolar disorder; mood charting. The first parent-only session in-
cludes presenting basic information about the diagnosis of bipolar disorder
and information on tracking mood symptoms. The most important aim of
the session, however, may be to set the tone for an empathic, hopeful, and
solution-focused approach to treatment. Essential to establishing this tone
is the presentation of bipolar disorder as a no-fault diagnosis (briefly
touched on in the introductory session), beginning with a focus on the bi-
ological nature of the disorder, including its high genetic heritability. Help-
ing parents view bipolar disorder as a brain disorder can assist them in
approaching their child’s mood and associated behavioral issues with com-
passion, while also easing parents’ fears that they are responsible for their
child’s problems.
Youth with bipolar disorder can exhibit exceedingly aversive behaviors,
occupy an inordinate amount of family resources, and be extremely diffi-
cult to manage. Parents, in turn, receive an unfortunate and often unfair
share of the blame for these issues, often in the form of criticism from
friends and family who attribute the child’s behavioral difficulties to noth-
ing more than poor parenting. Without proper psychoeducation, parents
can begin to view their affected child as selfish and willfully disruptive,
leading to a decline in positive interactions within the family and an in-
crease in expressed emotion (discussed earlier as a potentially significant
factor in the course of bipolar disorder).
Ironically, attempting to alleviate parental guilt over the child’s diagno-
sis by introducing information on the heritability of bipolar disorder can in-
advertently lead to more self-blame by some parents, who feel guilty over
passing down the disorder. No one, of course, selects his or her own genes;
as the saying goes, you can pick your friends but not your relatives. Re-
minding parents of this can be useful in reframing unproductive and guilty
cognitions regarding their child’s diagnosis.
Providing information to parents regarding the neuroanatomy and neu-
rochemistry putatively involved in bipolar disorder can also help place the
disorder in a biological light, though the level of sophistication that will be
useful to parents can vary significantly. In session, it is sufficient to explain
that various structures of the brain appear different in bipolar disorder
than in typical brains (e.g., different in size) and that these abnormalities,
in conjunction with chemical irregularities in the brain that affect how
messages are sent between brain structures, are thought to be involved in
the symptoms of bipolar disorder. If parents express a deeper curiosity and
would benefit from information regarding particular neuroanatomical and
neurochemical abnormalities, refer them to additional up-to-date scien-
tific findings (see References at the end of this chapter for suggestions).
Provide parents with information on how bipolar disorder is diagnosed,
including the symptoms, symptom duration, and impairment necessary to
meet diagnostic criteria. This process requires helping parents develop fa-
miliarity with clinical nomenclature, so that terms such as mania, hypoma-
nia, and major depressive episode can be used meaningfully in treatment,

without fear of confusion. In addition, present a rationale for the child’s
particular diagnosis (i.e., bipolar I, II, or not otherwise specified [NOS];
cyclothymia), as well as an explanation for how this diagnosis is subject to
change, depending on the future course of symptoms (e.g., a current diag-
nosis of bipolar II disorder would progress to bipolar I disorder in the event
of a manic or mixed episode).
Just as children should be introduced to the differences between mood
symptoms and symptoms of other disorders, so too should parents. In par-
ticular, address any other diagnoses the child may have been assigned,
along with how these symptoms differ from those of bipolar disorder. Re-
gardless of whether psychotic symptoms are present, describe psychotic
symptoms that can occur in the course of pediatric bipolar disorder, as well
as the potential for suicidality. Because youth with bipolar disorder are at
elevated risk for suicidal behavior, parents need to be aware this is a poten-
tial complicating feature of the disorder.
Mood charting, or the process of recording changes in a child’s mood,
is an important tool in monitoring treatment progress in a child with bipo-
lar disorder (Young and Fristad 2009). Not only can this process help par-
ents give treatment providers useful information in guiding medication
adjustments, but such charting can also aid parents’ understanding of how
psychosocial and somatic stressors (e.g., interparent conflict, child getting
less sleep than usual) can impact the course of their child’s disorder. Al-
though it is often difficult for parents to retrospectively report on a child’s
mood fluctuation and potential triggers for this variation when they come
in to a session, parents who have spent even a couple of minutes each day
detailing their child’s mood and the events of that day are typically much
more able to provide useful information. A multitude of different formats
have been proposed for charting mood, and the level of detail that is ap-
propriate depends on the family. Remember, even a low level of informa-
tion provided consistently is typically of greater value than a high level of
information provided sporadically. Reviewing mood logs at the beginning
of each session helps to reinforce their importance with parents.
Session 2
Child session 2: “Naming the Enemy”; medications. T h e p r i m a r y
goals of this session are twofold: 1) to assist the child in differentiating
symptoms of bipolar disorder from his or her “self,” and 2) to instill a
firmer understanding of the use of medication in treatment for bipolar dis-
order, thereby enlisting the child as a more informed and active participant
in treatment.
The first goal can be addressed with the exercise Naming the Enemy
(Fristad et al. 1999), inspired by the concept of “externalizing the symp-
tom” (White and Epston 1990), in which patients are encouraged to ob-
jectify problematic symptoms as separate from the self. Over time,
symptoms can come to be seen by the child and others as static and reflec-
tive of the child’s true self, as opposed to being surmountable and tempo-
rarily obscuring the child’s positive qualities. Identifying symptoms of
bipolar disorder as an external “enemy” reconceptualizes the problem as a
challenge to be overcome rather than a burden to be passively endured,
while simultaneously encouraging more positive self-esteem in children of-
ten in need of just such a boost.
To implement Naming the Enemy, write the child’s name at the top of a
page, with two columns splitting the page below. In the left-hand column, la-
beled “Self,” have the child write positive qualities about himself or herself
(e.g., “artistic,” “good sense of humor,” “helps Grandma”). In the right-hand
column, have the child write his or her mood symptoms as the child under-
stands them (e.g., “mean to brother,” “cries a lot,” “brags too much”). After
the lists are complete, fold the right side of the paper over the left, covering
the child’s positive qualities with the half of the paper listing symptoms. Ex-
plain how the symptoms of bipolar disorder can cover up the wonderful at-
tributes the child has to offer. Then, refold the paper so the right side is behind
the left side, and explain that treatment can help “uncover” the child’s posi-
tive qualities once more. The child will do this again at home with his or her
parents; it can be very helpful in changing the language families use to describe
symptoms (rather than negative attributes about the child).
Raising the topic of treatment provides a segue into discussing the role
medications play in managing bipolar disorder. All too often, children take
medications with no knowledge of the names and dosages, let alone the
purpose of these prescriptions. As medication adherence is essential to
treating bipolar disorder, children should have an awareness of what they
are taking, the reasons for doing so, how to manage the nearly inevitable
side effects that occur with medications, and how to provide useful feed-
back to the provider on how the medicine is working. Children invested
with this knowledge gain an additional stake in their treatment—a sense of
ownership likely to be welcomed by parents, who often struggle to ensure
daily medication adherence. To this end, review information with the child
about the medications he or she is taking, including dosages, the symptoms
each medication is intended to address, common side effects, and poten-
tial methods of mitigating these side effects (e.g., taking the medication
with food for prescriptions causing stomach upset; keeping a bottle of wa-
ter nearby for those causing dry mouth). Note that a discussion of why the
medication has been prescribed may necessitate consultation with the
child’s psychiatrist or pediatrician, as medications are often used off label

or to counteract side effects of other medications.
Parent session 2: medication and other treatments. Parents, too, ben-

efit from information regarding the treatment their children are receiving. In
particular, parents should be clear regarding their child’s current medication
regimen and the purpose of medication in treating bipolar disorder—in short,
management of symptoms rather than elimination of the disorder. Help par-
ents understand the basic classes of medications, the target symptoms for
which they are designed, and their common side effects, as well as how those
side effects can be managed. Be prepared to review fundamentals of taking
medication, such as what to do when a dose is missed (e.g., take as soon as pos-
sible or wait until the next scheduled dose), when and how medications are to
be taken (e.g., in the morning or evening; with food or without), and necessary
measures to ensure safety (e.g., blood draws for monitoring mood stabilizer
levels). Polypharmacy may be necessary, but ensure that parents understand
the reason for each medicine the child is taking.
Despite the primary role of psychopharmacology in treating bipolar dis-
order, communicate to parents that medications are not a panacea and only
part of managing what is typically considered a chronic illness. Familiarizing
parents with the limitations of pharmacotherapy is necessary to foster real-
istic expectations of treatment and the prospective course of bipolar disor-
der. In addition to the necessity of using medication regularly and according
to directions, parents need to be aware that somatic treatments may require
some time to take maximum effect and that medication adjustments are a
routine part of refining a bipolar disorder treatment regimen. Changes in
dosage, administration time, and even type of medication are not uncom-
mon or indicative of substandard treatment. On the contrary, competent
medication providers should alter prescriptions in response to feedback
from parents and the patient to optimize treatment response.
Parents should also know that the best way to handle concerns regard-
ing a perceived inadequate response to medication or impairing side ef-
fects is through a thoughtful analysis of the costs (side effects) and
benefits (symptom relief) of continued administration, in combination
with careful consultation with the prescribing physician. Effective com-
munication, including a mood-medication log that records treatment re-
sponse and side effects, enables the physician to proceed in the safest and
most efficient manner. Although it is clearly parents’ prerogative to make
important choices about their child’s health, decisions regarding alteration
or discontinuation of somatic treatment should not be undertaken without
proper medical supervision. This approach also applies once medications
begin to relieve symptoms or even appear to resolve them completely, as
it may be that medication is not only alleviating symptoms but preventing

their return. Depending on the extent and nature of the child’s mood his-
tory (e.g., one acute antidepressant-induced manic episode versus multi-
ple depressive and hypomanic episodes), pharmacotherapy may be
recommended until mood symptoms have remained dormant for several
months, or maintained indefinitely for prophylactic reasons.
It is possible that children may be receiving other treatments (e.g., par-
ticipating in a social skills group; receiving electroconvulsive therapy) for
bipolar disorder or comorbid conditions while engaged in a CBT program,
or other treatments may have been proposed. If so, this session is an op-
portunity to discuss these other treatment options and to provide basic in-
formation regarding the purpose of such therapies.
Case Example:
The Medication Dilemma
Emily is an 11-year-old girl who received a diagnosis of bipolar I disorder a
year ago after a manic episode that resulted in hospitalization. Since then,
she has undergone numerous medication trials. Upon beginning psychoed-
ucational psychotherapy, Emily’s parents are vocal regarding their medica-
tion concerns. On the one hand, Emily’s father views medication as a
crutch—moderately helpful in the short term, but ultimately undermining
Emily’s ability to “really deal with her problems.” Her mother, on the other
hand, has grown weary of Emily’s incomplete symptom remission, in spite
of frequent medication adjustments.
In response to these concerns, the therapist’s first step is to provide ba-
sic psychoeducation regarding the biological nature of bipolar disorder. Af-
ter the therapist discusses the high heritability of the disorder, Emily’s
parents are able to identify a familial pattern.
Mom: My sister is also bipolar, and there was some talk about my grand-
mother having manic depression. It also seemed like my dad always
had problems with depression.
Dad: I struggle with depression, too, and it seems like half my cousins
have been on antidepressants.
Mom: Between mood problems and diabetes, seems like our family can’t
catch a break.
Therapist: Diabetes runs in your family?
Mom: I actually have an insulin pump. My mom was diabetic, too, and so
is my brother.
The therapist uses this opportunity to address Emily’s father’s aversion to

Emily taking medication.
Therapist: So is there a difference between a diabetic who needs insulin

and someone with bipolar disorder who needs medication?
Dad: Well, sometimes diabetes can be controlled with diet and exercise.
Mom: Not me. I’m really careful. Without my pump, though, I’m in trouble.
Dad: But maybe Emily’s bipolar disorder isn’t that bad. Maybe she can
manage without it if she just had the right—I don’t know—tools.
Therapist: Research would suggest that learning coping skills may be
enough to address depression, and they’re very important in manag-
ing bipolar disorder, too, but only if manic symptoms like Emily’s are
stabilized first. That’s why the medication is essential.
Dad: I don’t know. ... I just don’t like it.
Therapist: I don’t think there are many parents who love the idea of their
child needing medications, but let’s look at Emily’s history. How
were her symptoms before she began the medication?
Dad: She ended up in the hospital. It was awful.
Therapist: Right. And has she needed to be hospitalized since starting her
medications?
Mom: No, but it’s not like she’s ever been ... better.
Therapist: Let’s talk about what you mean by “better.”
Mom: I hate to say it, but. . .normal. She still has rages sometimes, has
nights where she’s up forever, sometimes talks about sexual things—
it can be so embarrassing and frustrating. And that’s after who knows
how many med changes.
Therapist: OK, so when you say Emily’s not “better,” it sounds like you’re
saying that she still has some symptoms, and really, we may never to-
tally get rid of all those issues. It also sounds like, though, that her
medications have helped reduce her symptoms.
Mom: That’s true. But how can we be sure she’s on the right medications?
Dad: Yeah, sometimes it seems like her psychiatrist is just throwing darts
at a dartboard.
This is an opportunity for the therapist to foster an appreciation for the

active role Emily’s parents can play in the complex task of medication
management of bipolar disorder.
Therapist: Finding the best medication or even combination of medications

can definitely be a long process.
Dad: Maybe if we had a different doctor?
Therapist: Maybe. But Emily’s doctor has a lot of experience working with
kids like Emily, and it sounds like you feel comfortable with her.
Mom: Oh, yes, she’s been really supportive, and I like that she takes time
to explain what the medications are for.
Therapist: Those are important qualities in a physician, so before making a
big change like switching doctors, I think we should make sure we’re
working with her in the most effective way.
Dad: But we’re not doctors, and we can’t tell her what medications to pre-
scribe.
Therapist: And I’m not trained to prescribe medications either. We can
make sure the doctor has the most complete information about
Emily, though. (To the mother:) Managing your diabetes involves more
than just taking insulin, right?
Mom: Sure. I have to watch what I eat, watch my weight. Before I got my
pump, I had to monitor my sugar levels regularly.
Therapist: That monitoring is just as important with bipolar disorder.
When you take Emily to see the psychiatrist, I bet she asks you lots
of questions about her symptoms.
Dad: Yes, but it’s so hard to keep track of everything. Her symptoms can
change so much from week to week, even day to day.
Therapist: That’s why the daily mood logs we will discuss are so important.
The next time you go to the psychiatrist, you can actually take the log
to her, and she can see details of how Emily’s symptoms have fluctu-
ated without you having to recall them on the spot. As long as Emily
is taking the medications as prescribed, the doctor can make the most
informed decision about whether Emily’s medications should be
changed, the dosage adjusted, or both.
Session 3
Child session 3: establishing healthy routines. Regulating sleep, nu-
trition, and exercise is an important aspect of regulating mood. In this first
session devoted to healthy routines, provide an overview of these three
topics, and have the child pick the topic he or she finds most troublesome
to focus on first. Monitor the child’s progress with this first goal in each
subsequent session; the child will pick a second goal from this list in his or
her seventh session.
Inadequate sleep can trigger mania (Malkoff-Schwartz et al. 1998,
2000) and is a frequent cause of increased irritability. Help the child iden-
tify any dysfunctional sleep practices, set goals for proper rest, and de-
velop strategies for those goals to succeed. This involves structuring an
environment conducive to sleep and may require relocating a television or
video game system to another room and setting guidelines for hours of use.
Many medications prescribed for youth with bipolar disorder lead to
weight gain, which can lead to self-esteem concerns, not to mention very
real health concerns of type 2 diabetes and hypertension. Thus, a focus on
healthy food choices is often beneficial. Reviewing fundamentals of nutri-
tion guidelines and troubleshooting how the child can make wiser food
choices, often in the face of intense carbohydrate cravings, are important
steps. The emphasis here should not be on dieting, but rather on establish-
ing lifelong healthy eating habits.
Much as sleep can play a role in mania, exercise has been found to de-
crease depressive symptoms (Pollock 2001). Increasing physical activity
has several added benefits, including helping the child maintain a healthy
weight, which also has physical and mental health benefits. Additionally,
many ways in which a child can increase activity levels also increase social
interaction, for example, through a team sport, playing in the park where
other kids have gathered, or a martial arts class.
This session will likely require more parental involvement, particularly

for younger children. Changing patterns of sleep, exercise, and most of all,
diet, is integrally tied to how the child’s family functions. Healthy behav-
iors that become normative for the family as a whole are more likely to be
permanently adopted by the individual child.
Parent session 3: understanding the mental health system and the

school system. In this session, your task is to help parents understand
the mental health system and the school system in relation to their child.
By the end of the session, they should be able to construct a representation
of their child’s mental health treatment team and their educational team.
Children with bipolar disorder often require mental health treatment
teams composed of a range of service providers, frequently operating out
of different agencies or offices. Identifying these individuals, elucidating
the role each can or should be playing, and conceptualizing the group as a
team pursuing a common goal (i.e., successful management of the child’s
disorder) are necessary for optimal treatment utilization. Parents need a
fundamental understanding of the child’s current treatment providers,
their role and training, and the service each team member typically pro-
vides. This exercise provides an opportunity to identify gaps in provided
services and to address misconceptions parents may have about the re-
sponsibilities or capabilities of different treatment team members. When
parents understand, for example, that their child’s psychiatrist may focus
largely on medication management and depend on the child’s psychologist
to provide behavioral intervention and any necessary psychoeducational
testing, it can be easier to maintain a positive therapeutic relationship and
can reduce frustration over the limited time a psychiatrist may have to en-
gage in a discussion regarding effective problem-solving or the inability of
a psychologist to arrange a medication refill. Further, parents familiar with
the role of each service provider are better able to identify the most useful
contact to consult with questions that arise over time.
This discussion should emphasize the active role of parents and chil-
dren on the treatment team. Whereas treatment providers may change
over time depending on the child’s needs and logistical considerations
(e.g., family moves, changes in insurance coverage), parents are constant
members of the team and should feel empowered to serve as their child’s
primary advocates. Both parents and children will learn skills in treatment
to make them more effective contributing members to the treatment
team.
Children with bipolar disorder also frequently require school-based ser-
vices. The professionals who provide these services work in collaboration
with clinical treatment providers (e.g., rating school behavior, reporting
suspected medication side effects to parents, implementing behavior plans

constructed in conjunction with therapists). Additionally, school profes-
sionals also compose an educational team. Youth with bipolar disorder fre-
quently evidence significant dysfunction in the school setting, requiring
both academic and behavioral intervention to adapt successfully to the de-
mands of school (Geller et al. 2002; Wozniak et al. 1995). In addition to
neurocognitive deficits these students may exhibit, including impairment in
memory, attention, and processing speed, fluctuating symptoms of mania
and depression during the course of the disorder can also impact school per-
formance (McCarthy et al. 2004; Pavuluri et al. 2006). Thus, parents need
to understand what school services are potentially available. Review with
parents the various types of school personnel who might be beneficial for
their child, the different mechanisms of school-based support (i.e., a 504
plan vs. an Individualized Education Program, or IEP), and the myriad
school labels and classification systems (e.g., other health impaired [OHI],
severe behavior handicap [SBH]) so they can begin to determine how best
to advocate for their child in the school setting. Encourage a cooperative,
solution-focused relationship among parents, clinical treatment providers,
and school service providers that will facilitate better utilization of available
services (Fields and Fristad 2009b).
Review with parents several concrete steps they can take to enhance
their child’s school-based services. First, encourage parents to keep a
binder containing all materials related to the child’s school services. This
should include copies of all correspondence sent to or received from
school, dates and brief descriptions of phone calls and voice mails, and
notes taken at any meetings with school personnel. Second, coach parents
on how to ask questions when they are unclear regarding any procedures
or expectations. Competent school personnel will appreciate parents’ con-
cern for their child and appreciate the opportunity to clarify information
before miscommunication can sow conflict. Third, review information de-
scribed above with parents, so they have a more comprehensive and real-
istic understanding of what schools can provide.
Session 4
Child session 4: triggers, physical cues, feelings and actions, coping
tool kit. Perhaps the technique most identified with CBT is increasing
patient awareness of how thoughts, feelings, and behaviors impact each
other, then translating this knowledge into skills to relieve or prevent
symptoms and impairment. Undertaking this practice with children re-
quires a developmentally appropriate approach that organizes the process
into manageable, routinized steps. Begin by helping the child to identify a
recent trigger, an event that elicited negative feelings, and the somatic sen-
sations that accompanied those feelings. Often children claim no aware-
ness of physical indicators of mood states. If you provide examples (e.g.,
face flushing when angry, stomach tightening when afraid), children often
begin to respond. Next, have the child identify actions he or she took in
response to these negative feelings, along with the eventual consequences
of these actions. A child could indicate, for example, that she became an-
gry last week when her mother allowed a sibling to play the video game she
was hoping to play (the “trigger”). She could tell she was becoming angry
because her “forehead got wrinkled” and she began biting her lip (somatic
sensations). In response to her anger, the child grabbed the video game
controller from her brother and threw it against the wall (actions), break-
ing a button and rendering the game unplayable. As a result of these ac-
tions, she was unable to play the game at all and was yelled at by her
mother (consequences).
After identifying an example that illustrates how negative feelings can
lead to negative choices and behaviors, the next step is to assist the child
in developing a coping tool kit. This tool kit will contain reminders of ef-
fective strategies—identified by the child—to help the child regain control
of his or her emotions and self-soothe. Younger children often enjoy con-
structing and decorating an actual shoebox or other container for this pur-
pose, while adolescents may prefer to make a list that can be tucked into
a school binder or posted on their bedroom wall.
Regardless of the chosen format, the tool kit should include a range of
coping strategies that can be implemented in a variety of situations and in
response to a number of maladaptive or “hurtful” emotions. To help the
child successfully identify an assortment of coping responses, break strat-
egies down into four basic categories: creative, active, relaxation, and social
(CARS becomes a useful acronym to remember these categories—just as
a car can take someone places he or she wants to go, these coping CARS
take a person to the mood state he or she prefers). Creative “tools” might
include drawing or playing the piano; active tools might include shooting
baskets or playing on the jungle gym; relaxation tools might include read-
ing a book or listening to soothing music; and social tools might include
calling a friend on the phone or playing with the family dog.
Coping strategies need to match the child’s situation and mood. For ex-
ample, riding a bike might be an excellent strategy for the child to use at
home when feeling grumpy, but it won’t work when the child is at school.
Talking to a trusted teacher or using one of the breathing techniques taught
in therapy, on the other hand, would work in a school setting. Similarly, lis-
tening to dance music when feeling sad is a reasonable and adaptive strat-
egy to use at home; however, using that strategy when thoughts are starting
to race hypomanically could provide excess stimulation, potentially exac-

erbating symptoms and leading to poor decisions. Selecting a soothing ac-
tivity instead (e.g., taking a bath) would be a more appropriate choice in
this circumstance.
The concept of choice is of considerable significance in this exercise
and a theme to be emphasized throughout treatment. Children cannot
control the feelings they experience, but they can take responsibility for
their actions and choose to respond to feelings in a helpful manner.
Parent session 4: negative family cycles, Thinking-Feeling-Doing.

A child with bipolar disorder presents significant challenges for a family.
Symptoms of a child’s mood disorder, along with those of commonly co-
morbid conditions such as behavioral and anxiety disorders, can make the
child appear intolerant, wild, self-centered, lazy, and domineering, while
at the same time extraordinarily needy and unsure of himself or herself.
The use of the word appear is notable, in that it is likely more accurate
(and certainly more helpful) to view the child’s aversive behavior as a man-
ifestation of the disorder, rather than emblematic of core personality flaws
considered largely beyond the reach of therapeutic intervention.
Families with children who have bipolar disorder often inadvertently
engage in negative interactional cycles characterized by a focus on negative
behaviors, assigning blame for these behaviors (directed at both the af-
fected child and parents), coercive behavior, frustration, and eventual feel-
ings of rejection and isolation for parents and children. Addressing negative
family cycles begins with first identifying negative cognitions (e.g., “My
child doesn’t care about my feelings”; “My spouse never wants to help out
when Joey is raging”) and then using the traditional CBT technique of re-
framing negative or hurtful thoughts in a more positive or helpful manner.
The contrast between helpful and hurtful thoughts is quite salient, as it
orients parents to the treatment’s emphasis on progress and serves as a re-
minder of the ultimate goal of CBT for bipolar disorder—helping the child
(and the family as a whole) to function more effectively in the face of bi-
polar disorder, instead of identifying who is most at fault.
Keeping in mind developmental needs, a cartoon version of the link
among thoughts, feelings, and actions was developed, called “Thinking-
Feeling-Doing” (TFD; Fristad et al. 2008). To enhance communication be-
tween parents and children, use the same cartoon version for both parents
and children in their respective sessions. The cartoon has a light switch at
the bottom of the page, accompanied by the text “Something Happens!”
and an oval for the child to record the triggering event. The silhouette of
a cartoon figure is connected to a thought bubble, feelings heart, and ac-
tion box, each of which are divided in half, with space to record the “hurt-
ful” or negative thought, feeling, and action in the lower half and the
“helpful” or positive/desired thought, feeling, and action in the upper half.
To explain TFD, begin by asking parents to identify a recent event that
triggered negative feelings in themselves (e.g., sadness, anger, frustration,
or fatigue) and that they didn’t feel they handled particularly well (e.g.,
“Makayla threw a tantrum just as we were leaving for a nice dinner—the
babysitter refused to deal with her, and we had to cancel our night out”).
Next, have parents recall the negative thoughts that accompanied these
feelings (e.g., “Makayla is so selfish”; “We’ll never be a normal family”;
“What’s the use of trying?”). Simply acknowledging these inevitable and
understandable thoughts is a requisite step in this approach and provides
an opportunity to validate the frustration and hurt experienced by parents
struggling with a child with a mood disorder (e.g., “I can imagine how dis-
appointing it was to anticipate a relaxing night out and to have that fall
through at the last minute”). It’s not easy raising a child with bipolar dis-
order, and parents deserve to hear this from someone who understands the
challenges they face on a daily basis and who is supportive of their desire
to seek help.
Once parents have identified the negative feelings and thoughts that
arose in response to an event, have them specify the actions they took in
response to these thoughts (e.g., “I yelled at Makayla, went to my room,
and cried”). Ask parents to notice the negative cycle that occurs: negative
feelings lead to negative thoughts, which lead to negative behaviors. Then
help parents understand where they can intervene to break the cycle.
Although it might seem easiest just to eliminate the frustrating event
in the first place, this isn’t always under parental control, especially when
the issue stems from a child experiencing mood symptoms. Further, nega-
tive feelings are part and parcel of raising a challenging child. Thus, the
first area on which to focus is negative thinking. Encourage parents to
brainstorm more positive, realistic, and helpful ways of thinking about the
event. Instead of thinking “Makayla is so selfish,” they could reframe the
event in a way that differentiates the child from the symptom (e.g.,
“Makayla’s really struggling with her manic symptoms this week; she’s
been much more irritable and hasn’t been sleeping much”). Alternatively,
parents could reframe the event in a way that emphasizes learning some-
thing from the experience (e.g., “This is an opportunity to help Makayla
learn how to manage these emotions. Fortunately we were still here, be-
cause the babysitter might not have been able to help her through this as
well as we can”).
Next, help parents to generate ideas for actions that would have been
more helpful in this situation, while also noting how much easier it is to
act positively in response to problem-focused, helpful thoughts. For exam-
ple, instead of yelling at the child and retreating to the bedroom to cry,
parents could help the child choose a calming strategy from her tool kit
and could make a plan to call her psychiatrist the next day to voice con-
cerns that the child’s manic symptoms are increasing. They could take a
long walk together after the situation at home calmed down sufficiently
and order takeout from one of their favorite local restaurants.
Generating these more adaptive thoughts and actions not only moves
the family toward effectively managing the problem, but also positively
impacts parents’ emotions. Whereas hurtful cognitions and responses be-
get more negative feelings, helpful thoughts and actions beget more posi-
tive feelings.
Sessions 5 and 6
Child session 5: Thinking-Feeling-Doing. This session introduces the
TFD exercise to the child. As with the parents, help the child recall an up-
setting event, identify and acknowledge the negative emotions associated
with that event, discuss hurtful cognitions and actions arising in response to
the negative feelings, and finally guide the child through the experience of
restructuring thoughts and choosing more adaptive behaviors to alleviate
emotional dysregulation. This session builds on the work from the previous
session, in which the child focused on identifying triggers, accompanying so-
matic responses and negative affect, and hurtful actions. This new step adds
in the role of cognition and links thoughts, feelings, and actions together.
Parent session 5/child session 6: effective problem-solving. Parent

session 5 and child session 6 both focus on developing an effective ap-
proach to problem solving. This approach employs hypothesis testing, a
hallmark of CBT that encourages clients to predict (or hypothesize) the
consequences of actions, then reevaluate their predictions in light of actual
outcomes. Although parent and child sessions on problem solving are con-
ducted separately, most of the techniques used will be described here only
once, due to the similarity of material presented in each session.
• First, identify the problem. Although selected “problems” can be inci-

dents that the child finds upsetting (much as in TFD), it is also benefi-
cial to frame symptoms of the child’s disorder as problems, reinforcing
earlier content regarding depersonalization of symptoms as an external
enemy.
• After a problem has been identified (e.g., receiving detention, not get-
ting enough sleep), have the child brainstorm ways in which he or she
can regain control of his or her emotions in the face of a challenging sit-
uation. Again, this session builds on the work of the previous sessions,
as the child now has an understanding of how thoughts, feelings, and
actions are integrated and affect each other. Because excessive emo-
tional reactivity can compromise problem-solving skills (Pavuluri et al.
2004), a child needs to calm down affectively before he or she is likely
to be successful in generating, selecting, and implementing sound deci-
sions.
• Next, have the child generate a list of possible solutions to the prob-
lem. Using a brainstorming approach, write down every suggestion
made before weighing their merits. For example, a child dealing with
anger over receiving a detention might generate suggestions that range
from “Ask the teacher what I did wrong and try to avoid doing this in
the future” to “Refuse to attend detention.”
• Then, have the child think through the pros and cons of each action.
After doing so, select an appropriate plan of action and encourage the
child to implement the solution next time the situation arises. Most
importantly, draw the child’s awareness to the results of his or her de-
cision. If the child’s choice solves the problem, he or she should plan
to use the strategy again in the future. If, on the other hand, the child’s
choice fails to ameliorate the situation, a new strategy should be con-
sidered next time, taking into account what has proven previously un-
successful.
Case Example: Making Responsible

and Reasoned Choices
Alejandro is a 9-year-old boy who was diagnosed with bipolar disorder
NOS 2 years ago. Alejandro’s school behavior has improved with medica-
tion management and the implementation of special education services, in-
cluding the identification of a “safe spot” where Alejandro can go when
feeling overwhelmed, as well as an adjusted schedule that places his most
demanding courses early in the day, when Alejandro tends to be at his best.
However, his parents are concerned that Alejandro continues to blame oth-
ers for his outbursts at home. When this occurs, Alejandro frequently says
he can’t help it, and blames his actions on his “bipolar.”
The therapist begins a discussion of effective problem-solving with
Alejandro by bringing up an issue Alejandro identified earlier in treatment.
Therapist: So, Alejandro, remember when we talked about some of your

symptoms, and one thing you identified was hitting Paul when you
get angry?
Alejandro: That happened yesterday when Paul knocked over the Lego cas-
tle I was building. But that’s not the real me. That’s my bipolar. The
real me is usually nice to Paul, like I show him how to build things.
Therapist: Is it your fault that you have bipolar disorder?

Alejandro: No. It’s not my fault.
Therapist: Right. But even though having bipolar disorder is not your fault,
it is still your.. .(pauses to let Alejandro answer).. .do you remem-
ber?
Alejandro: Um, it’s not my fault?
Therapist: Yes. But it is your challenge. That means it’s your responsibility
to make good choices, even when you’re feeling angry. You can’t just
say, “Oh well, I can’t help it; I have bipolar disorder.”
Alejandro: Oh, yeah. Dad always says, “That’s no excuse.”
Therapist: Right. So now we’re going to talk about how to make good
choices, because that can seem hard sometimes.
Alejandro: It’s really hard.
Therapist: Is it harder to think of good choices when you’re very angry or
when you’re more calm?
Alejandro: When I’m angry. That’s what I tell my mom. I tell her I’m too
mad.
Therapist: OK, so the first step in making a good choice is calming down
so you can think more clearly. We talked about ways to calm down
earlier when you made your tool kit. What’s something in your tool
kit you could use to calm down if you’re angry at Paul?
Alejandro: I could squeeze my stress ball very hard. Oh, or I could talk to
Mom and she could rub my shoulders.
Therapist: You have a great memory! Now let’s think of another solution
to your problem. What did you do yesterday when Paul knocked
over your castle?
Alejandro: I told you. I hit him.
Therapist: OK. What are some other things you could have done, besides
hitting Paul?
Alejandro: I don’t know, tell Mom?
Therapist: Good! Let’s look at those two choices and see what the good
and bad things are about each one. Are there any good things about
hitting Paul?
Alejandro: No. I mean, yes. It made me feel better.
Therapist: OK, it felt good. Did it feel good for a long time, or just for a
little while?
Alejandro: Just a second. Then Paul started to cry and Dad came and
yelled at me and gave me a time-out.
Therapist: So those were bad things about choosing to hit Paul, right?
Alejandro: Yeah, and when I said that I still wanted to play with my Legos,
Dad said that because I hit Paul, I couldn’t play with them anymore
that day.
Therapist: So the good thing about your choice was that you felt better for
just a second, and the bad things were that you got yelled at and had to
go to time-out. And in the end, your Legos got taken away and you
couldn’t even rebuild your castle. Now what about your other choice—
telling Mom? What are the good things about telling your mom?
Alejandro: She would know that it was Paul who did something wrong and
not me, and Dad wouldn’t have yelled at me.
Therapist: And would you have been sent to time-out?

Alejandro: No, they would make Paul go play with his own toys.
Therapist: And are there any bad things about telling your mom?
Alejandro: Maybe she would say I was being a tattletale.
Therapist: Does she usually say that?
Alejandro: No.
Therapist: OK, then it doesn’t sound like that’s very likely. So in the end,
what do you think would have happened if you had told your mom
instead of hitting Paul?
Alejandro: I would get to play with my Legos without Paul interrupting
me. But it would be hard to make the exact same castle that I made
before.
Therapist: Maybe so. But maybe the next castle you made would have
been even better.
Alejandro: Yeah, I’m pretty good at making castles.
In this interaction, the therapist makes it clear that although Alejandro

is not responsible for having bipolar disorder, he is responsible for the
choices he makes. To this end, the therapist helps guide Alejandro through
the process of making a good choice in a developmentally appropriate
manner. For instance, the therapist poses questions by giving Alejandro
choices (e.g., “Is it harder to think of good choices when you’re very angry
or when you’re more calm?”), as opposed to posing completely open-
ended questions that may be difficult for the child to answer. In addition,
the therapist helps the child to deepen his analysis of the situation by ask-
ing follow-up questions (e.g., “OK, it felt good. Did it feel good for a long
time, or just for a little while?”).
Children are likely to require less such scaffolding as they become
more experienced with analyzing problematic situations and their out-
comes, although the rate of this progression is specific to each individual
child. Structured practice, however, in which each step of the problem-
solving process is explicitly addressed, is essential.
Parent session 6: revisiting the mental health team and educational

team. Often after learning more about how the mental health system and
educational system can work on behalf of a child, parents will return to treat-
ment with specific questions about how to implement effective change. Is-
sues with schools are particularly common; use this session to plan for the
pending school professional session (parent session 7). Assuming there are
sufficient school issues to warrant direct communication with the school, use
this session to plan the nuts-and-bolts of how, when, and where to accomplish
this task. Examples include your going to a school meeting, video conferenc-
ing, conference calling, or inviting members of the school staff to attend a
therapy session. Also, set a clear and realistic agenda with the parent at this
session (i.e., What should be communicated? What questions need to be an-

swered? What concerns does the parent have?).
Session 7
Child session 7: revisiting healthy routines. Given the importance of
healthy routines in maintaining affective stability, revisiting these routines is in
order. Progress on the child’s first goal should have been monitored at each
session since the child began tracking sleep, nutrition, or exercise. At this ses-
sion, have the child select the topic of second most importance, set reasonable
goals around that behavior, and begin to track it. Suboptimal treatment adher-
ence regarding healthy behaviors is common; because the child has now
learned problem-solving skills, work with him or her to apply those skills to
increase compliance. Often, the first step of identifying the problem is very
important to successful problem-solving. For example, the problem “I need to
lose 15 pounds before my senior pictures” may not lead to a successful out-
come in a teenager 2 months before the event, but changing the problem to “I
need to cut out most of the junk food in my diet” is more likely to lead to con-
crete but not extreme behaviors that can be maintained over a lifetime.
Parent session 7: school treatment team. Use this session to prob-

lem-solve and share information directly with the previously identified
member(s) of the child’s school. This might be the school psychologist,
school social worker, school counselor, child’s IEP chair, intervention spe-
cialist or special education teacher, regular education teacher, resource
room teacher, tutor, paraprofessional, school nurse, behavioral specialist,
principal or vice principal, physical or occupational therapist, district spe-
cial education coordinator, and other staff pertinent to the child’s school.
Session 8
Child session 8: nonverbal communication. Impaired communica-
tion, including the presence of expressed emotion, has been identified as
a possible influence on the course of bipolar disorder. Thus, addressing
maladaptive communication patterns between parents and children as
well as every dyad in the family is important. Parents can usually absorb
information, can typically practice using effective verbal and nonverbal
communication in a single session (as will be discussed in parent session 8),
and likely are at least somewhat familiar with the concepts. In contrast,
children may benefit from separate presentations about verbal and nonver-
bal communication, with eventual integration of the two topics. Research
indicates children with bipolar disorder tend to struggle with interpreting
nonverbal cues, especially facial expressions; thus, devoting a session spe-

cifically to nonverbal communication is considered beneficial.
Begin by discussing the communication cycle. That is, one individual sends
a message, which is then received by another individual. This second individ-
ual then sends a message, which is received by the first individual. A problem
in any step of this cycle has the potential to disrupt communication and un-
derstanding. In reality, of course, the process can be infinitely more compli-
cated and involves issues such as how each member of a communication dyad
interprets the other’s verbal and nonverbal cues. The intent here, however, is
only to establish basic rules requisite to effective communication.
Next, raise the child’s awareness of nonverbal communication cues and
provide practice in accurately interpreting these signals. Though many
children have some concept of helpful and hurtful language, they are often
less aware of how nonverbal signals (i.e., posture, gestures, facial expres-
sions, eye contact, level of personal space, and tone of voice) can influence
interactions. After explicitly identifying and eliciting examples, introduce
an activity in which the child and an adult take turns guessing the emotions
displayed by the other. This activity, which can be framed as a game of cha-
rades, should be practiced by the child and parents before the next child
session. Further, parents can employ this general technique (either asking
the child to interpret the nonverbal cues of others to confirm comprehen-
sion or using the child’s own nonverbal cues to gauge his or her current emo-
tional state) in the course of everyday interactions to increase the child’s
facility with this often deficient skill and to enhance communication.
Parent session 8: communication. Addressing how parents communi-

cate, both verbally and nonverbally, also requires identification of the basic
communication cycle that was discussed with the child in child session 7.
Next, provide common examples of hurtful communication, including
name-calling, blaming, denying, rehashing past or unrelated conflicts, in-
terrupting, and lecturing. After drawing parents’ attention to these nega-
tive interactions, provide guidelines for more adaptive communication,
including staying positive and calm, keeping instructions brief, taking turns
speaking, paying attention to others’ verbal and nonverbal cues, listening
to the child rather than lecturing, and being direct. Additionally, let par-
ents know that asking questions and restating what the listener believes
the other to be saying can be effective methods of eliminating confusion.
Encourage practice of these communication strategies. In particular, ask
parents to monitor their use of hurtful communication, then have them
identify more helpful communication they could implement instead. Use of
these strategies in interactions with all members of the family can signifi-
cantly reduce the level of expressed emotion and confusion in the home.
Session 9
Child session 9: verbal communication. As a follow-up to the session
on nonverbal communication, begin this session with a quick review of the
communication cycle. Then, focus on helping children to differentiate be-
tween helpful and hurtful words (e.g., “D’Shaun keeps coming in my room,
and it’s making me angry” vs. “D’Shaun’s being a brat!”). Using helpful words
involves standard training in assertive communication—i.e., describe the situ-
ation, express your feelings, state your desired outcome. Making the distinc-
tion between helpful and hurtful language increases children’s awareness of
how they are speaking and how their words are impacting others.
Parent session 9: managing symptoms of bipolar disorder. Being a

good enough parent isn’t good enough to know how to manage the unique
symptoms of bipolar disorder. Parents benefit from specific coaching on
how to handle troublesome symptoms. An initial rule of thumb is to ad-
dress symptoms before they escalate to levels where the child and parent
are less able to use the tools and skills with which they have been equipped
in treatment. A child who has progressed to full-blown mania, for exam-
ple, is unlikely to successfully employ his or her coping tool kit or to engage
in effective problem-solving. Likewise, when depressive symptoms appear,
parents should encourage the child to use his or her tool kit, especially
tools that involve physical activity and staying socially engaged. An adoles-
cent experiencing an increase in depression may not feel like keeping plans
to attend a movie with friends, but doing so (and engaging in other health-
promoting behavior) may help to mitigate symptoms and prevent eventual
progression into a major depressive episode.
With the onset or increase of the child’s manic symptoms, parents should
limit stimulation such as loud music, bright lights, heavy physical exertion,
large gatherings, overscheduling of events, and intake of caffeine or sugar. Rou-
tines should be kept consistent and healthy habits maintained, including at-
tempts to keep the child’s sleep schedule as normal as possible. Encourage the
child to use his or her tool kit, particularly coping techniques involving relax-
ation, because behavioral activation may exacerbate symptoms of mania.
Even if suicidal behavior has not been an issue for the child, making prior
arrangements for how to handle it in case it becomes a concern is preferable
to attempting to design and implement appropriate measures in the midst of
a crisis. Parents should have prearranged places to lock away guns, knives,
medications (both prescription and over-the-counter), and toxic household
cleansers. They should have easy access to essential information, including
contact information for mental health care providers, a list of all medications
the child is taking, and any relevant insurance information. A child who ex-
presses an immediate intent to harm himself or herself and who may have the
ability to do so should be immediately referred for emergency services, partic-
ularly if parents have any doubt about their ability to constantly monitor the
child and ensure safety. Especially with children who have demonstrated sig-
nificant physical aggression toward themselves and others, helping parents se-
cure training in administering therapeutic holds may be advisable, as well as
knowing when (and how) to call the police for assistance.
Hospitalization, if necessary, should never be used punitively or as re-
spite for overstressed parents. Stress that hospitalization is a setting for
short-term stabilization of acute symptoms and a means of returning chil-
dren to everyday routines as efficiently as possible.
Managing the symptoms of a child with bipolar disorder also requires
parents to manage the inherent stress of dealing with a chronically ill child.
Use your knowledge of the family and its resources to help parents iden-
tify sources of emotional support and how to utilize them (e.g., family and
friends who feel comfortable supervising the child for short periods; sup-
port groups for parents of children with mood disorders, including online
forums; spiritual or religious groups, if consistent with the family’s be-
liefs). In addition, all family members, regardless of age or relationship to
the child, should make time for themselves and for enjoyable activities
with others. Parents are often so overwhelmed with the demands of man-
aging their child’s disorder that they don’t realize the necessity of self-care.
Those who do recognize the need often feel guilty about considering their
own needs, out of understandable yet counterproductive concern for the
child. Remind parents this is a marathon, not a sprint. They need to give
self-preservation a high priority, and set aside time for exercise, medita-
tion, other “refueling” activities, or therapy for themselves.
Family Session: Working With Siblings

Easily lost in the wake of a child suffering from bipolar disorder are the
needs of siblings. Including these children in the treatment process reminds
parents that the impressive needs of the patient do not diminish those of
their other children. In this session, which should be undertaken in the ab-
sence of the patient to encourage siblings to communicate openly, the clini-
cian should validate siblings’ often conflicting emotions (e.g., concern for the
patient and yet frustration over the disruption the disorder often causes). As
parents are often unsure how much information to give siblings about the
child’s condition, discuss with parents beforehand the level of information
to impart on the basis of the relative sophistication of siblings. Additionally,
the child with bipolar disorder should have an awareness of how information
about the illness will be presented to siblings, in order to allay fear of embar-
rassment. A key challenge in this session is balancing the need to involve sib-
lings in helping to create an environment conducive to the health of all
members of the family, while also maintaining appropriate boundaries that
avoid placing excessive responsibility on these other children. Finally, as sib-
lings have the same familial risk as the child with bipolar disorder, referral
for an evaluation and treatment of one or more siblings may also be in order.
Closing Session: Summary and Graduation

Up to four additional sessions to review necessary information and skills have
been built into the treatment model that has been tested. Of course, clinically,
you can follow a family as long as needed. An ideal model of care is one in
which you as the family clinician are able to see the child intensively to begin
treatment, then as needed over the course of his or her development. Often,
this translates to additional sessions around times of transition—elementary
school to middle school, middle school to high school, high school to college.
When the end of the intensive initial treatment phase is reached, em-
phasize the importance of the family and child continuing to use skills
learned during the intervention, in times of both symptom exacerbation
and remission. Although symptoms will almost inevitably fluctuate to
some degree, consistent application of these skills, sustained awareness
that recurrence is possible, and medication adherence provide the best
possible prognosis for the child in the future.
This session should serve as a graduation ceremony. Children can be pro-
vided with a developmentally appropriate “diploma,” signifying successful
completion of an intense course of treatment and recognition of their hard
work. Parents, too, deserve praise for tackling their child’s disorder and their
commitment to the well-being of their child and family—a proactive ap-
proach that if maintained should continue to pay dividends into the future.
Cultural Considerations
Due to the relative infancy of research regarding psychosocial interventions
for youth with bipolar disorder, evidence-based guidelines for making cul-
turally specific adaptations to a CBT program of this type are not yet avail-
able. In lieu of such information, an emphasis on sensitivity to the specific
needs of each family is likely the most optimal approach (see Chapter 3). A
strength of the intervention described here is that it allows for therapists to
adjust content to meet the family “where they are” as opposed to “where
they should be.”
Special Challenges to Treatment

Distinguishing Mood From
Behavioral Symptoms
Given the extremely high levels of comorbidity between bipolar disorder
and behavioral disorders, helping parents to differentiate mood from behav-
ioral symptoms (i.e., the “can’ts” from the “won’ts”) is a particularly rele-
vant exercise. On one hand, therapy urges compassion and tolerance for the
maladaptive emotions these children often cannot control; on the other
hand, treatment urges children (and parents) to take responsibility for their
actions, regardless of their emotions. Striking an appropriate balance—
knowing when to give way and when to push back—can be difficult for par-
ents. Aside from educating parents about how the symptom presentation of
bipolar disorder differs from behavioral disorders, identifying particular cues
that indicate the source of a child’s inappropriate behavior can often benefit
parents. Parents, for example, sometimes speak of a blank look in their
child’s eyes or a feeling that the child is “gone” when in the midst of a mood-
induced rage. In contrast, a child throwing a tantrum in the course of testing
limits may be described as having a mischievous or petulant look, suggesting
a purposeful quality to his or her actions. As parents become more adept at
observing fluctuations in their child’s mood (perhaps through the use of
mood logs), they are often able to identify the manner in which mood symp-
toms fluctuate in concert with other symptoms (e.g., a rise in mania may be
indicated not just by increased irritability but by increased irritability ac-
companied by markedly agitated movements and increased speech).
Heightened insight into how mood and behavioral symptoms tend to mani-
fest in their particular child leads to more confidence in choosing when to
give the child more leeway and when to stand firm.
Bringing Unspoken Negative

Thoughts to the Forefront
A good deal of CBT for bipolar disorder is directed at helping parents and
children break the negative cycles that too often typify interactions within
these families. Identifying overly negative and maladaptive thinking and
helping individuals to reframe situations from a more helpful perspective
can be exceptionally powerful and enlightening. The opportunity to finally
express these negative thoughts (e.g., “Why can’t my child just be normal?”
“He feeds off making me unhappy”; “The way my husband avoids interven-
ing with our daughter, I’d be better off raising her alone”) is often uncom-
fortable for parents but can be ultimately cathartic and empowering,
especially when the parents are interacting with an empathic therapist who
responds to the presence of these thoughts with a sense of understanding
(though without confirmation that the thoughts are accurate or helpful).
Once negative cognitions have been brought to the forefront and stripped of
the guilt that so often accompanies them, parents can begin to examine their
thoughts from a fresh perspective more conducive to progress.
Conclusion
While additional research is needed to further refine CBT-based, adjunc-
tive treatments for pediatric bipolar disorder, the intervention described
in this chapter (IF-PEP) has shown promise in helping patients and fami-
lies to meet the challenges of this complex illness. Because bipolar disorder
is typically believed to have a lifelong, chronic course, the intervention’s
focus on providing families with a sound knowledge base and the develop-
ment of essential skills (e.g., effective communication, problem-solving)
should appeal to clinicians who wish to equip their patients with more
than just a “band-aid” to address immediate concerns.
Key Clinical Points

• CBT for child and adolescent bipolar disorder is adjunctive to med-
ication management. Psychoeducational materials stress the need
for close communication with the prescribing physician and consis-
tent adherence to the prescribed medication regimen, even after
symptoms have subsided.
• Similarly, medication management in the absence of psychosocial
intervention is likely to result in suboptimal outcome and is therefore
best viewed as a necessary but not sufficient condition of effective
treatment.
• The involvement of families in treatment is essential. Parents who
are more informed regarding the nature of bipolar disorder and ef-
fective management of symptoms are better equipped to serve as
the eyes and ears of their child’s treatment team. Children with sim-
ilar information are also more likely to take an active role in their own
treatment.
• Helping the family to create a home environment consistent with main-
tenance of the child’s long-term mood stability requires the develop-
ment of a number of skills in both parents and child, including affect

regulation, problem solving, communication training, and self-care.
• Breaking maladaptive family cycles typified by negativity, criticism,
and poor communication requires an understanding of the interre-
latedness of emotions, cognitions, and behaviors.
6.1. CBT would be considered an appropriate treatment strategy for a
child with bipolar disorder
A. Only when a strong family history of bipolar disorder is identi-

fied.
B. In conjunction with mood stabilization with medication.
C. If the child is of well above-average intelligence.
D. As a stand-alone treatment.
6.2. Children with bipolar disorder are at increased risk for
A. Academic problems.
B. Social problems.
C. Suicidal ideation.
6.3. A 14-year-old adolescent girl is diagnosed with bipolar I disorder.

__________ is/are considered the first-line treatment(s).
A. CBT.
B. Antidepressants.
C. Mood stabilizers or atypical antipsychotics.
D. Electroconvulsive therapy.
6.4. Although the etiology of bipolar disorder is thought to be largely

___________________, illness course is likely influenced by
___________________________.
A. The result of trauma; biological factors.

B. Biological; a combination of biological, psychological, and social
factors.
C. Due to impaired parenting; a combination of biological, psycho-
logical, and social factors.
D. Medication induced; the child’s level of intelligence.
6.5. _____________ is almost always recommended as a part of CBT for

a child with bipolar disorder.
A. Family involvement.
B. Use of a therapist of the same sex as the child.
C. Residential treatment.
D. Psychoeducational testing.
Suggested Readings
and Web Sites
For Families
Books
Andersen M, Kubisak JB, Field R, et al: Understanding and Educating
Children and Adolescents With Bipolar Disorder: A Guide for Educa-
tors. Northfield, IL, The Josselyn Center, 2003—a book for parents to
share with school professionals
Child and Adolescent Bipolar Foundation: The Storm in My Brain. Evans-
ton, IL, 2003. Available at: Child and Adolescent Bipolar Foundation
(CABF): (800) 256–8525, www.bpkids.org—a book for children
Fristad MA, Goldberg Arnold JS: Raising a Moody Child: How to Cope
With Depression and Bipolar Disorder. New York, Guilford, 2004—a
book for parents
Jamieson PE, Rynn MA: Mind Race: A Firsthand Account of One Teenag-
er’s Experience With Bipolar Disorder. New York, Oxford University
Press, 2006—–a book for adolescents
Miklowitz DJ, George EL: The Bipolar Teen: What You Can Do to Help
Your Child and Your Family. New York, Guilford, 2007—a book for
parents
Web Sites
The Balanced Mind Foundation: www.thebalancedmind.org—for parents
and adolescents
BPChildren: www.bpchildren.com—for parents and children; features
“BPChildren Newsletter”
For Clinicians
Books
Fristad MA, Goldberg Arnold JS, Leffler J: Psychotherapy for Children
With Bipolar and Depressive Disorders. New York, Guilford, 2011
Kowatch RA, Fristad MA, Findling RL, et al: A Clinical Manual for the
Management of Bipolar Disorder in Children and Adolescents. Wash-
ington, DC, American Psychiatric Publishing, 2009
Web Sites
Juvenile Bipolar Research Foundation (JBRF): www.bpchildresearch.org—
includes a Listserv for therapists treating children with bipolar disorder
MF-PEP and IF-PEP workbooks can be ordered directly from
www.moodychildtherapy.com
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7
Childhood Anxiety
Disorders
The Coping Cat Program

ANXIETY disorders are commonly experienced by youth, with reported

rates of 10%–20% in the general population and primary care settings (Chavira
et al. 2004; Costello et al. 2004). Anxiety disorders in youth include general-
ized anxiety disorder (GAD), social phobia, separation anxiety disorder
(SAD), specific phobias, obsessive-compulsive disorder, and posttraumatic
S This chapter has a video case example on the DVD (“The Coping Cat Program”)
demonstrating CBT for an anxious child.
Preparation of this chapter was facilitated by research grants awarded to Philip C.

Kendall (MH MH080788 and UO1MH63747).
227
stress disorder (American Psychiatric Association 2000). In this chapter, we

focus on a treatment for three youth anxiety disorders (GAD, social phobia,
SAD) that have similar features and high rates of co-occurrence.
Anxiety disorders do not remit with time, and most, if left untreated,
are associated with impairments in adulthood. Anxiety disorders in chil-
dren are also associated with difficulties in academic achievement (Am-
eringen et al. 2003), social and peer relations (Greco and Morris 2005),
and future emotional health (Beidel et al. 1991). Anxiety in youth places
children at increased risk for comorbidity (Verduin and Kendall 2003) and
psychopathology in adulthood (e.g., anxiety, substance abuse, depression;
Kendall et al. 2004). The consequences of untreated anxiety disorders in
youth highlight the need for early intervention.
Empirical Evidence
Cognitive-behavior therapy (CBT) for youth anxiety has been found to be
effective in several randomized clinical trials conducted in the United
States (e.g., Kendall 1994; Kendall et al. 1997, 2008b; Walkup et al.
2008). Additional studies with similar outcomes have been conducted in
Australia (e.g., Barrett et al. 1996), Canada (e.g., Manassis et al. 2002),
and the Netherlands (e.g., Nauta et al. 2003). Collectively, although not
all participants are responders, the results of these trials indicate that be-
tween 50% and 72% of children with GAD, social phobia, and/or SAD
who receive CBT do have a positive response—they no longer meet crite-
ria for their presenting anxiety disorder following treatment. In contrast,
such trials indicate that between 10% and 37% of youth who receive pill
placebo, wait-list assignment, or active comparison treatment for their
anxiety disorder have a positive response following treatment (Barrett et
al. 1996; Kendall et al. 2008b; Nauta et al. 2003.
The maintenance of therapeutic gains has been found up to 7 years
posttreatment. In two follow-up studies of different samples of anxious
youth (3.35 and 7.4 years after treatment), 80%–90% of successfully
treated children continued to not meet criteria for their presenting anxiety
disorder (Kendall and Southam-Gerow 1996; Kendall et al. 2004). To
date, rates of long-term treatment maintenance following CBT have not
been compared with a control group, because generally, the wait-listed
youth in such trials were offered treatment following the initial wait-list
period. It is pleasing to note that reviews of the evaluation literature sup-
port the utility of CBT for childhood anxiety disorders. Such reviews ap-
pearing earlier than 2008 and applying Chambless and Hollon’s (1998)
criteria for evidence-based treatments conclude that CBT for youth with
Childhood Anxiety Disorders 229
anxiety disorders is probably efficacious (Albano and Kendall 2002; Kaz-

din and Weisz 1998; Ollendick and King 1998; Silverman et al. 2008).
Given studies published since these reviews (e.g., Walkup et al. 2008), it
is reasonable to suggest that the treatment be considered efficacious.
CBT Approaches
Consistent with a cognitive-behavioral model (Kendall 2010), CBT for
childhood anxiety disorders targets the somatic, cognitive, and behavioral as-
pects of anxiety. For a discussion of the theoretical underpinnings of CBT for
childhood anxiety disorders, see Gosch et al. 2006. Several CBT approaches
to treating child anxiety have been developed and the majority have core
treatment components in common: psychoeducation, recognition and man-
agement of somatic symptoms, cognitive restructuring, and exposure. The
Coping Cat Program (Kendall and Hedtke 2006a, 2006b) is a manual-based
individual CBT for youth with considerable empirical support when com-
pared with a wait-list control condition, active comparison treatment, and
pill placebo (Kendall 1994; Kendall et al. 1997, 2008b; Walkup et al. 2008).
Other CBT approaches, such as Social Effectiveness Therapy for socially
phobic youth (Beidel et al. 2000), may include a greater emphasis on social
skills training. Individual CBT with an added parent component (e.g., Bar-
rett et al. 1996), group CBT (e.g., Manassis et al. 2002), and family CBT
(e.g., Wood et al. 2006) also have empirical support. In this chapter, we de-
scribe the CBT approach used at the Child and Adolescent Anxiety Disor-
ders Clinic of Temple University, the Coping Cat Program. Although we
describe the implementation of the Coping Cat Program to treat GAD, so-
cial phobia, and/or SAD specifically, the core principles of CBT for child
anxiety are highlighted throughout the chapter.
Treatment Planning
There are several important issues to consider when implementing CBT
for childhood anxiety, such as assessment, the format and length of treat-
ment, and the structure and content of sessions. We consider each of these
issues below.
Assessment
We recommend a multimethod, multi-informant approach to assessment.
Clinical interviews, youth self-report measures, and parent- and teacher-
reports provide useful information regarding the presenting symptoms and

related impairment across settings.
We use the Anxiety Disorders Interview Schedule for DSM-IV—Parent
and Child Versions (ADIS-C/P; Silverman and Albano 1996), a semistruc-
tured diagnostic interview administered separately to parents and children.
The ADIS-C/P has demonstrated favorable psychometric properties (Rapee
et al. 1994; Silverman et al. 2001; Wood et al. 2002) and sensitivity to treat-
ment-related changes (Kendall et al. 1997; Silverman et al. 1999).
For child self-report, there are several options. One is the Multidimen-
sional Anxiety Scale for Children (MASC; March et al. 1997). The MASC
is a 39-item self-report measure of children’s anxiety symptoms over the
past 2 weeks. The MASC has been found to have good psychometric prop-
erties (March et al. 1997).
In addition to parent versions of self-report anxiety measures (e.g.,
MASC-P), parent and teacher measures of overall child symptomatology are
informative. The Child Behavior Checklist (CBCL; Achenbach and Rescorla
2001) is a 118-item parent report of behavioral problems and social and ac-
ademic competence, and the Teacher Report Form (TRF; Achenbach and
Rescorla 2001) is a parallel teacher report. The CBCL and TRF do not alone
diagnose anxiety disorders, but the CBCL and TRF effectively discriminate
between externalizing and internalizing disorders (Seligman et al. 2004; see
also Aschenbrand et al. 2005) and provide information on the child’s areas
of disturbance, social activities, and peer interactions.
Format
Typically, the Coping Cat Program involves child-focused therapy, with
two specific parent sessions included in the program. In the Coping Cat
Program, parents serve as consultants (i.e., provide the therapist with in-
formation about the child) and as collaborators (i.e., help with implemen-
tation of the program). Therapists who wish to work with parents in the
sessions (family CBT) can consult the family therapy manual (Howard et
al. 2000). Additionally, youth anxiety disorders have been treated within
a group format.
Length of Treatment
The Coping Cat Program is designed as a 16-session program. As opera-
tionalized in one study, treatment was 14 sessions provided within
12 weeks (Walkup et al. 2008). In accordance with the concept of “flexi-
bility within fidelity” (e.g., Kendall et al. 2008a), some youth may require
slightly more or fewer than 16 sessions.
Structure of Sessions
The Coping Cat Program is designed to be implemented in weekly child-
focused sessions lasting 50–60 minutes. There are two parent sessions, and
each may be scheduled for the same day as an adjacent child-focused ses-
sion. Each child-focused session begins with a review of the weekly home-
work assignment (referred to as a STIC [Show That I Can] task). The
majority of each session is devoted to psychoeducation (phase I) or expo-
sure (phase II) content. Each session ends with an assignment of a STIC
task (i.e., homework) and a fun activity or game.
Content of Sessions
The Coping Cat Program combines behavioral strategies (e.g., modeling,
relaxation training, in vivo exposure tasks, and contingent reinforcements)
with cognitive strategies (e.g., problem solving, cognitive restructuring) to
help youth identify and cope with anxiety. The content of the Coping Cat
Program is described below. Therapists interested in using the Coping Cat
Program with an anxious child should consult the therapist manual (Ken-
dall and Hedtke 2006a) and the child’s workbook (Kendall and Hedtke
2006b). The therapist manual and the client workbook are designed to be
used together: the manual guides the sessions of the treatment, whereas
the workbook contains corresponding client tasks. A similar program is
available for adolescents (Kendall et al. 2002a, 2002b), and a computer-
assisted version of the treatment (Camp Cope-A-Lot; Kendall and Khanna
2008) has been evaluated in research (Khanna and Kendall 2010).
Overview: The Coping Cat Program

The overarching goal of the Coping Cat Program is to teach youth to recognize
signs of anxiety and use these signs as cues for the use of anxiety management
strategies. In addition to the core CBT components of psychoeducation, skills
for managing somatic symptoms, cognitive restructuring (changing self-talk),
and exposure, the Coping Cat Program also places emphasis on coping mod-
eling and homework assignments to practice newly acquired skills.
The program has two phases of eight sessions each. Phase I focuses
on psychoeducation, whereas phase II emphasizes exposure to anxiety-
provoking situations. Within the psychoeducation phase, the child learns
to identify when she is feeling anxious and to use anxiety management
strategies. The therapist presents these strategies to the child as a tool set
that she may carry with her and draw from when she is feeling anxious.
The strategies include identifying bodily arousal, engaging in relaxation,

recognizing anxious thoughts (self-talk), using coping thoughts, and prob-
lem solving. Anxiety management strategies are taught in a sequence that
allows the child to build skill upon skill. In the last eight sessions (phase
II), the therapist provides exposure tasks for the child to approach anxi-
ety-provoking situations and to use the skills learned in the first eight ses-
sions. The exposure tasks are guided by a collaboratively determined
hierarchy so that the child practices skills in increasingly anxiety-provoking
situations. The therapist serves as a “coach,” teaching the child the neces-
sary skills and guiding the child to practice the skills while in real anxiety-
provoking situations.
Coping Modeling
An important component of the Coping Cat Program is for the therapist to
serve as a coping model for the child. A mastery model demonstrates success,
whereas a coping model demonstrates encountering a problem, developing a
strategy to deal with the problem, and then success. Therapists serve as a cop-
ing model by demonstrating their own anxiety, strategies that helped them
cope with the anxiety, and then success. The therapist continues to serve as a
coping model throughout treatment as each new skill is introduced. The ther-
apist demonstrates the skill first, then asks the child to participate with him
or her in role-playing. Finally, the therapist encourages the child to role-play
scenes alone, practicing the newly acquired skills.
Weekly Homework
Homework is an important component of the Coping Cat Program.
Throughout treatment, ask the child to complete weekly homework as-
signments (STIC tasks). STIC tasks provide the child with an opportunity
to test out and practice each of the skills learned in session. Consistent
with behavioral theory, reward the child for STIC task completion.
Psychoeducation
In phase I, the therapist presents four important concepts.
1. Recognition of bodily reactions to anxiety and management of these

symptoms (e.g., using relaxation).
2. Recognition of anxious self-talk and expectations.
3. Modification of anxious self-talk using coping thoughts and the use of
problem solving to develop a way to cope with anxiety more effectively.
4. Self-reward for effort (partial or full success) in facing anxiety-provok-

ing situations.
To teach these concepts to the child, the therapist uses an acronym, re-
ferred to as the FEAR plan, to help the child learn, remember, and apply
these four concepts.
F = Feeling frightened?
E = Expecting bad things to happen?
A = Attitudes and actions that can help
R = Results and rewards
Exposure Tasks
In phase II, the therapist guides the child through exposure tasks—creat-
ing anxiety-provoking situations and helping the child practice the FEAR
plan during anxious arousal. The purpose of exposure is prolonged, sys-
tematic, and repeated contact with the avoided stimuli or situation. The
goal is to have the child remain in the situation until she has reached an
acceptable level of comfort (i.e., habituation). Be sure to tailor the expo-
sure tasks to each child according to the child’s specific anxieties and fears.
For example, anxiety-provoking situations for a child with social phobia
might include playing a game with a new person or peer, whereas anxiety-
provoking situations for a child with separation anxiety might include
waiting for a parent who is late. The exposure tasks increase in difficulty
over the course of the second half of treatment; later exposure tasks are
more anxiety provoking than earlier ones.
S Case Example:
The Coping Cat Program
We illustrate the Coping Cat Program using the case of a youth named
Zoe. (See the DVD for a demonstration of the FEAR strategy and STIC
assignment.)
Zoe, a 10-year-old girl, met criteria for a diagnosis of social phobia at the
intake assessment. She is easily embarrassed, and afraid that others will
laugh at her in social situations. Zoe’s feared situations include speaking to
adults, reading aloud in class, giving presentations, and asking questions in
class. Her parents report that Zoe’s distress is highly impairing and affects
her academic performance. When Zoe is faced with a social situation, she
“freezes up.” She has great difficulty maintaining eye contact.
Session 1: Building Rapport and

Treatment Orientation
Because the child-therapist relationship is so vital, a main goal of the first
session is to build rapport with the child. The therapist and child should
spend the first part of the session getting to know one other by asking
questions or playing an icebreaker game. Next, give the child a brief over-
view of the program and share logistics of the program with the child, such
as how often and for how long the two of you will meet. After introducing
the program, ask the child if she has any questions. This encourages the
child’s participation in treatment and emphasizes that you and the child
will be a collaborative team working together. At the end of the session,
assign the child an easy STIC task (homework) from The Coping Cat
Workbook and plan a reward for completing the task. Finally, end the ses-
sion by playing a game or engaging in another fun activity.
On the day of her first appointment, Zoe enters the therapy room without
looking at the therapist. The therapist invites Zoe to make herself comfort-
able. The therapist asks Zoe to look around the room and see if there are any
interesting games that she would like to play later in the session. Zoe finds
the game Guess Who? and brings it to the therapist. The therapist lets Zoe
know that they will save time at the end of the session to play the game to-
gether. The therapist gives Zoe an overview of what the session will involve.
They play a get-to-know-you game (asking each other for personal facts, such
as “What is your favorite TV show?”). During the game, Zoe’s eye contact
improves slightly and the therapist notes that she seems more relaxed.
After the get-to-know-you game, the therapist shares some of the logis-
tics of the Coping Cat Program with Zoe. The therapist shares with Zoe that
they will learn skills that can help kids when they are feeling worried or
scared. She explains to Zoe that for the first half of the program, they will
focus on recognizing and learning about anxiety, and in the second half, they
will focus on knowing what to do about feeling anxious. The therapist points
out to Zoe that they will work as a team, with the therapist as the coach. She
encourages Zoe to ask questions and is enthusiastic when Zoe talks.
The therapist introduces The Coping Cat Workbook and Zoe is assigned
a STIC task from the book (e.g., “Write about a time you felt great”). The
therapist and Zoe agree that she will earn stickers for each STIC task com-
pleted and can exchange those stickers for rewards every four sessions. As
promised, the therapist and Zoe spend the last 10 minutes playing Guess
Who?
Session 2: Identifying Anxious Feelings

The aim of the second session is to help the child learn to distinguish anxious
or worried feelings from other feelings. To begin, review the STIC task from
session 1 and give an appropriate reward. If the child did not do the STIC
task, complete it together. Next, discuss with the child how different feel-
ings have different physical expressions. Collaborate with the child to list
various feelings and their corresponding physical expressions. Once the child
has a general understanding that different feelings correspond to different
expressions, normalize the child’s own experience of fears and anxiety. To
serve as a coping model, disclose a time when you felt anxious and how you
handled it. Be a coping model rather than a mastery model—everything
doesn’t always go well! Discuss the child’s own anxiety, including the types
of situations that are difficult, and the child’s responses in the anxiety-pro-
voking situation. Introduce the feelings thermometer, which is used to rate
anxiety on a scale from 0 to 8 (see the therapist manual for details). With
the child, begin to construct a hierarchy (or FEAR ladder; Figure 7–1) using
the ratings from the feelings thermometer.
Zoe and her therapist begin session 2 by reviewing her STIC task. Zoe
wrote about feeling great during a recent soccer game. The therapist listens
with interest to the account of Zoe’s soccer game. Together they pick out
two stickers as Zoe’s reward. Next, the therapist introduces Zoe to the
concept that different feelings have different physical expressions. Zoe and
the therapist create a feelings dictionary by cutting out pictures of people
with various expressions from magazines and labeling the pictures with the
emotions depicted. During this project, Zoe and the therapist note that
different facial or physical expressions (e.g., a smile, head hanging down)
are linked to different emotions (e.g., feeling happy, feeling sad). The ther-
apist and Zoe also play a brief feelings charades game. They take turns act-
ing out various feelings and having the other person guess the feeling.
The therapist shares with Zoe that everyone (including the therapist) feels
anxious at times. The purpose of the program is to help Zoe learn to recognize
when she is feeling anxious and then to use skills to help herself cope. Zoe and
her therapist begin to develop a fear hierarchy of anxiety-provoking situations
by categorizing the things Zoe is afraid of into easy, medium, and challenging
categories. Zoe identifies talking to a new adult (e.g., store clerk) as a medium
fear and giving an oral presentation as the most challenging fear.
Zoe is assigned a STIC task: record one anxious experience and one
nonanxious experience in her workbook. Zoe and her therapist play a game
of Guess Who? before the session ends.
Session 3: Identifying Somatic

Responses to Anxiety
The main goal of this session is to teach the child to identify how her body
responds to anxiety. First, discuss somatic symptoms that might occur
when someone is feeling anxious, such as a racing heart or stomach butter-
flies. Ask the child to describe somatic responses that people have when
anxious, and ask how she notices when she is in an anxiety-provoking sit-
FEAR Ladder
up there!
’re
u
Yo
Getting hig
he
r...
high...
oo
tt
No
FIGURE 7–1. FEAR ladder.

Source. Reprinted from Kendall PC, Hedtke K: Coping Cat Workbook, 2nd Edi-
tion. Ardmore, PA, Workbook Publishing, 2006. Used with permission.
uation. Next, practice identifying these responses (via coping modeling

and role-playing), first in low anxiety–provoking situations and then in
more stressful situations. After practice with identifying somatic re-
sponses, introduce the F step: Feeling frightened? In the F step, the child
will ask herself, “How does my body feel?” and will monitor her somatic
responses associated with anxiety.
The therapist and Zoe start session 3 by reviewing Zoe’s STIC task and
putting stickers in her bank. Next, the therapist introduces today’s topic:
identifying the body’s reaction to anxiety. The therapist mentions several
possible physical expressions of anxiety, such as sweating or a stomachache.

The therapist asks Zoe to think about other ways that someone’s body
might react when he or she is nervous. Zoe shares that when she has to an-
swer a question at school aloud, her stomach starts to hurt. Together, the
therapist and Zoe discuss what kinds of bodily reactions they have during
anxiety-provoking situations of varying degrees (low, medium, high). The
therapist acts as a coping model by sharing with Zoe that she blushes (gets
red in her face) when she feels anxious. Zoe and her therapist create a body
drawing depicting Zoe’s somatic reactions to anxiety, with Zoe permitted
to be creative in her artwork. The therapist introduces this process of pay-
ing attention to what’s happening in Zoe’s body as a cue that Zoe is “Feel-
ing frightened?” as the F step.
At the end of session, the therapist reminds Zoe that she has the next
week off as the next session will be with her parent(s). The therapist asks
Zoe if she has any questions about the parent session and if there is any-
thing specific the therapist should or shouldn’t say when meeting with the
parent(s). Finally, the therapist assigns a STIC task from the workbook,
and she and Zoe kick around a Nerf soccer ball for 5 minutes.
Session 4: First Parent Meeting

Although parents have been involved already (providing information about
the child), the goal of the first parent session is to encourage parental co-
operation with the program and to answer the parents’ questions or con-
cerns. Begin by providing an outline of the entire treatment program.
Invite the parents to discuss any concerns that they may have, and ask for
any input they feel will be helpful regarding their child’s anxiety. Finally,
offer specific ways that the parents can be involved in the program.
The therapist meets with Zoe’s mother and father. She shares with the
parents that she has enjoyed meeting with Zoe and notes some of Zoe’s
strengths. The therapist briefly outlines the treatment program, noting
what Zoe has learned so far and what will happen in the remainder of treat-
ment. The therapist explains that a parent can be involved in treatment by
providing information about Zoe’s anxiety and by helping to carry out ther-
apy tasks at home. The therapist talks with the parents to learn more about
situations where Zoe becomes anxious. The parents describe Zoe’s reac-
tion in several recent social situations, such as refusing to order for herself
in a restaurant.
Session 5: Relaxation Training

A main aim for the child in session 5 is learning to relax. Acknowledge the
previous parent meeting, and be prepared to provide a very brief recap. Re-
view the F step by suggesting to the child that when she is feeling anxious,
her body has somatic responses that may serve as cues. These somatic re-
actions may be associated with tension, which can be reduced by relax-

ation. Discuss the difference between feeling tense and feeling relaxed.
Introduce useful ways to relax, including deep breathing, progressive mus-
cle relaxation, and relaxation aids such as relaxation CDs. Practice relax-
ation with the child using coping modeling and role-play.
The therapist begins Zoe’s session 5 by mentioning the parent session and
inviting her to ask questions. Next, they review Zoe’s STIC task. Zoe has
accumulated enough stickers to trade in for a small prize.
The therapist introduces relaxation as a tool that Zoe can use when she
is anxious. The therapist recalls that when Zoe has to answer a question in
class, she gets a stomachache and feels tense. The therapist links this bodily
response to the F step (Feeling frightened?) of the FEAR plan. The thera-
pist explains that our bodies provide cues when we are feeling nervous, and
these cues can be signals for us to relax. The therapist and Zoe engage in a
robot–rag doll exercise (Kendall and Braswell 1993) and note the differ-
ence between feeling tense and feeling relaxed.
Next, the therapist and Zoe practice deep breathing. The therapist
suggests that Zoe sit comfortably on a beanbag chair. She asks Zoe to take
a deep breath and then let it out slowly, focusing on how her body feels.
The therapist asks Zoe how her body feels after a few deep breaths. Then,
the therapist introduces relaxation. She gives Zoe a CD with the thera-
pist’s voice guiding her through a progressive muscle relaxation exercise.
The therapist and Zoe practice relaxation together with the therapist serv-
ing as a coping model. The therapist suggests that Zoe can use the CD to
practice these skills at home. She also asks Zoe to consider times when re-
laxation may be useful. The therapist suggests that even when Zoe can’t
complete an entire relaxation session, she may be able to take deep breaths
Afterward, the therapist and Zoe invite Zoe’s parents into the session. Zoe
“teaches” her parents relaxation and everyone follows along with the CD.
Together, they discuss when and where Zoe will be able to practice her re-
laxation during the coming week (her STIC task). Zoe plans to practice
each night in a comfortable chair in her bedroom.
Session 6: Identifying and Challenging

Anxious Self-Talk
The goal of this session is to learn to identify and challenge anxious self-
talk. After introducing the concept of thoughts or self-talk, use exercises
in The Coping Cat Workbook to help the child generate thoughts that
might occur with various feelings. Discuss self-talk with the child and de-
scribe the connection between anxious thoughts and anxious feelings.
Work together to discriminate anxious self-talk from coping self-talk.
Next, introduce the E step of the FEAR plan: Expecting bad things to hap-
pen? In the E step, the child will ask herself, “What is my self-talk?” and
monitor the thoughts associated with anxiety. Practice the use of various
TABLE 7–1. Questions the child can ask himself or herself to

challenge anxious self-talk
Do I know for sure this is going to happen?
What else might happen other than what I first thought?
What has happened in the past?
Has this happened to anyone I know?
How many times has it happened before?
After collecting evidence, how likely do I think this is going to happen?
What is a coping thought I can have in this situation?
What is the worst thing that could happen?
What would be so bad about ____________________?
TABLE 7–2. Coping thoughts

Trying is the most important thing.
No one is perfect.
Everyone makes mistakes sometimes.
I will try my best.
I can do it!
I will be proud of myself if I try.
What’s the worst that can happen?
It’s probably not as scary as I think it is.
I have done it before, so I can do it again.
types of coping self-talk using the first two steps in the FEAR plan (see Ta-
bles 7–1 and 7–2).
Zoe and the therapist begin session 6 by reviewing the STIC task from last
week. Zoe reports that she was able to relax while listening to her CD and
that her mom joined in some nights.
The therapist introduces Zoe to the idea that thoughts are connected
to feelings. They work on a thought-bubble exercise in Zoe’s Coping Cat
Workbook. They also look through magazines and give people in the pic-
tures a thought bubble. The therapist helps Zoe differentiate between anx-
ious self-talk and coping self-talk. The therapist introduces the E step
(Expecting bad things to happen?) of the FEAR plan. She tells Zoe that in
this step, she will ask herself, “What’s in my thought bubble? Am I expect-
ing bad things to happen?” and that Zoe will start to pay attention to her
thoughts when she is anxious. Together, Zoe and the therapist practice cop-
ing self-talk and review the F and E steps of the FEAR plan. At the end of
the session, Zoe’s therapist assigns a STIC task from the workbook. They
play a game on the clinic Wii for the final 5 minutes of the session.
Session 7: Attitudes and Actions:

Developing Problem-Solving Skills
The main goal of session 7 is to introduce problem solving as a strategy for cop-
ing with anxiety. First, review the F and E steps. Next, introduce the A step,
“Attitudes and actions that can help.” In this step, the child learns that she
may take action and change her reactions when feeling anxiety. Introduce
problem solving as a tool to help the child deal with anxiety. Describe the four
steps of problem solving (i.e., define the problem, explore potential solutions,
evaluate the potential solutions, select the preferred solution). To begin, have
the child practice using problem solving in a concrete, nonstressful situation.
Slowly build to practicing problem solving in anxious situations.
Zoe and the therapist review the STIC task and pick out stickers to place
in the bank. Next, the therapist reviews the F and E steps with Zoe by ask-
ing her to describe what they stand for. Following Zoe’s explanations, the
therapist presents the idea that now that Zoe knows how to check what’s
going on in her body and her thoughts when she is nervous, it’s time to
learn how to cope with that anxiety. The therapist introduces the A step in
the FEAR plan: Attitudes and actions that can help. The therapist briefly
describes the process of problem solving. She begins the discussion of
problem solving with a concrete, nonstressful situation. The therapist gives
the following example: “You can’t find your shoes. How would you try to
find them?” The therapist and Zoe go through the steps of problem solving,
having some fun along the way as they include silly solutions in their brain-
storming. After they have practiced with a nonstressful situation, the ther-
apist guides Zoe in using problem solving in low and high anxiety–
provoking situations. To end the session, Zoe’s therapist assigns a STIC
task from the workbook, and she and Zoe play a game of tic-tac-toe.
Session 8: Results and Rewards

The aim of session 8 is to introduce the final step of the FEAR plan: Re-
sults and rewards (Figure 7–2). Introduce the concept of self-rating and
self-rewarding for effort. Collaborate with the child to create a list of pos-
sible rewards that are both material and social. Serve as a coping model by
describing a situation where you experienced some distress but were able
to fully cope with the anxiety, rate your effort, and then give yourself a re-
ward. Review the FEAR plan and then work with the child to identify a
stressful situation and apply the FEAR plan together to get through it.
Feeling frightened?
Expecting bad things to happen?
Attitudes and actions that can help
Results and rewards
FIGURE 7–2. FEAR steps.

Source. Reprinted from Kendall PC, Hedtke K: Coping Cat Workbook, 2nd Edi-
tion. Ardmore, PA, Workbook Publishing, 2006. Used with permission.
Inform the child that the next part of the program involves practicing
the FEAR steps in anxiety-provoking situations. Remind the child that the
practice will be gradual, starting with a situation that makes the child only
a little anxious—an easy one. Let her know that the FEAR steps will need
to be practiced in the same situations more than once.
Zoe and her therapist begin by reviewing the STIC task. The therapist in-
troduces the final step in the FEAR plan: Results and rewards. The thera-
pist asks Zoe what she thinks about rewards, and they discuss the
difference between a reward and an award. Together, Zoe and the therapist
create a list of potential rewards (e.g., baking cookies with her mom, a
high-five from the therapist, a new soccer ball) that she might be able to
earn for completing challenging tasks in and out of session.
Zoe and her therapist practice self-reward for effort through the exer-
cises in the workbook and role-plays. They review the steps of the FEAR
plan. Together they create a Coping Keychain with a personalized FEAR
plan for Zoe to use as a keychain and when she is feeling anxious. Zoe and
her therapist review Zoe’s fear hierarchy, which includes speaking to an
adult she doesn’t know that well, reading in front of others, and answering
questions in class.
The therapist tells Zoe that the next part of treatment involves practicing
the skills Zoe has learned in the program thus far. The therapist explains that
Zoe may feel anxious during the practices but now she has the FEAR plan to
help her cope. The therapist also reminds Zoe that she is going to meet with
her parents again next time. The therapist assigns Zoe a STIC task from her
workbook. They end the session by kicking around the Nerf soccer ball.
Session 9: Second Parent Session

The second parent session aims to provide an opportunity for the parents
to learn more about the upcoming exposure tasks. Begin by describing the
rationale behind exposure practice and the difference between avoidance
and approach. Remind the parents that the goal of treatment is not to re-
move all of the child’s anxiety, but to reduce the amount of distress expe-
rienced and to help the child learn to manage it. This goal is accomplished
through practicing the FEAR plan in anxiety-provoking situations, in and
out of session. Inform the parents that it is expected that the child will feel
some anxiety during the exposures. After this overview of exposure tasks,
give the parents an opportunity to ask questions or discuss concerns. Fi-
nally, solicit the parents’ assistance in the planning of exposure tasks.
Both of Zoe’s parents attend the second parent meeting. The therapist be-
gins the session by giving them an overview of the remainder of treatment.
She introduces the exposure tasks by explaining that Zoe has learned ways
to cope with her anxiety in social situations and that now she will get to
practice in real situations. As Zoe starts to face her fears, she will gain a
sense of mastery and her anxiety will be reduced in future situations. The
therapist notes that most children feel anxiety during the practices, and
this is OK.
Zoe’s mother expresses some concern about putting Zoe in upsetting
situations. The therapist validates this concern and reminds Zoe’s parents
that Zoe and the therapist will start with the least challenging practice and
work their way up the hierarchy. Zoe now has the tools to cope with these
upsetting situations. The therapist reminds the parents that the goal of
treatment is not to get rid of all Zoe’s anxiety, but to “turn down the vol-
ume” on Zoe’s anxiety so she can cope in social situations.
Finally, the therapist reviews Zoe’s fear hierarchy with her parents.
Zoe’s mother emphasizes that Zoe needs practice presenting or reading in
front of others, as this fear is currently causing interference in the school
setting. The therapist agrees that this is an important situation for practice,
and lets the parents know that she may ask for their help in planning some
of the exposures.
Sessions 10 and 11: Practicing in

Low Anxiety–Provoking Situations
The goals of sessions 10 and 11 are similar: to practice the FEAR plan in a
low anxiety–provoking situation, both imaginally and in vivo. Begin by re-
minding the child that the program shifts from learning skills to practicing
using the skills in real situations (not unlike learning a sport and then play-
ing a real game). Together, pick a low anxiety–provoking situation (see Ta-
ble 7–3 for examples of exposure tasks). Practice using the FEAR plan
Childhood Anxiety Disorders
TABLE 7–3. Examples of exposure tasks
Out of Props Others

Description of exposure Disorder In session session needed needed?a
Give a speech or presentation or do show-and-tell: Social phobia X Yes

1. Have people whispering during the speech or
presentation
2. Have people ask questions during the speech or
presentation
Buy something from a street vendor or at a store Social phobia X Money Yes
Trip in front of a group of people Social phobia X X Yes
Wear strange makeup and make hair look messy in front of Social phobia X Makeup Yes
others
Call a friend on the phone Social phobia X X Yes
Go in the elevator to various floors SAD X X No
Play a game where the rules keep changing GAD (afraid of X X Game No
change)b
Play a game with a new person Social phobia X Game Yes
Find the therapist in a different part of the building GAD X No
Therapist and child pop balloons Social phobia X Balloons No
Therapist arranges for the parent to pick up the child late SAD, GAD X X Yes
243
from session
244
TABLE 7–3. Examples of exposure tasks (continued)
Out of Props Others


The child walks around with toilet paper stuck to his or Social phobia X Toilet paper No
her shoe
Treasure hunt: the child receives a list of people and/or Social phobia, X Objects for Yes
objects to find in the building and goes alone to find GAD treasure hunt
these people (the people then have to sign a paper to
indicate the child found them)
Pay a food vendor with the wrong amount of money (good GAD, social X Money Yes
for fear of embarrassment, perfectionism) phobia
Surveys: the child goes around the building asking various Social phobia X Yes
people different questions (e.g., What’s your favorite ice
cream flavor?)
Make a worry box and place worries in the box only to be GAD X X Shoebox, No
looked at once a day for a designated amount of time markers
“Break the rules” or “get in trouble” (e.g., ask the child to GAD X Yes
go in part of the building where other staff are and have
someone say, “No kids allowed here!”)
Look at pictures or watch videos of a feared stimulus Specific phobia X X Pictures or No
(e.g., thunderstorms, insects, vomit) videos
Sit in a room with the lights off (dark) Specific phobia X X Timer No
Childhood Anxiety Disorders
TABLE 7–3. Examples of exposure tasks (continued)
Out of Props Others

Take a difficult “test” and receive a “poor grade” GAD X Fake test No
Read or record an imaginal exposure script about the GAD X X Paper for No
child’s worst fear (e.g., parents dying, world ending) and script or tape
read or listen to the script repeatedly until anxiety recorder
decreases by 50%
Therapist and child take a ride on a bus, train, or other GAD, specific X X Money for No
feared form of transportation phobia trip
Therapist and child go to the top of a tall building Specific phobia, X X No
GAD
Call to order pizza or takeout on the phone (to make it Social phobia, X X Money if Yes
more difficult, call back to change or cancel the order) GAD actual order
Give the child or have someone else give the child a Specific phobia X Syringe Yes
pretend injection
Draw a “mystery challenge” or “mystery practice” out of a GAD (fear of X Jar or hat, No
jar or hat uncertainty)b paper
Note. GAD=generalized anxiety disorder; SAD=separation anxiety disorder.
aIn addition to therapist.
bSymptoms targeted are included in parentheses.
245
through an imaginal exposure. With the child, prepare for the exposure
task. Write out the FEAR plan for the specific situation in The Coping Cat
Workbook. Serve as a coping model by thinking aloud about the situation.
Then have the child walk through all the steps during the imaginal expo-
sure task. Make the imagined situation as real as possible by using props or
details. Ask for ratings on the feelings thermometer before, after, and ev-
ery minute during the imaginal exposure.
Next, it’s time for an in vivo exposure task. Develop a FEAR plan and
negotiate a reward for completing the in vivo exposure. It is important to
help the child prepare and think through any possible roadblocks or other
outcomes to the task. A main goal of the exposure is to assist the child in
approaching (not avoiding) until she feels an acceptable level of comfort in
the anxiety-provoking situation. Ask for ratings on the feelings thermom-
eter before, after, and at a regular time interval (every minute or two) dur-
ing the in vivo exposure. A general guideline is to have the child stay in the
situation until her ratings decrease by about 50%. After the exposure task,
reward the child for effort. To end the session, plan an exposure task for
the next session.
At the beginning of Zoe’s session 10, the therapist reminds Zoe that they
are going to start “doing challenges”—practicing the FEAR plan in real-life
situations. They begin by agreeing on a situation that makes Zoe a little
anxious, such as conducting a survey of several unfamiliar adults. Together,
Zoe and the therapist develop a FEAR plan for coping with the challenge.
Zoe plans to ask survey questions about favorite sports. She and her ther-
apist decide to kick a soccer ball outside for 5–10 minutes as a reward for
completing the challenge.
First, Zoe and her therapist practice the FEAR plan by having Zoe
imagine herself in the situation. The therapist has Zoe close her eyes and
pretend that she is asking the survey questions. The therapist asks Zoe to
talk through the FEAR plan. Zoe shares that she knows she is feeling fright-
ened because her stomach hurts. She is having the anxious thought “What
if I mess up one of the questions?” She shares the coping thought “It’s no
big deal if I mess up. They probably won’t make a big deal of it, or even
notice, and everyone makes mistakes.” She also practices taking deep
breaths to help herself cope. Finally, she imagines herself doing a good job
(not perfect) and receiving her reward. Zoe successfully completes the
imaginal exposure task, providing ratings of her anxiety using the feelings
thermometer.
Next, Zoe and her therapist prepare for the in vivo exposure task. Zoe
is able to ask her survey questions of five unfamiliar people. Throughout
the exposure, the therapist asks for Zoe’s ratings of her anxiety and pro-
vides her own ratings as well. Zoe rates her anxiety at a 5 before asking the
first person her survey questions, and the ratings decrease to a 2 by the
fifth person. Afterward, the therapist asks, “What did you notice about
your anxiety during the survey?” and Zoe responds that it went down, and
the task became easier. As a reward, Zoe and the therapist play soccer out-
side the clinic. Finally, the therapist and Zoe plan a challenge for the up-
coming session and complete a brief relaxation exercise together. For her
STIC task, Zoe agrees that she will practice the FEAR plan in one low anx-
iety–provoking situation (an at-home challenge).
Sessions 12 and 13: Practicing in Moderately

Anxiety-Provoking Situations
The goal of sessions 12 and 13 is for the child to apply the FEAR plan in both
imaginal and in vivo situations that are moderately anxiety-provoking.
Zoe and her therapist begin session 12 by talking about Zoe’s at-home chal-
lenges from the prior week. Zoe is proud of how well she coped with them
and excited about the rewards. Together, Zoe and her therapist develop the
FEAR plan for today’s challenge—Zoe will read a passage from a book in
front of two members of the clinic staff. Zoe shares that her stomach hurts
already and that she is thinking, “What if I mess up? They will laugh at me!”
Zoe and her therapist come up with the coping thought “It’s not likely that
I will mess up because I’ve practiced. Even if I do, it’s OK because every-
one makes mistakes.” Zoe is reminded of a TV star who made a few slips
when interviewed, but it wasn’t a big deal. The therapist and Zoe agree to
go get a special snack together as a reward.
First, Zoe practices reading the passage to the therapist and talks
through the FEAR plan. Zoe provides ratings of her anxiety on the feelings
thermometer while she practices. Next, it’s time for the challenge. Zoe
and the therapist invite two unfamiliar clinic staff members to join them
in the therapy room. Zoe takes a deep breath, goes to the front of the
room, and then reads a passage from her book. Afterward, Zoe and the
therapist talk about the challenge. Zoe shares that her stomach hurt at
first, but both her stomach and her anxiety felt better once she started. She
“messed up” a few times, but she reminded herself that everyone makes
mistakes. The therapist and Zoe note that the other audience members did
not seem to notice the mistakes. Zoe is very proud of her effort and accom-
plishment today. Zoe and the therapist plan at-home challenges and next
week’s exposure task before heading out for a treat.
Sessions 14 and 15: Practicing in

High Anxiety–Provoking Situations
The goal of sessions 14 and 15 is to apply the skills for coping with anxiety
in high anxiety–provoking situations through both imaginal and in vivo ex-
posure tasks.
Zoe’s session 14 begins with a review of her STIC task and at-home chal-
lenges. Zoe and her therapist prepare for today’s high-level exposure by de-
veloping a FEAR plan. Zoe’s challenge today is to order food for herself but
purposely make a mistake and need to change the order. The therapist helps
Zoe to identify aspects of the exposure task that may generate anxiety. Zoe
describes how her body will feel (stomachache), what she is expecting
(“They will laugh at me for the mistake”), and what she can do to help her-
self cope during the challenge (take deep breaths; use the coping thought
“Everyone makes mistakes”). The therapist and Zoe plan for a reward of eat-
ing the snack that she orders. After practicing in the therapy room, Zoe and
her therapist head out to the nearby fast-food restaurant for the challenge.
Zoe provides ratings on the feelings thermometer before, during, and after
the exposure task. Zoe is able to complete the task and enjoys her snack as
a reward. Zoe, Zoe’s mother, and the therapist plan challenges for the re-
maining two sessions. The therapist reminds Zoe about the “commercial”
that she can create in the final session. The therapist explains that the com-
mercial is something to show off what she has learned and accomplished and
to teach other kids about the FEAR plan. Zoe immediately decides she
would like to create a collage and the therapist encourages her to keep think-
ing about what she would like to include in the collage.
Session 16: Final Practice, Commercial,

and Termination
The goal of the final session is to practice using the FEAR plan for a final
time (in session) and to allow the child to “produce” a commercial to show
off and celebrate her success. Prepare for and conduct a final exposure.
Discuss the child’s performance, again noting effort and progress. Then,
have some fun producing the commercial! The commercial should be a
celebration of the child’s progress, efforts, and success in treatment. It is
an opportunity for the child to teach others about how to manage anxiety
(e.g., the Coping Cat Program). If the child chooses, invite the parents
and/or others to watch the commercial. Review the child’s treatment gains
with the family. Note that it is normal for there to be difficult times ahead
in terms of coping with anxiety, but suggest that with continued practice
there will be continued improvement. Provide the child with an official
certificate (provided as the last page of The Coping Cat Workbook) to com-
memorate completion of the program. Invite the family to check in in ap-
proximately 1 month—to report progress and positive outcomes or
additional concerns. Finally, give a final reward for participation, such as
going out for ice cream or having a pizza party.
During Zoe’s final session, Zoe and the therapist complete one final imag-
inal and in vivo exposure task: a personal speech in front of a group of clinic
staff members. Zoe and the therapist put the finishing touches on Zoe’s
commercial (a collage that includes the FEAR plan and pictures of some of
Zoe’s at-home challenges). Zoe, the therapist, and Zoe’s parents review
Zoe’s progress in treatment. They list ways that Zoe can keep practicing
her skills at home. The therapist reminds the family about calling to check
in next month. The therapist presents Zoe with a certificate of completion
and a list of all the challenges she completed in the program with a little
ceremony. To conclude, Zoe, her family, and the therapist have a pizza
party to celebrate Zoe’s successful completion of the Coping Cat Program.
Given the rich cultural diversity in most countries, it is important for ther-
apists to be aware of the cultural factors that can impact the perception,
etiology, symptom expression, and treatment of anxiety in youth. Though
limited, the available literature suggests some differences in symptom ex-
pression among anxious youth. For example, research shows that Latino
youth tend to report higher rates of somatic symptoms compared with
white youth (Canino 2004; Pina and Silverman 2004), Asian American
youth tend to exhibit somatic symptoms as early signs of anxiety (Gee
2004), and African American youth tend to score higher than white youth
on measures of anxiety sensitivity (Lambert et al. 2004). It is possible that
therapists will find these same patterns when working with diverse youth.
However, bear in mind that research on cultural differences is based on
group averages; clinicians will likely encounter variations in symptom ex-
pression in youth from the same cultural background.
In addition to informing therapist expectations for symptom expres-
sion, research on treatment outcomes has implications for how therapists
treat diverse clientele. A majority of the participants in randomized con-
trolled trials examining the efficacy of CBT for anxious youth have been
white, limiting the examination of race and ethnicity as potential modera-
tors of treatment outcome. However, available literature suggests that
CBT is an appropriate treatment option for youth from various racial and
ethnic groups. Treadwell et al. (1995) found comparable outcomes for
white and African American youth who received the Coping Cat Program
for their anxiety. Pina et al. (2003) found comparable outcomes for white
and Latino youth who received exposure-based CBT for their anxiety. Al-
though Asian American youth responded similarly to others in one study
(Walkup et al. 2008), more research is needed regarding the responses of
Asian American youth to CBT for anxiety. Nevertheless, on the basis of
the available findings, therapists can have confidence in choosing CBT as a
treatment choice for anxious youth from various cultural backgrounds.
Although race and ethnicity have not been found to moderate treatment
outcomes, they have been found to predict lower rates of treatment-seeking
behavior and higher attrition rates among racial and ethnic minority groups
(Hwang et al. 2006; Sood and Kendall 2006). Possible reasons for these
findings include the presence of stressors (e.g., low socioeconomic status),
lack of trust in psychology, unfamiliarity with treatment, and reliance on
family or church for mental health needs. Given these findings, it is possible
that therapists will encounter difficulty initially engaging and then maintain-
ing in treatment some youth from minority racial and ethnic groups. If this
occurs, we recommend spending additional time building rapport with these
clients and their families, as well as seeking to identify and address the spe-
cific barriers inhibiting their involvement in treatment.
With each client, regardless of his or her background, we and others
(e.g., Hwang et al. 2006) encourage therapists to adopt an ecological ap-
proach to assessment and therapy practices. An ecological approach involves
evaluating how a client’s affect, cognition, and behavior are influenced by
contextual factors, including cultural background. An ecological approach
is warranted at each stage of the therapeutic process: assessment, concep-
tualization, and treatment.
Assessment
Before treatment begins, assess the client’s presenting problem with an
eye for contextual factors. To accomplish this, use measures that have been
validated for the cultural group of the child being assessed or choose cul-
ture-specific assessment instruments (when available). Supplement ques-
tionnaires with interviews to gather contextual information and to better
understand the client’s and parents’ worldview (Gee 2004).
Conceptualization
Develop treatment goals and tailor treatment for individual clients based
on knowledge of cultural norms. For example, the normative age at which
a child sleeps in her own bed may vary by cultural background.
Treatment
Be flexible when delivering treatment. Given the variation found within
cultural groups, it is important not to establish strict protocols for all mem-
bers of a cultural group. Instead, we advocate adopting an open mind-set
that seeks to understand and personalize treatment for each individual cli-
ent. We do not advise eliminating the core components of CBT (i.e., psy-
choeducation and exposure). However, we do encourage therapists to
flexibly adapt the treatment to meet the needs of diverse clients. For ex-
ample, during the A step, the therapist might enlist various cultural and/
or religious beliefs and practices as coping thoughts or actions to help the

youth (Harmon et al. 2006).
Overall, we encourage a collaborative dialogue among the therapist, cli-
ent, and often the client’s parents regarding contextual factors. Be amena-
ble to discussing such factors as culture, religion, and family practices. (For
a more detailed discussion on cultural considerations when treating anx-
ious youth, see Harmon et al. 2006.)
Potential Obstacles to Treatment

As with any treatment, challenges exist when implementing CBT for the
treatment of childhood anxiety disorders. Potential obstacles include comor-
bid psychopathology, varying cognitive abilities, noncompliance, and parental
psychopathology. Each of these challenges is discussed, including two brief
vignettes demonstrating strategies for addressing the potential obstacles.
Comorbidity
Comorbidity is the rule, not the exception, among childhood anxiety dis-
orders (Kendall et al. 2001). Although research indicates that the presence
of comorbidity does not affect the efficacy of the Coping Cat Program
(Kendall et al. 2001), making some flexible adjustments may be necessary
in the implementation of the intervention nonetheless (while maintaining
its fidelity). If, as is typical, a child presents with multiple anxiety disor-
ders, assess which disorder is primary and causes the greatest interference.
This information guides and prioritizes treatment goals. When construct-
ing a list of graduated exposure tasks, for example, the therapist and the
youth may decide to create multiple hierarchies addressing different sets
of situations and then complete each hierarchy sequentially (e.g., first con-
struct a hierarchy for social fears corresponding to the child’s social phobia
and then complete a hierarchy for GAD fears). Alternatively, the therapist
and the youth may opt to construct one hierarchy incorporating fears
across various domains.
Children with a primary anxiety disorder may also present with a co-
morbid externalizing disorder, such as attention-deficit/hyperactivity dis-
order (ADHD). First, check that the ADHD is adequately managed (e.g.,
through medication and/or behavioral intervention). Even when ADHD is
controlled, it can still complicate intervention practices for treating anxi-
ety. For instance, because youth with comorbid ADHD may benefit from
very clearly structured sessions, consider providing the youth with a writ-
ten agenda at each session and reinforcing on-task behavior with rewards.
Developmental Level
and Cognitive Abilities
Throughout treatment, keep in mind the youth’s developmental level and
cognitive abilities. The Coping Cat Program (Kendall and Hedtke 2006a)
is for treating children ages 7–13 years. The Being Brave program (Hirsh-
feld-Becker et al. 2008), an adaptation of the Coping Cat, was developed
for children ages 4–7 years and includes a greater emphasis on parent train-
ing. The C.A.T. Project Manual (Kendall et al. 2002a, 2002b) is for ado-
lescents. Regarding overall cognitive functioning, the various programs are
best matched for youth with an IQ>80.
Younger children or children with cognitive limitations can benefit from the
simplification of some of the cognitive-behavioral concepts. For example, it
may be easier for them to rely on one or two general coping thoughts such as
“I can do this!” or “I will be brave!” rather than 1) having to generate a wide
range of novel responses to various situations or 2) having to self-reflect to iden-
tify what type of “thinking trap” they commonly fall into. Similarly, relaxation
strategies can be simplified by demonstrating them in a fun, brief manner and
by having children focus on just one or two steps. For example, children can
choose their favorite part of progressive muscle relaxation (e.g., pretending to
squeeze lemons in their hands) and use it to help relax when facing an anxiety-
provoking situation. The therapist can provide visual and aural reminders of
coping strategies to facilitate recall of session information. For example, youth
may create index cards with brief statements or pictures reminding them of
the FEAR plan or specific coping thoughts and actions. Parents may help cue
children to follow the steps outside of therapy. To help solidify gains and foster
a sense of accomplishment, particularly for children with cognitive limitations,
incorporate the use of creative projects for children to take home. One such
project that youth often find enjoyable and beneficial is creating a photo album
documenting the exposure tasks completed during treatment.
Case Example
Chloe is a 7-year-old who was diagnosed with SAD. She and her therapist
begin today’s session by reviewing a STIC task that Chloe completed at
home during the week. Because Chloe has difficulty reading and writing,
her mother jotted down a few notes in Chloe’s workbook about Chloe
staying in her bedroom by herself for the night. The therapist spoke to
Chloe’s mom on the phone before the therapy session to find out how the
exposure task went because Chloe sometimes has trouble accurately re-
calling and reporting her experiences. In session, Chloe shows the therapist
a picture she drew of herself completing the exposure task. The therapist
asks Chloe a few questions, such as “What were you feeling when you were
first in your room all by yourself?” “What did you think might happen?”
and “What did you tell yourself to help?” Sometimes the therapist has to
prompt Chloe. For example, in response to the first question, Chloe states
that she is not sure how she felt. The therapist provides her a few foils,
such as “Were you feeling happy?” or “How about angry?” before Chloe en-
dorses feeling “scared.” Chloe states that she used her coping card that she
made with the therapist in the previous session to remind her to tell her-
self, “I can do this!” She notes that when she got really nervous, she colored
a picture. Chloe and the therapist set up these activities with her mother
before completing the exposure task. The therapist reinforces such effort
by enthusiastically telling Chloe that she is proud of her for showing that
she can be brave. Chloe receives two stickers of her choice, which she puts
in her workbook. On the sticker chart is a picture of the prize that Chloe
is working toward (a small stuffed animal).
Noncompliance With STIC Tasks or

Exposure Tasks
Youth may not complete the STIC tasks (homework assignments) for mul-
tiple reasons, and it is important to understand the problem and address
it. For instance, youth with comorbid ADHD may have difficulty organiz-
ing material used in therapy, forget they have homework, and/or lose re-
sources they need to complete it. For younger children, it is helpful to
inform parents of the child’s homework task and request that they remind
their child to complete it. For all youth, it may be helpful to have them
keep their therapy materials (e.g., workbook) in one location at home
where they know they can find them. The therapist can also take time to
try to figure out when the youth is more likely to complete certain tasks
during the week and provide appropriate reminders (e.g., hanging a sched-
ule on the wall).
Youth may avoid completing STIC (homework) tasks due to anxiety.
Don’t judge youth for the quality of their work, but praise them for effort
and trying their best. Highlight that there are typically no right or wrong
answers—what you are interested in is their thinking and feelings. Be sure
to reward youth for completion of STIC tasks either at home or at the
start of the session. Although youth typically need to complete several
tasks before earning enough points to obtain a tangible reward, noncompli-
ant youth may benefit from a more frequent reward schedule (smaller,
more frequent rewards). Immediate positive reinforcement at home, from
their parents, can be taught and emphasized. Keep in mind that through-
out treatment, avoidance of anxiety-provoking situations (e.g., STIC
tasks) is not permitted. Accordingly, if a child fails to complete the STIC
task at home, use time at the start of the session to complete the work.
You can use this opportunity to practice the necessary coping skills.
Reluctance or outright opposition to doing an exposure task can im-

pede progress in treatment if not handled well. Not surprisingly, children
with anxiety disorders have difficulty facing feared situations. In a sense,
you are asking them to do the opposite of what they have been doing for
some time. Establishing a strategy of approach to feared stimuli, as op-
posed to one of avoidance, can be fostered during the skill-building phase
of treatment and reinforced when completing exposure tasks. Explain the
rationale for completing exposure tasks, and allow the youth to help you
construct their own hierarchy—a collaborative process that helps increase
motivation and buy-in for the exposure tasks. If an exposure task is too dif-
ficult, it can be broken down into smaller steps. However, even when all
the necessary preparations have been made, difficulties can still arise when
completing an exposure task. We encourage youth to face the anxiety-
provoking situation, but it is sometimes appropriate to scale back the task
for the moment. For example, ask the youth to 1) complete a variation of
the exposure task that may be less anxiety-provoking or 2) repeat a previ-
ous exposure task to increase a sense of mastery. Be supportive and rein-
force efforts made by the youth. Ultimately, the youth still needs to
attempt the difficult exposure task, but there may need to be smaller steps
along the way. On occasion, a child may claim not to need to complete an
exposure task because “it doesn’t make me anxious.” Don’t argue the
point; just encourage the child to complete the exposure task anyway. (In
this way, you do not permit the child’s verbal statement to serve as a way
to avoid doing the task.) Occasionally, youth who deny experiencing anxi-
ety—but who have parents who claim otherwise—can be persuaded to
complete exposures to prove their parents wrong. And as usual, the use of
meaningful rewards can facilitate cooperation.
Chloe is about to complete a moderately anxiety-provoking exposure task.

The exposure task is to go up to the tenth floor of the building by herself
in the elevator. Chloe and the therapist reviewed her FEAR plan in the
therapy room, and Chloe is now standing in front of the elevator, anxiously
clutching her coping card that reminds her to be brave. Chloe refuses to
push the button for the elevator, so the therapist does so for her while stat-
ing that Chloe can do this task. The elevator doors open, and Chloe refuses
to go in. The elevator doors close without Chloe placing a foot inside. She
is on the verge of tears, and the therapist senses that a meltdown is mo-
ments away. The therapist remains undeterred and calmly goes through the
FEAR plan again. Chloe identifies that she is feeling nervous and states that
she is worried that someone will kidnap her if she is alone in the elevator.
She stares at her coping card, looking for inspiration, but she is still unwill-
ing to complete the exposure task. Unflustered, the therapist tells Chloe,
“I know you can be brave and do this.” She reminds Chloe of all her accom-
plishments so far. Chloe responds, “I know, but this challenge is different!”
The therapist waits and then tells Chloe that this is a really difficult
challenge—and maybe they should try other challenges first to get more
practice. The therapist has Chloe repeat an exposure in which she goes up
on the elevator one floor by herself with a walkie-talkie so she can talk to
the therapist. Chloe receives a sticker for completing this exposure. Now
that Chloe’s inertia has been overcome, the therapist suggests that Chloe
go up one floor without the walkie-talkie. Chloe appears reticent, but she
takes a peek at her sticker chart and notices she is one sticker away from
that adorable teddy bear she has so longed for. The therapist praises Chloe
again and acknowledges that she can earn her teddy bear today if she com-
pletes one more challenge (i.e., exposure task). Chloe musters the energy
to complete the challenge, and with a big smile, high-fives the therapist
when she gets back from her courageous, walkie-talkie-free journey. Al-
though they have run out of time for the session, Chloe agrees to complete
the tenth-floor challenge next week and to complete other exposure tasks
at home during the week.
Parental Psychopathology
Although the Coping Cat Program is largely a child-focused, individual
treatment, parents play an important role in the intervention. As such, pa-
rental psychopathology is a potential obstacle to favorable outcomes.
There are two specific parent sessions built into the program, but parents
are involved even more as they help youth implement exposure tasks out-
side of the therapy setting. Parental anxiety is common when working with
anxious youth, and although parental anxiety management is not a neces-
sary part of treatment, the therapist can help parents manage their own
anxiety using the same cognitive-behavioral strategies taught to the chil-
dren. For example, parents may express anxiety about allowing their child
to be in an anxiety-provoking situation. In these instances, the therapist
can explore what is the worst that can happen, how likely is that scenario,
what can the parents tell themselves to help, and what can they do to help.
Note that parental anxiety management is not the focus of treatment and
it is not a substitute for parents’ own treatment when necessary.
Conclusion
CBT for child anxiety has been found to be effective in several randomized
controlled trials. The Coping Cat Program is a manual-based CBT for anxious
youth that comprises two phases of treatment: psychoeducation and expo-
sure. Within the psychoeducation phase, the child learns to identify when he
or she is feeling anxious and to use anxiety management strategies. The strat-
egies include identifying bodily arousal, engaging in relaxation, recognizing
anxious thoughts (self-talk) and using coping thoughts, and problem solving.
In the second phase of treatment, the child practices the skills learned in the
first phase through exposure tasks. The exposure tasks are guided by a collab-
oratively determined hierarchy so that the child practices skills in increasingly
anxiety-provoking situations. Potential obstacles to implementing CBT for
child anxiety may include comorbid psychopathology, varying cognitive abili-
ties, noncompliance, and parental psychopathology. However, in order to ad-
dress these potential barriers and individualize treatment, the Coping Cat
Program should be implemented flexibly while maintaining fidelity.
Key Clinical Points

• The core components of CBT for child anxiety are psychoeducation,
recognition and management of somatic symptoms, cognitive re-
structuring (changing anxious self-talk), and importantly, multiple
exposure tasks.
• The Coping Cat Program uses the FEAR plan to describe the con-
cepts learned in the psychoeducation phase of treatment:
F=Feeling frightened? E= Expecting bad things to happen?
A=Attitudes and actions that can help; R= Results and rewards.
• Exposure tasks are a key component of the several versions of CBT
for child anxiety. The main goal of exposure is to have the child ap-
proach (not avoid) anxiety-provoking situations and remain in the
situations until she has reached an acceptable level of comfort.
• We recommend that the Coping Cat Program be implemented flexi-
bly while maintaining fidelity. Treatment can be individualized accord-
ing to the child’s comorbidities, age, cognitive ability, and culture.
7.1. Which of the following clients is an appropriate candidate for CBT
for child anxiety?
A. A 16-year-old white adolescent girl with primary social phobia,

obesity, and a learning disability.
B. A 6-year-old Hispanic girl with primary separation anxiety disor-
der and a specific phobia of blood.
C. A 13-year-old African American adolescent boy with primary gen-
eralized anxiety disorder and comorbid attention-deficit/hyperac-
tivity disorder (ADHD) managed with stimulant medication.
7.2. Which of the following is NOT a core component of CBT for child
anxiety?
B. Exposure tasks.
C. Psychoeducation.
7.3. A 7-year-old girl diagnosed with separation anxiety disorder presents

for treatment. The best role for her parents in CBT treatment is
A. No parental involvement in the child’s treatment.

B. Parents as co-clients in treatment, with treatment for the child
and treatment for the parents.
C. Parents as collaborators in conducting exposure tasks involving
the child’s separation from the parent(s).
D. Parents as consultants regarding the child’s symptoms and im-
pairment.
7.4. A 12-year-old boy with generalized anxiety disorder expresses worry

about an upcoming test; he thinks, “I’m worried that I am going to
fail, and then I’ll have to repeat seventh grade!” Which of the follow-
ing is a reasonable coping thought in this situation?
A. There’s no way I’ll fail. The teacher likes me.... I think.

B. All I have to do is study every day before the test and then I won’t
fail.
C. Even if I fail seventh grade, I still have my friends ...so why
bother studying?
D. It’s unlikely that I will fail the test because I studied pretty hard.
Even if I did fail this one test, I have plenty of time to bring up
my grades before the end of seventh grade.
7.5. Which of the following is NOT an example of an appropriate flexible

implementation of CBT for child anxiety (i.e., a flexible application
that maintains treatment fidelity)?
A. Simplifying cognitive restructuring to the use of a single coping

thought (“I can do it!”) for a 7-year-old boy with primary separation
anxiety disorder who didn’t fully grasp the concept of self-talk.
B. Eliminating at-home exposure tasks for an 11-year-old girl with
social phobia, because of parental concerns about causing the
child too much stress.
C. Using frequent breaks and additional rewards for an 8-year-old

boy with primary generalized anxiety disorder and comorbid
ADHD who is having difficulty staying on task in session.
D. Downplaying “sleeping in own bed” as an exposure task for a 9-
year-old girl with primary social phobia, due to parental beliefs
and preferences regarding a shared family bed.
Suggested Resources
Treatment Manuals
Kendall PC, Hedtke K: Cognitive-Behavioral Therapy for Anxious Chil-
dren: Therapist Manual, 3rd Edition. Ardmore, PA, Workbook Pub-
lishing, 2006a
Kendall PC, Hedtke K: The Coping Cat Workbook, 2nd Edition. Ard-
more, PA, Workbook Publishing, 2006b
Training DVD
Kendall PC, Khanna M: CBT4CBT: Computer-Based Training to Be a Cog-
nitive-Behavioral Therapist (for Child Anxiety). Ardmore, PA, Work-
book Publishing, 2009
Further Reading
Beidas RS, Benjamin CL, Puleo CM, et al: Flexible applications of the Coping
Cat Program for anxious youth. Cogn Behav Pract 17:142–153, 2010
Kendall PC: Treating anxiety disorders in youth, in Child and Adolescent
Therapy: Cognitive-Behavioral Procedures, 4th Edition. Edited by
Kendall PC. New York, Guilford, 2010, pp 143–189
Kendall PC, Robin JA, Hedtke KA et al: Considering CBT with anxious
youth? Think exposures. Cogn Behav Pract 12:136–150, 2005
Podell JL, Mychailyszyn M, Edmunds J, et al: The Coping Cat Program for
anxious youth: the FEAR plan comes to life. Cogn Behav Pract 17:
132–141, 2010
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8
Pediatric Posttraumatic
Stress Disorder
MORE than two-thirds of children and adolescents (hereafter referred

to as “children”) experience trauma, with half of these children experienc-
ing multiple traumatic events (Copeland et al. 2002). Posttraumatic stress
disorder (PTSD) symptoms are common in trauma-exposed children.
However, many children with significant trauma symptoms and functional
impairment do not meet full PTSD diagnostic criteria according to DSM-
IV-TR (American Psychiatric Association 2000) because of criteria that
may be less developmentally appropriate for children, such as a sense of
foreshortened future (Meiser-Stedman et al. 2008; Scheeringa et al.
2006).
Several cognitive-behavior therapy (CBT) models have been found to
be efficacious in addressing childhood PTSD and related problems follow-
ing trauma exposure. CBT models have been tested for children who have
experienced sexual abuse, domestic violence, terrorism, disaster and war,
community violence, and multiple trauma exposures.
263
This chapter will focus on two types of CBT trauma treatment models:
1) individual CBT, represented by trauma-focused cognitive-behavior ther-
apy (TF-CBT); and 2) group (primarily school-based) CBT, represented by
the Cognitive-Behavioral Intervention for Trauma in Schools (CBITS; Stein
et al. 2003). TF-CBT (Cohen et al. 2006) has been evaluated in eight ran-
domized controlled treatment trials (RCTs) for sexual abuse, domestic vio-
lence, and multiple traumas among children ages 3–17 years (reviewed in
Cohen et al. 2009). CBITS has been tested in two RCTs for children exposed
to community violence (Kataoka et al. 2003; Stein et al. 2003). Other CBT
models have been tested for single-episode traumas (Smith et al. 2007) and
for war-exposed children and adolescents. Described later in this chapter,
these models include largely overlapping components, which emphasizes the
broad applicability of CBT interventions for traumatized children across dif-
ferent types of traumas and a broad developmental spectrum.
Cognitive-Behavioral Theory
for PTSD
PTSD was only officially recognized in the Diagnostic and Statistical Man-
ual of Mental Disorders in 1980 (American Psychiatric Association 1980).
Several complementary theories explain its complex symptoms. Accord-
ing to learning theory, PTSD results from overgeneralization and failure of
extinction of fear and other negative emotions. Traumatic experiences are
by definition accompanied by negative emotions such as horror, fear, help-
lessness, and anger (American Psychiatric Association 2000, p. 463); these
emotions are often associated with physiological arousal in such forms as
rapid heartbeat, elevated blood pressure, flushing, and sweating. Studies
indicate that interpersonal violence such as child sexual or physical abuse,
neglect, and domestic and community violence have a clearly negative im-
pact on children; that early and/or multiple traumatic exposures lead to
increasingly negative outcomes for children; and that if left untreated, im-
pairment cuts across multiple domains of functioning as described in the
case examples below (e.g., Felitti et al. 1998).
Case Examples
Mariel, age 8 years, is referred for a mental health evaluation because of
several recent episodes of getting into fights with boys at school. Her
mother brings Mariel to you for an initial evaluation. According to the
mother’s report, Mariel’s main problems are the fighting at school and fall-
Pediatric Posttraumatic Stress Disorder 265
ing grades. Her mother also reports that recently Mariel has started going
to the school nurse’s office with headaches. During the evaluation, you ask
Mariel whether anything bad or scary has happened to her. She says, “Peo-
ple fighting.” You ask, “Do you mean the fights that have happened at
school?” to which Mariel replies, “No, fighting at home.” You administer a
brief interview to assess trauma exposure and symptoms of PTSD. Mariel
endorses witnessing domestic violence between her parents and the fol-
lowing symptoms: Mariel loves her father but has scary thoughts about him
hurting her mother. She tries to push these thoughts out of her head, but
some boys at school remind her of this fear. They make her very mad some-
times. She can’t concentrate at school or sleep at night because she is al-
ways worried about what her father will do, and she is more jumpy and
irritable than she used to be. She doesn’t want to spend time with her
friends like she used to.
Joaquin, a 14-year-old middle school student, is referred to the school-

based social worker by his math teacher. His teacher explains that Joaquin
is typically a conscientious student, especially in math, and socially popu-
lar. For the last couple of months, however, the teacher has noticed that
Joaquin misses class frequently, that his grades are dropping, and that when
he is in class, he has difficulty concentrating and appears sad and socially
withdrawn. Joaquin often asks for a pass to the bathroom or to the nurse’s
office, stating that he is sick to his stomach. The teacher explains that last
week, he raised his voice to get the class’s attention, and Joaquin jumped
visibly in his seat and became very upset, prompting him to walk out of
class. When you meet with Joaquin, you ask if he has recently experienced
any frightening, difficult, or very stressful events, and he replies that
3 months ago, he and his best friend witnessed a gang shooting in the park
on their walk home. Since then, he hasn’t been able to stop thinking about
what happened and worrying that it could happen to him or his family and
feeling sick to his stomach. He feels upset each time he sees his best friend
and feels sad and alienated from his peers in general. “How do they expect
me to concentrate on my math test when I can’t stop thinking about the
sound of that bullet and the look on that gangster’s face when he spotted
us before we ran?”
Classical conditioning occurs when neutral cues that either were

present at the time of the initial trauma or have enough resemblance to
trauma reminders (i.e., sights, sounds, people, or places that were present
at that time and remind the child of the original trauma) become associ-
ated with the negative emotions and physical responses the child had at
that time and begin to elicit those same responses.
For example, Mariel became angry around boys at school; the boys
themselves were not dangerous or violent, but because they were loud
males, they reminded her of her father and thus served as trauma remind-
ers and elicited the same feelings she experienced during the traumatic
event. Likewise, Joaquin became upset when he was around his best
friend; although his friend was simply another witness to the traumatic
event, he became a cue to the traumatic experience.
Memories and thoughts about the trauma can also become conditioned
trauma reminders and trigger highly negative physical and psychological
responses in traumatized children. Operant conditioning may teach chil-
dren to avoid such cues in order to reduce the likelihood of experiencing
these negative emotions. As avoidance is reinforced (i.e., if it successfully
keeps the child from feeling bad, even intermittently), the child will learn
to avoid talking about or being around trauma reminders. For example,
Mariel loved her father but was scared of him and tried to avoid him when
he was “mad.” She also avoided talking or thinking about her family situa-
tion, which contributed to her avoidance of friends or social situations. As
avoidance becomes more generalized, it is rarely successful, because most
traumatized children have experienced multiple episodes of interpersonal
violence and reminders of these experiences are so internally and exter-
nally ubiquitous that it is difficult to totally avoid them.
Children with high levels of avoidance or emotional numbing may have
trouble using optimal coping strategies such as implementing a safety plan
or seeking help from supportive adults when violence occurs. In Joaquin’s
case, he hadn’t even shared his traumatic experience with his mother and
siblings, both because he didn’t want to think about it and because he
didn’t want to burden his hardworking mother. Avoiding thinking and talk-
ing about the experience also meant avoiding his guilt and fear that not be-
ing able to stop the shooting meant that he was incompetent to protect his
siblings and mother, something his father had implored of him as the old-
est son when he was deported to their country of origin last year.
Children, like adults, are prone to developing maladaptive cognitions
about the cause and/or impact of having experienced trauma, such as being
inherently defective or damaged (i.e., shame), being responsible for the
trauma (i.e., self-blame), or being undeserving of love or care from others
(i.e., low self-esteem). In addition, there can be cognitive developmental
issues, particularly in younger children, such as magical thinking or causal
misattributions. These cognitions may have been modeled for children
(e.g., the perpetrator, a neglectful parent, or bullying peers may have told
the child he or she was worthless or deserved to be maltreated), or chil-
dren may come to these cognitions through faulty deductive reasoning
(e.g., “Other children aren’t treated badly; therefore, I must be treated
badly because of something bad about myself ”). Children who have expe-
rienced long-standing, severe, and/or interpersonal traumas such as child
maltreatment, neglect, or domestic violence often lack skills such as affect
expression, self-soothing, and affective and behavioral regulation. There-
fore, these skills can be important components of a trauma treatment plan.
Most CBT models for traumatized children integrate these various

needs into their intervention components. CBT models for PTSD typically
include 1) behavioral, 2) cognitive, and 3) parent-child relationship build-
ing components. Typically, but not always, they begin with skills-based in-
terventions such as relaxation, labeling feelings, affective modulation,
general cognitive coping skills, and problem solving. Exposure-based or
trauma-specific interventions, such as developing a trauma narrative and
undertaking in vivo exposure to generalized trauma cues, are usually pro-
vided after the earlier coping skills. Many models also include an active
parent component that focuses on enhancing parenting and the parent-
child relationship. CBT models that include all three components gener-
ally have more evidence for improving PTSD and related trauma problems
than models that include only a single component. Including parents or
other caregivers (hereafter referred to as “parents”) in CBT for trauma-
tized children produces significant improvement in parents’ mental health
(e.g., depression, emotional distress), parenting skills, and support of the
child. Some evidence supports the use of brief skills in the absence of ex-
posure components for the following groups of traumatized children:
1) younger children (4–11 years) who have relatively high levels of behav-
ioral problems (e.g., Deblinger et al. 2001), and 2) children who have rel-
atively mild levels of PTSD symptoms (UCLA PTSD Reaction Index
levels <23 at the start of treatment) (CATS Consortium 2010).
Assessment
A major challenge to effectively treating traumatized children is that child
PTSD symptoms can be very difficult to accurately identify. How CBT is
applied depends on this accurate assessment. Several self-report instru-
ments, such as the UCLA PTSD Reaction Index for DSM-IV, assess PTSD
symptoms. However, children often underreport PTSD symptoms due to
trauma avoidance (not wanting to think or talk about the trauma or symp-
toms associated with it) or due to general child unreliability in reporting
externalized symptoms such as anger or behavioral problems. Including
parents in assessment is helpful in gaining additional information about
children’s behaviors. However, parents may be unaware of the child’s in-
ternal trauma symptoms (e.g., having frightening recurrent thoughts about
the trauma; being hypervigilant about the trauma recurring; avoiding
trauma reminders or thoughts about the trauma; having maladaptive cog-
nitions related to the trauma, such as self-blame, shame, or fear of trusting
others), or parents may minimize these problems. For example, Mariel’s
mother did not think Mariel was aware of the domestic violence occurring
in the home and was shocked to learn that her daughter had serious PTSD
symptoms related to these occurrences. Parents are typically more focused
on children’s externalized trauma symptoms (e.g., irritability, sleep prob-
lems, anger, aggression). Mariel’s mother had made no connection be-
tween Mariel’s fighting in school and the father’s behavior at home.
To optimally assess children for PTSD symptoms, consider the ABCs
of trauma impact:
• A—Affect: The classic feelings associated with PTSD are anxiety and
fear, but clinicians should also ask about sadness, anger, or flat affect,
as well as affective dysregulation (e.g., “going from 0 to 60,” not being
able to soothe oneself after becoming upset) and dissociation.
Mariel both loved and feared her father. It was not safe for her to show anger
at home, but she was angry and experienced affective dysregulation at school.
She also did not feel her usual happiness around her friends (flat affect).
Joaquin exhibited sadness and anxiety in his classes and at home and had
lost interest in what he used to find enjoyable, but he also would very
quickly “fly off the handle” for what appeared to others as minor things,
such as someone bumping into him or a teacher raising his or her voice to
get the class’s attention.
• B—Behavior: Avoidance of trauma reminders and cues is a prominent

behavior associated with PTSD.
Joaquin avoided his best friend, who was with him during the shooting, as
well as the park where the shooting occurred. His anxiety generalized to
other outdoor settings, and he refused to let his younger siblings play out-
side when they were under his care in the afternoons and on weekends
when his mother was working.
Traumatized children may also display problem behaviors learned or

modeled during their traumatic experiences.
Mariel was aggressive toward boys in part because they reminded her of her
father’s aggression toward her mother. She was afraid of them but also angry
because they reminded her of times when her father had hurt her mother.
Other trauma-associated behavior problems include self-injury; sub-

stance use and abuse; and irritable, aggressive, angry outbursts that are
a manifestation of general behavioral dysregulation.
• B—Biological changes: A variety of biological changes can be mani-

fested as somatic symptoms or illness, including headaches, stomach-
aches, muscle pains, trouble sleeping, hyperalertness and increased

vigilance to danger, trouble relaxing, and hyperresponsiveness to sen-
sory stimuli. Children who are biologically on alert may react in very
negative ways to occurrences that they perceive as threatening and that
lead these children to lash out in anger or to defend themselves.
Joaquin was able to avoid going to school and walking near the park (on the
route between school and home) by complaining of stomachaches. Like-
wise, when he felt anxious or overwhelmed at school, he frequently asked
for a pass to go to the bathroom or to the nurse’s office with the same com-
plaint.
Mariel reported frequent headaches at school.
• C—Cognition: Ask about maladaptive cognitions, including self-blame,

shame, feeling different, incompetence (“I can’t stop bad things from
happening or protect myself or my family,” “I can’t do anything”), survi-
vor guilt (“Why am I still alive when someone else died?”), generalized
loss of trust in adults and supportive social systems, loss of faith in the
social contract (i.e., that justice is served), the general notion that “the
world is a dangerous place,” and other inaccurate or unhelpful thoughts.
Mariel thought that her father’s “bad moods” and his subsequent abuse of
her mother were in part her fault because they were sometimes preceded
by her father yelling at her.
Joaquin blamed himself for what happened because he came home later
than usual that day, and he felt guilt and shame for not being able to stop
the shooting and for potentially endangering his family by being a witness
to gang-related violence.
• S—School interference: Difficulty in school may occur because of re-

current intrusive thoughts about the trauma; ongoing attempts to avoid
thinking about the trauma; trying to numb oneself, which leads to gen-
eralized distance from cognitive tasks; and possible trauma reminders
in the school setting. School problems may include difficulty with con-
centration and attention, difficulty learning, poor grades, and class-
room behavior problems, among others.
Because of intrusive thoughts, flashbacks, and hyperarousal, Joaquin exhib-

ited difficulty concentrating, distractibility, jumpiness, poor attendance,
and decreasing grades.
Mariel experienced trauma reminders in school, leading to her trouble con-

centrating and declining grades.
• S—Social and relationship problems: These problems may include

new or increased fighting; social withdrawal; associating with deviant
peers; and other social and relationship problems often resulting from
loss or lack of trust in others, feeling that old friends don’t understand,
and feeling different or alienated from others.
Mariel felt alienated from her friends and became socially isolated.
Likewise, Joaquin’s feelings of sadness and guilt and his isolation from his
best friend left him feeling very different from his peers and made him
withdraw from all social activity.
Application
Reviews of individual (Cohen et al. 2009) and school-based (Jaycox et al.
2009) child CBT trauma treatments document that these treatments
share many common treatment components (described later in this sec-
tion). In addition to these core components, two general treatment con-
cepts are critical when implementing CBT for traumatized children: 1)
engaging families in treatment and 2) use of gradual exposure throughout
the treatment process.
Treatment Concepts
Treatment Engagement
Treatment engagement is essential for effectively treating any family but is
especially critical in addressing the needs of traumatized individuals, be-
cause trauma typically has a negative impact on trust. Children and parents
may feel betrayed by a trusted person, community, educational system,
criminal justice system, their faith, and/or society at large that allowed such
an unfair thing to happen. When the trauma was perpetrated by a parent
or other caregiver or over a long period of time, attachment is often nega-
tively impacted. Because successfully engaging families in psychotherapy
requires that they trust the clinician, this may be more challenging with
traumatized children and their parents. The following strategies are effec-
tive for engaging even multiply traumatized children and their parents:
• Ask what the family wants and expects from mental health treatment.
• Ask about potential barriers to participation in mental health treat-
ment, including differences between the family and yourself based on
ethnicity, race, religion, socioeconomic status, or other factors that may
lead the family to doubt your ability to understand their problems or

needs.
• Explain your understanding of the child’s problems and their relation-
ship (if any) to the child’s trauma experiences, and see whether the
family can accept this information. If the family doesn’t understand or
accept this explanation, they are not agreeing to engage in trauma-
focused treatment, and another type of treatment should be offered
(Cohen et al. 2010; McKay and Bannon 2004).
Gradual Exposure
Gradual exposure refers to the process through which you gradually, pur-
posefully, and incrementally increase the intensity, duration, and/or degree
to which you introduce trauma-related material during each subsequent
treatment session. As you implement subsequent CBT components, con-
nect them to children’s trauma experiences by asking how children will
implement these components when they are reminded of the traumatic
events they experienced.
It is important not to do anything that inadvertently models avoidance
to children or parents. For example, you may avoid the topic of the trauma
or do so indirectly by communicating that trauma is embarrassing or diffi-
cult for you to talk about. This may be the case when you start using
trauma CBT models. Children who have experienced trauma are apt to
blame themselves or feel ashamed about what happened. Either out of em-
barrassment or in an attempt to convey empathy, you may lower your
voice, look away, use euphemisms, or say “I’m sorry” when talking directly
about children’s trauma experiences. Children or parents may interpret
these behaviors to mean that you think what happened was shameful. It is
important to make a conscious effort not to do these things.
Refer to traumatic events by their accurate descriptions (e.g., “sexual
abuse,” “domestic violence,” “your father’s death,” “the car accident”). Do
not use euphemisms such as “the scary thing,” “the upsetting situation,”
“the events of September 11th,” or “passing away.” Do not use the term
“down there” to refer to private parts (e.g., “vagina,” “penis,” “anus,”
“breasts”). These behaviors may seem inconsequential, but they commu-
nicate to the child that you are not ready to hear or talk about the child’s
trauma.
Be conscious not to avoid talking about children’s trauma experiences
(the opposite of gradual exposure). Gradual exposure is a critical part of
trauma CBT models. Do not wait for children to give you a cue or other-
wise show you that they are ready to talk about their traumatic experi-
ences. Because avoidance is a core feature of PTSD, few children will
spontaneously talk about traumatic experiences. It is up to the clinician to

provide sufficient trauma-related exposure so that when children reach
the part of treatment where they need to describe the details of their per-
sonal trauma experiences, this will not overwhelm them.
Core Components
Parenting Component
When feasible, include parents in CBT treatment of child PTSD in order to
provide effective parenting skills, as well as to parallel other CBT compo-
nents. This may be accomplished in parallel parent groups, in parallel indi-
vidual child and parent sessions, in family sessions, or in a combination of
these formats. Help parents understand the connection between the child’s
behavior problems and past traumatic exposure, so that trauma-focused
treatment makes sense. Behavioral parenting skills might include encourag-
ing parents to use active praise; selective attention (i.e., to actively attend to
and praise desired behaviors while attending less to undesired behaviors);
and appropriate contingency reinforcement and other reward and punish-
ment procedures that are tailored to the specific child behaviors.
If parents can’t attend sessions regularly, provide them with written in-
formation about what the child is learning in treatment so that the parents
can reinforce the skills their child is learning. In school-based trauma treat-
ments, teachers may receive some instruction regarding how to support
the implementation of CBT skills in the educational setting. This will en-
hance children’s optimal use of such skills in school and help teachers un-
derstand manifestations of trauma symptoms in the classroom.
Psychoeducation
Many children and parents have inaccurate information about trauma because
of societal stigma, family or cultural beliefs, or other reasons. They may also
feel alone because they do not understand that trauma is a common experi-
ence that they share with many other children and families. Moreover, chil-
dren and parents often do not make a connection between what the child has
been through and the current difficulties they are having. Psychoeducation
can reverse the negative impact of inaccurate information and normalize trau-
matic experiences. Educate children, parents, and/or teachers about the im-
pact of trauma. Help them to understand the child’s current symptoms from
a trauma perspective; normalize these problems as common reactions to trau-
matic events while providing hope for recovery. Also share information about
how many children experience the type(s) of trauma the child has experi-
enced. Information sheets about child trauma are available on the Web site of
the National Child Traumatic Stress Network (www.nctsn.org).
Relaxation Skills
Help children and parents understand and recognize the physiological im-
pact of trauma (e.g., rushing pulse, pounding head, stomachache, in-
creased muscle tension, “seeing red”), and ideally, help them to identify
the early warning signs of these symptoms (i.e., recognize them when they
first start to occur). Ask children what the earliest manifestations or ante-
cedents of physical trauma-related symptoms are, and ask them to keep a
record of when these early signs occur during the week. Their responses
will assist you in developing tailored relaxation strategies for preempting,
preventing, and/or “turning down the volume” (i.e., decreasing the inten-
sity) of these symptoms when they occur in specific settings. Individualize
different relaxation skills if the setting allows (e.g., individual therapy).
Group settings may offer fewer opportunities for tailoring interventions to
individual needs. Younger children may need ongoing assistance from par-
ents or other adults to implement relaxation strategies. Teach parents
these strategies so that they can encourage their children to use them.
Affect Expression and Regulation Skills

It is very important to be aware of whether the children you treat are living
with ongoing violence. Be cautious about encouraging children to express
a range of feelings outside of therapy (e.g., with the perpetrator or other
family members) unless you are sure that it is safe for children to do so.
Use games or other engaging activities to encourage children to label and
express new emotions that they may not be used to talking about. Help
children gain skills to manage difficult emotions—for example, by seeking
social support; problem solving; negotiating; learning skills in turning down
the volume of their symptoms; using humor and faith; and learning opti-
mism. Parents or other caregivers need to support children as they start to
use these skills outside therapy.
Cognitive Coping
Cognitive coping is a specialized skill for helping children to regulate upset-
ting emotions and negative behaviors. Help children recognize maladaptive
(inaccurate and/or unhelpful) thoughts that are related to their negative
emotions and how these in turn are connected to their behaviors. For ex-
ample, if a child gets a bad grade on a test, he might think, “I’m stupid,”
leading him to feel very upset and to not pay attention or to misbehave in
school because he has given up any hope of success there. Examine with the
child whether another thought besides “I’m stupid” could explain getting a
bad grade (e.g., “I didn’t study enough”; “I didn’t study the right things to
do well on this test”; “I didn’t understand the material on that test”; “The
teacher picked really hard questions”; “I can do better if I ask for help”).
Ask the child how he would feel if he focused on one of these thoughts in-
stead of the thought “I’m stupid” and how this feeling (e.g., better, hopeful,
OK) might lead to different behavior (e.g., studying harder, asking the
teacher or a parent for help with studying, paying more attention in class,
not giving up). Practice this for a variety of ordinary (non-trauma-related)
situations and help the child generate alternative thoughts in order to feel
better. Parents typically need to practice cognitive coping also. Provide cog-
nitive coping skills to parents and help them to start processing their diffi-
cult feelings about the child’s trauma experiences. Typically, you will not
start processing details of the traumatic experiences with the child until af-
ter he or she has developed a personal trauma narrative, described in the
next section, “Trauma Narration and Processing.”
Trauma Narration and Processing

Develop a narrative of the child’s trauma experiences, including all of the
important types of trauma the child experienced. Allow the child to
choose which trauma to start with, but plan at the beginning what to in-
clude in the narrative so that you leave enough time to include everything.
Also be proportionate in timing so that the narrative component of therapy
lasts no more than about a third of the total treatment duration. This will
maintain the balance between present (skills), past (narrative), and plan-
ning for the future (final components). Through several sessions, help the
child develop a trauma or life narrative. It may be helpful to start the nar-
rative with paragraphs or chapters about “Who I am” and “My relationship
with the perpetrator before the trauma started” (if appropriate) before
proceeding to “What happened during the trauma episode I am describ-
ing.” Each trauma episode should include thoughts, feelings, and body sen-
sations. Include as many episodes as needed to capture the important
traumas the child has experienced. A final chapter about “How I have
changed” is also important. Then return to what the child has already writ-
ten (or produced in another format) and begin to cognitively process mal-
adaptive trauma-related cognitions about core traumatic experiences using
cognitive coping methods described above. As with other components, as
the child is developing the narrative, you will be sharing this with the par-
ent or caretaker in preparation for joint sessions.
In Vivo Mastery of Trauma Reminders

If the child has developed generalized fear of neutral cues, you may elect
to use graduated exposure exercises to help the child master increasingly
challenging trauma cues that are associated with generalized fear re-
sponses. This component should only be used 1) if the cue is safe (i.e., no
real danger is associated with it); and 2) if the family and other adults are
in full support of the exposure plan and committed to supporting gradu-
ated exposure, because stopping in the middle will worsen rather than im-
prove the child’s avoidance symptoms.
Conjoint Child-Parent Sessions

As treatment is nearing an end, have two to three conjoint sessions with
the child and parent together. In order to prepare for these, meet with the
child and parent separately for 10–20 minutes before bringing the child
and parent together for the rest of the session. Typically use the joint ses-
sions to help the child share the trauma narrative with the parent, enhance
optimal child-parent communication about the child’s trauma experience,
and move forward together toward treatment termination.
Remember that although you have already shared the narrative with
the parent, for the parent to hear it from the child’s own mouth is likely
to be highly emotional for both the child and parent. Gauge the parent’s
ability to cope with this and to support the child during this process. If the
parent is not supportive (for example, if the parent still does not believe
the child, calls the child a liar, is extremely angry or emotionally unstable),
develop an alternative activity for the joint session or do not have a con-
joint session.
Enhancing Safety and

Future Developmental Trajectory
Remember that after trauma, the most important thing many children and
parents have lost is their belief that the world is a safe place or that others
have benign intentions. Help the child and parent develop optimal age-
appropriate safety skills for their life situations. Before terminating treat-
ment, address treatment closure issues that may be particularly salient for
children who experienced the traumatic death of a family member. Usu-
ally, address safety later in treatment so that children do not feel shame or
embarrassment about safety strategies they may have failed to use to pro-
tect themselves previously. However, for children who have immediate
safety concerns (e.g., they are living with a perpetrator of domestic vio-
lence or with ongoing community violence), you will probably need to ad-
dress safety issues early in treatment instead of later.
Case Management
It may be important to collaborate with systems of care such as child wel-
fare, juvenile justice, pediatric, educational, and other providers who are
working with traumatized children.
Selecting an Optimal CBT Model

and Logistics
Several different child CBT trauma models have been empirically tested
(Cohen et al. 2009; Jaycox et al. 2009). However, to select an optimal
CBT treatment model for a specific traumatized child, you must know not
only about alternative treatment approaches but also 1) which (if any) op-
tions are available at the child’s school and 2) which (if any) are acceptable
to the child’s family. As more schools become proficient at providing
trauma-focused CBT treatment, school-based group or individual CBT
trauma treatment may become a feasible option (Jaycox et al. 2010); how-
ever, do not suggest this option unless you know that it is available at the
child’s school. If the child’s school does not offer trauma treatment, it may
be feasible to offer group therapy in outpatient settings that serve suffi-
cient numbers of traumatized children.
Individual treatment may be most appropriate for children who
1) have more severe symptoms (because individual therapy can be more
easily tailored to individual needs) and/or 2) have experienced child abuse
or domestic violence (parents often have concerns about their children
talking about these experiences with other children). Group treatment
may be most appropriate for children who 1) have somewhat less severe
symptoms (i.e., because treatment cannot be tailored to the individual
child’s needs to the same degree); 2) can only access treatment in school
settings; and/or 3) might particularly benefit from peer support, social
skills training, and other aspects of group therapy.
However, these are only guidelines, and these considerations are less
crucial than providing some form of effective treatment. For example,
group therapy has helped many children with severe initial symptoms. Ei-
ther group or individual CBT trauma therapy is likely to be helpful for
most traumatized children. Although group or school-based treatment
may be optimal for some children, if no group is available, offer individual
therapy and vice versa. Be aware that many individual child treatments
such as TF-CBT are also effective without parent involvement. Although

inclusion of parents is always optimal, positive outcomes have been docu-
mented without parental involvement for TF-CBT and other individual
child CBT models (e.g., Deblinger et al. 1996; Weiner et al. 2009). Thus,
when deciding on a treatment plan, although you may consider factors
such as symptom severity and the availability of group treatment (includ-
ing in the child’s school), the most important consideration is to offer a
form of treatment that the family will attend. Most CBT models are 10–
12 sessions, which is a reasonable duration of treatment for the clinician
to suggest as a starting point, ensuring that families understand that some
children may need fewer sessions, and some may need more.
Developmental Adaptations
Child CBT trauma models (and TF-CBT in particular) have been used and
tested for children ages 3–17 years with relatively minor adaptations on
the basis of children’s developmental level. Adaptations for preschoolers
and adolescents are briefly described.
Preschool (Ages 3–7 Years)

Even very young children are able to use the core treatment components with
positive outcomes if these components are provided appropriately for their
developmental level (e.g., Cohen and Mannarino 1993; Deblinger et al.
2001). Because play is the primary activity of preschool children, play is the
medium through which you will accomplish most effective therapy. It is im-
portant to develop engaging, fun activities for implementing all of the core
components. Providing psychoeducational information, talking about feel-
ings, learning about relaxation, and talking about “what your brain is telling
you” (cognitive coping) can all be made into enjoyable, funny, soothing, or ex-
citing guessing games, storytelling, or other activities for you to play with
young children during therapy sessions. Providing small prizes (e.g., an M&M,
a sticker, and most importantly, lavish praise such as “Oh my goodness, you
are SO SMART!”) after children give each correct answer keeps young chil-
dren engaged, excited, and involved in these activities.
Adolescents (Ages 13–17 Years)

Traumatized adolescents are often challenging to engage in treatment for a
variety of issues. Often they resent having to come to therapy, especially if
they are coming because someone else (parent, teacher, judge) wanted them
to. If they are coming because of trauma-related issues, you may hear com-
plaints like “I didn’t do anything wrong”; “What happened was not my

fault”; “Why should I be punished (by coming to therapy)?” “I’m not crazy”;
or “I don’t want to talk to a shrink.” Start by validating these concerns as
teenagers have a right to these feelings—they are not being brought to ther-
apy because they were responsible for the trauma or because they are
“crazy,” but almost always because of emotional or behavioral problems that
often are related in some way to the traumatic experiences they have had.
Addressing these concerns at the outset is a natural segue into psychoeduca-
tion about the impact of trauma and will also give you a chance to ask them
what they are hoping to get out of coming to therapy, as well as any other
concerns they may have about starting therapy. These are critical parts of en-
gaging youth in psychotherapy (McKay and Bannon 2004) and have been
used effectively to retain traumatized youth in TF-CBT.
Cultural Adaptations
At least three child CBT trauma models have been culturally adapted and
pilot-tested:
• CBITS for Latino immigrant children (De Arellano et al. 2005) and
American Indian children (Morsette et al. 2009)
• TF-CBT for Latino immigrant (Kataoka et al. 2003), American Indian
(Bigfoot and Schmidt, in press), and Zambian HIV-affected sexually
abused children (Murray 2007)
• KidNET for international war refugee immigrants to Germany (Ruf et
al. 2010)
In all cases, these adaptations recognized the importance of engaging lo-

cal consumers in the adaptation process, both to assess cultural variations of
how traumatized children presented clinically and in adapting the interven-
tion itself. Interestingly, across the three models used in diverse settings
(schools, clinics, and refugee camps and clinics), all of the models retained
their core components, whereas language and examples were adapted to be
culturally, developmentally, and contextually salient to the child or children
being served. In each case, the models gained culturally sensitive engage-
ment and implementation techniques that have achieved strong acceptabil-
ity and positive initial outcomes among children cross-culturally.
Obstacles to Treatment
You may encounter many obstacles when first starting to implement child
CBT trauma treatment. These might include child-related challenges, such
as children who are highly trauma avoidant; parents who have their own se-
vere trauma history (and thus raise concerns about whether they can handle
hearing the material this type of treatment might raise); children who have
serious affective or behavioral dysregulation (whether or not related to
trauma); and “crises of the week” (i.e., children and/or parents who come in
each week with a new crisis, usually but not always caused by the child’s
negative behaviors, that threatens your ability to follow the treatment
plan). To help therapists who face these common problems, a new online
resource has been developed through funding by the Annie E. Casey Foun-
dation, TF-CBTConsult (www.musc.edu/tfcbtconsult).
Case Examples
Mariel: Individual TF-CBT

During the first session, you ask Mariel whether she would like to play a
game or draw pictures. She chooses to play a game. You play What Do You
Know? (CARES Institute 2006). You select cards that focus on domestic
violence. Because there are immediate safety concerns, you also address
safety during this first session instead of waiting until later in treatment,
and provide psychoeducation about domestic violence and examples of
children’s safety skills (e.g., don’t play with matches; only cross the street
on a green light; don’t get between adults during a fight; how and when to
call 911). You also provide information about PTSD: that having problems
like hers has a name, that they are common after children experience really
scary things like domestic violence, and that children can get better from
PTSD. When talking about safety, Mariel says she is afraid that she cannot
keep her family safe. You ask her whose job it is to do this, and she says
that it is hers. You use the metaphor of children wearing a backpack and
parents carrying suitcases. You draw a suitcase and a backpack, and then list
a variety of jobs (e.g., paying the bills, doing your homework, going to
school, going to work, buying food, brushing your teeth, keeping the family
safe) on note cards and ask Mariel to put the cards in the correct container
according to which jobs belong to parents and which jobs belong to chil-
dren. Mariel puts all of the jobs in the correct containers until she comes
to keeping the family safe. Then she says, “I know it’s supposed to be the
parents’ job, but they don’t do it so I have to.” You say, “We’ve talked about
things you can do to keep YOU safe. Keeping your family and your parents
safe is a grown-up job, and it belongs in the grown-up suitcase, not the
child’s backpack.” Mariel agrees to your talking about the family’s need for
more safety with her mother. By the end of the session, Mariel seems rel-
atively comfortable talking about these topics.
When meeting with Mariel’s mother, Anita, at the first session, you tell
her that one of the best predictors of children recovering from PTSD is
“having a parent like you who believes and supports her child through ther-
apy. Mariel already has that, so she is already on her way toward getting
over this. She is so lucky to have you here.” Anita is visibly relieved to hear
you say this. You then describe to Anita Mariel’s concerns about safety and
her belief that she must keep the family safe. Anita becomes tearful, but
says, “I understand why she feels that way; my husband has been angry a
lot, and it must not feel safe to her sometimes.” You ask, “Help me under-
stand what it is like at your house.” Anita gradually confirms more about
what Mariel has told you, and additional information about the father’s
controlling behavior. You provide Anita with written information about do-
mestic violence that describes these behaviors as being part of a pattern of
domestic violence. You also provide her with information about other re-
sources for domestic violence, including a local domestic violence treat-
ment center, and suggest that it might be helpful for her to look online and
consider going to this center to seek counseling or other services. Anita de-
nies that her husband would ever seriously hurt her. You tell her that you
and Mariel are both very concerned about her safety, and you do not want
anything to happen to her, not only because you care about her, but be-
cause Mariel loves her and needs her. You suggest that if Mariel could have
a safety plan, this might help her to feel safer right now. Anita agrees to this
idea but does not know what to include in the plan. You ask whether any
of Anita’s friends or relatives know about how her husband treats her and
Mariel and whom Mariel could call on the phone when she is afraid. Anita
tearfully admits that she has been too ashamed to tell them. You encourage
Anita to consider telling her sister, Carolina, who is the closest to Anita in
her family. Anita also agrees to talk to Mariel about calling her aunt Caro-
lina if she is afraid.
During the next session, Mariel tells you that her mother talked to her
about safety and said that she could call her aunt Carolina if she was scared
about her parents’ fighting. Mariel says that she feels safer since her mother
told her this. You teach Mariel progressive relaxation and focused breath-
ing, and in collaboration with Mariel, her mother, and the school develop
the following plan in order to address Mariel’s headaches in school:
1. When getting ready for school, Mariel will use visualization. She
loves butterflies, so these will be her focus during visualization.
She will keep this vision in her head when she is walking to school
and will use deep breathing and progressive muscle relaxation on
the way to school. If she is not relaxed, she will tell her mother,
who will practice these relaxation strategies with her before she
leaves for school.
2. Once in school, she will go to her first classroom. In her backpack,
she will have a picture of butterflies. She will arrive 5 minutes
early so that she has time to look at the butterfly picture before
class begins. She will sing her favorite song in her head (a lullaby
her mother used to sing to her), which makes her feel safe.
3. If she starts getting a headache, she will have a special signal (put-
ting her hair in a ponytail) that her teacher recognizes as her help
signal. Her teacher will come to her desk if she puts her hair in a
ponytail and will ask her to do her deep breathing and butterfly
visualization exercise. Mariel has a second visualization exercise
to use as well. She can do this at her desk quietly without attract-
ing the attention of other children in the class. If this doesn’t
work, she will be allowed to go to the nurse’s office to get some
aspirin, after which she will return to class.
You meet alone with Anita, who tells you that she told her sister Caro-
lina about the domestic violence. Carolina was very upset when she heard
this but was supportive of Anita and quickly agreed to Mariel calling her
anytime, day or night, if she was worried or scared. Anita explained that
she and Mariel were getting help for the problem, and Carolina was re-
lieved and told Anita that she was proud of her for telling someone about
it and getting help. Anita says, “I was surprised that Carolina said this;
I thought she would put me down for staying with him, but she actually
said she was proud of me for coming to therapy. I feel so much better now
that someone knows about this. I wasn’t sure it was the right thing to do,
but I’m really relieved that I told her.” Anita agrees to practice the above
relaxation strategies with Mariel.
During the following session, you begin working on affective expres-
sion and modulation skills. Mariel reports that she called her aunt Carolina
twice this week. Once she called when she was upset, and this helped her
feel safer. She says, “Once I just called her to talk—I just liked knowing
I could talk to her.” She has also been using the relaxation strategies in
school and has had fewer headaches. You and Mariel play Emotional Bingo,
and she is able to name times when she has felt happy (when her mother
is happy), sad (when her parents fight), anxious (when her father comes
home in a bad mood), angry (when the boys at school are loud), confused
(when she doesn’t understand what her teacher says in school), and ex-
cited (when she gets a present). When she can’t think of a time she has felt
hopeful, you ask, “When would another child feel hopeful?” Mariel says,
“When her family gets along and is happy.” You then ask what kids can do
to feel better when they have upsetting feelings like being sad or angry. Ma-
riel is not sure at first, but you say, “Some kids go to their rooms and read
a book, other kids talk to their moms or a friend, other kids like to get ac-
tive, and other kids have a hobby or something else they like to do. Is there
anything you can do to help yourself feel better when you’re upset?” Mariel
says, “I try not to think about things that upset me.” You ask, “Does that
help you feel better?” Mariel says, “Sometimes.” You say, “I bet sometimes
it’s really hard not to think about your parents fighting. Let’s see if we can
figure out some other ways to help you feel better.” Mariel thinks for a
minute and says, “I call Aunt Carolina.” You say, “Has that been helping
you to feel better?” Mariel says, “Yes, that helps me feel less scared.” You
say, “So that’s another way to feel better—reaching out to adults who can
help you feel safe is called asking for support. Are there other grown-ups
you can ask to help you feel better? How about at home—are there other
adults you can ask for help?” Mariel says, “Mommy, if Daddy isn’t fighting
with her.” You say, “So Mommy is someone you can ask for help when
you’re feeling sad or scared. Anyone at school you can ask for help?” Mariel
says, “Mrs. Jones, my teacher, is really nice. She’s been helping me do my

breathing at school this week. And the school nurse, Mrs. Tomas, is nice
too.” You say, “So those are two other people you can talk to if you are feel-
ing upset.” You then work with Mariel to identify the early signs of getting
mad at school and to recognize these early warning signs before she loses
her temper and starts fighting with boys at school. She agrees to try to talk
to one of the helping grown-ups at school before she loses her temper. You
also introduce the use of thought stopping (e.g., using the visual image of a
red light when Mariel has intrusive scary thoughts at school when she is
trying to do schoolwork). She likes the idea that she can be in charge of her
thoughts and draws a stoplight to practice thought stopping. After practic-
ing this, she agrees to bring the drawing to school and practice thought
stopping when she has intrusive thoughts about her father at school.
You meet with Anita to address affect regulation skills. Anita tells you
that her husband found out that she is bringing Mariel to therapy. He has
demanded that she stop coming, but Anita is determined to get Mariel the
help that she needs. Her husband has beaten her up severely twice this
week. She shows you several bruises on her body. However, she is worried
about leaving him because she has read that perpetrators can become deadly
when their wives try to leave. She asks you if you think she and Mariel are
in danger. You tell her that she is already in danger and that she needs to get
help immediately. You emphasize that you are very concerned about her be-
cause no one should be beaten and mistreated the way she is. You offer to
help Anita call the local domestic violence program from your office and ar-
range for her and Mariel to go directly to this program from your office. An-
ita agrees to this plan. You meet together with Anita and Mariel to explain
to Mariel that her mother is taking her to a special place that helps mothers
and children to deal with domestic violence. Mariel hugs her mother and
asks whether she can call her aunt Carolina. Anita says OK, and you praise
Mariel for using the coping skills you just discussed. You say that maybe
sometimes Aunt Carolina could even go with Mariel and her mom to the
domestic violence program. Mariel calls her aunt, who says she will meet
them as soon as she can catch the bus to the domestic violence center. Anita
and Mariel are very reassured and leave for the center.
The following week, you start by meeting briefly with Anita to follow
up on what has happened since the last session. Anita reports that she is
still living with her husband but has gone to her first session of a women’s
support group at the domestic violence center, and she has met with a legal
advocate there. She has heard a lot of frightening stories, and these have
made her both more scared to stay and more scared to leave. She is not
sure what to do. On the positive side, Mariel is doing better in school.
When you meet with Mariel, she tells you that her headaches have de-
creased significantly at school. She has talked to her teacher about “feeling
mad,” and to her surprise, Mrs. Jones thanked her for “using your words”
instead of fighting. This comment was very reinforcing to Mariel, and she
felt very pleased with her new skills. She is continuing to talk to her
mother, her aunt, and her teacher when she is feeling scared or upset and
has not had any new episodes of fighting. You introduce cognitive coping
by asking whether Mariel has had any upsetting feelings during the past
week. She says, “Yes, for the first time in a while I felt like playing with
some of my friends during lunch, but none of them asked me to play with
them. I felt really sad.” You say, “That’s a perfect example. When you felt
sad, what were you thinking? What was your brain saying to you?” Mariel
says, “I don’t know, I guess it was saying that I feel sad.” You say, “Sad is
what you were feeling. Usually we can say our feelings in one word, like
sad, mad, or happy, like we talked about last week. So I’m really glad that
you are so good at recognizing your feelings. Thoughts are connected to
feelings, but they are a little different. When we have a feeling, we often
have a more complicated thought that is connected to it, like something we
are telling ourselves in our head that is more than a one-word feeling, like
a sentence. So when you felt sad, what sentence were you telling yourself
in your head about your friends?” Mariel says, “Um... maybe they didn’t
like me anymore.” You say, “Great job, Mariel, that’s exactly what I mean
by a thought. So when you thought, maybe my friends don’t like me any-
more, this was the thought that made you feel sad. Of course it did;
I would feel sad, too, if I thought my friends didn’t like me anymore. When
you felt sad, what did you do?” Mariel says, “I went back inside and sat in
the bathroom by myself.” You say, “So, this is how we would write this
down to show the connection between what you thought, what you felt,
and how you acted” (Figure 8–1).
You say, “What if you had a different thought instead of that they didn’t
like you? Can you think of any other thought a child could possibly have in this
situation?” Mariel thinks for a minute and shakes her head no. You say, “What
about this thought: Maybe they thought that you didn’t want to play with
them anymore because it’s been so long since you’ve wanted to spend time
with them. You didn’t ask them to play either, did you? So maybe your friends
thought you still wanted to stay by yourself? If you thought that, how would
you feel?” Mariel says, “I never thought of that. I guess I wouldn’t feel so bad.”
You say, “And if you didn’t feel so bad, what might you have done?” Mariel
says, “I might have asked them if I could play with them.” You say, “That’s
right. So this is how we would write this down” (Figure 8–2).
You encourage Mariel to use cognitive coping during the coming week
when she is upset and to replace maladaptive thoughts with more accurate
and/or more helpful ones. You meet again with Anita to introduce her to
cognitive coping and to encourage Mariel to use this in the coming week.
During the next three sessions, Mariel writes the following trauma narra-
tive. As she is writing it, you share it with Anita during her individual sessions.
Chapter 1: All About Me

Hi, my name is Mariel. I am 8 years old. I live with my mother and
father in Oakland. I go to school at St. Christopher’s School, and my
best friend is Barbara. We both have black hair and brown eyes. My
favorite food is pizza. I don’t like to eat peas. I like to play with dolls,
sing and dance, and read. I want to be a teacher when I grow up.
Chapter 2: My Family
I have a very big family that includes lots of aunts, uncles, cousins,
and three grandparents, but my family in my house is just three peo-
ple: Mommy, Daddy, and me. When I was little, things were better.
Daddy played with me and said he loved me. That was when we had
a happy family.
Chapter 3: Fighting
My parents started to not be happy when I was little, like about
when I was 5, in preschool. My parents were not happy like before.
My father had trouble with working, and his anger was bad. He and
Mommy were fighting, and it was bad a lot at home. One time I re-
member was when Daddy came home, and he was really mad. He
yelled at me to get in my room right now. He yelled, “What is wrong
with you?” I ran to my room crying. I thought, “Daddy is mad at me.
He does not love me anymore. I am not a good child.” My stomach
hurt. I had to go to the bathroom, but I was afraid it would make him
madder, so I did not go and it made my stomach hurt more and
more. What will happen if he doesn’t love me and Mommy any-
more? I felt sad and scared about what he would do to Mommy.
I heard the door slamming and Mommy crying. I tried not to hear,
but I know Daddy was hitting Mommy, and I heard her head hit the
wall. I heard Daddy call her bad names; he said really bad things to
her over and over so that I held my hands over my ears so I couldn’t
hear. It was so bad, I can’t even stand to think about it. I was afraid
he would hurt her or kill her and who will love me then? I am sick
when I think about this. I wish I had hit him. I felt really mad, but
I was too sick and too scared, and I cried to sleep at night. And
Mommy cried all night and so did I, and I was praying and please let
it stop, but all night long he was hitting and yelling and kicking and
she was crying, and I just wanted to stop him and hit him, but I was
so afraid that he would kill her. The next day she had a black eye and
her face was swollen up, and she said she fell down but I knew it was
because of Daddy. I was scared to tell her what I heard, so I just
hugged her and went to school.
When you read this to Anita, she is shocked. She is sobbing and says she
had no idea that Mariel knew about this episode. She says, “I thought I had
hid it from her, but she’s known all along. This makes him look like a mon-
ster. She is growing up with these horrible things, and I’ve let it happen.”
You say, “You have both been the victims in this story, and until now you
didn’t understand what Mariel’s trauma experiences have been like. How
does hearing about her experiences change this for you as her mother?” An-
ita says, “I—I just, I can’t believe it. I can’t believe I let my own child live
through this. I have to get her out of here. I can’t let her live through this
one more minute. I can hardly live with myself knowing that I let. ..” Anita
sobs at this point, saying, “How could I not see—how could I think she
wouldn’t know?” You validate Anita’s pain and support her use of cognitive
processing to replace these maladaptive thoughts with more accurate and
helpful ones (e.g., “My husband perpetrated the violence, not me”; “Now
that I understand what Mariel has gone through, I can protect her”; “If
I hadn’t brought her to therapy, she might not have talked about this and
Situation:
My friends didn’t play with me.
Thought: They don’t like me anymore.
Feeling: Sad. Behavior: I went in the

bathroom and stayed
by myself.
FIGURE 8–1. Mariel’s initial cognitive triangle.
Situation:
My friends didn’t play with me.
New thought: They didn’t know I wanted to play with them.
New feeling: New behavior: Ask them

Not so bad. if I can play with them.
FIGURE 8–2. Mariel’s new cognitive triangle.

gotten better”; “Mariel is getting better, and this is largely because I’ve
been a good mother to her”).
During the following week, Anita calls to tell you that she and Mariel
have moved to the shelter, but they will attend their appointment as sched-
uled. At the next session, you ask Mariel how she has been, and she says
that she is relieved, mad, and sad. She is relieved that her mother is safe
but mad at both of her parents for “making it be like this. Why can’t they
love each other like they did before? Why does he have to be so mean, and
why can’t she make him be nicer? I never want to get married.” You vali-
date Mariel’s sadness and anger at losing the family she had. You take out
three cans of Play-Doh and use the metaphor of Mariel (blue Play-Doh),
Mommy (red Play-Doh), and Daddy (yellow Play-Doh). At the start of
their family, there was just red and yellow; then there was red, yellow, and
blue. You ask Mariel to put them into a shape that shows the family in
Chapter 2 of her story. Mariel makes a circle with red, blue, and yellow to-
gether. Then you explain that the family changed in Chapter 3; they were
not the same as in Chapter 2: red and yellow were fighting, and blue was
hiding from yellow sometimes, so their shapes were very different from in
Chapter 2 when they were all happy together. You ask Mariel to show what
shape the family looked like in Chapter 3. Mariel makes a configuration
with blue away from red and yellow, which are mashed together with her
fists. Now you explain that there will be a Chapter 4, when blue and red
live in one place and yellow lives somewhere else. But all three people are
still part of a family even if they live in different places. So how will their
shapes change in this chapter? You ask Mariel to show what their shapes
will look like in this next chapter. Mariel thinks and makes a circle of blue
and red, with yellow on the outside. You ask what the feeling is, and she
says, “Sad, but not scary. It’s quieter than fighting.” Mariel completes her
narrative with Chapter 4.
Chapter 4: How I Have Changed

Since I have come to therapy, I have learned a lot about domestic vi-
olence. I have learned that grown-ups have to keep kids safe. The po-
lice came to my house and brought us to the shelter. I miss Daddy
but not the fighting. I worry about Daddy living alone and if he is
okay without us. It makes me sad to think that he is alone but then
I remember all the fighting, and I don’t want to go back to the way
it was. I don’t want my mother to get hurt again. That was worse
than anything else. I call Aunt Carolina or Mommy or talk to my
teacher when I feel sad or worried. I met other kids who had domes-
tic violence. It happens to lots of kids; I am not the only one. I feel
sad that our family is not together. I didn’t make Daddy get mad. He
needs to get help for doing domestic violence. I would tell other kids
it’s not their fault. Tell a grown-up if you are scared. Don’t get in the
middle of grown-ups when they fight. You might make it worse. It
will get better someday. You are not alone.
Anita and Mariel meet together with you for Mariel to read her narra-
tive to her mother (until now you have been reading it to Anita in her in-
dividual sessions) and to fine-tune safety plans. Mariel and her mother
have just moved to a small apartment near Carolina and her family, and
Mariel’s symptoms have significantly improved. She has started to visit
with her father at her paternal grandmother’s house; this has decreased her
worry about her father. At the end of treatment, she is doing well and her
UCLA PTSD Reaction Index has fallen to within the normal range.
Joaquin: Group CBITS

During your initial meeting with Joaquin, you assess his PTSD symptom
level (which is in the moderate to severe range), and after you have pro-
vided him with some information, the two of you agree that he could ben-
efit from a group you are offering at school. You get permission from
Joaquin’s mother to include him in a 10-week CBT group at school for stu-
dents who have been exposed to very stressful or traumatic events. Al-
though his mother is not aware of the shooting, she knows that they live in
a dangerous neighborhood, that the kids see fights at school, and that their
father was deported last year. She recognizes that Joaquin has become sad,
tired, and sick to his stomach over the last few months, that he does not
have any patience with his siblings, and that he does not like to go to
school. She agrees that she would like Joaquin to receive support and learn
coping skills so he can feel better. His mother works two jobs and has three
younger children, making it feel impossible for her to accompany Joaquin
or provide transportation for services, so she is grateful that he can attend
a group at school. While you have her on the phone, you provide his mother
with some brief information about the skills that Joaquin will be learning
and let her know he will be given the opportunity to talk about the expe-
riences he has been through. She agrees to do her best to get time off to
attend parent sessions at the school when possible. You give her your con-
tact information and ask her to provide you with any alternative contact in-
formation for her and best times to contact her if needed.
During the first group session, you facilitate a game with the students
so they can get to know one another and feel comfortable talking in the
group. Joaquin smiles when he realizes that two other students name sim-
ilar interests to his and that there is another youth who is the eldest in his
family and whose father does not live with them. You talk about the prev-
alence of violence and trauma among youth and what those words mean.
When you ask each of the six participants to briefly state why he or she is
in the group, Joaquin says that he “saw a kid get shot on the way home from
school.” You discuss confidentiality, and the group arrives at a set of “group
rules”; you also introduce the reinforcement chart so that the students see
how they will be rewarded for participation and practice. Next, you create
a triangle with thoughts, feelings, and behaviors for each point and discuss
that scary or traumatic events affect everything about us—all three of
these things—and provide an example of how they are linked and affect
each other. After others talk, Joaquin joins in and says that he sees how
what happened to him makes him think that if he goes to the park again or
lets his siblings play outside, he thinks they could get shot. These fears
make him feel “crazy nervous,” and so he yells at them not to go outside
and doesn’t hang out with his friends anymore near the park. The group
supports him by saying that those thoughts, feelings, and behaviors make
sense given what he went through. You talk about how this CBITS group
can help him and the others learn to think, feel, and act in a way that makes
them feel better so that each person can get back to doing what he or she
likes and needs to do that is safe. At the end of the first group session, you
ask students to fill out a goals worksheet to give you information to better
understand what each student hopes to get out of the group and for you to
begin to individualize their treatment plans. They are sent home with a
similar form for parents to write in goals they have for their child.
The week after the first session, you have scheduled an early morning
parent session, which Joaquin’s mother attends along with a couple of
other parents from the group. After some introductions and brief sharing
at the meeting, you review common reactions to stress and trauma; have
the parents engage in the same relaxation training exercises you will do
with the students; discuss the link among thoughts, feelings, and behaviors;
explain the rationale for the group; and answer any questions. You highlight
the issue of avoidance and why it is important for youth to be able to pro-
cess and digest their experiences by telling their stories. You emphasize
that students will be practicing skills between sessions at home and that
they may need support in doing so, especially as they work toward getting
back to doing things that they may have been avoiding. You explain that the
next parent group will be in 3 weeks and that you will further discuss
avoidance and exposure along with problem solving. You provide handouts
for the content of both sessions in case some parents do not return for the
second session. You notice that some parents exchange contact informa-
tion, and you have provided time in the room in case anyone wants to speak
to you afterward.
In the second group session, you facilitate a discussion with the stu-
dents about common reactions to stress and trauma, and as each is dis-
cussed, you are able to normalize why that symptom would occur and
provide hope for how the group may help it improve. For example, Joaquin
offers that one reaction may be to not want to go places or see people that
remind you of what happened. You reinforce him for participating and
state, “Avoidance is common and makes sense because you may feel better
for the moment, but just like not wanting to talk or think about the trauma,
avoiding situations or people that remind you of the shooting can keep you
from doing normal things that are an important part of your life, right? In
this group, we’ll be learning about how to cope with some of these bad feel-
ings so you can get back to doing those things. Can anyone else relate to
what Joaquin just said about avoidance?” Following the discussion of com-
mon reactions, where many symptoms that come up are related to physi-
ological arousal, you transition into teaching different forms of relaxation
training, including deep breathing, progressive muscle relaxation, and pos-
itive imagery. You explain the idea of a feelings thermometer (i.e., rating
how you feel on a scale of 0–10, where 0 is feeling OK and 10 is feeling
very, very upset, anxious, or scared) and ask for ratings before and after the
relaxation exercises. You give students a “Common Reactions to Stress or
Trauma” handout to take to their parents, and ask them if they are com-
fortable doing so, to share with their parents which reactions they may be
experiencing. In addition, you ask them to practice some form of relax-
ation two times during the next week and report back.
You spend the next two group sessions reviewing and practicing cogni-
tive coping (similar to the description in “Mariel: Individual CBT”), allow-
ing each student to practice how to replace negative thoughts with more
helpful and accurate thoughts. Between sessions, you monitor each stu-
dent’s practice with relaxation and cognitive coping. Joaquin reports that
he finds taking deep breaths before his tests in class useful, and when an-
other group member mentions that she is trying to do deep breathing and
positive imagery when she gets headaches, Joaquin decides this could be
something for him to try when his stomach is bothering him and when
teachers or kids are loud. When he has thoughts about the shooting,
Joaquin uses positive imagery of his “safe and happy place” (his grand-
mother’s kitchen in El Salvador) and imagines the feeling of warmth and
calm and the good smells of his favorite foods there that comfort him. He
later reports that he has been able to find privacy in the bathroom at home
to do muscle relaxation and that helps him feel “less angry” when his sib-
lings frustrate him. When you ask group members to write down a couple
of helpful thoughts on a small card to carry with them, it reminds Joaquin
of his brother’s Yu-Gi-Oh! Power (Japanese video animation) cards, so he
begins to carry the power card in his pocket to remind him to check his
thoughts and to use helpful and accurate thinking when negative thinking
gets in his way.
In addition to the group sessions, during weeks 3 and 4 you meet indi-
vidually with Joaquin twice to work on his trauma narrative (and with each
student one to three times). During the initial discussion, you find out that
Joaquin has experienced other traumatic events, including his family being
robbed and temporarily separated while crossing the border into the
United States 7 years ago, a home invasion 5 years ago, and his father being
deported during a raid at his workplace last year. However, Joaquin reports
that it is the recent shooting that is causing him the most distress currently.
You ask Joaquin to tell you the story of what happened the day of the
shooting and to add information so you can imagine what is happening as
if it is projected onto a movie screen in front of you. You let him know that
you are going to jot down parts of the story as he tells it.
Joaquin shares the following: “My best friend, Carlos, and I stayed af-
ter school for a while that day because some kids were playing basketball
and we watched. I started thinking that I should get home so my brothers
and sister wouldn’t be alone, because I’m supposed to take care of them
after school. So finally, Carlos and I took off for home. When we got to the
park on 3rd Street, it was starting to get dark, and we cut through by the
rec [recreational center] like we always did on the way home. When we
got past the corner of the building, we saw two guys from a gang pointing
a gun at a high school kid in a big jacket near the other corner of the rec.
They were cursing and yelling back and forth, and I felt frozen, like I was
just stuck in time and didn’t know what to do. The next thing I knew there
was the gunshot—loud in my ears—and the other gangster looked right in
my eyes. Carlos pushed me, and we both started running through the park.
We were so scared, we didn’t even shout out or warn anyone there. We

didn’t even know if the boy was killed or nothing. We just ran until it
burned too much to run, and we were home by then. Carlos went straight
to his house, and I went to mine. I just went to the bathroom at home and
sat on the ground, and I was shaking and just told the kids to leave me
alone. When my mom came home from work that night, I was still shaking
and had a stomachache. My mom looked so tired and worried that I was
sick. She works all the time since they sent my dad back to El Salvador, and
I just couldn’t tell her what I saw. I couldn’t say it. My dad told me to take
care of her and my brothers and sister until he could figure out how to get
back.”
You work with Joaquin to retell his story several times over the two ses-
sions, providing support and assistance in reframing some of his maladap-
tive thoughts about what happened and his role in it. By the second session,
it is much easier for Joaquin to talk about what he went through. You then
help him plan for later group sessions, which will provide continued prac-
tice at processing his trauma memory. You ask if there are parts of his story
he would like to continue working on in the group, some of which he may
want to keep private and some of which he may be willing to share with
the group. You make a note of these things for him. You also prepare
Joaquin to be supportive in the group by first asking what he may need
from the group in order to feel supported and comfortable. He states that
he would “like others to be paying attention and not be messing around”
and that “others will also have a turn so I am not the only one sharing.” You
then use that information to ask Joaquin for ideas about how he can be re-
spectful and show support for other group members. Joaquin agrees to do
the same for the others and also to look at them while they are talking, but
in a “nice way, not straight at their eyes.” At the conclusion of the second
individual session, Joaquin thinks that he is ready to talk to his mom about
what happened. You help him think through and plan a good time to talk
to her and role-play how it might go. You also offer to invite his mother to
join you for a third individual session next week in case he doesn’t find a
time to do it himself during the week, or after he has shared the informa-
tion, either way. You encourage Joaquin to do something fun this week to
take care of himself because he has been working through difficult stuff.
He agrees that he will play basketball or video games at his cousin’s house,
something he used to do frequently and hasn’t done in a while, on his
mom’s day off from work.
Following individual sessions with each group member, you refer back
to the individual treatment plans you have started and add new informa-
tion gleaned from these sessions, including symptoms, family structure,
and so forth, and note particular skills that will be important for each indi-
vidual based on his or her presentation. For example, because of Joaquin’s
somatic complaints and jumpiness, you want to ensure he finds a relaxation
technique that really works for him. Likewise, because Joaquin’s anxiety
since the shooting has generalized to his friend and is interfering with his
home life in that he is refusing to let his siblings play outside, you want to
be sure that these issues are addressed with in vivo exposure and/or prob-
lem solving. You also note that Joaquin would like to share his story with
his mother and that the family may benefit from a referral to some com-
munity and social resources given the father’s deportation. Some time be-
fore session 5, you also try to make phone contact with each parent, letting
him or her know that beginning in session 5, youth will begin working on
concrete steps toward things that may be anxiety provoking or that they
have been avoiding that they want or need to be able to do. You assess the
extent to which parents, other caregivers, or extended family may be avail-
able to provide support and /or transportation if needed during that prac-
tice. You invite parents to the second parent session and briefly review the
information you will be providing in case they do not attend. In your phone
conversation with Joaquin’s mother, you realize she will not be able to at-
tend the parent session, so you provide her with information on the re-
maining sessions over the phone. She shares with you that Joaquin told her
about the shooting and that he is starting to talk with her about other things
when he is upset. She tells you that things are very difficult for her now
that she is supporting her family alone and that she sometimes does not
know how they will survive financially. You validate her concerns and rein-
force all she is doing for the well-being of her children and family. You refer
Joaquin’s mother to a community agency that provides resources and ser-
vices for recent immigrants and to a nonprofit legal aid group that may be
able to provide her with information regarding her husband’s status and
any options the family may have for reuniting. You praise her again for be-
ing involved with Joaquin’s program even though she is so terribly busy.
During group session 5, you focus on things that students may have
been avoiding since their traumatic event. Each child makes a list of things
he or she has been avoiding but would like to be able to do again. You cir-
culate to each student, helping each one refine his or her hierarchy of grad-
ual approach steps, getting feelings thermometer ratings for each of the
steps, and having each student choose one to two things that can feasibly
be practiced over the next week that are rated at 3–4 or under on his or
her feelings thermometer. Joaquin lists that he has been avoiding Carlos,
his best friend, and that he has stopped letting his siblings play outside
when he cares for them. After assessing for the safety of having siblings
play outside (“Do other children in the neighborhood play outside?” “Did
your siblings used to be able to play outside safely?” “Is there a place it is
safest to be while playing outside?” “Is it safe to do so during the day,
evening, or weekends?”), you help Joaquin list steps for allowing the kids
to play outside, and he accords each step with a rating of how anxious it
will make him feel to do so (at present), as shown in Figure 8–3.
You also help him create a hierarchy of gradual steps for getting back
in touch with Carlos. He constructs the steps and ratings shown in Figure
8–4.
Joaquin decides that this week, he will practice letting his siblings play
outside at his cousin’s house, where he has started hanging out again on
weekends. He will also text message Carlos after school one day.
You begin group session 6 by checking in with group members about
their progress with in vivo exposures and how they used their coping strat-
egies to manage their anxiety during exposure practice. Joaquin reports
that he let his siblings play outside two times at their cousin’s house and
that it got easier for him by the second time. He even went in the house to
play video games while they played outside at one point. He also sent a text
message to Carlos, but as soon as he sent the text, he felt much more anx-
ious than he anticipated (he had written an 8 on his practice sheet for his
feelings thermometer rating at the time). On the same form, Joaquin had
logged his automatic thoughts and alternative helpful thoughts for why
Carlos didn’t get right back to him and noted that he took some deep
breaths to reduce his anxiety. You ask how it all worked out, and Joaquin
says that Carlos was surprised and happy to hear from him. They texted
back and forth a few times, joked, and ended with “See ya at school.” You
use the opportunity to remind the group that the next time they feel upset
or anxious, they can reflect back on how they have felt that way before and
what coping strategies helped them get through it, and remember that
things may even turn out well. You then help each group member decide
on which in vivo steps he or she is ready to progress to in the coming week.
In group sessions 6 and 7, you focus on allowing students to continue pro-
cessing their trauma memory. First, by passing each student the notes you took
during his or her individual sessions, you remind each student of the parts of
the story that he or she wanted to continue digesting in group. You then guide
the group through an imaginal exposure. The students imagine a particular
point in their story as you slowly ask questions to guide them to think about
what they are picturing—engaging their senses around what is happening, who
is there, how they are feeling, what they are thinking, and so forth (they do not
answer, but use your guidance to create an individual exposure experience
even though they are in a group setting). You pause intermittently and ask for
students to show you their feelings thermometer ratings on their fingers so
that you have a sense for when ratings have gone down across the group and
you can move forward. Next, you provide art supplies and paper and ask each
student to draw a picture of part of his or her story. You allow students to draw
without instructions or asking questions about what they are doing, being re-
spectful that each may do something very different. Joaquin draws a picture
of him and Carlos near the corner of the recreational center and the two boys
holding another one at gunpoint on the other side of the building. You check
in with students to see how they are feeling as they finish their drawings. You
decide to do a relaxation exercise with the group, and afterward you help to
focus everyone back to the present by asking about what classes they have next
and who is doing what after school that day.
In group session 7, you review in vivo exposure practice and progress.
Joaquin describes that he played outside at home with his siblings over the
weekend and that he has been eating lunch with Carlos and his old group
of friends again. You again help each student decide what his or her next
in vivo steps will be and then distribute the students’ drawings from the
previous week and allow some time for them to finish their drawings.
Next, you lead the group in a verbal sharing of part of each student’s story,
explaining that students can show their drawing to the group and talk about
what is happening in the picture if they like, or they can tell about a differ-
ent part of their story. You let them know that if someone does not feel like
sharing verbally that day, he or she can take a few minutes to write out the
story instead—and either keep it private or read it to you at the end of the
Siblings outside in yard while Joaquin is inside (weekdays). 8
Siblings outside in yard with Joaquin (weekdays). 6
Siblings outside in yard while Joaquin is inside (weekends). 5
Siblings outside in yard with Joaquin (weekends). 4
Siblings play outside at cousin’s house. 3
Imagine siblings playing outside with Joaquin supervising. 2
FIGURE 8–3. Joaquin’s anxiety ratings.
Hang out with Carlos at Carlos’s house. 7
Hang out with Carlos at Joaquin’s house. 5
Hang out with Carlos at lunch with a group of other kids. 5
Say hello to Carlos during two passing periods. 4
Text message him a “Hey, what’s up” message. 2
FIGURE 8–4. Joaquin’s hierarchy of exposure tasks with anxiety

ratings.
group session. Joaquin shares his drawing, describing what he saw at the
park to the group. You then lead the group through another drawing or
imaginal exposure and end the group in a similar fashion to group session 6.
At the outset of group session 8, you review students’ progress with
in vivo practice and plan for continued movement up their hierarchy.
Group sessions 8 and 9 focus on problem solving to enable group members
to look at options for managing their real-life problems. You illustrate the
link between thoughts and actions by working through an example with the
group, listing potential actions someone could take and making links to the
underlying thoughts. You ask the group for ideas of problems they encoun-
ter in daily life. The situations include someone writing something bad
about you on the bathroom wall, a teacher yelling at you, and parents fight-
ing with each other. You engage the group via games and teamwork in
brainstorming and in rating and selecting potential actions for these situa-
tions. You emphasize that there are many things a person cannot control in
situations like these, but someone can always control how he or she thinks
about the situation and what he or she decides to do. Toward the end of
group session 9, you engage the students in a trivia game, CBT Jeopardy,
which reviews the skills they have learned thus far. You discuss plans for
celebrating their success in the final session. You reassess student PTSD
symptom levels and find that Joaquin’s PTSD scores have significantly de-
creased. You also note that he has reconnected with Carlos, even having
him over to his house; is spending time with extended family on the week-
ends; has been allowing his siblings to play outside before dark; and is at-
tending class on a more regular basis.
Group session 10 includes a celebration of each student’s progress,
marked by your verbal acknowledgment of each child; the handing out of
certificates of accomplishment; and a piece of paper for each student, with
his or her name on it, passed around for each student to write something
positive and to be taken home afterward. Most of the students exchange
contact information with one another, and you let them know that al-
though the group is ending, you will still be at school each week and how
to contact you if they need anything. You ask the group if they would like
to check in before the semester ends and have a booster session, and the
group agrees this is a great idea. You hand out a small bag or folder with
reminders of their CBT skills and ways to take care of themselves, includ-
ing small cards for them to write helpful thoughts on; steps they want to
continue to make with their hierarchy; relaxation scripts or reminders,
such as a worry stone to rub; and lists of things that make them happy, the
people they can go to when they feel upset or need advice, and pros and
cons for problem-solving issues that come up.
You contact parents of group members to let them know that the group
has ended and how to contact you if any concerns arise. You remind par-
ents of the skills their children have learned and how to reinforce them at
home. Joaquin’s mother is very grateful for the changes she sees in Joaquin.
She also reports that she has followed up with the community referral you
have given her and has an appointment with a legal advocate to discuss im-
migration options and community and social services her family may be el-
igible for. You also get information about students’ classroom functioning
from their teachers. Joaquin’s math teacher reports that he is coming to
class more settled down, that his concentration and participation level have
improved, and that he is no longer asking for passes out of class.
Conclusion
Individual (TF-CBT) and group (CBITS) trauma-focused CBT have been
extensively tested and found to be effective for traumatized children, in-
cluding those with multiple traumatic exposure and comorbid difficulties.

Other CBT treatments for traumatized children have also shown efficacy
for improving PTSD symptoms. Child trauma-focused CBT interventions
have been successfully disseminated to large numbers of providers in the
United States and internationally. Future research will examine to what
extent these dissemination efforts have changed outcomes for traumatized
children.
Key Clinical Points

• CBT treatment is appropriate for children who have significant trau-
ma symptoms even if they do not meet full PTSD diagnostic criteria.
• Gradual exposure is a core feature of most CBT trauma treatments
for children.
• Skills-based components of child CBT trauma treatments include
psychoeducation, parenting skills, relaxation skills, affective modu-
lation skills, and cognitive coping skills.
• Trauma-specific components of child CBT treatments include devel-
oping a trauma narrative, in vivo mastery of trauma reminders, and
safety planning. Some models also include conjoint child-parent
sessions.
• Individual and group CBT models are both effective; selecting the
optimal treatment is primarily a matter of feasibility and accessibility.
8.1. Which of the following is a characteristic of gradual exposure?
A. Incrementally increasing the duration and intensity of traumatic

material in each sequential treatment component.
B. Therapists being mindful not to model avoidance.
C. Connecting each component, including the skills-based compo-
nents, to the child’s trauma in some way.
D. Instructing children to think about their trauma experiences for
at least an hour every day.
E. A, B, and C only.
F. All of the above.
8.2. Connections among which of the following three components form

the basis of cognitive coping?
A. Thoughts, feelings, behaviors.

B. Thoughts, antecedents, consequences.
C. Antecedents, behaviors, consequences.
D. Thoughts, behaviors, beliefs.
8.3. Which of the following factors may be considered in choosing be-

tween individual and group CBT trauma treatments?
B. Accessibility of school-based treatment.
C. What treatment parents will accept.
8.4. Which of the following may inadvertently communicate trauma

avoidance to children during therapy?
A. Using euphemisms for traumatic experiences.

B. Attempting to show empathy by changing voice tone or volume
when talking about trauma.
C. Change in body language.
D. Preparatory statements when introducing traumatic themes.
8.5. Cultural adaptations of CBT trauma treatments have
A. Found some core components to be ineffective with certain pop-

ulations.
B. Retained all core components of the efficacious treatments.
C. Found that manuals cannot be properly translated into other lan-
guages.
D. Created new models for different ethnic groups.
Suggested Readings
and Web Sites
Cohen JA, Mannarino AP, Deblinger E: Treating Trauma and Traumatic
Grief in Children and Adolescents. New York, Guilford, 2006
Jaycox L: Cognitive Behavioral Interventions for Trauma in Schools. Long-
mont, CO, Sopris Educational Press, 2003
CTGWeb: A free online training course for applying TF-CBT for childhood
traumatic grief that provides 6 free continuing education credits upon
completion. http://ctg.musc.edu
The National Child Traumatic Stress Network: Provides information
sheets about child trauma, as well as a host of other resources for cli-
nicians and families. www.nctsn.org
TF-CBTConsult: An online consultation tool for therapists maintained by
the National Crime Victims Research and Treatment Center.
www.musc.edu/tfcbtconsult
TF-CBTWeb: An online training course that offers 10 free continuing ed-
ucation credits upon completion. http://tfcbt.musc.edu
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CARES Institute: What Do You Know? A therapeutic card game about child sexual
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Cohen JA, Mannarino AP, Deblinger E: Treating Trauma and Traumatic Grief in
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9
Obsessive-Compulsive
Disorder
OBSESSIVE-COMPULSIVE disorder (OCD) is a serious

mental health condition with a prevalence rate of 1%–3% across various ep-
idemiological studies (Flament et al. 1988; Sasson et al. 2001; Valleni-Basile
et al. 1996). Among adults with OCD, approximately one-half began strug-
gling with symptoms during childhood or adolescence (Rasmussen and Eisen
1990). Considering that both a long duration of illness and early onset are
strongly associated with OCD persistence (Stewart et al. 2004), youth with
OCD need to be aggressively treated with empirically supported approaches
S This chapter has a video case example on the DVD (“Obsessive-Compulsive

Disorder”) demonstrating education and exposure and response prevention meth-
ods of CBT for an adolescent with obsessive-compulsive disorder.
299
as soon as the disorder is identified. Since the mid-1990s, there have been
tremendous advances in the treatment of pediatric OCD, and cognitive-
behavior therapy (CBT) has consistently been shown to be the monother-
apy of choice for OCD in youth (Abramowitz et al. 2006).
Although the superiority of CBT as a monotherapy or in combination
with serotonin reuptake inhibitor (SRI) treatment is clear, there remains a
need to disseminate this efficacious approach from treatment laboratories
to frontline clinicians. From our years of experience in successfully treat-
ing youth, including treatment-resistant patients referred from seasoned
CBT therapists, we have developed a CBT approach that facilitates treat-
ment compliance and avoids common pitfalls that may lead to ineffective
implementation of CBT principles. For clinicians seeking to better serve
patients with OCD, this chapter is geared toward improving implementa-
tion of an exposure and response prevention (E/RP) approach.
This chapter begins with a general review of the CBT treatment out-
come literature and then illustrates our particular CBT approach for pediat-
ric OCD. First, we present the empirical evidence for cognitive-behavioral
approaches in pediatric OCD in both clinical and research settings. Second,
we describe the various theoretical models within the CBT framework used
to treat OCD and how elements of these various models are typically imple-
mented within pediatric OCD protocols. Next, we explain in detail our clin-
ical assessment, treatment planning, and treatment approach for pediatric
OCD. Finally, we discuss common issues that arise in special populations,
particularly for children with OCD content related to scrupulosity or sexual
obsessions.
Empirical Support
Since the mid-1990s, there has been significant work developing CBT in-
terventions for pediatric populations with OCD. Initially, these interven-
tions began with age-downward extensions of protocols found efficacious
with adults, which led eventually to open clinical trials involving these pro-
tocols (Franklin et al. 1998, 2001; March 1998). Collectively, the pub-
lished uncontrolled evaluations led to randomized studies evaluating the
efficacy of CBT (e.g., Barrett et al. 2004; Bolton and Perrin 2008; de Haan
et al. 1998; Franklin et al., in press; Pediatric OCD Treatment Study
Team 2004; Storch et al. 2007). Our research group did a quantitative re-
view of the child and adolescent CBT literature. Efficacy studies in youth
have consistently demonstrated large effect sizes for CBT interventions,
particularly for individual and family-based formats (Freeman et al. 2007).
Obsessive-Compulsive Disorder 301
The effects of CBT interventions in these populations are durable after

treatment, observably sustained as long as 9 months after treatment ter-
mination (Bolton and Perrin 2008; Franklin et al. 1998; March et al. 1994;
Wever and Rey 1997).
CBT has proved to be effective even when applied flexibly outside of
efficacy trials. For example, large CBT effect sizes have been demon-
strated in community-based effectiveness trials with fewer methodologi-
cal controls than efficacy trials (Nakatani et al. 2009). In Norway, an open
trial involving community therapists and their supervisors showed that
having access to OCD experts periodically (every 3–4 weeks) led to treat-
ment effects comparable to those of efficacy trials (Valderhaug et al.
2007). This “supervision of supervisors” model indicates that the quality
of care by frontline clinicians in areas without extensive OCD expertise
can be significantly enhanced with only periodic contact with expert su-
pervisors. A final interesting development in pediatric OCD involves the
equitable effects demonstrated from outpatient versus intensive ap-
proaches. Although most CBT treatment for pediatric OCD is delivered
weekly, there is evidence indicating that CBT can be applied more in-
tensely (e.g., one session per day), demonstrating remarkably similar im-
provement in outcome to a weekly CBT approach (Franklin et al. 1998;
Storch et al. 2007). This suggests that the specific, skill-based CBT work
occurring in session is the main driver for improvements in functioning and
symptom reduction, regardless of the treatment session schedule.
The evidence to date suggests that OCD can effectively be treated
with CBT, notwithstanding the various CBT protocols in use. Both the
American Academy of Child and Adolescent Psychiatry (1998) and the
American Psychological Association (Task Force on Promotion and Dis-
semination of Psychological Procedures 1995) have concluded that CBT
including E/RP elements is the treatment of choice for both children and
adults with OCD. E/RP, simply stated, is a collection of behavioral tech-
niques that provide a systematic way of both approaching fear-inducing
triggers (exposure) and avoiding fear-neutralizing rituals or other safety
behaviors simultaneously. CBT for OCD may also include cognitive ther-
apy elements such as cognitive restructuring. Although a meta-analysis
comparing the relative effectiveness of E/RP and pure cognitive treatment
suggests superiority of E/RP (Abramowitz et al. 2002), the authors ac-
knowledge it is difficult to compare pure behavioral and pure cognitive
therapy approaches, given their overlap in treatment implementation. Al-
though we will discuss later how an overemphasis on cognitive techniques
can attenuate the impact of E/RP, the judicious use of cognitive therapy
during psychoeducation and initial exposure planning can be helpful for
patients beginning a CBT program.
Theoretical Models
Behavioral Learning
Most protocols used today are based on principles derived from conditioning
models or belief and appraisal models applied to the development and main-
tenance of OCD symptoms (Taylor et al. 2007). The theoretical models
closely tied to E/RP have their start in early learning models. The two-factor
model of fear describes a process in which unconditioned behavioral re-
sponses (e.g., unlearned escape responses) occur in situations where physi-
ologically mediated anxiety is experienced (Mowrer 1960). If an individual
performs a behavior that succeeds in reducing anxiety, the behavior will be
negatively reinforced; and subsequent situations where similar anxiety-pro-
voking stimuli occur will more likely reproduce this learned anxiety-reduc-
ing behavior. In addition, behaviors related to avoiding situations that evoke
physiological fear will also be reinforced. From this initial work, operant con-
ditioning models were described specifically for OCD (e.g., Rachman and
Hodgson 1980). When escape behaviors involve learned, compulsive rituals,
an individual could be considered to have OCD.
Using this descriptive framework, E/RP is thought to work because it
makes those learned connections between safety behaviors and the physi-
ological experience of anxiety more ambiguous (see Foa and Kozak 1986).
In a typical successful E/RP exercise, a patient begins by exposing himself
or herself to an OCD-related trigger that elicits a moderate level of fearful
arousal. If the patient then refrains from performing the ritual, the patient
will experience a gradual decline of the physiological arousal. With succes-
sive E/RP trials, the physiological response to the exposed trigger will grad-
ually reduce (i.e., habituation). As a patient habituates to the OCD trigger,
the extinction of OCD behaviors typically follows.
Cognitive Belief and Appraisal

Cognition-based theoretical models expanded on earlier efforts to explain the
etiology of OCD. Cognitive researchers argue that most forms of psychopa-
thology stem from individuals having and overvaluing dysfunctional beliefs
(e.g., Beck 1976). Cognitive theorists for OCD (e.g., Salkovskis 1989, 1996)
explain that ephemeral, intrusive thoughts, which occur routinely in most
people, may become obsessions when these thoughts are interpreted as having
serious consequences for which the individual is personally responsible. Com-
pulsions are reinforced by negative reinforcement, as described in earlier
learning models, because they serve to immediately reduce an individual’s dis-
tress. Cognitive theorists also advance the argument that compulsions persist
because they prevent individuals from having opportunities to test whether
obsessions lead to their unrealistic predictions of harm (Salkovskis 1989).
An enduring legacy of the early cognitive theorists includes articulating
the various themes of dysfunctional beliefs found in OCD obsessions. Al-
though it has been shown that using pure cognitive therapy techniques
(e.g., Socratic questioning) in isolation is not effective over and above ap-
plying E/RP techniques (Abramowitz et al. 2002), the nomenclature of cog-
nitive content is quite useful in setting up exposures that directly target the
core fears of an individual. Advancing on Salkovskis’s seminal ideas, a collab-
orative group of OCD treatment experts outlined additional cognitive do-
mains involved in obsessive content (Obsessive Compulsive Cognitions
Working Group 1997). Combining the expert consensus of its members,
the Obsessive Compulsive Cognitions Working Group outlined the most
common cognitive domains involved in OCD. The final cognitive domains
included inflated responsibility, overestimation of threat, thought-action fu-
sion (e.g., a belief that a thought is morally equivalent to performing the ac-
tion), superstitious or magical thinking, intolerance of uncertainty or doubt,
perfectionism, and concerns for controlling thoughts. Although these cogni-
tive constructs were not necessarily specified for child and adolescent OCD,
many of these cognitions have been observed as ways to differentiate chil-
dren with OCD from control subjects and those with other anxiety disor-
ders (Barrett and Healy 2003).
Despite the distinctions in theoretical explanations of OCD, it should be
emphasized that there is no evidence that any one of these can uniquely ac-
count for the symptom variability observed in OCD patients (Himle and
Franklin 2009). Our treatment approach emphasizes a neurobehavioral
framework, which combines biological, developmental, learning, and family
dynamic models (Freeman et al. 2003; March and Mulle 1998). However,
techniques used in other treatment approaches (e.g., motivational interview-
ing, mindfulness-based treatments) can also be useful in the flexible imple-
mentation of this program, particularly to promote sustained practice in E/RP
activities and remove family involvement in escape and avoidance behaviors
that reinforce OCD. Next, we describe our CBT approach in more detail.
Application
Assessment
A thorough clinical assessment is necessary to determine whether OCD is
present and if it should be considered primary over other comorbidities. If
other comorbid conditions are identified, the clinician must consider care-
fully whether E/RP should be the primary focus of treatment for the pa-
tient. For example, if OCD-appearing behavior could be better described
in terms of other disorders with intrusive thoughts or repetitive behaviors
(e.g., impulse-control disorders or tic disorder, respectively), then the best
approach would not normally involve E/RP. Furthermore, if the severity of
OCD symptoms would make E/RP hard to tolerate, SRI medication treat-
ment should be considered. In children, it is also important to determine
whether observed behaviors are clinically significant or fall within the
range of normal development (Evans et al. 1997). Finally, identifying fam-
ily factors such as family dynamics related to OCD behaviors (e.g., family
accommodation) and history of OCD members is also of tremendous im-
portance. The assessment process that occurs in our treatment clinic is de-
scribed in detail below.
Table 9–1 describes the assessment battery that is used in our collabo-
rative treatment studies and respective clinics. In general, we use the Chil-
dren’s Yale-Brown Obsessive Compulsive Scale (CY-BOCS; Scahill et al.
1997) and Anxiety Disorders Interview for Children (ADIS; Silverman
and Albano 1996) for most children and adolescents. However, at times
due to a patient’s age or comorbidity rule-outs, we also use sections of the
Schedule for Affective Disorders and Schizophrenia for School-Age Chil-
dren—Present and Lifetime Version (K-SADS-P/L; Kaufman et al. 1997),
Yale Global Tic Severity Scale (YGTSS; Leckman et al. 1989), or Child-
hood Autism Rating Scale—High Functioning, 2nd Edition (CARS2;
Schopler et al. 2010) as appropriate. We also routinely use the Multidi-
mensional Anxiety Scale for Children (MASC; March et al. 1997), Child
Obsessive-Compulsive Impact Scale—Revised (COIS-R; Piacentini et al.
2007), and Children’s Depression Inventory (CDI; Kovacs 1981) to
screen for comorbidities and improve treatment planning.
Next, we describe a few key assessment considerations for every po-
tential CBT candidate. These clinical considerations are important to de-
termine whether a CBT approach is appropriate for a given family.
OCD Versus Developmentally

Appropriate Behavior
Differentiating between OCD-related obsessions and rituals and develop-
mentally appropriate behaviors is important. A normally developing child
can get deeply immersed in specific interests, become rigidly rule bound,
or have behaviors that are stereotypic in nature. For children with OCD,
these behaviors are either not developmentally appropriate or are extreme
TABLE 9–1. Typical obsessive-compulsive disorder (OCD)

assessment battery
Age
Measure (years) Target Notes
Interviews
ADIS 8–17 DSM-IV criteria for Preferred for ruling out
anxiety disorders; anxiety comorbidities
ratings on severity and
impairment
CARS2-HF 6–17 High-functioning autism Best when ruling out
spectrum behaviors autism spectrum–
related stereotypies
and rigidity
CY-BOCS 5–17 OCD symptoms and Score of 16 indicates
severity clinically significant
OCD
K-SADS-P/L 5–17 Full range of DSM-IV Preferred for
criteria ages <8 years and
children with wider
range of comorbidities
YGTSS 5–17 Motor and vocal tics and
severity
Self-report
CDI 7–17 Depression symptoms Includes parent- and
child-rated scales
COIS-R 7+ OCD-related functional Includes parent- and
impairment child-rated scales
MASC 8–19 Child-rated anxiety Includes normed
symptoms severity and validity
ratings
Note. ADIS=Anxiety Disorders Interview for Children; CARS2-HF=Childhood Autism
Rating Scale—High Functioning, 2nd Edition; CDI=Children’s Depression Inventory;
COIS-R=Child Obsessive-Compulsive Impact Scale—Revised; CY-BOCS=Children’s
Yale-Brown Obsessive Compulsive Scale; DSM-IV=Diagnostic and Statistical Manual of
Mental Disorders, 4th Edition; K-SADS-P/L=Schedule for Affective Disorders and Schizo-
phrenia for School-Age Children—Present and Lifetime Version; MASC=Multidimensional
Anxiety Scale for Children; YGTSS=Yale Global Tic Severity Scale.
in their manifestation when compared with same-age peers. In either

OCD or nonclinical individuals, these behaviors can become more pro-
found during transitions or times of stress. However, for children with
OCD, these behaviors are typically more acute, pervasive, and hard to re-
sist even with parental encouragement. Repetitive behaviors that children
approach because they are considered fun or enjoyable are never consid-
ered OCD. Some examples of developmentally appropriate behavioral
routines are listed in Table 9–2.
OCD Versus Differential Diagnoses

Several childhood disorders involve behaviors that resemble OCD symptoms.
Furthermore, children with significant OCD symptoms often have comorbid
disorders, particularly tic disorders, attention-deficit/hyperactivity disorder,
and oppositional defiant disorder. For these reasons, a careful assessment
should differentiate OCD symptoms from these other conditions, because
many of these differential diagnoses will not benefit primarily from E/RP.
A few classes of disorders have behaviors that resemble obsessions or
compulsions but are clearly not OCD. A cardinal characteristic of OCD
obsessions is that they are both intrusive and ego-dystonic, which means
that the child experiences only fear, discomfort, or guilt when contemplat-
ing their content. Furthermore, in the presence of these obsessions, a be-
havior is considered a compulsion if it only serves to reduce or neutralize
the negative affect associated with obsessions. Therefore, children who are
“obsessed” with topics that interest them or who exhibit functional rigid
or repetitive behaviors cannot be considered to have OCD without evi-
dence of ego-dystonic content.
With this pure OCD context in mind, some disorders with similar behav-
iors can be differentiated more clearly. For example, stereotypies found in au-
tism (e.g., hand flapping, pacing, swaying) can at times be self-stimulating or
enjoyable, and they do not appear to be preceded by an ego-dystonic obses-
sion. Motor tics functionally are like OCD compulsions because they reduce
uncomfortable physical urges, but they are not reflective of OCD because the
urge does not contain thoughts (i.e., feared consequences of not completing
tic, save for immediate relief of uncomfortable urge). Children who attempt
to exhibit rigid control of parent behavior (e.g., resisting family routines, de-
manding play activities be always dictated by the child, receiving special treats
or favors) may be differentially diagnosed with oppositional defiant disorder,
particularly if no clear obsession-related fear is apparent and other defiant be-
haviors are similarly observed with other adults.
Importance of Identifying the Child’s Core Fears

One common pitfall for clinicians using CBT for OCD is not having an ade-
quate understanding of the child’s core fears. Granted, this task may be dif-
TABLE 9–2. Developmentally appropriate rigidity found in children
Age (years) Normal behavioral rigidity and rituals
1–2 Strong preference for rigid routines around home rituals (e.g.,
bedtime goodnight). Very aware and can get upset about
imperfections in toys and/or clothes.
3–5 Repeat same play activity over and over again.
5–6 Keenly aware of the rules of games and other activities (e.g.,
rules in classroom settings) and may get upset if rules are
altered or broken.
6–11 Engage in superstitious behavior to prevent bad things from
happening and may show increased interest in acquiring a
collection of objects (e.g., Pokémon cards).
12+ Become easily absorbed in particular activities enjoyed (e.g.,
video games) or with particular people (e.g., pop stars); may
also show superstitious behavior in relation to making good
things happen (e.g., performance in sports).
Source. Adapted from Evans et al. 1997; Freeman and Garcia 2009.
ficult especially with younger children, who may not be articulate or have
complete insight into their obsessions. But from the start of the assessment
and continuing into treatment, the clinician should at every opportunity at-
tempt to understand the specific characteristics of OCD triggers and the
feared consequences of not completing OCD rituals. For example, a child
may avoid things that are “germy,” but why? Does the child fear getting sick
himself or dread getting loved ones sick? If the child gets sick, does she fear
she might die or just experience acute illness (headaches, sore throat, vomit-
ing)? For a girl with scrupulosity obsessions, if she doesn’t confess to her
mom, does she fear only that her mom will be mad at her or that there is a
chance she will go to hell for the offense? These crucial details will assist the
therapist in developing a well-targeted fear hierarchy for E/RP activities later
in the program. Some typical obsession and compulsion themes we see in
children are described in Table 9–3. Note that in particular cases, the specific
fears may be a blend of two or more of these themes.
Overview of Treatment Program

The treatment protocol is typically 12–14 sessions delivered weekly, but
this format can be tailored to the specific needs and motivation of the fam-
ily. As discussed in the earlier section “Empirical Support,” the clinician can
apply this protocol efficaciously in either weekly or intensive (e.g., one ses-
sion per weekday) outpatient formats with similar results. Regardless of the
chosen session schedule, the general structure of the program is the same:
1) psychoeducation, 2) externalization from OCD, 3) mapping the hierar-
chy and identifiying family involvement in OCD, 4) engagement in “boss-
ing back” strategies, and 5) graded E/RP and family disengagement from
OCD. However, because of developmental considerations for insight and
maturation, we do adjust our protocol emphasis on the basis of the child’s
age. For an older child or adolescent, the treatment focus can be primarily
with the child. In this format, parental check-ins will be only at the begin-
ning and end of sessions, with periodic family sessions scheduled when
needed (see March and Mulle 1998). For younger children or in families
with extensive family involvement in rituals and avoidance of OCD trig-
gers, parents should be involved in most sessions, with a focus on differen-
tial attention, appropriate modeling of CBT skills, and scaffolding
assistance to the child in ways that do not reinforce OCD symptoms (Free-
man and Garcia 2009). Contingency management should also be develop-
mentally appropriate for the child. The clinician should help parents
provide appropriate rewards and privileges for the child completing as-
signed homework and using CBT skills spontaneously in unplanned situa-
tions. The clinician must also be explicit that the plan will reward behaviors
reflecting good effort toward CBT practice, not necessarily results.
Psychoeducation
The first task of the protocol is to ground the family in the neurobehavioral
model for OCD and highlight elements of the treatment program. By the
time a family comes to treatment, they have likely experienced excessive
distress, conflict between family members, fears of stigma, and feelings of
hopelessness. Therefore, the clinician’s initial focus should involve pre-
senting OCD as a neurobehavioral condition that is no one’s fault, as well
as providing hope that there are now proven tools to manage OCD’s influ-
ence on the child and the larger family. Depending on the clinician’s com-
fort level with describing recent advances in the understanding of OCD, it
may be helpful to briefly emphasize the point that OCD is a condition in
the brain, albeit influenced by how the individual and family interact with
OCD behaviors. Metaphors involving descriptions of “brain hiccups,” in-
effective “circuits,” or broken “alarms” have been used effectively. An ex-
ample of a typical explanation to the family is given below.
In recent years, we have learned a lot about what OCD is and how it can
be treated in families. The first thing to understand is that OCD is no dif-
ferent from other medical conditions found in childhood, like asthma or di-
TABLE 9–3. Common obsessive-compulsive disorder (OCD)

themes found in children and adolescents
OCD theme Related obsessions Related compulsions
Contamination Getting sick or dying from Washing or cleaning

germs, dirt, chemicals, or Reassurance seeking
other contaminants Actively avoiding contact
Getting others ill from own with feared targets (e.g.,
germs or fluids “surgeon hands”)
Feeling uncomfortable when in
contact with surfaces that are
sticky, wet, and so forth
Harm Harm or death coming to child Reassurance seeking
or family Checking
Child “losing control” and Superstitious behaviors
causing harm to others
Loss of essence Fear of losing or doubt about Hoarding
retaining own vitality, Superstitious behaviors
personality, or humor Checking
Essence can be lost or tainted
when personal objects are
misplaced or when one is in
contact with individuals with
undesirable traits (e.g., nerds)
Ordering/ Need to have things just right, Counting
arranging equitable, or symmetrical Repeating
Ordering and arranging
Scrupulosity Feelings of moral or religious Confessing
doubt Praying
Intrusive “bad words” Reassurance seeking
Ego-dystonic sexual thoughts
abetes. Where asthma is a problem in your lungs affecting your breathing,

OCD is a problem in your brain that affects how you can control thoughts,
feelings, and behavior.
As you might know, our brain is like a powerful computer. It has places
to store information we need to remember, places that handle new infor-
mation coming in from our senses, and electrical wires or “circuits” that
connect each part of the brain to every other part of the brain. Some cir-
cuits even help us stay safe by sounding an alarm to our bodies when we
might be in danger. Every animal you know has circuits like this, and when
danger is around, these circuits help the body get ready for action.
Now for kids with OCD, these danger circuits do not work as they
should. For some kids, these alarm circuits go off much too loud when
compared to the real danger. So when they (describe a fear trigger similar
to the child’s obsessions), their brain alarm goes off loudly even if there is
no real danger. These kids might even know that they are not in that much
danger, but that alarm circuit sounds off anyway! For other kids, the cir-
cuits might not be too loud, but once they go off it’s very hard for those
alarms to shut off. For example, when the alarm goes off for (insert obses-
sion) and (describe a relevant repetitive compulsive behavior), they either
don’t feel better for long or spend a lot of time trying to do it “just right.”
Again, they might know that they are safe by (doing the compulsion), yet
their alarm circuit does not remain quiet for long.
During the above psychoeducation portion, it is helpful to make the

neurobehavioral portion tailored to the families’ interest and clinical
needs. Some families are quite interested in a brief, focused discussion of
the role neural circuits play. As a clinician, it is good to dwell a little more
here if there are concerns that the child is “just being manipulative” or a
particular parent is being labeled as merely coddling the child. For exam-
ple, describing hypothetical situations that parents and children can relate
to with a touch of humor (walking in a park, tripping, and accidentally put-
ting your hand in dog poop) can be an excellent way to describe how the
cortical-thalamic-striatal-cortical circuit is activated for everyone and to
make the point that excessive hand washing can have some adaptive merit
in specific situations! The heritability of OCD can be described as having
a “birthmark” near these circuits, which leads to OCD behaviors. After the
biological components of OCD have been explained adequately, it is then
important to discuss how CBT and other behavior changes can influence
these “loud and leaky” circuits. This explanation should be tailored care-
fully to the amount of insight the child has.
So as I have been discussing, OCD is primarily a brain thing. A lot of people

with OCD know that these alarms don’t make sense and the behaviors
they do to feel better don’t work for long—yet they continue to do them
because the circuits in their brain will otherwise make them feel extremely
uncomfortable.
But the fact that these feelings come from a birthmark on your brain is
actually good news. Your brain is an incredibly flexible organ and can rewire
itself slightly when it learns how to do something new. Think about how
your brain works. Every time you learn something new, the brain slightly
rewires itself, some circuit connections get stronger, and some get weaker.
This is wonderful when we’re dealing with brain birthmarks and leaky cir-
cuits! If you had a similar problem in your kidney, you might have to have
surgery in order to fix it. But because we are dealing with the brain, we can
help make the brain healthier simply by learning new things and practicing
new skills.
The new things I’m going to teach you come from a program called cog-
nitive-behavior therapy, or CBT. There has been a lot of research already
showing that CBT works for kids just like you. Not only can kids feel better
after doing this program, but their brains look different. It’s true! Research-
ers have taken pictures of people’s brains with OCD before this treatment
and then taken pictures of those people’s brains after the people worked
with this program for 3 months. Amazingly, after a relatively short time,
their brains actually don’t look as much like OCD brains anymore. And the
only thing these kids have changed in those 3 months was how to think and
act toward their OCD in a different way. So what do you think, do you
want to learn more?
At this point, the clinician should check in about any questions the
family has about OCD as a neurobehavioral disorder and assess the overall
treatment engagement of each participant. After these issues have been
addressed, the clinician can continue by describing the nuts and bolts of
OCD and how CBT can help.
At this point, we should probably talk a little more about what OCD is. As
you know, OCD involves things called obsessions and compulsions. Do you
know what exactly makes something an obsession or compulsion? First, let
me say that having obsessions or compulsions is actually quite normal.
(Looking at parents) If you ever had an annoying song stuck in your head
for awhile, you had a brief obsession. Similarly, if you ever found yourself
checking and double-checking something very important, you were having
compulsions. But when these behaviors are happening every day, becoming
increasingly distressful, and they are getting in the way of life, that’s when
someone is considered to have OCD. Obsessions are persistent ideas,
thoughts, pictures, or sounds that get stuck in someone’s head even though
the person doesn’t want to think about them. These thoughts that get
stuck are either stressful or gross, and the person would do anything to not
think about them. Now, compulsions are things people do, either in their
head or where others can see them, to try to feel better about the obses-
sions they are thinking about. Typical compulsions include hand washing,
checking things, counting, arranging, and doing things just right; they may
even involve other people by causing the person with OCD to repeatedly
ask for reassurance from someone. Let me stress that although someone
with OCD spends a great deal of time doing these compulsions, they
would rather not be doing them. They only do them to “change the sub-
ject” or feel less bad about an obsession they are having; these compulsions
are never fun.
After the initial introduction of obsessions and compulsions, it’s often

helpful to illustrate how a typical OCD pattern works (Figure 9–1). OCD ep-
isodes typically involve a sawtooth pattern that begins with the child at low
distress. Once a child encounters an OCD-relevant trigger, anxiety increases
to the point where a compulsion is performed, which then leads to a repetitive
pattern of repetitive compulsions and oscillating anxiety. (This pattern is ex-
plained to a parent in a dialogue example in the section “Mapping the OCD
Hierarchy and Identifying Family Involvement” later in this chapter.)
Externalization From OCD

The transition from psychoeducation to the start of active treatment usually
begins with introducing externalization from OCD. The therapist should
save enough time in the first session with the child to adequately address
this concept. As we discuss in our previous treatment manuals on this topic,
externalization cumulates into giving OCD processes a nickname for
younger children or calling it simply “OCD” for older children. Even before
the clinician brings up externalization explicitly, his or her language about
the child’s issues should be consistent with externalization from the first
meeting onward. For example, with a young child worried that germs might
kill her mother, the therapist might say, “[OCD/nickname] makes you
worry that your mom will likely die if she gets sick from germs.”
The initial introduction of externalization, particularly for kids with
less insight about their OCD, should be conducted carefully. The clinician
should focus on validating the child’s specific values that OCD is preying
on, while drawing the distinction between these values and the avoidant
and ineffective processes OCD forces families to do. On the basis of how
the family is describing the child’s OCD, the therapist should use active
listening to then reflect back their frustration with OCD as “tricky” or
“annoying” but also validate the underlying value tied to the core fear; this
approach helps to highlight externalization and build rapport.
Therapist: The last thing for today is how we can start bossing back these
worries you are having. We have discussed already how OCD in-
volves a part of your brain hiccupping or not acting like it should, and
that part of the brain may be making you feel bad in a way that is not
as strong or loud as in other kids.
Child: But I don’t want to get sick ... and I definitely don’t want Mom to
get sick either.
Therapist: You absolutely don’t want to get sick, and you also care about
your mom so much that you don’t want her to get sick either.
Child: That’s right.
Therapist: And most people, myself included, don’t like getting sick, not
at all.
Child: The thought of getting sick from germs is just so gross.
Therapist: Absolutely—when you think about germs, OCD seems to be
yelling in your ears so loud that you just have to avoid germs and
wash whenever you think you’re germy.
Child: That’s right.
Therapist: And that must be so annoying.
Child: Yeah.
Therapist: I wonder what other kids your age feel when they think about
germs? Do you think they need to wash their hands as much? Do you
think their brains are screaming at them as loud?
10
9
C
8
Worry/anxiety rating
5 O
4
3
T
2
1
E/RP
0
Time
FIGURE 9–1. Example of drawing used in psychoeducation session
to explain typical obsessive-compulsive disorder pattern.
T= trigger; O=obsession; C= compulsion; E/RP= exposure and response
prevention.
Child: Maybe not.

Therapist: So I wonder if that might be something we work on together:
you can still care for your mom and do things that are good for your
health, but we are also going to boss back OCD so he’s not as annoy-
ing and yelling at you so loudly.
Child: Sounds good.
Mapping the OCD Hierarchy

and Identifying Family Involvement
Before the process of skill building and E/RP can begin, the family must
learn about how OCD is working in the family and the specific hierarchy
of their child’s symptoms. Some of these objectives might already be ac-
complished through the assessment and initial psychoeducation portion of
the program. However, as the clinician begins to understand—through the
functional analysis of the child’s triggers—the child’s particular obsessive
content, subsequent compulsions, and family accommodation of OCD,
the clinician should begin to conceptualize the best way to structure the
graded E/RP that will be implemented later in the program. The use of an
OCD fear thermometer to build the fear hierarchy will help the child and
family get a little insight into the relative distress each OCD symptom
causes. When the clinician reviews the hierarchy, it is important to care-
fully verify the feelings thermometer ratings that the child has given, mak-
ing sure that the ratings correspond to the level of difficulty or fear the
child anticipates when trying to alter or eliminate the ritual. This task has
the potential to be confusing if not done correctly, because it is possible
that the level of general distress or fear associated with a certain symptom
is not the same as the distress or fear associated with trying to resist that
ritual. For example, a child may rate the distress or fear associated with do-
ing his or her handwashing ritual as a 4 but may rate the distress or fear
associated with not doing (or resisting) this ritual as an 8. Finally, there are
often examples where a child may resist OCD differently outside the
presence of family members. For example, sometime children may be bet-
ter at resisting rituals, even if they feel general distress, at school or around
peers than they are at home. Identified instances where the child can resist
for a time, due to fear of peer rejection or other motivation, could be a
good place to start building E/RP tasks that can tried later on.
Case Example
Crystal is a 7-year-old white girl who has become increasingly concerned
about germs in the past few months. At school, she has been learning that
there are very dangerous germs out there that can get people very sick, and
she must be careful not to touch germy things without washing her hands
thoroughly. At home, she has been increasingly checking in with her mom
about whether certain places are completely clean from germs. If some-
thing has not just been washed, she will ask her mom if it’s clean enough
and the chances she will get sick if something is mostly clean. Crystal’s par-
ents, at first, were very patient with her concern about cleanliness, explain-
ing in detail how she’s safe from most germs. They even thought it was nice
that she was becoming aware of germs and taking an active role in washing
her hands, but lately things have become increasingly concerning. Crystal
is beginning to avoid touching anything that she thinks could have germs.
She even has begun avoiding her little brother, a toddler who is still in di-
apers and puts his hands in his mouth and touches things all over the house.
Crystal’s hands are getting pink with the amount of washing she is doing,
and she checks with her mom almost constantly about things related to
germs.
Therapist: So I want to understand better how Germy makes you feel

bad.
Child: OK.
Therapist: So we talked a little bit about how Germy makes you feel bad
before. But I have here a way you can tell me a little better, with
what is called a fear thermometer. As you can see, it has some faces
next to numbers that go from 0 to 10. You can see that next to the
0, there is a smiley face—meaning Germy is not talking to you and
you are not feeling bad. Next to 10 is a frown face—meaning Germy
is talking to you a lot and it can be like one of the worst times Germy
was messing with you.
Child: OK.
Therapist: Now before we go into how Germy is at home, I want to check
in on how you are feeling now. What do you think your number is
right now, from 0 to 10?
Child: About a 2.
Therapist: Oh, about a 2. You don’t feel completely relaxed, but you don’t
feel very bad either?
Child: Yes.
Therapist: OK, now when you are home, what’s a typical thing Germy can
talk to you about that makes you feel bad?
Child: Germy says I might get sick because I touched something my
brother touched. He sticks his hands in his mouth all the time. It’s
gross.
Therapist: That can be gross. So if you were close to touching something,
like a toy, that you just saw Jack touch after his hands were in his
mouth, what number would that be?
Child: A 10, maybe a 12.
Therapist: Wow.. .so even if you didn’t actually touch it, Germy would
make you feel that your thermometer was as high as it could go?
Child: Well, if I did touch it, that would be the highest. If I didn’t touch
it, but it was close to me, probably a 9.
Therapist: 9/10. (Near the 10 on fear thermometer, the therapist writes,
“Touch toy Jack’s wet hands just touched.” At 9: “Close to wet toy,
no touching.”) Most kids might think that stuff that their kid brother
drools on might be gross. ... Does Germy have you also worry about
stuff that Jack might not have touched for a while?
Child: Well, anything that is Jack’s might have germs on it, I guess.
Therapist: So, if you were to touch something that is Jack’s, like his high
chair, what would that number be?
Child: 10.
Therapist: What if he hadn’t been in it in a while? Like after lunch, Mom
had washed his high chair tray and put it back on the high chair.
What would be your number if you touched that?
Child: If Mom cleaned it and he hadn’t touched it? Probably a 9... . He
eats there and gets his food everywhere.
Therapist: So for places that Jack touches, even if they have been cleaned,
Germy can get loud, yelling at you about germs?
Child: Yes.
Therapist: What if it’s a part of the high chair he can’t touch? What about
the back of the high chair seat that is too tall for him to reach?
Child: Probably a 5.
Therapist: (Writes near 5: “Back of Jack’s seat—where he can never

reach.”) Now, what if instead of you touching the back of the seat
directly, we have something else touch it first, like a new pencil—
and then you touch the pencil?
Child: Hmmm. ..not very high, maybe a 3.
Therapist: So if something clean touches something dirty, and you touch
the clean thing, Germy doesn’t yell at you as loudly.
Child: Yes.
Therapist: So let’s take another clean pencil. But instead of touching the
back of his seat, it would touch Jack’s high-chair tray that Mom just
cleaned. What would your number be if you touched the pencil that
touched the tray Mom just cleaned?
Child: Well, if it was a 9, probably about a 7.
After summarizing and validating Crystal’s anxiety about touching any-

thing she normally sees (toys with toddler drool can be gross), the thera-
pist then curiously asks about things that could be safer. Notice that when
this line of questioning led to most objects receiving a high fear rating, even
if they were washed and not touched by Crystal’s brother, the therapist
switched gears to things Crystal’s brother never touches. Typically, chil-
dren will lower their fear ratings for these hypothetical targets they have
not thought about. Finally, once some targets are determined, even if they
are only hypothetical ones in the middle range of the thermometer, the
therapist should inquire about elements that might be manipulated in a fu-
ture E/RP exercise (touching something clean that briefly touched a
“dirty” item). If some gradients can be found in these milder targets, the
clinician can then go back and reassess these same gradients at the higher
numbers. It’s likely that the clinician will be more successful in finding
anxiety gradients at the higher ranges if they can first be fleshed out in the
lower ranges.
S Next, the case of Ashley, a 14-year-old white adolescent girl, is fea-
tured on the DVD accompanying this book. Ashley’s case is identical to
that of Crystal, except for her age. The video illustrates an educational
component about OCD followed by E/RP work, demonstrating an appro-
priate developmental approach with an adolescent.
The text example of a younger child and video example of an adolescent
allow for the illustration of similar points in a developmentally appropriate
manner. In both examples, several things are occurring that accumulate in-
formation about the child’s OCD as well as set the stage for future expo-
sures. First, the therapist is discussing OCD content with the child in an
open way, which for kids who spend a great deal of time avoiding thinking
about OCD is a minor exposure in itself. Second, the therapist’s stance
about OCD in this phase of treatment should be nonplussed about the con-
tent but curious about how the child’s OCD works. It is important for cli-
nicians not to get ahead of themselves by challenging the child’s inaccurate

OCD-inspired beliefs. Simply gather information to set up future E/RP
work. Third, especially for children who rate most OCD triggers as very
high, it is important to start introducing degrees of separation from the
usual OCD triggers.
Identifying family involvement in OCD symptoms should be ap-
proached with the same sensitivity used in introducing externalization of
OCD, with an acknowledgment of the child’s and family’s underlying val-
ues. This task will be particularly important for families with a history of
OCD, as well as for families with a parent who has been accused of facil-
itating OCD behaviors. At every opportunity, validate the parents’ desire
to reduce their child’s suffering and be effective parents. Proper psycho-
education and mapping of OCD processes at home can allow the parents
to view OCD as something that interferes with these two values. Using ex-
ternalization language (e.g., “OCD has the whole family running in cir-
cles”) and painting OCD as tricky, an enemy, or inconsistent with the
family’s values can all be useful in building rapport and getting everyone
united against OCD processes.
The following communication between the therapist and Crystal’s
mother demonstrates psychoeducation with an adult and parental coaching.
Therapist: Now, from all the research that has been done in OCD, we un-
derstand pretty well how OCD works in families. Let me describe
for you how OCD works and see if it makes sense to you (see Figure
9–1). So if we draw here (the y-axis) how stressed Crystal can feel
on a scale of 0 to 10 and this line (the x-axis) is just time, let’s draw
out how OCD might work at home. So let’s say she’s having a nor-
mal day (draws a horizontal line near the 2 on the fear axis), but then
she accidentally touches her baby brother’s high chair as she walks
past it (writes a “T”). Now on a typical day, what happens next?
Mother: Crystal gets extremely upset.
Therapist: OK, so she starts feeling really anxious (draws line at a
45-degree angle), and then what happens?
Mother: She will walk up to me and start saying, “Mom, I just touched
Jack’s high chair. Am I going to be OK? Am I going to get sick?”
Therapist: And then what happens?
Mother: Well, of course, I tell her that she’s OK and there’s nothing to
worry about, just like I always do.
Therapist: And does that help?
Mother: Yes, she typically is not as upset with a little reassurance.
Therapist: (Stops upward line at about 8/10; now draws the line turning
downward at a 45-degree angle from the apex; writes “C” at the
apex of the first sawtooth) OK, so her anxiety starts coming down.
And is that all it takes? Does it go all the way down to 0, and she’s
good for the rest of the day?
Mother: No, it might help for a few minutes, but then she’s touched
something else and is coming back to ask me if she’s dirty.
Therapist: Oh, so after a few minutes she’s getting increasingly anxious
again (draws line moving up again at a 45-degree angle), and then
what happens?
Mother: I’m again explaining to her that she’s OK, which reassures her,
but then this goes on all day when we’re home together... .
Therapist: So she comes to you upset, you again explain the facts and re-
assure her that she’s safe and nothing will happen... . (draws down-
ward, completing the second sawtooth)
Mother: Explaining things to her all the time is not helping, is it?
Therapist: Well, I don’t know, what do you think? How will the pattern go
as you go through the day?
Mother: It just keeps going up and down through the day, and my reassur-
ance never satisfies her. (Therapist draws a repeating sawtooth pat-
tern.)
Therapist: So let me summarize how it seems OCD is working with Crys-
tal. Crystal is fine until she becomes confronted with some sort of
OCD trigger, or the T here. Then, those OCD alarm circuits begin
going off and making Crystal feel very anxious (draws an “O” near
first upward line). When that happens, all she wants to do is to make
those thoughts and feelings stop, so sometimes she will go wash her
hands and other times she will check in with you about whether
she’s safe, or the O here. That washing or cleaning works very well
in the short term; she gets nearly immediate relief. But the relief is
short-lived and starts the pattern we have been talking about.
Mother: So what should we do? I feel in the moment I’m helping her feel
better, but I am afraid I’m part of these rituals. I just don’t see any
other way to help her!
Therapist: You are not expected to. No parent gets a manual on how to
help their kid in every situation. And for most kids, a little bit of re-
assurance, perhaps with some facts about how germs work and how
our bodies are equipped to fight them off, actually makes them feel
better. But for a child with OCD, where those leaky circuits are
never quite satisfied with Mom and Dad’s reassurance, we see this
sawtooth pattern over and over again. And as you guys know from
trying to help Crystal, this response can actually set up a pattern that
a kid will go through for hours and hours.
Mother: So what should I do instead?
Therapist: What we’ll do here is teach you a different strategy. It will take
a few weeks to teach you and several more weeks to practice. As we
get in the program, we’ll be able to teach everyone in the family how
to approach this differently so OCD doesn’t win. We may have cer-
tain situations where Crystal’s OCD is triggered and it goes up, but
instead of Crystal falling into the trap of a compulsion, we will teach
you and Crystal other things you can do instead. What we know by
seeing lots of kids with OCD is that when the family does these
other skills they learn in CBT, the anxiety does not go down imme-
diately (uses a different colored marker to draw gradual habituation
line), but it goes gradually yet steadily down to where it was before
the trigger happened.
The general approach looks like this. We will first teach you and
Crystal, when OCD shows up, what to do instead of the compulsion
that begins that sawtooth pattern. Second, we also will teach Crystal
how to proactively boss back OCD on her own, by helping her ap-
proach the triggers she’s currently avoiding or trying to neutralize with
compulsions. We do this by teaching her an approach called exposure
and response prevention, or E/RP. When we use E/RP, we will help her
actively practice feeling what OCD makes her anxious about in small
doses (draws an upward line at about 4/10) and using those skills to
show her that she doesn’t have to do any compulsions. Simply put, her
body will get calm all by itself. To get her to do this, we will be teach-
ing you how to encourage or reward her when she does her E/RP prac-
tice. What we know from working with lots of kids with OCD is that
the more a kid practices E/RP, the less her body reacts to those trig-
gers. And these peaks will become less extreme over time, and the
time it takes for her body to recover will decrease.
Bossing-Back Strategies
For active treatment components, our program is separated into two major
categories: 1) E/RP and 2) elements that facilitate engaging in E/RP. As
discussed earlier, our clinical experience and meta-analytic reviews show
that E/RP is the primary active component for symptom reduction in
OCD. Although this may suggest that clinicians should rush to do E/RP, an
early misplaced E/RP exercise can sabotage treatment irrecoverably, which
is why we carefully establish the CBT model, introduce symptom moni-
toring, and add other bossing-back skills that will facilitate future E/RP ad-
herence. Within bossing-back strategies (i.e., cognitive resistance), the two
major categories are 1) externalization from OCD and 2) cognitive ther-
apy elements such as cognitive restructuring and constructive self-talk.
The bossing-back strategies we have found to be the most helpful for treat-
ment success are those consistent with externalizing OCD. Identifying
OCD thoughts and feelings as external to the child and subsequently in-
teracting with these thoughts and feelings with a level of detachment is at
the heart of E/RP and the process leading to habituation. In contrast, we
have found cognitive restructuring strategies helpful only in very specific
situations. Although cognitive restructuring activities can be important to
a family before a given E/RP exercise (e.g., What is the likelihood we will
contract swine flu if we touch this table?), it is important not to emphasize
these activities too strongly as a means to reduce stress beyond the first
few sessions. We have found that for some kids, an overemphasis on talk-
ing back to OCD with coping thoughts during acute stress (e.g., reminding
themselves that “I’m safe” or “These germs can’t really kill me”) can elicit
OCD-reinforcing mental safety behaviors at times when an emphasis on
habituating to the stress without additional efforts to promote safety
would be more effective. We recommend that clinicians use only enough
cognitive training to make the child’s engagement in E/RP effective and to
facilitate approaching activities the child was otherwise avoiding due to
OCD-related triggers. For the most part, cognitive strategies should only
be used before and never during E/RP to maximize effectiveness. The ther-
apist must be vigilant to deemphasize anything that could potentially be-
come an emerging mental ritual.
Graded Exposure and Response Prevention

and Family Disengagement
Only after rapport building, establishing OCD externalization with the
child, mapping common OCD processes in the child and greater family,
and setting up enough cognitive training to portray OCD compulsions as
ineffective can E/RP training be initiated. The therapist’s primary goal is
to make those initial E/RP sessions relevant to the child’s core fears but
not so distressing that the child engages in safety behaviors. As discussed
earlier in the section “Mapping the OCD Hierarchy and Identifying Family
Involvement,” we recommend having a thorough discussion of areas where
the child already has some success resisting rituals. It is much easier to
convert partial to full success than it is to willy-nilly identify an E/RP task
that “sounds good.”
The first E/RP activities should focus on targets that are well fleshed-
out on the child’s hierarchy, including targets on the low (1–3), medium
(4–6), and high (7–10) ranges on the child’s fear thermometer. Although
the clinician will have a good understanding of the child’s hierarchy, it’s
important not to begin exposures too high on the hierarchy. Once the cli-
nician can observe how well the child participates in targets exclusively
in the low range, the clinician can adjust the targets accordingly. Once an
E/RP begins, the clinician should encourage the child to maintain aware-
ness or contact with the feared trigger until he or she feels at least a 50%
reduction in the initial stated stress, but absolutely try for 90%–100% re-
duction if habituation is occurring quickly. The clinician may check in on
the child’s fear level about every 30–60 seconds. As the child is doing the
exposure, the clinician can reflect the number the child reports with “OK,
going down a little bit” or “OK, about the same,” but should not try to re-
duce distress by reminding the child of coping thoughts or other things
that can take away from feeling the distress. We find that children can
usually report significant reduction in distress between 30 seconds and

10 minutes. If the clinician finds that a child’s anxiety begins to plateau or
go down and then begins to go up again, the clinician might want to explore
later (not then) what was happening at that moment. The clinician will
typically find behaviors ranging from losing focus (e.g., “This is taking too
long”) to overt experiential avoidance, such as mental rituals.
Subsequent E/RP targets should generally hit in the low to moderate
range of the fear thermometer at the child’s pace. Often targets that were
initially identified as moderate will be considered lower by the child after
some E/RP success. In these cases, the therapist may never need to get out
of the low to lower midrange of exposure difficulty. If after some E/RP suc-
cesses the only remaining targets are in the high range, take some time to
flesh out some gradients of separation (e.g., touch something clean that
first touched something appearing very dirty) from the very high targets
(e.g., touch something dirty). Once a child is successfully habituating to the
initial targets, continue E/RP by moving up the hierarchy on that particular
fear until the child achieves habituation to the core fear, perhaps over sev-
eral weeks. Only then should the clinician switch to the next OCD fear.
Imaginal exposure can be useful for obsessional content that cannot be
done in vivo (e.g., fears involving going to hell, hurting others, going to
prison). Before an imaginal exposure is proposed, the family should already
have some E/RP success in the fear target area and the rationale for doing
the exposure should be carefully explained and understood. It is important
that the clinician flesh out the plot of the imaginal exposure collaboratively
with the patient first. The arc of the story should begin with a typical trigger
that elicits obsessions related to the feared consequence, eventually leading
to an imagined catastrophic conclusion. As the clinician tells the story, in-
cluding as much of the child’s language as possible will give it the maximum
benefit. Like any well-conducted guided imagery exercise, the story should
also bring in details that will involve as many sensory descriptors as possible.
The imaginal exposure should then be taped in session and the tape pro-
vided to the child to replay at home. These re-exposures should be done at
home in a quiet place without other distractions.
The therapist should adhere to several key principles that will facilitate
effective E/RP in session. First, the therapist should always demonstrate
first and join the child in exposures as much as possible. There is nothing
that the therapist shouldn’t do that is reasonably safe in the service of the
patient. Granted, there are some non-zero risks to doing things like touch-
ing dirty surfaces or eating off the floor, but children do respond to these
ways to fight their OCD, particularly if the task is first demonstrated by a
supportive therapist willing to do it with them. To do this seamlessly before
an exposure, the therapist can talk about the plan for the child while dem-
onstrating the task concurrently (e.g., “So the first thing we can do against
OCD is take our finger like this, touch the table, and then quickly touch it
on our tongue”). Second, when planning in-session E/RP, the therapist
should discuss any proposed exposure matter-of-factly in front of the child.
Third, unless the family has demonstrated several successes with E/RP that
they did independently at home, it’s best to first initiate any increase in ex-
posure intensity in a treatment session. Allow the family to practice these
new exposures at home without escalating them, unless the child is no
longer getting anxious at home when these E/RPs are attempted. Finally, do
not disengage from an E/RP until the child habituates or has experienced
at least a 50% reduction. For this reason, budget enough time at the end of
sessions if a new E/RP exercise is to be attempted.
In conjunction with E/RP work for the child, the clinician must also be
mindful of helping the family disengage from OCD accommodation and
related behaviors. A recent text from one of our clinics describes in steps
how to systematically put this program into place for the parents while
concurrently working with the child (Freeman and Garcia 2009). Most of
the skills taught are consistent with other parent training approaches in-
volving differential attention and scaffolding more responsibility to the
child regarding distress management. Allowing parents to see how the
therapist conducts symptom monitoring, OCD mapping, and E/RP exer-
cises will also provide them a model on how to do similar behaviors at
home instead of accommodating OCD.
Relapse Prevention
Once E/RP activities have been introduced and successfully implemented in
session and during in-home practice, subsequent sessions will be devoted to
going ever higher up the hierarchy as the child habituates to previous triggers.
Once the child begins demonstrating little distress while doing E/RP on his or
her hierarchy and otherwise not exhibiting distress or interference from OCD
in home, school, transitions, or social situations, session frequency can be
scaled back and relapse prevention strategies can be introduced.
Effective relapse prevention involves anticipating when OCD might
likely try to return and using CBT skills proactively to boss back symptoms
as they occur. Therefore, the family should be educated about the poten-
tial for OCD to return at some point, particularly in times of developmen-
tal changes (e.g., advancing to middle or high school) or any acute stressful
time. It’s important to normalize the fact that OCD can try to come back,
but also to stress that the family and child now have the tools to boss it
back effectively when it is identified for what it is. OCD can look different
when children age because of developmental changes in concerns and val-
ues (see Table 9–2); however, the sawtooth pattern typically demonstrated
in OCD (see Figure 9–1) rarely changes. Parents should be encouraged to
be vigilant for signs of OCD but not to overprotect their child from stress
or triggers related to it. Rather, the child should be provided significant
support and encouragement to use his or her CBT skills using praise and/
or other rewards that work for the family in other areas. Families should
also be encouraged to seek a phone chat or booster session with their ther-
apist if symptoms do reappear and initial attempts of addressing it inde-
pendently from treatment appear not to be working.
CBT may need to be altered in order to be sensitive to the context of spe-
cific cultural backgrounds. Although reviews in the pediatric OCD litera-
ture find little support for race or ethnicity moderating treatment effects,
the reality is that OCD symptoms are often misdiagnosed or underdiag-
nosed in minority populations (Hatch al. 1996). More research is required
in tailoring CBT interventions to minority populations before we can com-
ment further on how to tailor our treatment to better serve them.
One particular cultural consideration that routinely comes up in our
clinic is treating children with scrupulosity, harm, or sexual obsessions in
families who are deeply religious. These families may pose some unique
challenges (e.g., being overly concerned about sinning) to clinicians trying
to treat OCD symptoms through exposure, yet continuing to be support-
ive and validating of the family’s spiritual values. Some families could even
be skeptical of the therapist’s motives, particularly if the therapist doesn’t
share the family’s particular religious tradition.
Huppert and Siev (2010) recently discussed some excellent ap-
proaches to treating religious individuals with scrupulosity obsessions that
we have used with success in treating children. The therapist’s stance
should be at all times respectful and supportive of the child’s wish to have
a more fulfilling religious life, regardless of the therapist’s personal beliefs.
Once OCD has been established as the main presenting problem, the ther-
apist must clearly explain to the family that the child’s OCD is not a result
of their religious beliefs. Rather, OCD typically preys on the core values
of the individual, leading to scrupulosity in children who are religious. The
therapist can explore this concept in detail during psychoeducation and
the initial effort of externalization of OCD from the family’s religious tra-
dition. If the therapist can paint OCD as opportunistically messing with
their faith, the therapist may be able to discuss some distinctions between
the religious practices of devout peers and how OCD might be distorting
the child’s sincere attempts to live a religious life. Most older children can
articulate a perceived distinction between the true joy or awe of being spir-
itually connected versus the emptiness felt when doing compulsive rituals.
Exposures for scrupulosity need to be handled sensitively and explic-
itly discussed ahead of time with both the child and family. The therapist
should provide sufficient time to discuss the rationale for engaging in ex-
posures and collaboratively discuss how these can be done in a manner
with which the family is comfortable. The family must provide the thera-
pist with guidance on the boundaries about what their faith considers in-
tentionally sinning (e.g., worshipping the devil) versus doing things that
elicit anxiety because they increase the person’s risk of sinning (e.g., saying
out loud the word devil). For example, one mother once said it was OK to
do exposures regarding sinful images because “OCD puts these in his head
all day anyway.” In some cases, collaborative discussions with the family’s
clergy could also be useful.
Conclusion
Since focused empirical attention began in the mid-1990s, CBT for pedi-
atric OCD has blossomed into an empirically supported treatment for an
often severe and disabling condition. As is the case in treatment studies for
adults with OCD, the effects of CBT for children and adolescents appear
to be both robust and durable. When used in combination with serotonin
reuptake inhibitors, weekly treatment as described above for approxi-
mately 12–14 weeks appears to be sufficient, although as noted earlier, the
format of sessions can be accelerated with little impact on overall efficacy.
Therefore, the primary challenge moving forward is less about improving
the techniques, but rather how to disseminate this approach to a wider va-
riety of trainees and community clinicians, particularly in geographical ar-
eas that do not have medical centers that routinely treat children with
OCD. This will remain a pressing challenge to the field, but recent studies
suggesting that a “supervision of supervisors” community model can yield
comparable results to efficacy studies involving academic medical settings
is encouraging and should be a focus of replication.
Key Clinical Points

• OCD is a neurobehavioral condition that can be treated effectively.
It is critical for families to understand that it is not their fault and that
these behaviors are not the child’s fault. Families must first buy into
individual and family externalization of OCD if subsequent CBT
techniques are to be successful. Discuss the literature about how

CBT can treat OCD effectively, including changes in brain activity.
• Successful treatment requires teaching families how OCD operates
for them and dispelling myths about OCD (e.g., family accommoda-
tion makes the child less anxious over time). In a developmentally
appropriate fashion, each family member participating should un-
derstand that OCD is negatively reinforced through the child’s com-
pulsions and any corresponding family accommodation of OCD.
• To facilitate OCD externalization, the clinician should emphasize
that OCD’s game is to prey upon what each family member cares
about most. This depiction of OCD as clever and opportunistic can
be effective in framing OCD content and family accommodation in
a nonblaming and validating fashion. It also can be useful in draw-
ing a clearer distinction between what each person cares about and
what is being distorted by OCD. This work will also assist the clini-
cian in developing a plan on what to target in E/RP and at what
pace.
• Habituation is the therapist’s primary ally, and E/RP should be the
therapist’s primary tool; other techniques can be useful if they facil-
itate progress toward E/RP targets. Remember to be vigilant for
signs that the therapeutic work is being exploited by OCD. For ex-
ample, note whether a patient is using coping thoughts during ex-
posures or is allowing anxiety to continue unabated. De-emphasize
anything that could become an emerging ritual.
• E/RP targets should be chosen very carefully, particularly in the initial

exercises. Initial targets should be in areas where the child is already
successful at times, and these E/RP tasks should not be terminated
until the child feels a 50% reduction in distress. Finish up an E/RP
target completely before moving up the fear hierarchy. E/RP work
should be approached collaboratively with the family, but the child
has the final say in pacing, as long as the child is moving forward on
OCD targets.
• Until the clinician feels that the family is proficient in doing E/RP at
home, the clinician should initiate any new or more difficult E/RP ex-
ercises in session first. That being said, the child is best served do-
ing some form of E/RP every day; therefore, assign slightly less
difficult exposures to be done at home.
• Effective relapse prevention involves anticipating when OCD might
likely try to return and using CBT skills proactively to boss back
symptoms as they occur. Educate the family that OCD might look
different when it returns (due to developmental changes or shifts in
the child’s interests/values), but the process of OCD reinforcement

(i.e., the sawtooth pattern) rarely changes. When OCD attempts to
make a comeback, the child should not be overprotected from
stress but rather be encouraged to use CBT skills to cope.
9.1. CBT treatment research has indicated that the most efficacious
component for decreasing obsessive-compulsive disorder (OCD)
symptoms is
A. Prolonged exposure.
B. Socratic questioning.
C. Progressive muscle relaxation.
D. Exposure and response prevention.
9.2. Research by Storch and colleagues has indicated that CBT with ex-
posure and response prevention (E/RP) is
A. Most effective when delivered in a weekly outpatient format.

B. Most effective when delivered in a daily outpatient format.
C. Equally effective in either a weekly or daily outpatient format.
D. Equally effective in either an outpatient or inpatient format.
9.3. What is considered to be the threshold for clinically significant OCD

on the Children’s Yale-Brown Obsessive-Compulsive Scale (CY-
BOCS)?
A. 10.
B. 12.
C. 16.
D. 20.
E. 30.
9.4. Which of the following is not considered relevant to at least some

OCD cognitions?
A. Feared consequence of not relieving urges.

B. Thought-action fusion.
C. Overestimation of threat.
D. Intolerance of uncertainty or doubt.
9.5. When is an E/RP exercise typically considered to be successfully

completed?
A. When the child and parent experience a 30% reduction in initial

distress.
B. When the child experiences a 50% reduction in initial distress.
C. When the child experiences a 90% reduction in initial distress.
D. When the child and parent experience a 90% reduction in initial
distress.
E. Either B or D.
F. Either B or C.
Selected Readings
For Clinicians
Freeman J, Garcia A: Family Based Treatment for Young Children With
OCD: Therapist Guide. New York, Oxford University Press, 2008
March J, Mulle K: OCD in Children and Adolescents: A Cognitive-Behav-
ioral Treatment Manual. New York, Guilford, 1998
Piacentini J, Langley A, Roblek T: Cognitive-Behavioral Treatment of
Childhood OCD: It’s Only a False Alarm: Therapist Guide. New
York, Oxford University Press, 2007
For Children and Families

Chansky T: Freeing Your Child From Obsessive-Compulsive Disorder: A
Powerful, Practical Program for Parents of Children and Adolescents.
New York, Crown Publishing, 2001
Huebner D: What to Do When Your Brain Gets Stuck: A Kid’s Guide to
Overcoming OCD. Washington, DC, Magination Press, 2007
March J, Benton C: Talking Back to OCD: The Program That Helps Kids
and Teens Say “No Way”—and Parents Say “Way to Go.” New York,
Guilford, 2006
Wagner AP: Up and Down the Worry Hill: A Children’s Book About Ob-
sessive-Compulsive Disorder and Its Treatment. Mobile, AL, Light-
house Press, 2000
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10
Chronic Physical Illness

Inflammatory Bowel Disease as a Prototype

THERE is increased evidence for a relationship between psychological

and physical processes, particularly in youth with chronic physical illness.
For example, physiological processes in the body can impact brain function-
ing (e.g., inflammation, infection, or metabolic dysregulation), which in turn
can influence emotional regulation and cognitions. Such disease-related neu-
robiological manifestations may adversely impact illness-related attitudes
(e.g., low contingency related to control over the disease leading to helpless-
ness and pessimism) and coping behaviors (e.g., medical nonadherence). In
addition, psychiatric comorbidities and functional physical symptoms not
This work was supported by grant nos. K23 MH064604, R01MH077770, and
1DP2OD001210 from the National Institutes of Health.
331
caused by an underlying medical condition have been reported in pediatric

physically ill populations (Burke and Elliott 1999). Because psychopathol-
ogy in adolescents with physical illness has been associated with higher
health care utilization, functional impairment, decreased quality of life,
poorer medical outcome, and increased mortality (Karwowski et al. 2009;
Lernmark et al. 1999; Strunk 1987), it is often necessary to provide psycho-
logical treatment alongside standard medical care in order to promote treat-
ment adherence, medical prognosis, and emotional well-being.
One of the most empirically supported treatment approaches for psy-
chological aspects of medical illness is cognitive-behavior therapy (CBT).
In the pediatric medical population, the goal of CBT is to help youth at-
tribute realistic meanings to illness-related life events and challenge dys-
functional thoughts and behavior patterns (e.g., pessimism, damaged sense
of self, denial that interferes with medical compliance, and sick-role be-
havior). Left untreated, such negative cognitive schemas and maladaptive
coping strategies can interfere with optimal development in youth with
lifelong physical conditions. CBT can also help youth with physical illness
deal with symptoms of pain and fatigue.
We will first summarize the empirical findings on CBT as applied to
general medical conditions. For the remainder of the chapter, we will then
illustrate the theory and application of one empirically supported CBT ap-
proach that combines individual and family sessions to target depression
and physical illness–related problems using pediatric inflammatory bowel
disease (IBD) as a model illness. More specifically, Primary and Secondary
Control Enhancement Training for Physical Illness (PASCET-PI; Szigethy
et al. 2007), which was modified to help depressed youth with IBD cope
with malaise, gastrointestinal symptoms, abdominal pain, pessimistic ill-
ness perceptions, and medical nonadherence, will be described in detail
with a case example to illustrate effective implementation. For further
guidance on using CBT with chronic physical illness, readers are directed
to Chapter 11, which focuses on the application of another CBT model to
address obesity and depression among female adolescents with polycystic
ovary syndrome and associated binge eating.
Empirical Evidence on CBT for

General Medical Conditions
Randomized controlled trials testing the effectiveness of CBT compared
with alternative forms of treatment in physically ill pediatric populations are
limited. Studies to date (Table 10–1) have focused on both specific illness-
Chronic Physical Illness 333
related factors (e.g., social isolation, adjustment to illness, damaged self, fam-
ily conflict, and health-related quality of life) and psychiatric comorbidities,
such as anxiety and depression. The existing literature, however, is difficult
to integrate and interpret given the wide diversity of presenting medical con-
ditions, specific subpopulations of youth sampled, variations in CBT ap-
proach and dose, and different outcomes assessed. Moreover, various
components of CBT have been studied, including cognitive restructuring,
contingency contracts, relaxation, systematic desensitization, social role-play,
problem solving, and conflict resolution, making it challenging to determine
which elements comprise the most “active ingredients” in CBT. Treatment
modality has also varied, with individual, group, and family-based interven-
tions having some empirical support (see Table 10–1).
PASCET Theory
The original PASCET program is a structured CBT approach developed by
John Weisz and his team (2009) for the treatment of depression in youth.
The PASCET program is based on the Skills-and-Thoughts (SAT) depres-
sion model, which focuses specifically on skill deficits and habits of
thought that underlie and prolong depression in youth. Skill deficits often
include poor activity selection, poor self-soothing skills, disengagement or
avoidant social style, and inferior performance in academic or extracurric-
ular domains (Hammen and Rudolph 1996; Weisz et al. 1992). Habits of
thought include 1) negative cognitions (e.g., inappropriate self-blaming,
catastrophizing, failure to find the “silver lining”); 2) rumination over de-
pressogenic events and cognitions; and 3) perceived helplessness, hope-
lessness, and/or lack of control leading to low-level persistence in coping
with stress and challenges (Gladstone and Kaslow 1995; Weisz et al. 1992,
2001). Youth with chronic physical illness are likely to be even more pre-
disposed to such skill deficits (from loss of social practice time due to
physical disease flares) and cognitive habits (from having to deal with a
medical stressor out of their control). The SAT perspective holds that
these skill deficits and cognitive habits can generate sad affect and make
youth vulnerable to overt depressive symptoms in response to adverse,
stressful, or ambiguous life events. Furthermore, these deficits and habits
may actually generate their own stressful cascade (e.g., unsuccessful inter-
actions and social rejection), which then stimulate further depression, in a
cyclical fashion (Hammen and Goodman-Brown 1990). Not only can this
cycle disrupt psychological functioning, but learned helplessness can also
compromise immune system functioning, thus leading to a worsened ill-
ness course in physically ill populations (Sieber et al. 1992). A central task
334
TABLE 10–1. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population
Type of
Study N Design intervention Findings

Asthma
Burkhart et al. 2007 77 Randomized Individual CBT group associated with greater treatment adherence in
controlled trial 1. CBT asthma self-monitoring.
2. Control
Cancer
Liossi and Hatira 1999 30 Randomized Individual Participants receiving brief hypnosis and coping skills
controlled trial 1. Coping skills treatment before bone marrow aspirations reported less
2. Hypnosis pain and pain-related anxiety postprocedure than control
3. Standard care subjects.
Poggi et al. 2009 40 Nonrandomized Individual CBT group showed greater improvement in internalizing
controlled trial 1. CBT symptoms, overall problems, somatic complaints,
2. Control attention, and social skills.
Chronic fatigue syndrome
Knoop et al. 2008; 71 Randomized Individual CBT group showed greater improvement in fatigue severity,
Stulemeijer et al. 2005 controlled trial 1. CBT functional impairment, and school attendance. Positive
2. Control effects were maintained at long-term follow-up.
Chalder et al. 2010 63 Randomized Family No difference found between treatment conditions on
controlled trial 1. CBT school attendance, fatigue, and social adjustment.
2. Education
Chronic Physical Illness
TABLE 10–1. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population (continued)
Type of
Inflammatory bowel disease

Szigethy et al. 2006, 2007 41 Randomized Individual PASCET-PI associated with greater improvement in
controlled trial 1. PASCET-PI depression, global functioning, and perceived control.
2. Standard care
Polycystic ovary syndrome
Rofey et al. 2009 12 Open trial Individual Decrease in weight and depressive symptoms.
1. PASCET-PI
Recurrent abdominal pain
Robins et al. 2005 69 Randomized Family CBT group reported less abdominal pain and fewer school
controlled trial 1. CBT absences at short-term and long-term follow-up. No
2. Standard care differences in functional disability and somatization.
Type 1 diabetes
Grey et al. 2000 77 Randomized Group Coping skills group showed improved glycosylated
controlled trial 1. Coping skills hemoglobin (A1C) levels, diabetes, and medical self-
2. Standard care efficacy and less impact of diabetes on quality of life at
long-term follow-up.
Ellis et al. 2005c 31 Randomized Family Multisystemic treatment group had a decreasing number of
controlled trial 1. Multisystemic inpatient admissions and lower medical costs.
335
2. Standard care
336
TABLE 10–1. Findings from cognitive-behavior therapy (CBT) trials in the pediatric medical population (continued)
Type of

Type 1 diabetes (continued)
Ellis et al. 2005a, 2005b, 127 Randomized Family Multisystemic therapy associated with short-term
2007 controlled trial 1. Multisystemic improvements in metabolic control, frequency of blood
2. Standard care glucose testing, inpatient admissions (decreased), and
diabetes-related stress. Some improvements in treatment
adherence lost at long-term follow-up.
Wysocki et al. 2006, 2007, 104 Randomized Family Behavioral systems treatment associated with improved A1C
2008 controlled trial 1. Behavioral systems levels, treatment adherence, and decreased family
2. Education conflict. Treatment adherence and relational outcomes
3. Standard care were variable and not maintained at long-term follow-up.
Grey et al. 2009 82 Randomized Group Coping skills group did not fare better statistically than
controlled trial 1. Coping skills education group on measures of distress, medical
2. Education outcome, quality of life, or familial functioning.
Note. PASCET-PI=Primary and Secondary Control Enhancement Training for Physical Illness.
in treatment is to break this cycle of reciprocal influence and self-gener-

ated stress by providing clients with a collection of solution-relevant tools
in the hopes of helping these youth counter depressive symptoms and
boost their immune functioning.
The change model that drives the PASCET program grows out of the
two-process model of perceived control and coping (Rothbaum et al.
1982; Weisz and Stipek 1982; Weisz et al. 1994). Perceived control as-
sumes a contingency between action and outcome (Weisz et al. 1982). In
the PASCET model, primary control involves an individual’s efforts to
cope by making objective conditions (e.g., the activities the individual en-
gages in) conform to his or her wishes. In contrast, secondary control
(Weisz et al. 1984a, 1984b, 1997) involves an individual’s efforts to cope
by adjusting himself or herself (e.g., his or her beliefs or interpretations of
events) to fit objective conditions so as to influence their subjective impact
without altering the events themselves. The model holds that depression
may be addressed, in part, by learning to apply primary control to distress-
ing conditions that are modifiable and appropriate secondary control to
those conditions that are not modifiable. Taken together, both skills help
individuals to realistically assess situations they cannot control and to de-
rive adaptive meaning in order to facilitate acceptance.
This change model aligns with the SAT depression model previously
described. In general, the skill deficits are addressed by primary control
coping strategies that are taught in the PASCET program, and the habits
of thought described in the SAT model are addressed by secondary control
coping strategies. Reduction in depression is seen as coming about gradu-
ally, through a growing working knowledge of various primary and second-
ary coping strategies that may be used to combat depressive symptoms and
the conditions that trigger them. This working knowledge is enhanced
through structured exercises with a therapist and through in vivo practice
activities that the youth engages in outside the treatment context.
The PASCET model recognizes that not all youth exhibit the same skill
and cognitive-habit deficits predisposing to depression. Thus, a flexible
toolbox approach is utilized to choose those skills that will be most appli-
cable to each youth’s specific problems and situations. Accordingly, the
therapist collaboratively assists in the youth’s selection of coping skills that
are most relevant and most likely to be helpful. The primary control skills
(i.e., how youth can ACT to change their environment) are covered in the
first half of the sessions, whereas the secondary control skills (i.e., how
youth can THINK differently to change expectations and adjust to objec-
tive conditions) are covered in the latter half of the treatment. ACT is an
acronym for skills involving primary control techniques, and THINK is an
acronym for skills involving secondary control techniques (Appendix 10–
A). It is hypothesized that the ACT skills help the youth reverse behavioral
inhibition and passivity by inducing positive or reinforcing appetitive behav-
iors. The resulting mood improvement likely makes the youth more recep-
tive to the THINK skills aimed at reversing erroneous cognitive processing
(i.e., negative distortions and attributional style). Using the principles of
learning theory, these early changes are reinforced with repetitive practice
of the skills, with the eventual goal of establishing automatic and more sta-
ble behavioral repertoires to counter the negative mood and thought-induc-
ing effects of depression. The developmental plasticity of the brain during
childhood provides a critical window in which to stamp in such cognitive
and behavioral changes, which is particularly relevant for youth who must
deal with lifelong physical diseases.
The original PASCET program involved 10 structured sessions with the
individual youth, focused on learning the ACT and THINK skills, followed
by 1–4 individually tailored sessions involving 1) applications of the most rel-
evant PASCET coping skills to important situations or problems in the
youth’s life and 2) planning for future applications of the PASCET skills after
the treatment has ended. The 10 structured sessions included in-session ex-
ercises and take-home practice assignments, guided by a workbook that each
youth used throughout the program and kept afterward. The individual ses-
sions were supplemented by three parent sessions designed to help parents
support the practice of the new coping skills in their children.
PASCET-PI: Inflammatory Bowel

Disease as a Model Illness
Pediatric IBD, which includes Crohn’s disease and ulcerative colitis, is a
chronic and debilitating autoimmune disease consisting of abdominal pain,
bloody diarrhea, and weight loss, as well as long-term sequelae (e.g., pu-
bertal and growth retardation). The onset of pediatric IBD is most often
between ages 10 and 20, with an unpredictable course requiring frequent
medical procedures, surgeries, or medications (e.g., corticosteroids) with
negative side effects. Pediatric patients with IBD have shown increased
rates of anxiety and depression, functional abdominal pain, and fatigue
even when the disease is in remission; and there is a growing literature
showing that stress can lead to exacerbations of IBD course (Tang et al.
2009). Youth with IBD often miss a significant amount of school, extra-
curricular activities, and social time with friends. For these reasons, IBD
was chosen as a model physical illness on which to base modifications of
PASCET to address problems related to a medical disease. Not only is
there support in adults with IBD that CBT can improve emotional distur-
bances, improve quality of life, and decrease patient suffering, but our
studies show a positive impact of PASCET-based CBT in terms of reduced
depression and improved functioning (Szigethy et al. 2006, 2007). Other
investigators have shown that a modified CBT approach using the Coping
Cat Program (see Chapter 7) for IBD-related anxiety in children has a pos-
itive impact on patient outcomes (Reigada et al. 2010).
Empirical Evidence
Our PASCET-PI model was empirically tested in both an open trial (Szi-
gethy et al. 2004) and randomized trial compared with a medical treat-
ment-as-usual condition (Szigethy et al. 2007, 2009). Not only did the
PASCET-PI group show improved depressive severity and global function-
ing posttreatment, but these positive effects were maintained 1 year post-
treatment compared to the standard care group (Szigethy et al. 2006). In
addition, IBD severity (as measured by validated disease activity measures
as well as circulating inflammatory markers) was reduced at 6-month fol-
low-up in youth receiving PASCET-PI. Although other factors could ac-
count for these positive changes in the CBT group, collectively these
results are consistent with PASCET-PI having a positive effect on both
emotional and physical aspects of IBD. Moreover, youth who had more
pessimistic illness narratives and received PASCET-PI showed significantly
more optimistic attitudes toward having IBD and more positive contin-
gency and active coping post–CBT treatment (McLafferty et al. 2010).
There are several potential mechanisms to explain the impact of PASCET-
PI on IBD activity, including improved medical compliance, integration of
a more positive attitude toward and active coping with IBD, and a brain-
mediated effect on the peripheral immune system. Recent data from our
laboratory suggest that depressed youth with IBD receiving CBT have in-
creased metabolism in the dorsolateral prefrontal cortex, which is linked
to emotional regulation relative to healthy matched controls (Szigethy et
al. 2010).
Domains
In addition to the traditional focus of PASCET-based CBT on altering mal-
adaptive skills and cognitions, PASCET-PI integrated three components
into the program.
1. Emphasis on the physical illness narrative of the youth, especially nega-

tive illness perceptions or cognitive misconceptions about his or her IBD.
2. Enhanced coping strategies targeting disease-specific problems, such as

medication adherence and disability from pain.
3. More intensive family work using a cognitive psychoeducational model
developed by Beardslee and colleagues (1996).
The Beardslee model is helpful in facilitating parents’ developmentally

appropriate support of their child and helps eliminate environmental influ-
ences that may be preventing the youth from letting go of sick-role behav-
ior. The modifications in PASCET-PI were drawn from examples in the
adult literature that suggest a beneficial impact of such interventions on
coping with physical illness—highlighting the importance of increasing pa-
tients’ knowledge of disease process and understanding of illness percep-
tion (Barlow et al. 2010; Bernstein et al. 2011), learning self-management
skills, and encouraging active coping strategies over passive ones (Gil et al.
1989).
Physical Illness Narrative

Narrative-based treatments emphasize the construction of meaning as a
central concept and goal (Grinyer 2009; Hörnsten et al. 2004), and using
narrative approaches has been linked to improved coping with illness (Pen-
nebaker 1997). In PASCET-PI, youth write about their illness experience,
including perceived causes and fears of their physical illness and its effects
on everyday life, positive and negative aspects of having a physical illness,
and their thoughts about how they can affect the course of their disease
(Appendix 10–A). For example, in youth with IBD, feelings of loss of con-
trol, poor body image, fear of disease relapse, fear of not reaching full
physical or functional potential, rejection by peers, and embarrassment are
common and may predispose youth to depression (McLafferty et al. 2009,
2010). Parents also are asked about their experiences, including the effect
of IBD on family life and how they cope with having a child with a physical
illness. Therapists can assist youth and their parents in the reconstruction
of narratives that have become too negative (or restrictive) by formulating
alternative narratives that more fully incorporate life events into a coher-
ent and positive story using PASCET skills. Studies have shown that such
self-understanding and shared understanding with a therapist are impor-
tant components of resiliency (Focht and Beardslee 1996).
Physical Illness–Related Problems

In addition to addressing the youth’s illness perceptions, it is important to
target maladaptive behaviors associated with IBD. These commonly in-
clude social withdrawal, inactivity, excessive preoccupation with eating or

bathroom access, traumatization, and avoidance of unpleasant external
factors (e.g., medical visits, invasive procedures, or medication side ef-
fects). Several strategies have been incorporated into PASCET-PI to help
with these types of problems.
1. Educating the family and youth about IBD in consultation with the ap-
propriate medical specialist is important to correct any misperceptions
about IBD and its treatment. For example, explaining depressive
symptoms as extra-intestinal manifestations of IBD instead of as an
additional and stigma-inducing psychiatric diagnosis is helpful and rec-
ommended.
2. Teaching strategies to reduce abdominal pain, including relaxation,
hypnosis, biofeedback, distraction, and cognitive coping strategies,
provides valuable education to the youth and his or her family. Daily
practice of relaxation and calming techniques alone with minimal ther-
apist contact has been shown to yield increased functionality in daily
activities and decreased health care utilization (Gil et al. 2001). In
adults with IBD, hypnosis not only improved quality of life, but also
decreased IBD-related inflammatory markers (Mawdsley et al. 2008;
Miller and Whorwell 2008).
3. Enhancing social skills through focused social problem-solving (e.g.,
how to share aspects of having a chronic physical illness with peers to
increase support), utilizing in-session role-plays that target cognitive
distortions and related feelings in settings with peers (e.g., perceived
social rejection due to physical illness), and facilitating problem solving
around social limitations related to physical illness (e.g., how to choose
and maintain fun activities during IBD disease flares) address an impor-
tant facet of the youth’s life and enhance coping skills. The develop-
ment of such coping strategies not only can help the youth overcome
depressive symptoms but also may serve to buffer the effects of stress
on IBD flares and improve daily functioning.
4. Medication nonadherence is an important issue to address and often
can be effectively targeted through cognitive restructuring and active
problem-solving.
Family Involvement
Living with a chronic physical illness often involves a host of psychosocial
stressors in addition to the demands of addressing illness symptoms and
medical treatment, including negotiating academic and occupational limi-
tations, financial burden and medical coverage, communication difficul-
ties, and lack of adequate leisure-work balance (Barakat and Kazak 1999).
Parents can experience difficulties related to the impact of the youth’s
physical illness on the family system, and how parents respond to these
difficulties directly influences how the rest of the family copes. Parents of-
ten focus most of their attention on the ill child and struggle to balance
their jobs, personal needs, and the needs of their other children effectively.
Although the normal developmental push during this critical period is to-
ward separation and individuation from the nuclear family, increased de-
pendence on parents because of physical illness–related issues and altered
parenting styles (overprotection or excessive lenience) can make the tran-
sition through adolescence particularly tumultuous. In addition, there is
evidence that families of children with comorbid depression and physical
illness deserve special attention. Families of children who have physical ill-
ness have increased rates of psychological distress and poor communica-
tion (Engstrom 1999). Depressed children are more likely to have parents
who are depressed, and parental depression may interfere with compli-
ance with both medical and psychological treatments (Beardslee et al.
1993; Cohen and Brook 1987). Cognitive approaches have been shown to
be quite effective in educating families about childhood depression, in-
creasing family understanding and communication, and decreasing risk
factors for future depression (Beardslee et al. 1997; Brent et al. 1993).
To meet the special needs of this population, family psychoeducational
sessions modeled after the clinician-facilitated family preventive interven-
tion of Beardslee (1990) are provided. Beardslee’s Family Talk Interven-
tion has been tested in a long-term randomized trial and has received very
high ranks in the National Registry of Effective Programs. It has been
adapted for use with low-income African American and Latino families
and used in country-wide programs in Scandinavia and Costa Rica. We
have chosen those core components most relevant to PASCET adaptation
and integrated them with treatment of the child.
In PASCET-PI, adolescents and their families participate in three family
psychoeducational sessions corresponding to the beginning, middle, and end
of the individual CBT protocol. Content areas that are covered during these
separate family sessions help parents reinforce the child’s ability to use
PASCET-PI skills to cope, deliver education about depression and resiliency
in adolescents, address salient parental concerns about their adolescent and
family, and help families develop more effective communication. Beards-
lee’s work has shown the critical importance of linking cognitive material to
an individual’s narrative life experiences (Beardslee and Podorefsky 1988;
Focht and Beardslee 1996). This approach can help families identify affect,
deal with stigmatization, and decrease noncompliance, psychosocial deficits,
and resistance to the concept of illness. Training parents to become CBT
coaches for their children not only provides an active and constructive focus
of parental energy, but the role may also help them to avoid maladaptive pa-
rental coping practices such as distancing, denial, and overprotection of the
sick child. Furthermore, there is a preventive tone to these family sessions,
in that parents are building strengths that will help promote long-term resil-
ience in the family.
Just as in the original PASCET, both the youth and parents work from
a PASCET-PI workbook. The youth receives 9 individual sessions and up
to 3 flexible sessions to stamp in the skills most useful to the child. Parents
participate in 3 sessions during the approximately 3-month intervention.
In addition to modifications in content to incorporate physical illness–
related realms, structural changes include the choice of phone sessions for
up to 60% of the total sessions and coupling face-to-face sessions with
medical appointments to improve compliance with therapy. We have
found the phone sessions most helpful and effective when the initial ses-
sion is conducted face-to-face with the ongoing therapist. On the part of
the therapist, the key to making the phone sessions productive is ensuring
that youth have their PASCET-PI workbook at hand and that their envi-
ronment is private and free from distractions.
Application
The following section will outline the application of the PASCET-PI inter-
vention for youth with IBD and comorbid depression, with emphasis on the
case formulation and content of both the individual and family sessions.
Case Formulation
The successful application of the PASCET-PI skills is dependent on the
formulation of the case and the integration of psychological and physical
illness–related information. In addition to a thorough psychiatric and med-
ical history, it is also important to consider potential obstacles to treatment
progress, as well as personal and familial strengths so that these factors can
be used as building blocks to target more maladaptive areas of coping. Ad-
ditionally, an evaluation of precipitating events or situations, assessment of
how the youth shows depressed feelings, and a thorough exploration of the
youth’s social functioning can facilitate the development of a comprehen-
sive case formulation. Collectively, this type of reformulation of the classic
psychiatric evaluation into a CBT-based assessment can help the therapist
hypothesize a priori regarding which ACT and THINK skills will be most
applicable to the youth. The following is an example of a case history and
formulation for PASCET-PI.
Case History
Kyle is a 13-year-old Hispanic adolescent boy in the eighth grade. He was
diagnosed with Crohn’s disease 4 years ago. He presented for a psychiatric
evaluation with a 6-month history of feeling sad and frustrated, decreased
motivation and energy, intermittent hopelessness, insomnia, and low self-
esteem. He also had increased complaints of stomach pain that were out of
proportion to the degree of Crohn’s disease activity (as determined by in-
flammatory markers from his blood and endoscopy). He missed more than
40 days of school during the past 6 months due to the abdominal pain, re-
sulting in a downward drift in his usually above-average grades. He has been
on intermittent steroid therapy for the past 4 years and identified that he
sometimes feels down when his steroid dose is high. Kyle reported being
good about taking his morning medications but has variable compliance with
the evening doses. Family history is positive for colitis, depression, posttrau-
matic stress disorder, alcohol dependence, and hypothyroidism on the pa-
ternal side. Kyle identified stressors as feeling isolated from his friends,
being restricted in physical activities because of his physical illness, and the
constant tension between his parents, who were frequently arguing and con-
templating divorce. When he did spend time with his friends, he reported
difficulty in negotiating conflicts between his school and neighborhood
friends. Kyle’s parents are concerned about his depressive symptoms and
stomach pain, his anxiety about falling behind in school, how their parental
conflicts may be affecting Kyle, the problems he has been having with his
classmates (e.g., he received his first suspension from school for fighting
with a peer in the cafeteria), and how Kyle is coping with having Crohn’s
disease. His father is often unemployed, and he stays home with Kyle dur-
ing missed school days. Kyle’s mother works as a high school teacher, often
withdrawing from conflicts at home and burying herself in her work. Kyle’s
strengths include being bright and future oriented, having a good sense of
humor, being sensitive to the feelings of others, having a variety of interests,
and displaying skill at video games, soccer, and biking.
PASCET-PI formulation: A 13-year-old white adolescent boy with
long-standing Crohn’s disease presents with worsening depressive symp-
toms over the past 6 months, increased abdominal pain (in the absence of
objective evidence of Crohn’s flare), decreased school attendance with re-
sulting failing grades, increased social isolation and peer conflict, and de-
creased physical activity. IBD and steroid use in addition to family history
of depression, anxiety, and hypothyroidism could predispose Kyle to de-
pression. Stressors include decreased academic performance, marital con-
flict between parents, interpersonal difficulties with peers, and coping
with a chronic physical illness. In addition, modeling of sick-role behavior
and possibly learned helplessness by his father may also be a contributing
factor to Kyle’s maladaptive coping.
Skill deficits and cognitive habits: Kyle’s skill deficits include diffi-
culty negotiating social conflicts with peers; difficulty eliciting positive so-
cial reinforcement from adults in his life; difficulty self-soothing, with
increased focus on pain; and difficulty setting goals in different life do-
mains. Cognitive habits include lack of perceived control over his environ-
ment with resulting helplessness, negative cognitive distortions (e.g., “I
can’t do anything fun because of my Crohn’s”; “My friends will think I’m
weird if they know I am diseased”), and hopelessness. Together these neg-
ative behaviors and thoughts make him even more vulnerable to feeling de-
pressed. Using the following skills (i.e., ACT and THINK for relaxation,
STEPS problem-solving skills, and POWER skills) along with family ses-
sions aimed to increase parental communication and Kyle’s sense of pri-
mary control. (STEPS and POWER skills are discussed further in the
following section “Individual Sessions,” in “Session 2: Problem Solving”
and “Session 6: Talents,” respectively.)
This initial formulation is refined through information gathered during

individual and parent or family sessions. As the treatment reaches the flex-
ible final sessions 10–12, there is an increasing emphasis on identifying the
particular lessons and coping skills of the PASCET-PI program that seem
most likely to help the youth’s depressive symptoms and address the
cross-section between mental and physical well-being. In this process of
tailoring and fitting treatment to the patient, the therapist should rely on
an evolving formulation, information on how the youth has responded to
the various components of the PASCET-PI program (i.e., which parts the
youth seemed to like and use effectively), and input from the youth to de-
termine the best-fit coping skills. Continual reformulation of the case is es-
sential to achieving the best-fit coping skills for the youth, incorporating
both developmental growth and changes related to the course of the de-
pression and/or the youth’s environment (e.g., parental divorce, physical
illness flare). A carefully developed formulation is especially critical to the
success of the maintenance sessions. The maintenance sessions are de-
signed to be highly flexible, but their central aim is the application of the
PASCET-PI skills that will best fit the youth’s life.
Individual Sessions
The following section will provide an overview of the individual youth ses-
sions according to the PASCET-PI intervention. Table 10–2 provides an
outline of each session following the ACT and THINK skill format.
Session 1: mood monitoring. The key components of session 1 are to

explain the purpose and process of the sessions, deliver psychoeducation
about depression and IBD, introduce the ACT and THINK chart (see Ap-
pendix 10–A), and explain mood monitoring. As in other CBT protocols,
explain that this therapy will involve learning different ways of doing
things and of thinking about things to help improve mood. This aim will be
achieved over 9–12 weekly sessions, with the most important steps in suc-
cess being regular attendance to learn new skills and consistent practice of
the skills between sessions. Next, explain the two types of skills: ACT
skills to learn new behaviors and THINK skills to change thinking about
what distresses the patient but that are not in his power to change. These
two types of skills will be used to target problems related to IBD and other
life problems. Next, deliver psychoeducation about how depression can be
caused by chemicals released in the gut during IBD flare-ups, affecting the
brain and causing depressed mood, fatigue, changes in sleep and appetite,
and increased sensitivity to pain. For youth who do not have a current IBD
flare-up, depression may be a response to the realization that they have a
lifelong chronic illness, or perhaps it can be linked to other life stressors
that are not directly related to IBD. Irrespective of the root cause, the im-
portant take-home message for patients is that applying ACT and THINK
coping skills can help facilitate positive changes in mood in either of these
causes. Finally, introduce the new skill for this session: learning to be aware
of mood and how it relates to what the patient is doing (or not doing). For
each day of the week, have the youth rate his overall mood on a scale of
1 to 10 (1=very bad and 10=very good). Next, have the youth choose a
word or phrase that best describes his mood for the day and also list good
things and bad things that happened that day.
Session 2: problem solving. The key components of this session are

completing the illness narrative questions and teaching STEPS problem-
solving (Appendix 10–A). For this session and each subsequent session,
start by assessing the youth’s weekly ratings of mood, IBD symptoms, and
medication compliance. Review the assignment from the previous week
and process any difficulties with the youth. After the youth completes the
illness narrative (see Appendix 10–A), discuss any negative or pessimistic
answers in an empathic, open-ended manner. Younger children may prefer
drawing their “illness stories.” Listen with the intent of making an inven-
tory of illness-related problems that can be used to apply the STEPS prob-
lem-solving technique. Together with the youth, generate a list of both
general and IBD-related problems, having the youth prioritize the list from
smallest to largest problems. The STEPS approach teaches a type of deci-
sion matrix to produce a range of solutions, highlighting the importance of
examining potential outcomes and providing a way for the youth to decide
the order in which to try each solution. After the therapist and youth com-
plete the STEPS worksheet in session, the practice assignment will be for
the youth to complete the worksheet during the week with another prob-
lem—trying out the solutions for each problem and examining the impact
each solution may have on his mood. Appendix 10–A provides mood ther-
mometers for this activity.
TABLE 10–2. Outline of individual sessions for Primary and

Secondary Control Enhancement Training for
Physical Illness (PASCET-PI)
Session Goals
Session 1 Introduce PASCET-PI, ACT and THINK skills (see

Appendix 10–A), and education about
inflammatory bowel disease (IBD).
Session 2 Initiate completion of physical illness narrative and
apply problem-solving techniques for IBD.
Session 3 Establish which activities the youth enjoys. Find
agreement on importance of physical activity and
exercise.
Session 4 Apply relaxation techniques and hypnotherapy for
pain and immune system.
Session 5 Teach about showing positive self and improving
social skills.
Session 6 Focus on developing the youth’s talents and skills.
Sessions 7–8 Address negative cognitive distortions about
physical illness.
Sessions 9–12 Review skills learned and personalize skills.
Maintenance sessions 1–6 Reinforce use of coping skills.
This is also a good session to work on problem solving if medication

nonadherence is an issue. The more the youth is involved with generating
solutions, the more likely that compliance will improve.
Session 3: activities. The main purpose of this session is to teach a va-

riety of behavioral activation options. Several types of activities are cov-
ered, including activities that can be completed alone and are feasible in
terms of access and cost, activities that can be completed with others, and
activities that involve a group or club (e.g., extracurricular school activi-
ties, community class or activity, job pursuits for older teens). This behav-
ioral activation is meant to help the youth socialize and expand his
horizons, especially if having IBD has prevented him from participating in
his usual activities. In addition, other activities discussed include helping
others as a way to distract from the youth’s own problems and engaging in
moderate exercise. Creating a list of physical activities that are tolerable
and available for the youth is important, because exercise has been shown
to help keep IBD in remission among adults (e.g., walking, yoga, more
structured sports). For youth who have active IBD, the amount and type
of physical activity should be determined in consultation with their gastro-
enterologist.
Session 4: calm. The aim of this session is to teach calming techniques

to help the youth relax. These techniques involve muscle relaxation, dia-
phragmatic breathing, and visual imagery in which the youth imagines a
happy or calm place using all his senses (e.g., seeing the beach, hearing the
waves, feeling the warmth of the sun, smelling the seabreeze, and so
forth). Hypnotic scripts are provided in Appendix 10–B for youth experi-
encing either abdominal pain or active IBD inflammation. The purpose of
these scripts is to help the youth facilitate attentional control, ignore pain,
and boost immune system functioning. As in all hypnotic sessions, proper
trance induction and deepening techniques (e.g., counting from 1 to 10)
should be used before providing the hypnotic suggestions in the scripts and
to reorient the youth back to full conscious alertness (e.g., counting back
from 10 to 1). In addition to the words used during hypnosis, the more
closely the therapist’s voice cadence matches the youth’s changing physi-
ology (e.g., slowed breathing rate) during the trance, the better the results
will be.
The youth’s mood should be monitored before and after the relaxation
sessions, with any improvements noted. In addition, biodots (which
change color based on skin temperature, similar to mood rings) can also be
used to make practice more fun and to give biofeedback to the youth that
he can change his bodily functions. The following is an example of how the
biodots can be introduced to provide a type of ramification for the relax-
ation experience.
One way to measure the amount of stress we are holding in our body is to
measure the temperature in our hands. Hand temperature is caused, in
large part, by the distribution of blood in our body. When too much blood
is in our head, less blood is in our body, including our hands; and thus, our
hands are colder. This fact is useful to know because it is also the case that
too much blood in one area can cause pressure, which causes pain. So, for
example, tension headaches are often caused by too much blood in the
brain. Today we will work on learning to relax and use the power of our
mind to help shift the blood from the head to the hands. We will use
biodots to test how well our attempts are working. Here’s a biodot to place
on the back of your hand or another area of skin. Notice the color of the
biodot as we go through some relaxation training.
The practice tool for this session will consist of making a CD of the re-
laxation exercises completed during the session so that the youth can prac-
tice these techniques at home. Listening to music is another way in which
youth can relax. Incorporating soothing music or the youth’s favorite songs
into the recording can be helpful in creating a calming experience.
Session 5: confidence. The primary aim of this session is to help the

youth understand the meaning of confidence as believing in himself, even
if the youth feels down about having IBD. Feeling confident involves being
optimistic about interactions with others, a skill that can require practice
like any other skill that is learned. This skill is taught through the following
exercises. First, introduce the concept of showing a negative and positive
self, and identify specific behaviors that go with the specific features of the
youth’s negative and positive self (e.g., how the youth looks and acts, what
the youth says). Second, make a videotape during which the youth acts
gloomy, negative, and sad, to explore with the youth how IBD influences
his negative self. Next, make another videotape during which the youth,
after coaching and practice, does his best to present a positive self. Finally,
have the youth compare the negative- and positive-self videos, judging
which of the two shows a self that he and others will like better. It is help-
ful to use real-life experiences as anchoring points for how a youth shows
these attributes. Reviewing the illness experience and problem list gener-
ated in session 2 may also give clues of specific events or experiences to
use with the youth. For the video, it is useful to use a role-play, particularly
if it is relevant to the youth’s life. In the case of Kyle, one scenario may be
with a peer with whom he had a conflict. The therapist could role-play the
peer while Kyle would be himself, first as his negative self, then as his pos-
itive self. The practice assignment for this session is to have the youth prac-
tice his positive-self skills with others and write about the experience,
including the reactions of others.
There are certain pitfalls to avoid during this session. Avoid criticizing
the youth’s depressed self. Instead, the exercises should be presented in
the context of exploration and curiosity. That is, the therapist really does
want to know what the youth thinks about these two different videos, and
what the youth thinks the consequences of positive and gloomy behavior
may be for how he feels and how others feel about him. A second pitfall
to avoid is implying in any way that showing a positive self is the same
thing as “faking it.” Instead, the key idea to emphasize is that all individuals
have the capacity within themselves to behave in different ways; the pos-
itive ways seem to make a person feel better and to make others feel better
about being with that person. As the therapist and the youth work on iden-
tifying positive-self behaviors, a final issue to remember is to be aware of
the impact of new behaviors on both peers and adults. Avoid creating a
positive-self profile that might seem arrogant or obnoxious to adults, even
if it is likely to evoke a positive reaction from peers. Likewise, avoid coach-
ing the client to behave in a way that adults might like but that his peers
may find “nerdy” or socially undesirable. Use therapeutic judgment liber-
ally in coaching the youth to come up with his positive-self skills.
Session 6: talents. The goals of this session are to work with the youth
to further develop existing talents, develop new skills, and learn social
problem-solving to improve social skills. This session is particularly impor-
tant when illness symptoms are preventing youth from doing their usual
activities or from developing opportunities for socialization. The main con-
cept is that developing a skill takes three steps: goal setting, planning real-
istic steps, and practicing until the youth masters each of the small steps
and reaches his desired goal. Ask the youth to identify a goal involving
some talent or skill he wants to develop, and collaboratively identify some
of the small steps that would need to be mastered on the way to that goal.
For the weekly practice assignment, have the youth begin practicing one of
the steps.
The second part of this session focuses on teaching the youth social
problem-solving skills using the POWER steps (Problem with a relation-
ship, Outline the positive and negative parts of the relationship, Which
negative parts do I have the power to change? Explore the good and bad
aspects of making a change, Relationship improvement takes action; Ap-
pendix 10–A) to improve relationships with others. Introduce the idea
that everyone has had someone with whom they have had difficulty get-
ting along in a particular situation. The therapist can give common exam-
ples from other youth or from his or her own life (e.g., arguments,
breakups, disagreements with a parent). Tell the youth that just like there
are STEPS to solving other problems, there are concrete things someone
can do to improve a relationship with another person. Further, improving
relationships with others can help the youth feel good. For the practice as-
signment, have the youth pick one person to focus on to complete the
POWER worksheet on his own and to try out one of the solutions to im-
prove the relationship with this person. When going through the POWER
steps with the youth, make sure to hit on the following basic ideas, which
are organized according to the steps associated with each letter in the
POWER acronym.
• Problem with a relationship. This step involves identifying a specific

problem the youth is having with another person. Having the youth
pick a relatively specific problem (e.g., an argument with a specific
friend in the cafeteria yesterday) versus a more general one (e.g., I fight
with my friends) will make the subsequent steps of the problem solving
easier.
• Outline the positive and negative parts of the relationship. This step
is the most difficult and germane to the process of improving a relation-
ship. Sometimes when a person is having difficulty with another per-
son, it is difficult to think about things that are going well in the
relationship or that he does like about the other person. A big step in
improving a relationship is to overcome this tendency and recognize
that there are both good and bad things about the relationship. Explore
with the youth whether the positive aspects of the relationship out-
weigh the negative ones. Oftentimes, even though it is clear that the
positives outweigh the negatives, people can forget about the positives
when they become focused on the negatives.
• Which negative parts do I have the power to change? Looking at
each of the negative parts of the relationship that the youth has listed,
help him decide which parts he has control over or has the power to
change. Explain that often the things that are not within a person’s con-
trol are the characteristics or qualities of the other person. It may be a
good idea to illustrate this point using an example of someone the
youth knows or a hypothetical person who is caught up in trying to
change another person. Often it is much easier to see from an outside
perspective how frustrating and futile it is to have a mission of changing
another person. This step is a specific application of one of the main
tenets of the PASCET model: deciding when to have primary control
(changing the environment) versus secondary control (changing one’s
own thinking) of a situation and changing personal actions or thinking
accordingly.
• Explore the good and bad aspects of making a change. In this step,
help the youth examine the potential outcomes of each of the pro-
posed solutions for changing something about the relationship.
• Relationship improvement takes action. This step simply involves
the youth actually trying out one of the listed solutions and seeing how
it works. Encourage him to make a commitment about when he will at-
tempt to make the change.
Case Example
Kyle initially presented as quiet and lethargic. He yawned several times
throughout the session and did not display consistent eye contact. During
the first few sessions, the clinician focused not only on psychoeducation
and introducing ACT skills, but also on establishing rapport. The main way
rapport was established with Kyle was by linking ACT skills with the con-
cerns he reported during the illness narrative. With time, Kyle became
more invested in treatment. He was receptive to learning about the ACT
and THINK skills and began to complete his mood monitoring assign-
ments. Kyle openly discussed how his mood was lower on days when he
stayed at home and did not spend time with friends. His mood tended to
be better on days when he was busier. This pattern was discussed, and Kyle
agreed that he was happier when he was doing something social than when
he was home alone.
This discussion naturally led to introducing the ACT activities skill by
reminding Kyle that his mood ratings were better when he did fun activi-
ties and lower when he isolated himself. With the help of the clinician, Kyle
formed a list of pleasurable, social, active, and helpful activities in which
he could participate. He was assigned to take part in at least one of these
per day and to rate his mood both before and after taking part in the activ-
ity. Kyle followed through with this assignment, and his mood ratings began
to gradually improve. He also noted that the more time he spent with
peers, the closer he became with them and the less conflict he experienced
with them. Kyle explained that when he was not hanging out with friends
a lot, he began to assume that others thought he was “weird” and therefore
he needed to prove he was cool by fighting with others. However, as he in-
creased spending fun times with friends, he became less defensive and no
longer felt the need to appear tough; therefore, his fighting behavior de-
creased.
Another ACT skill that proved beneficial for Kyle was the set of
STEPS problem-solving techniques. Kyle rated his academic problems as
most upsetting to him currently. The STEPS problem-solving skills were
then introduced to Kyle, and together with the clinician, each step was ap-
plied to Kyle’s concerns regarding his dropping grades and poor attendance.
Eventually, Kyle was able to pick the solution of speaking with his teachers
and parents about 1) getting a tutor to help him to catch up on the work
he had missed and 2) starting to return to regular school attendance. He
was excited when the clinician explained that given his illness, the school
would likely agree to a specialized plan focused on providing him with ex-
tra time and support to catch up academically, as well as support him while
he gradually increased his time in school until attending full-time again.
Kyle’s parents joined in at the end of one session to sign a release for the
clinician to contact the school guidance counselor in order to begin the pro-
cess of obtaining accommodations in the school setting for Kyle because of
his health condition.
Kyle was pleased with how problem solving worked for him and there-
fore was also quite receptive to the POWER skill introduced during
session 6, focusing on talents. Kyle reported that one of the most concern-
ing things about his illness currently was that he was not able to tell his
friends what was going on for fear of being teased. This fear had caused him
to feel isolated from his friends, especially his best friend. Kyle realized
that it was his choice whether to open up to his friends, but that choosing
not to tell them caused him to feel more isolated from them. He formed
the solution of telling his best friend about his IBD diagnosis and seeing
how he would react. The clinician helped Kyle by role-playing how he
would bring this subject up with his friend, as well as how to deal with his
friend’s possible reactions. After sharing this information with his friend,
Kyle was surprised when his friend was “really cool” about it. Kyle said that
this made a big difference for him. Even though he wasn’t as close to his
friend as he was before the IBD diagnosis, he felt a lot better once his ill-
ness wasn’t a big secret.
Although Kyle’s mood ratings were gradually improving with the use of
ACT skills, his IBD ratings did not initially improve because Kyle was re-
porting high amounts of pain, especially in the mornings before school.
Kyle was open to the idea that some of his pain might be related to anxiety
regarding school rather than IBD symptoms alone. He was taught calming
skills, including breathing techniques, visualization, and hypnosis. Kyle es-
pecially benefited from the hypnosis skills and found that he could reduce
his level of pain when he practiced this technique regularly. After learning
and practicing these techniques, Kyle began to experience less pain and
also felt a higher amount of control over his symptoms. His IBD weekly
ratings began to decrease.
Session 7: think positive. This session represents the transition from

the ACT to the THINK skills. The primary skill to be delivered focuses on
the T (“Think positive”) in THINK and marks the beginning of the cogni-
tive portion of this cognitive-behavioral treatment. As is true for all cogni-
tive therapies, the rationale of this session is based on the idea that how
individuals think about events or situations will affect how they feel.
Therefore, one way that people can control their feelings in situations that
they cannot change (e.g., having a physical illness) is by changing their
thoughts about those situations. This is a defining feature of secondary
control coping.
BLUE thoughts are loosely based on Beck’s model (1967) of cognitive
errors:
B “Blaming myself ” refers to Beck’s concept of excessive responsi-

bility, or personalizing, and is defined as taking personal responsibility
for negative events.
L “Looking for the bad news” is related to Beck’s concept of selec-
tive abstraction and refers to selectively attending to negative aspects
of experiences.
U “Unhappy guessing” refers to jumping to conclusions—basically,
making negative predictions on the basis of scanty evidence (e.g., as-
suming that someone who did not say “hi” to you dislikes you).
E “Exaggerating—imagining a disaster” refers to Beck’s concept of
catastrophizing (i.e., imagining that the outcome of an event will be
catastrophic or that the event itself is catastrophic).
The practice assignment involves the youth logging his negative

thoughts each day with an associated mood rating on a scale from 1 to 10.
Next, the youth categorizes each of these thoughts according to the BLUE
letters. Finally, the youth will identify a less negative (or more neutral) way
of thinking and rate his associated mood. For example, instead of saying,
“I hate having IBD,” which may be an example of looking for the negative,
the youth might think, “It could be worse—I could be so sick that I would
need to be in the hospital, but I’m not.”
Session 8: help from a friend, identify the silver lining, and no

replaying bad thoughts. The focus of this session is to develop and use
alternative methods to reverse negative thinking. First, introduce how
seeking feedback from a trusted other person can be helpful in catching
negative thinking. Have the youth identify three people he could turn to
for help in identifying and altering negative or pessimistic thoughts. Sec-
ond, explain the proverb “Every cloud has a silver lining,” and link it to the
idea that even in bad or negative situations, there is something good that
he can focus on instead. Alternatively, some youth understand this concept
better by imagining how their situation could be worse. When they juxta-
pose the current situation and a potentially worse situation, the current
situation will not seem as bad. Finally, it can be developmentally challeng-
ing to work purely in the cognitive realm for some youth. For example,
younger children can often identify negative thoughts but have difficulty
with the idea that these can be replaced with positive thoughts. In these
situations, help the child come up with a list of activities he can utilize to
distract himself from negative thoughts as a way of feeling better. For the
practice assignment, the child is asked to try out all three of these skills
during the week and to rate his mood before and after each attempt.
Case Example
Once Kyle’s symptoms were beginning to lessen due to the ACT skills, the
clinician moved on to teaching the THINK skills in later sessions. At this
point in the treatment, Kyle was functioning at a much higher level. How-
ever, he continued to maintain some hopeless and negative cognition re-
garding his illness. The therapist explained to Kyle the relationship
between thoughts and feelings and introduced the concept of BLUE
thoughts. Kyle was able to recognize his pattern of “looking for the bad” by
overly focusing on how IBD negatively affected him. In addition, his pat-
tern of exaggerating the negative impact of IBD on his life was also dis-
cussed. Kyle practiced countering these thoughts and replacing them with
more helpful thoughts. He also began regularly practicing “finding the sil-
ver lining” because this helped him to challenge his tendency to focus on
the negative. Kyle’s illness narrative slowly began to change. Although ini-
tially his thoughts about his illness caused him to feel sad, by the end of
treatment, his thoughts had become much more realistic. Most of the
time, Kyle was able to recognize when his thoughts were making him feel
worse and then work to challenge these thoughts.
Sessions 9–12: keep trying. In the final structured session (session 9),
the overarching goal is to introduce the idea that often one skill alone is not
enough to optimally improve the youth’s mood. In fact, it is often the com-
bination of different skills that can lead to the best outcome. In session 9,
the ACT and THINK chart is reviewed, and the youth identifies a list of
current life and IBD-related problems. For each problem, encourage the
youth to think of three ACT and THINK skills that would be most helpful
in the given situation in an effort to develop plans for future action (Ap-
pendix 10–A). To solidify this concept of having several plans, it can be
useful for the youth and therapist to switch roles, with the therapist as the
depressed youth and the youth as the therapist who helps the “client” to
develop Plan A, Plan B, and Plan C for specific problems. This role reversal
not only allows the youth to experience mastery, but it also helps symbol-
ize a transition in the sessions, with the youth taking a more active role in
problem solving and generating solutions.
For the remaining sessions 10–12, the focus is on the application of the
most personally relevant PASCET-PI skills for the youth’s current prob-
lems, as well as the introduction of some skills that might be needed in the
future. These additional sessions may be most helpful for youth experienc-
ing only partial remission of depressive symptoms, youth with comorbid
anxiety problems, youth from more chaotic or less supportive families,
youth experiencing IBD flare-ups during the course of therapy, and youth
who are struggling to learn PASCET-PI coping skills or having trouble im-
plementing the skills into their daily routines. The session content will
consist of focused discussions, role-plays, brainstorming, and other exer-
cises aimed at practicing and reinforcing the application of specific PAS-
CET-PI skills to potentially depressogenic events and conditions that are
present in the youth’s daily life. Thus, a considerable part of each of these
later sessions will be devoted to collaboratively designing and trouble-
shooting the practice assignments for the following week.
Maintenance sessions. After completion of the acute phase of treat-

ment, six monthly booster sessions can be provided. These sessions follow
the format of the flexible sessions in terms of reinforcing coping skills to
address current problems and to anticipate future problems, particularly
in social, functional, or physical illness domains. To achieve these objec-
tives, it is essential to obtain a thorough interval history of the following
information since the preceding session:
• Depressive symptoms and mitigating circumstances

• Physical illness course
• Environmental stressors (family, school, peers)
• Problems encountered in implementing PASCET-PI skills

• Positive outcomes resulting from PASCET-PI skill use
Family Sessions
Individual youth sessions are complemented by contact with parents in
two forms. At the end of each individual youth session, a parent (or both,
if available) joins the therapist and youth for a 5-minute summary confer-
ence to discuss the main points of the session (excluding information the
youth does not want to share) and the youth’s practice assignment for the
upcoming week, which the parent is encouraged to assist the youth with.
Individual family sessions are held at the beginning, middle, and end of the
youth’s treatment. The goals of these family sessions are threefold, includ-
ing explaining the treatment program and soliciting the parent’s perspec-
tive on the youth’s depression and coping with IBD, educating the family
about depression and comorbid physical illness, and helping the family re-
inforce the youth’s ability to cope with depression and physical illness by
using PASCET-PI skills. Incorporate parents in a developmentally appro-
priate manner. For example, discuss confidentiality of the specific topics
brought up by the adolescent, but encourage the adolescent to share the
CBT coping skills learned with the parent at the end of the session. Help
the parents adopt a more appropriate perspective on the adolescent’s be-
havior, balancing firm control with warmth and granting autonomy.
The format of the family portion of the overall PASCET-PI protocol is
a short-term, intensive, psychoeducational, family-based intervention.
Just as the crux of the individual PASCET-PI is to help the adolescent de-
velop primary and secondary control, the central tool in the family sessions
is to apply a modified version of the STEPS skills for family problem-solv-
ing. To help families increase their behavioral problem-solving repertoire,
a variety of strategies are employed, including teaching about depression
and the interface of depression and physical illness, helping to develop a
sense of hope about the future, and linking cognitive information to both
the individual and family perspectives on affective illness and the unique
life experience of the family, including dealing with the physical illness.
Each family session is outlined below. Ideally, the first session involves
only the parents or parental figures in the youth’s life, and the subsequent
two sessions involve first the parents alone and then include the youth so
the therapist can help develop more constructive interactions between the
parents and the child. However, given differences in family structure and
degree of impairment, the therapist can decide on a case-by-case basis how
these family sessions will best assist the youth in the family’s ultimate goal
of learning more adaptive ways to cope with having IBD.
Family session 1: parents as partners. The main goal of this session is

to socialize the family to the cognitive-behavioral model, develop an un-
derstanding of the parents’ perspectives on the youth and family situa-
tions, and to deliver brief psychoeducation and apply skill building at the
familial level. First, gently ask for the parents’ perspectives about the
youth’s problems and the IBD-related illness experience of both the youth
and the family. Next, provide an overview of PASCET-PI structure and the
ACT and THINK chart, providing a rationale for how these skills apply to
their current situation and their child’s difficulties. Educate the family
about the relationship between IBD and depression, as well as provide
helpful tips for modifying school plans and improving medication adher-
ence (see information worksheets in Appendix 10–C). Finally, introduce
the family STEPS problem-solving exercise. This activity uses the same
STEPS worksheet completed by the youth in individual session 2; how-
ever, each family member contributes to the generation of solutions and
gives input examining what is good and bad about each solution. This ex-
ercise teaches families how to problem-solve in a respectful way, in which
everyone’s opinions are valued and communication is open.
Family session 2: parents as facilitators. The goals of this session are to

gather information, review ACT and THINK skills, and highlight the impor-
tance of positive communication. First, ask for feedback from the parents
about their child’s progress and ongoing problems. Next, educate parents
about how improving family communication can help their child cope better.
Explain how decreased communication or negatively expressed emotions to-
ward the youth can maintain a youth’s depressive or pessimistic stance (Figure
10–1). Help the parents develop goals for how they might change their com-
munication style with their child (e.g., stop nagging and praise the youth for
going to school every day). Review the ACT and THINK skills that have been
covered with the youth to date and how parents can reinforce these skills. If
the youth is present for the session, have him participate and possibly even
lead this part of the family session. Finally, introduce the family de-stressing
game described below, which aims to reduce stress at home by building more
positive interactions between family members.
Family de-stressing game: Each family member gets five popsicle sticks in
a certain color (red, orange, yellow, green, blue, or purple) or other unique
token identifiers. The idea of the game is for each player to get as many pop-
sicle sticks in colors other than his or her own from family members by the
end of the game. Players earn the sticks by saying something nice or doing
something nice for someone else in the family. For example, if the youth
says, “Dad, I really appreciate you spending time with me yesterday,” the
youth would get a stick from his father. If the youth’s mother baked him
cookies, he would give one of his sticks to her. The family decides as a unit
when they will begin and end the game, but ideally each game should be
played for 5–7 days. Negative comments or interactions are ignored.
Family session 3: parents as coaches. The main goal of this session is

to have the parent-child dyad determine the best way that parents can be-
come CBT coaches, facilitating the youth’s long-term maintenance of
treatment gains. As in previous sessions, the parents are encouraged to give
their perspectives about their child’s progress and ongoing problems. In
this session, these perspectives are provided in the presence of the youth
so that there can be in vivo STEPS problem-solving completed with the
family unit to address unresolved problems or issues. Next, the youth is
encouraged to review the ACT and THINK skills and to communicate to
the parents how they can be most helpful in reinforcing new skills. The
therapist can act as a mediator for this interaction.
Case Example
While Kyle’s individual sessions were greatly helpful for improving his
mood and functioning, the family sessions also played a large role in his im-
provement. Kyle’s parents attended the first session without Kyle to learn
about CBT and how they could support Kyle in his treatment. This educa-
tion helped Kyle’s mother to realize that she herself was also depressed.
She was referred for outside treatment and attended those sessions. Treat-
ing her own symptoms allowed her to more effectively support Kyle’s new
healthy lifestyle. At the same time, Kyle’s father was also encouraged to
support Kyle’s new healthy lifestyle by providing Kyle with praise and spe-
cial attention when he was using coping skills and reducing attention when
Kyle was not following through. In this way, the secondary gain of getting
more special time with his father when he did not go to school dissipated,
and this change also helped to improve Kyle’s attendance.
Follow-up family sessions also focused on problem-solving some difficul-
ties within the family unit. Kyle was able to explain that he often felt “put in
the middle” of his parents arguing and that this made him feel like he “can-
not win.” Therefore, the clinician helped Kyle’s parents to agree to discuss
marital problems privately and to avoid including Kyle in these discussions.
Although this intervention was not easy for the couple and at times they
made mistakes, Kyle noticed great improvement in his interactions with his
family, and his reported level of stress within the family was reduced.
Key Clinical Points

Several general considerations can optimize the outcome of using CBT
to treat depression, particularly in adolescents with physical illness.
Downward spiral of youth’s depression

Depressed mood Negative thinking Negative behavior
Family processes
Negative expressed emotions
Decreased communication
Upward spiral with CBT for youth

Adaptive thinking Modified behavior Improved mood
Education ACT and THINK skills

Improved communication
FIGURE 10–1. Family communication and impact on youth’s de-

pression.
ACT= Activities, Calm and Confident, Talents; CBT= cognitive-behavior therapy;
THINK= Think positive, Help from a friend, Identify the silver lining, No replay-
ing bad thoughts, Keep trying—don’t give up.
• Balancing rapport and education. The key to success in using

Primary and Secondary Control Enhancement Training for Physical
Illness (PASCET-PI) to enhance coping with physical illness is bal-
ancing rapport and didactic education in a manner that is fun and
that allows the youth to take on a progressively more active role in
problem solving throughout the course of therapy. Of course, what
is fun and interesting for a 12-year-old boy may not be at all fun or
interesting for a 16-year-old girl. As such, the fun and interesting as-
pect cannot be built into the manual very successfully. Instead, it be-
comes the therapist’s job to make the sessions enjoyable and en-
gaging by designing clever, witty, and memorable ways to present
and illustrate the main points of each session.
• Flexibility. The therapist should also be flexible whenever possi-
ble in coordinating therapy sessions with medical appointments or
visits for medication infusions. Sessions can also be completed
bedside if the patient is medically hospitalized.
• Review. After the initial session, each subsequent session begins

with a review of the previous week’s material and practice assign-
ment. This review is an important opportunity for the therapist to
provide positive reinforcement for the youth’s work. Additionally, the
practice assignment serves as an opportunity for the therapist to
note consistencies and patterns in the youth’s approach, which may
help in designing examples and setting up future assignments.
Thus, spending time on the practice assignments is worthwhile, and
the review should not be rushed to get to the remaining session
content. Along these lines, the practice assignment will often lead
quite naturally into the new session material, and efforts should be
made to facilitate this transition.
• Toolbox reminder. Remember that CBT is a skill-building treatment
based on the toolbox concept. The ACT and THINK chart encom-
passes numerous different ways of coping with depression and a
chronic physical illness. Not all of the tools will be useful for each
youth. Thus, the therapist must not oversell a particular coping skill
from the ACT and THINK list because of a sense that a youth rejects
the idea or will not use it. Instead, the therapist should ascertain that
the youth understands the notion and then move on. For those skills
that a particular youth appears to find especially helpful, it may be
beneficial to incorporate extra exercises to reinforce the lesson
learned. Tap into the youth’s creativity and interests to help personal-
ize the treatment tools for him (e.g., making a collage or drawing to
illustrate a particular skill, or writing a story about the use of the skill).
• Respect. The cognitive-behavioral therapist models treating each
person in a respectful way and models appropriate listening behav-
ior. He or she also helps parents and kids find their strengths.
• Developmental considerations. The therapist should make sure
that the process and content of the therapy is perceived and interpret-
ed within a framework of the youth’s developing cognitive capacity
(see Chapter 2). Age-calibrated adjustments in presenting issues,
concepts, and skills are essential to make the CBT experience a pos-
itive one for the youth. Prepubertal youth (i.e., ages 9–12) may still
have concrete thinking, and they often develop unusual beliefs about
why they are sick or why they need to go to the hospital. They may
have difficulty comprehending concepts like duration and quality
(e.g., “It will only last a minute” and “This will only hurt a little bit”) and
may manifest avoidant behaviors when faced with procedural stres-
sors. Moreover, they may have limited awareness of feelings or be-
lieve that certain feelings are unacceptable. Youth may express
feelings through activities like playing, drawing, painting, and role-
play (e.g., playing the role of the doctor); thus, it is important to use
these modalities as vehicles to deliver PASCET-PI skills. In addition,

continue to educate both the adolescent and the family about normal
adolescent processes to normalize development (e.g., links between
puberty and poor body image; parent’s role in helping the adolescent
transition from a “child” status that involves adult monitoring to an
“adult” status that requires more self-management).
• Regression. Sometimes if extremely stressed or when sick with a
flare-up, older youth can regress to coping styles used in earlier
times of their lives. This can result in a return to magical thinking
(such as attributing events in their lives to their own thoughts, feel-
ings, and behaviors) and inferring causal links between events that
occur in close physical or temporal proximity. Undergoing medical
procedures can also regress some teens, especially those with anx-
ious tendencies, resulting in misconceptions about the reasons for
the procedure, misunderstandings about the nature of the illness or
procedure, or a mistaken belief that the illness or procedure is “pun-
ishment.”
• Autonomy and treatment nonadherence. The adolescent’s am-
bivalence about his sick role is a common source of treatment non-
adherence. It is important to involve teens in treatment planning and
to foster a developing sense of autonomy from family and close
peer relationships. Developing a sense of identity and belonging
are important adolescent tasks that are often interrupted by the
presence of a chronic illness. Rapid physical changes associated
with puberty produce heightened self-awareness and concern
about appearance. Medical procedures can impinge on these
tasks, especially when procedures involve loss of functioning (e.g.,
colostomy). The acceptance of authority and relinquishment of con-
trol needed to undergo medical procedures can be difficult for this
age group and may foster feelings of helplessness and depen-
dence. Adolescent patients may become resistant and nonadherent
in an effort to regain a sense of control and independence in the
medical context. Fortunately, their growing abilities for abstract
thinking enable them to draw on a wider range of strategies for cop-
ing with anxiety and stress, including relaxation imagery and cogni-
tive reframing. Address noncompliance with attendance or practice
assignments immediately and directly by problem solving with the
adolescent and examining mitigating environmental factors. Give
consideration to flexible alternative solutions (e.g., phone sessions,
reminder calls from the therapist about homework, addressing pa-
rental contributions to the problem).
• Model of joint empiricism. Endorse a model of joint empiricism
with the older adolescent from the onset of therapy by focusing on
the problems raised by the adolescent and other jointly identified

goals. For example, adolescents who have missed substantial
amounts of school because of their illness need the problem-solv-
ing steps planned for school reentry to be realistic in scope and tim-
ing. Initial collaborative negotiation between the adolescent and
therapist, and later with other resources (e.g., parents and school),
can be instrumental in the development and execution of the plan.
• Therapeutic alliance. Expect a more tentative therapeutic alli-
ance and frequent comparison of the therapist to other adult figures.
Empathy, warmth, patience, and a genuine respect for the adoles-
cent’s strengths can help with rapport building and establish a
strong working alliance. Use the structure that the CBT sessions
provide and consider the use of phone sessions to help meet the
adolescent’s needs. Another key component to forming an ade-
quate therapeutic alliance is an assessment of the adolescent’s in-
terpersonal skills (e.g., sophistication in verbal and nonverbal
communication, capacity for perspective taking and empathy, de-
gree of social judgment).
• Social environment. Pay attention to the social environment at
school and in the home. This is essential in adequately assessing
which aspects of the environment the youth has control to change
and which aspects need the help of the therapist to resolve (e.g.,
addressing parental criticism or shame-inducing comments, using
school resources to provide more social or academic opportuni-
ties). Remember the school is a laboratory for developing not just
academic competence, but social skills and personal coping strat-
egies.
• Therapist education about IBD. Although a detailed understand-
ing about the etiology and treatment of pediatric physical illnesses
is not essential in working with physically ill youth, some under-
standing of the physical and psychological manifestations of the
physical illness involved will enhance the therapist’s ability to apply
the coping skills taught to this comorbid population.
• Etiology of depression does not preclude CBT. It is important
for the therapist to keep in mind that physical illnesses can be both
a physical and a psychological stressor, and that both aspects can
lead to missed social and academic opportunities, family distress,
and delayed physical growth and sexual maturation, all increasing
the risk for depression. It is important to consider that cause and
cure are not inextricably linked. Even a depressed state that is
heavily influenced by biological factors may, in principle, be treated
effectively by a psychosocial intervention such as PASCET-PI.
10.1. When CBT is used for the treatment of a youth with a chronic phys-
ical illness, which of the following treatment components will likely
be most useful for improving mood and positive coping?
A. Teaching the youth skills focused on changing negative thoughts

regarding illness.
B. Parent sessions focused on education regarding CBT and how
parents can best support their child.
C. Teaching the youth skills focused on how to behave differently
when feeling upset, such as increasing pleasurable activities.
10.2. Which of the following best describes the relationship between psy-
chological and physical processes?
A. Symptoms of physical illness, such as inflammation, can negatively

impact brain chemistry, resulting in psychological disturbances.
B. There is no relationship between physical illness and mental
health concerns.
C. The relationship is bidirectional. A preexisting mental health
concern can negatively impact physical illness by decreasing
healthy behaviors. Also, physical illness processes can contribute
to increased psychological concerns by increasing both internal
and external stressors.
D. Psychological difficulties can negatively impact a youth’s percep-
tion of control over illness, leading to a hopeless view regarding
health and a decreased participation in healthy behaviors.
10.3. A 14-year-old adolescent girl with comorbid Crohn’s disease and de-
pression spends most of her time lying in bed in her bedroom, isolat-
ing herself. Which of the following coping skills is a primary control
tool that will likely help her change this negative behavior?
A. The tool of identifying the silver lining so that the youth begins
to find the positive in her situation.
B. Taking part in relaxation training techniques such as deep breath-
ing and hypnosis.
C. Recognizing negative thought patterns and challenging them with
more helpful thoughts.
D. Activity scheduling: being encouraged to take part in an increased
variety of activities, including pleasurable, physically active, help-
ful, and social activities.
10.4. Which of the following is not a focus of treatment according to the

Skills-and-Thoughts (SAT) theory?
A. Identifying negative thought patterns and learning to change

them.
B. Improving self-soothing skills.
C. Using the therapeutic relationship as a model for outside rela-
tionships.
D. Increasing participation in pleasurable or rewarding activities.
10.5. When working with a 17-year-old adolescent boy, the therapist no-
tices that he appears bored when presented with the information.
Which of the following developmental adaptations may be most use-
ful for this situation?
A. Leave out the ACT (i.e., Activities, Calm and Confident, Talents)
skills when conducting treatment in order to focus more on the
complex skill of cognitive challenging.
B. Focus on making the sessions collaborative and fun by learning
about the teen’s interests and linking skills with the teen’s illness
narrative.
C. Increase parent participation in the teen’s sessions to ensure that
he participates actively.
D. Do not make any adaptations, as this would decrease the overall
efficacy of the treatment.
Suggested Readings
and Web Sites
American Society of Clinical Hypnosis, for hypnosis training and certifica-
tion: www.asch.net
Avery RR: Meet Thotso, Your Thought Maker. China, Smart Thot, 2008
Dudley CD: Treating Depressed Children. Oakland, CA, New Harbinger
Publications, 1997
Thomson L: Harry the Hypno-Potamus: Metaphorical Tales for the Treat-
ment of Children. Norwalk, CT, Crown House Publishing, 2005
Thomson L: Harry the Hypno-Potamus: More Metaphorical Tales for Chil-
dren. Bethel, CT, Crown House Publishing, 2009
Wester WC, Sugarman LI: Therapeutic Hypnosis With Children and Ad-
olescents. Bethel, CT, Crown House Publishing, 2007
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Appendix 10–A: PASCET-PI Selected Skills and Tools 369
Appendix 10–A
PASCET-PI Selected Skills

and Tools
• ACT and THINK skills

• STEPS problem-solving worksheet
• BLUE thoughts
• Physical illness narrative
• Mood thermometers for practice activities
• POWER relationship problem-solving
• Maintenance plan
ACT and THINK skills

A: Activities. Do activities that solve problems [use STEPS], activities that
I enjoy, activities with someone I like, activities that keep me busy, and
activities that help someone else.
C: Calm and confident. Stay calm—make myself relax. Stay confident—
show a positive self.
T: Talents. Develop a special talent or skill. Set a goal, plan steps to reach the
goal, then practice, practice, practice!
T: Think positive. No negative thinking allowed. Change BLUE (negative),

unrealistic thoughts into positive, realistic thoughts.
H: Help from a friend. Think things over with someone I trust.
I: Identify the silver lining. Figure out what’s good about my situation.
N: No replaying bad thoughts. Stop thinking about things that make me feel
bad. Get my mind on something else.
K: Keep trying—don’t give up. Keep trying ideas from my ACT and THINK
chart until I feel better.
Note. The spelled-out terms for STEPS and BLUE are included next in this appendix.
STEPS
S Stay calm and Say what the problem is: Solving problems creatively happens
best if a person is calm and relaxed. Thus, the first step in problem solving is
staying relaxed.
T Think of solutions: Thinking of as many solutions as possible will increase the

likelihood of coming up with the answer that will best solve the problem.
1. 3.
2. 4.
E Examine each one: What good and bad things might happen if you did this?
What is good, bad, easy, or difficult about each solution?
1. Good: Bad:
2. Good: Bad:
3. Good: Bad:
4. Good: Bad:
P Pick one and try it out: Which one will you try?
S See if it worked: If it worked, great! If it did not work, then go back to your list
of solutions and try another one.
Active STEPS to problem solving.
BLUE thoughts
B: Blaming myself
L: Looking for the bad news
U: Unhappy guessing
E: Exaggerating—imagining a disaster
Physical illness narrative

About my physical illness
1a. What are your thoughts about what caused your inflammatory bowel
disease?
1b. How do you think it works to cause your inflammatory bowel disease?
2a. Think about all of the problems you have had related to your inflammatory
bowel disease. What are they?
2b. Think about all of the symptoms of inflammatory bowel disease that you’ve
had in the past 2 weeks. What are they?
3a. How do you feel about having inflammatory bowel disease?
3b. How is the treatment of your inflammatory bowel disease going?
4a. How has your inflammatory bowel disease changed your life?
4b. How has having inflammatory bowel disease changed how you feel about
your body?
4c. How has your inflammatory bowel disease made things different for your
family?
5a. Is there anything good about having inflammatory bowel disease? What?
5b. Is there anything bad about having inflammatory bowel disease? What?
6. How much control do you think you have over your inflammatory bowel
disease and why?
7a. Can you change the course of your illness (make it better or make it worse)?
7b. What things can you do to make your inflammatory bowel disease better or
worse?
8a. What do you do to make your inflammatory bowel disease better or worse?
8b. Rate how well you have been taking care of your illness over the past month
using a scale of 1 to 10, in which 1= poor job and 10 =excellent job.
9. When you are sick with your inflammatory bowel disease, how do you make
yourself feel better?
10. What was happening in your life when your illness started?
How I Felt Before How I Felt After
Solution #1 10 very good 10 very good

9 9
8 sort of good 8 sort of good
7 7
6 6
5 so-so 5 so-so
4 4
3 sort of bad 3 sort of bad
2 2
1 very bad 1 very bad

9 9
7 7
6 6
5 so-so 5 so-so
4 4
2 2

9 9
7 7
6 6
5 so-so 5 so-so
4 4
2 2

9 9
7 7
6 6
5 so-so 5 so-so
4 4
2 2
Mood thermometers.
I have the POWER to improve relationships.

P Problem with a relationship: Name one. It can be with a friend, family
member, romantic interest, teacher, etc.
O Outline the positive and negative parts of the relationship:

Positive Negative
1. 1.
2. 2.
3. 3.
W Which negative parts do I have the power to change?
1. Part: How?
2. Part: How?
3. Part: How?
E Explore each one: What good and bad things might happen if I try to
change part of the relationship in this way? List the good and bad results
for each “How?” listed above.
1. Good: Bad:
2. Good: Bad:
3. Good: Bad:
R Relationship improvement takes action! Decide on one of the things I have

the power to change about the relationship, and do it.
Relational problem-solving skill.

Keep trying
What happened when I felt bad:
Use ideas from the ACT and THINK chart to come up with THREE PLANS for feeling better:
Plan A
Letter from the ACT and THINK chart:
What this client should do:
Plan B
Plan C
Maintenance plan.
Appendix 10–B: Guided Imagery 375
Appendix 10–B
Guided Imagery for Pain Management

Before starting this exercise, it is important to have the youth describe the
location of his pain, as well as the intensity and severity of his pain; the de-
scriptions and words used by the youth are what the therapist will incor-
porate into the script. Although the youth will have his eyes closed during
the exercise, the therapist will be asking him for verbal feedback to make
sure that he is able to visualize the scene being described to him. Let the
youth know that some children have mastered this skill so well that they
have been able to call on it during surgery, thus avoiding the need for an-
esthesia or pain medications.
Induction
Make yourself as comfortable as you can either sitting or lying down. Gen-
tly close your eyes, feeling comfortable and relaxed—let your body go. ..
no need to tense any of your muscles ... all you need to do is listen to my
voice. Now begin to focus in on the feelings in your right fingers and right
hand and let go of whatever tension may be in those muscles—just relax—
you will feel relaxation like a warmth or perhaps a pleasant tingling sensa-
tion—let it happen—naturally... let the feeling of relaxation spread gradu-
ally up your right hand . . . forearm . . . upper arm . . . and into your right
shoulder—let go of the tension—relax, just relax... . Now do the same on
your left side. .. begin with relaxing the muscles in your left fingers and
hand. ..let it spread up your left arm and forearm... upper arm.. .and into
your left shoulder. ..now both your left and right shoulders, arms, hands,
and fingers are relaxed—keep feeling relaxed. ...
That’s great—you’re doing well. ..now, let’s turn your attention to the
muscles of your head and neck . . .smooth out the muscles in your fore-
head—above your eyebrows—down the muscles of your face—over your
eyes, your cheeks; your jaw is loose and relaxed—feel the relaxation
spreading around your ears—over your head—down the muscles of your
neck.. .. You’re doing great—just keep relaxing like that.. .feel relaxation
now spreading over your shoulders, down your back, and over your stom-
ach—let it flow further down the muscles of your left and right legs—over
your knees, feet, and toes... .
Sometimes it is useful to imagine the relaxation as warm waves of wa-
ter that begin at the top of your head and trickle gently over the muscles
of your face, further down over your shoulders, arms, back, legs, and down
to your feet—and with each gentle wave of water, feel the tension flushed
from your body. ... Now focus on the muscles in your stomach—relax these
muscles, releasing all the tension. Relax, just relax. In this way, you will be
able to chase away any pain or discomfort, leaving you tension-free and
calm.
To help you relax even more, I’m going to count slowly from 1 to 10,
and with each number I call out, you are going to feel even more comfort-
able and even more relaxed—even when you think it’s impossible to relax
any further—there’s always more relaxation you can enjoy just by letting
go. ... You may want to picture each number in your head as I call it out.. ..
Let’s begin—1, you’re very relaxed... 2, more and more—further and fur-
ther relaxed. . . 3, feel your whole body getting heavier and looser. . . 4,
deeper and deeper relaxed... 5, more and more relaxed. ..6, you are feeling
your whole body become totally relaxed.. .7, your body continues to be-
come more and more deeply relaxed.. .8, deeper and deeper into a relaxed,
comfortable state. ..9, no cares or concerns, just a carefree, gentle state of
relaxation.. .and 10, completely and totally relaxed, feeling carefree, with-
out worries or concerns.
Now turn your attention to your breathing...this is the breathing of deep
relaxation .. . rhythmic, smooth, effortless. . .listen to your breathing.. ..
I would like you to try the following exercise—every time you let out a
breath, think quietly to yourself of the word calm—this will help you to as-
sociate the word calm with the calm and relaxed state you’re now in—so that
at any time in the future you can bring on this state of deep relaxation just
by breathing rhythmically, slowly, and saying the word calm every time you
let out a breath—do that for a few minutes until I return to talk to you once
again (1–3 minutes). Now you are in a deep state of relaxation, and you are
going to become even more relaxed...and still more relaxed as we continue.
You will be able to shift your body to become more comfortable, and this will
not disturb your relaxation or your concentration. You will stay in this re-
laxed state until I tell you to wake up.
In Trance
Now focus on your body. Scan your body and notice the places that cause
you pain. When you are asked, you will be able to verbally communicate
these areas in your body to me without breaking your trance (pause).
When you are ready, please tell me which areas of your body experience
pain (pause and wait for the response). Thank you, you are doing a great job.
Please imagine your (name a body part that the patient verbalized to
you—e.g., stomach) and paint your (name the body part) with an imaginary
paintbrush. Paint the entire area that causes you pain. On a scale from 1 to
10, 1 being hardly any pain and 10 being the most pain you have ever had,
how much pain are you experiencing in your (name body part)?
Focus your attention on your (name the body part), imagining the exact
place you feel your pain and the type of pain you feel. Now, imagine a cable
or wire connecting your (name the body part) to your brain, the control
center for all your feelings, including pain. Can you see this cable? (Wait
for a response.) Good. Now, imagine a room in your brain, called the thal-
amus. When you look inside this room, it is a bright room and you see four
walls—each wall is covered by light switches from the ceiling to the floor.
Appendix 10–B: Guided Imagery 377
As you look around at these switches, you see that each switch has a piece
of tape under it with the name of a body part. You look around the room
until you find the switch that has the word “(name the body part)” under
it. Did you find this switch? Good. Now as you look closely at this switch,
you see it is labeled from 1 to 10, with 10 being the most intense pain set-
ting and 1 being almost no pain. Describe what setting the light switch you
are imagining is at. (Wait for a response.) Now imagine the setting being
cranked up to a 10, the most intense (name the body part) pain imaginable.
Describe how your (name the body part) feels right now. Now visualize
yourself turning the light switch down in the control room from 10, 9, 8,
and with each number on the switch that you see, imagine the pain becom-
ing less and less intense. Keep turning the switch lower and lower. What is
the lowest number you can see the switch turned to?
Encourage the child to keep imagining this until he can visualize the
switch being at least a 4 or 5, and continue reinforcing his control over the
switch and the corresponding change in pain experienced. Finish the exer-
cise on the lowest pain setting the child can achieve.
Appendix 10–C
Information Worksheets for Parents

Helping Your Child Reintegrate Into School After
Being Absent for Physical Illness
Working With Schools
You are your child’s helper in dealing with the school system. Inflamma-
tory bowel disease (IBD) is uncommon, so the school may not understand
it or may confuse it with less serious disorders. Your gastroenterologist can
provide you with a letter as well as a pamphlet from the Crohn’s and Coli-
tis Foundation of America explaining IBD, the ways it can affect school
function, and the special needs that children with IBD may have. It will be
important for you to get to know the contact people in the school, as well
as school policies on absences and making up work.
Should My Child’s Friends Be Told?

Respect your child’s wishes—he or she should decide whether to tell
friends about the illness. Your child may choose not to tell peers, especially
in the beginning, but this may change.
Should My Child’s Teacher Be Told?

Yes, teachers should be told about your child’s illness and symptoms and
what they can do to help:
• Give your child permission to leave class to use the bathroom without
asking each time, or provide a private bathroom or nurse’s facility.
• Provide makeup work and extra help if your child is absent for long pe-
riods of time.
• Facilitate administration of medications by the school nurse so that
your child is not singled out at inappropriate times.
• Communicate with you and your child’s medical team about possible
flares or other difficulties noticed.
Handling Academic Concern

• Meet with your child’s principal and teacher to discuss a catch-up plan
for long absences, tutoring options, and an individualized educational
plan.
Appendix 10–C: Parent Information Worksheets 379
• Set up a buddy system with one of your child’s friends who will keep
track of homework assignments, bring over necessary books, and let
your child know what went on in school that day.
• Create a homework plan—set reasonable goals for completing home-
work, designate time in the day as homework time, and be available to
assist your child.
• Be clear on expectations for each class and the consequences of not
keeping up with schoolwork.
Section 504 of the Americans With Disabilities Act Prohibits Schools

That Receive Federal Funds From Discriminating Against Children
With Medical Disabilities
A 504 plan is a map of needed assistance for students with medical disabil-
ities, and having one in place can smooth reentry after absence for illness.
IBD can be a medical disability. If you believe your child needs special sup-
ports or services to participate fully in school, you must write to your
school district and explain the type of assistance you believe is needed. Ac-
commodations that are commonly needed include the following:
• When the child needs to miss school for medical reasons, the child
should not be penalized for it.
• The child should be given the assignments for missed work in writing.
• The child should be allowed a reasonable time after he or she has re-
covered from the episode to complete missed schoolwork, including
examinations.
• It is medically necessary that the child be able to self-limit physical ac-
tivity.
• It is medically necessary that the child have unrestricted access to a
bathroom.
Your gastroenterologist can provide you with a letter stating that IBD
is a medical disability and the types of accommodations frequently
needed, but you will need to work with the school to get these accommo-
dations implemented.
Chronic Physical Illness in a Child or Adolescent Can Cause Parents

to Become Overprotective: What Can You Do?
• Foster independence by encouraging your child to take responsibility
for some medical routines (taking medications and calling the doctor),
so that you won’t have to constantly remind him or her.
• Whenever possible, encourage your child to make decisions and to try
new things and activities.
• Praise small steps of independence in your child.

• Encourage participation in fun activities with your child’s friends. This
is especially important, because teens with physical illness can miss out
on social opportunities due to sickness.
Encourage Your Child to Find Practical Ways of

Dealing With the Illness at School
• Learn where the nearest bathrooms are.
• Carry extra underclothing.
• Visit the nurse’s office when necessary.
Handling Curiosity and Questions About the Illness

• Again, it is up to your child to determine whether he or she will tell
classmates about the illness.
• Let your child know that he or she can make casual responses without
going into too much detail; for example, “I was sick and in the hospital,
but I feel better now, so I can come back to school”; or “Yeah, I was
feeling sick, but I don’t like to think or talk about that now that I’m
feeling OK.”
• If questions are about medication side effects (such as a puffy face), mat-
ter-of-fact statements like “That’s because I have to take strong medica-
tion, but it’ll go away when I stop taking it” may be helpful in diffusing
curiosity. Even a shrug and an “I don’t know” can stop questions.
Handling Teasing and Name Calling

Depending on your child’s comfort level, a good strategy is often a nonchalant
response such as those given above. If that is unsuccessful, ignoring is best.
Reintegration Into Extracurricular Activities

• Although prolonged high-dose steroid therapy may make contact
sports such as football or wrestling ill-advised (ask your doctor), your
child should be able to do anything he or she feels like doing.
• Speak to the coach or activity supervisor about modifications that
could be made to facilitate your child’s participation (e.g., fewer laps if
easily fatigued in basketball, bathroom breaks in art class or music les-
sons).
Initiating a Preventive Plan Before Illness

• It may be helpful to begin creating a plan before a disease flare-up so
that a system for your child to stay connected academically is already
in place.
Appendix 10–C: Parent Information Worksheets 381
• Familiarize yourself with the necessary contact persons and the

school’s policies regarding absences.
What About Homeschooling?

• Consult with the medical team if there is any medically necessary reason
for the child to be homeschooled (e.g., severe immune suppression).
• Make sure to research computer-based school programs you are consid-
ering, for credentials, academic rigor, and statistics about how these
students integrate back into school or college in the future.
• With the lost socialization opportunity of school contact with peers, it
is essential for children and adolescents who are homeschooled to have
other social opportunities with peers.
Improving Medical Compliance of Your

Teenager or Child
Understanding How Developmental Factors Can
Influence Compliance
• Physical illness can interfere with adolescents’ ability to separate from
their parents and create their own identity because they are more de-
pendent on caretakers.
• Adolescent omnipotence: the belief in invulnerability to harm. Many
adolescents make statements such as “That will never happen to me”
or “I could never get that.” The ideas adolescents have about being in-
vincible may contribute to medical noncompliance.
• Peer issues play an important part in medical compliance. Having a
chronic illness is stigmatizing, and taking medications in front of peers
may be embarrassing for adolescents. It is also important to keep in mind
that some inflammatory bowel disease (IBD) medications have cosmetic
side effects, making them particularly undesirable for teenagers.
Understanding How Physical Illness Issues May

Influence Compliance
As noted above, the side effects of some IBD medications (e.g., weight
gain, irritability, puffiness) may keep adolescents from complying with
their course of treatment, as they are very sensitive to changes in body
shape and size.
Creating a Consistent Behavioral Plan With Input From Your Teenager

• Consider the level of parental supervision needed to keep your child
medically compliant. It is important to set firm yet empathic limits.
• Try setting up a reward system with your child to reinforce medical

compliance. You may remember creating a similar plan to reward your
child for completing his or her practice assignments. You can use this
as an example or come up with a new system that would work better
for your family.
• Although it is important to reinforce compliant behavior, it is also im-
portant to discuss ways in which medical noncompliance can be ad-
dressed. You and your child may want to think about certain privileges
that can be taken away if medications or medical appointments are
missed.
• To make it easier for your child to remember his or her medications,
use home-based visual cues or reminders (e.g., phone calls). In addi-
tion, organize all medications so that it is easy to figure out when each
medication should be taken. Pillboxes are great investments. Below are
some helpful hints for improving medical compliance.
1. Keep a medication calendar.
2. Have your child take medications at the same times every day.
3. Have your child take medications at the same time as another ac-
tivity he or she does every day, like brushing his or her teeth or eat-
ing meals.
• Use ACT and THINK coping skills to improve medical compliance.
For example, the K stands for “Keep trying—don’t give up.” Apply this
to the various plans you and your child come up with to improve med-
ical compliance. If one system doesn’t work, think about ways to im-
prove it and keep trying until it works.
Improving Communication With the Medical Team

• Always feel comfortable discussing any treatment concerns or commu-
nication issues with your doctor. It is crucial that you and your child
feel supported and respected by the treatment team. If this is not true
for your family, please discuss this with your doctor and therapist.
• Keep track of symptoms and report them rapidly to your child’s doc-
tor. Recording symptoms in a journal and dating each entry may help
your child remember exactly how he or she was feeling when the doc-
tor asks. Also, let the doctor know about any medical compliance issues
and/or side effects your child may be experiencing from his or her IBD
medications.
11
Obesity and
Depression
A Focus on Polycystic Ovary Syndrome

Ronette Blake, M.S.
ACCORDING to U.S. Centers for Disease Control and Prevention

data, approximately 17% of children and adolescents are obese, with sig-
nificant medical sequelae into adulthood (Ogden et al. 2006). The myriad
health risks associated with childhood and adolescent obesity include car-
diovascular complications, insulin resistance, and chronic inflammation
(Ford et al. 2001; Freedman et al. 1999). Obesity, along with cardiovascu-
lar disease, has been shown to track into adulthood (Fuentes et al. 2003;
S This chapter has a video case example on the DVD (“Polycystic Ovary Syn-
drome”) demonstrating CBT for a depressed adolescent with obesity.
Supported by grants K12HD-043441; K23HD-HD061598.
383
Hemmingsson and Lundberg 2005; Magarey et al. 2003). In contrast to

the well-established physical health consequences, the psychological cor-
relates of obesity in childhood are less clear (Friedman and Brownell 1995;
Wardle and Cooke 2005). However, growing evidence suggests that obese
youth often exhibit depressive symptoms and are often the targets of bias
by peers (Kraig and Keel 2001; Latner and Stunkard 2003; Neumark-
Sztainer et al. 2002), teachers (Bauer et al. 2004; Neumark-Sztainer et al.
1999), and guardians (Davison and Birch 2004). Thus, similar to long-term
physical consequences, the negative impact of obesity-related stigma may
have lasting effects on emotional well-being (Phillips et al. 2010).
Polycystic Ovary Syndrome as a

Model Physical Illness
Polycystic ovary syndrome (PCOS) is the most common endocrine disorder
among women of reproductive age, and rates have been exponentially in-
creasing at 5%–10% prevalence each year (Arslanian and Witchel 2002;
Azziz and Kashar-Miller 2000; Knochenhauer et al. 1998). Although the ex-
act etiology of PCOS is unknown, two theories exist: 1) hypothalamic/pitu-
itary dysregulation of luteinizing hormone and follicle-stimulating hormone
leads to increased ovarian androgen production; and 2) hyperandrogenism
occurs secondary to insulin resistance. According to criteria resulting from
an expert conference sponsored by the National Institutes of Health in April
1990, a diagnosis of PCOS requires the following: 1) clinical or biochemical
evidence of hyperandrogenism (i.e., excess production of male hormones by
the ovaries); 2) infrequent, irregular ovulation; and 3) exclusion of other
known disorders (Azziz et al. 2006). The spectrum of metabolic abnormal-
ities for adolescents with PCOS is complicated, but typically includes insu-
lin resistance and inflammation (Apter et al. 1995; Legro 2002; Lewy et al.
2001; Morin-Papunen et al. 2003; Palmert et al. 2002).
The majority of adolescents with PCOS are overweight or obese. Obe-
sity appears to be closely associated with PCOS; for example, in the
United States, more than half of the patients with PCOS are either over-
weight or obese. It is well known that obesity influences the phenotypic
expression of PCOS, and obesity might play a significant role in the patho-
physiology of associated physical symptoms. Furthermore, obese patients
with PCOS have more severe cardiometabolic risk factors compared to
their lean counterparts (Yildiz et al. 2008). Moreover, symptoms of de-
pression have been found to be common comorbidities of the PCOS diag-
nosis (Elsenbruch et al. 2003; Himelein and Thatcher 2006; Hollinrake et
Obesity and Depression 385
al. 2007; Rasgon et al. 2003; Weiner et al. 2004). To our knowledge, data
that have been collected from 2008 through 20011 reveal a rate of depres-
sion in adolescents with PCOS with rates of approximately 50% (n=119)
in a treatment-seeking sample. The intriguing aspect of the relationship
between obesity and depression is that it is biochemical in nature. To date,
only two studies have carefully explored the relationship among laboratory
values, depression, and weight in adult women with PCOS. Preliminary
findings reveal 1) testosterone levels that are slightly elevated and signifi-
cantly related to depression after controlling for weight (Weiner et al.
2004), and 2) higher body mass index (BMI) and insulin resistance in de-
pressed women (Rasgon et al. 2003). Therefore, adolescents with PCOS
present as an ideal treatment-seeking pediatric population given the high
comorbidity of obesity and depression.
In this chapter, we review the psychological consequences associated
with childhood obesity; provide empirical evidence for cognitive-behavior
therapy (CBT) to treat obesity; and provide an overview of the theory and
application of Healthy Bodies, Healthy Minds—a manualized CBT inter-
vention created to address concomitant obesity and depression in female
adolescents with PCOS.
Psychological Correlates of
Pediatric Obesity
In addition to the adverse physical health effects of pediatric obesity (BMI
percentile ≥95), a growing body of evidence indicates damaging psychoso-
cial consequences of severe overweight (BMI percentile ≥85). These in-
clude weight-based teasing (Eisenberg et al. 2003), social isolation and
discrimination (Latner and Stunkard 2003), body dissatisfaction and low
self-esteem (Eisenberg et al. 2003; Pierce and Wardle 1997), and depres-
sion and anxiety (Goodman and Whitaker 2002).
Teasing and Social Rejection

Weight-based teasing encountered by obese youth may take several forms,
including verbal remarks such as name calling; being the target of rumors;
and being ignored, avoided, or otherwise socially excluded. More recent
data reveal an alarming trend that may involve physical bullying as well
(see review by Puhl and Latner [2007]). Obese children are rejected more
often by peers and are more likely to be socially isolated than their non-
overweight counterparts (Pearce et al. 2002; Strauss and Pollack 2003).
Body Dissatisfaction
Reviews conclude that obese children, particularly girls, exhibit greater
body dissatisfaction than their normal-weight peers (Ricciardelli and Mc-
Cabe 2001; Wardle and Cooke 2005). Further, body dissatisfaction may
have a negative impact on self-esteem in obese children. More recent data
document a mediation effect for body dissatisfaction in the association be-
tween obesity and self-esteem in a sample of elementary school children
(Shin and Shin 2008).
Low Self-Esteem
The internalization of weight-based discrimination may have negative im-
plications for self-esteem in obese youth. Weight-based teasing has been
associated with poorer self-esteem and an increased likelihood of depres-
sion among adolescents (Eisenberg et al. 2003). Prospective data demon-
strate that weight-based peer teasing, along with parental weight criticism,
mediates the relationship between overweight and low self-concept in
obese adolescents (Davison and Birch 2002). Further, weight-related teas-
ing has been shown to account for associations between weight and body
dissatisfaction in youth (Lunner et al. 2000; van den Berg et al. 2002). This
result appears to extend into adulthood, as a retrospective study of adults
reported an association between childhood weight-based teasing and
adulthood body dissatisfaction (Grilo et al. 1994).
Prospective studies examining the development of low self-esteem and
obesity generally show that excess weight in children predicts future low
self-esteem (Brown et al. 1998; Davison and Birch 2001, 2002; Hesketh
et al. 2004; Strauss 2000; Tiggemann 2005). Epidemiological (French et
al. 1996) and clinical (Zeller et al. 2004) data also demonstrate that body
mass is inversely related to self-esteem in children, although compre-
hensive reviews of self-esteem and obesity reveal this relationship to be
modest (French et al. 1995; Wardle and Cooke 2005). However, the rela-
tionship between self-esteem and obesity appears to be stronger when
obese children are compared with their nonobese peers, specifically on
measures of physical self-perception (Braet et al. 1997) rather than global
self-esteem.
Anxiety and Depression

To date, the evidence supporting an association between anxiety-related
disorders and pediatric obesity is inconclusive. Some studies demonstrate
no significant differences for anxiety symptoms between overweight and
normal-weight children (Tanofsky-Kraff et al. 2004) and adolescents

(Lamertz et al. 2002). In contrast, obese adolescents participating in an in-
patient weight-loss program reported higher lifetime prevalence of anxiety
disorders as compared with nonobese control subjects (Britz et al. 2000;
Buddeburg-Fisher et al. 1999). A more recent longitudinal investigation of
childhood psychopathology and body mass in youth ages 8–18 years
showed a significant increase in anxiety for obese boys as compared to con-
trol subjects (Rofey et al. 2009a).
Evidence of a relationship between obesity and depression in children
is also mixed. Research generally shows that community-based samples of
obese children do not differ in levels of depression compared to average-
weight peers (Brewis 2003; Eisenberg et al. 2003; Wardle et al. 2006).
However, in treatment-seeking clinical samples, obese children appear to
display higher levels of depression than normal-weight controls (Britz et al.
2000; Erermis et al. 2004). As for cause-and-effect relationships, more re-
search is needed. Two prospective studies did not show that obesity pre-
dicted depression in adolescent girls (Stice and Bearman 2001; Stice et al.
2000), whereas research among boys demonstrates a modest relationship
between chronic obesity and higher levels of depression over time (Mus-
tillo et al. 2003). In contrast, other evidence indicates that it is childhood
depression that predicts the development of obesity in both children
(Goodman and Whitaker 2002) and adults (Anderson et al. 2006; Rich-
ardson et al. 2003; Rofey et al. 2009a). Thus, no clear association between
child psychopathology and obesity has been established, yet the possible
long-term negative sequelae of these disorders reinforce the need for fu-
ture research, particularly regarding the elucidation of any directional re-
lationships. Regardless of the causal relationship, given the high rate of
obese children presenting with depression, an empirically validated inter-
vention to target both weight and mood is warranted.
An extensive literature spanning several decades has addressed the im-
portance of the relationship between weight and mood, specifically de-
pression (Faith et al. 1997, 2002; Franko et al. 2005). Because mood
disturbances commonly occur during childhood (Dahl and Spear 2004;
Lewinsohn et al. 1993), recent studies have investigated whether depres-
sion experienced in childhood affects obesity in young adulthood. Pine et
al. (1997) noted a positive predictive relationship between depressive
symptoms at age 14 and both BMI and obesity at age 22. Franko et al.
(2005) extended these data and traced depressive symptoms at ages 16
and 18 to an increased risk of obesity in adulthood. More recently, Rofey
et al. (2009a) found that depression and anxiety (in girls) and anxiety (in
boys) predict BMI percentile over time in a nonobese sample, which rep-
licates previous work in obese samples (Goodman and Whitaker 2002).
An efficacious (and effective) intervention is crucial given the long-stand-

ing relationship between these two variables and the high likelihood that
patients present with constellations of both obesity and depressive symp-
toms. (See Chapter 5 for empirically supported treatments for childhood
depression.)
Empirical Research in Behavioral

Treatments for Pediatric Obesity
Fortunately, a number of strategies have been shown to help prevent or re-
duce childhood obesity, and research demonstrates the positive health im-
pacts of weight-loss interventions for pediatric populations (Becque et al.
1988; Epstein et al. 1995; Katch et al. 1988; Rocchini et al. 1988). Simi-
larly, long-term improvements in psychological factors (e.g., depression)
have been noted in children who have completed weight-loss programs
(e.g., Levine et al. 2001). The increased prevalence of childhood obesity,
although likely due to a combination of factors, has been largely attributed
to the influence of environmental factors (i.e., nutrition and lifestyle)
(Miller and Silverstein 2007), and evidence indicates that some combina-
tion of caloric restriction and exercise education has a greater impact on
weight loss than one isolated component (Epstein et al. 1984, 1985; Roc-
chini et al. 1988). Thus, empirically supported treatments for pediatric
obesity typically include nutritional education (Emes et al. 1990; Epstein
et al. 1984, 1985) and the promotion of increased physical activity (Ep-
stein and Goldfield 1999; Epstein et al. 1995). In addition, findings sug-
gest that the involvement of both children and parents in treatment
(Brownell et al. 1983; Kingsley and Shapiro 1977; Renjilian et al. 2001)
contributes significantly to pediatric weight-loss efforts.
CBT
One of the most empirically validated modalities for psychosocial aspects
of obesity is CBT. In pediatric obesity, the goal of CBT is to assist youth in
reducing self-defeating thoughts around wellness behaviors. It is important
to assist the patient in identifying more adaptive coping strategies, such as
less emotional eating, more assertiveness, and greater need sharing. When
applied in this context, CBT helps patients gain insight into the connec-
tions among their thought processes, emotional responses, and eating be-
haviors. CBT strategies attempt to address issues that may have been
overlooked in early behavioral programs, including cognitive distortions re-
garding body image and eating; instruction in self-monitoring, problem-

solving techniques, and motivational issues; and specific weight-loss goals
and barriers to healthy behavior.
Although some evidence suggests that a behavioral approach to pediat-
ric obesity may be superior to cognitive strategies (Herrera et al. 2004),
the inclusion of cognitive treatment components in laboratory-based in-
vestigations of childhood and adult weight loss has shown favorable results
(Brownell et al. 1983; Coates and Thoresen 1981; Senediak and Spence
1985; Williams et al. 1993). Similar to behavioral programs, cognitive
components are typically used in conjunction with dietary and physical ac-
tivity education. One early cognitive-behavioral treatment program for
children ages 9–13 years involved a 9-week program that included dietary
and activity self-monitoring, cognitive strategies for managing negative
self-statements, and assertiveness training (Kirschenbaum et al. 1984).
Children in the cognitive treatment group lost significantly more weight
than control subjects and retained their weight loss at 3-month follow-up.
Duffy and Spence (1993) randomly assigned 27 overweight children (ages
7–13 years) to eight sessions of either behavioral management or com-
bined behavioral-cognitive treatment. No differences between treatment
groups were noted, and both groups of children demonstrated significant
improvements in weight at 6- and 9-month follow-up. Thus, although ad-
ditional research is needed to establish whether differences in outcome
may exist between behavioral treatment and cognitively based strategies,
it appears that the two approaches to pediatric weight loss may be equally
valuable.
Motivational Interviewing
Although CBT is considered to be the safest modality for weight loss in
youth, compliance issues often lead the families of obese children and ad-
olescents to seek alternative, though riskier, strategies (e.g., pharmaco-
therapy, bariatric surgery) (Miller and Silverstein 2007). Motivational
interviewing techniques aimed toward enhancing adherence to dietary and
exercise recommendations in children and families could play a key role in
promoting safe and effective long-term weight management. Motivational
interviewing is a therapeutic strategy aimed at helping individuals to ex-
plore ambivalence about making behavioral changes and has been sug-
gested as a possible tool for helping achieve dietary and physical activity
modifications (DiLillo et al. 2004). Using reflective listening and methods
to elicit “change talk,” motivational interviewing seeks to resolve ambiva-
lence and strengthen clients’ reasons for engaging in positive behavior
change consistent with their goals and values (Miller and Rollnick 1991).
Research on motivational interviewing for the treatment of obesity in

pediatric populations is limited, yet promising. To date, little research has
been done in the area of motivational interviewing and pediatric weight
loss. Some data suggest that motivational interviewing assists in promoting
more healthful eating habits, increasing physical activity, and improving
weight status in adults, but these findings are not consistent (Berg-Smith
et al. 1999; Dunn et al. 2001; Smith et al. 1997). Thus far, only two pedi-
atric weight-loss interventions have employed motivational interviewing
techniques, and these are the Healthy Lifestyles Pilot Study (Schwartz et
al. 2007) and Go Girls (Resnicow et al. 2005). The Healthy Lifestyles Pi-
lot Study, conducted from 2004 to 2005, was aimed at the prevention of
overweight among children ages 3–7 years (Schwartz et al. 2007). Pediat-
ric Research in Office Settings clinicians were trained to provide motiva-
tional interviewing to patients during office visits. Patients in the control
group received usual care, whereas those in the minimal intervention
group received one motivational interviewing session and those in the in-
tensive intervention group received two motivational interviewing sessions
during office visits. At 6-month follow-up, patients in the minimal inter-
vention and intensive intervention groups showed a trend of decreasing
BMI-for-age percentiles, although results were not statistically significant.
Decreases in families’ eating-out behavior and high-calorie snacking were
also noted. Thus, although children’s weight changes failed to reach signif-
icance, this study demonstrated the feasibility of implementing a physician
office–based obesity prevention program using motivational interviewing.
Go Girls was a church-based nutrition and physical activity program de-
signed for overweight African American adolescent females. In one of the
treatment conditions, girls received four to six motivational interviewing
telephone counseling calls focused on participants’ progress. Unfortu-
nately, both 6-month and 1-year follow-up assessments indicated no sig-
nificant BMI differences between the motivational interviewing group and
control subjects. Thus, at present, insufficient data exist to determine the
efficacy of motivational interviewing for the prevention or treatment of
pediatric obesity in children (Resnicow et al. 2006).
Key CBT Techniques Targeting

Pediatric Obesity
A variety of CBT techniques are used to target obesity (see Chapter 5 for
how some of these same techniques assist with depression in children). Sev-
eral techniques are broad-based CBT concepts that may overlap with tech-
niques presented in other chapters throughout this book. These key

ingredients can be broken down into behavioral and cognitive facets, linked
by the fact that cognitive change is the primary aim of CBT. (Note that some
data also support the efficacy of pharmacological and surgical interventions
in the treatment of the most severe cases of pediatric obesity; see “Sug-
gested Readings and Web Sites” at the end of this chapter for sources).
Behavioral Facets
Dietary Guidelines
The National Heart, Lung, and Blood Institute and The Obesity Society
recommend low caloric intake that is intended to induce a caloric deficit
greater than 500 kcal/day and thus assist children in losing approximately
0.5–1 pound per week. Moreover, specific guidelines are given for girls try-
ing to lose excess body weight, with consideration given to medical factors
(e.g., a certain percentage of calories should come from protein versus car-
bohydrates).
Physical Activity
The American College of Sports Medicine recommends 60 minutes per day
of physical activity for children. Physical activity refers to any movement
that occurs throughout the course of the day. For obese patients, small, man-
ageable changes typically lead to an increased heart rate and subsequent
weight loss. Therefore, physical activity during a CBT obesity treatment
should focus on activities targeted to the abilities of obese patients.
Self-Monitoring
Self-monitoring, or recording food intake (time, amount, calories, rela-
tionship to mood) and physical activity (type, duration, steps taken), is the
most important skill taught in standard behavioral programs. Being able to
accurately measure caloric intake and energy expenditure assists patients
and their families in reaching weight-loss goals.
Goal Setting
Setting goals is important for achieving success and overcoming challenges.
In a CBT obesity treatment, setting weekly reasonable goals for nutrition,
physical activity, and general lifestyle (i.e., positive thinking) is a major
component.
Stimulus Control and Family Involvement

Family-based involvement is a key CBT component in managing the partici-
pant’s environment. Research on adolescent obesity treatment indicates that
family involvement is crucial for maximized success (Epstein et al. 1995).
Family members are educated about the relationship between obesity and
depression, as well as ways to help the participant engage in a healthier life-
style. Moreover, the essence of stimulus control in pediatric obesity consists
of removing the high-risk foods from the home. Given that some family
members may feel as though “this is not fair,” we discuss the concept that
everyone in the family can benefit from healthy lifestyle changes.
Relaxation Training
Diaphragmatic breathing, progressive muscle relaxation, and guided imag-
ery are also taught during the intervention, to help the participant cope
with stressful situations. As more data show that aberrant eating patterns
may be due to emotionally stimulating events, relaxation training becomes
an even more salient component of obesity treatment.
Behavioral Activation
The participant is reminded to increase time spent in pleasurable activities
on a daily basis. Given the nature of obesity, small, manageable aspects of
behavioral activation are discussed (e.g., putting tennis shoes on as a first
step to being more active).
Homework and Between-Session Assignments

Patients are encouraged to set their own goals, especially surrounding food
intake and energy expenditure. Because CBT encourages practice between
sessions, patients may be assigned “experiments” or to set their own goals.
Cognitive Skills
Problem Solving
This lifestyle skill is emphasized to address healthier food intake, more
consistent and variable physical activity, and roadblocks to positive think-
ing. In the intervention, problem solving is encouraged by identifying what
the problem is, generating different solutions, and evaluating the conse-
quences of each solution.
Cognitive Restructuring
When using this critical component of CBT for obesity, the coach (i.e.,
therapist) encourages the participant to identify dysfunctional thinking
and identify more adaptive, countering ways to reduce negative thinking.
By the end of the intervention, participants should be able to provide
countering alternatives to minimize stressors and maladaptive thinking
surrounding the presenting problem.
Relapse Prevention
This skill is used to help reinforce the CBT model and monitor for recur-
rence of weight gain and/or depression and to prepare for future stressors.
Further, the distinction between lapses (“slip-ups”) and relapses is dis-
cussed with the patient to prevent lapses from becoming relapses.
Healthy Bodies, Healthy Minds:

A Manualized Intervention
Leonard Epstein and colleagues have shown that family-based lifestyle
change—including the incorporation of exercise into daily living (Epstein et al.
1995), decreasing sedentary behaviors (Epstein et al. 2008), and dietary
changes (Epstein et al. 2001)—promotes greater decreases in percentage
overweight in children. In the creation of Healthy Bodies, Healthy Minds
(HBHM), we have expanded on Epstein’s family-based weight management
program (the Traffic Light Diet; Epstein and Squires 1988) to incorporate
more client-centered tools for adolescents with PCOS (e.g., introducing a
healthy plate that incorporates a starch, protein, and fruit or vegetable with
appropriate portions for each meal; following a <5 g fat/>2 g fiber/<10 g
sugar guideline; increasing pedometer steps per day), along with motivational
interviewing concepts to elicit intrinsic motivation while decreasing resistant
behaviors (Table 11–1 shows key components of Epstein’s program that have
been integrated into HBHM). In addition, we incorporated depressive targets
from the manual for Primary and Secondary Control Enhancement Training
for Physical Illness (PASCET-PI; Szigethy et al. 2007, 2009; see Chapter 10
for discussion of this model) to target depressive symptoms in these physically
ill adolescents. The resulting intervention, HBHM, showed favorable initial
results in a pilot trial (Rofey et al. 2009b), which has recently been extended
to recruit adolescents with PCOS and depression, who are then randomly as-
signed to the HBHM manualized treatment versus treatment as usual.
HBHM uses CBT and motivational interviewing to educate and moti-

vate PCOS patients to make lifestyle changes through eight intensive one-
on-one sessions with a behavior coach. Each session begins with the behav-
ior coach going over the manualized treatment (i.e., the content of each
session) for approximately 45 minutes. After the content is reviewed, the
coach or an exercise physiologist completes 15–20 minutes of physical ac-
tivity with the patient. The type of physical activity is provided on the ba-
sis of the participant’s interest (e.g., walking, video, resistance training,
cardio) and depending on her level of existent physical movement. An em-
phasis is placed on healthy lifestyle goals, and secondarily, on the impact
that positive thinking (i.e., decreasing depressive symptomatology) can
have on the participant. Moreover, there is an attempt to reduce stigma
and increase compliance by emphasizing the health focus and decreasing
pathologizing the patient. The therapist is typically referred to as a coach;
several focus groups were conducted that indicated the participant’s desire
to “avoid psychotherapy.” The reasoning behind this term is not to under-
mine the utility of mental health counseling but instead to increase intrin-
sic motivation, because many adolescents with PCOS have failed therapy
on numerous occasions.
Following the intensive portion of the intervention, in which the partic-
ipant meets on a weekly or biweekly basis with her coach, treatment contin-
ues with three booster sessions, in which the participant meets monthly
with the coach to check in on her progress. During the entire intervention,
family involvement is strongly encouraged as data show this to be one of the
best predictors of obesity management and depression treatment.
Empirical Research and Results

In HBHM, facets of PASCET (Szigethy et al. 2007; Weisz et al. 2009)
were adapted to treat depression in a physically ill sample, and aspects of
Epstein’s family-based pediatric weight management program (the Traffic
Light Diet) and additional motivational interviewing–compliant goal set-
ting were used to target improving nutrition, increasing physical activity,
and decreasing sedentary behavior. Epstein’s weight management program
has been empirically validated since the 1980s and in more than 25 ran-
domized controlled trials (e.g., see Epstein and Goldfield 1999; Epstein et
al. 1981, 1984, 1985, 1995, 2000, 2001, 2008). The PASCET model has
been repeatedly validated in youth with obesity and depression and in
youth with depression and physical illness (see Chapter 10 for extensive
empirical evidence of this treatment).
Two trials have been conducted testing this specific, combined treat-
ment. First, an open trial (Rofey et al. 2009b) was conducted to evaluate the
TABLE 11–1. Key components of the Traffic Light Dieta incorporated

into Healthy Bodies, Healthy Minds
Component Description
Self-monitoring Writing down food intake and steps

taken in an effort to heighten self-
awareness.
Stimulus control Getting high-fat, high-calorie foods out
of the house to decrease temptation.
Family-based components Having a supportive person who assists
the child in weight-loss endeavors and
serves as a model or coach.
Traffic Light Guide (caloric restriction) Focusing on increasing foods with < 2 g
of fat (i.e., GREEN foods),
moderating foods with 2–5 g of fat
(i.e., YELLOW foods), and
decreasing foods with >5 g of fat
(i.e., RED foods).
Decreasing sedentary time and Limiting screen time per night
increasing physical movement (excluding schoolwork) and assisting
the child to identify fun ways to move
that incorporate everyday lifestyle
activities (e.g., walking) and
purposeful exercise (e.g., playing
soccer).
a Epstein and Squires 1988.
feasibility and effectiveness of an enhanced CBT, HBHM, for physical (obe-

sity) and emotional (depression) disturbances in adolescents with PCOS.
Twelve adolescents with PCOS, obesity, and depression underwent eight
weekly sessions and three family-based sessions of CBT enhanced by life-
style goals (nutrition and exercise), a physical illness narrative (meaning of
having PCOS), and family psychoeducation (family functioning). Weight
showed a significant decrease across the eight sessions, from an average of
104 kg (SD±26) to an average of 93 kg (SD±18). Depressive symptoms
on the Children’s Depression Inventory (CDI) significantly decreased, from
a mean of 17 (SD±3) to a mean of 9.6 (SD±2). This open trial revealed
that a manual-based CBT approach to treat depression in adolescents with
PCOS and obesity appears to be promising.
Subsequently, a comparative treatment trial has been under way for ap-
proximately 2 years. Changes to enhance the weight management portion of
the current HBHM manual include the following: more nutritional compo-
nents addressing eating healthy with PCOS; extension of treatment from 8

sessions to 11 sessions through a combination of 4 weekly sessions, 4 bi-
weekly sessions, and 3 monthly booster sessions; and incorporation of more
motivational interviewing. Fifty participants (thus far) have participated in
this comparative treatment trial. By the end of the trial, 63 participants will
have received HBHM and approximately 50 participants will have received
treatment as usual. Currently, 50 patients receiving HBHM have experi-
enced significant decreases in weight, from an average of 105.82 kg
(SD=25.94) to an average of 104.10 kg (SD=26.20), and a decreased
score on the CDI, from a mean of 13.85 (SD=8.48) to a mean of 10.05
(SD=8.92). A similar trend was seen between session 1 and session 11 (the
last booster session), with weight significantly decreasing, from an average
of 103.63 kg (SD=21.42) to an average of 99.30 kg (SD=23.10), and de-
creased CDI scores, from an average score of 12.11 (SD=6.24) at session 1
to 7.36 (SD=6.45) at session 11. Although recruitment for the treatment-
as-usual group (i.e., standard endocrine management of PCOS) has not been
completed, data from 39 participants with PCOS who received treatment
as usual showed that they gained approximately 2 pounds (starting
weight = 99.8 kg [SD = 20.6] and posttreatment weight = 101.2 kg
[SD=23.6]) over the same time frame as young women receiving HBHM,
who lost, on average, approximately 2 pounds. These data will continue to
be collected, with an end goal of a randomized controlled trial that incorpo-
rates other sites across the country to recruit the number of adolescents
with PCOS needed to exhibit findings that can be generalized.
Treatment Overview
Table 11–2 provides an overview of the behaviors targeted in HBHM. This
11-session “dose” is an initial active-phase treatment for adolescents with
obesity and co-occurring mood disturbance presenting within a clinical set-
ting. Because 8–12 sessions have been empirically validated for adoles-
cents with major depression and 4–12 sessions have been associated with
significant initial weight loss for adolescents presenting to outpatient obe-
sity centers, an 11-session intervention is implemented. However, the ac-
knowledgment needs to be made that longer, more intensive HBHM
treatments may be more efficacious.
Family-Based Sessions
Incorporating the family into the treatment plan is crucial for success. Of-
ten, parents and other family members dictate what food choices the ad-
olescent has at home. Additionally, the lifestyle habits of adolescents tend
TABLE 11–2. Overview of behaviors targeted by session in

Healthy Bodies, Healthy Minds
Session Behaviors
1 Overview of the program, description of healthy eating and

physical activity, and difference between dieting and lifestyle
change
2 Logging food and movement, reading food labels, and avoiding
food traps
3 Managing emotions, avoiding sneak eating, and psychological
versus physiological hunger
4 Using the Traffic Light Guide and other self-selected tools to
increase health and wellness
5 Staying motivated, increasing physical activity, everyday lifestyle
movement, and decreasing sedentary behavior
6 Changing self-talk to be more positive, developing a healthy body
image and self-esteem
7 Being more self-aware with regard to eating, being active, and
staying positive
8 Overcoming barriers; planning ahead for healthy meals, special
occasions, and eating out
Monthly booster sessionsa
1 Coping with polycystic ovary syndrome

2 Adjusting to the Healthy Bodies, Healthy Minds plan
3 Reflecting on the intervention
a Subsequent to eight sessions above.
to be heavily influenced by parents’ habits; therefore, targeting and work-

ing with parents is important. Through three parent sessions, HBHM
strives to motivate parents to make changes to the home environment and
to serve as coaches for their child. (For clarity in further discussion,
“coach” will refer to the therapist or behavior coach, and not to the parent
as coach, unless otherwise indicated.)
The first parent session focuses on creating a home environment that en-
courages healthy eating habits. During this session, the behavior coach dis-
cusses ways that the parents can create this environment through their grocery
store purchases and cooking habits (e.g., baking instead of frying foods). Ad-
ditionally, parents are encouraged to create an eating environment that en-
courages healthy food consumption habits (e.g., eating meals as a family).
Many parents cannot easily cook every meal at home due to time constraints,
so the coach also addresses ways that parents can encourage healthy food
choices when dining out, complete with calorie charts from many restaurants.
The second parent session focuses on parenting strategies that the par-
ent can use to encourage healthy behaviors and discourage less healthy
habits. The coach will discuss the difference between reinforcement and
punishment, describing in detail the difference between positive rein-
forcement (giving something to encourage a behavior) and negative rein-
forcement (taking something away to discourage a behavior). During this
session, the coach guides and encourages parents to use positive reinforce-
ment (such as praise) by describing the utility of this strategy. The coach
also provides brief assertiveness training and techniques for setting limits
and rules within the home.
The third parent session focuses on preparing parents to serve as coaches
at home by providing an overview of the content that the behavior coach
has covered with the participant during the intervention. Here, the behavior
coach describes all of the tools that the participant has been educated to use
so that parents can encourage use within the home environment.
Motivational Interviewing Components

While CBT serves as the empirically validated therapeutic approach in
HBHM and teaches adolescents how to reduce their physical and emotional
disturbances, motivational interviewing techniques elicit health behavior
change by enhancing intrinsic motivation (Resnicow et al. 2006). An engage-
ment session that transpires at the first meeting with each participant uses
the key principles of motivational interviewing (Miller and Rollnick 2002):
suspension of the clinician’s assumptions, use of open-ended questions, ex-
pression of empathy and reflective listening, rolling with patients’ resistance,
working with change and adherence talk, and supporting the patients’ self-
efficacy. HBHM draws on motivational interviewing components to en-
hance the likelihood that adolescents with PCOS who are struggling with
weight and mood disturbances will enter, attend, and participate actively in
the CBT protocol. In this modified therapy, CBT and motivational inter-
viewing serve as complementary approaches.
Asking open-ended questions, encouraging the patient to tell her own
story, seeking elaboration on important or unclear points, and identifying
and affirming strengths are common themes throughout the HBHM inter-
vention. Motivational interviewing emphasizes the potential for partici-
pants’ own goals, preferences, values, and ideas about what is healthy or
adaptive. The work of motivational interviewing is to place the patient’s
personal perspective at the center of the discussion and not to have the be-
havior coach express his or her own desires (i.e., for the coach to avoid the
impulse of “righting the wrong”).
Suspension of behavior coach’s biases. Most coaches inevitably bring

a set of values and beliefs about what constitutes healthy or adaptive be-
haviors, especially in the case of pediatric obesity, where health is of ut-
most concern. Although these values and beliefs cannot (and should not)
be eliminated, the coach must work to suspend them during the encounter
with the patient. Moreover, although the coach may have significant expe-
rience reading about therapeutic intervention strategies, the patient is the
only expert on her own life. At specific points during the interview, the cli-
nician does take on an expert role, providing psychoeducation about de-
pression and overweight and about the nature of CBT. However, even at
these moments, the coach does not insist on his or her own perspective in
the face of patient resistance, but the clinician either defers to the pa-
tient’s expertise on her own life or offers his or her own views as alterna-
tives for the patient to consider if the patient is willing to do so.
Open-ended questions. The coach employs open-ended questions

throughout HBHM. Unlike closed questions, open-ended questions can-
not be answered with a “yes” or “no” and do not pull for specific informa-
tion; rather, they draw the patient out and encourage her to express her
thoughts, feelings, and concerns. Open-ended questions can be used both
to gently guide the direction of the session and to encourage the patient to
elaborate on something the clinician believes is important. There will be
times when the clinician will be talking more; however, in general, the pa-
tient should talk for two-thirds of each session.
Empathy and interpretations using reflections. Empathy is defined as

an accurate understanding of the patient’s communications and experi-
ence, as if from inside the patient’s world. The clinician expresses empa-
thy through the technique of reflective listening, in which the patient’s
words, meanings, and/or feelings are communicated back to the patient in
the form of a statement. These statements are made with humility, given
that clinicians can never be certain that their understanding is correct, and
presented in a warm, accepting, nonjudgmental manner. Although clini-
cians may go beyond the explicit statements the patient makes and convey
their understanding of the underlying meanings or feelings that the patient
is expressing, clinicians do not make interpretations of the patient’s hidden
motives or of the presumptive causes of the patient’s behavior.
Affirmations. Just as in CBT, the clinician is not neutral, but is a support-

ive advocate for the patient’s well-being. Affirmation—or expression of
sincere appreciation by the clinician of the patient’s efforts and strengths

in coping with life challenges or the patient’s participation in the treatment
process—is an effective way of communicating this support.
Summarizing. Bringing together several of the patient’s previously ex-

pressed thoughts, feelings, or concerns, often including the coach’s under-
standing of how these fit together, has several important functions.
Summarizing can help the coach ensure correct understanding of the pa-
tient’s situation, help the patient see connections between things she has
been saying (linking summaries), and prepare the way for the coach to
shift focus or move on to the next part of the session (transitional summa-
ries). Patients are almost always more willing to follow the coach once they
feel confident that their own agenda has been understood.
Working with resistance talk. Patients are expected to be ambivalent

about whether they are really depressed, need to lose weight, or want to
be working more intensively with a coach. From this perspective, resis-
tance simply reflects the negative side of ambivalence, and rather than
challenging or confronting it, the clinician seeks to understand and work
with it (i.e., rolling with resistance). Techniques for working with resis-
tance include the following:
• Working with change and adherence talk: Change talk and adherence talk
are the “positive” side of ambivalence—indications that the patient desires
to work at overcoming her eating habits, physical activity behavior, or de-
pression. A patient’s change and adherence talk also indicate that she
would like to receive help, sees a need for treatment and/or change, has
reasons for committing to treatment and/or change, or believes she has the
ability to succeed at changing or sustaining a commitment to treatment.
• Supporting self-efficacy: Self-efficacy refers to a patient’s beliefs about
how likely she is to succeed at something she tries to do. Self-efficacy
plays a key role in engaging patients in treatment. No matter how much
the patient comes to believe she needs support, a patient who doesn’t
believe that she can succeed at treatment is unlikely to try very hard to
stick with it.
S Case Example
Mary, a 16-year-old, overweight, depressed adolescent girl diagnosed with
PCOS, was referred by her family doctor. Mary currently lives at home
with her parents, who are also overweight, and her older brother, who is
athletic and is not overweight. Mary is currently in the eleventh grade and
attends a local public high school.
Mary has been overweight for most of her life, and she currently has a
BMI of 32. In addition to struggling with weight-loss issues, most recently,
Mary has found herself struggling academically and socially: her grades
have plummeted from As and Bs to Cs and Ds, and she is brutally teased
by her classmates because of her weight. Mary states that she has stopped
doing her homework because she won’t do well on it anyway, and she re-
cently failed a science test. Mary has started to eat her school lunch by her-
self because she is teased when she eats with classmates.
Mary finds herself feeling depressed 4 out of 7 days of the week and
often isolates herself during these periods, preferring to spend time alone
in her bedroom watching television or sleeping. Mary’s mother states that
during these episodes, Mary is irritable and argumentative and usually ends
up crying when confronted. Lately, Mary has been truant from school, re-
fusing to attend school at least once a week because she “feels sick.”
Mary often finds herself feeling out of control when she is eating, and
these bingeing episodes usually occur during her postschool snack. In the
past, Mary has tried a national weight loss program, a popular fad diet, and
diet pills. She lost weight with all three approaches but gained it all back
within a few months. Mary states that she eats fast food weekly and knows
that she “shouldn’t” because it is “bad.” Mary is frustrated and believes
that she is incapable of losing weight permanently and believes that nothing
will ever work, so why should she try?
At the beginning of the therapeutic intervention, Mary, a straight talker,
quickly admitted that she is not happy to be seeing a counselor and feels that
her mother is forcing her to be involved. Mary states that she doesn’t care to
be told what to do by someone who doesn’t understand her personal situation.
However, by Mary’s second session with her new counselor, she has admitted
that she does not dread attending sessions anymore. She has started to consis-
tently complete her in-between session assignments but always prefaces her
discussion about them by saying that she’s sure that she “didn’t do it right.”
Application
Session 1: Introduction to the Program
During this session, the behavior coach will introduce the purpose of The
PCOS Lifestyle Program. The coach will discuss the definition of lifestyle
change and how this differs from a diet. There will be ongoing conversa-
tions about all-or-nothing thinking and how it may be more helpful to the
patient to engage in behaviors that are sustainable. The concept of weight
maintenance, gain, and loss will be elucidated using calorie-in/calorie-out
scales with an emphasis on caloric intake and energy expenditure. Also, it
may be helpful to discuss the patient’s previous successes or failures,
which may serve as building blocks for future goals.
The next objective of this session is to discuss the link between PCOS
and depression and to assess how the participant is personally affected by
depression. The coach will help the participant to connect sadness through
emotions, thoughts, and behaviors (Appendix 11–A, Worksheet 1). Note
that some patients may have depressive symptoms but not depression per
se. Coaches should be cognizant of how they phrase “depression” and al-
low the adolescent to claim or disclaim the symptoms. Assist the adoles-
cent in making a connection between family history, stressful life events,
PCOS, and focusing on negative experiences. Following this discussion, a
general overview of CBT and how it can help with weight loss and mood
is provided. The coach also introduces the general concepts for the ACT
and THINK acronyms: that people can control their feelings by 1) how
they act and/or 2) how they think (see Chapter 10, Appendix 10–A, for
the ACT and THINK chart).
The session includes a get-acquainted exercise designed to build rap-
port, in which the participant talks about three of her strengths. This ex-
ercise not only allows the coach to get to know the participant but also
serves to emphasize positive thinking over negative self-thoughts. Note
that some participants may be so depressed that they cannot think of three
strengths. If this happens and the coach has given the participant plenty of
silence, the coach should help the patient in order to reduce any discom-
fort in the first session. For example, the coach can say, “Would it be OK
if I shared something with you that I noticed from our work today that
I think is one of your strengths?” Additionally, depending on rapport, the
coach can then highlight the fact that the participant had difficulty coming
up with three strengths. This observation can serve as a building block to
emphasize empowering the participant to think positively, both generally
and about herself. Following this exercise, the participant sets three spe-
cific lifestyle goals to accomplish over the course of the program (Appen-
dix 11–A, Worksheet 2). Note that if the participant sets a specific weight-
loss goal, direct her to break it down into behaviors that are realistic (not
idealistic) and that could lead to weight loss.
Toward the end of the session, the coach should also start the weight
tracker (Appendix 11–A, Worksheet 3) that will be used at the beginning
of each session when the participant gets weighed. Discuss what it feels
like for the participant to get weighed. In very rare exceptions, weights are
not shared with the participant; otherwise, explain that actual weight is
important as a concrete measure of behavioral changes that the participant
is making throughout the program.
The session concludes with an explanation of the first practice assign-
ments:
1. Having the participant monitor her mood using the Mood Monitoring
sheet (Appendix 11–A, Worksheet 4).
2. Setting goals for the next week (Appendix 11–A, Worksheet 2).
3. Using the ACT and THINK chart before the next session (Chapter 10,
Appendix 10–A).
Session 2: Eating Well With PCOS

There are four main goals for session 2:
1. Discuss lifestyle goals and wellness accomplishments over the past week.
2. Review the ACT and THINK chart.
3. Introduce the PCOS food pyramid.
4. Establish food and activity logging.
To begin the session, thermometer ratings are used to gauge the partic-
ipant’s perception of her current levels of eating healthy, being active, feel-
ing good, and feeling bad (Appendix 11–A, Worksheet 5). Research has
shown that in adolescents with depression, feeling “good” and “bad” are
actually two distinct facets of emotion. In other words, on separate mood
thermometers for feeling good and feeling bad, an adolescent can feel
mildly good but still feel really bad (i.e., depressed kids ruminate about
bad things but have difficulty savoring good events). After the participant
states a number, ask what that number means to her. The coach can also
use motivational interviewing to better understand why the number is a 5
and not a 4. The coach will also discuss the worksheet “What It’s Like
When I Feel Good” (Appendix 11–A, Worksheet 6) with the participant.
At this point, focus on helping the patient to identify that feeling good isn’t
just a feeling, but that it makes other people feel a certain way toward her
and that it has somatic and behavioral consequences as well.
Proper nutrition plays a large role in the management of PCOS, and
this session focuses on how to eat healthy with PCOS. For the next several
pages of the manual (not provided here), allow the patient to read the in-
formation about a healthy diet, if she would like to. We don’t want this ac-
tivity to get too monotonous, especially if the patient already knows the
material. Instead, focus on the fact that even very minimal weight loss has
a long-standing impact on health. Also emphasize that the participant is
not going on a diet, but instead making lifestyle changes that will become
part of her life. The coach then discusses different weight management
tools (the PCOS Pyramid, 5/2/10 Guideline, Healthy Plate [Appendix
11–A, Worksheets 7–9, respectively], and the Traffic Light Diet) but en-
courages the participant to select only those tools that work best for her.
This session concludes with a discussion about the role that self-moni-
toring plays in weight loss with a focus on 1) tracking weight, 2) monitor-
ing food and physical activity, and 3) making conclusions about the
relationship between weight and mood. Lifestyle and mood goals are set
for the following week.
Session 3: Managing Your Emotions

There are five objectives for session 3:
1. Discuss goals and accomplishments over the past week.

2. Review the lifestyle log and how it was to wear the armband.1
3. Learn about emotional eating versus overeating.
4. Introduce the concept of craving and how to pay attention to hunger.
5. Explore self-talk and common cognitive errors.
The coach will start this session by reviewing the concept of emotional
eating versus overeating and explore whether these are challenges for the
patient. The coach will discuss these concepts by normalizing both types of
eating and attempting to elicit intrinsic motivation to identify these situa-
tions. The participant may have a lot of shame surrounding these concepts,
and at times, her self-disclosure may also be warranted. If nothing is dis-
closed, the coach can say something like “Other young women with PCOS
share with me that after school is their high-risk time. And I guess carbs are
the hardest to resist.” The coach will also address how negative thinking can
lead to emotional eating by reviewing different cognitive distortions (e.g.,
“I’ve always failed when I’ve tried to lose weight, so I’ll never be able to”);
revealing what negative self-talk (e.g., “I didn’t go to the gym today so my
weight loss efforts are a total failure”) can lead to, with a focus on eating
and wellness (e.g., concession of weight loss goals); and discussing how to
overcome overeating. The coach will want to return to the ACT and
THINK chart to illustrate that some of the skills used for addressing nega-
tive mood can also help with overeating and emotional eating.
Next, the session focuses on overcoming overeating by discussing food
cravings and PCOS. Many women with PCOS experience food cravings,
1As part of the HBHM research protocol, participants wear a BodyMedia

SenseWear armband that measures physical activity and sleep. Participants are
given a watch that records the number of steps they take each day. The armband
not only provides data for the research protocol, but it also serves to provide
insight to the participants. Summaries are provided to each participant the session
after she wears the armband.
especially for starchy foods. The coach will discuss that these cravings can
sometimes lead to overeating, but more importantly, will focus on pointers
for combating food cravings cognitively. When cravings won’t stop, the
coach also provides pointers for how to cope with them behaviorally.
There are worksheets to complete after review of the session. One of
the most important worksheets for this program is the cognitive restruc-
turing worksheet, Cognitive Self-Monitoring (Appendix 11–A, Worksheet
10). Generally, the coach completes the first example provided and asks
for the patient to provide another example to elucidate the concept. Em-
phasize that the “Countering (alternatives, evidence)” column may be the
most challenging. Stress the importance of using material from this session
in the patient’s daily life after she leaves the session meeting place. Be-
cause the coach and patient exercise at the end of each session, coaches
periodically meet participants outside the clinical setting. Relaxation train-
ing is also incorporated. Typically, coaches allow the patient to pick one of
three relaxation methods (deep breathing, imagery, or progressive muscle
relaxation), but some patients may want to try each one. Feel free to be
creative and let the patient guide the activity (e.g., yoga with deep breath-
ing). Encourage the patient to practice these skills (e.g., turning negative
thoughts into positive thoughts, relaxation training).
Session 4: The Traffic Light Guide

There are three objectives for session 4:
1. Educate about nutrition labels.

2. Introduce the Traffic Light Guide (Epstein and Squires 1988).
3. Discuss portion sizes.
The coach will discuss nutrition labels with the participant; typically, the
patient may know what the nutrition label shows but may feel confused
about exactly what to concentrate on changing. Go back to the 5/2/10 guide-
line and ask if the patient has used this tool. Explain that the Traffic Light
Guide is yet another tool that she may find helpful. Emphasize that some
people like it, whereas others find it too elementary. Overall, >5 g fat=RED
food, 2–5 g fat=YELLOW food, and <2 g fat=GREEN food. Although re-
ducing red foods to one or two per day is a goal, ask the participant what
would seem reasonable for her. Encourage the patient to record the red foods
as an in-between session assignment and to reduce those foods by one or two
items the subsequent days until she reaches the goal that was agreed on.
Explain that the Traffic Light Guide fits well with the PCOS Eating
Plan. The PCOS Eating Plan contains primarily green and yellow foods,
and the coach can use the PCOS Pyramid (see Appendix 11–A, Worksheet
7) to help guide appropriate serving sizes. Focus on portion sizes and por-
tion distortion. Be aware that most adolescents know this information but
that implementing the knowledge is a challenge. Remember to set goals
with the patient: logging food intake, physical activity, and mood; labeling
red foods consumed; and any other goals.
Session 5: Having Fun While Moving

1. Discuss physical activity.

2. Discuss My Activity Pyramid.
3. Set physical activity goals.
The coach will begin this session by eliciting from the participant what
she thinks the difference is between physical activity and exercise and dis-
cussing her response. Physical activity is any activity that causes the body
to work harder than normal and can involve a number of daily tasks,
whereas exercise is a planned, structured, and repetitive movement done
to improve or maintain physical fitness.
Additional ways in which physical activity can be increased should be
discussed. The coach will also discuss the different types of physical activ-
ity with the participant: aerobic exercise—activity that increases breathing
and heart rate; resistance exercise—exercise that increases the ability to
exert or resist force and makes the muscles stronger; and stretching—
activity that improves flexibility by warming up and lengthening the mus-
cles. After showing the participant the activity pyramid (Appendix 11–A,
Worksheet 11), probe for understanding. Ask about anything that stands
out or that she finds surprising. Clarify any confusion. At the end of the
session, help the participant set realistic physical activity and exercise goals
to complete before session 6. Although working out every day is ideal, em-
phasize realistic goals. Share with the participant that setting idealistic
goals sometimes leads to failure and an exacerbation of negative mood
symptoms. Set physical activity goals and encourage the participant to use
her pedometer to increase the number of steps taken.
Session 6: A Focus on Body Image

1. Introduce and define body image.

2. Discuss myths that impact body image.
3. Introduce eight steps for building a better body image.
Body image is a concept that most participants have explored in the

past. The coach should discuss how the patient defines body image and
how her thoughts about her body affect her behavior using the worksheet
provided for the session (not included here). This session also includes a
list of myths about body image. Going through each myth and discussing
whether the participant has heard it before and whether she believes it can
be helpful. Then discuss why it is not true, referring to the facts section
underneath each myth. Last, the coach shares with the participant a list for
developing a healthier body image, Eight Steps for Building a Better Body
Image (Appendix 11–A, Worksheet 12). Read through this list with the
participant, or have the participant look through the list, and discuss the
steps that she would find most helpful or that stand out for her. Goals for
this session include identifying lifestyle goals (see Appendix 11–A, Work-
sheet 2) and completing the body image worksheet, Helpsheet for
Change: My Desire for Change (Cash Body Image Workbook 1997).
Session 7: Being More Self-Aware

There are four objectives for session 7:
1. Introduce and define self-awareness.

2. Discuss challenges to maintaining a healthy lifestyle.
3. Introduce the STEPS problem-solving worksheet (see Chapter 10,
Appendix 10–A).
4. Discuss in-between session assignments.
First, assess the patient’s level of familiarity with the term self-aware-
ness, asking what she thinks it might mean. Many participants have never
heard this term used before in this context, so it is important to discuss its
meaning. Once the general definition is discussed and understood, discuss
what it means to be aware when eating. This type of self-awareness in-
volves focusing on what she is eating and drinking and noticing all of the
physical and mental sensations that occur before, while, and after the item
is consumed. Next, the coach should discuss awareness of physical activity.
Start by assessing what the participant thinks this could mean and discuss-
ing her experience with physical activity awareness. Awareness of physical
activity generally means noticing how her body feels when in motion:
breathing, heart rate, muscle movements, posture, coordination, and flow
(or being “in the zone”). Discuss with the participant whether she has ex-
perienced any of these things during physical activity. Last, discuss the par-
ticipant’s awareness of her mood. This means paying attention to her
emotions, knowing how she is feeling, and recognizing ways that she can
change her emotions. The coach can then practice the mood awareness ac-
tivity with the patient by focusing on the patient’s ability to control her
emotions (Appendix 11–A, Worksheet 13). Note that more succinct dis-
tinctions for the concepts of mood, emotion, and affect are given in other
manualized treatments but that HBHM focuses on overall emotion, and at
times, depressive symptoms.
During this session, the coach will also discuss challenges to maintain-
ing a healthy lifestyle. The coach will talk about food temptations that
seem to be everywhere, inappropriate portion sizes that have become
common practice, and environmental cues that can signal overeating. Al-
low the participant to openly talk about challenges that she may face.
Given that most people encounter problems and challenges throughout
life, it is important to learn how to effectively manage them. During this
session, the coach will introduce the STEPS worksheet, allowing the par-
ticipant to apply this method of problem solving to an example that she
has faced recently.
This week, the participant should complete the STEPS worksheet for
one challenge she faces between now and the next session. Talk about jour-
naling and how this relates to self-awareness, and set a goal with the par-
ticipant for her to journal a certain number of days. Set any additional
wellness goals that the participant would like to achieve.
Session 8: Planning Ahead for

Continued Success
There are two objectives for session 8:
1. Review wellness goals from previous sessions, the STEPS problem-

solving worksheet, and any journaling.
2. Discuss strategies for planning to make healthy choices.
The coach should make sure that the participant understands how to
use the problem-solving worksheet when faced with a challenge; see if the
participant can state the challenge, brainstorm possible solutions, weigh
pros and cons of each solution, try one out, and assess whether that solu-
tion worked. Planning ahead for the future is important to ensure future
success when challenges are faced. During this session, the coach will dis-
cuss with the participant ways to plan ahead for daily meals, snacks, phys-
ical activity, special occasions, and challenges to positive thinking. An
entire packet is available highlighting healthier choices while dining out,
with a special emphasis on meals and foods that fall within the 5/2/10
guideline. Because this is the last session in the intensive intervention (be-
fore the monthly booster sessions), goals are set that highlight continued
change. Encourage the patient to call to move the appointment to an ear-
lier date if challenges arise. Commend the participant for completing the
intensive part of the intervention and make sure to set wellness goals.
Booster Sessions
After the intensive part of the intervention, participants are encouraged to
attend three monthly booster sessions. For some young women, these are
maintenance sessions where they check in on their weight and mood. For
others (and contrary to the outcome in some pediatric obesity treat-
ments), young women begin to use the skills that they have learned and
begin to lose more weight and feel more positive. Booster session 1 con-
centrates on the patient’s physical illness narrative (see Chapter 10, Ap-
pendix 10–A). This serves to assist the coach and patient in better
understanding what it means for the patient to have PCOS. Booster ses-
sion 2 focuses on living with PCOS and attaining support from the pa-
tient’s environment. Topics that may be discussed consist of support
networks and feeling uncomfortable talking with peers about having
PCOS. Booster session 3 centers on reflecting not only about the program
but also about having PCOS (Appendix 11–A, Worksheet 14). Although
some participants decide that this session is the end of their HBHM jour-
ney, we offer participants follow-up sessions in our clinical PCOS pro-
gram.
Conclusion and Caveats

Obesity in pediatric and adolescent populations has reached epidemic pro-
portions in the United States. Depressive disorders in children are com-
mon, recurrent, and impairing. Depression is prevalent in 1%–2% of
children and 3%–8% of adolescents (Lewinsohn et al. 1998). Existent in-
terventions for obese adolescents have excluded patients experiencing co-
morbid conditions. Given the long-standing link between obesity and
depression and the questions many providers have expressed about which
disorder to treat first, HBHM provides an infrastructure with a model
physical illness (PCOS) in which adolescents present frequently with both
obesity (~70%) and depression (~50%). Fortunately, several evidence-
based pediatric obesity and depression treatments have been successful in
promoting weight loss and in improving mood in adolescents. As reviewed
here, the inclusion of complementary therapeutic strategies has been

shown to be effective in enhancing standard pediatric weight management
programs. As can be seen in Chapter 5, similar strategies have been shown
to be efficacious in childhood depression. Both behavioral (Aragona et al.
1975; Brownell et al. 1983; Coates et al. 1982; Epstein and Wing 1980;
Epstein et al. 1995; Flodmark et al. 1993) and cognitive (Brownell et al.
1983; Coates and Thoresen 1981; Senediak and Spence 1985; Williams et
al. 1993) techniques, used in conjunction with dietary and activity change
strategies, have demonstrated favorable results for weight loss and depres-
sion remittance in adolescents.
By targeting dietary, activity, and other behavioral skills in both adoles-
cents and parents, family-based behavioral programs have been shown to
be more effective than targeting children alone (Epstein et al. 1981; Ep-
stein et al. 2008) and benefit all family members by encouraging reciprocal
weight loss and a positive home environment between parent and child
(Wrotniak et al. 2004). Although data supporting the efficacy of motiva-
tional interviewing techniques in weight-loss interventions are sparse,
these strategies may provide additional safe, cost-effective methods for
enhancing motivation for behavior change, especially in psychiatrically ill
adolescents who have repeatedly failed at weight loss or mood improve-
ment. Even in more severe cases of obesity, when practitioners may con-
sider additional approaches such as pharmacotherapy or bariatric surgery,
these therapies can make a significant contribution to enhancing patients’
quality of life and compliance with the weight-loss intervention (Kal-
archian and Marcus 2003). Moreover, careful consideration of which
patients may benefit from this combined intervention is crucial. For exam-
ple, providers should think of excluding patients from HBHM who have a
family history of major depressive disorder, have been hospitalized for psy-
chiatric reasons in the past, or have active suicidal ideation. In these cases,
a more direct CBT approach to treat only the depressive disorder, possibly
along with antidepressants, should be considered.
Key Clinical Points

• Many facets that underlie maladaptive eating and a lack of physical
activity also relate to problematic mood symptoms.
• Before the introduction of Healthy Bodies, Healthy Minds (HBHM),
most pediatric obesity interventions excluded adolescents with co-
morbid mood symptoms. A manualized treatment, HBHM aims to
provide more broad-based CBT techniques that will assist an ado-
lescent struggling with both weight management concerns and
mood symptomatology.
• Although CBT serves as the content for HBHM treatment, motiva-

tional interviewing components assist in working with adolescents
who may exhibit resistant behaviors. However, the motivational in-
terviewing components of HBHM are not be appropriate for adoles-
cents with depression who need more intensive treatment (see
Chapter 5 for their treatment).
• HBHM was validated for adolescents with PCOS who exhibit difficul-
ties abiding by healthy lifestyle goals, as well as managing their de-
pressive symptoms. Carefully selecting patients who may benefit
from HBHM is crucial in optimizing the likelihood of its utility. For ex-
ample, if a patient presents with long-standing, recurrent, severe
major depressive disorder, more intensive treatment that targets
solely mood symptoms may be warranted. Conversely, patients
who have depressive thinking secondary to body image concerns
and compromised self-esteem may greatly benefit from HBHM.
• Although CBT and motivational interviewing skills are summarized
as a blueprint, this intervention may need to be individualized on the
basis of each patient’s needs. Many adolescents with PCOS and/or
obesity may have difficulty with cognitive skills required for CBT.
Moreover, cultural and age-specific aspects from the patient’s per-
spective need to be addressed to optimize treatment outcome.
• Although the sessions are numbered sequentially, patients will cy-
cle back to previous sessions on an as-needed basis. Frequently,
adolescents will learn a skill and then regress due to either a lapse
or environmental circumstances.
• Continuation of CBT treatment is effective in preventing relapse
once weight maintenance and positive thinking are achieved.
11.1. Which is not typically a psychological correlate of adolescent obesity?
A. Low self-esteem.
B. Compromised body image.
C. Depression.
D. Obsessive-compulsive traits.
11.2. Why is polycystic ovary syndrome an appropriate physical illness for

a CBT approach?
A. CBT helps adolescents restructure their psychosomatic complaints.

B. CBT assists adolescents in better understanding why they are obese.
C. CBT can target both the obesity and depression that these ado-
lescents may experience.
D. CBT can activate adolescents to exercise more frequently.
11.3. Which comorbid condition may CBT assist in the treatment of ado-
lescents with obesity and depression?
A. Obsessive-compulsive disorder.
B. Posttraumatic stress disorder.
C. Eating disorder not otherwise specified.
D. Alcohol dependence.
11.4. Which of the following is not a key strategy used during motivational
interviewing as a complementary approach to CBT?
A. Open-ended questions.
B. Nondirective empathy.
C. Affirmations.
D. Reflective listening.
11.5. An 8-year-old boy comes into the clinic with a body mass index per-
centile of 99.9. He complains that his family has a lot of high-fat,
high-calorie food in the home. Both parents are obese, and they
question why they should have to change their habits for their child.
Which of the following CBT techniques is most logical to employ
with this child and his family?
B. Self-monitoring.
C. Stimulus control.
Suggested Readings
and Web Sites
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dissemination, adoption, and implementation of motivational inter-
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www.motivationalinterview.org
Motivational Interviewing Network of Trainers: Provides resources for infor-
mation on motivational interviewing; includes general information
about the approach, as well as links, training resources, and information
on reprints and recent research. www.motivationalinterviewing.org
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Appendix 11–A
Healthy Bodies, Healthy Minds:
Selected Patient Worksheets

Worksheet 1
The Guiding Principles of Wellness
Thoughts
Emotions Behaviors
How our emotions, thoughts, and behaviors are connected:
Negatives Bring Us Down.

Negative thought Negative behavior Negative emotion
I look terrible. I’m not going out tonight. Sadness
Negative thought Negative behavior Negative emotion

I’ll never pass the I’m not studying. Hopelessness
test anyway.
Positives Bring Us Up.

Positive thought Positive behavior Positive emotion
My friends like me. Going out will help me. Happiness
Positive thought Positive behavior Positive emotion

I can do well if I try. I’m going to study for the test. Confidence
Appendix 11–A: HBHM Selected Patient Worksheets 421

Worksheet 2
Healthy Lifestyle Goals

Now, take some time to think about three specific lifestyle goals that you would like to begin to work
toward. It is important to be as specific as possible and to write down the steps that you will take to
achieve these goals. We also will ask you to think of barriers (that is, things that may get in the way
of success) and ways that you can overcome these challenges. Make sure to be realistic, not idealistic,
so that your goals can be achieved.
Goal 1:
To achieve this goal, I/we will:
Goal 2:
Goal 3:


Worksheet 3
Healthy Bodies, Healthy Minds

Weight Tracker
Initials:
Gender:
Birth date:
Session Height Weight BMI Percentile
10
11
12

Worksheet 4
Mood Monitoring
Practice assignment: During the next week, write down what your mood was for most of each
day (e.g., bored, happy, sad, angry, irritable, grumpy). Rate your mood for the day on a scale of
1–10 (1 being worse mood/more bored than ever, 10 being best mood ever/rarely bored). Then
write down what good and bad things happened that day.
Changes
Mood Good things Bad things in my eating
Describe rating that happened that happened (e.g., felt like
mood (1–10) today today eating more or
Day less than usual)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday

Worksheet 5
Ratings
Eating Healthy Being Active
10 Wonderful 10 Wonderful
5 Better than Nothing 5 Better than Nothing
1 Not so Well 1 Not so Well
Feeling Good Feeling Bad
10 Great 10 Worst Ever
5 OK 5 OK
1 Not so Well 1 Not so Bad


Worksheet 6
What It’s Like When I Feel Good

Things I do or things that happen to me that make me feel good:
How my body feels when I feel good:
How I look when I feel good:
What thoughts I have when I feel good:
How I act when I feel good:


Worksheet 7
Tool 1: The PCOS Pyramid

The PCOS Pyramid reflects current nutrition recommendations for girls
and women who have PCOS. To be sure you’re getting the nutrients you
need, we recommend you make choices according to the pyramid.
At the end of this session, we have provided copies of this pyramid, which
you can use daily to help guide your food choices.
Sweets
Lower
sugar varieties
1 serving
Fats & ils

(healthy O fats)
Olive and cano
nuts, flaxseeladoils,
3-4 servings
Dairy
Low-fat milk, Meat
yogurt, cheese Fatty fis
3 servings lean meat/ph, ou
3 servings ltry
Whole Gra
Pasta, bread, ric ins
e, cere
4-6 servings als
Fr
Fresh and frozeuits
n whole fruits Vegetables
3 servings Non-starchy ve
geta
5 servings bles

Worksheet 8
Tool 2: Reading Nutrition

Labels & the 5/2/10 Guideline
The Nutrition Facts label can be used to help you choose healthier items.
To choose healthy items, it is important to look at the fat, fiber, and sugar content
of the food. Too much fat or sugar may cause weight gain and too little fiber may leave
you feeling hungry. Healthier items will have less than 5 grams of total fat per serving,
more than 2 grams of fiber per serving, and less than 10 grams of sugar per serving.
Start by looking at the labels of items you have at home and decide if the foods
are healthy items to keep around the house.
This is the recommended serving size.

Nutrition Facts The amounts of TOTAL FAT, FIBER, and SUGAR
Serving Size 1 cup (30g) in this item are for this serving of the food. If you
eat two servings, you will be getting two times the
Amount Per Serving amount of fat, fiber, and sugar.
Calories 111 Calories from Fat 16
% Daily Value*
Total Fat 2g 3% Limit TOTAL FAT to less than 5 grams per serving.
Saturated Fat 0g 2%
Trans Fat
Cholesterol 0mg 0%
Sod ium 213mg 9%
Total Carbohydrate 22g 7%
Dietary Fiber 4g 14% Increase FIBER to at least 2 grams per serving.
Sugars 1g Limit SUGAR to less than 10 grams per serving.
Protein 4g
Vitamin A 10% • Vitamin C 10%

Calcium 12% • Iron 57%
*Percent Daily Values are based on a 2,000 calorie diet.
Your daily values may be higher or lower depending on
your calorie needs:
Calories 2,000 2,500
Total Fat Less than 65g 80g
Sat Fat Less than 20g 25g
Cholesterol Less than 300mg 300mg
Sodium Less than 2,400mg 2,400mg
Total Carbohydrate 300g 375g
Fiber 25g 30g
Calories per gram:

Fat 9 • Carbohydrate 4 • Protein 4
NutritionData.com
By choosing items that fit the guidelines for fat, fiber, and sugar, you will have healthier
foods at home to put together for meals and snacks.

Worksheet 9
Tool 3: Healthy Plate (HP):

HP is a model of how meals should typically look.
Attempt to follow the HP at each meal to eat a nutritious, balanced diet.
It is important to follow the serving sizes listed on the HP as well.
See the Portion cheat sheet.
STARCH:
Rice, pasta, potatoes
Corn, bread, cereal LOW-FAT
FRUIT 1/2 to 1 cup MILK OR YOGURT
SALAD 1 cup
VEGGIES
2 cups total PROTEIN:
Meat (3-4 oz = size of
palm)
Beans (1 cup)
Milk or yogurt (1 cup)
Cheese (1 oz =1 slice)
Peanut Butter
(2 tbsp)
Egg (1)
Now it is time to put what you have learned into action.

LOGGING your eating habits and physical activity plays a very important role in weight
management and lifestyle change.
Benefits of Logging:
Shows eating and physical activity patterns so that you can see your habits
Helps you to plan physical activity into your daily routine
Assists you in identifying benefits and challenges
Helps you set realistic goals to make lifestyle changes
Tracking your weight every week when you meet with us also is useful when
trying to make healthy changes to lose weight.
Session 3: Managing Your Emotions

Worksheet 10
Cognitive Self-Monitoring
Trigger/Event Automatic Anxiety Problem Countering Realistic Anxiety
thought (0–8) (0–100%) (alternatives, problem (0–8)
evidence) (0–100%)
I don’t have It’s because 6 75% Many girls 10% 3

a date for of my looks; weren’t
the prom. no one asked yet.
likes me. There are more
important
things in life.
I have lots of
good friends
and family.
Session 5: Having Fun While Moving

Worksheet 11
My Activity Pyramid* Inactivity:

Cut down
< 2 hrs per day
(TV, computer,
videogames)
Flexibility &
Stre
2-3 times a we ngth:
(stretching, yoga ek
, rope climbing,
push-ups)
Active Aero
bic & Recrea
tional Activ
3-5 ities:
(basketball, so times a week
ccer, swimming
, rollerblading)
Everyday Ac
tivities:
(cleaning your As of
room, taking th ten as possible
e stairs, playing
outside, going
shopping)
* Adapted from the USDA’s MyPyramid by the University of Missouri Extension
These levels correspond to how many calories you are burning. “Inactivity” burns the least number
of calories, whereas “Active Aerobic & Recreational Activities” burn the most, in a short period of time.
You’ll be surprised how many calories you can burn by increasing your “Everyday Activities.” Your
armband and pedometer/watch will help tell you how many calories you are burning on the
weekends that you wear it.
METs are an estimate of the intensity of a particular activity and are based on your resting metabolic
rate (or the amount of energy your body uses while at rest). The higher the MET, the more calories
you burn while doing the activity.
Sedentary activities require less than 2.0 METs and will not help you lose weight.
Moderate activities require between 2.0 and 2.9 METs. They are better than sedentary
activities but not as healthy as vigorous activities.
Vigorous activities require MET levels of 3.0 or higher. They make your body work
hard and will help you to lose weight.
Session 6: A Focus on Body Image

Worksheet 12
Eight Steps for Building a Better Body Image

Step 1: Discover your body image strengths and weaknesses. You have your own distinctive
appearance and your own experience of how you look. Even though someone else may see it
differently, how you see yourself will be our focus.
Step 2: Why do you have a negative body image? We know that body image stems from your
developmental past as well as from the current forces in your life. We will focus on where your beliefs
about your body image originate.
Step 3: A negative body image is emotionally draining. Feeling self-conscious or even ashamed
about your looks impairs your ability to feel in charge of your life.
Step 4: Typically, you feel what you think. How you feel about your looks is influenced by the
beliefs you have about yourself. Most people have assumptions about the importance of looks—
this can sometimes lead to trouble. We discussed these assumptions or myths and their opposing facts.
Step 5: In this step, we will talk about the negative ways of thinking from Session 2 and learn how
to identify these mental mishaps. Identifying the times when you are thinking negatively is a huge
first step to feeling better about yourself.
Step 6: A negative body image may lead you to act in ways that protect you from uncomfortable
feelings (for example, not going out with friends because you don’t like the way you look).
Avoidance can sometimes make your body image worse—after all, it only prevents you from having
fun. Learning that these behaviors are self-defeating will be an important step for change.
Step 7: Creating a positive body image is important. At times (and sometimes frequently),
the negative thoughts will come back, but it is important to recognize these thoughts and challenge
yourself to come up with countering and healthier ones.
Step 8: Planning ahead for possible challenges is an important step for staying healthy. It will be
important to continually check in with yourself to make sure you are staying on track.
Session 7: Being More Self-Aware

Worksheet 13
Activity:
Pretend you are in a room all by yourself and the door is closed. There are a set of knobs on the wall,
and each one has a different label: angry, sad, happy, jealous, selfish, greedy, and humorous.
As you turn each knob, you begin to feel that emotion. You can choose to turn any or all of the
knobs. You can also decide how much you want to turn each knob.
What knobs would you choose? Would you turn them all the way? Let’s assume you step
out of the room and are back to your normal self. Can you be more aware of your mood?
Can you choose to keep some of those emotions after leaving the room?
Create Awareness
The first step to making changes in your food choices, physical activity, and mood begins
with increasing your awareness of your current habits. You have already been doing this by
keeping a journal. You may have found from your own experience with logging that this has
been an important tool for raising your awareness in many areas, such as which foods give you
lasting energy and more satisfaction, what types of physical activity you enjoy, and when you feel
most positive. You are encouraged to continue keeping a journal to help you increase your
awareness of your own unique needs.
Keeping a journal will also show you that you don’t have to “go on a diet” and “exercise all
of the time” to lose weight, but a balanced approach to healthy living will support you in feeling
your best—physically and emotionally.
Booster Session 3: Reflection Activity

Worksheet 14
Reflection Activity:
You have come a long way. We would like to hear your reflections about this process.
What helped you make positive changes?
How could this process have been better?
Compared to the beginning of these sessions, how are you different?
Is there anyone in particular who you would like to thank for his or her
support throughout this process? If so, who and why?
For our purposes, can you please provide feedback on the intervention delivered?
• Are there any changes you would recommend?
• How was it to work with your coach?
• Would you recommend this intervention to someone else?
Anything else you would like to tell us about this process?

12
Disruptive Behavior
Disorders
THE focus of this chapter, disruptive behavior disorders (DBD) in chil-

dren and adolescents, includes the diagnosable disorders of oppositional
defiant disorder (ODD) and conduct disorder (American Psychiatric As-
sociation 2000), as well as behavioral patterns of aggressive, noncompliant,
and delinquent behavior. Children with these recurrent patterns of hostile,
disobedient, and rule-breaking behaviors typically have poor abilities to
self-regulate and inhibit their prepotent impulsive and antisocial behav-
iors. These externalizing behaviors lead to external social reinforcement,
sometimes in unwitting ways from the adults and peers around these chil-
S This chapter has a video case example on the DVD (“Disruptive Behavior”)
demonstrating CBT for an adolescent with oppositional defiant disorder.
435
dren, and can be maintained by children’s social-cognitive processes (Mat-

thys and Lochman 2010).
Empirical Research
Several reviews have examined the efficacy of psychosocial treatments for
conduct problems in children and adolescents in comparison to no treat-
ment or wait-list control conditions (Kazdin 2005; Lochman and Pardini
2008). These reviews indicate that a vast majority of the empirically sup-
ported treatments for conduct problems in youth are based on behavioral
or cognitive-behavioral theoretical frameworks (Brestan and Eyberg 1998;
Farmer et al. 2002; Kazdin and Weisz 1998; Nock 2003). Many traditional
behavioral programs have cognitive-behavioral elements (e.g., stress man-
agement sessions during behavioral parent training), and most cognitive-
behavioral programs have substantial operant reinforcement elements, so
that there are few strictly behavioral or strictly cognitive programs in this
area of psychopathology. Meta-analytic reviews suggest a range of medium
to large effect sizes (0.47–0.90) for cognitive-behavioral interventions tar-
geting conduct problems (for review, see Nock 2003). In addition, re-
search suggests that cognitive-behavioral interventions that include a child
component focusing on social problem-solving and social skills develop-
ment together with a parent-management training component produce
broader positive effects and better maintenance of behavioral improve-
ments over time than interventions with either component in isolation
(Kazdin et al. 1992; Nock 2003; Webster-Stratton and Hammond 1997).
However, the parenting component of these interventions has been shown
to produce particularly robust reductions in conduct problems and delin-
quent behaviors (Beauchaine et al. 2005; Lochman and Wells 2004). Re-
search on cognitive-behavior therapy (CBT) programs has examined CBT
interventions that have both parent and child components and CBT inter-
ventions that focus only on parents or only on children. Parent-only inter-
ventions are more likely to be delivered to families with younger children
with DBD.
In the sections below, we will first briefly summarize the results of in-
tervention research with the Coping Power Program, a CBT program for
preadolescent children with disruptive behaviors. We will also provide an
overview of results of several other examples of treatment and prevention
programs with substantial cognitive-behavioral elements for children with
DBD. These other programs target many of the same cognitive, emotional,
and behavioral processes that are the focus of the Coping Power Program,
and as a group, these programs cover three different developmental peri-
Disruptive Behavior Disorders 437
ods (Matthys and Lochman 2010). Later in the chapter, discussion of the
Coping Power Program components will provide the structure for the dis-
cussion of CBT techniques for children with DBD.
Coping Power Program

The Coping Power Program was derived from earlier research on the An-
ger Coping Program (Lochman 1992). Coping Power has cognitive-behav-
ioral child and parent components (Lochman et al. 2008; Wells et al.
2008). Coping Power was originally designed to be implemented with
fourth- to sixth-grade children in school or clinic settings, but has been
successfully adapted for younger and older children.
In comparison to randomly assigned control groups in two separate
samples (one sample with only boys, the other with both boys and girls),
the Coping Power Program produced decreases in self-reported delin-
quency, substance use, and aggressive behavior at school at follow-up as-
sessments 1 year after the end of intervention (Lochman and Wells 2003,
2004). Results indicated that the Coping Power intervention effects on
lower rates of parent-rated substance use and of delinquent behavior at the
1-year follow-up, in comparison with the control group, were most appar-
ent for the children and parents who received the full Coping Power Pro-
gram with child and parent components (Lochman and Wells 2004). In
contrast, boys’ teacher-rated behavioral improvements in school during
the follow-up year appeared to be primarily influenced by the Coping
Power Child Component. Mediation analyses, using path analytic tech-
niques, indicate that the intervention effect for both intervention groups
on outcomes at the 1-year follow-up were mediated by intervention-pro-
duced improvements in children’s internal locus of control, their percep-
tions of their parents’ consistency, children’s attributional biases, person
perception, and children’s expectations that aggression would not work for
them (Lochman and Wells 2002).
In a dissemination study that used a clinical sample, Coping Power re-
duced the overt aggression of children with ODD or conduct disorder in
Dutch outpatient clinics in comparison with care-as-usual children (van de
Wiel et al. 2007). Long-term follow-up analyses of this sample 4 years af-
ter the end of intervention indicated that the Coping Power Program also
had preventive effects by reducing adolescent marijuana and cigarette use
in children who participated in the Coping Power Program in comparison
with care-as-usual children (Zonnevylle-Bender et al. 2007). Other dis-
semination studies have found that Coping Power reduces externalizing
behavior problems in comparison with control groups when implemented
by regular school counselors in urban and suburban settings (Lochman et
al. 2009); when used with aggressive children in a more abbreviated 24-
session format (Lochman et al. 2006a); when used with children with
DBD in Puerto Rico (Cabiya et al. 2008); and when used with specialized
populations, such as deaf children who have aggression problems in resi-
dential settings (Lochman et al. 2001). Coping Power in dissemination
studies has also been found to reduce children’s disciplinary suspensions
from schools (Cowell et al. 2008; Peterson et al. 2009).
Programs in the Preschool and

Early Childhood Years
Universal Prevention Programs
The Promoting Alternative Thinking Strategies (PATHS) program is an ex-
ample of a teacher-delivered universal prevention program that seeks to
promote general social-emotional competencies and cognitive skill build-
ing in elementary school children (Greenberg and Kusché 2006). Results
at 1- and 2-year follow-up indicated that children receiving the PATHS in-
tervention were better at understanding emotions, were better at problem
solving, and had reported decreases in self-reported and teacher-reported
conduct problems and externalizing behavior compared with children in
control groups (Greenberg and Kusché 2006; Greenberg et al. 2001).
Treatment and Targeted Prevention Programs

The Incredible Years program includes parent training, a child training pro-
gram (Dinosaur School), and a teacher component for young children with
DBD (Webster-Stratton 2005). Research findings regarding the effective-
ness of the Incredible Years parent, child, and teacher training interven-
tions alone and in combination have been impressively replicated across
multiple samples. The parent training component has repeatedly pro-
duced significant reductions in child conduct problems at home, in school
with teachers, and with peers; decreases in negative parenting; and in-
creases in positive parenting in comparison with wait-list control condi-
tions (Webster-Stratton and Hammond 1997; Webster-Stratton et al.
2004). In addition, evidence suggests that overall improvements evident in
reductions in children’s behavior problems as the result of the parenting
intervention can still be seen at 3-year follow-up (Webster-Stratton
1990). The Incredible Years child intervention has also been shown to pro-
duce significant reductions in the amount of conduct problems children
exhibit at home and school and to produce increases in social problem-
solving skills in comparison with wait-list control conditions (Webster-

Stratton and Hammond 1997; Webster-Stratton et al. 2004). The inclu-
sion of both child and parent components produced the most significant
improvements in children’s behavior at 1-year follow-up (Webster-Strat-
ton and Hammond 1997).
Programs in the Preadolescent Years

The Seattle Social Development Project (SSDP) is a universal prevention
program designed to reduce aggression by creating a positive school envi-
ronment. The SSDP includes training for teachers to increase the use of
nonpunitive classroom behavioral management strategies such as positive
reinforcement, and more recent versions of the intervention have also in-
cluded parent training and child problem-solving and social skills training
(Hawkins et al. 1999). Longitudinal research conducted with the SSDP
has found significant prevention or reductions of alcohol use (Hawkins et
al. 1999; Lonczak et al. 2001), reductions in delinquency, a lower fre-
quency of sexual intercourse and number of sexual partners, and de-
creased reports of pregnancy for females and causing pregnancy for males
(Hawkins et al. 1999). In addition, students receiving the prevention pro-
gram reported more positive feelings and stronger commitment to school
compared with control groups, improved academic achievement, and less
student-reported school misbehavior (Hawkins et al. 1999).
Treatment and Targeted Prevention Programs

A program similar in structure to the Coping Power Program in the pread-
olescent age range is the Problem-Solving Skills Training Plus Parent Man-
agement Training (PSST+PMT) program. Similar to Coping Power, this
program has a component addressing parent training and a component ad-
dressing prosocial problem-solving skills among children with DBD. This
program is targeted for school-age children ages 7–13 years who have se-
vere antisocial behavior. Although PSST has been found to do better than
parent management training at increasing children’s social competence at
school and reducing self-reports of aggression and delinquency, a combina-
tion of both treatments is optimal for most outcomes (Kazdin et al. 1992).
The combination of PSST with a parent-focused intervention was found to
produce the greatest improvements in statistical and clinical significance in
reducing children’s aggressive and delinquent behaviors, as compared with
PSST or parent-focused interventions alone (Kazdin et al. 1992).
Programs in the Adolescent Years

The Life Skills Training Program is an example of a universal prevention
program designed to prevent substance abuse in adolescents (Botvin and
Griffin 2004). The program was developed for middle school students.
The program has been shown to be highly effective in reducing alcohol, to-
bacco, marijuana, and polydrug use in a series of randomized controlled ef-
ficacy trials and in two effectiveness studies.
Treatment Programs
The Art of Self-Control is a cognitive and behaviorally oriented group (and
individual) adolescent control program (Feindler and Ecton 1986). Out-
come research for this program, with adolescents in in-school programs for
multisuspended youth and in inpatient and incarcerated settings, has indi-
cated reductions in aggressive and disruptive behavior and improvements
in problem-solving abilities, social skills, cognitive reflectivity, and adult-
rated impulsivity and self-control (Feindler and Ecton 1986).
Multisystemic therapy (MST) is an intensive family- and community-
based treatment program that has been implemented with chronic and violent
juvenile offenders, substance-abusing juvenile offenders, adolescent sexual of-
fenders, youth in psychiatric crisis (i.e., homicidal, suicidal, psychotic), and
maltreating families (Henggeler and Lee 2003). MST is an individualized in-
tervention that focuses on the interaction between adolescents and the multi-
ple environmental systems that influence their antisocial behavior, including
their peers, family, school, and community (Henggeler et al. 1992). Although
the techniques used within these treatment strategies can vary, many of them
are either behavioral or cognitive-behavioral in nature (e.g., contingency man-
agement, behavioral contracting). Evaluations of the effectiveness of MST
with chronic and violent juvenile offenders have produced promising results.
Several investigations have shown that families who receive MST report lower
levels of adolescent behavior problems, improvements in family functioning at
posttreatment, and lower recidivism in a 4-year follow-up in comparison with
alternative treatment conditions (Borduin et al. 1995; Henggeler et al. 1992).
Conceptual Framework
A contextual social-cognitive model serves as the basis for many CBT pro-
grams for children and adolescents with DBD and is based on empirically
identified risk factors that predict children’s antisocial behavior (Lochman

and Gresham 2008). As children develop, they can experience an accumu-
lation of risk factors, increasing the probability that they will eventually
display serious antisocial behavior (Loeber 1990). Malleable risk factors
that are incorporated into CBT interventions include risks in the family
context, in the peer context, and in social cognitive processes and emo-
tional regulation.
Family Factors
A wide array of factors in the family can affect child aggression, ranging
from poverty to more general stress and discord within the family (Loeber
and Stouthamer-Loeber 1998). Children’s aggression has been linked to
general family background factors, such as parent criminality, substance
use and depression, poverty, and stressful life events. All of these family
risk factors interrelate with one another, build on one another, and in turn,
can influence child behavior through their effect on parenting processes.
Parenting processes linked to children’s aggression (Patterson et al. 1992)
include 1) nonresponsive parenting at age 1, with the pacing and consis-
tency of parent responses not meeting children’s needs; 2) coercive, esca-
lating cycles of harsh parental demands to child noncompliance starting in
the toddler years, especially for children with difficult temperaments;
3) harsh, inconsistent discipline; 4) unclear directions and commands;
5) lack of warmth and involvement; and 6) lack of parental supervision and
monitoring as children approach adolescence. The relations between
parenting factors and childhood aggression are bidirectional, as child tem-
perament and behavior also affect parenting behavior (Fite et al. 2006).
Peer Factors
Children with disruptive behaviors are at risk for being rejected by their
peers. Aggressive children who are also socially rejected exhibit more se-
vere antisocial behavior than children who are either aggressive only or re-
jected only (Lochman and Wayland 1994). The match between the race
of students and their peers in a classroom influences the degree of social
rejection that students experience (Jackson et al. 2006), and race and gen-
der appear to moderate the relation between peer rejection and negative
adolescent outcomes. For example, Lochman and Wayland (1994) found
that peer rejection ratings of African American children within a mixed-
race classroom did not predict subsequent externalizing problems in ado-
lescence, whereas peer rejection ratings of white children were associated
with future disruptive behaviors. Similarly, whereas peer rejection can pre-
dict serious delinquency in boys, it can fail to do so with girls (Miller-

Johnson et al. 1999).
As children with conduct problems enter adolescence, they tend to as-
sociate with deviant peers. Adolescents who have been continually re-
jected from more prosocial peer groups because they lack appropriate
social skills turn to antisocial cliques for social support (Miller-Johnson et
al. 1999). The tendency for aggressive children to associate with one an-
other increases the probability that serious antisocial behavior will later oc-
cur (Fite et al. 2007).
Social Cognition
On the basis of children’s temperament, biological dispositions, and con-
textual experiences with family, peers, and community, children begin to
form stable patterns of processing social information and regulating their
emotions. A contextual social-cognitive model (Lochman and Wells
2002), based on social information processing theory (Crick and Dodge
1994), stresses the reciprocal interactive relationships among children’s
initial cognitive appraisal of problem situations, their efforts to think about
solutions to the perceived problems, children’s physiological arousal, and
their behavioral response. The level of physiological arousal will depend on
the individual’s biological predisposition to become aroused and will vary
depending on the interpretation of the event (Williams et al. 2003). The
level of arousal will further influence social problem-solving, operate to in-
tensify the fight-or-flight response, and interfere with the generation of so-
lutions. Because of the ongoing and reciprocal nature of interactions, it
may be difficult for children to extricate themselves from aggressive be-
havior patterns.
Aggressive children have cognitive distortions at the appraisal phases of
social-cognitive processing because of difficulties in encoding incoming so-
cial information and in accurately interpreting social events and others’ in-
tentions. In the appraisal phases of information processing, aggressive
children have been found to recall fewer relevant nonhostile cues about
events (Lochman and Dodge 1994), and reactively aggressive children
have a hostile attributional bias, as they excessively infer that others are
acting toward them in a provocative and hostile manner (Dodge et al.
1997; Lochman and Dodge 1994).
Aggressive children also have cognitive deficiencies at the problem-
solution phases of social-cognitive processing. They tend to have domi-
nance- and revenge-oriented social goals (Lochman et al. 1993), which
guide the maladaptive action-oriented and nonverbal solutions they gener-
ate for perceived problems (Dunn et al. 1997; Lochman and Dodge 1994).
Aggressive children frequently have low verbal skills, which contributes to

their difficulty in accessing and using competent verbal assertion and com-
promise solutions. When aggressive children consider possible solutions to
socially challenging situations, they evaluate aggressive behavior in a posi-
tive way at the next processing step (Crick and Werner 1998) and expect
it will lead to positive outcomes for them (Lochman and Dodge 1994).
Deficient beliefs at this stage of information processing are especially char-
acteristic for children with proactive aggressive behavior patterns (Dodge
et al. 1997) and for youth who have callous-unemotional traits consistent
with early phases of psychopathy (Pardini et al. 2003). Indeed, children’s
schematic beliefs and expectations affect each of these information pro-
cessing steps (Lochman and Dodge 1998; Zelli et al. 1999).
Application
Cognitive-behavioral interventions are frequently applied to the treatment
of conduct problems in children and adolescents, and a number of CBT
programs have been developed for this purpose. As noted earlier, CBT pro-
grams are available for preschool-age children, school-age children, and ad-
olescents. Some CBT programs focus on prevention of conduct problems,
whereas others are designed to treat youth with clinical diagnoses. Still
other differences among CBT programs involve the inclusion of multiple
components (e.g., parent training, teacher consultation) and program
length. Nonetheless, most CBT programs for youth with conduct prob-
lems incorporate common elements such as goal setting, rewards, manag-
ing anger, and problem solving. In the following sections, cognitive-
behavioral elements for treatment are described, using the Coping Power
Program as an example.
Coping Power Child Component

The Coping Power Child Component (Lochman et al. 2008) is a 34-
session manualized cognitive-behavioral intervention targeting aggression
and other disruptive behaviors in fourth- through sixth-grade students.
Originally designed for delivery to small groups of students in schools, the
program has been successfully adapted for use with individual students
and for implementation in clinical settings. With minor modifications, the
program is also appropriate for younger elementary and middle school stu-
dents. Coping Power groups typically include five to seven students and
two coleaders, one of whom takes on the role of delivering the program
content while the other coleader monitors and manages group behavior.
Coping Power group leaders meet with students individually on a monthly

basis to build rapport, assess and ensure comprehension of material, and
individualize the program as needed. In the school setting, leaders also
maintain regular communication with classroom teachers.
The Coping Power Child Component curriculum comprises seven
main foci: goal setting, organization and study skills, emotion awareness,
anger management, perspective taking, social problem-solving, and han-
dling peer pressure (examples of these activities are discussed later in this
chapter in the section “Main Foci”). Sessions are highly structured, follow-
ing a standard format of recurring opening and closing activities with topic-
based, session-specific activities in between.
Group Behavior Management

A group behavior management system is included in the program, incor-
porating rewards for appropriate behavior and consequences for disruptive
behaviors. A token economy forms the basis of the behavior management
system. Students earn points for following group rules, for appropriate
participation in group activities, and for completion of program-related ac-
tivities between sessions (e.g., working toward individual goals, as de-
scribed later in the section “Goal Setting”). Leaders provide warnings or
“strikes” for inappropriate behaviors, and students lose the opportunity to
earn a point after three such warnings. When disruptive behaviors con-
tinue after this consequence is delivered, students may be excused from
the remainder of the session. At the end of each session, students are given
the opportunity to visit the program’s prize box. Small prizes worth only a
few points are available, but students are encouraged to delay gratification
and work toward accumulating points to purchase more desirable items.
Opening Activities
At the beginning of each session, ask students to recall key points from the
previous session, and conduct a brief review of the previous session’s con-
tent. Next, ask students to produce their weekly goal sheets for review.
The goal sheets are an integral part of the Coping Power Program, serving
as the main tool by which students practice target behaviors between ses-
sions. Goal sheets also provide students and leaders with feedback about
the students’ behavioral progress in the classroom. Each week, students
and leaders work together to identify an individualized, operationally de-
fined target behavior (e.g., “I will complete my math class work before go-
ing to the computer”). On a daily basis, teachers provide written and
verbal feedback to the child. At the end of the week, students bring their
goal sheets to the Coping Power meeting and are awarded one point for
each day the goal was achieved.
Closing Activities
At the end of each session, ask each student to provide positive feedback
to another student in the group, commenting on the student’s prosocial
behavior during the meeting or on a time the other child used appropriate
coping between the previous and current meetings. Next, review points
earned by each student during the meeting, announce point totals, and al-
low students to spend or save their points. Finally, award a brief free-play
period to all students who have displayed appropriate behavior during the
meeting. This activity serves as a reward for the students as well as an op-
portunity for leaders to observe peer interactions, providing coaching and
support as needed. Students who fail to earn the free-play period use the
time to discuss their difficulties with a leader and to problem-solve better
choices for future meetings.
Main Foci
Goal setting. The initial Coping Power Child Component sessions in-
troduce the concept of goal setting, a theme that is continued for the du-
ration of the program. Obtain input from teachers, then help students to
identify personally meaningful long-term goals to work on for the current
school year (e.g., to raise Cs to Bs, to be promoted to the next grade). As-
sist students in breaking down these long-term goals into manageable
steps. For example, a student who strives to raise his or her grades might
identify daily short-term goals such as accurately writing down homework
assignments, bringing books home, and completing and turning in home-
work. Students can then use these short-term goals on the weekly goal
sheets. Students may work on a short-term goal for 1 week or several
weeks, until they have mastered the goal or until it is apparent that the goal
requires modification for the student to achieve success.
Other activities in the goal-setting component involve students inter-
viewing or listening to an interview with an adult who set goals during his
or her youth and later achieved them. Community leaders, local business
owners, and college athletes can be effective role models for this task.
Organization and study skills. Given the frequency with which exter-
nalizing problems co-occur with behavioral difficulties in the school set-
ting, the Coping Power Child Component includes two sessions that
directly address students’ study habits. Have students discuss the impor-
tance of organization to academic success and participate in activities that

highlight the effectiveness of good organization. For example, ask students
to bring their backpacks to the meeting and direct them to find a common
item (e.g., pencil, list of spelling words) as quickly as possible. Next, help
students to organize their materials, then complete the activity again, not-
ing the decreased time and effort required to locate items when the back-
pack has been organized. Other activities involve identification of helpful
and unhelpful study habits and planning for completion of larger projects.
Games and role-plays are used to bring the concepts to life for students.
Emotion awareness. As a precursor to anger management training, stu-

dents participate in several sessions designed to normalize the experience
of various emotions and to help them accurately recognize and label their
feelings. Help students to describe various emotions in terms of associated
physiological sensations, behaviors, and cognitions. Next, have students
use a thermometer analogy to help them recognize the range of intensity
with which emotions occur. Labels are given to emotions at varying levels
on the thermometer (e.g., “annoyed” at the bottom, “mad” in the middle,
and “furious” at the top). These activities are helpful to students who
might experience their feelings in an on-off manner, failing to recognize
the range in intensity of their experience and resultantly missing early op-
portunities to manage their angry feelings. Subsequently, use the ther-
mometer analogy to help students recognize that different events may
evoke different levels of anger for them. For example, classroom noise may
cause them to feel annoyed and a teacher’s reprimand may lead them to
feel mad, whereas they may become furious when peers make disparaging
comments about their family members.
Anger management. Students learn several active strategies for self-

control in the anger management unit, including distraction, relaxation, and
coping self-statements. Assuming they have learned to recognize their earli-
est signs of anger in the emotion awareness sessions, students can imple-
ment anger management skills before they become flooded with emotion
and while their anger is still at a manageable level. To help them manage low
levels of anger, have students participate in distraction exercises in which
they practice directing their focus away from an annoying situation. For ex-
ample, other group members can be directed to make noise and taunt a tar-
get student while he or she engages in a memorization task. By concentrating
on the task, the student learns that he or she can keep his or her anger from
escalating and that thinking about or doing other things can be an effective
way to control angry feelings. Additionally, teach relaxation techniques,
such as progressive muscle relaxation exercises and guided imagery.
A sequence of progressively more challenging activities is built into the

program to teach students to use coping self-statements (e.g., “I won’t let
this get to me”) to manage their anger. In the initial activities, have stu-
dents use puppets to practice using self-statements in response to peer
teasing. Using puppets keeps the task fairly impersonal, allowing students
to focus on learning the skill without eliciting strong feelings. When stu-
dents demonstrate proficiency with the puppet task, make the task more
challenging by having one student use coping statements in response to di-
rect taunts by other group members. Closely monitor this activity, as it is
designed to elicit mild to moderate levels of anger in students. Provide
coaching or interrupt the activity if students demonstrate problems main-
taining control. Although the activity can be challenging for leaders and
students, the experience of appropriately managing anger in a real-to-life
situation can be particularly salient and corrective for students.
Perspective taking. The next set of sessions targets the problems with
perspective taking commonly seen in children with disruptive behavior
problems. The clinician can engage students in discussions and role-plays
to illustrate individual differences in perspectives. For example, have stu-
dents act out a situation and then interview each other about their percep-
tions of the events. The differing viewpoints highlight how the same event
can be perceived differently by different people. Lead additional role-
plays and games to foster awareness of how difficult it can be to accurately
understand another person’s intentions. Because the tendency to make
hostile inferences about others’ intentions is common among Coping
Power participants, make sure to encourage students to consider more be-
nign alternatives. Lead activities involving perspective taking in peer rela-
tionships and in interactions with teachers. For example, students can be
asked to interview a teacher, asking questions that allow the teacher to cor-
rect common student misperceptions about disciplinary procedures and
classroom management.
Social problem-solving. Work with students to develop mastery in the

use of a structured social problem-solving model, PICC, in problem situa-
tions. The PICC model comprises three steps: 1) Problem Identification,
2) Choices, and 3) Consequences. In the first step, help students learn to
carefully assess the problem situation and to define the problem in objec-
tive, behavioral terms. In the second step, have students generate a list of
possible choices that could be enacted in response to the problem. Encour-
age students to think broadly about choices, and accept even “bad” choices
as discussion points for the next step. In the third and final step, ask stu-
dents to discuss the likely consequences for each of the choices that have
been proposed. Clarify the benefits of choosing prosocial options, as well

as the negative outcomes associated with aggressive and antisocial solu-
tions. Finally, have students rate the various choices and consequences and
identify the solution with the highest likelihood of success. Use hypothet-
ical problem situations as well as examples of problems from students’
own lives to illustrate the use of the PICC model. Include peer conflicts,
problems with siblings, and teacher-student problems.
As a final activity in the social problem-solving unit, work with stu-
dents to create a video that explains and demonstrates the PICC model in
action. Have students decide on a problem situation to portray, generate
ideas for depicting several choices and consequences, write a script, and
act out their ideas on video. The activity provides an engaging way for stu-
dents to solidify their understanding and to gain additional practice using
the PICC model.
Handling peer pressure. The final sessions in the curriculum focus on

peer relationships, and a main goal of this unit is for students to learn to
identify and effectively manage peer-pressure situations. Discuss the
meaning of peer pressure and reasons students might give in to it. Help
students identify a variety of ways to resist peer pressure, such as making
an excuse and finding other friends to hang around with. Lead students in
role-plays to practice using the strategies. Also discuss peer pressure that
may occur outside school (e.g., in students’ neighborhoods) and open the
discussion to general neighborhood problems if relevant (e.g., violence and
gang activity). Have students discuss their involvement in groups or
cliques, and encourage them to consider the implications that associating
with various groups might have for them. Ask students to self-identify per-
sonal strengths and leadership qualities and discuss how they can use their
abilities to become involved with prosocial peer groups.
Coping Power Parent Component

The Coping Power Parent Component includes sixteen 90-minute sessions
that are held during the same 16- to 18-month time period as the child ses-
sions. Parent groups are led by two coleaders and include up to 12 parents
or parent dyads. Many elements of the Coping Power parent sessions de-
rive from well-established parent training programs and focus on nurturing
positive parenting skills. Parent sessions also include a focus on stress man-
agement, building family cohesion and communication, and family prob-
lem-solving. Moreover, an additional aim of the parent sessions is to teach
parents how to reinforce the skills their children are learning in their
groups. Although new content is introduced to parents in each session, all
sessions include a review of previous session content and activities to facil-

itate the generalization of skills (e.g., interactive worksheets, role-plays,
homework). Leaders deliver this intervention in a flexible manner, with an
aim of adapting session activities to best address the specific problems and
issues that group members present. The Coping Power Parent Compo-
nents described below are typical of most programs for parents of youths
with DBD.
Academic Support in the Home

Leaders introduce the idea of a homework completion system that would
allow for increased parent-teacher communication about homework and
thereby promote children’s academic success. Brainstorm possible systems
(e.g., an assignment notebook in which the teacher initials each homework
assignment) and discuss how parent-teacher conferences might provide
additional academic support for children. Provide parents with potential
questions they might ask during these conferences, and role-play with par-
ents. Emphasize that additional support structures are needed to increase
children’s likelihood of homework completion. Strategize with parents
about what support structures might be useful (e.g., a protected home-
work time, in which phone calls are not accepted and the television is off).
Also discuss how parents might monitor their child’s progress. It is impor-
tant to acknowledge parents’ concerns about the level of time and energy
required to implement these strategies. Efforts should be made to help
parents create a system that will work well for them given their particular
demands. Encourage parents to establish a homework system with input
from their child.
Stress Management
Introduce the topic of stress management by defining stress and leading
parents through a discussion of how stress can undermine their positive
parenting behaviors. Ask parents for their ideas about how they might take
care of themselves to reduce stress. Introduce the notion of active relax-
ation as a way to reduce stress. Practice in session, and ask parents to prac-
tice between sessions. In the second session, discuss time management as
a way to reduce stress and introduce the cognitive model of stress and
mood management, in which parents develop cognitive coping strategies
for stressful events and learn to recognize the connection between cogni-
tive perceptions and beliefs and related emotions. In reviewing this model,
discuss how thoughts can contribute to feelings and subsequent behaviors
in parenting situations. Role-play a stressful parent-child situation with
parents and identify the thoughts and feelings that resulted in a behavioral
overreaction by the parent.
Basic Social Learning Theory, Praise, and

Improving the Parent-Child Relationship
Present the basic social learning model using an ABC Chart to introduce
the concepts of antecedents (A), behavior (B), and consequences (C). Dis-
cuss how parents might modify children’s behavior by rewarding good be-
havior with positive consequences. Work with parents to identify positive
consequences (e.g., a favorite dessert, labeled praise) and introduce a
tracking system whereby parents will become more aware of their child’s
positive and negative behaviors. Also introduce the importance of parent-
child “special time” and help parents set goals for special time (e.g., the
number of times per week they will engage with their child in a certain ac-
tivity) for the coming week.
Ignoring Minor Disruptive Behavior

The focus here is on managing children’s minor disruptive behaviors
through ignoring. First define minor disruptive behavior (e.g., changing the
television channel repeatedly) and distinguish these behaviors from more
serious transgressions that cannot be ignored (e.g., beating up a sibling).
Then discuss how to appropriately ignore. Although these discussions lay
important groundwork, the centerpiece of this work is role-play. Leaders
should first model a parent-child interaction in which the parent ignores
the child’s escalating behavior. Parents should then role-play a similar sce-
nario. After these role-plays, engage parents in a debriefing discussion
about what they think about ignoring and how they felt about the role-
plays. Be prepared to address negative reactions parents might have to the
concept of ignoring.
Antecedent Control: Giving Effective Instructions

and Establishing Rules and Expectations
Revisit the ABC Chart and point out the ways in which instructions can be
the antecedents to compliant or noncompliant behaviors. Ineffective in-
structions often precede child noncompliance, whereas clear instructions
often precede child compliance. Identify the qualities of “good” and “bad”
instructions and work with parents to identify specific examples. “Bad” in-
structions include buried instruction (the instruction is buried in other un-
related talk), chained instructions (too many instructions at one time),

vague instructions, and indirect instructions (instruction is given as a ques-
tion). Encourage parents to practice giving good instructions and monitor-
ing whether their child subsequently complies.
A distinction is made between rules and expectations. Behavior rules
establish the behaviors that children should decrease (e.g., hitting),
whereas behavior expectations establish the behaviors that children should
increase (e.g., making the bed). In discussing rules and expectations with
parents, emphasize the importance of labeling rule violations (e.g.,
“Tommy, you just hit your sister and that is against our behavior rules”) so
that children are made more aware of the rules. Also emphasize the im-
portance of keeping expectations age-appropriate. Coach parents in how
to establish behavior rules and expectations at home and encourage them
to track their child’s compliance, their positive reinforcement of compli-
ance, and their labeling of noncompliance.
Discipline and Punishment

Introduce the concept of punishment, provide a definition of punishment,
and explain why physical punishment is often ineffective in curbing chil-
dren’s misbehavior. Solicit parents’ ideas regarding punishments. Intro-
duce the time-out procedure. Outline the steps for time-out, strategize
with parents about how to handle child misbehavior on the way to time-
out and while in time-out, and discuss parents’ reactions and attitudes to-
ward the time-out procedure. Ask parents to identify the behaviors that
will result in time-out and to name their time-out procedures (e.g., loca-
tion, length). Introduce other discipline techniques, such as the removal of
privileges and the assignment of chores. Incorporate role-plays of parents
implementing these discipline techniques and children protesting. These
role-plays will give parents additional practice and aid in the generalization
of skills. Also engage parents in an open-ended conversation about punish-
ment for major misbehavior, with an aim of helping parents find alterna-
tives to physical punishment and lengthy, unspecified grounding.
Family Cohesion Building, Family Problem-

Solving, and Family Communication
Ask group members to invite their spouse, significant other, or other im-
portant caretakers in the child’s life to this session. Discuss parents’ con-
cerns for their child as he or she matures. Emphasize that having a positive,
healthy parent-child relationship will become increasingly important as
the child grows older. Brainstorm strategies for how families might build
their cohesion both in the home (e.g., family game nights) and outside of
the home (e.g., going to a park). Parents are encouraged to follow through
with family cohesion–building activities.
Present the steps of the problem-solving PICC model. Describe (and
show) how through worksheets and videotaped role-plays the children are
coached in this problem-solving model—and encourage parents to use this
model to resolve family conflicts.
Lead parents through a discussion about their ongoing family commu-
nication patterns. Do family members have a way of talking with each
other about their concerns? When someone wants to change a preestab-
lished rule, how is that negotiated? Are family members satisfied with the
way they communicate? Introduce the notion of a family meeting as one
way to preserve positive parent involvement in children’s lives and to
tackle potential problems before they arise. Guide parents through a dis-
cussion regarding how they might establish family meetings at home. Also
present a communication system for helping parents monitor their child’s
outings with peers.
Cultural Issues
Culturally competent clinicians are those who can anticipate the culturally
related appropriateness of, and obstacles to, the use of common assessment
or intervention procedures for children and families. Ethnic and community
factors can require some adaptations in the delivery of CBT for children and
adolescents with DBD (Lochman et al. 2006b), especially among minority
low-income individuals. Parents may model and promote the use of physi-
cally aggressive problem-solving strategies by their greater dependence on
corporal punishment, as well as by actively teaching their children to retal-
iate when confronted with physically or verbally aggressive situations. These
parents’ messages can result from their ongoing struggle to protect their
children from danger in their impoverished neighborhoods and from their
efforts to inculcate responsibility for safety and personal rights. Another
factor that may interfere with easy dissemination of CBT techniques is that
children may receive conflicting messages from parents and other authority
figures (such as school personnel) about the use and value of aggression.
Thus, when working with minority children and families, clinicians should
attend to how contextual variables may have an effect on problem behaviors
and on children’s and families’ abilities to generate a culturally relevant
range of alternative solutions to their problems. These differences require
discussion, and intervention can focus initially on the utility of less aggres-
sive solutions in certain environments (e.g., the child’s school).
Case Examples
The following two case examples illustrate key points and challenges of
CBT for children with DBD addressed through the Coping Power Child
Component and the Coping Power Parent Component.
S Coping Power Child Component

Tim is a 15-year-old boy who has been diagnosed with ODD and attention-
deficit/hyperactivity disorder (ADHD). Tim has been seeing a psychiatrist
for medication treatment for ADHD. His psychiatrist referred him to out-
patient CBT when he continued to exhibit behavior problems while on
stimulant medication.
Clinical challenges: Blames others, has difficulty accepting responsi-
bility for actions, angers easily.
Cognitive techniques demonstrated: Reducing hostile attribution bias,
increasing ability to see things from others’ perspectives, coping self-state-
ments, monitoring emotional activation, generation of alternative solutions.
Behavioral techniques demonstrated: Functional behavior assessment,
behavioral rehearsal, skill acquisition, skill generalization.
Clinician: Your mom said you got in some trouble at school yesterday. Tell
me what happened.
Tim: My teacher is so mean. She always gets on my case, way more than
she does anyone else.
Clinician: So, you feel like your teacher gets onto you a lot. What was it
that she got onto you about yesterday that led to you getting sus-
pended?
Tim: I KNOW my teacher gets onto me a lot. All I did yesterday was get
up to sharpen my pencil, and she put my name on the board.
Clinician: So you got up to sharpen your pencil, and your teacher put your
name on the board. Was that enough for you to get suspended? Your
mom said you spent the rest of the day in the vice principal’s office.
Tim: I got suspended for disrespecting the teacher. I got fed up with her
getting onto me so much and not anybody else.
Clinician: It sounds like you started feeling angry when your teacher put
your name on the board and that you must have said something or
done something that she thought was disrespectful enough to send
you to in-school suspension. What happened after she put your
name on the board?
Tim: I threw my pencil down, and it accidentally bounced off my desk and
hit the teacher. I called her a bad name, too. I wasn’t even saying it
to her. I was just talking to myself. She wouldn’t have even heard me
say it if she hadn’t been standing right in my space. She should just
back off and leave me alone.
Clinician: Is it safe to say that what happened after you got your name on
the board—getting angry, hitting the teacher with your pencil, and
calling her a name—caused you to get suspended?
Tim: Yeah, but it’s all her fault. She lets other people sharpen their pencils
all the time. If she hadn’t made such a big deal out of it, none of that
would have happened.
Clinician: Well, let’s take a look at that. Do you remember when you in-
terviewed your teacher to get to know her better and find out where
she is coming from?
Tim: Yeah.
Clinician: What do you remember learning about her during that inter-
view?
Tim: She didn’t like having a lot of homework when she was in elementary
school, and she even got in trouble for talking too much in class
sometimes.
Clinician: That’s right. And what did she say about why she has rules for
the classroom?
Tim: So that we know what is expected of us and to help us learn.
Clinician: That’s right. And what did she say about what she wants most
for her students?
Tim: She wants us to enjoy learning and do well so that we can get a good
education and have a good life someday.
Clinician: That sounds like what she said. So let’s think again about the
situation that happened yesterday. Do you think she put your name
on the board just to make you mad?
Tim: No.
Clinician: Do you think she put your name on the board just because she
doesn’t like you?
Tim: Maybe—it sure seems like she doesn’t like me a lot of the time.
Clinician: Can you think of any other reason why she might have put your
name on the board?
Tim: Well, I guess maybe she could have just been trying to enforce her
rule. She said that she wants us to get better about staying in our
seats, especially because we’re getting close to testing time. She got
on Jamal’s case for asking to go to the bathroom.
Clinician: Oh, so you weren’t even the only one who got in trouble for get-
ting out of your seat?
Tim: No, I forgot about her getting on Jamal’s case until just now.
Clinician: So do you think that maybe she’s just trying to get better at en-
forcing her rule about staying in your seat as testing gets closer, and
you and Jamal happened to be the first ones who got in trouble now
that she is enforcing the rule more strictly?
Tim: Yeah, that could be it.
Clinician: OK, so let’s think about how the situation might have gone dif-
ferently if you had told yourself that instead. By the way, what did
you say to yourself when your teacher put your name on the board?
Tim: I said, “She’s a [something I can’t repeat].. ..” I said, “She’s mean and
she has it out for me.”
Clinician: And what happened to your anger on your anger thermometer
when you said that to yourself?
Tim: I got real mad and that’s when I threw my pencil.
Clinician: OK, so you’ve given a really good example about the way that
our thoughts are related to our feelings. When you told yourself that
your teacher is mean and has it out for you, you got really angry and
threw your pencil and called her a name, which is what led you to
get suspended. Now, what do you think might have happened if you
had noticed yourself getting angry and said a coping statement to
yourself instead?
Tim: Like what?
Clinician: Like, you could have said to yourself, “Mrs. Stephens seems like
she is getting nervous for our standardized testing, and she really
wants us to do a better job of staying in our seats for the next few
days. I should just not make a big deal of it right now and go back to
my seat and try to borrow a pencil from Terri instead.”
Tim: That probably would have been a better thing to do.
Clinician: That’s an example of a coping statement that you could have
used in the situation with your teacher to control your anger and stay
out of trouble. Now, it’s much easier to talk about using coping strat-
egies to stay calm than it is to do in real life. So how about if we act
out the situation from yesterday and see how it goes? I’ll pretend I’m
Mrs. Stephens, and I’ll start to write your name on the board for get-
ting out of your seat. How about if you start to respond like you did
yesterday, but then try to catch yourself and use a coping statement
instead? We’ll keep acting out the rest of the scene for a while and
see how it goes.
(The clinician and Tim conduct a role-play of the situation.)
Clinician: What did you think of that?

Tim: It went better.
Clinician: What was it like for you to try to use a coping statement to con-
trol your anger when I wrote your name on the board?
Tim: It was hard at first because I wanted to talk back to you, but when
I remembered that Jamal had already gotten in trouble and that you
were starting to get nervous about the testing coming up, it helped
me calm down.
Clinician: Good, so that was an example of how you can use your thoughts
to help keep from getting so angry that you do something that causes
you to get in trouble. As your teacher in the role-play, I noticed that
you responded differently than you usually do, and I felt proud of
you for not getting angry or making it a big deal. That seemed like a
big improvement for you. Do you think it would help you to control
your anger and act that way more often?
Tim: Yeah, probably.
Clinician: Well then, how can you use what we’ve been talking about to-
day to help you have a better week?
Tim: I can try to think of where the other person is coming from and try
to use coping statements to stay calm instead of getting angry.
Clinician: That sounds like a good idea. We’ll see how it goes. Would that be
something you might want to pick as your goal on your goal sheet for
the week? Then you could earn points for working on it, and it could
help you get feedback from your parents and teacher to see how you do.
Tim: Sure.
Clinician: How would you feel about bringing your mom in and telling her
what we’ve been talking about so she knows how to help you work
on your goal this week?
Tim: That’s fine.
Clinician: OK, is there anything else we should talk about before she
comes in?
Coping Power Parent Component

Naomi is a 34-year-old single mother of three children. She has received
prior mental health services to deal with her own mood disorder and a past
abusive relationship. Naomi is currently seeking treatment for her youngest
daughter, Anna (age 8), who has been getting into trouble for fighting and
refusing to follow directions at school. Naomi hardly speaks with Anna at
home because she is too tired when she gets off work to deal with Anna’s
“attitude.” Anna currently spends most of her free time in her room. Anna’s
father lives in a different state, and she sees him one to two times a year.
Clinical challenges: Overextended mother with her own mental
health and social support needs; poor parent-child bond as a result of fre-
quent conflictual parent-child interactions; need for clearer behavioral
contingencies to foster compliance at home; balancing parent and child in-
volvement in therapy.
Cognitive and behavioral techniques demonstrated: Parent-child spe-
cial time, stress management, behavioral monitoring, behavioral contingen-
cies, positive reinforcement, extinction and planned ignoring.
Naomi (with Anna and clinician in the waiting room): Will you want to
meet with me or Anna today?
Clinician: I would like to meet with each of you individually for part of
the time today and to spend some time with both of you together.
Naomi: OK. Who would you like to see first?
Clinician: Anna, do you have a preference about who I meet with first to-
day?
Anna: I don’t care.
Clinician: All right then—because I met with you first last week, Anna, why
don’t I go ahead and meet with your mom first today. There are some
games you can play in the waiting room. Cathy should be at the front
desk the whole time, so let her know if you need your mom or need
anything else, OK? We’ll make sure to get you in about 25 minutes.
Anna: OK.
Clinician (to Naomi as they enter the therapy room): So, tell me how your
week has been.
Naomi: It’s been pretty rough. I had to keep Anna home from school on
Wednesday and Thursday because she got in a fight. The principal really
let me have it when I went to check her back in on Friday. I had to go
without pay those 2 days, so needless to say, I was pretty mad at Anna.
Clinician: Gosh, I’m sorry to hear that. It does sound like you had a diffi-
cult week. Last week, we talked about helping you reconnect with
Anna in two ways. We talked about having you try to set aside some
special time to do an activity with Anna that you thought she would
enjoy to help you two reestablish a positive bond. We also talked
about having you use a tracking grid to catch her being good, to make
sure you’re noticing the times she follows directions, puts effort into
her schoolwork, and helps you out around the house. How did those
things go for you this week?
Naomi: Not very well. I was going to take her shopping on Wednesday
night, but when she got in serious trouble at school that day, I did
not think it was a good idea to reward her like that. Then I had to
work overtime to make up for the days I missed at work, so we have
not had a chance to do that yet.
Clinician: Those do sound like real barriers to doing something special
with Anna this week, like taking her shopping. It’s still important to
not give up on the goal of you two having some positive time to-
gether though, so let’s think about how you might be able to do that
this week. Do you have any ideas about what you could do?
Naomi: Well, it might need to be something that doesn’t cost very much
money, because money is tight right now.
Clinician: That’s fine. The important thing is that you make it a priority and
set the time aside and find something that you think you’ll both enjoy.
Naomi: We both like watching the same singing competition on television,
so I was thinking of asking her if she would like to watch it with me
instead of watching it in her room.
Clinician: That sounds like a nice thing for the two of you to do together.
It would also be nice for you to find something the two of you can
do that is interactive as well. I know you are probably exhausted at
night when you get home from work. Are there any nights that you
get home earlier or that are less hectic for you?
Naomi: I’ve been trying to leave a little bit early on Friday afternoons.
Clinician: Would that be a good day to try to do something with Anna?
Naomi: Actually, it would because her brother and sister go to their aunt’s
house for a few hours after school on Fridays.
Clinician: OK, great. Now, what do you think might be a fun, inexpensive
thing you and Anna could do on Friday?
Naomi: Well, she has been begging me to let her get a pedicure. I don’t
have the money to let her get one at the salon, but I have all of the
stuff to give her one at home.
Clinician: That sounds fun. Have you ever done that before? Do you think
Anna would like it?
Naomi: Well, I was going to do it a few weeks ago, but Anna blew up about
something. I can’t even remember what it was. But the pedicure
never happened.
Clinician: So it sounds like to make it work, you’ll have to try to keep the
mood pretty light with Anna beforehand so there aren’t any major
blowups.
Naomi: Yeah. ... How do I do that?
Clinician: Well, sometimes in order to keep special time special, you’ll
have to let things go with Anna that you wouldn’t ordinarily let go.
For example, if you don’t approve of how she’s wearing her hair
when you pick her up, don’t make a big deal of it. It might also help
to be cautious about how you react to things she brings up. For ex-
ample, if she tells you that she had a bad day at school, you might
say, “I’m sorry to hear that, honey,” instead of jumping in with an in-
quiry such as “Why? Did you do something wrong?” It can help if
you’re in the right frame of mind to interact calmly with her. We
talked a few weeks ago about how parenting is stressful and about
how our own feelings of stress affect our mood and our interactions
with our children. It is easier to be more patient with them when
we’ve had some time to rejuvenate ourselves. Any chance you’ll get
some time to yourself before you spend time with Anna on Friday?
Naomi: Well, I have a coworker who is always asking me to walk with her
for exercise on our lunch break. I would really like to do it but never
make time for it. Maybe I could do that on Friday so I’ll be more re-
laxed when I hang out with Anna.
Clinician: That sounds like a great idea. What will it take to make sure you
have the time to do that?
Naomi: I just need to write it in on my calendar like any other appointment.
Clinician: Do you want to take out your calendar and do that right now?
Naomi: There, I just did it.
Clinician: Great. I’ll check back next time and see how it goes, both the
walking and the special time with Anna. The other thing we were go-
ing to follow up on was whether you were able to pay attention to
how often Anna exhibited some of the target behaviors we’ve set for
her, such as following your directions, putting more effort into her
schoolwork, and helping you around the house. Tell me how that
went this week.
Naomi: Well, I have to confess, I forgot all about the sheet you gave me
until right before we came here. Sorry, it was just that kind of a
week.
Clinician: Even though you didn’t fill out the sheet, did you pay any more
attention to Anna’s behavior?
Naomi: I did pay more attention to her behavior early in the week, before
she got in trouble at school. I did notice that there are quite a few
things that she does around the house that I tend to overlook.
Clinician: Like what?
Naomi: Well, she pretty much takes care of herself a lot of the time, be-
cause I’m gone for work. She gets herself dressed for school in the
morning and fixes herself breakfast. I think she helps her brother and
sister with the dinner dishes some before I get home from work and
she does keep her room pretty clean.
Clinician: It sounds like you noticed quite a few things that she’s doing al-
ready to help out around the house that you weren’t very aware of
before. Did you say anything to Anna about that?
Naomi: Not really, because those are all things I think she should be doing
because she’s part of the family and we all have to do our part.
Clinician: It’s appropriate to have expectations for your children to help
out around the house. The difference is that in trying to improve
Anna’s compliance at home, it’s important to recognize where she is
already showing effort in this area and to provide her with some pos-
itive reinforcement. Quick labeled praise, such as telling Anna that
you appreciate her effort in getting herself ready in the morning and
cleaning up the kitchen at night, lets her know that you notice and
appreciate these things and can help her feel very encouraged.
Naomi: Yeah, I’ll try to do more of that this week.
Clinician: What I would like you to do is to make an effort to praise her
for her effort around the house several times this week and then to
pay attention to what effect it has on her willingness to help out
around the house and also on your relationship. We’ll follow up next
time to see if it made any difference. The other side of the equation
that we talked about last time is that it can also be helpful to ignore
small annoyances that could lead to a big blowup and might be better
left alone. Tell me about how that went this week.
Naomi: I did try that a few times this week.
Clinician: Great, can you give me an example?
Naomi: Yeah, it drives me crazy when Anna tracks water in the hallway
after she takes a bath and then she leaves the sink messy and sticky
after she brushes her teeth. In the past, when I’ve tried to make her
come back and clean these things up, it has led to a big blowup right
before bedtime. I decided to let it go a few times this week. It went
better than I expected. We were able to have some nice time to-
gether before bedtime several nights this week, and I guess that’s
what should be more important than having a perfectly clean bath-
room. Anna even cleaned out the sink on her own at one point.
Clinician: That’s terrific. What did you learn from that?
Naomi: I learned that it helps to pick my battles, especially with Anna,
where even the littlest thing could lead to a big rift between us.
Clinician: That seems like an important lesson for you to draw on in the
future. It’s almost time for us to bring Anna back in. Would you like
to use the time to tell her that you appreciate what she does to help
out around the house and also to talk about what you might do to-
gether on Friday?
Naomi: That sounds good. We will still need to talk about what happened
at school on Wednesday.
Clinician: Yes, we’ll talk about that, too. Perhaps we can use it as an op-
portunity for Anna to show you the approach she’s learning to stop
and think about the best way to solve problems when she is angry, so
that you can help her use it at home.
Naomi: That sounds good. I’ll go get Anna... .
Conclusion
This chapter summarizes research-supported prevention and treatment
programs for DBD. The Coping Power Program, used in targeted preven-
tion and treatment interventions for aggressive children, is described in de-
tail. Coping Power is based on a contextual social-cognitive model and has
been tested in a series of efficacy and effectiveness studies. The major foci
of the Coping Power Child and Parent Components are described and are
illustrated with case examples.
Key Clinical Points

• Problematic parenting practices that are especially associated with
children’s aggressive behavior include harsh punishment, inconsis-
tent discipline, lack of warmth and positive attention, and poor mon-
itoring.
• Peer factors that can contribute to the development and mainte-
nance of children’s aggressive behavior are high levels of peer re-
jection and involvement in deviant peer groups.
• Numerous deficits in social information processing and problem
solving have been found. Children with aggressive behavior and
DBD attend to fewer nonhostile cues in social situations than their
peers do, and they then have a bias in attributing hostile intentions
to others. When compared with their peers, they generate fewer ver-
bal assertion and compromise solutions to their social problems.
When evaluating their responses, they consider aggressive solu-
tions acceptable and expect that aggressive solutions will lead to
positive outcomes for them.
• Key elements of most CBT programs include a focus on children’s
behavioral goals, emotional awareness and self-regulation, per-
spective taking and attribution retraining, social problem-solving
skill training, and avoidance of deviant peer processes.
• Social problem-solving is an especially common element of most
evidence-based CBT programs for children with conduct problems
and can be delivered through discussion, role-play, homework ex-
ercises, and creation of therapeutic products such as videos.
• Positive reinforcement is effective not only for increasing the amount
of appropriate behaviors but also for decreasing the amount of in-
appropriate behaviors. The clinician and parents may reinforce ap-
propriate behaviors that are “positive opposites” of inappropriate
behaviors.
12.1. A 10-year-old boy with a history of aggressive, disruptive behavior at
home and at school is referred for psychological treatment. The most ef-
fective treatment for his referral problems is which of the following?
A. Parent training alone.

B. Cognitive-behavioral interventions with the child alone.
C. Cognitive-behavioral interventions with parent and child compo-
nents.
D. Relationship therapy with the child.
12.2. David is a 10-year-old boy who attends individual therapy to address his
diagnosis of oppositional defiant disorder. When his therapist asks about
his feelings, his responses are limited to “happy” and “mad.” In seeking
to broaden his recognition of various feeling states, his therapist should
work on helping him recognize which of the following?
A. Physiological sensations.
B. Behaviors.
C. Cognitions.
12.3. Amanda, age 11, has been referred for therapy because of her fre-
quent angry outbursts. When she is calm, she can articulate appro-
priate responses to problems such as peer teasing, but she tends to
act out aggressively when confronted with real-life problems. Which
of the following areas should Amanda’s therapist focus on first?
A. Social problem-solving.
B. Perspective taking.
C. Anger management strategies.
D. Identifying consequences for aggressive behaviors.
12.4. In one of the clinical vignettes in this chapter, 15-year-old Tim as-
sumes that his teacher “has it out for him” when she puts his name
on the board for getting out of his seat to sharpen his pencil. Tim’s
CBT-oriented clinician seeks to help him see the situation from his
teacher’s perspective to modify his initial
A. Intermittent explosive disorder.

B. Hostile attribution bias.
C. Reactive attachment.
D. Relational aggression.
12.5. In another clinical vignette in this chapter, Naomi has sought mental
health services to reduce her daughter Anna’s disruptive behavior.
The family’s CBT-oriented clinician has asked Naomi to praise
Anna’s prosocial behaviors (such as following directions and helping
out around the house) and to ignore minor disruptive behavior (such
as whining or not cleaning out the sink thoroughly). The clinician is
likely trying to help Naomi use which of the following?
A. Behavioral rules and expectations.

B. Mood management.
C. Discipline.
D. Contingency management.
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Nelson WM III, Finch AJ, Hart KJ (eds): Comparative Treatment of Con-
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13
Enuresis and
Encopresis
ALTHOUGH incontinence continues to be one of the leading causes

of child abuse in this country, children with urinary or fecal accidents to-
day fare much better than children of antiquity. The methods then used to
attain continence seem freakishly harsh given the benign nature of the
problem. Penile binding, buttock and sacrum burning, and forced urine-
soaked pajama wearing are among the many aversive treatments reported
in a review of ancient approaches to incontinence (Glicklich 1951). But
perhaps the question of whether incontinence was a bigger threat to health
in antiquity than it is now could at least partly explain why treatments
were so harsh. The health-based consequences of prolonged incontinence
during that time could be severe due to the limited means for cleaning
bedding, beds, and clothing coupled with ineffective methods for manag-
ing infection. Another concern may have been the unpleasant olfactory
sensations resulting from close contact with soiled bedding and clothing in
homes where air circulation may have been poor. Fortunately for many in-
467
continent children (unfortunately not all), practitioners and parents have

mostly abandoned physically harsh treatments for incontinence and now
use methods that are much more humane from a physical perspective and
much more effective from an outcomes perspective.
Although many forces contributed to the shift in the treatment of chil-
dren with incontinence, the most potent force was the advent of behavioral
theory and the conditioning-type treatments derived from it. Behavioral
theory and treatment inaugurated a veritable paradigmatic shift in the ap-
proach to and management of enuresis, and to a lesser but still significant ex-
tent, encopresis. For example, behavioral theory eschewed historical
tendencies to interpret incontinence in moral, characterological, or psycho-
pathological terms in favor of a biobehavioral view emphasizing genetic pre-
dispositions coupled with environmental circumstances. The biobehavioral
view has proven superior in at least two important ways. First, it does not
disparage afflicted children to the degree that the moral, characterological,
and psychopathological views do. Second, it leads much more directly to
treatment options. Clinicians do not have direct access to the mechanics of
a child’s soul, character, or psyche, but they do have direct access to the cir-
cumstances that initiate and/or perpetuate incontinence. This is a book de-
voted to cognitive-behavior therapy (CBT), and CBT for incontinence
involves the strategic manipulation of circumstances to establish continence.
Although the cognitive dimension of CBT is minimal in CBT treatment of
incontinence, it does play a role, and therefore we refer to treatments for
enuresis and encopresis as CBT throughout the chapter. The chapter is di-
vided into two sections, one for enuresis and one for encopresis, and each
section includes brief descriptions of the conditions (i.e., diagnosis), a brief
review of empirical support, theoretical perspectives on treatment, the as-
sembly of an optimal treatment, the implications of diversity, and challenges
to treatment.
Enuresis
Diagnosis and Prevalence
Enuresis is the collective term for chronic urinary accidents occurring after
the conventional age of completed toilet training. The diagnostic criteria in
the Diagnostic and Statistical Manual for Mental Disorders, 4th Edition,
Text Revision (DSM-IV-TR; American Psychiatric Association 2000) in-
clude repeated urination into beds or clothing at least twice a week for at
least 3 months after the age of 5 years or the attainment of a 5-year level of
development if the child has a developmental disability. Additionally, the ac-
Enuresis and Encopresis 469
cidents must not be directly due to the physiological effects of a substance

(e.g., diuretics) or a general medical condition. DSM classifies enuresis into
primary (in which the child has never achieved urinary continence) and sec-
ondary (in which incontinence develops after a period of continence) cases
and subdivides it into three subtypes: nocturnal, diurnal, and combined noc-
turnal and diurnal. This chapter will focus almost solely on primary noctur-
nal enuresis for three reasons: 1) because it is, by a very wide margin, the
most frequently presenting type; 2) because empirically supported treat-
ment is the same for primary and secondary cases, just as it is for the noc-
turnal type and the nocturnal portion of the combined type; and 3) because
there is very little published research on treatment of diurnal enuresis.
Prevalence estimates range as high as 25% for 6-year-old boys and 15%
for 6-year-old girls (Gross and Dornbusch 1983), and although enuresis is
much less prevalent by the teenage years, it is not rare. For example, as
many as 8% of boys and 4% of girls are still enuretic at age 12 (Byrd et al.
1996; Friman 2007, 2008).
Empirical Support
The primary active component in all empirically supported CBT treat-
ments for enuresis is the urine alarm. Reviews of the literature show that
the success rate of the alarm is higher and its relapse rate lower than any
other method, including drug treatment and empirically supported non-
drug treatments, such as retention-control training. Outcomes from alarm-
based treatment range as high as 80% for success and as low as 17% for re-
lapse (Christophersen and Friman 2010; Friman 2007, 2008; Mellon and
McGrath 2000). One problem with interpreting the review literature on
alarm treatment is that adjunctive components are often added to improve
effectiveness, resulting in treatment “packages.” Following the section on
theoretical perspectives below, we will describe the treatment components
and the treatment packages that have the most empirical support. How-
ever, because the effectiveness of the urine alarm when used alone ranges
as high as 70% and because it is the central component of the major treat-
ment packages, it should be considered the most empirically supported
treatment for all types of enuresis—nocturnal, mixed, and diurnal.
Theoretical Perspectives
Early psychological theory attributed the cause of enuresis to defective intra-
psychic variables (Sperling 1994); however, the forward march of science has
significantly reduced the relevance of the psychopathological perspective on
enuresis (Christophersen and Friman 2010; Friman 2007, 2008). Among the
many contributors to this turn of events are the absence of scientifically se-
cured outcomes of treatment based on that perspective, the abundance of sci-
entifically secured outcomes of CBT (especially but not only alarm based),
and research showing the significant role a family history of enuresis plays in
the genesis of enuresis, regardless of whether afflicted children live with af-
flicted blood relatives. For a brief time in the 1990s, a cognitive perspective on
enuresis emerged following a report of cognitive therapy competing favorably
with conditioning treatment in a comparative trial (Ronen et al. 1992). Two
other papers describing successful cognitive therapy were published by the
same group (Ronen and Wozner 1995; Ronen et al. 1995), but they essentially
report the same findings. The relevance of cognitive theory that emerged fol-
lowing the initial study has diminished to almost nil, however, for at least four
reasons. First, after more than 15 years, the findings still have not been inde-
pendently replicated, despite the ease of their application. Second, the find-
ings are dramatically inconsistent, with over 50 years of research showing the
routine success of behavioral approaches and the routine failure of purely psy-
chological (e.g., cognitive) approaches to treatment of enuresis (Christo-
phersen and Friman 2010; Friman 2007, 2008; Houts 1991, 2000; Mellon
and McGrath 2000). Third, the authors made no attempt to explain how a
purely cognitive approach could so powerfully influence a problem that has
such a fundamentally biological basis. Fourth and finally, the original study is
flawed methodologically in several ways (see Houts 2000 for a thorough cri-
tique). At present, the dominant theoretical perspective on enuresis is the
biobehavioral model, which assumes that enuresis results from a combination
of genetic predisposition and manipulable environmental events (Christo-
phersen and Friman 2010; Friman 2007, 2008). Those manipulable events
provide the behavioral source material for CBT for successful treatment.
However, there is a role for cognition in the treatment of enuresis, al-
beit a supportive rather than a directly active one. Specifically, the incon-
tinent child is typically included in all discussions of treatment—and the
child’s understanding of the condition, its likely course, the benefits of
treatment, and the value of full compliance is important for treatment
progress. It is extremely important that the child be made aware that the
condition is not due to any psychological or characterological deficiency on
his or her part, and this too is a cognitive rather than a behavioral matter.
Treatment Components
Urine Alarm
Bed devices. The urine alarm uses a moisture-sensitive switching sys-
tem that when closed by contact with urine-seeped bedding, completes a
small-voltage electrical circuit and activates a stimulus that is theoretically

strong enough to cause waking (e.g., buzzer, bell, light, vibrator). The bed
device typically involves two aluminum foil pads, one of which is perfo-
rated, with a cloth pad between them. The bed pads are placed under the
sheets of the target enuretic child’s bed, with the perforated pad on top.
A urinary accident results in urine seeping through perforations in the top
pad, collecting in the cloth pad, and causing contact with the bottom suf-
ficient to complete an electrical circuit and activate a sound-based alarm
mechanism. In principle, the awakened child turns off the alarm and com-
pletes a series of treatment steps. In practice, initially at least, the alarm
often alerts parents first, who then waken the child and guide him or her
through the training steps.
Pajama devices. Pajama devices are similar in function, yet simpler in

design than bed devices. The alarm itself is either placed into a pocket sewn
into the child’s pajamas or pinned to the pajamas. Two wire leads extending
from the alarm are attached (e.g., by small alligator clamps) on or near the
pajama bottoms. When the child wets during the night, absorption of urine
by the pajamas completes an electrical circuit between the two wire leads
and activates the alarm. A range of stimuli are available for use with the pa-
jama devices and include buzzing, ringing, vibrating, and lighting.
Child- and parent-focused methods. Actual alarm use can be divided

into different methods, depending on the primary roles of the child and
parent. In the child-focused method, the alarm awakens the child, who in-
dependently completes treatment steps. In the parent-focused method,
the alarm awakens or alerts the parent, who awakens the child and guides
him or her through treatment steps. The treatment steps vary across pub-
lished accounts and guides but generally include full arousal, going to the
bathroom to complete (or attempt) urination, changing bedding and paja-
mas, resetting the alarm, and going back to bed. Parent-focused methods
are obviously dependent on the saliency of the alarm stimulus, and with
the bed-device wire leads, can be extended to the parents’ auditory range
(e.g., in their bedroom). For the pajama device, either a very loud alarm or
periodic checking is necessary to allow parents to readily attend to acci-
dents. Our clinical experience suggests that optimal treatment compliance
is attained only with parent-focused practice.
Retention-Control Training
Retention-control training (RCT) was developed following the observation
that many enuretic children had reduced functional bladder capacity, the
primary characteristic of which is frequent small volume urinations
(Muellner 1960, 1961; Starfield 1967). RCT expands functional bladder

capacity by having children drink extra fluids (e.g., 16 oz of water or juice)
and delaying urination as long as possible, thereby increasing the volume of
their diurnal urinations and expanding the interval between nocturnal
urges to urinate (Muellner 1960, 1961; Starfield and Mellits 1968). To use
RCT, establish a regular time to begin training each day and ensure that it
is concluded at least a few hours before bedtime. Encourage enuretic chil-
dren to drink as much of their favorite beverage as they can and forestall
urination as long as they can. When they reach their limit, have them uri-
nate in a washable receptacle that is designed to measure volumes of fluid.
Explain that the goal for each target urination is to produce more urine
than was produced with the previous target urination. Use a reward sys-
tem (discussed in the section “Reward Systems” later in this chapter) to
maintain motivation. Rewards can be delivered for increasing the amount
of fluid drunk, increasing the time between urinations, and/or exceeding
the previous amount of urine produced.
Kegel and Stream-Interruption Exercises

Kegel exercises involve purposeful manipulation of the muscles necessary
to prematurely terminate urination or to contract the muscles of the pelvic
floor (Kegel 1951; Muellner 1960). These exercises were originally devel-
oped for stress incontinence in women, and a version of Kegel exercises,
called stream-interruption exercises, has been used in enuresis treatment
packages for years. Clinicians train children to conduct Kegel exercises by
having them start and stop their urine flow multiple times during active
urinations at least once a day. When they have mastered “wet practice,”
teach them “dry practice” by telling them to employ the same urogenital
contractions they use with wet practice. Teach children to hold the con-
traction for 5–10 seconds, followed by a 5-second rest, 10 times on three
separate occasions a day.
Waking Schedule
This treatment component involves waking enuretic children and guiding
them to the bathroom for urination. There are multiple potential benefits,
including changes in arousal, increased access to the reinforcing properties
of dry nights, managing urinary urge in lighter stages of sleep, and reduc-
tion in the length of time children must hold their urine. The early use of
waking schedules typically required full awakening, often with sessions
that occurred in the middle of the night, but subsequent modifications to
the procedure involved only partial awakening and conducting waking ses-
sions just before the parent’s normal bedtime, with no loss of effective-
ness. To use the waking schedule, have the parent who goes to bed latest
wake the incontinent child and take him or her to the bathroom for urina-
tion. If the bed is already wet, wake the child 15 minutes earlier the next
night. After one week of accident-free nights, have the parent awaken the
child one half-hour earlier. Continue making the wake times earlier until
the child’s original bedtime is reached.
Overlearning
Overlearning is a nocturnal version of RCT. Like the RCT procedure, this
method requires that children drink extra fluids—but just before bedtime
rather than during the day. Overlearning is an adjunctive strategy only, and
is used primarily to enhance the maintenance of treatment effects estab-
lished by alarm-based means. Thus, it should not be initiated until a dry-
ness criterion has been reached (e.g., 7 dry nights; Houts and Liebert
1985).
Cleanliness Training
Some form of consequential effort directed toward returning soiled beds,
bed clothing, and pajamas to a presoiled state is a standard part of empir-
ically supported treatment packages for enuresis. It has not been evaluated
independently of other components, and thus, the extent of its contribu-
tion to outcome is unknown. However, its contribution to the logic of
treatment is obvious, as is its relevance to the training of responsibility in
childhood, and thus we recommend its inclusion in all treatment for en-
uresis.
Reward Systems
Although contingent rewards alone are unlikely to cure enuresis, they are a
component of multiple empirically supported programs, and they are rou-
tinely recommended in papers describing effective treatment (Christo-
phersen and Friman 2010; Friman 2007, 2008). With the current state of the
literature, it is impossible to determine their independent role in treatment.
A plausible possibility is that they sustain the enuretic child’s motivation to
participate in treatment, especially when the system reinforces success in
small steps. If dry nights are initially infrequent and motivation begins to
wane, decreases in the size of the urine stain can be used as the criterion for
earning a reward. To measure these decreases, merely place tracing paper
over the urine spot and trace it and then compare it with previous tracings.
An example of a reward system we often use in enuresis treatment programs

involves a dot-to-dot drawing. The child or parent draws a dotted picture of
an item the child would like and the parents are willing to buy. To determine
the number of dots, determine the amount of money parents would be will-
ing to let their child have on a daily basis and divide that amount into the cost
of the item. Each time the child reaches a specified criterion (e.g., accident-
free night, smaller urine spot), have him or her connect one dot; when all the
dots are connected, have the parent buy the item and give it to the child. Us-
ing this method allows parents to reward their incontinent child for small
amounts of progress made on the way to continence, and thus potentially in-
creases motivation (this system can also be used for accident-free days or
successful defecations in encopresis treatment programs).
Fluid Restriction
Listing fluid restriction among treatment components with well-estab-
lished contributions to effective treatment presents an anomaly. Specifi-
cally, no research of any kind has ever shown fluid restriction to contribute
to the success of an enuresis treatment program. We mention fluid restric-
tion here because despite the complete absence of supportive evidence, it
continues to be an integral part of most treatments. We base our position
on the absence of evidence for several compelling reasons. First, fluid re-
striction is probably the most widely used intervention for enuresis in the
world. Second, it is probably the easiest form of treatment to conduct.
Third, its effects, if there were to be any, would be relatively easy to mea-
sure. Despite these characteristics of fluid restriction, it still has absolutely
no empirical support. Thus, we assert that it should not be part of any
treatment plan, with one exception. Specifically, if an enuretic child drinks
fluids to excess before bedtime, then his or her fluid intake should be re-
duced—not because of the enuresis, but because of the excess.
Medication
There are two primary drugs used for treatment of enuresis: imipramine
(Tofranil) and desmopressin (DDAVP). The former is a tricyclic antidepres-
sant whose mechanism for reducing bed-wetting is not clear; it appears to
make the bladder less sensitive to filling, thus allowing it to hold more urine
before urinary urge. Desmopressin is a synthetic antidiuretic that concen-
trates urine, thus decreasing urine volume and intrabladder pressure. Be-
cause of alarming reports of the potential cardiotoxic effects of imipramine
overdose (Herson et al. 1979) and other side effects of imipramine, desmo-
pressin briefly emerged as the most preferable medication for enuresis
treatment (Christophersen and Friman 2010; Friman 2007, 2008). How-

ever, reports by the U.S. Food and Drug Administration (FDA) in 2007
alerted the public to potential dangers posed by desmopressin, especially
when delivered in its most popular form—intranasal spray. Specifically,
some persons taking desmopressin are at risk for developing a sodium defi-
ciency in their blood—a condition called hyponatremia—that can result in
seizures and death. Children treated for enuresis with the intranasal form of
desmopressin are particularly susceptible to severe hyponatremia and sei-
zures. Therefore, the FDA has ruled that the intranasal form of desmo-
pressin not be used for treatment of enuresis and has recommended only
very cautious use of the tablet form (U.S. Food and Drug Administration
2007). These rulings are likely to have a notable impact on interventions for
enuresis, given the pervasiveness of the problem and the popularity of des-
mopressin as a treatment. Psychologists may be able to successfully capital-
ize on the resulting gap in treatment options available to medical providers
by offering evidence-based CBT alternatives such as those offered here.
Empirically Supported
Treatment Packages
The oldest, best-known, empirically supported treatment package is dry-bed
training (Azrin et al. 1974). Initially evaluated for use with a group of adults
with profound mental retardation, it has been systematically replicated nu-
merous times across child populations. In addition to the bed alarm, its initial
composition included overlearning, intensive cleanliness training, intensive
positive practice (of alternatives to wetting), hourly awakenings, close mon-
itoring, and rewards for success. In subsequent iterations, the stringency of
the waking schedule and the cleanliness training was reduced, positive prac-
tice was eliminated, and RCT was added. Other similar programs have also
been developed, the best known and most empirically supported of which is
full-spectrum home training (FSHT; Houts and Liebert 1985). FSHT in-
cludes use of the alarm, cleanliness training, RCT, and overlearning. Multiple
variations are now available (Christophersen and Friman 2010; Friman 2007,
2008). Component analyses have been conducted on both dry-bed training
and FSHT programs, and the findings show that the alarm is the critical ele-
ment and that the probability of success increases as additional components
are added (Bollard and Nettelbeck 1982; Houts et al. 1986).
Optimal Treatment Planning

An optimal treatment plan is presented in Table 13–1. During the assess-
ment phase (steps 1–4), the clinician’s initial concern should be to obtain
TABLE 13–1. Sample enuresis treatment plan

Assessment
1. Refer child for physical exam.
2. One to two weeks before treatment, initiate collection of data on wet and
dry nights or documentation of size of urine spot (using tracing paper to
draw outline of the spot).
3. Assess developmental and motivational readiness and tailor treatment
according to findings.
4. Discuss the elimination of punishment with parents and child.
Initial treatment
5. Establish a trial treatment period.
6. Help parent and child select and purchase the type of alarm to be used (see
Table 13–2).
7. Negotiate for inclusion of as many treatment components as child and
parents are willing and able to perform.
Monitoring progress and planning for termination
8. When initial dryness goal is achieved (e.g., 1 week), add an overlearning
component.
9. When 14 consecutive days of dryness have been achieved, discontinue
alarm, retention-control training, and overlearning.
10. Address relapses by resuming use of treatment components that have been
discontinued.
a history of wetting episodes. There is some evidence that children who

wet less frequently and children who wet only at night have a better prog-
nosis (Houts et al. 1994), although the type of enuresis (primary or sec-
ondary) does not appear to moderate treatment outcomes. Next, the
clinician provides information about enuresis, including the most effective
parental response to accidents. For example, the child and parents should
be informed that numerous other children, many probably in the child’s
neighborhood and school, are also afflicted with enuresis. With the child
in attendance, firmly instruct the parents to avoid blaming, shaming, and/
or punishing their child for wetting. Then obtain the child’s cooperation in
treatment and work with the child and family on a treatment plan. How-
ever, do not proceed with direct treatment until a medical examination is
completed and pathophysiological variables are ruled out.
During the initial treatment phase (steps 5–7 of Table 13–1), base the
number and selection of treatment components on child readiness, child
TABLE 13–2. Sample urine alarms
Device Type Manufacturer Cost
Wet-Stop Pajama, buzzer PottyMD $50.00

Knoxville, TN
(877) 768-8963
http://wetstop.com/
index.php
Potty Pager Pajama, buzzer Ideas For Living $75.00
Boulder, CO
(800) 497-6573
www.pottypager.com
SleepDry Pajama, buzzer Star Child Labs $53.95
Santa Barbara, CA
(800) 346-7823
http://sleepdryalarm.com
Malem Bedwetting Pajama, various Bedwetting Store $84.95
Alarm combinations Ashton, MD
of sounds and (800) 214-9605
light www.bedwettingstore.com
Wet Call Bed pad, buzzer Bedwetting Store $84.95
Ashton, MD
(800) 214-9605
www.bedwettingstore.com
Vibrating Enuresis Pajama, vibrating Enabling Devices $65.95
Alarm Hawthorne, NY
(800) 832-8697
http://enablingdevices.com
Note. Manufacturer and pricing information subject to change; verified at time of writing.
and parent willingness, and family resources (see Table 13–2 and Sug-
gested Readings and Web Sites at the end of this chapter for information
on obtaining necessary materials, such as the alarm). Strive to include the
waking schedule, reward system, and responsibility training with the
alarm. “Titrate” the components in the plan over time in accord with fam-
ily resources and motivation until a cure is obtained. For example, a two-
parent, one-wage earner, middle-income family with a motivated 10-year-
old bed-wetting child whose parents are also motivated could start with all
treatment components at once (i.e., alarm, waking schedule, Kegel exer-
cises, overlearning, RCT, cleanliness training, rewards).
When families have fewer resources or less motivation to conduct treat-
ment, prescribe fewer components but strive to ensure the alarm is one of
them. If the home situation changes in a way that heightens motivation or

frees up more resources, renegotiate treatment to include more components
(remember that the alarm is effective, but its effects increase even further
with addition of other treatment components). In the rare case in which the
child is motivated but the parents are much less invested, prescribe only com-
ponents that can be independently completed by the child. Unfortunately,
this may preclude use of the alarm, either because the parents will not pur-
chase one or because the child is not capable of using it without assistance. If
an alarm can be obtained, however, older children or sophisticated younger
children may be able to use it independently with training provided by the cli-
nician or the clinical team. If not, prescribe the treatment components that
can readily be performed independently (e.g., Kegel exercises, self-monitor-
ing, RCT, possibly a waking schedule activated by the child’s alarm clock). The
chances for cure are less likely when fewer components are used (especially if
the alarm is not used) but still higher than if no treatment were used. Further-
more, the active involvement of the child may lead to increased involvement
by the parents, at which point more components can be added.
The final steps of treatment involve progress monitoring and planning for
termination (steps 8–10 in Table 13–1). If progress is limited, add adjunctive
components with primary emphasis on RCT and stream interruption. When
14 consecutive days of dryness have been achieved, discontinue the alarm.
As with most enuretic treatments, the potential for relapse is a serious con-
cern, so schedule follow-up contact as a routine element of treatment.
Implications of Diversity
The major diversity issue in studies of enuresis involves gender. Enuretic boys
outnumber enuretic girls by as much as 3 to 1. On the basis of the abundance
of evidence indicating this disparity, one group of epidemiological researchers
has recommended changing the diagnostic criteria for boys from age 5 to age
8 because the proportion of enuretic girls at age 5 is about the same as the pro-
portion of boys at age 8. The implication of this position is our recommenda-
tion that clinicians consider delaying treatment for boys who at age 5 meet
criteria for enuresis but who clearly lack the motivation to participate in treat-
ment or the maturity to benefit from it. Cross-cultural research also indicates
that although enuresis is more prevalent in the United States than in Europe
and other developed countries such as Thailand and China, it may be more
prevalent in some developing countries, such as Nigeria. Enuresis is also more
prevalent in populations that have lower socioeconomic status or that exhibit
significant psychosocial deviancy, such as children in institutionalized settings
(for reviews covering this material, see Friman 1986, 2007).
Challenges to Treatment
One critical challenge to treatment is the rare but real possibility of a phys-
iopathic cause of enuresis (e.g., diabetes, urinary tract infection). Although
fewer than 10% of cases are attributed to these causes, alarm treatment in
these cases may be contraindicated. For this reason, it is paramount to re-
fer all enuretic children to a physician for a physical examination before
beginning CBT in earnest. When physiopathic causes are ruled out, age,
developmental level, and motivation levels are cardinal concerns. For ex-
ample, we recommend that CBT be forestalled until enuretic boys are at
least 7 years old or until girls are at least 5 years old (unless either younger
boys or girls are highly motivated). The difference in ages is due to the
lower incidence of enuresis, higher motivation, and advanced maturation
in enuretic girls versus boys. If the enuretic child is not motivated, suspend
treatment for 3–6 months and schedule a follow-up with the child and
family at that point.
Another challenge to treatment involves punishment. As mentioned
earlier, incontinence is a major cause of child abuse. With no access to ef-
fective treatment, parents faced with their child’s chronic incontinence
are at risk for directing punishing responses to their child’s accidents, rang-
ing from direct and indirect expressions of frustration to harsh physical
discipline. Prescribing effective treatment can reduce the risk, but to elim-
inate it altogether, we recommend that clinicians assess for a history of
punishment and obtain a verbal commitment from parents (with the en-
uretic child present) to never again punish or even criticize the child for
having accidents.
A final challenge involves nonadherence to treatment, in the child, par-
ents, or both. To limit child nonadherence, assess for motivation and capac-
ity to perform prescribed treatment steps and refrain from prescribing
steps that children are unwilling or unable to perform. To increase motiva-
tion, use a system that rewards progress in small increments—for example,
for dry nights, decreases in the size of the urine spot, or even compliance
with components of treatment. To limit parental nonadherence, follow sim-
ilar steps: assess for motivation and capacity and prescribe only steps that
parents are willing and able to perform. Help parents identify signs of
progress, which range from multiple dry nights for some children to mere
performance of treatment steps for others. More generally, describe conti-
nence as a skill that can be attained readily with diligent practice of treat-
ment steps; disclose that dry nights could be slow in coming, especially for
children with multiple nightly accidents; and schedule periodic booster
clinic visits and/or telephone calls to monitor progress.
Case Example
Tommy is a white 8-year-old boy who lives at home with his natural parents
and two younger siblings, a girl age 5 and a boy age 3. His medical, psychi-
atric, developmental, and educational histories are unremarkable. He is in
the second grade and works a little below his potential, but routinely earns
grades in the B range. He is well liked in school and has at least two good
friends. At home, beyond some moderate resistance to bedtime, he does
not pose any behavior problems. His relationship with his siblings is de-
scribed as positive. The referral concern involved primary nocturnal enure-
sis. According to the parents, Tommy has been nocturnally incontinent
since birth and to the best of their memory, has never had a dry night. In
fact, they complained that he sometimes has more than one accident at
night. Although approached by grandparents, aunts and uncles, and his par-
ents about working harder to stay dry, he exhibited little interest in conti-
nence until a recent episode involving an accident while on a camping trip.
He had a friend along for the trip and was embarrassed by the friend’s dis-
covery of his accident, and from that point forward, he has been very con-
cerned about learning how to have dry nights.
His parents brought him to his primary care physician, who did a routine
physical examination including a urinalysis, and ruled out all organic causes
for nocturnal enuresis. During the history, it was revealed that Tommy’s fa-
ther had a history of nocturnal enuresis that ended at about age 9. Following
the physical examination, the physician referred Tommy and his parents to
a psychologist specializing in CBT, and that person began treatment by con-
ducting a joint interview with Tommy and his parents.
The psychologist explained the role of family history in the cause of en-
uresis and that it was unlikely that any form of psychopathology played a
significant determining role. However, he explained that the parental, fam-
ily, and social response to accidents could cause psychological problems if
it was aversive and perpetuated. Following that, he solicited Tommy’s par-
ticipation in treatment and reviewed all of the available treatment options
he had at his disposal, which included the urine alarm, RCT, waking sched-
ule, responsibility training, a reward system, and Kegel exercises. Also, in
the presence of the parents, he explained to Tommy that children who wet
their bed should never be punished for wetting. Additionally, he also com-
municated that it would be fine for Tommy to have water before bed as
long as he didn’t drink an excessive amount. He explained to the parents
that fluid restriction had never shown a significant role in reducing noctur-
nal accidents unless incontinent children were shown to be drinking exces-
sively before bed. Finally, he drew a picture of the bladder and explained
how the process of urination worked and how the alarm system, along with
the other treatment components, would influence Tommy’s system and
help him learn how to have dry nights.
Jointly, Tommy and his parents selected all of the treatment compo-
nents that were described. For the reward system, the parents selected the
dot-to-dot program, and Tommy selected a new video game as his reward.
While in the doctor’s office, Tommy and his mother drew a picture of the
video game using dots and the psychologist provided a handout describing
the reward system for the parents to bring home. The psychologist also
asked that the parents monitor progress along with Tommy using a calendar
to be attached to the refrigerator that could be easily inspected by them
and by Tommy. The parents also asked to include one other component in
the treatment program, one that has not been shown to play a role in the
treatment of enuresis, but that very well could play a role in the social ac-
ceptability of treatment. Specifically, the parents asked whether it might
be helpful if when Tommy said his prayers at night, he could ask for God
to help him have a dry night, and the psychologist agreed that it would be
a good idea. The parents obtained the urine alarm by consulting the Bed-
wetting Store online, and the brand they selected was the Nytone, which
attached to the pajamas.
The outcome of the case was successful, although Tommy did not have
a dry night for the first month or so. In fact, the parents initially com-
plained that he slept through the alarm and that its sound awakened one
or the other of them, and they then would wake him and take him to the
bathroom. However, as the program progressed, the alarm began to
awaken Tommy, at which point he would take himself to the bathroom, but
he would also alert one of his parents to help him. As the program pro-
gressed further, the alarm would quickly awaken Tommy, at which point
he would turn it off, and his accident would be so small that it didn’t re-
quire that he do anything about the accident until his typical wake-up time.
And finally, he began sleeping through the night without the alarm going
off, eventually one or two times a week, and ultimately ending with only
one or two accidents per month. At that point, the psychologist terminated
care and recommended that the parents stay in touch if questions arose.
Although the amount of clinical contact varies, for this case, the psycholo-
gist saw Tommy and his parents for the initial session and then Tommy with
one parent for two subsequent sessions, and the rest was done by tele-
phone follow-up.
Conclusion: Enuresis
Enuresis is the third most distressing experience reported by children, ex-
ceeded only by divorce and parental fights (Van Tijen et al. 1998). Left un-
treated, enuresis will likely persist for years, and in some cases, into young
adulthood, with considerable negative social consequences and disruption
of family life. Urine alarm treatment is an easily used, highly effective
method for treating one of the most prevalent and chronic of all childhood
problems. It represents an enormous breakthrough for enuretic children
because 1) it does not involve the physically aversive experiences typical
of ancient treatments; 2) its effectiveness undermines the historical psy-
chopathological characterization of enuresis; and 3) it eliminates much of
the expense, high relapse, and potential side effects of medication treat-
ment. Furthermore, the effectiveness of urine alarm treatment when used
alone is high and can be raised even higher when combined with any or all
of a variety of adjunctive treatment components (Houts et al. 1994). At

this point in the evolution of alarm-based treatment, it seems safe to assert
that this method should be part of the armamentarium of every child ther-
apist seeing children with enuresis, and if it is not, it seems appropriate to
pointedly ask why.
Encopresis
Diagnosis and Prevalence
The diagnostic criteria for encopresis outlined in DSM-IV-TR (American
Psychiatric Association 2000) include 1) repeated passage of feces into
inappropriate places (e.g., clothing or floor), whether voluntary or unin-
tentional; 2) at least one such event a month for at least 3 months; 3) chro-
nological age of at least 4 years (or equivalent developmental level); and
4) the determination that the behavior is not exclusively due to a physio-
logical effect of a substance (e.g., laxatives) or a general medical condition,
except through a mechanism involving constipation. Similar criteria are
outlined in the International Statistical Classification of Diseases and Re-
lated Health Problems, 10th Revision (ICD-10; World Health Organiza-
tion 2007).
Two subtypes are identified with the DSM-IV-TR criteria for enco-
presis: with constipation and overflow incontinence (787.6) and without
constipation and overflow incontinence (307.7). For the subtype with con-
stipation, there should be evidence of constipation from a physical exam-
ination by a physician or a history of having a bowel movement on no more
than three occasions during a week. Individuals with this subtype typically
have stools that are poorly formed, with continuous leakage during the day
and in rare cases at night. Only small amounts of feces are passed in the
toilet and successful treatment usually involves intervention components
aimed at relieving the constipation (i.e., enemas, laxatives). In cases of
encopresis without constipation, stools are generally well formed, with
soiling intermittent and deposited in a toilet. Children with encopresis
without constipation typically present with comorbid emotional and be-
havioral problems; thus, treatment efforts for this subtype focus on the re-
mediation of psychological and behavioral problems (Friman 2008).
Prevalence rates in the United States are estimated to be around 1%–
3%, with boys three to six times more often affected than girls (Schonwald
and Rappaport 2008). Rates of fecal incontinence have shown to be 4.4%
in primary care pediatric settings (Loening-Bauck 2007). A Dutch popula-
tion-based study found that 4.1% of children ages 5–6 years and 1.6% of
children ages 11–12 years experienced soiling incidents once a month (van
der Wal et al. 2005), and comparable rates were found in the United King-
dom (Joinson et al. 2007).
Empirical Support
An obstacle to supportive research for CBT treatment of encopresis in-
volves the transdisciplinary, biobehavioral approaches to the disorder that
are most frequently used. It is virtually impossible to tease out the unique
cognitive, behavioral, or biomedical components, because successful treat-
ment almost always involves all three (Christophersen and Friman 2010).
Biofeedback represents a fourth, less commonly used biomedical-CBT ap-
proach that appears to have no greater level of effectiveness than behav-
ioral-medical interventions (Brooks et al. 2000). Medical interventions
have traditionally focused on three areas: 1) cleansing the bowels, 2) en-
couraging regular bowel movements with the use of facilitative medica-
tions, and 3) regulating dietary intake (Christophersen and Friman 2010).
In their most basic forms, CBT approaches emphasize the use of posi-
tive reinforcement to motivate the child’s adherence and success in using
appropriate toileting practices. Mildly aversive components are also some-
times used, in the form of overcorrection practices in which the child par-
ticipates in cleaning himself or herself and the soiled clothing after a bout
of encopresis (Reimers 1996). Many CBT treatment programs also incor-
porate stimulus-control procedures, enhanced scheduling, enhanced
health education, and various types of monitoring. These CBT approaches
are often administered alone or used to supplement biomedical interven-
tions put into place.
A number of studies have examined the effectiveness of these differ-
ent treatment modalities. In their meta-analysis, McGrath et al. (2000)
found that no published study at the time met criteria frequently used by
psychologists to determine which interventions can be declared empiri-
cally well established (Chambless and Ollendick 2001). Two studies using
a combination of medical plus behavioral interventions were shown to be
probably efficacious. Two extensive behavioral interventions plus medical
interventions also were shown to meet the efficacy criteria for the treat-
ment of constipation plus incontinence.
Another study published at the same time (Brooks et al. 2000) in-
cluded a review of randomized controlled published studies involving
medical, behavioral, psychological, and biofeedback treatments for enco-
presis, functional constipation, and stool-toileting refusal in preschool-age
and school-age children. This review found that anal sphincter biofeed-
back in the treatment of pediatric fecal elimination dysfunctions was no

more effective in treating encopresis or functional constipation than com-
prehensive medical-behavioral intervention. Furthermore, the paradoxical
constriction of the external anal sphincter did not appear to influence the
treatment outcome of either biofeedback or medical-behavioral interven-
tions. Despite the similarities in outcomes across these two approaches,
medical-behavioral interventions may have certain advantages given that
these approaches are generally less intrusive than procedures used in bio-
feedback interventions.
Another randomized controlled trial compared treatment outcomes of
CBT and the conventional approaches involving the use of laxatives, a
bowel diary, and education (van Dijk et al. 2008). These researchers found
that the outcomes for the CBT approach and conventional treatments
were comparable. The authors of this study noted that in some circum-
stances, CBT or a referral to mental health services should be considered,
particularly when a child presents with behavioral problems. Below, we de-
scribe the CBT techniques that can be used to successfully assess and treat
encopresis.
Theoretical Perspectives
There have been multiple theoretical perspectives on encopresis through-
out history, but the current dominant viewpoint involves a combination of
biological, learning/behavioral, and cognitive components; and consistent
with the theme of this book, we will refer to it as the CBT perspective.
Historically, early unpleasant toileting experiences were thought to deter-
mine personality and behavior (Freud 1905/1953). Although no actual re-
search confirmed or even supported this perspective, vestiges of this
position remain operative to this day (Friman 2002); this viewpoint is so
deeply rooted in antiquated theory and so resistant to the influence of
abundant contrary scientific evidence that it can be discarded as nonsense
with impunity (Sperling 1994). The problem with this position involves its
association with psychodynamic theory. The predicate for the initial posi-
tion involved infant sexuality (Freud 1905/1953), and as the position
evolved, a sexualized perspective on toilet training and incontinence re-
mained (Aruffo et al. 2000; Sperling 1994). As a blatant and disturbingly
mainstream example, the description of encopresis without constipation
in DSM-IV-TR (American Psychiatric Association 2000) includes an asso-
ciation with anal masturbation, despite there being no supportive scientific
evidence.
In early attempts to sketch an account of encopresis consistent with
the CBT theoretical perspective, Levine (1982) and colleagues described
a developmental trajectory resulting from disordered defecation dynamics

(rather than disordered psychodynamics) and their subsequent influence
on toileting behaviors. Not surprisingly, the cardinal variable in this ac-
count is constipation, which increases the difficulty and discomfort that
accompany bowel movements. Avoidance of discomfort associated with
bowel movements negatively reinforces toileting resistance. In turn, suc-
cessful toileting resistance leads to stool withholding, which has the same
effects on bowel movements as constipation itself—and thus, it is possible
that the resistance rather than the constipation is the more important con-
sideration. Research on this question, however, has suggested that consti-
pation usually precedes toileting refusal, and thus it is more likely to be the
primary influence. Other research has shown that children who resist toi-
let training often have histories of painful bowel movements and/or con-
stipation (Luxem et al. 1997). In sum, the theoretical perspective with the
most empirical support and that which leads most directly to effective
treatment is the CBT model that emphasizes defecation dynamics, disor-
dered fecal toileting, and toileting resistance (Christophersen and Friman
2010; Friman 2007, 2008).
Assessment
Obviously assessment is an important dimension of CBT treatment for any
disorder, but it is particularly important to conduct a thorough assessment
of the child’s behavioral, family, and bowel-training history before develop-
ing a treatment plan. Additionally and most importantly, it is critical with
encopresis to refer all cases to the primary care physician for a physical ex-
amination before initiating treatment (as with enuresis). It is not necessary
to refer affected children to a gastroenterologist; doing so prematurely
could lead to unnecessarily invasive and expensive biomedical evaluations.
We recommend that clinicians surrender the decision of whether to involve
specialists to the primary care physician. As for the clinician’s own assess-
ment, we recommend that it be conducted separately with the parents and
then with the child (age 4 and above). This approach allows both parties to
be less inhibited when sharing sensitive information (e.g., family mental
health history, negative behaviors or attributes of the child).
Parent Intake
Below, we will highlight a few general questions that are likely to be in-
cluded in the standard clinical assessment, highlighting those issues that
are relevant to the assessment and treatment of encopresis. Although it
will often be helpful to gain the child’s perspective on these issues, the cli-
nician may choose to reserve some of these questions for the parent intake
when considering the age of the child and the sensitivity of the questions.
Is there a history of developmental delays or ongoing difficulties?

It is important that the child possess developmental skills that allow for
effective management of toilet training. In general, the child needs to be
ambulatory to the point that he or she is able to independently remove his
or her clothing and is able to walk (or run) to the bathroom when he or she
feels the urge to defecate. All developmental skills need to be at least at a
2-year age level. If motor skills are significantly delayed or if cognitive and
speech/language skills are below a 2-year level, consideration should be
given toward delaying intervention.
Are there any relevant medical problems? A variety of medical con-

ditions can significantly contribute to a child’s constipation and/or bowel-
related difficulties. Relevant medical diagnoses or histories such as Hirsch-
sprung’s disease, celiac disease, Crohn’s disease, or other similar conditions
do not rule out behavioral treatment for encopresis, but certainly have sig-
nificant medical implications, and working closely with the medical profes-
sional is imperative. Additionally, children with a history of distended colon
or megacolon, or who have a chronic history of stool impaction and consti-
pation, warrant close monitoring and periodic follow-up with their primary
care physician.
Is there a history of constipation? If the child is constipated, the con-

dition must be managed before behavioral treatment is initiated. Children
with a history of constipation or fecal impaction often also present with a
history of a distended colon, and in some cases, megacolon. Children with
this history can experience limited or poor feedback regarding the volume
of fecal matter in the rectal vault. Some children with constipation also ex-
perience a solid fecal mass in their colon, but they continue to have bowel
movements because fecal matter moves around the fecal impaction, allow-
ing the child to pass what are typically loose or soft stools. The presence
of loose or soft stool in this scenario can lead parents to wrongly assume
that the child is not constipated. Having parents monitor and document
their child’s stooling pattern (see Figure 13–1) will help the clinician to
monitor the frequency of stools and will provide valuable information to
the child’s primary care physician.
Children with a recent or past history of constipation will likely be on
some type of stool softener. Miralax is currently the most common stool
softener prescribed for children with constipation. If a client is using
Miralax or some other type of stool softener, ask the parents to document
the amount of stool softener provided to their child and the time of day
Name:
Date of birth:
Stool Assessment
Date
Number of
stools in toilet
Number of
soiling episodes
Consistency
of stools a
Difficulty
ratingb
Medicine
taking
Medicine
amount
a
Enter number from Stool Consistency Continuum.
b
See Difficulty With Stool Passage Scale.
Difficulty With Stool Passage Scale

Was passing a stool a problem?
0 No problem 1 Some problem 2 Severe problem
Stool Consistency Continuum
1. Watery 2. Water ring with 3. Liquid, creamy

formed particles
4. Loose, soft 5. Soft, formed
6. Normal, formed 7. Hard, formed 8. Hard and dry
FIGURE 13–1. Stool assessment chart.
that it is taken. The timing of stool softener can sometimes have an effect
on the pattern of the child’s bowel movements.
What are the quality of the child’s diet and quantity of daily exercise?
The child’s dietary habits and level of exercise can impact both the fre-
quency and consistency of his or her bowel movements. In general, learn-
ing that a child has a “typical” diet and level of physical activity is probably
sufficient. In some cases, it is helpful to have the parents provide a descrip-
tion or log of a typical day regarding their child’s diet and physical activity.
This description will allow an assessment of whether a child has a diet that
is high in fat or low in fiber. Both fat and fiber intake can impact the bowel
habits of some children. Although high-fat diets are often blamed for fecal
impaction or infrequent stools in some children, the effect of high-fat diets
is idiosyncratic. However, if a child presents with a dietary history that is
atypical—that is, in which the balance is tilted in one direction or an-
other—then it may be necessary to have a discussion with the parents
about balancing their child’s diet and possibly increasing their child’s level
of physical activity.
Are there any behavioral or emotional difficulties? Some studies (Cox

et al. 2002) have suggested that children with encopresis have a higher
percentage of related or comorbid behavioral difficulties that can interfere
with treatment planning. The use of any number of standardized behavior
checklists (e.g., Child Behavior Checklist; Achenbach and Edelbrock
1983) will provide a good, age-based behavioral profile to identify relevant
behavioral difficulties. Children who are not under good instructional con-
trol or who present with high levels of hyperactivity or oppositional defi-
ant–type behavior present with additional challenges when managing
encopresis. For clinicians working with children with encopresis and these
comorbid behavioral problems, it may be necessary to prioritize working
with the parents and child to help improve instructional control and to re-
duce levels of noncompliance or oppositional behavior before behaviorally
managing the child’s encopretic symptoms. On the other hand, if the be-
havioral concerns are specific to the encopresis, then moving forward with
a treatment plan for managing the encopresis is warranted.
What was the child’s experience with toilet training? Ascertain at what
age the parents started toilet training; whether the parents focused on
urine training, bowel training, or both; and the level of success achieved.
Question the parents about the type of approach that they have used and
the use of both positive reinforcement and punishment, as well as the
length of time spent during the training process. Determine the child’s re-
sponse to the parents’ training efforts, and focus on how the parents man-
age resistance on the part of their child, soiling accidents, and other
setbacks. It is especially important to determine to what level, if any, pun-
ishment techniques have been used. Finally, it is important to determine if
the child has ever experienced partial or complete success with either
urine or bowel training. Many children present with no experience with
complete success in the area of bowel training, while others have experi-
enced months or even years of success before the onset of the encopresis.
How frequently does the child have soiling incidents? Assess what
percentage of the child’s bowel movements result in some type of soiling
episode. Some children with encopresis will have occasional successful
bowel movements in the toilet, whereas other children experience a soil-
ing episode of some type with each bowel movement. Other children ap-
pear to have what can be considered an “accident” when they pass fecal
matter into their clothing because of the loose consistency of their stool or
because they did not respond quickly enough to the physical urge to have
a bowel movement. For some children, the soiling episode clearly involves
some volitional control. This includes children who hide in their room or
in a quiet part of the house while they intentionally have a bowel move-
ment, or children who have a bowel movement in their clothing regardless
of where they are, with no interest or intention of attempting to void in
the toilet.
What is the routine for managing the child’s toileting? The toileting
routine used by parents of encopretic children will likely vary from the ap-
proach that they used when they were initially toilet training their chil-
dren. The frustration caused by the child’s lack of success or the onset of
soiling accidents will cause parents to develop a variety of approaches and
routines to manage their child’s toileting habits. Ask parents to describe
their general routine for managing their child’s toileting habits and include
questions pertaining to scheduled sit times on the toilet, the parents’ re-
sponse when they see their child gesturing that he or she is about to have
a bowel movement, and the length of time that the child is expected to sit
on the toilet.
Has the child developed a resistance to approaching the bathroom

and toilet? It will also be important to assess the child’s resistance to the
bathroom or the toilet itself. Children resist going into the bathroom and/
or sitting on the toilet for a variety of reasons. Some children exhibit sig-
nificant levels of resistance toward having a bowel movement because of a
history of painful bowel movements or discomfort associated with the use
of enemas or suppositories. This avoidance can lead to a reciprocally de-
volving process composed of toileting resistance, constipation, and painful
stools (Borowitz et al. 2003; Levine 1982).
How do the parents respond to their child’s resistance to toileting?

The manner in which parents respond to their child’s resistance toward sit-
ting on the toilet and toward having bowel movements is an integral com-
ponent of the treatment plan. Parents’ responses to their child’s resistance

will range from pleading to corporal punishment. Parent who are frus-
trated with managing their child’s soiling episodes often rely on verbal rep-
rimands, corporal punishment, and time-out. Therefore, it is important to
identify the frequency, length, and severity of the parents’ use of punish-
ment during their attempts to manage their child’s encopresis, because
children who have experienced significant levels of punishment are likely
to engage in stool holding or experience increased soiling episodes, regard-
less of the management approach used. Therefore, obtaining details about
parents’ responses to their child’s resistance can often shed some light on
the severity of the avoidance behavior as well as the contingencies that are
contributing to the child’s negative behavior.
How do the parents respond to successful bowel movements?

Make a note as to whether the parents have used verbal praise, sticker
charts, edible or tangible rewards, or some type of activity reward. Also,
determine the schedule and intensity of rewards used by parents. For ex-
ample, some parents will establish unreasonable goals (e.g., no accidents
for 1 month) that must be met to earn small rewards, whereas other par-
ents will offer large rewards for small goals (e.g., each successful bowel
movement). In general, determine which behaviors parents have targeted
for change (e.g., sitting, voiding), the types of rewards that they have of-
fered, and the frequency with which these have been distributed.
What type of underclothing does the child usually wear? The type
of underclothing that children wear can have an important effect on their
success with managing encopresis. Allowing children to wear diapers and
Pull-Ups beyond the developmentally appropriate age inhibits motivation
to use the toilet and is an obstacle to success. Some children insist on put-
ting on a Pull-Up when they need to have a bowel movement, only to be
accommodated by their parents. Ask parents about their child’s history
with the use of diapers, Pull-Ups, training pants, and regular underwear
and their current use of all of these throughout the day.
Child Intake
Conducting the child intake assessment separately will allow the clinician
to obtain more accurate information and perceptions from the child with-
out him or her being influenced by the parents’ presence. Learn the termi-
nology parents and child use to describe bowel movements and the
toileting practices that are in place. Obtaining the child’s perception of the
physical cues to which he or she attends when the toileting urge occurs is
important. This will allow discussion with the child about how he or she
responds to those physical cues. For example, does the child ignore them,
seek the parents’ assistance, or make an effort to have a bowel movement
independently? Review with the child his or her understanding of any
scheduled sit times that have been put in place, his or her perception of
personal responsibilities regarding toileting practices, what consequences
are in place for soiling accidents, and any rewards that may be available to
him or her for successfully voiding in the toilet. Finally, meeting with the
child separately will provide an opportunity to discuss, at the child’s level,
the treatment goals that involve helping him or her to learn to successfully
and reliably have all bowel movements in the toilet. This should be reiter-
ated with the parents as well.
Treatment
The treatment of encopresis does not follow the same course as that of
other disorders. For example, the treatment of disorders such as anxiety,
depression, and attention-deficit/hyperactivity disorder (ADHD) involves
the assessment and treatment of a constellation of symptoms that consti-
tute the disorder, whereas encopresis can be assessed and defined in a
much more concrete manner—that is, the child is either successfully void-
ing in the toilet 100% of the time or he or she is not. Some children with
encopresis have never successfully voided in the toilet, whereas other chil-
dren have had good success with toilet training and are having only occa-
sional accidents. Thus, children vary regarding where they fall in the
appropriate bowel movement continuum. Because of that, it is perhaps
more prudent to develop a treatment plan based on the point in the toilet-
ing process where children are struggling. Thus, we have developed a sim-
ple task analysis to allow clinicians to determine where in the toileting
process their client is having success and where he or she needs interven-
tion. The steps below compose the task analysis that we typically use.
1. Attend to anticipatory physical cues.

2. Enter the bathroom, remove clothing, and sit on the toilet.
3. Have a successful bowel movement.
4. Use toilet paper and clean self adequately.
5. Replace clothes, flush, wash hands, and leave the bathroom.
Children who are being evaluated for encopresis are experiencing prob-
lems with one of the above steps. Thus, the treatment approach and the na-
ture of the initial treatment session(s) will be dependent on where each child
falls on the task analysis continuum. Accordingly, we have outlined below a
number of treatment approaches that focus on educational, proactive, and

corrective approaches that can be used on their own or in combination.
Educational Approach
The gastrointestinal system. Most parents, understandably, do not
have a thorough or full understanding of how the gastrointestinal (GI) sys-
tem works. A diagram (e.g., Levine 1982) or some other visual aid can be
beneficial when educating parents about the mechanics of the GI system
in general and about how fecal impaction and constipation affect the colon
in particular. It is important to help parents understand that when their
child’s colon becomes stretched from impaction, he or she is likely to lose
colonic sensation, thus adversely affecting the normal bowel movement
cycle. This explanation will also help parents understand that in most
cases, their child’s encopresis is not intentional and that there are clear
physical factors that need to be addressed, along with the behavioral inter-
vention. Parents’ increased understanding of the mechanics of the colon,
along with the importance of keeping their child’s stools soft, will hope-
fully help parents establish and maintain good compliance with their
child’s daily regimen of stool softeners as well as the behavioral recom-
mendations that are offered to them.
Mechanics. Young or physically small children will often sit on the toilet
with their feet dangling. This positioning makes it difficult for them to ad-
equately relax or to use proper musculature when attempting to have a
bowel movement. To avoid this problem, ensure that there is solid support
for the child’s feet when he or she is seated on the toilet and attempting a
bowel movement. A small stepstool can make a large difference in the me-
chanics needed for a child to have a successful bowel movement.
Diet and exercise. If the child has a diet that is inadequate in fluid in-
take and/or low in fiber, or if the child does not get an adequate amount
of exercise, then it will be important to educate parents about the benefits
of balancing the child’s diet, increasing fluids, and encouraging more phys-
ical activity. All of these factors will help promote normal bowel activity
(Dwyer 1995). The role of stool softeners, diet, and exercise is a critical
part of the treatment approach, and it is important for parents to know the
importance of any needed changes in these areas.
Parental demeanor. By the time that parents bring their child for man-
agement of encopresis, they are likely to be frustrated and to have yelled
or screamed at, or even spanked, their child for having accidents. Punitive
or severely negative responses to a child’s soiling episodes hinder the treat-

ment process or cause secondary negative behaviors, such as stool holding,
hiding soiled underwear, or general defiance with the toileting regimen.
Help parents understand that maintaining a neutral and matter-of-fact de-
meanor will help to place the emphasis on their child’s behavior and
choices regarding the toileting process.
Caregivers outside the home. If the child is in day care or is school

age, then it will be important to provide appropriate education to teachers,
day care providers, and so forth regarding the child’s encopresis and toilet-
ing regimen. Explain to teachers that the child may need to take more fre-
quent toileting breaks and/or that making use of the nurse’s bathroom (if
one is available) may be necessary. Also, keeping an extra set of clothing at
the school or day care will be helpful for many children.
Positive or Proactive Approaches

Responding to physical cues. Children with encopresis often respond
inconsistently to physical cues to have a bowel movement. Some children
have limited sensation, and others have normal sensation yet ignore phys-
ical cues for a variety of reasons. Regardless of the reasons, it is important
for children to respond consistently and in a timely manner to physical
cues and urges to have a bowel movement. Treatment success is not possi-
ble without this response. It will be important for the clinician to reinforce
the importance of the child’s response to these cues and urges. Before hav-
ing a bowel movement, many children will posture themselves in a certain
way or will quietly remove themselves to another room. When parents ob-
serve these behaviors, encourage them to prompt their child to sit on the
toilet or to offer to escort the child to the bathroom. Parents should not
physically guide or place their child on the toilet if the child is being resis-
tant. This will only serve to create or exacerbate negative associations
either with sitting on the toilet or with the toileting regimen. One alterna-
tive contingency is to teach the child that sitting on the toilet at the as-
signed times has more positive than negative consequences. Some sample
contingencies will be described later in the section “Successful Bowel
Movements.”
Shaping and scheduling sit times. It is important to promote a rou-

tine of having the child sit on the toilet on a regular basis and at scheduled
times. The treatment goals should focus on having the child sit anywhere
from 15 to 20 minutes after each meal for a period of 5 to 10 minutes. To
accomplish this goal, it will be important to help the child feel comfortable
with sitting on the toilet and reaching a level of relaxation that will facilitate
a successful bowel movement. For young children, have parents “practice”
having their child sit on the toilet for very brief (30–60 seconds) periods of
time. This can be done multiple times throughout the day, with the parent
verbally praising or rewarding the child in some small way for participating.
The use of a timer can help facilitate the child’s cooperation, because the
child will know that the time that he or she spends sitting on the toilet is
limited. As the child’s level of cooperation increases, the amount of time
can be increased until the child is sitting on a regular basis for 5–10 minutes.
Once children are cooperatively sitting on the toilet for 5–10 minutes, help
parents establish a routine for regular sit times. As mentioned above, an
ideal time for children to sit on a regular basis is 15–20 minutes after a
meal, with the child sitting for 5–10 minutes. Having the child sit after
meals is designed to coordinate with the increased activity of the GI system
following meals. This will hopefully increase the probability for the child
passing stool in the toilet. As treatment progresses, work toward fading out
scheduled sit times and promoting and reinforcing independence. How-
ever, initially, scheduled sit times will be important. For young children, the
use of small, tangible rewards can help to promote cooperation. Continued
use of a timer to regulate the time spent sitting will also continue to be im-
portant. These and other shaping techniques should be used to promote
teaching the child to sit cooperatively for a length of time that will provide
him or her with the opportunity to relax and have a bowel movement. Once
sitting cooperatively has been accomplished, efforts can be made toward
promoting successful bowel movements.
Successful bowel movements. Once children are sitting coopera-

tively, or better yet, sitting on the toilet independently after responding to
a physical urge to have a bowel movement, the opportunity to promote
and reinforce successful bowel movements increases dramatically. Because
encopretic children naturally resist sitting on the toilet, and in particular
voiding in the toilet, the use of some type of tangible reward seems to be
important toward promoting successful bowel movements. Until the nat-
ural contingencies associated with sitting and successfully voiding in the
toilet become evident to the child, it is important to make use of some
type of reward system to promote both sitting on and voiding in the toilet
(van Dijk et al. 2008). Below are several types of tangible rewards that can
be used to promote both sitting on and voiding in the toilet.
Candy dispensers. This tends to be particularly effective for young chil-

dren. The advantage of some type of candy or food reward is that it is im-
mediate, meaningful, and relatively inexpensive. The small size of the food
reward also does not tend to be problematic for most parents, who are un-
derstandably concerned about their child’s nutrition. We recommend plac-
ing the dispenser on a bathroom counter or in a location that is visible to
the child but not easily accessible. These types of rewards could be used
to promote both sitting on and voiding in the toilet. For example, the child
could receive one Skittle (or other similar small candy) for sitting and sev-
eral for passing stool into the toilet. The main point here is that for young
children especially, the visual and immediate benefits of having this type
of reward evident for sitting and/or voiding are often necessary.
Sticker charts. Depending on the child’s level of motivation and the value
that he or she attributes to earning stickers, the use of a sticker chart can be
very motivating toward reinforcing both sitting and voiding. For children
who can count to a particular number or who understand quantity, consid-
eration should be given toward providing an additional reward for earning a
set number of stickers. For example, the clinician might ask a 4-year-old
child to draw four circles on a piece of paper and decorate it to signify its use
for documenting sitting and voiding. Each time that the child voids in the
toilet, a sticker would be placed on one of the circles. Once the child has
earned four stickers, he or she would earn an additional (not easily accessi-
ble) reward. This type of strategy will provide immediate feedback to the
child for his or her successfully sitting and voiding, and at the same time,
provide some intermediate reward for cumulative progress.
Wrapped rewards. These types of rewards are often useful for children
ages 3–6. Have the parents purchase small, inexpensive trinkets at a local
novelty store and wrap them using aluminum foil or some other wrap. The
reward should be placed in a basket that is visible to the child but not easily
accessible. The child should be told that each time that he or she voids in
the toilet, he or she will earn one of the rewards and will be allowed to un-
wrap it. Many children are motivated to put forth additional effort to void
in the toilet in order to earn the “mystery reward.”
Reward jar. The use of a reward jar is likely more appropriate for older
children (age 5 and older) and should be combined with immediate, tangi-
ble rewards. To implement this strategy, the parents select a jar in which
some type of token will be placed. The parent should discuss with the child
the different types of activities or rewards that the child would like to earn,
starting with small rewards and working up toward something larger. Once
a series of four or five rewards has been identified, the parent and child
should work together to rank the items from least expensive and motivating
to most expensive and motivating. The parent then writes the names of the
items on pieces of masking tape and places them on the jar in order, begin-
ning with the least expensive–motivating reward on the bottom and ending
with the most expensive–motivating reward at the top of the jar. The child
will earn one token each time that he or she sits on the toilet cooperatively
and two tokens each time that he or she voids in the toilet. The tokens
could include things such as pennies, marbles, poker chips, cotton balls, and
so forth. The size of the token will depend on the size of the jar and how
quickly the parent wants the child to earn the rewards. The child will con-
tinue to receive immediate, tangible rewards for sitting on or voiding in the
toilet but will also add tokens to the reward jar. The tokens should be in a
visible place, ideally in the bathroom. Parents should review with their child
his or her progress and how closely the child is getting toward earning the
next reward. Once the child has filled the reward jar, the process can start
over, with the child selecting new rewards, if he or she so chooses.
Access to a special activity or item. This technique is probably most suit-

able for older children (age 5 and above), but it can certainly be used with
younger children. Have parents identify an activity or item to which the child
will have access, but only for a limited amount of time, once the child has suc-
cessfully had a bowel movement in the toilet. This might include a special
book, video game, movie, or some other activity that can be set aside and only
provided to the child once he or she has voided in the toilet. The parents
should put a limit on how much time that the child has access to it, to main-
tain its value. For example, if the parent purchases a special book, then the
parent and child might sit and read the book for 15 or 20 minutes after the
child has successfully had a bowel movement, with the book then being put
away until the next time that the child has a bowel movement in the toilet. A
variety of other activities and toys can be used in this manner.
Fading rewards. Reward systems should be put in place to initiate and

shape behavior, as well as to maintain positive toileting and bowel habit rou-
tines. Once the behavior has been established, it will be important to work
with parents to help reduce these interventions. This is best accomplished by
increasing the demands on the child (e.g., more sit times or bowel move-
ments) to earn the same reward, or by eventually fading the use of specific re-
wards for less critical behaviors (e.g., sitting). If a reward jar is used, then
either the child can earn fewer tokens for previously targeted behaviors or the
number of tokens needed to gain access to a reward can be increased.
Cleaning technique. Many children with encopresis will continue to

have minor soiling episodes (e.g., “skid marks”). These are often caused
mostly by a child’s poor wiping technique. It may be necessary for parents
to check the technique that their young children (under age 5) are using
to make sure that they are wiping appropriately. Older children should be
reminded to wipe and clean themselves appropriately. Parents can check
the child’s underwear periodically to monitor this. Instruct the parents to
provide some type of reinforcement to their child when his or her under-
wear is found clean (e.g., a treat, points, verbal praise) to enhance compli-
ance with the monitoring procedure.
If possible, help the parent understand the difference between mild
soiling due to poor hygiene and unintentional minor soiling that can be as-
sociated with the use of stool softeners. Some children will occasionally
pass small amounts of stool with the addition of fiber and Miralax (or other
laxatives) to their daily regimen. The parents should be educated that
these types of minor soiling episodes may occur until the amount of stool
softener needed to promote regular bowel movements is reduced.
Corrective Approach
Parents need an effective way to respond to their child’s soiling episodes
(Reimers 1996). Whether soiling occurs intentionally or unintentionally,
an effective response to soiling episodes is an important component of suc-
cessful treatment (also see the section “Challenges to Treatment” later in
this chapter). An overcorrection technique is usually an effective conse-
quence that is naturally associated with the child’s soiling accident. Use of
this type of approach will remove the need for parents to use other, less
effective punishment techniques such as time-out, corporal punishment,
and verbal reprimands. In general, have parents follow the steps below af-
ter a soiling episode:
1. Have parents check their child’s underwear periodically to make sure

that the child has not soiled himself or herself.
2. If a soiling episode has occurred, the parents should bring this to the
child’s attention and inform the child that he or she will need to
change and assist with the cleanup.
3. Emphasize to parents that it is important that they maintain a neutral,
matter-of-fact demeanor to the best of their ability. Maintaining a neu-
tral, matter-of-fact demeanor is important to reducing avoidant behav-
ior on the part of the child and keeping the focus of the consequences
on the child’s behavior.
4. Children should be expected to help clean themselves and their cloth-
ing to the best of their ability, based on their age and developmental
ability. The rationale behind an overcorrection procedure is to place
the responsibility for the soiling episode on the child while also apply-
ing a mild to moderate negative consequence for the soiling episode.

Because the consequence is logically connected to the child’s soiling
episode and behavior, it avoids the pitfalls associated with using puni-
tive consequences (e.g., time-out, losing privileges) that are not di-
rectly connected to the child’s soiling episode.
5. Emphasize to the parents that they should make every effort to make
the overcorrection procedure “inconvenient.” In other words, the par-
ents should not make the cleanup process easy and time efficient. The
parents should focus on taking 10–20 minutes for the cleanup process
to be completed. This will reinforce for the child that sitting on the
toilet and having a bowel movement is much more efficient and less
time-consuming than taking the time to clean himself or herself and
his or her clothing. One way of extending the overcorrection proce-
dure is to have the child sit in a few inches of bathwater (with no toys,
bubbles, bubble bath, etc.). The purpose for such soaking is for the
child to avoid developing a rash. Some children who have been wearing
soiled clothing for an extended period of time or who are chronically
soiled may need the benefit of a sitz bath to help prevent a rash. This
activity also enhances the effect of the overcorrection procedure.
6. Once the child has adequately cleaned himself or herself and appro-
priately placed the soiled clothing in its proper place, he or she should
return to the bathroom and sit on the toilet for a brief period of time
to practice appropriate toileting. It is unlikely that the child will defe-
cate, but it is important for the parent to reinforce what is expected
of the child. The child should then put on clean clothing and be redi-
rected to his or her normal activities.
Implications of Diversity
There is much less epidemiological research on encopresis than there is on
enuresis. As with enuresis, the prevalence rate of encopresis is much
higher for boys. In terms of cultural variation in encopresis, very little is
found in the peer-reviewed literature on the subject, beyond the occa-
sional suggestion that encopresis is more likely to be found in families with
lower incomes (van der Wal et al. 2005). Although this suggestion is con-
sistent with our own experience, it has been questioned by others, who
have suggested it is merely a reflection of biased population sampling
(Fritz and Armbrust 1982). At least some early research on prevalence in-
dicates encopresis is much more frequent in boys than girls, with the ratios
ranging from 3:1 to 6:1 (Fritz and Armbrust 1982; Wright et al. 1978).
Some of the relevant research was conducted in foreign countries (Bell-
man 1966), but the samples were primarily whites from industrialized cul-
tures and thus not substantially different from the populations studied in
the United States. In sum, on the basis of extant empirical literature, there
are no significant implications of diversity to highlight here.
Challenges to Treatment
The most frequent and difficult challenge to treatment involves resistance
and noncompliance. Some children are resistant toward sitting on the toi-
let or entering the bathroom because of their painful bowel movement his-
tory or their negative experience with the training process that has been
used. For children who avoid entering a bathroom at all, some type of
shaping approach can be helpful by first establishing positive associations
with the bathroom itself. This could include reading, listening to music,
playing a game, or other fun activities to help eliminate the negative asso-
ciations of being in the bathroom. Once the child is able to engage in other
activities that are pleasurable in the bathroom, efforts can be made toward
shaping him or her to sit on the toilet. This may involve starting with the
child sitting on the toilet fully clothed while parents engage in some simple
activity, such as reading a book, listening to music, and so forth. For older
children, it might involve having them play some portable video game or
read a magazine while sitting. Gradually increase the expectations for the
child, such as having him or her go from being fully clothed to sitting in his
or her underwear to finally sitting unclothed on the toilet. For younger
children, the use of some type of simple, tangible reward (e.g., stickers,
small food items) may be helpful toward motivating them to follow the di-
rections. Any resistance by the child to participate should result in him or
her having no access to other preferred activities, with the parent remind-
ing the child of his or her choice to either play while sitting on the toilet
or not play at all.
For many children, the use of some simple contingency management
(described earlier) will be effective enough to promote compliance with
sitting on the toilet. We recommend avoiding time-out when possible, be-
cause it further creates negative associations with the toileting regimen
and increases conflict between the parent and child. Additionally, many
children would rather sit in time-out than sit on the toilet. Most children
will acquiesce to sitting on the toilet for a few minutes in order to gain ac-
cess to their preferred activities. Once this occurs, it will create an oppor-
tunity to shape more cooperative sitting for longer periods of time, until
the child is able to sit long enough to relax. For children who are highly re-
sistant toward sitting on the toilet or entering the bathroom, it may be nec-
essary to spend some time working with the parents on developing more
effective parenting skills and focusing on improved levels of instructional
control across a number of domains. Once these goals have been accom-
plished, it would likely be prudent to return to the management of the en-
copresis.
Case Example
Sam was a 5-year-old boy who was referred because of recurring soiling ep-
isodes. He had never been successfully toilet trained. Sam’s medical his-
tory was unremarkable. He took no medication other than Miralax for
periodic constipation. He met all developmental milestones as expected.
Outside of the encopresis, the parents noted no significant behavioral con-
cerns. Sam was otherwise compliant with demands made of him, outside
of toileting requests.
His parents had begun toilet training him when he was about 2½ years
of age. In time, he had begun engaging in some stool-holding behavior,
which led to constipation and large, painful bowel movements. Sam had
been placed on a regimen of Miralax for management of the constipation.
He continued to be resistant to his parents’ attempts to toilet train him.
His parents had reinstituted various toilet-training attempts approximately
every 6 months up to the current time. The parents had used a variety of
positive reinforcement programs, as well as some forms of punishment to
address Sam’s soiling episodes and resistance to sitting on the toilet. The
punishment strategies included time-out, spanking, and loss of privileges.
The parents noted that their efforts had not caused any significant im-
provements in Sam’s voiding in the toilet. Sam would urinate in the toilet
but was not having bowel movements in the toilet.
Despite taking Miralax, Sam would frequently attempt to hold his
stool for as long as possible. This would often lead to him having a large
bowel movement every 2–3 days, with some apparent overflow inconti-
nence multiple times each day. Sam would also hide when having a bowel
movement, and at times, hide his soiled underwear. This increased his par-
ents’ frustration and led to additional forms of punishment. Most recently,
he had seen a gastroenterologist, who admitted Sam to the hospital for a
fecal impaction clean-out. Sam’s pediatrician continued to monitor his
constipation and toileting difficulties. Given the long-standing soiling epi-
sodes and toileting difficulties, Sam and his parents were referred to a CBT
psychologist. (It is important to note here that we did not refer Sam for a
physical examination because he was referred to us by his primary care
physician.)
CBT Evaluation
During the intake assessment, the psychologist reviewed with Sam’s par-
ents his past medical history and their efforts to toilet train Sam. The ther-
apist obtained a thorough description of the toilet-training strategies the
parents had used as well as their use of different punishment techniques.
The parents had used a variety of sticker charts and other tangible reward
systems to motivate Sam to void in the toilet. The psychologist also learned
that the parents used time-out, corporal punishment, and restricting access
to preferred activities each time that Sam refused to sit on the toilet or any
time that he had a soiling episode in his clothing. The punishment tech-
niques had been used for the past 6–12 months. The parents indicated that
as their efforts met with limited success, their level of frustration in-
creased.
The psychologist met separately with Sam. It was learned during the
intake with Sam that he was afraid to sit on the toilet because he said that
it “hurt” when he had bowel movements while sitting on the toilet. Sam
also commented that he did not want his parents to know when he had a
soiling episode because he “didn’t want to get in trouble.” Sam was also
questioned about his awareness of physical cues and urges to have a bowel
movement. Sam indicated that his “tummy hurt” when he needed to “go
poop.” When asked if he tried to sit on the toilet and have a bowel move-
ment when his tummy hurt, Sam responded, “No, it will hurt.” Following
the intake assessment, the psychologist met with the parents and asked
them to collect data on Sam’s soiling episodes and their toilet-training
practices.
Data Collection
Sam’s parents were provided with a data form that allowed them, on a
daily basis, to record the number of bowel movements that Sam had in the
toilet, the number of soiling episodes, the consistency of Sam’s stools (a
chart was provided to the parents to help them record stool consistency),
a rating of the difficulty that Sam had with passing a stool, any medicine
that he was taking, and the amount of medicine taken. Additionally, the
parents were asked to record the number of times that Sam hid his soiled
underwear. They were also asked to journal their efforts toward prompting
Sam to have a bowel movement, as well as how they responded to Sam’s
successful bowel movements and accidents.
Treatment Sessions
Session 1. During the first treatment session, it was learned that Sam
was having a large bowel movement approximately every 2 days. None of
his bowel movements occurred in the toilet; all were soiling episodes. Sam
also had approximately five small liquid soiling accidents each day. Sam sat
on the toilet only on two occasions during the first week. Based on these
data and Sam’s history, the following treatment recommendations were
put in place:
1. Sam was expected to sit on the toilet for a period of 5 minutes

after each meal. A timer was set to help Sam know how much
time he needed to remain seated. Sam’s parents agreed to read a
book to Sam or allow him to play a video game on a portable video
game console while he was sitting. Sam was to be rewarded in
some small way for sitting cooperatively on the toilet. Sam’s par-
ents rarely provided any candy or sweets to him at home. The par-
ents agreed to provide Sam with a piece of candy for sitting
cooperatively. They purchased a small candy dispenser, and Sam
earned one Skittle for successfully sitting on the toilet for
5 minutes (Sam seemed excited about the opportunity to earn
the Skittles).
2. The parents agreed to purchase small toys and other items, such
as action figures, that were meaningful to Sam in order to rein-
force his use of the toilet. They wrapped the toys in aluminum foil
and placed them in a basket that was placed on a shelf out of Sam’s
reach, but visible to him. Sam was told that he would be able to
unwrap one of the items any time that he had a bowel movement
in the toilet. The parents were instructed to provide one of the
items to Sam no matter how small the stool was that he passed in
the toilet.
3. The parents were asked to provide no verbal reprimands or any
form of punishment to Sam for having a soiling episode. Rather,
they were instructed on how to engage Sam in assisting them with
cleaning himself and his soiled clothing and placing new clothing
on himself to the best of his ability. The parents were encouraged
to make the cleanup process mildly aversive while maintaining a
neutral, matter-of-fact demeanor. If Sam had multiple soiling ac-
cidents and the parents were concerned about a possible rash,
then Sam was expected to soak in a bathtub for 5–10 minutes to
reduce the possibility of rash. Sam was to be provided with no
bathtub toys.
Session 2. At the next follow-up treatment session 1 week later, Sam’s

cooperation with sitting had improved. He was now sitting fairly coopera-
tively on the toilet 70% of the time. The parents noted that his resistance
toward sitting had decreased. Sam continued to have frequent minor soil-
ing accidents and became increasingly agitated when he was required to
help his parents with cleaning his clothing and himself. On two occasions,
he had hidden his underwear after a minor soiling episode. Sam lost the op-
portunity to play outside for the remainder of the day after his parents dis-
covered the hidden, soiled underwear. He had thus far not voided in the
toilet but was now having approximately one bowel movement per day in
his clothing.
Session 3. Sam continued to sit cooperatively and was now sitting on

the toilet approximately 90% of the time requested. His parents also noted
that there were no instances in which Sam had hidden his soiled under-
wear. The parents were very excited because Sam had had two successful
bowel movements in the toilet (one small, one large) during the past week.
Sam also seemed more excited about having bowel movements in the toilet
than about the tangible rewards that he had received for them. The parents
continued to have Sam assist with the cleanup associated with any soiling
episodes. The frequency of his soiling episodes had decreased to approxi-
mately two times per day.
Session 4. Two weeks later, the parents reported significant improve-

ment in Sam’s level of cooperation and the frequency of his bowel move-
ments in the toilet. The parents noted no instances in which Sam either hid
to have a bowel movement in his clothing or hid his soiled underwear. Sam
had had only two minor soiling episodes during the past 2 weeks, both of
which occurred while he was busy playing outside. Sam was much more
cooperative and clearly expressed his satisfaction with the progress that he
had made, telling the psychologist how many times that he had gone
“poop” in the toilet. He also shared with the psychologist the action figures
that he had earned over the past 2 weeks. The components of the treat-
ment protocol were reviewed with the parents and Sam, and they were
asked to return in 1 month.
Session 5. Sam’s parents reported that the soiling episodes had almost
completely ceased. Sam occasionally would have very small amounts of liq-
uid stool in his underwear, but the parents attributed these to the loose
consistency of his stools. Sam was now having all bowel movements in the
toilet. Sam was also able to tell the psychologist that each time that he felt
his “tummy hurt,” he would go to the bathroom and attempt to have a
bowel movement. Sam was now voiding independently the majority of the
time. The parents were instructed to discontinue regular sit times after
meals, and instead to reward Sam only if he had a bowel movement in the
toilet independently. They were to continue to have Sam assist with any
cleanup for minor soiling episodes. It was also suggested that they consult
with Sam’s pediatrician to receive recommendations on possibly titrating
his Miralax dosage. Sam was praised for his progress, and it was evident
that he was very proud of his accomplishment.
Final session. Sam was seen 8 weeks later, and his encopresis had re-
solved fully. Sam was now voiding completely independently in the toilet
and was having no soiling episodes. Sam’s parents were working with the
pediatrician to reduce and eventually eliminate the Miralax dosage, which
helped to reduce the minor soiling episodes. The treatment components
were again reviewed with the parents, and final recommendations were of-
fered. The parents were encouraged to contact the psychologist with any
questions that arose in the future.
Conclusion: Encopresis
Although enuresis is one of the most distressing experiences reported by
children (Van Tijen et al. 1998), unfortunately no similar type of research
has been conducted on how distressing encopresis is for affected children.
Our clinical experience suggests that encopresis is even more distressing
for afflicted children than enuresis. Furthermore, the psychological, emo-
tional, social, and medical complications that result from chronic un-
treated cases of encopresis are greater than the complications that arise
from untreated enuresis. Although effective treatment for encopresis is
more invasive and potentially embarrassing for affected children and their
families than treatment for enuresis, it can actually involve less effort. For
example, all of the parental treatment efforts occur during the day,
whereas with enuresis, important treatment efforts are needed at night.
Presently, physicians are the major first line of defense against encopresis,
but their approach typically is mostly biomedical, and as we hope we have
clearly demonstrated, there is a substantial cognitive-behavioral dimension
to the condition. As with CBT for enuresis, CBT for encopresis is not an
obvious example of CBT. Classic examples of CBT application include
treatment for anxiety, depression, or habit disorders. Those conditions are
more dominantly psychological, and thus with the exception of cases in-
volving drug treatments, the emphasis in CBT treatment for these disor-
ders is mostly on the cognitive and emotional behavior of those affected.
With encopresis, however, the condition is quite obviously dominantly bio-
medical and so too is its most significant cause, constipation. Nonetheless,
effective treatment always involves cognitive and motoric behavior
changes, and therefore encopresis is an appropriate target for CBT-trained
therapists, with the caveat that they be highly familiar with the physiology
of defecation.
Conclusion
Enuretic and encopretic children have been misunderstood, misinter-
preted, and mistreated for centuries. Fortunately for them, scientists and
practitioners working in the latter half of the twentieth century supplied
a more accurate, humane, and treatment-relevant characterization of these
conditions. These characterizations have led to empirically supported
treatments, and the best known of these have been described in this chap-
ter. Although in this chapter we refer to the general category for these
treatments as CBT, this form of treatment is also characterized as biobe-
havioral in other work (Christophersen and Friman 2010; Friman 2007,
2008). The CBT understanding and approach to enuresis and encopresis is
substantially superior to the historically psychogenic understanding and
approach, and even more so to the moral and characterological under-
standing and approach of antiquity. The CBT approach incorporates the
physiology of elimination, and although it also incorporates the psycholog-
ical state of the child, it does not view psychological variables as necessarily
causal. Rather, psychological variables are viewed as critical to active par-
ticipation in treatment, and CBT provides methods for using or modifying
these variables to promote participation. When psychological abnormali-
ties are present, they are more likely to be viewed as a consequence rather
than a cause of either condition. The psychogenic approach virtually ig-
nores the physiology of elimination and views psychological variables as
dominantly causal. Although the psychogenic approach views psychologi-
cal variables as relevant to participation in treatment, it provides no meth-
ods for using these same variables to promote participation.
From the CBT perspective, the evaluation and treatment of enuresis
and encopresis always require the direct involvement of a physician, but
ideal management results from a partnership with the child, family, cogni-
tive-behavioral therapist, and physician. This unified approach, when ac-
companied by empirically supported CBT, can alleviate incontinence
completely—and eliminate or dramatically minimize the possibility of the
harmful overinterpretation and unhealthful forms of treatment that have
tarnished the health care approach to incontinence in children throughout
history.
Key Clinical Points

Enuresis
• A physical exam of the child that includes a urine analysis should be
included in the assessment phase.
• All forms of punishment for urinary accidents should be abolished.
• The child and parents should be educated about enuresis with em-
phasis on definition, causes, prevalence, and treatment options.
• The most empirically supported treatment by a wide margin is alarm-
based treatment.
• Because of the health risks associated with medications used for
treatment of enuresis, medication should not be used as a primary
treatment agent.
Encopresis
• A physical exam to rule out fecal impaction and gastrointestinal dis-
eases (e.g., Crohn’s disease) should be conducted before behav-
ioral consultation is sought.
• The child and parents should be educated about encopresis with
emphasis on definition, causes, prevalence, and treatment options.
• Punishing the child for having soiling accidents should be avoided
because of the risk for stool holding and a reduction in cooperation
with the behavior plan.
• Shaping the child’s cooperation for sitting on and voiding in the toi-
let through positive behavioral strategies should be the center of
any intervention plan.
• The child’s stool consistency, successful bowel movements, and soil-
ing accidents should be monitored closely throughout treatment.
Enuresis
13.1. Which of the following statements best characterizes enuresis?
A. It is a benign condition.
B. It is a psychopathological condition.
C. It is a psychopathological condition medically but not psycholog-
ically.
D. It is a psychopathological condition psychologically but not med-
ically.
13.2. Regarding physician involvement in the initial assessment of enure-

sis, which of the following is most accurate?
A. Because enuresis is a psychological condition, there is no need to

involve a physician.
B. Because enuresis is a medical condition, physicians are solely re-
sponsible for assessment and diagnosis.
C. Involvement of the physician is best left to the psychologist’s
discretion.
D. All cases of enuresis should be referred to a physician for an ini-
tial evaluation so that potential medical causes can be detected
and treated or ruled out.
13.3. Which of the following does not have strong evidence supporting its
role as a cause of enuresis?
A. Family history.
B. Reduced functional bladder capacity.
C. Difficulty arousing from sleep.
D. Psychopathology.
13.4. Which of the following is true of drug-based treatment for noctur-

nal enuresis?
A. Drugs are highly effective as treatment for enuresis and should

always be considered as primary treatment.
B. Drugs are highly ineffective for treatment of enuresis and should
never be considered in a treatment plan.
C. Both drugs and biobehavioral treatment methods are effective as
primary treatment for enuresis, and the therapist should choose
between them.
D. Because of unhealthy side effects and temporary results, drugs
should be considered only as adjuncts to treatment.
13.5. Which of the following treatments for diurnal enuresis has the most
empirical support?
A. Scheduled toilet visits.

B. Retention-control training.
C. Alarm-based treatment.
D. Fluid restriction.
Encopresis
13.6. Compared to enuresis, the prevalence rate for encopresis is
A. Lower.
B. Higher.
C. About the same.
D. Not available for the general population.
13.7. Which of the following factors is not known to contribute to the de-
velopment of encopresis?
A. Fiber intake.
B. History of painful bowel movements.
C. Volitional stool-holding.
D. Sodium intake.
13.8. From a treatment standpoint, the research suggests that which

treatment modality is most efficacious when treating encopresis?
A. Medical treatment only.

B. Behavioral treatment only.
C. Collaborative medical and behavioral treatment.
D. Dietary modifications, with consultation by a psychologist.
13.9. Regarding physician involvement in the management of encopresis,

which of the following is most accurate?
A. All cases of encopresis should be referred to a primary care phy-

sician to rule out potential medical causes.
B. All cases of encopresis should be referred to a pediatric gastro-
enterologist.
C. Psychologists should decide, at their discretion, whether in-
volvement by a physician is needed.
D. Because there is a strong behavioral component to encopresis,
further involvement by a physician is not needed.
13.10. Which of the following best characterizes encopresis?
A. It is a condition that has many contributing factors, including

medical, behavioral, and nutritional.
B. Encopresis is primarily a medical condition.
C. Encopresis is primarily a behavioral disorder.
D. The contributing factors for encopresis are not well known.
13.11. Which of the following is true about the role of biofeedback treat-
ment for encopresis?
A. It has demonstrated superior long-term effects over traditional

medical interventions.
B. Biofeedback does not increase treatment rates above those
achieved with conventional treatment alone.
C. There is no support for the use of biofeedback, and it should
generally be avoided.
D. Biofeedback has been shown to be a critical and essential treat-
ment component, especially when combined with medical and
behavioral interventions.
Suggested Readings
and Web Sites
Christophersen ER, Mortweet SL: Treatments That Work With Children:
Empirically Supported Strategies for Managing Childhood Problems.
Washington, DC, American Psychological Association, 2001
The Journal of the American Academy of Child and Adolescent Psychiatry

October 2001 issue provides an extensive review of the research liter-
ature on enuresis and encopresis.
McGrath ML, Mellon MW, Murphy L: Empirically supported treatments
in pediatric psychology: constipation and encopresis. J Pediatr Psychol
25:225–254, 2000 (a comprehensive review of the empirically sup-
ported treatments for constipation and encopresis)
Schonwald AD, Sheldon GG: The Pocket Idiot’s Guide to Potty Training
Problems. Indianapolis, IN, Penguin, 2006
Vemulakonda VM, Jones EA: Primer: Diagnosis and Management of Uncom-
plicated Daytime Wetting in Children. Nat Clin Pract Urol 3:551–559,
2006. Available at: http://www.medscape.com/viewarticle/546017. Ac-
cessed July 28, 2011.
For a variety of toilet training accessories: www.pottytrainingconcepts.com

For more information on toilet training and the Toilet School at Children’s
Hospital Boston (Massachusetts): http://www.childrenshospital.org/
az/Site1755/mainpageS1755P0.html
The Web site for the University of Virginia Health Sciences Center fea-
tures a tutorial for patients and families, “Chronic Constipation and
Enuresis”: http://www.medicine.virginia.edu/clinical/departments/
pediatrics/clinical-services/tutorials/constipation/home
The Bedwetting Store: www.bedwettingstore.com
Bedwetting facts: www.aacap.org/cs/root/facts_for_families/bedwetting
Bedwetting general information: http://en.wikipedia.org/wiki/Bedwetting
Bedwetting and soiling information and treatment: www.soilingsolutions.com
Diurnal enuresis: http://en.wikipedia.org/wiki/Diurnal_enuresis
General information and products for all aspects of child incontinence:
www.pottymd.com
FamilyDoctor.org: “Stool Soiling and Constipation in Children”: http://
familydoctor.org/online/famdocen/home/children/parents/toilet/
166.html
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APPENDIX 1
Self-Assessment
Questions and Answers
Chapter 1: Cognitive-Behavior Therapy:

An Introduction
1.1. What is the most readily available form of core beliefs called?
Answer: Automatic thoughts are the most readily available form

of core beliefs.
1.2. What is a negative schema?
Answer: A negative schema is an information processing “lens,”

informed by early life experiences and negative life events, through
which an individual views the world and makes sense of new infor-
mation. This schema is activated in situations that remind the indi-
vidual of the original learning experiences, leading to maladaptive
negative beliefs about the self, the world, and the future.
513
1.3. Define collaborative empiricism.
Answer: Collaborative empiricism is a process by which the

therapist and client carefully consider all available evidence and
identify “clues” that support the maladaptive cognition and those
that do not support the thought or belief.
1.4. How are behaviors reinforced? How are they extinguished?
Answer: Behaviors are reinforced when an event, privilege, ma-

terial item or behavior that follows a behavior is rewarding. Ex-
tinction refers to the reduction in frequency or total elimination
of a behavior by use of nonrewarding occurrences.
Chapter 2: Developmental Considerations

Across Childhood
2.1. True or False: Adolescents are always better able to engage in cog-
nitive-behavioral strategies than are young children.
Answer: False.
2.2. Which of the following is NOT a reason to use a developmentally

sensitive framework in treatment planning?
A. Different treatment strategies require different develop-

mental skills.
B. Developmental level impacts children’s ability to both
learn and apply therapeutic skills.
C. Development level within a domain is uniform at each
chronological age.
D. Different areas of development (e.g., cognitive, social,
and emotional) are interdependent.
Answer: C.
2.3. Little Johnny is asked in therapy to recognize that when he thinks

“I will fail this math test no matter what,” he feels discouraged and
is less likely to study for the test. Which of the following develop-
mental skills are necessary to understand this connection?
A. Metacognition and perspective taking.

B. Causal reasoning and emotion identification.
Appendix 1: Self-Assessment Questions and Answers 515
C. Self-reflection and social skills.

D. Hypothetical thinking and emotion management.
Answer: B.
2.4. True or False: Adapting adult language to be more age-appropriate

is the primary way to developmentally tailor CBT for children.
Answer: False.
2.5. Clinicians should assess children’s developmental level
A. Before starting treatment.

B. Before introducing a new developmentally challenging
technique.
C. After implementing strategies designed to improve de-
velopmental skills.
Answer: D.
Chapter 3: Culturally Diverse

Children and Adolescents
3.1. Which of the following is NOT a strength of CBT when imple-
mented with ethnocultural minority youth?
A. It is time limited and problem oriented.

B. It is focused on the present and future.
C. It is focused on intrapsychic, unconscious processes.
D. It involves collaboration in defining treatment goals.
Answer: C.
3.2. Parent training protocols with ethnic minority youth may improve
treatment retention and outcomes by including an emphasis on
A. Time-out.
B. Physical discipline.
C. Natural consequences.
D. Racial socialization.
Answer: D.
3.3. Antoine is a 9-year-old African American boy who is struggling in

school. One of his core beliefs is that “only white kids do well in
school.” This belief is an example of
A. Acculturation stress.
B. Internalized oppression.
C. Feelings as facts.
D. Ableism.
Answer: B.
3.4. CBT with an Iraqi (Muslim) 12-year-old girl with externalizing

problems might be enhanced by
A. Family-focused sessions.
B. Individual-focused sessions.
C. Emphasis on assertiveness training in all contexts.
Answer: A.
3.5. The clinician must be especially cautious in implementing which

CBT skill because of its cultural acceptability in different settings
(e.g., home vs. school)?
B. Problem solving.
C. Assertiveness training.
Answer: C.
Chapter 4: Combined CBT

and Psychopharmacology
4.1. The only other medication besides fluoxetine that the U.S. Food
and Drug Administration has approved for the treatment of major
depressive disorder in adolescents (12–17 years) is
A. Sertraline.
B. Escitalopram.
C. Paroxetine.
D. Fluvoxamine.
E. Imipramine.
Answer: B.
4.2. On the basis of the results of the Children/Adolescent Anxiety

Multimodal Study (CAMS), the following statement is true:
A. CBT is the most effective intervention for children and

adolescents.
B. Pharmacotherapy is the most effective intervention for
children and adolescents.
C. Combined treatments (CBT and pharmacotherapy)
showed a superior response rate compared to CBT or
pharmacotherapy alone.
D. No intervention was shown to be better than placebo.
E. The results were inconclusive.
Answer: C.
4.3. Which of the following statements is true regarding evidence for

combined treatments (CBT plus pharmacotherapy) for depression?
A. Combined treatments (CBT and pharmacotherapy) are

always better than either treatment alone.
B. CBT is consistently better than pharmacotherapy and
thus should be the first line of treatment.
C. Pharmacotherapy is consistently better than CBT and
thus should be the first line of treatment.
D. The results are mixed, with some studies showing effi-
cacy of combined treatments and others the advantages
of a combined approach.
E. None of the above statements is true.
Answer: D.
4.4. For a 13-year-old patient presenting with a first episode of major

depression, the clinician should
A. Always start with CBT first and switch to medications if

CBT does not work.
B. Take a detailed history and make a decision on treatment
interventions on the basis of the inventory of factors, such
as symptom severity and patient and parent preferences.
C. Always start with pharmacotherapy first and then add

CBT if symptom resolution has not been achieved by
pharmacotherapy alone.
D. Take a detailed history, assess for various factors, and
then always start with a combined approach (CBT plus
pharmacotherapy) because it has been shown to be the
most efficacious.
E. Let the patient decide.
Answer: B.
4.5. Which of the following are important factors to consider when de-
ciding which intervention to choose from?
B. Prior experience with treatment.
C. Comorbidities.
D. Availability of resources.
E. All of the above.
Answer: E.
Chapter 5: Depression and Suicidal Behavior
5.1. A 14-year-old Hispanic boy diagnosed with a major depressive dis-

order has not responded to a trial of a selective serotonin reuptake
inhibitor (SSRI). The next management step that the youth would
most likely respond to is to
A. Switch to another SSRI.

B. Switch to venlafaxine.
C. Switch to another SSRI and add CBT.
D. Treat with the same SSRI for a period longer than 12
weeks.
Answer: C.
5.2. A 13-year-old girl with a history of depression gets easily irritable

at school and becomes aggressive with teachers and friends. The
most helpful CBT technique to include in her treatment plan is
A. Exposure and response prevention.

B. Cognitive restructuring.
C. Emotion regulation
D. Safety planning.
Answer: C.
5.3. You tell your depressed adolescent youth that it is important to

schedule activities that he or she finds pleasurable and to engage in
these activities on a regular basis. This is an example of
Answer: C.
5.4. A feasible and acceptable therapeutic intervention with a de-

pressed adolescent who recently attempted suicide is
A. Interpersonal therapy.
B. CBT used with depressed youths.
C. Relaxation techniques.
D. Cognitive-behavior therapy for suicide prevention.
Answer: D.
5.5. You see an adolescent youth with depression who is having difficul-
ty initiating and maintaining relationships with peers. The most
helpful CBT technique to include in the treatment plan of this
youth is
Answer: D.
Chapter 6: Bipolar Disorder

6.1. CBT would be considered an appropriate treatment strategy for a
child with bipolar disorder
A. Only when a strong family history of bipolar disorder is

identified.
B. In conjunction with mood stabilization with medication.
C. If the child is of well above-average intelligence.
D. As a stand-alone treatment.
Answer: B.
6.2. Children with bipolar disorder are at increased risk for
A. Academic problems.
B. Social problems.
C. Suicidal ideation.
Answer: D.
6.3. A 14-year-old adolescent girl is diagnosed with bipolar I disorder.

__________ is/are considered the first-line treatment(s).
A. CBT.
B. Antidepressants.
C. Mood stabilizers or atypical antipsychotics.
D. Electroconvulsive therapy.
Answer: C.
6.4. Although the etiology of bipolar disorder is thought to be largely

___________________, illness course is likely influenced by
___________________________.
A. The result of trauma; biological factors.

B. Biological; a combination of biological, psychological,
and social factors.
C. Due to impaired parenting; a combination of biological,
psychological, and social factors.
D. Medication induced; the child’s level of intelligence.
Answer: B.
6.5. _____________ is almost always recommended as a part of CBT for

a child with bipolar disorder.
A. Family involvement.
B. Use of a therapist of the same sex as the child.
C. Residential treatment.
D. Psychoeducational testing.
Answer: A.
Chapter 7: Childhood Anxiety Disorders

7.1. Which of the following clients is an appropriate candidate for CBT
for child anxiety?
A. A 16-year-old white adolescent girl with primary social

phobia, obesity, and a learning disability.
B. A 6-year-old Hispanic girl with primary separation anxi-
ety disorder and a specific phobia of blood.
C. A 13-year-old African American adolescent boy with pri-
mary generalized anxiety disorder and comorbid atten-
tion-deficit/hyperactivity disorder (ADHD) managed
with stimulant medication.
Answer: D. The clients described in A, B, and C are all appro-

priate candidates for CBT for child anxiety. Treatment manuals
exist for CBT for child anxiety for youth ages 4–17, and CBT for
child anxiety can be implemented with flexibility for youth with
learning differences and comorbid conditions.
7.2. Which of the following is NOT a core component of CBT for child
anxiety?
B. Exposure tasks.
C. Psychoeducation.
Answer: D. Although behavioral activation is a component of

some CBT protocols for child depression, it is not a common core
component of CBT approaches to child anxiety.
7.3. A 7-year-old girl diagnosed with separation anxiety disorder presents

for treatment. The best role for her parents in CBT treatment is
A. No parental involvement in the child’s treatment.

B. Parents as co-clients in treatment, with treatment for
the child and treatment for the parents.
C. Parents as collaborators in conducting exposure tasks in-
volving the child’s separation from the parent(s).
D. Parents as consultants regarding the child’s symptoms
and impairment.
Answer: C. Though it might seem tempting to include parents

as co-clients, the core component of treatment will be graduated
exposure to the feared situation—specifically, separation from
parents. Parents can be involved as collaborators in planning and
carrying out the exposure tasks. Parents can and do serve as con-
sultants, but the best role for them in this case is as collaborators.
7.4. A 12-year-old boy with generalized anxiety disorder expresses worry

about an upcoming test; he thinks, “I’m worried that I am going to
fail, and then I’ll have to repeat seventh grade!” Which of the follow-
ing is a reasonable coping thought in this situation?
A. There’s no way I’ll fail. The teacher likes me.... I think.

B. All I have to do is study every day before the test and
then I won’t fail.
C. Even if I fail seventh grade, I still have my friends...so
why bother studying?
D. It’s unlikely that I will fail the test because I studied pretty
hard. Even if I did fail this one test, I have plenty of time
to bring up my grades before the end of seventh grade.
Answer: D. This coping thought is realistic about the probabili-

ties of the various feared outcomes.
7.5. Which of the following is NOT an example of an appropriate flex-

ible implementation of CBT for child anxiety (i.e., a flexible appli-
cation that maintains treatment fidelity)?
A. Simplifying cognitive restructuring to the use of a single

coping thought (“I can do it!”) for a 7-year-old boy with
primary separation anxiety disorder who didn’t fully
grasp the concept of self-talk.
B. Eliminating at-home exposure tasks for an 11-year-old
girl with social phobia, because of parental concerns
about causing the child too much stress.
C. Using frequent breaks and additional rewards for an 8-

year-old boy with primary generalized anxiety disorder
and comorbid ADHD who is having difficulty staying on
task in session.
D. Downplaying “sleeping in own bed” as an exposure task for
a 9-year-old girl with primary social phobia, due to parental
beliefs and preferences regarding a shared family bed.
Answer: B. This application would not be an example of “flexi-

bility within fidelity” because the child will not face her fears in
settings other than the therapy clinic. The therapist should review
the rationale behind exposure tasks with the parents and the im-
portance of allowing the child to learn to cope with the distress.
A, C, and D are all appropriate ways to individualize CBT for
child anxiety according to age, comorbidities, and culture, while
maintaining treatment fidelity.
Chapter 8: Pediatric Posttraumatic

Stress Disorder
8.1. Which of the following is a characteristic of gradual exposure?
A. Incrementally increasing the duration and intensity of trau-

matic material in each sequential treatment component.
B. Therapists being mindful not to model avoidance.
C. Connecting each component, including the skills-based
components, to the child’s trauma in some way.
D. Instructing children to think about their trauma experi-
ences for at least an hour every day.
Answer: E.
8.2. Connections among which of the following three components form

the basis of cognitive coping?
A. Thoughts, feelings, behaviors.

B. Thoughts, antecedents, consequences.
C. Antecedents, behaviors, consequences.
D. Thoughts, behaviors, beliefs.
Answer: A.
8.3. Which of the following factors may be considered in choosing be-

tween individual and group CBT trauma treatments?
B. Accessibility of school-based treatment.
C. What treatment parents will accept.
Answer: D.
8.4. Which of the following may inadvertently communicate trauma

avoidance to children during therapy?
A. Using euphemisms for traumatic experiences.

B. Attempting to show empathy by changing voice tone or
volume when talking about trauma.
C. Change in body language.
D. Preparatory statements when introducing traumatic
themes.
Answer: F.
8.5. Cultural adaptations of CBT trauma treatments have
A. Found some core components to be ineffective with cer-

tain populations.
B. Retained all core components of the efficacious treatments.
C. Found that manuals cannot be properly translated into
other languages.
D. Created new models for different ethnic groups.
Answer: B.
Chapter 9: Obsessive-Compulsive Disorder

9.1. CBT treatment research has indicated that the most efficacious
component for decreasing obsessive-compulsive disorder (OCD)
symptoms is
A. Prolonged exposure.
B. Socratic questioning.
C. Progressive muscle relaxation.

D. Exposure and response prevention.
Answer: D.
9.2. Research by Storch and colleagues has indicated that CBT with ex-
posure and response prevention (E/RP) is
A. Most effective when delivered in a weekly outpatient

format.
B. Most effective when delivered in a daily outpatient
format.
C. Equally effective in either a weekly or daily outpatient
format.
D. Equally effective in either an outpatient or inpatient
format.
Answer: C.
9.3. What is considered to be the threshold for clinically significant

OCD on the Children’s Yale-Brown Obsessive-Compulsive Scale
(CY-BOCS)?
A. 10.
B. 12.
C. 16.
D. 20.
E. 30.
Answer: C.
9.4. Which of the following is not considered relevant to at least some

OCD cognitions?
A. Feared consequence of not relieving urges.

B. Thought-action fusion.
C. Overestimation of threat.
D. Intolerance of uncertainty or doubt.
Answer: A.
9.5. When is an E/RP exercise typically considered to be successfully

completed?
A. When the child and parent experience a 30% reduction

in initial distress.
B. When the child experiences a 50% reduction in initial
distress.
C. When the child experiences a 90% reduction in initial
distress.
D. When the child and parent experience a 90% reduction
in initial distress.
E. Either B or D.
F. Either B or C.
Answer: F.
Chapter 10: Chronic Physical Illness

10.1. When CBT is used for the treatment of a youth with a chronic
physical illness, which of the following treatment components will
likely be most useful for improving mood and positive coping?
A. Teaching the youth skills focused on changing negative

thoughts regarding illness.
B. Parent sessions focused on education regarding CBT and
how parents can best support their child.
C. Teaching the youth skills focused on how to behave dif-
ferently when feeling upset, such as increasing pleasur-
able activities.
Answer: D. When using CBT, the behavioral, cognitive, and

family skills introduced are all equally important to the overall
outcome of improving mood and positive coping for youth. Ulti-
mately, CBT is a toolbox approach, and the best treatments pro-
vide youth with several options for coping with negative situations
they may encounter in the future.
10.2. Which of the following best describes the relationship between psy-
chological and physical processes?
A. Symptoms of physical illness, such as inflammation, can

negatively impact brain chemistry, resulting in psycho-
logical disturbances.
B. There is no relationship between physical illness and
mental health concerns.
C. The relationship is bidirectional. A preexisting mental

health concern can negatively impact physical illness by
decreasing healthy behaviors. Also, physical illness pro-
cesses can contribute to increased psychological con-
cerns by increasing both internal and external stressors.
D. Psychological difficulties can negatively impact a youth’s
perception of control over illness, leading to a hopeless
view regarding health and a decreased participation in
healthy behaviors.
Answer: C. The relationship between physical illness and psy-

chological processes is bidirectional. This supports providing
mental health treatment alongside medical treatments in order to
promote medical adherence and to increase quality of life and
feelings of well-being.
10.3. A 14-year-old adolescent girl with comorbid Crohn’s disease and

depression spends most of her time lying in bed in her bedroom,
isolating herself. Which of the following coping skills is a primary
control tool that will likely help her change this negative behavior?
A. The tool of identifying the silver lining so that the youth

begins to find the positive in her situation.
B. Taking part in relaxation training techniques such as deep
breathing and hypnosis.
C. Recognizing negative thought patterns and challenging
them with more helpful thoughts.
D. Activity scheduling: being encouraged to take part in an
increased variety of activities, including pleasurable,
physically active, helpful, and social activities.
Answer: D. Choices A and C are secondary control techniques;

they focus on changing the youth’s perception in order to improve
mood. Choice B is a primary control tool; however, relaxation
training would not be the most helpful skill for decreasing the
youth’s isolative behavior. Activity scheduling is a primary control
tool because it encourages the youth to behave in a different way
to change the negative situation.
10.4. Which of the following is not a focus of treatment according to the

Skills-and-Thoughts (SAT) theory?
A. Identifying negative thought patterns and learning to

change them.
B. Improving self-soothing skills.

C. Using the therapeutic relationship as a model for outside
relationships.
D. Increasing participation in pleasurable or rewarding ac-
tivities.
Answer: C. Choices A, B, and D all describe components of the

SAT theory, which focuses on improving negative cognitions as
well as behavior patterns. Choice C describes the interpersonal
therapy approach.
10.5. When working with a 17-year-old adolescent boy, the therapist no-
tices that he appears bored when presented with the information.
Which of the following developmental adaptations may be most
useful for this situation?
A. Leave out the ACT (i.e., Activities, Calm and Confident,

Talents) skills when conducting treatment in order to fo-
cus more on the complex skill of cognitive challenging.
B. Focus on making the sessions collaborative and fun by
learning about the teen’s interests and linking skills with
the teen’s illness narrative.
C. Increase parent participation in the teen’s sessions to en-
sure that he participates actively.
D. Do not make any adaptations, as this would decrease the
overall efficacy of the treatment.
Answer: B. When working with teens, it is especially important to

create a collaborative relationship and to link the skills presented
with the reported concerns in the illness narrative. Making these
adaptations will likely strengthen the efficacy of the treatment. Be-
cause teens are often seeking independence, increasing parental
participation in individual sessions would likely not increase the
therapist’s rapport with the teen. It is important for therapists to
present both ACT and THINK (i.e., Think positive, Help from a
friend, Identify the silver lining, No replaying bad thoughts, Keep
trying—don’t give up) skills to patients of all ages with whom they
are working; these are the key components of the treatment.
Chapter 11: Obesity and Depression

11.1. Which is not typically a psychological correlate of adolescent obesity?
A. Low self-esteem.
B. Compromised body image.
C. Depression.
D. Obsessive-compulsive traits.
Answer: D.
11.2. Why is polycystic ovary syndrome an appropriate physical illness

for a CBT approach?
A. CBT helps adolescents restructure their psychosomatic

complaints.
B. CBT assists adolescents in better understanding why
they are obese.
C. CBT can target both the obesity and depression that
these adolescents may experience.
D. CBT can activate adolescents to exercise more fre-
quently.
Answer: C.
11.3. Which comorbid condition may CBT assist in the treatment of ad-
olescents with obesity and depression?
A. Obsessive-compulsive disorder.
B. Posttraumatic stress disorder.
C. Eating disorder not otherwise specified.
D. Alcohol dependence.
Answer: C.
11.4. Which of the following is not a key strategy used during motiva-
tional interviewing as a complementary approach to CBT?
A. Open-ended questions.
B. Nondirective empathy.
C. Affirmations.
D. Reflective listening.
Answer: B.
11.5. An 8-year-old boy comes into the clinic with a body mass index
percentile of 99.9. He complains that his family has a lot of high-
fat, high-calorie food in the home. Both parents are obese, and they
question why they should have to change their habits for their
child. Which of the following CBT techniques is most logical to
employ with this child and his family?
B. Self-monitoring.
C. Stimulus control.
Answer: C.
Chapter 12: Disruptive Behavior Disorders
12.1. A 10-year-old boy with a history of aggressive, disruptive behavior

at home and at school is referred for psychological treatment. The
most effective treatment for his referral problems is which of the
following?
A. Parent training alone.

B. Cognitive-behavioral interventions with the child alone.
C. Cognitive-behavioral interventions with parent and child
components.
D. Relationship therapy with the child.
Answer: C.
12.2. David is a 10-year-old boy who attends individual therapy to ad-

dress his diagnosis of oppositional defiant disorder. When his ther-
apist asks about his feelings, his responses are limited to “happy”
and “mad.” In seeking to broaden his recognition of various feeling
states, his therapist should work on helping him recognize which of
the following?
A. Physiological sensations.
B. Behaviors.
C. Cognitions.
Answer: D.
12.3. Amanda, age 11, has been referred for therapy because of her fre-
quent angry outbursts. When she is calm, she can articulate appro-
priate responses to problems such as peer teasing, but she tends to
act out aggressively when confronted with real-life problems.
Which of the following areas should Amanda’s therapist focus on
first?
A. Social problem-solving.
B. Perspective taking.
C. Anger management strategies.
D. Identifying consequences for aggressive behaviors.
Answer: C.
12.4. In one of the clinical vignettes in this chapter, 15-year-old Tim as-
sumes that his teacher “has it out for him” when she puts his name
on the board for getting out of his seat to sharpen his pencil. Tim’s
CBT-oriented clinician seeks to help him see the situation from his
teacher’s perspective to modify his initial
A. Intermittent explosive disorder.

B. Hostile attribution bias.
C. Reactive attachment.
D. Relational aggression.
Answer: B.
12.5. In another clinical vignette in this chapter, Naomi has sought men-
tal health services to reduce her daughter Anna’s disruptive behav-
ior. The family’s CBT-oriented clinician has asked Naomi to praise
Anna’s prosocial behaviors (such as following directions and helping
out around the house) and to ignore minor disruptive behavior
(such as whining or not cleaning out the sink thoroughly). The cli-
nician is likely trying to help Naomi use which of the following?
A. Behavioral rules and expectations.

B. Mood management.
C. Discipline.
D. Contingency management.
Answer: D.
Chapter 13: Enuresis and Encopresis

Enuresis
13.1. Which of the following statements best characterizes enuresis?
A. It is a benign condition.
B. It is a psychopathological condition.
C. It is a psychopathological condition medically but not
psychologically.
D. It is a psychopathological condition psychologically but
not medically.
Answer: A.
13.2. Regarding physician involvement in the initial assessment of enure-

sis, which of the following is most accurate?
A. Because enuresis is a psychological condition, there is no

need to involve a physician.
B. Because enuresis is a medical condition, physicians are
solely responsible for assessment and diagnosis.
C. Involvement of the physician is best left to the psychol-
ogist’s discretion.
D. All cases of enuresis should be referred to a physician for
an initial evaluation so that potential medical causes can
be detected and treated or ruled out.
Answer: D.
13.3. Which of the following does not have strong evidence supporting
its role as a cause of enuresis?
A. Family history.
B. Reduced functional bladder capacity.
C. Difficulty arousing from sleep.
D. Psychopathology.
Answer: D.
13.4. Which of the following is true of drug-based treatment for noctur-

nal enuresis?
A. Drugs are highly effective as treatment for enuresis and

should always be considered as primary treatment.
B. Drugs are highly ineffective for treatment of enuresis

and should never be considered in a treatment plan.
C. Both drugs and biobehavioral treatment methods are ef-
fective as primary treatment for enuresis, and the thera-
pist should choose between them.
D. Because of unhealthy side effects and temporary results,
drugs should be considered only as adjuncts to treatment.
Answer: D.
13.5. Which of the following treatments for diurnal enuresis has the
most empirical support?
A. Scheduled toilet visits.

B. Retention-control training.
C. Alarm-based treatment.
D. Fluid restriction.
Answer: C.
Encopresis
13.6. Compared to enuresis, the prevalence rate for encopresis is
A. Lower.
B. Higher.
C. About the same.
D. Not available for the general population.
Answer: A.
13.7. Which of the following factors is not known to contribute to the de-
velopment of encopresis?
A. Fiber intake.
B. History of painful bowel movements.
C. Volitional stool-holding.
D. Sodium intake.
Answer: D.
13.8. From a treatment standpoint, the research suggests that which

treatment modality is most efficacious when treating encopresis?
A. Medical treatment only.

B. Behavioral treatment only.
C. Collaborative medical and behavioral treatment.

D. Dietary modifications, with consultation by a psychologist.
Answer: C.
13.9. Regarding physician involvement in the management of encopresis,

which of the following is most accurate?
A. All cases of encopresis should be referred to a primary

care physician to rule out potential medical causes.
B. All cases of encopresis should be referred to a pediatric
gastroenterologist.
C. Psychologists should decide, at their discretion, whether
involvement by a physician is needed.
D. Because there is a strong behavioral component to enco-
presis, further involvement by a physician is not needed.
Answer: A.
13.10. Which of the following best characterizes encopresis?
A. It is a condition that has many contributing factors, in-

cluding medical, behavioral, and nutritional.
B. Encopresis is primarily a medical condition.
C. Encopresis is primarily a behavioral disorder.
D. The contributing factors for encopresis are not well known.
Answer: A.
13.11. Which of the following is true about the role of biofeedback treat-
ment for encopresis?
A. It has demonstrated superior long-term effects over tra-

ditional medical interventions.
B. Biofeedback does not increase treatment rates above
those achieved with conventional treatment alone.
C. There is no support for the use of biofeedback, and it
should generally be avoided.
D. Biofeedback has been shown to be a critical and essential
treatment component, especially when combined with
medical and behavioral interventions.
Answer: B.
Index
Page numbers printed in boldface type refer to tables or figures.
ABC Chart, 450 ADIS (Anxiety Disorders Interview

ABCs of trauma impact, 268–270 for Children), 304, 305
A-B-C-D-E sequence, 4–5, 99–100 ADIS-C/P (Anxiety Disorders
Abstract reasoning, 43, 66 Interview Schedule for DSM-
Acceptance, and peer relationships, 48 IV—Parent and Child Versions),
Acceptance and commitment therapy, 230
25 Adolescent Depression Antidepressants
Acculturation, and cultural issues, 87– and Psychotherapy Trial
89 (ADAPT), 164
ACT (acronym) Adolescents and adolescence. See also
chronic physical illness and, 337– Age
338, 346, 353–354, 355, 357, behavioral plan and chronic
359, 369, 382 physical illness in, 381–382
obesity and, 402 Coping Cat Program for anxiety
Active stance, of therapist in CBT, 14– disorders in, 252
15 cultural identity and, 84
Activities, and chronic physical illness, developmental adaptations of CBT
347–348, 380. See also Exercise; for PTSD in, 277–278
Physical activity developmental characteristics and
ADAPT (Adolescent Depression efficacy of CBT for, 32, 33
Antidepressants and obesity and
Psychotherapy Trial), 164 prevalence of anxiety, 387
Adaptation, and cultural issues in CBT prevalence of depression,
trials, 79 409
ADDRESSING model, for Adolescent Swinburne University
assessment, 93 Emotional Intelligence Test
ADHD. See Attention deficit/ (A-SUEIT), 64
hyperactivity disorder Aerobic exercise, 406
Adherence, to treatment for enuresis, Affect, and PTSD, 268, 273. See also
479. See also Compliance Emotion(s); Mood
Adherence talk, and motivational Affirmations, and motivational
interviewing, 400 interviewing, 399–400
535
African Americans Antisocial behavior, and disruptive

anxiety disorders and, 249 behavior disorders, 441
combined therapy and, 137 Anxiety, and childhood obesity, 386–
cultural issues and, 85, 86–87, 89, 388
96, 98, 101, 103, 106, 107 Anxiety disorders
peer rejection and disruptive approaches in CBT for, 229
behavior disorders in, 441 assessment of, 229–230, 250
Age. See also Adolescents and combined therapy for, 125–126,
adolescence; Preschool children 130, 131, 133, 156–160
adaptation of CBT for children Coping Cat Program and, 230–256
and, 33–34 cultural issues in, 249–251
behavioral rigidity in OCD and, 307 efficacy of CBT for, 228–229
challenges to treatment of enuresis pediatric psychopharmacology and,
and, 479 122–123
desensitization strategy and, 34 potential obstacles to treatment of,
diagnosis of encopresis and, 482 251–255
efficacy of CBT as function of, 30 prevalence of, 227
of therapist, 141 psychopathology in parents and, 255
use of term development and, 32 treatment planning and, 229–231
Agenda, and organization of CBT Anxiety Disorders Interview for
sessions, 12, 166 Children (ADIS), 304, 305
Aggression Anxiety Disorders Interview Schedule
bipolar disorder and, 218 for DSM-IV—Parent and Child
disruptive behavior disorders and, Versions (ADIS-C/P), 230
437, 438, 441, 442–443 Arab Americans, and cultural issues,
American Academy of Child and 84, 89
Adolescent Psychiatry, 301 Arousal, and disruptive behavior
American College of Sports Medicine, disorders, 442
391 Art of Self-Control program, 440
American Psychological Association, Asian Americans, and cultural issues,
76, 301 105, 249
American With Disabilities Act, and Assertiveness training, 69, 80, 105–106
Section 504, 379 Assessment. See also Case
Analogies, and cognitive development, formulation; Diagnosis
43, 66 of anxiety disorders, 229–230, 250
Anger management, and disruptive cultural issues and, 91–95
behavior disorders, 446–447 developmental considerations in,
Annie E. Casey Foundation, 279 38–39, 44–45, 48–49, 52, 62–
Antecedent control, and disruptive 64
behavior disorders, 450–451 of encopresis, 485–491
Antidepressants, and suicidal behavior of enuresis, 476
or ideation, 122. See also Selective of OCD, 303–307
serotonin reuptake inhibitors; of PTSD, 267–270
Tricyclic antidepressants Asthma, 334. See also Chronic
Anti-Semitism, 86 physical illness
Index 537
A-SUEIT (Adolescent Swinburne depression and, 167, 172–173

University Emotional Intelligence obesity treatment and, 392
Test), 64 reinforcement principles and, 21
Atomoxetine, 123, 124 Behavioral Assertiveness Test for
Attention deficit/hyperactivity Children (BAT-C), 63
disorder (ADHD) Behavioral learning, and theoretical
cognitive-behavior therapy models of OCD, 302. See also
formulation and, 9 Learning theory
combined therapy for, 126–127, Behavioral model, of depression, 166
133, 161 Behavioral theory, of incontinence,
comorbidity and, 133, 251 468
differential diagnosis of OCD and, Behavior therapy
306 for ADHD, 133
pharmacotherapy for, 123–124 Coping Cat Program for anxiety
Autism, 306 disorders and, 231
Automatic thoughts, 17, 35, 169–170 cultural identity and, 107
Avoidance, and PTSD, 266, 271 for pediatric obesity, 388–390
BEI (Bryant’s Index of Empathy for
Barriers, to treatment. See also Children and Adolescents), 63
Logistical concerns Being Brave program, 252
anxiety disorders and, 251–255 Beliefs
cultural issues and, 97 development and, 34
PTSD and, 278–279 OCD and dysfunctional, 303
BAT-C (Behavioral Assertiveness Test role of in CBT, 17–20
for Children), 63 Bibliotherapy, 107
Beck, A.T., 3–4, 5, 17, 353 Biobehavioral view, of encopresis and
Behavior. See also Aggression; enuresis, 468
Behavioral activation; Behavior Biodots, 348
therapy; Disruptive behavior Biofeedback, and encopresis, 483–484
disorder Biological changes, in PTSD, 268–
conceptualization of problems in 269. See also Biobehavioral view;
terms of cognition and, 7–8 Neurobiology
encopresis and, 488 Bipolar disorder
inflammatory bowel disease and characteristics of CBT for, 193–
maladaptive, 340–341 195
mood symptoms of bipolar clinical applications of CBT for,
disorder and, 220 195–219
OCD and developmentally cultural issues in, 219
appropriate, 304–306, 307 efficacy of CBT for, 185–193
PTSD and, 268 refractory nature of pediatric, 185
weight loss programs and, 391 special challenges to treatment of,
Behavioral activation 220–221
chronic physical illness and, 347– BLUE thoughts, 353–354, 370
348 BMI (body mass index), 385, 387,
cultural issues and, 102–103 390
Body image, and obesity, 386, 406– of Coping Cat Program for anxiety
407, 431 disorders, 233–234, 235, 236–
Body mass index (BMI), 385, 387, 390 237, 238, 239–240, 241, 242,
Booster sessions, and obesity 246–249, 252–253, 254–255
treatment, 409 of cultural issues, 94, 99, 101–102,
Bossing-back strategies, and OCD, 103, 108
319–320 of depression, 173–175
Brainstorming approach of development, 31, 33
to bipolar disorder, 212 of disruptive behavior disorders,
to disruptive behavior disorders, 453–459
452 of encopresis, 500–503
Bryant’s Index of Empathy for of enuresis, 470–481
Children and Adolescents (BEI), of obesity, 400–401
63 of OCD, 105, 314–319
Bullying, and childhood obesity, 385 of PTSD, 264–265, 279–287, 287–
Bupropion, 124, 161 294
of suicidal ideation, 177–179
Calming techniques, and chronic Case formulation, and chronic
physical illness, 348–349 physical illness, 343–345
Camp Cope-A-Lot, 231 C.A.T. Project, 138, 252
CAMS (Child/Adolescent Anxiety Causal reasoning, 43
Multimodal Study), 126, 130, CBCL (Child Behavior Checklist), 49,
160 230, 488
Cancer, 334. See also Chronic physical CBITS (Cognitive-Behavioral
illness Intervention for Trauma in
Candy dispensers, and encopresis, Schools), 264, 278, 287–294
494–495 CBT. See Cognitive-behavioral therapy
Caregivers CBT-SP (cognitive-behavioral therapy
bipolar disorder and, 197 for suicide prevention), 176
encopresis and, 493 CDI (Children’s Depression
CARS (acronym), and bipolar Inventory), 304, 305, 395, 396
disorder, 208 Centers for Disease Control and
CARS2 (Childhood Autism Rating Prevention, 383
Scale—High Functioning, 2nd CFF-CBT (child- and family-focused
Edition), 304, 305 cognitive-behavior therapy), 186,
Case conceptualization, and suicide 190, 193
prevention, 177 Chain analysis, and suicidal ideation,
Case examples 176
of bipolar disorder, 203–205, 212– Change talk, and motivational
214 interviewing, 400
of chronic physical illness, 344– Child abuse, and incontinence, 467,
345, 351–353, 354, 358 479. See also Sexual abuse
of combined therapy, 132, 134– Child/Adolescent Anxiety
135, 136 Multimodal Study (CAMS), 126,
of common principles of CBT, 6–16 130, 160
Index 539
Child Behavior Checklist (CBCL), 49, Cleanliness training, and enuresis, 473
230, 488 Clinical applications, of CBT
Child- and family-focused cognitive- for bipolar disorder, 195–219
behavior therapy (CFF-CBT), combined therapy and, 127–141
186, 190, 193 cultural issues and, 91–108
Childhood Autism Rating Scale— for depression, 166–175
High Functioning, 2nd Edition for disruptive behavior disorders,
(CARS2), 304, 305 443–452
Child Obsessive-Compulsive Impact for obesity, 390–393
Scale—Revised (COIS-R), 304, for OCD, 303–323
305 for PTSD, 270–278
Children. See Adolescents and Coaches, and obesity, 399
adolescence; Age; Child abuse; Cognition-based theoretical models,
Chronic physical illness; of OCD, 302–303
Development; Encopresis; Cognition and cognitive skills. See also
Enuresis; Obesity; Patients; Cognitive restructuring;
Preschool children; specific Metacognition
disorders anxiety disorders and, 252
Children’s Depression Inventory conceptualization of problems in
(CDI), 304, 305, 395, 396 terms of behavior and, 7–8
Children’s Yale-Brown Obsessive developmental issues in, 34, 40–
Compulsive Scale (CY-BOCS), 44, 65–68
304, 305 obesity and lifestyle changes, 392–
Choice, as theme in CBT for bipolar 393
disorder, 209, 212 PTSD and, 266, 269
Chronic fatigue syndrome, 334 role of in treatment of enuresis,
Chronic physical illness. See also 468, 470
Polycystic ovary syndrome; Cognitive Abilities Test, Form 6, 62
Primary and Secondary Control Cognitive-Behavioral Intervention for
Enhancement Training for Trauma in Schools (CBITS), 264,
Physical Illness 278, 287–294
efficacy of CBT for, 332–333, Cognitive-behavioral therapy (CBT).
334–336 See also Assessment; Behavioral
encopresis and, 486 therapy; Chronic physical illness;
guided imagery for pain Clinical applications; Cognitive
management and, 375–377 therapy; Combined therapy;
inflammatory bowel disease as Culture; Development; Efficacy;
model illness in studies of Obesity; Treatment planning;
CBT for, 338–358 specific disorders
information worksheets for parents common myths and
and, 378–382 misperceptions in, 22–24
relationship between psychological common principles of, 6–16
and physical processes in, evidence-based treatments and,
331–332 1–2
Citalopram, 121, 123, 154 history of, 2–6
Cognitive-behavioral therapy (CBT) disruptive behavior disorders and,

(continued) 451–452
new challenges for, 24–25 Comorbidity, of psychiatric disorders
role of beliefs in, 17–20 anxiety disorders and, 251
role of reinforcement principles in, bipolar disorder and, 220
20–22 combined therapy and, 133, 151,
Cognitive-behavioral therapy for 152, 153, 156, 158, 159, 160,
suicide prevention (CBT-SP), 161
176 Competence, and social skills, 46–48
Cognitive restructuring Compliance. See also Adherence
cultural issues and, 99–102, 103 anxiety disorders and, 253–255
depression and, 167, 169–170 bipolar disorder and, 194–195
obesity and, 393 chronic physical illness and, 381–
treatment planning and, 66 382
Cognitive theory, of enuresis, 470 combined therapy and, 138
Cognitive therapy, and history of CBT, culture and potential barriers to, 97
3–4 importance of in treatment of
Cognitive triad, 3 enuresis, 470
Cognitive triangle, 285 Concrete thinking, 43
Cohesion building, and disruptive Conditional Reasoning Task, 62
behavior disorders, 451–452 Conditional Syllogism Test, 62
COIS-R (Child Obsessive- Conduct disorder. See Disruptive
Compulsive Impact Scale— behavior disorder
Revised), 304, 305 Confidence, and chronic physical
Collaboration, between therapist and illness, 349–350
patient Conflict resolution
common principles of CBT and, bipolar disorder and, 197
10–12, 22 treatment planning
cultural issues and, 82–83 recommendations and, 71, 73
Collaborative empiricism, 19 Constipation, and encopresis, 482,
Collectivism, as cultural issue, 80–81, 485, 486–487, 504
85, 98 Contamination, and themes in OCD,
Combinations Task (CT), 62 309
Combined therapy Contextualism, and cultural issues,
ADHD and, 126–127 79, 84, 90
anxiety disorders and, 125–126, Contextual social-cognitive model, for
130, 131, 133, 156–160 disruptive behavior disorders,
clinical implications and 440–443
application of, 127–141 Contingency management, for OCD,
depression and, 124–125, 130, 308
131, 133, 150–156 Contingency reinforcement
Communication encopresis and, 499
bipolar disorder and, 215–217 PTSD and, 272
chronic physical illness and, 359, Control, and chronic physical illness,
382 337
Index 541
Coping Cat, The (Kendall 1990), 33, DANVA2 (Diagnostic Analysis of

138 Nonverbal Accuracy Scale—Form
Coping Cat Program, for anxiety 2), 64
disorders, 230–256 Day care, and encopresis, 493
Coping Power Program, for disruptive DBD. See Disruptive behavior
behavior disorders, 436, 437–438, disorder
443–459 DBT. See Dialectical behavior therapy
Coping skills DDAVP (Desmopressin), 474–475
chronic physical illness and, 337 Deafness, and aggression in residential
coping tool kit for bipolar disorder, settings, 438
208–209, 217 Delinquent behavior, and disruptive
PTSD and, 273–274 behavior disorders, 437
Core beliefs, 17 Delis-Kaplan Executive Function
Core clinical skills, in cognitive- System (DKEFS), 62
behavior therapy manuals, 38, 39 Depression. See also Major depressive
Corrective approach, to treatment of episode
encopresis, 497–498 chronic physical illness and, 359
Crohn’s disease, 338. See also Chronic clinical applications of CBT for,
physical illness 166–175
CT (Combinations Task), 62 combined therapy for, 124–125,
Culturally Informed Functional 130, 131, 133, 150–156
Assessment, 92 efficacy of CBT for, 163–165
Culture. See also Popular culture exercise and, 205
anxiety disorders and, 249–251 obesity and, 384–385, 386–388, 409
bipolar disorder and, 219 pediatric psychopharmacotherapy
clinical recommendations and, 91– for, 120–122
108 Desipramine, 124
combined therapy and, 137–138 Desmopressin (DDAVP), 474–475
definition of, 75 Development
developmental considerations and, anxiety disorders and, 252
53, 83–85 assessment and assessment tools,
disruptive behavior disorders and, 38–39, 44–45, 48–49, 52, 62–
452–453 64
encopresis and, 498–499 compliance issues in chronic
enuresis and, 478 physical illness and, 381
evidence-based treatment and, 76, cultural issues and, 53, 83–85
77–79 diagnosis and treatment of
mental health disparities and, 76–77 encopresis and, 486
OCD and, 323–324 domains of, 40–45
pros and cons of CBT for children emotions and, 50–52, 64, 72–73
of diverse backgrounds, 79–83 future directions in, 53–54
PTSD and, 278 impact of on efficacy of CBT, 29–
CY-BOCS (Children’s Yale-Brown 30
Obsessive Compulsive Scale), information needed to adapt CBT
304, 305 to stages of, 36–40
Development (continued) conceptual framework for, 440–443

OCD and, 304–306, 307 Coping Power Program for, 436,
PTSD and, 266, 275–276, 277–278 437–438, 443–459
social skills and, 45–49, 63, 68–71 cultural issues in, 452–453
treatment of enuresis and level of, efficacy of CBT for, 436–440
479 DKEFS (Delis-Kaplan Executive
treatment planning and Function System), 62
considerations of, 30–36, 39– Dot-to-dot drawing, and reward
40, 49, 52, 65–73 systems, 474
use of term age and, 32 Downward arrow technique, 18
Dextroamphetamine, 123, 161 Dry-bed training, and enuresis, 475
Diabetes, 335–336 DSM. See Diagnostic and Statistical
Diagnosis. See also Assessment; Case Manual of Mental Disorders
Formulation; Differential Dysthymic disorder, 152, 155
diagnosis Duration of treatment
of bipolar disorder, 195, 199–200 anxiety disorders and, 230
of encopresis, 482 depression and, 166
of enuresis, 468–469 developmental considerations and,
Diagnostic Analysis of Nonverbal 53
Accuracy Scale—Form 2 PTSD and, 277
(DANVA2), 64 time-limited structure of CBT and,
Diagnostic and Statistical Manual of 12–13
Mental Disorders (DSM), 108,
263, 264, 468, 482, 484 Eating environment, and weight loss,
Dialectical behavior therapy (DBT) 397–398
bipolar disorder and, 188, 191–192 EBT. See Evidence-based treatment
newer forms of CBT and, 25 Ecological approach, to anxiety
suicidal ideation and, 175 disorders, 250
Diathesis-stress model, of CBT, 129, Education. See also Psychoeducation
165–166 common principles of CBT and, 11
Diet cultural issues in CBT and, 81
bipolar disorder and, 205, 206, 215 encopresis and, 492–493
encopresis and, 487–488, 492 inflammatory bowel disease and,
obesity and, 391, 393, 397–398, 341
403, 405–406, 426–427 Efficacy, of CBT
Differential diagnosis, of OCD, 306 anxiety disorders and, 228–229
Directive nature, of CBT as cultural bipolar disorder and, 185–193
issue, 82 chronic physical illness and, 332–
Discipline, and disruptive behavior 333, 334–335
disorders, 451 depression and, 163–165
Discontinuation syndrome, 121 disruptive behavior disorders and,
Discovery-oriented research, 109 436–440
Disruptive behavior disorder (DBD) effectiveness as focus of research
clinical applications of CBT for, on CBT and, 24–25
443–452 encopresis and, 483–484
Index 543
impact of development on, 29–30 cultural issues in studies of, 478

OCD and, 300–301 diagnosis of, 468–469
psychosocial aspects of obesity prevalence of, 469
and, 388–389 theoretical perspectives on, 469–
suicidal ideation and, 175–176 470
Ego-dystonic character, of OCD urine alarms and, 469, 470–471,
obsessions, 306 477, 481–482
Ellis, A., 4, 5, 17 EQ-i:YV (Emotional Quotient
Emotion(s). See also Affect; Inventory: Youth Version), 64
Expressed emotion; Feelings E/RP (exposure and response
thermometer; Mood prevention), and OCD, 301, 302,
concepts of emotional competence 304, 307–308, 316, 317, 319–
and emotional intelligence, 50, 323. See also Exposure therapy
51 Escitalopram, 121
depression and regulation of, 167, Ethnicity. See also Culture; Race
170–172 combined therapy and, 137
development and, 50–52, 64, 72– experience of oppression and, 82,
73 86–87
disruptive behavior disorders and mental health disparities and, 76–
awareness of, 446 77
encopresis and, 488 treatment engagement and, 270
obesity and, 404–405 Evidence-based treatment (EBT)
PTSD and numbing of, 266 CBT protocols and, 1–2
Emotional Quotient Inventory: Youth cultural issues in, 76, 77–79
Version (EQ-i:YV), 64 Executive functions, and
Empathy, and treatment planning development, 53
recommendations, 70, 399 Exercise. See also Physical activity
Encopresis bipolar disorder and, 205, 206, 215
assessment and treatment of, 485– chronic physical illness and, 347–
491, 500–501 348
challenges to treatment of, 499–500 encopresis and, 487–488, 492
cultural issues and, 498–499 obesity and, 391, 406
diagnosis of, 482 Expectations, and behavior rules in
efficacy of CBT for, 483–484, 503 disruptive behavior disorders,
prevalence of, 482–483 451
theoretical perspectives on, 484– Experiences, and regulation of
485 emotions, 52
treatment planning for, 491–498, Exposure therapy. See also E/RP
502 Coping Cat Program for anxiety
Enhancing engagement, and evidence- disorders and, 233, 243–245,
based treatment, 79 246, 253–255
Enuresis cultural issues and, 104–105
challenges to treatment of, 479 PTSD and, 271–272, 293
components of treatment for, 470– Expressed emotion, and bipolar
475 disorder, 193–194
Expression, and regulation of Friendships, importance of, 48. See

emotions, 52 also Peer relationships
Externalization, and OCD, 312–313 Full-spectrum home training, and
Extinction, and reinforcement, 20 enuresis, 475
Eysenck, H.J., 3
GAD. See Generalized anxiety
Family. See also Family history; Family disorder
therapy; Parents; Siblings Gastrointestinal system, and
bipolar disorder and negative cycles encopresis, 492
in, 209, 220–221 Gay, lesbian, bisexual, and transsexual
chronic physical illness and, 341– (GLBT) youth
343, 356–358, 359 behavioral interaction and, 103
combined therapy and, 138 cognitive restructuring and, 100–
cultural issues and, 80, 88–89, 92– 101
93, 98 exposure therapy and, 105
disruptive behavior disorders and, social oppression and, 86
441 Gender
obesity and, 392, 395, 396–398 culture and roles of, 93, 102–103
OCD and, 313–314, 320–322 encopresis and, 482, 498
success or failure of treatment for enuresis and, 478
bipolar disorder and, 193 Generalized anxiety disorder (GAD),
Family-focused treatment for 160, 228, 243–245
adolescents with bipolar disorder Generation of Alternatives Task, 62
(FFT-A), 187, 190–191, 193 Genetics. See also Family history
Family history, of enuresis, 470. See bipolar disorder and, 199
also Genetics OCD and, 310
Family therapy, and depression, 167 Geography, and clinical decision-
FDA (U.S. Food and Drug making, 139
Administration), 121, 122, 475 Germany, and KidNET for refugees,
FEAR plan, and Coping Cat Program, 278
233, 236, 238–241, 242, 246– Get-acquainted exercise, and
248, 252 treatment for obesity, 402
Fears, and OCD, 306–307 GLBT. See Gay, lesbian, bisexual, and
Feelings thermometer, 35, 167, 168, transsexual youth
171, 197, 235, 246, 288, 291– Goals and goal-setting
292, 314–316, 320–321, 372, behavioral facets of obesity and,
403, 424, 446 391
FFT-A. See Family-focused treatment bipolar disorder and, 198
for adolescents with bipolar disruptive behavior disorders and,
disorder 445
Fluid restriction, and enuresis, 474 focus of CBT on specific, clearly
Fluoxetine, 121, 122, 124, 150, 154 defined, 10
Fluvoxamine, 122, 123 Go Girls program, 390
Food cravings, and diet, 404–405 Gradual exposure, and PTSD, 271–
Friendship Quality Questionnaire, 63 272
Index 545
Graduation ceremony, and Hypnotic scripts, 348

termination of treatment, 219 Hypomania, use of term, 199–200
Group therapy Hyponatremia, 475
for disruptive behavior disorders, Hypothesis testing, 109, 211
444 Hypothetical reasoning, 43, 66
for PTSD, 276, 287–294
Guanfacine, 123 ICD-10 (International Statistical
Guided discovery, 18 Classification of Diseases and
Guided imagery, for pain Related Health Problems, 10th
management, 375–377 Revision), 482
Guidelines, for healthy diet, 391 Identification, of thoughts and beliefs,
17–19
Haloperidol, 161 Identity, and cultural issues, 84, 86–
Harm, and themes in OCD, 309 87, 106–108
HBHM. See Healthy Bodies, Healthy IEP (Individualized Education
Minds Program), 207
Health care. See Chronic physical IF-PEP (individual-family version of
illness; Mental health care PEP), 193, 195–196
system; Physical examination Imaginal exposure, 321
Health insurance, and combined Imaginary audience, 47
therapy, 139, 141 Imipramine, 156, 161, 474
Healthy Bodies, Healthy Minds Immigration, and cultural issues, 87–
(HBHM), 385, 393–409, 395, 89
397, 420–433 Incontinence, and child abuse, 467,
Healthy Lifestyles Pilot Study, 390 479. See also Encopresis; Enuresis
Healthy routines, and bipolar disorder, Incredible Years program, 438–439
205–206, 215 Individual-family version of PEP
HEAR ME (acronym), 171 (IF-PEP), 193, 195–196
Hispanic Americans. See Latino/ Individualism, and cultural issues, 80,
Latina 85
Homeschooling, and chronic physical Individualized Education Program
illness, 381 (IEP), 207
Homework. See also STIC tasks; Induction, and guided imagery for
Workbooks pain management, 375–376
bipolar disorder and, 196 Inflammatory bowel disease, 335,
Coping Cat Program for anxiety 338–358, 371. See also Chronic
disorders and, 231, 232 physical illness
disruptive behavior disorders and, Insomnia, and combined therapy, 132
449 Insulin resistance, and polycystic
obesity and, 392 ovary syndrome, 385
Hospitalization, and bipolar disorder, Intermediate beliefs, 17
218 International Statistical Classification
How I Ran OCD Off My Land of Diseases and Related Health
(March and Mulle 1998), 33 Problems, 10th Revision
Hyperandrogenism, 384 (ICD-10), 482
Interpersonal conflict, and social Learned helplessness, and chronic

skills, 48, 71 physical illness, 333
Interpersonal and social rhythm Learning, of maladaptive behaviors
therapy for adolescents with and cognitions, 8–10
bipolar disorder (IPSRT-A), 188, Learning theory, and history of CBT,
192 2. See also Behavioral learning;
Interpersonal Understanding Social learning theory
Interview, 63 Legal status, of immigrants and
Introductory sessions refugees, 88, 90
bipolar disorder and, 198 Life Skills Training Program, 440
Coping Cat Program for anxiety Literacy, and cultural issues, 90
disorders and, 234 Logistical concerns. See also Barriers
Coping Power Program for combined therapy and, 138–139
disruptive behavior disorders optimal model of CBT for PTSD
and, 444–445 and, 276–277
In vivo mastery, of trauma reminders, London, P., 2
275 Loss of essence, and themes in OCD,
IPSRT-A (interpersonal and social 309
rhythm therapy for adolescents with
bipolar disorder), 188, 192 Maintenance sessions
chronic physical illness and, 355–
Joint expertise, and therapist/patient 356, 374
collaboration in CBT, 10–12 obesity and, 409
Jones, M.C., 2 Major depressive episode, and bipolar
disorder, 200, 217
K-SADS-P/L (Schedule for Affective Mania
Disorders and Schizophrenia for management of symptoms, 217
School-Age Children—Present sleep patterns and, 205, 206
and Lifetime Version), 304, use of term, 199–200
305 MASC (Multidimensional Anxiety
Kegel exercises, and enuresis, 472 Scale for Children), 230, 304,
KidNET, 278 305
Mastery model, of coping, 232
Language. See also Analogies; Matson Evaluation of Social Skills
Metaphors with Youngsters, 63
cultural issues and, 81, 97 Mayer-Salovey-Caruso Emotional
description of traumatic events Intelligence Test, 52, 64
and, 271 MCQ-A (Metacognitions
development and, 53, 72 Questionnaire for Adolescents),
Latino/Latina, and cultural issues, 84– 62
85, 89, 96, 98, 100, 102, 103, MCQ-C (Metacognitions
106, 249, 278 Questionnaire for Children), 62
Laxatives, and encopresis, 482, 484, Means-end thinking, 43
497. See also Miralax Medication. See also
Lazarus, A.A., 2 Psychopharmacology
Index 547
for chronic physical illness, 341 Mood monitoring

for enuresis, 474 chronic physical illness and, 345–
Meditative traditions, and new 346
approaches in CBT, 25 depression and, 167, 168
Megacolon, and encopresis, 486 obesity and, 402, 423
Meichenbaum, Donald, 5–6 Motivation, and treatment planning
Mental health care system, and for enuresis, 477–478, 479
bipolar disorder, 206, 214–215. Motivational interviewing, and obesity,
See also Comorbidity; 389–390, 394, 398–400, 403
Hospitalization; Logistical MST (multisystemic therapy), 440
concerns; specific disorders MTA. See Multimodal Treatment
Metacognition Study of Children With ADHD
cognitive development and, 41, 44, Multidimensional Anxiety Scale for
67 Children (MASC), 230, 304, 305
definition of, 17 Multidimensional Ecosystemic
Metacognitions Questionnaire for Comparative Approach (Falicov
Adolescents (MCQ-A), 62 1998), 92
Metacognitions Questionnaire for Multifamily format of PEP (MF-PEP),
Children (MCQ-C), 62 192–193, 195
Metaphors Multimodal Treatment Study of
cognitive development and, 66 Children With ADHD (MTA),
OCD and, 308–310 123, 126–127, 133, 161
Methylphenidate, 123, 161 Multisystemic therapy (MST), for
MF-PEP (multifamily format of PEP), disruptive behavior disorders,
192–193, 195 440
Minor disruptive behaviors, 450 Music, and relaxation exercises, 348–
Miralax, 486, 497. See also Laxatives 349
Mirtazapine, 121
Modafinil, 124 Naming the Enemy, and bipolar
Monitoring, of enuresis, 476. See also disorder, 201
Mood monitoring; Self-monitoring Narratives
Mood. See also Emotion(s); Mood chronic physical illness and, 339–
monitoring 340, 371
bipolar disorder and, 196–197, PTSD and descriptions of trauma,
200, 220–221 274
relationship between weight and, National Heart, Lung, and Blood
387 Institute, 391
Mood charting, and bipolar disorder, National Institutes of Health, 384
200 National Registry of Effective
Mood disorders, and combined Programs, 342
therapy, 133 Native Americans, and cultural issues,
Mood-medication log, and bipolar 80, 81, 89, 278
disorder, 202 Nefazodone, 121
Negative reinforcement, 20, 398 clinical applications of CBT for,

Netherlands 303–323
Coping Power Program for combined therapy for, 126, 157,
disruptive behavior disorders 158
and, 437 cultural issues in, 323–324
study of age and encopresis in, efficacy of CBT for, 300–301
482–483 pharmacotherapy for, 123
Neurobiology, and bipolar disorder, prevalence of, 299
199. See also Biological changes theoretical models of, 302–303
“New Wave,” and recent treatment OCD. See Obsessive-compulsive
approaches in CBT, 25 disorder
“No fault” disorder, bipolar disorder ODD. See Oppositional defiant
as, 198 disorder
Nonspecific therapy elements, 22 Open-ended questions, and
Nonverbal communication, and motivational interviewing, 398,
bipolar disorder, 215–216 399. See also Socratic questioning
Norway, and trial of CBT for OCD, Operant conditioning, and PTSD, 266
301 Opposite action, and emotion
Number, of sessions regulation, 172
bipolar disorder and, 197 Oppositional defiant disorder (ODD),
developmental considerations and, 133, 306, 488. See also
53 Disruptive behavior disorder
time-limited structure of CBT and, Oppression, ethnic minorities and
13 experience of, 82, 86–87, 100, 102
Nutrition labels, 405, 427 Ordering/arranging, and themes in
OCD, 309
Obesity Orientation, cultural issues in
behavioral therapy for, 388–390 videotapes for, 97. See also
depression and, 384–385, 386– Introductory sessions
388, 409 Outcome, and client-therapist
Healthy Bodies, Healthy Minds relationship, 22–23. See also
intervention for, 385, 393– Efficacy
409 Overcorrection, and encopresis, 497–
key CBT techniques for, 390– 498
393 Overlearning, and enuresis, 473
polycystic ovary syndrome and, Overprotectiveness, and parents of
384–385 children with chronic physical
prevalence of, 383 illness, 379–380
psychological correlates of in
childhood, 384, 385–388 Pain management, and guided
Obesity Society, The, 391 imagery, 375–377
Obsessive Compulsive Cognitions Pajama devices, and enuresis, 471,
Working Group, 303 477
Obsessive-compulsive disorder (OCD) Panic disorder, and
assessment of, 303–307 psychopharmacology, 122–123
Index 549
Parents. See also Family Peer relationships

Afrocentric model of training for, achievement of social competence
87 and, 47
bipolar disorder and, 196, 197, disruptive behavior disorders and,
198–199, 202–203, 206–207, 441, 448
209–212, 214, 216, 217 PTSD and, 270
chronic physical illness and, 357, treatment planning
378–382 recommendations and, 71
combined therapy and, 135–136, Pemoline, 161
138 PEP (psychoeducational
Coping Cat Program for anxiety psychotherapy), 188–189, 192,
disorders and, 237, 242, 255 193
Coping Power Program for Performance, of social skills, 49
disruptive behavior disorders Perspective taking, and social skills,
and, 448–452, 456–459 46–47, 68, 70, 447
cultural issues in assessment and, Photo album, and Coping Cat
93 Program, 252
developmental level of child and Physical activity. See also Exercise
involvement of in treatment, encopresis and, 488
33 obesity and, 391, 394, 395, 406,
encopresis and, 485–490 430
enuresis and, 471, 479 Physical cues, and encopresis, 493
prevention of depression in Physical examination
children of parents with encopresis and, 485
history of, 165 enuresis and, 479
PTSD and, 272, 275 Piaget, J., 43
Paroxetine, 121, 122–123, 154 Planning, for continued success in
PASCET-PI. See Primary and obesity treatment, 408–409. See
Secondary Control Enhancement also Treatment planning
Training for Physical Illness Play, and Coping Power Program for
Past, and focus on present in CBT, 8 disruptive behavior disorders, 445
PATHS (Promoting Alternative Polycystic ovary syndrome (PCOS),
Thinking Strategies), 438 335, 384–385, 393–409. See also
Patients Chronic physical illness
collaboration with therapist in Popular culture, and societal factors in
CBT, 10–12, 22 mental health care, 140
combined therapy and, 128–132 Positive reinforcement. See also
needs of as focus of CBT, 13–14 Reinforcement principles
Pavlov, I.P., 2 encopresis and, 483–484
PCOS. See Polycystic ovary syndrome obesity and, 398
PCOS Lifestyle Program, The, 401– Posttraumatic stress disorder (PTSD)
409 assessment of, 267–270
Pediatric OCD Study (POTS), 126, clinical applications of CBT for,
157 270–278
Posttraumatic stress disorder (PTSD) Coping Cat Program for anxiety

(continued) disorders and, 240
cognitive-behavioral theory of, cultural issues and, 103–104
264–267 depression and, 167, 169
combined therapy for, 126, 159 disruptive behavior disorders and,
cultural issues and, 278 447–448, 451–452
obstacles to treatment of, 278–279 obesity and, 392
POTS (Pediatric OCD Study), 126, Problem-Solving Skills Training Plus
157 Parent Management Training
Poverty. See also Socioeconomic status (PSST+PMT), 439
cultural issues and, 90 Promoting Alternative Thinking
risk factors for disruptive behavior Strategies (PATHS), 438
disorders and, 441 Prosocial behavior, and peer
POWER steps program, 350–351 relationships, 47
Preschool children, and PSST+PMT (Problem-Solving Skills
developmental adaptations of Training Plus Parent Management
CBT for PTSD, 277 Training), 439
Present focus, of CBT, 8, 81 Psychodynamic theory, and
Prevalence encopresis, 484
of anxiety disorders, 227 Psychoeducation. See also Education
of anxiety in obese adolescents, 387 bipolar disorder and, 194, 198–199
of depression in obese children and chronic physical illness and, 342
adolescents, 409 combined therapy and, 129
of encopresis, 482–483 Coping Cat Program for anxiety
of enuresis, 469 disorders and, 232–233
of obesity, 383 cultural issues in, 96–97
of OCD, 299 depression and, 167, 168
Prevention, of suicide, 176–179. See OCD and, 308–313, 317–319
also E/RP; Relapse prevention PTSD and, 272–273
Primary control, and chronic physical suicidal ideation and, 177
illness, 337 Psychoeducational psychotherapy
Primary and Secondary Control (PEP), 188–189, 192, 193
Enhancement Training for Psychological correlates, of obesity,
Physical Illness (PASCET-PI), 384, 385–388
332, 333, 337–358, 347, 369– Psychological mindedness, and
374, 393, 394 combined therapy, 129–130
Proactive approaches, to treatment of Psychopharmacology. See also
encopresis, 493–497 Combined therapy; Medication
Problem solving ADHD and, 123–124
bipolar disorder and, 211–212 anxiety disorders and, 122–123
chronic physical illness and, 346– bipolar disorder and, 185, 201–203
347, 350, 370, 373 depression and, 120–122
cognitive development and PTSD. See Posttraumatic stress
treatment planning, 65, 69, 73 disorder
Index 551
Puerto Rico Reinforcement principles, role of in

Coping Power Program for CBT, 20–22
disruptive behavior disorders Relapse and relapse prevention
and, 438 depression and, 167, 173
cultural issues for mental health enuresis and potential for, 478
care in, 84 obesity and, 393
Punishment OCD and, 322–323
definition of reinforcement and, Relaxation techniques
20 chronic physical illness and, 341,
disruptive behavior disorders and, 348–349
451 Coping Cat Program for anxiety
encopresis and, 490 disorders and, 237–238, 252
enuresis and, 479 cultural issues and, 103
Puppets, and Coping Power Program depression and, 167
for disruptive behavior disorders, modification of for age levels, 34
447 obesity and, 392, 405
PTSD and, 273
Race. See also African Americans; Religion
Culture; Ethnicity; Native cultural issues and, 83, 89, 94,
Americans; Racism 101–102, 251, 481
combined therapy and, 137 OCD and, 105, 323–324
mental health disparities and, 76– stress management with bipolar
77 disorder and, 218
treatment engagement and, 270 treatment engagement and, 270
Racism, and cultural identity, 82, 86– Resilience, and negative influences of
87, 107. See also Oppression racism and discrimination, 86
RAINBOW program, 186, 190. See Resistance
also Child- and family-focused encopresis and, 489–490
cognitive-behavior therapy motivational interviewing for
Rational emotive therapy (RET), 3, 4– obesity and, 400
5, 35–36 Resistance exercise, 406
RCT (retention-control training), for Responsibility training, and enuresis,
enuresis, 471–472, 473, 478 477
Real world, implementation of CBT Restaurants, and calorie charts, 398
in, 15–16 RET (rational emotive therapy), 3, 4–
Reappraisal, of thoughts or beliefs, 5, 35–36
19–20 Retention-control training (RCT), for
Reasoning, and cognitive enuresis, 471–472, 473, 478
development, 41, 43, 66, 67 Rewards. See also Positive
Reasons for living, and suicide reinforcement; Token economy
prevention, 177 Coping Cat Program for anxiety
Recurrent abdominal pain, 335 disorders, 240–241, 248
Refugees, and cultural issues, 88, 278 Coping Power Program for
Regulation, of emotions, 51–52, 73, disruptive behavior disorders
167, 170–172 and, 445
Rewards (continued) Seattle Social Development Project

encopresis and systems of, 490, (SSDP), 439
494–496 Secondary control, and chronic
enuresis and systems of, 472, 473– physical illness, 337
474, 477 Section 504, of Americans With
Risk factors Disabilities Act, 207, 379
for disruptive behavior disorders, Selective attention, and PTSD, 272
441 Selective serotonin reuptake inhibitors
for suicide, 176 (SSRIs), and depression 120,
Role-playing, and disruptive behavior 121, 122, 125, 151, 153
disorders, 447, 449–450 Self-awareness, and obesity, 407–408,
Ross Test of Higher Cognitive 432
Processes, 62 Self-control, and social skills, 47
Rules, and behavior expectations in Self-disclosure, and cultural issues, 96
disruptive behavior disorders, Self-efficacy, and motivational
451 interviewing, 400
Self-esteem, and obesity, 386
Safety Self-instructional training (SIT), 5–6
PTSD and enhancement of, 275– Self-monitoring, and obesity, 391,
276 395, 403–404, 429. See also
suicide prevention and planning Monitoring; Mood monitoring
for, 176–177 Self-reflection, and cognitive
SAT (Skills-and-Thoughts depression development, 41, 44, 67, 68, 70
model), 333, 337 Self-Reflection and Insight Scale for
Schedule for Affective Disorders and Youth, 62
Schizophrenia for School-Age Self-talk, and Coping Cat Program,
Children—Present and Lifetime 238–240
Version (K-SADS-P/L), 304, 305 Sertraline
Scheduling, and encopresis, 493–494. anxiety disorders and, 122, 123,
See also Waking schedule 126, 157, 158, 159, 160
Schemas, and cognitive diathesis- depression and, 121, 125, 152
stress model, 165 SES. See Socioeconomic status
Schizophrenia, 151 Sexual abuse, and PTSD, 159, 278
Schools and school systems Sexual behavior, and cultural issues,
bipolar disorder and, 206–207, 85
214–215 Shaping approach, to treatment of
chronic physical illness and, 378– encopresis, 499
381 Show That I Can (STIC) tasks, 231,
disruptive behavior disorders and, 232, 234–235, 253–255
449 Siblings, and bipolar disorder, 197,
encopresis and, 493 218–219
PTSD and, 269, 276 SIT (self-instructional training), 5–6
refusal to attend, 14, 156 Skills-and-Thoughts (SAT) depression
Scrupulosity, and themes in OCD, model, 333, 337
309, 323–324 Skinner, B.F., 2
Index 553
Sleep, and bipolar disorder, 205, 206, Somatic symptoms

215. See also Insomnia; Waking anxiety disorders and, 235–237, 249
schedule cultural issues and, 89–90, 103
Social anxiety disorder, 160, 228, Special time, of parents with child,
243–245 450
Social cognition, and disruptive Spirituality, and cultural issues, 80,
behavior disorders, 442–443 83, 89. See also Religion
Social information processing theory, SPSI-R (Social Problem-Solving
and disruptive behavior disorders, Inventory—Revised), 63
442 SSDP (Seattle Social Development
Socialization, and cultural issues, 84, Project), 439
86–87, 107 SSRIs. See Selective serotonin
Social learning theory, and disruptive reuptake inhibitors
behavior disorders, 450 SSRS (Social Skills Rating System), 63
Social phobia, 133, 160, 228, 243– STEPS problem-solving skills, 356,
245 357, 370
Social Problem-Solving Inventory— STIC (Show That I Can) tasks, 231,
Revised (SPSI-R), 63 232, 234–235, 253–255
Social rejection Stigma, and combined therapy, 139–
childhood obesity and, 385 140
disruptive behavior disorders and, Stimulant medication, for ADHD,
441–442 123–124
Social skills. See also Conflict Stimulus control, and obesity, 392, 395
resolution; Peer relationships Stool assessment chart, 487
chronic physical illness and, 341, Stream-interruption exercises, and
350 enuresis, 472, 478
definition of, 45 Stress and stress management
depression and, 167, 173 bipolar disorder and, 194, 218
development and, 45–49, 63, 68– chronic physical illness and family
71 de-stressing game, 357–358
disruptive behavior disorders and, disruptive behavior disorders and,
447–448 441, 449–450
Social Skills Rating System (SSRS), 63 Stretching, and exercise, 406
Social support networks, and GLBT Sticker charts, and rewards, 495
youth, 103 Study skills, and disruptive behavior
Socioeconomic status (SES) disorders, 445–446
assessment and, 92, 93 Substance abuse, and disruptive
combined therapy and, 137 behavior disorders, 437
enuresis and, 478 Subtypes, of encopresis, 482
immigrant populations and, 90 Suicide and suicidal ideation
treatment engagement and, 270 bipolar disorder and, 200, 217–218
Socratic questioning, 11–12, 34. See black box warning on
also Open-ended questions antidepressants and, 122, 124
Solution-focused approach, to bipolar CBT for, 175–179
disorder, 198, 199 combined therapy and, 155
“Supervision of supervisors” model, of TFD (Thinking-Feeling-Doing), and

CBT for OCD, 301 bipolar disorder, 209–211
Symptoms Therapeutic relationship
bipolar disorder and management cultural issues in, 96
of, 217–218, 220–221 importance of in CBT, 22–23
combined therapy Therapists
and severity of, 130–131 active stance of in CBT, 14–15
and type of, 131–132 collaboration with patient in CBT,
culture and expression or 10–12, 22
presentation of, 89–90, 249 combined therapy and, 140–141
misperceptions of CBT and, 23– culture and self-assessment of, 91
24 misperceptions about CBT and
Symptom substitution, 23–24 creativity and flexibility of, 24
Systematic desensitization, 34 Thermometer. See Feelings
System factors, and combined thermometer
therapy, 135–140 THINK (acronym)
chronic physical illness and, 337–
TADS. See Treatment for Adolescents 338, 346, 353–354, 355, 357,
with Depression Study 359, 369, 382
Talents, chronic physical illness and obesity and, 402
development of, 350–351 Thinking-Feeling-Doing (TFD), and
TASA (Treatment of Adolescent bipolar disorder, 209–211
Suicide Attempters), 128, 155– Think Task, 62
156, 176 Third wave, of CBT, 25
Task analysis, and treatment of Thought forecasting, 35
encopresis, 491 Thought record, 170, 171
TCAs. See Tricyclic antidepressants Thoughts and thinking
Teacher Report Form (TRF), 230 chronic physical illness and, 353
Teamwork, and therapist/patient cognitive development and
collaboration in CBT, 11 monitoring of, 66
Teasing, and childhood obesity, 385, Coping Cat Program for anxiety
386 disorders and, 239
TEIQue-AF (Trait Emotional identification of, 17–19
Intelligence Questionnaire— reappraisal of, 19–20
Adolescent Form), 64 Tic disorders, 306
TEIQue-CF (Trait Emotional Time. See Duration; Past; Present
Intelligence Questionnaire— Time-outs, and encopresis, 499
Child Form), 64 Toilet training, and encopresis, 484,
Termination, of treatment 485, 488–489, 491
bipolar disorder and, 219 Token economy, and disruptive
Coping Cat Program for anxiety behavior disorders, 444. See also
disorders and, 248 Rewards
Testosterone, 385 TORDIA. See Treatment of SSRI-
TF-CBT. See Trauma-focused Resistant Depression in
cognitive-behavioral therapy Adolescents
Index 555
Tourette’s syndrome, 123–124 encopresis and, 491–498

Traffic Light Diet, 393, 394, 395, 403, enuresis and, 475–478
405–406 Treatment of SSRI-Resistant
Trait Emotional Intelligence Depression in Adolescents
Questionnaire—Adolescent Form (TORDIA), 125, 128, 154, 164–
(TEIQue-AF), 64 165, 179
Trait Emotional Intelligence TRF (Teacher Report Form), 230
Questionnaire—Child Form Tricyclic antidepressants (TCAs), 121.
(TEIQue-CF), 64 See also Imipramine
Trance, and guided imagery for pain Triggers, and bipolar disorder, 208
management, 376–377
Trauma. See also Posttraumatic stress UCLA PTSD Reaction Index for
disorder DSM-IV, 267
cultural issues and, 100 Ulcerative colitis, 338
language and description of events, United Kingdom, and study of age and
271 encopresis, 483
narratives of, 274 Urine alarms, for enuresis, 469, 470–
reminders of, 265–266, 275 471, 477, 481–482
Trauma-focused cognitive-behavioral U.S. Census Bureau, 76
therapy (TF-CBT), 126, 264, U.S. Food and Drug Administration
277, 278, 279–287 (FDA), 121, 122, 475
Treatment. See Barriers; Behavior
therapy; Cognitive-behavioral Values, and cultural issues, 80, 88–89
therapy; Combined therapy; Venlafaxine, 122, 125, 154
Compliance; Efficacy; Outcome; Videotapes
Psychopharmacology; chronic physical illness and, 349
Termination; Treatment for orientation, 97
engagement; Treatment planning Visual imagery, 348
Treatment for Adolescents with
Depression Study (TADS), 98, Waking schedule, and enuresis, 472–
122, 124, 128, 130, 150, 164, 473, 477
175–176 Watson, J. B., 2
Treatment of Adolescent Suicide Wechsler Intelligence Scale for
Attempters (TASA), 128, 155– Children, 4th Edition (WISC-IV),
156, 176 45
Treatment engagement Weight gain, and pharmacotherapy for
cultural issues in, 95–97 bipolar disorder, 205. See also
PTSD and, 270–271 Obesity
Treatment modality, and Weight tracker, 402, 422
developmental considerations, 53 WISC-IV (Wechsler Intelligence Scale
Treatment planning. See also Planning for Children, 4th Edition), 45
adaptation of CBT for Wolpe, J., 2
developmental stages, 32–36, Workbooks. See also Homework
39–40, 49, 52, 65–73 chronic physical illness and, 343
anxiety disorders and, 229–231 Coping Cat Program and, 231
Working hypothesis, 7, 15 YGTSS (Yale Global Tic Severity

Worksheets, and obesity, 402, 403, Scale), 304, 305
405, 407, 408, 420–433
Wrapped rewards, 495 Zambia, and TF-CBT for HIV-
affected sexually abused children,
Yale Global Tic Severity Scale 278
(YGTSS), 304, 305 Zone of proximal development, 31,
Yates, A. J., 2 40

Cognitive Behavior Therapy For Children and Adolescents

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Cognitive-Behavior Therapy

Eva Szigethy, M.D., Ph.D.

3 Culturally Diverse Children

5 Depression and Suicidal Behavior . . . . . . . . . .163

6 Bipolar Disorder . . . . . . . . . . . . . . . . . . . . . . . .185

7 Childhood Anxiety Disorders:

8 Pediatric Posttraumatic Stress Disorder. . . . . .263

9 Obsessive-Compulsive Disorder . . . . . . . . . . .299

11 Obesity and Depression: A Focus on

12 Disruptive Behavior Disorders . . . . . . . . . . . . 435

13 Enuresis and Encopresis . . . . . . . . . . . . . . . . 467

Rachel E. Baden, M.A.

William Beardslee, M.D.

Sarah Kate Bearman, Ph.D.

Ronette Blake, M.S.

Caroline L. Boxmeyer, Ph.D.

David A. Brent, M.D.

Douglas M. Brodman, M.A.

Angel Caraballo, M.D.

Jeremy S. Cohen, M.A.

Judith A. Cohen, M.D.

Patty Delaney, L.C.S.W.

Julie M. Edmunds, M.A.

Benjamin W. Fields, Ph.D., M.Ed.

Robert L. Findling, M.D., M.B.A.

Rebecca Ford-Paz, Ph.D.

Sarah A. Frankel, M.S.

Martin E. Franklin, Ph.D.

Jennifer Freeman, Ph.D.

Patrick C. Friman, Ph.D.

Mary A. Fristad, Ph.D., ABPP

Catherine M. Gallerani, M.S.

Judy Garber, Ph.D.

Gayle Y. Iwamasa, Ph.D.

Philip C. Kendall, Ph.D., ABPP

Audra Langley, Ph.D.

John Paul Legerski, Ph.D.

Laurie Reider Lewis, Psy.D.

John E. Lochman, Ph.D., ABPP

John S. March, M.D., M.P.H.

Kelly A. O’Neil, M.A.

Fadi T. Maalouf, M.D.

Jennifer E. Phillips, M.S.

Nicole P. Powell, Ph.D.

Annie E. Rabinovitch, B.A.

Thomas M. Reimers, Ph.D.

Dana L. Rofey, Ph.D.

Moira A. Rynn, M.D.

Jeffrey J. Sapyta, Ph.D.

Sarabjit Singh, M.D.

Eva Szigethy, M.D., Ph.D.

Rachel D. Thompson, M.A.

Susan Turner, Psy.D.

John R. Weisz, Ph.D., ABPP

THIS book, edited by three experts in developmental psychopathology,

Mina K. Dulcan, M.D.

AROUND the world, children are at risk. Rates of pediatric psychiat-

We want to offer special thanks to colleagues who have meant so much