Cognitive-Behaviour therapy and its efficacy for young children

Cognitive behaviour therapy (CBT) is commonly used with adults and children alike (Beck 1995). The search for the appropriate matching of client and therapy variables is complicated by the range of cognitive and behaviour techniques that are combined in different variations and are collectively described as CBT (Blagys & Hilsenroth 2002). Cognitive therapy is focused on determining therapy targets (negative thought and images, faulty patterns of attention, problematic memory processes), rather than therapy procedures. The treatment process involved in CBT aims to link thoughts, affect (feelings) and behaviour to enable clients to understand and manage these processes. Central to cognitive theory is the way in which an individual structures and interprets his or her experiences. These interpretations are likely to impact upon mood and subsequently our behaviour, thus, influencing the individual’s interpretations and meaning from their world (Beck 1967). There is evidence of the efficacy of CBT with children and adolescents with a range of disorder, such as depression (Harrington, Wood & Verduyn 1998), anxiety (Kendall 1994), and conduct disorder (Kazdin, Siegal & Bass 1992). 

Measuring psychotherapy outcome is a complicated endeavor, since different measures of improvement can be used, at different points in time pursuant to discontinuation of therapy, and because various therapist and patient variables as well as an integration effect between the two play a role (Luborsky,et al., 1982). The optimum combination of client and therapy variables is still unclear and in particular the extent to which the age and developmental level of the child interacts with the success of the treatment (Spencer 1994). The present review is an attempt to critically review the evidence and identify if CB therapy is developmentally appropriate for young children and briefly consider the implications for alternative approaches. Due to the limited space of this essay the focus is in the early school-aged children.

Many early behavioural treatments were based on animal learning theory and emphasised the changing cognitions which is very important in cognitive therapy and is supported with a substantial number of evidence in the literature that demonstrates the association of cognitive biases and psychiatric disorders (Clark 2004).

Clark (2004) asserts that the link between theories, experimental science and treatment developments in cognitive-behaviour therapy is complex and the relationship between them has changed over time. In the early days of behaviour therapy, learning theory was seen as the theoretical basis of most treatments and the therapy procedure were often seen as direct analogues of procedures that had been demonstrated to be effective in animal experiments (Wolpe 1958).

Current treatments labeled CB have emerged from a foundation in behavioral and cognitive models of psychpathology and treatment. The behavioural model suggests that an individual’s actions (both adaptive and maladaptive ) are developed and maintained largely by basic learning principles (Goldfried & Davison 1994). Through the principles of classical conditioning, a previously neutral stimulus may come to bring forth an unhealthy affective, physiological, or behavioral response. Through the principles of operant conditioning, behaviour is controlled by the consequences that follow it (Craighead et al, 1994).

Individuals can also learn to behave in problematic ways by observing others in some behaviour, through the principles of Bandura’s social learning (Craighead et al., 1994) without necessarily being reinforced or punished. Behavioural approach claims that psychological difficulties are emanating according to basic contiguity and contingency principles, therefore behavioural treatments are based moderately on such learning mechanism (Craighead et al 1994).

While behavioural treatments emphasize the importance of basic learning principles in developing, maintaining, and treating maladaptive behaviors, cognitive treatments tend to focus more on the potentially mediating role that cognitions play in the development of psychological and behavioural difficulties (Beck 1976). Cognitive theory conceptualizes problematic behaviour as the origin of dysfunctional, unhelpful, or distorted thinking. A cognitive perspective focuses more on an individual’s interpretation or understanding of an event as an important determinant of behaviour than the stimulus itself or the consequences of a particular action. Therefore, treatment focuses more cognitions than overt behaviour.

Cognitive interventions are based to a degree upon the belief that a decrease in symptomatic distress occurs via a reduction in dysfunctional, unhelpful or distorted thinking (Beck 1976, Craighead 1994). Currently, treatments referred to as CB are often a blend of cognitive and behavioural procedures with some treatments emphasizing the cognitive more than the behavioural techniques and vice versa. These interventions typically share an appreciation for both basic learning principles and the role that cognitions play in human behaviour and affective experience (Hill & O’Brien 1999).

Recent psychotherapy process research investigating the relationship between cognitive behavioural (CB) interventions and client outcome provided contradictory results. Some authors have suggested a favourable relationship between specific CB processes and client improvement (Harrington, Wood & Verduyn 1997; Kendal 1994), Contrary to these authors other researchers (Castonguay et al. 1996; Jacobson et al. 1996) have reported a lack of relationship between specific CB interventions and outcomes. Castonguay et al. 1996) investigated the effect of unique CB processes (such as a focus on distorted cognitions) and common factors (such as the therapeutic alliance and a patient’s emotional investment in treatment) on treatment outcome. The researchers reported that common treatment factors measured in the study predicted patient improvement while a focus on unique cognitive interventions was negatively correlated with treatment outcome. Jacobson et al. (1996) postulated that the behavioural activation component of a CB treatment for depression was just as effective as a full CB treatment package that included a specific focus on identification and modification of maladaptive cognitive errors and restructuring of fundamental schemas.

A further complicated issue emerges when attempting to evaluate the most appropriate matching of client and therapy variables through a large range of cognitive and behavioural techiniques, combined in different versions and collectively presented as CBT for children and adolescence (Ronen 1997).

Due to the lack of sophistication in cognitive functioning among younger children, it is important the different cognitive elements of any CBT intervention and the extent to which therapeutic change is cognitively or behaviorally mediated. The fact that CBT originated partly from cognitive theory and therapy with adults, it raises the question of whether children could benefit from the therapeutic approach and what role their developmental status plays in this success or failure.

A small number of authors have discussed the relationship between developmental psychology and CBT with children. These authors concluded that CBT with children needs to consider the developmental stage of the child and integrated with a developmental approach so that the child is not limited in participation with more complex cognitive aspects of CBT (Ollendick, Grills, & King 2001). Piaget’s stage model of intellectual functioning identifies the capacities of this developmental stage as being preoperational, suggesting a prelogical period in which thinking is dominated by perception. This is qualitatively different from the concrete operational child (7 years plus), who can use logical thinking about concrete concepts. This is followed by the development of abstract and hypothetical thinking of the formal operational adolescent (12 and over).

Developmental psychology provide evidence of the evolving structure of the physical, emotional and cognitive abilities of the developing child, making it possible to identify the particular cognitive capacities of younger children in relation to the demand made by the CBT process (Kovacs & Lohr 1995). Meadows (1993) argues that the post-Piagetian theorists has moved away from the rigid stage model, but despite that diversity in the field Piagetian theory remains influential and provides a detailed structure to understand the development of cognitive ability. Although Piaget’t account of cognitive development identifies the ability to reason as beginning in the concrete operational stage, post-Piagetian theorist provide a more mixed  picture of reasoning abilities of children under 8 years of age (see Meadows, 1993, for review). A distinction between formal and everyday reasoning in looking at developing reasoning capacity suggest that formal reasoning is an abstract, rule governed activity that requires the child to move from the given grounds to the only correct answer without any more information.

Meadow’s (1993) asserts that everyday reasoning emerges earlier in children’s development than formal reasoning and it uses familiar contextual information that is not rigidly specified and allows for more than one possible answer. This indicates how children can be lost and will not comply if the information is new and the task instructions incomprehensible. Siegal (1997) suggest that it is not that a child under 8 years of age he/she did not know the answer but he/she did not understand the question. Meadow (1993) also posited that apart from the familiarity of the material there are other cognitive operations ( e.g., attention span, working memory capacity) that affects a child’s ability to understand a reasoning task. Another interesting piece of research is by Robinson and Beck (2000) and Mitchell and Riggs (2000) through their research these authors they suggests that preschool children have difficulties with counterfactual reasoning, for example, they find it hard to ignore what they know to be true.

Causal reasoning about behaviour (a process of making judgements about the relationship between events based on a hierarchy of increasing complex concepts) is also of major significance to CBT (Shrik 1988). A child’s understanding of the causal connections between his/her cognitions and behaviour. Shrik (1988) explains that at a simple level, judgments are made between cause and effect and at a more sophisticated level, the judgements differentiates whether a cause was intentional or accidental.

From a Piagetian perspective, the functioning of the preoperational child is characterized by ecocentrism or the inability to see the world from another person’s perspective ( Wadsworth 1996) With cognitive development children begin to build the capacity to stand back and reflect on one’s own thoughts in relation to the external world, and vice versa. Piaget’s original meaning of egocentrism is important since the egocenric child cannot be conscious of himself as a separate being or as a separate from his environment, which he also sees as part of himself. Egocentric thinking produces syncreticism, for example, perceiving subjective reality as absolute, global schema (Favre & Bizzini 1995). Thus, the normal cognitive processing of the preoperational child encompasses deficits and distortions when viewed from the perspective of adult functioning.

In the context of CBT for adults, the egocentric thinking of the preoperational child would be regarded as a cognitive error and is similar to the thinking of a depressed person who is unable to perceive the world in relation to the perspective of others and who can only focus on his/her own origins of depression (depressogenic) cognitions. When is an adult the cognitive therapy and target would be to assist the client by making him/her more aware of their own thought processes and then to point out the distortions of thinking in an empirical way. Similarly this analysis of thoughts and beliefs is a key activity in CBT with children (Ronen 1997).

Bartsch & Estes (1996) refer to the process of thinking about thinking ( metacognition) as a development of childe cognitive capacities at the age of 3-4. Generaly 5 year old are capable of identifying other’s behaviour, as a result of their mental states in terms of beliefs or desires. At this age the child can understand the difference between mental and physical state and has a causal-explanatory framework for the interaction between mental state and behaviour (Bartsch & Estes (1996). Metacognitive development includes also the development of understanding about emotions among our selves and others. The speed of this development varies with a variety of factors, including the extent to which emotional conditions are discussed within the home and are facilitated properly by the family or surrounding socio-cultural system (Dunn et al. 1991). A child with impairment in metacognition functioning is likely to be less responsive in a therapeutic context (Wenar & Kerig 2000). At about 8 years old generally developing children are able to determine that different situations will bring different reactions in different people and that people can experience more than one emotion at a time (Friend & Davis 1993).

We have identified a number of significant qualitative differences in cognitive skills and processing of children and we will now move to some of the quantitative differences all of which will affect upon their functioning in the cognitive therapeutic domain. Younger children have limited experiential knowledge, memory capacity, attention span and general mental organizational ability (Crick & Dodge 1994). Theory and evidence propose the limitations of CBT therapy at the preoperational and early operational-stage, since the mental capacity and children’s cognitive skills are developmentally inadequate.

Siegel (1997) argues that is not the abilities of the children at that stage but the way in which they are tested. The author demonstrated that when complex cognitive tasks are set using familiar, explicit, and attractive concepts, settings, instructions, and goals, even very young children are able to complete them. Shaffer 1996 noted that children’s age and capability of certain activities is often an artifact of experimental design or limitations in children’s language rather than actual ability. Moreover, children who are exposed to basic training in order to familiarize with experimental procedure or requirements can successfully complete the task at which their untrained age matched peers fail and can apply their new knowledge to tasks for which they had not received training (Field 1981). The implication for cognitive behavioral theory and therapy is that given clear simple instructions in the use of these skills, based upon familiar material from their everyday lives, children may be capable of, and could clinically benefit from cognitive procedures at an earlier age than experimental psychology argues.

The basic assumption underlying cognitive therapy is that psychopathology is an indication of either distorted or absent cognitive products, schemata, or operations ( Spencer 1994). There are many evidence in adult clinical literature compared with the child literature (DiGiuseppe 1989). The question remains as to whether current models underlying cognitive behavioural approaches to therapy with children are grounded on the complex and shifting nature of the developing child or do they represent downsized models based on adult functioning?  In the light of this mixed picture, many researchers call for a more carefully defined relationship between the theoretical conceptualization and the application of cognitive therapies (Dush et al 1989)

One area of developmental theory that has influenced cognitive-behaviour theory and therapy with children is the role of language in mediating and controlling behaviour. The normal development of the process of taking self-control is drawn from the theories of Vygotsky (Mechenbaum & Goodman 1971). Self-control begins in the form of the verbal direction of the child’s behaviour by significant adults, then moves to the child’s explicit verbalization of behaviour self-control, and at the end the self-talk becomes internalized cognitions of behavioural self-control (Ronen 1997).

Self-instructional training form part of a cognitive behavioural treatment package, is based on the notion that certain childhood disorders represent a failure at some point in the development of these self-control mechanisms (Dush et al 1989). Meichenbaum & Goodman (1971) provide evidence for such hypothesis and they found in impulsive children aged 5 and 6 years, who showed deficiencies both in quantity and quality of self control verbalization compared with a matched group of reflective children.  

Durlak et al (1991) investigated in a meta-analysis the interaction between cognitive developmental level and treatment effect size. Durlak grouped these studies according to the Piagetian developmental stage of children treated, however this was only based on age. The effect size for children aged between 11 and 13 ( formal operational stage) was nearly twice of that for children in the concrete operational and preoperational stages. Thus, cognitive developmental level is clearly crucial in the success of the therapy since children of 11 years and over seems to benefit more from the range of techniques known as CBT than those aged 5-11.

Cognitions are considered to be the core element, if not causal, in behavioral and emotional problems. Attempts have been made to confirm that changes in cognitive processes have mediated therapeutic success (Durlak et al 1991). Powell and Oei ( 1991) examined 63 studies of CBT and found only 9 that had tried to demonstrate that changes in children’s cognitions were influential in therapeutic effectiveness. Significantly, the authors cite children’s rapid changes in cognitive development and “the interaction of the cognitive stages with the child’s ability to develop and utilize certain skills `` (Powell & Oei 1991 p. 258) as one of the main obstacles to assessing and measuring the evidence they were researching.

Subsequently the findings from  Dulak et al (1991) meta-analysis of 33 selected studies out of 64 well-designed outcome studies of CBT that included at least one measure of cognitive change, the researchers found no significant correlation between cognitive change and behavioural change. Thy conclude: “ the specific connection between cognitive functioning and adjustment is unclear and the underlying mechanism of change in CBT remains unknown``( p.211).

The lack of evidence in the relationship may be due to difficulties in measuring change in children’s cognitions, but could also be that the mechanism for change is not a cognitive one, in the way set out in the existing theoretical model.

Problem-solving training, social perception skills training, self-control training techniques and cognitive restructuring with children are the most common cognitive techniques reported in the literature and are blended sometimes and include always behavioural techniques (Spencer 1994). Meta-analysis have failed to provide clear evidence about the best combination of these different approaches with different presenting problems (e.g depression, anxiety, impulsivity and hyperactivity) and different population characteristics (boys and girls aged 4-18 years; Durlak et al 1991).

There are few studies that examined children under the age of 8 and also methodological issues when attempting to draw conclusions about the efficacy of CBT in that age group. CBT research in this area is therefore presenting efficacy with non-clinical samples (Roth & Fonagy 1996) over short periods of time, with narrowly specified behaviours and in laboratory setting, such as testing teacher-rated impulsive children on the matching familiar figures test in a classroom (Whalen et al 1958). Other reviews show a lack of adequate control groups, problems with maintenance of treatment gains over time, and generalization of treatment effects outside the setting conditions (Powell & Oei 1991). There is often a lack of clear specification of therapeutic activity and integrity checks (Durlak et al. 1991), which is problematic due to the range of strategies encompassed in CBT.

Cognitive restructuring approaches have been widely tested for their effectiveness with adults, but not with children. Those few studies that are reported in the literature fail to yield convincing validity and reliability for the effectiveness of restructuring maladaptive cognitions over control and waiting list groups for 8-12 years old ( Target & Fonagy 1996). There is strong evidence that age and by implication, cognitive developmental play a vital mediating role in the efficacy of CBT. However, there is little support for cognitive shift being the mechanism for behavioural change.

Perhaps the inability to provide validity in the relationship between cognitive change and therapeutic outcome is due to the failure of adequate measurements of the cognitive function and change in children. Also age or developmental level is not a client variable that has been singled out for analysis, and the variety of techniques combined and refer to as CBT is very complicated for measurement.  However, all the evidence in this short review of literature fails to allow strong conclusions out of developmental perspective. Contemporary cognitive therapist have responded to the criticism that CBT has failed to recognize the mediating role of developmental level in the success of CBT, with an argument that young children are constantly learning skills and knowledge and therefore are able to learn the lessons of CBT (Ronen 1992). Treatment goals and concepts should be modified and use simple verbally based techniques that examine irrationality and more concrete pictures, play, and story based representations of the therapeutic task.



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