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Treatment Programs for Children
Appendix at the end of this Manual for reproducible
Client Worksheet #5)
Perhaps the major concern in the diagnosis/clarifications
of anxiety from a behavioral perspective is how the term is defined and used.
Traditionally, anxiety has been viewed as a transient emotional time behavior,
a trait, or even a cause or explanation for behavior. Nietzel and Bernstein, in
contrast, advanced a social learning framework for conceptualizing anxiety:
1. Anxiety is not a trait or personality characteristic.
can be acquired through different mechanisms.
3. Anxiety consists of
4. Anxiety response channels are not highly correlated.
conceptual framework is useful because the terminology employed in the clinical
literature has often been imprecise and not always helpful in understanding how
children actually behave. The idea that anxiety consists of multiple response
components and that these may not be highly related, has important implications
for treatment. For example, treatment made needs to be focused and independent
on each response channel. Also, the focus on three response channels may help
advance knowledge of what treatments may affect different types of response patterns
within the anxiety, fear or phobia construct.
Major Forms of Cognitive Behavior Therapies
Mahoney and Arnkoff
identified three major forms of cognitive behavior therapies: rational psychotherapies,
coping-skills therapies, and problem-solving therapies.
rational-emotive therapy (RET) is the oldest of the rational psychotherapies.
Irrational ideas or self-statements are said to be the fundamental cause of emotional
disorder. The task of therapy is to assist the client in recognizing self-defeating
irrational ideas and replacing them with more constructive, rational thoughts.
variation of rational psychotherapy is self-instructional training (SIT).
Meichenbaum gives less emphasis to the logical analysis of irrational beliefs
and argues that the incidence of irrational beliefs per se does not distinguish
normal from abnormal populations. Rather, the two groups are said to differ in
their coping response to irrational thoughts. The procedure developed by Meichenbaum
places heavy emphasis on the modeling of cognitive strategies by the therapist
and on assisting the child through operant procedures to develop answers to four
primary questions: "What is my problem?" "What is my plan?"
"Am I using my plan?" and "How did I do?" (Meichenbaum
& Goodman). The child is taught self-instructions to handle each of these
aspects of problem resolution and thus learns how to cope with future problems.
In this way, self-instructions can be viewed as establishing self-control over
third variation of rational psychotherapy is Beck's cognitive therapy
(Beck & Emery). As with RET and SIT, the ultimate goal is to develop rational
adaptive thought patterns. Beck's cognitive therapy involves the following phases
for the client:
(1) becoming aware of his or her thoughts.
learning to identify inaccurate or distorted thoughts.
inaccurate thoughts with accurate and more objective cognitions.
feedback and reinforcement are important parts of the process.
second major form of cognitive-behavior therapy identified by Mahoney and Arknoff
is coping-skills therapies. These therapies represent a different use of
existing methods and overlap considerably with other approaches such as SIT. Examples
include: anxiety management training (Suinn & Richardson), stress inoculation
(Meichenbaum) and modified systematic desensitization (Godfried). The critical
dimension that characterizes these diverse methods is that of the individual coping
with distress producing events.
and Self Regulation
Self-control refers to a set of aroused processes
(cognitive and instrumental) through which an individual consciously and
consistently contributes to changing the likelihood of engaging in a behavior
with conflicting temporal contingencies. The behavior in question may result in
immediate reward, but have eventual adverse consequences (as in various addictive
disorders) or may involve immediately unpleasant, long-range positive, outcomes.
The aroused processes help to facilitate either avoidance (of the short-range
positive payoff) or approach (to the short-run negative outcome). Typically, the
individual must be motivated to counteract the cues in the immediate environment,
which are arranged so as to facilitate the more probable, but maladaptive patterns
of responding (approach to the short-range positive outcomes or avoidance of short-range
discomfort or loss).
refers to a set of aroused processes through which an individual consciously and
consistently contributes to maintaining the course of goal-directed behavior in
the relative absence of external supports or when external supports are of limited
utility. As noted earlier, self-control is a process through which individuals
become the primary agents in directing and regulating those aspects of their behavior
that lead to preplanned and specific behavioral outcomes and/or consequences.
Conceptual Framework of Cognitive-Behavioral Therapy
In order to
implement cognitive-behavioral strategies with children and to design an effective
assessment and treatment program, it is necessary to consider a conceptual
model for working with children experiencing fears, phobias, and anxiety disorders.
In this regard, Karoly provided a working model for self-management that takes
into account the following components:
First, the child's discrimination of rules and situational response
requirements is necessary. Any comprehensive assessment of the child who is experiencing
problems in this area will need to be assessed for their knowledge of self-management
rules, acceptance of content and logic or rules, memory for rules, and ability
to recognize the benefit of certain performance standards or codes of conduct.
A second feature of the model involves the child's awareness that his
or her non-self-managing behavior has become dissonant with the environmental
demands and is problematic in terms of obtaining reinforcing outcomes. Within
this context, Karoly suggests assessing the accuracy of the child's awareness
of the short-term nature and effects of behavior, the accuracy of the child's
awareness of the long-term effects of behavior, the child's recognition of problematic
features of short-run or short-term behavioral patterns and the child's awareness
of his or her impact on the behavior of others in the short and long term.
A third component of the model involves motivation or effort and commitment
to behavior change. In this regard, the child is assessed along the following
dimensions: (1) the child's perception of the value of the self-managed response
as compared with the perceived alternatives, (2) the nature of potentially active
physiological factors either facilitating or inhibiting the desire to self-manage,
(3) the stringency of the child's self-evaluative standards, (4) the child's expectancy
of future goal attainment compared with the perceived cost of engaging in self-management,
and (5) the child's habitual mode of attributing responsibility for the accomplishment
of tasks relevant to self-management.
The final component of the model involves skills for extended self-management.
A variety of skills have been identified as necessary in order for implementation
of a self-management program. Such skills as self-observation, self-monitoring,
and self-recording; self-evaluation and goal setting; administration of rewards
and punishments; self-instructional control of performance; information processing,
planning, and problem-solving style; imaginal control of thought and affect, self-perception,
and causal attribution; and manipulation of stimuli response, response outcome,
and self-efficacy expectations will be necessary.
In the context of this model, the clinician can develop
a detailed and comprehensive assessment of the child's ability to manage his or
her own performance. The seven questions raised by Karoly can be useful in guiding
assessment and eventual intervention with the child. Specifically, the following
questions should be considered:
1. Would a self-management treatment
model be appropriate?
2. Has the child's overt behavioral disturbance
ever been conceptualized within a self-management framework?
Would self-management oriented interventions contribute to the maintenance of
adaptive learning and/or prevention of future problems?
4. Is self-mediated
form of intervention warranted on ethical grounds?
5. Is the child
invested in changing a high-probability response pattern?
the assessor have access to the child's performance on a day-to-day basis with
significant others or for extended periods of time?
7. Is it possible
to identify the primary causes of the child's failure to achieve criterion performance
by ruling out knowledge deficiencies, developmental or biological incapacities,
motivational insufficiencies, skill deficits, or non-facilitative environments?
In the treatment of children's anxiety disorders, cognitive
self-control procedures focus on helping the child develop specific thinking skills
and apply them whenever he or she is confronted with a particular fear-or-anxiety
producing stimulus, event or object. According to Meichenbaum and Genest, the
self-control approach involves helping the child in the following areas:
1. Become aware of the negative thinking styles that impede performance
and that lead to emotional upset and inadequate performance.
in collaboration with a trainer, a set of incompatible, specific, self-statements,
rules, strategies, and so on, which the trainee can then employ.
Learn specific adaptive, cognitive behavior skills.
in order for the child to participate in cognitive therapy, he or she should be
aware of the phobia or anxiety to the extent that he or she can identify
the various motor aspects of the fear (i.e., what the child does when he or she
is afraid); cognitive components (i.e., what the child thinks or says to himself
or herself when afraid); physiological components (i.e., how the body reacts when
the child if afraid, and which part(s) of the body is involved); and under which
conditions he or she becomes fearful. Second, it demands that the child
have the verbal capacity to generate, with the therapist, a series of incompatible
self-statements and rules, which the child can incorporate (at least temporarily)
into his or her verbal repertoire. Third, it demands that the child be
able to apply these self-statements and rules under those conditions in
which he or she experiences anxiety. In addition to these factors, Kanfer outlined
the following features that must be taken into account in development of a cognitive
self-control treatment program.
1. A behavior analysis,
including a description of specific problem behaviors, and of positive and negative
reinforcers appropriate for the client's environment that can be enlisted to aid
in the behavior change process.
2. Observation and self-monitoring
of the target behavior.
3. Development of a plan for behavior
change. Negotiation of a contract that includes clear specification of the goals
to be achieved, the time allowed for the program, and the consequences for achieving
it, as well as the methods for producing the behavior change.
brief discussion with the client on the underlying assumptions and rationale
of the techniques to be used.
5. Modeling and role play of the
6. Frequent external verification of
progress and of factors that have retarded progress, as well as feedback and re-evaluation
of the contract.
7. Recording and inspection of qualitative and
quantitative data documenting the change. Extension of the desired behavior to
many different situations or areas of life.
8. A self-reinforcement
program that relies increasingly on the person's self-reactions is sufficiently
varied to avoid situation and is effective in changing the target behavior.
9. Execution of new behaviors by the client in his or her natural environment
with discussion and correction of the behavior, as needed.
verbalization of the procedural effects, the means by which they are achieved,
and situations to which they can be applied in the future.
strong support by the helper for any activity in which the client assumes
increasing responsibility for following the program accurately and extending it
to other problematic behaviors.
12. Summarizing what has been learned
in the change process and preparing the client to transfer the new knowledge and
skills to future situations.
It is useful to review a typical cognitive-behavior therapy
format for a child experiencing a phobic problem. Richards and Siegel provide
and example of the use of cognitive-behavior therapy in the modification of a
child's severe dog phobia. The child was taught Meichenbaum's self-control technique
(self-instruction) as a supplement to other procedures. The self-instructional
treatment involved the following five steps:
1. Therapists modeled
adaptive self-verbalizations by talking out loud and administering task-relevant
instructions to themselves while performing the task (e.g., while petting a dog
appropriately, saying, "Relax, take a slow, deep breath; I'm doing fine;
this dog is obviously friendly; notice his wagging tail; pet him softly; nothing
to worry about").
2. The child performed the task while the therapist
instructed her aloud.
3. The child performed the task and instructed
4. The child performed the task and whispered
the instructions to herself.
5. The child interacted with dogs while
using entirely covert self-instructions.
Step 2 through 5 also included
extensive performance feedback and positive reinforcement to the child.
A token economy program was also established whereby the
children received tokens for doing their exercises at home and for going to bed
and being brave throughout the night. The parents were instructed to initiate
the children's exercises at night and to use tokens and praise. The outcome measures
included parent ratings of the number of child fears, strength of fears, and behavioral
criteria (i.e., 10 consecutive fearless nights).
results showed that it took from 3 to 19 weeks (mean=8.7 weeks) for all the children
to meet the behavioral criteria. The authors further reported that each child's
"fear strength" steadily decreased through post-treatment and the 3-month,
6-month, and 1-year follow-up periods. Also, total number of fears decreased,
with only one out of the seven children not completely free of fears at the 1-year
follow-up. Finally, both parents and children reported that the program improved
the children's fear behavior and sleeping patterns.
Self-control treatments have also been applied with children experiencing medical-
and dental-related fears. Using a variation of the self-control approach, Peterson
and Shigetomi conducted a study with children who were to receive elective tonsillectomies.
The 66 children (35 girls and 31 boys), aged 2.5 to 10.5 years (mean=5.47 years)
were assigned to one of four conditions:
1. Preoperative information, where
children were invited to a "party" four days before their surgery and
informed via a story and a puppet of the "typical hospital stay from admission
2. Coping procedures, where children received the
preoperative information plus cue-controlled muscle relaxation (using the cue
"calm"); distracting mental imagery training (imagining a scene that
was "quiet and made them feel happy"); and comforting self-talk (the
children, for example, were encouraged to think of the phrase "I will be
all better in a little while").
3. Filmed modeling, where the
children received the preoperative information.
4. Coping plus filmed
modeling, where the children were also given a 15-minute hospital tour and spent
another 15 to 20 minutes eating ice cream and cookies following the tour.
categories of dependent measures were used. The assessment included observational
ratings, physiological measures (pulse rate and temperature), and child and parent
results indicated that children receiving the two coping conditions experienced
less distress during their hospital stay than did the children in the modeling-only
or information-only groups. Furthermore, children receiving the coping-plus-modeling
procedure were more calm and cooperative during invasive procedures than were
those in the coping or modeling alone conditions.
another study, Siegel and Peterson conducted similar research with children undergoing
dental treatment. They compared the coping-skills condition described earlier
with a sensory information condition (i.e., children were told what to expect
and heard audio tape recordings of the dental equipment) and no-treatment/attention
condition. The results indicated that there was no significant difference between
the coping and sensory information conditions on any of the measures taken during
or after restorative treatment, and that both treatment groups fared better on
the measures than did the no-treatment control children.
Cognitive procedures have been integrated into other forms
for the treatment of children's anxiety disorders. For example, one variation
desensitization involves "emotive imagery," a method first used
by Lazarus and Abramovitz to adapt the desensitization procedure to children.
Generally, the procedure involves the use of anxiety-inhibiting images that arouse
feelings of excitement associated with positive experiences. In the procedure,
a gradual hierarchy is developed. The clinician establishes child hero
images, and the child is then asked to close his or her eyes and imagine a sequence
of events in which a story is developed about the child's favorite hero. Once
the child's emotions are maximally aroused within the story, the lowest item on
the hierarchy is presented. The procedure is repeated throughout the systematic
desensitization hierarchy until each item is tolerated without distress.
procedure depends greatly on the child's visual imagery or cognitive skills.
Unfortunately, there is little empirical research on this topic. For example,
Lazarus and Abramovitz reported some descriptive case studies in which the procedure
was used with a dog-phobic 14-year-old, a 10-year- old who was afraid of the dark,
and and 8-year-old who was afraid of going to school. The procedural steps discussed
earlier were implemented, and the authors reported a reduction in the children's
fears. In addition, Ayer reported the use of this visual imagery technique with
three children who were afraid of going to the dentist. Specifically, the children
were afraid of receiving the anesthetic and were said to have needle phobias.
The children were asked to imagine they were playing with their dogs and the dogs
were yelping loudly (minor variations were scheduled with one child). They were
then told to keep their eyes closed so they would see none of the dental instruments.
This was practiced several times while they imagined the dogs yelping louder and
louder. During the dental procedure the children were encouraged by the clinician
to intensify the dog's yelping. The anesthetic was then administered in
a routine fashion. The author reported that by the third appointment, the children
were "visibly relaxed and friendly." More recently, Jackson and King
successfully treated a 5-1/2-year-old boy who was afraid of the dark. A fictional
character, Batman, was chosen in a scenario in which the child and Batman joined
forces to overcome the fear of the dark. Unfortunately, work in this area has
remained at the descriptive case study level, so firm conclusions cannot be drawn
from this area of research.
Interestingly, some behavior therapy treatments developed
independently of the cognitive therapies have been conceptualized as having a
cognitive component or focus. For example, Goldfried viewed systematic desensitization
as training in self-control -- that is, an active, cognitively mediated process
of learning to cope with anxiety, rather than a passive, counter-conditioning
one. Procedural modifications to increase self-control features with this method
include the following
1. Clients are taught how to relax, how to recognize
tension, and how to use relaxation skills to relieve tension.
the tension phase of relaxation exercises, clients focus on feelings of tension
and become more sensitive to them. These feelings serve as cues for the application
3. Hierarchies are used that include many different
anxiety-arousing themes in order to maximize transfer of the coping skills and
increase the variety of situations in which self-control is practiced.
4. At the first experience of tension, clients signal and then continue
imagining the scene while actively relaxing away the tension.
signal when the anxiety is brought under control and they are once again deeply
relaxed. The scene is then cleared, representing a successful trial of coping
6. Relaxation homework is emphasized, and in vivo
application is reinforced and modified in light of the homework assignments.
(Excerpted and adapted from Michelson and Ascher)
Reflection Exercise #5
The preceding section contained Research and
Treatment interventions to use with Children. Write three case study examples
regarding how you might use the content of this section of the Manual in your
13: What are three examples of behavioral treatments to use with anxiety disordered
children? To select and enter your answer go to .