Planeamiento de la Producción

Cognitive behaviour therapy with prepubertal children

Paul Stallard

Royal United Hospital, Bath, UK

8.1 Introduction

Cognitive behaviour therapy (CBT) embraces a range of psychotherapeutic inter-ventions that aim to ameliorate and/or reduce psychological distress and mal-adaptive behaviour by altering cognitive processes. CBT uses both behavioural and cognitive strategies and seeks to ‘preserve the efficacy of behavioural tech-niques but within a less doctrinaire context that takes account of the child’s cognitive interpretations and attributions about events’ (Kendall and Hollon, 1979). Identifying, challenging and learning alternative skills to counter and replace the cognitive deficits and distortions assumed to underpin emotional and behavioural problems is the primary focus of CBT.

8.2 At what age are children able to engage in CBT?

The age at which children have sufficient cognitive development to engage in CBT has been the subject of debate. Some argue that CBT requires the ability to

‘think about thinking’ and that this meta-cognition allows children to reflect on their own behaviour and cognitive processes and to detect patterns and structures within them. This level of cognitive maturity and sophistication has led to a view that CBT is best suited for children of middle and later childhood. In a meta-review, Durlak et al. (1991) found that children aged 11–13 derived significantly more benefit from CBT than younger children. The influential sequential staged approach to cognitive development proposed by Piaget adds further support to the view that older children are better suited for CBT. Piaget suggested that more complex mental processes that allow the development of logical reasoning do not develop until the concrete operational stage, typically acquired at 7–8 years of age.

Cognitive Behaviour Therapy for Children and Families, ed. Philip J. Graham.

Published by Cambridge University Press.
^C Cambridge University Press 2004.

121

In practice, although CBT can involve sophisticated and complex cognitive tasks, the cognitive demands of most CBT programmes with children are quite limited. Many tasks require an ability to reason effectively about concrete matters and issues rather than higher order abstract and conceptual thinking (Harrington et al., 1998). This has led some to suggest that the cognitive development of 7-year-old children is sufficient for many of the basic tasks of CBT. By the age of 7, children are reasonably able to competently reflect on their own cognitive processes (Salmon and Bryant,2002).

While there is an emerging consensus that children as young as 7 years of age can engage in CBT, the question arises as to whether children below this age have sufficient cognitive skills to engage actively in a modified form of CBT. Support for this possibility comes from research exploring how children develop a representational understanding of mind, i.e. how they understand that people have internal mental states such as thoughts, beliefs and images that may represent or misrepresent the world (Wellman et al.,1996). In a series of studies examining preschool children’s understanding of thought bubbles, Wellman et al. (1996) showed that with preliminary training 3-year-old children could understand that thought bubbles represent what a person may think. In addition, their results suggest that children of this age can distinguish between thoughts and actions, can acknowledge that thoughts are subjective and thus that two people can have different thoughts about the same event and that thoughts can misrepresent an event. In terms of self-awareness and recognition of inner speech, Flavell et al. (2001) suggest that this is acquired during the first years at school. This implies that some children of 5 or 6 years of age are able to articulate their cognitions and understand the concept of ‘talking to oneself ’, one of the most commonly used strategies in CBT programmes with children.

Further evidence supporting the possibility that younger children may be able to engage in some of the tasks of CBT has come from research evaluating Piaget’s theory of cognitive development. Piaget’s assumption that failure on particular cognitive tasks indicates the absence of a particular set of underlying cognitive skills has been challenged. Performance on similar cognitive tasks can vary depending on the specific way the task or information is presented and does not necessarily reflect the absence or presence of an assumed set of cognitive skills (Thornton2002). Interest in a more process-orientated approach to the understanding of cognitive development has led to the questioning of another basic tenet of Piaget’s theory – namely, the assumed link between a set of cognitive skills (i.e. logical processes) and their use (i.e. logical reasoning).

Thornton (2002) argues, for example, that logical inferences may not necessarily

reflect the use of logical cognitive processes. Cognitive reasoning may be based around information and meaning rather than rules of logical inference. Relevant information can, therefore, be used to construct a mental model, which in turn can be used to reach conclusions about the relationships between one event and another. Changes in knowledge can therefore create powerful new ways of reasoning leading Thornton (2002) to conclude that it is information not age that plays an important part in determining a child’s performance on cognitive tasks.

These findings lead to the intriguing possibility that children as young as 5 or 6 years of age may be able to participate in some forms of CBT if sufficient attention is paid to the way tasks are structured and presented. Clinicians need to attend to the child’s cognitive development to ensure that cognitive inter-ventions and techniques are adapted and modified so they do not exceed the child’s cognitive or emotional capabilities (Salmon and Bryant,2002). How this essential task is achieved in clinical practice has received surprisingly little atten-tion. Standardized CBT programmes, often spanning wide age ranges, seldom specify how they have been adapted for use with younger age groups. Many programmes appear to assume that the techniques and strategies are universally applicable to children of all ages (Barrett,2000).

There are some helpful examples in the literature where clinicians have mod-ified CBT to match the child’s cognitive capabilities. Kane and Kendall (1989) for example found that, although younger children had problems identifying their own anxious cognitions, both in imaginal situations and in vivo, they could engage in a third party discussion about what might happen to another child in a similar situation. Williams et al. (2002) noted that, although young people often failed to report any cognitions spontaneously, a therapist-led guided approach could help the children discover possible thoughts associated with emotional reactions. Similarly, Spence et al. (2000) observed that, while younger children experienced difficulty with cognitive restructuring involving challenging and testing the evidence for their thoughts, they were able to use simpler cognitive strategies such as positive self-instruction.

These examples highlight how the cognitive processes and tasks of CBT can be adapted to match the capabilities of the child. This would suggest that younger children may be able to engage with less sophisticated, specific, concrete cog-nitive techniques such as developing positive coping self-talk. Providing specific and relevant information that would allow the development of cognitive models of reasoning appears to be important. The provision of such information may help the child to reach conclusions about specific problems even though they

may be unable to recognize overarching rules, the cognitive processes they use or generalize their conclusions to other situations. Understanding the mecha-nisms by which change is achieved – e.g. that emotions are effected by partic-ular cognitions – may not be possible for children under 5 years of age (Flavell et al.,2001). The process of guided discovery which underpins CBT may therefore require a more active and direct therapeutic approach with younger children, with the therapist providing information and developing strategies for the child to use and test. The clinician’s role with older children may be more facilitative as adolescents may be more able to develop and evaluate cognitive strategies for themselves. Working with higher order, more abstract and complex tasks such as identifying dysfunctional assumptions, evaluating evidence for and against beliefs or cognitive restructuring may not be appropriate until middle adoles-cence (Bailey,2001).