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(See Appendix at the end of this Manual for reproducible
Client Worksheet #5)
The 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
A 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 one's behavior.
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:
The 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-regulation 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
1. 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.
2. 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.
3. 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.
4. 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 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.
The 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.
Six categories of dependent measures were used. The assessment included observational ratings, physiological measures (pulse rate and temperature), and child and parent self-reports.
The 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.
In 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.
The 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.
Cognitive Behavioral Therapy in Anxiety Disorders:
- Otte, C. (2011). Cognitive Behavioral Therapy in Anxiety Disorders: Current State of the Evidence. Dialogues Clin Neurosci., 13. p. 412-421.
- Bystritsky, A., Khalsa, S. S., Cameron, M. E. (2013). Current Diagnosis and Treatment of Anxiety Disorders. P&T, 38(1). p. 30-57.
Reflection Exercise #5
Online Continuing Education QUESTION 22: What are three examples of behavioral treatments to use with anxiety disordered children? To select and enter your answer go to CEU Answer Booklet.
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