COGNITIVE AND

BEHAVIORAL
THERAPIES
Anne Cristine D. Guevarra, MD
Child Psychiatry Rotator

Lewiss Child and Adolescent Psychiatry:

A Comprehensive Textbook 4th edition

Objectives
To introduce cognitive-behavioral

therapy as a modality for treatment of

psychiatric disorders especially in
children and adolescents
To review basic concepts that form
the basis for CBT
To discuss specific disorders wherein
CBT may be effective

Cognitive Therapy
Foundations

it is not events, but people's interpretations of events, that

cause psychological disturbance

focuses on identifying and changing people's cognitions as
a way of changing their feelings and reducing psychological
distress

Behavior Therapy Foundations

behavioral changes are thought to influence thoughts and

feelings
Setting concrete goals and measuring specific behaviors
FUNCTIONAL PERSPECTIVE Functional Assessment /
Evaluation
Antecedents = BEHAVIOR = Consequences

Classical Conditioning

Establishes the connection of

an existing response to a new stimulus

Classical Conditioning &

Phobias

Classical Conditioning & CBT

The subsequent avoidance behavior does not allow

extinction to occur, such that the phobia is maintained

Classical Conditioning & CBT

Emotional responses, addictions, and

psychosomatic disorders
Therapy techniques:
Counterconditioning
Systematic desensitization
Covert sensitization
Exposure and response prevention

Classical Conditioning

Operant Conditioning

Operant Conditioning:

Schedules of Reinforcement
Continuous schedule initially teaching a new

behavior
Thinning to decrease the ratio of reinforcers to
responses
Intermittent
1) fixed interval
2) variable interval
3) fixed ratio
The variable ratio schedule is the
variable
most 4)
effective
scheduleratio
when trying
to maintain a behavior because it
creates relatively high steady rates of
responding.

Extinction Graph
Extinction
Burst

Spontaneous
Recovery
Extinction
Occurs

Initial Behavior
Response Frequency

Reinforcement
Removed

Operant Conditioning & CBT

Applied behavior analysis (ABA)
Parent management training (PMT)
Problem solving skills training (PSST)

Common Therapy Techniques Associated

With
Principles Of Operant Conditioning
Reinforcement to Increase Behavior
Type and Technique
Token
economy
DRO
(Differential
Reinforcement
of Other Behavior)

Shaping

Description
Reinforcing target behavior with tokens (stickers, points, poker
chips) that can then be traded in for reinforcers once multiple tokens
have been earned
Reinforcing specific appropriate behaviors while ignoring inappropriate behaviors that serve
the same function

Reinforcing gradual approximations of a behavior

Punishment to Decrease Behaviors

Overcorrection

Applied consequence that involves engaging in a series of retribution

steps that are related to the inappropriate behavior (washing soiled clothes after toileting accident)

Response cost

Removal of previously earned reinforcers as consequence of negative behavior. Used especially in

conjunction with token economy when tokens are removed

Time out

Removing all sources of reinforcement for allotted period of time. Typically involves placing the individual
in a location where access to reinforcing activities, including social attention, is not available

Extinction to Decrease Behaviors

Removing previously available reinforcement from an inappropriate behavior to decrease the
probability that the behavior will occur in the future

Cognitive-Behavior Therapy
Foundations

Behavior

Thoughts
Feelings

Cognitive-Behavioral Model
Escape or Avoidance Conditioning
why negative thoughts and beliefs persist
why behavioral cycles do not get broken over time
avoidance, escape and safety-seeking behaviors
individuals erroneously believe they prevented the feared situation
from occurring by engaging in certain behaviors
Attention-related Factors
Selectively attend to cues that confirm or exacerbate their condition

Cognitive images
Images are interpreted as signs of danger likelihood that
distressing events will occur
Memory Processes
Recall of instances that confirm anxiety
Rumination thinking of the likelihood of the event occurring
Makes the event more abstract and threatening vs. constructive processing

Clinical Considerations In Use of CBT

with Children and Adolescents
Collaborative empiricism
Patient-therapist relationship; team
High degree of collaboration and scientific attitude toward

testing the validity and accuracy of the patients cognitions

and behaviors
developing hypotheses about thoughts and behaviors,
collecting data on those thoughts and behaviors,
examining patterns, and generating alternative, more
adaptive, ways of thinking and behaving

Developmental Perspective
The child's level of autonomy and independence

must be taken into consideration

Consider what other individuals or systems and
how they are involved in the child's life and what
their role should be in therapy
Parent, teacher, and other adult-focused training is
often necessary in addition to individual therapy
sessions
Adapting treatment concepts to children's
developmental level
Cognitive-behavioral play therapy (CBPT) in very
young children

Family-Related Factors
The Role of Families and Other

Systems in Cognitions and Behaviors

Other people in the child's life are making

accommodations that support and maintain,

rather than discourage, the maladaptive
behaviors
Parent/Family Involvement in Therapy
family context, and parental cognitions,
emotions, and behaviors
family routines, dynamics, and discipline
practices

Generalization and
Maintenance
Across settings

Across functional domains (behavior, cognitions)

Over time (maintenance)
For successful change, the patient must use the techniques learned in
session across settings, learn to apply them to a variety of domains, and
continue to use them over time for as long as necessary.

Strategies for promoting generalization

and maintenance of improvements in
functioning (Kendall and Lochman )

Rewarding behavior change using attainable goals

that are applied across an increasing number of

settings over time
Treatment length is an important consideration in
programming for maintenance of changes made (6
months or longer); intensity may be an important
factor as well
Use of behavioral rehearsal (role-playing)
Problem solving processes that apply to multiple
behaviors and situations

Course of Therapy
General Characteristics of CBT Treatment
Plans
1) The patient will be an active participant in trying new
strategies
2) the patient will be expected to complete homework
3) therapy outcomes will be measured via data collection,
and techniques will be modified if they are unsuccessful
4) therapy will focus on symptoms and daily functioning
5) therapy will be time limited
6) maintenance of treatment gains and relapse prevention
will depend on generalization of techniques into everyday
life

Three Phases of Treatment

Initial

Active

Final

Frequency and Duration of

Treatment
3- to 6-month period

once or twice per week in an outpatient setting

Booster session
Tapering the therapy

PHASES OF TREATMENT

Phases of Treatment
Assessment for Treatment Planning
Psychoeducation
Middle Phase of Treatment
Termination and Relapse Prevention

Assessment for Treatment

Planning

To develop a cognitive behavioral model of the presenting

problem that can be used to guide treatment

Descriptions of when the symptoms occur
Cognitions that accompany each symptom
Behaviors that accompany each symptom
Emotions that occur with each symptom
If cognitions and behaviors relieve symptoms, detailed description of

how this occurs

Information about factors that help or exacerbate the symptoms
Maintaining variables: avoidance, escape, safety behaviors,
attention/focus, dysfunctional/faulty beliefs, automatic thoughts
Overall beliefs (cognitive schemas) that lead to cognitions, behavior,
and feelings
Previous treatment and treatment outcome
Onset: including any possible causal factors that are not maintaining
factors (e.g., traumatic event in PTSD, negative situation paired with
stimuli in specific phobias)

Ways of Eliciting
Ask patient to describe a recent event in detail,

while asking pointed and specific questions, such

as:
What were you thinking when that happened? or
How did your body feel at that moment?

Homework
Explicit information from children
Self-monitoring

Psychoeducation
Techniques utilized in CBT are driven by theoretical

or empirical underpinnings that, when understood,

allow the patient to better grasp why such
techniques are being used and how change will
occur, thus increasing motivation and follow
through
Explained or demonstrated
Physiological
Cognition
Connection between thoughts and events

Middle Phase of Treatment

Ongoing active participation in therapy
Homework

Goals and content of therapy sessions during this

phase will vary widely depending on the chief
complaint.

Termination and Relapse

Prevention

Programming for generalization and maintenance

Thinning of schedule of therapy sessions
Relapse prevention
Cognitive framework for thinking about brief relapses
Identifying antecedents to relapse behaviors
Booster sessions

CBT TECHNIQUES

CBT Techniques
Cognitive Restructuring
Identifying Automatic Thoughts
imagerey & role-playing, thought recording

Socratic Questioning/Examining the Evidence

eliciting automatic thoughts and calling their validity into
question
Thoughts are considered hypotheses determine and
evaluate evidences for and against them
Can be combined with self monitoring

Correct Misinterpretations

Cognitive Errors
COGNITIVE ERROR

DESCRIPTION

EXAMPLE

Catastrophizing

Placing unrealistic importance on thoughts and

events
and assuming terrible negative outcomes will
occur as a result

I got a C on my report card, so I will never get

into college and I will fail in life.

Magnifying/Minimizing

Placing an inaccurate amount of importance on

thoughts, feelings, Events (either too much or too
little)

Believing getting caught doing drugs is not

important because the Implications of having
a drug problem are too anxiety provoking
(minimizing)

Absolutism

All events and experiences are thought of in

extreme
categories, rather than moderately

I will never lose any weight because I just ate

a cookie.

Personalization

Attributing responsibility for external events to the

self with no basis for the attribution

It is my fault that my parents are getting

divorced.

Selective Abstraction

Taking information out of context and ignoring

relevant details

My soccer coach hates me when s/he did not

play you in spite of the fact that you have
started the last three games

Arbitrary inference

Making arbitrary conclusions contrary to or

without evidence

Believing homework is too hard when in fact

the child completed the same work that day
in class

Ignoring evidence

Leaving out important information when forming

thoughts about events

Believing that werewolves are a danger at

night in spite of the fact that multiple adults
have told the child they do not exist, and all
the doors in the house are locked.

Attending to negative
features of events

Placing greater cognitive importance on negative

features of events and ignoring positive features

Focusing on one poor grade when all others

were good

CBT Techniques
Behavioral

Experiments
Modification of
Imagery
Altering Core Beliefs
Physiological
Techniques
Regulated Breathing
Relaxation Training
Exposure Techniques
Activity Scheduling

Applied Behavior

Analysis (ABA) /
Behavioral
Modification
Counterconditioning
Systematic
Desensitization
Aversive
Counterconditioning
Covert Sensitization
Habit Reversal

CBT Techniques
Behavioral Experiments
During psychoeducation; exercises that patient can complete in
a session; demonstrates error in thinking in a concrete manner
Thought suppression increased frequency of a thought (e.g.
pink elephants)
Instead of supressing thoughts observe thoughts as they
come & go
reduction of intrusive thoughts
Modification of Imagery
Identify exaggerated aspects of the imagery associated with

traumatic event
Often stops at the height of crisis help patient continue
image to a positive resolution
Passing out Falling to the ground getting embarrassed
standing up

CBT Techniques
Altering Core Beliefs
Underlying belief cognitive schemas automatic thought
(Stupid kids are unlovable) (I am stupid) If I dont write that sentence
everyone will know I am stupid Therefore, no one loves me
Maladaptive Adaptive
Physiological Techniques
Anxiety; catastrophizing physical symptoms
Regulated Breathing
Counteracts hyperventilation, reduces physical tension, decreases
physical sensations associated with anxiety
Uncovering the patients understanding of the physiology decreases fears
Relaxation Training
Progressive tensing and relaxation of muscles; target large muscle groups
Effective for sleep-onset insomnia, anger management, impulsive children

CBT Techniques
Exposure Techniques
Based on Avoidance / Safety Behaviors
Graded series of exposures
Habituation (Classical Conditioning) anxiety extinguish over time
Anxiety, phobia
OCD compulsive behavior (safety behavior)
Flooding not graded; begins by eliciting a full-blown fear response;
needs good self-control to prevent avoidance/escape
Challenge core beliefs Cognitive Response Prevention
Behaving inconsistently with pathological belief
Do homework with some imperfections (a couple of mistakes do not make

me stupid)

Activity Scheduling
Becks cognitive triad negative (thinking, evaluations of self, world,
future)
Reinforcing daily activities

CBT Techniques
Self-Monitoring / Self-Management
Automatic thoughts, habits, evaluation plan
Applied Behavior Analysis (ABA) / Behavioral

Modification
Increase desirable = decrease undesirable
Contingent reinforcers reinforcement is applied to a

positive behavior increases the frequency of that

behavior occurring

Counterconditioning
Wolpe If a response antagonistic to anxiety can be made
to occur in the presence of anxiety-provoking stimuli so that
it is accompanied by a complete or partial suppression of
the anxiety responses, the bond between these stimuli and
the anxiety response will be weakened.

CBT Techniques
Systematic Desensitization
Most commonly used counterconditioning technique; subclinical fears
Relaxation training
Constructing anxiety heirarchy
Desensitization in imagination
In vivo Desensitization

Imaginal or in vivo exposure heirarchy paired with progressive

muscle relaxation to reduce fear/anxiety

Visualization in vivo training

Aversive Counterconditioning
Addictions, sexual fetishes
Target behavior or conditioned stimulus paired with unconditioned
stimulus that naturally elicits an unpleasant response maladaptive
behavior is avoided
Disulfiram + alcohol consumption = physical ilness reduce
drinking behavior

CBT Techniques
Covert Sensitization
Imagining an aversive condition while imagining engaging
in maladaptive behavior
Habit Reversal
Trichotillomania, Tourettes syndrome, Tic disorders
Awareness training
Training in an incompatible competing response
Social support

COGNITIVE BEHAVIORAL
MODELS AND TREATMENT
FOR EACH DISORDER

ANXIETY
Cognitive Behavioral Model
overestimation of the danger

associated with certain

situations, bodily sensations,
or even thoughts
1) the likelihood of an event
2) the severity of an event
3) one's coping skills and the
availability of help, support, or escape

interpret events from a

negative and therefore

inaccurate perspective
two-factor learning theory
Physiological symptoms,
especially ongoing somatic
complaints, are often the most
common anxiety symptoms in
children

Treatment

Physiological

treatment strategies
Behavioral Treatment
strategies
Cognitive strategies
Combined Strategies

OCD
Cognitive Behavioral Model

Treatment

Intrusive and

Exposure and

distressing thoughts,
impulses, or images
about possible harm
coming to oneself or
others
counterthoughts or
behaviors to prevent
harm or negative
consequences from
occurring

response prevention
(ERP) has substantial
based on models of
classical extinction
CBT alone was found
equally efficacious as
CBT + SSRI - Pediatric
OCD Treatment Study
(POTS)

PHOBIAS
Cognitive Behavioral Model

Treatment

two-factor learning

Graded exposure

theory
breaking the operant
conditioning cycle and
teaching the individual
that the feared
situation is unlikely to
occur again even when
it is not avoided

Systematic

desensitization
Relaxation training

PANIC DISORDER
Cognitive Behavioral Model
fear of impending

disaster, which is
confirmed by
physiological and
cognitive symptoms
misinterpret their
symptoms as
confirmation that their
anxiety represents real
danger MORE ANXIETY
precipitating factor in the
attack is a fear of having
one, rather than a fear of
a specific stimulus

Treatment

cognitive and

physiological
strategies
exposure therapy

PTSD
Cognitive Behavioral Model
Inability to cope with

intrusive, unwanted
distressing thoughts
and memories after a
traumatic event

Treatment

Exposure
Cognitive

restructuring
Relaxation
Anxiety management
training

Alternative set of diagnostic criteria for

preschool-aged
trauma victims (Scheeringa)

1) the individual does not have to be able to report the anxiety

reaction, as many young children are incapable of doing so
2) recurrent recollection of the event may manifest in repetitive
trauma-related play themes
3) recurrent distressing dreams do not have to include trauma-related
content, but must be distressing
4) flashbacks may be behavioral in nature, with no accompanying
verbal description
5) diminished interest in significant activities may present as
constriction of play
6) a feeling of detachment or estrangement may manifest as
withdrawal
7) loss of developmental skills may occur
8) increased arousal may manifest as tantrums and fussiness.

Additional Cluster Of
Symptoms
1) new separation anxiety

2) new onset of aggression

3) new fears (e.g., fear of the dark) without

obvious links to the trauma

DSM-5 Criteria for PTSD in

Children

DSM-5 Criteria for PTSD in

Children

DEPRESSION
Cognitive Behavioral Model
intrusive negative thoughts

(e.g., selective ruminations

about past unpleasant
events, hopelessness about
the future, and
helplessness about
improving their situation)
overgeneralization,
catastrophizing, taking
responsibility for negative
outcomes, and attending to
negative features of events
restricted behavioral
repertoires

Treatment

Cognitive

restructuring
Self control strategies
Skills training
Adolescent Coping
with Depression
Course (CWD-A)

AUTISM & PERVASIVE DEVT DISORDERS

Cognitive Behavioral Model
lack of motivation and

learned helplessness

Treatment

Applied Behavior

Analysis (ABA)
discrete trial training
pivotal response training
incidental teaching
Techniques
Prompting
Fading
Shaping
Task Analysis
Backwards Chaining

Behavior plans
Overcorrection

EMOTIONAL & BEHAVIORAL DISTURBANCE

Cognitive Behavioral Model
Coercive interactions
Information Processing

Model

Treatment

Four types of

therapeutic change
Ecological
Operant methods
Medication
Behavioral parent

training

Perspective taking and

social problem solving

Parent management
training (PMT)
Problem solving skills
training (PSST)

ADHD
Cognitive Behavioral Model

Treatment

Inattention, hyperactive,

Pharmacological and

impulsive symptoms
poor self-monitoring and
self-evaluation skills, may
have difficulty with
receptive and expressive
language, and suffer from
associated executive
functioning deficits

behavioral treatments
Programming at home
School intervention
Long-term goal in ADHD
treatment is gradually to
fade the adult control to
child-driven selfmanagement

BULIMIA
Cognitive Behavioral Model
Cognitive distortions
mistaken view that

compensatory behaviors
(vomiting, laxative use,
diuretics, overexercising)
are effective means of
weight control
binge-purge cycle is also
associated with the
antecedent of negative
affect

Treatment

Stages (Fairborn)
Teaching the patient self-

monitoring of eating and

related behaviors
Educating the patient about
eating and weight (physical
effects of binge eating,
information about weight
fluctuation, ineffectiveness
of compensatory strategies,
effects of dieting)
Prescribing a regular
pattern of eating (regular,
planned meals and snacks)
Developing a plan to
address post-meal vomiting
when this behavior is part
of the illness.

ANOREXIA
Cognitive Behavioral Model

Treatment

Cognitive distortions

First goal weight gain

do not believe they have a

Address the lack of

problem
they believe that they are
fat and truly need to lose
weight

motivation of the
patient
Stages (Garner, Vitousek, and Pike)
Stabilization of the

patient's physical health

and building a therapeutic
alliance
Continued emphasis on
weight gain and normal
eating
Progress is summarized
and emphasized

TOURETTE SYNDROME
Cognitive Behavioral Model
role of negative

reinforcement (dissipation
of the urge upon
performance of the tic) as a
contributing factor in the
shaping and maintenance
of tic expression

Treatment

Habit reversal

procedures
Assessment phase
Awareness training
Competing response

training
Social support

TRICHOTILLOMANIA
Cognitive Behavioral Model
hair pulling behaviors are

maintained by a negative
reinforcement paradigm
similar to OCD and tic
disorders, as tension is
reduced when the
hairpulling behavior occurs

Treatment

Habit reversal

procedures
Assessment phase
Awareness training
Competing response

training
Social support

Other Problems
Enuresis night alarm
Encopresis - laxative prescription, dietary changes,

and behavioral methods

Selective mutism - behavioral methods: shaping,
fading (situational & individual)
Stuttering relaxation training