Hi All,

sharing details of a webinar on Child Psychiatry Therapies organized by Sri Ramachandra Hospital on 15^th Aug 2020 at 6:30 pm to 8:30 pm, which was free of cost. There were two speakers who spoke on two different topics, in this post you will find the details of the session conducted by Dr Poongodi Bala. She is a Visiting Consultant – Child and Adolescent Psychiatrist, SRIHER(DU), Chennai. Her topic was

Cognitive Behavioral Therapy (CBT)

INTRODUCTION

• Aaron Beck developed CBT (Cognitive Behavioral Therapy). Schemas are core beliefs, which are developed from our early experience; it determines our emotional state and behavior. Thoughts are connected with Schema
• Cognition > Behavior
• Thoughts > Behavior > Feeling (Triad)
• Padesky’s five factor model i.e. Thoughts > Feelings > Behavior > Physical reactions > environmental factors

CBT IS DIFFERENT IN CHILD PSYCHIATRY ?

• No
• Same techniques for both adult and child is followed, however it is modified according to the age level.
• Usual communication skills with kids based on their age level is used.
• May use stories, pictures and drawing
• Name it as, “Secret Problem”, “Villan”, “Enemy” instead of calling it as bad thoughts, troublesome etc.

SUITABILITY OF CBT

• Age is prescribed as above 7, however as long as the child is able to understand their thoughts, and its relationship between thought and behavior, they are eligible. Studies have shown that CBT has been used in Trauma based therapies from the age of 3 itself which has shown improvement.
• Normal IQ – It should be normal or borderline, so that they are capable enough to understand.
• No acute Psychosis
• Willingness to attend sessions – CBT cannot be done within one session, it require few sessions in order to be effective.
• Not Suitable for Learning Disability kids, as they will not be able to understand the difference between thoughts and behavior.

CBT USED IN

• Depression
• Anxiety
• OCD (Obsessive Compulsion Disorder)
• Behavioral Problems
• Anger Management
• Tics
• Emerging Personality Disorder
• Self Harm
• Addiction
• Relationship Issues
• Eating Disorder
• ADHD Behavioral problems (In elder children having ADHD, it can be used to understand the impulsivity, to make them control it)
• ASD with anxiety (For ASD kids who are not having intellectual disabilities, we can use it for managing social anxiety)
• Psychosis (Once symptoms controlled) – It can be used to reduce the severity of hallucinations and delusions.

CBT IN CHILDREN HELPS TO 

Control

• Self-defeating thoughts
• Impulsivity
• Defiance
• Tantrums

Improve

• Self-image
• Coping mechanisms
• Problem solving skills
• Self control

CBT SESSIONS ARE

• Structured – 1 hour, Weekly, 6-12 sessions (Normally one hour sessions, for children it is flexible say 30 mins, based on her clinical practice it was not possible for all of them to be present for 6-12 sessions, even attending 2-4 sessions can make them feel the change)
• Time Limited
• Collaborative – Both therapist and client
• Problem Oriented – Focus on Solving problem
• Focus on present and future (It does not focus on the past)

TYPES OF CBT

• Brief CBT – Typically it requires 4-8 sessions, in her clinical experience she always uses this model, most of the children and adolescents struggle to come for regular therapies due to the academic, extra curricular and official commitments. Especially areas like anxiety, phobia related and OCD areas, CBT can be really helpful. Even 2-3 sessions would be really helpful.
• Cognitive Emotional behavior therapy – It is same as CBT but the focus is more on the emotional behavior like emerging personality disorder, anger issues, etc.
• Computer based CBT – There won’t be a therapist, the sessions are programmed. Available in western countries. They will attend weekly sessions, submit assignments at the end of it like self learning model.
• Complement other therapies – IT can be used to complement other therapies like psychotherapy and family therapy etc.

CAN BE OFFERED AS AN

• Individual (It can be an one to one session in genera)
• Parent – Child (In case of a child parent to be included, so that what is being done in the therapy is told to the parent who can observe the child at the home when practicing those skills))
• Family Based – For behavioral problems family therapy is suggested
• Group – For kids with anxiety and depression, group therapies are more effective.

CBT TECHNIQUES

• Exposure response prevention – It is useful mainly in OCD patients, the child is exposed to a fearful stimulation. For example, a child has an OCD for excessive washing of hands whenever he touches a dirty surface. We will ask the child to touch a dirty surface, where he is now exposed to the fearful stimuli, now we are stopping or preventing the child from getting his hands washed for few minutes. By doing this, the child can now learn that he can wait for some more time without washing the hands immediately, it is not that bad.
• Systemic desensitization – It is mainly used in social phobia and social anxiety. For example, a child is having a spider phobia we have to do step by step. First week, we will talk about the spider to the child, then we would ask him to imagine it, next week we would show the picture of the spider and next week we would show the video of the spider and in the following week we would expose the children to the real spider. This is a step by step process. She prefers this model.
• Flooding – It is an exact opposite to systemic desensitization. The child will be exposed to the spider with the assistance of therapist initially. In case of anxiousness in the child, relaxation therapy needs to be done. In her clinical practice she has not done this flooding, as it may affect the rapport with the patient.
• Aversion therapy – It is used for addiction like smoking. Every time the adolescent has the thought of wanting to smoke, we will give some punishment like pinching etc.
• Relaxation therapy – Any relaxation techniques like mind body relaxation, breathing relaxation can be taught to them.
• Play therapy – For younger kids, we use boy or girl toys, family structure toys, emotional toys etc can be used to create a scenario like a child’s scenario and teach through stories.
• Trauma Focused – It is mainly used for PTSD, in this we are only focusing on the previous Trauma.
• Modeling – For children who has difficulty in understanding a concept, the therapist or a staff can be a role model and act in few scenarios to understand it.
• Restructuring – When the child is having negative thoughts, we are trying to change the negative thoughts to positive thoughts
• Exposure

HOW EFFECTIVE IS CBT

• Meta-analysis showed 60% of children with anxiety symptoms showed improvement with their symptoms
• ADHD symptoms severity reduced with CBT, mainly the impulsivity.
• Systematic review showed that 63% reduction of depressive symptoms in adolescents
• Effective for children aged 3 and 18, Trauma focused CBT for PTSD

HOW DOES IT WORK 

• Help clients to review their thoughts as just thoughts and not as facts (When someone says they are useless there is no evidence to it, we are making them to understand this is your thoughts and not fact. In some cases, the thoughts can be true, in that case we have replace it with positive thoughts.)
• It helps them to understand their rumination in case of OCD diagnosis

BASIC RULES

• Active – The client must be involved in therapeutic process, not an observer, should be an active participant and a key person
• Motivational – Therapists need to take responsibility of motivating the client towards change in behavior and thinking. They also need to setup formats and rationale for the client to consider a change of value and thinking.
• Directive – Therapists need to develop a treatment plan and help the client to understand and actively participate into it.
• Non Judgmental – The therapist should avoid giving advice.

COGNITIVE DISTORTIONS 

We need not explain all the types of cognitive distortions to the child, but we need to explain about the distortion that is relevant to them.

• All or Nothing – Either they believe everything is good or everything is bad. Like a black and white thinking , there is nothing in between or there is no midway/middle ground. For example, always mummy is bad and always daddy is good.
• Over generalization – If the child fails in one exam, he thinks that he would fail in all future examinations that he is going to appear.
• Filtering – If the child gets only 60% of the marks in one subject and in all other subjects he has scored 90%, the child will only focus on the negative i.e. the subject in which he scored 60% marks, forgetting about the good marks he scored in all other subjects.
• Jumping to conclusion – when they appear for examination, as soon as they see the question paper they would come to a conclusion that it is either an easy one or a difficult one.
• Magnification or minimization – This webinar if interrupted due to internet once, I may feel at the end that this particular webinar did not go well, which is a one single instance, it means Magnification. If I had interruption 10 times, but still I feel like I did well, that is called Minimization.
• Personalization – When the child is punished for not doing homework, child things that the parents do not love him. Based on one incident, they take it personalized that no body loves them.
• Always being right – Some people are of the opinion that they are always right and there is no chance of them going wrong.
• Labelling – That person is cranky etc…
• Catastrophizing – Thinking always about the worst case scenario, i.e. nothing is going to work for me, I have no future, I want to die.
• Magical thinking – It is related to astrological belief. I am going out for visa interview, but a cat crossed in front of me, so the thinking is formed that just because the cat has crossed his visa would be rejected. There is no logic attached to it.

NATs (NEGATIVE AUTOMATIC THOUGHTS)

• Core component of CBT
• Helps to change clients relationship to own thoughts by encourage them to scrutinize them
• Depressed and anxious patients may have very distressing content to thoughts
• Assumptions

CHALLENGE THE NATs

• How do I know this NAT is true? (Child says i am worthless to my parents, we should challenge the child and ask how do you know that? Mom might have said it only once, but she would have praised the child million times, we need to bring the positivity to challenge it)
• Is there any evidence? (In some cases there will not be any evidence to prove the negative thought)
• What other information do I need to make a more reasonable conclusion?
• Can I see any problems with my reasoning here?

NEGATIVE COGNITIVE TRIAD

• Self – I am useless
• World – Nothing ever goes right for me
• Future – Life is hopeless

SCHEMA

• NATs are thought of as being driven by underlying schema
• Schemas are core beliefs which are developed from our early experience
• Schema is a fundamental organizing principle we use to understand, explain and predict the world.
• It arises from childhood experience
• “I am worthless”, If the child was told constantly he/she is useless, he/she can’t study.
• This will cause NATs in the future

SAFETY BEHAVIORS and AVOIDANCE 

• Safety behavior – An Action taken in a fearful situation with the aim of preventing harm. Eg. Compulsion in OCD, Rumination in GAD
• Avoidance – Any action undertaken with the intention of preventing an anticipated outcome. Eg. Avoiding going out in social phobia.

INITIAL ASSESSMENT

• First Day – Introduction of the assessor and their role
• Confidentiality
• Discuss the purpose of the assessment, goals and anticipated outcome
• You have background information
• List the problems (as hierarchy)
• Set the goal

MEASUREMENT

Even though the child is undergoing CBT and having improvement, but they have denial in accepting it. So we have to show them the improvement.

• Mood diary (1 to 10)
• Self Questionnaire
• RCADES, SMFQ, SDQ, HADS, CY-BOCS, PSS, SCARED
• To be done – Start, Middle and end of therapy – Have the questionnaires scores in the beginning of the session, middle of the session and end of the session, so that you can show the difference and let them identify how much they have improved.

RISK ASSESSMENT

• Self-harm, suicidal ideation
• Protective factors
• Risk factors
• Shared plan of action – discuss
• Vulnerable time for future

SMART MODEL

• Specific
• Measurable
• Attainable
• Relevant
• Time Based

GOAL SETTING

• What small steps would take you closer towards your goal?
• How long will it take to achieve it?
• What would be the first sign of progress?
• If it was your friends goal, what advice would you give him/her?
• Can you break your goals down into smaller steps?

HIERARCHY

• List the problems
• Grade the severity of the problem from 1to 10
• What is your main problem right now?
• Focus on the less severe problems first, because successful rate is higher in this case. So that the child gets the confidence that he/she can do it, then we can move on to the higher severity problems.

HOME WORK

• Set of assignments given by therapist to patient in every session
• Core part of CBT
• Opportunity to practice CBT skills
• Clinicians should write clear instructions
• Instead of using terms like “homework, assignment” use words like “small task, I want you to write something”
• Review it at the start of the next session and encourage it

FORMULATION

• Shared explanation of the problem
• Adaptation of cognitive ability, developmental stage and culture of the client.
• Can be disorder specific or generic

Should contain

• Problem lists
• Dysfunctional beliefs
• Maintenance factors
• Emotional State
• Behaviors

DIAGNOSIS VS FORMULATION

Diagnosis tells us the nature of the person’s difficulties. Formulation is a way of generating testable hypothesis about presenting problems. Clinician and client should generate maps of the presenting problem and look for evidence to support or disprove it.

RELAPSE PREVENTION

it helps in future occurrence of issues, even though they are now adjusted to the current anxiety, they have face a new anxiety in future, so we have tell them the below:

• Core principle of CBT
• Giving patients the skills to go and manage their mood themselves
• To be done at the end of the last session
• Encourages the patient to do it themselves
• Identifies trigger for relapse in future
• Identifies symptoms and signs
• Identifies NATS and behaviors
• Identifies coping skills E.g. What useful behavior should you start?

BOOSTER SESSIONS

• Should be done after few weeks of completing the therapy
• They remind the patient of successful strategies and where things have not gone well, to plan for the future.

CASE STUDY

Patient A is a 10 year old boy who lives with his parents (both are working). He is in 5^th std. He is diagnosed with generalized anxiety. He has been referred to CBT.

Suitability

He is suitable to receive CBT because:

• He has a diagnosis of mild generalized anxiety
• There was no active psychosis
• He is motivated to attend CBT
• He is willing to attend weekly sessions

List the problems

He listed his difficulties as below:

• Can’t go upstairs on his own
• can’t go to his neighbours house on his own
• Can’t stay on his own at downstairs at his house
• Can’t go to the toilet on his own

Goals

• To go upstairs on his own
• To go to his neighbours house on his own
• To stay downstairs on his own
• To go to the restroom on his own

Hierarchy

4) To go to his neighbours house on his own

3) Going upstairs on his own

2) Staying alone downstairs

1) Going to the restroom alone

SMART Goal

Goal: Going to the toilet on his own

• S – Going to the toilet
• M – Yes, doing activity card daily
• A – Yes
• R – Yes
• T – 7 Days

TFB

• Thoughts (Someone might be there in the restroom)
• Feelings (Anxious)
• Behaviors ( asking mum to come with him)

Formulation

• Situation – Going to restroom
• Assumption – Someone is there
• NAT – I don’t want to go on my own
• Self Image – anxious and sweaty
• Safety behavior – ask mum to come with him

Challenging NATs

• What is the evidence that someone is there in the rest room? – Ask the child what is the evidence that there is someone inside the rest room.
• Has any incident such as some unknown person being there ever occurred before? – Have you see any person inside the restroom before
• How many times was this person there?
• If yes, how are other family members using the restroom?

Homework

• First day – He should go to restroom and comeback with in a minute while his mom stays outside
• Second day – Stay inside the restroom for 2 mins, increase the time duration progressively
• Continue this for following days but the mom should not wait outside for him. The number of days depends on the severity of the symptoms, few children can do it in few days, few would take months to do it.
• Make a note of it in a diary.

MY PERSONAL FEEDBACK

Dr Poongodi Bala, went through the presentation in a very detailed manner, she spoke loud enough ensuring that she is audible with clarity to everyone. She did not miss any bullet point, covered every word mentioned in the deck. The presentation was structured and had a proper flow which made it easier to understand. I have got a reasonable idea now, on how a psychiatrist approaches an issue using CBT and the reasons behind their actions. Some concepts shared by her are very interesting even for a novice like me, i am sure this session must have been beneficial to many.

Regards,

Karthik and Saranya

Karthiksaranyaparents@gmail.com