Is cognitive behavior therapy developmentally appropriate for young children? A critical review of the evidence

This paper questions the extent to which developmental considerations have been incorporated into the theory and practice of cognitive behavioral therapy (CBT). It focuses on children aged between 5 and 8 years because Piagetian developmental theory places them at a prelogical cognitive level, and thus, the use of a therapeutic approach that is based on a rationalist paradigm would be considered inappropriate. The cognitive demands made upon 5- to 8-year-old children by CBT are outlined, and the current developmental literature is reviewed in the light of this to evaluate the cognitive abilities of this age group. The models underpinning CBT are examined for evidence of the influence of developmental psychology, and the outcome literature of CBT techniques is then scrutinized to evaluate the efficacy of these techniques with young children. Conclusions are reached regarding the appropriateness of current cognitive-behavioral approaches with young children, and the implications for alternative approaches are briefly considered.     

Using Family‐Based Exposure With Response Prevention to Treat Obsessive‐Compulsive Disorder in Young Children: A Case Study

Cognitive‐behavioral therapy (CBT) using exposure with response prevention (ERP) is the treatment of choice for obsessive‐compulsive disorder (OCD); however, developmental modifications should be considered when treating young children. This article presents a case study illustrating family‐based CBT using ERP with a 7‐year‐old boy. The delivery of ERP for this case was guided by 3 main principles: (a) family involvement with a focus on reducing family accommodation, (b) understanding the functional relation between the client's obsessions and compulsions, and (c) creating conditions to facilitate habituation during exposure. Outcomes for this case indicate significant improvement in functioning and OCD symptoms. Results highlight the importance of family involvement and the applicability of using a function‐based habituation framework when delivering ERP to this unique population.     

Cognitive‐Behavioral School‐Based Interventions for Anxious and Depressed Youth: A Meta‐Analysis of Outcomes

A meta‐analysis of school‐based interventions for anxious and depressed youth using QUORUM guidelines was conducted. Studies were located by searching electronic databases, manual effort, and contact with expert researchers. Analyses examined 63 studies with 8,225 participants receiving cognitive‐behavioral therapy (CBT) and 6,986 in comparison conditions. Mean pre–post effect sizes indicate that anxiety‐focused school‐based CBT was moderately effective in reducing anxiety (Hedge's g = 0.501) and depression‐focused school‐based CBT was mildly effective in reducing depression (Hedge's g = 0.298) for youth receiving interventions as compared to those in anxiety intervention control conditions (Hedge's g = 0.193) and depression intervention controls (Hedge's g = 0.091). Predictors of outcome were explored. School‐based CBT interventions for youth anxiety and for youth depression hold considerable promise, although investigation is still needed to identify features that optimize service delivery and outcome.     

Emotion regulation as mediator of treatment outcome in therapy for deliberate self‐harm

This study presents the outcomes of mediator analyses as part of a randomized controlled trial of Cognitive‐Behavioural Therapy (CBT) for young people who engage in deliberate self‐harm (DSH). The study involved 90 people, aged 15–35 years, who were randomly assigned to CBT in addition to treatment as usual or to treatment as usual only. The findings showed that changes in DSH were partially mediated by changes in emotion‐regulation difficulties, particularly difficulties with impulse control and goal‐directed behaviours. In addition, the potential mediating role of symptoms of depression, anxiety and suicidal cognitions was examined. Although the CBT intervention significantly reduced depression, anxiety and suicidal cognitions, these measures of symptom severity did not play a mediating role. These findings suggest that interventions for DSH should not primarily focus on mental disorders associated with DSH, but should be DSH‐specific and should target specific emotion‐regulation difficulties. Copyright © 2008 John Wiley & Sons, Ltd.     

Cognitive‐behaviour therapy with youth: advances,challenges, and future directions

Cognitive‐behavioural therapy (CBT) is one of the most widely‐researched therapies for children and adolescents. In this paper, the general tenets of CBT are described, followed by a review of the treatment outcome literature. Overall, there is strong empirical support for CBT with internalizing disorders such as anxiety and depressive disorders whereas more moderate empirical support exists for CBT with externalizing disorders such as attention‐deficit hyperactivity disorder and conduct disorder. The relative efficacy of individual, family, and group forms of CBT is also examined. Finally, future directions for research on CBT are discussed, including (a) determining the focal person(s) of treatment; (b) the importance of field effectiveness trials; and (c) the integration of CBT with other approaches (e.g. function analytic techniques, acceptance‐based approaches). Copyright © 2000 John Wiley & Sons, Ltd.     

The use of mindfulness in obsessive compulsive disorder: suggestions for its application and integration in existing treatment

Treatment for obsessive–compulsive disorder (OCD) is a standard activity of psychologists, particularly those in Community Mental Health Teams (CMHT). In 2005, NICE published guidelines recommending Cognitive Behavioural Therapy (CBT) with Exposure and Response Prevention (ER‐P) as the evidence‐based psychological treatments of choice. In recent years there have been significant developments within cognitive behavioural theory, including what has been referred to as the ‘Third Wave’. This paper explores the contribution of mindfulness; a practice that has previously been integrated into other CBT models of treatment, to cognitive interventions in OCD, suggesting that in complements both CBT and ER—However it had previously been suggested by Freeston that mindfulness may prevent successful ER‐P by becoming a neutralising technique. Examples of the application of a mindfulness‐based approach are explored (MOCD), including reference to an OCD group run by the author, and areas of potential overlap are identified, in particular thought‐action Fusion. It is concluded that if applied properly, mindfulness not only complements traditional CBT interventions, but could also increase their efficacy and perhaps prevent relapse. Copyright © 2008 John Wiley & Sons, Ltd.     

Cognitive‐Behavioral Treatment of Hoarding in Youth: A Case Illustration

Hoarding in children is associated with more severe ancillary psychopathology, and has poor treatment outcome. At present, there are no empirically established procedures for treating hoarding in youth. The present case illustration is of a 10‐year old child (“Grace”) who presented for treatment with significant hoarding related to academic concerns and additional unrelated symptoms of obsessive‐compulsive disorder (OCD). Grace was treated with cognitive behavior therapy (CBT) primarily comprising exposure with response prevention, behavioral experiments, and cognitive therapy, along with a program of reinforcement delivered by her parents to maintain her motivation for therapy. After 23 sessions and one booster session, Grace's symptoms improved significantly, with gains maintained at 1‐year follow‐up. In addition to the benefits of the specific interventions chosen, the role of therapist–patient/parent alliance as a contributory factor for good outcome is emphasized. As hoarding is underinvestigated in youth, suggestions for further investigation are offered.     

Problem‐maintaining circles: Case illustrations of formulations that truly guide therapy

The cognitive behaviour therapy (CBT) emphasis on treatment relevance in assessment, and on evidence‐based intervention, has led to an increasing focus on problem maintenance factors (vs. precipitants) in both its models of psychopathology and in its individual case formulations. This article describes the reasons for this growing focus, and presents a generic CBT model based on the functional analysis of “problem‐maintaining circles” (PMCs) of causes. Some samples of the profuse literature implicating PMCs in many psychological disorders are presented, and the utility of PMC‐based functional analysis, case formulation, or modelling of psychopathology is advanced, not only as a guide to selection of therapeutic interventions, but as an alternative to standard psychiatric diagnosis. A sampling of a taxonomy of such PMCs is presented. And finally, the clinical application of PMC‐based functional analysis, case formulation, and treatment selection is illustrated in five case illustrations drawn from a recent clinical caseload.     

Psychological Treatments for Provoked Vestibulodynia: Integration of Mindfulness‐Based and Cognitive Behavioral Therapies

Provoked vestibulodynia (PVD) is a chronic and distressing genital pain condition involving sharp pain to the vulvar vestibule with lifetime prevalence as high as 12%. PVD is the most prevalent cause of pain during sexual intercourse (dyspareunia) in premenopausal women, and gives rise to considerable sexual and relational concerns. As intercourse for women with PVD is either painful or impossible, PVD has pronounced negative effects on women's romantic relationship adjustment and sexual intimacy, as well as their emotional well‐being and sense of sexual self‐efficacy. Given the low efficacy and high side‐effect profile of medications for the treatment of PVD, attention has shifted toward psychological interventions over the past decade. Psychological treatments for PVD have the advantage of targeting both the experience of pain and its many psychosexual consequences, such as reduced desire and arousal. Cognitive behavioral therapy (CBT) currently represents one of the most popular first‐line psychological interventions for PVD. Mindfulness has been increasingly used alongside, or instead of CBT for a variety of health‐related conditions, particularly with respect to chronic pain disorders and more recently in women with PVD. This review provides a detailed overview of CBT and mindfulness‐based approaches in treating PVD.     

Comparing the acceptability of a positive psychology intervention versus a cognitive behavioural therapy for clinical depression

There is growing evidence on the efficacy of positive psychology interventions (PPI) to treat clinical disorders. However, very few studies have addressed their acceptability. The present study aimed to analyse 2 key components of acceptability (i.e., client satisfaction and adherence to treatment) of a new PPI programme, the Integrative Positive Psychological Intervention for Depression (IPPI‐D), in comparison to a standard cognitive behavioural therapy (CBT) programme in the treatment of clinical depression. One hundred twenty‐eight women with a DSM‐IV diagnosis of major depression or dysthymia were allocated to a 10‐session IPPI‐D or CBT group intervention condition. Results showed that both interventions were highly acceptable for participants. Attendance rates were high, and there were no significant differences between conditions. However, the IPPI‐D condition showed significantly higher client satisfaction than the CBT condition. Moreover, acceptability did not differ based on participants' severity of symptoms, regardless of condition. These findings encourage further investigations of the applicability of PPI in clinical settings in order to broaden the range of acceptable and suitable therapies for depressed patients. Key Practitioner Message

• This study sheds light on the client satisfaction and adherence to a positive intervention.
• For participants, positive psychology interventions (PPI) may be more satisfactory than CBT as PPI are framed within a positive mental health model and, consequently, may reduce the risk of stigmatization
• Because acceptability of treatments and preferences may affect the efficacy of treatments, this study provides an excellent opportunity to offer professionals more therapeutic options to tailor treatments to clients' needs and expectations

     

Modified Cognitive Behavior Therapy for Severe,Treatment‐Resistant Obsessive‐Compulsive Disorder in an Adolescent With Autism Spectrum Disorder

There is a high rate of comorbidity between obsessive‐compulsive disorder (OCD) and autism spectrum disorders (ASD). Standard cognitive‐behavior therapy (CBT) protocols have been shown to be less effective in treating OCD in young people with ASD than in typically developing youth. This case study describes the treatment of an adolescent boy with severe, treatment‐resistant OCD and ASD using a modified CBT approach. Modifications to a standard evidence‐based CBT for OCD protocol included extended psychoeducation about anxiety; regular home‐based sessions; and increased involvement of systems, including family and school. Multi‐informant outcome data indicated significant improvements in OCD symptoms over the course of treatment with gains being maintained over a 12‐month follow‐up period. These findings demonstrate the potential efficacy of modified CBT for pediatric OCD in the context of ASD.     

Comparison of therapeutic action,style and content in cognitive–behavioural and psychodynamic group therapy under clinically representative conditions

It is still an open question whether psychotherapists adhere to their therapeutic conceptions in routine practice (clinician's treatment adherence) and thus to what extent the two most common approaches, cognitive–behavioural (CBT) and psychodynamic therapy (PDT), differ from each other as theoretically expected (treatment differentiation). This holds true especially in case of group therapy. The study compares essential process components of CBT and PDT group treatments under clinically representative conditions using non‐participating observer ratings. Results demonstrate that CBT group therapists use more cognitive, behavioural and psychoeducational strategies, foster self‐efficacy to a larger extent and are more supporting and empathetic. PDT group therapists use more interpretative and confrontative interventions and focus on interactional and dynamic aspects. The results strongly support that not only in individual psychotherapy—as shown in prior research—but also in the group setting do CBT and PDT reveal very distinct profiles and that therapists primarily abide by their theoretical training also in clinical practice. They allow one to identify differential process components of the group setting and to trace back parameters of outcome to the process of CBT and PDT for clinical routines. Copyright © 2008 John Wiley & Sons, Ltd.     

Loving‐Kindness in the Treatment of Traumatized Refugees and Minority Groups: A Typology of Mindfulness and the Nodal Network Model of Affect and Affect Regulation

This article discusses how loving‐kindness can be used to treat traumatized refugees and minority groups, focusing on examples from our treatment, culturally adapted cognitive‐behavioral therapy (CA‐CBT). To show how we integrate loving‐kindness with other mindfulness interventions and why loving‐kindness should be an effective therapeutic technique, we present a typology of mindfulness states and the Nodal Network Model (NNM) of Affect and Affect Regulation. We argue that mindfulness techniques such as loving‐kindness are therapeutic for refugees and minority populations because of their potential for increasing emotional flexibility, decreasing rumination, serving as emotional regulation techniques, and forming part of a new adaptive processing mode centered on psychological flexibility. We present a case to illustrate the clinical use of loving‐kindness within the context of CA‐CBT.     

Behavior Therapy for Youth With Tourette Disorder

Persistent tic disorders and Tourette disorder (TD) are neuropsychiatric conditions that commonly co‐occur among youth with obsessive‐compulsive disorder. Although historically managed with pharmacological agents such as antipsychotics and alpha‐2 agonists, behavioral interventions like habit reversal training (HRT) and the comprehensive behavioral intervention for tics have demonstrated considerable efficacy in reducing tic symptom severity. This case study illustrates the implementation of behavior therapy in reducing tic symptom severity of an adolescent with TD. Arlene was a 14‐year‐old girl with TD who presented with moderate tic symptom severity that caused her physical, academic, and social impairment. In addition to concurrent pharmacotherapy, Arlene completed a 20‐session weekly course of HRT, and experienced a clinically meaningful reduction in tic symptom severity and tic‐related impairment. This example provides further evidence of the benefit of behavior therapy in reducing tic symptom severity and highlights key considerations for treatment of youth with TD.     

Intervention fidelity in family‐based prevention counseling for adolescent problem behaviors

This study examined fidelity in multidimensional family prevention (MDFP), a family‐based prevention counseling model for adolescents at high risk for substance abuse and related behavior problems, in comparison to two empirically based treatments for adolescent drug abuse: multidimensional family therapy (MDFT) and cognitive‐behavioral therapy (CBT). Randomly selected videotapes of 109 MDFP sessions, 57 MDFT sessions, and 31 CBT sessions were observationally rated along two key dimensions of implementation: intervention parameters and intervention techniques. Overall, MDFP was similar to MDFT and different from CBT in a manner congruent with its theoretical principles of interactional, systemic intervention. However, deficiencies in parental monitoring and developmental knowledge interventions point the way for continued model development. The utility of fidelity process research for conveying intervention technology along the prevention‐treatment continuum of mental health services is discussed. © 2005 Wiley Periodicals, Inc. J Comm Psychol 33: 191–211, 2005.     

Hypoxia‐induced changes in recovery sleep,core body temperature,urinary 6‐sulphatoxymelatonin and free cortisol after a simulated long‐duration flight

Fatigue and sleep disorders often occur after long‐haul flights, even when no time zones are crossed. In this controlled study, we assessed the effects of two levels of hypoxia (at 8000 ft and 12 000 ft) on recovery sleep. Core body temperature (CBT), a circadian marker, urinary 6‐sulphatoxymelatonin and free cortisol were studied in 20 young healthy male volunteers exposed for 8 h (08:00–16:00 hours) in a hypobaric chamber to a simulated cabin altitude of 8000 ft and, 4 weeks later, 12 000 ft. Each subject served as his own control. Sleep was recorded by polysomnography for three consecutive nights for each exposure. CBT was monitored by telemetry during the three 24‐h cycles (control, hypoxic exposure and recovery). Free urinary cortisol and 6‐sulphatoxymelatonin levels were assayed twice daily between 08:00 and 20:00 hours (day) and between 20:00 and 08:00 hours (night). We showed significant changes in circadian patterns of CBT at both altitudes, suggesting a phase delay, and changes in recovery sleep but only at 12 000 ft. We observed an increase in sleep onset latency which correlated positively with the increase in CBT levels during the first recovery night and a decrease in the duration of stage N₂ (formerly S₂), which correlated negatively with the mid‐range crossing time, a reliable phase marker of CBT rhythm. This study shows clearly the impact of hypobaric hypoxia on circadian time structure during air flights leading to a phase delay of CBT, independent of jet lag and consequences on sleep during recovery.     

Cognitive-behavioral therapy for premenstrual syndrome and premenstrual dysphoric disorder: a systematic review

We systematically reviewed empirical studies that investigated the use of cognitive-behavioral therapy (CBT) for premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD). Our multi-database search identified seven published empirical reports. Three were identified as randomized controlled trials (RCTs). The methods utilized to investigate therapeutic efficacy of CBT in these studies varied widely from case reports to RCTs with pharmacotherapy comparison groups. Initially we provide a brief overview of CBT and justifications for its potential use to treat PMS/PMDD. Next, we provide critical evaluations of the analyses used in each study focusing on the detection of intervention effects assessed by statistically significant time by group interactions. When possible we calculate effect sizes to elucidate the clinical significance of results. Our review revealed a dearth of evidence providing statistically significant CBT intervention effects. Issues such as overall time investment, latency to treatment effects, and complementary and combined therapies are considered. We present a theoretical argument for applying mindfulness- and acceptance-based CBT interventions to PMS/PMDD and suggest future research in this area. In conclusion, to produce the necessary evidence-base support for PMS/PMDD given the limited empirical evidence reported here, researchers are called on to produce methodologically rigorous investigations of psychosocial interventions for PMS/PMDD.     

Let's talk about sleep: a systematic review of psychological interventions to improve sleep in college students

Sleep problems are a common occurrence in college students. Insomnia, nightmares and impaired sleep quality lead to several mental health issues, as well as impaired academic performance. Although different sleep programmes exist, a systematic overview comparing their effectiveness is still missing. This systematic review aims to provide an overview of psychological interventions to improve sleep in college students. Seven databases were searched from November to December 2016 (MEDLINE, EMBASE, PsycINFO, Cinahl, Cochrane Library, PubMed, OpenSigle). The search string included search terms from three different topics: sleep, intervention and college students. Outcome measures included subjective as well as objective measures and focused on sleep, sleep‐related and mental health variables. Twenty‐seven studies met the inclusion criteria. They were assigned to four intervention categories: (1) sleep hygiene, (2) cognitive–behavioural therapy (CBT), (3) relaxation, mindfulness and hypnotherapy and (4) other psychotherapeutic interventions. Fifteen studies were randomized controlled trials. While sleep hygiene interventions provided small to medium effects, the CBTs showed large effects. The variability of the effect sizes was especially large in the relaxation category, ranging from very small to very large effect sizes. Other psychotherapeutic interventions showed medium effects. CBT approaches provided the best effects for the improvement of different sleep variables in college students. Five studies included insomnia patients. The other three intervention categories also showed promising results with overall medium effects. In the future, CBT should be combined with relaxation techniques, mindfulness and hypnotherapy. Furthermore, the interventions should broaden their target group and include more sleep disorders.     

Integrating Between‐Session Interventions (Homework) in Therapy: The Importance of the Therapeutic Relationship and Cognitive Case Conceptualization

Between‐session interventions, or homework, are crucial to a range of psychological therapies, including cognitive behavior therapy (CBT). Therapeutic interventions often involve experiencing emotions and situations, or examining strongly held views about their problems, that clients can find distressing. Hence, the clinician faces a particular challenge in collaborating with the client to carry out these interventions between sessions. In this article, we convey how this process in CBT requires not only a consideration of the theoretically meaningful determinants of adherence behavior but also a sophisticated cognitive case conceptualization. Using case material, we illustrate the interplay between in‐session design, planning, and review of between‐session interventions and the conceptualization. We also include a distinction between generic elements of the therapeutic relationship and CBT‐specific elements. The case material also attends to the person of the therapist, and his or her own cognitive and emotional reactions occurring throughout the process of discussing between‐session interventions.     

Components Analyses of a School-Based Cognitive Behavioral Treatment for Youth Depression

The current study sought to build upon research on cognitive behavioral therapy (CBT) as the first-line treatment for depressed youth by investigating the effects of the various components of a CBT treatment on changes in depressive symptoms in young female participants. Female participants 9–14 years of age (n = 40; M age = 10.58 years) with a diagnosis of a depressive disorder from the CBT-only treatment condition of a larger randomized clinical trial were included in the current study. Participants engaged in a 20-session, 11-week, school-based CBT group intervention (ACTION Treatment; Stark et al., 2006). Depressive symptoms were assessed pre- and posttreatment, and intervention components were coded based on review of audio recordings of treatment sessions. Data were examined using two-level mixed-effects models using hierarchical linear modeling with full maximum likelihood estimation. Results indicated that higher quality behavioral intervention components were associated with greater improvement in posttreatment depression scores, higher quality cognitive intervention components were marginally associated with worsening posttreatment depression scores, and relational intervention components were not associated with depression outcome. Age significantly moderated the relationships between intervention components and depression outcome, with younger female participants benefiting most from higher quality behavioral and relational intervention components. These findings provide preliminary evidence about the differential impact of CBT components on depression treatment outcome for young female participants, with consideration of age as a moderator. This study highlights the importance of continuing to dismantle CBT treatment components for youth depression, as such findings can be used to design more potent, developmentally tailored interventions.