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

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Abstract

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.

Introduction

Cognitive behavior therapy (CBT) is widely used with adults and children alike (Beck, 1995) and, after behavior modification, is the most extensively researched child therapy technique (Kazdin, Bass, Ayers, & Rodgers, 1990). Characteristics that account for the popularity of CBT with children are its emphasis on teaching coping skills, promoting self-control, and enhancing self-efficacy (Kendall & Panichelli-Mindel, 1995). It is also the active participation of the child exploring his/her thoughts and beliefs in partnership with the therapist that is one of the key features that sets it apart from its behavioral and psychodynamic counterparts. Within the British National Health Service, its appeal derives from it being goal directed, evidence based, and relatively short term.

There is evidence of the efficacy of CBT with children and adolescents with a range of disorders, such as depression (Harrington, Wood, & Verduyn, 1997), anxiety (Kendall, 1994), and conduct disorder (Kazdin, Siegal, & Bass, 1992). However, the optimum combination of client and therapy variables is, as yet, unclear. In particular, there is uncertainty about the extent to which the age and developmental level of the child interacts with the success of the treatment (Spence, 1994). This is brought into stark relief by the poor long-term prognosis of childhood mental health disorders and the consequent need to develop and test the impact of effective early intervention (Target & Fonagy, 1996).

The search for the appropriate matching of client and therapy variables is complicated by the range of cognitive and behavioral techniques that are combined in different permutations and collectively described as CBT for children and adolescents (Ronen, 1997). There is therefore a question about the relative impact of the different cognitive elements of any CBT intervention and to what extent therapeutic change is cognitively or behaviorally mediated. The significance of this question is most acute with younger children because of their lack of sophistication in cognitive functioning. These effects are most likely to be pronounced in children aged between 5 and 8 years because, in general, these children have a level of verbal ability and independence, which allows for participation in an individual verbal therapy, but a relative developmental immaturity, which may preclude the use of such a therapy. The fact that CBT is derived partly from cognitive theory and therapy with adults raises the question of whether this age group of children does benefit from this therapeutic approach and what role their developmental status plays in this success or failure.

Few authors have discussed the relationship between developmental psychology and CBT with children. However, recently, a small number of authors have attempted to summarize the challenges posed by the integration of developmental and cognitive behavioral approaches Ollendick et al., 2001, Southam-Gerow & Kendall, 2000, Stallard, 2002. Despite the differing focus of each of these reviews, all of these authors conclude that (1) in practice, CBT with children needs to take into account the developmental stage of the child; (2) cognitive behavioral theory needs to be integrated with a developmental approach; and (3) specific areas of concern for CBT in children exist as a result of both children's inability to conceptualize certain issues at certain ages and specific deficits, which may have brought the child to the attention of the mental health service and also preclude or limit their participation in the more complex cognitive aspects of CBT.

Overall, the research evidence suggests that CBT is an effective treatment for childhood internalizing disorders, such as anxiety and depression (e.g., Harrington et al., 1998, Southam-Gerow & Kendall, 2000). There has been little support for the use of CBT alone with externalizing disorders such as ADHD and conduct disorder. Several authors have suggested that broader based treatment strategies may be effective in these groups, including the use of parent training and medication Kazdin et al., 1992, Southam-Gerow & Kendall, 2000. Many of the developmental characteristics of externalizing disorders (e.g., impaired executive function in ADHD, reduced empathy in conduct disorder, see Wenar & Kerig, 2000) may help to explain, from both theoretical and therapeutic perspectives, the reduced effectiveness of CBT within these groups. Executive function has been defined as “a complex cognitive construct that encompasses the set of processes that underlie flexible goal directed behavior (e.g., planning, inhibitory control, attentional flexibility, working memory)”… and it is “…crucial in situations that involve novelty, troubleshooting, multiple constraints or ambiguity” (Hughes, 2002, p. 69). Effective problem solving is therefore significantly impeded by problems with executive function. Individual differences in executive function also parallel individual differences in theory of mind (the ability to attribute mental states to self and others). Indeed, Happe and Frith (1996) suggested that the deficits in social insight observed in children with conduct disorder are similar with the deficits in theory of mind seen in children with autism. It is therefore likely that these specific deficits, which may have been responsible for bringing the child to the attention of clinical services, are also likely to significantly impede their ability to engage with a variety of cognitive operations required in traditional forms of CBT.

For a therapeutic approach to be shown to be effective with a particular age group of children, this paper examines whether its theoretical foundations should be couched in theory and evidence from developmental psychology. This paper will first examine the developmental status of 5- to 8-year-old children in relation to the demands of the cognitive therapeutic process. In the light of this, the theoretical models underpinning CBT will then be evaluated for evidence of the influence of developmental psychology in their construction. Finally, the outcome literature will be reviewed for indications of the efficacy of CBT with specific reference to this age group. Conclusions will then be drawn about the developmental appropriateness and clinical usefulness of CBT with young children, incorporating some recent findings from cognitive developmental psychology, which can inform specific aspects of CBT practice with children.

Section snippets

Do young children have the cognitive developmental capacity to use CBT?

Developmental psychology reveals a detailed understanding of the evolving, interwoven strands of the physical, emotional, and cognitive abilities of the developing child, making it possible to identify the particular cognitive capacities of younger children in relation to the demands made by the CBT process. This review is specifically targeted at early school-aged children because they have been shown to be underrepresented in the CBT outcome literature. Furthermore, existing review articles

The role of cognitive development in the therapeutic process

To assess the cognitive requirements made on young children by a CBT approach, it is necessary to provide a general description of its theory and practice. Cognitive therapy is based on the assumption that irrational or maladaptive cognitive schemata (attitudes and beliefs), cognitive products (thoughts and images), and operations (processing) influence problematic behavior. The aim of therapy is to help the child to identify possible cognitive deficits and distortions, to reality-test them,

Evidence of a developmental perspective in cognitive models underpinning therapeutic approaches

The basic assumption underlying cognitive therapy is that psychopathology is an indication of either distorted or absent cognitive products, schemata, or operations (Spence, 1994). There is a relatively large evidence base for this in the adult clinical domain compared with the child literature DiGiuseppe, 1989, Urbain & Kendall, 1980, which brings into question the origin of this assumption. Have the models underlying cognitive behavioral approaches to therapy with children taken the complex

The efficacy of CBT with young children

Problem-solving skills training, SSM, social perception skills training, self-control training techniques, and cognitive restructuring with children are the most common cognitive techniques reported in the literature and invariably used in some combination, always including behavioral techniques (Spence, 1994). A close examination of outcome studies using these techniques with children aged between five and eight would provide strong evidence in the developmental debate, although the

Attempts to integrate cognitive developmental level into CBT

Contemporary cognitive therapists have responded to the criticism that CBT has failed to recognize the mediating role of developmental level in the success of CBT, with the argument that young children are constantly learning skills and knowledge and are therefore quite able to learn the lessons CBT has to offer and benefit from its use DiGiuseppe, 1989, Ronen, 1992. It is suggested that treatment goals and concepts be modified to use less complex, verbally based techniques that examine

Conclusions about the efficacy and developmental appropriateness of CBT with young children

Theoretical models underpinning CBT with children fall into two groups: the cognitive deficit and the cognitive distortion models. The latter has not considered developmental issues, being derived from adult theories. The former group has paid some attention to the normal development of cognitive skills and has consequently produced applications that are more successful with children. However, it remains unclear how these deficits develop over time, what relationship they have to the

An alternative approach?

Psychodynamic or client-centered play therapy approaches to working with young children have models that are based on developmental theories, and these may offer viable alternatives to CBT for this age group. These approaches are reported to be more widely practiced than behavioral and cognitive behavioral treatments (Target & Fonagy, 1996), and there is much anecdotal evidence of their positive impact on children and adolescents. However, drawing conclusions about the efficacy of

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