How to Do Cognitive Behavioral Therapy With Young Children
By Robert D. Friedberg, Ph.D.
Originally published in the Brown University Child and Adolescent Behavioral Letter 18(4):1, 6, 2002, April 17, 2002
Cognitive behavioral therapy (CBT) represents an appealing treatment option for clinicians working with children experiencing emotional and behavioral problems. Unfortunately, many therapists may limit their options and eschew CBT with young children due to several misconceptions.
Some therapists think all cognitive behavioral approaches are rigid manualized strategies that fail to consider individual characteristics, developmental level and environmental context. Others contend that CBT requires sophisticated reasoning and logical analysis skills that are beyond the reach of elementary school children. However, CBT presents a robust conceptual framework that permits full consideration of a child's inner world and outer context. In fact, flexibility in cognitive therapy is de riguer.
Additionally, cognitive behavioral procedures are playful, filled with metaphors and can be simplified so even young children can profit from the treatment. CBT can be effective, creative, and user-friendly to children. This clinically focused article describes several innovative CBT techniques—e.g., self-monitoring activities; problem-solving; self-instruction; and behavioral experiments.
Self-Monitoring Activities
The Thought-Feeling Watch is a craft activity that teaches self-monitoring skills. Children create play watches using construction paper, velcro dots, and brass fasteners. They then draw mad, sad, glad, and worried faces at 12:00, 3:00, 6:00 and 9:00 on the watch face. Children set their watch to the feeling they are experiencing or expressing. This gives them a fun way to tell their feelings to therapists and parents and they also learn that like time, emotions always change. Further, once children are skilled in identifying and expressing their feelings, they use the watch as a prompt, cueing them to capture the thoughts accompanying their mad, sad, or worried feelings.
The Thought-Feeling Watch lends itself to several augmentations and applications. Therapists could play a game where the youngster sets the watch to a specific feeling and then role-plays a circumstance where these feelings emerge. Additionally, therapists and children can turn the clock hands to certain feelings and practice coping strategies to manage the dysphoric feelings. Finally, unexpressive children could be instructed to point to the feeling rather than having to say it.
Tracks of My Fears is a self-monitoring task that makes use of a train metaphor for fears and anxieties. Therapists liken anxiety to a train that is barreling out of control. They draw a picture of a train engine and pick a crayon color that best represents the nature of their anxiety. Then, the train goes through several stations (e.g. action, mind, who, where, body, and feeling stations) and children fill out specifics of their anxiety on the Tracks of My Fears worksheet.
Often, psychological concepts such as anxiety are ambiguous and difficult for children to grasp. Drawing a train gives a "face" to anxiety and provides a concrete referent. Therapists also need to know the specific details of youngsters fears and anxieties. Talking about a train visiting different "stations" makes the task more interesting and engaging for children. Tracks of My Fears also teaches children about cognitive, physiological interpersonal, emotional, and behavioral components of anxiety in a non-threatening manner. The train metaphor is particularly handy since it lends itself to other metaphors such as "putting brakes on your anxiety" and "steering your anxiety in the way you want it to go."
Problem-Solving Activity
Mask-Making is an engaging way to guide problem-solving which combines covert modeling and problem-solving into a fun craft activity. It is conceptually similar to superhero modeling used by Kendall and his colleagues (1992). Therapists invite children to choose a hero—e.g. parent, teacher, peer, sports figure, actor/actress, historical figure.
Then, they paste a picture of the hero on a face-shaped piece of cardboard. If a picture is not available, the child might draw their rendition of the hero or simply write the name on the mask. Eye and mouth spaces are cut out and then the card board is glued to a popsicle stick, paint stirrer, or tongue depressor.
Once the mask is made, the problem-solving process begins. The child puts the mask up to her/his face and pretends she/he is the hero facing various challenges. As the hero, the child tries to generate alternative solutions to problems. By donning the mask, the children gain valuable distance from the problems and enjoy the opportunity of thinking about what their hero may do in different situations.
Frequently, this distance prompts greater flexibility and creativity in their problem-solving efforts. Finally, Mask Making helps children not feel like they are in the hot seat when problem-solving.
Self-Instruction Activity
Replace Mint is a self-instructional technique incorporating play, crafts, and metaphors. Habitual, well-practiced negative thoughts are equated to old, worn out dollars that need to be replaced and recirculated. On the other hand, coping counter thoughts are fresh, crisp bills. The task, then, for youngsters is to replace the old currency with the new one. Children write out their negative thoughts on crumpled construction paper and the go to the cognitive therapy "mint" to replace them with coping statements or reattributions written on a new crisp paper.
Replace Mint simplifies self-instruction for youngsters. First, it takes an abstract concept (e.g. substituting coping statements for negative automatic thoughts) and transforms it into a concrete, real experience. The task requires the children to physically turn in the old bill and replace it with a new one. By tying the coping process to a physical act, the practice becomes memorable. When the child has written a coping statement on the crisp bill, she/he has created a coping card for herself/himself. Consequently, the child can use the card outside the therapy office making the treatment more portable.
Red Light, Green Light is a variation of the familiar children's game; children move to the command of Green Light and stop when the Red Light prompt is given. In CBT, it becomes a way to help children identify cognitive, emotional, and physical accompaniments to their anxiety and helps children develop coping skills and self-instructions.
Basically, the game begins with the therapist saying" Green Light," and the children start walking. After the children take a few steps, the therapist shouts, Red Light" and the children freeze in place. The freeze response creates some bodily tension and the therapists asks the youngster to scan their body for signs of tension—e.g., What do your muscles feel like now? Next, the therapist asks the children to compare how their bodies feel now to when they are worried or scared. This experience allows children to see how anxiety may " stop" them in their tracks.
The Red Light, Green Light game also gives children practice applying coping strategies that can help them move forward. For example, at the Red Light command, the therapist works with the children to help them imagine they are in a distressing situation and then guides them in self-instruction that facilitates productive coping. The youngsters literally must think on their feet in order to complete the task and move forward.
Developing creative interventions based on cognitive therapy principles and procedures extends existing clinical practices. If the approach is based on a sound grasp of cognitive behavioral therapy, there are endless inventive methods that can be designed. As they say on ESPN's Sportscenter, "Like gravity on biscuits, it's all good."
Robert D. Friedberg, Ph.D., is at Wright State University School of Professional Psychology.
