New developments in CBT with children and adolescents Robert D. Friedberg, Ph.D., ABPP Penn State University Milton Hershey Medical Center April 3, 2009

KIDS Kids! I don't know what's wrong with these kids today! Kids! Who can understand anything they say? Kids! They are so ridiculous and immature! I don't see why anybody wants 'em! Just you wait and see Kids! They are just impossible to control! Kids! With their awful clothes and their rock an' roll! Strouse and Adams, 1963 Kids from Bye, Bye Birdie

Agenda Established and growing areas of application Renewed interest in the working alliance Increased emphasis on the role of emotion Increased focus on family system and application to family therapy Expanding uses of group CBT

Established areas of application Depression Adolescents Coping with depression course (Clarke, Lewinsohn and colleagues) http://www.kpchr.org/public/acwd/acwd.html TADS https://trialweb.dcri.duke.edu/tads/manuals.html Brent and the Univ of Pitt group http://www.wpic.pitt.edu/research/Tordia/Default.htm Children ACTION program (Stark et al.)

Anxiety spectrum Generalized Anxiety Social Anxiety Separation anxiety Kendall (Temple University) Coping Cat http://www.childanxiety.org/ Social Anxiety Kendall Coping Cat Albano (Columbia U) Masia-Warner and colleagues (NYU Child Study Center) http://www.aboutourkids.org/ Separation anxiety

Anxiety spectrum contd OCD March and colleagues (DUKE) http://www2.mc.duke.edu/pcaad/pcaad_march.htm Piacentini and colleagues (UCLA) http://www.semel.ucla.edu/caap/ Franklin and colleagues (U PENN) http://www.med.upenn.edu/ctsa Storch and colleagues (University of South Florida)

Disruptive Behavior Disorders Incredible years program (ages 2-10 yrs) (Webster-Stratton and colleagues) Group anger control training (Chill out Program) Feindler and colleagues (Long Island University) Coping Power (Lochman and colleagues, University of Alabama) Problem-solving skills (Kazdin, Yale University)

Expanding areas PTSD Bipolar Depresion PDD Trauma-Focused Cognitive Behavioral Therapy (TF- CBT) (Cohen & Mannarino, University of South Carolina) http://tfcbt.musc.edu/ Bipolar Depresion Fristad and colleagues (Ohio State University) PDD Atwood and colleagues Wood and colleagues (UCLA)

Renewed focus on the treatment relationship Creed and Kendall (2005) Collaboration is key Patients preferred a “less formal” stance by the therapist Shirk and Karver (2003) Rapport may be more important to children with externalizing disorders than children with internalizing disorders Karver et al. (2006) Collaboration with parent and child increased positive outcome

Emphasis on emotion Necessary for self-monitoring (Burum & Goldfried, Ehrenreich et al., 2007) Fundamental for developing adaptive responses (Zeeman et al., 2006) Pivotal for increasing interpersonal perception ad social skills (Burum & Goldfried, 2007) Poor emotional awareness pervades anxiety, depression, and eating disorders (Sloan & Kring, 2007)

Emotion in CBT Emotional arousal in session creates new action tendencies (Barlow, 1988) Emotional arousal in fundamental in exposure treatment (Barlow et al., 2004) Emotionally focused CBT help patients free themselves from “holds old habits place upon them ( Samilov & Goldfried, 2000, p. 380) Emotion in CBT facilitates transfer of learning Consistent with the state-dependent learning hypothesis

Family CBT Appreciates the fact that children and adolescents are embedded in a systemic context There is a reciprocal relationship between members in the system. Therefore the child is not sole target of the session Recognizes the family contribution in the development and maintenance of the problem behavior as well as the potential role in change Emphasizes the central role of cognition The most effective and efficient path toward change is through cognitive restructuring, behavioral rehearsal, and performance attainment

FCBT Parents of depressed and anxious children tend to display overprotective, overcontrolling, and/or hostile behaviors (Rapee, 1997) Greater parental involvement increases the probability of increased tx outcome in depression (Clarke et al) FCBT outperformed ICBT when both parents had anxiety disorders (Kendall et al., 2008)

Group Cognitive Behavioral Therapy Accomodates greater number of pts Represents a social learning lab Includes a peer modeling, feedback, social comparison Promotes universality; decreases social isolation

Group applications Anxiety Disruptive behavior PTSD with victims of crime and violence (Silverman & Berman, 2000) Social anxiety SET-C (Beidel, 2006) Group CBT (Albano) Disruptive behavior Chill out program (Feindler et al) Coping power (Lochman) Positive Adolescent Choices Training (PACT) (Hammond, 1991)