Cognitive and Behavioral Therapies

Mendy A. Boettcher

John Piacentini

Introduction

Cognitive-behavioral therapy (CBT) is the most widely researched and evidence-based form of psychotherapy today. Although CBT technically refers to a group of therapeutic interventions employing an integrated approach to both behavior and cognition, this chapter also covers interventions addressing each of these domains in relatively isolated fashion (behavior therapy and cognitive therapy, respectively; all collectively referred to hereinafter as CBT). CBT can be differentiated from other psychotherapeutic approaches by its historical roots in experimental and learning psychology and ongoing emphasis on experimental validation of efficacy and treatment mechanisms. Over the past decade, CBT has rapidly progressed from a specialized intervention into a mainstream therapeutic approach that is now a mandated part of psychiatric residency training in the United States (1). This widespread acceptance is due in no small part to the fact that CBT is, by design, a problem-based, short-term, and contextually relevant treatment approach.

Background and History

Cognitive Therapy Foundations

Cognitive therapies are based on the notion that it is not events, but people’s interpretations of events, that cause psychological disturbance. As such, therapy from a cognitive perspective focuses on identifying and changing people’s cognitions as a way of changing their feelings and reducing psychological distress.

Behavior Therapy Foundations

When working within a purely behavioral framework, overt behavior is typically the primary concern or symptom. “Overt behavior that one can see” (2) is targeted through a variety of intervention strategies, and behavioral changes are thought to influence thoughts and feelings. Setting concrete goals and measuring specific behaviors is an integral part of this approach and is considered the primary means of evaluating progress and outcomes.

When focusing on overt behaviors in behavior therapy, an emphasis is placed on the determinants of or current influences on behavior (2,3). That is, one does not view the behavior in isolation, rather events leading up to (antecedents) and resulting from (consequences) the behavior are examined and patterns are discerned. This view of behavior is known as the functional perspective and attempts to pinpoint functions that behaviors serve so that intervention can be tailored accordingly. Taking a functional perspective on behavior allows one to understand how certain behaviors are maintained over time. A functional analysis or assessment is performed when variables that maintain a behavior must be identified. This assessment consists of systematically observing or manipulating variables to ascertain antecedents and consequences of specific target behaviors. Analysis of data obtained from a functional analysis/assessment allows one to determine what variables are maintaining the behavior; however, it often does not reveal original causes of behavior. For purposes of behavioral intervention planning, maintaining variables are typically more important than the original cause.

Classical Conditioning

Classical conditioning studies were some of the earliest demonstrations of learned behaviors resulting from manipulation of consequences (4). In these studies, a stimulus (unconditioned stimulus) that elicited a reflexive response (unconditioned response) was paired with a stimulus (conditioned stimulus) that initially would have elicited no response. Over repeated trials, this conditioned stimulus came to elicit the same response as the original unconditioned stimulus. In Pavlov’s (4) classic study, meat powder (unconditioned stimulus) was paired with a bell (conditioned stimulus) to elicit a salivating response (unconditioned response) in dogs. Over time, the bell came to elicit this response even when the meat powder was not presented (conditioned response). It is important to note that, unlike operant conditioning, classical conditioning does not entail the acquisition of a new response; rather it establishes the connection of an existing response to a new stimulus.

The cognitive behavioral approach to therapy dates back to early applications of classical conditioning to phobias (5). In classical conditioning of phobias, phobic stimuli (which were previously neutral) were paired at one point in time with a traumatic event, which then lead to avoidance of stimuli related to that event. This avoidance behavior is said to be classically conditioned because it arose when an inherently fear-producing event became paired with an otherwise neutral event in an individual’s mind. The subsequent avoidance behavior does not allow extinction to occur, such that the phobia is maintained (the person does not allow him-or herself to be exposed to the feared stimuli, so cannot see that the traumatic event will not occur again). For example, if a person is attacked on a street that they walk every day, a previously neutral stimulus (the street) is then associated with a traumatic event (being attacked). If the person avoids that street in the future as a result, classical conditioning has occurred.

The classical conditioning paradigm is often used to explain other phenomena, such as emotional responses, addictions, and psychosomatic disorders. As a result, many treatments for these disorders are based on the notion of classical extinction. Extinction occurs once the connection between the conditioned stimulus and response has been established and the conditioned stimulus is then presented repeatedly without the unconditioned stimulus (the bell is presented without the meat powder). When this occurs, the conditioned response will decay over time because the reflexively reinforcing stimulus is no longer available. So in the case of Pavlov’s dogs, when they are repeatedly presented with the bell without the meat powder, over time their salivating response will decline. Therapy techniques that are associated with classical conditioning and classical extinction include counterconditioning, systematic desensitization, covert sensitization, and exposure and response prevention. These techniques will be discussed in further detail later in this chapter.

Operant Conditioning

Principles of operant conditioning underlie functional analysis and assessment procedures. These techniques are based on the work of B.F. Skinner (6,7), who demonstrated that new behaviors could be shaped through reinforcement (behavior followed by a positive consequence is likely to occur again) and its subsequent removal (when reinforcement is removed, behavior will decline over time).

Principles of operant conditioning are also often used in behavioral interventions. Operant conditioning has been described in the following way: “Responses are increased or strengthened (and thus shaped) by having consequences that are rewarding (positive reinforcement), or that lead to the avoidance of, or escape from, punishment (negative reinforcement); they are reduced or eliminated by sanctions (fines, penalties, etc.) as outcomes”(8). That is, positive reinforcement is the application of a consequence that the individual finds rewarding. Negative reinforcement is the removal of a negative stimulus that results in a positive outcome for the individual. Similarly, punishment is a consequence that decreases the likelihood that a behavior will occur in the future. Positive punishment is the application of negative consequence and negative punishment is taking away positive consequences.

Schedules of Reinforcement

Reinforcement occurs in multiple schedules, which have different impacts on behavior. Schedules of reinforcement are either continuous or intermittent. A continuous schedule is best for initially teaching a new behavior, because the behavior is reinforced each time it occurs. Once the behavior is established, it is best to then decrease the ratio of reinforcers to responses (called thinning the schedule of reinforcement) so that the individual does not become satiated and therefore unmotivated. When thinning a continuous schedule of reinforcement, there are four types of intermittent schedules that can be used. These are: 1) fixed interval (the individual is reinforced on a fixed time interval), 2) variable interval (the individual is reinforced after varying time intervals), 3) fixed ratio (the individual is reinforced after a fixed number of responses), and 4) variable ratio (the individual is reinforced after a variable number of responses). The variable ratio schedule is the most effective schedule when trying to maintain a behavior because it creates relatively high steady rates of responding.

Extinction

Operant extinction occurs when reinforcement that was previously available is withheld in order to decrease or eliminate that behavior. That is, a behavior that was previously followed by positive consequences can be eliminated by withholding those positive consequences. When using extinction as an intervention, it is important to understand the phenomenon of an extinction burst. An extinction burst occurs immediately after removal of a previously available reinforcer. When the reinforcer is initially removed, the individual will engage in the behavior at a higher, more intense rate before learning that the behavior no longer results in reinforcement. Once this learning has occurred, the behavior will gradually decrease. Understanding this characteristic pattern can be very important for intervention, as the initial increase in behavior often leads therapists and patients alike to believe that the intervention is not working. In fact, if the reinforcement is consistently not available during this time, the burst will occur and the behavior will decline.

Many therapy techniques are associated with the principles of operant conditioning. Some common techniques can be found in Table 6.2.2.1.

Therapies that involve multiple techniques based on operant conditioning are applied behavior analysis (ABA) and various
types of behavior management programs, such as parent management training (PMT) (112,147) and problem solving skills training (PSST (2)). These therapies will be discussed in detail elsewhere in this chapter.

TABLE 6.2.2.1 COMMON THERAPY TECHNIQUES ASSOCIATED WITH PRINCIPLES OF OPERANT CONDITIONING

Type and Technique	Description
Reinforcement to Increase Behaviors
Token economy	Reinforcing target behavior with tokens (stickers, points, poker chips) that can then be traded in for reinforcers once multiple tokens have been earned
DRO (Differential Reinforcement of Other Behavior)	Reinforcing specific appropriate behaviors while ignoring inappropriate behaviors that serve the same function
Shaping	Reinforcing gradual approximations of a behavior
Punishment to Decrease Behaviors
Overcorrection	Applied consequence that involves engaging in a series of retribution steps that are related to the inappropriate behavior (washing soiled clothes after toileting accident)
Response cost	Removal of previously earned reinforcers as consequence of negative behavior. Used especially in conjunction with token economy when tokens are removed
Time out	Removing all sources of reinforcement for allotted period of time. Typically involves placing the individual in a location where access to reinforcing activities, including social attention, is not available
Extinction to Decrease Behaviors	Removing previously available reinforcement from an inappropriate behavior to decrease the probability that the behavior will occur in the future

Cognitive-Behavior Therapy Foundations

Behavioral difficulties and other symptoms of disorders often result from a complicated interaction among thoughts, feelings, and behaviors. As such, treatment will often include both cognitive and behavioral techniques. For example, when completing a functional analysis of behavior, it is possible that antecedents and consequences are covert, rather than overt. Covert variables are often internal and consist of cognitions or emotions. As such, thorough analysis of a behavior that involves covert variables will require that the clinician obtain detailed information about the patient’s thoughts and feelings before and after the observable behavior. It has also been noted that while traditional behaviorists believed that changes in behavior result in changes in thoughts and feelings, this relationship can be reversed such that changes in thoughts and feelings results in behavioral changes (2). As such, many symptoms and disorders are more thoroughly addressed by the combination of cognitive and behavioral techniques that is known as cognitive behavioral therapy.

Cognitive-Behavioral Model

Escape or Avoidance Conditioning

Much of cognitive-behavioral therapy is based on an understanding of why negative thoughts and beliefs persist and why behavioral cycles do not get broken over time. For example, it has been proposed that avoidance, escape and safety-seeking behaviors (5) maintain anxiety because the individual does not have the opportunity to disconfirm beliefs by experiencing that the negative outcome does not occur if they do not avoid or escape. Instead, they are lead to believe that they did not experience danger because they made a good decision to avoid or escape. People who do not avoid situations may engage in other types of behaviors (safety-seeking behaviors) that allow them to believe that danger was avoided. For example, individuals who engage in compulsions in OCD are lead to believe that their obsessive thought did not result in a negative outcome because they engaged in the compulsive behavior. Similarly, individuals who “take it slow” to prevent a heart attack in panic disorder believe that they did not have a heart attack because they modified their activity level. In these examples, individuals erroneously believe they prevented the feared situation from occurring by engaging in certain behaviors. Through this cycle, the preventative behaviors are reinforced, which confirms in the individual’s mind that the anxiety was legitimate.

Attention-Related Factors

It has also been proposed that attentional factors play a role in disorders that can be treated using a cognitive-behavioral model. For example, individuals with anxiety disorders, depression, and other disorders that involve disturbance in cognitions often selectively attend to cues that confirm or exacerbate their condition. Individuals with social phobia may be overly attentive to negative cues from others at the expense of positive cues, and individuals with panic disorder may attend closely to bodily sensations, which they then interpret as dangerous.

Cognitive Images

Cognitive images are often examined when viewing a disorder from a cognitive-behavioral perspective. Images of distressing events are common among all individuals; however, in individuals with pathology, these images are interpreted as signs of danger. For example, individuals with OCD may believe that thinking about hurting someone increases the likelihood that it will happen. As a result, they believe that something must be done to prevent the danger. Similarly, in posttraumatic stress disorder (PTSD), intrusive memories may occur frequently and are interpreted as a sign that recurrence of the trauma is likely.

Memory Processes

Similarly, memory processes may play a role as well. For example, anxious individuals may have a tendency to recall
situations that confirm their anxiety, such as a person with social phobia who recalls situations in which s/he performed poorly, but not those where s/he performed successfully. Finally, rumination may perpetuate and enhance fear (5). That is, thinking about an event may lead to the interpretation that the event is more likely to occur. Further, selective attention for negative past events may lead to the perception that they are more likely to happen again in the future. In contrast to some forms of cognitive treatment that involve reliving an event through imagery, rumination does not focus on constructive reprocessing of events. Rather it focuses on elaboration that makes the event more abstract and therefore threatening. For example, an individual with PTSD may persistently ruminate about the event, while asking, “What else could I have done?” without realistically considering the limits of what a person is capable of doing.

Clinical Considerations In Use of CBT with Children and Adolescents

Generally speaking, the patient–therapist relationship in CBT treatment has been referred to as one of “collaborative empiricism” (9,10). This relationship is characterized by a high degree of collaboration and a “scientific attitude” (11) toward testing the validity and accuracy of the patient’s cognitions and behaviors. That is, the cognitive-behavioral therapist typically works as a team with the patient to examine and understand thoughts, feelings, and behaviors. This is done by developing hypotheses about thoughts and behaviors, collecting data on those thoughts and behaviors, examining patterns, and generating alternative, more adaptive, ways of thinking and behaving.

When working with children and families, however, certain factors must be taken into consideration with regard to this model. For example, children may have difficulty reporting on their thoughts, feelings, and behaviors. Further, parent and family thoughts, feelings, and behaviors may influence those of the child. As a result, the following areas are briefly examined with regard to engaging in cognitive-behavioral treatments with children and families.

Developmental Perspective

Adopting a developmental perspective when working with children and adolescents is critical for effective intervention planning. Several developmental considerations are suggested for use when doing CBT with children. First, the child’s level of autonomy and independence must be taken into consideration. This issue is important both in terms of giving older children and adolescents enough autonomy in setting and following through with their treatment goals, and in making sure that younger children have enough support from parents and other involved individuals. As such, it is also important to consider what other individuals or systems are involved in the child’s life and what their role should be in therapy. Further, analysis of how these individuals and other family or systems variables may be maintaining the child’s difficulties is an important clinical consideration as well. That is, families, schools, and other systems may have adapted to a child’s symptoms in ways that actually maintain, rather than decrease, the difficulties. Parent, teacher, and other adult-focused training is often necessary in addition to individual therapy sessions with the child (2). It may also be important to involve such individuals because treatment in the natural environment often produces more rapid and enduring effects than treatment that only occurs during therapy sessions.

Adapting treatment concepts to children’s developmental level is an important part of using CBT with children and adolescents. For example, efforts to address the cognitive biases and distortions underlying a number of psychiatric disorders (e.g., anxiety, depression) can be complicated by the lack of strong abstract thinking skills in most young children. To address this limitation, multiple strategies have been developed to concretize target cognitions and abstract concepts (12). For example, symptoms can be characterized as persona that the child can relate to, such as the “Bad Thought Monster” who must be conquered (13). Similarly, obsessions in OCD can be understood as external and can be blamed on a pesky bug, named “OC Flea” (14), whose ideas must be resisted. Children can also be encouraged to play the role of detective or team up with a detective in testing assumptions and beliefs (13). These types of developmentally appropriate adaptations assist children in understanding concepts that are otherwise verbally explained, which may not be an appropriate treatment vehicle for them.

With very young children, cognitive-behavioral play therapy (CBPT) may be indicated, as it embeds cognitive-behavioral strategies into play-based interactions (15). As young children may have difficulty understanding concepts in CBT, CBPT allows teaching and therapeutic work to occur in play. The primary way in which this happens is through modeling, which has been shown to be effective in teaching new behaviors (16). Many different CBT concepts are modeled with puppets or other toys, such as demonstrating that a puppet gets over his fear gradually the more he enters into a situation. CBPT also involves some adult administration of CBT concepts, such as scheduling activities for a withdrawn child.

Other developmental considerations include the child’s age, language level, cognitive ability, and the intensity, duration, and frequency of the symptoms. It has been suggested that younger children benefit more from behavioral techniques than cognitive ones, especially because they often have difficulty reporting cognitions that accompany symptoms and behaviors. Cognitive techniques that younger children have benefited from include relaxation training, imagery, and positive self-talk. Children over the age of 9 are thought to have increased capacity for reporting and understanding cognitions and may begin to benefit from more sophisticated cognitive aspects of treatment. Each child must be individually evaluated, however, as other factors, such as language level, may cause cognitive techniques to be difficult for older children as well.

Family-Related Factors

The Role of Families and Other Systems in Cognitions and Behaviors

Assessing the child’s symptoms within the context of the family is an important part of treatment programming when using CBT. Because CBT interventions place an emphasis on antecedents and consequences of behaviors, avoidance behaviors that maintain symptoms, and other factors that may be affected by the environment, the role of family and other relevant systems is critical in assessment and treatment planning (17). Depending on the nature of the symptoms, it is likely that others in the child’s life are making accommodations that support and maintain, rather than discourage, the maladaptive behaviors. For example, in a child with OCD, the family may tolerate extensive rituals that interfere with daily routines to avoid having the child engage in a temper tantrum should the ritual be stopped (18). As such, careful analysis of the child’s symptoms within family, school, and
other relevant contexts is critical for CBT treatment planning with children and adolescents.

Parent/Family Involvement in Therapy

Families play a pivotal role in therapy for children in several ways. First, it is often important to have information about family context, and parental cognitions, emotions, and behaviors, to better understand the child’s symptoms within a cognitive behavioral framework. Changes in family routines, dynamics, and discipline practices may be critical in facilitating changes in individual child-focused symptoms (as discussed earlier). Young children, in particular, may need ongoing assistance from parents and other relevant adults to follow through with treatment goals and homework. Moreover, with older children, families may need to learn to allow the child or adolescent to take responsibility for treatment goals and homework, which may require decreasing their level of involvement. All of these issues are important when deciding whether to work with a child individually, a parent individually, or with the child and other family members. Older children and adolescents often attend therapy sessions individually, and parents are informed during the latter portion of the session about session content and subsequent homework to occur between sessions. It is sometimes necessary to work individually with parents, however, especially with young children who are having behavioral difficulties. Finally, the child’s symptoms are often a large source of family stress and parent/child conflict. In these cases, it can be beneficial to work individually with the child and/or the parents. It is sometimes helpful to instruct that parents not remind their child about therapy homework and treatment goals, rather that performance be evaluated by the child and the therapist during sessions. This tactic can be useful in decreasing negative parent–child interactions, especially with adolescents, until symptoms have decreased.

Generalization and Maintenance

Three types of generalization are important to consider in CBT interventions with children. These are a) generalization across settings; b) generalization across functional domains (behavior, cognitions); and c) generalization over time, which is termed maintenance. Generalization and maintenance must be considered with regard to intervention strategies as well as improvements in functioning. That is, for successful change, the patient must use the techniques learned in session across settings, learn to apply them to a variety of domains, and continue to use them over time for as long as necessary. Similarly, when change begins to occur it is important that the change is observed across settings (not just in the therapy setting), that change in multiple domains occurs, and that the change is maintained over time.

Kendall and Lochman (19) propose several strategies for promoting generalization and maintenance of improvements in functioning when using CBT strategies with children. First, they propose rewarding behavior change using attainable goals that are applied across an increasing number of settings over time. These goals should be reinforced in each successive setting, and reinforcement should only be faded when the behavioral change appears stable and lasting. Second, they propose that treatment length is an important consideration in programming for maintenance of changes made in therapy. Specifically, it has been suggested that 6 months or longer may be most effective. It has also been suggested that length of treatment over time may be more important than the number of sessions (20); however, intensity may be an important factor as well (148). Use of behavioral rehearsal (e.g., role playing) to emphasize use of techniques in specific situations has also been proposed as an important mechanism for generalization of skills. That is, once a child has learned the concept of a skill, the likelihood that the skill will be used outside therapy in an actual situation is increased if the child has had opportunities to practice it under low demand, low stress circumstances. Role-plays can then be used to assist the child in refining skills to fit increasingly specific situations. Finally, generalization is promoted when the child is taught skills that apply to multiple behaviors and situations, such as problem solving processes rather than specific behaviors. For example, self-instruction training has been proposed as a means of promoting generalization of skills, especially across settings and behaviors. Because self-instruction training involves having the child learn a series of steps in self-instruction of positive decision-making, this skill is considered more flexible than a series of specific steps that apply to a specific situation. In this way, the child can apply the steps to multiple problems in multiple settings.

Although these techniques may be helpful in generalizing skills across settings and over time, long-term data on such procedures are limited, especially with children. The mean duration of followup data is 5 to 7 months posttreatment (21,22), with little available data to indicate outcomes over longer periods.

Course of Therapy

General Characteristics of CBT Treatment Plans

Some general aspects of treatment are characteristic of CBT regardless of diagnosis, age, developmental level, or other individual qualities, and are important for the patient to understand at the outset of treatment. According to Friedman, Thase, and Wright (11), these are: 1) The patient will be an active participant in trying new strategies; 2) the patient will be expected to complete homework; 3) therapy outcomes will be measured via data collection, and techniques will be modified if they are unsuccessful; 4) therapy will focus on symptoms and daily functioning; 5) therapy will be time limited; and 6) maintenance of treatment gains and relapse prevention will depend on generalization of techniques into everyday life. When working with children, families may need to be incorporated in these treatment aspects. For example, it may be that the child and the parents must be active participants, rather than the patient alone.

The cognitive-behavioral therapies are generally characterized by three phases of treatment. In the initial stage, the nature of the patient’s presenting problem is assessed, rapport is established and psychoeducation (described later) occurs to prepare the patient for the active phase of treatment. Once the symptoms, related variables, and cognitive and emotional characteristics have been identified, a treatment plan is developed. This plan typically begins with psychoeducation of the patient about symptoms, cognitive behavioral understanding of those symptoms, and rationale for treatment. In the middle phase, active treatment occurs, which involves the acquisition, application, and mastery of cognitive-behavioral treatment strategies. This phase involves regular treatment sessions as well as consistent homework. Over the course of treatment, goals and hypotheses about symptoms are reevaluated and modified as necessary on an ongoing basis. The middle phase tapers off when symptomatic relief has occurred and the patient appears ready for maintenance and relapse prevention.
The final phase then focuses on generalization and maintenance of techniques, and relapse prevention. During this phase, the treatment schedule is thinned and the patient assumes greater responsibility for implementation of techniques on an ongoing basis. Finally, as necessary, “booster sessions” may occur after treatment has been completed to ensure that long-term changes are maintained.

Frequency and Duration of Treatment

CBT sessions typically occur once or twice per week in an outpatient setting. Generally speaking, it is important that enough time elapse between sessions for homework exercises to be meaningful. In inpatient settings, sessions may occur as frequently as once per day; however, the severity of illness is generally proportional to the frequency of sessions in such cases (i.e., the child is significantly ill to warrant daily monitoring and practicing of techniques). In general, it is recommended that the therapist decide on a case-by-case basis whether sessions should occur any more than once per week, as with any type of therapeutic intervention.

With some exceptions, CBT typically occurs over a 3- to 6-month period, with some type of tapering period near the final termination of therapy. Using clinical judgment, it is generally recommended that a tapering strategy be used in termination due to the concrete nature of the need for generalization of techniques learned in therapy. That is, once termination has occurred, patients will be required to continue using strategies learned in therapy. Tapering the therapy can be a helpful way to monitor the patient’s success in using the techniques on an ongoing basis over increasing periods of time.

It is not uncommon for patients to require a brief “booster” session(s) after termination has occurred. In such cases, patients’ use of previously learned CBT techniques may have declined, or new unanticipated situations may have arisen that have resulted in a reoccurrence of symptoms. Frequently, patients do not require an additional full course of therapy; rather, they can benefit from one or several sessions to “refresh” their skills or assist them with application of their skills to new problems.

The phases of treatment outlined here each involve specific areas of focus.

Assessment for Treatment Planning

CBT treatment for any disorder must begin with a thorough assessment of the patient’s cognitive, behavioral, and emotional symptoms. Assessments should address detailed information about the patient’s symptoms (chief complaint) and identification of maintaining factors. Normalization of the patient’s problems can be an important therapeutic aspect of the assessment phase, which may lead to immediate symptomatic relief. The goal of this phase should be to develop a cognitive behavioral model of the presenting problem that can be used to guide treatment. Depending on the chief complaint, the initial assessment may include the following types of information:

Descriptions of when the symptoms occur (time, place, circumstances, antecedents, consequences)
Cognitions that accompany each symptom (may be different for different symptoms)
Behaviors that accompany each symptom (also may be different for different symptoms)
Emotions that occur with each symptom (also may be different for different symptoms)
If cognitions and behaviors relieve symptoms, detailed description of how this occurs
Information about factors that help or exacerbate the symptoms
Maintaining variables: avoidance, escape, safety behaviors, attention/focus, dysfunctional/faulty beliefs, automatic thoughts
Overall beliefs (cognitive schemas) that lead to cognitions, behavior, and feelings
Previous treatment and treatment outcome
Onset: including any possible causal factors that are not maintaining factors (e.g., traumatic event in PTSD, negative situation paired with stimuli in specific phobias)

One helpful way of eliciting cognitive and behavioral factors can be to have the patient describe a recent event in detail, while asking pointed and specific questions, such as “What were you thinking when that happened?” or “How did your body feel at that moment?” Sometimes it is difficult to elicit enough explicit information from children and homework is required as part of the assessment phase. Such homework might include writing down thoughts, feelings, and behaviors when certain events occur to gain a better understanding of these variables if the patient has difficulty reporting in session. It might also include having the patient or parent self-monitor frequency of symptoms and associated variables. Once this initial assessment is complete, the patient’s symptoms can be framed and described in terms of a cognitive-behavioral model and treatment can begin with psychoeducation about this model.

Psychoeducation

Cognitive behavioral interventions typically begin with some form of psychoeducation, which often continues throughout treatment. Psychoeducation is particularly important because many of the techniques utilized in CBT are driven by theoretical or empirical underpinnings that, when understood, allow the patient to better grasp why such techniques are being used and how change will occur, thus increasing motivation and followthrough. When working with children and adolescents, psychoeducation often occurs separately for children and their parents. This way, parents can have a more in-depth understanding of their child’s treatment plan and children’s psychoeducation can be developmentally appropriate to their age and cognitive level.

Psychoeducation may be conducted using a variety of procedures. Symptoms and related variables may be explained to individuals, and basic concepts may also be demonstrated. For example, when in the early stages of teaching patients that thoughts do not increase the likelihood of events occurring, behavioral experiments to demonstrate this point may be helpful (e.g., have the patient think about making someone else in the room stand up to demonstrate that the thought does not cause the event to occur). Bibliotherapy and CBPT techniques may also be helpful, with young children in particular, to illustrate concepts and educate about symptoms. These techniques may be particularly useful for young children who are resistant to change, as the focus is initially on the symptoms of the characters in the story or play, as opposed to the patient.

Psychoeducation often covers a variety of topic areas as well. For many disorders it is important to educate the individual about physiological symptoms, which can lead to an immediate reduction in anxiety as they learn that such symptoms are normal and do not represent serious health or physical risk. Education about cognitive symptoms is typically relevant as well, such as teaching a patient with PTSD that intrusive memories are normal reactions to traumatic experiences, or teaching patients with OCD that intrusive thoughts are common in the general population. Education about the connection between
thoughts and events may also be relevant during this phase. Patients who have specific beliefs about the connection between thoughts and events need to begin to learn that such connections do not exist. Thought–action fusion (TAF), an OCD-related phenomenon that is characterized as the belief that thinking about a despicable act is as morally wrong as actually doing it, is one example of the kinds of irrational cognitions that need to be addressed in treatment (23). Behavioral experiments (discussed above) may be helpful when educating about this topic. Psychoeducation may also include identification of past experiences that disprove the patient’s dysfunctional beliefs. Finally, once the patient is educated about symptoms, education about the rationale and plan for treatment must occur. Understanding the connection between the cognitive behavioral model of the symptoms and the rationale for treatment can be particularly important, as it can have an important effect on motivation and followthrough in treatment.

Middle Phase of Treatment

Once assessment and psychoeducation are complete, the middle, and most active, phase of treatment begins. This phase typically involves ongoing active participation in therapy, as well as homework. Homework often must be completed on a daily basis. Goals and content of therapy sessions during this phase will vary widely depending on the chief complaint. Some general CBT techniques commonly utilized during this phase are discussed later in this section. More information about the active phase of treatment can also be found under the discussion of specific disorders. During the active phase of treatment, significant symptom reduction should occur.

Termination and Relapse Prevention

Once symptoms are substantially reduced, therapist and patient must begin planning for termination. This phase of therapy involves concrete planning in several areas when using CBT. First, programming for generalization and maintenance must be considered, as discussed earlier. Ideally, active phase intervention was planned to target generalization of skills. The schedule of therapy sessions is also often thinned during this time to promote maintenance of therapeutic changes with decreasing therapist support. Finally, relapse prevention must be addressed to ensure that changes endure over time. Relapse prevention strategies may include a cognitive framework for thinking about brief relapses (160,161), such as helping patients to identify antecedents to relapse behaviors and to think about them in ways that do not lead to total loss of treatment gains. Another common relapse prevention strategy is the use of “booster sessions.” Should old symptoms return or new ones emerge, one or a small number of sessions is often enough to assist the patient in returning to their termination level of functioning.

CBT Techniques

Cognitive Restructuring

Cognitive strategies are a primary component of CBT interventions (24). Commonly used cognitive strategies focus on restructuring dysfunctional cognitions and intervening on automatic thoughts and their underlying schemas. Automatic thoughts are defined as “cognitions that stream rapidly through an individual’s mind” (25). Such thoughts can be spontaneous or in response to stimuli, a situation, prompt, or other antecedent. Individuals with automatic thoughts typically do not question them for believability. That is, individuals believe that because the thoughts are present they are true or valid. Such thoughts occur with increased intensity and frequency in disorders such as anxiety, depression, and obsessive-compulsive disorder. Automatic thoughts may be valid worries (about events that have or actually could happen) or they may contain cognitive errors or distortions. Common cognitive errors are identified and described in Table 6.2.2.2.

The following cognitive strategies are commonly used to assess and intervene on automatic thoughts and cognitive errors in CBT.

Identifying Automatic Thoughts

Assessment of automatic thoughts does not always rely on interview techniques, especially with children, who may have difficulty understanding and reporting specific thoughts. Techniques such as imagery and role playing can be helpful in identifying automatic thoughts because they set the scene for an event or situation in which specific questions can be asked. For example, when asked to role play a situation, a child can be asked while acting out the scenario what s/he is thinking, feeling, etc. Such exercises are less hypothetical for children, which often helps them generate important information that they cannot report during an interview.

Thought recording is another technique that can be used in a similar fashion. This technique is a form of self-monitoring in which events, thoughts, and feelings are recorded on a daily basis. Self-monitoring is a helpful way to assess automatic thoughts, as it does not rely on recollection of thoughts in a specific situation; rather it requires that the individual record thoughts as they occur or immediately following an event. Although children often require reminders and assistance from adults to keep this type of data on a daily basis, this technique can be developmentally appropriate, as it does not rely on children’s memories to assess cognitions.

Socratic Questioning/Examining the Evidence

Socratic questioning is discussed as an important part of CBT, and one of the main components of cognitive restructuring. This technique involves questioning the patient with the goal of eliciting automatic thoughts and calling their validity into question. During this process, thoughts are considered to be hypotheses, rather than truths, and the patient is taught to determine and evaluate evidence for and against automatic thoughts. This technique is an important way to begin teaching children that such thoughts are not true simply because they occur. This technique may be especially helpful with distorted thoughts because rational consideration of evidence increases the patient’s awareness that such thoughts are not grounded in reality.

Once automatic thoughts have been called into question, the therapist and patient can begin to revise them based on evidence and reality, and generate new coping thoughts that are more accurate. Examining the evidence can be helpful when combined with self-monitoring because it forces the patient to examine the evidence each time they have a maladaptive thought. This repetition is often helpful in changing a patient’s beliefs over time, as s/he is constantly challenging thoughts and generating new coping thoughts throughout the day.

Correct Misinterpretations

Socratic questioning may also be helpful in correcting misinterpretations. Individuals with anxiety and depression
may in particular misinterpret events, the behavior of others, thoughts, feelings, and other stimuli. Calling into question an individual’s interpretation and noting how it impacts thoughts, feelings, and behaviors can be an important aspect of cognitive restructuring as well.

TABLE 6.2.2.2 COMMON COGNITIVE ERRORS TO TARGET IN COGNITIVE RESTRUCTURING

Cognitive Error	Description	Example
Catastrophizing	Placing unrealistic importance on thoughts and events and assuming terrible negative outcomes will occur as a result	“I got a C on my report card, so I will never get into college and I will fail in life.”
Magnifying/ minimizing	Placing an inaccurate amount of importance on thoughts, feelings, events (either too much or too little)	Believing getting caught doing drugs is not important because the implications of having a drug problem are too anxiety provoking (minimizing)
Absolutism (black and white thinking)	All events and experiences are thought of in extreme categories, rather than moderately	“I will never lose any weight because I just ate a cookie.”
Personalization	Attributing responsibility for external events to the self with no basis for the attribution	“It is my fault that my parents are getting divorced.”
Selective abstraction	Taking information out of context and ignoring relevant details	“My soccer coach hates me” when s/he did not play you in spite of the fact that you have started the last three games
Arbitrary inference	Making arbitrary conclusions contrary to or without evidence	Believing homework is too hard when in fact the child completed the same work that day in class
Ignoring evidence	Leaving out important information when forming thoughts about events	Believing that werewolves are a danger at night in spite of the fact that multiple adults have told the child they do not exist, and all the doors in the house are locked
Overgeneralization	Believing the outcome of one situation applies in many situations, when it may not	“All my teachers hate me” when one teacher yelled at the child at school
Attending to negative features of events	Placing greater cognitive importance on negative features of events and ignoring positive features	Focusing on one poor grade when all others were good

Behavioral Experiments

Many different types of behavioral experiments may be helpful when using CBT, especially during the psychoeducation phase. These “experiments” are exercises that a patient can complete in session, which demonstrate errors in thinking in a concrete manner.

For example, patients are often taught during psychoeducation that attempts at thought suppression actually lead to increased thinking about distressing topics. To demonstrate this principle, the patient may be asked to engage in an exercise where s/he is told to not think of a specific topic (e.g., pink elephants) for a period of 2 minutes. Inevitably, patients find during such an exercise that, in fact, they were unable to avoid thinking about the forbidden topic no matter what it was. This behavioral thought experiment allows patients to learn that an increase in the frequency of a thought is a typical consequence of thought suppression. Instead of trying to suppress thoughts, patients are encouraged to observe their thoughts as they “come and go” without trying to suppress them. This technique typically results in a reduction in intrusive thoughts.

Modification of Imagery

Anxious patients, in particular, often have cognitive imagery associated with their symptoms (e.g., imagery associated with a feared or traumatic event). Such patients may benefit from modification of such imagery, such as by identifying aspects of it that are exaggerated. Patients may also benefit from learning to continue the image through to a positive outcome. That is, negative or anxiety-producing images often stop at the height of the crisis in a patient’s mind (5), and never come to a positive or adaptive resolution. For example, the images end when the patient has passed out, embarrassed himself in public, or helplessly experienced the traumatic event. Therefore, helping the patient continue the image to a positive resolution (getting up off the floor after fainting, making statements to others when embarrassed, modifying the outcome of a traumatic event) can be an important exercise in decreasing anxiety and catastrophic thinking. Role-playing exercises may serve a similar role, as they allow the patient an opportunity to understand an event in a new way with the assistance of a therapist and then experience a new, more adaptive, outcome (known as behavioral rehearsal).

Altering Core Beliefs

In addition to identifying automatic thoughts, CBT focuses on the more complex task of identifying the core beliefs, or cognitive schemas, that underlie those thoughts. That is, the thought is typically generated because the individual has an underlying belief about him/herself, which is typically maladaptive. For example, a child who has to complete homework perfectly for fear of being thought stupid may have the automatic thought, “If I don’t write that sentence with perfect handwriting everyone will know I am stupid.” Core beliefs that may underlie such a thought might be, “I am stupid” or “Stupid kids are unlovable, therefore, no one loves me.” Understanding these core beliefs is important for relapse prevention in particular, as modification of automatic thoughts will generally be temporary if the underlying belief or schema is not addressed.

Modification of the child’s existing cognitive structures or schemas is an important way to decrease automatic thoughts and cognitive distortions, increase adaptive thoughts, and promote coping (19). Through use of many of the cognitive techniques described in the earlier section, therapy must result in a reduction of support for dysfunctional schemas. As such, a primary goal of CBT when addressing thoughts and schemas is the acquisition and use of a coping template through modification of schemas.

It is important to note that identification of underlying cognitive schemas can be a complicated process, which relies on insight, self-awareness, ability to articulate thoughts, and cognitive ability. As such, this level of cognitive intervention is not always appropriate for all ages and ability levels when working with children. Although adolescents can have difficulty articulating themselves, identifying core beliefs may be more successful with this age group than with younger children.

Physiological Techniques

CBT also relies on many physiological techniques for modifying thoughts, feelings, and behavior. These techniques are particularly useful when treating anxiety disorders, as a core component of such disorders can be misinterpreting and catastrophizing physical symptoms and bodily sensations. These techniques can also be particularly useful with children, as they do not rely on cognitive ability to the same extent as cognitive techniques.

Regulated Breathing

Breathing control exercises are often taught in CBT, especially in the treatment of anxiety. These exercises are helpful in two ways. First, they are physically effective for counteracting hyperventilation, reducing physical tension, and decreasing physical sensations associated with anxiety. Second, uncovering the patient’s understanding of the physiology behind them is helpful in decreasing their fears of bodily sensations. This change in perception thereby interrupts the vicious cycle in which patients believe that physical symptoms are a sign of danger, thus increasing anxiety. Although understanding how to physically interrupt this cycle may be beyond the cognitive capacity of young children, learning regulated breathing is nonetheless effective without this understanding. Regulated breathing is most effective when practiced during low stress circumstances on a regular basis to acquire the skill. This technique can then be applied to increasingly more stressful situations.

Relaxation Training

Relaxation training is another commonly taught physiological technique in CBT. This technique incorporates regulated breathing, but also involves progressively tensing and relaxing individual muscle groups in the body until the entire body is relaxed. When doing muscle relaxation with children it may be necessary to focus on large muscle groups (arms, stomach, legs, whole body at once) such that the progression does not take too long and to ensure that children have adequate muscle control (it may be difficult for children to isolate small muscles). It has been suggested that this technique is helpful for treatment of sleep-onset insomnia (26). Relaxation training is also often incorporated into anger management treatment protocols (159) so that children may learn physiological techniques for calming down. The goal of relaxation in this context is often to reduce disruptive behaviors that accompany anger, especially in impulsive children.

Exposure Techniques

Exposure therapy is based on the premise that patients with anxiety symptoms engage in avoidance or “safety behaviors” that do not allow them to experience that their fears will not be realized if they put themselves in feared situations (27). As such, exposure involves developing a progressive hierarchy of feared situations. The patient then engages in a graded series of exercises whereby these situations are experienced or recreated such that anxiety is initially present, but decreases over the course of the exercise until it has diminished completely. Anxiety typically decreases during such exercises, as the patient has the experience that the feared outcome will not occur (e.g., if I think about death, it will not actually cause someone to die). Historically, this type of treatment has been viewed as a habituation process, whereby the anxiety reaction decreases over time with repeated exposure to anxiety-provoking situations. Habituation has been conceptualized within a classical conditioning framework, as the anxiety reaction is thought to extinguish over time. More recently, especially with older children, adolescents, and adults, the cognitive aspects of exposure exercises have been emphasized. For example, rather than just practicing putting oneself in a feared situation and experiencing that the worst does not happen, thus resulting in a decrease of anxiety over time, this exercise might also include specific discussion of what the patient thought would happen, whether it actually did happen, reasons for the outcome, etc. With children, this cognitive component may be more difficult depending on developmental level. Exposure therapy is still effective, however, as anxiety reactions extinguish over time with repeated exercises even without this level of insight.

Exposure techniques are often used in treatment of fears and phobias and research indicates their efficacy. For example, children with specific phobias can be gradually and systematically exposed to situations that increasingly resemble or represent their fear. Over time, they come to realize that the feared outcome does not occur and fear diminishes.

In the treatment of obsessive-compulsive disorder, the compulsive behaviors are the “safety behaviors” that prevent bad things from happening as a result of the obsessive thoughts. Therefore, exposure exercises in these cases involve having the patient think about or experience their obsessions, which are often urges accompanied by a worry, without engaging in compulsions. This process facilitates the repeated experience that their feared outcome does not occur (e.g., have the patient experience that if they do not check the door, a robber will not enter the house).

Flooding is similar to exposure, with the exception that it does not utilize a hierarchy, thus, exposure to the target stimuli is not graded and begins by eliciting the full-blown fear response. While flooding typically works more quickly than hierarchical exposure, substantial self-control is required to prevent the individual from engaging in avoidance, escape, or other anxiety-reducing behaviors. As a result, flooding may be very difficult with children and adolescents, who may lack this self-control and therefore engage in extreme behaviors (e.g., tantrums) to avoid the level of anxiety that is required to complete a flooding intervention. It is also questionable from an ethical perspective, as use of this procedure may cause the child significant psychological distress.

Exposure can also be used to challenge core beliefs. When used this way, it is known as cognitive response prevention. Cognitive response prevention entails giving the patient homework assignments that involve behaving in a
manner inconsistent with the pathological or problematic belief. This exercise allows the patient a real-life opportunity to cope with thoughts that accompany behavior. For example, a child who has to do homework perfectly or s/he will think “I am stupid and a terrible student” will be assigned to do homework with some imperfections while thinking coping thoughts (“A couple of mistakes does not make me stupid.”). Similarly, a girl who must exercise a certain amount of time per day to prevent thoughts such as, “I am fat” will be assigned to exercise for a shorter period of time and see that her pants still fit and her weight has not changed.

Self-Monitoring/Self-Management

Self-monitoring was mentioned above as an important part of assessing and intervening on automatic thoughts. This technique can be used in other ways as well, such as to keep track of moods and plan for pleasant events in the treatment of depression, increase awareness and train competing responses in habit disorders (Tourette’s disorder, trichotillomania), assess and modify eating and exercise habits in the treatment of eating disorders, and track use of breathing and relaxation procedures in treatment of anxiety disorders.

Extending from self-monitoring techniques are interventions in which the child not only monitors his/her behavior, but is responsible for administration of a behavior intervention plan. Such techniques, known as self-management procedures, are also used to treat a variety of chief complaints (e.g., disruptive behaviors, communication disorders, developmental disabilities, anxiety disorders). These interventions have been successful in improving a variety of skill areas [play skills, on-task responding, social skills; (28,29,30,31)] as well as in decreasing undesirable behaviors [off-task responding, disruptive behaviors; (29,32)].

Activity Scheduling

Activity scheduling is commonly used in the treatment of depression. Models of depression suggest that part of the disorder can be accounted for by a lack of reinforcement in the individual’s life (33,34). Individuals with depression often engage in negative patterns of thinking, including negative evaluations of the self, the world, and the future [Beck’s cognitive triad; (33,34)]. This triad of negative thoughts is believed to be a primary source of cognitive distortions associated with depression. Further, they often cease engaging in previously enjoyed activities due to decreased motivation and interest. As such, treatment typically includes a component to increase the individual’s participation in reinforcing daily activities. In activity scheduling, the patient and therapist agree upon homework assignments to engage in activities that result in pleasurable feelings, feelings of competence/mastery, or other similar positive emotional and cognitive outcomes. Using this technique, a change in behavior often results in an improvement in emotional functioning.

ABA/Behavior Modification

Applied behavior analysis (ABA) and behavior modification are techniques used to increase desirable behaviors and decrease undesirable behaviors (35). These techniques primarily rely on use of contingent reinforcers. Specifically, when reinforcement is applied to a positive behavior, it increases the frequency with which that behavior occurs. In contrast, when reinforcement is removed from a negative behavior or when a punishment is applied, it decreases the frequency with which the negative behavior occurs. Many specific therapeutic techniques to treat a variety of disorders are based on these principles.

Counterconditioning

Counterconditioning techniques are used to decrease specific maladaptive behaviors, such as anxiety-related behaviors. Use of such techniques requires pairing a maladaptive behavior with an incompatible behavior in order to eliminate the maladaptive behavior. Counterconditioning techniques are based on the work of Wolpe (36), who stated, “If a response antagonistic to anxiety can be made to occur in the presence of anxiety-evoking stimuli so that it is accompanied by a complete or partial suppression of the anxiety responses, the bond between these stimuli and the anxiety response will be weakened”. For example, in one of the earliest demonstrations of counterconditioning, Joes (37) cured a child’s phobia of a rabbit by systematically exposing the child to the rabbit while pairing the exposures with the incompatible response of eating food.

Systematic Desensitization

Systematic desensitization (36) is perhaps the most commonly used counterconditioning technique. It involves training relaxation techniques to be used in conjunction with an anxiety hierarchy for the purpose of reducing fear and anxiety over time. The four stages of systematic desensitization are: 1) relaxation training; 2) constructing the anxiety hierarchy; 3) desensitization in imagination; and 4) in vivo desensitization. Specifically, this technique uses an imaginal or in vivo exposure hierarchy (discussed later) paired with progressive muscle relaxation techniques to reduce the anxiety/fear reaction to specific situations. This treatment is typically done first through visualization, followed by in vivo training.

Originally, this technique was based on the premise of counterconditioning, that is, pairing the feared stimulus with relaxation to counter the fear reaction, which results in decreased anxiety. Recent evidence suggests, however, that the exposure exercises may be the active ingredient in this treatment (38), rather than the counterconditioning.

Systematic desensitization is supported in the literature for use with children. However, studies that demonstrated efficacy typically targeted specific, subclinical fears. Little research has been conducted on its use with more generalized anxiety (19) in children. This technique may have limited use with children under age 9 because they have difficulty understanding the notion of a hierarchy and problems using visual imagery (19).

Aversive Counterconditioning

Aversive counterconditioning is another related technique, based on principles of classical conditioning. This technique pairs the target behavior or stimulus associated with it (conditioned stimulus) with a stimulus (unconditioned) that naturally elicits an unpleasant response. As a result, the maladaptive behavior is increasingly avoided in order to avoid the negative outcome. This technique is most commonly used in the treatment of addictions and problematic sexual fetishes. For example, the use of medications such as disulfiram (Antabuse) that cause an individual to be physically ill when consuming alcohol rely on principles of aversive counterconditioning to reduce the patient’s drinking behavior. While these techniques may be periodically relevant in the treatment of adolescents, they rarely apply to treatment with children.

Covert Sensitization

Covert sensitization relies on the same principles as aversive counterconditioning; however, the individual imagines an aversive condition while imagining engaging in maladaptive behavior, rather than actually experiencing the negative stimuli.

Habit Reversal

Habit reversal procedures are most commonly used in the treatment of habit disorders, such as trichotillomania and skin-picking, and Tourette syndrome and other tic disorders (39). Habit reversal involves three stages: 1) awareness training; 2) training in an incompatible competing response; and 3) social support, which is particularly important when using this technique with children and adolescents.

Indications and Efficacy

A wide variety of disorders are commonly treated using cognitive-behavioral treatment strategies. These are outlined in this section with a cognitive-behavioral model of each disorder, followed by a description of the application of CBT to its treatment.

Anxiety Disorders

Cognitive-Behavioral Model

Cognitive-behavioral therapy for anxiety “focuses on dysfunctional cognitions and their implications for the child’s subsequent thinking and behavior” (2).

Similar to adults, cognitive distortions are thought to play a major role in the development of anxiety in children and have been defined as “information processes that lead to misperceptions of oneself or the environment” (2). The primary cognitive distortion in patients with anxiety disorders is overestimation of the danger associated with certain situations, bodily sensations, or even thoughts (40). Distortions or overestimations may include inaccurate estimates of: 1) the likelihood of an event, 2) the severity of an event, or 3) one’s coping skills and the availability of help, support, or escape (5). Individuals with anxiety may also tend to interpret events from a negative and therefore inaccurate perspective, especially with regard to beliefs about self. For example, an individual with anxiety may have negative thoughts in specific situations when s/he is anxious (e.g., kids don’t want to play with me because I am stupid, versus kids don’t want to play with me because they all like soccer and I don’t).

The two-factor learning theory (41) has been proposed to explain the development and maintenance of fearful behavior. This theory proposes that an anxiety reaction is initially elicited via classical conditioning when a feared stimulus or event is experienced. As a result, the individual avoids the situation in the future to avoid experiencing the anxiety again. The avoidance behavior is then reinforced under an operant conditioning paradigm when anxiety is avoided as a result. The individual does not have an opportunity to learn that exposure to the stimuli is unlikely to result in the traumatic outcome again. For example, if a child encounters a scary dog while walking outside, s/he might come to believe that going outside is dangerous (classical conditioning). As a result, staying inside reinforces this notion, as the child does not experience anxiety unless s/he goes outside (operant conditioning). Therefore, until the child can learn that going outside does not result in negative outcomes, the anxiety reaction will continue to be reinforced. Similarly, Clark (5), has proposed that reflexively elicited somatic and cognitive symptoms of anxiety become problematic when they are misinterpreted as indicating danger is present (“I’m going crazy”). Such an interpretation can lead to further increased physiological arousal, which then serves to confirm the initial incorrect hypothesis.

Symptoms of anxiety in children may be physiological, behavioral, and/or cognitive (19,42). For example, physiological symptoms may include shaky voice, rigid posture, perspiration, abdominal pain, flushed face, need to urinate, trembling, and increased heart rate. Physiological symptoms, especially ongoing somatic complaints, are often the most common anxiety symptoms in children, as their cognitions may not be as clear and identifiable as those of adults. Behavioral symptoms may include nail biting, avoidance, thumb sucking, crying, toileting accidents, and others. Cognitions may include thoughts of being hurt or scared, thoughts of danger, self-critical thoughts, preoccupation with evaluation by self and others, worries about likelihood of severe negative consequences, and intrusive images. These can be difficult to determine in anxious children who may not be accurate reporters or may not have enough self-awareness to understand their thoughts clearly (43). Distorted information processing is another cognitive area that may be involved in anxiety. For example, distorted/biased views of social or environmental cues, preoccupation with evaluation by self and others, preoccupation with likelihood of negative consequences, or misperception of demands in the environment (19) are common distortions.

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