The theory of cognitive development that Piaget constructed on the basis of an immense amount of experimental work was characterized by stages of development. He described characteristic features of the sensori-motor (0–2 years), pre-operational (2–7 years), concrete operational (7–12 years), and formal operational (12 years onwards) stages. Before the end of a stage is reached the child is incapable of showing more advanced thinking. In particular, the child’s thinking before the concrete operational stage is characterized by egocentricity and an inability to take the perspective of another person. Abstract reasoning is not possible for the child until the formal operational stage is reached.

Even though Piaget’s views of the limitations of the cognitive abilities of young children have been strongly criticized especially on the grounds that he was judging egocentricity on the basis of findings obtained in highly artificial situations, Piaget remained a dominant influence in cognitive psychology and education throughout the twentieth century. It is now widely accepted that, although obviously young children are less competent than those in middle childhood and these are less competent than adolescents, cognitive competence advances much more rapidly than Piaget described and the social context in which a child’s competence is investigated has a much more profound influence on performance than he allowed. Children do a great deal better in naturalistic circumstances than when they take part in experiments. Further, coaching can improve performance to a level not previously obtainable. For example, it has been shown that, with preliminary training, 3-year-old children understand that drawings of thought bubbles can represent what people think. They can distinguish between thoughts and actions, recognize that thoughts are subjective and that two people can have different thoughts about the same events.⁽³⁾

Investigation of the development of the ‘theory of mind’ held by children has revealed that between 3 and 4 years they begin to realize that other children can be deceived by appearances and hold false beliefs they themselves do not hold. This shows that, given the right circumstances, children of this young age are able to ‘de-centre’ and are not necessarily limited by egocentricity. By the age of 8 years children have such stable concepts of their own self-esteem that they are capable of reliably completing self-esteem questionnaires about their own feelings and performance in comparison to other children.⁽⁴⁾ Some schemas in young children are however relatively unstable, gradually increasing in stability as they get older. For example, it has been shown that attributional style (the tendency to attribute adverse events either to the self or to external circumstances) does not become stable until early adolescence,
though it may be identified earlier if the events are particularly salient to the child in question.⁽⁵⁾

It has been hypothesized⁽⁶⁾ that maladaptive schemas developed during childhood are responsible for the formation and maintenance of adult psychopathology. Building on this model, a therapeutic approach (schema-focused therapy) based on the identification of particular maladaptive schemas has been proposed for adults. Subsequently Stallard and Rayner⁽⁷⁾ have developed a schema questionnaire that builds on adult work to identify such maladaptive schema in 11 to 16-year-old school children.

Where experience with adults suggests that cognitive tasks add significantly to the effectiveness of treatment, as in depressive disorders and problems of social relationships, even young people in early adolescence will usually be able to co-operate as well as adults. The cognitive treatment of younger children with these conditions may be helped by the use of age-adapted techniques.⁽⁹⁾ For example, card-sorting games have been devised to help children distinguish between thoughts, feelings, and situations. Puppets can be used to facilitate discussion as part of the assessment process, to model alternative ways the child might cope with difficult situations and to engage the child in rehearsal and practice of new skills. Story telling can provide an insight into the child’s inner world; they provide a way of externalizing and accessing the child’s cognitions, allow an opportunity to challenge the child’s assumptions, introduce the child to more positive ways of coping, and can be used to model success and help the child gain more functional assumptions and beliefs.

Parents play many roles in the delivery of CBT to children and adolescents. To begin with, even up to mid-adolescence, it is nearly always parents who identify the behaviour and emotional problems that lead to advice being sought. They are the people most likely to press for psychological help. It is they who have to persuade often reluctant children and adolescents to attend and participate in a service that their offspring may fear, not without reason, will result in stigmatization.

They are then likely to play a major part in the assessment process. From mid- to late adolescence, the patient or client will be the main source of information, but before that it is the parents and teachers who will often provide most relevant information. If treatment is proposed it is they who need to give consent, though their child will also need to assent if the therapy is to have any chance of succeeding.

Once treatment planning has begun, the part that parents play will depend very much on the age of the child or adolescent, the diagnosis, family circumstances (especially the quality of the relationships between parents and child), and the degree to which the assessment has revealed that the parents as well as being the main carers are also involved in the origin and maintenance of the problem. Most explanatory theories of anxiety disorders in children, for example, point to the ways in which parents can provide inappropriately anxious models for imitation by their children. In a small scale study it has been shown that changing parental attributions can, in itself, result in improvements in problem behaviour scores on a questionnaire.⁽¹⁰⁾ Parents may also be seen as clients in their own rights in parallel sessions, as co-therapists or as facilitators of therapy for their children. Therapists dealing with adolescent offspring are often in a difficult position vis-à-vis parents in that they will wish to encourage autonomy and independent decisionmaking in the child or adolescent, while needing the parents to monitor homework, encourage further attendance, and provide information on progress.

The involvement of parents also brings ethical dilemmas. There are three main areas of ethical concern.⁽¹¹⁾ The therapist often has to balance the different viewpoints of parents and children, a particular problem in the management of oppositional and conduct disorders where children often fail to acknowledge the existence of problems that are causing distress to their parents. There is frequently need to address family issues such as marital conflict that are clearly relevant yet not the reasons why the child has been brought for treatment. Finally, there is the need to achieve genuine collaboration with parents, making explicit their role as co-therapists. This is made easier if children are also actively involved as fellow
collaborators, taking responsibility for progress and being encouraged to make suggestions for alternative approaches. A collaborative stance may however not be possible if it becomes clear that there are child protection issues with one or both parents involved in maltreatment of their children. Wolpert and her colleagues provide a useful checklist for clinicians to help assess how far they are attempting to balance different viewpoints in issues involving different family members and promoting collaboration.

In adolescents, lack of motivation for change is often a major impediment to engagement in therapy. Not only is there often a failure to recognize the importance of a problem, to accept the need for change or to appear to understand why change is necessary, but there may also be an absence of the level of self-belief, self-confidence, or self-efficacy that is necessary before hopeful steps can be taken in the right direction. In these circumstances techniques of motivational interviewing will help the therapist to achieve engagement.⁽¹²⁾

The reasons for non-response to CBT in adults have been discussed by Kingdon et al.⁽¹³⁾ Common problems include unsuitability for treatment possibly arising from misdiagnosis, resistance to treatment, an inadequate number of sessions, difficulties in the therapeutic relationship and the presence of concurrent social and/ or physical pathology. Non-response in children and adolescents arises from similar issues, with, additionally, complicating problems arising from negative parental attitudes and behaviour.

A characteristic constellation of cognitive deficits and distortions underlies the presence of anxiety disorders in children and adolescents. A central feature is the exaggerated perception of threat arising from an inability to assess accurately the seriousness of danger. Thus a deficit in perceptual competence results in cognitive distortion. The characteristic nature of the threat involved will depend to a considerable degree both on the stage of cognitive development of the child and on the social demands that are encountered during that particular phase of life. Pre-school children are most likely to be threatened by separation from parents; children aged 5 to 12 years by feared situations at school and adolescents by social situations as well as wider concerns such as environmental pollution. Certain fears and phobias such as fear of spiders and snakes appear more biologically based and are present through childhood to adolescence.

These cognitive deficits and distortions both result in and are maintained and increased by abnormal levels of physiological arousal and by behavioural avoidance of the feared situations. Autonomic arousal produces symptoms such as dry mouth, palpitations, and abdominal pain and these may be misinterpreted as implying serious threatening illness. Panic attacks may be catastrophized and taken to mean that death is imminent. Avoidance of feared situations such as separation from parents in younger children, refusal to go to school in older children or to social events such as parties in adolescence prevent cognitive testing of the reality of the supposed threat and reinforce the cognitive distortion.

The fact that anxiety disorder is partly genetically determined means that children suffering from this condition have an increased risk of having anxious parents. Such parents are likely to model anxious behaviour, especially in the way they show over-protection to their children. Anxious children are therefore likely to be exposed to social learning situations at home that will increase the risk of avoidance of feared situations. Gene-environment interactions ensure that many parents who cannot bear to be separated from their children or who are anxious every time they leave the house will transmit their fears to their children both directly and indirectly. In adolescence, anxious young people may selectively choose shy, inhibited friends who reinforce their sense of unrealistic threat.

The assessment of children with anxiety disorders by a cognitive behaviour therapist focuses on the identification of cognitive deficits and distortions and the manner in which they are currently being reinforced, especially by avoidant behaviour. Nevertheless it is important that before enquiry is made along these lines a full history is taken of the development of anxious symptoms, the presence of other symptomatology, the situations that increase and reduce anxiety, the presence of anxiety in parents, sibs, and friends, and the measures that have already been taken, especially by parents, to improve the condition. Skilled assessment involves listening to the anxious preoccupations of both children and parents sympathetically and without any hint of criticism.

There are a number of systematic cognitive approaches to the reduction of anxiety in children of which the most widely used is the four-step coping or FEAR plan, in which F = Feeling frightened (awareness of anxiety symptoms such as somatic aches and pains), E = Expecting bad things to happen (awareness of negative selftalk), A = Attitudes and actions that can help (problem-solving strategies), and R = Results and rewards (rewarding for success, dealing with failure).⁽¹⁴⁾ The ‘Cool Kids’ programme is generally similar but puts more emphasis on parent involvement.⁽¹⁵⁾ When parents show significant levels of anxiety themselves, effectiveness of treatment is enhanced if parental anxiety management is included as part of treatment.⁽¹⁶⁾ A self-help book for parents broadly based on the same principles provides a practical approach to the management of anxiety, using the so-called COPE programme.⁽¹⁷⁾

Treatment begins with one or two psycho-educational sessions in which the child and parent(s), together or separately, are given information about the way anxiety develops and is maintained, the manner in which the body shows anxiety (somatic symptoms), and the effects of avoidant behaviour and exposure to feared situations. It is important that these sessions are interactional with the child being encouraged to talk spontaneously about, for example, how he or she experiences somatic symptoms. The next few sessions involve children engaging in an exercise to identify their own negative thoughts, to test them against reality and to develop positive thinking in situations that have previously triggered anxiety. This will usually need to be done in imagination before it is tried out using ‘graded exposure’ in real situations. There are advantages in teaching relaxation techniques before the child embarks on exposure to feared situations. The use of imagery, such as the ‘stepladder’ approach to a hierarchy of feared situations may also be helpful. When the child makes progress, as is usually the case, rewards such as outings or other treats may be built in to the procedure.

Therapists vary in the degree to which they involve parents in management. The therapy can be delivered in a family context, parents can be seen separately from children, parents may not be seen at all, or the therapy may only be delivered to parents. Some centres use a group approach, with one or two therapists providing a group experience for parents and anxious children who go through the stages of treatment together and benefit from learning of each others’ experiences. Some programmes have now been developed for use via the Internet with minimal personal contact with the child and family. Some therapists combine CBT with the use of medication, generally not anxiolytic agents because of the risk of dependency, but tricyclics or selective serotonin reactive inhibitors.

A systematic review of the effectiveness of CBT for anxiety disorders in childhood and adolescence identified 10 randomized controlled trials that met inclusion criteria.⁽¹⁸⁾ The outcome measure used was the remission of anxiety disorder. The remission rate was higher in the CBT groups (56.5 per cent) than in the control groups (34.8 per cent). The pooled odds ratio was 3.3 (CI = 1.9–5.6). The authors of this review conclude that CBT definitely provides benefit to children and adolescents with anxiety disorder, but that there is a lack of information concerning the value of CBT in younger children and that there are virtually no satisfactory studies comparing effectiveness with alternative treatments.

There is contradictory evidence concerning the importance of involving parents in therapy. Some^(19,20) find little or no benefit, while others^(21,22) find a trend towards benefit. A pilot study has found benefit from a programme that did not involve children directly but only involved parents seen in a group, who applied what they had learned in the group in managing the situations in which their children showed anxiety at home. Information on the use of therapy delivered via the Internet is limited, but those that exist suggest that Internet treatment is highly acceptable to families, creates minimal dropout and is effective when added to clinic treatment.⁽²³⁾ Dropout from more conventional treatment is likely to be high in single-parent families, ethnic minority families, and where anxiety levels are not conspicuously high.⁽²⁴⁾ There is evidence that the presence of co-morbid disorders does not reduce the efficacy of CBT.⁽²⁵⁾ The addition of antidepressants may increase the efficacy of CBT, especially in the treatment of school refusal.⁽²⁶⁾ Limited findings from long-term studies suggest that treatment benefits from the delivery of CBT to anxious children are maintained over at least 6 years.⁽²⁷⁾

There is also evidence from controlled studies for the effectiveness of interventions, especially the FRIENDS programme⁽²⁸⁾ in the prevention of anxiety and depression in early adolescence. Stallard et al.⁽²⁹⁾ have shown how this programme can be delivered successfully by school nurses.

These evaluative studies have provided most encouraging findings for the effectiveness of CBT in this condition. However the findings also make clear that CBT, while producing worthwhile and persistent benefits in most children and adolescents with anxiety disorders, is not effective in a significant number of cases and in a significant number of others it is only partially effective. It is also less effective in socially disadvantaged groups. Finally, most evaluative studies have been carried out in highly specialist centres and there is a lack of evidence for their value in everyday practice.⁽¹⁸⁾

The classical signs of depressive disorders, such as chronic misery and unhappiness, lack of interest in food, and motor retardation, may be seen as early as the first year of life. Infants and young children who show such symptomatology may well suffer depressive experiences similar to those of older people though in the pre-verbal phase there is no reliable method available to confirm this possibility. Awareness of feeling states develops towards the end of the second year of life.⁽³⁰⁾ By 2 to 3 years children realize that there can be a variety of personal reasons for an emotional reaction. By 4 years there is some consensus about the kind of situations that will provoke the common emotional reactions, including fear, sadness, and anger.⁽³¹⁾ By 5 or 6 years a child is capable of understanding the concept of stability of mood, ‘always being unhappy or just now and again’, and by 7 or 8 years concepts of shame and guilt are understood at least in simplified form. Enduring and relatively stable negative attributions about the self become possible at around this age and the concept of death as a permanent state is established. By 13 to 14 years, emotional experiences of adult intensity occur and mature cognitions about different mood states will have been attained. Although the above account relates stage of development to chronological age, there is wide variation in the ages at which cognitive competence is gained. Further, the settings in which children are questioned or encouraged to express themselves freely and spontaneously, for example in play situations will greatly influence their capacity to show their abilities.

The cognitive model underlying CBT approaches to children and adolescents does not differ from that with adults. It is assumed that thoughts are the primary experience of depression and that depressed mood is secondary. Dysfunctional assumptions, including low feelings of self-worth, self-blame for events in the past, and hopelessness about the future are present either as stable features of a depressive personality or as a reaction to adverse experiences, real or imagined. Depressed children and adolescents systematically distort their experience to match their beliefs about themselves. At some point, these negative thoughts are automatically experienced without reflection. Increasingly situations are avoided because of a fear of negative outcomes. Therapy involves identifying and reality testing these negative thoughts. In addition the patient is encouraged to enter into activities that will be rewarding and disconfirm pessimistic assumptions.

Initial assessment will involve taking a full history of the development of symptoms and the factors that reduce or exacerbate them, the child’s functioning in different settings, and an account of family relationships. If the child is taken on for CBT, a typical approach⁽³²⁾ begins with the establishment of symptom status by the use of questionnaires such as the Children’s Depression Inventory⁽³³⁾ in young patients and the Mood and Feelings Questionnaire⁽³⁴⁾ in adolescents. The goals of therapy are then discussed in a collaborative manner with emphasis on what the child or young person wishes to achieve. The proposed therapeutic approach is then explained together with the importance of homework outside the
therapy sessions. An indication of the number of sessions likely to be required, usually 12–16, is given. In early sessions an account of the child’s current daily activities is obtained. Adolescents are helped to keep a diary of their activities and moods. In a form of ‘affective education’ a check is made on the vocabulary the child uses to describe feelings and links are then established between the child’s mood and the activities he or she is undertaking.