Ana M. Ugueto, Lauren C. Santucci, Lauren S. Krumholz, and John R. Weisz
Introduction
Originally described by D’Zurilla and Goldfried (1971), problem solving is one of the most common and versatile treatment approaches used to help children overcome anxiety and depressive disorders (Chorpita and Daleiden 2009). Children with depression and anxiety often have difficulty solving problems and usually give up easily, or they apply one overlearned behavioral strategy to resolve a problem. When the problem persists, they may feel that problems are impossible to solve – or, more specifically, impossible for them to solve. Depressed children who have a negative or depressogenic cognitive style (Gladstone and Kaslow 1995; Jacobs, Reinecke, Gollan, and Kane 2008) may not recognize that having problems is part of life and is “normal.” Instead they may see everyday or common problems as something that is happening to them alone, and they may think: “Why does bad stuff only happen to me?” Similarly, anxious youth with a cognitive bias toward threat interpretation (see Vasey and MacLeod 2001 for a review) may see the world as a dangerous place, where they must avoid any possible perilous situation to stay safe. Finally, children with traumatic stress may have learned maladaptive behaviors as a way to cope with uncontrollable traumatic experiences and, subsequently, use these same behaviors to manage difficult social situations and emotional dysregulation (Cohen, Mannarino, and Deblenger 2006).
Teaching youths that problems are universal and should be expected is fundamental in training children and adolescents to use problem solving. Problem solving helps youth inhibit the tendency to react impulsively (e.g., by running away) or act passively (e.g., by waiting for the situation to resolve itself, or for someone else to fix it). Learning how to solve problems, through the generation and evaluation of solutions, helps counteract rigid thinking associated with anxiety and depressive disorders and teaches children how to use a specific strategy to increase cognitive flexibility and to gain a broader perspective on events. Problem solving can be used to help youth solve a variety of problems, whether academic (e.g., poor grades), social (e.g., bullying), familial (e.g., negotiating with parents) or related to activating events (e.g., divorce of parents), treatment goals (e.g., making friends), and moods (e.g., feeling bored). When youth are able to recognize a problematic situation, apply the sequential problem-solving method, and successfully solve a problem, they may feel empowered and be more likely to use the skill to solve future problems. Problem solving helps children break abstract and overwhelming problems into concrete and solvable parts.
The following sections of this chapter were based on a selection of cognitive behavioral therapy (CBT) treatment manuals for anxiety (Kendall and Hedke 2006; Rapee et al. 2006), trauma (Cohen et al. 2006), and depression (Brent and Poling 1997; Clarke, Lewinsohn, and Hops 1990; Curry et al. 2005), as well as on the clinical experiences of the authors (e.g., Chorpita and Weisz 2009). For the purposes of this chapter, children and adolescents are collectively referred to as “children” or “youth.”
Key Features of Problem-Solving Competencies
When you teach children problem solving, it is important to teach them that problems are part of life, that everyone has them, and that one can learn how to cope or solve problems effectively. Problems can be small (e.g., forgetting homework) or large (e.g., fight with a boy-/girlfriend), and may be fixed quickly (e.g., by apologizing to a friend) or may take time to solve (e.g., studying daily for an upcoming test). Regardless of type or size, any problem that is within the control of the youth can be solved by using a sequential approach. The CBT approach to problem solving typically involves five steps:
- identifying and defining the problem;
- generating a list of possible solutions;
- evaluating the strengths and weaknesses of each possible solution;
- choosing a solution;
- using the solution and determining whether the problem was solved or whether another solution is needed to solve it.
In step 1 – identifying and defining the problem – it is critical that children choose a problem that is within their ability to solve; trying to solve a problem that it outside of one’s control will only lead to feelings of frustration, helplessness, and hopelessness. Therapists should help them determine whether they can change the situation or need instead to change their reaction when the situation cannot be changed (Rapee et al. 2006). For example, youth may not be able to change the divorce of their parents, but they may be able to change their emotional reaction to the divorce. Therapists should educate children that changing one’s reaction to a situation is something that is within one’s control, even if the situation itself cannot be altered.
Once an appropriate problem has been selected, the problem should be defined in specific and concrete terms. Problems that are too vague (e.g., “I hate school”) or too ambiguous (e.g., “School is boring”) will be difficult to solve because they do not define the exact problem or identify the goals of problem solving. Additionally, it will be difficult to generate alternative solutions if the problem is not defined clearly. If a youth defines a problem too broadly, the therapist should ask questions in order to better understand and to help the child refine the problem. Take the example of “I hate school.” Using Socratic questioning, the therapist can guide the child to reframe the problem thus: “I failed my science test and need to get a passing grade on the next test.”
In step 2 – generating a list of solutions – the therapist should help the youth think of as many alternatives as possible. During this phase, encourage the child to think creatively. Quantity, not quality of solutions is the goal, as brainstorming is a way to stimulate cognitive flexibility (Curry et al. 2005). If the child is having difficulty brainstorming ideas, the therapist may offer some suggestions to stimulate the child’s thoughts; the greater the number of ideas, the greater the likelihood of finding an effective solution. In order to increase the number of alternatives, combinations of ideas also are encouraged. For example, a youth may list “Ask questions in class” and separately list “Go to afterschool tutoring.” These solutions can be combined into an additional one, “Ask questions in class and go to after-school tutoring,” which would be a third solution. Remember, too, that ideas should not be criticized or ruled out from the start; any solution the child describes should be listed, even if it seems implausible (e.g., “Study every day after school for five hours”), ridiculous (e.g., “Break into school and steal the test”), or antisocial (e.g., “Cheat off another student”). The inclusion of unrealistic or ridiculous solutions makes the task more fun and more engaging for the child, and encourages the child to think more creatively, “outside the box,” about possible solutions. In fact, if the child does not generate such a solution, the therapist should volunteer one, to demonstrate that any solution that comes to mind should be listed, regardless of how outrageous it might be. In our experience, children are usually thinking of such solutions even if they do not say them aloud to the therapist; so, if the therapist articulates an outlandish solution, the child may then do the same. Evaluation of the merits of each possible solution should be withheld until the next step.
In step 3 – evaluating the strengths and weaknesses of each possible solution – each solution is scrutinized as to its unique advantages and disadvantages for solving the problem. Children should think about, and predict, the utility of each solution and then list as many “strengths and weaknesses,” “pros and cons,” “positive and negative consequences,” or “good and bad reasons” as they can. If youth are having difficulty generating the advantages and disadvantages of a given solution, therapists can query the youth, or even suggest possible benefits and limitations, to ensure that the evaluation is a fair appraisal of the solution. Moreover, therapists should encourage children to think of both short- and long-term consequences of the solution. This is particularly important for solutions that are implausible, ridiculous, or antisocial. For example, a child who lists “Cheat off another student” would also have to list the advantages (e.g., “Wouldn’t have to study,” “Would probably get a better grade”) and the disadvantages (e.g., “Would get expelled if I were caught,” “The other student may not know more than I do,” “Would never learn the material which I may need some day”). If the evaluation does not accurately reflect the strengths and weaknesses of a solution, youth will be at a disadvantage when they have to select one solution to try to solve the problem.
In step 4 – choosing a solution – children must choose the solution they think will best solve the problem. Ideally, they would choose the solution with the most advantages and fewest disadvantages, and thus the one most likely to actually solve the problem. To help the child choose the most effective solution, the therapist and the child can list the solutions in the order of their likely success, from highest to lowest. This technique helps the child pick the most preferred solution, while it also guides the child’s next steps should the first solution prove ineffective. However, some children may feel strongly about a solution that the therapist does not favor. In these instances, youth should be allowed to choose the solution they want to use without any criticism from the therapist. For example, a child may choose “Study with a friend,” while the therapist thinks “Ask questions in class and go to after-school tutoring” would be a more successful solution. In this case, the therapist should defer to the child, who may then learn something useful after implementing the solution. Also, to facilitate use of the solution, the chosen solution may need to be broken down into smaller steps (Rapee et al. 2006). For example, “Study with a friend” might involve asking a friend to study together, setting up a study schedule, bringing books and other materials to the study session, and studying for two hours. It is important for the therapist to explain to the child that there is no one “correct” or “perfect” solution; most problems may be addressed adequately in a number of different ways, and choosing a solution that is “good enough” is better than doing nothing and simply waiting for the problem to subside, or for someone else to solve it (Curry et al. 2000).
In step 5 – using the solution and determining whether the problem was solved or whether another solution is needed to solve it – children are encouraged to implement the solution and determine its effectiveness for solving the problem. Without this step, youth may continue implementing an ineffective solution without thinking about why it failed and without choosing another one, which may work better. Usually children are not able to implement the solution during a therapy session, so the therapist should assign step 5 as homework and review it with the child at the next session. If the child implements the solution and this does not produce the desired effects, the child should repeat step 4 and choose the next best solution. If the child had ranked the possible solutions in step 4 (as described above), (s)he can then try the second solution on the list; and, if that does not work, the third, the fourth, and so on – until a solution successfully solves the problem. When the first solution does not solve the problem as expected, youth with anxiety and depression may feel helpless and ineffective. It is important to reiterate to them that problem solving is a learning process and that it is impossible to predict all the consequences of a solution before it is implemented.
Competence in Treating Anxiety Disorders and Depression
Anxiety
Problem solving is a particularly important skill in the context of anxiety treatment, as anxious youth tend to rely on unhelpful strategies, such as escape or avoidance, to manage fear (American Psychiatric Association 2000; Dadds and Barrett 2001). Problem solving can be a helpful tool when a child is confronted with an anxiety-provoking situation, as happens during in vivo exposures (Kendall et al. 2005). In such a situation, anxious youth may overestimate the likelihood that something scary or dangerous will happen and may underestimate their ability to cope in case “something” occurs, which may ultimately lead them to avoid (or try to avoid) the situation (Dadds and Barrett 2001). Going through sequential problem solving may help the child plan in advance how to handle an anxiety-provoking situation (e.g., by thinking positive thoughts and then by “riding the wave of anxiety”), how to choose a less challenging exposure when what was planned feels too difficult for the time being (e.g., by saying hello to one stranger instead of saying hello to two strangers), or how to know what steps to take if his/her mind goes blank in the face of anxiety (e.g., take a deep breath). In the case of traumatic stress, children may have a limited repertoire of responses when dealing with interpersonal situations and may cope with anger or withdrawal. Thus, problem solving may help youth manage strong emotions in a more prosocial manner (Cohen et al. 2006).
When teaching sequential problem solving to anxious youth, therapists should consider that children may be reluctant to solve their own problems when these are related to fears. Additionally, youth with anxiety may have difficulty defining clearly what problem to solve. For example, a child might say “I hate swimming class,” which may lead to solutions such as “bring a friend” or “try out another sport,” when in fact the child dislikes swimming class because he misses his mother and worries that something bad will happen to her when she is not with him. So it is important that the therapist use Socratic questioning to identify the real problem (e.g., “I’m afraid something bad will happen to my mom when I am at swimming class”). Furthermore, if the therapist sets a goal with the child by discussing what the latter hopes to achieve through problem solving and by making this achievement into a goal, the therapist should also ensure that the goal is realistic for the child. For example, if a socially anxious child tends to blush when speaking to others, the goal “Don’t turn red” may not be realistic. A better goal may be instead this: “Keep talking to a friend even when I start turning red.”
When generating solutions, it is important to allow “bad ideas,” or the unhelpful solutions that the child currently engages in, to make it onto the list (e.g., “Stay home from school the day I have to give a book report”). However, given that youth with anxiety tend to rely on escape or avoidance to manage negative emotions, the therapist should encourage the child to generate other possible solutions as well. Similarly, if the list includes solutions that involve avoiding a feared situation, use the evaluation step to consider the weaknesses of such solutions. While a “pro” of avoidance may be “I wouldn’t feel anxious if I stayed home from school,” the “cons” may include long-term consequences such as “I would never learn that I can handle it,” or “I won’t get over my fears.” If a child chooses an avoidant solution to practice, the therapist should refrain from criticizing the choice and, instead, allow the child to implement the solution and then evaluate the results. During the evaluation stage, the child may uncover for himself or herself why this avoidant choice is not the best option (see section “Common obstacles to competent practice and methods to overcome them”). Sequential problem solving helps to break down overwhelming situations into problems that can be solved. When large problems are broken down, anxious youth have an opportunity to increase their sense of self-efficacy and to gather evidence that contradicts their anxious thoughts and feared outcomes.
Depression
Problem solving is an integral component of depression treatment (Chorpita and Daleiden 2009); it is the key strategy for depressed youth to employ in the face of situations that cause distress. Symptoms associated with depression, such as low energy or fatigue, a sense of helplessness and hopelessness, and suicidal ideation can interfere with a child’s or adolescent’s ability to effectively solve problems (Stark, Streusand, Arora, and Patel 2012). These symptoms often lead to maladaptive behavioral tendencies related to problem solving: avoidance of activities due to the energy and effort that must be exerted to engage in problem solving; tendency to attempt only one – overlearned – behavioral strategy; difficulty generating beneficial solutions; tendency to give up quickly if the desired outcome is not achieved; impulsive suicide attempt when no other solution can be fathomed (Abela and Hankin 2008). These tendencies express and support the depressed youth’s belief that (s)he is unable to successfully manage life stressors. Therapists can help depressed children break this vicious cycle by teaching them problem solving, while remaining aware of the common difficulties that interfere with a depressed youth’s ability to effectively apply this approach. Therefore therapists must carefully consider factors that could affect depressed children’s acquisition and application of the problem solving approach. These factors encompass negative thoughts, feelings, and behaviors that characterize depressive disorders, which should be addressed by therapists before, during, and after teaching this skill. Prior to initiating problem-solving steps, therapists may need to address interfering feelings (e.g., depressed or irritable mood) and behaviors (e.g., social withdrawal and lethargic behavior) through mood boosting activities; or they may need to address interfering thoughts about the problem – or about one’s ability to solve the problem (e.g., “I can’t do anything right”) – through cognitive restructuring.
When helping depressed youth identify and define a problem, therapists should be aware of possible cognitive distortions related to all-or-nothing thinking (e.g., “If I don’t get 100 percent on the test, I’m a failure”) and exaggeration (e.g., “Nothing ever works out for me”), which may become apparent and may interfere with this step. In addition, depressed youth may benefit from breaking a problem into smaller parts in order to feel more hopeful about being able to solve it. Examples of problems that may occur for depressed youth are low mood, interpersonal conflict, academic failure, social isolation, suicidal ideation, and thinking that one is not good (smart, funny, attractive, or athletic) enough. When generating a list of possible solutions, therapists may initially need to provide increased support to depressed children in order to help them brainstorm a variety of solutions. It is especially important that solutions not be evaluated at this point, in part because of the tendency of depressed youth to criticize their own ideas. When evaluating the strengths and weaknesses of each solution, therapists should ensure that there is careful consideration of its advantages and disadvantages, since depressed youth are more likely to focus on the potential disadvantages of each solution. In contrast, for children who list suicide as a possible solution and only see the advantages of self-harm, the disadvantages need to be considered and discussed thoroughly. To increase the sense of mastery and agency, therapists should encourage youth with depression to select the solution of their choice to implement, except in cases where the solution involves self-harm (e.g., suicide or non-suicidal self-injury). Children should also be reminded that sometimes multiple solutions must be tried before the outcome they desire is achieved. Therefore it can be beneficial for youth to create a backup plan involving several additional solutions in case the initial one did not work. After therapists have taught problem solving, they should encourage children continuously to use this approach through therapeutic homework assignments and opportune moments in session.
Successfully solving a problem can increase a youth’s sense of competence about being able to manage problems that arise as a normal part of the developmental process. In addition, effectively solving a specific problem can lead to enhanced mood, at least temporarily. Most importantly, each problem that depressed children effectively solve provides evidence contradicting the belief that they are hopeless or helpless. And for youth at risk of suicide, problem solving helps them re-evaluate the consequences of an impulsive and life-threatening act, think of alternatives that may be more effective, and try something other than self-harm (Brent and Poling 1997). Thus problem solving should be incorporated into the treatment of depression for youth because it is a key ingredient in alleviating depressive symptoms and building a more positive sense of self.
Competence in Treating both Children and Adolescents
Children
Problem solving can be a useful tool when planning for the life events that children may encounter – such as starting school, attending camp for the first time, getting in a fight with a friend, moving to a new town, or the birth of a sibling. Already a relatively concrete skill, sequential problem solving can be made even more developmentally appropriate for children by using child-friendly language to describe the process, presenting the skill in an engaging manner, providing scaffolding such as visual cues and writing down the five steps, and encouraging caregiver involvement.
Language such as “what’s the problem,” “think of solutions,” “pick one,” and “try it” may be helpful for children. Additionally, visual cues with smiling and frowning faces can be used as headings to signify the strengths and weaknesses of each solution. Acronyms like “RIBEYE” (Relax, Identify the problem, Brainstorm solutions, Evaluate solutions, say Yes to one solution, and Encourage child to try solution: see Curry et al. 2005: 79) and “STEPS” (Say what the problem is, Think of solutions, Examine each one, Pick one and try it out, and See if it worked: see Weisz, Thurber, Sweeney, Proffitt, and LeGagnoux 1997), or a mnemonic like “The Five Ps of Problem Solving: Problem, Purpose, Plans, Predict and pick, and Pat yourself on the back”: see Stark et al. 2007, pp. 33–5) can make it easier for youth to remember and implement all of the problem-solving steps. Therapists can also suggest possible solutions for young children, who may have difficulty generating ideas independently.
To introduce the skill, choose a silly or fun problem to solve. For example, tell the child he or she has to move a piece of paper from one side of the room to the other without getting out of his or her chair. Potential solutions might be making the paper into a ball and throwing it across the room, or creating a paper airplane and sailing it to the other side. Then, after evaluating the strengths and weaknesses of each solution, the child gets to pick one and try it out in session. Alternatively, the therapist can present the child with a cartoon image of a dog who appears sad, on one side of a fence, and a bone wrapped in a bow, on the other side of the fence. Using this image as an example, the therapist can walk through the problem-solving steps to help the dog get its bone. Once familiar with the problem-solving process, children can discuss problems in their own life.
Instructing the caregiver in the use of sequential problem solving may facilitate the use of this skill outside of therapy. If possible, the child should teach the caregiver the steps to problem solving and should show the caregiver how to apply these steps to a particular problem – perhaps the silly problem presented to the child initially. Once the caregiver knows the sequential problem-solving steps, (s)he can support the child in the use of this skill by gently reminding the child when and how the skill can be used, and, if needed, by helping the child apply these steps to problems as they arise. In addition, the caregiver can be encouraged to give praise for the application of this skill, in order to promote its use. Caregiver involvement can be particularly helpful for younger children who may have difficulty completing homework, identifying appropriate problems, or remembering the sequence of steps. Behavioral rehearsal, both in and out of session, will help promote generalization of this tool to the child’s life.
Adolescents
In order to competently teach adolescents to use problem solving, therapists should make adaptations that are developmentally (e.g., cognitively, emotionally, and socially) appropriate. Although the core components of problem solving are the same across developmental levels, therapists will need to make adjustments in the way problem solving is taught. Adolescents with lower cognitive functioning may benefit from the use of concrete strategies for problem solving, initially with more frequent support from therapists and caregivers. Adolescents with limited social maturity may need more assistance in generating prosocial solutions and in evaluating how others would respond to their solutions; some help in the area of perspective-taking skills may be welcome. The types of problems that adolescents face will likely differ in content from the types of problems experienced by children. For example, adolescents may struggle with developing and navigating romantic relationships, desiring more independence from their caregivers, questioning their sexual orientation, and experimenting with drugs and alcohol. While these are common developmental challenges, they can generate problems for the adolescent that can be addressed through problem solving. Before helping adolescents apply problem solving to distressing situations in their own lives, therapists should provide adolescents with engaging examples of problems to be solved that are common for youth of the same age (e.g., an adolescent girl who feels self-conscious because other classmates are spreading a rumor that she is promiscuous; or an adolescent boy who is insulted by older boys in the locker room for being small). Encouraging the active participation of adolescents in applying problem solving is beneficial: such participation helps them establish increased autonomy, empowers them, and equips them to solve problems independently. While some caregivers may be helpful and supportive of the adolescent where this skill is concerned, therapists should carefully consider to what extent caregivers should be involved; and this should be done on the basis of the developmental level of the teen as well as on the dynamic of the adolescent–caregiver relationship (e.g., the therapist should ask him/herself: “Would the caregiver’s presence facilitate or antagonize the adolescent?” If the latter, that would result in further conflict with caregivers).
