Principles of Behavioral and Cognitive Behavioral Therapies with Children and Adolescents

Erik Halgunseth

Feb 17, 2022

There seem to be so many forms of therapy it can be confusing to know if you are choosing the right one. In the following pages I would like to describe some of the features of Behavior Therapy (BT) and Cognitive Behavior Therapy (CBT). There was a growing dissatisfaction with forms of therapy that were difficult to prove and validate. About this time Behaviorism began moving to the forefront on psychological thought. It sprang from the scientific method and unlike some other forms of therapy, behavioral assessment leads directly to how to perform
the treatment.

Behavior Therapy is an off spring of Behaviorism which emphasizes the role collecting data on observable behavior (frequency of head slaps; amount of pounds lost; etc) to measure success of the treatment. BT defines how to measure behavioral success in therapy and design interventions to achieve that goal. BT has been quite successful in reducing anxiety, stimulating freedom from depression, and teaching coping behaviors.

Cognitive Behavior Therapy is a melding of Behavioral and Cognitive theory. A grounding principle is that by making one's cognitions more adaptive it will positively affect learned behaviors and emotions. Emphasis is put on challenging irrational thoughts and replacing distorted cognitions with ones that are more adaptive.

CBT clinicians usually treat children under the age of 7 exclusively with BT techniques. Children of this age group generally lack the abstract reasoning and general cognitive development to benefit from CBT procedures. As children move through the ages of 7-11 they gradually aquire greater abstract reasoning and facility to understand rational arguments. Treatment for the younger group usually requires heavy involvement of the parental figures to teach desired behaviors such as self-control. The younger the child, the more involvment from those who control the child's environment. Behavior change arises from strategic changes in the environment implemented by the child's parents and/or teachers.


This is the briefist of summaries of a very large and varied set of therapeutic techiques. Below I will outline some of the theory and key features of these therapies. A general strategy for analyzing the presenting problem in therapy is to look at the antecedent, the behavior, and the consequences. To do this three basic questions should be kept in mind. This is called the Functional Behavioral Assessment (FBA). Both BT and CBT uses this general approach but in CBT thoughts are treated as in the FBA as elements to be assessed and treated.

  • First, what events usually precede the client's problem behavior. These events may be observable behavior or covert (thoughts) ones. It is assumed that the nature of the preproblem environment often leads to the occurrence of the behavior. Usually these occur just before the behavior (being screamed at) but may extend back further (setting events). For example, a married couple may have had a disturbing argument an hour ago which leads to the husband later overreacting by yelling at his son for being too loud at home.
  • Second, What exactly is the problem behavior. The description must be specific because it will help identify the treatment. For example, if the child hits himself on the right side of his face with his right hand, an intervention might be to have him engage in a rewarded, incompatible behavior, such as pencil drawing, with his right hand. It is also important to know what the child is thinking when the behavior occurs as these thoughts may increase or decrease the intensity of the behavior. For example, a child who obsesses on a negative thought, such as, "I am ugly", before or during a problem behavior might be helped by asking him to attend to what his happening in the area around him rather than on his internal thoughts.

  • Finally, what events follow the client's problem behavior? Very often studying what follows the problem behavior leads to an understanding of what the child is really attempting to achieve or, at the very least, what is maintaining the behavior. In an environment where a child gets little attention, being repeatedly told to "shut Up" or "sit down" is better than being ignored. More frequently than not, behavior can be understood in terms of these "operant" behaviors than in the "trigger" behaviors found in antecedents.

 

Some common questions used in the FBA would be. When did the problem begin; How frequently does it occur; When and in what situation does it occur; generally, what occurs before and after the behavior; What do they think about while the problem is occuring; and what has been done to change the problem so far?

Once the problem has been assessed, it is a good time to ask about the client's assets and strengths. This helps build the child's confidence and can be incorporated into the later therapeutic recomendations as ways to reinforce desired behaviors.

The inital phase of the program often involves taking data on the behavior. Having a record of the frequency and intensity of the preprogram behavior (baseline) allows the counselor to assess the success of the program in subsequent weeks after the intervention has begun.

Primary or unconditioned reinforcers: These are reinforcers do not need to be learned (food items; tasty drinks). To learn new behaviors it is necessary to have frequent reinforcements applied and primary reinforcers are good for this purpose.

Secondary reinforcers: These reinforcements are learned through association with primary reinforcers. Social praise, like ("good job"), aquires reinforcing properties because they occur together with the primary reinforcers. Over time they may become stronger than the primary reinforcers. Check marks on a chart are an example of secondary reinforcers.

The PREMACK PRINCIPLE is defined as the behaviors that frequently occur under free choice which can be used to reinforce behaviors that have a low probability of occurence. Grandma's law is an example, ("You can have ice cream after you eat the broccoli").

Reinforcment Schedules: Behaviors are rewarded by individual occurences or by intervals of time depending on what you are trying to achieve. Frequent, predictable reinforcement is good to begin building a behavior, while unpredictable occurence reinforcement is better to maintain and generalize a behavior. A compulsive gambler receives unpredictable reinforcement when he unpredicaly wins or loses. This is why this addiction is so hard to extinguish, because he is waiting for one more unpredicatable reward.

Extinction: This is the process of discontinuing a undesired behavior through witholding reinforcement, such as, not responding when another tries to make you angry.

Shaping: This refers to rewarding behaviors that come closer and closer to the desired behavior. An example would be teaching a child to learn to say a word by rewarding successively closer approximations of the target word over time.

Negative Reinforcement NR: This is often confused with punishment. NR means that behaviors which help you escape or avoid an unpleasant situation become reinforcing. An example would be that you sneak away whenever a person you do not like comes to visit.

Punishment: Punishment refers to intervening with a person after he has performed a maladaptive response in a way that is likely to reduce the frequency of that response in the future. Some examples are, reprimands, disapproval, short term social isolation, monetary fines, withdrawal of privileges, detention, and "the silent treatment."


Punishment is limited in that it only teaches a child what not to do and not what one should do. Thus, it is desirable to always pair punishment with a reinforcable reasponse that is desired so he will know what he is supposed to do. It is better to withold priviliges than to just have a harsh punishment response. Time out is preferable to direct punishment. This is removing a child from a reinforcing environment for a period of time as a response to an undesired behavior. A child may misbehave when you are out in public and it is not possible to place him in a time-out room. He may do this because he knows you are reluctant to punish behavior in public or that you will forget about the problem when you do get home. In this case you can use marking time time out. Have a water based marker available and when he misbehaves record it with a mark on his arm or a pad. When you get home, institute the regular time out at five minutes per mark.

Response cost is a proccedure by which you assess a child a fine if a certain behavior occurs. A speeding fine is an example of response cost. If a child is on a program where he earns points for desired behaviors he could lose points for undesirable behavior.

The use of harsh punishment often produces negative side effects. The child begins to intensly dislike the punishers and is less likely to comply with their wishes. The punishing person unfortunately provides a bad role model for the child and when the child grows up he also focus on applying punishement to his chldren. Sometimes severe punishment leads to the child counter attacking the parent.

 

If some punishment is needed in a program with a child:

  1. Use it sparingly;
  2. Provide a reason for the punishment;
  3. Make other means available for the child to receive positive reinforcement;
  4. Avoid physical punishment;
  5. Do not punish when you are angry or in an emotional state;
  6. Use punishment early in the course of the behavior for maximum benefit.

 


Cognitive Behavior Therapy is represented by a great many forms of treatment. Below are a few to give you a flavor of CBT techniques.

Anger Management Techniques: These techniques work to overcome angery behaviors that are too intense and inappropriate in response to the provocation. CBT works to reduce the power of the "triggers", reframe the thoughts related to the source of the anger, and improve the client's skill set regarding self control. Assertivness Training is an important form of anger management which helps the child recognize the maladaptive nature of hostile aggression and/or passivity when facing a situation where they feel anger. The Child learns to respond in a manner that shows self respect (standing up for themselves) and respect towards others.

Cognitive Restructuring: The basic assumption of these therapies is that emotional disorders and problematice behaviors are a result of maladaptive thought patterns. The therapeutic approach then, is to challange and replace the irrational thoughts with ones which are more adaptive. For example, he might think, "I am no good at school", but this thought could be challanged by pointing out his top performance in the Auto Mechanics course.

Competing Response Training: These are a set of procedures designed to reverse habit disorders such as tics. The client learns to become aware of the triggers for the behavior or the occurance of the problematic behavior and how to replace them with competing responses that are more adaptive. For example, if a client has a habit of bouncing his right foot on the floor in social situations he could learn to cross his legs.

Covert Modeling: Older children, who have the ability to imagine what happens in social situations, they can be taught to imagine models engaging in behaviors (assertive responding, social mingiling, etc) the client wishes to develop. In place of using models to act out the desired behavior, the client could imagine a series of events through covert modeling which leads to the desired outcome.

Self -Efficacy: This is when a client develops the belief that he has the ability to cope successfully with a variety of threatening situations. Broadly, it is akin to self confidence.


Self-Instruction Training (SIT): In SIT the client is taught specific self-statements that will help him perform certain tasks or control his behavior. For example, a child might be afraid of snakes. As part of a comprehensive CBT approach he could be taught to covertly use self-statements such as "I can easily move away from that snake" or "He is more afraid of me than I am of him." Or, through direct exposure he learns that he can control his anxiety.

 


This has just been a brief window into the field of Cognitive Behavioral Therapy which is science based and thought oriented. Different therapeutic approaches are effective with a variety of presenting psychological problems. CBT is a flexible and effective tool in the hands of a skilled therapist.

Written by:

Erik Halgunseth

M.A., LPC

Feb 17, 2022

Share: