Behavioral Approaches for Children and Adolescents: Challenges for the Next Century PDF
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Behavioral Approaches for Children and Adolescents Challenges for the Next Century Behavioral Approaches for Children and Adolescents Challenges for the Next Century Edited by Henck P. J. G. van Bilsen PedologischInstitut Rotterdam,TheNetherlands Philip C. Kendall Temple University Philadelphia,Pennsylvania and Jan H. Slavenburg PedologischInstitut Rotterdam,TheNetherlands Springer Science+Business Media, LLC LibraryofCongressCataloging-in-PublicationData Onfile Proceedingsofan InternationalConferenceonCognitiveBehaviorTherapiesandApplied Behavior AnalysiswithChildrenandAdults:Challengesforthe Next Century, held July3-5, 1995,inRotterdam, TheNetherlands IIISSSBBBNNN 999777888---111---444777555777---999444000888---333 IIISSSBBBNNN 999777888---111---444777555777---999444000666---999 (((eeeBBBooooookkk))) DDDOOOIlI 111000...111000000777///999777888---111---444777555777---999444000666---999 © 1995 SpringerScience+BusinessMediaNewYork OriginallypublishedbyPlenum Press,NewYorkin1995. Soficoverreprintofthehardcover Istedition1995 Allrightsreserved 10987654321 Nopartofthisbookmaybereproduced,storedinaretrievalsystem,ortransmittedinanyformorbyany means.electronic, mechanical, photocopying,microfilming,recording,orotherwise,withoutwritten permissionfrom thePublisher PREFACE Challenges for the nextdecade as the subtitle ofa book isa statementofambition. In the present time we have to be ambitious as scientists, clinicians, and teachers. Without ambition we would not be able to confront the problems ofyoung people in an effective way. In this decade, we can see an abundance of problems of young people: football hooliganism,school drop out,vandalism,delinquency,lack ofsocialskills,aggression,and depression. The problem seems to grow. Governments, parents,and concerned citizens call for action now. Unfortunately, the action that is taken is often impulsive and not based on scientificallyproven methods: longerjailsentencesfor youngfirst offenders,puttingyoung offenders in military look-aliketrainingcamps,etc. For some reason, the usage ofeffective interventions is limited. In this, book the reader will find an extensive overview of what we know to be effective as a "cure" or prevention for the above-mentioned problems.The first four chapters will give the reader a clear insight ofwhat the"stateofthe art" is today. An integrative overview ofcognitive behavioural therapies with children and ado lescentsisgivenbyKendall,Panichelli-Mindel,andGerow.Russoand Navaltaprovidesome new dimensionsofbehavioranalysisand therapy.What behavioral approachescan offerto education is described by Slavenburgand van Bilsen in two chapters. In Part II authors from Australia, the United States, and the Netherlands describe programs for specific clinical populations: attention deficit disorder, anti-social youth, learning problems,socialskills problems,depression,and aggression. In Part III theproblemofunwillingandunmotivatedclients isdiscussed.What todo when theydon't want? Henck P.J. G.van Bilsen Philip C. Kendall Jan H.Slavenburg v CONTENTS I. Cognitive-Behavioral TherapieswithChildrenand Adolescents:An Integrative Overview . Philip C. Kendall, Susan M. Panichelli-Mindel,and Michael A.Gerow 2. Some New DimensionsofBehaviourAnalysisand Therapy. ................. 19 Dennis C. Russo and Carryl P.Navalta 3. BehaviourTherapy and Educational Reform:AReview ofStudy Findings 41 Jan H.Slavenburg 4. Unused Opportunities for BehaviourTherapy in Education " 53 Hcnck P.J.G.van Bilsen 5. Cognitive BehaviorModificationofADHD:AFamilySystem Approach 65 Harry van der Vlugt, Huub M.Pijnenburg, Paul M.A.Wels,and Aly Koning 6. Competency-BasedTreatmentfor Antisocial Youth ......................... 77 N.W.Slot 7. BehaviourTherapy with Learning Problems. .............................. 87 Chris Struiksma 8. TreatingChildren Who Lack Social Skills ina Pedological Institute School .... . 95 Ria Swager 9. StopThink Do: Improving Social and Learning Skills for Children in Clinicsand Schools 103 Lindy Petersen 10. Cognitive and Behavioral TreatmentofChildhood Depression 113 Kevin D.Starkand Anne Smith II. Cognitive Behavioral TherapyofAggressiveChildren: EffectsofSchemas 145 John E. Lochman and L. Lenhart vii viii Contents 12. Motivationas a Preconditionand Bridgebetween Unmotivated Clientand OvermotivatedTherapist 167 Henck PJ.G.van Bilsen Index 175 1 COGNITIVE-BEHAVIORAL THERAPIES WITH CHILDREN AND ADOLESCENTS An Integrative Overview Philip C. Kendall, Susan M.Panichelli-Mindel, and Michael A. Gerow TempleUniversity Dept. ofPsychology Weiss Hall Room 478 (265-67) Philadelphia, Pennsylvania 19122 In general, psychological theory and underlying world views guide psychological therapy.One beginswith ontological and epistemological assumptionsabout the worldand how humans operate within it (stated either explicitly or implicitly), and from these assumptions, one constructs either a theory ofhuman behavior or a research paradigm to study human behavior or both. In the field ofclinical child psychology there has been an increasing interest in the formulation ofcognitive-behavioral theories, especially as they relate to psychopathology and psychotherapy. These theories, tied to empirical data (i.e., observationsofphenomena),attempttoidentifyconceptsthat generalizetobroadercircum stances.This chapter providesan overview ofthe emergingand evolvingcognitive-behav ioral position, especially as it relates to psychosocial therapy with children. We will begin by brieflydiscussingthe theoretical framework on which the cognitive-behavioral position is based. Next, we will illustrate how this theory guides the therapeutic posture of the cognitive-behavioraltherapist. Inabriefreviewofthe extantliterature, weconsidercogni tive-behavioralapplicationswith avarietyofclinical problemsinyouth.Finally,wesuggest future directions for theory and practice. BRIEF HISTORY AND THEORETICAL OVERVIEW Cognitive-behavioral theory is a mediational theory and represents a hybrid of behavioral andcognitiveresearchand theory.Inintegratingthesetwoapproaches,theorists have removed the doctrinaire attitude ofstrictly behavioral theorists by incorporating the cognitiveactivitiesofthechildintotheequation.Strictbehavioraltheory(e.g.Skinner,1987) recommends the shunning of"internal" (i.e., not visible to direct observation) variables. Observable behavior represents, according to behaviorists, the only possible domain for scientific psychological research. In clinical realms, this translated into therapies, for example systematic desensitization and flooding (e.g. Wolpe, 1958), where the focus of BehavioralApproachesfot ChildrenandAdolescents, Editedby H.1.'J.G.vanBilsenctal..PlenumPress.NewYork.1995 2 P.C.Kendall et al. attentionwasprimarilyonchangingobservablebehavior.This directionradicallyconflicted with the historically-dominantpsychodynamic view ofpsychology,which held that intrap sychic forces were responsible for behaviorand therefore the crux oftherapeutic effort lay in"working through" internal conflict. The theoretical revolution which brought behaviorism into a dominant position of several recent decades lead to a counter-revolution. Cognitive theorists re-introduced "in ternal" variables into research and clinical practiceand built a body ofresearch suggesting that cognition (i.e. thought) influenced behavior. The so-called cognitive revolution pro ceeded in several directions (e.g. information-processing, connectionist theory, etc.), the details of which we omit here (see Ingram, 1986; Kendall and Hollon, 1979; Varela, Thompson,and Rosch, 1991, and others for details), and created aspace for an integration ofthe two approaches. Cognitive-behavioral theory, as described here, represents an inte gration ofcognitive and behavioral positions in the realm ofinformation-processing and social learningtheories(Kendall and Bacon, 1988). The cognitive-behavioral position, when applied to psychopathology and its treat ment, consists of several components. First, it posits that psychological problems (e.g., disorders, difficulties) result from behavioral and cognitive antecedents. For example, the distress of an anxious youth is associated with both behavioral avoidance and/or the contingencies surrounding the feared event(s) as well as cognitive appraisal,attitudes, and beliefs surrounding the behavioral events. In other words, a child who worries about interactingwithpeersdoessobecauseofpast learninghistory(e.g.,distresswhen withpeers) and cognitiveappraisalofthepast events and anticipatoryappraisal offutureevents(e.g.,a self-statementsuch as"Theywillcriticize/rejectme," reflectingabeliefsuch as"peopleare to be feared becausepeerfailure isunavoidable"). Given this framework, a therapeutic pathway becomesclear.Remedy occurs within both behavioraland cognitiverealms.Itdoes notsuffice,cognitive-behavioraltheorystates, to have a socially anxious child to face numerous social situations; nor does it suffice to simply teach coping skills. Rather, the combination represents the preferred route where behavioral and cognitive dysfunctions are addressed. Cognitive-behavioral therapy is a skill-buildingapproachthatusesknowledgeofdevelopmentaltrajectoriestoaffectnecessary change, adjusting the dysfunctional path ofa troubled youth. Acognitive-behavioral inter vention involves both the teachingofcoping skills and the practiceofthese skills inactual situations, with opportunity for feedback from the therapist. While thetheory hasgarneredmuchsupportfrom practitionersand researchersalike, cognitive-behavioral theory continuestohave itscritics(e.g.Lee, 1990).Forexample,strict behavioristscriticize cognitive-behavioral theory because itrelieson"undefinedandunob servable variables in order to explain behavior" (Lee, 1990, p. 143). This position arises from thebeliefthat while"humanbehavioriscomplex...itisdeterminedbymaterial events" (Lee, 1990, pp. 144). Wemaintain that human behavior is complex and multi-determined. We are sceptical that behavior will find simple, linear explanations in material causes. Although so-called "internal" causes are not observable, we believe that cognition and emotioninfluencebehaviorinwaysthatsimple stimulus-responserelationshipsoften cannot explain. Because of its stress on cognitive and behavioral factors, one could argue that cognitive-behavioral theory and practice fails totake emotion into account. Kendall (1991) described how cognitive-behavioral theory includes emotion.Cognitiveappraisal ofaffect, for example, iscritical intheetiology ofmany childhoodand adolescent disorders.Never theless,cognitionand affect are interrelated:thevarianceinetiologyofsome disorders may be best accounted for by cognitive assessments and analyses (Kendall, 1991) while other disorders may find best explanation from within otherperspectives(e.g.emotional, behav- Cognitive-BehavioralTherapieswith Children and Adolescents 3 ioral). This position underscores the cognitive-behaviorist's beliefin the multi-determined natureofhuman behavior. Cognitive-behavioraltheoryconsiderscontextsuch asthesocial/interpersonal world of the child. These contexts provide the behavioral settings in which events impact the functioning ofchildren and youth.Unfortunately, the precise role ofthese contexts has yet tobewell researched.Forexample,althoughparentsareconsideredimportantintheetiology ofseveral childhood problems, we remain uncertain ofthe specific role(s) they play. The cognitive-behavioral theorist and therapist seeks to determine the effect of the familial (school, peer) contexts on the development (both "normal" and maladaptive) ofyouth. Considerationofdevelopmental pathwaysrepresentsan under-investigated but criti cal arena that cognitive-behavioral theorists and therapists have begun to explore. Cogni tive-behavioral theory allows for abroaderframework within which tostudypsychological problems.Cognitive-behavioral interventionsare designed with at least two developmental considerations in mind. First, the current developmental level ofthe child (i.e. cognitive ability, current developmental challenges) is assessed to affect the thrust and inform the interventiontobeused.Forexample,ayoung,cognitivelyimmaturechildmightbenefitless from long,didactic sessionsand would bebetterservedby brief, activesessions,oftenwith the cognitivecontentofthe sessionoccurringinvivo.Second, the intervention isbest when it occurs in the context of the developmental challenges facing the child. Therefore, a cognitive-behavioral therapist seeing a child dealing with separation anxiety at age nine intervenes within the appropriate developmental challenge (i.e. issues ofautonomy). Cognitive-behavioral theory represents an amalgam of behavioral and cognitive positionswith an integrationofemotionaland contextual factors:the theoryremainsflexible toreformulationinaccordwithdata. However,theflexiblenatureofthecognitive-behavioral position leaves the theory vulnerable to the criticism that it fails to take a true position. Because we do not maintain that the theory can explainall ofhuman behavior,the theory's weaknesses are acknowledged from the start. In this sense, cognitive-behavioral theory is not so much a theory as its isan approach to theory formulation and, more importantly to this paper,an approach to therapy.It isadata-driven, hypothesis-testingapproach,combin ing cognitiveand behavioral interventions into anew -and hopefully more useful -hybrid. THERAPISTS' ROLES AND COGNITION Posture ofthe Therapist The cognitive-behavioral therapist plays a number ofroles when treating children and adolescents.Theseroles can bedescribedasconsultant,diagnostician,and educator.As aconsultant,the therapisthelps thechildtodevelopskillstothink independentlyratherthan providing specific solutions to the child's problems.Both therapistand child collaborate in this problem-solving effort, together generating ideas to try and to evaluate in an effort to helpthechildhandledifficultiesheorsheisexperiencing.Thetherapistprovidessuggestions for the child to think about and describes experiments to use to determine whether these ideas have value for the individual child. The child is given the opportunity to "test-out" these ideas, implementand practicethosethat seem most helpful,and intheprocessexamine and correctdysfunctionalbeliefs.The therapistandchildshareexperiences,and the therapist helps the childto makesenseoftheexperiences-all without telling thechild what to do.In this way the therapist facilitates the processofproblem-solving, without providing specific solutionstoproblems.The therapist fosters the child's independenceand affordsopportuni ties for the child to think and problem-solveon his or her own.
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