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Fundamentals and Applications of Cognitive-Behavioral Therapy with

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 85

B J Psychotherapy
Brazilian Journal of Psychotherapy
15 number 1,
Volume 16, 3 20144

REVISION ARTICLE

Fundamentals and Applications of Cognitive-Behavioral

Therapy with children and adolescents

Juliana da Rosa Purezaa

Agliani Osório Ribeirob
Janice da Rosa Purezac
Carolina Saraiva de Macedo Lisboad

a
Psychologist and Master in Psychology - Universidade do Vale do Rio dos Sinos (São Leopoldo/RS).

b
Psychologist and specialist in Clinical Psychology - WP Centro de Psicoterapia Cognitivo-Comportamental
(Porto Alegre/RS).

c
Psychologist and Doctor in Psychology - Pontifícia Universidade Católica do Rio Grande do Sul (Porto
Alegre/RS).

d
Psychologist and Professor/Researcher at the Pontifícia Universidade Católica do Rio Grande do Sul
(Porto Alegre/RS).

Institution: Pontifícia Universidade Católica do Rio Grande do Sul

Resumo

Embora a Terapia Cognitivo-Comportamental (TCC) com crianças e adolescentes esteja crescendo

significativamente no contexto das psicoterapias, atualmente ainda são poucos os profissionais que têm
conhecimento de como é realizada a terapia de crianças e adolescentes na abordagem cognitivo-
comportamental. Este artigo tem como objetivo apresentar um panorama geral sobre os aspectos teóricos

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86 JULIANA DA ROSA PUREZA, AGLIANI OSÓRIO RIBEIRO, JANICE DA ROSA PUREZA, CAROLINA SARAIVA DE MACEDO LISBOA

e práticos da TCC com crianças e adolescentes. São apresentadas as características da TCC com crianças e
adolescentes, assim como as principais diretrizes para a avaliação da TCC na infância e adolescência e para
o treino de pais. Ainda, são descritas as principais intervenções cognitivas e comportamentais na infância
e adolescência, de modo a desfazer mitos e confusões acerca da aplicação das técnicas. Em seguida é
apresentado o caso clínico de uma criança atendida em TCC, de modo a servir como exemplo ilustrativo e
proporcionar um maior entendimento acerca do manejo e adequação das técnicas aos objetivos da TCC
com crianças e adolescentes.

Palavras-chave: Terapia Cognitivo-Comportamental; Crianças; Adolescentes.

Abstract

Although cognitive-behavioral therapy - CBT focused on children and adolescents has been growing
significantl1y in the context of psychotherapy, still nowadays there are few professionals who have
adequate knowledge of how cognitive- behavioral approach for children and adolescents is performed.
This article aimed to present an overview of the theory and practice of CBT with children and adolescents.
The characteristics of CBT with children and adolescents were presented, as well as the main guidelines
for the evaluation of CBT in childhood and adolescence and training programs for parents. Still, the main
cognitive and behavioral interventions in childhood and adolescence have been described in order to
demystify myths and confusion about the application of techniques. Then a clinical case of a child that has
received psychological treatment in CBT was described in order to serve as an example and provide a
greater understanding of the management and adequacy of the interventions and techniques with the
goals of CBT with children and adolescents.

Keywords: Cognitive behavior therapy; Children; Teenagers.

Introduction

Psychotherapy with children is an area that is becoming the focus of interest in recent years, especially
in the context of promotion and prevention1. In fact, recently the psychological treatment of children and
adolescents has been considered not only as a therapeutic measure, but mainly as a way to prevent
mental illness and promote health2. Added to these facts also the movement in defense and recovery of
early diagnosis in childhood to find more effective treatments and prevention of psychopathology in
adulthood1.

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 FUNDAMENTALS AND APPLICATIONS OF COGNITIVE-BEHAVIORAL THERAPY WITH CHILDREN AND ADOLESCENTS 87

One of the current theoretical approaches that have shown therapeutic proposals in relation to the
care of children and adolescents is the Cognitive-Behavioral Therapy (CBT). In the context of psychotherapy,
CBT is a theoretical approach that can be considered recent, developed in the 60s by Aaron Beck from the
assumption that how the patient processes and interprets situations is what causes suffering 3. The goal of
Cognitive-Behavioral Therapy is to achieve flexibility and reframing of pathological modes of information
processing, since it postulates that individuals do not suffer from the facts and circumstances in themselves,
but by the distorted and rigid interpretations that they make of them 4. It is already possible to find
scientific evidence in literature that this treatment modality is effective for a large number of psychiatric
disorders and psychological demands5,6.

This clinical oriented theoretical approach was primarily directed to adult care, since some of the
4.7
techniques used initially require some degree of cognitive maturity . However, we observe that, from
the 1980s, the works related to Cognitive-Behavioral Psychotherapy with children and adolescents begin
to grow and provide more consistency 8, which may be related to constructivist models within the cognitive-
behavioral approach9-10.11, which emphasize proactive and dynamic role of individuals in their experiences.
These approaches retake the importance of interventions focused on emotions and interpersonal nature
of knowledge construction. The so-called third wave Cognitive-Behavioral Therapy12, which proposes
interventions that focus on the adaptive role of emotions, enabled a broadening of vision and improvement
of CBT treatments with children and adolescents.

Along this same line of reasoning, if observed, in common sense, some mistaken beliefs that underlie
the cognitive-behavioral approach can not base psychotherapy with children and adolescents. This difficulty
to discern the applicability of CBT in childhood has led to several “myths” about its carrying out, which
often hinder the dissemination and access to child and adolescent psychotherapy in this theoretical
approach and may also be related, since this is an area that still needs development and investment. The
main myths about CBT in childhood and adolescence can be identified in Table 1.

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Table 1

Major myths about CBT in childhood and adolescence:

Contrary to what is often imagined about the CBT with children and adolescents, there are many
similarities with respect to this attendance approach with the approach used with adults. Especially, it is
emphasized, for example, the focus on the present, the objective of behavioral and cognitive changes,
the use of structured sessions, among others. However, the approach to children and adolescents differs
with respect to the type of intervention, which is based on the creation of languages (often nonverbal)
to access the cognitive functioning of children and adolescents. In addition, treatment with children also
has other differential points, such as intervention with the parents, which often consists of a large, and
sometimes even the largest, part of the treatment. Therefore, the focus of interventions in CBT with
children and adolescents, as well as focus on activation and understanding of emotions - which young
people have difficulty differentiating from thoughts - should also work in terms of adaptive and non-
adaptive thoughts (“that help and do not help”)4,14.

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 FUNDAMENTALS AND APPLICATIONS OF COGNITIVE-BEHAVIORAL THERAPY WITH CHILDREN AND ADOLESCENTS 89

Currently there are few professionals who have knowledge of psychology and conduct consultations
with children and adolescents in cognitive-behavioral approach. There are still many distorted beliefs
that complicate the dialogue between different theoretical lines, often hindering discussion of cases and
referral of patients. Unawareness or lack of knowledge of how it is possible to conduct CBT with children
and adolescents is reinforced by the distorted belief that CBT with young people would be a direct
transposition of the techniques used with adults, which certainly does not make this field of intervention
effective. The still scarce dissemination of scientific studies on the effectiveness of specific techniques
for children and adolescents, as well as intervention protocols, scientifically developed and tested, also
favors this unfamiliarity and difficulties for the referral of young people to the CBT clinic. Thus, the aim of
this paper is to present an overview of the theoretical and practical aspects of CBT with children and
adolescents.

Assessment of CBT in childhood

Increasingly it can be seen that children and adolescents come to the psychology clinics, seeking
help for emotional and behavioral problems, which may cause harm to their life quality and subsequent
development. Thus, it is critical that therapists seek to gain an overall understanding of the global
functioning of the child, in their various contexts, and be able to identify the aspects and / or symptoms
that hinder their adjustment to daily routine, as well as the role that cognitive aspects play in the etiology
of these problems and disorders2. Is also emphasizes the focal and directive nature of CBT, which requires
a properly conducted diagnostic evaluation3,4.

Therefore, the practice of child CBT assessment has some important aspects that need to be
considered: a) identify and understand the complaints of the child and / or adolescent b) cognitive
conceptualization process. Normally, the spokesmen of complaints and symptoms are the parents and /
or caregivers. It becomes important to conduct a thorough anamnesis, for it is through this process that a
better understanding of the emotional aspects (links established, prevailing mood, how he reacts to
various life situations), psychosocial (family relationships, interpersonal, academic) which are planned
and addressed towards future conduct, are obtained. The clinical practice of CBT shows that the more
complete the anamnesis, regarding a child and adolescent, the better the planning and conducting of the
case. This stage allows the assessment of children’s use of scales and questionnaires to be answered by
parents and often by the child, teacher or other specific professional who has direct contact with him or
her 4,2.

More specifically, in the performing of a childhood in care CBT evaluation, should investigate whether
the data relating to the prior history of the child - pregnancy, childbirth postpartum, maternal diseases
and other intercurrences - as well as the conditions of their development - neuromotor development,
language, feeding, habits developed by the child and family history (health, economic, occupational,

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religious and other conditions). In addition, understanding how the child relates to his parents, siblings
and other family members is extremely useful for the construction of diagnostic hypotheses of the case15.

School life (in the case of children already attending nursery school or a regular school) should also
be included in a child’s assessment, because academic performance and relationships with peers provide
data that can contribute, in a specific way, in this process. How the child behaves in the classroom, what is
his relationship like with authority figures and how he adapts to the specific standards of the school are
valuable data in the investigative process of the cognitive and behavioral aspects of children and
adolescents. It is essential that this anamnesis seek to identify the first symptoms and the evolution of
cognitive and behavioral difficulties presented by the child. The investigation of the prior history
contributes significantly to the characterization of the onset of symptoms and behavioral difficulties
presented by the child and adolescent when delivering care in CBT16.

From the realization of the anamnesis the next step of treatment is cognitive conceptualization of
the case. CBT in this process is crucial to a full understanding and planning therapeutic practices to be
2.17
worked on with the patient . Cognitive CBT conceptualization in childhood and adolescence denotes
some differentiated aspects with respect to the same process in adult patient CBT, because the
characteristics of the child, as well as the stage of development in which he is at and the context in which
he is inserted must be always considered2.

Since CBT focuses on the role that cognitive aspects play in the etiology of difficulties and / or
emotional and behavioral disorders in children, it is common to use specific protocols on cognitive
conceptualization process. In a general way, these protocols seek to cover mainly the following demands:
a) identification of the child’s current difficulties; b) important factors of childhood; c) the perception the
child has of himself and of others, as well as the perception the family has of the child, always trying to
identify the main emotions, thoughts and behaviors regarding the child and his relatives, and also related
beliefs, compensatory strategies and the consequences of each situation8,18.

The protocols of child cognitive conceptualization must be reviewed and reassessed throughout
the process of psychotherapy, since CBT for children and adolescents is a dynamic process and undergoes
constant changes, sometimes faster than in the care of adults, which is a point that reinforces the importance
of psychotherapy with young people in this theoretical approach.

Some authors highlight cognitive conceptualization models that emphasize the focus on different
emotional intensities of each specific situation, as well as the ability to solve problems in different
conflict situations. In this investigation, you should have as its central focus the current problems related
to the child’s thoughts and what are the difficulties in processing information related to the dysfunctional
behavior of the child2. This process of realization of cognitive conceptualization is key to the diagnosis in
child CBT, as well as for therapeutic planning being implemented. In the case of child CBT, some techniques

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 FUNDAMENTALS AND APPLICATIONS OF COGNITIVE-BEHAVIORAL THERAPY WITH CHILDREN AND ADOLESCENTS 91

and resources can be used in the conceptualization and diagnosis process, such as drawings, toys, games
and others. It should be taken into account which form of cognitive access is more effective with a particular
patient. A very interesting and available resource for child and adolescent therapists is the Emotions,
Thoughts and Behavior Pack of Cards; a therapist tool that can facilitate access to the cognitive content of
the child19,20,21,7.

Therapeutic interventions with children and adolescents

Working with the parents

Interventions with parents in CBT of children and adolescents may occur in different forms and at
different times of the treatment, according to demand. In general, with children 0-6 years, working with
parents is essential, often constituting most of the treatment 2. From this age on, with older children and
teens, this work is considered desirable being a factor of strengthening and successful treatment.

Parents and caregivers, when participating in the attendance of the child or adolescent, may play
different roles in the treatment: facilitators - the intervention is predominantly focused on the child and
parents are involved only to become aware of the interventions being undertaken with children ; co-
clinical - the role of parents is more active in the treatment, in order to understand the intervention,
monitor and supervise the use of clinical strategies and assist in achieving attendance; customers - the
focus of treatment is in the direct cognitive and behavioral functioning of parents, and they will be helped
to reevaluate their beliefs about children and change their behavioral patterns 2.

It is crucial to emphasize the importance of the relationship of the the therapist with the parents as
a fundamental and essential factor of any CBT attendance for children and adolescents. In this type of
attendance,, parents are the main source of data for the therapist often the main agents of change in
children’s lives, and are responsible of concrete form (with respect to attendance and payment) for
treatment, and disruption of the bond with the parents is the main risk factor for dropping out of care15,7.

Training parents

Within this perspective about working with parents in children and adolescents psychotherapy, it is
common to conduct parent training (PT) in the cognitive-behavioral treatment program of children and
adolescents. PT enables the therapist to investigate, focus and modify cognitive and behavioral aspects
of parents regarding their child’s behavior. In clinical practice, it is possible to observe positive changes,
sometimes faster, in the child’s behavior when the parents are able to understand the symptoms and the

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child’s functioning and act positively in this process, allowing changes in their children’s actions and
attitudes.

PT in CBT for children and adolescents is a program of psycho-education and parental guidance and
is aimed at helping and encouraging them in the management and conducting of their children with
behavioral difficulties who have impairments in their functioning and life quality. This approach equips
the parents for learning and the use of techniques and strategies for handling specific situations,
encouraging people to learn more adaptive behaviors for parents and children22,23.

In practice, one can see that the PT programs bring some benefits for child CBT: a) allow parents a
better understanding of their role in the management of their own child; b) provide an “adequate” space
so that they can exchange information and talk about the difficulties experienced in raising and educating
children; c) provide the transfer of control from the therapist to the parents because, with learning,
parents end up managing more appropriately and effectively the various situations involving their
children 24.

In general, PT programs have demonstrated efficacy in the management of specific situations, such
as dysfunctional behaviors (tantrums, intransigence, oppositional behavior), and provide a better
development of social skills in children with difficulties in interpersonal relationships, and behavioral
problems 4.22 23. Besides that, they can be applied to the most diverse clinical conditions such as Disruptive
disorders, particularly Attention Deficit Hyperactivity Disorder (ADHD) and Resister Defiant Disorder RDD),
anxiety disorders, eating disorders, pervasive developmental disorders, learning difficulties, and others,
stimulating and facilitating the development of functional skills in these families25,23.

Clinical practice demonstrates that disruptive disorders are clinical conditions that are most being
addressed by the PT programs, since these approaches help the parents to acquire important resources
for family relationship, stimulating the communication, assertiveness and civility capacities22,26. These
disorders usually cause important antisocial losses, generating involvement in family, school and social
areas, as well as one of the causes of truancy for children who exhibit such symptoms and behaviors24.
Due to the importance of this resource in child and adolescent CBT, the parent training programs can
present differentiated modalities, depending of the case being treated. Referring to treatment modality,
the most usual is the use of group attendance programs for PT. However, these treatments can be
performed individually, encompassing only the child and his parents25,23.

PT protocols usually follow some assumptions, such as: evaluation of the characteristics of children
and their families, presenting the program to the parents, parental process of psycho-education regarding
the clinical and behavioral conditions in children, teaching specific techniques and management strategies
for every situation or clinical condition, with the aim of encouraging more adaptive and healthy behaviors
in children and their parents.

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 FUNDAMENTALS AND APPLICATIONS OF COGNITIVE-BEHAVIORAL THERAPY WITH CHILDREN AND ADOLESCENTS 93

Finally, an overall evaluation of the program and its effects on the lives of participating families is
performed. In this process, the therapist can make use of various instruments such as scales, questionnaires,
inventories, and other interviews, as well as, specific protocols that can be developed or adapted, Barkley
(1997) being the most used model in PT programs23,27.

Among the subjects most worked on in PT programs, are the techniques for Management
Contingencies and Social Skills Trainings, as well as Parental Psycho-education process. However, the
choice of techniques depends on the specific clinical condition in question and the objectives of the
program, and many resources are available for the therapist, as stimulation of skills for Troubleshooting,
Monitoring Behaviors (saving chips), Anxiety and Stress Management, among other28,29,30,31,32. In general,
parental training programs are developed in a specific time period, a total of 12 sessions, which occur
once per week being the most common. Moreover, considering the new family configurations, common
nowadays, it is necessary to mention that these trainings can count with the participation of other family
members, such as grandparents, uncles and aunts and anyone else directly linked to child behavior, as
well as the school community, because the change of the child’s behavior at school can be one of the goals
of the CBT23.

Working with the child

The work of the therapist in CBT with children and adolescents begins before the patient arrives,
from the preparation of the room and the choice of toys. The room should include some basic items (such
as a toilet, for example), and varied toys that can assist the child in the expression process (e.g.: clay and
drawing material), for identification processes (such as a family of dolls, animals and other characters),
plus structured games (both cooperative and competitive, which allow the evaluation of the child’s
processes). Furthermore, it may be interesting to have useful toys for metaphors in the work of cognitive
restructuring (such as magnifying lenses, glasses, scales, etc.). It is important before starting the attendance,
always to check the child’s preference and history in order to adapt materials and toys before the session.
Still, as the child is able to understand the logic of things, but their thinking is still developing, resources
for concrete representation of the concepts are also needed 7.

It is essential that, in the first session with the child, parents be instructed to explain to him why he
is going to a psychotherapist. It is interesting to include the whole family in the problem, to eliminate the
punitive aspect of treatment. From that first session, according to the demand and the child’s diagnosis,
cognitive and behavioral techniques, which are described in more detail below, will apply.

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Interventions with children and adolescents

Techniques for the identification of thoughts and feelings

It is during early childhood that human emotions begin to develop, forming a characteristic pattern
and acting in the formation of personality33. Regardless of the child’s diagnosis, it is important that they
know how to identify their emotions and those of others, as this will interfere in the types of relationships
that will be established throughout life. Emotions are a mixture of subjective sensations and physiological
states which all people experience and express in different ways, and even though emotions are subjective
responses of the individual, they are practically the same in all cultures of the world34.

To help children understand and identify emotions, Caminha and Caminha (2011) developed the
Playing Cards of Emotions. This deck consists of 24 cards, each containing an expression of an emotion.
Among them are included 6 cards with six basic emotions, e.g.:, the first emotions felt from an early age,
which are love, sadness, joy, anger, fear and disgust. These emotions will be extended to more complex
emotions during the child’s development33.

Another way that can be used to help children identify their emotions and their thoughts is a
technique called Clock of Thoughts-Feelings. This clock is made during the session together with the
patient, and in place of numbers the patient will draw small faces depicting emotions. The idea is to help
the child realize and understand his feelings and show them that their emotions change and pass, as well
as time changes and passes. Through the hands of the clock, the child can indicate what he is feeling at
that moment, and the therapist can help identify the thoughts that are leading him to feel like this.35.

When working with children, you must take into consideration what age he is and the stage of
development he is at, for choosing the most appropriate technique or intervention. Young children often
do not respond well to questions or directive issues . Therefore, for these children to identify their
emotions, one can use Developing Story Techniques. These stories should be similar to the situation
experienced by the child and that is generating certain emotions in everyday life. The characters can be
animals or any character that does not directly refer to the patient. Thus, the child can identify with the
situation and the character can say, even indirectly, what it is feeling or even thinking.

Techniques for psycho-education

Psycho-education has the key role to guide the patient for their functioning, diagnosis, symptoms
and the treatment itself, facilitating the process of change15. In child psychotherapy, psychoeducation
technique is usually performed with both the parents and to the children themselves, but the way it must

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be done should respect the age and developmental stage in which the patient is in. With younger children,
you can make use of an Indirect Psycho-education , e.g.: through metaphors, stories or characters that do
not relate directly to them. For aggressive behaviors, for example, one can work with the Metaphor of the
Superhero The Incredible Hulk*, for example, identifying together with the child, the feeling of anger, as
it appears in the body and what he does when it feels like this . The Volcano Metaphor can also be used,
that represents the human body and the lava as the anger, since the volcano starts heating up until it
erupts and from its inside, the lava flows out.

Contact with stories is common in childhood, which makes children feel comfortable dealing with
and talking about stories and tales15. The story “Out of my mouth snakes and lizards come out,” for
example, tells of a boy who is being dominated by snakes and lizards that come out his mouth all the time,
so other people begin to turn away from him. Through this story, psycho-education of aggression, the
boy’s feelings and of the repercussions that his behavior has on other children36. A Directive Psycho-
education can also be quite helpful with children, as far as it maintains the childish character of playfulness.
To educate how feelings appear in the body, the child can, for example, draw the shape of the body or
draw a boy or girl, choose a color that represents the most frequent emotions and paint the place of the
body where they appear and the shape with which they represent the feeling.

Techniques for the solving of problems

A technique commonly used in CBT with adults is Technical Troubleshooting, which consists of
specifying a problem in order to project viable solutions and, in this way, select a solution that is followed
by the implementation and evaluation of its effectiveness3. This technique can be adapted for use with
children considering that, at this stage of development, they are starting to learn to solve problems of
different complexities, and often tend to experience difficulties in solving these problems.

Among the techniques adapted for children, there is the Hero’s Mask, in which the patient chooses
a hero, that can be characters, famous people or even parents and teachers, and then sticks the figure of
the hero on a mask. By using the mask and “becoming” the hero, the child begins to see another perspective
of the problem and can feel empowered. He is encouraged by the therapist to explore all alternatives to
his problem and select the best option to solve it. Being a hero, the child can challenge dysfunctional
beliefs and recognize resources it possesses to deal with the situation, generating self confidence35.

Behavioral Techniques

Behavioral techniques are widely used in the treatment of children and adolescents, because,
depending on the age of the child and of his demand, this may present more difficulty paying attention to

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their cognitions and monitoring them than in adults, so the use of behavioral interventions is preferable15.
Accordingly, behavioral techniques reduce the intensity and frequency of dysfunctional behaviors and
increase desired behaviors.

Among the behavioral techniques, Relaxation Techniques are quite useful for patients with different
demands, but mostly in anxious patients, since in addition to psychological processes, these techniques
have an influence on physiological responses that affect the physical symptoms of anxiety 15. Progressive
Muscle Relaxation is widely used in adults and is also used in children in an adapted way. It is a technique
in which patients are led to tense and relax different muscles in turn. To be used with children, this
technique must be adapted in order to obtain greater patient compliance. There are some adjustments
such as to imagine the body rigid like a robot, then limp as a rag doll and then ask the child to describe how
they felt each time38.

Another important technique is Diaphragmatic Breathing Training, which also helps in relaxation.
For this, it is indicated that the patient breathe in and out slowly and deeply. With children, soap bubbles
can be used, therefore for the bubbles to form, the child should be blowing slowly, which helps regulate
breathing and causes distraction of the physical symptoms caused by anxiety. Soap bubbles can also be
used with children who have difficulty tolerating frustration, which leads to irritation and anger36.

The Graduated Exhibition, widely used technique with anxious adults that aim to achieve a goal, but
do not feel capable 3, is crucial in the treatment of children with different types of anxiety. The use of
metaphors, in this case, also helps the child to engage in the technique. In the first place, the goal is
defined; after that, the goal is divided into a “step by step”, explaining to the child that it will be, for
example, as a staircase that he will ascend step by step up to the top, or like a video game that he will have
to beat each stage as a challenge. Together with the patient, a hierarchy is established about the degree
of difficulty. At each step achieved, the therapist should reinforce the patient, encouraging him to continue.

Another behavioral technique very useful in child treatment is the Economy of Chips. It serves to
help children increase appropriate behavior through positive parental attention for these behaviors. The
technique works as a system of rewards and points and wherein the first selected are the desired behaviors.
It should be begun with a few behaviors, one to three, depending on the age, then a number of points for
each behavior is established. Each time a child makes the desired behavior, she gets chips with the
39.40
relative points . The therapist will define how many minimum points the child must collect weekly to
be able to exchange for pre-established rewards. Each reward also has different values ; so the more
tokens the child collects, the better the rewards will be. It is always important to remember that it is not
recommended that the rewards be food, money or any material thing of high financial value. Ideally they
39,40
are leisure activities and preferably together with the family .

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Cognitive Techniques

Cognitive techniques have been increasingly developed and adapted for child therapy. There are
different cognitive techniques used with children, including the Analogy of the Stop Lights, which was
developed through the FRIENDS program. This technique teaches the child to identify and classify different
types of thoughts: “Red thoughts,” those unproductive, negative and preventing welfare; “Yellow
thoughts”, which serve to reflect; and “Green thoughts” that are productive and that encourage well
being 41.

To help the children understand and transform dysfunctional thoughts into functional thoughts, the
Analogy of the Caterpillar can also be used. In this case, the caterpillar, which are negative thoughts, is
transformed into a butterfly, which are positive thoughts 42. The purpose of this technique is to teach
them to classify thoughts as those that help and those that hinder us, always in an illustrative and concrete
way.

The Scales of Advantages and Disadvantages, a technique used for decision making, is important in
child treatment. For this technique, the therapist can cut out a small paper scale, leaving the two movable
arms to weigh. On one side, the patient writes the advantages and the disadvantages on the other. Each
item or argument written on it makes it tilt the scales down, the end being more geared towards the side
that has more arguments, supporting, in this way, the decision to be taken.

Presentation of a clinical case of CBT in childhood

Fernando**1 is 9 years old, lives with his parents and older brother. Fernando’s parents sought help
for their son because he is having difficulty staying in the classroom or anywhere else where he needs to
stay away from his parents or older brother who is 15 years old. Fernando is very anxious, and every time
he is away from his parents or brother he thinks that something bad might happen to them or to himself.
When they are close by, he manages to stay more relaxed.

According to the parents, the boy always been that way, but the anxiety and concern have increased
even more. During class he calls his mother many times to know how she is, coming to call five times in
half an hour. He also calls at the end of class to make sure they are going to pick him up. The anxiety felt by
Fernando is at such a high level that he starts to cry and throw up at school, and often his parents had to
pick him up before the end of the class.

**1
The people responsible consented to the submission of the case and the personal data and the description of the
patient were altered by the author to ensure the anonymity of the child and make his identification impossible.

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98 JULIANA DA ROSA PUREZA, AGLIANI OSÓRIO RIBEIRO, JANICE DA ROSA PUREZA, CAROLINA SARAIVA DE MACEDO LISBOA

Fernando has no learning problems and has good marks. According to the teachers, he has a few
friends, but has not been able to interact with them, being usually alone.

At home, this also happens: he becomes very anxious when someone is late to arrive, asks to call
and check if all is well. Does not want to be alone not even if his mother goes to take the garbage down.
Fernando’s father also suffers from anxiety, but never underwent treatment. The mother is overprotective
toward the child, as with the older brother.

From sessions with Fernando, the diagnosis of Separation Anxiety was reached. After the diagnosis
the confection of the cognitive conceptualization diagram, which culminated in Table 2 was worked out.

Table 2

Cognitive Conceptualization Diagram of a Clinical Case

Relevant data of the case history

Anxious father. Overprotective mother. Also overprotective elder brother.

Central belief

"I am vulnerable." "The world is dangerous."

Conditional beliefs

"IF I am vulnerable, then I must stay together with my parents"

"IF the world is dangerous, then my family and I must remain together all the time"

Compensation strategies

Does not want to stay alone or far from his parents and his brother; controls the time when
someone goes out; calls his parents to make sure everything is all right; worries about his family's
safety.

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 FUNDAMENTALS AND APPLICATIONS OF COGNITIVE-BEHAVIORAL THERAPY WITH CHILDREN AND ADOLESCENTS 99

At the beginning of treatment with Fernando, the Deck of Emotion Cards was used. Fernando was
asked to select the cards with the emotions that he were feeling most lately. He selected the cards
referring to “worry” when he thought that something bad might happen to him or his parents; “Fear” of
being alone or that some stranger might harm him; “Joy” when the family is together; and “Pride” when
he manages to go to school without fear.

Then a Directive Psycho-education about fear and concerns was performed. Fernando was asked to
choose colors to represent these emotions and to paint in the drawing of a boy, where these emotions
appeared on his body and what size they were.

Fernando painted, throughout the length of the abdomen of the child, in black and red, stressing
the heart. Fernando was also asked to imagine his fears and concerns as having a shape and what would
that shape be like.

Now, the patient drew a “really ugly monster” (sic) black and red and called it the Monster of
Worries. It was fundamental in this case, that the patient was able to externalize his emotions in a creative
way and as something separate from himself, and that, consequently, he can face.

It was later explained to Fernando that this monster looks quite large, and every time he escapes
from the monster, it strengthens and grows even more but, that if he decided to face the monster, it
would become so small it would fit in the palm of his hand.

Then, the patient and the therapist drew both situations: he running away and the monster becoming
enormous and after that, the boy confronting it and the monster becoming very small. In order to be able
to confront the monster through the Graduated Exhibition, Fernando had to pass through several stages,
and when he reached the final stage, he would beat the monster and win a medal as a reward.

To help him face his tasks, he was taught the Soap Bubble Breathing, for him to do whenever he felt
anxious. A list was made for each stage to be overcome. The first of the stages was for Fernando to spend
one day a week, at least, without calling his mother at the end of classes. He managed to do it. In the
following weeks the days he could not call his mother began to increase. Then, he also could not call his
mother during the school breaks. Soon he went with his classmates to a school outing and, little by little,
he was able to overcome his fears.

With the passing of time, Fernando was becoming able to do what he most liked, which was playing
football with his classmates and have fun. So as agreed, Fernando won his gold medal. The therapist
asked him to draw the Monster of Worries now that he had managed to face it. Fernando then drew it as
a prisoner, with bars and chains, stuck on a desert island, surrounded by sharks where he would not leave
so easily.

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100 JULIANA DA ROSA PUREZA, AGLIANI OSÓRIO RIBEIRO, JANICE DA ROSA PUREZA, CAROLINA SARAIVA DE MACEDO LISBOA

Final considerations

This article aimed to present an overview of the theoretical and practical aspects of CBT with children
and adolescents and finish with the illustration about a clinic case. From the presentation of the CBT
characteristics with children and adolescents, as well as the main guidelines for CBT assessment in
childhood and cognitive and behavioral interventions in childhood and adolescence, we sought to dispel
myths and misunderstandings about CBT with children and adolescents, reinforcing this clinical practice
and the effectiveness of this theoretical approach. The description of a case history of a child attended to
in CBT had as its aim to serve as an illustrative example and foster reflection, providing a greater
understanding of the application and suitability of the technical goals of treatment.

As in other theoretical approaches, clinics with youngsters must be fostered and stimulated in a
preventive sense and also increasing and valuing the attention to psychological distress in childhood and
adolescence, which, unfortunately, can exist and that, however difficult it is to identify it, can not be
neglected. Besides being of fundamental importance for the promotion of resilience at an early stage of
life, that can ensure a healthy development throughout the life cycle, the cognitive-behavioral work with
children and adolescents is dynamic, stimulates creativity and is extremely gratifying. Within this context,
the childhood and adolescence cognitive therapist must exercise his practice with sensitivity and creativity,
with the certainty that each child is a unique and special being and that working with children can contribute
significantly for the clinical and personal enrichment of the professional.

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 FUNDAMENTALS AND APPLICATIONS OF COGNITIVE-BEHAVIORAL THERAPY WITH CHILDREN AND ADOLESCENTS 101

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Correspondence
Juliana da Rosa Pureza
Av. Ipiranga, 6681, Partenon, prédio 11, 9º andar
90619-900 Porto Alegre/RS
julianapureza@yahoo.com.br

Submitted on: 01/01/2014

Reformulations requested on: 01/15/2014
Returned by the authors on: 01/29/2014
Accepted on: 02/05/2014

REVISTA BRASILEIRA DE PSICOTERAPIA 2014;16(1):85-103

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