Cognitive-behavioral treatments typically begin with a focus on behavioral components. If necessary, therapists first manage suicidal symptoms. They also seek to increase the child's experience of positive reinforcement through their relationship with the child, activity scheduling and pleasant-events monitoring. The therapist provides positive incentives for the child to engage in adaptive activities, social interaction, and mastery experiences. Therapists may seek to decrease the child's reinforcement for depressive symptoms (e.g., ignore non-life-threatening depressive behaviors such as whining). Therapists also increase the child's use of self-reinforcement (e.g., pleasurable activities or self-praise) for engaging in adaptive behavior. If skill deficits exist, the therapist teaches skills (e.g., social skills, problem solving) that will help the child receive more positive reinforcement from the environment. Social skills training approaches have frequently been implemented in a group where children are taught to engage in eye contact, smile, play games, plan social activities, and make age-appropriate conversation. Children are also encouraged to decrease socially inappropriate behaviors (e.g., temper tantrums). The therapist uses instruction, modeling, role-play, shaping, practice, and feedback to help children learn new skills. Homework or take-home projects help the child generalize therapeutic benefits. For example, children may be asked to engage in pleasurable activities or to log and dispute their self-talk when feeling sad.
Cognitive therapy components aim to change the child's maladaptive beliefs, images, thoughts, and self-talk which influence their behavior and perceptions. The therapist often does so through eliciting what the child is thinking when experiencing negative mood states or during upsetting events. The child engages in affect education exercises (practice recognizing and differentiating feelings) and learns about the cognitive model in which thoughts impact feelings and behavior. The therapist helps the child identify maladaptive or distorted thinking and engage in cognitive restructuring activities. These activities include identifying the type of distortion being exhibited (e.g., overgeneralization, mind reading), weighing the evidence for and against the thought or belief, testing the belief through behavioral experiments, and substituting more realistic interpretations. To help children interact more effectively with their environment, they are taught problemsolving skills (orientation, problem definition, generation of alternatives, evaluation of alternatives, selection of alternatives, and evaluation of outcome). Younger or cognitively delayed children may not be able to engage in complex cognitive evaluation exercises and may only change cognitions through direct experiences that contradict their beliefs or the use of self-instruction/self-statements.
Given that a major source of reinforcement for children is their interpersonal environment, particularly the family, the therapist seeks to ameliorate negative or coercive interaction patterns in the family that interfere with the child receiving positive reinforcement and promote negative cognitive patterns in the child. For example, studies have established that children who are depressed often have parents suffering from depression. Parents who are depressed may neglect their children, model depressed affect, or be excessively critical. Children, in turn, may suffer from the lack of positive reinforcement and learn depressive beliefs from their experiences with their parents. Recent treatment studies have begun to include parents by providing education about depression and interventions to change parenting practices that may exacerbate depressive symptoms. Children may also experience rejection from peers and school personnel that exacerbates depression. In this case, social skills training and interventions to address the peer or school environment are required.
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