Terapie Cognitiv Com. La Copii

7/29/2019 Terapie Cognitiv Com. La Copii

1/11

Viorel Lupu 19

PARTICULARITILE PSIHOTERAPIEI COGNITIVCOMPORTAMENTALE LA COPIL I ADOLESCENT

Viorel Lupu1, Iaela Ramona Todiri2

REzUMAT

Terapia cognitiv la copii este o extensie a undamentelor terapiei comportamentale bazat pe teoria nvrii clasice, operante iprin modelare, putnd util n tratamentul tulburrilor psihiatrice e externalizate (hiperactivitate, agresivitate, comportamentedisruptive), e internalizate (depresie, anxietate). Terapeuii comportamentaliti au adaptat tehnicile la nivelul de dezvoltare alcopilului.Metodele operante au inclus: utilizarea ntririlor pozitive i negative, supracorecia, contractele terapeutice, extincia i pedep-sele. Metodele nonverbale i nondirective (terapia prin joc sau artterapia) sunt cele mai rspndite, n timp ce ormele cognitivesau hipnoza sunt mai rare. Exist aproximativ 230 de tehnici psihoterapeutice care pot aplicate la copii i adolesceniEste nevoie de o evaluare precis i de adaptarea strategiilor i metodelor verbale i nonverbale la nivelul de nelegere a copiilorn suerin. Cele mai bune rezultate se obin la adolesceni (ntre 13-18 ani) i la preadolesceni (11-13 ani) i rezultate mai

modeste la copiii mai mici (5-11 ani), dar orice copil poate benecia de terapia cognitiv-comportamental.Prin reevaluarea i corectarea gndirii, copiii i adolescenii nva: s-i stpneasc problemele, s-i monitorizeze gndurilenegative automate (cogniiile); s recunoasc legtura dintre cogniie, trire i comportament; s examineze evidena pro icontra gndurilor automate; s substituie interpretrile bazate pe realitate n locul celor bazale negative; s nvee s-i identicecredinele disuncionale care-i predispun la astel de experiene.Cuvinte cheie: psihoterapie cognitiv-comportamental, copii i adolesceni.

1 Con. Dr., Disciplina de Psihiatrie pediatric, UMF Iuliu Haieganu Cluj-Napoca2 MA Psih. clinician i Psihoterapeut, c. Gen. Iuliu Haieganu Cluj-Napoca

Adresa de coresponden:Viorel Lupu, Str. Osptriei F.N., Cluj-Napoca,

jud. Cluj, cod 400660, e-mail: [email protected]

Motto: H. Ey: Dac psihoterapia nu este ntotdeaunasucient, ea este ntotdeauna necesar.

ermenul de psihoterapie cognitiv-comportamen-tal are mai multe sensuri. n cel restrns acoper terapiacognitiv i comportamental clasic, iar n cel larg sereer la o perspectiv cognitiv asupra ntregii psihotera-pii n msura n care vizeaz modicarea comportamen-tului, a modului de prelucrarea a inormaiei i a eluluin care este trit o situaie traumatic. Unele tehnicidinamice de orientare psihanalitic i experienialsunt reevaluate n lumin cognitiv-comportamental.

RDCINILE TERAPIEI COGNITIV-COMPORTAMENTALE A COPILULUII ADOLESCENTULUI

erapia cognitiv la copii este o extensie a unda-mentelor terapiei comportamentale bazat pe teorianvrii clasice, operante i prin modelare, putnd

util n tratamentul tulburrilor psihiatrice (Eysenck,1959).

Multe dintre tehnicile cognitive utilizate la co-pii i aduli se aseamn cu cele utilizate n terapiacomportamental. De exemplu, trainingul abilitilorsociale este considerat actualmente o strategiecognitivist, dar i are rdcinile adnci n terapiacomportamental, prin utilizarea modelelor, joculuide roluri, repetiiei. La el, relaxarea este o importanttehnic n terapia cognitiv, dei iniial a ost pus la

punct de ctre Jacobson (1938, apud Ronen, 1997)i apoi dezvoltat de ctre Wolpe (1982), indutilizat ca o parte a desensibilizrii clasice n terapiacomportamental.

erapia expunerii a ost dezvoltat de ctre Marks(1987) ca o parte a condiionrii operante, iar n terapiacognitiv a ost integrat ca centrare pe propria expu-nere, ca o condiie necesar n imageria dicultilor (nspecial n nvarea de a-i accepta emoiile). erapeuiicomportamentaliti n-au creat tehnici specice pentru

copii, ci doar le-au adaptat acestora.


2/11

20 Revista de Neurologie i Psihiatrie a Copilului i Adolescentului din Romnia - 2010 - vol. 13 - nr. 1

Cea mai popular tehnic utilizat la copii estederivat din nvarea operant i prin modelare, -ind aplicabil tulburrilor de externalizare cum ar agresivitatea. Aplicarea metodelor operante a inclus:utilizarea ntririlor pozitive i negative, supracorecia,contractele terapeutice, extincia i pedepsele. Aceasttehnic, aplicat i la adult, cnd este utilizat la copii

trebuie s e clar, concret, uor de neles i de enunatde ctre copil. Copiii sunt expui i n mod natural unortehnici bazate pe modelare ca parte a procesului de ma-

turizare (de exemplu: n rolurile sexului, n deprindereaabilitilor sociale prin interaciunile sociale).

Utilizarea modellingului n terapie este nsoiti de alte tehnici ca sel-talk-ul sau ntririle, cares-au dovedit utile n cazul anxietii i a stresului in nvarea de a gndi nainte de a aciona. ehni-cile bazate pe condiionarea clasic cum ar relaxarea

i desensibilizarea (Wolpe, 1982) sunt mai dicil deaplicat la copii, necesitnd adaptri speciale sub ormaimageriei auto-instruciei, conciziei instruciunilor,

Tabelul 1. Criterii comportamentale care determin nevoia de terapie (adaptare dup Ronen, 1997)

Comportament Necesitatea terapiei

Corespunztor criteriilor de diagnostic pentru o boal (tulburare) - ICD-10, DSM-IV-TR DAConorm normelor mediului cultural NUConorm vrstei cronologice (ex. enurezis) NUS-a ameliorat NU

S-a agravat sau este stabil DAExist riscuri pentru viitor DAAre un prognostic bun DAExist o mare motivaie pentru schimbare DAEste important pentru copil i amilie DAA schimbat o situaie anterioar DASe poate remite spontan NU

Tabelul 2. Caracteristicile cadrului terapeutic (adaptare dup Ronen, 1997)

CadruTip deintervenie

Vrstacopilului

Problemelecopilului

Obiective

Grup parental Educativ Orice vrst(n special cei mici) Dezvoltarenormal Aport inormaii, suport

Consiliere parentalindividual

Educativterapeutic

Orice vrst (n special ceioarte mici i adolesceni)

Tulburri de con-duit, neascultare mprtirea de abiliti pentru schimbare

Consiliereaeducatorilor Educativ colari

Comportamentnecontrolat Dobndirea de abiliti

Intervenie colar Educativ colari Sociale Modicarea normelor, interaciunilorTerapie amilial Terapeutic colari Comunicare Modicarea comunicrii, rolurile

Terapie de grup Terapeutic Preadolesceni iadolesceni Orice tulburare Schimbarea competenelor, noi abiliti

Terapie individual Terapeutic Vrsta grdiniei i pesteaceast vrst Orice tulburareSchimbarea comportamentului, gndirii iemoiilor

Tabelul 3. Criterii de selecie pentru psihoterapia individual a copilului (adaptare dup Ronen, 1997)

Variabile Terapie nonverbal Terapie verbalVrst < 7 ani Copilrie mijlocie, > 7 ani - adultNivel abiliti cognitive Mai puin avansate Abiliti nalte

Tipul problemei Internalizare, supracontrol Externalizare, subcontrol

Tabelul 4. Cele patru alternative n psihoterapia cognitiv-comportamental a copilului (adaptare dup Ronen, 1997)

Direct Indirect

Terapie verbalDiscuii directe sau discuii despre evenimente,comportamente i sentimente

Comunicare refectiv (discuii despre alii), biblioterapie

Terapie nonverbal Utilizarea direct a jocului, artei,constituind un model pentru schimbare

Utilizarea artei i jocului r o reerire direct


3/11

Viorel Lupu 21

ajutorului din partea prinilor, jocului, picturii, bom-boanelor i jucriilor oerite ca recompens, care toateduc la creterea motivaiei copilului i a abilitii aces-tuia de a se relaxa.

TEHNICI PSIHOTERAPEU TICEAPLICAbILE LA COPII I

ADOLESCENICele mai multe orme de psihoterapie a copilului

i adolescentului se bazeaz pe metode nonverbalei nondirective, cum ar terapia prin joc sau art-terapia, ormele cognitive sau hipnoza ind mai puinrspndite, dar n continu cretere prin adaptarea lacopii ale unor tehnici de la adult. n zilele noastre,exist aproximativ 230 de tehnici psihoterapeuticecare pot aplicate la copii i adolesceni (Kazdin,1988). Dintre aceste tehnici, trebuie selecionate acele

orme care se potrivesc cel mai bine cu cazurile con-crete din practica curent.

CONDIII PENTRU REUITAPSIHOTERAPIEI

Pentru a asigura reuita deplin a oricrei psi-hoterapii, la copii sunt necesare evaluri precise alesituaiei copilului prin:

1) Obinerea unor inormaii despre copil din maimulte surse:

prini (pentru tulburri de tip acting out neascultare, agresivitate, negativism, hiperactivitate,impulsivitate)

educatori, proesori, nvtori date priv-ind raportarea copilului la normele corespunztoare

vrstei cronologice (randament colar, intelectual,abiliti sociale de comunicare);

direct de la copil pentru nelegerea emoiilorsale, aprecierii stimei de sine, depresiei;

observaia direct.

2) Compararea acuzelor actuale cu comportamenteconsiderate normale pentru vrsta copilului.

3) Aprecierea dac tratamentul copilului trebuieiniiat sau dac sunt anse ca problemele s se rezolvede la sine (tabelul 1).

4) Alegerea celui mai potrivit cadru terapeutic (ta-belul 2).

5) Alegerea celei mai bune tehnici pentru pro-blemele prezentate de copil (tabelul 3 i tabelul 4)(Ronen, 1997).

-

-

-

-

ALI fACTORI IMPORTANIIMPLICAI N REUITAPSIHOTERAPIEI

1) Vrsta: copiii i adolescenii sunt cei mai recep-tivi la psihoterapie, inclusiv la hipnoz, spre deosebirede persoanele de peste 40-50 de ani, care sunt mai

reractare;2) Nivel cognitiv extremele: superdotaii i ceisubdotai nu se preteaz la psihoterapie - este necesarun ascendent asupra clientului;

3) Nivel de culturalitate: cu ct copilul este maiprimitiv, cu att este mai dicil colaborarea;

4) Este necesar un diagnostic precis, pentru c existindicaii i contraindicaii precise ale psihoterapiilor.

n general, alegerea metodei se ace n principaldup trei criterii:

a) dup valenele psihoterapeutului;b) dup client (diagnostic, personalitate);c) dup timpul avut la dispoziie.

PARTICULARITI LA COPIL IADOLESCENT

Psihoterapia copiilor i adolescenilor dier decea a adulilor din mai multe puncte de vedere. Unadintre dierene const n nsi natura copilriei,copilul ind comparat cu o int mictoare, ind

ntr-un permanent proces de schimbare. Aciunile icomportamentul su sunt o rezultant a stadiul sude dezvoltare, situaiei amiliale, inuenelor mediuluiambiant i caracteristicilor individuale.

Psihoterapeuii care se ocup de aceast perioadde vrst trebuie s cunoasc oarte bine sociologiacopilriei, psihologia developmental, normele deconduit i procesele amiliale, nainte de a intra npsihopatologia copilului i n deprinderea tehni-cilor psihoterapeutice. Psihoterapia copilului estecomparat cu abilitatea de a combina mai multe pieseale unui puzzle uria, ind n acelai timp tiin i arti necesitnd talent nnscut, disponibilitate i creati-

vitate din partea psihoterapeutului n comunicareacu copiii. Psihoterapeutul trebuie s nvee anumitestrategii i metode verbale i nonverbale transpuse lanivelul de nelegere a copiilor n suerin.

ntrebri orientative pentru psihoterapeutn aplicarea oricrei orme de psihoterapie indivi-

dual cu copilul, terapeutul se poate orienta dupurmtoarele ntrebri:

Copilul cu probleme se a n stadiul de dez-voltare n care s e posibil terapia verbal?

-

Edited by Foxit ReaderCopyright(C) by Foxit Software Company,2005-2008For Evaluation Only.


4/11


Are copilul abilitatea s stea s asculte i s seconcentreze?

Are copilul motivaie pentru terapie sau tre-buie aplicat o terapie prin joc, pentru a-i capta ateniai motivaia?

Are copilul abiliti verbale sau este mai per-ormant n art, muzic sau joc?

TERAPIA COGNITIV A COPILULUI IADOLESCENTULUI

erapia cognitiv a copilului i extrage o mareparte din ascenden de la teoria lui Bandura (1977)reeritoare la rolul expectaiilor n orice nvare i acapacitii expectaiilor de a acilita succesul terapiei.De asemenea, i ali teoreticieni au inuenat aceastorm de terapie la copii, cum ar Ellis (1962) (terapiaraional emotiv), Beck (1979), Meichenbaum (1985),DZurilla (1986) (trainingul rezolvrii pro-blemelor).

ratamentul cognitiv al copilului trebuie s sereere la nvarea celor mai potrivite abiliti i apli-carea celor mai adecvate tehnici. Consideraiile teo-retice au dus la ipoteza c cel mai important modera-tor n ecacitatea implementrii teoriei cognitive lacopii este nivelul lor de dezvoltare cognitiv.

TERAPIA COGNITIV A COPILULUI I

ADOLESCENTULUI REzULTATECele mai bune rezultate se obin la adolesceni

(ntre 13-18 ani) i la preadolesceni (11-13 ani) irezultate mai modeste la copiii mai mici (5-11 ani)(Durlak, 1991).

n ciuda acestor constatri, se consider actual-mente c orice copil, indierent de vrst, poate bene-cia de terapia cognitiv-comportamental, cu condiiaca terapeutul s adapteze terapia la stilul cognitiv per-sonal al copilului (Ronen, 1992; Knele, 1993). Copiiimai mari i pot dezvolta strategii cognitive indepen-dent, n timp ce cei mai mici au nevoie de terapeut sle dezvolte aceste strategii.

Copiii cu un nalt nivel cognitiv pot adopta strate-gii generale i abstracte n timp ce cei cu un nivelmodest au nevoie de strategii mai concrete. erapiacognitiv se adreseaz att copilului cu tulburriexternalizate (hiperactivitate, agresivitate, compor-tamente disruptive) ct i cu tulburri internalizate(depresie, anxietate).

Copiii cu tulburri externalizate i cu lips de au-tocontrol dovedesc diculti n tolerana la rustrri,

-

-

-

n ntrzierea graticaiilor, meninerea ateniei asu-pra obiectului sau utilizarea abilitilor de rezolvare aproblemelor directe.

Copiii cu tulburri internalizate sau supracontrolau abilitile necesare, dar acestea sunt ru olosite. Eipercep greit situaiile sociale i pot benecia cel maibine de modalitile terapeutice non-verbale, n spe-

cial de cele de expunere i de cele experieniale.Kendall (1993) sugereaz c n timp ce copiii

introveri sunt limitai de gndirea distorsionat,cei extroveri acioneaz r s gndeasc sau s-i planice aciunile i nu proceseaz inormaiilen situaiile n care gndirea le-ar putea benec.

erapeuii cognitiviti arm c orice copil care estecapabil s nvee este un bun subiect pentru terapiade tip cognitiv.

APLICAREA TEHNICILORCOGNITIV-COMPORTAMENTALELA COPII I ADOLESCENI

Exist o mare varietate de tehnici cognitiv-com-portamentale pentru copii care presupun manipularearspunsurilor comportamentale, cum ar : model-lingul, repetiia secvenial i trainingul abilitilor.Scopul terapiei const n modicarea distorsiunilor idecienelor cognitive care inueneaz comportamen-tul. oate tehnicile cognitive intervin cu scopul de ainuena gndirea. Aceste tehnici identic, testeaz re-alitatea i corecteaz concepiile distorsionate i schemele(credinele disuncionale) care nsoesc aceste cogniii.

Prin reevaluarea i corectarea gndirii, clieniinva s-i stpneasc problemele i situaiile.

Copiii sunt nvai:s-i monitorizeze gndurile negative auto-

mate (cogniiile);s recunoasc legtura dintre cogniie, trire

i comportament;

s examineze evidena pro i contra gnduri-lor automate;

s substituie interpretrile bazate pe realitaten locul celor bazale negative;

s nvee s-i identice credinele dis-uncionale care-i predispun la astel de experiene(Beck, 1979).

Un program de intervenie poate include varia-tecombinaii de proceduri i metode. Nu exist o ormulgeneralizat, cum ar : metoda X pentru problema

Y. Planicarea interveniei terapeutice se bazeaz peconsideraii individuale. Un criteriu de decizie n ceea

-

-

-

-

-

Edited by Foxit ReaderCopyright(C) by Foxit Software Company,2005-2008For Evaluation Only.


5/11

Viorel Lupu 23

ce privete procedura de intervenie este dac problemareprezint un decit sau un exces comportamental. Sar-cina terapeutului n condiiile unei probleme de decitcomportamental este de a crete puterea comportamen-tului particular (proceduri de cretere a rspunsului), saude a aduga achiziii sau noi patternuri de comportament(proceduri de achiziie a rspunsului). Dac este vorba de

un exces n comportament, sarcina terapeutului estede a elimina sau reduce puterea comportamentului(proceduri de descretere a rspunsului).

Prinii adeseori se ntreab: Cum pot s-l deter-min s ac asta? Cum pot s-l ac s continue com-portamentul dezirabil? Cum pot s-l opresc?

Un copil care nu doarme sucient poate iritabil,nepoliticos. Un somn timpuriu poate rezolva pro-blema. Cererile directe pentru schimbare pot uneori se suciente. Schimbrile n mediul zic, schimbrile

n rutin sau responsabiliti pot unciona n anumitecircumstane. Metoda terapeutic va determinat deinta problemei. Nu se va olosi tehnica desensibilizriila o persoan care chiulete de la coal, motivndplictiseala de la cursuri.

Problema nu apare numai la nivel de aciune, dari n gndurile i tririle clientului. Exist dou sarcinide baz n nvare, des ntlnite n terapia copilului:

1) achiziia, nvarea comportamentului dorit,dezirabil (autocontrol, uen verbal, abiliti socia-le, academice) sau a acelui comportament care este ndecit;

2) reducerea rspunsului nedorit n repertoriulcomportamental al copilului (agresiune, urt, ticuriaciale, anxietate, obie, bulimie etc.), sau nlocuireaunui rspuns cu altul (asertivitate n locul timiditii).

oate aceste sarcini pot realizate prin combina-rea a patru tipuri majore de nvare:

a) condiionare clasicb) condiionare operantc) nvare prin observare

d) nvare cognitivAlegerea abordrii terapeutice nu depinde nu-

mai de natura comportamentului int sau stimuliicare l menin, dar i de vrsta, maturitatea copilului,circumstanele n care comportamentul problem semaniest i de unele aspecte ale mediului (HerbertMartin, 1981).

Succesul terapiei cognitiv-comportamentaleeste condiionat de o bun evaluare a cazului i de ocorect conceptualizare a acestuia i de aplicarea ace-

lor tehnici care au ost validate tiinic prin studiirandomizate (Lupu, 2009).

CONCLUzII

1. Se consider actualmente c orice copil, in-dierent de vrst, poate benecia de terapia cogni-tiv-comportamental, cu condiia ca terapeutul sadapteze terapia la stilul cognitiv personal al copilu-lui. Copiii mai mari i pot dezvolta strategii cogni-

tive independent, n timp ce cei mai mici au nevoie deterapeut s le dezvolte aceste strategii.2. Succesul terapiei cognitiv-comportamentale

este condiionat de o bun evaluare a cazului i de ocorect conceptualizare a acestuia i de aplicarea ace-lor tehnici care au ost validate tiinic prin studiirandomizate.

bIbLIOGRAfIE

Bandura A. (1977): Social Learning Teory. Englewood

Clifs, N.J. Prentice Hall.

Beck A.., Rush A.J., Show B.F. & Emery G. (1979): Cog-nitive Terapy o Depression. Guilord, New York.

DZurilla .J. (1986): Problem-solving Terapy: A Social Com-petence Approach to Clinical Interventions. Springer, N.Y.

Durlak J.A., Fuhrman . & Lapman C. (1991):Efective-ness o Cognitive-behavior Terapy or Maladaptive Children:

A Meta-analysis. Psychological Bulletin, 110-204-214.

Ellis A. (1962): Reason and Emotion in Psychotherapy. LyleStuart, New York.

Eysenk H.J. (1959): Learning Teory and Behavior Terapy.Journal o Mental Science, 105, 61-75.

Kazdin A.E. (1988): Child Psychotherapy: Development andIdentiying Efective reatments. Pergamon, New York.

Kendall P.C. (1993): Cognitive Behavioral Terapies withYouth: Guiding Teory, Current Status and EmergingDevelopments. Journal o Consulting and Clinical Psychol-

ogy, 61, 235-247.

Knell S.M. (1993): Cognitive Behavioral Play Terapy.Northvale: Aronson.

Lupu V. (2009): Introducere n hipnoterapia i n psihote-rapia cognitiv-comportamental a copilului i a adolescen-tului. Ed. ASCR, Cluj-Napoca.

Marks I. (1987): Fears, Phobias and Rituals. Oxord Univer-sity, New York.

Martin H. (1981): Behavioral reatment o Problem Chil-dren. A Practice Manual, Academic Press, London.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.


6/11


Meichenbaum D.H., Bream L.A. & Cohen J.S. (1985):A Cognitive-behavioral Perspective o Child Psychopathology:

Implications or Assessment and raining. In R.J. McMahon& R. De V. Peters (EDs.). Childhood Disorders: Behavio-ral Developmental Approaches (pp 36-52). Bruner/Mazel,New York.

Ronen . (1992): Cognitive Terapy with Young Children.

Child Psychiatry and Human Development, 23, 19-30.

Ronen . (1997): Cognitive Developmental Terapy withChildren,John Wiley and Sons, N.Y.

Wolpe J. (1982): Te Practice o Behavior Terapy(3rd ed. n.),Pergamon, New York.

13.

14.

15.

16.


7/11

Viorel Lupu 73

1 Lecturer o University o Medicine and Pharmacy Iuliu Hatieganu,Cluj-Napoca, Discipline o Child Psychiatry

2 Clinical Psychologist and Psychotherapist, School Iuliu Hatieganu, Cluj-Napoca

Correspondence address:Viorel Lupu, Ospatariei Street, F.N., Cluj-NapocaCluj district, cp. 400660, e-mail:[email protected]

PARTICULARITIES OF COGNITIVE BEHAVIOURALPSYCHOTHERAPY WITH CHILDREN AND ADOLESCENTS

Viorel Lupu1, Izabela Raona Todiri2

ABSRAC

Cognitive therapy with children is an extension o the undamentals o behaviour therapy based on the classical theory o learn-ing merged with modelling, being useul in the treatment o externalized (hyperactivity, aggression, disruptive behaviours) orinternalized disorders (depression, anxiety). Behavioural therapists adapted techniques to the specic level o development oeach child.Operational methods include: using positive and negative reinorcements, overcorrection, therapeutic contracts, extinction andpunishments. Nonverbal and nondirective methods (therapy through play and art therapy) are the most notorious while cogni-tive orms and hypnosis are rarer. Tere are 230 psychotherapeutic techniques that can be applied to children and adolescences.

We have to make a precise evaluation and an adaptation o the verbal and nonverbal methods and strategies to the level o thechildren. Te best results are obtained with adolescents (between 13-18 years) and preadolescents (between 11 and 13 years) butany child may benet rom cognitive-behavioural therapy.

Trough re-evaluation and correction o the way o thinking, children and adolescents learn: to control their problems; to observetheir negative automatic thoughts (cognitions); to recognise he connection between cognition, emotion and behaviour; to exam-ine evidences or and against automatic thoughts; to substitute interpretations based on reality in the place o negative ones; tolearn to identiy dysunctional belies which predispose to those kinds o experiences.Key words: cognitive behavioural psychotherapy, children and adolescents.

Motto: H. Ey: I psychotherapy is not alwayssucient, it is always necessary.

Te cognitive behavioural psychotherapy term hasa lot o meanings. In a restricted sense, the term cov-ers classic cognitive and behavioural therapy, and in alarger sense it reers to a cognitive perspective on theentire psychotherapy insoar as it aims at modiyingthe behaviour, the way in which the inormation isprocessed and the way a traumatic situation is lived.Some psychoanalytical and experiential dynamictechniques o orientation are reevaluated rom a cog-nitive-behavioural perspective.

THE BEGINNINGS OF CHILD ANDADOLESCENT COGNITIVEBEHAVIOURAL PSYCHOTHERAPY

Cognitive therapy in children is an extension othe basic behaviour therapy based on classic learning

theory which is operational through modelling, toowhich can be useul in the treatment o psychiatricdiseases. (Eysenck, 1959).

Many o the cognitive techniques used with chil-dren and adults resemble those that are used in thebehaviour therapy. For example, the training o socialabilities is considered at present a cognitive strategy,but the roots are deep in the behaviour therapy, bymaking use o models, role-play and repetition. Also,the relaxation is an important technique in cognitivetherapy, although it was initially dened by Jacob-son (1938, ater Ronen, 1997) and then developedby Wolpe (1982), being urther used as a part o theclassical desensitization in behaviour therapy.

Marks (1987) developed the exposure therapy, aspart o operational conditioning, which was then in-troduced into the cognitive therapy, helping to cen-tre on ones exposure, as a necessary condition in theimages o diculties (especially in learning to acceptones own emotions). Behaviour therapists did notcreate special techniques or children, they just ad-

justed these techniques to suit their particularities.Te most popular technique used with children arise

rom operational and pattern making learning, which

can be applied to externalization disorders such as ag-gressiveness. Te application o operational methods in-


8/11

74 Journal of Romanian Child and Adolescent Neurology and Psychiatry - 2010 - 13thvol. - no. 1

proved to de useul in anxieties, stress and learning tothink beore acting. Te techniques based on classi-cal conditioning such as relaxation and desensitiza-tion (Wolpe, 1982), are dicult to be applied withchildren, requiring special adjustments like sel- in-struction image, concision o instructions, parentshelp, playing, painting, lollipops and toys which can

be oered as a reward, all o these leading to increasedchild motivation and training o relaxation abilities.

Table 1. Behavioral criterion which cause the need or therapy (ater Ronen, 1997)

Behavior Terapy Necessity

According to the diagnosis criteria or a disease (disorder) ICD-10, DSM-IV-R yesAccording to cultural environment norms NoAccording to chronological age ( ex. enuresis) NoIt has improved No

It has aggravated or it is constant YesTere are uture risks YesIt has good expectations Yes

Tere is a greate motivation or change YesIt is important or the child and his amily YesIt has changed a previous situation YesIt can be remitted spontaneously No

Table 2. Te characteristics o the therapeutic rame (ater Ronen, 1997)

Frame Intervention Childs age Childs problems ObjectivesParental group Instructive Any age (especially the little ones) Normal development Inormation and supportParental IndividualCounselling

Terapeuticinstructive

Any age (especially the verylittle and adolescents)

Problems o conductand disobedience

Gaining skills or change

Educators Counselling Instructive Scholars Incontrollable behavior Gaining skills

School intervention Instructive Scholars SocialTe modication o the normsand interactions

Family Terapy Terapeutic Scholars CommunicationTe modication ocommunication, roles

Group therapy TerapeuticPreadolescentsAdolescents

Any problemTe change o abilities,new abilities

Individual therapy TerapeuticKindergarten andover that age

Any problemTe change o the behavior,ideas and emotions

Table 3. Te selection criteria or child individual psychotherapy (ater Ronen, 1997)

Variables Non-verbal therapy Verbal therapyAge < 7 years old Middle age childhood, > 7 years old - adultLevel o cognitive abilities Less advanced High abilities

Te problem type Internal, over control External, under control

Table 4. Te our alternatives in child cognitive-behavior psychotherapy (ater Ronen, 1997)

Direct Indirect

Verbal therapy Direct discussions, or discussions about behavior and eelings Refection ( talking about the others), bibliotherapyNon-verbal therapy Using directly the games, art like a change model Using art and game without a direct reerence

clude: the usage o positive and negative reinorcement,over-castigation, therapeutic contracts, extinction, andpunishment. When it is applied to children, this tech-nique, which is also applied to adults, must be clear, con-crete, acile, and easy to explain to the child. Te childrenare ordinarily exposed to pattern making techniques aspart o a maturing process (or example: the role o the

sex, gaining social skills by social interaction).Beside models based therapy, other techniques

are used too, like sel-talk or reinorcements which


9/11

Viorel Lupu 75

PSYCHOTHERAPEUTIC TECHNIqUESAPPLICABLE TO CHILDREN ANDADOLESCENTS

Most o the psychotherapeutic orms applicable tochildren and adolescents are based on non-verbal andnon-directive methods, like the playing therapy or art

therapy, cognitive orms or hypnosis being less usedor the moment but they are in a continuous develop-ment by adjusting adult techniques to children. Nowthere are almost 230 psychotherapeutic techniquesthat can be applied to children and adolescents (Kaz-din, 1988). One must select rom current practicethose orms o psychotherapy which are appropriateto the cases that are treated.

CONDITIONS FOR THESUCCESS OF PSYCHOTHERAPY

A precise evaluation o the childs situation is nece-ssary in order to guarantee the complete success o anypsychotherapy method that is applied. Tis evaluationmust take into consideration the ollowing aspects:

1) Obtaining inormation about the childssituation rom varied sources:

parents (or problems like acting-out- diso-bedience, aggressiveness, negativism, hyperactivity,rashness);

pedagogue, teacher, schoolmaster-inormation

regarding the way that child is related to the norms othe chronological age ( intellectual and school eca-ciousness, social and communication abilities);

directly rom the child- to understand his emo-tions, evaluate sel-esteem, depression;

direct observation.2) Te comparison o the present problems/disor-

ders with behaviours that are considered normal orthe childs age.

3) Evaluating i the child needs treatment or ithere are chances that the problems will be solved

without any intervention. (table 1

)4) Choosing the most appropriate therapeuticrame. (table 2)

5) Choosing the best technique or the childsproblems. (table 3 and table 4) (Ronen, 1997).

OTHER ImPORTANT FACTORSINVOLVED IN THE SUCCESS OFPSYCHOTHERAPY

1) Age: children and adolescents are the most sus-

ceptible to psychotherapy, including hypnosis, in com-parison to 40-50 year old people, who are reluctant;

2) Cognitive level - the extremes: the very gitedand the least gited do not respond to psychotherapy it is necessary to have an ascendant over the client;

3) Cultural level: the co-operation is dicult i thechild is primitive;

4) A precise diagnosis is necessary, because thereare precise indications and contraindications or

dierent types o therapy;Generally speaking, the method is chosen basedon three criteria:

a) therapist valences;b) the client ( diagnosis, personality);c) the time available or therapy.

CHILD AND ADOLESCENTPARTICULARITIES

Child and adolescent psychotherapy is dierent

rom adult psychotherapy, or many reasons. One othose dierences is the nature o childhood, since thechild is compared with a moving target, and he isin a process o continuous change. His actions and hisbehaviour are the result o the stage o developmenthe is in, his amily situation, the infuences o the en-

vironment and the individual characteristics.Psychotherapists that handle this age group must

become amiliar with childhood sociology, develop-mental psychology, conduct norms and amily proc-esses, beore they begin their struggle with child

psychopathology and start learning the therapeutictechniques. Child psychotherapy is compared with theability to combine a lot o pieces rom a giant puzzle,

which is at the same time science and art and requiresnatural talent, availability and creativity on the part othe therapist in communication with children.

Te psychotherapist must learn certain strategies bothverbal and non-verbal methods that must be adjusted tothe understanding level o the suering children.

INFORmATIVE qUESTIONS

FOR THE PSYCHOTHERAPIST

In order to apply any orm o individual psycho-therapy to a child, the therapist can take the ollowingquestions as a guide:

Is the child with problems in a developmentalstage where the verbal therapy can be applied?

Is the child able to sit, listen and concentrate? Is the child motivated to do therapy or a playing

therapy must be applied in order to gain his attentionand his motivation?

Has the child verbal abilities or has he got betterperormances in art, music or play?


10/11

76 Journal of Romanian Child and Adolescent Neurology and Psychiatry - 2010 - 13thvol. - no. 1

CHILD AND ADOLESCENTCOGNITIVE PSYCHOTHERAPY

Child cognitive therapy has a big part o its originin Bandura s (1997) theory, which reers to the roleo learning expectations and the expectation abilitiesthat acilitate a successul therapy. Also, there have

been other theorists who infuenced this orm otherapy with children, such as Ellis (1962) (rational-emotive therapy), Beck (1979), Meichenbaum (1985),DZurilla (1986) (solving problems training).

Child cognitive treatment must be based on lear-ning the most appropriate abilities and on the appli-cation o the most adequate techniques. Teoreticalconsiderations led to the hypothesis that the mostimportant actor involved in cognitive therapy e-cacy in children is their cognitive development level.

CHILD AND ADOLESCENTCOGNITIVE THERAPY RESULTS

Best results are obtained with adolescents (be-tween 13- 18 years old) and preadolescents (11-13

years old) and modest results are noted with youngchildren (5-11 years old). (Durlak, 1991).

Despite these ndings, at present it is consideredthat despite the childs age, any child can benet romcognitive-behavioural therapy, i the therapist adjuststhe therapy to the childs personal cognitive style (Ro-

nen, 1992; Knele, 1993). Older children can developindependent cognitive strategies, while the youngerneed the therapist to help them develop these strate-gies.

Te high cognitive level children can achievegeneral and abstract strategies while modest levelchildren need concrete strategies. Cognitive therapyaddresses both the externalization troubles (hyper-activity, aggressiveness, a disruptive behaviour) andthe internalization troubles (depression, anxiety).

Children with externalization disorder and lacko sel-control, have diculties with their blight tole-rance, with their gratuities, maintaining attentionover the objects or using their abilities o solving di-rect problems.

Children with internalization disorders or over con-trol have the necessary abilities but they are not usedproperly. Tey misunderstand social situations and theybenet the most rom non-verbal therapeutic strate-gies, especially the exposure and experiential ones.

Kendall (1993) suggests that, while introverted

children are limited by the distortion thinking, ex-troverted ones act without thinking or planning their

actions and they do not process data in the situationswhere thinking can be avourable.

Cognitive therapists assert that any child who canlearn is a good candidate or the cognitive therapy.

APPLYING COGNITIVE-BEHAVIOURAL TECHNIqUES WITH

CHILDREN AND ADOLESCENTS

Tere is a large variety o cognitive-behaviour tech-niques or children that assume behaviour response han-dling, such as: modelling, sequential repetition and abili-ties training. Te therapy purpose is to modiy cognitivedistortion and deciency that infuence the behaviour.All the cognitive techniques have as intervention pur-pose to infuence the thinking. Tey identiy, test thereality and correct distortion views and schemes (dys-

unctional belies) that accompany those cognitions.By thinking reevaluation and correction, clients

learn how to overrule their problems and situations.Children are taught how to:

handle their automatic negative thoughts(cognitions);

recognize the connection between cognition,eelings and behaviour;observe armative and negative evidence o

the automatic thoughts;substitute basic negative interpretations with

reality based interpretations;learn to identiy dysunctional thoughts

which predispose them to those kinds o experiences.An interventional programme may include vari-

ous types o procedures and methods o combina-tion. Tere is no general ormula like: method X orproblem Y.

Te planning o therapeutic intervention is based on

individual considerations. One o the intervention de-cision criteria is the nature o the problem: behaviouraldecit or excess. I there is a decit behaviour problem,the therapist s obligation is to increase the power o theparticular behaviour (answer increasing procedures), orto add acquisitions or new behaviour patterns (answeracquisition procedures). I there is a behaviour excessthe therapists obligation is to eliminate or reduce thepower o the behaviour (answer decrease procedures).

Oten, the parents ask themselves: How can I that

to him? How can I make him continue the desirablebehaviour? How can I stop him?

-

-

-

-

-

-


11/11

Viorel Lupu 77

I a child does not sleep enough he may become

irritable and impolite. A good sleep can solve the prob-

lem. Direct demands or the change can be enough

sometimes. Environment changes, changes o routines

or responsibilities can be useul in certain situations.

Te therapeutic method will be established by the

target o the problem. Te desensitization techniquewill not be used with those who do not go to school

because they say they are bored in class.

Te problem does not appear only at action level

but also at the thinking and emotional level. Tere are

two basic learning tasks in child therapy:

1) acquisition, learning the wanted, desirable be-

haviour (sel-control, verbal fuency, social and aca-

demic skills) or the decit behaviour;

2) decreasing the unwanted answer in the child

behaviour (aggression, thet, acial twitch, anxiety,

phobia, bulimia) or changing one answer with an-

other (timidity with assertion).

All o those tasks can be achieved by combining

the our major learning types:

a) classical conditioning;

b) operational conditioning;

c) learning by observing;

d) cognitive learning.

Te decision about the therapeutic approach de-pends not only on the nature o the target behaviour

or on the stimulus that maintain this behaviour, but

also on age, childs maturity, the circumstances o the

behaviour maniestations and on some environment

aspects (Herbert Martin, 1981).

Success o cognitive-behaviour therapy, is condi-

tioned by an appropriate evaluation o the case and

a correct conceptualization and the applicability o

those techniques that had been validated scienticallythrough randomized studies (Lupu, 2009).

CONCLUSIONS

1). At the moment it is considered that no matter

the age, any child can benet rom the cognitive-

behavioural therapy, on condition o adjusting the

therapy to the childs personal cognitive style. Older

children can develop independent cognitive strategies,

while the younger need the therapist to help them de-velop these strategies.

2). Success o cognitive-behaviour therapy, is con-ditioned by an appropriate evaluation o the case anda correct conceptualization and the applicability othose techniques that had been validated scienticallythrough randomized studies.

BIBLIOGRAPHY

Bandura A. (1977): Social Learning Teory. EnglewoodClis, N.J. Prentice Hall.

Beck A.., Rush A.J., Show B.F. & Emery G. (1979):Cognitive Terapy o Depression. Guilord, New York.

DZurilla .J. (1986): Problem-solving Terapy: A Social Com-petence Approach to Clinical Interventions. Springer, N.Y.

Durlak J.A., Fuhrman . & Lapman C. (1991): Efective-ness o Cognitive-behavior Terapy or Maladaptive Children:

A Meta-analysis. Psychological Bulletin, 110-204-214.

Ellis A. (1962): Reason and Emotion in Psychotherapy.

Lyle Stuart, New York.

Eysenk H.J. (1959): Learning Teory and Behavior Terapy.Journal o Mental Science, 105, 61-75.

Kazdin A.E. (1988): Child Psychotherapy: Development andIdentiying Efective reatments. Pergamon, New York.

Kendall P.C. (1993): Cognitive Behavioral Terapies with Youth:Guiding Teory, Current Status and Emerging Developments.Journal o Consulting and Clinical Psychology, 61, 235-247.

Knell S.M. (1993): Cognitive Behavioral Play Terapy.Northvale: Aronson.

Lupu V. (2009):Introducere n hipnoterapia i n psihoterapiacognitiv-comportamental a copilului i a adolescentului. Ed.ASCR, Cluj-Napoca.

Marks I. (1987): Fears, Phobias and Rituals. Oxord Univer-sity, New York.

Martin H. (1981): Behavioral reatment o Problem Chil-dren. A Practice Manual, Academic Press, London.

Meichenbaum D.H., Bream L.A. & Cohen J,.S. (1985):A Cognitive-behavioral Perspective o Child Psychopathology:Implications or Assessment and raining. In R.J. McMahon& R. De V. Peters (EDs.). Childhood Disorders: Behavio-ral Developmental Approaches (pp 36-52). Bruner/Mazel,New York.

Ronen . (1992): Cognitive Terapy with Young Children.Child Psychiatry and Human Development, 23, 19-30.

Ronen . (1997): Cognitive Developmental Terapy withChildren,John Wiley and Sons, N.Y.

Wolpe J. (1982): Te Practice o Behavior Terapy(3rd ed. n.),Pergamon, New York.

1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

Terapie Cognitiv Com. La Copii

Documents

Transcript of Terapie Cognitiv Com. La Copii