When working with young clients, there can be challenges in adapting the language, strategies, and interventions of the different therapeutic modalities to the age group you are working with. Cognitive behavioral therapy (CBT) is no different, but it has a lot to offer your youngest clients. Research has shown that it’s effective in treating common childhood conditions such as anxiety, depression, and externalizing disorders. And when you tailor CBT to your young clients― addressing and overcoming the challenges that come with it―you can ensure that each child you treat will get the most out of their therapy sessions.
Fostering Engagement Keeping a client focused and engaged on the session at hand is absolutely essential to getting the most benefit from CBT. But most children have a shorter attention span than adults do. For this reason, therapists must find ways to draw kids into the therapy process.
Regina Galanti, PhD, a clinical psychologist and author of the forthcoming book, Parenting Anxious Kids, notes that most young clients don’t have the attention span for a 45-minute, one-on-one session. To keep children on task, she makes the “work” of therapy seem more like play; the client is learning a skill, but it feels much more like they are having fun: “I make it much more participatory,” Galanti said. “If I’m talking too much, I try to check myself.”
Paul Kesselman, PsyD, a clinical psychologist in private practice and the director of Kesselman Clinical Associates, finds that visual aids are essential when working with kids. “Having something in front of them that they can look at and relate to really engages them and keeps their attention,” he said. “It works a lot better than if I’m talking theoretically without those tools and kids have to imagine what I’m describing.”
Like many CBT therapists, Galanti has a large whiteboard in her office, along with many different colored dry-erase markers, that she uses to draw out concepts and explain new skills. The physical engagement of writing and drawing fosters engagement and focus—especially when the child has the power of the pen in their hands.
But visual aids don’t have to be made up on the spot. Worksheets, flipcharts, and books work well to keep client engaged, and they can be chosen or created before the session or planned for future sessions. The concepts in these aids are easy to move between and don’t need to be recreated every session.
“When [a visual aid is] premade, I can focus on just explaining it for [my client], and I don’t have to multitask,” Kesselman said. He also likes to use The CBT Flip Chart with his clients, which allows him to mark up the pages with dry-erase markers to highlight concepts and incorporate examples.
Building Motivation Motivation is a key part of helping kids to practice their new skills outside of therapy. Most kids go to therapy because their parents decided they needed it. And even if kids want to feel better and overcome the limitations that come with their symptoms, they are often rather ambivalent about the process of therapy itself (not unlike adults). There are no doubt many things they would like to be doing besides sitting in their therapist’s office.
Galanti acknowledges this ambivalence up front, talking with her clients about the reasons they want to be in therapy—and just as importantly, the reasons they don’t. That candor and honesty is a key part of connecting with young people, and connection makes it easier for clients to open up, build trust, and form a relationship with you.
Galanti makes sure the children she works with understand that the skills they’re learning will help with their real-life concerns. She uses tangible examples—ones that will help young clients to truly envision exactly how therapy will help. “I make it concrete enough that they can see how we’re getting from point A to point B,” she said.
In a similar way, Kesselman always aims to show how the tools of CBT apply to the things that the child cares about. “I try to tie in their specific areas that they want to work on with the content in the materials,” he said. “There’s a fine art to interweaving them.”
Starting small provides the space for motivation to grow over time, because it makes therapy feel manageable and prevents kids from getting overwhelmed. “I like to set modest goals up front,” Kesselman said. “We’re going to work on getting a bit of momentum.”
Encouraging Practice Between Sessions When I did physical therapy a few years ago, I always left my sessions with a strong memory of the exercises we had worked on and what to practice—which I promptly forgot by that evening. My practice was much more consistent when my physical therapist started emailing me a plan, complete with pictures of the exercises. It’s hard enough for adults to complete homework between sessions, and it can be even more challenging for kids.
It’s important to write down the CBT practice plan so it’s clear and easy to remember. “I make sure they go home with a list,” Galanti said. “It’s super clear what the homework is, including when they’re going to do it and how they’re going to do it.”
It’s also important that a client’s homework is achievable and not too overwhelming. Simplicity helps. For instance, Galanti will give her clients a seven-day checklist with one small task—perhaps to be mindful for one minute a day.
She also relies on reinforcement principles, an integral part of CBT, to encourage practice. While extrinsic motivation can come with downsides at times, it can be a crucial step in helping kids to reach their goals in therapy. “I’m all for rewards,” Galanti said. “It’s fine to have a therapy-based reward that they get for practicing.”
Involving Parents Closely related to homework completion is the parents’ involvement. You can only accomplish so much in a weekly session, which leaves 167 hours per week that they’re not in your office. Accordingly, parents have a key role in helping their kids to practice the CBT skills they’re learning with you.
“I really see parents as a collaborator and fellow coach,” Kesselman said. “I want us to feel like we’re walking the same path together.” He typically debriefs with parents at the end of session, showing parents exactly what they covered in the session and what the child will be working on for the remainder of the week.
Kesselman also shows parents how to work with their kids in a way that doesn't create a negative association with the homework or the skills. Investing this time in working with parents tends to pay off. “Parents feel really empowered and excited about what they were able to do when they come back the next week,” he said. “When their child responds to it in a really positive way, it creates a strong sense of teamwork.”
Galanti agrees that parents’ involvement is key. She sets that expectation up front and talks with parents about how to work with their child to reinforce the things they’re learning. “Kids really need that scaffolding for any hard skill,” she said.
Adjusting the Language CBT comes with a lot of terminology—"internal dialogue,” “negative schema,” “selective abstraction,” and “cognitive distortion”—and it’s not always clear how to make the terms kid-friendly. It’s important to consider the client and the concept at hand before adjusting your language. “I err on the side of simplifying terminology,” Galanti said. “[And] if the word is important, I’m going to define the word and use the word,” she said—for example, “anxiety” or “exposure.”
Kesselman models the principles of CBT in the language he uses. “I try to use language that’s not too strongly colored so there’s no polarization,” he noted. For example, he avoids “words like ‘good’ or ‘bad.’ I like to use other adjectives so we’re not getting into extreme ways of thinking.”
All in all, it’s most important that the client understands the concept—no matter which words you use to explain them. For instance, Kesselman prefers “awfulizing” over “catastrophizing” when working with a child. Sometimes, you can even let the child take the lead! Pay attention and notice how your young clients talk about CBT concepts. “If they use certain terms, I’ll try to use their own language,” Kesselman said, “which helps them to internalize it more.”
Trust YourselfAs you’re offering evidence-based treatment to children, keep in mind that your expertise and creativity will always be essential in the therapy process. What helps in therapy can’t be reduced to theoretical constructs or words in a treatment manual. It’s found in the moment-by-moment decisions that turn an abstract intervention into meaningful change.
So trust yourself as the artist who integrates science and practice in real time to meet the needs of the young client in front of you. The challenge and the beauty of therapy is that there’s no single right way to do it, and you can always keep honing your craft.