(e.g. you can do either X or Y).
Technologically delivered CBT
There is increased interest in the use of technology to support and deliver CBT to children and adolescents. Technology offers the potential to reach geographically isolated populations; flexible access; increased convenience; fewer visits to specialist clinics; greater privacy and anonymity; enhanced treatment fidelity; rapid scalability; and low‐cost delivery (Clarke et al. 2015; MacDonell & Prinz 2017). It is also very acceptable and particularly appealing to adolescents, who are typically early adopters and regular users of new technologies (Johnson et al. 2015; Wozney et al. 2018).
Internet or technologically delivered CBT programmes have attracted much interest and have demonstrated encouraging results (Grist el al. 2019; Pennant et al. 2015; Vigerland et al. 2016). Digital technologies deliver interventions via computers, or through web‐based platforms via mobile tablets or smartphones (Hollis et al. 2017). The structured nature of CBT lends itself well to digital delivery, resulting in several computerised CBT interventions being developed. For example, the face‐to‐face CBT anxiety programme Cool Teens can be effective when delivered via a CD‐ROM with minimal therapist support (Wuthrich et al. 2012). Similarly, online CBT anxiety programmes such as BRAVE were found to be very acceptable to young people and as effective as face‐to‐face CBT (Spence et al. 2011). In terms of depression, encouraging results have been reported for Stressbusters, a computerised CBT program (Smith et al. 2015; Wright et al. 2017) and a computer game (SPARX) when used both as an intervention and as a prevention programme (Merry, Hetrick, et al. 2012; Merry, Stasiak, et al. 2012; Perry et al. 2017).
Reviews indicate that technologically delivered CBT is effective (Grist et al. 2019) and is now recommended in the United Kingdom as a first line treatment for mild to moderate depression (NICE 2019). Other technologies such as apps, virtual reality, and games have seldom been developed or evaluated.
Involving parents
Parents have a central role in supporting their child, and by involving them in the intervention important parental behaviours and contextual factors can be addressed. Their involvement can therefore facilitate generalisation, practice, and reinforcement of new skills in the young person’s everyday life. However, there is no consistent evidence to suggest that involving parents in CBT programmes results in better outcomes (Breinholst et al. 2012). For example, reviews have shown that CBT for anxiety is effective with and without parental involvement (Higa‐McMillan et al. 2016; Reynolds et al. 2012). Neither the age of the young person nor whether both parents are involved appears to be related to enhanced outcomes (Carnes et al. 2019; Manassis et al. 2014). Similarly, school‐based CBT anxiety prevention programmes have been found to be effective without any parental involvement (Stallard, Skryabina, et al. 2014). However, assessing the benefits of parental involvement is complex and the potential beneficial impact on parents or other family members has seldom been assessed (Breinholst et al. 2012). In addition, whilst the additional short‐term benefits may not be evident, parental involvement in CBT may support the longer‐term maintenance of treatment gains (Manassis et al. 2014).
There has been less research focusing on parental involvement in depression programmes. In a review, Oud et al. 2019 found that parental (caregiver) involvement may enhance outcomes compared to child‐only CBT. The way in which parents are involved in programmes has received limited attention and may explain some of the differences between studies. Stallard (2005) described four models of parental involvement: facilitator, co‐clinician, clinician, and co‐client. The most limited involvement is that of the facilitator where parents attend one or two review meetings with their child. The focus of the intervention is on the child’s problems, with parents receiving information about the intervention and the skills their child will be developing. As co‐clinicians, parents are more actively involved in treatment. They attend each session with their child, either for the whole session or joining for the last 15 minutes. The intervention remains focused on the child’s problems, but parents have greater awareness of the skills their child is acquiring and so can prompt and encourage generalisation. This role is further enhanced when parents are involved as clinicians. In this role parents are provided with the information and support required to teach their child CBT skills. Finally, parents may be involved as a co‐client. This model recognises that parents may be behaving in a way that contributes to their child’s problems. The intervention therefore helps the child to develop and practise skills to deal with their anxiety whilst parents learn new ways of encouraging and rewarding their child for facing their worries.
In summary, parental involvement needs to be considered on a case‐by‐case basis and a decision made about whether parental involvement may be beneficial and, if so, how parents/carers need to be involved (Carnes et al. 2019).
The competencies to deliver child‐focused CBT
There are many materials and structured workbooks available which provide helpful ideas about how CBT can be undertaken with children and young people. These include specific manuals such as the Coping Cat programme for young people with anxiety (Kendall 1990); How I Ran OCD Off My Land (March & Mulle 1998), and the Adolescent Coping with Depression Course (Clark et al. 1990). In addition, there are materials to help young people with social skills problems (Spence 1995) and chronic fatigue syndrome (Chalder & Hussain 2002) and anxiety and depression prevention programmes such as Friends for Life (Barrett 2010). There are also books that provide practical ideas about how CBT can be adapted for use with children and young people (Friedberg & McClure 2015; Fuggle et al. 2012; Stallard 2019a) and how CBT can be used as a modular approach which flexes according to how the young person responds (Chorpita 2007). Finally, there are self‐help books for parents to help them overcome their child’s fears or worries (Cartwright‐Hatton et al. 2010; Creswell & Willetts 2018) or to help their depressed teenager (Reynolds & Parkinson 2015)
Such good quality child‐friendly materials make available many helpful ideas about how to introduce and use specific CBT strategies with children and young people. However, comparatively less attention has been paid to how these techniques are used, that is, the process of undertaking CBT with children, adolescents, and young adults. Attending to the process of CBT is essential and ensures that the theoretical model and the core principles that underpin CBT are preserved. This will ensure that CBT is used in a coherent and theoretically robust way thereby avoiding a simplistic approach in which individual strategies are used in a disconnected and uninformed way.
Think Good, Feel Good (Stallard 2002a, 2019a) and Thinking Good, Feeling Better (Stallard 2019b) provide a number of practical ideas about how some of the specific techniques of CBT could be conveyed to and adapted for use by children, adolescents, and young adults. This book looks behind these strategies to focus upon the process that underpins their use. This book is not intended to be prescriptive and does not advocate a particular style. Instead it aims to promote awareness of some of the key issues that need to be considered and integrated into CBT in a way that is engaging and helpful for the young person and their carer whilst maximising the effectiveness of the intervention.
Assessing competence
A clear strength of CBT is the underpinning philosophy and theoretical model. The philosophy underpins the collaborative process of self‐discovery whilst the theoretical model informs and guides the use of specific techniques. It is therefore important to develop a good understanding of the basic model and to ensure that the process and rationale for use of specific techniques is understood and competently executed.
The most widely used tool for measuring CBT competence with adults is the Cognitive Therapy Scale–Revised (CTS‐R) (Blackburn et al. 2001). This is a revised version of the original Cognitive Therapy Scale developed by
