ADHD is a neurodevelopmental disorder, one of the most common mental disorders affecting children. It is a developmental impairment of the brain’s executive functioning. This affects a child’s ability to focus, stay organised, sit still and manage impulse control. Treatment for children with ADHD will often involve stimulant medication and therapy. The most promising improvements seen in children with ADHD are those who are on medication combined with CBT, Cognitive Behavioural Therapy.
What is CBT?
Whilst CBT was developed from various ideas, the work of Dr Aaron T. Beck (1921-2021) is recognised as the most prominent. He believed that negative schema, thoughts, caused so much harm, particularly to those who had greater vulnerability (I’m seeing our kids with ADHD here). In very basic terms, he believed that people’s automatic thoughts on a situation affected how they behaved. If your automatic thought was negative, then this will affect your behaviour negatively.
Some examples of negative thinking are, that if something didn’t work once, it would NEVER work again. Totally defeatist. If it rains on your child’s birthday, YOU are a complete failure, not the weather. If you don’t get picked for a team, it’s because everyone hates YOU. If you don’t get a good grade on just one test this PROVES you are stupid. A plant dies, you have ruined your garden. One criticism and you may as well give up! Now I don’t know about you, but this sooooo sounds like my daughter with ADHD. One thing doesn’t go to plan and that’s the end of the world!
Beck believed in identifying these negative thought patterns and challenging them. Maybe instead of black or white, there are other boxes that something could fall into? Instead of guessing that someone has crossed the road to avoid you, maybe there is another, simple explanation. Maybe there is a shop they needed to go to on that side. They may not even have seen you! The plant may have died but does it really change how beautiful your garden is? Framing situations differently can greatly alter how the individual feels.
How does CBT work?
Cognitive Behavioural Therapy is deemed a talking therapy, although it is often much more than that. It can be accessed by all ages from young children to adults. It focuses on how thoughts, behaviour and emotions all interact, and when these are negative it teaches you how to change your thought patterns around to see something in a different way. Thoughts affect behaviour which in turn affect emotions which affect thoughts, so to speak.
Unlike other therapies, CBT does not delve back into why these thought patterns occur but is more about how to solve them in the here and now. It is more problem focussed, helping your child/teen with the problems that are affecting their daily life, now, today.
At the start of therapy, the CBT therapist will talk about the goal that you wish to achieve and normally give a time frame of how many sessions this will require. CBT is generally a short-term therapy where only a few sessions may be needed. The average amount of sessions can be between six and 20. I think of it as getting a personal trainer to help you when you first go to the gym and have no idea about the equipment or the exercises that are beneficial to you. Once you have been shown a few times consistently you no longer need a trainer and can continue by yourself. Maybe getting a refresher now and again.
Cognitive Behaviour Therapy can be carried out with the individual, with the parents and child, the whole family or as a group with others dealing with similar issues.
The therapy teaches your child how to look at a negative thought pattern differently, instead of seeing it as an all-consuming problem or issue. It uses Socratic questioning, a way of restructuring negative thoughts and beliefs. Basically, they will ask your child/teen
- Is that a realistic thought?
- Is it based on facts or just a feeling?
- What actual proof is there for this feeling?
- Is it possible you may be misreading/misunderstanding the evidence?
- Instead of just black or white, could there be something else?
Obviously, these will be phrased in an age-appropriate way and manner.
CBT for Children
Many children will claim, ‘that made me angry’ or ‘that made me scared’ in a sense of having no control over how they feel. But it’s our thoughts and beliefs that make us angry or scared about something. If you have a child that is overly anxious or depressed already then, most situations will be perceived as negative even if they are not. Using the ‘cognitive triangle can help show a child visually how they are viewing something negatively and how it is impacting their responses, and then showing them how to turn that thought around.
CBT has been shown to help children with:
CBT Methods for Children
For younger children, CBT may involve play therapy using arts, crafts, dolls etc to explain an issue or problem and work through this to a positive resolution. The use of puppets takes the focus off the child but keeps the child engaged. Children as young as three have been shown to see benefits of using CBT.
Worksheets are also often used for children where the characters have thought bubbles that the children can fill in or ask the adult to scribe/draw for them if too young.
For slightly older children, modelling may be used in the form of role-playing. The therapist will pre-empt a situation they have difficulty with, and they can work through it together to find appropriate responses. For example, not getting picked for a team, being bullied, and fear of being laughed at.
Writing down the negative thoughts for example, ‘I don’t want to move house, I will have no new friends and I won’t be able to make any’, could be adjusted to ‘It’s exciting to move house, I will still be able to talk to my old friends, but I get to make new ones!’
This is like restructuring which older children can be taught. A method of taking a negative thought, such as, ‘I got a low grade in my science compared to Joe, I must be stupid, I’m useless at science, I’m useless at everything’, to ‘I didn’t do so well this time, science probably isn’t my strongest subject, I know I’m better in English’. Taking these negative thought patterns and turning them around into something far more positive, and closer to the truth is constantly worked on in therapy until they become the child’s automatic thoughts. There is normally an amount of homework in between sessions to ensure that the continuity of these thought patterns continues and becomes the norm.
Teaching children what they can and can’t control is another useful tool used in CBT.
What I can control:
- Being kind
- Asking for help
- Apologising when I need to
- Asking for help when I need it
- Friend choices
- Eating right
- Things I like and don’t like
- Making good choices
- Taking care of myself
- Kind words and phrases
*Obviously with ADHD, some of these can be very difficult at times.
What I can’t control:
- The weather
- Predicting the future
- Being sick
- Other people
- Societies routines e.g., shop times, train times
- Past decisions
Getting children to acknowledge this really helps. Raining on your birthday was not your fault or because everyone hates you. It’s just the weather. And if you are in the UK, even the weathermen can’t predict it!
CBT and Teens
The teenage years are an important yet difficult part of development. Marked as the maturing phase into adulthood. Teenage hormones are through the roof and many parents really struggle with their ‘moody’ teens. Mine are just entering this phase!
Many teenagers can experience mental health issues, for example, depression, low self-esteem, and anxiety etc during this period. CBT can give your teen tools for changing these negative thought patterns about themselves into more positive thoughts.
CBT can be used for teens dealing with:
- Eating disorders
- OCD (obsessive-compulsive disorder)
- Substance abuse
- Anxiety and panic attacks
- Low self-esteem
- Sleep disorders
CBT Methods for Teenagers
CBT for teenagers can include
- Roleplay and modelling to practise the skills
- Relaxation techniques
- Self-talk in how to restructure unhelpful worries
Exposure is when the person is gradually introduced to a trigger for negative thoughts. This is often used in the treatment of phobias. For example, someone who fears snakes may start by just talking about them, a picture may later be brought in and left on a table for them to see, and next they may be asked to hold the picture when they are ready. In further sessions, it may be that you are able to visit a place with snakes with the goal being that you hold the snake. I really should do this myself for spiders! But this could be used for anxiety about anything.
So many teens can suffer from low self-esteem, especially our teens with ADHD who have heard so many negative and unhelpful comments during their years. Low self-esteem can be the underlying cause of so many other mental health issues including depression, anxiety, eating disorders, and substance abuse to name a few.
Helping your teen with low self-esteem is so important and one of the ways is to help is to stop them from self-criticising and being so hard on themselves. A tactic used in CBT to help this is to ask them to imagine that the situation they are being so critical about is happening to a friend or loved one. So, say their friend didn’t get picked for the team this week. How would your child feel about their friend? What would they say to their friend? Would they tell their friend, ‘You are useless, you will never get picked again!’, I doubt it! Yet they say that to themselves. This can be a great exercise, turning the scenario around.
Again, it’s practising this daily so that these thoughts become their automatic thoughts over the negative ones they have become used to. There will be homework between sessions to ensure they are using these thought patterns daily. If you only run a 10k once a week without maintaining shorter runs mid-week I imagine that’s quite tough! Not sure why I keep talking gym and running, I’m the laziest person you’ll meet, fitness-wise!
How can CBT help ADHD in children?
CBT won’t ‘cure’ ADHD, it is used as a complement to medication and any other strategies you may be utilising. It is very useful in helping with the below, all highly comorbid to an ADHD diagnosis:
- OCD (obsessive-compulsive disorder)
- ODD (oppositional defiance disorder)
- Low Self-Esteem
- RSD (Rejection Sensitive Dysphoria)
- Sleep Disorders
- Anger Management
For example, with ODD, a child is taught how to solve problems and communicate better, in a more regulated way. Anxiety can be helped by asking them, for example, what they fear is going to happen? How likely that would be to happen, realistically, and even if something did occur, suggestions on how it could be managed. This is known as decatastrophising. For children who self-harm, CBT works on regulating the child’s emotions and enabling them to tolerate more and practise mindfulness.
For both children and teens involving the parents, caregivers and even wider family has been shown to be very effective with this therapy.
Evidence for Benefits of CBT in Children and Teens
14 Benefits of CBT in Children and Teens (taken from Positive Psychology)
- CBT therapy enhances self-control, perceptions of personal efficacy, rational problem-solving skills, social skills, and participation in activities that bring a sense of pleasure or mastery (Clabby, 2006).
- Children between the ages of 7 and 15 can experience a reduction in anxiety, increased coping skills, and improved emotional awareness and regulation post-CBT treatment (Suveg, Sood, Comer, & Kendall, 2009).
- CBT can equip children with the skills needed to understand and cope with their emotions: children and adolescents who can effectively manage their emotions are 60% less likely to develop mental disorders in later life (University of Cambridge, 2011).
- Trauma-focused CBT significantly improves symptoms of PTSD and reduces abuse-related depression, shame, and harmful sexual behaviours in children below the age of 7 (Cohen, Deblinger, Mannarino, & Steer, 2004). Cohen et al. (2004) also found that the inclusion of a parent or guardian in TF-CBT led to significantly greater improvements in traumatized children with respect to interpersonal trust and perceived credibility.
- Group CBT has been shown to improve expressiveness and social skills while decreasing social anxiety and self-reported loneliness in young adults aged 11-18 years with autism (PenCRU: Childhood Disability Research, 2017).
- CBT can be adapted to allow children who cannot or will not verbalize to express their emotions via other avenues.
- An examination of school-based CBT programs found improvements in resilience, positive thinking, an increased sense of control, and a reduction in negative self-talk and non-productive coping strategies (Cunningham, Brandon, & Frydenberg, 1999).
- CBT may improve moderate to severe anger, irritability and physical aggression in children and adolescents (Sukhodolsky et al., 2016). During CBT, children can learn how to regulate frustration, improve social problem-solving skills, and role-play assertive behaviours that can be used during conflicts instead of aggression.
- CBT is flexible and interventions can be adapted to accommodate the developmental stage of the patient in order to treat specific disorders using age-appropriate methods.
- Cognitive-behavioural play therapy (CBPT) can be used in the treatment of selective mutism, anxiety disorders, separation anxiety, sexual abuse, sleep problems, acting out behaviour, and the effects of parental divorce in young children (Knell, 1999). During CBPT age-appropriate instruments are used to act out scenarios portraying healthy ways to deal with negative emotions, thus helping children to learn new ways of coping with trauma.
- Among children experiencing chronic migraines, the use of CBT combined with medication resulted in greater reductions in headache occurrence and migraine-related disability compared with the use of pharmaceutical treatment alone (Powers et al., 2013).
- Sleep in children and teens can be affected by a number of factors including biological factors, stress, increasing school and social obligations. CBT has been shown to significantly improve sleep onset latency, instances of waking after sleep onset, total sleep time, and sleep efficiency (de Bruin, Oort, Bogels, & Meijer, 2014).
- CBT for anxiety-related school refusal has shown clinically significant improvements in the attendance of 88% of participants at a small ‘school-refusing’ study. In a five year follow-up, 76% of participants demonstrated normal levels of school attendance and required no additional treatment for school refusal behavior (King et al., 2001).
- CBT is as effective a treatment for OCD in children and adolescents as medication alone; decreasing symptoms of childhood OCD over a 12-week program with enduring improvement found at a 9-month follow-up (Asbahr et al., 2005).
Finding a CBT Therapist
Recommendations for a therapist from someone known to you would be my first choice. Especially someone who has experience with ADHD. Failing that I would visit my GP.
CBT is available on the NHS in the UK, you can go through your GP to be referred or, according to the NHS website ‘you can refer yourself directly to an NHS psychological therapies service (IAPT) without a referral from a GP’. Private therapy sessions can vary from £40-100. The British Association for Behavioural & Cognitive Psychotherapies (BABCP) keeps a register of all accredited therapists in the UK and The British Psychological Society (BPS) has a directory of chartered psychologists, some of whom specialise in CBT.
Please do let me know of any recommendations you may have so I can list them. I would love to know what the process is in any other country too to provide this information.
I think from the above evidence, you can probably see why CBT would benefit our children. I’m yet to try it, but having researched this I’m seeing many benefits and will definitely look into it. Even if it just means buying a book to help in the first instance! I have seen several books on CBT for children on amazon, and again I would really value any personal endorsements for books you have read, for all age groups, to add to this post to help other parents, and myself.