A clinician recently told me that cognitive-behavior therapy (CBT) wasn’t appropriate for children because it was “too cerebral.” I asked her what she meant by this and she said that CBT just wasn’t any fun. It didn’t look fun to her so it couldn’t be fun to a kid. And, if it wasn’t fun then it wasn’t accessible. This clinician, to a degree, is correct. The effectiveness of psychosocial interventions for a kid rests on our ability to take a treatment protocol (often developed for adult populations) and adjust for the developmental age of the kid and engage the kid in the therapeutic process and tasks. Play and fun help with that. Play is an essential feature of CBT with kids. In fact, I have a blast with the kids and I think they do too. Before throwing out CBT with the proverbial bath water, I’d like to suggest a few guidelines to incorporate play and fun in conventional CBT strategies when treating depressed kids.
Don’t say it when you can play it. I learned early with kids that talking only gets me into trouble. Whenever possible, I try to illustrate a point through play or a game. For example, a behavioral experiment is a common CBT strategy for helping a client test the validity of a belief or attitude. Most kids understand the idea of an experiment and can be easily convinced to engage in a behavioral experiment if it looks like it might be a little fun. For example, James was a depressed nine-year old boy who believed that no one liked him. He told me that his older sister was well liked because her school yearbook was signed “by everybody in the whole school.” I asked James whether kids in his school would sign a yearbook if he had one. He said “No way. Only your friends sign your yearbook and I don’t have any friends.” James agreed to check this out if we could devise a way to do it. James didn’t have a school yearbook but he did remember a kid who broke his arm last year and had his cast signed by his friends. James and I made a simple paper-mache cast. I also alerted James’ teacher to the experiment. James brought the cast the following week and we colored it and made it ready for school the next day. When James arrived for his next therapy session, I met him in the waiting room. He held his arm behind his back. As we stepped into the office, he brought his arm forward and smiled. The cast was covered with names and James was one happy kid. We spent the remainder of the session discussing each signature while I reinforced the more balanced view that while not everybody liked James (not everybody signed his cast) there were many kids in school who did.
Don’t write it when you can draw it. Most depressed children are highly avoidant. They won’t try new things because they are certain they will fail or they avoid new activities because they think they will not have fun. It is helpful to obtain from children a measure of the difficulty of a task before it is undertaken. Cognitive-behavior therapists often use what is called a subjective unit of distress (SUD) for this purpose. With kids, I use a feeling thermometer to measure the difficulty of a task or the intensity of any feeling (such as fear, guilt, or shame). The child and I use part of a session to design a feeling thermometer and I have lots of glue, tape, and colored markers, stickers, and colored ribbons on hand. Once we finish constructing the feeling thermometer, I use the remainder of the session to explain the many ways we can use it. For example, James was reluctant to ride his bike, which he loved to do before he became depressed, because he predicted that he would not have any fun. I suggested to James that is Predict-o-meter might be accurate, that he would not have any fun if he rode his bike, but what if his Predict-o-meter is out of wack? He might be missing more fun than he thinks. James was intrigued and agreed to an experiment. We used the feeling thermometer to predict the “degree of fun” he might have if he rode his bike around the block. James agreed to try the activity and pay attention to what his feeling thermometer told him while he was riding his bike. Not surprisingly, James discovered that he had more fun than he predicted which confirmed that his “predict-o-meter is out of wack.” This lead to more pleasant activity scheduling which greatly improved his mood.
Keep it simple, simple, and (did I say) simple. Kids, well… they are different. They have shorter attention spans and they have not quite mastered that “delayed gratification” gig that seems to be the raison d’être for being a successful adult. So, in order for kids to take advantage of CBT interventions it is essential that they are simple, brief and straightforward. For example, pleasant activity scheduling is a powerful intervention that helps depressed kids get moving and doing. I use an Pleasant Activity Scheduling form that is a variation of the form used in the treatment of adults. The child form is much simpler than the adult form. It is segmented into morning, afternoon, evening and bedtime sections rather than by the hour. I work with kids to schedule no more that two or three activities each day which they note on their Pleasant Activity Schedule form (by either writing or drawing a picture). Other simplifications of common CBT interventions include a “Power Ranger” grip-and-release rather than a four-muscle group relaxation; blowing bubbles rather than calming breaths; and short punchy affirmations instead of lengthy coping statements.