Journal of ChiM and Family Studies, Vol. 2, No. 4, 1993, pp. 389-395
Book Review
Cognitive-Behavioral Procedures with Children and Adolescents: A Practical Guide. Edited by A. J. Finch, W. M. Nelson, and E. S. Ott. Needham Heights, MA: Allyn & Bacon. 1993. Pp. 418.
Writing for clinicians about mental health treatment procedures is a path fraught with a variety of pitfalls. Some authors appear consumed by the desire to communicate the beauty and elegance of their conceptual model and the need to describe how a favorite treatment case illustrates the validity of that model. Others fall prey to the sirens of psychometric sophistication and dazzling effect sizes, and in their drive to demonstrate the superiority of the intervention, fail to provide meaningful information about the procedure itself. And still others, in a spirit of true democracy, seek to review all of the procedures that might be employed for a particular symptom picture with little attention to their relative efficacy and without offering a useful description of any. Few enough are able to find the narrow path where the chief question is not "why does it work?" or "how well does it work?" but rather, "how do you do it?" The text under review represents a collection of authors who have found that path and who are able to communicate clearly and with sufficient detail the nature of the procedures they use, such that they offer a valuable resource to the field of child and adolescent psychology. Cognitive-Behavioral Procedures with Children and Adolescents is an edited volume designed for the needs of persons who are implementing or teaching cognitive-behavioral (C-B) psychotherapeutic interventions with children (for the purpose of this review, the term children is intended to include adolescents.) The text is divided into three sections. The first section consists of four chapters covering general issues related to the use of C-B procedures with children: an historical overview, a discussion of developmental issues, a review of self-management with children, and an 389
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1993 Human Sciences Press, Inc.
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overview of assessment techniques. Next comes a section of seven chapters covering major childhood problem areas and the application of related C-B procedures. Finch et al. indicate that the problem areas to be included were chosen in part on the basis of empirical studies of childhood psychopathology and reflect common problems in the two major dimensions of behavior disturbance, internalizing disorders and externalizing disorders. The final section is a single chapter that aims to offer a general conceptual formulation for psychotherapeutic intervention with children. The opening chapter of the text by Hart and Morgan seeks to define the territory to be explored and to trace the development of the field. The authors present the often-cited dissatisfaction with "radical behavioral" approaches and briefly discuss the experimental support for including cognitive events in models for treatment procedures. They then identify the "general characteristics of a cognitive-behavioral approach" including a commitment to combining approaches frequently seen to be opposing, affirmations of methodological behaviorism, cognitive mediation of behavior and learning, reciprocal determinism, and assertions that cognitions are appropriate concerns of the therapist and can be the target of learningbased techniques. Hart and Morgan next trace the streams of research (verbal control of behavior, self-regulation, cognitive style, problem solving) which have contributed to the C-B interventions currently in use. The chapter continues with a summary of the efficacy of C-B interventions, concluding that comparisons with "pure" behavioral interventions have yielded equivocal results. A closing section identifies several key concepts which may guide the future development of C-B interventions: metacognition, attributions, and self-efficacy. Chapter 2 of the text takes up the question of developmental variables in C-B interventions with children. Kimball, Nelson, and Politano introduce the topic by examining the relationship between cognitive and social development. They discuss two major theoretical perspectives on the relationship, social learning theory and cognitive developmental theory, and suggest that social learning theory has had the more central role in the development of C-B interventions. Kimball et al. then review the relevant literature in four areas related to social/cognitive development: the comprehension of social acts, role taking and moral reasoning, interpersonal problem solving, and verbal self-regulation. In each case, the authors discuss definition and assessment, developmental trends, relationship to behavior, and training. The chapter closes with a model for developmentally based assessment and intervention with examples of the differences in strategies depending upon the developmental level of the child. The focus of Chapter 3 by Evans and Sullivan is on self-management. The three aspects of self-management covered in this chapter are self-moni-
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toring, self-evaluation, and self-reinforcement. The authors provide a brief description of each of the techniques as applied to children and a discussion of their application in the school classroom. The remainder of the chapter consists of case material, an individual case study on thumbsucking and a description of a "self-control group" protocol for child psychiatric center residents. The authors emphasize that self-management may be useful as an addition to other behavior change programs to diminish dependence on external reinforcement systems. The authors acknowledge the importance of developmental factors in planning and implementing self-management programs; however, little space is devoted to this aspect of the techniques, perhaps as a result of the limited literature on this issue. The final chapter in the first section, written by Pellegrini, Galinski, Hart, and Kendall, is an overview of the measures and methods for the C-B assessment of children. The organization of the chapter is from general to specific assessment. Included under the general category are descriptions of clinical interview and behavior observation procedures, problem behavior checklists, and self-report procedures. In the sections devoted to more specific dimensions of assessment, the authors address "problems in social relationships," "problems in attention and impulsivity," and "problems in mood and affect." This chapter suffers somewhat from uncertain organization. At the intermediate levels of section headings, nonparallel construction interferes with the forward movement of the text. As an example, subsequent sections are entitled "Behavioral observation of peer interaction," "Social cognition," and "Interpersonal problem solving;" these headings represent an assessment method, a general class of cognitive abilities, and a more specific cognitive skill, respectively, and transitional material which "glues" these topics together is notably absent. More careful attention to the outline of the chapter would have helped the reader gain a more systematic understanding of the field of C-B assessment. Nonetheless, for the persistent reader, a good deal of useful information can be gleaned from this relatively comprehensive compendium of assessment instruments and procedures relevant to the C-B treatment of children. The authors close their discussion with several astute criticisms of the state of the art of C-B assessment. The second section of the volume opens with a chapter on childhood aggression by Finch, Nelson and Moss. The authors approach the problem of aggression as a manifestation of deficient anger control. Consequently, they introduce the substance of the chapter with a discussion of the assessment of anger. Such assessment includes not only angry and aggressive behavior but also the cognitive events associated with anger. The anger management treatment program offered by Finch et al. is based on the principle of stress inoculation which emphasizes self-instruction and relaxa-
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tion. Practical guidelines and examples are offered with an outline of an eight-plus session treatment program designed to implement stress inoculation with aggressive children. A case study with extended treatment session scripts further illustrates the approach. Finally, the authors offer an alternate treatment approach which retains the notion of stress inoculation but places greater emphasis on problem-solving skills. Again, a detailed outline of the treatment program is offered including session goals and activities. The authors provide a clear conceptual framework for their discussion of the treatment of aggressive behavior and a set of treatment interventions which are logical extensions of their formulation. Further, the chapter exudes a sense of "having been there," giving the reader additional confidence in the approaches described. Polyson and Kimball, in Chapter 6 also address the problem of aggressive behavior in children, albeit from a slightly different perspective. Proceeding from the assumption that some childhood aggressive behavior is associated with social skills deficits, the authors present an intervention program that seeks to identify the child's deficient skills and to remediate them through modeling, role playing, rehearsal, feedback, guided practice, and reinforcement. A training manual is included which offers considerable detail in the description of 14 training sessions. The presentation of the chapter is at a disadvantage in that it follows the Finch et al. chapter and displays some overlap of material. Nonetheless, the focus on social skill development provides a slightly different perspective that may be better matched to some patients and some clinicians. The last chapter to focus on externalizing behavior problems, Chapter 7, examines the use of a self-instructional training program in treating children with impulse control deficits. Finch, Spirito, Imm, and Ott first review a 20-year program of research that builds the case for, and demonstrates the efficacy of, cognitive self-instruction in this population. The authors then present an eight-session self-instruction training program and offer specific and practical suggestions for its implementation. A final section of the chapter discusses the child variables of age, cognitive level, and child involvement, which may affect the clinician's choice to use such a training program. Chapter 8 takes up the issue of coping skills in children who manifest anxiety disorders. Written by Grace, Spirito, Finch, and Ott, the chapter is aimed at "the practicing clinician who is interested in developing a cognitive-behavioral treatment program for a child client whose presenting problem is anxiety" (p. 257). The introductory review of the literature examines the use of coping techniques in the treatment of test and evaluation anxiety, anxiety associated with medical and dental procedures, and general fears and phobias. The specific treatment approaches discussed at some
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length are based on the Anxiety Management Training program developed by Suinn and colleagues and the Stress Inoculation Training program developed by Meichenbaum. Both are outlined in some detail, in the latter case including several scripts for portions of the training sessions. Useful practical guidelines are offered for the implementation of a Stress Inoculation Training program, many of which may be generalized to most C-B interventions with children. The chapter closes with a script for a video-tape modeling self-instruction to manage text anxiety. In Chapter 9, Carey discusses the use of C-B methods in the assessment and treatment of childhood depression. Four treatment models based on the work of Ellis, Beck, Rehm, and Lewinsohn are discussed briefly, followed by a review of the (relatively scanty) treatment outcome literature for C-B treatment. By virtue of the fact that the author discusses four treatment models, the amount of specific information offered in the chapter about any single approach is limited compared to the other papers included in the volume. Section two of the volume concludes with two chapters that do not fit neatly into the internalizing/externalizing dimensions of child behavior problems. The first is on drug abuse, a problem which is frequently associated with both internalizing and externalizing behaviors. Nay and Ross are working from the premise that drug abuse in youths is associated with a prominent behavioral and belief system that perpetuates the problem. They expand this premise into a conceptual model that involves Environmental Factors, Attitudes/Beliefs, Feeling States, Motives, and Behavior. Nay and Ross go on to describe an intensive treatment program for drug abusers. Considerable detail is provided for each stage of the program, particularly the stage that involves "the identification of dysfunctional thoughts and cognitive structures." The chapter closes with a description of the LIFE day treatment program in Sarasota County, Florida which demonstrates the model. The final chapter in section two is on pain management. The editors of the volume point out in the preface that the referral rate for coping with pain and medical procedures has been rapidly rising in recent years and clinicians are increasingly being asked to provide consultation or treatment in this area. Nelson begins the chapter with a discussion of pain theory and a brief section on the assessment of pain in children. The author then offers an overview of the "psychological preparation" interventions intended to offer information about painful medical procedures and to help the child develop coping strategies. More specific cognitive-behavioral assessment techniques are discussed with particular attention to imagery, behavioral exposure, and projective storytelling. Nelson then presents a modified stress inoculation procedure, tailored for children who will en-
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counter and must cope with pain. The final section of the chapter is devoted to presentation of a case study of the treatment of dental phobia. In the last section of the text, a single chapter, Politano offers a "conceptualization of psychotherapy with children and adolescents." The author briefly traces the history of the status of children in western society and summarizes the primary differences between adults and children in the areas of expectations, maturation, cognitions, and emotions. Politano suggests the metaphor of straightening up a house in which the furniture is all awry as a way of conceptualizing the task of psychotherapy. Differing theoretical orientations are shown to have different goals, objectives, and activities for the process of straightening up, but all seek to help the patient achieve some greater order in their internal "house." Finally, Politano describes the process of change in children's psychotherapy with a model that incorporates the components of Elaboration and Exploration (when, what, and where questions), Pattern Development (linking experiences with maladaptive behavior), and Amplification (elevating cognitive and behavioral events to promote further elaboration and exploration). This reviewer's criticisms of the volume as a whole are largely in the editorial realm; the text manifests some puzzling organizational features (Why does the chapter on self-management precede the chapter on assessment?) and there is some redundancy in the three chapters devoted to externalizing behavior problems. In addition, although some attention is paid to the importance of developmental factors in the C-B treatment of children, in fact this is mostly of the "armchair philosopher" variety. One is struck again by the dearth of data regarding the developmental appropriateness of specific interventions. This is not so much a criticism of the volume under review as of the field in general. Everyone agrees that developmental factors must be taken into account; however, the efforts to systematically explore how to do so are few and far between. In general, however, the impression left by the Finch et al. volume is very positive. The subtitle, "A practical guide", conveys the sense that the text will offer useful guidance for clinical work and in large part, this promise is fulfilled. The editors state that the authors of the various chapters were asked to "tell of [their] own experience in conducting and teaching a cognitive-behavioral approach" (p. xi). As a result, the contributions are generally quite readable and, in fact, inform the reader about not only what to do, but also how to go about doing it. Taken as a whole, this volume represents a welcome addition to the clinician's library, providing down-to-earth, usable suggestions and even entire treatment protocols aimed at some of the childhood behavior disorders most frequently encountered in clinical practice today.
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This text will be particularly useful for clinicians who are looking for practical, detailed direction in the implementation of C-B procedures with children. Each chapter contains enough conceptual background to provide a rationale for the treatment under discussion but the bulk of the material focuses on actually doing it, a refreshing and welcome addition to the literature on the treatment of children. The clinicians most likely to gain maximum help from the text are those who have a good general child clinical background and some familiarity with C-B interventions with adults; the authors generally appear to assume such familiarity so as to avoid having to consume the chapters with background material. This volume could also be useful with less advanced clinicians if used as a text in a formal training course in which additional background could be provided as needed. In sum, the text has much to recommend it and represents a valuable addition to the literature for the clinician who works with children.
Donald P. Oswald
Medical College of Virginia Virginia Commonwealth University
