Self-instructional training programmes might be thought to be appropriate for children with ADHD, who have core problems of inattentiveness, impulsivity and restless overactivity (the inability to ‘stop, look, listen and think’). The programmes essentially train children at home and/or in the classroom using a five-step approach summarised in Box 1⇓. Kendall's (1989) Stop and Think Workbook would be useful support to such a programme.
Self-instructional training programme: the five-step approach (Meichenbaum & Goodwin, 1971; Kendall & Braswell, 1993)
1. Watching a trainer model and talk through a task, including planning and talking through possible difficulties (cognitive modelling)
2. Carrying out the task, prompted by a trainer
3. Carrying out the task, prompting themselves aloud
4. Carrying out the task, prompting themselves by whispering
5. Carrying out the task silently using covert self-instruction/self-talk
While these approaches are good practice and a helpful adjunct to behavioural approaches at home and school when combined with medication, results have been variable and disappointing (Abikoff, 1991). The training has frequently been too short, unrelated to clinical need and with insufficient focus on generalisation and maintenance for hard-to-train children with ADHD.
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Addressing more than the child
A number of related issues need to be addressed in the therapeutic formulation when working with children and adolescents.
The therapist needs to engage both parent and child. The younger the child, the more the parents will need to be included in the therapy and to be instructed in the cognitive–behavioural model and its application to their child's problem.
The parents may also need specific instruction in management techniques, for example avoiding reassurance for a child with OCD and using positive reinforcement for compliance with a child with a conduct disorder.
The therapist must be aware of the family's structure and its belief system, the systemic implications of any intervention and reality factors such as abuse or a specific learning disability.
Complementary behavioural input for parents is particularly important for oppositional defiant disorder and conduct disorder, for which parent management training has been shown to be effective (Patterson, 1982; Webster-Stratton, 1982, Webster-Stratton, 1984). Parent training also enhances problem-solving skills training for children, giving a consequent decrease in aggressive behaviour problems at home and at school and an improved overall adjustment (Kazdin et al, 1992). It is also useful for parents whose own anxiety provides powerful modelling for their children's anxiety disorders to have CBT in their own right (Barratt et al, 1996, Barratt et al, 1998).
Information and adjunctive behaviour programmes may be necessary to reinforce therapeutic achievements for the child. For example, information about exposure helps a school to support a returning school-avoidant child and reinforcing developing social skills is helpful for a child with a conduct disorder.
Engaging the child or adolescent
Attractive published materials such as Kendall's workbooks (1989, 1994a) may need to be supplemented by individual tailor-made charts or materials prepared by the therapist.
The therapist has a role as reinforcer to increase the child's motivation, and should use appropriate supportive phrases: “Well done. Even though it was difficult, I can see how hard you've tried”.
Overcoming developmental limitations
While a bright well-motivated adolescent's grasp of unmodified adult-type CBT principles or programmes can be very rapid and rewarding for both adolescent and therapist, younger children may find the adult programme and materials, such as thought diaries (Fig. 2⇑), beyond them unless these are suitably modified.
Before therapy proper is begun,