Running Head: TREATING DEPRESSION WITH CT

Using Cognitive Therapy to Treat Depression in School-Aged Children

Melinda Parkins
Marshall University

TREATING DEPRESSION WITH CT

Introduction
Cognitive Therapy (CT) is an effective method for treating depressive disorders in
school-aged children. Depression is a serious mental health issue across the nation among both
adults and young people alike. The National Institute of Mental Health (2016) reported that 20%
of adolescents (aged 13-17 years) have experienced a depressive disorder at some point in their
lives. Depression effects both males and females during childhood the same. However, during
adolescents, although both still experience depression, females exhibit a higher amount of
depression when compared to males. Based on reports from the Substance Abuse and Mental
Health Services Administration, (2009) the ratio of female to male instances of depression in
adolescents are 3:1.
In addition, a depressed youth provides a strong indicator for a depressed adult based on
much research over the years. Depressive disorders have a proven history of recurrence and
when left untreated can continue for many years, which can carry over into adulthood. An altered
mood is a result of depressive disorders and ultimately impacts many areas of the young persons
life. These changes in mood can cause academic concerns based on poor motivation, decreased
self-worth, and poor attendance. In addition to poor academic success, many young people begin
to withdraw from peers and family, and turn to food or substances to help them feel better, not
realizing this is just a temporary solution. The most important concern however, is the increased

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risk for depressed youth and suicide. This being the third leading cause of death for this age
group, per the National Institute of Health. (2012)
Research published in the journal of Couples and Family Psychology: Research and
Practice suggests that a multitude of factors can contribute to childhood depression. Depressed
parents, parental absence, as well as environmental factors contributing to childhood depression.
The researchers went on to stress the need for effective treatment in school-aged children and its
importance with increasing suicide rates. The purpose of the study was to determine the
importance and effectiveness of treatments that included familial involvement. Comparisons
were made between child-focused therapy and family-focused therapies using a variety of
techniques. The family-focused treatments did have an impact on the reduction of depressive
symptoms; however, the family-focused treatments did not prove to be more effective than
individual-focused treatments. When comparing CT with an individual group versus a family
group, no additional advantages were noted. The researchers found that youth-focused
individual CT was more effective than a family condition. (Stark, Banneyer, Wang, and Arora,
2012)
A study in the Journal of Consulting and Clinical Psychology considered participants who
were suffering from substantial depression evidenced by scores on the Childrens Depression
Rating Scale-Revised (CDRS-R), the Clinical Global Impression-Severity Scale (CGI-S), and
criteria from the Diagnostic and Statistical Manual for Mental Disorders 4th ed. (DSM-IV). The
participants selected for the study had been unresponsive to treatment with Selective Serotonin
Re-Uptake Inhibitors (SSRIs) for at least 6 weeks with increased dosing modifications
throughout. The participants were randomly assigned to one of four treatment categories: 1)
change to a second SSRI; 2) change to venlafaxine; 3) change to a second SSRI combined with

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CT; or 4) change to venlafaxine combined with CT. No differences were found in outcomes
following medication alterations for participants. As for the 166 participants pairing SSRI
medications with a minimum of 9 CT sessions, improvement was evident. Thus, providing
support for pairing CT with SSRI medications to promote reductions in depressive symptoms for
young people. (Kennard, Clarke, Weersing, Asarnow, and Shamseddeen, 2009)
A meta-analysis study in the journal of Couple and Family Psychology: Research and
Practice was conducted to determine what is most effective in treating depression from a
relational perspective. The outcome being that CT was a strong contender. The study determined
that CT could be as effective as medications if treatment techniques were completed in an
acceptable manner with highly qualified therapists. Often CT is a suggestion for the treatment of
depression per guidelines set by American Psychological Association and National Institute for
Clinical Excellence. Additionally, it was proven that CT had lasting effectiveness even after
treatment had ended unlike Individual Focused Therapy and Antidepressant Medications. This
was based on evidence from six of seven trials that found participant response to CT created a
lower relapse level. The belief being that CT helped the participant learn to address their
depression in a manner that was impossible with medication alone. The study suggested CT to be
a learning-based approach that provided participants specific skills for use of symptom
reduction and potential relapse prevention in the future. (Hollon & Sexton, 2012)
Cognitive Therapy (CT), also known as Cognitive Behavior Therapy (CBT) was
introduced during the 1960s by Aaron T. Beck. Beck was a psychoanalyst at the University of
Pennsylvania who researched depression. He was responsible for opening a depression clinic and
introduced the Beck Depression Inventory (BDI) which is still used currently to determine the
various scales of depression. Beck concluded that cognition, an individual perception,

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interpretation, and attribution to ones daily functioning was an important aspect to therapeutic
treatment. (Licata, 2016) Becks continued research regarding depression led to his development
of Cognitive Therapy, and was explained in his first book, Depression: Clinical Experimental and
Theoretical Aspects. His daughter, Judith Beck, is the leading proponent of CT today. (Gladding
p. 214)

Basic Assumptions
Cognitive therapy is based on the belief that how an individual thinks (cognition), how an
individual feels (emotion), and how the individual acts (behavior) are all intertwined. Cognitive
theorists believe that ones thoughts determine their feelings and behaviors. This brings
understanding to the idea that negative and irrational thoughts can impact the individual in a
harmful way and cause additional consequences. The way a person interprets events becomes
distorted and has a negative effect on their choices and actions. Cognitive therapy aims to adjust
information processing and initiate positive change in all systems by acting through the cognitive
system. (Corsini and Wedding p. 231) Cognitive therapy is a time-limited, structured, active, and
theoretical approach that focuses on the here-and-now for treatment purposes.
Key Concepts
The fundamental concepts to be considered relevant in cognitive therapy include
collaborative empiricism, socratic dialogue, and guided discovery.
Collaborative empiricism describes the relationship between the patient and the therapist.
The relationship is to be collaborative with active participation from both entities. Setting
treatment goals, as well as prompting and contributing during feedback will demystify how
therapeutic changes occur.

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Socratic dialogue stresses the importance of questioning to cognitive therapy. The

therapist strategically designs a set of questions that will help the patient learn new skills. The
purposes of the therapists questions are generally to: 1) clarify or define the problems; 2) assist
in the identification of thoughts, images, and assumptions; 3) examine the meaning of events for
the patient; and 4) asses the consequences of maintaining maladaptive thoughts and behaviors
Ultimately through questioning the therapist helps the patient reach conclusions about the reality
of their thoughts, feelings, and actions. (Corsini and Wedding p. 247)
Guided discovery is used in cognitive therapy to change irrational thoughts and
speculations. The therapist guides the patient through an experimental process of skills training
to alter undesirable behaviors. The therapist only provides encouragement to the patient as a
motivator to use acquired skills to obtain realistic views of thoughts, feelings, and actions.
(Corsini and Wedding p. 247)
Role of the Therapist
The role of the cognitive therapist is to work with the client to make covert thoughts more
overt. This is especially important in examining cognitions that have become automatic, such as
Everyone thinks Im boring. (Gladding, p. 215) In this evidenced-based approach the therapist
assists the patient with gaining insight into misconceived and irrational thinking patterns. This in
turn helps the patient alter the behaviors and emotions that are attached to the ill thoughts. The
role played by the therapists is one that provides listening, teaching, and encouraging of the
patient. The therapist does not demand or direct the client in what they need to do to resolve
concerns. The therapist assesses patient strengths and uses them as a teaching technique. Per
Corsini and Wedding (2014) the cognitive therapist specifies problems, focuses on important
areas, and teaches specific cognitive and behavioral techniques

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Therapeutic Relationship
In cognitive therapy the therapist views the therapeutic relationship as a secondary factor
of therapy. The primary focus of this therapeutic approach is changing the thoughts and
behaviors of the client. The relationship between the therapist and client in cognitive therapy is
mutual and agreed upon, it is a working relationship. As part of the collaboration, the patient
provides the thoughts, images, and beliefs that occur in various situations, as well as emotions
and behaviors that accompany the thoughts. (Corsini and Wedding p. 246) Both the therapist and
the client work together to decide on treatment goals, development of homework assignments,
defining what successful treatment means, and determine specific requirements for maintaining
success in treatment. The therapist is open and honest in sessions and provides the client with
clear, detailed, and easily understandable feedback. Since changing the clients current beliefs
could take time, the therapist must also be sensitive and flexible as well. The therapist
encourages the clients point of view and feedback during each session, which allows for a
continuation of mutual efforts in the treatment process. (Corsini and Wedding p. 246)
Process of Psychotherapy
The cognitive therapist will employee a variety of procedures to help the client. Teaching
is stressed and very important in cognitive therapy. Initially, the therapist will start to establish a
relationship with the patient, extract necessary information, and generate relief from the patients
depressive symptoms. The relationship building might begin with questions about the patients
thoughts and feelings about therapy. Corsini and Wedding suggest that discussing the patients
expectations helps to put the patient at ease, yields information about the patients expectations,
and presents an opportunity to demonstrate the relationship between cognition and affect (p.
247). The initial sessions are also a time to introduce the patient to cognitive therapy, develop

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framework for treatment, and address any misunderstandings about the therapeutic process.
During these initial sessions, the therapist plays a more active role than the client, gathering
information, defining the problem, and providing symptom relief. A problem list is compiled and
importance of addressing each is assigned initially as well. (Corsini and Wedding p. 248)
During the middle and later sessions, the direction of therapy changes from the patients
symptoms to the patients thinking. Now the correlation between thoughts, emotions, and
behaviors are indicated based on the analysis of automatic thoughts. During later sessions
techniques change and cognition becomes more important than the behavior. Also during later
sessions, the patient begins to have more value in their treatment with the recognition of
situations, problem-solving solutions and development of homework assignments. The therapist
takes on the role of advisor rather than teacher as the patient becomes better able to use cognitive
techniques to problem solve. (Corsini and Wedding p. 248-249) The need for sessions decreases
because the patient has become better equipped to handle stressors in their life.
The therapy relationship is discontinued once all treatment goals have been accomplished
and the patient feels ready to implement new skills on their own. The length of treatment is based
on the intensity of the patients concerns. The average length of treatment can last anywhere
from 15 to 25 weekly sessions. For more severe cases, sessions could be twice weekly for 4 to 5
weeks and then decrease to weekly for 10 to 15 additional weeks. From the initial interview, it is
understood that cognitive therapy is time limited and this usually prevents complications for
ending treatment. Termination is usually followed by one or two booster sessions, usually one
month and two months after termination. (Corsini and Wedding p. 249)
Goals and Objectives

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The belief of a cognitive therapist being that a specific situation or event was improperly
processed, given meaning, and in turn caused ones behaviors and emotions to be altered,
provides an assumption that cognitions affect and cause behaviors. The primary goals of
cognitive therapy are to alter the individuals methods of processing information and help with
the transformation of inadequate beliefs that are causing them to exhibit dysfunctional emotional
and behavioral actions. In many therapeutic situations both cognitive and behavioral techniques
are used in combination to provide effective treatment to the client. Cognitive therapy
immediately focuses its efforts on attempting to provide the client with symptom relief.
However, the most important goals of cognitive therapy are to alleviate all distorted thoughts and
transform the clients ingrained judgements with the hope that future situations will become
averted. Cognitive therapy fosters change in patients beliefs by treating beliefs as testable
hypotheses to be examined through behavioral experiments jointly agreed on by patient and
therapist. The cognitive therapist does not tell the client the beliefs are irrational or wrong;
instead asks questions to elicit the meaning, function, usefulness, and consequences of the
patients beliefs. The client decides the rationality or irrationality of the beliefs and how to
proceed. (Corsini and Wedding p. 244-245)
Cognitive therapy is an empirically supported method of treatment that is reality based.
Cognitive therapy allows the client to actively participate in their treatment by making decisions
right or wrong and applying the learned skills to these specific situations. Cognitive therapy does
not attempt to substitute positive beliefs for negative beliefs, instead an opportunity to analyze
the beliefs is provided in a therapeutic setting. Cognitive changes occur at several levels:
voluntary thoughts, continuous or automatic thoughts, underlying assumptions, and core beliefs.
Based on the cognitive model, cognitions are organized in a hierarchy, each level differing from

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the next in its accessibility and stability. The easiest to gain access to being voluntary thoughts
and then continuous or automatic thoughts being more difficult to access. (Corsini and Wedding,
p. 245)
Techniques and Methods
Considering the primary goal of a cognitive therapist is to provide a change in the clients
thoughts, feelings, and behaviors; specific and effective techniques to promote these changes
must be implemented. Cognitive therapy uses a combination of both cognitive and behavioral
techniques for treatment purposes. The techniques and methods considered in cognitive therapy
must be specific and help to educate the patient on ways to track their thoughts, develop an
understanding of the connection between their thoughts and actions, investigate the validity of
their thoughts, replace untrue thoughts with meaningful ones, and acquire the skill to recognize
and change core beliefs that are causing them to struggle. Therapists use a multitude of
techniques and methods over the course of treatment to help them analyze their thoughts and
behaviors.
Specific cognitive techniques and methods include decatastrophizing, reattribution, and
redefining.
Decatastrophizing or the what-if-technique is used to help patients prepare for feared
consequences. In turn this decreases avoidance when combined with coping plans. The idea of
these technique is to help identify problem-solving strategies.
Reattribution techniques are used to test automatic thoughts and assumptions by
considering alternative causes of the events. This technique is helpful when patients personalize
or perceive themselves as the cause of events. Reattribution techniques encourage reality testing
and appropriate assignment of responsibility by examining all factors.

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Redefining is way to encourage change in a patient who thinks a problem is beyond their
control. This technique may include making the problem more concrete and specific as well as
exposing it based on the patients own behavior. (Corsini and Wedding p. 252)
Specific behavioral techniques and methods include homework, hypothesis testing,
behavioral rehearsal and role playing, diversion techniques, and activity scheduling.
Homework provides patients with the possibility to apply cognitive principles between
sessions. These assignments usually focus on self-observation and self-monitoring, structuring
time effectively, and implementing new skills to challenge automatic thoughts and reactions.
Hypothesis testing provides both cognitive and behavioral aspects. To frame a hypothesis,
it must be specific and concrete. In an example provided by Corsini and Wedding, a resident
insisted, I am not a good doctor was asked to list what was needed to arrive at that conclusion
by the therapist. The therapist also contributed additional suggestions such as rapport with
patients and the ability to make decisions under pressure, as the resident had overlooked these
areas. The resident was to monitor his behavior and acquire feedback from his colleagues and
supervisors to test his hypothesis, concluding, I am a good doctor for my level of training and
experience.
Behavioral reversal and role playing are used to practice skills and techniques that will be
applied later in real-life situations. Modeling is also an effective technique used in skills training.
Diversion techniques are used to reduce powerful emotions and negative thinking,
implement physical activity, social contact, work, play, and visual imagery.
Activity scheduling provides structure and encourages patient involvement. The patient
uses a rating scale (0 to 10) to describe the level of pleasure experienced during activities. This

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allows the patient to recognize mood changes and accomplishments based on documented
evidence and planned pleasurable activities. (Corsini and Wedding, p. 253)

Case Study
James, an eight-year old Caucasian male in the second grade, lost his mother due to
cancer when he was in kindergarten. He was a very bright student, was in good academic
standing, and had good peer interaction prior to her death. However, since his mothers death, his
motivation and grades had consistently declined and he seemed to be withdrawing more. James
teacher asked him if he would like to start talking with the school counselor. James agreed to talk
to the counselor and expressed he was feeling a little sad and missing his mom. James teacher
followed up with the counselor and expressed her concern that he was very much unmotivated
and was starting to sleep in class more frequently.
The school counselor set up a time with the teacher to get James from class to introduce
herself and get to know him. Initially, James seemed comfortable but somewhat reserved in what
he wanted to discuss. The counselor asked James some questions about school, friends, home,
and his feelings about those things. He informed the counselor that his mom died and he thinks
about her a lot and it makes him feel sad most of the time. He also reported these sad thoughts
happen at home, school, on the bus, and just everywhere. He said it helps if he sleeps because he
doesnt think about it as much. James also shared that he was tired in class because he stays
awake most nights and cant sleep. He said thats when he sees and talks to his mom. He didnt
talk about having or wanting friends.

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James told the counselor that since his mom died, he lives with his grandparents, along
with his dad, older sister, and older brother. James also said no one except his grandma will let
him talk about his mom. He reported that his dad and older sister tell him to be quiet and that he
is going to cause everyone to be upset by talking about it. Towards the end of the initial meeting,
the counselor asked James why he was so sad? James said, I didnt get to tell her I love you.
The day the ambulance came and got her I was trying to get out of the house to go tell her but
there were a lot of people to get past. I ran out to the ambulance to tell her, but they just closed
the doors and drove off. James broke down crying and repeatedly said, I just wanted to tell her
I loved her. That was the last time I got to see her. I never got to see her again, she never came
back home.
James agreed with the counselor that they would start meeting on a weekly basis. The
initial meetings with James were very informal and he did some of the talking. The counselor
would ask questions of James and he would answer them. He talked about his dad being gone all
the time and how he gets in trouble with the cops for stealing. He said Child Protective Services
(CPS) had been to their house because of his dad getting in trouble.
The counselor knew that some depression in relation to the death of a parent was normal
and to be expected. However, this had taken place two years ago and James was still struggling
with symptoms of depression. In addition, the counselor suspected that a change in his living
situation, a non-nurturing father, and an unstable environment also contributed to his depression.
The counselor felt James had not been allowed to properly grieve the loss of his mother. James
said he felt like he bothered his family and he was in their way. He thought they would be
happier and things would be better if he wasnt there. The counselor asked where would he go.
He said, I dont have anywhere else to go.

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James was exhibiting many of the signs and symptoms of childhood depression. A change
in sleep, specifically sleeplessness, was causing him to sleep during the day in class. He had
continuous feelings of sadness most of the time. He was having difficulty concentrating and
staying focused on the tasks at school. James exhibited fatigue and low energy during recess and
gym. He didnt engage with the other students and was somewhat withdrawn. James also had
feelings of guilt about not getting to say I love you to his mom. He had feelings of worthlessness
and thought his family felt the same way about him.
The counselor thought it would be helpful to complete a depression inventory and a
depression scale. This would provide a better understanding of the severity and areas of his
depression for additional treatment goals. For the depression scale James scored 21 out of 33.
Higher scores indicate more severe depression. For the Beck Youth Inventory, he scored 69,
which is moderately elevated depression. In addition, James and the counselor discussed any
thoughts about harming himself and he said he had none. The counselor emphasized the
importance of letting someone know if he does begin to feel like hurting himself. James said he
would let the counselor know if he started to have those thoughts.
The counselor provided James with a safe and confidential environment that allowed him
to feel secure. The counselor was non-judgmental when James expressed his thoughts and
feelings about his experiences, which in turn allowed for a trusting relationship to develop. The
counselor and James talked about current life situations, reflected on past life situations, and
anticipated future life situations. Talking with the counselor allowed James to recognize and
express that he felt better. The counselor and James discussed ways that might help him feel
happier. They also discussed that this could take some time and might not happen right away.

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James and the counselor talked about setting goals to work toward helping him become happier.
James agreed that he would continue to see the counselor weekly for more help.
James was given an assignment right away to get the treatment started and begin working
toward symptom relief. He was to make a list of three things he thought were his biggest
problems at home and at school. James listed at home; he felt he was in the way, was not
important, and was a pest to his family. For school, he wrote; he felt like he didnt have friends,
his teacher didnt like him, and he was dumb. The counselor and James then processed the list
together and discussed why he thought these things. Here the connection between James
emotions, thoughts, and behaviors were obvious. The counselor asked James if anyone had ever
said any of these things to him and he replied no. The counselor talked about automatic thoughts
and how James needed to examine his way of thinking because what he thinks might not always
be accurate.
The next assignment for James was to work on using I Think, I Feel, I Am Cards to help
him identify thoughts, feelings, and behaviors and how they connect to one another. James
worked with the counselor to discuss problems like a poor grade on a test. For example, this
caused him to choose an I Think card suggesting he thought he was dumb. James chose an I Feel
frustrated card to describe how he feels when he doesnt get a good grade. Then James had to
pick an I Am card that offered a positive alternative to how he would rather feel about himself in
that situation. James was given a homework assignment to come up with positive things he could
say to or about himself and bring them back to next weeks meeting to talk about. The counselor
and James continued to address the guilt he felt about not saying I love you to his mom on that
last day he got to see her. The counselor continued to work with James regarding his automatic
thoughts and what was factual. The counselor asked James, do you think your mom knew you

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loved her? Yes, he replied. The counselor asked James why he was carrying this sadness and
guilt about not telling her, when she knew that he loved her. James replied, I didnt get to say
goodbye.
The counselor and James talked about the positive comments he came up with at the
following meeting. He was encouraged to draw one comment out of the bag every morning and
say it to himself and report back how that made him feel. In the next meeting James completed
another assignment with the counselor to work through some grief. James had to write a letter to
his mother about the day she didnt come back home and how he felt that day. The counselor and
James placed the letter in a balloon and released it up into the clouds to his mother. James began
to show marked improvement in his mood after this activity. His teacher went to the counselor
and shared that he seemed to be smiling more and was engaging more with his classmates. James
and the counselor continued the weekly meetings and at each one completed an assignment
addressing the concerns he had listed in the initial homework assignment. They continued to
work on changing the thoughts and feelings of guilt and sadness through positive modifications
over the course of a twelve-week period.
During one of the meetings James asked if his brother and sister could come too, as they
were in the same school. James said he wanted to tell them how he was feeling and how he
thought they could get better too if they talked to the counselor. The counselor gave James
siblings the option to come and talk as well. They agreed to come to a meeting with the
counselor and James. After James explained his feelings to his siblings, through tears they
apologized and expressed their love for him and his importance to their family. As the meetings
progressed James would often show marked improvement in his ability to problem solve
situations and recognize when he was expressing an automatic thought and tell the counselor

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how he could change it to the truth. Since James began meeting with the counselor he showed
great progress in all areas targeted. He began engaging with his peers, participating in class,
smiling, and reported increased happiness. James also said he felt like he was loved by his family
and they were planning to make a cake for his moms birthday to celebrate her.
The counselor suggested decreasing his meetings to monthly to see how he could manage
on his own with the skills he had learned. James said he thought that would be ok. At the last
weekly meeting, the counselor asked James to explain how he handled previous problems to help
him feel happier to ensure he understood the treatment process. In addition, cognitive rehearsal
was used with James to practice some problems that might come up in the future and how to
address them. James came up with a scenario in which someone called him names like stupid or
dumb. He said I know Im not stupid or dumb so I will ignore them or say something like,
excuse me but I am very smart. The counselor suggested a future concern with handling his
moms birthday celebration and what to do if someone got upset about it. James said, I will tell
them that it is ok to be upset. I will give them a hug and say, mom loves you.

Conclusion
Depression is common in school-aged children and is often a serious condition that
affects their academics and friendships. Childhood depression, if left untreated can often lead to
withdrawing, suicidal ideations or attempts, and often can follow them into adulthood. Research
has shown cognitive therapy to be as effective as medications in the treatment of depression in
young people and adults alike. For those suffering with depression, cognitive therapy is an
effective treatment option. Cognitive therapy is the treatment of choice for those who do not
desire to take medications, and for children that is a common concern of parents. Cognitive

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therapy can be beneficial and very effective for anyone who can understand the correlation of
thoughts, feelings, and behaviors, as well as have the willingness to be responsible and do their
part in the treatment process.

References
Corsini, R.J. & Wedding, D. (2014). Current Psychotherapies (Tenth ed.) Raymond J. Corsini
and Danny Wedding
Gladding, S.T. (2013). Counseling: A Comprehensive Profession (7th ed., The Merrill
Counseling Series). Upper Sadler River, NJ: Pearson
Stark, K. D., Banneyer, K. N., Wang, L. A., & Arora, P. (2012). Child and adolescent depression
in the family. Couple and Family Psychology: Research and Practice, 1(3), 161-184.
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Hollon, S.D., & Sexton, T.L., (2012). Determining what works in depression treatment:
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Spirito, A., Esposito-Smythers, C., Wolff, J., & Uhl, K. (2011). Cognitive-behavioral therapy for
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Cognitive-Behavioral Therapy for Childhood Anxiety and Depression. (2009, December 28).
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