CBT for Kids: How Therapy Is Adapted for Children and What Parents Can Expect

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CBT for kids is cognitive behavioral therapy adapted for children, usually between about seven and twelve, with a version for adolescents that looks closer to adult treatment. The core idea is the same at every age: thoughts, feelings and behavior affect each other, and changing what you do and how you think about a situation changes how you feel. What differs is everything around that idea. Children's CBT is concrete and visual rather than abstract, it is taught through play, drawing, stories and games rather than discussion, sessions are shorter, and parents are in the room or in the plan as co-therapists. A child cannot be sent home with a thought record and told to practice.

The thought-feeling-behavior triangle is drawn as a cartoon. A child might see a figure with a thought bubble ('nobody will talk to me'), a feeling face (scared, with a thermometer beside it showing how much) and a picture of what they did (stayed by the wall). The therapist then helps them draw a different bubble and a different picture, and tests whether the feeling face changes. Unhelpful thoughts become 'thinking traps' with names a child can remember, feelings are rated on a feelings thermometer rather than a 0 to 100 scale, and being brave is a ladder with small rungs. Nothing is dumbed down in the sense of being less accurate; it is translated.

Aaron Beck's cognitive therapy was developed for depressed adults in the 1960s and 1970s. In the late 1980s and 1990s Philip Kendall at Temple University built the first manualised CBT program for anxious children, Coping Cat, in which a cartoon cat learns the FEAR plan: Feeling frightened? Expecting bad things to happen? Attitudes and actions that can help; Results and rewards. Children work through the steps with the cat, practice them in gradually harder situations, and earn rewards for trying. Coping Cat has been tested in randomised trials since the 1990s, adapted for teenagers and for other countries, and most children's anxiety programmes since have borrowed from it. Paul Stallard's Think Good, Feel Good, first published in 2002, did a similar job for a broader age range in the UK. For children who have been through trauma, Judith Cohen, Anthony Mannarino and Esther Deblinger's Trauma-Focused CBT adds skills for calming the body, a gradual telling of what happened, and a parallel track for the parent.

A typical course is twelve to sixteen weekly sessions of thirty to fifty minutes, often shorter for younger children. The first two or three sessions are about getting to know the child, agreeing what to work on in words the child chose, and teaching the model with the cartoon. The middle sessions build skills: naming feelings, spotting thinking traps, relaxing the body, problem-solving, and, for anxiety, a fear ladder of 'brave steps' practiced between sessions. The last sessions are about keeping the skills going and planning for setbacks. Parents usually get their own time at the start, in the middle and at the end, and the youngest children's work may run mostly through the parent.

In children's CBT the parent is a co-therapist, not a driver in the waiting room. You will be asked to notice and name feelings at home, to praise effort rather than outcome, to resist rescuing your child from a feared situation they have agreed to face, and often to run a reward chart that rewards trying. For anxiety, the single most useful thing a parent can do is to stop accommodating: the repeated reassurance, the letting them skip the party, the sitting outside the classroom door. It is hard, it goes against instinct, and the therapist will help you do it in stages rather than all at once.

The strongest evidence is for anxiety. A 2020 Cochrane review of CBT for anxiety disorders in children and adolescents found it clearly better than waiting list or no treatment, with roughly half of children free of their main anxiety diagnosis afterwards, and rated that evidence as moderate quality. Evidence that it beats an active comparison treatment or medication was weaker and less certain, and long-term follow-up data were thin. For depression in young people CBT helps, but the effects are more modest. For trauma, trauma-focused CBT has a good trial record. For behavior problems such as oppositional behavior or ADHD, parent-training programmes do better than child-focused CBT, and a good therapist will say so. The fair summary is well supported for anxiety and reasonably supported elsewhere, not a blanket guarantee for every child.

It suits children who can talk about what goes on in their head, usually from about seven, with worries, fears, low mood, anger they cannot control or a specific trauma. Children under seven generally get behavioral and parent-led work rather than the cognitive part, because the ability to stand back from a thought and examine it develops later. It suits less well a child in the middle of a crisis at home, where the first job is to make things safer, or a child whose main difficulty is developmental and needs assessment first. It is not a replacement for medical care, and no therapist should tell you to start or stop a medication; that is a conversation with the prescriber.

The mistakes parents make are understandable. Expecting the child to do the homework alone. Describing therapy to the child as a fix for being bad. Stopping after four sessions because nothing has changed, when the skill-building has barely started. Asking the child what they talked about in a way that makes the session feel reported on. And doing the brave steps for them, which teaches the child that the fear was right.

If a child's worry, sadness, anger or fear is lasting weeks, keeping them from school, friends or sleep, or following something frightening that happened, a child therapist can assess what is going on and say whether CBT is the right fit. Ask about training in CBT with children specifically, and about how parents are involved. Psychology.com's directory lists therapists who work with children and families and is free to search.

Reviewed by Michael Callans, MSW
Checked that the page addresses the parent, the description of developmental adaptations, the Coping Cat and FEAR plan details, and the evidence summary for anxiety versus other problems.

References

1. Kendall PC, Hedtke KA. Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual. 3rd ed. Workbook Publishing; 2006.
2. James AC, Reardon T, Soler A, James G, Creswell C. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews. 2020;(11):CD013162.
3. Stallard P. Think Good, Feel Good: A Cognitive Behaviour Therapy Workbook for Children and Young People. Wiley; 2002.
4. Cohen JA, Mannarino AP, Deblinger E. Treating Trauma and Traumatic Grief in Children and Adolescents. 2nd ed. Guilford Press; 2017.
5. Friedberg RD, McClure JM. Clinical Practice of Cognitive Therapy with Children and Adolescents: The Nuts and Bolts. 2nd ed. Guilford Press; 2015.

CBT for Kids FAQ