CBT for Stress-Related Problems in Parents of Children with Disabilities

CBT studyMany parents who have children suffering from some form of chronic illness or mental disorder may experience chronic stress reactions of various types. Cognitive behavioral therapy (CBT) has been proved to be effective in reducing stress-related problems, but there seems to be no study to date in which CBT has been tested on this specific parent group. Two case studies were therefore performed. Case 1 centered on a 47-year-old married woman, who has lived in Sweden for 12 months. She described how she had become increasingly exhausted, and she wanted help to find strategies enabling her to cope with everyday life. Case 2 featured a 45-year-old single mother, who had been on part-time sick leave due to depression and stress.10727349955_269cb8144b_z She described how she had always been anxious and worried and had had two episodes of depression. Both women had sons diagnosed with autism/Asperger syndrome. One of the women met the criteria for pathological burnout, while the other woman was just below the limit. The focus of the therapy for both women was on exhaustion, depression, and sleeping difficulties. In addition, therapy in Case 1 involved under-stimulation and in Case 2, anxiety. When the therapy ended, genuine improvements were registered for both clients. The results show that CBT can be an effective treatment of symptoms for this group of parents so that they can provide adequate support to their children, thus facilitating everyday life for a child with a chronic illness or disorder.

Anclair, M., & Hiltunen, A. J. (2014). Cognitive behavioral therapy for stress-related problems: Two single-case studies of parents of children with disabilities. Clinical Case Studies, 13, 6, 472-486.

An Introduction to CBT for people with an Autism Spectrum Disorder

By Torrey Creed, PhD     Adjunct Faculty, Beck Institute

While a description of CBT for Autism Spectrum Disorders (ASD) would require a large volume (at least), let’s highlight several important areas to consider when working with people with an autism spectrum disorder (ASD). 5299266366_0b6c8ae172_oFirst, a word about what we do not do in CBT for ASD: we do not treat the ASD itself. CBT will not move someone to being neurotypical, nor should it. Instead, we focus on secondary issues that are related to the experience of life on the autism spectrum: depression, bullying, stress, anger, aggression, anxiety, social skills deficits, and limited social support.


People with ASD have unique cognitive and behavioral styles, which vary with the severity of their ASD symptoms. Therefore, as with any client, we creatively adapt and adjust CBT to meet the strengths and needs of the individual. People on the ASD spectrum are generally very concrete thinkers, so we need to modify standard CBT to be more experiential and concrete than usual. Individuals who are cognitively on the higher end of functioning may benefit from a mix of both cognitive and behavioral strategies, but when their functioning is more impaired, the therapist de-emphasizes cognitive techniques.  The ideas described below may be a better fit for a higher-functioning client,  but most can be made more concrete for someone whose cognitive style makes abstract thought even more challenging.


As with all CBT clients, we start with a cognitive conceptualization, identifying key cognitions and behaviors to target in treatment. Engagement and the therapeutic relationship are key with any client, but building these with clients with ASD may be even more essential, and also challenging. Therefore, from the beginning of treatment, we help clients explore their goals, passions, and values, then identify specific steps that CBT can help them make in service of that long term goal. Framing treatment about things the individual truly values can increase both engagement and the relationship. Aspects of the ASD or the sequelae from secondary issues (e.g. information from the case conceptualization) are framed as challenges to reaching the goals, and CBT then becomes a way to address those challenges in order to move toward the tailored goals.


A component of treatment often focuses on the “rules of the game” in social situations, which may be intuitive to others but are generally very hard for a person with ASD to penetrate. CBT helps them learn to better read social interactions and read others’ reactions and behavior more accurately so they can more easily monitor and adjust their own behavior and responses. We help people work toward self-acceptance and compensatory strategies to mitigate the impact of things that cannot be changed (like specific cognitive deficits). We also help them learn to recognize and modify unhelpful patterns of information processing which contribute to stress, anxiety, and depression. Our major focus, as in any CBT, remains on teaching cognitive and behavioral skills and strategies that will help the person move closer to his or her goals, as well as preventative strategies to decrease or prevent symptoms of comorbid mental health concerns, such as anxiety disorders and depression.


Common beliefs of people with ASD include “I must stay in control because there may be danger;” “If I try to fit in, I’ll fail;” “If I stay away from people, I won’t get hurt;” “I can’t understand what is going on in [my] world;”  or “Everyone takes advantage of me.” They also have negative beliefs about themselves, “I’m flawed;” “I’m weird,” “I’m out of control;” “I’m incompetent;” or “I’m vulnerable.” These beliefs may pose serious challenges to reaching a person’s individualized goals, and often these beliefs can become self-fulfilling prophecies. Helping people to shift to more accurate and more helpful cognitions is a powerful tool in helping them realize their goals and potential.


When the client is a child with ASD, that child is usually the identified client; however, working with families is also essential. Families may struggle with ASD-related issues, including a child’s obsessive interests, angry outbursts, poor self-care, repetitive rituals, and odd behavior. Parents may also experience frustration (with the child, or with others’ reactions to the child), and siblings may have strong reactions to their own experiences of being in a family with a child with ASD. Helping family members to identify ways in which their patterns of thinking, feeling, or behaving may be more or less helpful (or accurate) can help shift the dynamic of the family in a positive direction.


There is much more to learn about CBT with individuals with ASD. The work can be challenging but is also highly creative-and rewarding, as we see them and their families reaching their own meaningful goals.

CBT for Children and Adolescents: Advanced Workshop

Topics covered include how to:

  • Develop an individualized cognitive case conceptualization for youths with OCD or other anxiety disorders or Autism Spectrum Disorder
  • Create a tailored treatment plan from early treatment through relapse prevention
  • Deliver specific, empirically based CBT interventions for individuals and for families, and
  • Determine whether those interventions have been effective.

Training focuses on therapy with clients between the ages of 7 and 18 with Autism Spectrum Disorder, OCD or other anxiety disorders.

This workshop features a special question and answer and role-play session with Dr. Aaron Beck. Participants are encouraged to prepare or have in mind cases for discussion or role-play.

When:    June 1-3, 2015
Where:      Beck Institute, Suburban Philadelphia
Time:   8:45am – 4pm
Faculty: Torrey Creed, PhD
Enrollment:  Limited to 42 participants
CE/CMEs:  18


To register:

The Role of Play in CBT with Children

By Torrey Creed, PhD

Seasoned child therapists who pursue training in cognitive behavioral therapy (CBT) often ask the same question: “I usually spend time playing with my clients, but in CBT, do you ever actually just play with kids?” This question is not as simple as it may first appear, and the answer addresses two important principles behind the therapeutic work.

First, the answer to this question is yes… and no. Yes, a CBT therapist often uses play with child clients. Any child therapist whose repertoire is limited to holding a conversation with a child while both parties sit still, hands folded in their laps, will likely find limited success. CBT therapists and clients might be observed playing a game, going for a walk, painting, singing, playing basketball, and more. The part that makes the question less simple than it may appear is the word “just.” A CBT therapist certainly may play with a child, but “just” play? Perhaps not.

Principle 1: Children may benefit from CBT that is experiential. CBT (with clients of any age) focuses on the cognitive model, or the connection between thoughts, feelings, and behavior. When the client’s thoughts, feelings, or behavior are related to distress or impairment, intervention aims to make a shift in at least one of these three components. In other words, intervention may target a shift in thoughts, leading to different feelings and behavior. Alternatively, intervention may target a shift in behavior, leading to different thoughts and feelings. When we begin by examining thoughts, particularly through discussion about the thoughts, we are focused on the abstract. Asking a client to identify a thought, consider whether the thought is as accurate or helpful as it might be, and then shift to a new thought, relies in part on a client’s meta-cognitive abilities. In children, those skills for thinking about thinking are still developing. If instead CBT begins with behavior, the child may have a new experience that can lead to new ways of thinking and feeling. For example, imagine 8-year old Ben, who avoids challenges because he thinks that if he cannot do something perfectly, he will be unable to enjoy doing it at all. Ben’s CBT therapist may design a behavioral experiment where they play a new game while tracking Ben’s anticipated and actual enjoyment. If the behavioral experiment is successful, Ben may find that he actually enjoyed himself quite a bit even though he had to learn the game as they went along. Beginning with behavior (playing the game while learning it) leads to a new experience that Ben can use as concrete evidence against his original unhelpful belief.

Principle 2: Within legal and ethical limits, there is very little a CBT therapist will not do in session – as long as there is a rationale behind the action. Using the example above, the therapist was not playing the game “just” to play the game. Instead, the intervention was selected based on a case conceptualization to strategically target the belief that was causing Ben to avoid challenges. Using case conceptualization as a guide, a CBT therapist has great opportunities to be creative, playful, engaging, and flexible in designing interventions. When the therapist is able to identify why he or she is playing a game, collaborating on a song, or taking a walk, the activity has the potential to become a powerful intervention.

Using these two principles as a guide, a child CBT therapist may quite often use play with clients in session, but very rarely will they be “just” playing. They may be practicing new skills, gathering evidence, testing out negative predictions, and having fun at the same time.


Dr. Torrey Creed leads Beck Institute’s CBT for Children and Adolescents Workshop. For more information, or to register, visit

CBT plus Medication is Effective for Chronic Migraine in Children and Adolescents

According to a recent study published in JAMA, cognitive behavior therapy (CBT) plus amitriptyline (a tricyclic antidepressant used in the treatment of migraines) may be an effective treatment for chronic migraines in children and adolescents. In the current study, researchers compared the efficacy of CBT plus amitriptyline versus headache education plus amitriptyline. Participants included 135 youth aged 10 to 17 diagnosed with chronic migraine. They were randomized to either the CBT plus amitriptyline group (n = 64) or headache education plus amitriptyline group (n = 71). Participants received either 10 CBT sessions or 10 headache education sessions involving equivalent time and therapist attention. At post-treatment, 66% in the CBT group had at least a 50% reduction in headache days versus 36% in the headache education group. At the 12-month follow up, 86% in the CBT group had at least a 50% reduction in headache days versus 69% in the headache education group. These findings support the efficacy of CBT in the treatment of chronic migraine among children and adolescents.

Powers, S. W., Kashikar-Zuck, S. M., Allen, J. R., LeCates, S. L., Slater, S. K., Zafar, M., Kabbouche, M. A., … Hershey, A. D. (December 25, 2013). Cognitive Behavioral Therapy Plus Amitriptyline for Chronic Migraine in Children and Adolescents. Jama, 310, 24, 2622.

CBT Helps Prevent Depression in At-Risk Adolescents

Research from a randomized clinical trial recently published in JAMA Psychiatry indicates that group cognitive-behavioral prevention (CBP) may help prevent depression in at-risk adolescents. Participants included 316 adolescents with current or past elevated depressive symptoms and whose parents experienced current and/or prior depression. They were randomly assigned to either the CBP group or care as usual (CU). The CBP intervention consisted of eight weeks of weekly 90-minute group sessions, as well as six monthly 90-minute booster sessions. Cognitive restructuring and problem solving were emphasized throughout the course of treatment.

Participants were assessed pre-intervention, after the acute intervention, after the booster sessions, and at one year (21 months) and 2 years (33 months) post intervention. Results showed that adolescents in the CBP group had significantly fewer onsets of depressive episodes than the care as usual group. However, parental depression significantly moderated the effect of the intervention. That is, when parents were depressed at baseline, average onset of depression between the CBP group and usual care did not differ. These results indicate that CBPs may be an evidence-based alternative to preventing depression, and that improvements are needed to strengthen the CBP intervention particularly when active parental depression is involved.

Beardslee, W. R., Brent, D. A., Weersing, V. R., Clarke, G. N., Porta, G., Hollon, S. D., … & Garber, J. (2013). Prevention of Depression in At-Risk Adolescents: Longer-term Effects. doi:10.1001/jamapsychiatry.2013.295

CBT Shows Promise for Anxious Youth with Autism Spectrum Disorders

Autism Spectrum Disorders (ASD) is an umbrella term representing a range of persistent cognitive deficits and impairments in communication and social interaction, often diagnosed by age two, and includes autistic disorder, Asperger’s syndrome, and pervasive developmental disorders. Children with ASD are at an elevated risk for developing anxiety disorders, which can become highly debilitating across environmental contexts (home, school, and social contexts). The results of previous research (case studies, small group studies, and randomized clinical trials) have provided evidence and support for the efficacy of modified CBT for youth with ASD and anxiety.

In a 2012 study published in Autism Research and Treatment, researchers developed a modified version of a CBT intervention (“Facing Your Fears”) for adolescents with ASD, titled “Facing Your Fears: Group Therapy for Managing Anxiety in Children with High Functioning ASD” (FYF-A). They then assessed the feasibility and acceptability of the FYF-A intervention program.

Participants included 24 adolescents and their families, age 13-18, with ASD and anxiety. They attended 14, 90-minute sessions, plus 1 booster session, which included large group activities with teens and parents, small-group activities with teens and parents alone, and dyadic work with parent and teen pairs. The program focused on core CBT components (including an introduction to anxiety symptoms and implementation of CBT strategies) and several modifications for teens with ASD. These modifications included: (1) a social skills module to address areas of social challenge; (2) parent-teen dyadic work focused on achieving a mutual understanding and shared goals; (3) the use of technology to both monitor symptoms of anxiety and remind participants to utilize CBT strategies; and (4) a parent curriculum.

At post-treatment, participants showed significant reductions in anxiety severity and intrusiveness. These reductions were maintained at the 3-month follow up. Further, nearly half of the participants met criteria for a positive treatment response on primary diagnosis following the intervention. These finding are encouraging, as they add further evidence that modified CBT for adolescents with ASD is effective in decreasing anxiety symptoms among this group.

Reaven, J., Blakeley-Smith, A., Leuthe, E., Moody, E., & Hepburn, S. (January 01, 2012). Facing Your Fears in Adolescence: Cognitive-Behavioral Therapy for High-Functioning Autism Spectrum Disorders and Anxiety. Autism Research and Treatment, 2012, 2, 1-13.

CBT for Depression

Dr. Aaron Beck explains the history of biological and psychological research on depression. He also discusses studies that looked at the likelihood of depression in people who experienced trauma during childhood. This video was taken at Beck Institute’s CBT for Children and Adolescents workshop, for more information, or to register for our next workshop visit:

CBT for Children and Adolescents

OCTOBER 2011:  Earlier this week, 43 child psychiatrists, school psychologists, school counselors, and other health and mental health professionals working with children and adolescents, came from 5 countries including: Brazil, Canada, Cayman Islands, Singapore, and South Africa; and from 11 US states to participate in our first ever CBT for Children and Adolescents workshop at Beck Institute. This 3-day workshop began with the basics of cognitive behavioral therapy and progressed to the application of CBT with complex cases. Cognitive theory, case conceptualization and CBT session structure were introduced. Then cognitive and behavioral interventions were explored and practiced.

Participants engaged in variety of role plays, to increase knowledge and ability to use CBT with children and adolescents and to experience using cognitive case conceptualization to select and implement interventions tailored for individual clients.

Participants received professional training from Aaron T. Beck, M.D., Torrey Creed, Ph.D., Luke Schultz, Ph.D. and Judith S. Beck, Ph.D.

One of the highlights of the workshop was a special question and answer session with Dr. Aaron Beck (video clip below).  Dr. Beck discussed. For more information on future CBT for Children and Adolescents workshops, visit our website.

Using Cognitive Behavioral Therapy to Treat Children with Asperger’s Syndrome

A recent report by Donoghue et al (2011) explored the use of Cognitive Behavioral Therapy (CBT) in children and young people diagnosed with Asperger’s Syndrome (AS).  Children with AS have impairments in social interactions, language and communication problems, theory of mind deficits, and they display difficulties in executive functioning.  Previous studies have shown that children with AS may also develop an affective disorder, such as depression, anxiety, or Obsessive Compulsive Disorder (OCD).  Recent reviews have concluded that CBT is effective in treating depression and OCD in young patients, but there has been little research exploring the efficacy of  CBT to treat these disorders in children with AS.

This article examines different methods of modifying CBT to meet the needs of children with AS.  The authors used the PRECISE framework of cognitive therapy developed by Stallard (2005), which focuses on the active role of patients in therapy and the importance of forming a helpful therapeutic relationship.  The investigators’ intent was to explore various aspects of CBT and how they can be adapted to treat patients with AS.  The study suggests that therapists should set specific expectations about the goals of each session, using literal language that the child can understand, visual materials to identify the patient’s feelings and technology such as pictures and text messages in order to communicate better with the child.  Therapists should also strive to make treatment  fun by using non-verbal materials to help engage the child. Therapists should also use role-playing in sessions to teach children that their initial cognitions and beliefs can be changed in certain situations.

This study suggests that using CBT to treat children with AS is promising; however, randomized controlled trials are needed to investigate the effectiveness of using the suggested changes in CBT.

Donoghue, K., Stallard, P., & Kucia, K. (2011). The clinical practice of cognitive behavioural therapy for children and young people with a diagnosis of Asperger’s Syndrome. Journal of Clinical Child Psychology and Psychiatry.

Cognitive Therapy for Adolescents in School Settings

We are pleased to announce the publication of “Cognitive Therapy with Adolescents in School Settings” – a concise guide for clinicians which features in-depth case examples and hands-on clinical tools. The authors – including renowned CT originator Aaron T. Beck, clinical child psychologist Torrey A. Creed, and school psychologist Jarrod Reisweber – provide an accessible introduction to the cognitive model and demonstrate specific therapeutic techniques that have been used successfully in the schools. Strategies are illustrated for engaging adolescents in therapy, rapidly creating an effective case conceptualization, and addressing a range of clinical issues and stressors frequently experienced in grades 6–12. The challenges and rewards of school-based CT are discussed in detail. In a convenient large-size format with lay-flat binding for easy photocopying, the book contains 16 reproducible handouts, worksheets, and forms. This guide will be a valuable resource for a wide range of professionals, from graduate students seeking a solid knowledge base to experienced professionals looking to expand their repertoire of CT interventions.