Cognitive problem-solving skills training
Cognitive problem-solving skills training (CPSST) attempts to decrease a child's inappropriate or disruptive behaviors by teaching the child new skills for approaching situations that previously provoked negative behavior. Using both cognitive and behavioral techniques and focusing on the child more than on the parents or the family unit, CPSST helps the child gain the ability to self-manage thoughts and feelings and interact appropriately with others by developing new perspectives and solutions. The basis of the treatment is the underlying principle that children lacking constructive ways to address the environment have problematic behaviors; teaching these children ways to positively problem-solve and challenge dysfunctional thoughts improves functioning.
The goal of CPSST is to reduce or terminate inappropriate, dysfunctional behaviors by expanding the behavioral repertoire (including ways of cognitive processing). The behavioral repertoire is the range of ways of behaving that an individual possesses. In children with conduct disorder , intermittent explosive disorder , oppositional-defiant disorder , antisocial behaviors, aggressive acting-out, or attention-deficit/hyperactivity disorder with disruptive behavior, the number of ways of interpreting reality and responding to the world are limited and involve negative responses. Although CPSST originally focused on children with problem behaviors or poor relationships with others, it has generalized to a variety of different disorders in children and adults (this treatment has the most research supporting its use in children).
The therapist conducts individual CPSST sessions with the child, once a week for 45 minutes to an hour, typically for several months to a year. The cognitive portion of the treatment involves changing faulty or narrow views of daily situations, confronting irrational interpretations of others' actions, challenging unhelpful assumptions that typically underlie the individual's problem behaviors, and generating alternative solutions to problems. For example, meeting with a child who has received a school suspension for becoming physically enraged at a teacher, the therapist starts by exploring the situation with the child, asking what thoughts and feelings were experienced. The child might state, "My teacher hates me. I'm always getting sent to the principal and she yells at me all the time." The therapist helps the child see some faulty ways of thinking by asking what the child has seen or experienced in the classroom previous to this incident, thus exploring the supporting evidence for the "my teacher hates me" notion. Questions would be ones that could confirm or disconfirm the assumptions, or that identify the precipitants of the teacher disciplining the child. The therapist tries to help the child shift his or her perceptions so that, instead of seeing the student-teacher negative interactions as something external to the self, the child comes to see his or her part in the problem. This discussion also helps the child to discern opportunities to influence the outcome of the interactions. When the child makes a global, stable, and negative attribution about why the interactions with the teacher are negative—where the attitude of the teacher is the cause of the problems—the child loses the sense of having any efficacy and is liable to show poorer behavior. By changing the child's perceptions and examining different options for the child's-responses in that situation, however, the child can identify ways that changing his or her own behavior could improve the outcome.
The behavioral aspect of CPSST involves modeling of more positive behaviors; role-playing challenging situations; and rewarding improvement in behavior, providing corrective feedback on alternative (and more appropriate) ways of handling situations when undesirable behavior occurs. In each session, the child is coached on problem-solving techniques including brainstorming a number of possible solutions to difficulties, evaluating solutions, and planning the steps involving in gaining a desired goal (also called means-end thinking ). For instance, if the child in the above example felt that the teacher's accusations were unfair, the therapist would help to come up with some options for the child to use in the event of a similar situation (such as visualizing a calming scene, using a mediator to work out the conflict, or avoiding the behaviors that precipitate a trip to the principal's office). The options generated would be discussed and evaluated as to how practical they are and how to implement them.
The child is given therapy homework of implementing these newer ways of thinking and behaving in specific types of problematic situations in school, with peers, or at home. The child might be asked to keep track of negative, externalizing thoughts by keeping a log of them for several days. The therapist would ask the child to conduct an experiment—try one of the new options and compare the results. Typically, the between-sessions work begins with the conditions that appear the easiest in which to successfully use the updated ways of thinking and behaving, gradually progressing to more complex or challenging circumstances. The child would get rewarded for trying the new techniques with praise, hugs, or earning points towards something desired.
Although the bulk of the sessions involve the individual child and the therapist, the parents are brought into the therapy for a portion of the work. The parents observe the therapist and the child as they practice the new skills and are educated on how to assist the child outside the sessions. Parents learn how to remind the child correctly to use the CPSST techniques for problem-solving in daily living and assist the child with the steps involved in applying these skills. Parents are also coached on how to promote the positive behaviors by rewarding their occurrence with praise, extra attention, points toward obtaining a reward desired by the child, stickers or other small indicators of positive behavior, additional privileges, or hugs (and other affectionate gestures). The scientific term for the rewarding of desired behavior is positive reinforcement , referring to consequences that cause the desired target behavior to increase.
In research studies of outcomes, CPSST has been found to be effective in changing children's behavior. Changes in behavior have been shown to persist long-term after completion of treatment. Success in altering undesirable behaviors is enhanced when CPSST is combined with parent management training . Parent management training is the in-depth education of parents or other primary caretakers in applying behavioral techniques such as positive reinforcement or time away from reinforcement opportunities in their parenting.
Inappropriate or inept application of cognitive-behavioral techniques such as those used in CPSST may intensify the problem. CPSST should be undertaken with a behavioral health professional ( psychologist , psychiatrist , or clinical social worker) with experience in CPSST. Parents should seek therapists with good credentials, skills, and training.
While individual results vary, problematic behaviors are reduced or eliminated in many children.
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Association for the Advancement of Behavior Therapy. 305 Seventh Avenue, 16th Floor, New York, NY 10001-60008. (212) 647-1890.
Deborah Rosch Eifert, Ph.D.