General Considerations in Adapting MCT to Children
The development of MCT-c was based on the structure and general outline of the treatment plan for adults with GAD (Wells
2009). However, downward extensions of adult treatment programs must be adjusted to the specific needs of children (Spence et al.
2008), as they lack the social, linguistic and cognitive sophistication that unmodified treatment techniques require (Reinecke et al.
2002). Many children find it difficult to generalise knowledge gained during verbal therapeutic conversations to real-life situations with elevated anxiety levels (Stallard
2009). Socratic dialogue may assist the child in the process; however, the child will often respond with “I don’t know”. Prompting assisted with visual cues, work sheets and practical exercises, as well as group treatment, where the child can observe other children with different experiences may increase the child’s awareness of their metacognitions, thoughts and emotions. This may increase the child’s motivation for the therapeutic task. In the present case series, these factors were taken into consideration. The child sessions consisted of a mixture of psycho-education, group discussions attempting to engage the children in Socratic dialogue, use of work-sheets, pictures, metaphors (unhelpful metacognitions being like old computer software, we need to upgrade the system) and experiments. Metacognitions were identified and challenged, and techniques were practiced in vivo. Socialisation to the CAS was made developmentally appropriate by an illustration of a child with a glass bubble closing in around him, being overly attentive to thoughts and bodily feelings, being so occupied that he does not register all the other aspects of the environment outside the bubble. In contrast to MCT for adults, our adaptation for children relied heavily on practising MCT components in vivo with therapist guidance. The treatment applied in the case series study consisted of two individual family sessions, two parent group workshops, ten child group sessions and one booster session.
Adapting Specific MCT Components to Children
Attention Training Although typically not part of MCT for GAD, attention training was included in MCT-c for two reasons. First, it increases awareness that thoughts are like noise. The child can choose not to react to them. Second, it teaches the child that he may take voluntary control over his attention. The children practiced acknowledging that attention sometimes slips, but can voluntarily be redirected to the selected stimuli. A parallel was drawn between attention slipping to an irrelevant stimulus and responding to intrusive thoughts, suggesting that this is a habit, rather than an uncontrollable process. As with adults, the training included selective attention, rapid attention shifting and divided attention. An audio file was created for the children to practice at home. Attention training was conceptualised as a mental workout for the brain that will help interrupt the self-focused attention in CAS. Attending voluntarily to selected stimuli in the environment, while leaving worries alone (situational attentional refocusing), was applied as the first-choice coping mechanism by some of the children in anxiety and worry provoking situations.
Detached Mindfulness and Challenging Negative Metacognitive Beliefs DM involves to notice thoughts that trigger worry, but to leave them alone without responding to them. It may be applied to challenge the belief that worries are uncontrollable. DM was explained as a new way of responding to thoughts, and several metaphors were used in order to illustrate the rationale behind the technique. One metaphor was the train metaphor. It illustrates that it is your own choice whether you want to engage in a trigger thought or leave it alone. When you see a train entering the station, you can get on it, but you can also choose not to. If you wait and do nothing, it will move along, which is analogous to a triggering thought. A field trip to the local subway station was conducted for the children to see how trains moved along similar to thoughts. The outing provoked fears and worry, and this provided opportunities to practise DM in vivo, and gave therapists the opportunity to ensure that techniques were applied correctly. In line with the train metaphor, we explained that you cannot force the train to move, you have to wait until it drives off in its own tempo. Children received cue cards to remind them of the DM metaphors.
To increase the use of DM, homework included applying DM to triggers and postponing worry until a certain time of the day. The postponement of worry was used to further challenge beliefs regarding lack of control; i.e. “if you have no control, how were you able to postpone the worry then?”. Finally, negative metacognitive beliefs that worry can make you ill were challenged. The beliefs were elicited with help from worksheets where children could cross off metacognitive beliefs that were true for them. Individual experiments were planned where the children would conduct anxiety-provoking tasks investigating if their worry would make them ill or go crazy. These included trying to worry as much as possible and investigate what happened, and interviews of strangers to investigate if they held metacognitive beliefs that worry would make them ill.
Challenging Positive Metacognitive Beliefs Positive metacognitive beliefs include that worry is helpful and prepares you for future events. In MCT-c these were elicited by worksheets. Following psychoeducation on how positive beliefs contribute to maintain worry, these were challenged using the worry-mismatch strategy (Wells
2009). Children wrote down individual worry and reality scripts to investigate if worry is useful. Both retrospective scripts, based on a recent episode of worry, and prospective scripts about near future events were made. Experiments were carried out in session and the homework was to test whether worrying was helpful in predicting what actually happened.
Involving parents in MCT for children
One must consider if and how to involve parents in their child’s treatment. Studies on parent–child relations suggest that parental over-involvement and intrusiveness are related to anxiety as it reduces the child’s experience of control (McLeod et al.
2011). From an MCT perspective, perceived lack of control over internal events such as worry, may maintain the belief that worry is uncontrollable and can only be stopped by seeking reassurance from parents. We therefore addressed such processes in the parent–child relation.
Parent workshops were conducted prior to and halfway through child treatment. Individual family sessions were conducted halfway through therapy and after the tenth child session. The first workshop included psychoeducation on GAD and socialisation to the MCM. We discussed how CAS behaviours were likely to maintain worry. Therapists moderated the discussions and identified behaviours that may be helpful in the short term (e.g., avoidance or reassurance seeking), but be negative in the long term. For example, most parents are very engaged in their child’s worries and often reassure their child that they would not happen in reality. We explained how analysing the probability of worries and giving worries attention becomes a maintaining factor of CAS, and discussed alternative ways of supporting their child, e.g. by telling the child that they were to try not to give their trigger attention. As children started to experience more control over their worries, part of their homework became to let go of maladaptive coping behaviours, such as calling parents to check if they are alright, seeking reassurance or avoiding situations that could trigger worry. The second workshop and the individual family sessions consisted of discussions about the model, techniques and progress or lack of progress in their child’s therapy.