Pesky Gnats
Adapting CBT for Children
Dr Gary O’ Reilly,
Senior Lecturer/
Doctoral Programme in Clinical Psychology,
University College Dublin
E-mail: gary.oreilly@ucd.ie
Pesky Gnats
Challenges in adapting CBT for young
people
•
How we are using a computer game to
translate CBT into user friendly format for
young people
•
Demonstration of our CBT Computer
game for children
•
Evidence so far
•
Future directions
–  Utility of programmes like pesky
gnats for wide-scale dissemination of
CBT?
Since CBT works with adults it is a good candidate for an
evidenced based intervention for children and adolescents
Disorder
Absolute
efficacy
Relative to
medication
Relative to other
psychotherapy
Depression
Yes
Yes
Mixed evidence
General anxiety
Yes
Yes
Better
Anorexia nervosa
Yes
Yes
Equivalent
Schizophrenia
OCD
Chronic PTSD
Chronic Pain
Somatic difficulties
Substance abuse
Yes
Yes
Used in combination
Insufficient evidence
Better
Better
Yes
Insufficient evidence
Equivalent
Yes
Insufficient evidence
Mixed evidence
Yes
Yes
Yes
Yes
Insufficient evidence
Equivalent
Dozois, D. & Beck, A. (2011) Cognitive therapy. In J. D. Herbert, & E. M. Forman (eds). Acceptance and Mindfulness in Cognitive
Behaviour Therapy. Understanding and Applying the New Therapies. New York: Wiley.
The Cognitive Behavioural Model
SITUATION
THINKING…
Yipee! It’s the
weekend no more work
after today…
I’m at work in my
office…
FEELINGS…
BEHAVIOUR…
I leave work with a
hop, skip & a jump…
Great happiness & Joy!
The Cognitive Behavioural Model
SITUATION:
NEGATIVE
AUTOMATIC
THINKING…
Uh-Hooo I think I’m
boring these people
with me rubbish talk…
I’m at work giving a
talk to a bunch of
brainy people…
PROBLEMATIC
BEHAVIOUR…
Stumble & stutter &
deliver the rest of my
talk poorly…
OVERWHELMING
FEELINGS…
Anxiety!!!
Key theoretical ideas in CBT…
Another key idea in CBT is that our many and frequent negative automatic
thoughts share underlying schemata we hold about ourselves referred to as Core
Beliefs….
Negative Automatic Thought
Level 1:
Surface Level
Cognition
Negative Automatic Thought
Negative Automatic Thought
Negative Automatic Thought
Negative Automatic Thought
Negative Automatic Thought
Behaviours, Behaviours, Behaviours…
Feelings, Feelings, Feelings…
Selective Attention
Level 2:
Intermediate Cognitive
Processes and Beliefs
Biased Memory Processing
Interpretation of neutral
or ambiguous events
Attitudes & Beliefs
Level 3:
Deeper Organising
Schema: “a well organised cognitive structure of stored information and
Cognitive Information
memories that forms the basis of CORE BELIEFS about self” (Dozois &
Abstracted from Experience
Beck 2011; p.27)
Dozois, D. & Beck, A. (2011) Cognitive therapy. In J. D. Herbert, & E. M. Forman (eds). Acceptance and Mindfulness in Cognitive
Behaviour Therapy. Understanding and Applying the New Therapies. New York: Wiley.
Central ingredients in most CBT based interventions include…
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Psycho-education and problem formulation of specific disorder
Monitoring of thoughts, feelings and behaviour
Identification, challenging and testing of cognitions
Developing new cognitive skills
Discovering core beliefs
Learning new ways to manage anxiety or unpleasant emotions
Learning new behaviours
Target setting and home-based practice assignments
Positive reinforcement
In essence CBT is a complicated adult oriented individual therapy
based on meta-cognitive tasks! Its not at all child friendly…
Stallard, P (2002; p.11). Think Good Feel Good: A Cognitive Behavioural Therapy Workbook for Children and Young People. New
York: Wiley
Developmentally when are children ready?
Jean Piaget. Developed a staged theory of cognitive
development. CBT is like “Formal Operational” thinking so
children about 12 yrs + should benefit…
Lev Vygotsky. Children have a zone of proximal development
so with the right scaffolding younger children can achieve
cognitive tasks beyond those of their current completed
developmental stage: Children younger than 12 might
benefit from CBT…
Margaret Donaldson. Piaget missed the specific scaffolding
offered by the social context of children’s thinking: Children
younger than 12 might benefit from CBT……
4 simple ingredients in our translation of cbt for children
1. An unfolding concrete metaphor for CBT ideas:
Negative Automatic Thoughts (NATs) are described as
being like gNATs or little flies that sting you into certain
thoughts usually without you noticing.
Thought Monitoring becomes gNAT trapping.
Cognitive Restructuring becomes gNAT swatting.
Understanding Core Beliefs becomes hunting gNATs back
to their hives.
4 simple ingredients in our translation of cbt for children
2. We embedded these ideas in a socially meaningful story:
In our programme the child plays a computer game where
they control a character who represents them on a visit
to an island where they help a world famous explorer
called David gNATenborough and his team of
investigators.
As the narrative of the game unfolds they learn about
themselves, gNAT trapping, gNAT swatting, and tracing
gNATs back to their hive by helping with experiments
devised by David gNATenbourough and his team in the
world’s first gNAT lab.
4 simple ingredients in our translation of cbt for children
3. Providing an adult to help:
In our programme children play the game over the
course of 6 appointments side by side with a suitably
qualified mental health professional who understands
CBT (such as a clinical psychologist, child therapist,
child psychiatrist, therapeutic social worker etc).
Characters in the game ask questions and set tasks that
the young person responds to with the help of their
therapist. This is a unique feature of our programme.
4. An environment where children feel at home:
Do you know many children who don’t like computer
games?
David Gnatenborough’s Island
by Gary O’ Reilly, Nicola McGlade & David Coyle
A 6 session
computerised CBT
programme that the
young person plays
in session with their
therapist
July 2009
Age range 9-13
Internalising
disorders
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
The therapeutic space between client & therapist
Therapist
Client
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
David Gnatenborough’s Island
by Gary O’ Reilly, Nicola McGlade & David Coyle
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
David Gnatenborough’s Island
by Gary O’ Reilly, Nicola McGlade & David Coyle
Every session proceeds with
review, introduce cbt skill,
example from another young
person called Shona, do an
example with your therapist,
practice outside the session
Session One: Meet David
Gnatenbourough, learn about
the gNAT lab, and meet Prof
Alannah Karr who teaches you
that thoughts, feelings and
behaviours go together
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
David Gnatenborough’s Island
by Gary O’ Reilly, Nicola McGlade & David Coyle
Session Two: Meet Scott
Livingstone, an explorer who is
an expert on catching footage of
gNATs.
Teaches the young person how
to set a gNAT trap…aka Thought
Monitoring
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
David Gnatenborough’s Island
by Gary O’ Reilly, Nicola McGlade & David Coyle
Session Three: Meet Shona, a young person
who is a former visitor to the gNAT lab
Learn how to swat gNATs…aka cognitive
restructuring
Learn how to relax and receive your own
relaxation CD/MP3 file
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
David Gnatenborough’s Island
by Gary O’ Reilly, Nicola McGlade & David Coyle
Session Four: Meet Sarah, a scientist working
in the gNAT lab.
Learn how gNATs come from Hives…aka Core
Beliefs and how to gather your gNATs into their
Hives.
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
David Gnatenborough’s Island
by Gary O’ Reilly, Nicola McGlade & David Coyle
Sessions Five & Six: Work with David
Gnatenborough outside the gNAT lab to
challenge and change your Core Beliefs
Learn how to evaluate and change your Core
Beliefs
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
No charge for any of our materials
The game
Installation CD
Relaxation CD
Child’s Manual
O’ Reilly, G., McGlade, N., & Coyle, D., (2009). David Gnatenborough’s Island. A Computerised Cognitive Behavioural Therapy
Programme for Children & Adolescents. Version 1.0
Do mental health professionals like Pesky
Gnats?
Ratings of 941 mental health professionals from Ireland, UK & USA of their
overall impression of cCBT game Pesky Gnats
Key point!
95.6% of mental
health professionals
from 3 countries
rate Pesky Gnats as
“above average” or
“excellent”
Does Pesky Gnats add or subtract from the quality of
the therapeutic process with children?
Quality of therapeutic relationship – 16 Pesky Gnats V 13 TAU young people 9-16 yrs
attending a Health Service Executive child mental health setting
Ryan, A., O’ Reilly, G., Coyle, D. & Delahunty, A. (2013). A Pilot-Study of a Computer-Assisted CBT Game in a Chid and Adolescent
Mental Health Setting. School of Psychology; University College Dublin
Does Pesky Gnats improve the mental health
status of children with internalising disorders?
Parent Report (CBCL) Internalising Scores – 16 Pesky Gnats V 13 TAU young people
9-16 yrs attending a Health Service Executive child mental health setting
Clinical Range
Borderline Range
Normal Range
F values: group = 1.14; time = 31.98 ***; group x time = 2.54
Ryan, A., O’ Reilly, G., Coyle, D. & Delahunty, A. (2013). A Pilot-Study of a Computer-Assisted CBT Game in a Chid and Adolescent
Mental Health Setting. School of Psychology; University College Dublin
Young Person Self Report (YSR) Internalising Scores – 16 Pesky Gnats V 13 TAU
young people 9-17 yrs in a attending a Health Service Executive child mental health
setting
Clinical Range
Borderline Range
Normal Range
F values: group = 0.40; time = 12.12 ** ; group x time = 0.54
Ryan, A., O’ Reilly, G., Coyle, D. & Delahunty, A. (2013). A Pilot-Study of a Computer-Assisted CBT Game in a Chid and Adolescent
Mental Health Setting. School of Psychology; University College Dublin
Child self rating of outcome– 16 Pesky Gnats V 13 TAU young people 9-16 yrs
attending a Health Service Executive child mental health setting
t values: Me= 2.32* ; Family= 2.06* ; School = 2.06 *; Everything = 2.11*
Ryan, A., O’ Reilly, G., Coyle, D. & Delahunty, A. (2013). A Pilot-Study of a Computer-Assisted CBT Game in a Chid and Adolescent
Mental Health Setting. School of Psychology; University College Dublin
Theme
Less worry
Comment
“I don’t worry about as many things”
“About finding out my core belief and now I don’t worry as much”
I’m not as anxious”
More positive
“I can think more positive”
“I am more positive and better armed to deal with my depression”
More confident
“I am more confident in swatting gNATs”
Feeling better
“I am getting better”
McGlade, N. (2010). An Exploration of a Computer-Assisted CBT Game and a Measure of Automatic Thoughts In Adolescents.
Unpublished Doctoral Thesis: School of Psychology; University College Dublin
Does Pesky Gnats have potential for use in
non-clinical settings such as schools?
CBCL & YSR Internalising Scores – 18 (10 boys 8 girls) young people 9-17 yrs (mean
age 11.8) who played Pesky Gnats with a School Psychologist
CBCL
YSR
Clinical Range
Borderline Range
Normal Range
CBCL n =18
YSR n = 10
t values: CBCL = 3.95*** ; YSR = 3.21**
O’ Dwyer-O’ Brien, A., O’ Reilly, G., Coyle, S. & Coyle, D. (2012). A Pilot-Study of a Computer-Assisted CBT Game in an Educational
Psychology Setting. School of Psychology; University College Dublin
Our budget to-date…
0 Euro 0 cent
What’s Next…?
Revised Version: Pesky Gnats 2!
Additional adaptation of
technology
The Future
Development of online training
A range of games
tailored for children
with different needs
and adults with an ID
Pesky Gnats 2
Pesky Gnats 2
Pesky Gnats 2
Pesky Gnats 2
Pesky Gnats 2!
We are embedding standardised measures into the game.
1.  To assess symptoms of Anxiety and Depression… Revised Children’s Anxiety
and Depression Scale (RCADS)
2.  To assess how things are going for the young person at the start of every
session… Child Outcome Rating Scale (CORS - for every player 12 and under)
and the Outcome Rating Scale (ORS - for every player 13 and older)
3.  To assess how each session went at the end of every session using the Child
Session Rating Scale (CSRS - for every player 12 and under) and the Session
Rating Scale (SRS - for every player 13 and older)
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How a child scores on these measures will be instantly scored and graphed for
the young person and displayed on screen.
Each administration displayed will also display previous administrations for
previous levels.
All measures automatically appear but option to skip can be selected by
players.
The ratings will build week by week and the outcome always be printable…
Integrating Apps
O’ Reilly G. & Erkan, Y. (2011). The Pesky Gnats CBT App. Cork, DeCare Systems Ireland.
www.PeskyGnats.com
A range of games for young people…
•  Different age ranges and tailor for
different regions/countries
•  Trauma Focused CBT
•  Children with ASD
•  Eating Disorders
•  Adults with an ID
Thank you…
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Dr Mary Belton
Prof Alan Carr
Sadhbh Coyle
Laura De Burca
Alan Delahunty
Dr Gavin Doherty
Chris Donnelly
Yagiz Erkin
Eamon Franklin
Clare Gormley
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Katie Hendrick
Muriel Keegan
Aisling O’ Dwyer O’ Brien
Paul O’ Donoghue
Aisling Ryan
Jackie Shipp
Staff at HSE Galway
Staff at NEPS Fredrick Court
Conal Tunney
and anyone who has tried to help us
www.PeskyGnats.com
THE END...
Contact details for more info or copies of overheads Dr Gary O’ Reilly,
Senior Lecturer
Doctoral Programme in Clinical Psychology,
School of Psychology
University College Dublin
E-mail: gary.oreilly@ucd.ie