Cognitive behavioral therapies (CBT) constitute a family of therapeutic interventions that have been applied to a wide variety of presenting problems with both adult and child populations. The fundamental basis or premise for the majority of CBT approaches is that cognitive factors, including cognitive schemas, belief systems, cognitive distortions, and dysfunctional or maladaptive beliefs, serve to predispose and or maintain various types of psychological distress. It is argued that targeting and altering these maladaptive cognitions or beliefs can alleviate distress. CBT also includes some interventions that may appear less “cognitive” and more behavioral, including behavioral activation (Kanter et al. 2010) and exposure techniques. CBT approaches have been applied to depressive disorders, anxiety disorders, general distress, sleep disorders, and somatoform disorders, among many others in literally hundreds of studies, and the evidence base for the efficacy of these interventions is considerable. CBT has targeted distress associated with medical conditions in adults and children, as well as in pediatric cancer populations.

In the 1990s, Hoekstra-Weebers et al. published one of the first studies examining CBT in parents of children newly diagnosed with cancer (Hoekstra-Weebers, et al. 1998). Cognitive behavioral strategies employed in the study included the encouragement of emotional expression, identification of distorted automatic thoughts, use of problem-focused coping skills, discussion of psychosocial impact on the family, and training in assertiveness and communication skills. Importantly, the intervention was tailored to meet the expressed needs of the parents and also took into account the developmental level of their child. Compared to standard care (which did include provision of psychosocial services from a social worker), few differences in outcomes were found. This may have been a function of the overall lack of intensity of the intervention or lengthy time periods between intervention sessions. Importantly, it may have also been the result of high-quality services delivered to the standard care group. However, it did appear that the intervention was both feasible and acceptable to the families and set the stage for future structured/semistructured psychosocial interventions.

Streisand and colleagues (2000) also piloted a brief (one 90-min session) stress management intervention using cognitive behavioral techniques with a small sample of parents of children undergoing bone marrow transplant (Streisand et al. 2000). This intervention included an educational component, the teaching of relaxation skills, and communication skills, augmented by handouts that reviewed the components of the program as well as a tape player and headset for them to practice their relaxation skills. Although no differences were found between the treatment and control group, the results did indicate that parents in the intervention group successfully learned and subsequently employed these strategies in their efforts to manage stress.

More recently, efforts have been made to pilot and test the potential effectiveness of CBT in conjunction with other therapies. Seitz and colleagues (2014) developed an Internet-based intervention called “Onco-STEP” for cancer survivors who are off treatment (Seitz et al. 2014). Based in part on Pennebaker’s expressive writing disclosure task, this intervention consists of 10 writing sessions that involve standard text messages and instructions. “Onco-STEP” includes two essential treatment modules, one of which involves helping the individual reprocess traumatic experiences associated with their cancer experience and the second module focusing on developing coping skills for dealing with remaining fears related to their cancer. Although this was only a single arm study, the authors did find significant decreases in self-reported anxiety, posttraumatic symptoms, depressive symptoms, and fears of relapse. Notwithstanding the small sample size and control group, this work demonstrates the promise of CBT interventions delivered through electronic means and certainly warrants replication (see Chap. 20 eHealth).

Importantly, children undergoing treatment for cancer and survivors of childhood cancer have been identified as being particularly at risk for anxiety and somatic concerns. The Coping Cat is a well-established manualized cognitive behavioral treatment that assists children ages 10–17 years in (Kendall 1994; Kendall 2000; Kendall et al. 2005):

Techniques presented to children throughout each training session include modeling real-life situations, role-playing, relaxation training, and contingent reinforcement. In addition, therapists use social reinforcement to encourage and reward the child, who is then encouraged to verbally reinforce their own successful coping. The Coping Cat is comprised of 16 sessions; the first eight sessions are training sessions in which each of the basic concepts is introduced individually and then practiced and reinforced (Kendall 1994; Kendall 2000). During the second set of eight sessions, the child practices the new skills in both imaginary and real-life situations varying from low stress/low anxiety to high stress/high anxiety situations, depending on their needs (Kendall 1994; Kendall 2000). Although there are currently no published studies available in the literature using the Coping Cat specifically with pediatric cancer patients, the strong empirical support for this approach in reducing anxiety in youth would argue for its use, particularly with youth who are experiencing significant symptoms of anxiety.

Similar to the strategies of the Coping Cat, a program targeting coping with cancer featuring a stuffed toy named “Cellie” was developed by psychologists at The Children’s Hospital of Philadelphia for children aged 6–12 years (Marsac et al. 2012). The Coping Kit includes “Cellie,” cancer coping cards, and a book for caregivers. The cancer Coping Cards, found hidden inside “Cellie’s” zippered mouth, provide children with strategies to deal with numerous cancer-related stressors, ranging from medical procedures and hospital visits to feelings of anxiety, distress, and uncertainty (Marsac et al. 2012). The “Cellie Cancer Coping Kit” is flexible and can be used in a number of settings including the home, clinic, and/or hospital (see http://​www.​chop.​edu/​health-resources/​cellie-cancer-coping-kit-prezi#; Marsac et al. 2012). “Cellie” can also help families begin discussions surrounding difficult topics including care, treatment decisions, and managing hospital stays via the deck of Coping Cards. Once a problem has been identified, the child or caregiver finds the relevant Coping Card and takes the card(s) along wherever they go by placing and zipping them into “Cellie’s” mouth. In addition to providing support, “Cellie” also comes with a caregiver book that offers advice for dealing with common cancer-related challenges caregivers often face, such as caring for siblings and working with the medical team (Marsac et al. 2012). The acceptability and efficacy of “Cellie” has been examined in families who have a child diagnosed with cancer, and all parents reported that Cellie was an engaging, helpful, and easy-to-use coping tool they would recommend to other parents of children with cancer (Marsac et al. 2012). Children reported using the “Cellie” Kit for multiple reasons, including it being a playtime activity as well as a way to express difficult topics surrounding their treatment and care.

Another unique intervention that employs a cognitive element is the game “Shop Talk” (Wiener et al. 2011). “ShopTalk” is a therapeutic game with versions in Spanish and English, designed for children ages 7–16 diagnosed with cancer. It also can be used with children and youth who have been diagnosed with other types of serious medical illness (Wiener et al. 2011). “ShopTalk” can be used in individual or group therapy sessions to assist in starting conversations about difficult emotional issues related to the child or adolescent’s medical illness and the impact their illness has in various situations (e.g., school, home, peer relations). During the game, “ShopTalk” players visit ten different “shops” around the board, choosing one of six “gifts” from each store to place in their individual shopping bag when they choose to answer the question. One example of a “shop” that is visited during the game is a pet store called “Unconditional Love,” that provides a series of questions pertaining to aspects of the child’s life that are accepting, supportive, and helpful in addition to assessing for fears of rejection and/or abandonment. Another shop visited during game play is a sports store called “Balls in Your Court,” which provides a series of questions examining different social scenarios that can occur throughout the course of treatment and then specific ways to handle these situations. “ShopTalk” is an effective tool in identifying a multitude of psychological adjustment issues, such as family relationships, sadness, peer relationships, and self-esteem (Wiener et al. 2011). Two additional versions of “ShopTalk” are now available. A sibling version can be obtained through (http://​www.​alexslemonade.​org/​campaign/​supersibs) and a version for children whose parents have cancer is available through the National Cancer Institute (http://​pediatrics.​cancer.​gov/​scientific_​programs/​psychosocial/​educational.​asp)

Cognitive behavioral interventions have become a mainstay treatment for many psychological disorders, including the distress associated with a diagnosis of pediatric cancer. Although studies evaluating the impact of CBT have not always shown significant improvement in symptoms above and beyond standard care, it is worth noting that there have actually been very few studies that have attempted to deliver CBT as a stand-alone, intensive intervention. The existing studies involved very brief interventions and used personnel with limited training in use of these techniques. Indeed, it may also be that these studies included a significant number of individuals who evidenced relatively low levels of depression and anxiety, both of which are traditional targets of CBT interventions. Thus, CBT may be best suited for individuals with higher levels of distress.

As will be seen later in this chapter, some clinicians have integrated CBT techniques with other modalities (e.g., family therapy, communication training) and have witnessed stronger findings. Indeed, a strength of CBT is the ease in which it can be integrated into other psychotherapeutic approaches (e.g., family therapy, mindfulness training, acceptance and commitment therapy), as well as its strong empirical underpinnings. For more information on CBT and its implementation, see Cognitive Behavior Therapy: Core Principles for Practice (O’Donohue and Fisher 2012), General Principles and Empirically Supported Techniques of Cognitive Behavior Therapy (O’Donohue and Fisher 2009), as well as The Case Formulation Approach to Cognitive Behavior Therapy: Guides to Individualized Evidence Based Treatment by Jacqueline Persons (Persons 2012).

Problem-solving therapy (PST), a well-established model of intervention, has considerable empirical support for a wide range of psychosocial issues. Originally, this therapeutic modality was developed to help clients solve “real-life” problems and was not necessarily targeted at psychopathology per se. Problem-solving therapy involves teaching the client a very broad, general strategy that is designed to address any given problem situation and involves the following steps: (1) teach the patient to identify and clearly define the problem, (2) establish all available strategies that will address or solve the problem, (3) evaluate the specific pros and cons of each possible solution to the problem, (4) select a solution and take action, (5) evaluate the effectiveness of that action, and (6) determine whether another option or course of action is needed in order to effectively solve the problem (Nezu et al. 2013) (Table 6.2).

Problem-solving therapy has received considerable attention as an effective treatment for parents of youth with pediatric cancer. In a programmatic series of studies, Sahler and colleagues (2002, 2005) and Varni and colleagues (1999) evaluated the effectiveness of PST with mothers of children newly diagnosed with cancer. The problem-solving intervention utilized was called “Bright IDEAS.” The term “bright” was meant to convey a sense of optimism to the parents as they approached the problem-solving process. The acronym IDEA refers to:

Eight one hour therapy sessions were conducted in either the clinic or hospital setting, so that parents need not travel back to the hospital for additional meeting times. Parent worksheets facilitated the problem-solving process, and homework tasks were included as part of the intervention to help parents continue to practice problem-solving skills outside of the clinic and hospital setting.

Importantly, this study found considerable support for its efficacy in reducing what has been referred to as “negative affectivity” (e.g., anxiety, depression, and posttraumatic stress symptoms) as well as improvement in overall problem-solving skills. Additionally, this intervention was particularly effective for younger, single mothers, as well as for Hispanic mothers. PST has also been incorporated into other multimodal treatments in the context of pediatric cancer. Sahler et al. (2013) later compared the “Bright IDEAS” problem-solving intervention to a more active treatment (nondirective supportive therapy) and concluded that PST is not only effective in reducing symptoms of distress but also in eliciting improvements that continue over time. These positive long-term changes are most likely due to the acquisition of active coping skills.

Problem-solving therapy appears to have great promise in the pediatric cancer setting. Such an approach is very easily taught to both older children and parents, is cost-effective in terms of the number of sessions needed to teach these skills, can be delivered in virtually any setting by a number of modalities (e.g., outpatient clinic, hospital room, by phone or Skype), and is acceptable to diverse populations (Nezu et al. 2013). PST is also a strategy that can be readily incorporated with other cognitive behavioral intervention tools. Law et al. (2014) recently concluded in their meta-analysis that PST is one of the few interventions with considerable demonstrated research support as an effective treatment for parents of children with a medical condition. An excellent resource for clinicians on problem-solving therapy is “Problem-Solving Therapy: A Treatment Manual” by Arthur and Christine Nezu et al. (2013).

In light of the fact that cancer affects the entire family, structured interventions have been developed to broaden the focus of psychological support to encompass the parent and the family system of the child with a diagnosis of cancer. These interventions are structured to provide education and psychological skills, which are typically provided within a CBT framework.

Mullins and colleagues (2012) developed an interdisciplinary intervention to provide support for mothers of children with newly diagnosed pediatric cancer (i.e., within 6–12 weeks following the initial diagnosis), which was tested as part of a randomized controlled trial. This intervention focused on illness uncertainty as a mechanism for reducing parental stress. Six modules were developed as part of the standardized intervention, including (1) understanding the nature of uncertainty in the context of pediatric cancer, (2) enhancing communication with medical staff, (3) training in cognitive coping skills (i.e., CBT), (4) problem-solving training, (5) learning how to garner social support, and (6) consolidating all of these skills (Mullins et al. 2012). Sessions were led in clinic by a psychologist, followed by a nurse interventionist contacting mothers by phone to provide additional support and reinforcement related to each module topic. The intervention was designed to allow mothers to meet with the psychologist on odd weeks and receive follow-up care from the nurse interventionist on even weeks.

Other structured parent and family interventions have similarly been developed. “The Surviving Cancer Competently: An Intervention Program (SCCIP)” was a pilot study designed by Kazak and colleagues (1999). SCCIP is a 1-day, 4-session intervention that incorporates both CBT strategies and family therapy in order to reduce symptoms of distress and posttraumatic stress. During the intervention, families meet all together and in four separate groups. These four groups include (1) the child with the cancer diagnosis, (2) siblings, (3) mothers, and (4) fathers. Families received psychoeducation, practiced self-talk and reframing, and discussed beliefs about cancer.

The SCCIP study was later adapted to the Surviving Cancer Competently Intervention Program – Newly Diagnosed (SCCIP-ND; Kazak et al. 2005). This protocol was developed for caregivers of newly diagnosed cancer patients. This specific intervention consists of 3-sessions lasting 45 min each conducted during the first month after the child’s cancer diagnosis. During Session 1, the goal is to develop a collaborative relationship with caregivers and introduce an A-B-C framework for identifying concerns about cancer-related difficulties or concerns and examining thoughts, feelings, behaviors, and relationships. Session 2 provides psychoeducation, modeling, and practice for caregivers to change their maladaptive thoughts in order to produce different behaviors. Specifically, these cognitive strategies examine the relationship between thoughts or beliefs and behaviors that result in negative consequences for the family. Caregivers are given tools to be able to identify maladaptive thoughts and then identify new beliefs that address: (1) accepting events related to their child’s illness that cannot be controlled, (2) turning their attention on events that can be controlled, (3) bringing their attention and efforts towards utilizing and maximizing their strengths, and (4) focusing on positives. The third session is aimed at encouraging caregivers to nurture the growth of their family beyond the cancer diagnosis. Tools the psychologist provided in order to accomplish this included “The Family Survival Roadmap” and “Putting Cancer in Its Place.” The Family Survival Roadmap is a visual map that caregivers utilize to plan a course of action for themselves and their family as they maneuver through the cancer diagnosis and plan for resuming a more typical course in light of the uncertainty their child’s illness may cause. Putting Cancer in Its Place helps caregivers to incorporate their child’s cancer diagnosis into the family structure while also providing boundaries so the diagnosis does not take over all aspects of family life. Studies suggest that the SCCIP-ND is both useful to families and that caregivers in the intervention group show reduced posttraumatic stress. Importantly, the Intervention Manual for SCCIP-ND is available at https://​www.​healthcaretoolbo​x.​org/​images/​pdf/​sccipnd_​info.​pdf.