Cognitive Behavioural Therapy for children and adolescents with intellectual disability and anxiety: a therapist manual

Up to 50% of children with intellectual disability (ID) have a comorbid mental illness, yet to date, there has been a lack of evidence-based treatments for this population. This paper discusses the development and application of the Fearless Me! © treatment program, a multimodal Cognitive Behavioural Therapy (CBT) intervention for children with mild to moderate ID and anxiety. The program development involved a review of the literature to identify the neuropsychological deficits present for children with ID and suggested ways in which therapy could be adapted for their needs. This was followed by gathering feedback from parents and mental health practitioners. From this, the Fearless Me! © program was developed, involving face-to-face sessions and an online component to support the practice of CBT skills. The program has been trialed among children and adolescents with ID, and shows promise in reducing anxiety in children with mild to moderate ID.

response was correct or incorrect. It is recommended that these tasks be completed with a therapist, or parents when completing homework, in order to discuss any mistakes. The vignettes on the website allows for repeated practice with different scenarios to facilitate the consolidation of each step in the cognitive challenging module. Parents are encouraged to be actively involved in the process and to assist with homework where possible. Therapists are also able to run shorter therapy sessions than would be typical, or to include breaks in therapy to accommodate for possible deficits in attention. The program encourages that therapist implement adaptations to the therapy with flexibility, identifying what adaptations may be best suited to the individual child.

Evaluation of the Fearless Me! © program among adolescents with intellectual disability
The Fearless Me! © program was evaluated for feasibility and acceptability amongst a cohort of 21 female adolescents with mild ID, moderate ID, or intellectual functioning in the Borderline range, aged between 12 and 18 years [20]. A case series approach was adopted as this was deemed to be the most appropriate form of evaluation given that research in this area is still in its infancy. The intervention was delivered in a group format during school hours, and participants remained in their pre-assigned classes which were based on age and ability levels. Overall, the program appeared to be appropriate and feasible for adolescents with mild to moderate ID, with good uptake and engagement. The participants described actively using the skills they had learned, and reported thoroughly enjoying the videos and online activities. Additionally, it was found that many children with initially heightened levels of anxiety experienced significant reduction in anxiety, or reductions which placed them within the non-elevated range of anxiety on the School Anxiety Scale-Teacher Report (SAS-TR; [25]).
The Fearless Me © program has also been evaluated among children and adolescents with ID in an individual therapy context [22]. A case series evaluation was conducted of nine children aged between eight and seventeen who completed the program. Children has either a mild or moderate intellectual disability, or intellectual functioning within the borderline range. The results indicted that all children have a significant reduction on at least one measure of anxiety (as measured by the Spence Children's Anxiety Scale-Parent Report or Child Report, [26,31], or anxiety life interference (as measured by the Children's Anxiety Life Interference Scale-Parent Report, [24].

Implications of the research
It is hoped that the Fearless Me © program will increase the access in which vulnerable children and adolescents with ID can have to therapy, and reduce barriers to treatment. The program has been evaluated, with future research aiming to conduct a full scale randomized controlled trial. While the program has only been evaluated for anxiety, the evidence suggests that CBT can be helpful for children and adolescents with ID, and it is therefore hoped that this could also be applied to the treatment of other clinical disorders for those with ID.

Fearless Me! ©: therapist treatment manual
The Fearless Me © therapist treatment manual is presented below. Note that the manual is designed to be used in conjunction with the online program available at www. fearl essme. com. au  Anastasia also works clinically with children, adolescents and adults experiencing mental health concerns, and combines a strong interest and background for research into her clinical work. She is also passionate about working with 1 3 adults with chronic mood disorders and interpersonal difficulties. In addition, Anastasia has published research in the area of problem gambling.
Associate Professor Rachel Roberts BA(Hons), MPsych (Clinical), PhD Rachel Roberts is an Associate Professor at the University of Adelaide and a clinical psychologist with extensive experience working with children with a range of developmental disabilities including intellectual disability, and their families. She teaches in the Master of Psychology (Clinical) and (Health) programs, and conducts research in the areas of clinical psychology, health psychology and neuropsychology. She has received grants and funding for much of her research, and has published numerous papers in high-ranking peer-reviewed journals.

About the program
The Fearless Me! program is a Cognitive Behaviour Therapy (CBT) treatment program which has been specifically adapted for children with intellectual disabilities and anxiety. It was developed in recognition that children and adolescents with intellectual disabilities experience very high rates of mental illness, yet there are very few psychotherapy treatment programs available which cater for the unique needs of children with intellectual disabilities.
Children can sometimes fall into patterns of thinking which are unhelpful. They may think negative and unhelpful thoughts such as "I'm not good at this", "this is too hard", "my friends will laugh at me", "I can't do it" etc. These types of thoughts can lead children to feel sad, worried, scared or anxious. As a result, children may avoid particular tasks, situations and activities. In this case, the role of the clinician within a CBT framework is to help children link what they think, to how it makes them feel and to what actions they take. Therapists may help children learn ways to "catch" their thoughts, check whether their thoughts are helpful and realistic, and challenge unhelpful/unrealistic thoughts. Some adults will automatically challenge their own thoughts, but children with an intellectual disability may need to be taught these skills.
Fearless Me! is a multimodal treatment approach, in that it involves both face to face therapy sessions, as well as an online component. A multimodal approach is used as a means of breaking down the CBT skills in a way that can hopefully be engaging and fun for children with disabilities. This manual provides information on how to use and deliver the components of both the online program and the content for face-to-face sessions. It is recommended that before using the online program, clinicians access the material themselves and explore the various online modules.
It is important to keep in mind that this treatment manual has been developed as a guide for therapy. As with any intervention, it is crucial to adapt the treatment and therapy process to suit the needs of the individual. This is particularly important when working with children with developmental delays and unique needs. More on how to adapt therapy for children with developmental and intellectual disabilities can be found on page 11.

Who is the Fearless Me! program for?
The Fearless Me! program was designed to be used with children and adolescents who have mild to moderate intellectual disabilities, or intellectual abilities in the borderline range, aged from approximately eight years to eighteen years of age. It is designed to assist children with subclinical or clinical anxiety concerns.

How do sessions work?
Outlined in this manual is a ten session treatment program, to be delivered after a comprehensive assessment has been conducted. It is recommended that each session run for approximately 45-60 min, and involve both teaching and practicing skills. While the treatment manual has ten session plans provided, it is at the clinician's discretion to adapt this however best appropriate for the client.
The aim of the program is to break down the skills of CBT in a way that can be understood and used by children with intellectual disabilities. In particular, there is additional focus on the cognitive components of CBT. It is recommended that both practical and online components be used in most sessions to help facilitate the child's engagement in the therapy process. Therefore, it is important that the clinician have access to a computer or electronic device during the sessions, or that the child bring an electronic device with them to sessions (i.e. laptop, tablet or iPad. Using a mobile phone to access the online site is not recommended).
We highly recommend having a carer or parent present for all sessions. We have found that having a carer involved in the treatment is beneficial to the progress of therapy, as they are able to provide valuable clinical information as part of the assessment, can provide relevant examples of times when the child has felt anxious, and can learn the skills as part of the program to facilitate practice and generalisation of skills outside of therapy sessions.
As is typical within a CBT treatment program, sessions involve homework tasks for children to do between session. These involve a combination of exposure exercises, use of relaxation skills, and practice of cognitive skills. This is where parents/carers may be able to assist with a child's progress outside of therapy sessions.

Group vs individual therapy
The Fearless Me! program has been designed to be an intervention which can either be delivered in an individual or group setting. Throughout the treatment manual you will note that there are options for adaptations, based on whether the program is being delivered in an individual or group setting.
For both individual therapy and groups, we recommend having a carer or parent present for all sessions. In addition, group therapy programs may benefit from having two group facilitators. Group sizes are likely to vary according to the level of disability of the children in the group and clinical judgement should be used to determine group size (i.e. groups of children with mild intellectual disabilities may be larger than groups predominately comprised of children with moderate intellectual disabilities).

Optional session 9
In the treatment manual, you will note that Session 9 had been identified as optional content to teach. This has been designed in this way as we recognise that some children may require additional teaching of previous steps and content, before being able to move onto the next steps. Thus the content of Session 9 does not need to be delivered if a child requires additional time to be spent on the other components of the program.

Components of the online Fearless Me! program
The Fearless Me! online program consists of three modules:

3
In this example the answers are: Thought→"Lucy thinks that she has always wanted a puppy" Feeling→"Lucy is excited" Doing→"Lucy picks up the puppy and hugs it.

Thought catching
This activity helps children to learn that unhelpful thoughts can lead to feeling stressed, worried, anxious or sad. The task requires them to read/listen to two different thoughts and choose, or "catch", the worry thought.
See the example below: In the example above, the "worry" thought is "I am going to have no one to sit with at lunch". Thinking this would make a child feel more worried than thinking "I can go and sit with some of my other friends". This exercise helps children build the ability to "catch" the worrisome or unhelpful thoughts they may think.

Detective thinking
Once children can identify their thoughts (by practicing Think Feel Do) and can catch their worry thoughts (by practicing Thought Catching) they can next move onto Detective Thinking.
Detective Thinking involves children challenging their unhelpful thoughts. They practice being a "detective" and finding more helpful thoughts. Children do this by asking "What else can it be?", "What happened before?" and "What is a helpful thought?". See the example below: In the example above, children are encouraged to challenge the thought "Frank thinks if he asks a question the other students might make fun of him". Children are encouraged to question what else could happen (i.e. maybe the other children won't laugh and make fun) and what happened before? (i.e. last time someone asked a question the other students did not laugh and make fun). By doing this, children can come to choose a more helpful thought such as "If I ask the teacher a question she can help me and maybe other students too".

Module 3-facing fears
This module focuses on the behavioural component of CBT. As is common with subclinical and clinical anxiety, avoidance of the feared stimuli is usually a key factor in maintaining the anxiety. This module therefore focuses on graded exposure, and working in small steps to achieve a goal.
This module includes a video called Brave Ben which explains how we can work step by step to reach a goal. Children can create their own steps and goals in the activity Facing Your Fears.

Facing your fears
In this activity, children choose something which they usually avoid or are scared of. Together with parents, a teacher or psychologist, they can develop a list of components which are related to their fear. These activities are then put in order from least anxiety provoking to most anxiety provoking. Children start with the least anxiety provoking task, and receive a reward when they complete it. By working through these steps children are able to eventually face the fear at the top of their list. For example, a child who becomes anxious in social situations may avoid going to parties. To work up to being able to attend a party, they may start by having a conversation with a friend at school, then saying hello to a student they do not know, then inviting one friend over to their house, then going over to a friend's house, and finally going to a party. It is important that each step is repeated multiple times. It is also important that steps are gradual. The steps for one child will be different for another child.

Working with children with intellectual disability
As has been outlined in the previous sections, this program is an adapted Cognitive Behaviour Therapy (CBT) treatment. In the past, clinicians have placed greater emphasis on behavioural and pharmacological interventions for people with intellectual disabilities. This program aims to make use of both behavioural and cognitive strategies to help children and adolescents with anxiety.
Consideration of a child's cognitive, social and emotional development is crucial prior to undertaking therapy and these factors should be examined during the initial assessment. Children with intellectual disabilities have cognitive deficits and as such, the therapy and therapist must adapt to meet the needs of the child. Neurocognitive deficits exist in the areas of attention, memory, learning, working memory, executive functions and language and reading. It is thus these factors which are likely to have an additional impact on the therapy process and needed to be accommodated and adapted for.
The authors of the Fearless Me! program have conducted a review into the research looking at the neurocognitive deficits of children with intellectual disabilities, the implications these may have for therapy, and suggested adaptations to therapy. The table below is taken from the review paper and is included to help clinicians and facilitators understand the ways in which they may consider additional adaptations to therapy to suit the needs of the individual child they are working with. Catching unhelpful thoughts Session 7 Check the facts Session 8 Check the facts Session 9 Linking helpful thoughts to exposure hierarchies (optional) Session 10 Review of skill

Introductions
• Psychologist Introduces self and role • Name tags for everyone (if delivered in group setting)

Confidentiality
• Explain confidentiality. Emphasise working as a team (child, psychologist, carer/parents, teacher etc.). • If delivered in group format, explain that we do not discuss about what other people say outside of group.

What are my fears?
Everyone has different fears and worries, and things that make them feel anxious.
• Hand out-things that make me anxious. Circle what applies to you. Go through these one by one. Draw in the blank space any other fears/worries.

What does anxiety feel like?
Imagine that you have to do something that you circled. Imagine you have to give a speech, or go to the doctor, or spend the night away from mum and dad. Close your eyes. Where can you feel the anxiety in your body?
• Activity: colour/draw in where you feel anxiety in the body. What do these feel like? Butterflies, heart racing, tension etc.?

Thermometer
One way we can tell how anxious we feel is by using this thermometer to help us. If we don't feel a lot of anxiety, then we are low on the thermometer. If we feel a bit of anxiety, we are in the middle. If we feel a lot of anxiety, we are at the top!

Session 2: balloon breathing and safe place
Review anxiety psychoeducation from previous week.

Balloon breathing
Often when we feel anxious or scared, we start to breathe really fast. If we breathe fast, this makes our heart beat faster. This can make us feel even MORE anxious than we already are! One way we can help ourselves feel more calm, is to do some balloon breathing. Balloon breathing helps us to take slower and deeper breaths. When we do Balloon Breathing we imagine that we have a balloon inside of us. When we breathe in through our nose, we blow up the balloon. When we breathe out through our mouth, we let the air out of the balloon.
Practice Balloon Breathing with video first, then without.

Safe place
Another thing we can do when we feel scared or worried, is imagine a place that we call our Safe Place. When we imagine our safe place, nothing can hurt us or upset us. We are 100% safe. This is where we can go to feel calm. But it's not a real place. We just go there in our mind. Activity: Imagine the safe place.

3
Q/ What can we learn from the video about Brave Ben? Highlight how Brave Ben was able to conquer his fear of heights by going "step by step".

Rewards
Q/ What did Brave Ben get after he did every step? (A: reward). Develop a list of potential rewards.

Developing own hierarchy
Develop hierarchy/steps for something they are fearful of doing. Refer back to information from parents/carers and what they identified as anxiety provoking from session 1. For each step on the hierarchy, add in rewards.
(If there is additional time, can work on developing a second hierarchy). Use Fearless Me! online program to develop exposure hierarchy steps.

Homework
• Watch Brave Ben video again at home. • Try to do the steps at the bottom of the exposure hierarchy and monitor progress using the website.

Resources
• Fearless Me! Brave Ben video • Activity Sheet 4: Facing Fears Worksheet

Session 5: identify thoughts, feelings & behaviours
Review homework to take steps on exposure hierarchy. . Practice together the activity titled "Think, Feel, Do", which asks children to practice identifying thoughts, feelings and behaviours.

Identifying thoughts, feelings and behaviours
Practice "Thought Catching" again in session to clarify child's progress and in what areas they may be having difficulty and require further focused intervention. Consolidate this before moving onto next step of unhelpful thoughts.

Check the facts
Explain what a fact is. Recap how thoughts can be true or untrue.
Explain detective thinking means looking for the facts of a situation. You are learning to ride a bike but think you will never be able to do it. Stop and think. What are the facts? What happened before? Is thinking this way helpful? Activity: "Detective Thinking" computer exercise.

Resources
• Fearless Me! "Detective Thinking" computer exercise

Homework
• Fearless Me! "Detective Thinking" computer exercise • Continue with exposure hierarchy steps 5.8 Session 9: linking helpful thoughts to exposure hierarchies (optional) (Note: this session can either be used to continue and consolidate the cognitive skills from sessions 5-8, or can be delivered according to the session plan below) Review homework to practice "Detective Thinking" and exposure hierarchy progress.

Activity
Practice developing exposure hierarchies for a specific concern a friend may have, to help them face their fear.
-Fear of making new friends -Fear of catching the train alone -Fear of spiders -Fear of the dark -Fear of hospitals Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/.