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psychological problems; for example, using ‘exposure’ to overcome avoidance of anxiety-provoking stimuli, and ‘response prevention’ to minimise compulsive behaviours. To date many CBT treatments with younger populations have been predominantly behavioural in content. Recently, however, there have been exciting developments in the understanding of cognitive aspects of psychological problems in childhood. In addition, recent models have begun to incorporate the maintaining role of environmental influences. For example, in Rapee’s (2001) model of the development of generalised anxiety disorder (GAD), parental reaction and factors associated with socialisation are hypothesised to promote the expression of anxious vulnerability in young people. As cognitive and behavioural models of childhood disorder become further refined, so will treatments, leading to greater specificity of treatments to particular disorders and a clearer understanding of how best to include families in treatment.
    CBT is based on the idea that psychological problems are maintained by unhelpful patterns of thinking and behaviour.
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    Creswell and Waite
    Developmental issues in CBT
    In order to benefit from CBT for OCD, young people need to be able: (a) to distinguish between thoughts, feelings and behaviours; (b) to reflect on their own cognitive processes; (c) to understand the relationship between cause and effect. It appears that the majority of children can demonstrate these skills by seven or eight years of age (Salmon and Bryant, 2002). For example, Quakley et al. (2004) presented children with a thought–feeling– behaviour sorting task and whilst four-year-old children performed at a level that did not differ from chance, by seven years of age most children performed at the ceiling level. Interestingly, at younger ages using a glove puppet to present the task improved performance, highlighting the need for careful consideration not only of what we do in therapy, but also how we do it to maximise children’s engagement and understanding. In terms of reflect-ing on thoughts, or ‘thinking about thinking’, a number of studies have demonstrated that pre-school children can attribute different thoughts to different people. By five years of age they can use mental state terms to explain behaviours, and by eight years to explain feelings (see Grave and Blissett, 2005). In terms of causal reasoning, again pre-school children are able to accurately use internal states to inform reasoning, and furthermore are able to consider ‘counterfactuals’; in other words, what if something different happens next time they are in this situation? Again though, studies have highlighted the importance of how these questions are asked in younger children (Robinson and Beck, 2000).
    Does the basic cognitive model apply to children?
    Research over the last decade has shown that characteristic cognitions are associated with particular mood disorders, including anxiety (Barrett et al. , 1996b), depression (Abela et al. , 2002) and conduct disorder (Crick and Dodge, 1994) in young people, largely mirroring those cognitive patterns found in adult populations. For example, in comparison to adolescents (11–18 years) with other anxiety disorders and non-anxious participants, adolescents with OCD have been found to have inflated responsibility beliefs, increased thought–action fusion (the idea that having a thought of something bad happening increases the likelihood of the event occurring) and concern over mistakes (Libby et al. , 2004). An integral relationship between cognitive style and OCD is also supported by a case series of six adolescents where measures of inflated responsibility decreased as OCD
    symptoms decreased (Williams et al. , 2002). Among younger children, these characteristic cognitive styles may not be fully developed. For example, in a younger sample, children (aged 7 to 13 years) with OCD also reported inflated responsibility and increased