The effect of cues on young children’s abilities to discriminate among thoughts, feelings and behaviours

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Abstract

Objective: To determine if cues help young children discriminate among thoughts, feelings and behaviours.

Participants: Ninety-six children aged 4–7 years from three schools in Norwich, UK.

Design: Within each age band (4, 5, 6, 7), children were randomised to the cue or the no cue condition on a stratified basis ensuring that equal numbers of boys and girls from each school were in each of the eight cells (cue condition×age). Cues were glove puppets and post boxes. The effect of IQ was controlled.

Measures: A discrimination task, in which children were asked to identify a thought, a feeling and a behaviour from each of six brief stories, and a brief IQ assessment were administered to children individually.

Results: There was a significant effect of age and cue condition on performance; older children and those who were presented with the cue performed better. There were no gender differences and no interaction between cue condition and age.

Conclusion: Many young children discriminated among thoughts, feelings and behaviours suggesting that they may be able to engage in this aspect of cognitive behaviour therapy. Simple cues (puppets and posting boxes) improved children’s performance and these may be useful therapeutic tools with young children.

Introduction

The ability to discriminate among thoughts, feelings and behaviours is an important requirement of participation in cognitive behaviour therapy (CBT). This paper seeks to examine the performance of children aged 4–7 years and determine if the use of cues aids performance. The development of cognitive behaviour therapy for young children is of considerable practical importance and this study aims to contribute to this development.

Mental health problems affect approximately 10% of children under 10 years (Office for National Statistics, 1999) and psychological interventions for young children are, as yet, poorly developed compared with those available for adults. For example, for adults, CBT is effective for many common mental health problems including depression (e.g. Gloaguen et al., 1998) and anxiety disorders (e.g. Westen & Morrison, 2001), as well as for chronic and enduring problems such as psychosis (e.g. Gould et al., 2001). There is however, a difficulty in simply transferring CBT to the treatment of young children because of specific concerns about the extent to which children’s limited cognitive development precludes them from actively participating in therapy (e.g. Reinecke et al., 1996, Stallard, 2002). However, there is evidence that developmentally appropriate CBT approaches can improve the behaviour of 4–8 year old children with conduct problems (Webster-Stratton, Reid, & Hammond, 2001). In addition, Greenberg et al. (1995) demonstrated that school-based preventative training programmes which include components related to CBT (the PATHS programme) can improve children’s knowledge about emotions and their cognitive abilities.

There remains considerable uncertainty about the development of children’s understanding about thinking and feeling, although recent research in cognitive development suggests that children’s development may be substantially in advance of that proposed by Piaget (1952). According to Piagetian stage theory, young children cannot engage in abstract reasoning (e.g. about their own thinking) until late childhood or adolescence. However, more recent developmental research provides a range of evidence that young children have considerable emotional and meta-cognitive skills. For example, Dunn and Hughes (1998) reported that 4 year old children talk about real-life negative emotions (anger and sadness) and that this ability was related to their performance on a set of “theory of mind” tasks. At age 7, these children were followed up. Their emotional understanding was further advanced and they often identified thoughts and beliefs as causes of anger or sadness (Hughes & Dunn, 2002). A series of studies by Flavell, Green and Flavell has identified that by 8 years of age, children recognise that thinking is a process (Flavell, Green, & Flavell, 1995) that thoughts can be difficult to control (Flavell, Green, & Flavell, 1998) and that thoughts and feelings are linked (Flavell, Flavell, & Green, 2001).

There is evidence that in clinical work, practitioners are influenced both by Piagetian models and by more recent research. For example in line with Piagetian theory, Reinecke et al. (1996) in describing cognitive behaviour therapy with children and adolescents stated that

“School age children, for example, typically are unable to readily identify their current thoughts or to discriminate and label specific emotional states” (p. 5).

In contrast, clinicians such as Ronen, 1992, Kendall, 1992, Young and Brown, 1996 argue that, with appropriate adaptation, young children can understand the principles of, and engage in, cognitive behaviour therapy. This is consistent with Vygotsky’s ideas about child cognitive development and in particular the concept of the “zone of proximal development”. This, according to Vygotsky (1962), refers to the potential ability of a child if they are provided with appropriate “scaffolding”, i.e. assistance from adults or more advanced peers.

Some clinicians have suggested specific methods that would help children engage in cognitive therapy. These include the use of stories (e.g. Friedberg, 1994), cartoons (Kendall, 1992), and thought bubbles (e.g. Young & Brown, 1996). There is some indirect evidence that such methods may help children understand. Dyer, Shatz and Wellman (2000) examined the text in books for children aged 3–4 years and 5–6 years and reported that references to mental states were high for both age groups and that story books provide a rich context for learning about mind. Wellman, Hollander and Schult (1996) demonstrated that children as young as 3 years old understood that the content of a thought bubble referred to a thought or belief. However, Quakley et al. (2003) asked children aged 7–11 years to discriminate between sentences referring to thoughts and sentences referring to behaviours and found that minimal visual cues (i.e. an action doll and a stick person with a thought bubble) did not improve children’s performance. The majority of children performed the task at a high level and some were at ceiling; thus the task may have been too easy for these children and/or the cue may not have been sufficiently helpful for them.

The current study builds on Quakley et al. (2003) by increasing task difficulty, increasing the impact of the cues, and observing the performance of children aged 4–7 years to avoid ceiling effects. The main aim of the study is to examine if the use of salient age-appropriate cues will improve task performance. Secondary aims involve examining the effects of age and gender on performance. If cues do aid performance, this will provide important practical and conceptual information for clinicians working with children.

Section snippets

Design

Children aged 4, 5, 6, or 7 were assigned to the cue or non-cue conditions through stratified randomisation by gender and school. This ensured that each cell (age by condition) had equal numbers of boys and girls, and equal numbers of children from each school.

Participants

Ninety-six children aged between 4 and 7 years were recruited from three schools in Norwich, UK. There were 24 children in each of four age bands; 4, 5, 6 and 7 years. Within each age band, there were 12 boys and 12 girls and eight

Results

The results are shown in Fig. 2. At all ages, children in the cue condition (i.e. used the posting boxes and puppets) obtained higher scores than the children who did not have cues. In addition, older children performed better than younger children. The mean score for 4-year old children was close to that obtained by chance (i.e. 6). However, by age 7, the mean score was much closer to the maximum possible score (i.e. 18).

The relationship between IQ and task performance was of interest with the

Discussion

The results of this study provide clear evidence that using simple cues with young children enhances their ability to discriminate among thoughts, feelings and behaviours. This evidence thus supports those clinicians who argue that young children can engage in cognitive therapy if appropriate age adjustments are made, and is in accord with the developmental literature which shows that young children have good understanding of thinking by about 8 years. At all ages between 4 and 7 years,

References (27)

  • R Haynes et al.

    Atlas of health needs indicators in Norwich

    (1997)
  • C Hughes et al.

    “When I say a naughty word”. A longitudinal study of young children’s accounts of anger and sadness in themselves and close others

    British Journal of Developmental Psychology

    (2002)
  • P.C Kendall

    Coping cat workbook

    (1992)
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