Family Involvement in Cognitive-Behavioral Therapy for Children’s Anxiety Disorders

July 2006, Vol. XXIII, No. 8

Cognitive-Behavioral Therapy for Adolescent Depression

Developing an Effective Treatment Protocol

Family Therapy in the Treatment of Depression

NAMI Programs Educate Families of Mentally Ill

From Prevention to Preemption: A Paradigm Shift in Psychiatry

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Cognitive-behavioral therapy (CBT) for children with anxiety disorders may be especially effective when the family is included in treatment.^1-3 Family CBT (FCBT) has consistently yielded a high proportion of treatment responders (more than 70%) and in some studies has outperformed CBT programs with little family involvement.³ This article presents the rationale supporting FCBT, provides a case study illustrating FCBT techniques, and summarizes the findings of a recent clinical trial.

RATIONALE SUPPORTING FCBT

FCBT for children’s anxiety disorders draws on effective cognitive-behavioral techniques⁴ and supplements these with targeted family interventions. A good description of fundamental CBT techniques was published in 2003.⁵ CBT for children’s anxiety disorders consists of 2 phases: skills training, and application and practice. During the skills training phase, children are taught techniques for reappraisal of feared situations, relaxation, and self-reward. In the application and practice phase, a hierarchy is created in which feared situations are ordered from least to most distressing. Children work their way up the hierarchy and are rewarded as they attempt increasingly fearful activities.

Seven studies have compared versions of FCBT with versions of child-focused CBT (CCBT) with little family involvement for children presenting with anxiety disorders.³ Five of the studies have reported some outcome measures favoring FCBT over CCBT at the posttreatment assessment, whereas no outcome measures have favored CCBT over FCBT. In contrast, there were no differences found between the FCBT and CCBT programs studied,^6,7 and some longer-term outcome studies have suggested that differences between FCBT and CCBT lessen over the course of time. Nonetheless, the extant evidence suggests that there may be some advantage of the FCBT paradigm, particularly with regard to immediate effects.

Most FCBT programs have not focused on the specific parenting practices that are hypothesized to contribute to the development and maintenance of anxiety in children. In comparison, the FCBT program Building Confidence (J.J. Wood et al, unpublished manual, 2006) was developed by drawing on basic research in parent-child interaction patterns in families of children with anxiety disorders,^8,9 with the goal of enhancing treatment effectiveness. These studies suggest that high levels of parental intrusiveness and a lack of parent-granted autonomy are linked with anxiety disorders in children.

Parents who act intrusively tend to take over tasks that children are (or could be) doing independently and impose an immature level of functioning on their children. Among schoolaged children, parental intrusiveness can manifest in at least 3 domains: unnecessary assistance with children’s daily routines (eg, dressing), infantilizing behavior (eg, using baby words, excessive physical affection), and invasions of privacy (eg, parents opening doors without knocking).¹⁰ Parents who act intrusively are posited to interfere with the process of habituation (fear reduction) by preventing children from actually confronting feared but benign stimuli.^9,11 Conversely, parents who grant appropriate levels of autonomy may enhance children’s feelings of mastery and self-efficacy,¹² and thus contribute to the regulation of anxiety.

The Building Confidence FCBT manual goes beyond previous CBT programs by directly intervening with parental intrusiveness and parentgranted autonomy.¹⁰ The Building Confidence program includes individual sessions with the child and complementary parent-training sessions. These parent-training sessions emphasize:

• Giving choices when children are indecisive (rather than making choices for them).
• Allowing children to struggle and learn by trial and error rather than taking over tasks for them.
• Labeling and accepting children’s emotional responses (rather than criticizing them).
• Promoting children’s acquisition of novel self-help skills.

An incentive system is also taught to parents to encourage their children’s courageous behavior. A typical FCBT session begins with a 20-minute individual meeting with the child to conduct skills training or application/practice. Skills are reviewed less thoroughly with the child than in CCBT, permitting time for parent-training (20 minutes) and conjoint parent-child meetings (10 minutes). The following case describes a child with separation anxiety, but the issues it raises are also applicable to other types of anxiety disorders.

Case Study

Ben is an 11-year-old boy living with his single mother in a semirural area of California. They share a small apartment with another single mother and her school-aged son. Ben’s mother works from home and their income is below the poverty line.

Ben is a slender boy with a friendly smile who is extremely nervous about being away from his mother, a behavior that meets the criteria for separation anxiety disorder. He has missed 20 days of school in the 2 months before intake because of reluctance to be away from home, has left school early 5 times because he felt “sick,” and frequently goes to the nurse’s office in school. His pediatrician has found no medical problem that would explain these difficulties.

Ben sleeps in his mother’s bed every night. He is distressed by worries about his mother being in a car accident while he is away from her, a concern not based on previous experience. Ben has avoided playdates, team sports, and afterschool activities because of separation anxiety, causing his mother to worry about his social development. Ben is exceptionally well-behaved and polite, and he has a precocious sense of humor. He noticeably perked up when interacting with male clinicians, flopping around the therapy room in mock slapstick routines or rushing to initiate conversation about topics he thought would be of interest.

There are numerous signs of intrusive parenting: Ben’s mother encourages his sleeping with her; she showers with him and washes his hair (an atypical scenario for an 11- year-old), she dresses and undresses him, and grooms his hair (which tangles easily and is difficult to manage) on a daily basis. Despite receiving assistance from his mother during these routines, Ben is actually capable of self-care in each of these areas. Ben also often sits on his mother’s lap, both he and his mother assert that all of these interactions help him feel less anxious.

FCBT USING THE BUILDING CONFIDENCE PROGRAM

The case study illustrates a typical pre-sentation of a child with separation anxiety disorder.¹⁰ Commonly, as in Ben’s case, sexual abuse is screened for and ruled out; nonetheless, the intrusive interactions in question are developmentally inappropriate. In Ben’s case, the interactions appeared to be unintentionally reinforcing to his mother, since she indicated that she enjoyed being able to “be there for him and comfort him.”

Paradoxically, such comforting seems to support Ben’s separation anxiety rather than eradicate it. He feels dependent on his mother’s comforting for the regulation of his anxiety, and when he is away from her he finds it challenging to cope with the anxiety he experiences. Child psychiatrists and psychologists do not always screen for these kinds of intrusive parenting behaviors and, therefore, may be unaware of the role such behaviors play in the maintenance of anxiety disorders in children.

Skills training and focus on autonomy-granting

The first 4 sessions of FCBT focus on teaching core CBT skills, such as positive self-talk, and core parenting skills that can facilitate a child’s independence and self-confidence. Ben was exceptionally motivated, thrived on praise from his therapist, and made rapid progress in learning CBT skills. Coping skills that were emphasized included challenging Ben’s worries about his mother’s safety (eg, “My mom has never been in a car accident before, how likely would it be?”). However, Ben’s separation anxiety symptoms were slow to remit early in treatment. A major focus of parent training was increasing parentgranted autonomy and reducing intrusiveness. In talking with Ben’s mother, it was noted that children feel more confident when they do things for themselves that others have previously done for them and that this confidence can lead to courageous behavior.

Like many parents, Ben’s mother seemed to be caught between agreement (“He is very clingy,” she would acknowledge) and doubt (“He is only 11; can’t he still be a little boy?”). She emphasized that Ben’s clingy behaviors were not burdensome to her. To address her ambivalence, several techniques were employed:

• Empathizing with her desire to keep Ben close to her.
• Warning her that without him becoming a bit more independent, Ben’s maladaptive anxiety-related behaviors were likely to get worse.
• Offering a plan of action that emphasized gradual changes in parent-child interaction.

Parent communication skills, such as giving choices, as described above, were taught to Ben’s mother to support his development of autonomous behaviors. (Note that all parent-training activities in FCBT are directly related to 1 of 2 goals: altering the targeted parent-child interaction patterns or enhancing the child’s application/practice of CBT skills.)

Initial steps in increasing autonomygranting and reducing intrusiveness were selected by Ben, who noted that showering on his own and dressing himself would not be a problem as long as his mother was somewhere in the house. In a family meeting, Ben presented this to his mother and a plan was made to try it out. At the following session, Ben was praised for his followthrough. The therapist assessed the progress of these independent skills during each session, and Ben would flash an enormous smile, proudly affirming his mastery of the self-help tasks. Hair-brushing was added to the list, and when his mother could not tolerate his “lack of skill,” she simply gave him a shorter haircut that was largely maintenance- free-an excellent solution that supported Ben’s autonomy.

Ben’s mother-while not undermining these changes-did express sadness about his emerging independence. This reaction was normalized by the therapist (“All parents feel this way as their children become more mature”). Frequent reminders of the treatment rationale, and particularly the important role parents play in children’s anxiety reduction (by supporting their autonomy), were helpful in maintaining the mother-therapist alliance, as well as the changes in family routines that had been achieved.

Skills application and practice with parent support

A key tenet of FCBT is that early increases in parent-granted autonomy and independent child behaviors in sessions 1 through 4 pave the way for (a) increased self-confidence in the child, which facilitates the child’s engagement in facing feared situations in sessions 5 through 16 and (b) parental adoption of communication techniques (eg, giving choices) that enhance the effectiveness of the application and practice phase of CBT.

Ben’s first task in the application/practice phase was returning to school, and the timing of this coincided closely with his upsurge in self-confidence following the independent behavior sessions. Typical CBT techniques for addressing school refusal were employed,¹³ and Ben stayed at school for longer and longer periods each day. Though predictably nervous, he tried his hardest, focused on challenging his fearful thoughts about his mother’s safety, and successfully ignored his anxious feelings (which were labeled “false alarms”). Incentives offered by his mother (eg, earning television time) also helped promote his adherence to the school-return plan.

Ben returned to school full time by session 10, evidencing habituation and a humorous “blas” attitude about his success. It is worth additional emphasis that the rapidity and ease with which full school return was accomplished was facilitated by Ben’s early self-confidence in the independent skills exercises and by his mother’s use of parenting skills to support his autonomy, both of which are FCBT-specific strategies.

Reducing cosleeping-a key goal in separation anxiety treatment-proved to be a formidable challenge. Ben agreed in principle by session 8 to sleep in his own bed on a nightly basis, but his mother was noncommittal. Ben’s anxiety was moderately high about sleeping independently even after the many successes he had achieved by midtreatment. Without his complete investment in this task, and with his mother’s reticence about changing their routine, treatment progress plateaued for several sessions (Ben’s mother said they had simply forgotten to have him sleep by himself).

Two shifts in the therapist’s approach proved critical. First, to increase the mother’s motivation, it was noted to her that full remission of separation anxiety rarely occurs unless children sleep on their own (which is true, in our clinical experience) and that excessive anxiety could ultimately interfere with Ben’s social and intellectual development. Second, to increase Ben’s motivation, a checklist was made of a number of highly feared tasks that when completed would lead to what he considered a large reward (a video his mother agreed to purchase for him). This checklist included Ben sleeping independently for 4 weeks in a row, inviting children from school over at least 4 times, and joining an after-school activity (choices were given).

Of course, Ben was given help in applying CBT skills in preparation for these activities. It was thought that by appealing to both Ben and his mother, chances for success would be doubled compared with relying on the solitary (and wavering) motivation of either of them alone.

This multifaceted approach proved effective. Ben’s mother was sufficiently persuaded by the therapist’s logic to permit a trial of the sleeping plan, while Ben was quite invested in his checklist incentive program and began sleeping independently. Within 2 weeks, Ben’s ratings on a 0-to-10 anxiety scale indicated that he felt no anxiety when sleeping by himself (again, reflecting habituation to a feared-but benign- situation). Simultaneously, he initiated playdates with a neighborhood boy that soon became reciprocal, and joined an after-school music program that he enjoyed. Ben’s mother was pleased with these accomplishments and began to praise the therapy program, including its emphasis on Ben’s independence. She voiced no further reservations about the new sleeping arrangements.

While still exhibiting a shy, eagerto- please disposition, Ben had no core anxiety disorder symptoms by session 16 when he was interviewed by an independent evaluator (using a structured diagnostic interview). Treatment gains were maintained at a 1-year follow-up interview

FINDINGS FROM A RECENT CLINICAL TRIAL

In a recent clinical trial, the Building Confidence FCBT program was compared with traditional CCBT with minimal family involvement.³Forty children with anxiety disorders (aged 6 through 13 years) were randomly assigned to FCBT or CCBT. Anxiety disorders (separation anxiety disorder, social phobia, and/or generalized anxiety disorder) were confirmed by an independent evaluator using a structured diagnostic interview. The 2 treatment conditions were matched for therapist contact time (12 to16 therapy sessions lasting 60 to 80 minutes each). Outcome measures included independent evaluators’ diagnoses, severity ratings for each diagnosis on the Clinician’s Rating Scale,¹⁴ and improvement ratings on the Clinical Global Impressions (CGI) scale; child-reports on the Multidimensional Anxiety Scale for Children (MASC)¹⁵; and parent reports on the MASC.

Overall, results favored FCBT over CCBT, highlights included:

• 79% of children in FCBT met CGI criteria for good treatment response, compared with only 26% of children in CCBT.
• Children in FCBT had greater improvement on independent evaluators’ ratings on the Clinician’s Rating Scale than children in CCBT.
• Parent reports of child anxiety on the MASC-but not children’s selfreports- were lower in FCBT than CCBT at posttreatment.

Although both treatment groups showed statistically significant improvement on all outcome measures, FCBT provided additional benefit over and above CCBT on most indices of improvement.

It should be noted that FCBT appears to be equally effective for children with primary diagnoses of separation anxiety disorder, social phobia, and generalized anxiety disorder. Although the case study presented above illustrates how FCBT can address separation anxiety, parental involvement is also beneficial for the treatment of the other 2 primary child anxiety disorder diagnoses. For example, parental intrusiveness is often seen in cases of children with social anxiety. Parents may offer excessive comfort when children are fearful in social situations and take over social tasks (eg, by speaking for their children) that children could handle independently. Variations of the FCBT techniques described above have proved helpful in addressing such family interaction patterns.

CONCLUSION

FCBT involves a complex interplay of cognitive-behavioral techniques and family restructuring, drawing on the combined (and sometimes complementary) resources and motivations of children and their parents. While CCBT is quite effective by itself, FCBT can lead to even greater improvements in anxiety, at least in the short term.³ Therefore, it may be beneficial for clinicians to assess for parental intrusive-ness and autonomy-granting in cases of school-aged children with anxiety disorder and consider the use of a structured FCBT protocol that explicitly addresses such family dynamics when they are present.

Disclosures:

Dr Wood is an assistant professor of psychological studies in education in the department of education at the University of California, Los Angeles. His research focuses on the psychopathology of childhood anxiety, with an emphasis on randomized, controlled trials of cognitive- behavioral therapy interventions. The writing of this paper was supported, in part, by a grant from NIMH awarded to Dr Wood (MH075806). He reports that he has no conflicts of interest with the subject matter of this article.

References:

1. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342.
2. Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consut Clin Psychol. 1998;66:893-905.
3. Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006; 45:314-321.
4. Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol. 1994;62:100-110.
5. Silverman WK. Using CBT in the treatment of social phobia, separation anxiety and GAD. Psychiatr Times. September 2003; Vol 20.
6. Nauta MH, Scholing A, Emmelkamp PM, Minderaa RB. Cognitive-behavioral therapy for children with anxiety disorders in a clinical setting: no additional effect of a cognitive parent training. J Am Acad Child Adolesc Psychiatry. 2003;42:1270-1278.
7. Spence SH, Donovan C, Brechman-Toussaint M. The treatment of childhood social phobia: the effectiveness of a social skills training-based, cognitivebehavioural intervention, with and without parental involvement. J Child Psychol Psychiatry. 2000;41: 713-726.
8. Hudson JL, Rapee RM. Parent-child interactions and anxiety disorders: an observational study. Behav Res Ther. 2001;39:1411-1427.
9. Rapee RM. The development of generalized anxiety. In:Vasey MW, Dadds MR, eds. The Developmental Psychopathology of Anxiety. New York: Oxford University Press; 2001.
10. Wood JJ. Parental intrusiveness and children’s separation anxiety in a clinical sample. Child Psychiatry Hum Dev. In press.
11. Fox NA, Henderson HA, Marshall PJ, et al. Behavioral inhibition: linking biology and behavior within a developmental framework. Annu Rev Psychol. 2005;56:235-262.
12. Chorpita BF, Barlow DH. The development of anxiety: the role of control in the early environment. Psychol Bull. 1998;124:3-21.
13. Kearney CA, Hugelshofer DS. Systemic and clinical strategies for preventing school refusal behavior in youth. J Cog Psychother. 2000;14:51-65.
14. Silverman WK, Albano AM. The Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions. San Antonio, TX: Graywind; 1996.
15. March JS, Parker JD, Sullivan K, et al. The Multidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry. 1997;36:554-565.

Evidence-based References

Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342.
Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006;45:314-321