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Family Cognitive Behavioral Therapy for Children and Adolescents With Clinical Anxiety Disorders
Family Cognitive Behavioral Therapy for Children and Adolescents With Clinical Anxiety Disorders ¨ GELS, PH.D. SUSAN M. BO
AND
LYNNE SIQUELAND, PH.D.
ABSTRACT Objective: A family cognitive-behavioral therapy for children and adolescents ages 8 to 18 years with clinical anxiety disorders was developed and evaluated. Method: Seventeen families were measured before and after waitlist, after treatment, and at 3-month and 1-year follow-up. Results: No children changed their diagnostic status during waitlist, whereas of the treated children, 41% were free of their primary anxiety disorder posttest, 57% at 3-month follow-up, and 71% at 1-year follow-up. Effect sizes of improvement were large for childrenÕs fears, dysfunctional beliefs, and interpretations of ambiguous situations and medium for childrenÕs internalizing and externalizing symptoms. Interestingly, fathers but not mothers reported less anxiety themselves after treatment. Large improvements were observed on parentsÕ dysfunctional beliefs about their childÕs anxiety and their role as a parent. Finally, some improvements occurred in family and rearing variables. Conclusions: Family cognitive-behavioral therapy seems effective for clinically anxious children and their families. J. Am. Acad. Child Adolesc. Psychiatry, 2006;45(2):134–141. Key Words: family treatment, anxiety disorders in youths, overprotection.
Anxiety disorders run in families; an overlap of up to 80% between parental and child anxiety disorders (ADs) has been reported (Ginsburg and Schlossberg, 2002). In addition to genetic factors, ‘‘anxiety-enhancing’’ parenting seems to contribute to this co-occurrence of parental and child anxiety (Rapee, 1997). Two factors of anxiety-enhancing behavior characterize such parenting: an overprotective or controlling rearing style versus encouraging childrenÕs autonomy and a critical or rejecting versus a warm or accepting rearing style (Hudson
Accepted September 20, 2005. Dr. Bo¨gels is with the Department of Medical, Experimental and Abnormal Psychology, University of Maastricht, Maastricht, The Netherlands; and Dr. Siqueland is with the ChildrenÕs Center for OCD and Anxiety, University of Pennsylvania, Philadelphia. This study was supported by ZonNW, grant number 945-02-052. The authors thank Lucienne Beckers, Bert Hoogstad, Peter Muris, Bertien Paanakkers, Ardy Quadackers, and Eugene Wijnands for treating and Miryam Weckx and Marion van Melick for assessing the families. The authors are grateful to Paula Barrett for her input in the treatment manual. Correspondence to Dr. Bo¨gels, Department of Medical, Clinical and Experimental Psychology, University of Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands; e-mail: [email protected]. 0890-8567/06/4502–01342006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000190467.01072.ee
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and Rapee, 2001; Siqueland et al., 1996; Whaley et al., 1999). A longitudinal study by Lieb et al. (2000) demonstrated that such parental behavior indeed maintains child AD. Overprotective and critical parenting can directly result from parental AD or be caused by childrenÕs AD. To illustrate the latter pathway, dependent child behavior evokes controlling parenting (Osofsky and OÕConnell, 1972). Both child and parental anxiety contribute to parental overprotection and criticism (Bo¨gels and van Melick, 2004; Whaley et al., 1999). Not only parentsÕ current anxiety but also parentsÕ own childhood experiences may play a role in their current overprotective and critical rearing. Parents of children with AD report more overprotection and rejection by their parents compared with parents of clinical control children (Bo¨gels et al., in press). Few studies have investigated general family functioning in families with AD. Families of children with AD are found to be less sociable, more enmeshed, more disengaged, and more conflictual and have more marital problems (for a review, see Bo¨gels and BrechmanToussaint, in press). Cognitive-behavioral therapy (CBT) is ineffective in 20% to 50% of the children with AD, possibly because of family factors (Ginsburg and Schlossberg, 2002).
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Two studies indeed demonstrated that the effects of CBT are enhanced by involving parents (Barrett et al., 1996), especially if parents are anxious (Cobham et al., 1998). Most studies did not demonstrate superior effects for a parental component (Barrett, 1998; Mendlowitz et al., 1999; Nauta et al., 2001, 2003; Spence et al., 2000), however, and the superiority of the family management CBT of Barrett et al. (1996) disappeared at 12-month follow-up (Barrett et al., 2001). Studies may have underestimated the impact of a parental component in the following six ways. First, in the studies of Barrett et al. (1996) and Cobham et al. (1998), children were recruited through advertisements or families traveled to a university anxiety clinic. Results may not generalize to community mental health care, in which children are referred to specialty care, most often after other care failed. These families may have more severe psychopathology, child-rearing problems, and family dysfunction, and therefore, the parental component needs to be more intense. Second, the studies of Barrett (1998), Spence et al. (2000), and Mendlowitz et al. (1999) were conducted in groups in which interventions can hardly be tailored to specific family issues. Individual family CBT may be more effective because treatment can be adapted to the specific needs of the family (Ginsburg and Schlossberg, 2002). Third, most studies did not include older adolescents for whom the parental component may be more essential because of their developmental need to move away from the family, but need a different focus—more on granting of autonomy and expressing differences in opinion (Siqueland and Diamond, 1998). Fourth, results of family CBT have been studied primarily with respect to child variables and not so much with respect to family variables, such as dysfunctional parental thinking, rearing, family functioning, and parental psychopathology. With respect to family variables, family CBT may be superior. Fifth, the number of individual child sessions in the family condition of the mentioned studies was large (8–12). A family CBT with more focus on working primarily with and through parents, according to a ‘‘transfer of control’’ model (Ginsburg et al., 1995), modifying dysfunctional parental beliefs that impede treatment progress (Siqueland and Diamond, 1998) will have greater impact. Finally, siblings have not participated, aside from case studies by Howard and Kendall (1996). Involving siblings may increase the impact of the family component.
The present study evaluated a family CBT for youths ages 8 to 17 with ADs in a specialty care setting. An individual-format family therapy was developed in which the most time was spent with parents, parents and anxious child together, and the whole family, rather than with the anxious child individually. We hypothesized that family CBT would (1) decrease child anxiety; (2) decrease child dysfunctional thinking but also (3) decrease parental anxiety, (4) decrease parental dysfunctional beliefs, (5) decrease anxiety-enhancing parenting, and (6) improve family functioning.
METHOD Participants Children (n = 24) who were referred to specialty community child mental health care in Maastricht and met inclusion criteria were approached for participation. Inclusion criteria were a primary AD other than obsessive-compulsive or posttraumatic stress disorder, IQ >80, at least one parent willing to participate, and no current suicidal threat. Of the 24 families approached, 7 (29%) did not participate; the reasons given were refusing research (1 family), child refused family involvement (1 family), parents did not want CBT (1 family), complaints disappeared (1 family), and other psychiatric diagnoses became primary (3 families). Seventeen children participated, 9 boys and 8 girls, all white, with a mean age of 12.7 years (SD = 2.1; range 8–17). The average duration of their AD was 6.1 years (SD = 4.6; range 1–13). Their primary ADs were social phobia (6 children), separation anxiety disorder (5 children), generalized anxiety disorder (4 children), simple phobias (1 child), AD not otherwise specified (1 child). Fourteen (82%) had comorbid diagnoses: simple phobias (5 children), social phobia (3 children), generalized anxiety disorder (3 children), panic disorder and agoraphobia (3 children), separation anxiety disorder (1 child), affective disorder (3 children), parent–child relationship problem (5 children), identity problem (1 child), attention-deficit/ hyperactivity disorder (1 child), and oppositional defiant disorder (1 child). Nine children had a history of (unsuccessful) treatment for anxiety; eight of them received some form of psychotherapy, and one received medication. Six children came from divorced families. Eight children were in elementary school, and nine children in secondary school (two at the lowest level, three average, two above average, and two at the highest level of secondary education; this average does not have a U.S. equivalent). The mean age of the fathers was 44.3 (SD = 6.1) and of the mothers 42.8 (SD = 5.1) years. Parental education, measured on a scale from 1 (elementary education) to 8 (university education), was 3.5 (SD = 2.2; range 1–7) for fathers and 3.8 (SD = 1.8; range 1–7) for mothers, indicating average educational level. On DSM-IV axis IV, 14 families had primary support group problems, 4 had social problems, 3 had educational problems, and 1 had working problems. Procedure and Design Trained clinicians assessed for DSM-IV axis I diagnoses (using child and parent reports from separate interviews) with the Kids
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Semi-structured Clinical Interview for DSM-IV diagnoses (KSCID; Hien et al., 1997), which possesses good interrater reliability (Matzner et al., 1997). Informed consent was obtained. Then, a natural waitlist assessment took place for those families who had to wait for treatment because there was no therapist available yet (n = 13; mean waiting time, 73.5 days; SD = 40.2; range 16–167). After the waitlist, a second assessment (pretest) took place. After 3 months of treatment, families were reassessed (posttest), followed by a 3-month period without additional treatment. Then, a followup assessment took place, after which therapists informed families about the results and discussed possible further treatment (if needed). One year after posttest, another follow-up assessment was completed.
Assessments Psychopathology of the Child. At every measurement occasion, the diagnostic status of the children was evaluated by a trained research assistant (clinical psychologist), based on one (KSCID) interview with both parents and one with the child. The child and both parents completed the Screen for Child Anxiety Related Emotional Disorders (Birmaher et al., 1999), measuring panic, generalized, separation, and social anxiety. This screening tool is a reliable and valid questionnaire (Muris et al., 2004). Both parents completed the Child Behavior Checklist (CBCL; Achenbach and Edelbroek, 1983) concerning their childÕs internalizing and externalizing psychopathology. Externalizing symptoms were assessed because parents of clinically anxious children often complain about their oppositional behavior. Before pretest, the therapist listed, with the help of child and parents, the five situations that the child fears and/or avoids most and that are important treatment targets (e.g., ‘‘picking up the telephone’’). Child and both parents rated each target on fear and avoidance (0–10). Dysfunctional Beliefs of the Child. The child listened to three audiotaped stories concerning ambiguous events (one social, one separation, one generalized anxiety) at pretest. At posttest, three other stories were used. The stories were randomly selected from nine validated stories (Bo¨gels and Zigterman, 2000) and were systematically varied across pretest-posttest. After each story, children expressed (1) all of the thoughts that went through their minds and (2) what they would do. Two trained psychologists, blinded for pretest-posttest, rated all of the responses. Thoughts were rated according to valence (positive, negative, neutral [Bo¨gels and Zigterman, 2000]) and actions as ‘‘coping,’’ ‘‘neutral,’’ ‘‘avoidant,’’ and ‘‘aggressive’’ (Barrett et al., 1996). Interrater reliability (k) was high: 0.80 for thought valence and 0.80 for action type. The number of positive thoughts divided by the number of positive plus negative thoughts across the three stories, averaged across raters, indicated the balance of positive versus negative thinking. Second, the number of coping actions divided by the total number of avoidant plus coping actions (aggressive actions were not given by the children) across stories, averaged across raters, was calculated. Therapists listed with the children alone their five main dysfunctional beliefs related to their fears, in an ‘‘if, then’’ format (e.g., ‘‘if I ask a question in class, then everybody will laugh’’). The five target situations were the starting point for collecting dysfunctional beliefs, but because one situation can trigger different beliefs and the same belief can be triggered by different situations, the goal was to formulate five beliefs that differ in content and together cover the different fears. The formulated beliefs were checked in supervision. Children rated each belief on level of conviction (0–10).
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Dysfunctional Parental Beliefs. The therapist formulated with each parent five main dysfunctional beliefs concerning the anxiety of their child and their parental role (e.g., ‘‘if my child is anxious, I should take over’’). Parents rated their own as well as their partnerÕs beliefs on conviction (0–10). Parental Psychopathology. Parents filled in the Adult Self Report (Ferdinand et al., 1995), a 110-item questionnaire, based on the CBCL, measuring ‘‘internalizing’’ (social withdrawal, somatic complaints, and anxiety/depression) and ‘‘externalizing’’ (delinquent and aggressive behavior) symptoms. Test-retest and internal reliability are satisfactory, respectively, 0.89 and 0.84 (Ferdinand et al., 1995), and the discriminant validity is good (Wiznitzer et al., 1992). Parents also completed the Fear Questionnaire (FQ; Marks and Mathews, 1979). The FQ measures adult social phobia, agoraphobia, and blood/injury fear and possesses established reliability and validity. Parental Rearing. Parental rearing was measured by the scales Acceptance and Psychological Control of the Child Rearing Parental Behavior Inventory (Siqueland et al., 1996) and by the Egna Minnen Betraffande Uppfostran-Child (Muris and Merckelbach, 1998), measuring warmth, rejection, overprotection, and anxious rearing. Children and both parents rated the 60 items. Family Functioning. Children and both parents completed the Family Functioning Scale (Bloom, 1985). The scale consists of 15 factors and contains three dimensions. The first is the relationship dimension, defined as the extent to which family members feel that they belong to and are proud of their family, there is open expression, and conflictual interactions are not characteristic of the family. It consists of the factors cohesion, expressiveness, conflict, family sociability, and disengagement. The second dimension, system maintenance, yields information about the structure and organization within the family and the degree of dysfunctional control exerted by family members. It consists of organization, external locus of control, enmeshment, democratic, laissez-faire, and authoritarian family style. The last dimension, personal growth, consists of two factors that we did not include because they did not measure areas of possible change in the present treatment (religious and intellectual-cultural orientation) and active-recreational orientation. Because active-recreational orientation correlated highly with the relationship dimension (r = 0.76, p < .001), we added this scale to that dimension. Father’s Participation, Dropouts, and Missing Values We tried to have both parents participate. All biological fathers, including those of split-up families who had no contact with their child, were approached. Three of the six divorced fathers participated. Stepfathers (n = 2) participated in treatment, but not in the assessment. All fathers of the intact families participated in the treatment and assessment, however, one father refused to complete the questionnaires after treatment. Four of the 17 families dropped out during treatment because of rapid improvement (n = 2), medical hospitalization (n = 1), and child neglect (n = 1). Because half of the dropouts were actually success dropouts, a last-assessment-carried-forward approach, assuming no change, could not be applied for the three dropouts who refused to complete further questionnaires. Therefore, questionnaire results are reported only for the 13 families who completed treatment. Results on the KSCID of all dropouts, however, were obtained and therefore reported as ‘‘intent-to-treat’’ analysis. At 1-year followup, two families failed to complete the questionnaires, but their diagnostic status was measured through a telephone KSCID. Because these two families had completed treatment, their questionnaire
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results were estimated based on the change pattern of the completer sample applied to their individual change pattern so far. Data Analytic Approach. The number of dependent variables was reduced, first by combining the highly similar subscales acceptance and warmth (r = 0.82), and second by aggregating child ratings of both parentsÕ rearing behaviors, which are typically highly correlated (Bo¨gels and Melick, 2004). Using paired t tests, changes from waitlist to pretest and pretest to posttest, 3-month, and 1-year follow-up were analyzed. All p values were adjusted for type I errors using Bonferroni-Holm correction. Effect sizes of change (CohenÕs d) were calculated by the mean of the differences (post minus pre) divided by the SD of these differences. Effect sizes <0.4 are considered small, 0.4 to 0.8 as medium, and >0.8 as large. Treatment Based on the earlier work of Siqueland and Diamond (1998), Ginsburg et al. (1995), and Barrett et al. (1996), a family CBT was developed according to the following assumptions: (1) the child has a genetic predisposition for fear; (2) the childÕs fear is reinforced by parental anxiety, rearing, marital conflicts, and/or family dysfunction; and (3) parents coach their child in coping with fear. The treatment starts with a whole-family session (including all siblings), in which the therapist establishes contact with all family members and gathers their opinions on what caused the anxiety problem and what should be done. A systemic formulation of the problem is made. Finally, the treatment rationale is explained to the family. The subsequent treatment consists of three phases of each of the four sessions. In phase 1, CBT skills are taught to the anxious child and parents, that is, identification and challenging negative beliefs, exposure in vivo, and rewards (two sessions with parents and child, one with child alone). Furthermore, parents are encouraged to use CBT skills to guide their anxious child and to cope with their own fears and to do ‘‘courageous modeling’’ in one session with parents alone. In phase 2, dysfunctional beliefs between parents and child that may block the process of change are modified. Three sessions with the parents alone focus on parental beliefs about their anxious child, parenting, and the safety of their childÕs world, often based on their own upbringing or anxiety. ChildrenÕs dysfunctional beliefs about communication with their parents are modified in one session with the child alone. In phase 3, communication and problem solving between the spouses about their childÕs anxiety (in one session with parents), and between all family members including siblings (in two sessions with the whole family) are improved. In the last session with parents and child, the treatment is evaluated and relapse prevention is rehearsed. Child and parents each receive a workbook. (The manual is available by request from the first author.)
Therapists Three male and three female child therapists, five clinical psychologists, and one social worker who were being educated for or registered as cognitive-behavioral therapist conducted the treatments of about three cases each, applying a detailed session-to-session protocol. The second author trained them in family CBT, and the first author supervised them weekly, checking protocol adherence. RESULTS Waitlist Change
No diagnostic changes occurred in the 17 children from pretest I to pretest II. For the 13 families who had waitlist assessments, no significant changes were observed in child psychopathology (Screen for Child Anxiety Related Emotional Disorders, CBCL), and parental psychopathology (Adult Self Report, FQ). Stability coefficients for these measures ranged from 0.40 to 0.94, mean r = 0.71. Child Diagnoses
Table 1 presents the number and percentages of children who were free of their first, second, and third disorder at posttest and follow-ups. Child Psychopathology
In Table 2, results concerning childrenÕs psychopathology and dysfunctional thinking are given. Significant reductions were obtained after treatment in children’s anxiety and internalizing symptoms. A significant decrease in fear and avoidance on children’s targets was observed. Children’s conviction of their dysfunctional beliefs decreased. Also, children interpreted ambiguous situations more positively and reported more coping actions. At both follow-ups, child improvement maintained or further improvement occurred. Moreover, children’s externalizing symptoms significantly reduced. Effect sizes of change were large for
TABLE 1 Number of Children No Longer Meeting Diagnostic Criteria, for Completers (n = 13) and the Full (‘‘Intent-to-Treat’’) Sample (n = 17) Posttest 3-Month Follow-up 12-Month Follow-up Free of Diagnosis
Completers
Intent-to-Treat
Completers
Intent-to-Treat
1st diagnosis 2nd diagnosis 3rd diagnosis
6/13 (46%) 4/9 (44%) 1/5 (20%)
7/17 (41%) 5/12 (42%) 2/7 (29%)
8/13 (62%) 7/9 (78%) 2/5 (40%)
10/17 (59%) 9/12 (75%) 3/7 (43%)
Completers 10/13 (78%) 7/9 (67%) 4/5 (80%)
Intent-to-Treat 12/17 (71%) 9/12 (75%) 5/7 (71%)
Note: First diagnosis is always an anxiety disorder, not all children have a second or third diagnosis.
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TABLE 2 Change in Child Psychopathology and Dysfunctional Thinking for Completers: Means (SDs), t Tests, and Effect Sizes (d ) Pre-post Pre-FU I Pre-FU II SCARED Child Father Mother CBCL-int. Father Mother CBCL-ext. Father Mother Targets Child Father Mother Therapist Ambiguous stories Pos/neg Coping/avoid. Dysf. beliefs
Pretest
Posttest
3-mo. Follow-up
12-mo. Follow-up
t
d
t
d
t
d
29.9 (10.7) 34.2 (16.7) 34.8 (16.9)
20.2 (14.3) 19.9 (12.7) 23.5 (10.4)
21.3 (12.0) 19.2 (15.4) 22.1 (8.6)
18.6 (9.4) 14.9 (11.2) 17.9 (9.9)
2.1* 3.8* 4.1*
0.6 1.2 1.1
2.2* 4.0* 3.3*
0.6 1.3 0.9
4.3* 4.3* 4.5*
1.2 1.5 1.2
62.9 (14.4) 68.8 (11.9)
59.4 (13.4) 61.4 (10.6)
59.1 (14.2) 60.2 (11.9)
55.4 (9.0) 58.7 (10.2)
1.6 3.7*
.5 1.0
0.9 4.6*
0.3 1.3
2.1* 6.2*
0.6 1.0
52.6 (7.8) 52.7 (9.5)
49.0 (8.7) 51.5 (10.5)
48.6 (10.2) 49.4 (9.3)
46.0 (10.2) 49.0 (9.6)
2.1* 0.7
0.7 0.2
2.6* 2.5*
0.8 0.7
3.9* 1.9*
1.2 0.5
14.8 13.7 14.8 15.5
9.9 10.2 9.9 9.1
3.5* 1.7 3.4* 5.7*
1.0 0.5 1.0 1.6
3.6* 3.2* 4.2* 4.1*
1.0 1.0 1.2 1.1
5.4* 3.3* 5.5* 7.0*
1.5 1.2 1.6 2.0
–2.6* –2.7* 3.5*
0.7 0.7 0.9
4.5*
1.3
4.7*
1.3
(2.9) (3.4) (3.5) (3.0)
0.27 (0.25) 0.74 (0.21) 56.5 (25.8)
(5.5) (6.1) (5.5) (4.0)
0.53 (0.32) 0.88 (0.15) 33.3 (26.1)
9.5 7.5 9.1 8.6
(5.8) (5.5) (4.6) (4.4)
23.4 (22.4)
7.9 6.3 7.9 7.3
(5.7) (4.1) (4.6) (3.2)
20.6 (17.8)
Notes: df = 12 for mother and child and 9 for father, * p < .05, one-tailed, Bonferroni-Holm corrected.
anxiety and dysfunctional thinking measures. Concerning the interpretation of follow-up II, note that three children (18%) received additional treatment: antidepressants (n = 1), and CBT (n = 2). Parental Psychopathology
Immediately after treatment, no significant improvement on parental psychopathology and dysfunctional thinking was observed (Table 3). Note that fathersÕ FQ at pretest is significantly elevated compared with normal Dutch fathers (FQ mean of normal fathers, mean [SD], 15.2 [12.3], n = 65, t 73 = 2.1, p < .05), but mothersÕ FQ is not elevated (mean of normal mothers 21.3 [11.7], n = 65, t 76 = 1.4, not significant [Bo¨gels and van Hoorn, submitted]). FathersÕ improvements on anxiety became significant at follow-up assessments. Moreover, at follow-up, both parents reported medium to large d improvement on internalizing symptoms, and mothers also reported large d improvement on externalizing symptoms. Both parentsÕ dysfunctional thinking concerning their childÕs anxiety and their role as parents significantly reduced at follow-up, with large d measures. Because 1-year follow-up questionnaire results were estimated for two families, these analyses were repeated excluding these two families. Results were similar.
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Family Functioning and Rearing
Table 4 presents results on family functioning and rearing. With respect to family functioning, children and fathers reported medium d improvement on systemic control, and children also on relationships, of large d. Mothers report no family functioning improvement. Regarding parental rearing, children perceived no changes; however, mothers reported applying less overprotection and psychological control and fathers reported less anxious rearing, of medium to large d. Moreover, fathers reported less rejection, of large d. After Bonferroni-Holm correction, none of these improvements reached significance. DISCUSSION
Family CBT was associated with reduced child and parental anxiety, reduced dysfunctional child and parental beliefs, and improved parental rearing and family functioning. Our percentage of intent-to-treat children without AD at posttest (41%) was somewhat low, but increased steadily (59% at 3-month follow-up and 71% at 1-year follow-up) and is in the range of other treatment outcome studies on child anxiety (56% in the
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TABLE 3 Change in Parents’ Psychopathology and Dysfunctional Thinking for Completers: Means (SDs), t Tests, and Effect Sizes (d ) Pre-post Pre-FU I Pre-FU II Fear questionnaire Father Mother ASR-internalizing Father Mother ASR-externalizing Father Mother Dysfunctional beliefs Father Mother
Pretest
Posttest
3-mo. Follow-up
12-mo. Follow-up
t
d
t
d
t
d
24.2 (15.3) 26.3 (13.7)
19.3 (12.5) 26.4 (12.6)
18.2 (16.1) 26.8 (13.7)
20.1 (16.4) 23.8 (13.4)
2.4 –0.1
0.8 0.0
3.2* –0.3
1.0 –0.1
2.7* 1.7
1.0 0.5
9.7 (8.2) 12.5 (8.7)
8.3 (7.5) 12.0 (8.7)
7.6 (6.6) 9.8 (7.3)
6.0 (5.4) 9.6 (6.2)
2.1 0.4
0.7 0.1
1.9 3.4*
0.6 1.0
3.1* 2.2
1.0 0.6
5.4 (3.8) 6.2 (4.2)
6.0 (2.5) 5.8 (5.1)
5.6 (4.1) 4.1 (3.7)
5.0 (2.9) 3.6 (3.4)
–0.7 0.3
0.2 0.1
–0.1 0.6
.4 3.1*
0.1 0.8
63.3 (20.6) 55.3 (16.8)
42.3 (29.3) 41.0 (16.4)
38.5 (23.5) 34.9 (17.9)
31.3 (20.7) 22.6 (16.0)
2.8 2.5
0.9 0.7
1.3 1.1
4.7* 6.5*
1.5 1.9
–0.2 2.2 4.1* 4.1*
Note: Df = 12 for mothers and 9 for fathers, * p < 0.05, one-tailed, Bonferroni-Holm corrected.
meta-analysis of Cartwright-Hatton et al. [2004], note that their percentage concerned completers). Moreover, our children, being referred to specialty care, are probably more severely disturbed than those in studies using advertisement-recruited children (e.g., Barrett et al., 1996), and therefore more likely to still meet AD criteria after treatment, despite large improvement. The magnitude of improvement is demonstrated by large effect sizes for the child anxiety measures, which are comparable to the effect size of child anxiety CBT based on another meta-analysis (0.9; In-Albon and Schneider, 2003). Moreover, childrenÕs high comorbidity rates may have contributed to slower improvement. Because our rationale was that change through the parents and family will lead to a better outcome in time, long-term follow-up is particularly important. Our 12-month follow-up shows that families continue to improve, which holds for child and parental psychopathology. Given the large overlap between child and parental AD in clinical populations, effects of family versus child CBT should be evaluated not only on child outcome but also on improvement of other family members. Despite the little time that therapists spent with children to challenge negative thoughts (one session), childrenÕs cognitive improvement was impressive (d = 1.3). The success of family CBT in changing child cognitions may result from parents coaching their child in challenging dysfunctional thoughts, also after treatment was completed. Therefore, family CBT seems to succeed in empowering and educating parents to facilitate the necessary changes in their anxious child. Because
cognitive changes mediate treatment gain in anxious children (Treadwell and Kendall, 1996), the large cognitive gain is encouraging. Family CBT was also successful in changing parental dysfunctional beliefs concerning their childÕs anxiety and their own role (d = 1.5 for fathers and 1.9 for mothers). It is assumed that such parental beliefs impede child treatment progress (Siqueland and Diamond, 1998). How important change in parental thinking is for child outcome remains to be investigated. The finding that only fathers and not mothers improved on self-reported fear was unexpected. Note, however, that fathers but not mothers had elevated fear. Therefore, it may be that only fathers needed to change. Because both fathers and mothers genetically contribute to child anxiety, the fact that only fathers had elevated fear requires an explanation. First, mothers may have not wanted to ‘‘admit’’ their own fear because of the pervasive tendency to blame mothers for causing maladjustment in children while ignoring fathers (Phares and Compas, 1992). As such, mothers may have underreported their own fears. Second, children of anxious fathers may be more at risk of anxiety. Especially as children grow older, fathers function as models for transactions outside the family (Shulman and Klein, 1993). Therefore, fathers may be crucial in helping adolescents conquer their fear of the outside world. Consistent with this explanation, in childhood, mothersÕ psychopathology is related more to childrenÕs psychopathology, whereas in adolescence, fathersÕ psychopathology is related more to that of children (Connell and Goodman,
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TABLE 4 Change in Family Functioning and Parental Rearing for Completers: Means (SDs), t Tests, and Effect Sizes (d ) Pretest Posttest t d Family functioning Relationship Child Father Mother System maintenance Child Father Mother Parental rearing Anxious rearing Child Father Mother Overprotection Child Father Mother Psychological control Child Father Mother Acceptance/warmth Child Father Mother Rejection Child Father Mother
81.8 (13.4) 84.3 (11.1) 84.9 (11.9)
85.8 (12.6) 83.4 (8.1) 84.4 (10.8)
–3.2 0.4 0.3
0.9 –0.1 0.0
62.0 (6.4) 63.1 (6.6) 60.5 (6.4)
59.5 (7.3) 61.1 (6.2) 59.8 (7.3)
1.5 2.3 0.5
0.4 0.7 0.2
Limitations 19.2 (4.0) 20.8 (7.0) 21.2 (3.1)
19.3 (4.3) 17.8 (6.7) 20.5 (4.8)
–0.2 2.9 0.8
0.0 0.9 0.2
18.8 (3.7) 21.8 (2.0) 22.8 (2.5)
19.2 (2.5) 20.5 (3.2) 20.6 (2.6)
–0.5 1.6 2.8
–0.1 0.5 0.8
15.0 (3.4) 15.5 (3.8) 16.3 (2.7)
14.2 (4.3) 14.8 (4.0) 14.7 (3.8)
0.9 0.6 2.0
0.3 0.2 0.6
60.0 (7.8) 57.7 (11.2) 65.5 (6.4)
58.4 (6.3) 59.0 (11.0) 66.8 (7.2)
0.9 –0.7 –0.7
–0.2 0.2 0.2
12.4 (1.9) 14.6 (2.6) 14.2 (2.3)
12.5 (2.6) 12.5 (2.2) 14.2 (2.5)
–0.3 2.6 –0.1
0.1 0.8 0.0
Note: df = 12 for child and mother and 9 for father report.
2002). Because the majority of our children entered adolescence, this may explain the higher paternal anxiety. Indeed, this is one of the few studies that includes fathers and speaks to the importance of a fatherÕs role. Consistent with treatment goals, both parents reported somewhat less overprotective rearing and fathers somewhat less rejection after treatment. Next to the direct effect of family treatment on parenting, a decrease in such parental attitudes may indirectly result from a reduction in the parentsÕ own anxiety. To illustrate this, parental anxiety makes parents more irritable toward their child (Ficker et al., 2002). Alternatively, change in parental rearing results from decreases in child anxiety. Parents ultimately respond to their childÕs chronic anxiety with anxiety, rejection, and control. Children
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do not report any improvement on parental rearing scales, but they do report improvement in family functioning, especially with respect to family relationships. It may be that this child-perceived improvement in family functioning reflects changes in parental rearing behavior on child perceptions. Little is known about differences between childrenÕs and parentsÕ perspective on parental rearing and family functioning, but agreement between parent reports and child reports is low (Tein et al., 1994). Therefore, it seems helpful to include both child and parental perspectives.
This study has several limitations. First, the power is low because of the small sample size. Second, family functioning, parental rearing, and parental psychopathology were solely measured with self-report. Parents and children may have been unaware of or defensive about ‘‘admitting’’ family problems. Third, siblings were not assessed. Fourth, changes in parental psychopathology, rearing, and family functioning may as well be observed after individual CBT because a successfully treated child may affect the whole family (‘‘treatment spill-over,’’ as described by Kendall and FlannerySchroeder, 1998). Finally, no simultaneous control treatment was evaluated other than natural waitlist. Taken together, future research should compare the effects of family versus child CBT for youths with clinical AD, including the child, parents, and siblings as informants, and relying on perceived as well as objective measures. Clinical Implications
This study has various clinical implications. First, fathers can and should be included in treatment, even after parents divorce. Second, family CBT seems a good alternative for child CBT in a clinical context. Third, the further improvement of families after treatment (e.g., 32% became free of their first anxiety disorder between posttest and 1-year follow-up) supports our clinical impression that ending family treatment after a limited number of sessions is important, even if there is little improvement. The ideal treatment length of family CBT for childhood anxiety disorders remains to be investigated. Disclosure: The authors have no financial relationships to disclose.
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REFERENCES Achenbach T, Edelbroek C (1983), Manual for the Child Behavior Checklist and Revised Child Profile. Burlington: University of Vermont, Department of Psychiatry Barrett P (1998), Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol 27:459–468 Barrett P, Dadds M, Rapee R (1996), Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol 64:333–342 Barrett P, Duffy A, Dadds M, Rapee R (2001), Cognitive-behavioural treatment of anxiety disorders in children: long-term (6 years) follow-up. J Consult Clin Psychol 69:135–141 Birmaher B, Brent D, Chiappetta L, Bridge J, Monga S, Baugher M (1999), Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. J Am Acad Child Adolesc Psychiatry 38:1230–1236 Bloom B (1985), A factor analysis of self-report measures of family functioning. Fam Process 24:225–239 Bo¨gels S, Brechman-Toussaint M (in press), Family issues in child anxiety: attachment, parental rearing, family functioning, and beliefs. Clin Psychol Rev Bo¨gels S, Hoogsteder A, van Ree C (submitted), Intergenerational attachment: a comparison of anxious, depressed, and oppositional children with clinical and normal control children Bo¨gels S, van Melick M (2004), The relationship between child-report, parent self-report, and partner report of perceived parental rearing behaviours and anxiety in children and parents. Pers Ind Diff 37:1583–1596 Bo¨gels S, Zigterman D (2000), Dysfunctional cognitions in children with social phobia, separation anxiety disorder, and generalized anxiety disorder. J Abnorm Child Psychol 28:205–211 Cartwright-Hatton S, Roberts C, Chitsabesan P, Fothergill C, Harrington R (2004), Systematic review of the efficacy of cognitive-behavioural therapies for children and adolescents with anxiety disorders. Br J Clin Psychol 43:421–436 Cobham V, Dadds M, Spence S (1998), The role of parental anxiety in the treatment of childhood anxiety. J Consult Clin Psychol 66:893–905 Connell A, Goodman S (2002), The association between psychopathology in fathers versus mothers and childrenÕs internalizing and externalizing behavior problems: a meta-analysis. Psychol Bull 128:746–773 Ferdinand R, Verhulst F, Witznizer M (1995), Continuity and change of self-reported problem behaviors from adolescence into young adulthood. J Am Acad Child Adolesc Psychiatry 34:680–690 Ficker C, Schneider S, Nu¨ndel B, Wolke D (2002), Interaction between mothers with panic and their children. Presented at the Congress of the European Association of Behaviour and Cognitive Therapies, Maastricht, September 18–21 Ginsburg G, Schlossberg M (2002), Family-based treatment of childhood anxiety disorders. Int Rev Psychiatry 14:143–154 Ginsburg G, Silverman W, Kurtines W (1995), Family involvement in treating children with phobic and anxiety disorders: a look ahead. Clin Psychol Rev 15:457–473 Hien D, Matzner F, First M, Spitzer R, Williams J, Gibbon M (1997), Structured Clinical Interview for DSM-IV Childhood Diagnoses. New York: Columbia University Press Howard B, Kendall P (1996), Cognitive-behavioural family therapy for anxiety disordered children: a multiple-baseline evaluation. Cogn Ther Res 2:423–443 Hudson J, Rapee R (2001), Parent-child interactions and anxiety disorders: an observational study. Behav Res Ther 39:1411–1427 In-Albon T, Schneider S (2003), Treatment of childhood anxiety disorders: a meta-analysis. Presented at the Congress of the European Association of Behaviour and Cognitive Therapies, Prague, September 10–13
Kendall P, Flannery-Schroeder E (1998), Methodological issues in treatment research for anxiety disorders in youth. J Abnorm Child Psychol 26:27–38 Lieb R, Wittchen H, Hofler M, Fuetsch M, Stein M, Merikangas R (2000), Parental psychopathology, parenting styles, and the risk of social phobia in offspring: a prospective-longitudinal community study. Arch Gen Psychiatry 57:859–865 Marks I, Mathews A (1979), Brief standard self-rating for phobic patients. Behav Res Ther 2:59–68 Matzner F, Silva R, Silvan M, Chowdhury M, Nastasi L (1997), Preliminary test-retest reliability of the KID-SCID. Paper presented at the Annual Meeting of the American Psychiatric Association, San Diego, May 17–22 Mendlowitz S, Manassis K, Bradley S, Scapillato D, Miezitis S, Shaw B (1999), Cognitive-behavioral group treatments in childhood anxiety disorders: the role of parental involvement. J Am Acad Child Adolesc Psychiatry 38:1223–1229 Muris P, Dreessen L, Bo¨gels S, Weckx M, van Melick M (2004), A questionnaire for screening a broad range of DSM-defined anxiety disorders in clinically referred children and adolescents. J Child Psychol Psychiatry 45:813–820 Muris P, Merckelbach H (1998), Perceived parental rearing behaviour and anxiety disorders symptoms in normal children. Pers Ind Diff 25: 1199–1206 Nauta M, Scholing A, Emmelkamp P, Minderaa R (2001), Cognitive-behavioural therapy for anxiety disordered children in a clinical setting: does additional cognitive parent training enhance treatment effectiveness? Clin Psychol Psychother 8:330–340 Nauta M, Scholing A, Emmelkamp P, Minderaa R (2003), Cognitivebehavioral therapy for children with anxiety disorders in a clinical setting: no additional effect of a cognitive parent training. J Am Acad Child Adolesc Psychiatry 42:1270–1278 Osofsky J, OÕConnell E (1972), Parent-child interaction: daughtersÕ effects upon mothersÕ and fathersÕ behaviors. Dev Psychol 7:157–168 Phares V, Compas B (1992), The role of fathers in child and adolescent psychopathology: make room for daddy. Psychol Bull 111:387–412 Rapee R (1997), Potential role of childrearing practices in the development of anxiety and depression. Clin Psychol Rev 17:47–67 Shulman S, Klein M (1993), Distinctive role of father in adolescent separation-individuation. In: Father-Adolescent Relationships: New Directions for Child Development, Shulman S, Collins A, eds. San Francisco: JosseyBass/Pfeiffer, pp 41–57 Siqueland L, Diamond G (1998), Engaging parents in cognitive behavioral treatment for children with anxiety disorders. Cogn Behav Pract 5:81– 102 Siqueland L, Kendall P, Steinberg L (1996), Anxiety in children: perceived family environments and observed family interaction. J Clin Child Psychol 25:225–237 Spence SH, Donavan C, Brechman-Toussaint M (2000), The treatment of childhood social phobia: the effectiveness of a social skills training-based cognitive-behavioural intervention with and without parental involvement. J Child Psychol Psychiatry 41:713–726 Treadwell K, Kendall P (1996), Self-statements in youth with anxiety disorders: states of mind, content specificity and relationship to outcome. J Consult Clin Psychol 64:941–950 Tein J, Roosa M, Michaels M (1994), Agreement between parent and child reports on parental behaviors. J Marriage Fam 56:341–355 Whaley S, Pinto A, Sigman M (1999), Characterizing interactions between anxious mothers and their children. J Consult Clin Psychol 67:826–836 Wiznitzer M, Verhulst F, Van den Brink W, et al. (1992), Detecting psychopathology in young adults. A comparison of the Young Adult Self Report, the General Health Questionnaire and the Symptom Checklist as screening instruments. Acta Physiol Scand 86:32–37
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AND
LYNNE SIQUELAND, PH.D.
ABSTRACT Objective: A family cognitive-behavioral therapy for children and adolescents ages 8 to 18 years with clinical anxiety disorders was developed and evaluated. Method: Seventeen families were measured before and after waitlist, after treatment, and at 3-month and 1-year follow-up. Results: No children changed their diagnostic status during waitlist, whereas of the treated children, 41% were free of their primary anxiety disorder posttest, 57% at 3-month follow-up, and 71% at 1-year follow-up. Effect sizes of improvement were large for childrenÕs fears, dysfunctional beliefs, and interpretations of ambiguous situations and medium for childrenÕs internalizing and externalizing symptoms. Interestingly, fathers but not mothers reported less anxiety themselves after treatment. Large improvements were observed on parentsÕ dysfunctional beliefs about their childÕs anxiety and their role as a parent. Finally, some improvements occurred in family and rearing variables. Conclusions: Family cognitive-behavioral therapy seems effective for clinically anxious children and their families. J. Am. Acad. Child Adolesc. Psychiatry, 2006;45(2):134–141. Key Words: family treatment, anxiety disorders in youths, overprotection.
Anxiety disorders run in families; an overlap of up to 80% between parental and child anxiety disorders (ADs) has been reported (Ginsburg and Schlossberg, 2002). In addition to genetic factors, ‘‘anxiety-enhancing’’ parenting seems to contribute to this co-occurrence of parental and child anxiety (Rapee, 1997). Two factors of anxiety-enhancing behavior characterize such parenting: an overprotective or controlling rearing style versus encouraging childrenÕs autonomy and a critical or rejecting versus a warm or accepting rearing style (Hudson
Accepted September 20, 2005. Dr. Bo¨gels is with the Department of Medical, Experimental and Abnormal Psychology, University of Maastricht, Maastricht, The Netherlands; and Dr. Siqueland is with the ChildrenÕs Center for OCD and Anxiety, University of Pennsylvania, Philadelphia. This study was supported by ZonNW, grant number 945-02-052. The authors thank Lucienne Beckers, Bert Hoogstad, Peter Muris, Bertien Paanakkers, Ardy Quadackers, and Eugene Wijnands for treating and Miryam Weckx and Marion van Melick for assessing the families. The authors are grateful to Paula Barrett for her input in the treatment manual. Correspondence to Dr. Bo¨gels, Department of Medical, Clinical and Experimental Psychology, University of Maastricht, PO Box 616, 6200 MD Maastricht, The Netherlands; e-mail: [email protected]. 0890-8567/06/4502–01342006 by the American Academy of Child and Adolescent Psychiatry. DOI: 10.1097/01.chi.0000190467.01072.ee
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and Rapee, 2001; Siqueland et al., 1996; Whaley et al., 1999). A longitudinal study by Lieb et al. (2000) demonstrated that such parental behavior indeed maintains child AD. Overprotective and critical parenting can directly result from parental AD or be caused by childrenÕs AD. To illustrate the latter pathway, dependent child behavior evokes controlling parenting (Osofsky and OÕConnell, 1972). Both child and parental anxiety contribute to parental overprotection and criticism (Bo¨gels and van Melick, 2004; Whaley et al., 1999). Not only parentsÕ current anxiety but also parentsÕ own childhood experiences may play a role in their current overprotective and critical rearing. Parents of children with AD report more overprotection and rejection by their parents compared with parents of clinical control children (Bo¨gels et al., in press). Few studies have investigated general family functioning in families with AD. Families of children with AD are found to be less sociable, more enmeshed, more disengaged, and more conflictual and have more marital problems (for a review, see Bo¨gels and BrechmanToussaint, in press). Cognitive-behavioral therapy (CBT) is ineffective in 20% to 50% of the children with AD, possibly because of family factors (Ginsburg and Schlossberg, 2002).
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Two studies indeed demonstrated that the effects of CBT are enhanced by involving parents (Barrett et al., 1996), especially if parents are anxious (Cobham et al., 1998). Most studies did not demonstrate superior effects for a parental component (Barrett, 1998; Mendlowitz et al., 1999; Nauta et al., 2001, 2003; Spence et al., 2000), however, and the superiority of the family management CBT of Barrett et al. (1996) disappeared at 12-month follow-up (Barrett et al., 2001). Studies may have underestimated the impact of a parental component in the following six ways. First, in the studies of Barrett et al. (1996) and Cobham et al. (1998), children were recruited through advertisements or families traveled to a university anxiety clinic. Results may not generalize to community mental health care, in which children are referred to specialty care, most often after other care failed. These families may have more severe psychopathology, child-rearing problems, and family dysfunction, and therefore, the parental component needs to be more intense. Second, the studies of Barrett (1998), Spence et al. (2000), and Mendlowitz et al. (1999) were conducted in groups in which interventions can hardly be tailored to specific family issues. Individual family CBT may be more effective because treatment can be adapted to the specific needs of the family (Ginsburg and Schlossberg, 2002). Third, most studies did not include older adolescents for whom the parental component may be more essential because of their developmental need to move away from the family, but need a different focus—more on granting of autonomy and expressing differences in opinion (Siqueland and Diamond, 1998). Fourth, results of family CBT have been studied primarily with respect to child variables and not so much with respect to family variables, such as dysfunctional parental thinking, rearing, family functioning, and parental psychopathology. With respect to family variables, family CBT may be superior. Fifth, the number of individual child sessions in the family condition of the mentioned studies was large (8–12). A family CBT with more focus on working primarily with and through parents, according to a ‘‘transfer of control’’ model (Ginsburg et al., 1995), modifying dysfunctional parental beliefs that impede treatment progress (Siqueland and Diamond, 1998) will have greater impact. Finally, siblings have not participated, aside from case studies by Howard and Kendall (1996). Involving siblings may increase the impact of the family component.
The present study evaluated a family CBT for youths ages 8 to 17 with ADs in a specialty care setting. An individual-format family therapy was developed in which the most time was spent with parents, parents and anxious child together, and the whole family, rather than with the anxious child individually. We hypothesized that family CBT would (1) decrease child anxiety; (2) decrease child dysfunctional thinking but also (3) decrease parental anxiety, (4) decrease parental dysfunctional beliefs, (5) decrease anxiety-enhancing parenting, and (6) improve family functioning.
METHOD Participants Children (n = 24) who were referred to specialty community child mental health care in Maastricht and met inclusion criteria were approached for participation. Inclusion criteria were a primary AD other than obsessive-compulsive or posttraumatic stress disorder, IQ >80, at least one parent willing to participate, and no current suicidal threat. Of the 24 families approached, 7 (29%) did not participate; the reasons given were refusing research (1 family), child refused family involvement (1 family), parents did not want CBT (1 family), complaints disappeared (1 family), and other psychiatric diagnoses became primary (3 families). Seventeen children participated, 9 boys and 8 girls, all white, with a mean age of 12.7 years (SD = 2.1; range 8–17). The average duration of their AD was 6.1 years (SD = 4.6; range 1–13). Their primary ADs were social phobia (6 children), separation anxiety disorder (5 children), generalized anxiety disorder (4 children), simple phobias (1 child), AD not otherwise specified (1 child). Fourteen (82%) had comorbid diagnoses: simple phobias (5 children), social phobia (3 children), generalized anxiety disorder (3 children), panic disorder and agoraphobia (3 children), separation anxiety disorder (1 child), affective disorder (3 children), parent–child relationship problem (5 children), identity problem (1 child), attention-deficit/ hyperactivity disorder (1 child), and oppositional defiant disorder (1 child). Nine children had a history of (unsuccessful) treatment for anxiety; eight of them received some form of psychotherapy, and one received medication. Six children came from divorced families. Eight children were in elementary school, and nine children in secondary school (two at the lowest level, three average, two above average, and two at the highest level of secondary education; this average does not have a U.S. equivalent). The mean age of the fathers was 44.3 (SD = 6.1) and of the mothers 42.8 (SD = 5.1) years. Parental education, measured on a scale from 1 (elementary education) to 8 (university education), was 3.5 (SD = 2.2; range 1–7) for fathers and 3.8 (SD = 1.8; range 1–7) for mothers, indicating average educational level. On DSM-IV axis IV, 14 families had primary support group problems, 4 had social problems, 3 had educational problems, and 1 had working problems. Procedure and Design Trained clinicians assessed for DSM-IV axis I diagnoses (using child and parent reports from separate interviews) with the Kids
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Semi-structured Clinical Interview for DSM-IV diagnoses (KSCID; Hien et al., 1997), which possesses good interrater reliability (Matzner et al., 1997). Informed consent was obtained. Then, a natural waitlist assessment took place for those families who had to wait for treatment because there was no therapist available yet (n = 13; mean waiting time, 73.5 days; SD = 40.2; range 16–167). After the waitlist, a second assessment (pretest) took place. After 3 months of treatment, families were reassessed (posttest), followed by a 3-month period without additional treatment. Then, a followup assessment took place, after which therapists informed families about the results and discussed possible further treatment (if needed). One year after posttest, another follow-up assessment was completed.
Assessments Psychopathology of the Child. At every measurement occasion, the diagnostic status of the children was evaluated by a trained research assistant (clinical psychologist), based on one (KSCID) interview with both parents and one with the child. The child and both parents completed the Screen for Child Anxiety Related Emotional Disorders (Birmaher et al., 1999), measuring panic, generalized, separation, and social anxiety. This screening tool is a reliable and valid questionnaire (Muris et al., 2004). Both parents completed the Child Behavior Checklist (CBCL; Achenbach and Edelbroek, 1983) concerning their childÕs internalizing and externalizing psychopathology. Externalizing symptoms were assessed because parents of clinically anxious children often complain about their oppositional behavior. Before pretest, the therapist listed, with the help of child and parents, the five situations that the child fears and/or avoids most and that are important treatment targets (e.g., ‘‘picking up the telephone’’). Child and both parents rated each target on fear and avoidance (0–10). Dysfunctional Beliefs of the Child. The child listened to three audiotaped stories concerning ambiguous events (one social, one separation, one generalized anxiety) at pretest. At posttest, three other stories were used. The stories were randomly selected from nine validated stories (Bo¨gels and Zigterman, 2000) and were systematically varied across pretest-posttest. After each story, children expressed (1) all of the thoughts that went through their minds and (2) what they would do. Two trained psychologists, blinded for pretest-posttest, rated all of the responses. Thoughts were rated according to valence (positive, negative, neutral [Bo¨gels and Zigterman, 2000]) and actions as ‘‘coping,’’ ‘‘neutral,’’ ‘‘avoidant,’’ and ‘‘aggressive’’ (Barrett et al., 1996). Interrater reliability (k) was high: 0.80 for thought valence and 0.80 for action type. The number of positive thoughts divided by the number of positive plus negative thoughts across the three stories, averaged across raters, indicated the balance of positive versus negative thinking. Second, the number of coping actions divided by the total number of avoidant plus coping actions (aggressive actions were not given by the children) across stories, averaged across raters, was calculated. Therapists listed with the children alone their five main dysfunctional beliefs related to their fears, in an ‘‘if, then’’ format (e.g., ‘‘if I ask a question in class, then everybody will laugh’’). The five target situations were the starting point for collecting dysfunctional beliefs, but because one situation can trigger different beliefs and the same belief can be triggered by different situations, the goal was to formulate five beliefs that differ in content and together cover the different fears. The formulated beliefs were checked in supervision. Children rated each belief on level of conviction (0–10).
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Dysfunctional Parental Beliefs. The therapist formulated with each parent five main dysfunctional beliefs concerning the anxiety of their child and their parental role (e.g., ‘‘if my child is anxious, I should take over’’). Parents rated their own as well as their partnerÕs beliefs on conviction (0–10). Parental Psychopathology. Parents filled in the Adult Self Report (Ferdinand et al., 1995), a 110-item questionnaire, based on the CBCL, measuring ‘‘internalizing’’ (social withdrawal, somatic complaints, and anxiety/depression) and ‘‘externalizing’’ (delinquent and aggressive behavior) symptoms. Test-retest and internal reliability are satisfactory, respectively, 0.89 and 0.84 (Ferdinand et al., 1995), and the discriminant validity is good (Wiznitzer et al., 1992). Parents also completed the Fear Questionnaire (FQ; Marks and Mathews, 1979). The FQ measures adult social phobia, agoraphobia, and blood/injury fear and possesses established reliability and validity. Parental Rearing. Parental rearing was measured by the scales Acceptance and Psychological Control of the Child Rearing Parental Behavior Inventory (Siqueland et al., 1996) and by the Egna Minnen Betraffande Uppfostran-Child (Muris and Merckelbach, 1998), measuring warmth, rejection, overprotection, and anxious rearing. Children and both parents rated the 60 items. Family Functioning. Children and both parents completed the Family Functioning Scale (Bloom, 1985). The scale consists of 15 factors and contains three dimensions. The first is the relationship dimension, defined as the extent to which family members feel that they belong to and are proud of their family, there is open expression, and conflictual interactions are not characteristic of the family. It consists of the factors cohesion, expressiveness, conflict, family sociability, and disengagement. The second dimension, system maintenance, yields information about the structure and organization within the family and the degree of dysfunctional control exerted by family members. It consists of organization, external locus of control, enmeshment, democratic, laissez-faire, and authoritarian family style. The last dimension, personal growth, consists of two factors that we did not include because they did not measure areas of possible change in the present treatment (religious and intellectual-cultural orientation) and active-recreational orientation. Because active-recreational orientation correlated highly with the relationship dimension (r = 0.76, p < .001), we added this scale to that dimension. Father’s Participation, Dropouts, and Missing Values We tried to have both parents participate. All biological fathers, including those of split-up families who had no contact with their child, were approached. Three of the six divorced fathers participated. Stepfathers (n = 2) participated in treatment, but not in the assessment. All fathers of the intact families participated in the treatment and assessment, however, one father refused to complete the questionnaires after treatment. Four of the 17 families dropped out during treatment because of rapid improvement (n = 2), medical hospitalization (n = 1), and child neglect (n = 1). Because half of the dropouts were actually success dropouts, a last-assessment-carried-forward approach, assuming no change, could not be applied for the three dropouts who refused to complete further questionnaires. Therefore, questionnaire results are reported only for the 13 families who completed treatment. Results on the KSCID of all dropouts, however, were obtained and therefore reported as ‘‘intent-to-treat’’ analysis. At 1-year followup, two families failed to complete the questionnaires, but their diagnostic status was measured through a telephone KSCID. Because these two families had completed treatment, their questionnaire
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FAM ILY CBT FOR AN XIOUS CH ILD REN
results were estimated based on the change pattern of the completer sample applied to their individual change pattern so far. Data Analytic Approach. The number of dependent variables was reduced, first by combining the highly similar subscales acceptance and warmth (r = 0.82), and second by aggregating child ratings of both parentsÕ rearing behaviors, which are typically highly correlated (Bo¨gels and Melick, 2004). Using paired t tests, changes from waitlist to pretest and pretest to posttest, 3-month, and 1-year follow-up were analyzed. All p values were adjusted for type I errors using Bonferroni-Holm correction. Effect sizes of change (CohenÕs d) were calculated by the mean of the differences (post minus pre) divided by the SD of these differences. Effect sizes <0.4 are considered small, 0.4 to 0.8 as medium, and >0.8 as large. Treatment Based on the earlier work of Siqueland and Diamond (1998), Ginsburg et al. (1995), and Barrett et al. (1996), a family CBT was developed according to the following assumptions: (1) the child has a genetic predisposition for fear; (2) the childÕs fear is reinforced by parental anxiety, rearing, marital conflicts, and/or family dysfunction; and (3) parents coach their child in coping with fear. The treatment starts with a whole-family session (including all siblings), in which the therapist establishes contact with all family members and gathers their opinions on what caused the anxiety problem and what should be done. A systemic formulation of the problem is made. Finally, the treatment rationale is explained to the family. The subsequent treatment consists of three phases of each of the four sessions. In phase 1, CBT skills are taught to the anxious child and parents, that is, identification and challenging negative beliefs, exposure in vivo, and rewards (two sessions with parents and child, one with child alone). Furthermore, parents are encouraged to use CBT skills to guide their anxious child and to cope with their own fears and to do ‘‘courageous modeling’’ in one session with parents alone. In phase 2, dysfunctional beliefs between parents and child that may block the process of change are modified. Three sessions with the parents alone focus on parental beliefs about their anxious child, parenting, and the safety of their childÕs world, often based on their own upbringing or anxiety. ChildrenÕs dysfunctional beliefs about communication with their parents are modified in one session with the child alone. In phase 3, communication and problem solving between the spouses about their childÕs anxiety (in one session with parents), and between all family members including siblings (in two sessions with the whole family) are improved. In the last session with parents and child, the treatment is evaluated and relapse prevention is rehearsed. Child and parents each receive a workbook. (The manual is available by request from the first author.)
Therapists Three male and three female child therapists, five clinical psychologists, and one social worker who were being educated for or registered as cognitive-behavioral therapist conducted the treatments of about three cases each, applying a detailed session-to-session protocol. The second author trained them in family CBT, and the first author supervised them weekly, checking protocol adherence. RESULTS Waitlist Change
No diagnostic changes occurred in the 17 children from pretest I to pretest II. For the 13 families who had waitlist assessments, no significant changes were observed in child psychopathology (Screen for Child Anxiety Related Emotional Disorders, CBCL), and parental psychopathology (Adult Self Report, FQ). Stability coefficients for these measures ranged from 0.40 to 0.94, mean r = 0.71. Child Diagnoses
Table 1 presents the number and percentages of children who were free of their first, second, and third disorder at posttest and follow-ups. Child Psychopathology
In Table 2, results concerning childrenÕs psychopathology and dysfunctional thinking are given. Significant reductions were obtained after treatment in children’s anxiety and internalizing symptoms. A significant decrease in fear and avoidance on children’s targets was observed. Children’s conviction of their dysfunctional beliefs decreased. Also, children interpreted ambiguous situations more positively and reported more coping actions. At both follow-ups, child improvement maintained or further improvement occurred. Moreover, children’s externalizing symptoms significantly reduced. Effect sizes of change were large for
TABLE 1 Number of Children No Longer Meeting Diagnostic Criteria, for Completers (n = 13) and the Full (‘‘Intent-to-Treat’’) Sample (n = 17) Posttest 3-Month Follow-up 12-Month Follow-up Free of Diagnosis
Completers
Intent-to-Treat
Completers
Intent-to-Treat
1st diagnosis 2nd diagnosis 3rd diagnosis
6/13 (46%) 4/9 (44%) 1/5 (20%)
7/17 (41%) 5/12 (42%) 2/7 (29%)
8/13 (62%) 7/9 (78%) 2/5 (40%)
10/17 (59%) 9/12 (75%) 3/7 (43%)
Completers 10/13 (78%) 7/9 (67%) 4/5 (80%)
Intent-to-Treat 12/17 (71%) 9/12 (75%) 5/7 (71%)
Note: First diagnosis is always an anxiety disorder, not all children have a second or third diagnosis.
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TABLE 2 Change in Child Psychopathology and Dysfunctional Thinking for Completers: Means (SDs), t Tests, and Effect Sizes (d ) Pre-post Pre-FU I Pre-FU II SCARED Child Father Mother CBCL-int. Father Mother CBCL-ext. Father Mother Targets Child Father Mother Therapist Ambiguous stories Pos/neg Coping/avoid. Dysf. beliefs
Pretest
Posttest
3-mo. Follow-up
12-mo. Follow-up
t
d
t
d
t
d
29.9 (10.7) 34.2 (16.7) 34.8 (16.9)
20.2 (14.3) 19.9 (12.7) 23.5 (10.4)
21.3 (12.0) 19.2 (15.4) 22.1 (8.6)
18.6 (9.4) 14.9 (11.2) 17.9 (9.9)
2.1* 3.8* 4.1*
0.6 1.2 1.1
2.2* 4.0* 3.3*
0.6 1.3 0.9
4.3* 4.3* 4.5*
1.2 1.5 1.2
62.9 (14.4) 68.8 (11.9)
59.4 (13.4) 61.4 (10.6)
59.1 (14.2) 60.2 (11.9)
55.4 (9.0) 58.7 (10.2)
1.6 3.7*
.5 1.0
0.9 4.6*
0.3 1.3
2.1* 6.2*
0.6 1.0
52.6 (7.8) 52.7 (9.5)
49.0 (8.7) 51.5 (10.5)
48.6 (10.2) 49.4 (9.3)
46.0 (10.2) 49.0 (9.6)
2.1* 0.7
0.7 0.2
2.6* 2.5*
0.8 0.7
3.9* 1.9*
1.2 0.5
14.8 13.7 14.8 15.5
9.9 10.2 9.9 9.1
3.5* 1.7 3.4* 5.7*
1.0 0.5 1.0 1.6
3.6* 3.2* 4.2* 4.1*
1.0 1.0 1.2 1.1
5.4* 3.3* 5.5* 7.0*
1.5 1.2 1.6 2.0
–2.6* –2.7* 3.5*
0.7 0.7 0.9
4.5*
1.3
4.7*
1.3
(2.9) (3.4) (3.5) (3.0)
0.27 (0.25) 0.74 (0.21) 56.5 (25.8)
(5.5) (6.1) (5.5) (4.0)
0.53 (0.32) 0.88 (0.15) 33.3 (26.1)
9.5 7.5 9.1 8.6
(5.8) (5.5) (4.6) (4.4)
23.4 (22.4)
7.9 6.3 7.9 7.3
(5.7) (4.1) (4.6) (3.2)
20.6 (17.8)
Notes: df = 12 for mother and child and 9 for father, * p < .05, one-tailed, Bonferroni-Holm corrected.
anxiety and dysfunctional thinking measures. Concerning the interpretation of follow-up II, note that three children (18%) received additional treatment: antidepressants (n = 1), and CBT (n = 2). Parental Psychopathology
Immediately after treatment, no significant improvement on parental psychopathology and dysfunctional thinking was observed (Table 3). Note that fathersÕ FQ at pretest is significantly elevated compared with normal Dutch fathers (FQ mean of normal fathers, mean [SD], 15.2 [12.3], n = 65, t 73 = 2.1, p < .05), but mothersÕ FQ is not elevated (mean of normal mothers 21.3 [11.7], n = 65, t 76 = 1.4, not significant [Bo¨gels and van Hoorn, submitted]). FathersÕ improvements on anxiety became significant at follow-up assessments. Moreover, at follow-up, both parents reported medium to large d improvement on internalizing symptoms, and mothers also reported large d improvement on externalizing symptoms. Both parentsÕ dysfunctional thinking concerning their childÕs anxiety and their role as parents significantly reduced at follow-up, with large d measures. Because 1-year follow-up questionnaire results were estimated for two families, these analyses were repeated excluding these two families. Results were similar.
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Family Functioning and Rearing
Table 4 presents results on family functioning and rearing. With respect to family functioning, children and fathers reported medium d improvement on systemic control, and children also on relationships, of large d. Mothers report no family functioning improvement. Regarding parental rearing, children perceived no changes; however, mothers reported applying less overprotection and psychological control and fathers reported less anxious rearing, of medium to large d. Moreover, fathers reported less rejection, of large d. After Bonferroni-Holm correction, none of these improvements reached significance. DISCUSSION
Family CBT was associated with reduced child and parental anxiety, reduced dysfunctional child and parental beliefs, and improved parental rearing and family functioning. Our percentage of intent-to-treat children without AD at posttest (41%) was somewhat low, but increased steadily (59% at 3-month follow-up and 71% at 1-year follow-up) and is in the range of other treatment outcome studies on child anxiety (56% in the
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TABLE 3 Change in Parents’ Psychopathology and Dysfunctional Thinking for Completers: Means (SDs), t Tests, and Effect Sizes (d ) Pre-post Pre-FU I Pre-FU II Fear questionnaire Father Mother ASR-internalizing Father Mother ASR-externalizing Father Mother Dysfunctional beliefs Father Mother
Pretest
Posttest
3-mo. Follow-up
12-mo. Follow-up
t
d
t
d
t
d
24.2 (15.3) 26.3 (13.7)
19.3 (12.5) 26.4 (12.6)
18.2 (16.1) 26.8 (13.7)
20.1 (16.4) 23.8 (13.4)
2.4 –0.1
0.8 0.0
3.2* –0.3
1.0 –0.1
2.7* 1.7
1.0 0.5
9.7 (8.2) 12.5 (8.7)
8.3 (7.5) 12.0 (8.7)
7.6 (6.6) 9.8 (7.3)
6.0 (5.4) 9.6 (6.2)
2.1 0.4
0.7 0.1
1.9 3.4*
0.6 1.0
3.1* 2.2
1.0 0.6
5.4 (3.8) 6.2 (4.2)
6.0 (2.5) 5.8 (5.1)
5.6 (4.1) 4.1 (3.7)
5.0 (2.9) 3.6 (3.4)
–0.7 0.3
0.2 0.1
–0.1 0.6
.4 3.1*
0.1 0.8
63.3 (20.6) 55.3 (16.8)
42.3 (29.3) 41.0 (16.4)
38.5 (23.5) 34.9 (17.9)
31.3 (20.7) 22.6 (16.0)
2.8 2.5
0.9 0.7
1.3 1.1
4.7* 6.5*
1.5 1.9
–0.2 2.2 4.1* 4.1*
Note: Df = 12 for mothers and 9 for fathers, * p < 0.05, one-tailed, Bonferroni-Holm corrected.
meta-analysis of Cartwright-Hatton et al. [2004], note that their percentage concerned completers). Moreover, our children, being referred to specialty care, are probably more severely disturbed than those in studies using advertisement-recruited children (e.g., Barrett et al., 1996), and therefore more likely to still meet AD criteria after treatment, despite large improvement. The magnitude of improvement is demonstrated by large effect sizes for the child anxiety measures, which are comparable to the effect size of child anxiety CBT based on another meta-analysis (0.9; In-Albon and Schneider, 2003). Moreover, childrenÕs high comorbidity rates may have contributed to slower improvement. Because our rationale was that change through the parents and family will lead to a better outcome in time, long-term follow-up is particularly important. Our 12-month follow-up shows that families continue to improve, which holds for child and parental psychopathology. Given the large overlap between child and parental AD in clinical populations, effects of family versus child CBT should be evaluated not only on child outcome but also on improvement of other family members. Despite the little time that therapists spent with children to challenge negative thoughts (one session), childrenÕs cognitive improvement was impressive (d = 1.3). The success of family CBT in changing child cognitions may result from parents coaching their child in challenging dysfunctional thoughts, also after treatment was completed. Therefore, family CBT seems to succeed in empowering and educating parents to facilitate the necessary changes in their anxious child. Because
cognitive changes mediate treatment gain in anxious children (Treadwell and Kendall, 1996), the large cognitive gain is encouraging. Family CBT was also successful in changing parental dysfunctional beliefs concerning their childÕs anxiety and their own role (d = 1.5 for fathers and 1.9 for mothers). It is assumed that such parental beliefs impede child treatment progress (Siqueland and Diamond, 1998). How important change in parental thinking is for child outcome remains to be investigated. The finding that only fathers and not mothers improved on self-reported fear was unexpected. Note, however, that fathers but not mothers had elevated fear. Therefore, it may be that only fathers needed to change. Because both fathers and mothers genetically contribute to child anxiety, the fact that only fathers had elevated fear requires an explanation. First, mothers may have not wanted to ‘‘admit’’ their own fear because of the pervasive tendency to blame mothers for causing maladjustment in children while ignoring fathers (Phares and Compas, 1992). As such, mothers may have underreported their own fears. Second, children of anxious fathers may be more at risk of anxiety. Especially as children grow older, fathers function as models for transactions outside the family (Shulman and Klein, 1993). Therefore, fathers may be crucial in helping adolescents conquer their fear of the outside world. Consistent with this explanation, in childhood, mothersÕ psychopathology is related more to childrenÕs psychopathology, whereas in adolescence, fathersÕ psychopathology is related more to that of children (Connell and Goodman,
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TABLE 4 Change in Family Functioning and Parental Rearing for Completers: Means (SDs), t Tests, and Effect Sizes (d ) Pretest Posttest t d Family functioning Relationship Child Father Mother System maintenance Child Father Mother Parental rearing Anxious rearing Child Father Mother Overprotection Child Father Mother Psychological control Child Father Mother Acceptance/warmth Child Father Mother Rejection Child Father Mother
81.8 (13.4) 84.3 (11.1) 84.9 (11.9)
85.8 (12.6) 83.4 (8.1) 84.4 (10.8)
–3.2 0.4 0.3
0.9 –0.1 0.0
62.0 (6.4) 63.1 (6.6) 60.5 (6.4)
59.5 (7.3) 61.1 (6.2) 59.8 (7.3)
1.5 2.3 0.5
0.4 0.7 0.2
Limitations 19.2 (4.0) 20.8 (7.0) 21.2 (3.1)
19.3 (4.3) 17.8 (6.7) 20.5 (4.8)
–0.2 2.9 0.8
0.0 0.9 0.2
18.8 (3.7) 21.8 (2.0) 22.8 (2.5)
19.2 (2.5) 20.5 (3.2) 20.6 (2.6)
–0.5 1.6 2.8
–0.1 0.5 0.8
15.0 (3.4) 15.5 (3.8) 16.3 (2.7)
14.2 (4.3) 14.8 (4.0) 14.7 (3.8)
0.9 0.6 2.0
0.3 0.2 0.6
60.0 (7.8) 57.7 (11.2) 65.5 (6.4)
58.4 (6.3) 59.0 (11.0) 66.8 (7.2)
0.9 –0.7 –0.7
–0.2 0.2 0.2
12.4 (1.9) 14.6 (2.6) 14.2 (2.3)
12.5 (2.6) 12.5 (2.2) 14.2 (2.5)
–0.3 2.6 –0.1
0.1 0.8 0.0
Note: df = 12 for child and mother and 9 for father report.
2002). Because the majority of our children entered adolescence, this may explain the higher paternal anxiety. Indeed, this is one of the few studies that includes fathers and speaks to the importance of a fatherÕs role. Consistent with treatment goals, both parents reported somewhat less overprotective rearing and fathers somewhat less rejection after treatment. Next to the direct effect of family treatment on parenting, a decrease in such parental attitudes may indirectly result from a reduction in the parentsÕ own anxiety. To illustrate this, parental anxiety makes parents more irritable toward their child (Ficker et al., 2002). Alternatively, change in parental rearing results from decreases in child anxiety. Parents ultimately respond to their childÕs chronic anxiety with anxiety, rejection, and control. Children
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do not report any improvement on parental rearing scales, but they do report improvement in family functioning, especially with respect to family relationships. It may be that this child-perceived improvement in family functioning reflects changes in parental rearing behavior on child perceptions. Little is known about differences between childrenÕs and parentsÕ perspective on parental rearing and family functioning, but agreement between parent reports and child reports is low (Tein et al., 1994). Therefore, it seems helpful to include both child and parental perspectives.
This study has several limitations. First, the power is low because of the small sample size. Second, family functioning, parental rearing, and parental psychopathology were solely measured with self-report. Parents and children may have been unaware of or defensive about ‘‘admitting’’ family problems. Third, siblings were not assessed. Fourth, changes in parental psychopathology, rearing, and family functioning may as well be observed after individual CBT because a successfully treated child may affect the whole family (‘‘treatment spill-over,’’ as described by Kendall and FlannerySchroeder, 1998). Finally, no simultaneous control treatment was evaluated other than natural waitlist. Taken together, future research should compare the effects of family versus child CBT for youths with clinical AD, including the child, parents, and siblings as informants, and relying on perceived as well as objective measures. Clinical Implications
This study has various clinical implications. First, fathers can and should be included in treatment, even after parents divorce. Second, family CBT seems a good alternative for child CBT in a clinical context. Third, the further improvement of families after treatment (e.g., 32% became free of their first anxiety disorder between posttest and 1-year follow-up) supports our clinical impression that ending family treatment after a limited number of sessions is important, even if there is little improvement. The ideal treatment length of family CBT for childhood anxiety disorders remains to be investigated. Disclosure: The authors have no financial relationships to disclose.
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