Cognitive behavioral and attachment based family therapy for anxious adolescents: Phase I and II studies

Anxiety Disorders 19 (2005) 361–381

Cognitive behavioral and attachment based family therapy for anxious adolescents: Phase I and II studies Lynne Siquelanda,*, Moira Rynnb, Guy S. Diamondc a

Center for Psychotherapy Research, Department of Psychiatry, Children’s Center for OCD and Anxiety, Philadelphia, PA, USA b Mood and Anxiety Disorders Section, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA c Center for Family Intervention Science, Children’s Hospital of Philadelphia, Department of Psychiatry, University of Pennsylvania, Philadelphia, PA, USA Received 6 November 2003; received in revised form 26 March 2004; accepted 20 April 2004

Abstract The goals of these two studies were to assess the acceptability and feasibility as well as to gather preliminary efficacy data on a modified combination cognitive behavioral (CBT) and attachment based family therapy (ABFT) for adolescents (ages 12–18), with the primary diagnosis of generalized (GAD), social phobia (SP), and separation (SAD) anxiety disorders. In Phase I, CBT was modified for an adolescent population and ABFT was modified for working with anxious adolescents in combination with CBT. Therapists were trained for both conditions and eight patients were treated as an open trial pilot of combined CBT-ABFT with positive results. In Phase II, 11 adolescents were randomly assigned to CBT alone or CBT and family based treatment (CBT-ABFT). Participants were evaluated at pre, post, and 6–9 months follow-up assessing diagnosis, psychiatric symptoms and family functioning. Results indicated significant decreases in anxiety and depressive symptoms by both clinical evaluator and self-reports with no significant differences by treatment. Sixtyseven percent of adolescents in CBT no longer met criteria for their primary diagnosis at post treatment as compared to 40% in CBT-ABFT with continued improvement of 100 and 80% at follow-up with no significant differences between treatments. Both CBT and CBT-

* Corresponding author. Present address: Mood and Anxiety Disorders Section, 3535 Market Street, Suite 670, Philadelphia, PA 19104, USA. Tel.: þ1 215 898 4301. E-mail address: [email protected] (L. Siqueland).

0887-6185/$ – see front matter # 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.janxdis.2004.04.006

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ABFT appear to be promising treatments for anxious adolescents and more treatment development and evaluation is needed. # 2004 Elsevier Inc. All rights reserved. Keywords: Anxiety; Adolescents; Cognitive behavior therapy; Family based treatment

1. Introduction Anxiety disorders are among the most common diagnoses reported in childhood and adolescent epidemiological studies (Costello, 1989; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; McGee, Feehan, Williams, & Partridge, 1990). Many children with anxiety disorders struggle with low self-esteem, social isolation and inadequate social skills, impairment in academic work, and physical problems (e.g., headaches and stomachaches) (Dweck & Wortman, 1982; Livingston, Taylor, & Crawford, 1988; Strauss, 1988). In addition, there is growing evidence that anxiety disorders and symptoms persist over time (Beidel, Fink, & Turner, 1996; Cantwell & Baker, 1989; Keller et al., 1992; Last, Perrin, Hersen, & Kazdin, 1996). Fortunately, a number of well-controlled clinical trials have demonstrated that 10–16 weeks CBT treatments combined with in vivo exposure significantly reduce anxiety in 50–80% of treated children with generalized anxiety disorder, separation anxiety or social phobia (Barrett, Dadds, Rapee, & Ryan 1996a; Cobham, Dadds, & Spence, 1998; Kendall, 1994; Kendall et al., 1997; Last, Hansen, & Franco, 1998; Silverman et al., 1999a; Silverman et al., 1999b). However, since 20–50% of children in CBT treatment remain symptomatic after treatment, it is clear that psychosocial treatments could be improved. The last few years have also shown promising developments in pharmacological treatments for anxious adolescents (e.g., Pediatric Psychopharmacology Anxiety Study Group, 2001; Rynn, Siqueland, & Rickels, 2001; Birmaher et al., 2003), but more studies are needed before this approach can be considered first line treatment. There is limited to no information about the long term outcome and effect of psychopharmacological treatment. Research on family factors has suggested that particular family characteristics and interactional patterns may have a role in the development and/or maintenance of childhood anxiety. Children with anxiety disorders describe their family environments as more controlling, less cohesive and supportive, and more conflictual than children of control families (Stark, Humphrey, Crook, & Lewis, 1990; Stark, Humphrey, Laurent, Livingston, & Christopher, 1993). Parental overcontrol, defined as intrusive parenting or limiting of autonomy (e.g. McClure, Brennan, Hammen, & Le Brocque, 2001) and overprotection (e.g., Merikangas, Avenevoli, Dierker, & Grillon, 1999) were found to be positively related to child anxiety. These self-report findings have been corroborated in the few studies available that employed direct observation of family interaction (Dumas,

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LaFreniere, & Serketich, 1995; Krohne & Hock, 1991; Siqueland, Kendall, & Steinberg, 1996). Finally, observational studies have found that in many families of anxious children, there is modeling of anxious interpretation of ambiguous situations and encouragement or tolerance of avoidance behavior (Barrett, Rapee, Dadds, & Ryan, 1996b; Chorpita, Albano, & Barlow, 1996; Dadds, Barrett, Rapee, & Ryan, 1996). These findings suggest specific areas of family interactions to target or to utilize parent based approaches (for review, see Ginsburg & Schlossberg, 2002). A number of studies have shown that family based interventions seem to improve outcome on both anxiety and other externalizing symptoms, as well as overall functioning (Barrett, 1998; Barrett et al., 1996a). Barrett et al. (1996a) compared individual CBT treatment with CBT plus a behavioral family intervention for children ages 7–14. The combined family treatment included teaching parents: to reward coping behavior and to extinguish excessive anxious behavior, to manage their own anxiety with CBT techniques, and to develop new family communication and problem-solving skills. Both individual and group formats with the combination of CBT with family intervention showed advantages on anxiety diagnosis, family related measures, avoidant behavior, and generalization of parenting skills to other behavioral domains at post-treatment and follow-up (Barrett, 1998; Barrett et al., 1996a). However, in a separate study, Cobham et al. (1998) found that children (ages 7–14), whose parents did not have anxiety did equally well in the CBT treatment and the combined family treatment, while children whose parents did have anxiety did poorly in the child CBT treatment but did well in the combined treatment. The individual CBT and combined CBT and family based approaches reviewed above have focused thus far on middle childhood (7–14 years). We have little evidence of the efficacy of CBT treatment for anxious adolescents specifically in the age range of 14–17. Two small studies assessing group CBT approaches for socially anxious adolescents in the school setting have reported significant decreases in symptoms and diagnosis relative to wait list control (Hayward et al., 2000, Masia et al., 2001). None of the family treatment studies has included children over 14 years of age, and family based treatment was most effective with younger children and females (Barrett et al., 1996a). The family based model (ABFT) used in this study has a different emphasis than the Barrett et al. (1996a) model, which focuses on modeling and rewarding of anxious behavior and targeting parental anxiety. ABFT attempts to address additional aspects of family interaction that have been associated with childhood anxiety disorders reviewed above: parental beliefs about anxiety, overprotection, and psychological control. This family therapy model shares a similar theoretical foundation and structure to ABFT for depression (Diamond, Reis, Siqueland, Diamond, & Issac, 2002; Diamond, Siqueland, & Diamond, 2003) in terms of types of sessions and specific therapeutic goals and tasks to address the needs of adolescents. While the primary interpersonal goals of ABFT for depressed adolescents focus on repairing the attachment bond (i.e., rebuilding trust and

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security), ABFT for anxiety focuses on making overly rigid attachment bonds more flexible. In general, therapists help parents promote adolescent autonomy by being less overprotective and controlling. The purpose of this treatment development study was to modify and tailor CBT and family therapy to the specific needs of anxious adolescents. Specifically, for CBT we sought to examine how therapeutic approaches and techniques might need to be modified from the original Kendall (1994) manual designed for children ages 8–13. For ABFT, originally developed for depressed adolescents, we sought to better target core family processes associated with anxiety, and to combine it with CBT hoping to maximize treatment efficacy. Phase I focused on manual development, therapist training, and an open trial pilot to explore treatment feasibility and acceptability for the combined condition. Phase II used a randomized design to assess the feasibility of implementing both individual CBT and a combined CBT plus ABFT. Preliminary efficacy data was collected as well.

2. Methods 2.1. Procedures 2.1.1. Patient recruitment and screening Recruitment, screening, and assessment procedures were similar for both Phase I and Phase II studies. Patients were recruited primarily through the Child and Adolescent Research Service (CAReS) at the University of Pennsylvania, an outpatient clinic focused on childhood anxiety and depressive disorders. Seventy percent of patients were direct referrals from pediatricians, family physicians, agencies, and previously treated patients, and the remainder came from advertising. Interested parents contacted the clinic and completed a 20–30 min semistructured telephone screening evaluation. If the adolescent appeared to meet inclusion/exclusion criteria, they were scheduled for an initial evaluation. At the conclusion of the initial evaluation, patients were offered participation and the details of the study design and treatments were explained. All questions were answered, and written informed consent was obtained from both adolescent and parents. Following completion of the intake assessment battery, patients who met inclusion criteria were assigned to a therapist. All procedures were reviewed and approved by the IRB of the University of Pennsylvania. 2.1.2. Inclusion/exclusion criteria In order to be included in either Phase I or II of the study, adolescents had to meet DSM-IV criteria for primary diagnosis of generalized, separation anxiety disorder, or social phobia; be between the ages of 12–18; and have at least one primary caretaker or parent willing to participate in family treatment. Exclusion criteria included: primary diagnosis of major depression (MDD) (however, comorbid MDD was allowed provided that the primary diagnosis and complaint

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was anxiety which preceded the onset of MDD); comorbid Obsessive Compulsive Disorder, Bipolar Disorder, Eating Disorder, Substance Abuse or Psychotic Disorder; or adolescents at significant suicide risk. Primary diagnosis was determined by clinician via the Anxiety Disorder Interview Schedule (ADISChild; Albano & Silverman, 1996) using severity ratings for each diagnosis to encompass both the level of severity of symptoms and impairment in functioning. In order to increase the study generalizability to real world treatment, adolescents on a stable medication dose (at least 8 weeks at an appropriate stable therapeutic dose, which was reviewed by the study psychiatrist—MR) meeting diagnostic criteria were included in the study if they agreed to not change the medication dose or medication for the course of the active treatment. Patients and families were informed about the option of increasing the medication dose rather than consenting to the psychosocial treatment with fixed dosing. 2.1.3. Patients 2.1.3.1. Phase 1. In this phase, a total of eight patients was enrolled and completed treatment with CBT-ABFT (16 sessions). All eight adolescents met criteria for GAD diagnosis; six had primary GAD and two had primary social phobia. There were four boys and four girls with an average age of 15.5 years (range from 14 to 17). All were Caucasian except for one Hispanic boy. All adolescents came from two-parent families. Seven out of the eight patients (88%) were also diagnosed with past or current major depression and had been on antidepressant medication for over 4 months at intake. 2.1.3.2. Phase II. The patient sample in Phase II included 11 adolescents with six randomized to individual CBT and five to CBT-ABFT. There were eight boys and three girls (two girls in CBT and one in CBT-ABFT). The average age was 14.9 (S.D. ¼ 1.8) with a range from 12 to 17. The sample was primarily Caucasian (N ¼ 10) with one African American boy. Both Phase I and II studies included adolescents from a relatively wide economic range from working class to upper middle class. The Phase II treatment sample also had high rates of comorbid diagnoses like those patients in Phase I. Three adolescents had school refusal of over 1 year (2 in family condition). See Table 1 for a summary of diagnoses. Finally, four adolescents had concurrent major depression, and all had been on adequate SSRI medication regimens for at least 2 months prior to randomization with only limited response. Randomization procedures used a 1:1 approach with no stratifying variables. This resulted in only one intact two-parent family in the CBT-ABFT condition, while there were four two parent families in the CBT condition. Other family constellations in ABFT included two divorced parents with fathers involved and two single mother families. In the CBT alone treatment, there were four twoparent family and two divorced families (one with regular contact with her father). All three school refusal patients came from single mother households.

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Table 1 Intake diagnoses for Phase II study participants

Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient

1 2 3 4 5 6 7 8 9 10 11

Diagnosis

Treatment

GAD, MDD GAD GAD, SP, MDD, school refusal GAD, SiP GAD GAD GAD GAD, MDD, panic GAD, MDD SAD, school refusal GAD, SP, school refusal

CBT CBT CBT CBT CBT CBT CBT-FAM CBT-FAM CBT-FAM CBT-FAM CBT-FAM

Note. GAD: generalized anxiety disorder, SAD: separation anxiety disorder, SP: social phobia, SiP: simple phobia, MDD: major depressive disorder.

2.1.4. Measures Measures were chosen to address clinician and patient self-report of anxiety and depressive symptoms and family functioning. All measures were given at pre, post treatment (16 weeks), and at 6–9 months follow-up with the exceptions cited below. Patients and families were encouraged to see how adolescents might manage without further treatment at the end of 16-week active treatment; however, they were not prohibited from seeking treatment in the follow-up phase. Only one adolescent assigned to CBT alone continued in treatment during the follow-up phase and was included in follow-up analyses. 2.1.4.1. Diagnosis. DSM-IV diagnosis was established with the Anxiety Disorders Interview Schedule for Children—Revised (Albano & Silverman, 1996). This structured interview (which is based on Diagnostic and Statistical Manual of Mental Disorders, 4th edition), was chosen because it contains an expanded anxiety section not found in other available instruments, and also allows the assessor to screen for other disorders. The instrument requires screening for and the ability to diagnose all anxiety disorders (adult and child) and affective disorders, as well as any exclusionary diagnoses. The ADIS has satisfactory test– retest reliability (Silverman & Eisen, 1992; Silverman & Rabian, 1995) and moderate to high inter-rater reliability on inclusion anxiety diagnoses (Rapee, Barrett, Dadds, & Evans, 1994; Silverman & Nelles, 1988). 2.1.5. Clinician rated outcome scales Hamilton Anxiety Rating Scale (HAM-A) (Hamilton, 1959). The HAM-A is a widely used 14-item inventory that assesses the severity of common anxiety symptoms. The HAM-A was completed by utilizing a structured interview guide for the HAM-A to increase reliability (HARS-IG; Bruss et al., 1994).

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Hamilton Depression Rating Scale (HAM-D) (Hamilton, 1960). A 24-item version of the HAM-D was administered utilizing the Structured Interview Guide (SIGH-D; Williams, 1988). The 17-item score was utilized in this study since it is most commonly cited. 2.1.6. Patient self reports Beck Anxiety Inventory (BAI) (Beck, Epstein, & Brown., 1988a). The BAI is a 21-item scale that assesses common features of anxiety, with a focus on cognitions and physical symptoms, on a 4-point severity scale. Adequate reliability and validity data have been reported (Beck et al., 1988a). Beck Depression Inventory (BDI) (Beck et al., 1961; Beck et al., 1988b). The BDI is a 21-item scale that assesses common features of depression, with a focus on cognitions, on a 4-point severity scale. This is a widely used scale with good reliability and validity (Beck et al., 1988b). The above clinician rated and patient self-report measures have been used with adolescents with anxiety and depression (e.g. Jolly, Wiesner, Wherry, Jolly, & Dykman, 1994), especially the BDI which has been used in numerous studies. However, there is less data on these clinician and self-report ratings in adolescents than for some of the children’s measures. The benefit of this assessment battery is that it includes both clinician and self-report ratings of anxiety and depression, as well as measures of family functioning, often missing from the child studies. 2.1.7. Family functioning The Children’s Report of Parenting Behavior Inventory (CRPBI- Schludermann & Schludermann, 1970 revision), is a 30-item, widely-used questionnaire designed to assess children’s perceptions of their parents’ behavior along three dimensions: Psychological Control (PC), Acceptance (AC), and Firm Control (FC). According to Schwarz, Barton-Henry, and Pruzinsky (1985), the internal consistency of the subscales ranges from .65 to .74. This measure has been used widely in child development studies as well as to differentiate families with child or parental anxiety disorders from normal controls (Siqueland et al., 1996; Whaley, Pinto, & Sigman, 1999). The adolescents completed separate CRPBI inventories about their mother and father. Each parent also rated his/her own parenting on the parent version. Given the number of single parents, mothers’ scores were chosen for analysis (with the exception of one divorced custodial father in the CBT only group). 2.1.7.1. Therapists. A total of 7 therapists (including the first author) treated the adolescents and their families within the two phases of the study. They included four Ph.D. and one Psy.D. psychologist, one M.S.W., and one master’s level therapist in family therapy. There were six female therapists and one male therapist. The four Ph.D. therapists had quite extensive experience in treating younger anxious children in the previous Kendall CBT clinical trials. The other two masters level therapists brought more experience with family based

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approaches. The latter therapists were familiar with CBT techniques but received additional training and supervision with the first author. All therapists were retained for Phase II with some requiring additional case supervision. Two CBT therapists never felt comfortable or achieved full competence (see below) in the combined family CBT approach and treated CBT only cases. 2.1.8. Therapist training and treatment development The focus of the Phase I study was to develop the manual for the combined CBT and family intervention and to train therapists to competence in delivering this integrated treatment. Five therapists were assigned two treatment development cases each. All therapists received one hour of supervision for every two therapy hours. Sessions were videotaped and a video of each case was reviewed at least every other week. The therapists and authors of this paper also met monthly to review videotapes and to discuss ideas to be incorporated into the manual, as well as therapists’ experiences and difficulties in implementing the manual with their patients. Treatment tasks were further elaborated and modified based on the treatment development work. Therapists were certified to see patients in Phase II of the study based on ratings of adherence and competence by the first author on the second training case, using the Cognitive Therapy Scale (CTS, Young & Beck, 1980; Vallis, Shaw, & Dobson, 1986), and the Therapeutic Behavior Rating Scale—3rd version (TBRS-3; Diamond, Hogue, Diamond, & Siqueland, 1998, based on Hogue et al., 1998). The CTS scale includes items on general therapeutic skills (such as setting an agenda) and items on cognitive conceptualization, strategy, and technique (e.g., guided discovery, focusing on key cognitions, strategy for change, and homework). The TBRS-3 is an observer-based instrument designed to measure the extent to which therapists employ each of 20 discrete ABFT therapist interventions over the course of a therapy session. The items most important to this study were (a) encouraged the identification and expression of affect, (b) worked to restructure the family, and (c) promoted adolescent-parent attachment. Therapists were certified once they received a mean score of 4 or higher on the CTS and family adherence scales (both scales use a 1–7 scale). Therapists needed to have a 4 or higher on all relevant items by the end of their second training case (an item might be appropriately missing depending on the phase of therapy). Ongoing adherence and competence were assessed by either regular tape review and/or live supervision weekly throughout the trial. 2.1.9. Treatment and treatment modification 2.1.9.1. Individual cognitive-behavioral treatment (CBT). The 16 session CBT treatment followed an already standardized manual (Kendall, Kane, Howard, & Siqueland, 1989), originally designed for children ages 8–13, that was modified for adolescents. The skill building sessions focused on the same four primary content areas: ‘‘(a) recognizing anxious feelings and somatic reactions to anxiety,

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(b) clarifying cognition in anxiety provoking situations (unrealistic or negative attributions), (c) developing a plan to cope with the situation (modifying anxious self-talk into coping self talk as well as determining what coping actions might be effective), and (d) evaluating performance and administering self-reinforcement as appropriate’’ (Kendall, 1994, p. 103). Behavioral techniques included relaxation training, cognitive restructuring, modeling, imaginal and in vivo exposure, and contingent reinforcement. These skills are incorporated into a FEAR acronym to help adolescents remember the steps for coping (F: feeling frightened/anxious, E: expecting bad things to happen, A: actions and attitudes that help, R: results and rewards). The main modifications of the treatment to better meet the needs of adolescent in Phase I were related to the manner of teaching the CBT skills rather than the content areas. The primary skills could be taught more quickly in adolescents and usually were introduced over 3–4 sessions rather than the 8 outlined in the original children’s manual. Visualization exercises developed by Wexler (1991) were added to diaphragmatic breathing and progressive muscle relaxation techniques. In addition, there was more use of cognitive restructuring and Socratic questioning with the adolescents. Finally, much of this cognitive work was framed using the language of choice and autonomy given that these are important developmental issues for teenagers. If homework was not completed between sessions, the therapist focused on in session review to elucidate the concepts. The remaining sessions were used to practice the skills in both imaginal and in vivo anxiety-provoking situations specific to the adolescent and involved the other primary modification for adolescents. The therapist did use imaginal exposure and tried to create in office exposure tasks when appropriate. However, the therapy was more reliant on the adolescent performing in vivo tasks outside of session on their own or with parents’ help compared to therapy with children where there is more office based exposure. There were two parent sessions within this individual CBT model as described in the original manual. The therapist met with parents briefly after session 2 and 8 to review the treatment program, to receive input in establishing the anxiety hierarchy, and to have the adolescent outline the coping steps for their parents. However, parents were not coached on how to change family interactions or anxious behavior. 2.1.9.2. Cognitive-behavioral plus attachment based family therapy (CBTABFT). This 16 session combined treatment included all components in the CBT alone described above but the treatment order and structure was modified. After the first session, which included the family, the therapist met alone with the adolescent for 3–4 CBT sessions to teach the primary anxiety management skills. This individual format was chosen to establish a boundary for the adolescent to begin to explore thoughts and feelings around anxiety and to establish autonomy from parents and responsibility within the adolescent around managing anxiety. In addition, parents were taught the FEAR acronym and the steps for coping usually

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at the last of these CBT educational sessions. In contrast to other CBT family treatment models (Barrett et al., 1996a; 1996b; Cobham et al., 1998), parents were not specifically taught to use the CBT skills for addressing their own fears or worries. Instead, in this treatment, discussion focused around how parents could be helpful in the level and type of involvement they provided during in vivo exposures and how they helped the adolescent overcome his/her anxiety. The therapist was able to directly address the confusion of roles and level of each family member’s anxiety or coping in completing the in vivo tasks or taking on new challenges. 2.1.9.3. ABFT theoretical framework. The family dynamics targeted by ABFT focus on helping adolescents competently negotiate autonomy in the areas of family beliefs, behavior and interactions. Family beliefs about parenting and anxiety can seriously impact the adolescent’s ability to cope with these challenges. Many parents view anxiety as threatening and something to be avoided at all costs. Consequently, they strive to protect their adolescent (and themselves) from these experiences. This leads to parenting behaviors that promote avoidance and dependency. Possibly more problematic is the parents’ use of psychological control. Here, parents discourage different viewpoints, feelings and experiences within the family, especially regarding negative affects (e.g., anger and sadness). The guiding belief system is that the expression of differences or conflict in the family will damage or lead to the loss of their intimate relationships. Therefore, open negotiation and communication are blocked, which can seriously derail the normal developmental task of autonomy development, where physical and psychological independence is perceived as a threat to closeness. These dynamics reinforce adolescents’ dependency on parents, which reinforces a self-concept of incompetence. While these kinds of dynamics can be driven by parents and/or parental anxiety (e.g., Cobham et al., 1998), we also appreciate the impact that anxious behaviors in children can have on shaping parents’ behavior. Many adolescents have come to depend on or like that their parents take over for them and may draw their parents in to these types of interactions or be reluctant to give up parental involvement. This line of treatment and research explores whether targeting change in both parents and adolescent simultaneously will potentiate change more than dealing with either alone. 2.1.9.4. ABFT treatment structure. The first session included the adolescent and their parents and set the frame for the family treatment. How did the family feel about and handle the adolescent’s anxious behavior, and could they be a better resource to the adolescent as he or she attempted to reduce or overcome these problems? Discussions directly or indirectly focused on issues of psychological control and autonomy, finding a balance between protecting and challenging the adolescent. Ideally, by the end of the session, the therapist (and the family) had an understanding of the problematic family interaction patterns that inhibit autonomy

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and a commitment from the family to work together to change these patterns. Just to clarify, we do not equate autonomy with separation and independence. Rather autonomy is defined as the freedom to have a self-identity within the context of close relationships. In the second session, the therapist met alone with the adolescent to establish a strong therapeutic alliance. This involved helping the adolescent identifying personally meaningful individual and family level treatment goals. Here the therapist explored the adolescent’s individual desires, fears, and barriers about autonomy and helped the adolescent to envision a life of psychological and physical independence and mastery. In regards to family issues, typically adolescents identified concerns about protecting or upsetting their parents, discomfort with conflict, or feeling their parents didn’t understand them. This alliance building/problem identification session was usually followed by 3–4 individual CBT skill sessions. Following the adolescent alliance building and CBT sessions, there was a session focused on building an alliance with the parents. The session focused on identifying parents’ own anxiety and fears, and how these worries might lead to parents restricting the adolescent’s autonomy and encouraging his or her avoidance. The therapist asked the family to re-examine their view of the adolescent’s challenges and their approach to helping him or her. The therapist encouraged and taught parents to promote psychological autonomy by allowing the adolescent to express opinions, differences or conflicts, and to learn to rely on themselves for self-soothing and coping. These sessions also could address marital conflict if there were arguments or disagreements over how to care for and help their adolescent in general and with his/her anxiety. When parents fail to provide support to each other, they can become polarized and rigid in ways that prevent them from sending a clear and consistent message to their child. Couples therapy for other areas of conflict was not provided in this model. There was no need for referral to couples therapy in the Phase II sample, and there was one referral to couples therapy in the Phase I sample at the end of treatment. While the groundwork for these issues were laid in these goal- building sessions, focus on these issues persisted throughout treatment. The remaining eight sessions involved combinations of parent-adolescent, adolescent alone or parent alone sessions as determined by the particular case. The sessions focused on the themes identified in individual adolescent and parent sessions. Discussions can directly addressed these family beliefs or focus on current problems that provide opportunities to alter interactional patterns that reinforce psychological control and restrain autonomy building. As in ABFT for depression, the therapist works to create opportunities for a different type of family interaction. This included: (a) encouraging parents to solicit adolescent input, (b). limiting parent speaking for adolescent, (c) helping family members highlight and accept differences, (d) encouraging conversations about fears regarding expression of differences and conflict, and (e) encouraging parents to foster adolescent autonomy. The goal of the family treatment is not only

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Table 2 Pre and post means and standard deviations for Phase I patients Measures BAI

HAM- A

BDI

HAM-D

Pre M S.D.

22.44 13.68

13.67 6.14

22.44 15.13

12.56 6.33

Post M S.D.

9.33 11.58

10.11 2.85

12.44 14.36

8.78 5.04

Note. BAI: beck anxiety inventory, HAM-A: Hamilton Anxiety Rating Scale, BDI: beck depression inventory, HAM-D: Hamilton Depression Rating Scale.

to encourage adolescent independence, but also to increase intimacy and healthy attachment.

3. Results 3.1. Phase I The goal of Phase I was primarily treatment development and therapist training. Efficacy of the treatment could not be optimally assessed while the manual was under development; however, pre and post blind evaluations were conducted on these patients. A total of eight patients was enrolled and completed Phase 1 all treated with CBT-ABFT. The results show significant change over time with majority of patients reporting Hamilton Anxiety (88%  12) and BAI scores (88%  18) in the non-clinical range (see Table 2). While these results were not definitive, we were encouraged with the results to proceed with Phase II of the study. 3.2. Phase II 3.2.1. Pre-treatment group differences The patients in the two treatments were compared on pre-treatment scores given the relatively rudimentary 1:1 randomization scheme with no blocking variables. Patients randomized to CBT alone showed a trend for higher intake BDI scores (F (1, 11) ¼ 3.6, P ¼ .10). All other psychiatric symptom measures did not differ at baseline. No significant differences were reported on pre-treatment family measures, even though the CBT-ABFT had worse scores on each these measures. 3.2.2. Retention Adequate dose of treatment was defined as attending 12 out of the 16 sessions, of which 91% achieved this goal and 55% completed the full 16 sessions. Twelve sessions allowed the therapist to teach the CBT skills and to have some

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opportunities for in vivo exposure, and in the combined condition, 12 sessions allowed for at least 4–6 family sessions. 3.3. Post treatment outcome 3.3.1. Diagnosis Chi square analyses were used to assess treatment condition differences in the percent of patients who no longer met criteria for their primary anxiety disorder diagnosis. There were no significant treatment differences on diagnosis at post treatment. However, four out of the six CBT patients (67%) no longer met criteria for their primary anxiety diagnosis compared to two out of five (40%) of CBT þ FAM. 3.3.2. Anxiety and depressive symptoms One way ANOVAs using change scores (pre minus post scores) were used to assess for treatment condition differences on the main anxiety and depression measures. There were significant decreases in all scores (see Table 3), but no significant differences between conditions except on BDI scores. There was a significant treatment advantage for CBT alone for BDI outcome (F (1, 10) ¼ 5.2, P ¼ .05). This is likely due to the low pre treatment BDI scores in the CBT-FAM condition and regression to the mean of the high CBT group BDI scores. 3.3.3. Parenting variables One way ANOVAs using change scores (pre minus post scores) were used to assess for treatment condition differences on the parenting measures. Both Table 3 Pre, post and follow-up mean scores on anxiety and depressive symptoms for Phase II patients Measure

CBT

CBT-ABFT

Pre

Post

BAI M S.D.

25.3 13.0

8.7 10.2

HAM-A M S.D.

18.5 8.14

BDI M S.D. HAM-D M S.D.

Follow-up

Pre

Post

Follow-up

2.7 3.6

17.4 9.6

7.0 6.0

4.5 5.3

8.3 6.1

4.8 4.7

15.8 3.0

5.4 4.6

4.4 5.3

24.7 14.1

7.8 9.9

6.3 11.6

10.8 8.8

8.4 7.1

5.2 5.6

18.7 10.6

8.0 8.2

5.5 8.0

13.0 6.9

5.0 3.1

3.2 4.3

Note. BAI: Beck Anxiety Inventory, HAM-A: Hamilton Anxiety Rating Scale, BDI: Beck Depression Inventory, HAM-D: Hamilton Depression Rating Scale.

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Table 4 Pre and post scores on family functioning measure CBT

CBT-ABFT

Pre

Post

Pre

Post

CRPBI—psych con adol M S.D.

15.4 3.6

17.0 5.2

18.5 5.0

17.0 2.9

CRPBI—accept adol M S.D.

25.0 4.5

26.8 2.4

22.0 3.6

23.8 3.8

CRPBI—beh con adol M S.D.

20.0 3.0

20.8 3.4

22.5 3.8

23.5 1.9

CRPBI—psych con parent M S.D.

15.3 2.1

14.7 4.0

16.0 2.8

16.0 3.6

CRPBI—accept parent M S.D.

26.3 1.8

26.5 2.6

25.2 3.3

24.5 3.5

CRPBI—beh con parent M S.D.

20.7 2.0

22.4 5.0

22.2 2.3

23.2 1.5

Note. CRPBI: Children’s Report of Parenting Behavior Inventory, accept: warmth/acceptance subscale, psych control: psychological control subscale, beh control: behavioral control subscale, adol: adolescent’s report of primary parent, parent: parent’s report on own parenting.

treatment conditions showed increases in acceptance/warmth at post treatment as reported by adolescents, but there were no treatment condition differences on this variable or behavioral control. There was a trend finding for adolescents’ report of psychological control (F (1, 11) ¼ 2.2, P ¼ .18) with adolescents in CBT reporting an increase in psychological control and adolescents in CBT-FAM reporting a decrease in psychological control. No significant differences were found on parent reports on the CRPBI with little change noted pre to post treatment (see Table 4 for means). In addition across the full sample, pretreatment CRPBI ratings of psychological control by both parent (r ¼ .65, P ¼ .04) and adolescent (r ¼ .68, P ¼ .04) were significantly correlated with intake BAI scores but not BDI scores. CRPBI acceptance/warmth ratings were not significantly correlated with intake BDI or BAI scores. 3.4. Post-study follow-up outcome 3.4.1. Diagnosis Chi square analyses were used to assess treatment condition differences in the percent of patients who no longer met criteria for their primary anxiety disorder

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diagnosis at 6-month follow-up after active treatment ended. There were no significant treatment differences on diagnosis at follow-up. However, all of the CBT patients (100%) no longer met criteria for their primary anxiety diagnosis compared to four out of five (80%) of CBT þ FAM. 3.4.2. Anxiety and depressive symptoms One way ANOVAs using change scores (pre minus follow-up scores) were used to assess for treatment condition differences on the main anxiety and depression measures. There were continued decreases in all scores (see Table 2) but no significant differences between conditions. The additional measures of family functioning were not available at follow-up because the measures were difficult to fill out over the phone.

4. Discussion The primary goal of this treatment development project was to set the foundation for future research on applying CBT and ABFT to the treatment of adolescents with anxiety. This foundation typically consists of developing a treatment manual, collecting pilot data for calculating effect sizes of treatments, and establishing the feasibility of the treatment. The study was not sufficiently powered to detect treatment differences. In terms of treatment manuals, we were able to modify a well-established CBT intervention for treating adolescents with anxiety disorders. In addition, we were able to modify ABFT for depression to treat adolescents with anxiety and to combine this family treatment with several CBT sessions. In regards to feasibility, we were interested in two issues. One was whether therapists could be trained to a level of competence in both these treatments. Indeed, we found that therapists in both conditions could be trained to a necessary level of adherence and competency. We did find however that some therapists who identified themselves as primarily CBT therapists had difficulty learning and applying the family therapy intervention. They found it difficult to engage multiple people at one time and felt uncomfortable working with the families who were in conflict or eliciting conflict in order to practice negotiation. In contrast, therapists with more family therapy training and some exposure to CBT models became competent in the CBT techniques. However, limited conclusions can be drawn given the small sample size. Although we can say that these treatments seem to require different skill sets. The second feasibility issue concerned the acceptability of the treatment for families. To the degree that retention reflects acceptability, we had very good retention in both treatments (mean number of sessions CBT alone ¼ 14; CBT/ ABFT ¼ 15) with all but one of the patients (13 sessions) in the CBT-ABFT completing treatment. Adolescents and parents reported in informal exit interviews that the family work was the most important or satisfying component of

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treatment for those in the combined condition. In fact, some parents and adolescents in the CBT alone condition expressed disappointment in the limited parental involvement in treatment. These findings contradict the often-held belief that both adolescents and their parents might prefer individual treatment at this age and that adolescents are difficult to retain in treatment. In terms of Phase II outcomes, the main goal of this stage of treatment development was for future estimation of effect size for larger trials. We can look at the outcomes from this study as providing some preliminary findings on the efficacy of treatment. In general, we were pleased that both treatments were effective in reducing the percent of patients with an anxiety diagnosis, in reducing anxiety and depressive symptoms, and in producing clinically meaningful change (Jacobson & Truax, 1991). Given the small sample size, one would not expect to find treatment differences, and the data was consistent with this expectation. Small sample sizes are sensitive to outliers or unaccounted for variables (i.e., there were a number of adolescent boys who met criteria for an anxiety diagnosis and had impaired functioning yet reported low levels of symptoms on self-reports and the other clinical interviews). In addition, there were higher levels of depression in the CBT group, and more single parent families and higher family psychopathology in CBT-ABFT, all of which could have affected outcome. Indeed, living in a single parent home is a risk factor for poor treatment outcome overall (Kazdin & Kendall, 1998). Still, neither CBT nor family based treatments have been well studied with adolescents, so this study gave us some indication that we could effectively use these interventions with this population. In fact, the results of our CBT alone condition showed similar efficacy to the studies with younger children, with approximately two thirds of the sample free of their primary anxiety disorder diagnosis (see Ginsburg & Schlossberg, 2002 for a summary). While there were not significant treatment condition differences for psychiatric symptoms, there were two interesting trends on change in family outcome. Both treatments led to increases in adolescent report of acceptance by parents. However, adolescents in CBT-ABFT report decreases in psychological control and adolescents in CBT report increases in this factor. These trends need to be examined in larger samples, but may indicate that changes in the adolescent are better assimilated when the family participates in treatment as well. Psychological control, refers to control attempts that intrude into the psychological or emotional development of the child (such as self-expression, emotions and thinking processes) and using the parent-child relationship to control the adolescent’s behavior (Barber, 1996). If the adolescent’s efforts to begin to become autonomous (both verbally and behaviorally) are constrained by the family, the adolescent experiences himself as unable to influence events in his/her world, or even the expression of their own emotions, which leads to anxiety (for review, see Chorpita & Barlow, 1998). Unfortunately, the CRPBI has not been used often as a change measure and could be less sensitive to change especially in the short term. Anxiety researchers are clearly limited by the lack of good self-report family functioning measures with adequate norms that assesses domains of

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interest specific to anxiety. Pre and post behavioral observation of family interaction, and/or parents’ and adolescent’s ratings of ability to manage anxious behavior may have better captured the changes we observed clinically. Based on previous experience with family therapy for depressed adolescents (Diamond et al., 2002), we were hopeful that the family treatment would reduce symptoms and target core family processes. While all the CBT skills are taught to adolescents in both treatments and both involve significant in vivo exposure and practice, clearly the treatments are different. The CBT component of the combined treatment was less intense and focused given the need to address the family interactional issues as well as practice the CBT skills. In fact, in the current structure of the combined treatment, we found it difficult to do either treatment well- that is give enough attention and time to both CBT practice and family interaction, as well as the difficulty of ‘‘switching gears’’ between the two components of treatment. In the future, we have considered a different sequencing approach to the combined treatment in which the family beliefs and interaction are addressed first (sessions 1 through 6) to lay the groundwork for the competency promoting CBT work with parental involvement (sessions 6 through 12). Although the findings are promising, there are several limitations to this study. The biggest limitations are the small sample size and the lack of a control group. A larger trial might elucidate significant advantages for either condition. Several other factors complicate these findings. First, the adolescents recruited for this study at this tertiary care center appeared to have severe anxiety levels and higher comorbidity, especially for major depression, than the younger children treated in previous clinical trials (e.g. Kendall, 1994; Kendall et al., 1997). Second, adolescents already on medication but who still met full diagnostic criteria for diagnosis were included in the study with the hopes of being more generalizable to patients seeking treatment in clinics. Alternatively, many of the adolescents had been in previous therapy and on medication with little change, and therefore could be considered a treatment resistant population. The clinical impression certainly suggested that the anxiety had been more chronic and patterns of thinking, behavior, and avoidance were more entrenched for these adolescents. Yet again, given the number of adolescents on medication in this study, these treatments could be considered more of an augmentation strategy. However, when examined, there were no significant differences in major outcome variables between patients on medication and those who were not. Belsher, Wilkes, and Rush (1995) report the same findings when using a similar design for the treatment of depressed adolescents. Finally, another confounding factor was that families in the CBT only condition did have two parent sessions where the CBT skills were reviewed. Given efficacy of the CBT treatment alone, one might question why continue to develop family based treatments. Clearly, some combined CBT and family approaches have shown superior efficacy to CBT for younger children (see Ginsburg & Schlossberg, 2002). It may be that adolescents can develop skills to manage their anxiety with CBT; however, these skills may be difficult to

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maintain if they return to a family context that does not encourage these changes. Family based treatment may reflect a different mechanism of change that lowers anxiety by focusing on increasing autonomy, lowering parental psychological control, and addressing and negotiating family conflict. Indeed, family conflict seems to be a risk for relapse for adolescents with depression (Birmaher et al., 2000); therefore, targeting this domain specifically may help the maintenance of gains in anxiety as well. Finally, the treatment studies have suggested that although CBT is efficacious for 50–65% of patients treated, approximately 40% of patients do not get better suggesting room for improvement. It may be that combined treatments are needed especially for a subset of patients where particular risk factors (e.g. parental anxiety or parental overcontrol) can be assessed and targeted. Finally, it may be that the rates of parental anxiety and depression were not particularly high in this study and previous research has found the combined conditions were most effective for anxious parents. Even with the limitations of the study, this paper presents promising initial pilot data that encourage the further development of these treatment interventions.

Acknowledgments This study was supported in part by the Mood and Anxiety Disorders Section, Department of Psychiatry, University of Pennsylvania, the National Institutes of Mental Health (NIMH K23MH01819-01A1) and NIMH Clinical Research Center grant awarded to Dr. Crits-Christoph (NIMH P30-MH 45178).

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