indicating no impairment and 8 indicating significant impairment. Additionally, the two children who dropped out had a high number of comorbid anxiety and non- anxiety diagnoses and the lowest global functioning as measured by the Children’s Global Assessment Scale. Finally, as reported by the investigators, one independent evaluator who was blind to treatment related data but not to assessment time points completed all research assessments at all time points.
In summary, Parent-Child Interaction Therapy and its derivative interventions, all of which have a strong behavioral focus, show promise in the treatment of anxiety disorders in young children, but have limited empirical evidence to document their efficacy and warrant further evaluation.
CBT strategies. For example, clinical research groups have used dyadic parent-child sessions (e.g., Hirshfeld-Becker, Masek, Henin, Blakely, Rettew, Dufton, et al.,2008) while others have utilized separate and concurrently held parent groups and child groups to deliver CBT to young children (e.g., Monga, Rosenbloom, Tanha, Owens,
& Young,2015; Monga, Young, & Owens,2009; Waters, Ford, Wharton, & Cobham, 2009). With the exception of the Taming Sneaky Fears program (Monga et al.,2009, 2015), which is described at length in Chaps.5–11, most CBT interventions focus primarily on behavior (exposure hierarchies) and feelings in the direct work with young anxious children, with little attention paid to the cognitive distortions that are a hallmark of anxiety disorders. Examples of such interventions are described below.
4.3.1 Parent-Child Dyadic Approach
Hirshfeld-Becker and colleagues used a 20-session intervention called Being Brave:
A Program for Coping with Anxiety for Young Children and Their Parents (Hirshfeld- Becker et al.,2008), which is an adaptation of the manualized Coping Cat program (Kendall, Kane, Howard, & Siqueland,1992), originally developed for older anxious children. The Being Brave program’s initial six parent-only sessions provide parents with psychoeducation about anxiety and anxiety management, parenting skills, and information on how to develop and use graded exposures with their children. The Being Brave intervention’s main focus is primarily behavioral, although an effort is made to help children identify feeling states. Hirshfeld-Becker and colleagues hypothesize that graduated exposure is the primary approach to use for reducing child anxiety symptoms and so sessions 7 through 20 are dyadic parent-child sessions during which the therapist focuses on helping children understand the rationale for treatment and learn basic coping strategies, such as recognizing anxious feelings and implementing a coping plan in order to complete exposures. As such, children are introduced to the idea of working on ‘being brave.’ They learn relaxation strategies in session 7 and how to develop ‘coping plans’ in order to begin to use exposures in session 8. The bulk of the dyadic sessions (sessions 9 to 17) focus on planning, rehearsing, and implementing graduated exposures to various feared situations. In session 18, children make a final project (a short video or book) to illustrate a strategy they learned to be brave. Session 19 consists of a party or graduation to celebrate the gains made by the child. A final session 20 is for parents only and focuses on relapse prevention.
In an open trial pilot study of the Being Brave program (Hirshfeld-Becker et al., 2008), nine children (including one who did not meet criteria for an anxiety disorder at baseline) completed a mean number of 17.1 sessions (SD2.4). At post-treatment, six (66.7%) of the nine children no longer met criteria for an anxiety disorder.
In a follow-up randomized control trial using the same Being Brave program (Hirshfeld-Becker, Masek, Henin, Blakely, Pollock-Wurman, McQuade et al.,2010), 64 four- to seven-year-old children (M age 5.4 years; SD 1.0) with vari- ous anxiety disorders diagnosed using the Schedule for Affective Disorders and
Schizophrenia, Epidemiologic Version (Orvaschel,1994) were randomized to either the dyadic parent-child CBT arm (N34) or a 6-month waitlist condition arm (N 30). Seventy-seven percent of children had more than one anxiety disorder at baseline. Children in the two arms did not differ on any of the baseline measures such as demographic variables, number of comorbid diagnoses, Child Behavior Checklist (Achenbach, 1991) scores, behavioral inhibition, rates of parental anx- iety, or cognitive testing using the Kaufman Brief Intelligence Test (Kaufman &
Kaufman, 1990). Fifty-seven children completed the study (five dropped out and two did not attend the post-treatment assessment). Using intent-to-treat analyses, seventeen (50%) of the 34 children in the CBT arm were free of anxiety disor- der post-treatment, compared to five (16.7%) of 30 children in the waitlist arm, χ2(1,N64)7.85,p< 0.01. At post-treatment, children in the CBT arm had a greater mean decrease in the number of anxiety diagnoses (M1.72;SD1.53), compared to children in the waitlist arm (M 0.93; SD 1.30),z −2.21,p
< 0.05. Additionally, significantly better Clinical Global Impression—Improvement (Guy & Bonato, 1970) scores were seen for children with social anxiety (t − 3.04; p < 0.01), separation anxiety disorder (t −2.12, p < 0.05), and specific phobia (t −2.20,p < 0.05), while no significant improvement was reported in children with generalized anxiety disorder (t −0.090, pn.s.) and agarophobia (t −0.057,pn.s.).
At one-year follow-up, seven (24%) of the 29 children who had completed the dyadic CBT program had sought out further treatment. Of the 22 children who had not had further treatment, 15 (68%) were free of anxiety diagnosis. The authors did not provide additional information to explain why nearly a quarter of children who participated in the dyadic CBT program sought out further treatment.
Results from this randomized control trial show support for the use of graduated exposures in the treatment of various anxiety disorders in young children.
4.3.2 Child Group Approaches
In this section, we describe the Take ACTION program, a group CBT protocol devel- oped by Waters and colleagues (Waters, Donaldson, & Zimmer-Gembeck, 2008;
Waters, Wharton, Zimmer-Gembeck, & Craske,2008; Waters et al.,2009) and an open trial of the Fun FRIENDS program with preschoolers (Barrett, Fisak, & Cooper, 2015). As previously mentioned, another evidence-based group CBT program for the treatment of anxiety disorders in young children, Taming Sneaky Fears (Monga et al.,2009,2015), is described in detail in Chaps.5–11.
4.3.2.1 Take Action Program
The Take ACTION program (Waters, Donaldson, et al., 2008; Waters, Wharton, et al.,2008; Waters et al.,2009) is a ten-week manualized program developed for children between ages four and 18 years. It includes a child component and a parent
component. The child program uses modules around the acronym ‘Take ACTION’
that include: ‘be AWARE’ of anxiety and body reactions to anxiety; ‘keep CALM’
and learn relaxation techniques; ‘THINK strong thoughts’ as a reminder to identify anxious self-talk and use coping statements and calm thoughts instead; ‘INITIATE action’ when faced with graded exposures; ‘use my OPTIONS’ as a reminder for children to use the strength cards they develop and problem solving skills, and identify a strong team (e.g., others who support them); and ‘NEVER stop taking action’ as a reminder to develop confident nonverbal behavior, including being assertive when dealing with bullies.
In a randomized control trial using the Take ACTION program (Waters et al., 2009), 80 four- to eight-year-old children who met criteria for an anxiety disorder using the Anxiety Disorders Interview Schedule (Silverman & Albano,1996) and their parents were randomized to one of three treatment arms: a Parent + Child CBT group arm (N 31;M age6.89 years;SD1.25), a Parent Only CBT group arm (N 38;M age6.68 years;SD1.2), or a waitlist control arm (N 11;
M age6.79 years;SD1.03). Parents in the Parent + Child CBT group arm and the Parent Only CBT group arm received the same content. Children in the Parent + Child CBT group arm attended ten one-hour, weekly group sessions with a therapist and received a workbook containing the weekly sessions’ curriculum. Children in the Parent Only CBT group arm did not attend any group program; instead, each week while at the parent session, their parents received the relevant section of the children’s workbook to work on at home with their children during the week.
There were no statistically significant differences among groups at baseline on demographic variables, primary anxiety disorder severity ratings, number of comor- bid diagnoses, or any other measures (Waters et al.,2009). Five children withdrew prior to randomization. Post-treatment assessments using the Anxiety Disorders Interview Schedule were completed by one of the group therapists; however, the six- and 12-month follow-up assessments were conducted by independent raters, blind to children’s diagnostic status and treatment condition. At post-treatment, using intent- to-treat analyses, 18.2% of children in the waitlist control, 54.8% of children in the Parent + Child CBT group arm, and 55.3% of children in the Parent Only CBT group arm no longer met criteria for a primary anxiety disorder. Compared to children in the waitlist control arm, the number of children who no longer met criteria for their primary anxiety disorder was significantly greater in the Parent + Child CBT group arm,χ2(1,N 41)4.79p< 0.05, and in the Parent-Only CBT group arm,χ2 (1, N 49)4.71,p < 0.05. There were, however, no significant differences at post-treatment between the two treatment arms,χ2(1,N68)0.01,pn.s.
Six months post-treatment, using intent-to-treat analyses, no statistical differences were noted between the two treatment arms with respect to loss of primary anxiety diagnosis, with 55% of children in the Parent + Child CBT group arm and 58%
of children in the Parent Only CBT group arm no longer meeting criteria for their primary anxiety disorder diagnosis,χ2(1,N69)0.07,pn.s. Similar findings were reported 12 months post-treatment, with 55% of children in each treatment arm no longer meeting criteria for their primary anxiety disorder diagnosis,χ2(1,N 69)0.03,pn.s. Although not statistically significant, higher dropout rates were
reported in the Parent Only CBT group arm (26% or ten of 38 children), compared to the Parent + Child CBT group arm (16% or five of 31 children),χ2(1,N20) 0.70,pn.s.
The Waters and colleagues (2009) study is one of the first studies on the treat- ment of anxiety disorders in young children that used a randomized control design to compare two active treatments and a waitlist control group with young anxious children. Waters and colleagues (2009) note that their study may not have been ade- quately powered to detect statistically significant results between the two treatment arms and that this may have contributed to the lack of differences noted. They fur- ther suggest that parents in the Parent + Child CBT group arm may have expected therapists in the children’s group to provide all the necessary instruction to children and therefore may not have practiced and/or supported their children as much as expected between sessions, thus contributing to the lack of difference between treat- ments. This observation highlights the pivotal role that parents play in the treatment of anxious young children. Additionally, although the investigators did not highlight this, it is possible that the approach and terminology used in the Take ACTION program, developed for a broader age range, may not have been as developmentally appropriate for the younger four- to eight-year-old age group in the study sample.
If accurate, this observation would highlight the importance of engaging younger children at their developmental level.
4.3.2.2 Fun FRIENDS Program
The Fun FRIENDS group CBT program was developed specifically for five- to seven- year-old children and is an offshoot of the FRIENDS for Life program, a social skills and resilience building program that is recognized by the World Heath Organization as an effective program to prevent anxiety in children aged eight to 11 (Barrett, 2007a,2007b). The Fun Friends group CBT program is primarily a child-based group intervention with children attending ten weekly, 90-minute group sessions with therapists who meet separately with the parents for the last 20 minutes of each session to inform parents about the skills their children learned during the child group session and how to use appropriate reinforcement at home (Barrett,2007a,2007b).
Additionally, parents attend two parent information sessions as part of the treatment program. The child program outline follows the acronym ‘FRIENDS,’ with the first session devoted to introducing participants to the group and presenting the concept of
‘being brave.’ Sessions 2 and 3 focus on the ‘F’ for feeling recognition, followed by coping with feelings through ‘thumbs-up’ (helpful) and ‘thumbs-down’ (unhelpful) behaviors, as well as recognizing the link between feelings and behavior. Session 4 teaches ‘R’ for relaxation and consists of teaching children various relaxation strategies. Sessions 5 and 6 focus on the ‘I,’ which stands for ‘I can try my best’ and uses a traffic light analogy with ‘red’ being unhelpful thoughts and ‘green’ being helpful thoughts, including the concept of challenging ‘red’ or unhelpful thoughts and finding more ‘green’ or helpful thoughts as a way of achieving goals. Session 7 uses the ‘E’ for Encourage as a way of trying new things by breaking them into
smaller steps and using ‘green’ thoughts to help achieve goals. Session 8 is ‘N’ for Nurture and brings in the idea of role models and support teams as people who help with achieving goals. Session 9 is ‘D’ for ‘Don’t forget to be brave’ and further discusses the concepts of support teams and planning ahead for difficult situations.
Finally, session 10 is ‘S’ for ‘Stay smiling’ and children dress up as their favorite brave person and celebrate their success in completing the program.
Although two previous published studies have evaluated the Fun FRIENDS pro- gram as a universal prevention program (Anticich, Barrett, Silverman, Lacherez, &
Gillies,2013; Pahl & Barrett,2010), there has been only one open treatment trial (Barrett, Fisak, & Cooper,2015) in young children with 31 parents and children (M age5.68 years;SD0.54; range5–7) diagnosed with at least one anxiety dis- order using the Anxiety Disorders Interview Schedule (Silverman & Albano,1996).
Barrett, Fisak, and Cooper (2015) reported that the young children who completed the Fun FRIENDS had fewer mean number of anxiety diagnoses post-treatment com- pared to pre-treatment,t(29)3.80,p< 0.01. However, the authors did not report on the type of anxiety diagnoses at pre- or post-treatment or clinical severity of the anxiety disorders. Additionally, although the authors reported a significant decrease in the total score of the Preschool Anxiety Scale (Spence, Rapee, McDonald, &
Ingram,2001) from pre-treatment to post-treatment,t (29)5.14,p< 0.01, they did not report the actual pre- and post-treatment data. Furthermore, as noted by the authors, attrition in the sample over the follow-up period limited the evaluation of 12-month follow-up data.
Early research with the Fun FRIENDS group CBT program shows promise. Fur- ther research is needed to evaluate this program in the treatment of young children with anxiety disorders using larger sample sizes and more rigorous methodology.