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Brief Interventions for Anxiety Disorders with Children and Adults
Anxiety Disorders continuing education Social Worker CEU

Section 22
Cognitive-Behavioral Treatment Programs for Children

CEU Question 22 | CE Test | Table of Contents | Anxiety
Social Worker CEU, Psychologist CE, Counselor CEU, MFT CEU

(See Appendix at the end of this Manual for reproducible Client Worksheet #5)

Perhaps the major concern in the diagnosis/clarifications of anxiety from a behavioral perspective is how the term is defined and used. Traditionally, anxiety has been viewed as a transient emotional time behavior, a trait, or even a cause or explanation for behavior. Nietzel and Bernstein, in contrast, advanced a social learning framework for conceptualizing anxiety:

1. Anxiety is not a trait or personality characteristic.
2. Anxiety can be acquired through different mechanisms.
3. Anxiety consists of multiple choices.
4. Anxiety response channels are not highly correlated.

The conceptual framework is useful because the terminology employed in the clinical literature has often been imprecise and not always helpful in understanding how children actually behave. The idea that anxiety consists of multiple response components and that these may not be highly related, has important implications for treatment. For example, treatment made needs to be focused and independent on each response channel. Also, the focus on three response channels may help advance knowledge of what treatments may affect different types of response patterns within the anxiety, fear or phobia construct.

Three Major Forms of Cognitive Behavior Therapies
Mahoney and Arnkoff identified three major forms of cognitive behavior therapies: rational psychotherapies, coping-skills therapies, and problem-solving therapies.

Albert Ellis's rational-emotive therapy (RET) is the oldest of the rational psychotherapies. Irrational ideas or self-statements are said to be the fundamental cause of emotional disorder. The task of therapy is to assist the client in recognizing self-defeating irrational ideas and replacing them with more constructive, rational thoughts.

A variation of rational psychotherapy is self-instructional training (SIT). Meichenbaum gives less emphasis to the logical analysis of irrational beliefs and argues that the incidence of irrational beliefs per se does not distinguish normal from abnormal populations. Rather, the two groups are said to differ in their coping response to irrational thoughts. The procedure developed by Meichenbaum places heavy emphasis on the modeling of cognitive strategies by the therapist and on assisting the child through operant procedures to develop answers to four primary questions: "What is my problem?" "What is my plan?" "Am I using my plan?" and "How did I do?" (Meichenbaum & Goodman). The child is taught self-instructions to handle each of these aspects of problem resolution and thus learns how to cope with future problems. In this way, self-instructions can be viewed as establishing self-control over one's behavior.

The third variation of rational psychotherapy is Beck's cognitive therapy (Beck & Emery). As with RET and SIT, the ultimate goal is to develop rational adaptive thought patterns. Beck's cognitive therapy involves the following phases for the client:
becoming aware of his or her thoughts.
learning to identify inaccurate or distorted thoughts.
(3) replacing inaccurate thoughts with accurate and more objective cognitions.
Therapist feedback and reinforcement are important parts of the process.

The second major form of cognitive-behavior therapy identified by Mahoney and Arknoff is coping-skills therapies. These therapies represent a different use of existing methods and overlap considerably with other approaches such as SIT. Examples include: anxiety management training (Suinn & Richardson), stress inoculation (Meichenbaum) and modified systematic desensitization (Godfried). The critical dimension that characterizes these diverse methods is that of the individual coping with distress producing events.

Self-Control and Self Regulation
refers to a set of aroused processes (cognitive and instrumental) through which an individual consciously and consistently contributes to changing the likelihood of engaging in a behavior with conflicting temporal contingencies. The behavior in question may result in immediate reward, but have eventual adverse consequences (as in various addictive disorders) or may involve immediately unpleasant, long-range positive, outcomes. The aroused processes help to facilitate either avoidance (of the short-range positive payoff) or approach (to the short-run negative outcome). Typically, the individual must be motivated to counteract the cues in the immediate environment, which are arranged so as to facilitate the more probable, but maladaptive patterns of responding (approach to the short-range positive outcomes or avoidance of short-range discomfort or loss).

Self-regulation refers to a set of aroused processes through which an individual consciously and consistently contributes to maintaining the course of goal-directed behavior in the relative absence of external supports or when external supports are of limited utility. As noted earlier, self-control is a process through which individuals become the primary agents in directing and regulating those aspects of their behavior that lead to preplanned and specific behavioral outcomes and/or consequences.

A Conceptual Framework of Cognitive-Behavioral Therapy
In order to implement cognitive-behavioral strategies with children and to design an effective assessment and treatment program, it is necessary to consider a conceptual model for working with children experiencing fears, phobias, and anxiety disorders. In this regard, Karoly provided a working model for self-management that takes into account the following components:

1. First, the child's discrimination of rules and situational response requirements is necessary. Any comprehensive assessment of the child who is experiencing problems in this area will need to be assessed for their knowledge of self-management rules, acceptance of content and logic or rules, memory for rules, and ability to recognize the benefit of certain performance standards or codes of conduct.

2. A second feature of the model involves the child's awareness that his or her non-self-managing behavior has become dissonant with the environmental demands and is problematic in terms of obtaining reinforcing outcomes. Within this context, Karoly suggests assessing the accuracy of the child's awareness of the short-term nature and effects of behavior, the accuracy of the child's awareness of the long-term effects of behavior, the child's recognition of problematic features of short-run or short-term behavioral patterns and the child's awareness of his or her impact on the behavior of others in the short and long term.

3. A third component of the model involves motivation or effort and commitment to behavior change. In this regard, the child is assessed along the following dimensions: (1) the child's perception of the value of the self-managed response as compared with the perceived alternatives, (2) the nature of potentially active physiological factors either facilitating or inhibiting the desire to self-manage, (3) the stringency of the child's self-evaluative standards, (4) the child's expectancy of future goal attainment compared with the perceived cost of engaging in self-management, and (5) the child's habitual mode of attributing responsibility for the accomplishment of tasks relevant to self-management.

4. The final component of the model involves skills for extended self-management. A variety of skills have been identified as necessary in order for implementation of a self-management program. Such skills as self-observation, self-monitoring, and self-recording; self-evaluation and goal setting; administration of rewards and punishments; self-instructional control of performance; information processing, planning, and problem-solving style; imaginal control of thought and affect, self-perception, and causal attribution; and manipulation of stimuli response, response outcome, and self-efficacy expectations will be necessary.

Seven Questions
In the context of this model, the clinician can develop a detailed and comprehensive assessment of the child's ability to manage his or her own performance. The seven questions raised by Karoly can be useful in guiding assessment and eventual intervention with the child. Specifically, the following questions should be considered:

1. Would a self-management treatment model be appropriate?

2. Has the child's overt behavioral disturbance ever been conceptualized within a self-management framework?

3. Would self-management oriented interventions contribute to the maintenance of adaptive learning and/or prevention of future problems?

4. Is self-mediated form of intervention warranted on ethical grounds?

5. Is the child invested in changing a high-probability response pattern?

6. Does the assessor have access to the child's performance on a day-to-day basis with significant others or for extended periods of time?

7. Is it possible to identify the primary causes of the child's failure to achieve criterion performance by ruling out knowledge deficiencies, developmental or biological incapacities, motivational insufficiencies, skill deficits, or non-facilitative environments?

Cognitive Procedures
In the treatment of children's anxiety disorders, cognitive self-control procedures focus on helping the child develop specific thinking skills and apply them whenever he or she is confronted with a particular fear-or-anxiety producing stimulus, event or object. According to Meichenbaum and Genest, the self-control approach involves helping the child in the following areas:

1. Become aware of the negative thinking styles that impede performance and that lead to emotional upset and inadequate performance.

2. Generate, in collaboration with a trainer, a set of incompatible, specific, self-statements, rules, strategies, and so on, which the trainee can then employ.

3. Learn specific adaptive, cognitive behavior skills.

First, in order for the child to participate in cognitive therapy, he or she should be aware of the phobia or anxiety to the extent that he or she can identify the various motor aspects of the fear (i.e., what the child does when he or she is afraid); cognitive components (i.e., what the child thinks or says to himself or herself when afraid); physiological components (i.e., how the body reacts when the child if afraid, and which part(s) of the body is involved); and under which conditions he or she becomes fearful. Second, it demands that the child have the verbal capacity to generate, with the therapist, a series of incompatible self-statements and rules, which the child can incorporate (at least temporarily) into his or her verbal repertoire. Third, it demands that the child be able to apply these self-statements and rules under those conditions in which he or she experiences anxiety. In addition to these factors, Kanfer outlined the following features that must be taken into account in development of a cognitive self-control treatment program.

1. A behavior analysis, including a description of specific problem behaviors, and of positive and negative reinforcers appropriate for the client's environment that can be enlisted to aid in the behavior change process.

2. Observation and self-monitoring of the target behavior.

3. Development of a plan for behavior change. Negotiation of a contract that includes clear specification of the goals to be achieved, the time allowed for the program, and the consequences for achieving it, as well as the methods for producing the behavior change.

4. A brief discussion with the client on the underlying assumptions and rationale of the techniques to be used.

5. Modeling and role play of the desired behaviors.

6. Frequent external verification of progress and of factors that have retarded progress, as well as feedback and re-evaluation of the contract.

7. Recording and inspection of qualitative and quantitative data documenting the change. Extension of the desired behavior to many different situations or areas of life.

8. A self-reinforcement program that relies increasingly on the person's self-reactions is sufficiently varied to avoid situation and is effective in changing the target behavior.

9. Execution of new behaviors by the client in his or her natural environment with discussion and correction of the behavior, as needed.

10. Frequent verbalization of the procedural effects, the means by which they are achieved, and situations to which they can be applied in the future.

11. Continuing strong support by the helper for any activity in which the client assumes increasing responsibility for following the program accurately and extending it to other problematic behaviors.

12. Summarizing what has been learned in the change process and preparing the client to transfer the new knowledge and skills to future situations.

Dog Therapy
It is useful to review a typical cognitive-behavior therapy format for a child experiencing a phobic problem. Richards and Siegel provide and example of the use of cognitive-behavior therapy in the modification of a child's severe dog phobia. The child was taught Meichenbaum's self-control technique (self-instruction) as a supplement to other procedures. The self-instructional treatment involved the following five steps:

1. Therapists modeled adaptive self-verbalizations by talking out loud and administering task-relevant instructions to themselves while performing the task (e.g., while petting a dog appropriately, saying, "Relax, take a slow, deep breath; I'm doing fine; this dog is obviously friendly; notice his wagging tail; pet him softly; nothing to worry about").
2. The child performed the task while the therapist instructed her aloud.
3. The child performed the task and instructed herself aloud.
4. The child performed the task and whispered the instructions to herself.
5. The child interacted with dogs while using entirely covert self-instructions.
Step 2 through 5 also included extensive performance feedback and positive reinforcement to the child.

Token Economy
A token economy program was also established whereby the children received tokens for doing their exercises at home and for going to bed and being brave throughout the night. The parents were instructed to initiate the children's exercises at night and to use tokens and praise. The outcome measures included parent ratings of the number of child fears, strength of fears, and behavioral criteria (i.e., 10 consecutive fearless nights).

The results showed that it took from 3 to 19 weeks (mean=8.7 weeks) for all the children to meet the behavioral criteria. The authors further reported that each child's "fear strength" steadily decreased through post-treatment and the 3-month, 6-month, and 1-year follow-up periods. Also, total number of fears decreased, with only one out of the seven children not completely free of fears at the 1-year follow-up. Finally, both parents and children reported that the program improved the children's fear behavior and sleeping patterns.

Self-control treatments have also been applied with children experiencing medical- and dental-related fears. Using a variation of the self-control approach, Peterson and Shigetomi conducted a study with children who were to receive elective tonsillectomies. The 66 children (35 girls and 31 boys), aged 2.5 to 10.5 years (mean=5.47 years) were assigned to one of four conditions:
1. Preoperative information, where children were invited to a "party" four days before their surgery and informed via a story and a puppet of the "typical hospital stay from admission to discharge."
2. Coping procedures, where children received the preoperative information plus cue-controlled muscle relaxation (using the cue "calm"); distracting mental imagery training (imagining a scene that was "quiet and made them feel happy"); and comforting self-talk (the children, for example, were encouraged to think of the phrase "I will be all better in a little while").
3. Filmed modeling, where the children received the preoperative information.
4. Coping plus filmed modeling, where the children were also given a 15-minute hospital tour and spent another 15 to 20 minutes eating ice cream and cookies following the tour.

Six categories of dependent measures were used. The assessment included observational ratings, physiological measures (pulse rate and temperature), and child and parent self-reports.

The results indicated that children receiving the two coping conditions experienced less distress during their hospital stay than did the children in the modeling-only or information-only groups. Furthermore, children receiving the coping-plus-modeling procedure were more calm and cooperative during invasive procedures than were those in the coping or modeling alone conditions.

In another study, Siegel and Peterson conducted similar research with children undergoing dental treatment. They compared the coping-skills condition described earlier with a sensory information condition (i.e., children were told what to expect and heard audio tape recordings of the dental equipment) and no-treatment/attention condition. The results indicated that there was no significant difference between the coping and sensory information conditions on any of the measures taken during or after restorative treatment, and that both treatment groups fared better on the measures than did the no-treatment control children.

Emotive Imagery
Cognitive procedures have been integrated into other forms for the treatment of children's anxiety disorders. For example, one variation desensitization involves "emotive imagery," a method first used by Lazarus and Abramovitz to adapt the desensitization procedure to children. Generally, the procedure involves the use of anxiety-inhibiting images that arouse feelings of excitement associated with positive experiences. In the procedure, a gradual hierarchy is developed. The clinician establishes child hero images, and the child is then asked to close his or her eyes and imagine a sequence of events in which a story is developed about the child's favorite hero. Once the child's emotions are maximally aroused within the story, the lowest item on the hierarchy is presented. The procedure is repeated throughout the systematic desensitization hierarchy until each item is tolerated without distress.

The procedure depends greatly on the child's visual imagery or cognitive skills. Unfortunately, there is little empirical research on this topic. For example, Lazarus and Abramovitz reported some descriptive case studies in which the procedure was used with a dog-phobic 14-year-old, a 10-year- old who was afraid of the dark, and and 8-year-old who was afraid of going to school. The procedural steps discussed earlier were implemented, and the authors reported a reduction in the children's fears. In addition, Ayer reported the use of this visual imagery technique with three children who were afraid of going to the dentist. Specifically, the children were afraid of receiving the anesthetic and were said to have needle phobias. The children were asked to imagine they were playing with their dogs and the dogs were yelping loudly (minor variations were scheduled with one child). They were then told to keep their eyes closed so they would see none of the dental instruments. This was practiced several times while they imagined the dogs yelping louder and louder. During the dental procedure the children were encouraged by the clinician to intensify the dog's yelping. The anesthetic was then administered in a routine fashion. The author reported that by the third appointment, the children were "visibly relaxed and friendly." More recently, Jackson and King successfully treated a 5-1/2-year-old boy who was afraid of the dark. A fictional character, Batman, was chosen in a scenario in which the child and Batman joined forces to overcome the fear of the dark. Unfortunately, work in this area has remained at the descriptive case study level, so firm conclusions cannot be drawn from this area of research.

Behavior Therapy
Interestingly, some behavior therapy treatments developed independently of the cognitive therapies have been conceptualized as having a cognitive component or focus. For example, Goldfried viewed systematic desensitization as training in self-control -- that is, an active, cognitively mediated process of learning to cope with anxiety, rather than a passive, counter-conditioning one. Procedural modifications to increase self-control features with this method include the following
1. Clients are taught how to relax, how to recognize tension, and how to use relaxation skills to relieve tension.

2. During the tension phase of relaxation exercises, clients focus on feelings of tension and become more sensitive to them. These feelings serve as cues for the application of relaxation.

3. Hierarchies are used that include many different anxiety-arousing themes in order to maximize transfer of the coping skills and increase the variety of situations in which self-control is practiced.

4. At the first experience of tension, clients signal and then continue imagining the scene while actively relaxing away the tension.

5. Clients signal when the anxiety is brought under control and they are once again deeply relaxed. The scene is then cleared, representing a successful trial of coping with tension.

6. Relaxation homework is emphasized, and in vivo application is reinforced and modified in light of the homework assignments.

(Excerpted and adapted from Michelson and Ascher)

Cognitive Behavioral Therapy in Anxiety Disorders:
Current State of the Evidence
Current Diagnosis and Treatment of Anxiety Disorders

- Otte, C. (2011). Cognitive Behavioral Therapy in Anxiety Disorders: Current State of the Evidence. Dialogues Clin Neurosci., 13. p. 412-421.

- Bystritsky, A., Khalsa, S. S., Cameron, M. E. (2013). Current Diagnosis and Treatment of Anxiety Disorders. P&T, 38(1). p. 30-57.

Personal Reflection Exercise #5

The preceding section contained Research and Treatment interventions to use with Children. Write three case study examples regarding how you might use the content of this section of the Manual in your practice.

Peer-Reviewed Journal Article References:
Gallagher, M. W., Phillips, C. A., D'Souza, J., Richardson, A., Long, L. J., Boswell, J. F., Farchione, T. J., & Barlow, D. H. (2020). Trajectories of change in well-being during cognitive behavioral therapies for anxiety disorders: Quantifying the impact and covariation with improvements in anxiety. Psychotherapy, 57(3), 379–390.

Reaven, J., Moody, E. J., Grofer Klinger, L., Keefer, A., Duncan, A., O'Kelley, S., Meyer, A., Hepburn, S., & Blakeley-Smith, A. (2018). Training clinicians to deliver group CBT to manage anxiety in youth with ASD: Results of a multisite trial. Journal of Consulting and Clinical Psychology, 86(3), 205–217.

Van der Giessen, D., Colonnesi, C., & Bögels, S. M. (2019). Changes in rejection and psychological control during parent–child interactions following CBT for children’s anxiety disorder. Journal of Family Psychology, 33(7), 775–787.

Online Continuing Education QUESTION 22: What are three examples of behavioral treatments to use with anxiety disordered children? To select and enter your answer go to CE Test.

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