Cognitive Behavioral Therapy for Generalized Anxiety in a 6-Year-Old

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DOI: 10.1177/1534650103259632

2004; 3; 216Clinical Case Studies Kristen G. Anderson

Cognitive Behavioral Therapy for Generalized Anxiety in a 6-Year-Old

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10.1177/1534650103259632CLINICALCASESTUDIES/ July 2004 Anderson/ CBTFOR GAD IN A6-YEAR-OLD

Cognitive Behavioral Therapy forGeneralized Anxiety in a 6-Year-Old

KRISTEN G. ANDERSONUniversity of California, San Diego

Abstract: Cognitive-behavioral treatment has been identified as a probably efficacioustreatment foranxiety disorders in children. In the treatment of generalized anxiety disorderin childhood, two cognitive-behavioral treatments have received the most empirical atten-tion, Kendall’s “Coping Cat” program and Silverman and Kurtines’s transfer-of-controlapproach. Thefollowingcase study involves theuse of thetransfer-of-controlapproach andmedication in the treatment of a 6-year-old with generalized anxiety disorder. At the onset

of treatment,this child wasunable to engage in age-appropriate socialactivities, eat in pub-lic, and be separated from his parents. In addition, he had lost 10 pounds and was havingsignificant difficulties sleeping.At 3-month follow-up, he wasreengagedwith hispeers,sep-arating from his parents, and had returned to his normal weight.

Keywords: cognitive-behavioral therapy,generalizedanxiety disorder, transfer-of-control

1 THEORETICAL AND RESEARCH BASIS

Prevalence rates for generalized anxiety disorder (GAD) in children range from3% to 6% (Moore & Carr, 2000). Previously identified as “Overanxious Disorder of

Childhood” (Diagnostic and Statistical Manual of Mental Disorders [3rd ed., rev.][DSM-III-R], American Psychiatric Association, 1987), this disorder was subsumedunder the diagnosis of GAD in DSM-IV (American Psychiatric Association, 1994).GAD is associated with excessive anxiety and worry about a wide range of activities oreventscausing clinically significant impairment and distress. In addition to being unableto control their anxiety, children must also have one of the following symptoms: restless-

ness, fatigue, concentration difficulties, irritability, muscle tension, and disturbed sleep.In childhood, these concerns often center on performance or competence in school(DSM-IV ) . Considered a chronic disorder (Ollendick & King, 1994), the mean age of onset of GAD in childhood has been identified as 8.8 years of age (Wagner, 2001).

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AUTHOR’S NOTE: The authorwishes to thank RichardMilich, Ph.D., for his guidance on this case and support in thepreparation of this article. Correspondence concerning this article should be addressed to Kristen G. Anderson, Ph.D.,University ofCalifornia,San Diego,Brown Lab, McGillHall,9500Gilman Drive,M/C 0109,La Jolla,CA 92093-0109.

CLINICAL CASE STUDIES, Vol. 3 No. 3, July 2004 216-233DOI: 10.1177/1534650103259632© 2004 Sage Publications


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The role of familial factors in the development and maintenance of generalizedanxiety disorder have been mixed (American Psychiatric Association, 1994; Southam-Gerow, Kendall, & Weersing, 2001; Wagner, 2001). In a review of the literature on

GAD, Wagner (2001) suggests that children of parents with an anxiety disorder havemore than a fivefold chance of manifesting an anxiety disorder. In addition, she citesresearch (Kendler, Neale, Kessler, Heath, & Eaves, 1992) suggesting that heritabilityestimates for GAD are about 30% for shared genetic factors.

Treatments for GAD in children range from cognitive-behavioral treatments topsychodynamic approaches to pharmacotherapy (Moore & Carr, 2000; Wagner, 2001).

Cognitive-behavioral treatment (CBT) with or without a family-based component hasbeen identified as a “probably efficacious treatment” for anxiety disorders in childhoodbased on the guidelines set for empirically supported treatments by the APA Task Force(Ollendick & King, 1998). Moore and Carr (2000) identify this type of treatment as thetreatment of choice for GAD. Kendall’s (1994) “Coping Cat” program and Silverman

and Kurtines’s (1996a, 1996b) CBT programs have been the focusof a number of empir-ical investigations (Berman, Weems, Silverman, & Kurtines, 2000; Moore & Carr,2000; Silverman, Kurtines, Ginsberg, Weems, Rabian, et al., 1999; Southam-Gerow etal., 2001).Thiscase study involves theuse of SilvermanandKurtines’s (1996)transfer-of-control approach in the treatment of a 6-year-old with generalized anxiety. This cognitive-behavioral treatment integrates parents into the treatment of a child’s anxiety disorder,

transferring the control of treatment as it progresses.The transfer-of-control approach is based on the idea that “effective long-term

child psychotherapeutic change involves a gradual ‘transfer of control’ where thesequence is generally from therapist to parent to child” (Silverman & Kurtines, 1996a,p. 58). In this model of treatment, the therapist functions as a consultant, providing par-

ents and child with the skills necessary to facilitate behavioral change and to maintaintreatment gains. The focus is on the control of anxiety and the use of exposure as themain mechanism for change. Exposure, both in vivo and imaginal, is used to reduce theanxiety experienced by children by providing them with the experience of conqueringtheir fears. Contingency management, through use of contracts, and self-control train-

ing are used to facilitate the child’s progressthrough the exposure experiences. The rein-forcement provided through the contracts allows the child to develop approach behav-iors to previously avoided stimuli. It also allows parents to become central agents inchanging their child’s behavior. Training for both parents and child in self-control tech-niques provides skills in cognitive restructuring and reward, fostering approach behav-iors in the child and self-reliance for maintenance of treatment gains within the family

(Silverman & Kurtines, 1996a).The basic structure is a 10- to 12-week treatment program involving both individ-

ual sessions with the parents, individual sessions with the child, and a joint session, total-ing 80 minutes. Included are an education phase, an implementation phase, and arelapse prevention phase. The education phase involves orientation of the family to the

Anderson / CBT FOR GAD IN A 6-YEAR-OLD 217




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treatment approach, providing an understanding and rationale for the mechanisms forchange in the program (exposure, fear hierarchies), introduction to contingency man-agement and self-control skills, and the strategies used in implementing the treatment

program (in- and out-of-session activities). In this phase, a fear hierarchy, the basis forexposure tasks, is developed. Specifying the treatment program to a particular anxiety

disorder is attained through formulation of the fear hierarchy and treatment goals; thehierarchy is based on anxiety-provoking situations for the particular child, reflecting hisor her particular disorder (Silverman & Kurtines, 1996a).

The implementation phase focuses on changing the child’s behavior. During thisphase, the child engages in gradually more fear-inducing tasks on the hierarchy, sup-

ported by behavioral contacts with rewards and self-control strategies. The therapistworks with the family to monitor the child’s progress through the hierarchy, problem-solve any issues that might arise, and support continued learning and use of skills. Thefinal phase of treatment involves relapse prevention, including a review of progress and

skill development,howto interpret “slips,” andstrategies forhandling issues in thefuture(Silverman & Kurtines, 1996a).

Empirical support has been shown for this type of treatment for anxiety disorders.Silverman, Kurtines, Ginsberg, Weems, Rabian, et al. (1999) examined efficacy of con-tingency management, self-controltraining, and educational supportin the treatment of childhood phobias (simple phobias, agoraphobia, and social phobia). They found thatall three were effective in generating clinically significant change in phobic symptoms

across time. However, they did find evidence that contingency management and self-control training were more effective than educational support on some outcome mea-sures. In an investigation of the effectiveness of the transfer-of-control approach in agroup-administered format, Silverman, Kurtines, Ginsberg, Weems, Lumpkin, et al.

(1999) found significant improvement in treatment groups over wait-list controls, withtreatment gains being maintained 12 months postimplementation.

Berman et al. (2000) investigated factors associated with treatment outcome in asample of children 6 to 17 years of age using this approach in individual and group set-tings. Predictors of treatment success, defined as either no longer meeting DSM criteriafor their primary diagnosis or showing a major reduction of symptom severity, were

examined. It was found that comorbid diagnoses of depression, trait anxiety, parentalsymptoms of depression, fear, and paranoia predicted poor treatment outcome. How-ever, age, ethnicity, and familyincomewere notrelated to treatmentoutcome. No differ-ences were found between treatment success and failures for type of primary diagnosis,number of concurrent diagnoses, or severity of the disorder (Berman et al., 2000). These

findings, in conjunction with more general findingsas to the efficacy of CBT (Ollendick& King, 1998) in the treatment of child anxiety, provide support for useof Silverman andKurtines’s (1996a) approach to treating child anxiety.

218 CLINICAL CASE STUDIES / July 2004




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2 CASE INTRODUCTION

Steven M., a 6-year-old White boy, was seen at an outpatient mental health center

in a large, midwestern city. All names within this case study have been changed andnon-essential information regarding his treatment was modified to protect the identity of hisfamily.

3 PRESENTING COMPLAINTS

His mother had contacted the clinic for an evaluation of Steven’s current level of cognitive abilities because of his complaints of being “bored” in school. Mrs. M alsoexpressed concerns that Stevenmaybe suffering from some form of anxiety related to hisschool experience. She reported that his teacher was concerned that he refused to eat at

school and seemed very anxious. In tandem with Steven’s lack of eating at school, Mrs.M reported that Steven had begun to resist going to school, stating that it was “boring”and that she was concerned that anxiety may be playing a role in both of these behaviors.

When the evaluator suggested that a more in-depth evaluationmight be needed,Mrs. Masked that an intellectual assessment be performed first to rule out boredomas the causeof his resistance to attending school.

4 HISTORY

Stevenwas the only child of upper-middle-class, professional parents. Both parents

were employed outside the home anddedicated a large amount of their nonwork time toSteven. Mrs. M reported that Steven’s pre- and postnatal development was typical, andthat he had not suffered from any major illnesses or injuries. Both parents reported thatSteven hadbeen an “irritable” and“challenging” infant. He hadbeen difficult to sootheas an infant and required a large amount of attention. In toddlerhood, Steven had dem-onstrated excessive control of his bowel movements. At one time, he required medicaltreatment owing to his refusal to go to the bathroom. Approximately 2 years before seek-

ing treatment, Steven had gone through a period of compulsive hand washing that hadspontaneously remitted. Steven’sparents andteacher indicatedthat hisschool transitionhad been “traumatic” (crying, screaming, etc.). It had taken him months to transitioninto kindergarten, but he had less difficulty with the first-grade transition because of the

presence of the same teacher and classmates. Approximately 6 monthsbeforecoming to the clinic, Stevenhad begun to demon-

strate increasing levels of fear. These included significant difficulties leaving his mother





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to go play with friends or allowing her to be away from him, refusing to attend SundaySchool, and difficulties in separating from his parents to stay with other family members(with whom he had stayed with many times previously). In addition, his parents also

reported that he had fears of people being away from him, fears of getting sick when eat-ing in public, and a preoccupation with being embarrassed. It was reported that he

seemed “tense” and “nervous” and consistently ground his teeth while sleeping. Signifi-cantly impairing checking behaviors (needing to know where his parents were withinthehomeatalltimesandcheckingtoseeiftheywerewheretheysaidtheywouldbe)andneeding the objects in his room in order were reported. Although the severity of thesebehaviorshadincreasedover time, many of these behaviorshadbeen reported, at a lesser

severity, for years.In a phone interview with Steven’s first-grade teacher, he was described as a very

“bright” and“well-liked”boy. Mrs. Smithindicatedthat he wasa “model student” in kin-dergarten but almost overly so. In first grade, he occasionally talked to his friends while

she was speaking and might speak without raising his hand, behaviors more normativefor his age. Socially, Mrs. Smith described Steven as well liked and appropriate. How-ever, she reported that he seemed to be more fearful than the average child.

Mrs. Smith also reported that Steven had significant difficulties with changes inroutine in the classroom. She reported that he had severe problems with fire drills andthat during his first fire drill, he had cried and displayed extreme fear. Mrs. Smith alsoindicated that Stevenseemed fearfulduring schoolwide assemblies and would sit on her

lap or right next to her during them. She spontaneously described similar checkingbehavior ashisparents. Mrs. Smith reported that he wanted to knowwhere she was whenhe was out of the classroom and where her aide was if he could not see her. The teacherreported an incident where Steven became very agitated and upset when the teacher’s

aide was out owing to illness.Steven had seen his pediatrician 1 month before seeking an assessment. Mrs. M

had expressed her concerns to the doctor about Steven’s refusal to eat in school and inpublic. Despite his recent 10-pound weight loss, the doctor had indicated that becauseStevencontinuedto grow,she was not especially concernedabout the eating difficulties.Steven’s mother indicated that Steven had weighed more than his age mates so that his

weight loss put him closer to the norm.Steven’s parents also reported that there was a family history of anxiety and depres-

sion on both sides of their family. Steven’s father had suffered from panic disorder in thepast and was on maintenance medication. His grandfather had also suffered fromuntreated bipolar depression. On his maternal side, it was reported that a number of

members of his mother’s family had sought treatment for internalizing disorders.





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5 ASSESSMENT

Given his mother’s request that Steven be administered an intellectual assessment

first, he was given the Wechsler Intelligence Scale for Children–Third Edition (WISC-III; Wechsler, 1991). After this was completed, Steven’s parents agreed to return to theclinic to provide information regarding his symptoms of anxiety.

BEHAVIORAL OBSERVATIONS

Steven was an attractive little boy who dressed neatly. He was very nervous at thebeginning of the assessment. He reported that he enjoyed school, especially playingdodge ball at recess and spelling. He indicated that he attended an after-school programat his school that he enjoyed. Steven said that he hadfriends both at school andat home.He indicated that he spent a lot of time with his best friend, playing after school and on

weekends. Steven also reported enjoying playing soccer on a team and playingvideogames. He denied concerns about going to school or eating lunch there.Steven refused to wait in the waiting room or in the room next door to the examina-

tion room while the examiner spoke with his mother. After negotiation, Steven allowedhis mother to be interviewed alone with the agreement that he couldstay next door if thedoor to the examination room were left open. Afterwards, Steven readily agreed to stay

with the examiner for testing and quickly developed rapport with the examiner. He wasopen and pleasant throughout the testing session.

During the test administration, Steven was highly motivated to perform andseemed concerned about doing well. He often commented that particular items were“getting hard.” He explained to the examiner that he liked testing because “It keeps

changing. It isn’t boring because we’re not doing the same thing over and over.” Stevenseemedfrustratedat times when theexaminerwasrequired to repeat directionsfora task.He said that he knew how to do the tasksafter the directions hadbeenexplainedonce.

TESTING RESULTS AND INTERPRETATION

On the WISC-III, Steven obtained a Full Scale IQ of 128 (CI = 122-132; 97th per-centile),placing himwithin theSuperior range of intellectual ability. Both hisVerbal IQ

andPerformance IQ scoreswere 126, falling withinthe Superior range.Stevenobtaineda score of 130 on the Verbal Comprehension Index, placing him in the Very Superiorrange. On the Perceptual Organization Index, Steven obtained a score of 123, placing

him in the Superior range. Steven obtained a score of 115 on the Freedom fromDistractibility factor, placing him in the High Average range for his age. The Freedom





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from Distractibility Index taps attention, concentration, and the ability to work withinformation in short-term memory. Compared to his performance on the other indices,this is an area of relative weakness for Steven. On the Processing Speed Index, Steven

received a score of 119, placing him within the High Average range.

CLINICAL EVALUATION

Mr. and Mrs. M returned to the clinic to complete a diagnostic interview (Parent Version–Children’s Interview of Psychiatric Symptoms; Weller, Weller, Fristad, &Rooney, 1999) at the examiner’s request. They reported significant difficulties in getting

to the clinic dueto an outburst by Steven prior to their leaving. Mr. and Mrs. M indicatedthat although they had attempted to prepare him for their departure, he had misunder-stoodandbelievedthatMr.Mwouldbestayinghomewithhim.Instead,hewastostayathis grandmother’s home while they attended the meeting. They reported that Steven

“lost control” and that it was always stressful for them to leave him. Mr. and Mrs. Mstated that he becomes “stressed” in these situations (scowling face, punching the air in

their direction, kicking at objects, saying something “nasty”). Mrs. M stated that hebecomes so “keyed up”in these situations that he is unable to stop this type of acting-outbehavior. Becauseof these outbursts, it seemedthe family waslimited in their options forchild care. Asa result, either Mr. orMrs. M stayed homewithStevenwhen necessary.

Steven’s parents reported that he was experiencing overwhelming anxiety, mani-

fested through symptoms of separation anxiety and obsessive-compulsive characteristics.It also seems apparent that this anxiety was setting the stage for explosive reactions tooverstimulation and a loss of control. Although Steven met full criteria for separationanxiety disorder, generalized anxiety disorder, and oppositional defiant disorder, it

seemed apparent that his oppositional behavior was an outgrowth of an inability to copewith hissymptoms of anxiety.It appeared thatSteven’sobsessive and oppositional behav-ior were manifested when he has lost control of his environment throughoverstimulation or an unexpected change in routine.

On the basis of parent and teacher interviews (see Section 4), Steven seemed to befacing significant impairments in functioning, as indicated by his high levels of anxiety.Such anxiety seemed to be manifested in clinically significant separation anxiety and

multiple symptoms of obsessive-compulsive disorder. Steven’s oppositional-defiantbehavior appeared to be evident in the home environment as a manifestation of hisattempts to cope with overwhelming anxiety and loss of control. Mrs.M reported feelinglike Steven “saved up” his agitation and aggression until he got home from school.

Greene (1998) described children with these levels of inflexibility and anxiety as puttingso much energy into maintaining control during the school day that they “melt down”when they get home from school (p. 58).





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DIAGNOSIS

Although Steven exhibited significant strengths in the area of intellectual abilities,he was demonstrating clinically significant impairments in his ability to cope with anxi-

ety. At the time of his evaluation, he met criteria for separation anxiety disorder, general-ized anxiety disorder, and oppositional defiant disorder. In addition, he demonstratedsome features of obsessive-compulsivedisorderthat mighthavebeen additionalattemptsto modulate his anxiety.

6 CASE CONCEPTUALIZATION

Given Steven’s family history of internalizing disorders, it is possible that geneticfactors and learning factors playeda role in the manifestation of his disorder. Mr. M’s his-tory of panic disorder could have affected Steven either through direct transmission of

risk or through modeling of anxious reactions to environmental stimuli. Past researchhas suggested that children of parents with panic disorder are more likely to have chil-dren who are behaviorally inhibited or fearful (Rosenbaum et al., 1988). Although thereis some evidence to suggest that temperamental characteristics might have a geneticloading (Plomin & Stocker, 1994), other research suggests that parental anxiety mightalso shape child behavior through the modeling of anxious reactions or parenting style

(Barrios & O’Dell, 1998).Steven seemed to demonstrate high levels of behavior inhibition in novel situa-

tions. From hisparents’ description of his behavior in early childhood, Steven seemedtohave difficulty self-regulating his emotional and physical states as well as having a lowtolerance for excess stimulation. These temperamental characteristics, or behavioral

style, are consistent with Thomas and Chess’s (1977) conception of a “difficult child”.Past research hassuggestedthatbehavioralinhibition, sometimesseen as associated withthe difficult temperamental style (Rothbart, 1991), has been linked to the developmentof later anxiety disorders (Caspi, 2000; Muris, Mercklebach, Wessel, & van de Ven,1999; Rosenbaum, Biederman, & Gersten, 1991). On the basis of Steven’s family his-tory, it was unsurprising that he was faced with an internalizing disorder.

7 COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS

During the feedback session, it was recommended to Steven’sparents thatthey seea child psychiatrist, well versed in the treatment of anxiety disorders, to provide themwith information about options for pharmacological treatment. Given his high levels of

anxiety, his ability to learn from psychosocial interventions seemedin doubt. Hisparents





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were also referred to parent training to learn strategies to manage Steven’s oppositionalbehavior. Although his parents were willing to seek a referral and parent training, theyasked if it was possible for Steven to have individual therapy in addition to their own. It

was agreed that the family would begin treatment after they had sought consultationwith a child psychiatrist.To selecta treatment program that best metthe needs of Steven’sfamily, a reviewof

the literature on the treatment of child anxiety and consultation with other professionalswas completed. The transfer-of-control approach seemed to best match the treatmentneeds of this family; its integration of individual sessions with the child, parents, and the

family, the presentation of behavior modification training that could be used acrossdomains by hisparents, and training in the use of coping skills seemed most appropriate.Given the high level of motivation demonstrated by Steven’s parents and Steven, thisprogram seemed an optimal way to meet the family’s needs.

SESSION 1

The first session was scheduled 6 weeks after the completion of the assessment

because of a holiday hiatus. Prior to this meeting, Steven had seen a child psychiatristwho had prescribed Prozac 5 mg per day for his anxiety. At the time of the initial session,he had been on the medication for almost 5 weeks. Mr. andMrs. M reported satisfactionwith the psychiatrist they had seen and reported some improvement on the medication.For example, Steven was able to play outside for 30 to 40 minutes without checking on

them. However, he continued to demonstrate significant difficulties with separation andhad difficulties returning to school after the recent holiday.Mrs.M was particularly con-cerned by a recent comment by Steven that he was “tired of being scared” and wanting

help.In this meeting, Steven reported that he was having difficulties eating in the morn-

ing before school and at lunch (during his assessment, he had denied these difficulties).He stated that he felt very hungry in the morning but was afraid that he would get sick orvomit if he ate in school. When asked if he had ever been sick in school, Steven said no.However, he did tell a story of an incident where he hadbeen sick after eating in a restau-rant with his parents. Mr. and Mrs. M verified this story and said that he had come down

with the flu a few months before. After eating at a restaurant, he had vomited when theyhad gotten home. Steven said he worried about being sick at school all of the time. Heacknowledged that he was also worried that his parents would not pick him up fromschool. When asked if they had ever left him at school, Steven said no.

The majority of this session was spent outlining the treatment program andtransfer-of-control approach. The treatment plan outlined was composed of 10 to 12treatment sessions consisting of 50-minute sessions (for modification of session length,see Silverman & Kurtines, 1996a, 1996b). It was agreed that these sessions wouldinclude individual meetings with Steven, parent meetings, and meetings as a family. In





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four sessions, it was agreedto discuss the progress of treatment andto reevaluate thetreat-ment plan.

SESSIONS 2-4

These sessions were dedicated to the education phase of the treatment program.Steven’s parents were provided with information on exposure, learning theory, contin-gency management programs, and relaxation skills. Individually, Steven was taughtrelaxation breathing whereas his parents were provided with information on how toguide Steven through the use of these strategies. Both individually with Steven and

jointly with his parents, a fear hierarchy wasdeveloped and refined. At the top of his hier-archy was being in a noisy place, followed by spending the night at someone’s house andother activities requiring being away from his parents or eating in public. Steven wasallowed to set the behaviors andratings of fearson his hierarchy. In the followingsession,

the family met to discuss these activities and negotiated to add other activities to the listthat also were the source of anxiety. In addition, an awards menu was developed to serve

as reinforcers forSteven’ssuccessfulengagement in activities on his fear hierarchy. In hisfirst menu, activities were chosenthat were naturally reinforcing forSteven(e.g., 30 min-utes of his father’s time playing a game of his choice or baking cookies with his mother)and were not generally available to him.

Beginning in Session 3, homework assignments and contracts were implemented.

The first contract was designed to provide Steven with success on his first attempt. Anactivity was chosen for hishomework that did not induce fear buthad been the source of conflict and defiant behavior from Steven. Tension between Steven and Mr. M hadbeen building over their weekly trip to martial arts class. They attended together and

seemedto enjoy the activity, but preparationforleaving had becomea source of conflict.Steven would begin to become agitated when asked to prepare his bag to leave and

would argue with his father about going. Steven denied feelings of anxiety about theactivity or leaving home, but seemed to be facing difficulties with the transition. A con-tract was drawn between Steven and his father statingthat Steven would attend class andget ready for class without argument.

Session 4 began to set the pattern for the rest of therapy. Steven and his parents

would meet briefly with the therapist to reviewhisprogress on his homework assignmentand what he had chosen from his awards menu. Praise and encouragement were pro-vided to the family for their accomplishments of the previous week. The therapist wouldthen meet with Stevenand hisparents individually. Prior to the endof session, the family

would meet again to set the new contract for next week’s homework.This session, Steven’s parents reported that Steven hadeaten twice at school andat

his after-school program the previous week, a small candy bar on one occasion and apiece of cake and juice on another. When asked how he was able to eat, Steven said that“I just did it” and that he did not feel scared anymore. This led to a modification of his





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hierarchy, dropping eating at school to a less feared task. Steven’s parents also reportedthat they had seen the child psychiatrist that week. The doctor had decided to increaseSteven’s dose of Prozac to 10 mg daily because of a leveling off of treatment gains from

the medication. With the aim of increasing the difficulty of the homework assignments, the thera-pist introduced tokens into the contingency program. Steven would earn one ticket foreach aspect of the contract he was able to complete. This would allow the activity to bebroken down into smaller units, providing Steven with the opportunity for successwithin each homework assignment even if he was unable to complete an entire expo-sure. It was agreed that Steven had to “spend” the tickets he earned before the next ther-

apy session because Steven’s father had expressed concerns that Steven tended to hoardmoney and suggested that Steven needed to use his tickets weekly. Given Steven’s spon-taneous eating at school, continuing his progress in this arena was targeted. His home-workwas toeatat least one biteof foodor drink one juice box atschool 3 out of5 days. For

each successful day, Steven would earn a ticket. Completion of this task would beverified by self-report and teacher report.

During this period, the therapist had the opportunity to consult with the child psy-chiatrist on the case. The doctor was very supportive of the cognitive-behavioral treat-ment being conducted with Steven and was very happy with Steven’s progress. Heexpressed his appreciation of Mr. and Mrs. M’s dedication to their son’s treatment andtheir compliance with recommendations. Given the family history of anxiety and Ste-

ven’s history of behavioral inhibition, he felt that medication treatment in tandem withexposure and skills-based training seemed an optimal treatment strategy.

SESSIONS 5 AND 6

Steven successfully completed his homework assignment of eating at school andearnedall of his tickets. In Session5, relaxation training wasreviewed andpracticed. Ste-

ven’s parents expressed concerns about potential side effects from the medication anddiscussed the progress of treatment with the therapist. They expressed concerns that themedication might be leading to hyperactive behavior in Steven. The therapist suggestedthey speak to their psychiatrist about these concerns. Despite these issues, Mr. and Mrs.M expressed satisfaction with the treatment gains so far. Steven and his parents contin-

ued to seem motivated for treatment and followed the treatment program. His nexthomework increased the quantity and frequency of his eating required to earn hisreinforcers.

Session 6 began with Steven’s report that he had eaten at his friend’s house the pastweekend. He seemed very excited and proud that he haddone so. He discussed what hadmade it easy or hard for him and what he had done to face his fear. Steven indicated that

he did not think eating at school or in his after-school program was a problem now. Afterdemonstrating his ability to eat at a friend’s house, it was decided to begin the process of





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working on his separation fears. During this session, Steven and the therapist identifiedhis fears about being away from his parents using a “thought bubble” technique. Stevenwas asked to draw a self-portrait. On a separate sheet of paper, the therapist had drawn a

thought bubble like those used in cartoons. Steven was asked what he thought aboutwhen he thought about being away from his parents. These thoughts were then writtenin the bubble. Examples of these thoughts included, “The person I will stay with will bemean”and“I will get sick while my parents are gone.” The therapist then guided Steventhrough a thought challenge procedure where Steven would generate alternativehypotheses of what could happen in these situations (e.g., “The person I would staywith

could be fun and play games with me.”).

SESSIONS 7-10

These sessions targeted Steven’s fears of separation using in vivo exposure. In the

first of these sessions, Stevenwasable to earn tickets forsuccessive steps involved in beingseparated from his parents at home. In Session 7, an exposure task was developed where

Stevenhad the opportunity to earn one ticket forbehaving appropriately whenhis fatherleft home (saying “Goodbye, Dad” and wavingas his father left), the secondfor doing thesame when his motherleft 2 minuteslater,and the third forcompleting thoughtbubblesabout the experience with his therapist while his parents were away. Steven did not evi-dence fear until it was time for his mother to leave. At that time, he seemed nervous but

was able to complete his assigned task. He indicated that he felt “a little scared” when sheleft. Steven successfully earned all three tickets and said that the experience was “fun” atthe end of the session.

In the secondin vivo session, Stevencompletedthesame process but increasedthe

length of time away from his parents. During this session, he was introduced to thethought-stopping and self-praise aspects of self-control training. In the “Stop Signal”

task, Steven was taught how to identify that he was afraid (by identifying physiologicalfear cues), identifying the thoughts associated with his fear, generating alternativethoughts about the event, and praising himself for completing the task. Steven quicklyunderstood the procedure. He completed the stop signal assignment and earned allthree of his tickets. During the exposure, he neither reported nor displayed any fear.

After the exposure was over, his parents expressed concerns that Steven’s trust of the therapist had limited the fear he had experienced during the exposure. The gradualnature of exposure was reiterated and plans were made to meet at their home the follow-ing week to introduce a stranger into the exposure task.

In Session 9, the therapist arrived at the session with a therapist from the clinic whowas unknown to Steven. The goal of this session was for Steven to be faced with stayingalone with a stranger. The contract afforded Steven the opportunity to earn one ticketeach forappropriatelysayinggoodbye to hisparents, saying goodbyeto his therapist a fewminutes later, and then playing with the stranger for 30 minutes until the therapist and





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then his parents returned. Steven earned all three tickets during the exposure taskwithout much difficulty.

When meeting with his parents, Mrs. M reported that Steven had gone out to din-

ner the previous weekend with their neighbors. She stated that he had seemed hesitantto accept the invitation at first butwithout prompting had decided to go. Steven said that

he had a good timeand seemed proud ofhis ability to go out with his friend. Mrs. M alsoreported that Mrs. Smith had commented on a change in his behavior at school. Theteacher had remarked that Steven was being more social in the classroom and seemedhappier. Mrs. M stated that she felt his demeanor had changed in the last few months.She also felt he seemed more “gregarious”and “lighthearted.” Given his progress in sep-

arating from his parents, it was decided that Steven was ready to try to stay with ababysitter. A homework contract was drawn in which Steven could earn his tickets bystaying with a babysitter for 2 hours.

Session 10 took place in the clinic with Steven andhis father (his mother was ill). It

was reported that Steven had successfully earned his tickets for staying with hisbabysitters. In the individual meeting with the therapist, Steven stated “I have doneeverything onmy list!”He was able to articulate what he had accomplishedon his hierar-chy, and described the skills and strategies he had learned in treatment, but indicatedthat he “hadn’treally needed to use them.” After reviewing Steven’s treatment gains withhis father,including his spontaneousactivities of dining out with neighbors andeating atschool, it was decided to meet in 2 weeks. Steven drew up a contract with his father to

engage in three completed activities from his hierarchy (staying at a friend’s house, stay-ing with a babysitter, or eating in public with someone other than his parents) in the next2 weeks.

SESSIONS 11 AND 12

Session 11 began the relapse prevention portion of the program. Steven’s last

homework assignment and the treatment plan were discussed. Steven had successfullycompletedhis last homework assignment and had earned his reward.He had also joineda friend on a trip to the zoo 2 hours away, gone out to dinner, and a movie with friends,and had attended a sleepover next door. Mrs. M indicated that Steven had stated that hefelt he did not need to come to the clinic anymore because “I’m not scared anymore.”

She also reported that Steven had regained the 10 pounds he had lost before coming totreatment and was sleeping much better. In discussing his treatment plan, it becameobvious that Steven had been able to complete all of the tasks in his hierarchy and had

met his treatment goals. It wasdecided that the family would meet with the therapist in 1month’s time for a booster session and then decide if termination was appropriate.

During the booster session, Mr. and Mrs. M reported that Steven continued to

show improvement. His parents had been ableto successfully implement a contingency





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9 FOLLOW-UP

The family returned to the clinic 3 months later for a termination session. Steven

excitedly described his trip to stay with an aunt in another state without his parents. Heenjoyed the “adventure” with his cousins, and his parents reported no difficulties withthe separation. In addition, he had gone on a number of overnights with friends and hadno difficulties eating in public. Mr. and Mrs. M indicated that there had been anincrease in Steven’s anxiety within the last few weeks over the beginning of the new

school year. Steven was being advanced to a combined 2-3 classroom and would have anewteacher. However, that evening they hadattended an open house at the school.Mrs.M reported that Steven had used his relaxation breathing in the car on the way to theschool and after meeting his new teacher seemed muchmore relaxed. When asked howhe felt about going to school, Steven indicated that he felt much better after meeting theteacher and thought that going to school would be fun. When asked about the use of his

skills in the car, Steven said “I don’t think those skills help very much . . . they just makeme not pay attention to being nervous!”Mr. and Mrs. M reported that they were very pleased with Steven’sprogress andfelt

that his treatment had been very effective. He had gained 13 pounds since the onset of treatment and was behaving more like other children his age. They reported that they

had seen Steven’s psychiatrist over the summer, who continued him on thesame dose of medication. The therapist talked with them alone about the possibility of removing Ste-ven from medication, under the supervision of his psychiatrist, in the future. Reiterationof the risks of slips in the future and strategies to handle them were reviewed. The thera-pist offered to be a resource for consultation or treatment in the future if need arose.

10 TREATMENT IMPLICATIONS OF THE CASE

There was a confluence of factors that contributed to the rapid treatment gains inthis case. Most notable wasthe high level of motivation andtreatment adherence by Ste-ven and his family. They immediately responded to recommendations by the therapist,including seeking outside consultation with a psychiatrist andimplementingthe contin-

gency management program. Their high level of motivation andwillingness to try differ-ent things made working with them very pleasurable.

In addition, there were a number of characteristics of Steven and his parents thatlent themselves to treatment success. They were very intelligent, well-educated, and

articulate individuals.As parents, they quickly understoodthe purpose andoutline of theprogram, enabling them to implement it effectively. Steven’s verbal and intellectualability made it easier for him to understand what was expected of him and to articulatehis feelings about his experiences.





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Although there was not consistent contact between the therapist and the child psy-chiatrist, the willingness of the therapist and the psychiatrist to consult and their agree-ment on how to proceed with thecasewas extremely helpful. Because rapport was devel-

oped between the familyand both practitioners, Steven’s familywasable to feel secure inthe course of treatment. For the therapist, the ability to consultwith another professional

involved with the family who respected and supported the psychosocialinterventionwasinvaluable.

This case underscores the usefulness of integrated treatment using psychotherapyapproachessupported by empiricalinvestigation andpharmacotherapy. Although use of CBT for anxiety disorders does not necessitate the use of medication, medication can bea useful tool to support psychosocial treatment. In addition, use of a treatment manual

based on empirical findings in the literature allows the therapist the knowledge that heor she is working with a protocol that has been used successfully in the past.

11 RECOMMENDATIONS TO CLINICIANS AND STUDENTS

Cognitive-behavioral therapy is the current state-of-the-art treatment for anxietyand phobic disorders in childhood. Knowledge of the available research on treatmentoutcomes and periodic review of alternative strategies for meeting treatment goals pro-vide clinicians and students with innovative ways to best meet the needs of clients. Theuse of empirically validated treatments allows therapists to feel confident that the inter-

ventions they use have scientific support. Although the use of a manualized treatmentprotocol is not the panacea for all forms of psychological distress, the ability to rely onstrategies that have been validated on individuals with specific disorders is extremely

helpful.The specific benefit of Silverman and Kurtines’s (1996a, 1996b) approach is that

the structure provides flexibility forclinicians to tailor the treatment to the specificneedsof the client. Within the framework of behavior modification, exposure, and cognitivestrategies, the clinician has immense freedom to target specificcharacteristics of familialinteraction, environmental contingencies, and irrational beliefs that contribute to thedistress the child and family is facing. Through the integration of family and individual

treatment, a holistic approach to the treatment of anxiety disorders in childhood isavailable.

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Explorations in temperament: International perspectives on theory and measurement (pp. 61-75). New

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Silverman,W.K.,Kurtines,W.M.,Ginsberg,G.S.,Weems,C.F.,Rabian,B.,&Serafini,L.T.(1999).Con-tingency management, self-control, and education support in the treatment of childhood phobic disor-ders: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67(5), 675-687.

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Weller, E. B., Weller, R. A., Fristad, M. A., & Rooney, M. T. (1999). Children’s Interview for Psychiatric Syn-dromes–Parent Version (P-ChIPS). Washington, DC: American Psychiatric Press.

Kristen G. Anderson, M.Ed., Ph.D. is a NIAAA Postdoctoral Research Fellow at the University of Califor-nia, San Diego, Department of Psychiatry. Dr. Anderson’s primary area of research is the developmentalpsychopathology of addictive behaviors in children and adolescence. She has alsopublished in the areas of affective andeatingdisorders,the treatmentof childhoodbehavioraldisordersand genderbias in diagnosis.


Cognitive Behavioral Therapy for Generalized Anxiety in a 6-Year-Old

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