A key tenet of FCBT is that early increases in parent-granted autonomy and independent child behaviors in sessions 1 through 4 pave the way for (a) increased self-confidence in the child, which facilitates the child’s engagement in facing feared situations in sessions 5 through 16 and (b) parental adoption of communication techniques (eg, giving choices) that enhance the effectiveness of the application and practice phase of CBT.
Ben’s first task in the application/practice phase was returning to school, and the timing of this coincided closely with his upsurge in self-confidence following the independent behavior sessions. Typical CBT techniques for addressing school refusal were employed,13 and Ben stayed at school for longer and longer periods each day. Though predictably nervous, he tried his hardest, focused on challenging his fearful thoughts about his mother’s safety, and successfully ignored his anxious feelings (which were labeled “false alarms”). Incentives offered by his mother (eg, earning television time) also helped promote his adherence to the school-return plan.
Ben returned to school full time by session 10, evidencing habituation and a humorous “blasé” attitude about his success. It is worth additional emphasis that the rapidity and ease with which full school return was accomplished was facilitated by Ben’s early self-confidence in the independent skills exercises and by his mother’s use of parenting skills to support his autonomy, both of which are FCBT-specific strategies.
Reducing cosleeping—a key goal in separation anxiety treatment—proved to be a formidable challenge. Ben agreed in principle by session 8 to sleep in his own bed on a nightly basis, but his mother was noncommittal. Ben’s anxiety was moderately high about sleeping independently even after the many successes he had achieved by midtreatment. Without his complete investment in this task, and with his mother’s reticence about changing their routine, treatment progress plateaued for several sessions (Ben’s mother said they had simply forgotten to have him sleep by himself).
Two shifts in the therapist’s approach proved critical. First, to increase the mother’s motivation, it was noted to her that full remission of separation anxiety rarely occurs unless children sleep on their own (which is true, in our clinical experience) and that excessive anxiety could ultimately interfere with Ben’s social and intellectual development. Second, to increase Ben’s motivation, a checklist was made of a number of highly feared tasks that when completed would lead to what he considered a large reward (a video his mother agreed to purchase for him). This checklist included Ben sleeping independently for 4 weeks in a row, inviting children from school over at least 4 times, and joining an after-school activity (choices were given).
Of course, Ben was given help in applying CBT skills in preparation for these activities. It was thought that by appealing to both Ben and his mother, chances for success would be doubled compared with relying on the solitary (and wavering) motivation of either of them alone.
This multifaceted approach proved effective. Ben’s mother was sufficiently persuaded by the therapist’s logic to permit a trial of the sleeping plan, while Ben was quite invested in his checklist incentive program and began sleeping independently. Within 2 weeks, Ben’s ratings on a 0-to-10 anxiety scale indicated that he felt no anxiety when sleeping by himself (again, reflecting habituation to a feared—but benign— situation). Simultaneously, he initiated playdates with a neighborhood boy that soon became reciprocal, and joined an after-school music program that he enjoyed. Ben’s mother was pleased with these accomplishments and began to praise the therapy program, including its emphasis on Ben’s independence. She voiced no further reservations about the new sleeping arrangements.
While still exhibiting a shy, eagerto- please disposition, Ben had no core anxiety disorder symptoms by session 16 when he was interviewed by an independent evaluator (using a structured diagnostic interview). Treatment gains were maintained at a 1-year follow-up interview
FINDINGS FROM A RECENT CLINICAL TRIAL
In a recent clinical trial, the Building Confidence FCBT program was compared with traditional CCBT with minimal family involvement.3Forty children with anxiety disorders (aged 6 through 13 years) were randomly assigned to FCBT or CCBT. Anxiety disorders (separation anxiety disorder, social phobia, and/or generalized anxiety disorder) were confirmed by an independent evaluator using a structured diagnostic interview. The 2 treatment conditions were matched for therapist contact time (12 to16 therapy sessions lasting 60 to 80 minutes each). Outcome measures included independent evaluators’ diagnoses, severity ratings for each diagnosis on the Clinician’s Rating Scale,14 and improvement ratings on the Clinical Global Impressions (CGI) scale; child-reports on the Multidimensional Anxiety Scale for Children (MASC)15; and parent reports on the MASC.
Overall, results favored FCBT over CCBT, highlights included:
- 79% of children in FCBT met CGI criteria for good treatment response, compared with only 26% of children in CCBT.
- Children in FCBT had greater improvement on independent evaluators’ ratings on the Clinician’s Rating Scale than children in CCBT.
- Parent reports of child anxiety on the MASC—but not children’s selfreports— were lower in FCBT than CCBT at posttreatment.
Although both treatment groups showed statistically significant improvement on all outcome measures, FCBT provided additional benefit over and above CCBT on most indices of improvement.
It should be noted that FCBT appears to be equally effective for children with primary diagnoses of separation anxiety disorder, social phobia, and generalized anxiety disorder. Although the case study presented above illustrates how FCBT can address separation anxiety, parental involvement is also beneficial for the treatment of the other 2 primary child anxiety disorder diagnoses. For example, parental intrusiveness is often seen in cases of children with social anxiety. Parents may offer excessive comfort when children are fearful in social situations and take over social tasks (eg, by speaking for their children) that children could handle independently. Variations of the FCBT techniques described above have proved helpful in addressing such family interaction patterns.
FCBT involves a complex interplay of cognitive-behavioral techniques and family restructuring, drawing on the combined (and sometimes complementary) resources and motivations of children and their parents. While CCBT is quite effective by itself, FCBT can lead to even greater improvements in anxiety, at least in the short term.3 Therefore, it may be beneficial for clinicians to assess for parental intrusive-ness and autonomy-granting in cases of school-aged children with anxiety disorder and consider the use of a structured FCBT protocol that explicitly addresses such family dynamics when they are present.
Dr Wood is an assistant professor of psychological studies in education in the department of education at the University of California, Los Angeles. His research focuses on the psychopathology of childhood anxiety, with an emphasis on randomized, controlled trials of cognitive- behavioral therapy interventions. The writing of this paper was supported, in part, by a grant from NIMH awarded to Dr Wood (MH075806). He reports that he has no conflicts of interest with the subject matter of this article.
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Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64:333-342.
Wood JJ, Piacentini JC, Southam-Gerow M, et al. Family cognitive behavioral therapy for child anxiety disorders. J Am Acad Child Acolesc Psychiatry. 2006;45:314-321