BEHAVIOR THERAPY 35,263-287, 2004 Efficacy of Modular Cognitive Behavior Therapy for Childhood Anxiety Disorders BRUCE E CHORPITA ALISSA A. TAYLOR SARAH E. FRANCIS CATHERINE MOFFITT AYDA A. AUSTIN University of Hawai'i at M~noa The present investigation evaluated the initial efficacy of a modular a pproach to cog- nitive behavior therapy (CBT) for anxiety disorders in youth. Modular CBT consists of the guided combination of individually scripted techniques that are explicitly matched to the child's individual strengths and needs. Eleven youth primarily of Asian and Pacific Island ethnicity rangin g in age from 7 to 13 were referred for treat- ment. Comparisons in a multiple baseline across children provided preliminary support for the efficacy of the intervention. Among the 7 completers, all principal diagnoses were absent at posttreatment and 6-month follow-up assessments, and measures of anxiety symptoms and life functioning almost uniformly evidenced clinically significant improvements. Anxiety disorders are the most commonly diagnosed psychiatric disorders in children and adolescents (Albano, Chorpita, & Barlow, 2002; Bernstein & Borchardt, 1991), frequently presenting with other comorbid anxiety, depres- sive, or externalizing disorders (Albano et al., 2002; Keller et al., 1992). Anx- iety disorders are often characterized by an early onset in childhood or ado- lescence. Without proper treatment they may worsen over time (Albano et al., 2002; Kendall, 1994) and lead to long-term negative consequences for adult functioning (Kendall, 1992; Ollendick & King, 1994). Accordingly, much effort has been focused on the development of treatments for anxiety disorders in youth. Preparation of this article was supported in part by National Institute of Mental Health Grant R03 MH60134, an award from the University of Hawai'i Research Council, and an award from the Hawaii D epartment of Health to the first author. Address correspondence to Bruce F. Chorpita, Department of Psychology, University of Hawai'i at MAnoa, 2430 C ampus Road, Honolulu, HI 96822; e-mail: [email protected]. 263 005-7894/04/0263-028751.00/0 Copyright 2004 by Association or Advancement of Behavior Therapy All righ ts for reproducti on in any form reserved.
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7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
Eff icacy of M odular C ogn itive Behavior Therapyfor Childhood Anxiety Disorders
B R U C E E C H O R P IT A
A L I S S A A . T A Y L OR
S A R A H E . F R A N C I S
C A T H E R I N E M O F F I T T
A Y D A A . A U S T I N
Universi ty o f Ha wa i ' i a t M~ noa
The p r e se n t i nve s t i ga t i on e va lua te d t he i n i t i a l e f f ic a c y o f a m odu la r a pp r oa c h to c og -
n i t iv e b e h a v i o r th e r a p y ( C B T ) f o r a n x i e t y d i s o r d er s i n y o u t h . M o d u l a r C B T c o n s i s ts
o f t he gu ide d c om bina t ion o f i nd iv idua l ly s c r ip t e d t e c hn ique s t ha t a r e e xp l i c i t l y
m a t c h e d t o t h e c h i l d ' s i n d i v id u a l s t r en g t h s a n d n e e d s . E l e v e n y o u t h p r i m a r i l y o f
A s ia n a nd P a c i f i c Is l a nd e thn i c i t y r a ng in g in a ge f r om 7 to 13 w e r e r e f e r r e d f o r t r e a t-
m e n t . C o m p a r i s o n s i n a m u l t i p l e b a s e l i n e a c r o s s c h i l d r e n p r o v i d e d p r e l i m i n a r y
suppo r t f o r t he e ff i c ac y o f t he i n t e r ve n t ion . A m ong the 7 c om ple t e r s , a ll p r inc ipa l
d i a g n o s e s w e r e a b s e n t a t p o s t t r e a t m e n t a n d 6 - m o n t h f o l l o w - u p a s s e s s m e n t s , a n dm e a s u r e s o f a n x i e t y s y m p t o m s a n d l i f e f u n c t i o n i n g a l m o s t u n i f o r m l y e v i d e n c e d
c l in i c a l ly s ign i f i c a n t im pr ov e m e n t s .
A n x i e t y d i so r d e r s a r e th e m o s t co m m o n l y d i ag n o s e d p s y ch i a t ri c d i s o rd e r s
in ch i ld ren and ado lescen t s (Albano , Chorp i t a , & Bar low, 2002 ; Berns t e in &
Borcha rd t , 1991) , f r equen t ly p resen t ing wi th o ther com orb id anx ie ty , depres -s ive , o r ex t e rna li z ing d i so rder s (A lbano e t a l. , 2002 ; K el l e r e t a l. , 1992) . An x-
i e ty d i so rder s a re o f t en charac t e r i zed by an ear ly onse t i n ch i ldhood o r ado-
l e s cen ce . W i t h o u t p r o p e r t r ea tmen t t h ey ma y w o r s en o v e r t ime ( A l b an o e t a l .,
2002 ; Kendal l , 1994) and l ead to l ong- t e rm negat ive consequences fo r adu l t
f u n c t i o n i n g ( K en d a l l , 1 9 9 2 ; O l l en d i ck & K i n g , 1 9 9 4 ) . A c co r d i n g l y , m u chef fo r t has be en foc used on the deve lop m ent o f t rea tmen t s fo r anx ie ty d i so rder s
in you th .
P r e pa r a t i on o f t h i s a rt i c le w a s suppo r t e d i n pa r t by N a t iona l I n s t i t u t e o f M e n ta l H e a l th G r a n t
R 0 3 M H 6 0 1 3 4 , a n a w a r d f r o m t h e U n i v e rs i t y o f H a w a i ' i R e s e a r c h C o u n c i l , a n d a n a w a r d f r o m
the H a w a i i D e pa r tm e n t o f H e a l th t o t he f i r s t a u tho r .
A d d r e s s c o r r e s p o n d e n c e t o B r u c e F . C h o r p i t a , D e p a r t m e n t o f P s y c h o l o g y , U n i v e r s i t y o f
H a w a i ' i a t M A n o a , 2 4 3 0 C a m p u s R o a d , H o n o l u l u , H I 9 6 8 2 2 ; e - m a il : c h o r p i ta @ h a w a i i .e d u .
The majority of research supports the use of behavioral and cognitive be-
havioral interventions as efficacious strategies for treating anxiety disorders
in youth (Ollendick & King, 1998). Numerous between-group design investi-gations examining cognitive behavior therapy (CBT) for anxiety disorders havedemonstrated superior treatment effects for CBT compared with no-treatment
or wait-list control conditions (Barrett, Dadds, & Rapee, 1996; Cobham, Dadds,
& Spence, 1998; Kendall, 1994; Kendall et al., 1997; Silverman et al., 1999).
In addition, research has demonstrated that many benefits exist with the use
of manualized cognitive behavioral treatments for anxiety disorders in youth,
including higher rates of systematic delivery and more accurate implemen-
tation of treatment components (e.g., Kendall, Kane, Howard, & Siqueland,
1990). Research conducted on the efficacy of manualized CBT for anxiety
disorders has established the benefits of this approach in several randomizedclinical trials (Barrett et al., 1996; Dadds, Heard, & Rapee, 1992; Kendall,
1994; Kendall et al., 1997).
Despite this accumulation of support, Ollendick (2000) noted that a pro-
portion of children treated with manualized CBT approaches nevertheless failto show symptomatic improvement. For example, Kendall et al. (1997) found,
in comparing CBT with a wait-list control condition, that 47% of children in
the experimental condition still received their initial diagnosis at posttreat-
ment evaluations. In another investigation comparing manual-based CBT to a
wait-list control condition, Barrett et al. (1996) found that 43% of children in
the CBT condition were not diagnosis free at posttreatment. Although diag-
nostic remission rates above 50% are among the most impressive in childoutcome research, it is important to consider whether this ceiling could be
raised further through continued adaptations of CBT protocols (e.g., Hudson,
Krain, & Kendall, 2001).
As argued by Ollendick (2000), one possible means of addressing suchissues may lie in the application of CBT procedures in a more highly individ-
ualized manner (e.g., Hudson et al., 2001). However, this strategy must be
balanced against the evidence that lack of structure in a protocol can compro-
mise integrity and lead to poorer outcomes (Wilson, 1996). Fortunately, re-search in childhood anxiety is beginning to outline a framework by which to
allow substantial individualization while adhering to a structured protocol.Such efforts, sometimes referred to as prescriptive treatment approaches,
have been examined among children diagnosed with generalized anxiety dis-order (GAD; Eisen & Silverman, 1998), as well as among children exhibiting
school-refusal behaviors (Kearney & Silverman, 1990). For example, Eisen
and Silverman (1998) applied one treatment approach for children with pri-marily cognitive features of GAD, and a different approach for children pre-
senting with primarily somatic symptoms of GAD and found that treatments
prescribed or matched with client characteristics resulted in greater improve-
ments over a shorter duration of time (Eisen & Silverman, 1998). Similar
findings were obtained in a related examination of the prescriptive treatmentof anxiety-disordered youth demonstrating school-refusal behavior (Kearney
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
& S i lverman , 1990) . F ina l ly , Ol l end ick (2000 ) r ev i e we d ev iden ce tha t amon g
ch i l d r en w h o f a i l ed t o r e s p o n d t o man u a l i zed C B T ap p r o ach es , o n e h a l f t o
two th i rds showed ga ins a t pos t t r ea tmen t once more ind iv idua l ly t a i l o redt rea tmen t p rac t i ces we re u t i li zed in tr ea tmen t ( c f . Hu dso n e t a l ., 2001) .
Given such cons idera t ions , t he t r ea tmen t manual i n t he cu r ren t i nves t iga-
t i on (Modular CBT; Chorp i t a , 1998) was des igned to cap i t a l i ze on observa-
t i ons tha t t rea tmen t s fo r ch i ldhood anx ie ty d i so rder s and co m orb id cond i t ions
a r e co mp r i s ed o f a l a rg e l y h o mo g en eo u s s e t o f b eh av i o ra l an d co g n i t iv e t e ch -
n iques t ha t have been inves t iga t ed in over 40 year s o f empi r i ca l r esearch
(Ol l end ick & King , 1998) . The cu r ren t manual em ploys a "m odu lar " approach
to t rea tm en t t ha t i s a ime d a t p reserv ing the benef i t s o f s tandard i za t ion inher-
en t i n manual i zed p ro toco l s wh i l e a l l owing h igh l eve l s o f f l ex ib i l i t y t h rough
the use o f a gu id ing a lgor i t hm fo r t he app l i ca t ion o f i nd iv idua l t r ea tmen tt echn iques ( see F igure 1 ). The M odu lar CB T pro toco l cons i s t s o f 13 ind iv id -
ua l t r ea tmen t t echn iques (modu les ) t ha t i nc lude se l f -moni to r ing , psychoedu-
cat ion, expo sure , cog nit ive restructuring, social skil ls t raining, re wa rds, differen-
t ial reinforcem ent s trategies , t ime-out , and m aintenance and relapse prevent ion.
Th e a s s em b l y o f t h e s e co d i fi ed t e ch n iq u es i s d e te r mi n ed b y i n d i v id u a l n eed s
of t he ch i ld and fam i ly . The p resen t s tudy a im ed to t es t t he i n it ia l e f f i cacy o f
the Modular CBT pro toco l i n a mul t i p l e base l ine across ch i ld ren , wi th t he
p r ed i c t i o n t h a t t h e C B T ap p r o ach w o u l d l ead t o s u s t a i n ed i mp r o v emen t s i n
anx ie ty sy m ptom s, d i agnos i s , and func t ion ing . ~
Method
Measures
Anxiety Disorders Interview Schedule for DSM-IV, Child and Parent Ver-sions (ADIS-IV-C/P). D i ag n o s es w e r e d e r i v ed u s i n g t h e A D I S - I V - C / P ( S i l -
v e r man & A l b an o , 1 9 9 6 ) . Th e A D I S - I V - C / P i s a s emi s t r u c t u r ed d i ag n o s t i c
in t e rv i ew fo r ch i ld ren be tw een the ages o f 7 and 17 , des ign ed fo r the assess -
men t an d d i ag n o si s o f DSM-IV d i ag n o s es o f ch i l d h o o d an x i e t y , m o o d , b eh av -
io ra l , and a t t en t iona l d i s tu rbances . The in t e rv i ew i s admin i s t e red separa t e ly
1The r e a r e som e po in t s o f d i f f e r e nc e be tw e e n de s igns t ha t s t a r t a l l pa r t i c ipa n t s s im u l t a -
ne ous ly ve r sus t hose t ha t e n r o l l pa r t i c ipa n t s s e que n t i a ll y . The se ha ve be e n t e r m e d in t he l i t e ra -
tu r e a " s im u l t a ne o us" m u l t i p l e ba se l ine ( c f . B a e r , W o l f , & R i s l e y , 1968 ) a nd a " na tu r a l "
m u l t i p l e ba se l ine ( H a ye s , 1985 ) , r e spe c t ive ly . H a ye s a r gue d tha t a na tu r a l m u l t i p l e ba se l ine
in t r oduc e s a dd i t i ona l t h r e a t s t o va l id i t y on ly i n so f a r a s one c a n in f e r t ha t t he e f f e c t s o f e a c h
w i th in - se r i e s pha se c ha nge w e r e due t o e x t e r na l ( non the r a py ) e ve n t s . W he r e a s a s im u l t a ne ous
m ul t i p l e ba se l ine c a n o f t e n c on t r o l f o r suc h c o in c ide nc e by a l l ow ing f o r obse r va t ion o f s t a b i l i t y
in un in t e r r up t e d s e r i e s w h i l e c ha ng e s a ppe a r i n i n t e r r up t e d s e r i e s , t he na tu r a l m u l t i p l e ba se l ine
c a n a l so p r o t e c t a ga in s t suc h th r e a t s t o t he e x t e n t t ha t e x t e r na l e ve n t s ar e un l ike ly t o c o inc ide
w i t h t h e t i m i n g o f t h e w i t h i n -s e r ie s c h a n g e s . P a rt i cu l a rl y w h e n u s e d w i t h r a n d o m t i m i n g o f
pha se c ha nge s a nd the i nc lu s ion o f a l a r ge num be r o f s e r i e s , t he na tu r a l m u l t i p l e ba se l ine i s fe l t
t o r e p r e se n t a f e a s ib l e de s ign f o r p r a c t i c e s e t t i ngs t ha t a f f o r d s g r e a t e r i n t e m a l va l id i t y t ha ns im p le r e p l i c a t i on o f A - B de s igns ( H a ye s , 1985 ) .
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
t o c h i l d r e n a n d t h e i r p a r e n t s , a n d d i a g n o s e s a r e m a d e s e p a r a t e l y f o r b o t h t h e
c h i l d a n d p a r e n t i n t e r v i e w s b e f o r e t h e f i n a l c o m p o s i t e d i a g n o s t i c p r o f i l e i s
d e r i v e d . G o o d t o e x c e l l e n t i n te r r a t e r r e l i a b i li t y h a s b e e n d e m o n s t r a t e d f o r t h eA D I S - I V - C / P ( S i l v e rr n a n , S a a v e d r a , & P i n a , 2 0 0 1 ). C l i n i c a l s e v e r i ty r a t in g s
( C S R ) a r e a s s i g n e d t o d i a g n o s i s o n t h e b a s i s o f t h e i n f o r m a t i o n p r o v i d e d d u r -
i n g t h e i n t e r v i e w p r o c e s s . C S R s r a n g e f r o m 0 t o 8 , i n d i c a t i n g t h e c l i n i c i a n -
p e r c e i v e d s e v e r i t y o f e a c h d i a g n o s i s , w i t h 4 o r h i g h e r i n d i c a t i n g a c l i n i c a l
d i a g n o s i s .
I n t e r v i e w e r s u n d e r w e n t a t h o r o u g h t r a i n i n g p r o c e d u r e i n t h e a d m i n i s t r a -
t i o n o f t h e A D I S - I V - C / P b e f o r e a d m i n i s t e r i n g t h e m e a s u r e o n t h e i r o w n
a c c o r d . E a c h t r a in e e o b s e r v e d a t l e as t t h r e e i n t e r v i e w s , f o l l o w e d b y c o n d u c t -
i n g a s e r ie s o f f i v e i n te r v i e w s u n d e r t h e s u p e r v i s i o n o f a s e n i o r i n t er v i e w e r .
T h e t r a i n e e h a d t o m a t c h w i t h t h e s e n i o r i n t e r v i e w e r o n a l l d i a g n o s e s a n dseve r i ty ra t ings (w i th in one p o in t ) fo r a t l e a s t th ree ca se s in the s e r i e s o f f ive .
A l l i n t e r v i e w e r s w e r e s e n i o r d o c t o r a l s t u d e n t s .
Child and Adolescent Functional Assessment Scale (CAFAS). T h e C A F A S
i s a c l i n i c i a n - s c o r e d , m u l t i d i m e n s i o n a l r a t i n g s c a l e d e s i g n e d t o a s s e s s f u n c -
t i o n a l i m p a i r m e n t a s e x p e r i e n c e d b y c h i l d r e n a n d a d o l e s c e n t s , a g e s 5 t o 1 7 ,
a c r o s s e i g h t d o m a i n s o f f u n c t i o n i n g ( H o d g e s & W o n g , 1 9 9 6 , 1 9 9 7 ). R a t e r s
a r e p r o v i d e d w i t h a l i s t o f b e h a v i o r a l d e s c r i p to r s o n e a c h o f t h e s u b s c a l e s ,
f r o m w h i c h t h e y m u s t c h o o s e t h o s e i t e m s t h a t a r e m o s t c o n g r u e n t w i t h t h e
y o u t h ' s m o s t s e v e re l e v el o f d y s f u n c t i o n d u r i n g t h e m o n t h p r e c e d i n g t h e a s-
s e s s m e n t ( H o d g e s & W o n g , 1 9 9 6 ) . I t e m s w i t h i n e a c h s u b s c a l e a r e g r o u p e d
a c c o r d i n g t o f o u r d e g r e e s o f i m p a i r m e n t : s e v e r e , m o d e r a t e , m i l d , a n d m i n i -
m a l o r n o i m p a i r m e n t , y i e l d i n g s c o r e s o f 3 0 , 2 0 , I 0 , o r 0 p o i n t s , r e sp e c t i v e ly .
D a t a g e n e r a t e d f r o m t w o l a r g e - s c a l e e v a l u a t i o n s t u d i e s h a v e i n d i c a t e d t h a t
t h e C A F A S p o s s e s s e s g o o d i n t e r n a l c o n s i s t e n c y (r a n g i n g f r o m .6 3 to .7 8) a n d
h i g h i n t e r r a t e r r e l i a b i l i t y ( a b o v e . 9 2 f o r t h e T o t a l C A F A S s c o r e , a n d a b o v e
.8 3 f o r t h e i n d i v i d u a l s ca l e s; H o d g e s & W o n g , 1 9 9 6 ) . C o n t e n t , c o n c u r r e n t ,
a n d p r e d i c t i v e v a l i d i t y h a v e a l s o b e e n e x a m i n e d w i t h t h e C A F A S , s u g g e s t i n g
t h a t t h e C A F A S c o r r e l a te s s i g n i f i c a n t l y a n d p o s i t i v e l y w i t h o t h e r i n d i c a t o r s
o f i m p a i r m e n t , i n c l u d i n g s e v e r i t y o f p s y c h i a t r i c d i a g n o s i s a n d s u b s e q u e n t
s e r v i c e u t i li z a t io n ( H o d g e s & W o n g , 1 9 9 6 ).
Child Behavior Checklist (CBCL). T h e C B C L ( A c h e n b a c h , 1 9 91 ) i s a p a r -e n t q u e s t i o n n a i r e t h a t m e a s u r e s b o t h c h i l d c o m p e t e n c i e s a n d n e e d s , w i t h 1 18
i t e m s r e l a t e d t o a v a r i e ty o f c h i l d h o o d p r o b l e m s . E a c h i t e m i s r a t e d o n a 0 - t o -
2 s c a l e , w i t h h i g h e r s c o r e s r e f le c t i n g g r e a t e r e n d o r s e m e n t o f e a c h i t e m . T h e
p r o b l e m i t e m s o n t h e C B C L c a n b e s u m m e d t o y i e l d s e v e n s p e c i f i c s c a l e s
a n d t w o b r o a d s c a l e s . O n e o f t h o s e t w o s c a l e s , t h e I n t e r n a l i z i n g S c a l e , w a s
u s e d i n th i s s t u d y a s a g e n e r a l m e a s u r e o f a n x i e t y , d e p r e s s e d m o o d , s o m a t i c
c o m p l a i n t s , a v o i d a n c e , a n d w i t h d r a w a l . V a l i d i t y a n d r e l i a b i l i t y a r e e x c e l l e n t
( A c h e n b a c h , 1 99 l ) , a n d e x t e n s i v e n o r m a t i v e d a t a a r e a v a i l a b le f o r c h i l d r e n
r a n g i n g i n a g e f r o m 4 t o 1 8.
Revised Child Anxiety and Depression Scale (RCADS). T h e R C A D S i s a4 7 - i t e m r e v i s i o n o f t h e S p e n c e C h i l d r e n ' s A n x i e t y S c a l e ( S C A S ; S p e n c e ,
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
1 9 9 8 ) , d e s i g n e d t o c o r r e s p o n d c l o s e l y t o DSM-IV a n x i e t y d i s o r d e r s a n d i n -
c o r p o r a t i n g a s u b s c a l e f o r m a j o r d e p r e s s i o n . O n t h i s in s t r u m e n t , c h i ld r e n a r e
a s k e d t o r a t e th e e x t e n t t o w h i c h e a c h i t e m i s t r u e o f t h e m s e l v e s , b y i n d i c a t -i n g t h e i r r e s p o n s e s o n a 0 - t o - 3 s c a l e , c o r r e s p o n d i n g t o a n c h o r s o f " n e v e r "
" s o m e t i m e s " " o f t e n " a n d " a l w a y s . " A l ar g e- s ca le s c h o o l- b a se d s t u d y o f t h e
R C A D S y i e l d e d f a c t o r a n a ly t i c re s u lt s s u g g e s t i n g th e f o l l o w i n g s u b s c al e s:
S e p a r a ti o n A n x i e t y D i s o r d e r, S o c i a l P h o b i a , G e n e r a l i z e d A n x i e t y D i s o r d e r ,
O b s e s s i v e - C o m p u l s i v e D i s o r d e r , P a n i c D i s o r d e r , a n d M a j o r D e p r e s s i v e D i s -
o r d e r. T h e s u b s c a l e s d e m o n s t r a t e d g o o d f a c t o r ia l v a l i d it y , i n t e r n a l c o n s i s t e n c y ,
1 - w e e k t e s t - r e t e s t r e l i a b i l i t y , a n d g o o d c o n v e r g e n t a n d d i s c r i m i n a n t v a l i d i t y
( C h o r p i ta , Y i m , M o f f i tt , U m e m o t o , & F r a n c i s , 2 0 0 0) . I n a s e c o n d s t u d y , th e
s u b s c a l e i n t e m a l c o n s i s t e n c i e s r a n g e d f r o m .7 1 t o . 81 ( C h o r p i t a e t a l. , 2 0 0 0 ) .
T h e r e s u lt s o f s e v e r al i n v e s t ig a t i o n s h a v e p r o v i d e d s u p p o r t f o r th e R C A D Sa s a m e a s u r e o f i n t e r n a l d i s t r e s s . S p e c i f i ca l l y , c o n v e r g e n t v a l i d i t y c o r r e l a t i o n s
w i t h th e R e v i s e d C h i l d r e n ' s M a n i f e s t A n x i e t y S c a l e ( R e y n o l d s & R i c h -
m o n d , 1 9 7 8) t o t a l s c o r es r a n g e f r o m .6 3 to . 74 , a n d d i s c r i m i n a n t v a l i d i ty
c o e f f ic i e n ts o f a n x i e t y s u b s c a l es w i t h t h e C h i l d r e n ' s D e p r e s s i o n I n v e n t o r y
( C D I ; K o v a c s , 1 9 8 0 / 1 9 8 1 ) r a n g e d f r o m .1 8 to .4 5 ( C h o r p i t a e t a l ., 2 0 0 0 ) . A d -
d i t io n a l l y , t h e R C A D S M a j o r D e p r e s s i o n s u b s c a l e w a s h i g h l y c o r r el a te d w i t h
t h e C D I ( r = . 70 ) .
Participants
C h i l d r e n r e f e r r e d f o r t re a t m e n t a t t h e U n i v e r s i t y o f H a w a i i C e n t e r f o r C o g -
n i t i v e B e h a v i o r T h e r a p y p a r t i c i p a t e d i n t h e s t u d y . R e f e r r a l s c a m e f r o m p a r -
e n ts o r f r o m s c h o o l p e rs o n n e l t h r o u g h t h e H a w a i i D e p a r t m e n t o f E d u c a t i o n .
A f t e r t h e i n i t i a l a s s e s s m e n t , c o n s e c u t i v e l y r e f e r r e d c h i l d r e n w i t h a p r i n c i p a l
o r c o - p r i n c i p a l DSM-IV d i a g n o s i s o f a n a n x i e t y d i s o rd e r w h o a c c e p t e d t re a t-
m e n t w e r e i n c l u d e d in t h e in v e s t i g a t i o n . I n s u m , 1 1 c h i l d r e n w e r e o f f e r e d
t r e a t m e n t a s p a r t o f t h e i n v e s ti g a ti o n . T h r e e d r o p p e d o u t o f t r e a t m e n t w i t h i n
t h e f i rs t 2 w e e k s , a n d o n e m i s s e d o r d i d n o t s h o w u p f o r e i g h t o f th e f i r s t n i n ea p p o i n t m e n t s a n d w a s a ls o d r o p p e d . 2 C h i l d r e n w e r e e x c l u d e d f r o m t h e
p r e s e n t i n v e s t i g a t i o n a n d r e f e r r e d t o a p p r o p r i a t e s e r v i c e s i f t h e y w e r e n o t b e -
t w e e n t h e a g e s o f 7 a n d 1 7 , h a d a p r i m a r y d i a g n o s i s o f a n e x t e r n a l i z i n g d is -
o r d e r , e x h i b i t e d s y m p t o m s i n d i c a t i v e o f p s y c h o s i s , c o g n i t i v e i m p a i r m e n t s ,c h r o n i c m e d i c a l c o n d i t i o n t h a t w o u l d i n t e r f e r e in t r e a t m e n t , o r g a n i c b r a i n d i s -
o r d e r , o r d e v e l o p m e n t a l d i s a b i l i t i e s . A l l p a r t i c i p a n t s ' d i a g n o s t i c a n d s u p p l e -
m e n t a l a s s e s s m e n t i n f o r m a t i o n ( e. g ., c l in i c al s e v e r it y ra t in g s , R C A D S , C B C L ,
a n d C A F A S s c o r e s ) a p p e a r i n T a b l e 1 .
Child 1. T h e f ir s t c h i l d w a s a C a u c a s i a n f e m a l e w h o r e s i d e d w i t h h e r p a r-
e n t s a n d o l d e r s i s te r . B o t h p a r e n t s h a d g r a d u a t e d e g r e e s , a n d t h e a n n u a l f a m -
i l y i n c o m e w a s r e p o r t e d a s $ 1 4 0 , 0 0 0 . C h i l d 1 w a s a s s e s s e d a t th e a g e o f 11
y e a r s , 6 m o n t h s , w i t h t h e A D I S - I V - C / P , a n d w a s d i a g n o s e d w i t h G A D . P r i o r
2These dro pout rates are com parable to tho se in ma jor CBT trials for childho od anxiety,which range from 20% to 32% (e.g., Silverman et al., 1999).
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t o h e r i n it i a l e v a l u a t i o n , C h i l d 1 h a d b e e n p r e s c r i b e d V a l i u m t o a s s i s t in t h e
r e d u c t i o n o f h e r a n x i e ti e s r e g a r d i n g s c h o o l a t t e n d a n c e ; h o w e v e r , th i s m e d i c a -
t i o n d i d n o t y i e l d t h e r a p e u t i c e f f e c ts , a n d w a s t h u s d i s c o n t i n u e d . A t t h e t i m eo f t h e a s s e ss m e n t , C h i l d 1 h a d b e e n e x h i b i t in g s c h o o l - r e f u s a l b e h a v i o r f o r
a p p r o x i m a t e l y 9 m o n t h s , a n d h a d t r a n s f e r r e d s c h o o l s d u r i n g t h e m i d d l e o f
h e r s i x t h g r a d e y e a r d u e t o e x c e s s i v e w o r r i e s i n f l u e n c i n g h e r s c h o o l a t t e n -
d a n c e . A l t h o u g h C h i l d 1 w a s a t t e n d i n g s c h o o l a t t h e t im e o f h e r i n i ti a l e v a l u -
a t i o n , s h e c o n t i n u e d t o r e p o r t s e v e r a l w o r r i e s a f f e c t i n g s c h o o l a t t e n d a n c e ,
i n c l u d i n g t h e a t ta i n m e n t o f p o o r g r a d e s , h a v i n g i n a d e q u a t e t i m e t o c o m p l e t e
h e r a s s i g n m e n t s , d i s p l e a s in g h e r t e a c h e r s a n d p e e r s , a n d b e i n g u n a b l e t o r e a c h
h e r p a r e n ts w h i l e a t sc h o o l . S u c h w o r r i e s w e r e a c c o m p a n i e d b y e x c e s s i v e c r y -
i n g , a s w e l l a s s u c h p h y s i o l o g i c a l s y m p t o m s a s lo s s o f a p p e t i te , s t o m a c h a c h e s ,
a n d h e a d a c h e s . P a r e n t r e p o r t o n t h e C B C L i n d i c a t e d t h a t C h i l d 1 s c o r e d i nt h e c l in i c a l ra n g e o n t h e T o t a l I n t e rn a l i z in g S c a l e o f th e C B C L ( M o t h e r T =
7 7 ) . C h i l d 1 r e c e i v e d a s c o r e o f 30 o n t h e C A F A S , d u e t o m i l d i m p a i r m e n t o n
t h e R o l e P e r f o r m a n c e - S c h o o l s u b s c a l e , a n d m o d e r a t e i m p a i r m e n t o n t h e
M o o d s / E m o t i o n s s u b sc a le .
Child 2. T h e s e c o n d c h i l d w a s a m u l t i e t h n i c ( A s i a n a n d P a c i f i c I s l a n d )
f e m a l e r e s i d i n g w i t h h e r m o t h e r a n d f o u r s i b l i n g s . C h i l d 2 ' s m o t h e r h a d n o t
f i n is h e d h ig h s c h o o l , a n d th e a n n u a l f a m i l y in c o m e w a s r e p o r t e d a s $ 1 3 , 0 0 0 .
C h i l d 2 w a s a s s e s s e d a t t h e a g e o f 1 2 y e a r s , 5 m o n t h s , a n d w a s a s s i g n e d a p r i -
m a r y d i a g n o s is o f s e p a r a ti o n a n x i e t y d i s o r d e r, w i t h a d d i t io n a l d i a g n o s e s o f
s o c i a l p h o b i a a n d a s p e c i f ic p h o b i a o f c o n t r a c t i n g a n i l l n e s s o r d i s e a s e . C h i l d
2 w a s n o t p r e s c r i b e d a n y m e d i c a t i o n s a t th e t i m e o f t h e a s s e s s m e n t o r d u r in g
t r e a tm e n t . A p p r o x i m a t e l y 5 m o n t h s p r i o r to h e r a s s e s s m e n t , C h i ld 2 h a d
s t o p p e d a t te n d i n g s c h o o l a s a re s u l t o f t e a si n g b y c l a s s m a t e s , c o n c e r n s a b o u t
s e p a r a ti o n f r o m h e r m o t h e r a n d h o m e , a n d f e e l i n g s o f d i s tr e s s a n d d i s c o m f o r t
w h e n i n s o c i a l o r e v a l u a t i v e s i t u a t i o n s . I n a d d i t i o n t o r e c u r r e n t a n d e x c e s s i v e
f e e l in g s o f d i st re s s w h e n s e p a r a te d f r o m h e r h o m e o r h e r m o t h e r , C h i l d 2 a l s o
d e m o n s t r a t e d p e r s i s t e n t r e l u c t a n c e o r re f u s a l to g o t o s c h o o l , a c c o m p a n i e d b y
r e p e a t e d c o m p l a i n t s o f p h y s i c a l s y m p t o m s , in c l u d i n g h e a d a c h e s , s t o m a c h -
a c h e s , n a u s e a , a n d v o m i t i n g . C h i l d 2 a n d h e r m o t h e r a l s o i n d i c a t e d t h a t
C h i l d 2 c o n s i s t e n t l y b e c a m e n e r v o u s i n s e v e r a l s c h o o l a n d s o c i a l s it u a t io n s ,
s u c h a s w h e n s p e a k i n g o r r e a d i n g i n cl a ss , w o r k i n g w i t h a g r o u p o f o th e rc h i l d r e n , o r e a t in g i n f r o n t o f o t h e r s . S u c h s e p a r a t io n a n d s o c i a l fe a r s w e r e
a c c o m p a n i e d b y a n a d d i t i o n a l p e r s i st e n t f e a r o f c o n t r a c t i n g a n i l ln e s s o r d i s-
e a s e . O n s e l f - r e p o r t i n s t r u m e n t s u s e d t o s u p p l e m e n t t h e A D I S - I V - C / P , C h i l d
2 s c o r e d i n th e c l in i c al r a n g e o n t h e R C A D S S e p a r a t io n A n x i e t y D i s o r d e r
S c a l e ( T = 7 8 ) , a n d n e a r t h e c li n i c a l r a n g e o n t h e D e p r e s s i o n S c a l e ( T =
6 3 ) . O n t h e C A F A S , C h i l d 2 re c e i v e d a s c o r e o f 7 0 , in d i c a t i n g s e v e r e im -
p a i rm e n t o n t he R o l e P e r f o r m a n c e - S c h o o l a n d M o o d s / E m o t i o n s s u b s ca le s ,
a n d m i l d i m p a i r m e n t o n t h e B e h a v i o r T o w a r d O t h e rs s u b s ca l e. C h i ld 2 ' s
m o t h e r f a i l e d t o c o m p l e t e th e C B C L a s a r e s u l t o f c h r o n i c a n d r e c u r r e n t l if e
s t r e s s o r s t h a t i m p e d e d h e r a b i l i t y t o p a r t i c i p a t e i n t h e a s s e s s m e n t a n d t r e a t -m e n t p r o c e s s.
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
C h i l d 3 . T h e t h i r d c h i ld w a s a m u l t i e th n i c ( A s i a n a n d P a c i f ic I sl a n d ) f e m a l e
w h o r e s i d e d w i th h e r p a r e n t s a n d f o u r s ib l in g s . S h e w a s a s s e s s ed a t t h e a g e o f
7 y e a r s , 3 m o n t h s , w i th t h e A D I S - I V - C / P , a n d w a s d i a g n o s e d w i t h t r ic h o t i ll o -m a n i a a n d s p e c i f ic p h o b i a o f th e d a r k . C h i l d 3 ' s m o t h e r h a d a 2 - y e a r c o l l e g e
d e g r e e , a n d h e r f a t h e r h a d a g r a d u a t e d e g r e e . A n n u a l f a m i l y i n c o m e w a s
r e p o r t e d t o b e $ 4 2 , 0 0 0 . A t t h e t i m e o f t h e a s s e s sm e n t , C h i l d 3 a n d h e r m o t h e r
r e p o r t e d t h a t C h i ld 3 w a s f e a r f u l o f t h e d a r k t o th e e x t e n t t h a t sh e w o u l d w a k e
u p h e r p a r e n t s a p p r o x i m a t e l y t h r e e t i m e s p e r w e e k . C h i l d 3 a d d i t i o n a l l y
r e p o r t e d t h a t s h e f o u n d i t d i f f i c u lt t o s p e n d t h e n i g h t a t f r i e n d s ' h o u s e s , e n t e r
d a r k r o o m s , o r b e i n d a r k r o o m s o f th e h o u s e b y h e r s e lf . O n t h e C B C L , c o m -
p l e t e d b y t h e c h i l d ' s m o t h e r , C h i l d 3 r e c e i v e d a n e l e v a t i o n o n t h e T o t a l
I n t e r n a li z i n g S c a l e o f t h e C B C L ( M o t h e r T = 6 7 ) . C h i l d 3 ' s s c o r e o n t h e
C A F A S w a s 2 0 , i n d i c a t i n g m i l d i m p a i r m e n t o n t h e M o o d s a n d E m o t i o n ss u b s c al e a n d m i l d im p a i r m e n t o n t h e R o l e P e r f o r m a n c e - S c h o o l s u b sc a le .
C h i l d 4 . T h e f o u r t h c h i l d w a s a f e m a l e o f H a w a i i a n e t h n i c i t y r e s id i n g w i th
h e r m o t h e r a n d m a t e r n a l g r a n d m o t h e r . A t t h e a g e o f 8 y e a r s , 9 m o n t h s , C h i l d
4 w a s a s s e s se d w i th t h e A D I S - IV - C / P , a n d r e c e i v e d a p r i m a r y d i a g n o s i s o f
s e p a r a t i o n a n x i e t y d i s o r d e r w i t h a d d i t i o n a l d i a g n o s e s o f s o c i a l p h o b i a a n d
s p e c if ic p h o b i a o f v o m i t in g . C h i ld 4 ' s m o t h e r h a d n o t f i n i sh e d h i g h s c h o o l ,
a n d t h e a n n u a l f a m i l y i n c o m e w a s r e p o r t e d t o b e $ 3 0 , 0 0 0 . A t t h e t im e o f t h e
a s s e s s m e n t , C h i l d 4 a n d h e r m o t h e r r e p o r t e d th a t C h i l d 4 w a s e x p e r i e n c i n g
r e c u r r e n t a n d e x c e s s i v e d is t re s s w h e n s e p a r a te d f r o m h e r h o m e o r s e p a r a t io n
f r o m h e r m o t h e r o c c u r r e d o r w a s a n t i c i p a t e d , p e r s i s t e n t w o r r i e s a b o u t h a r m
b e f a l li n g h e r m o t h e r , a n d c o n s i s te n t r e l u c t a n c e o r r e f u s a l to g o t o p l a c e s s u c h
a s a fr i e n d ' s h o u s e o r in t o n e w s i tu a t i o n s b e c a u s e o f h e r f e a r s o f s e p a r a t io n .
S u c h c o n c e r n s w e r e a c c o m p a n i e d b y r e p e a t e d c o m p l a in t s o f p h y s ic a l s y m p -
t o m s , p a r t ic u l a r ly n a u s e a , w h e n s e p a r a te d f r o m h e r m o t h e r . C h i l d 4 w a s c o n -
c u r r e n t l y e x p e r i e n c i n g d i s c o m f o r t in a n d f e a r o f c e r t a i n s o c i a l s it u a t io n s , p r i -
m a r i l y t h o s e i n v o l v i n g h e r p e r f o r m a n c e i n s c h o o l , a n d h e r i n t e r a c t i o n w i t h
p e e r s . C h i l d 4 a n d h e r m o t h e r a d d i t i o n a l ly r e p o r t e d t h a t C h i l d 4 w a s e x p e r i -
e n c i n g a m a r k e d a n d p e r s is t e n t fe a r o f v o m i t i n g a t t h e t im e o f t h e i n ta k e . O n
t h e C B C L , C h i l d 4 h a d a n e l e v a ti o n o n t h e T o ta l I n te r n a l iz i n g S c a l e o f t h e
C B C L ( M o t h e r T = 6 8 ) . C h i l d 4 r e c e iv e d a s c o r e o f 2 0 o n t h e C A F A S , i n d i-
c a t i n g m o d e r a t e i m p a i r m e n t o n t h e M o o d s / E m o t i o n s s u b s c a l e .C h i l d 5 . T h e f i f th c h i l d w a s a m a l e o f J a p a n e s e e t h n i c i t y li v i n g a t h o m e
w i t h h i s m o t h e r , fa t h er , a n d m a t e r n a l g r a n d m o t h e r . H i s m o t h e r h a d c o m p l e t e d
c o l l e g e , a n d h i s f a th e r h a d r e c e i v e d a G E D . A n n u a l f a m i l y i n c o m e w a s
r e p o r t e d t o b e $ 7 0 , 0 0 0 . A t t h e t im e o f t h e a s s e s s m e n t , C h i l d 5 w a s 1 0 y e a r s ,
1 0 m o n t h s , a n d r e c e i v e d a p r i n c ip a l d i a g n o s i s o f p a n ic d i s o r d e r w i t h a g o r a -
p h o b i a a n d a d d i ti o n a l d i a g n o s e s o f m a j o r d e p r e s s i v e d i s o r d e r, r e c u r re n t ,
s e v e r e ; G A D ; a n d s p e c i f i c p h o b i a o f t h e d a r k . P r i o r t o t h e i n i t i a l e v a l u a t i o n ,
C h i l d 5 h a d b e e n p r e s c r i b e d P a x i l ( 2 0 m g p e r d a y ) a n d X a n a x a s n e e d e d .
C h i l d 5 a n d h i s m o t h e r r e p o r t e d a n e x t e n s i v e t r e a t m e n t h i s t o ry , in c l u d i n g t w o
s e p a r a t e i n - p a t i e n t h o s p i t a l i z a t i o n s f o r a n x i e t y a n d d e p r e s s i v e c o n c e r n s .A l t h o u g h C h i l d 5 w a s a t te n d i n g s c h o o l a t t h e ti m e o f t h e a s s e s s m e n t , h i s
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a t t e n d a n c e w a s s p o r a d i c a n d i t w a s r e p o r t e d th a t it w a s a d a i l y s t ru g g l e
b e t w e e n C h i l d 5 a n d h i s p a r e n ts f o r h i m t o a t te n d . I t w a s r e p o r t e d t h a t C h i ld 5
w a s e x p e r i e n c i n g a l a r g e n u m b e r o f p a n i c a t t a ck s t h a t w e r e l e a d i n g t o a ni n c r e a s i n g a v o i d a n c e o f s i t u a t i o n s , i n c l u d i n g s c h o o l , c r o w d e d p l a c e s , a n d
r o a d s w i t h f e w e x i t s. C h i l d 5 a n d h i s m o t h e r a l s o r e p o r t e d t h a t h e h a d b e e n
e x p e r i e n c i n g d e p r e s s i o n f o r th e p a s t 2 m o n t h s , a s w e l l a s t h e p r e s e n c e o f p e r-
s i st e n t a n d e x c e s s i v e w o r r i e s i n n u m e r o u s d o m a i n s a c c o m p a n i e d b y s e v e r e
p h y s i o l o g i c a l s y m p t o m s o f a r o u s al . S e l f -r e p o r t o n t h e R C A D S i n d i c a te d
c l in i c a l e l e v a t io n s o n t h e S e p a r a t i o n A n x i e t y D i s o r d e r ( T = 8 5 ) , P a n i c D i s -
o r d e r ( T = 8 7 ) , G e n e r a l i z e d A n x i e t y D i s o r d e r ( T = 8 0 ) , a n d D e p r e s s i o n ( T =
7 1 ) s c a l e s . F u r t h e r m o r e , C h i l d 5 ' s m o t h e r r e p o r t e d a c l i n ic a l e l e v a t io n T o t al
C B C L I n t e r n a li z i n g S c a le ( M o t h e r T = 8 1 ) . O n t h e C A F A S , C h i l d 5 r e c e i v e d
a s c o re o f 70 , in d i c at in g m i l d i m p a i r m e n t o n t h e R o l e P e r f o r m a n c e - S c h o o ls u b s c a l e , m i l d i m p a i r m e n t o n t h e R o l e P e r f o r m a n c e - H o m e s u b s c a l e , m i l d
i m p a i r m e n t o n t h e B e h a v i o r T o w a r d O t h e rs s u b s c al e , s e v e re i m p a i r m e n t o n t h e
M o o d s / E m o t i o n s s u b s c a l e, a n d m i l d i m p a i r m e n t o n t h e T h i n k i n g s u b s c a l e .
Child 6. T h e s i x t h c h il d w a s a m a l e o f J a p a n e s e e t h n i c i t y w h o r e s i d e d
w i t h b o t h h i s p a r e n t s a n d y o u n g e r s i s t e r . H i s m o t h e r h a d a 2 - y e a r c o l l e g e
d e g r e e a n d h is f a t h e r h a d c o m p l e t e d hi s G E D . N o a n n u a l f a m i l y i n c o m e w a s
r e p o r t e d . C h i l d 6 w a s a s s e s se d a t th e a g e o f 1 2 y e a r s , 1 0 m o n t h s , w i t h t h e
A D I S - I V - C / P a n d w a s a s s i g n e d a p r i m a r y d i a g n o s i s o f a n x i e t y d i s o r d e r n o t
o t h e r w i s e s p e c if i ed . A l t h o u g h C h i l d 6 e x h i b i t e d p e r v a s iv e a n d u n c o n t r o l l a b l e
w o r r y , as s e e n i n G A D , a n d e x h i b i t e d a n u m b e r o f f e a r s c o n c e r n i n g e v a l u a -
t i o n , p e r f o r m a n c e , a n d s o c i a l e v a l u a t i o n , h e h a d n o t b e e n w o r r i e d o r f e a r f u l
f o r a p e r i o d o f 6 m o n t h s . T h u s , h e f a il e d to m e e t c r i te r i a f o r G A D o r s o c i a l
p h o b i a . C h i l d 6 r e c e i v e d a n a d d i t io n a l d i a g n o s i s o f m a j o r d e p r e s s i v e d i s o r d e r ,
s in g l e e p i s o d e , m o d e r a t e . C h i l d 6 h a d b e e n e x p e r i e n c i n g e x t r e m e d i f fi c u lt y at -
t e n d i n g s c h o o l 1 m o n t h p r i o r to t h e a s s e s s m e n t . H i s d i f f i c u l ty a t t e n d i n g s c h o o l
c o m m e n c e d s u b s e q u e n t t o re t u r n in g h o m e a f t e r a t ri p to t h e m a i n l a n d . A f t e r
t h e tr ip , C h i l d 6 h a d b e c o m e i n c r e a s i n g ly w o r r i e d a b o u t s c h o o l , p e r f o r m a n c e ,
w o r l d e v e n t s, a n d o t h e r d o m a i n s . C h i l d 6 r e p o r t e d w o r r i e s a b o u t b e i n g g o o d
e n o u g h , f a m i l y m a t t e r s , h i s h e a l t h ( p a r t i c u l a r l y h i s m e n t a l h e a l t h ) , t h e h e a l t h
o f h is p a r e n t s , h is s c h o o l a t t e n d a n c e , g r a d e s , a n d p l e a s i n g o t h e r s . C h i ld 6 w a s
a t te n d i n g s c h o o l a t th e t i m e o f th e a s s e s s m e n t b u t w a s s p e n d i n g t h e d u r a t io no f t h e d a y i n t h e c o u n s e l o r ' s o f f i c e c r y i n g a n d d i s c u s s in g h i s w o r r i e s. O n t h e
s e l f - re p o r t m e a s u r e s u s e d t o s u p p l e m e n t t h e A D I S - I V - C / P , C h i l d 6 s c o r e d in
t h e c l in i c a l r a n g e o n th e R C A D S S e p a r a t i o n A n x i e t y D i s o r d e r ( T = 8 3 ) , S o -
c i a l P h o b i a ( T = 6 7 ) , a n d G e n e r a l i z e d A n x i e t y D i s o r d e r ( T = 8 3 ) , a n d D e -
p r e s s i o n ( T = 9 2 ) s c a l e s . H e a l s o r e p o r t e d a n e a r c li n i c a l e l e v a t i o n o n t h e
P a n i c D i s o r d e r S c a le ( T = 6 3 ) o f t h e R C A D S . O n t h e C B C L , th e m o t h e r o f
C h i l d 6 r e p o r t e d a c l i n ic a l e l e v a t i o n o n t h e T o t a l I n t e r n a l i z i n g S c a l e o f t h e
C B C L ( M o t h e r T = 7 0 ) . C h i l d 6 ' s C A F A S s c o r e a t t h e t i m e o f t h e in i ti al a s-
s e s s m e n t w a s 8 0 , i n d i c a t i n g m i l d i m p a i r m e n t o n t h e R o l e P e r f o r m a n c e -
H o m e s u b s c a l e a n d S e l f - H a r m f u l B e h a v i o r s s u b s c a le , a n d s ev e r e i m p a i r m e n to n th e R o l e P e r f o r m a n c e - S c h o o l an d M o o d s a n d E m o t i o n s s u b sc a le s .
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
C h i l d 7 . C h i l d 7 w a s a n 1 1 y e a r , 8 - m o n t h - o l d f e m a l e . C h i l d 7 ' s p a r e n t s
w e r e d i v o r c e d a n d C h i l d 7 r e s i d e d w i t h h e r m o t h e r b u t s a w h e r f a t h e r o n a
d a i l y b a s i s . C h i l d 7 w a s o f m u l t i e t h n i c d e c e n t ( A s i a n a n d P a c i f i c I s l a n d ) .C h i l d 7 ' s m o t h e r h e l d a g r a d u a t e d e g r e e a n d h e r f a th e r h a d a b a c h e l o r ' s
d e g r e e . A n n u a l h o u s e h o l d i n c o m e w a s r e p o r t e d a s $ 3 0 ,0 0 0 . C h i l d 7 r e c e i v e d
a d i a g n o s i s o f s p e c i f i c p h o b i a , s i t u a t i o n a l t y p e , o n t h e A D I S - I V - C / P . O n t h e
s e l f -r e p o r t m e a s u r e s u s e d t o s u p p l e m e n t t h e A D I S - IV - C / P , C h i l d 7 s c o r e d
w i t h i n t h e n o r m a l r a n g e f o r b o t h s e l f a n d p a r e n t r e p o r t . A t t h e t i m e o f t h e
a s s e s s m e n t , C h i l d 7 ' s m o t h e r e x p r e s s e d c o n c e r n o v e r h e r d a u g h t e r ' s f e a r s o f
p l a n e s a n d e l e v a t o r s a n d t h e s i g n i f i c a n t l i m i t s t h a t t h e s e f e a r s w e r e i m p o s i n g
o n C h i l d 7 ' s l i f e . C h i l d 7 w a s u n a b l e t o p a r t i c i p a t e i n f a m i l y v a c a t i o n s t h a t
n e c e s s i t a t e d t r i p s to t h e m a i n l a n d . A l t h o u g h s h e w a s a b l e t o fl y t o o t h e r
i sl a n d s, C h i l d 7 e x p e r i e n c e d i n t e n s e f e a r c o u p l e d w i th s e v e r a l d a y s o f w o r r yb e f o r e h e r d e p a r t u r e . C h i l d 7 a n d h e r m o t h e r h a d s o u g h t t r e a t m e n t a f t e r C h i l d
7 w a s i n v i t e d t o a c c o m p a n y a f r i e n d o n a t r i p b u t w a s u n a b l e d u e t o t h e f e a r s
o f a i r t r a v e l . F u r t h e r m o r e , C h i l d 7 w a s a l s o u n a b l e t o r i d e i n m o s t e l e v a t o r s .
I n m o s t s i t u a t io n s , C h i l d 7 c h o s e t o w a l k u p s t a ir s e v e n t o h i g h f l o o r s. C h i l d 7
l i v e d i n a h i g h - r i s e a p a r t m e n t b u i l d i n g b u t w a s u n a b l e t o t r a v e l t o t h e h i g h e r
f lo o r s o f h e r b u il d in g . O n t h e o c c a s i o n w h e n C h i l d 7 h a d a p p o i n t m e n t s o n a
h i g h f l o o r o f a b u i l d i n g , s h e a n d h e r m o t h e r h a d t o d e p a r t s i g n i f ic a n t l y e a r l ie r
t h a n t h e a p p o i n t m e n t t i m e i n o r d e r t o a ll o w C h i l d 7 ' s m o t h e r e n o u g h t i m e to
c o a x h e r i n t o t h e e l e v a t o r . C h i l d 7 ' s m o t h e r d i d n o t r e p o r t a n y c l i n i c a l e l e v a -
t io n s o n t h e C B C L T o t a l In t e r n a li z in g S c a l e . A t t h e t i m e o f t h e a s s e s s m e n t ,
C h i l d 7 ' s C A F A S s c o r e w a s 1 0, i n d ic a t in g m i l d i m p a i r m e n t o n t h e M o o d s /
E m o t i o n s s u b s c a l e .
T r e a tm e n t M a n u a l
T h e M o d u l a r C B T m a n u a l ( C h o r p it a , 1 9 9 8 ) d r aw s f r o m t h e w o r k o f B a r -
l o w ( 1 9 8 8 ) a n d B e c k a n d c o l l e a g u e s ( B e c k , R u s h , S h a w , & E m e r y , 1 9 7 9 ) i n
a d u l t s , m a n u a l i z e d C B T f o r c h i l d r e n ( e . g . , K e n d a l l e t a l. , 1 9 9 0 ; S i l v e r m a n e t
a l. , 1 9 9 9 ) , b e h a v i o r t h e r a p y f o r p h o b i c y o u t h d e v e l o p e d i n t h e e a r ly p a r t o f
t h e 2 0 t h c e n t u r y ( J o n e s , 1 9 2 4 ) , a n d i t s e x t e n s i o n s a n d e l a b o r a t i o n s o v e r t h e
p a s t 3 0 y e a r s ( e . g ., O l l e n d i c k & F r a n c i s , 1 9 8 8 ). T h e p r o t o c o l a i m s t o c o r r e c t
t h e c h i l d 's m i s p e r c e p t i o n o f t h r e a t s o t h at t h e a n x i e t y r e s p o n s e i s r e d u c e d .S u c h c h a n g e s a r e fo s t e r e d th r o u g h e d u c a t i o n a n d e x p o s u r e p r a c t i c e e x e r c is e s
d e s i g n e d t o t ea c h t h e c h i l d t h r o u g h r e a s o n i n g a n d e x p e r i e n c e t h a t th e i r a n x i-
e t y i s n o t n e c e s s a r y o r i s o u t o f p r o p o r t i o n t o t h e p e r c e i v e d d a n g e r . A l l s e s-
s i o n s t a k e a n a c t i v e a p p r o a c h , r e q u i r e a s e s s i o n a g e n d a , a n d e m p l o y r a p p o r t
b u i l d i n g a n d S o c r a t i c s t r a t e g i e s . A l t h o u g h C B T t r a d i t i o n a l l y f o c u s e s o n
w o r k i n g w i t h t h e c h i ld ' s t h o u g h t s a n d b e h a v i o r s , th e m a n u a l a l s o e m p h a s i z e s
t h e n e e d t o a d d r e s s f a c t o rs in t h e c h i ld ' s b r o a d e r e n v i r o n m e n t ( B r o n f e n b r e n -
n e r , 1 9 8 6 ) . P a r e n t s , te a c h e r s , p e e r s , a n d o t h e r i n f l u e n c e s t h a t m a i n t a i n , i n t e n -
s i fy , o r o t h e r w i s e a f f e c t a n x i e t y a r e i n c l u d e d a s t h e f o c u s o f t re a t m e n t . A c c o r d -
i n g ly , b e h a v i o r t h e r a p y s tr a te g i es f o r d i s ru p t iv e b e h a v i o r a n d p o o r m o t i v a ti o na r e a l so o u t l in e d i n th e m a n u a l ( c f . F o r e h a n d & M c M a h o n , 1 9 8 1; P a t te r s o n ,
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M O D U L A R C O G N I T I V E B E H A V I O R T H E R A P Y 273
Chamberlain, & Reid, 1982), and many of the parent strategies and accompany-
ing handouts are designed to be used with teachers as well.
An important feature of the Modular CBT manual is that it is designedexplicitly to encourage the individualizing of each child's treatment. For
example, some children might require a few sessions at school, others mightrequire several months of therapy in a clinic setting. Some children might
need to have parents incorporated into the program, others less so. According
to the manual, the specific steps and procedures of the treatment are dictated
by the needs of the child. The arrangement of techniques is outlined in Figure
1. Despite the flexible nature of such a program, all children receive a mini-
mum set of four procedures (i.e., the "core four") believed to represent the
main components of treatment, which are: (a) self-monitoring ("Fear Lad-
der"), (b) education about anxiety ("Learning About Anxiety"), (c) practiceof feared situations ("Exposure") , and (d) education about maintaining newskills ("Maintenance and Relapse Prevention").
The Fear Ladder is the term used to describe a fear hierarchy, created
jointly by the child and therapist to reflect gradations of 10 to 12 feared situa-tions or stimuli (Barlow & Seidner, 1983; Wolpe, 1958). The hierarchy is
completed twice weekly with ratings ranging from 0 to 8, and the average rat-
ing across all situations for each administration was used as the primary time-
series measure for the design. Although part of the manual, the Fear Ladder
m o d u l e i s d e s i g n e d t o a ll o w f o r c o n t i n u e d a s s e s s m e n t a n d s o i s n o t f o r m a l l y
c o n s i d e r e d a c t iv e t r e a t m e n t ( h e n c e , d e l i v e r e d in t h e b a s e l i n e p h a s e o f t h e
d e s i g n ). T h e L e a r n i n g A b o u t A n x i e t y m o d u l e i s d e s i g n e d t o i n tr o d u c e a l a n-g u a g e t o th e c h i l d w i t h w h i c h t o t a lk a b o u t t h o u g h t s a n d f e e li n g s a n d t o b e g i n
w o r k i n g w i t h t h e c h i ld o n t h e c o n c e p t th a t a n x i e t y c a n r e p r e s e n t a " f a ls e
a l a r m " ( c f. B a r lo w , 1 9 8 8 ). A s s u c h , th is m o d u l e l a y s a c o g n i ti v e f r a m e w o r k
f o r a n y e x p o s u r e t h a t i s t o f o l l o w . T h e E x p o s u r e m o d u l e t h e n i n v o l v e s t h e
s e l e c t i o n o f i t e m s f r o m t h e f e a r h i e r a r c h y t o b e u s e d i n p r a c t i c e e x e r c i s e s ,
d u r i n g w h i c h p e r i o d i c f e a r r a ti n g s a r e t a k e n t o tr a c k h a b i t u a t i o n p a t t e r n s .
T h e s e e x e r c i s e s a r e a ls o a s s i g n e d f o r h o m e w o r k . F i n a l l y , t h e M a i n t e n a n c e
a n d R e l a p s e P r e v e n t i o n m o d u l e i s d e s i g n e d t o a l lo w f o r a re v i e w o f sk i ll s
l e a r n e d a n d t o f o s t e r th e c h i l d ' s a t t r ib u t i o n o f g a i n s t o t h e b e h a v i o r s l e a r n e d
a n d p e r f o r m e d i n t r e a tm e n t .C h i l d r e n a n d f a m i l ie s w h o r e q u i r e m o r e t e c h n i q u e s t h a n t h o s e re p r e s e n t e d
i n th e c o r e f o u r m o d u l e s a r e t a k e n t h r o u g h t h o s e s t e p s a s t h e n e e d a r i s e s . T h e
s e l e c ti o n o f a p p r o p r i a te a d d i t io n a l m o d u l e s a n d t h e d e t e r m i n a t i o n o f w h e n t o
i n i ti a te a n d t e r m i n a t e e a c h a r e d e t e r m i n e d a s a p a r t o f t h e c l i n ic a l s u p e r v i s i o n
p r o c e s s , w h i c h is g u i d e d b y t h e u s e o f t h e f l o w c h a r t. T h u s , i f th e r e i s m u t u a l
a g r e e m e n t t h a t e x p o s u r e i s n o t p o s s i b l e , t h e t h e r a p i s t a n d s u p e r v i s o r w i l l
i n f e r w h a t s o u r c e s o f i n t e r f e r e n c e m i g h t e x i s t a n d t h e r e b y s e l e c t a n d d e p l o y a
m o d u l e r e p r e s e n t i n g a n a p p r o p r i a t e s t r a t e g y . I n t e r r a t e r r e l i a b i l it y d a t a r e g a r d -
i n g t h e u s e o f th e f l o w c h a r t i n a v a r i e t y o f c l in i c a l c o n t e x t s a r e b e i n g g a t h e r e d
a s p a r t o f a s e p a r a t e i n v e s t i g a t i o n . T h e e m p i r i c a l r a t i o n a l e f o r t h i s a r r a n g e -m e n t o f te c h n i q u e s i s b a s e d o n m o r e t h a n 5 0 s t u d ie s s h o w i n g t h e e f f ic a c y o f
e x p o s u r e f o r a n x i e t y i n v a r i o u s f o r m s ( C h o r p i t a e t a l . , 2 0 0 2 ; O l l e n d i c k &
K i n g , 1 9 9 8 ) . A l t h o u g h t h e l i te r a t u r e is n o t e x p l i c i t a b o u t th e n e c e s s i t y o f c o g -
n i t iv e e l e m e n t s i n i n t e r v e n t i o n s f o r a n x i e t y , t h e i r p r e p o n d e r a n c e i n t h e l it e r a -
t u r e o n n o n p h o b i c a n x i e t y d i s o rd e r s s u g g e s t e d t h a t s o m e a s p e c ts o f a d d r e s s-
i n g c o g n i t i o n a r e l i k e l y t o b e i m p o r t a n t . F o r t h i s r e a s o n , t h e p r o t o c o l i n t r o d u c e s
t h e i d e a o f e x p o s u r e i n t h e c o n t e x t o f te s ti n g a s s u m p t i o n s a b o u t p e r c e i v e d
t h r e a t . A l l o t h e r t e c h n i q u e s a r e s e e n a s e n a b l i n g t h e s e t e c h n i q u e s t h a t a r e s o
c o m m o n l y r e p r e s e n t e d i n t h e a n x i e t y t r e a t m e n t l i te r a tu r e .
T h e m a n u a l i n c l u d e s f o r m s t h a t h e l p t o s tr u c t u re a n d s t a n d a rd i z e t h e d e l iv -
e r y o f te c h n i q u e s . T h e s e f o r m s w e r e c r e a t e d s p e c i fi c a ll y f o r u s e w i t h t h is
m a n u a l . W o r k s h e e t s ( e . g . , p u z z l e s , g a m e s ) a r e u s e d i n - s e s s i o n o r a s h o m e -
w o r k e x e r c i s e s a n d i n c o r p o r a t e a n d i n t e g r a t e m a t e r i a l l e a r n e d i n th e r a p y . A
v a r i e ty o f m o n i t o r i n g f o r m s a r e u s e d t o t r a c k p r o g r e s s o r e v e n t s t h a t ar e
i m p o r t a n t t o t h e r a p y . F i n a l l y , e d u c a t i o n a l s h e e t s a n d b o o k l e t s a r e g i v e n t o
p a r e n ts a n d t e a c h e r s t o r e i n f o r c e i n f o r m a t i o n a b o u t a t e c h n i q u e t h a t h as b e e n
r e v i e w e d i n s e s si o n . T h e s e h a n d o u t s a r e d e s i g n e d t o b e a r e f e r e n c e f o r p a r-
e n t s a n d t e a c h e r s p a r t i c i p a t i n g i n t h e c h i l d ' s t h e r a p y .
P r o c e d u r e
T h e r a p i s t s i n t h e c u r r e n t i n v e s t i g a t i o n w e r e t h r e e d o c t o r a l - l e v e l g r a d u a t es t u d en t s . E a c h t h e r a p is t fo l l o w e d t h e M o d u l a r C B T m a n u a l a n d r e c e i v e d
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
w e e k l y s u p e r v i s io n f r o m t h e f ir st a u th o r . T h e e f f e c t s o f t re a t m e n t w e r e e v a l u a t e d
u s i n g a m u l t i p l e b a s e l i n e d e s i g n a c r o s s c h i l d r e n . F o l l o w i n g t h e p r e t r e a t m e n t
a s s e s s m e n t , c h i l d r e n w e r e r a n d o m l y a s s i g n e d t o a m i n i m u m 1 . 5 - o r 3 - w e e kb a s e l i n e . P r i o r t o b e g i n n i n g b a s e l i n e , e a c h c h i l d w o r k e d w i t h a t h e r a p i s t t o
c o n s t r u c t a f e a r h i e r a r c h y , t o b e c o m p l e t e d t w i c e w e e k l y a s a s e l f - m o n i t o r i n g
t o o l f o r th e d u r a t io n o f t h e s t u d y . T r e a t m e n t b e g a n a f t e r o b s e r v a t i o n o f a
s t ab l e t re n d i n t h e f e a r h i e r a r c h y d a t a, f o l l o w i n g t h e m i n i m u m 1 .5 - o r 3 - w e e k
w a i t in g p e r i o d ( H a y e s , B a r l o w , & N e l s o n - G r a y , 1 9 9 9 ) . T h u s , b a s e li n e w a s
s t a g g e r e d a n d t r e a t m e n t b e g a n f o r a ll c a se s w i t h " L e a r n i n g A b o u t A n x i e t y "
( s e e F i g u r e 1 ). S u b s e q u e n t c o n t e n t o f s es s io n s w a s d e p e n d e n t o n p a r t i c ip a n t
p r o g r e s s a n d g u i d e d b y t h e t r e a t m e n t a l g o r i th m o u t l in e d i n F i g u r e 1 . T r e a t m e n t
w a s t e r m i n a t e d w h e n c h i l d r e n d e m o n s t r a t e d a s t ab l e tr e n d o f i m p r o v e m e n t3 o r
r e p o r t e d c o n s i s t e n t l y l o w f e a r h i e r a r c h y r a t i n g s , a n d w h e n t h e y h a d c o m -p l e t e d t h e f i n a l m o d u l e s . C h i l d r e n w e r e t h e n a s s e s s e d b y a n i n d e p e n d e n t
e v a l u a t o r b o t h a t p o s t t r e a t m e n t a n d a g a i n a f t e r a 6 - m o n t h i n te r v a l.
Results
Mu l t ip l e Base l ine
Overa l l t rends. T h e m u l t ip l e b a s e l in e a c r o s s c h i l d r e n a p p e a r s i n F i g u r e 2 .
A l l s e v e n c h i l d r e n d e m o n s t r a t e d r e l a t i v e l y s t a b l e t r e n d s d u r i n g b a s e l i n e , w i t h
m o s t m a i n t a i n in g h i g h o r i n c r e as i n g l e v e ls o f a n x i e t y an d t w o s h o w i n g m i n i -
m a l d o w n w a r d t r e n d s. C h i l d 1 w a s a s s i g n e d t o a 1 . 5 - w e e k b a s e l i n e , b u t b e g a nt r e a tm e n t f o l l o w i n g a 4 - w e e k w a i ti n g p e r i o d b e c a u s e e x t r a n e o u s e v e n t s ( i. e .,
m e d i c a l e x a m s ) o c c u r r e d d u r in g t h e p l a n n e d t i m i n g o f t h e p h a s e c h a n g e a n d
w o u l d h a v e c o n f o u n d e d i n t e rp r e ta t io n o f e f f e c t s ( s ee b e l o w ) . C h i l d r e n 2 a n d 7
w e r e a s s i g n e d t o a 1 . 5 - w e e k b a s e l i n e , b u t C h i l d 2 w a s h e l d t o 2 w e e k s
b e c a u s e t h e f i r s t t h r e e d a t a p o i n t s s u g g e s t e d p o s s i b l e i m p r o v e m e n t s d u e t o
r e a c t iv i t y o r o t h e r e x t r a n e o u s v a r i a b l e s, a n d C h i l d 7 w a s h e l d t o a 2 - w e e k
b a s e l i n e b e c a u s e o f m i s s i n g d a t a d u r i n g t h e f ir st 1 0 d a y s , w h i c h w o u l d n o t
h a v e p r o v i d e d s u f f i c i e n t d a t a f o r t h e i n t e r p r e t a b i l i t y o f b a s e l i n e . C h i l d r e n 3
a n d 5 b e g a n t r e a t m e n t s u b s e q u e n t t o a 3 - w e e k b a s e l i n e , a n d C h i l d r e n 4 a n d 6
b e g a n t r e a t m e n t s u b s e q u e n t t o a 1 . 5 - w e e k b a s e li n e .T h r o u g h o u t th e d u r a t i o n o f t r e a tm e n t , a ll p a rt i ci p a n t s w e r e a s k e d t o c o m -
p l e t e th e i r r e s p e c ti v e f e a r h i er a r c h i e s t w i c e p e r w e e k . F i g u r e 2 p r e s e n ts t h e
c h i l d r e n ' s f e a r ra t i n g s o n t h e i r r e s p e c t i v e f e a r la d d e r s o v e r t h e c o u r s e o f tr e a t -
m e n t ( a v e r a g e d a c r o s s s i tu a t io n s a n d s ti m u l i o n t h e l a d d e r ) . A f t e r t h e c o m p l e -
t io n o f t h e i n it ia l b a s e l in e a n d t h e c o m m e n c e m e n t o f a c ti v e tr e a t m e n t , t h e
f e a r r a ti n g s f o r e a c h o f t h e p a r t ic i p a n t s w e r e o b s e r v e d t o d e c r e a s e o v e r t re a t-
m e n t , a s n o t e d b y t h e t r e n d l in e s .
3 V i sua l i n spe c t ion c r i t e ri a f o r de t e r m in ing s t a b i l i ty a r e t hose o u t l i ne d by H a ye s , B a r low , a nd
N e l son - G r a y ( 1999 ) , a nd ide n t i f i c a t ion o f im p r ove m e n t i nvo lve d a c on junc t ion o f s t a b i l i ty w i tha no t i c e a b le c ha nge in t r e nd f r om ba se l ine t o t he i n t e r ve n t ion pha se .
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
Individual results. C h i l d 1 w a s u n a b l e t o a t t e n d t h e r a p y s e s s i o n s a f t e r 1 .5
w e e k s , d u e t o t h e c h i l d ' s d a i l y v o m i t in g r e p o r t e d b y h e r f a m i l y . U n t i l d a y 2 5 ,
C h i l d 1 u n d e r w e n t m e d i c a l e x a m i n a t i o n s t o a s c e rt a in w h e t h e r m e d i c a l/ o r g a n i cc a u s e s m i g h t u n d e r l ie h e r f r e q u e n t v o m i t in g . F o r t h e se r e a s o n s , t h e b a s e l in e
f o r C h i l d 1 w a s n e c e s s a r i l y e x t e n d e d to 2 8 d a y s ( e x t ra d a y s w e r e a d d e d t o
a l lo w f o r s t ab l e b a s e l in e a f t e r c o m p l e t i n g m e d i c a l e v a l u a t i o n s , w h i c h a ll
f a i l e d t o i n d i c a te a n o r g a n i c c a u s e f o r th e c h i l d ' s v o m i t i n g ) . O v e r a r c h i n g g o a l s
o f C h i ld l ' s t r e a tm e n t i n c l u d e d d e c r e a s e i n f r e q u e n c y , se v e r i ty a n d b r e a d t h
o f w o r r y a n d i n c r e a s i n g c o n s i s t e n t s c h o o l a t t e n d a n c e . C h i l d 1 r e c e i v e d th e
L e a r n i n g A b o u t A n x i e t y m o d u l e i n th e f ir st a n d s e c o n d s e s s i o n s. E x p o s u r e
w a s s t ar te d i n S e s s i o n 2 , a n d w a s p r a c t i c e d f o r t h e n e x t f o u r t r e a tm e n t s e s -
s i o ns . E x p o s u r e e x e r c i s e s in v o l v e d g r a d u a l ly p r a c t ic i n g g o i n g t o s c h o o l a n d
e n g a g i n g i n r o l e - p l a y s i n v o l v in g h a n d i n g i n m e s s y h o m e w o r k , g i v e n h e r a n x -i e t y r e g a r d i n g e v a l u a t i o n in s c h o o l . T h e r e w e r e n o t a b l e d e c r e a s e s i n h e r a n x i e t y
o v e r t h e n e x t f e w w e e k s . D u r i n g t h is t i m e , v o m i t i n g d e c r e a s e d i n fr e q u e n c y
w h i l e s o m a t i c c o m p l a i n t s t o h e r p a r e n t s i n c r e a s e d . B y t h e f i f t h t r e a t m e n t s e s -
s i o n , s c h o o l r e s u m e d f r o m t h e s u m m e r r e c e s s , a n d a h i g h e r l e v e l o f t a n tr u m s
( e .g . , c u r s i n g a t f a m i l y a n d h i t ti n g f a m i l y m e m b e r s ) i n c o n j u n c t i o n w i t h s o -
m a t i c c o m p l a i n t s w a s o b s e r v e d . T h u s , i n t h e s i x t h t re a t m e n t s e s s io n , b o t h t h e
R e w a r d s a n d A c t i v e I g n o r i n g ( d i ff e r e n ti a l r e i n f o r c e m e n t o f o t h e r b e h a v i o r )
m o d u l e s w e r e c o v e r e d w i th t h e p a re n t s . S e s s io n s 6 t h r o u g h 1 0 i n c l u d e d o n -
g o i n g a p p l i c a t i o n o f d i f f e r e n t i a l r e i n f o r c e m e n t s t r a t e g i e s , r u l e s a n d r e w a r d s
w i t h p a r e n t s , a n d e x p o s u r e w i t h t h e c h i l d . A l s o , b e c a u s e o f s o m e h e s i t a n c e t o
c o n t i n u e w i t h e x p o s u r e e x e r c is e s , t h e S T O P m o d u l e ( c o g n i ti v e t e c h n i q u e s
t o a s s is t i n t h e d e c r e a s e o f n e g a t i v e t h in k i n g f o r y o u n g e r c h i ld r e n ) w a s i n t ro -
d u c e d i n S e s s i o n 8 .
C h i l d 1 b e c a m e i ll a t 1 0 w e e k s i n t o tr e a t m e n t , c o m p l i c a t i n g t h e c o n t i n u e d
a d m i n i s t r a ti o n o f d i f fe r e n t ia l re i n f o r c e m e n t , a n d r e n d e r i n g C h i l d 1 u n a b l e t o
m o n i t o r s u c c e s s f u l l y at th i s ti m e . C h i l d 1 r e s u m e d s e s s io n s a n d m o n i t o r i n g
1 3 w e e k s i n t o t re a t m e n t , a n d d e m o n s t r a t e d a d e c r e a s e i n s o m a t i c c o m p l a i n t s .
H e r a n x i e t y r e m a i n e d a t l o w l e v e l s, a n d h e r a t te n d a n c e i n t r e a t m e n t w a s c o n -
s i s te n t f o r t h e r e m a i n d e r o f t r e a t m e n t . S e s s i o n s 1 0 t h r o u g h 1 3 in c l u d e d r e v i e w
o f p r e v i o u s m o d u l e s a n d g a i n s . T h e l a st t h re e t r e a t m e n t s e s s i o n s i n v o l v e d t h e
M a i n t e n a n c e a n d R e l a p s e P r e v e n t i o n m o d u l e . T h e s e s e ss io n s w e r e f a d e d t oe v e r y o t h e r w e e k , a n d t e r m i n a t e d a t d a y 1 5 5 , a t w h i c h t i m e C h i l d 1 h a d c o m -
p l e t e d 1 5 a c t iv e t re a t m e n t s e s s i o n s .
T h e m o t h e r o f C h i l d 2 r e f u s e d t o p a r t ic i p a t e in t h e r a p y f r o m t h e f ir st s es -
s i o n , d e s p i t e r e p e a t e d r e q u e s t s i s s u e d b y t h e s c h o o l a n d t h e t r e a t i n g t h e r a p i s t.
C h i l d 2 ' s m o t h e r c o n s e n t e d f o r h e r c h i l d ' s p a r ti c i p a ti o n b u t w a s u n w i ll i n g t o
s p e a k o n t h e p h o n e t o t h e t h e r a p i s t o r t e a c h e r s . E a c h o f t h e f o u r i n i t i a l t r e a t -
m e n t s e s s io n s s c h e d u l e d w e r e m i s s e d o r c a n c e l e d b y C h i l d 2 ' s m o t h e r f o r
r e a s o n s w e w e r e u n a b l e t o d e t e r m i n e . S i n c e a ll a t te m p t s a t a f ir s t s e s s i o n a f t e r
t h e in i t ia l a s s e s s m e n t w e r e m i s s e d o r c a n c e l l e d , t h e t h e r a p i s t b e g a n t r a v e l i n g
t o t h e s c h o o l to e n s u r e c o n s i s t e n t m o n i t o r i n g o f s c h o o l a t te n d a n c e a n d a n x i -e t y a n d t o a d m i n i s t e r t r e a t m e n t p r o t o c o l s a s i n d i c a t e d . A s a r e s u l t , a l m o s t a l l
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
s e s s i o n s w i t h C h i l d 2 w e r e c o n d u c t e d i n s c h o o l . T h e g o a l s o f t r e a t m e n t f o r
C h i l d 2 w e r e t o i n c r e a s e h e r a b i l i t y t o b e a w a y f r o m h e r m o t h e r a n d h e r
h o m e , t o a t t e n d s c h o o l c o n s i s t e n t ly , t o d e c r e a s e h e r f e a r in s o c i a l s i t u a ti o n s ,a n d t o a s s i s t h e r w i t h f e a r s o f c o n t r a c t i n g a n i l ln e s s o r a d i s e a s e . C h i l d 2
r e c e i v e d t h e L e a r n i n g A b o u t A n x i e t y m o d u l e in t h e fi rs t s e s s i o n . I n t h e s e c -
o n d s e s s io n , e x p o s u r e w a s i m p l e m e n t e d s i m u l t a n e o u s l y w i th t h e R e w a r d s
m o d u l e , i n a n t i c i p a t i o n o f p r e d i c t e d d i f fi c u lt i es w i t h m o t i v a t i o n t o p a r t i c ip a t e
i n tr e a t m e n t a n d l o w l e v e l s o f s u p p o r t f r o m C h i l d 2 ' s f a m i l y . B e c a u s e o f th e
p a r e n t ' s r e f u s a l t o p a r ti c i p a t e i n tr e a t m e n t , th e d e l i v e r y o f r e w a r d s w a s i m p l e -
m e n t e d i n a c o o r d i n a t e d e f f o r t b e t w e e n C h i l d 2 ' s t h e r a p i s t a n d te a c h e r s .
E x p o s u r e i n v o l v e d t im e i n s c h o o l a n d s p e a k i n g t o o th e r s d u r i n g t h e n e x t s e v -
e r a l w e e k s . T h e t h i r d t h r o u g h s i x t h s e s s i o n s f o c u s e d o n c o n t i n u e d e x p o s u r e
e x e r c i s e s w i t h t h e c h i l d i n t h e s c h o o l s e t t i n g . H a b i t u a t i o n w a s o b s e r v e dw i t h in a n d b e t w e e n s es si on s .4 W i th i n 3 w e e k s o f th e c o m m e n c e m e n t o f a c t iv e
t r e a t m e n t a n d e x p o s u r e e x e r c i s e s , t h e ch i l d w a s a t t e n d i n g s c h o o l o n a c o n s i s -
t e n t b a si s . In t h e s e v e n t h s e s s i o n , t h e r e w a r d s s y s t e m w a s c h a n g e d t o r e i n f o r c e
a t t e n d i n g s c h o o l a f te r t h e w e e k e n d . T h e f r e q u e n c y o f th e r a p y s e s s i o n s w a s
d e c r e a s e d t o e v e r y o th e r w e e k , a n d t h e M a i n t e n a n c e a n d R e l a p s e P r e v e n t i o n
m o d u l e a n d g e n e r a l i z a t i o n s t r a t e g i e s w e r e d i s c u s s e d i n t h e e i g h t h s e s s i o n . I n
t o ta l , C h i l d 2 r e c e i v e d e i g h t s e s s i o n s o v e r 1 4 w e e k s .
C h i l d 3 b e g a n t r e a t m e n t a f t e r a 3 - w e e k b a s e l i n e . T h e g o a l o f t r e a t m e n t f o r
C h i l d 3 w a s t o d e c r e a s e f e a r f u l n e s s i n th e d a r k . T h e L e a r n i n g A b o u t A n x i e t y
m o d u l e w a s a d m i n i s t e r e d i n t h e f i r s t s e s s i o n . E x p o s u r e b e g a n i n S e s s i o n 2 .
P r a c t i c e e x e r c i s e s i n v o l v e d h a v i n g t h e c h i l d s i t i n a d a r k r o o m , f ir s t w i t h t h e
t h e r a p i s t a n d t h e n a l o n e . H a b i t u a t i o n w a s n o t e d a l m o s t i m m e d i a t e l y , a n d
e x e r c i s e s i n c o r p o r a t e d l o n g e r a n d l o n g e r d u r a t i o n s . B e i n g i n t h e b e d r o o m
w i t h t h e l ig h t o f f w a s a s s i g n e d f o r h o m e w o r k , a n d C h i ld 3 ' s p a r e n ts w e r e
i n s t r u c te d t o p r a i s e a n d e n c o u r a g e t h e p r a c t i c e e x e r c i s e s . W i t h i n 2 w e e k s ,
C h i l d 3 w a s n o l o n g e r w a k i n g h e r p a r e n t s d u r i n g t h e n i g h t , a n d s h e w a s a b l e
t o b e i n a d a r k r o o m a l o n e w i t h o u t b e c o m i n g f e a r f u l o r e x p e r i e n c i n g a f e a r f u l
r e s p o n s e . R e l a p s e p r e v e n t i o n a n d t h e i m p o r t a n c e o f c o n t i n u e d p r a c t ic e w e r e
d i s c u s s e d in t he r e m a i n i n g s e s s i o n s , a s in d i c a t e d b y t h e p r o t o c o l . O v e r a l l , f i ve
s e s s i o n s o f a c ti v e tr e a t m e n t w e r e d e l i v e r e d o v e r a 7 - w e e k p e r i o d t o C h i l d 3 .
C h i l d 4 b e g a n t r e a t m e n t a f t e r a 1 . 5 - w e e k b a s e l i n e . T h e g o a l s o f tr e a t m e n t
f o r C h i l d 4 i n c l u d e d ( a) i n c r e a s i n g a b i l i ty t o s e p a r a t e f r o m h e r m o t h e r , ( b )
d e c r e a s i n g f e a r i n s o c i a l e v a l u a t i v e s i t u a t i o n s , ( c ) d e c r e a s i n g f r e q u e n c y o f
s o m a t i c c o m p l a i n t s a n d c h r o n i c r e a s s u r a n c e s e e k i n g , a n d ( d ) d e c r e a s i n g f e a r
o f v o m i t in g . T h e L e a r n i n g A b o u t A n x i e t y m o d u l e w a s a d m i n i s te r e d i n th e
i n i t i a l t r e a t m e n t s e s s i o n . I n t h e s e c o n d s e s s i o n , e x p o s u r e w a s i m p l e m e n t e d ,
a n d C h i l d 4 w a s a s k e d t o e n g a g e i n a c t iv i t ie s th a t i n c l u d e d n o t s l e e p i n g i n h e r
4W ithin- and b etween -trial habituation are tracked on the w eek ly practice form, whichallows the therap ist to co nnect gra ph points indicating successive ratings within a trial and
across trials. Each series yields a line that corresponds to w ithin- and between -trial habituation,respectively.
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
m o t h e r ' s r o o m , h e r m o t h e r g o i n g o u t w i t h o u t h e r , a s s e r t i v e n e s s , a n d t a l k i n g
t o n e w p e o p l e . T h e s e t y p e s o f e x p o s u r e a c t i v it ie s w e r e c o n t i n u e d t h r o u g h o u t
t h e d u r a t i o n o f t re a t m e n t . I n t h e f o u r t h t r e a tm e n t s e s s i o n , th e A c t i v e I g n o r i n gm o d u l e w a s i m p l e m e n t e d w i t h t he m o t h e r o f C h i ld 4 t o d e c r e a s e C h i ld 4 ' s
r e a s s u r a n c e s e e k i n g a n d s o m a t i c c o m p l a i n t s . I n t h e f i f t h t r e a t m e n t s e s s i o n ,
t h e E x p o s u r e a n d A c t i v e I g n o r in g m o d u l e s w e r e c o n t i n u e d . I n S e s s i o n 6 , t h e
S T O P m o d u l e w a s i m p l e m e n t e d . E x p o s u r e a n d th e u se o f S T O P w e r e p ra c -
t i c e d in s e s s io n a s w e l l a s f o r h o m e w o r k i n S e s s io n s 6 t h r o u g h 9 . I n S e s s i o n
1 0 , p r o b l e m s o l v in g w i t h C h i l d 4 ' s m o t h e r a b o u t h e r o w n a n x i e t y w a s i n it i-
a t ed . In S e s s i o n s 11 a n d 1 2 , e x p o s u r e a n d m o n i t o r i n g o f th e m a i n t e n a n c e o f
g a i n s c o n t i n u e d . I n t h e f i n a l s e s s i o n s , t h e M a i n t e n a n c e a n d R e l a p s e P r e v e n -
t i o n m o d u l e w a s r e v i e w e d w i t h C h i l d 4 a n d h e r m o t h e r . O v e r a l l , w i t h i n 2
w e e k s o f t h e s t ar t o f a c t iv e t r e a tm e n t , C h i l d 4 w a s s l e e p in g i n h e r o w n b e d -r o o m o n a n ig h t l y b as is ; w i t h i n 5 w e e k s h e r m o t h e r w a s a b l e t o g o o u t w i th -
o u t C h i l d 4 o n a r e g u l a r b a s is ; a n d w i t h i n 1 1 w e e k s t h e c h i l d w a s a b l e to
a t te n d s l e e p o v e r s w i t h o u t f e a r o n a w e e k l y b a s is . M o r e o v e r , w i t h t h e i m p l e -
m e n t a t i o n o f th e A c t i v e Ig n o r i n g m o d u l e , C h i l d 4 ' s e x c e s s i v e r e a s s u r a n c e
s e e k i n g a n d s o m a t i c c o m p l a i n t s h a d d e c r e a s e d d r a s t ic a l ly a n d w e r e n o l o n g e r
i d e n t i f ie d a s p r o b l e m a t i c b y h e r m o t h e r . O v e r a l l , 1 5 se s s i o n s o f a c ti v e tr e a t -
m e n t w e r e d e l i v e r e d t o C h i ld 4 o v e r 25 w e e k s .
T h e g o a l s o f t r e a tm e n t f o r C h i ld 5 w e r e t o d e c r e a s e h i s e x p e r i e n c e o f p a n i c
a t t a c k s , a s s i s t h i m i n d e v e l o p i n g s k i l l s t o i n c r e a s e c o n s i s t e n t s c h o o l a t t e n -
d a n c e , i n c r e a s e h i s a b i l i t y t o b e i n s e t t i n g s o u t s i d e h i s h o m e , a n d t o d e v e l o p
s k il ls t o m a n a g e h i s e x p e r i e n c e o f s y m p t o m s o f a n x ie t y i n c lu d i n g p h y s i o l o g -
i c a l a n d c o g n i t i v e m a n i f e s t a t i o n s . C h i l d 5 b e g a n t r e a t m e n t f o l l o w i n g a 3 -
w e e k b a s e li n e w i t h th e L e a r n i n g A b o u t A n x i e t y m o d u l e , w h i c h s p a n n ed t w o
s e s si o n s . A f t e r th e c o m p l e t i o n o f t h is m o d u l e , t h e E x p o s u r e m o d u l e w a s
i m p l e m e n t e d i n S e s s io n 3 a n d c o n c e n t r a t e d o n i n t e r o c e p t i v e e x p o s u r e e x e r-
c i se s . T h e e x p o s u r e e x e r c i s e s m a i n l y i n v o l v e d e x p e r i e n c i n g b o d i l y s e n s a t io n s ,
s u c h a s f e e l i n g s h o r t o f b r e a th , n a u s e a t e d , a n d d i z z y . F u r t h e r e x p o s u r e e x e r -
c i s e s c o n c e n t r a t e d o n b e i n g i n n e w p l a c e s , b e i n g l o s t , d r i v i n g o n a o n e - w a y
s t re e t , a n d c o m b i n i n g t h e s e s i tu a t io n s w i t h th e e x p e r i e n c e o f s e n s a t io n s o f
h e i g h t e n e d p h y s i o l o g i c a l a r o u s a l . H a b i t u a t i o n p a t t e r n s w e r e o b s e r v e d b o t h
w i t h i n a n d b e t w e e n s e s si o n s o n t h e e x p o s u r e r e c o r d s ; h o w e v e r , f e a r h i e r a rc h y
r a ti n g s d e c r e a s e d o n l y s l ig h t ly o v e r th e c o u r s e o f t r e a t m e n t . I n t h e f o u r t h
a c t iv e tr e a t m e n t s e s s i o n , t h e S T O P m o d u l e w a s r e v i e w e d w i t h C h i l d 5 . A f t e r
t h is s e s s i o n , t h e c h i ld w a s e n c o u r a g e d a n d c o a c h e d i n u s in g t h e s e t e c h n i q u e s
w h i l e p a r t i c ip a t i n g i n e x p o s u r e e x e r c i s e s. D u e t o s o m a t i c c o m p l a i n t s p e r t a i n -
i n g t o h is s c h o o l - r e f u s a l b e h a v i o r , C h i l d 5 ' s m o t h e r w a s i n s t ru c t e d i n t h e u s e
o f A c t i v e I g n o r i n g i n S e s s i o n 8 . B y 1 0 w e e k s i n to t r e a t m e n t , C h i l d 5 w a s
a b l e to e n g a g e i n d e p e n d e n t l y i n in t e r o c e p t i v e e x p o s u r e w h i l e s y s t e m a t i c a l ly
i n c r e a s in g t h e d i f f ic u l t y o f t h e e x e r c i s e s w i t h o u t e x c e s s i v e f e a r o r d e m o n -
s t r a ti n g p a t t e r n s o f a v o i d a n c e . M o r e o v e r , h e w a s a b l e t o a r ti c u l a t e th e p h e -
n o m e n o n o f a n x i e ty a n d r e c o g n i z e t h e i m p o r t a n c e o f e n g a g i n g in f e a r e db e h a v i o r s a n d s i t u a t i o n s . A t 1 7 w e e k s i n t o t r e a t m e n t , C h i l d 5 w a s a b l e t o
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
e n g a g e i n e x e r c i s e s th a t i n v o l v e d h i s p r e s e n c e i n u n c o m f o r t a b l e si t u a ti o n s
w i t h o u t t h e p r e s e n c e o f o t h e rs . A f t e r 2 4 w e e k s o f t re a t m e n t , C h i l d 5 w a s a b l e
t o a c c o m p a n y h i s p a r e n t s o n a v a c a t i o n t h a t i n c l u d e d f l y i n g o n a n a i r p l a n ea n d p a r t i c ip a t in g i n fa m i l y e x c u r s i o n s . B e c a u s e C h i l d 5 e x p e r i e n c e d f e a r o f
n e w p l a c e s a n d s e t t i n g s ( e . g . , d r i v i n g i n a c a r , p a r k s , m a l l s ) , e x p o s u r e w a s
c o n d u c t e d i n b o t h t h e c l i n i c a n d c o m m u n i t y s e t t i n g s i n o r d e r t o a d d r e s s t h e
c o n c e r n s o f C h i l d 5 a n d i n o r d e r t o in c r e a s e a d a p t i v e f u n c t i o n i n g . I n t o t a l,
C h i l d 5 r e c e i v e d 1 7 s e s s i o n s o f a c ti v e tr e a t m e n t d e l i v e r e d o v e r 3 0 w e e k s i n
b o t h t h e c l in i c a n d c o m m u n i t y .
C h i l d 6 b e g a n t r e a t m e n t f o l l o w i n g a 1 . 5 - w e e k b a se l in e w i th t h e L e a r n i n g
A b o u t A n x i e t y m o d u l e . I n t h e s e c o n d s e s si o n e x p o s u r e w a s i n i t ia t e d w i t h th e
c l i e n t o n e x e r c i s e s t h a t i n c l u d e d t r i g g e r s o f h is p e r v a s i v e w o r r i e s a n d h e i g h t -
e n e d s o c i a l f e a r s , s u c h a s a t t e n d i n g c l a s s e s , s p e a k i n g t o t e a c h e r s a n d a d u l t s ,t a l k i n g t o o t h e r c h i l d r e n , i s s u e s o f a s s e r t i v e n e s s , p e r f o r m a n c e - r e l a t e d c o n -
c e r n s , a n d o t h e r i s s u e s t h a t p r o v o k e d w o r r y . B e g i n n i n g i n t h e t h i r d s e s s i o n ,
C h i l d 6 l e a r n e d c o g n i t iv e t e c h n i q u e s , f o l l o w e d b y P r o b a b i l it y O v e r e s t i m a t i o n
( S e s s io n s 3 a n d 4 ) a n d C a t a s tr o p h i c T h i n k i n g ( S e s s io n s 6 a n d 7 ) m o d u l e s . B y
6 w e e k s i n t o a c t i v e t r e a t m e n t , t h e c l i e n t w a s a t t e n d i n g s c h o o l o n a r e g u l a r
b a s is . D e s p i t e p a t t e rn s o f h a b i tu a t i o n , C h i l d 6 c o n t i n u e d t o e x p e r i e n c e l o w
m o o d , a n d c o g n i t i v e te c h n i q u e s w e r e f u r t h e r a p p l i e d to h is e x p e r i e n c e o f
l o w m o o d ( S e s s i o n 8 ). C h i l d 6 m a i n t a i n e d a c o n s i s te n t l e v e l o f a t te n d a n c e
t h r o u g h t h e f i r s t s e m e s t e r o f s c h o o l , a n d h a d n o d i f f i c u l t y r e t u r n i n g t o s c h o o l
a f t e r t h e s e m e s t e r b r e a k . I n t h e f i n a l s e s s i o n s , t h e M a i n t e n a n c e a n d R e l a p s e
P r e v e n t i o n m o d u l e w a s c o v e r e d w i t h C h i ld 6 a n d h i s p ar e n t s. I n s u m , 1 0
a c t iv e t r e a t m e n t s e s s io n s w e r e d e l i v e r e d o v e r 2 0 w e e k s t o C h i l d 6 .
C h i l d 7 b e g a n t r e a t m e n t w i t h t h e L e a r n i n g A b o u t A n x i e t y m o d u l e a f t e r a
2 - w e e k b a s e l in e . T h e g o a l o f tr e a t m e n t f o r C h i l d 7 w a s t o a s s is t h e r in
d e c r e a s i n g h e r f e a r o f r i d in g e l e v a t o r s a n d f ly i n g o n a i rp l a n e s. E x p o s u r e
b e g a n i n th e s e c o n d t r e a t m e n t s e s s i o n a n d f o c u s e d o n t h e c h i ld h a b i t u a ti n g t o
r i d i n g a n e l e v a t o r , w i t h s u b s e q u e n t s e s s i o n s f o c u s i n g o n r i d i n g e l e v a t o r s a n d
f l y i n g o n a i r p l a n e s . E x p o s u r e t o r i d in g e l e v a t o r s , b e i n g i n a i r p o r ts , a n d f l y i n g
o n p l a n e s w a s c o n t i n u e d i n S e s s i o n s 2 th r o u g h 8 , c u l m i n a t i n g i n s o m e in t e r -
i s l a n d f l i g h t s a r o u n d t h e H a w a i i a n i s l a n d s . C h i l d 7 s h o w e d h a b i t u a t i o n t o
b o t h e l e v a t o r s a n d f l y i n g t h r o u g h t h e c o u r s e o f t r e a t m e n t . I n t h e f i n a l se s -
s i o n s, th e M a i n t e n a n c e a n d R e l a p s e P r e v e n t i o n m o d u l e w a s r e v i e w e d w i t h
C h i l d 7 a n d h e r m o t h e r . C h i l d 7 r e c e i v e d 9 s e s s io n s o f a c ti v e tr e a t m e n t o v e r
t h e c o u r s e o f 9 w e e k s i n m u l t i p l e s e t ti n g s .
Po st t reatm ent Assessments" an d 6-M onth Fol low- Up Assessments"
Dia gno s i s and c l in i ca l sever it y ra t ing . A l l c h i l d r e n a n d t h e i r p a r e n t s w e r e
i n t e r v i e w e d u s i n g t h e A D I S - I V - C / P a t p r e t r e a t m e n t , p o s t t r e a t m e n t , a n d 6 -
m o n t h f o l l o w - u p . T a b l e 1 p r e s e n t s d i a g n o s e s a n d c l i n ic a l s e v e r i t y r a t in g s f o r
e a c h c h i l d a t p r e - , p o s t - , a n d 6 - m o n t h a s s e s s m e n t . E a c h c h i ld r e c e i v e d a d i a g -
n o s i s o f a t l e a s t o n e a n x i e t y d i s o r d e r a t t h e t i m e o f t h e p r e t r e a t m e n t a s s e s s -m e n t . R e s u l t s o f t h e a s s e s s m e n t s i n d i c a t e th a t , w i t h o n e e x c e p t i o n , al l c h i l d r e n
7/28/2019 Efficacy of Modular Cognitive Behavior Therapy of Childhood Anxiety Disorders
M O D U L A R C O G N I T I V E B E H A V I O R T H E R A P Y 281
w e r e d i a g n o s i s - f r e e at (t h e ) p o s t t r e a t m e n t a n d 6 - m o n t h a s s e s s m e n t s . C h i l d 5
r e c e i v e d t h re e c o m o r b i d d i a g n o s e s a t th e t i m e o f th e p r e t r e a t m e n t a s se s s -
m e n t , b u t w a s d i a g n o s i s f r e e a t t h e t im e o f t h e p o s t t r e a tm e n t a s s e s s m e n t .H o w e v e r , C h i l d 5 a n d h i s m o t h e r r e p o r t e d th a t h e h a d b e g u n t o e v i d e n c e
s y m p t o m s o f G A D ( o n e o f h i s in i ti a l c o m o r b i d d i a g n o s e s ) s o o n a f t e r h e
r e t u r n e d t o s c h o o l i n t h e f a ll , i n c o n j u n c t i o n w i t h t h e e v e n t s o f S e p t e m b e r 1 1 ,
2 0 0 1 .
A s s e s s m e n t s c a l e s . C B C L , C A F A S , a n d R C A D S d a ta a re s u m m a r i ze d in
T a b l e 1 , A l l c h i l d r e n b u t o n e ( C h i l d 7 ) e v i d e n c e d c l i n i c a l e l e v a t i o n s ( T > 6 5 )
o n t h e I n t e r n a l iz i n g S c a l e o f t h e C B C L a t p r e t r e a t m e n t , a s r e p o r t e d b y t h e i r
m o t h e r s . F o r t h e m o s t p a r t , C B C L I n t e r n a li z in g s c o r es d e c r e a s e d o v e r th e
c o u r s e o f tr e a t m e n t , w i t h o n l y o n e c h i l d ( C h i l d 1 ) s h o w i n g a c l i n ic a l e l e v a-
t i o n a t p o s t t r e a t m e n t a n d o n e ( C h i l d 5 ) a t 6 - m o n t h f o l l o w - u p . C h i l d 5 e v i -d e n c e d a d e c r e a s e a t p o s t t r e a tm e n t , f o l l o w e d b y a c l in i c a l e l e v a ti o n a t th e 6 -
m o n t h f o ll o w - u p a s se s sm e n t . C h i ld 2 ' s m o t h e r c o m p l e t e d th e C B C L o n l y a t
t h e 6 - m o n t h f o l l o w - u p ; t h u s , it is u n c l e a r w h e t h e r t h a t c h i l d ' s s c o r e d e c r e a s e d
d u r i n g t h e c o u r s e o f tr e a t m e n t . H o w e v e r , t h e 6 - m o n t h f o l l o w - u p s c o r e i n d i-
c a t e d t h a t C h i l d 2 f e l l w i t h i n t h e n o r m a l r a n g e a t t h a t ti m e .
S i m i l a r p a t t e r n s w e r e f o u n d w i t h C A F A S s c o r e s . R e s u l t s r e v e a l e d t h a t
C A F A S s c o r e s d e c r e a s e d o v e r t h e c o u r s e o f tr e a t m e n t w i t h a l l c h i l d r e n im -
p r o v i n g i n th e i r le v e l o f f u n c t io n a l i m p a i r m e n t f r o m p r e t r e a t m e n t t o t h e p o s t -
t r e a t m e n t a s s e s s m e n t . T h e a v e r a g e d r o p i n C A F A S s c o r e f r o m p r e t r e a t m e n t
t o p o s t tr e a t m e n t w a s 3 5 . 7 p o i n ts , a n d t h e a v e r a g e d r o p f r o m p r e t r e a t m e n t t o
6 - m o n t h f o l l o w - u p w a s 3 7 .1 p o i n t s .
F i n a l ly , R C A D S s c o r e s c o r re s p o n d i n g t o c h i l d r e n ' s d i a g n o s e s a r e a ls o
s u m m a r i z e d i n T a b l e 1 . F o r t h e m o s t p a r t , th e s e w e r e c l i n i c a l ly e l e v a t e d a t
p r e t r e a t m e n t ( t w o c h i l d r e n s c o r e d o n l y i n t h e s u b c l i n ic a l r a n g e o n d i a g n o s i s-
r e l a t e d s c o r e s ) . N o d i a g n o s i s - r e l a t e d s c o r e s w e r e c l i n i c a l l y e l e v a t e d f o r a n y
c h i l d a t p o s t tr e a t m e n t , a n d c l in i c a l e le v a t i o n s re e m e r g e d o n l y f o r C h i l d 5 a t
t h e 6 - m o n t h f o l l o w - u p . T h i s f i n d in g i s c o n s i st e n t w i t h s o m e o f th e o t h e r
a s s e s s m e n t d a t a re g a r d i n g C h i l d 5 , s u g g e s ti n g a r e t u r n in s y m p t o m s , d e s p i te
m a i n t a i n i n g i n c r e a s e d fu n c t i o n i n g a s m e a s u r e d b y t h e C A F A S .
Discussion
T h e p r e s e n t s t u d y i s i n f o r m a t i v e in t h a t it d e m o n s t r a t e d a s u c c e s s f u l e x t en -
s i o n o f t h e d e v e l o p i n g l i t e r a t u r e o n p r e s c r i p t i v e a p p r o a c h e s t o i n t e r v e n t i o n
w i t h a n x i o u s y o u t h ( e . g ., E i s e n & S i l v e r m a n , 1 9 9 8 ; K e a r n e y & S i l v e r m a n ,
1 9 9 0 ). T h e i n d i v i d u a l iz e d n a t u r e o f th e p r o t o c o l i s ra t h e r a p p a r e n t f r o m t h e
p r o c e s s m e a s u r e s o f th e C B T d e l iv e r y . A l t h o u g h a ll c h i ld r e n p a r t i c ip a t e d i n
t h e c o r e p s y c h o e d u c a t i o n , e x p o s u r e , a n d m a i n te n a n c e e x e r c is e s , o n l y t w o
( 2 9 % ) p a r t i c ip a t e d i n d i f fe r e n t ia l r e i n f o r c e m e n t s t ra t e g ie s , tw o ( 2 9 % ) w e r e
a d m i n i s t e r e d r e w a r d s , a n d t h r e e ( 4 3 % ) p a r t i c i p a te d i n f o r m a l c o g n i t i v e e x e r -
c i se s . O f t h e s e l a s t th r e e , t w o r e c e i v e d t h e c o g n i t i v e t ra i n in g d e s i g n e d f o ry o u n g e r c h i l d re n , a n d t h e o t h e r re c e i v e d tw o m o d u l e s d e s i g n e d f o r o l d e r
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c h i l d re n . T w o c h i l d r e n ( 2 9 % ) r e c e i v e d o n l y t h e c o r e c o m p o n e n t s o f t h e m a n -
u a l ( p s y c h o e d u c a t i o n , e x p o s u r e , a n d m a i n t e n a n c e ) . T h e s e s si o n s d e l i v e r e d
r a n g e d f r o m 5 t o 1 7 i n t o t a l , a n d o c c u r r e d i n d u r a t i o n s r a n g i n g f r o m 7 t o 3 0w e e k s . T h u s , f r o m a p r o c e s s p e r s p e c ti v e , t h e m a n u a l a l lo w e d f o r a h ig h d e g r e e
o f i n d i v i d u a l iz a t i o n o f t h e i n t e rv e n t i o n .
T h e m a n u a l w a s a b l e t o a c c o m m o d a t e a s i m i la r d e g r e e o f d iv e r s i ty a m o n g
t h e p a r ti c i p a n t s a s w e l l . T h e s o c i o e c o n o m i c s ta t u s o f t h e f a m i l i e s w a s w i d e
r a n g i n g , w i t h r e p o r t e d i n c o m e s r a n g i n g f r o m $ 1 3 , 0 0 0 t o $ 1 40 ~ 00 0 a n n u a ll y .
T w o o f th e c a s e s in v o l v e d m e d i c a ti o n n o n r e s p o n s e . O n e w a s c o n d u c t e d a l m o s t
e n t i r e l y a t s c h o o l . T h r e e o f t h e c a s e s i n v o l v e d s i n g l e - p a r e n t f a m i l i e s , a n d s i x
o f t h e s e v e n c a s e s i n v o l v e d n o n - W h i t e p a r t i c i p a n t s . T h i s l a s t o b s e r v a t i o n i s
p a r t ic u l a r ly n o t a b l e , a s su c c e s s f u l d e m o n s t r a t io n s o f C B T w i t h H a w a i i a n ,
A s i a n , a n d P a c i f i c I s l a n d y o u t h h a v e y e t t o a p p e a r i n t h e l it e r a tu r e .A m o n g t h e s e v e n c o m p l e t e r s , t h e r e s u l t s s h o w e d f a i r l y c o n s i s t e n t g a i n s
a c r o s s p a r e n t r e p o r t m e a s u r e s , d i a g n o s i s, a n d m e a s u r e s o f c h i l d f u n c t io n i n g .
A l l o f t h e c h i l d re n w e r e d i a g n o s i s f r e e a t p o s t tr e a t m e n t , a n d o n l y o n e c h i l d
( 1 4 % ) s h o w e d t h e r e t u rn o f a n y d i a g n o s is a t th e 6 - m o n t h f o l l o w - u p . T h e i ni -
t i a l p r i n c i p a l d i a g n o s i s f o r t h i s c h i l d , h o w e v e r , r e m a i n e d i n f u l l r e m i s s i o n .
T h e r e e m e r g e n c e o f i n it ia l ly c o m o r b i d d i a g n o s i s a t l o n g - t e r m f o l l o w - u p h a s
b e e n n o t e d a s a t r e n d e l s e w h e r e i n t h e l i t e r a t u r e , a n d i s t h e r e f o r e n o t a c o m -
p l e t e s u r p r i s e . T h i s s u g g e s t s t h a t p a r t i c u l a r a t te n t i o n t o t h e i n i ti a l ly c o m o r b i d
d i a g n o s e s m i g h t b e i m p o r t a n t a s t r e a tm e n t b e g i n s t o r e a c h i ts c o n c l u s i o n .
A n u m b e r o f w e a k n e s s e s i n t h e d e s i g n n e e d t o b e m e n t i o n e d . F i rs t, a c o m -
p l e x a n d f l e x i b le m a n u a l w o u l d b e s t b e a c c o m p a n i e d b y i n t e g r it y c h e c k s , to
e n s u r e t h a t th e t e c h n i q u e s w e r e d e l i v e r e d p r o p e r l y a n d t o v a l id a t e t h e t h er a -
p i s t c h o i c e s i n l i n e w i t h t h e g u i d i n g c l i n i c a l a l g o r i t h m . A l t h o u g h r e c o r d s o f
s e s s io n c o n t e n t w e r e c o m p l e t e d a n d d i d r e fl e c t p r o p e r a d h e r e n c e , t h e t he r a -
p i st c o m p l e t e d t h e s e a s p a r t o f c li n ic a l s u p e r v i s io n , a n d n o i n d e p e n d e n t r a t-
i n g s w e r e t a k en . A n o t h e r p o t e n t ia l t h r e a t to v a l i d it y i n v o l v e d t he i n d e p e n d e n t
e v a l u a ti o n s . T h e d e t a i le d n a t u r e o f th e i n t e r v i e w a n d t h e r o u t i n e a s s e s s m e n t
o f a l l a n x i o u s c h i l d r e n a t p o s t t r e a t m e n t m a d e i t i m p o s s i b l e t o p r e v e n t t h e
e v a l u a t o r s ' a w a r e n e s s t h a t c h i l d r e n h a d p a r t i c i p a t e d i n t r e a t m e n t . T h i s i n f o r -
m a t i o n c o u l d h a v e a l l o w e d e v a l u a to r s t o i n f e r t h e g o a l s o f t h e s tu d y ; h o w e v e r ,
t h e re s u l t s o f t h e s e l f - r e p o r t a n d p a r e n t - r e p o r t m e a s u r e s a p p e a r e d t o b e c o n -s i s te n t w i t h t h o s e o f t h e e v a l u a t o r r e p o r t , s u g g e s t i n g t h a t t h e s e p r o b l e m s w e r e
l i k e l y m i n i m a l . F i n a l l y , t h e i n c l u s i o n o f a n a c t iv e c o m p a r i s o n c o n d i t i o n ( e . g . ,
a t t e n ti o n o r s u p p o r t ) w o u l d h a v e b e e n a b l e t o s t re n g t h e n t h e s t u d y s u c h t h a t th e
e f f e c t s m i g h t b e m o r e e a s i l y a t t r i b u t e d t o s p e c if i c a s p e c t s o f t h e i n t e r v e n t i o n .
A m o r e s p e c i f ic is s u e i n v o l v e d t h e a m b i g u i t y o f th e t i m e - s e r i e s d a t a f o r
C h i l d 5 . O d d l y , C h i l d 5 w a s a b l e to h a b i t u a t e w i t h i n e a c h s e s s i o n a n d t o c o m -
p l e t e a n i n c r e a s i n g l y d i f f i c u l t s e r i e s o f e x p o s u r e e x e r c i s e s o v e r t i m e , y e t t h e
f e a r h i e r a r c h y r a ti n g s r e m a i n e d l a r g e l y t h e s a m e a l m o s t to d a y 2 0 0 . B o t h
t h e s u p e r v i s o r a n d t h e r a p i s t o b s e r v e d t h a t s u b s t a n t i a l p r o g r e s s w a s o c c u r r i n g
i n t e rm s o f i n c r e a se d f u n c t i o n i n g a n d d e c r e a s e d a v o i d a n c e , d e s p i te t h e s t a-t i o n a r y f e a r ra t i n g s . T h i s w a s d i s c u s s e d w i t h t h e c h il d n e a r d a y 2 0 0 , w i t h a
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M O D U L A R C O G N I T I V E B E H A V I O R T H E R A P Y 283
s u g g e s ti o n b e i n g m a d e t h a t p e r h ap s t h e c h i l d d i d n o t u n d e r s t a n d h o w t o c o m -
p l e t e t h e la d d e r o r d i d n o t k n o w w h a t i t w a s m e a n t t o r e fl e c t. A c o r r e s p o n d i n g
d r o p i n f e a r r a t i n g s w a s o b s e r v e d , b u t w a s n o t f u l l y s u s t a i n e d , a n d i t w a s d i f -f i c u lt t o i n t e r p re t t h e s e d a t a . O n a l l o th e r m e a s u r e s , t h e c h i l d s h o w e d i m p r o v e -
m e n t , a l t h o u g h t h e o b s e r v a t i o n t h a t a n i n i t i a l l y c o m o r b i d d i a g n o s i s r e t u r n e d
a t 6 - m o n t h f o l l o w - u p f u r t h e r c o m p l i c a t e s t h e i n f e r e n c e r e g a r d i n g w h e t h e r
g a i n s w e r e f u l l y a t t r i b u t a b l e t o t h e C B T p r o t o c o l o r t o o t h e r f a c t o r s f o r t h i s
c h i l d . G i v e n t h e m o r e t e n t a t i v e i n f e r e n c e s i n v o l v e d w i t h C h i l d 5 , i t m i g h t
h a v e b e e n a d v i s ab l e t o c o n t i n u e t r e a tm e n t f o r s o m e w h a t l o n g e r t o s u b s t an t i-
a t e t h e n e w p a t t e r n o f f e a r r a t i n g s a n d t o e n s u r e t h a t th e c h i l d h a d m a d e s u b -
s t a n t i v e g a i n s . A l s o , g i v e n t h e p o s s i b l e r o l e o f t h e e v e n t s o f S e p t e m b e r 1 1 ,
a d d i t io n a l i n t e rv e n t i o n m i g h t h a v e b e e n w a r r a n t e d f o r t h i s y o u t h d u r i n g t h e
f o l l o w - u p p e r i o d , w h i c h m i g h t h a v e i n c l u d e d c o g n i ti v e t e c h n i q u e s r e l at e d t ot h e p e r c e i v e d t h r e a t o f t e r ro r i s m .
A m o r e g e n e r a l i s s u e t h a t b e a r s c o n s i d e r a t i o n i n v o l v e s t h e d i f f i c u l t y f a c i n g
t e s t s o f a m o d u l a r p r o t o c o l . T h a t i s , e v e n i n a l a r g e r a n d o m i z e d t r i a l , s o m e
q u e s t io n s a b o u t t h e m a n u a l c a n n o t e a s il y b e a n s w e r e d . F o r e x a m p l e , i n t hi s
i n v e s t i g a t i o n , s e v e r al c o m p o n e n t s o f t h e m a n u a l w e r e n e v e r u s e d ( e . g . , S o c i a l
S k i l ls ) . A l t h o u g h i t ap p e a r s t h a t t h e m a n u a l a l l o w s f o r c o n s i d e r a b l e f l e x i b i l i t y
a n d h e n c e e f f i c ie n c y , a s s u m p t i o n s a b o u t w h i c h m o d u l e s a r e n e e d e d a n d
w h i c h a r e n o t f o r a g i v e n c h i l d r e m a i n d i f f i c u lt t o t e s t. A t t h i s p o i n t t h e d a t a
s u g g e s t o n l y t h a t t h e u s e o f t h e m a n u a l a p p e a r s p r o m i s i n g f o r a v a r i e ty o f
a n x i e t y d i s o r d e r s a n d a c r o s s a r a n g e o f a g e s .
I n s u m m a r y , t h er e i s in i ti a l su p p o r t f o r th e u s e o f M o d u l a r C B T f o r a n x i e t y
d i s o rd e r s i n y o u t h . A l t h o u g h t h e r e i s n o e v i d e n c e t h a t t h e m o d u l a r a p p r o a c h
i s m o r e o r l e ss s u i t a b l e t h a n o t h e r C B T a p p r o a c h e s a t th i s p o i n t , t h e p r e s c ri p -
t i v e s t r a t e g y f i t s w i t h b r o a d e r C B T t h e o r y ( B e c k e t a l . , 1 9 7 9 ) a n d l o g i c a l l y
i n d i c a t e s p o t e n t i a l i n c r e a s e s i n e f f i c i e n c y . F u t u r e r e s e a r c h i s n e e d e d t o e v a l u -
a t e th i s p r o t o c o l a n d s i m i l a r m o d u l a r a p p r o a c h e s i n l a rg e r i n v e s t i g a t i o n s , u l t i-
m a t e l y c o m p a r i n g a s i m p l i fi e d m o d u l a r a p p r o a c h w i t h a f i x e d ap p r o a c h , t o
b e g i n t o i d e n t i f y e m p i r i c a l l y th e r e l a t iv e m e r i t s o f e a c h , a n d t o d e t e r m i n e
w h i c h a p p r o a c h m i g h t b e m o r e s u i t a b l e in a g i v e n c o n t e x t .
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RECEIVED." Au gu st 2 8, 20 02ACCEPTED: June 17 , 2003