REVIEW

Cognitive-Behavioral Intervention with Young

Anxious Children

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Dina R. Hirshfeld-Becker, PhD, Bruce Masek, PhD, Aude Henin, PhD, Lauren Raezer Blakely, PhD,
David C. Rettew, MD, Lynette Dufton, MS, Natasha Segool, MA, and Joseph Biederman, MD

Despite evidence that preschool and early elementary school-age children can present with anxiety disorders that may put them at risk for later psychopathology and dysfunction, the cognitivebehavioral protocols available for treating anxiety in children have been tested almost exclusively
in older children. However, there could be benefits to treating children earlier, before anxiety disorders begin to impair their social and academic development. This report discusses the adaptations
necessary in providing cognitive-behavioral therapy to young anxious children and describes a manualized, cognitive-behavioral intervention, with child and parent components, that was piloted openly
in nine families with children aged 4 to 7 yearseach of whom had multiple risk factors for developing anxiety disorders, and most of whom had already presented with anxiety disorders. Eight of
the nine children were judged much or very much improved at postintervention on number of
anxiety diagnoses, number of DSM-IV anxiety symptoms, and ability to cope with feared situations.
Cases are presented to illustrate the way that cognitive-behavioral therapy can be conducted with
youngsters in this age range. Whereas randomized, controlled trials are needed to confirm the efficacy of this manualized treatment, our experience suggests that cognitive-behavioral protocols for
anxiety can be adapted and successfully implemented with young children. (HARV REV PSYCHIATRY
2008;16:113125.)
Keywords:

behavioral inhibition, childhood anxiety disorders, cognitive-behavioral therapy

From Harvard Medical School and Massachusetts General Hospital,

Boston, MA.
Supported, in part, by a Career Development Award (NIMH/K08
MH-001538-05) (Hirshfeld-Becker). The Brandon Shedd Fund at
Massachusetts General Hospital also assisted in funding initial
project development.
Correspondence: D. R. Hirshfeld-Becker, MGH Pediatric Psychopharmacology, 185 Alewife Brook Pkwy., Suite 2100, Cambridge,
MA 02138. Email: dhirshfeld@partners.org
Original manuscript received 25 April 2007, accepted for publication
subject to revision 12 November 2007; revised manuscript received
3 January 2008.
c 2008 President and Fellows of Harvard College
!

DOI: 10.1080/10673220802073956

Anxiety disorders are among the most prevalent disorders in children1,2 and are associated with significant social and academic dysfunction,3,4 as well as with risk for
later comorbidity with major depression5 and substance use
disorders.6 Research suggests that childhood anxiety disorders often have a chronic course if untreated7 and may
be associated with anxiety disorders in adolescence and
adulthood.2,6,8 Recent studies document that anxiety disorders can emerge early in development and are already prevalent in preschool-age children.9,10 In such cases, the ability
to intervene early would therefore be of major clinical value.
Research over the past two decades has improved our
understanding of which children may be at greatest risk for
anxiety disorders. A growing number of studies have documented that the offspring of parents with anxiety disorders
are themselves at elevated risk,1117 with 30% to 40% developing anxiety disorders. Manifestations of this risk may
appear as early as toddlerhood or the preschool years.13,18,19

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Hirshfeld-Becker et al.

A recent study by our group suggested that offspring of parents with panic disorder who have elevated Child Behavior
Checklist (CBCL) internalizing scales at mean age 5 often
continue to manifest clinically significant anxiety at a mean
age 10.20
In addition, the temperamental construct behavioral
inhibition to the unfamiliar (BI)which represents a
tendency, observable as early as toddlerhood, to exhibit
restraint, avoidance, and reticence in the face of unfamiliar people or settings21 has been demonstrated to confer subsequent risk for social phobia in childhood and
adolescence.2226 However, the observation that BI shows
only moderate stability across toddlerhood to middle childhood, with at least a quarter of children becoming less inhibited over time,21 suggests that this risk factor may be
modifiable.
Finally, a recent, prospective study by our group of
the course of anxiety disorders among offspring at risk
has suggested that certain anxiety disorders that are
present in early childhood (e.g., separation anxiety disorder and agoraphobia) may themselves confer risk for later
psychopathology.27 It is possible that teaching youngsters
adaptive strategies for managing anxiety early on may mitigate the course of subsequent anxiety symptoms.
Over the past decade, much progress has been made in
the development of cognitive-behavioral approaches to treating childhood anxiety disorders.28 One widely tested protocol is the Coping Cat program.2931 This intervention
teaches children to identify anxious feelings and thoughts,
to devise plans for coping with anxiety, and to practice these
coping skills in progressively more anxiety-provoking situations, using graduated exposure exercises.32 Four studies published to date using this protocol or its adaptations (involving a total of 255 children, aged 7 to 14 years)
have demonstrated improvements compared to untreated
controls,29,30,33,34 with treatment gains maintained over
longer-term follow-up (3 to 7 years).31,35,36 Studies have suggested that adaptations of the Coping Cat protocol may
also be useful as a preventive intervention for children
aged 7 to 14 years selected on the basis of elevated anxiety symptoms,37,38 as well as for unselected children aged
10 to 13 years.39,40
Although the benefit of these protocols is clear in older
children, there could be significant advantages to intervening at an earlier stage of development.41 First, children in
the preschool or early primary years are highly plastic behaviorally and neurodevelopmentally.42 Moreover, intervening in early childhood has the potential to influence the
representations of self and others that become consolidated
during this age period.42,43 Finally, intervention in early
childhood enables the child to master anxiety-management
skills before entering elementary school, thereby reducing
the impact of anxiety on academic and social progress.

MarchApril 2008

KEY CHARACTERISTICS OF
COGNITIVE-BEHAVIORAL INTERVENTIONS FOR
YOUNG CHILDREN
An intervention in early childhood requires maximal
parental involvement. Because many parents may themselves have anxiety disorders44,45 and be unskilled in implementing anxiety-management strategies, they may have
difficulty helping their young children learn to manage
anxiety. Indeed, studies of older children have suggested
that parents of anxious children tend to exhibit behaviors thought to be associated with onset or maintenance
of child anxiety. Examples of such behaviors include modeling maladaptive coping behaviors or limiting childrens
autonomy in problem-solving tasks46,47 or in discussions
of conflictual issues;48 expressing more protective and less
disciplinarian attitudes;49 conveying attitudes of greater
emotional overinvolvement;50,51 and actively encouraging
avoidant responses.52,53 Therefore, early intervention offers
the opportunity to teach parents how to help children cope
with anxious behaviors, at a developmental stage when parents are salient models for child behavior and when parenting behaviors are especially influential in the development
of emotional-regulation skills. Parental involvement may
also increase the efficacy of interventions with children for
childhood anxiety disorders33 and may be crucial in cases in
which one of the parents is acutely anxious. For example, one
study has suggested that the efficacy of cognitive-behavioral
treatment of school-age children with anxious parents may
be compromised if the anxious parents do not also receive
parental anxiety-management training.54
In addition to our group, three groups to date have piloted interventions for young children with anxiety disorders or at risk for anxiety, each with a focus on parent-child
interactions. In assessing an integrative, home-based intervention for anxious/withdrawn preschoolers, LaFreniere
and Capuano55 randomized 43 preschoolers (aged 31 to
70 months) rated as high on anxious withdrawal by their
teachers to a parent-child intervention or a monitoring-only
control condition. The intervention was conducted over six
months (20 sessions of 90 minutes each) and included education for the parent about the childs developmental needs;
child-directed play sessions; behavior modification; training
in parenting skills; and a focus on building support networks. Although children improved on teacher-rated social
competence, and mothers reduced their intrusive control,
the childrens anxious/withdrawn behavior at post-trial did
not differ significantly between groups. In an open pilot
study,56 Choate and colleagues treated three families with
children with separation anxiety disorder (aged 5 to 8 years)
in a multiple-baseline design, using parent-child interaction
therapy,57 a program that seeks to improve parent-child interactions by teaching parents to follow their childrens lead

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Volume 16, Number 2

during play and to give effective directions and administer

praise and time-outs during parent-directed situations. The
three children improved on separation anxiety as well as on
disruptive behaviors. In a randomized, controlled trial the
same research group is currently piloting an adaptation of
this approach that includes a three-session module incorporating exposure to separation events.58
In a larger-scale selected-prevention study, Rapee
and colleagues59 tested a six-session cognitive-behavioral,
parent-group intervention addressing anxiety in young, inhibited children. They screened over 1,600 preschoolers and
identified 146 (aged 36 to 62 months) who were rated by their
parents as low on approach behaviors, were observed in the
laboratory to show BI, and agreed to participate in the intervention; 90% already had at least one anxiety disorder. The
children were randomized to receive the parent intervention
or a monitoring-only control condition, and were assessed
12 months later. The 90-minute parent sessions focused on
psychoeducation about anxiety, parental management techniques, the role of overprotection in maintaining anxiety,
principles and application of exposure hierarchies, cognitive restructuring of the parents own worries, and identifying high-risk transition periods. Although only 73% of
mothers attended five or more sessions, children assigned to
the intervention had fewer anxiety disorders (mean = 0.7;
SD = 0.8) at 12-month follow-up than controls (mean = 1.1,
SD = 1.0), with 50% of treated and 63.5% of untreated children having an anxiety disorder at follow-up. The effect of
assignment to the intervention on number of anxiety disorders was, using structural equation modeling, significant.
No effect was found on BI, which decreased over the year
in both groups. Although the intervention showed a small
effect size for reducing anxiety diagnoses, it does point to
the potential of cognitive-behavioral strategies for reducing
anxiety in young children.
Whereas each of these interventions incorporated aspects
of behavioral approaches to treating anxiety in young children, none so far has implemented the sort of integrative, individual, cognitive-behavioral protocol that has been found
to be generally efficacious for the treatment of anxiety disorders in older children. In addition, none has attempted
to integrate rudimentary cognitive (as well as behavioral)
strategies that might be implemented by young children.
An approach that was still more comprehensive or integrative might be even more efficacious for reducing anxiety in
young children. In addition, directly teaching coping skills
to young children might improve their ability to generalize
those skills across anxiety-provoking situations. Moreover,
graduated exposure is highly efficacious for reducing anxiety disorders in older children, and working directly with
younger children may reduce anxiety symptoms in a more
rapid, efficient, and efficacious manner than working indirectly through the parents. Given that early childhood is a

Young Anxious Children

115

critical period in developing a sense of agency, teaching these

young children skills for coping and for directly confronting
feared situations may be especially salient developmentally
and enhance generalization and maintenance of treatment
gains.
In an earlier article,41 we outlined principles for a comprehensive, cognitive-behavioral intervention with young children at risk for anxiety. These principles include teaching
parents concepts of basic anxiety management and principles for graduated exposure, and educating parents about
helpful versus unhelpful approaches to handling childrens
anxious symptoms. For children, the principles include
teaching the child that anxiety can be overcome through
facing feared situations, providing the child with some basic
coping skills, and implementing reinforced exposure practice. Guided by these principles, we developed a manualized,
20-session, parent-child intervention with an accompanying
parent workbookthe Being Brave interventionand piloted it in a series of nine children aged 4 to 7 years with
multiple risk factors for developing anxiety disorders. In the
present article, we describe this intervention, present specific examples of its implementation with young children,
and discuss the results of our pilot study.

THE BEING BRAVE INTERVENTION

Being Brave: A Program for Coping with Anxiety for Young
Children and Their Parents is a manualized, cognitivebehavioral, parent-child treatment that is offered in up to
20 weekly, 50-minute sessions (see text box). It is accompanied by a parent workbook. The protocol begins with 6
parent-only sessions that focus on general principles of anxiety management (3 sessions) and strategies for coaching the
child to face feared situations (3 sessions). These sessions are
followed by up to 13 others that the child and one or both parents attend. The child is presented with a model for coping
with anxiety, taught basic coping skills, and then encouraged
to practice coping with feared situations through graduated
exposureall with reinforcement, both in and outside of sessions. The manual allows for a flexible number of sessions on
graduated exposure, depending upon each particular childs
needs (range, 8 to 11 sessions). In the penultimate session
with the child, he or she creates a final project (book or short
video) reinforcing what has been learned; this session is followed by one celebrating his or her successes. The program
concludes with a final, parent-only session that focuses on
maintaining gains and preventing relapse.
The child sessions of the intervention were loosely
adapted from Kendalls Coping Cat program,32 which
treats symptoms of separation anxiety disorder, social phobia, and generalized anxiety disorder, and can also be applied to specific phobias. To adapt that program for use with

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MarchApril 2008

Being Brave: Contents of Individual Sessions

Session
Attendees
Content of Session
Parent anxiety management
1
Parent(s) only
Psychoeducation about anxiety model (physical, cognitive, and
behavioral components; antecedent events and responses) and
rationale for intervention; focus on observing childs anxiety
responses.
2
Parent(s) only
Cognitive errors that contribute to anxious or pessimistic
feelings and to perfectionistic expectations or overprotection of
the child; cognitive restructuring for parents
3
Parent(s) only
Modeling coping skills; helpful vs. unhelpful parental responses
to child anxiety
Parenting a coping child
4
Parent(s) only
Psychoeducation about factors that contribute to child anxiety;
focus on playing with the child in a relaxed way
5
Parent(s) only
Protection versus overprotection; contingent reinforcement of
coping responses; use of specific praise
6
Parent(s) only
Planning and implementing graduated exposure exercises
Child anxiety management
7
Child and parent(s)
Introduction of model for working on being brave; relaxation
exercises
8
Child and parent(s)
Introduction of coping plans; begin planning or carrying out
exposure
917
Child and parent(s)
Planning, rehearsing, and practicing in vivo exposure with
contingent reinforcement
18
Child and parent(s)
Child makes final project (book or short video) reinforcing what
he/she has learned
19
Child and parent(s)
Termination with child; celebration of gains
Relapse prevention
20
Parent(s) only
Maintaining gains; planning for new challenges and transitions;
managing new symptoms; discussion of when to seek further
help

four- to seven-year-olds, we incorporated techniques

developmentally appropriate for younger children, including age-appropriate relaxation-training procedures,60 selfinstructive strategies to control or cope with anxiety61,62
(instead of more sophisticated cognitive-restructuring techniques), and exposure exercises modified to include both
games (e.g., treasure hunts for darkness exposure)63 and immediate positive reinforcement.6466
Because of the young age of the children, we actively involved parents in the process of modeling and reinforcing
techniques for coping. Parents were enlisted as coaches to
assist their children. In the initial sessions of treatment, parents learned anxiety-management strategies (which could
be applied to their own, as well as their childrens, anxiety symptoms) and also some coaching techniques (i.e.,
parenting-skills training). Once a child joined the sessions,
the parents observed the therapist helping the child in learning to develop coping plans and in practicing exposure. The
parent sessions incorporated modules on models of anxiety (adapted from Otto and colleagues)67 and, using exer-

cises adapted from other treatment manuals68 or self-help

books,69,70 on recognizing cognitive errors and doing basic
cognitive restructuring (e.g., of parents own pessimistic or
all-or-nothing thinking about the childs coping or need for
protection). Parent sessions also included a suggested nondirective play exercise similar to that used in Barkleys parent
manual for defiant children71 and in Eybergs parent-child
interaction therapy,72 as well as strategies for effectively
praising and reinforcing adaptive behaviors.
Parents were given a workbook that summarized the didactic material from each session, included written exercises
illustrating that material, and gave general instructions for
the practice exercises for each week. Written exercises included recording the childs verbal, emotional, and physical
signs of anxiety, the childs behavioral responses, and the
consequences for the child, including the parents responses;
monitoring the parents own anxious thoughts; performing
cognitive-restructuring exercises; monitoring the play exercise; generating sample exposure hierarchies for specific
situations feared by the child; and differentiating helpful

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versus unhelpful coaching responses. The exercises were introduced in session, and parents were asked to complete one
or two practice exercises between sessions.

PILOT STUDY

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Method
Our aim in this pilot study was to test the intervention
openly in a small group of children (n = 9) as a first step
toward launching a larger, controlled trial. Children aged 4
to 7 years were included in the study based on the presence
of one or more of the following criteria: (1) BI based on a laboratory assessment; (2) elevated symptoms (T-score 60) on
the withdrawn or anxious/depressed scale of the CBCL,73
and a parent with a lifetime history of anxiety disorder; or
(3) a current DSM-IV anxiety disorder. Families were excluded if the child or either parent was psychotic, suicidal,
mentally retarded, or autistic; if either parent met criteria
for a substance use disorder in the past three months; if the
child had already been in psychiatric treatment; or if the
child was judged too uncooperative or inattentive to take
part in sessions.
We recruited participants through letters to clinicians
treating parents with anxiety disorders at the Massachusetts General Hospital or at other local practices (three
participants), email advertisements to employees of the hospital (two participants), posters in local pediatrics practices
(one participant), and print advertisements to the greater
community (three participants). All parents signed written
informed consent for their own participation, and one parent per family signed written informed consent for the childs
participation. Children assented to study procedures.
In order to determine the parents diagnoses (if any), both
parents from each family were interviewed with the Structured Clinical Interview for DSM-IV.74 Interviews were conducted by raters with bachelors or masters degrees in psychology, under the supervision of senior psychiatrists and
psychologists. Final diagnoses were assigned by consensus
of two senior clinicians.
Children were assessed at baseline and postintervention
using structured diagnostic research interviews administered to mothers and also by clinical interviews, standardized behavioral observations, and questionnaire measures.
They were assessed at two-year follow-up using diagnostic
interviews and questionnaires administered to mothers.
Structured diagnostic research interviews. The research interviews (administered to mothers) used the child version
of the Schedule for Affective Disorders and Schizophrenia, Epidemiologic Version (K-SADS-E),75 supplemented
by the DSMIII avoidant disorder module from the Di-

Young Anxious Children

117

agnostic Interview for Children and Adolescents, Parent

Version.76 In addition to determining the presence or absence of a diagnosis, we counted the total number of anxiety disorder symptoms met on the K-SADS-E. At baseline and two-year follow-up, interviews were administered
by trained raters as described above; at posttreatment
they were administered by the clinicians who had treated
the children. All KSADSE diagnoses and severity ratings were based on a consensus judgment by two senior
clinicians.
Clinical interviews. To ensure direct clinician input into diagnoses at each assessment point, at baseline each clinician conducted both an evaluation with the family to identify parental concerns about the child and a play interview with the child. Clinicians also confirmed K-SADSE results by administering a DSM-IV symptom checklist
to the parents. At postintervention the clinician who had
treated and was familiar with the child conducted the KSADS-E and also assigned a Clinical Global Impression
(CGI)Anxiety improvement rating from baseline (ranging
from 1 [very much improved] to 7 [very much worse],
with 4 indicating no change). Clinicians reviewed their
interviews for consensus with a senior psychiatrist or psychologist. Parents were also asked in a self-report measure to rate their global impression of the childs change
along the same seven-point scale. At two-year follow-up,
evaluations were conducted by an independent clinician
who was blind as to whether or not the child had received
the intervention. This clinician reviewed the-follow-up K
SADSE conducted by the rater and then assessed the
mothers concerns about the child, using a DSM-IV symptom
checklist.
Behavioral observations. Children were assessed for BI using standardized, age-specific, observational laboratory protocols at baseline and at posttreatment. At two-year followup, BI assessments were not conducted since most children
were outside the age range in which BI could be assessed
in the laboratory. The BI protocols were closely adapted in
consultation with Jerome Kagan and Nancy Snidman from
those used in our previous longitudinal study of high-risk
children.19 In these behavioral assessments, the child, accompanied by the mother, was brought into the laboratory,
and his or her reactions to unfamiliar people, rooms, objects,
and cognitive tasks were videotaped and coded for indicators of BI, such as low number of spontaneous comments,
low number of smiles, and global ratings of inhibition or
shyness. To estimate the childs intellectual functioning, we
included the Kaufman Brief Intelligence Test (KBIT) vocabulary and matrices subtests as two of the cognitive tasks.77
Videotaped protocols were coded by a single rater who had
been trained to reliability with Jerome Kagan (all kappas

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>.70). Children were considered inhibited if they achieved

a global rating score of 3 (more inhibited than not) or 4
(extremely inhibited). As a reliability check, 15 tapes were
recoded by a second trained rater, with perfect agreement
on the dichotomous classification of BI (kappa = 1.0).
Questionnaire measures. Laboratory ratings of temperament
were supplemented at baseline and postintervention by two
parent-report measures of temperament, the Retrospective
Self-Report of InhibitionPreschool Adaptation78 and the
Emotionality-Activity-Sociability Temperament Survey for
Children.79 The lattera widely used, 20-item temperament
inventoryincludes both a shyness and a sociability scale.
We used the shyness scale as a parent-report measure of
inhibition.
In addition, both parents completed the CBCL/41873 at
baseline, posttreatment, and follow-up. On the subscales,
scores over 70 are considered in the clinical range, and
those from 67 to 69 are considered borderline. Data from
our center suggested that on the anxious/depressed scale,
the cutoff point of 60 differentiates children who do or
do not meet DSM-III-R criteria for two or more anxiety
diagnoses.80 Finally, at the same intervals, we used an adaptation of Kendalls Coping Questionnaire29 to assess changes
in a childs ability to manage specific anxiety-provoking
situations. In that questionnaire, clinicians asked parents
to list their childs most feared situations (up to six) and
to rate the childs ability to cope with each of them on
a seven-point Likert-scale ranging from not at all able to
help him/herself feel more comfortable, at one end, to completely able to help him/herself feel more comfortable, at the
other.
As noted earlier, children and parents were assessed at
baseline, treated, and then reassessed at postintervention
(mean = 26 weeks; SD = 10). Follow-up assessments on all
children were also conducted approximately two years after
the completion of the intervention (range, 16 to 35 months;
mean = 27.9 months; SD = 6.3 months).

Summarized Results
Participants were seven girls and two boys, aged 4 to 7 years
(mean age = 5.8; SD = 1.0). All were European Americans
from intact middle-class families (Hollingshead Four Factor
SES81 classes III; mean = 1.3; SD = 0.5). Children functioned cognitively at the low-average range or higher (mean
KBIT vocabulary standard score = 112 [SD = 17; range,
96134]; mean KBIT matrices standard score = 109 [SD =
22; range, 77152]). Eight of the nine children had an elevated (T-score 60) baseline CBCL anxious/depressed or
withdrawn scale, and a parent with a lifetime history of anxiety disorder; six of nine children met criteria for laboratory-

MarchApril 2008

observed global BI; and eight of nine already met criteria

for at least one DSM-IV anxiety disorder. To give an indication of clinical severity, eight of nine children met criteria
for multiple (2) anxiety disorders, and seven of nine had
comorbid oppositional-defiant disorder. None of the children
had comorbid major depressive disorder.
All children completed the intervention. Because of the
allowance for flexible implementation of exposure sessions,
the duration of treatment ranged from 15 to 20 sessions
(mean = 17.1; SD = 2.4).
Based upon the CGI, eight of nine children were rated
as much improved (six) or maximally improved (two) at
posttreatment. Parents tended to assign higher ratings than
clinicians (two of eight much improved; six of eight maximally improved [1 missing]).
As seen in Table 1, the children improved on mean
number of anxiety diagnoses, mean number of DSM-IV
anxiety symptoms, and mean ability to cope with feared
situations.
Table 2 summarizes the participants clinical data. Although all but one of the nine children met criteria for at
least one DSM-IV anxiety disorder at baseline, six were anxiety diagnosisfree at posttreatment. There were reductions
in raw rates of most disorders, with significant (by symmetry test) reductions in the rate of multiple anxiety disorders
and of generalized anxiety disorder: the number of children
with multiple diagnoses fell from eight of nine to one, and
with generalized anxiety disorder from six of nine to zero.
There were no changes in rates of laboratory-observed BI
or in parent ratings of shyness on the Emotionality-ActivitySociability Temperament Survey. Of the six children rated
as BI at baseline, five were still rated as BI at postintervention. On the adapted Retrospective Self-Report of Inhibition,
parents did report slight, but significant, reductions in total
inhibition (see Table 1).
At two-year follow-up, six of nine children had no current anxiety diagnoses, and improvement from baseline was
noted on mean number of anxiety disorders and symptoms,
mean ability to cope with feared situations (see Table 1), and
rates of multiple anxiety disorders (see Table 2).
Whereas treated disorders appeared largely remitted,
four children had sought further treatment during the interval (denoted with asterisks in the follow-up diagnoses
column in Table 2), and three of these children were treated
for diagnoses other than those addressed specifically in the
intervention (i.e., obsessive-compulsive disorder and bipolar
disorder).

Case Illustrations
Child 3: Treatment of severe social anxiety disorder. Child 3
was a six-year-old boy who presented with severe social
anxiety and selective mutism with all but his immediate

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119

TABLE 1. Outcome Measures at Postintervention and Follow-Up

Significance (by sign test)

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Outcome (measure)
Number of anxiety disorders
(K-SADS-E)
Number of anxiety symptoms
(K-SADS-E)
Mean coping scoreb (adapted
Coping Questionnaire)
CBCL withdrawn scalec
CBCL anxious/depressed scalec
Behavioral inhibition (adapted
RSRI)c
Shyness (EAS)c

Baseline mean
(SD) [n = 9]

Postintevention mean
(SD) [n = 9]

2-year follow-up mean

(SD)a [n = 9]

Baseline to
postintervention

Baseline to
follow-up

2.8 (1.6)

0.6 (1.0)

0.6 (0.9)

p = .0156

p = .0078

5.7 (3.6)

4.9 (3.9)

p = .070

p = .039

4.7 (1.3)

4.7 (1.5 )

p = .0039

p = .039

p = .063
p = .38
p = .0078

p = .63
p = .45

10.8 (5.4)
2.3 (0.6)
63.2 (12.5)
67.3 (8.9)
2.89 (0.5)

55.3 (6.7)
60.0 (7.8)
2.36 (0.4)

3.82 (1.0)

3.27 (0.6)

56.9 (7.3)
63.3 (6.6)

p = 0.22

CBCL, Child Behavior Checklist; EAS, Emotionality-Activity-Sociability Temperament Survey for Children; K-SADS-E, Kiddie Schedule
of Affective Disorders and Schizophrenia, Epidemiologic Version; RSRI, Retrospective Self-Report of Inhibition (adapted to be administered
to parents about preschoolers).

p < 0.1; p < .05; p < .01 (all by sign test).

a
Including all children. If one excludes the four children who had received further treatment since follow-up, rates at two-year follow-up
(n = 5) were as follows (mean [SD]): number of anxiety disorders = 1.0 (1.0); number of anxiety symptoms = 6.3 (4.5); mean coping score =
4.2 (1.9); CBCL withdrawn = 54.7 (8.1); and CBCL anxious/depressed = 62.0 (10.4).
b
Mean coping scores represent the mean rated ability to cope with up to six most feared situations, as rated by parents on a seven-point
Likert scale, where 1 = completely unable, 4 = somewhat able, and 7 = completely able, to help self feel less upset.
c
For CBCL and RSRI values, the n at follow-up was 7, and for the EAS, the n was 8, because two families did not return their questionnaires.

family and familiar peerswhich led to his repeating

kindergarten. He would not attend new activities unaccompanied by a parent, would flee and hide if guests came to his
house, was fearful of dogs and elevators, worried frequently,
and had difficulty falling asleep.
Parent sessions focused on reducing pressure on the child
to speak, while implementing very gradual exposure expectations, with contingent reinforcement. For example, the
child was reinforced first for simply remaining in the same
room with guests, then for looking at them, then waving,
then answering greetings at a whisper, then at full voice,
and finally for initiating conversation. Other hierarchies included talking to employees in stores and ice cream shops, increasing his verbal participation in school, interacting with
dogs, and riding elevators.
At first, the child would speak to the therapist only
through nods and whispers. The child sessions focused on
in vivo exercises that emphasized speaking and interacting
with others, including playing a taped conversation with
his parents for the therapist, videotaping TV interviews
with one-word and then longer answers, saying hello to office staff, taking interesting toys to show office workers (and
starting conversations), telephoning stores to ask the price
of small toys, and role playing and making purchases. To
help with his exposure, the child thought, Just do it and focused on the desired rewards. By postintervention, the child

was participating fully in his first-grade class, volunteering to read stories to groups of younger children, helping
his gym teacher teach his classmates soccer, visiting friends
with dogs and riding elevators without fear, and agreeing
to take part in new activities (although with shyness and
anticipatory anxiety).
During the follow-up interval, child 3 maintained the remission of his social anxiety disorder but developed predominantly oppositional and anxious behavior (symptoms of generalized anxiety disorder) at home. The child underwent a
brief course of cognitive-behavioral therapy (CBT) to address
his behavior and family stressors, and was then started on
fluoxetine. The family reported that once the child was on
medication, he began more consistently using the coping
strategies that he had been taught in the intervention.
Child 7: Treatment of separation anxiety disorder. Child 7 was
a six-year-old girl who presented with prominent separation
anxiety, marked by an inability to sleep in her own bed and
fear of being in a separate room from her parents during the
day (because wild animals would harm her). She also had
anxieties around standing out from her group of peers (e.g.,
by wearing the wrong dress, bringing the wrong item for a
class project, or entering a classroom late) and worries about
germs and illness (with the consequence that she avoided
touching certain objects).

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MarchApril 2008

TABLE 2. Summary of Diagnostic Data in the Nine Children

Baseline
Child no.,
age, sex
1. 6 (F)
2. 4 (F)

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3. 7 (M)
4. 7 (F)
5. 6 (F)
6. 5 (M)
7. 6 (F)

8. 5 (F)
9. 6 (F)

Diagnoses
None
Social, GAD,
specific
Social, GAD,
specific
OCD, GAD, specific
Social, specific
Separation, social,
GAD
Separation, GAD,
social, specific,
agoraphobia,
OCD
Separation, GAD
Separation,
specific,
agoraphobia

Postintervention

CBCL-W/
CBCL-A

Coping

68/69
73/68

3.42
2.83

81/77

2-year follow-up

CBCL-W/
CBCL-A

Coping

CGI

Diagnoses

CBCL-W/
CBCL-A

Coping

None
None

53/61
53/57

4.67
5.83

3
1

Nonea
Specific, GAD

68/61
64/68

5.00
6.67

2.10

None

58/55

6.10

Nonea

58/62

6.67

50/72
68/54
50/66

2.13
2.17
1.58

50/50
61/54
50/70

6.00
3.00
4.00

1
2
2b

Nonea
None
Nonea

50/66

5.75
3.50
4.17

76/78

1.75

None
None
Separation,
social, OCD
Specific

61/54

4.14

Specific

53/54
50/68

1.79
2.50

None
Agoraphobia

50/70
70/70

4.14
2.83

2
2

None
Specific, GAD

Diagnoses

58/68

3.00

50/50
50/68

5.57
2.17

CBCL-A, Child Behavior Checklistanxious/depressed scale; CBCL-W, Child Behavior Checklistwithdrawn scale; CGI, Clinical Global
Impression; GAD, generalized anxiety disorder; OCD, obsessive-compulsive disorder; separation, separation anxiety disorder; social, DSMIV social phobia or DSM-III-R avoidant disorder; specific, specific phobia.
a
Denotes children who had further treatment after the intervention. None of these children met current diagnostic criteria at follow-up.
However, in the intervening two years, child no. 1 had been treated for bipolar disorder; nos. 4 and 6 had been treated for OCD; and no. 3
had been treated for GAD.
b
The discrepancy between child no. 6s CGI and other measures is a function of timing. Whereas the clinician rated improvement
immediately following the intervention, the family did not complete the postintervention assessment until several months later, by which
time the child had become more symptomatic.

Parent sessions focused on identifying and challenging

their cognitive errors (e.g., overestimating the risk to the
child of sleeping separately or being exposed to germs) and
on planning and implementing exposure hierarchies. For example, parents creatively implemented exposure to separate
rooms through treasure-hunting games in which the child
sought hidden objects, taking her farther and farther away
from where her parents were. When they began to implement more difficult exposures (e.g., the childs staying in
her own bed alone), they rewarded her with stickers and
bravery badges.
The child exposure sessions focused first on darkness exposure, in which the child remained for increasing intervals
in a completely dark room, first with the therapist (taking
turns telling riddles), then alone with a glow-in-the-dark
toy, and then with a soft puppet that emitted no light. Subsequent sessions focused on planning, rehearsing, and implementing separations from parents with contingent reinforcement. Although the child could not practice going to
sleep in her own bed during sessions, she could plan for
between-session exposures by drawing a schematic map of
her house and planning where her parents would stay dur-

ing successive steps of the hierarchy, by making a plan for

coping alone in her bed (e.g., what toy she could have with
her, what she could think about, and what she could say to
herself to feel brave [e.g., Im a big, brave girl]), and by rehearsing going to bed alone through role plays in which her
parents tucked her in and left her alone in the darkened
therapy office to practice her coping plan.
The childs fear of being the center of attention was addressed by playing a silly game, in which child and therapist deliberately dressed in silly ways and walked around
the clinic halls, getting accepting reactions from (coached)
office staff. By postintervention, the child was sleeping in
her own bed nightly with the overhead light off, tolerating being in a separate room or separate floor of the
house from her parents, and showing decreased social anxiety. At follow-up, she had only a mild specific phobia (insects), for which her parents were implementing exposure
exercises.
Child 5: Treatment of social phobia. Child 5 was a six-year-old
girl who presented with social anxiety, marked by difficulty
meeting new children and adults; attending new classes,

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birthday parties, and social gatherings; raising her hand in

her first-grade classroom; and speaking to her teacher. She
also displayed oppositional behavior and biweekly tantrums
at home, and had a specific phobia of insects and a fear of
darkness.
Parent sessions focused on helping the parents to manage their own worries about their daughters anxiety and
her difficulties in coping, to reframe her social difficulties
as involving skills that she could work on, and to increase
their attention to the gradual progress that she was making toward agreed goals. The parents constructed a hierarchy of initial situations for their daughter to work on (e.g.,
making eye contact when greeted by people at school, then
answering greetings with one word, etc.) and themselves
worked on reducing any critical statements and on reinforcing her successes with praise. They developed plans for coping with large family get-togethers, including setting limits
on avoidant behaviors and encouraging gradual interactions
with family members; using contingent reinforcement (e.g.,
a sticker for each interval that she followed the coping plan);
and planning some conversation starters (e.g., pictures to
show her family members). Other sessions focused on reducing overall parental directiveness and enhancing the childs
independence (for example, by allowing her to make decisions about what to eat for dinner, or which clothes to wear).
In the child exposure sessions, the child practiced progressively greeting and talking briefly with adults from
around the office, with reinforcement via stickers. Outside
of session, the child and her parents continued to practice
initiating greetings to friends and their parents at school,
at religious services, and in other settings. Each of these
exposures began with role plays with the parent or therapist, followed by in vivo exposure. Next, a plan was set up
whereby the childs teacher monitored her classroom participation and interactions on a daily basis, and the child was
reinforced (with stickers and small rewards) by her parents
for increasing specific behaviors (e.g., volunteering, sharing
in class, and talking to her teacher), which improved readily as a result. Subsequent sessions focused on helping the
child plan how to respond to peer conflict or teasing. Final
sessions addressed the childs darkness fears with exposure
in session and at home.
By the end of treatment the child was more comfortable and interactive at social gatherings, was responding
to greetings from unfamiliar adults, was talking readily to
her teacher and volunteering and participating animatedly
in class, was learning to be more assertive in disputes with
classmates, and was excited about presenting an oral report. Her temper outbursts at home were less frequent and
shorter in duration; her specific fears were reduced; and
her interactions with peers outside of school had increased
to weekly play dates. These gains were maintained at
follow-up.

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121

ADAPTATION OF CBT TECHNIQUES FOR YOUNG

CHILDREN AND THEIR PARENTS
Much of the work with parents involved focusing on parental
responses to the childs anxiety; the goal was to substitute
reinforcement of adaptive responses for reinforcement of
anxious or avoidant responses. We provided psychoeducation about factors known to increase or decrease anxiety responses, and then asked the parents to observe and analyze,
with the therapist, which responses were helpful or not helpful for their child. Through the use of a parent workbook, we
were able to provide parents with information that was not
taken as negative feedback about their own particular parenting style, but rather as general rules of thumb.
Different aspects of our protocol were helpful to different
parents. For example, some parents tended to respond to
their childs anxiety with overly solicitous behavior, which
inadvertently reinforced the childs anxiety by reducing his
or her opportunities to practice the feared activity independently (e.g., as in the case of a parents answering for
a socially anxious child). One mother had an especially
interventionist style with her child, compensating for the
childs general hesitancy by increasing her own directiveness. Rather than pointing out this dynamic directly, the
therapist suggested that at home the mother focus on the
nondirective play exercise with the childone in which the
parent was instructed to follow the childs lead, narrate the
play, and not interject any suggestions, criticisms, or questions. When the mother returned the next week, she talked
about how difficult it was for her to suppress her suggestions
to her child. I had a very difficult time keeping quiet . . . I
had suggestions coming out of my mouth like you wouldnt
believe . . . It was very hard for me not to say, Oh, dont do it
that way, do it this way . . . Half of me said . . . [my child] is
perfectly capable, very creative, and if you let [the child] go,
its amazing what [the child] comes up with. But the other
half of me said, no, I want to be a part of this, and the only
way I know of to be a part is to have those types of comments
. . . Its hard for me, I really need to work on this . . . I really
need to give [my child] space.
Other parents tended to restrict their childs behaviors
because of their own anxious thoughts or feelings. For example, several parents of children with separation anxiety
stated that they would not allow the children out of their
sight in stores because of fears that the children would be
kidnapped, or that they would not allow the children to go
on play dates unaccompanied because of fears that they
would be harmed. One mother was hesitant to have her
child stop sleeping with her because she would no longer
be able to hear if the child was breathing. These thoughts
came up as examples of the parents anxious cognitions.
By presenting and normalizing common types of cognitive
errors (e.g., catastrophic thinking, overestimation of risk)

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and by teaching strategies for challenging and restructuring

anxiety-provoking thoughts, we were able to help parents
conduct the behavioral experiments of allowing their children to enter the situations about which the parents had
anxious thoughts (e.g., to sleep alone, go on a play date, or
enter a store alone).
The specific techniques used with the children had to be
modified in accordance with their developmental levels. For
example, for the children in our protocol, cognitive restructuring of negative or catastrophic thoughts was deemphasized in favor of helping children substitute simple coping
statements, such as Im a brave girl, Just do it, or If I try
it, Ill feel better. To familiarize children with our general
approach, we presented a story about a child who overcame
a fear by learning coping skills and by engaging in exposure exercises. To engage children in learning to formulate
basic coping plans, we used stories, puppet play, and role
plays. Younger children found it easier to decide upon coping plans for a particular feared situation (e.g., joining a
group of children playing) through the medium of play (e.g.,
if their puppet had to help another puppet face a similar situation). Children would coach the puppet to rehearse the coping planand then, in turn, role play their own rehearsal.
Similarly, exposure exercises were turned into games and
either made into fun (if possible) or otherwise rewarded with
immediate praise or tangible prizes. Examples of fun exposures included, for separation fears, treasure hunt games
(as described for child 7); for social phobia, conducting surveys with interesting questions (e.g., Whats your favorite
ice cream?) either to unfamiliar adults in the office or to
children in the playground, or saying hello to new adults
or children and tabulating different eye colors (which required making eye contact); or for generalized anxiety disorder, playing games in which the child, parent, and therapist
intentionally make mistakes (exposure for fear of making
mistakes) or in which the child intentionally violates a rule
and gets reprimanded by the parent or therapist (exposure
for fear of reprimands). For less fun exposures (attending
classes alone, raising ones hand in school, sleeping alone),
we negotiated reinforcement that included enjoyable activities with parents; stickers; points toward a desired outing
or toy; or collectibles like trading cards.
The final sessions, in which the children completed
projects to demonstrate their mastery of the coping strategies (e.g., videos or books illustrating how a child can overcome a fear), represented an opportunity both to review what
was learned and, more broadly, to help other children in the
future. The childrens internalization of the process was evident when several children began suggesting coping plans
to friends or younger siblings facing similar fears. For example, one four-year-old told her friend, who wanted to leave
a parade they were watching, Its scary at first, but if you
stay, youll have fun.

MarchApril 2008

DISCUSSION
Our experience piloting this protocol suggests that manualized, cognitive-therapy protocols used to treat anxiety disorders in older children can be feasibly adapted for use with
younger children. The application of CBT techniques with
young children necessitates flexibility, creativity, and developmental sensitivity.82 Moreover, it is important to engage
parents in the treatment, both because of their role in monitoring and controlling the contingencies for the child, and
because parents anxiety can adversely influence the maintenance of their childs disorder(s). We found that with nonthreatening, generalized instructions, parents struggling
with their own anxiety symptoms, as well as parents without anxiety disorders, could become involved in creatively
planning exposure hierarchies and in discovering the best
ways to reinforce and motivate their children.
Our pilot study also presents preliminary data suggesting that the adapted parent-child intervention protocol (the
Being Brave program) shows promise as a treatment for
young (four- to seven-year-old) children with anxiety disorders. At postintervention, the reductions in rates of anxiety
diagnoses for these children were comparable to those following CBT protocols for older children.29,30,33,34 Moreover,
the children showed significant decreases in the number of
anxiety disorders and symptoms, and also significant improvement in parent-rated coping with feared situations.
The reduction in rates of a range of anxiety disorders suggests that this approach may be broadly applicable regardless of the particular anxiety diagnosis with which a child
presents. It is still worth noting, however, that further testing of these initial findings is required.
The rate of children who were free from anxiety disorders at two-year follow-up (67%) was also similar to the
rates in follow-up studies of older children treated with
CBT.29,31,33,35 Children presenting clinically with anxiety
disorders are known to be at risk for subsequent onset of
new disorders,83,84 however, and the children in our study
were no exception. The rate of emergence of new disorders appeared higher than in some other studies of children
treated for anxiety with CBT and lower than others. For example, the rate of children who sought further treatment
was not reported in the first follow-up study by Kendall and
colleagues;31 was 1 of 53 children recontacted in the followup study by Barrett and colleagues;35 but was higher in the
second follow-up (mean interval = 7.4 years) by Kendall and
colleagues (52.4% by parent report, including 5.5% hospitalized, 39.7% treated with outpatient therapy, and 31.5%
treated pharmacologically).36 The emergence of new disorders at follow-up in children in our study may reflect, in
part, the extremely high risk profiles of the children we enrolled, who had already presented with multiple risk factors and high levels of symptoms at a very young age. In

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addition, it is notable that three of the four children who received further treatment had done so for disorders not specifically addressed by our intervention (i.e., bipolar disorder
and obsessive-compulsive disorder). Studies of larger samples are needed to more fully evaluate the maintenance of
treatment gains and the ability of this intervention to serve
as a preventive intervention for the four anxiety disorders
specifically targeted in the treatment. In addition, it will be
important to assess in future studies whether the addition
of booster sessions may improve the outcome for children
receiving this intervention.
Our finding that inhibited temperament or shyness did
not change over the treatment or follow-up intervals highlights that the goal of early intervention is not to change
a childs temperamental disposition. Rather, the intervention aims to prevent a childs temperamental inhibition from
causing symptomatic and functional impairment (marked
by DSM-IV disorders) that interferes with developmental
tasks such as meeting and socializing with new children.
In summary, our intervention showed promise proximally
as a treatment for anxiety disorders in children aged 4 to 7
years. It suggests that CBT protocols similar to those used
with older children can be adapted for youngsters in this age
range. As an open case series, our study did not control for
the possibility that the children might have improved symptomatically with maturation over the six months of the study
or the two years of follow-up. With that question in mind, a
controlled trial comparing our intervention to a monitoringonly condition is being completed at our center.
We gratefully acknowledge Philip C. Kendall, Thomas H. Ollendick,
Michael W. Otto, Stephen V. Faraone, Jerrold F. Rosenbaum, Jerome
Kagan, and Nancy Snidman for their input as consultants to this
project, and Joanna Robin and Heather Violette for serving as early
research coordinators of the study.

REFERENCES
1. Costello E, Angold A, Burns B, et al. The Great Smoky Mountains study of youth: goals, design, methods, and the prevalence
of DSM-III-R disorders. Arch Gen Psychiatry 1996;53:1129
36.
2. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A. Prevalence and development of psychiatric disorders in childhood and
adolescence. Arch Gen Psychiatry 2003:83744.
3. Ialongo N, Edelsohn G, Werthamer-Larsson L, Crockett L, Kellam S. The significance of self-reported anxious symptoms in
first-grade children: prediction to anxious symptoms and adaptive functioning in fifth grade. J Child Psychol Psychiatry
1995;36:42737.
4. Strauss C, Frame C, Forehand R. Psychosocial impairment
associated with anxiety in children. J Clin Child Psychol
1987;16:2359.

Young Anxious Children

123

5. Brady E, Kendall P. Comorbidity of anxiety and depression in

children and adolescents. Psychol Bull 1992;111:24455.
6. Weissman MM. Children with pubertal-onset major depressive disorder and anxiety grown up. Arch Gen Psychiatry
1999;56:794801.
7. Keller M, Lavori P, Wunder J, et al. Chronic course of anxiety
disorders in children and adolescents. J Am Acad Child Adolesc
Psychiatry 1992;31:5959.
8. Newman DL, Moffitt TE, Caspi A, et al. Psychiatric disorder
in a birth cohort of young adults: prevalence, comorbidity, clinical significance, and new case incidence from ages 11 to 21. J
Consult Clin Psychol 1996;64:55262.
9. Egger HL. Anxiety disorders in preschool children [Abstract].
In: Program and Abstracts of the 52nd Annual Meeting of
the American Academy of Child and Adolescent Psychiatry,
Toronto, Canada, October 2005:40.
10. Egger HL, Angold A. Common emotional and behavioral disorders in preschool children: presentation, nosology, and epidemiology. J Child Psychol Psychiatry 2006;47:31337.
11. Beidel D, Turner S. At risk for anxiety: I. Psychopathology in
the offspring of anxious parents. J Am Acad Child Adolesc Psychiatry 1997;36:91824.
12. Biederman J, Rosenbaum JF, Bolduc EA, Faraone SV, Hirshfeld
DR. A high-risk study of young children of parents with panic
disorder and agoraphobia with and without major depression.
Psychiatry Res 1991;37:33348.
13. Biederman J, Faraone S, Hirshfeld-Becker D, et al. Patterns of
psychopathology and dysfunction in a large sample of high-risk
children of parents with panic disorder and major depression:
a controlled study. Am J Psychiatry 2001;158:4957.
14. Lieb R, Wittchen HU, Hofler M, et al. Parental psychopathology, parenting styles, and the risk of social phobia in offspring:
a prospective-longitudinal community study. Arch Gen Psychiatry 2000;57:85966.
15. Sylvester C, Hyde T, Reichler R. Clinical psychopathology
among children of adults with panic disorder. In: Dunner D,
Gershon E, Barrett J, eds. Relatives at risk for mental disorder.
New York: Raven, 1988:87102.
16. Turner SM, Beidel DC, Costello A. Psychopathology in the offspring of anxiety disorders patients. J Consult Clin Psychol
1987;55:22935.
17. Weissman M, Leckman J, Merikangas K, Gammon G, Prusoff B. Depression and anxiety disorders in parents and children: results from the Yale Family Study. Arch Gen Psychiatry
1984;41:84552.
18. Rosenbaum JF, Biederman J, Gersten M, et al. Behavioral inhibition in children of parents with panic disorder and agoraphobia: a controlled study. Arch Gen Psychiatry 1988;45:463
70.
19. Rosenbaum JF, Biederman J, Hirshfeld-Becker DR, et al. A controlled study of behavioral inhibition in children of parents with
panic disorder and depression. Am J Psychiatry 2000;157:2002
10.
20. Petty CR, Rosenbaum JF, Hirshfeld-Becker DR, et al. The Child
Behavior Checklist broad-band scales predict subsequent psychopathology: a 5-year follow-up. J Anx Disord 2008;22:5329.
21. Kagan J, Reznick JS, Snidman N. Biological bases of childhood
shyness. Science 1988;240:16771.

Harv Rev Psychiatry Downloaded from informahealthcare.com by University of Montreal on 09/23/10

For personal use only.

124

Harv Rev Psychiatry

Hirshfeld-Becker et al.

22. Biederman J, Hirshfeld-Becker DR, Rosenbaum JF, et al. Further evidence of association between behavioral inhibition and
social anxiety in children. Am J Psychiatry 2001;158:16739.
23. Hayward C, Killen J, Kraemer K, Taylor C. Linking selfreported childhood behavioral inhibition to adolescent social
phobia. J Am Acad Child Adolesc Psychiatry 1998;37:1308
16.
24. Hirshfeld DR, Rosenbaum JF, Biederman J, et al. Stable behavioral inhibition and its association with anxiety disorder. J Am
Acad Child Adolesc Psychiatry 1992;31:10311.
25. Hirshfeld-Becker DR, Biederman J, Henin A, et al. Behavioral
inhibition in preschool children at risk is a specific predictor
of middle childhood social anxiety: a five-year follow-up. J Dev
Behav Pediatr 2007;28:22533.
26. Schwartz C, Snidman N, Kagan J. Adolescent social anxiety as
an outcome of inhibited temperament in childhood. J Am Acad
Child Adolesc Psychiatry 1999;38:100815.
27. Biederman J, Petty C, Faraone SV, et al. Developmental trajectories of anxiety disorders in offspring at high risk for panic
disorder. Psychiatry Res 2007;153:24552.
28. Ollendick TH, King NJ. Empirically supported treatments for
children with phobic and anxiety disorders: current status. J
Clin Child Psychol 1998;27:15667.
29. Kendall PC. Treating anxiety disorders in children: results of a
randomized clinical trial. J Consult Clin Psychol 1994;62:100
10.
30. Kendall P, Flannery-Schroeder E, Panichelli-Mindel S, et al.
Therapy for youths with anxiety disorders: a second randomized
trial. J Consul Clin Psychol 1997;65:36680.
31. Kendall PC, Southam-Gerow MA. Long-term follow-up of a
cognitive-behavioral therapy for anxiety disordered youth. J
Consult Clin Psychol 1996;64:72430.
32. Kendall P, Kane M, Howard B, Siqueland. Cognitive-behavioral
therapy for anxious children: therapist manual. Ardmore, PA:
Workbook, 1992.
33. Barrett PM, Rapee RM, Dadds MR. Family treatment of
childhood anxiety: a controlled trial. J Consult Clin Psychol
1996;64:33342.
34. Flannery-Schroeder EC, Kendall PC. Group and individual cognitive-behavioral treatments for youth with anxiety
disorders: a randomized controlled trial. Cogn Ther Res
2000;24:25178.
35. Barrett P, Duffy A, Dadds MR, Rapee R. Cognitive-behavioral
treatment of anxiety disorders in children: long-term (6-year)
follow-up. J Consult Clin Psych 2001;69:13541.
36. Kendall PC, Safford SM, Flannery-Schroeder E, Webb A. Child
anxiety treatment: outcome in adolescence and impact on substance use and depression at 7.4-year follow-up. J Consult Clin
Psych 2004;72:27687.
37. Dadds MR, Spence SH, Holland DE, Barrett PM, Laurens KR.
Prevention and early intervention for anxiety disorders: a controlled trial. J Consult Clin Psychol 1997;65:62735.
38. Dadds MH, Holland DE, Laurens KR, et al. Early intervention
and prevention of anxiety disorders in children: results at 2year follow-up. J Consult Clin Psychol 1999;67:14550.
39. Barrett P, Turner C. Prevention of anxiety symptoms in primary
school children: preliminary results from a universal schoolbased trial. Br J Clin Psychol 2001;40(pt 4):399410.

MarchApril 2008

40. Lowry-Webster HM, Barrett PM, Dadds MR. A universal prevention trial of anxiety and depressive symptomatology in
childhood: preliminary data from an Australian study. Behav
Change 2001;18:3650.
41. Hirshfeld-Becker DR, Biederman J. Rationale and principles
for early intervention with young children at risk for anxiety
disorders. Clin Child Fam Psychol Rev 2002;5:16172.
42. Derryberry D, Reed MA. Temperament and the selforganization of personality. Dev Psychopathol 1994;6:65376.
43. Harter S. Developmental processes in the construction of the
self. In: T.D. Yawkey TD, Johnson, JE, eds. Integrative processes
and socialization: early to middle childhood. Hillsdale, NJ: Erlbaum, 1988:4578.
44. Last CG, Hersen M, Kazdin AE, Francis G, Grubb HJ. Psychiatric illness in the mothers of anxious children. Am J Psychiatry
1987;144:15803.
45. Last CG, Hersen M, Kazdin AE, Orvaschel H, Perrin S. Anxiety
disorders in children and their families. Arch Gen Psychiatry
1991;48:92834.
46. Hudson JL, Rapee RM. Parent-child interactions and anxiety disorders: an observational study. Behav Res Ther
2001;39:141127.
47. Krohne H, Hock M. Relationships between restrictive motherchild interactions and anxiety of the child. Anxiety Res
1991;4:10924.
48. Siqueland L, Kendall P, Steinberg L. Anxiety in children: perceived family environments and observed family interaction. J
Clin Child Psychol 1996;25:22537.
49. Manassis K, Bradley S, Goldberg S, Hood J, Swinson R. Behavioural inhibition, attachment and anxiety in children of
mothers with anxiety disorders. Can J Psychiatry 1995;40:87
92.
50. Hirshfeld DR, Biederman J, Brody L, Faraone SV, Rosenbaum
JF. Expressed emotion toward children with and without behavioral inhibition: associations with maternal anxiety disorders.
J Am Acad Child Adolesc Psychiatry 1997;36:9107.
51. Stubbe DE, Zahner G, Goldstein MJ, Leckman JF. Diagnostic
specificity of a brief measure of expressed emotion: a community
study of children. J Child Psychol Psychiatry 1993;34:13954.
52. Barrett PM, Rapee RM, Dadds MM, Ryan SM. Family enhancement of cognitive style in anxious and aggressive children. J
Abnorm Child Psychol 1996;24:187203.
53. Dadds MR, Barrett PM, Rapee RM, Ryan S. Family process
and child anxiety and aggression: an observational analysis. J
Abnorm Child Psychol 1996;24:71534.
54. Cobham V, Dadds M, Spence S. The role of parental anxiety
in the treatment of childhood anxiety. J Consult Clin Psychol
1998;66:893905.
55. LaFreniere PJ, Capuano F. Preventive intervention as a means
of clarifying direction of effects in socialization: anxiouswithdrawn preschoolers case. Dev Psychopathol 1997;9:55164.
56. Choate ML, Pincus DB, Eyberg SM, Barlow DH. Parent-child
interaction therapy for treatment of separation anxiety disorder
in young children: a pilot study. Cogn Behav Pract 2005;12:126
35.
57. Herschell AD, Calzada EJ, Eyberg SM, McNeil CB. Clinical
issues in parent-child interaction therapy. Cogn Behav Pract
2002;9:1627.

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58. Pincus DB, Eyberg SM, Choate ML. Adapting parent-child interaction therapy for young children with separation anxiety
disorder. Educ Treat Child 2005;28:16381.
59. Rapee RM, Kennedy S, Ingram M, Edwards S, Sweeney L. Prevention and early intervention of anxiety disorders in inhibited preschool children. J Consult Clin Psychol 2005;73:488
97.
60. Koeppen A. Relaxation training for children. Elementary Sch
Guidance Couns 1974;9:5218.
61. Ollendick T, Cerny J. Clinical behavior therapy with children.
New York: Plenum, 1981.
62. Kanfer F, Karoly P, Newman A. Reduction of childrens fear
of the dark by competence-related and situational threatrelated verbal cues. J Consult Clin Psychol 1975;43:251
8.
63. Mendez F, Garcia M. Emotive performances: a treatment package for childrens phobias. Child Fam Behav Ther 1996;18:19
34.
64. Leitenberg H, Callahan E. Reinforced practice and reduction of
different kinds of fears in adults and children. Behav Res Ther
1973;11:1930.
65. Menzies RG, Clarke JC. A comparison of in vivo and vicarious
exposure in the treatment of childhood water phobia. Beh Res
Ther 1993;31:915.
66. Sheslow DV, Bondy AS, Nelson RO. A comparison of graduated exposure, verbal coping skills, and their combination in
the treatment of childrens fear of the dark. Child Fam Behav
Ther 1983;4:3345.
67. Otto MW, Jones JC, Craske M, Barlow DH. Stopping anxiety
medication: panic control therapy for benzodiazepine discontinuation. Albany, NY: Graywind, 1996.
68. Craske M, Barlow D, OLeary T. Mastery of your anxiety and
worry. Albany, NY: Graywind, 1992.
69. Burns DD. The feeling good handbook. New York: Penguin,
1989.
70. Seligman ME. Learned optimism. New York: Simon & Schuster,
1990.
71. Barkley R. Defiant children: a clinicians manual for parent
training. New York: Guilford, 1987.

Young Anxious Children

125

72. Hembree-Kigin T, McNeil C. Parent-child interaction therapy.

New York: Plenum, 1995.
73. Achenbach TM. Manual for the Child Behavior Checklist/4-18
and 1991 Profile. Burlington, VT: University of Vermont Department of Psychiatry, 1991.
74. First M, Spitzer R, Gibbon M, Williams J. Structured Clinical
Interview for DSM-IV Axis I Disorders, Patient Edition (SCIDI/P, Version 2.0). New York: Biometrics Research Department,
New York State Psychiatric Institute, 1995.
75. Orvaschel H Puig-Antich J. Schedule for Affective Disorder and
Schizophrenia for School-Age ChildrenEpidemiologic 4th version. Ft. Lauderdale, FL: Center for Psychological Study, Nova
University, 1987.
76. Herjanic B, Reich W. Development of a structured psychiatric
interview for children: agreement between parent and child. J
Abnorm Child Psychol 1982;10:30724.
77. Kaufman AS, Kaufman NL. Kaufman Brief Intelligence Test.
Circle Pines, MN: American Guidance Service, 1990.
78. Reznick JS, Hegeman IM, Kaufman E, Woods SW, Jacobs M.
Retrospective and concurrent self-report of behavioral inhibition and their relation to adult mental health. Dev Psychopathol
1992;4:30121.
79. Buss AH, Plomin R. Temperament: early developing personality
traits. Hillsdale, NJ: Erlbaum, 1984.
80. Biederman J, Faraone SV, Doyle A, et al. Convergence of the
child behavior checklist with structured interview-based psychiatric diagnoses of ADHD children with and without comorbidity. J Child Psychol Psychiatry 1993;34:124151.
81. Hollingshead AB. Four Factor Index of Social Position. New
Haven, CT: Yale University, 1975.
82. Kendall PC, Chu B, Gifford A, Hayes C, Nauta M. Breathing
life into a manual: flexibility and creativity with manual-based
treatments. Cogn Behav Pract 1998;5:17798.
83. Cantwell DP and Baker L. Stability and natural history of DSMIII childhood diagnoses. J Am Acad Child Adolesc Psychiatry
1989;28:691700.
84. Last C, Perrin S, Hersen M, Kazdin A. A prospective study of
childhood anxiety disorders. J Am Acad Child Adolesc Psychiatry 1996;35:150210.