Family Cognitive Behavioral Therapy for Children and Adolescents with Clinical Anxiety Disorders 

Our philosophy at the Tarnow Center is one that believes in treating the family system.  Although one or another child may exhibit symptoms of anxiety, depression, behavioral problems or other psychological symptoms, the systems approach treats the entire family as it is posited that each person within the family system affects the other and each much learn to interact in a different manner in order for the symptomatic child to begin to feel better and to become less symptomatic.

An article entitled Family Cognitive Behavioral Therapy for Children and Adolescents With Clinical Anxiety Disorders, by Susan M. Bogels, Ph.D. and Lynne Siqueland, Ph.D.  elucidates this philosophy.

Anxiety disorders run in families. It is generally believed that there is an overlap of up to 80% between parental and child anxiety disorders.  Genetic factors as well as "anxiety enhancing" parenting contribute to the occurrence and exacerbation of parental and child anxiety.  Two factors of anxiety enhancing behavior characterize such parenting. An over protective or controlling rearing style versus encouraging children's autonomy and a critical or rejecting versus a warm or accepting rearing style. Studies indicate that such parental behavior maintains childhood anxiety.

Overprotection and critical parenting can directly result from parental anxiety disorder or be caused by a child's anxiety disorder. Dependent children evoke controlling parenting.  Both child and parental anxiety contribute to parental overprotection and criticism.

A parent's current anxiety as well as his or her childhood experience may play a role in their overprotective and critical rearing.

Families of children with anxiety disorder are found to be less sociable, more enmeshed, more disengaged and more likely to be in conflict.

Cognitive behavioral therapy is often ineffective with children with Anxiety Disorder because of family factors. Several studies have demonstrated that the effects of Cognitive Behavioral Therapy are enhanced by involving parents, especially anxious parents.

For the purpose of this study individual format family therapy was developed in which most of the treatment time was spent with parents, parents and anxious child together and the whole family rather than with the anxious child individually. The authors hypothesized that family Cognitive Behavioral Therapy would (1) decrease child anxiety, (2) decrease child dysfunctional thinking, (3) decrease parental anxiety, (4) decrease parental dysfunctional beliefs, (5) decrease anxiety enhancing parenting and (6) improve family functioning.

The study determined that Family Cognitive Behavioral Therapy was associated with reduced child and parental anxiety, reduced dysfunctional child and parental beliefs and improved parental rearing and family functioning.  The authors rationale in developing this study was that change through the parent and family would lead to a better outcome in time. Their twelve month follow up showed that families continued to improve. Despite the little time therapists spent with children on a one to one to challenge negative thoughts, that there was demonstrable improvement in cognition, impressed the authors.   The success of Family Cognitive Behavioral Therapy in changing a child's thinking may have resulted from parents challenging the dysfunctional thoughts of their child.  Therefore, Family Cognitive Behavioral Therapy seemed to succeed in empowering and educating parents to facilitate changes in their anxious child. Family Cognitive Behavioral Therapy was also successful in changing parental dysfunctional beliefs concerning their child's anxiety. It is believed that parental dysfunctional thinking can impede a child's progress.

Significant reductions were obtained after treatment in children's anxiety and internalizing symptoms.  A decrease in fear and avoidance was observed.  Children's conviction of dysfunctional beliefs decreased and they interpreted ambiguous situations more positively with improved coping mechanisms. Additionally, children's externalizing symptoms were reduced. Immediately after treatment no significant improvement on parental psychopathology and dysfunctional thinking was observed.  However, at follow up, both parents reported improvement on internalizing symptoms and mothers reported improvement on externalizing symptoms. Both parents dysfunctional thinking concerning their child's anxiety and their role as parents was reduced at time of follow up.

Children and father's reported improvement in family functioning but mother's reported no improvement. Children perceived no changes in parental rearing, however, mothers were less likely to be over protective and controlling and fathers less anxious in child rearing.

The authors found that only fathers and not mothers improved on self-reported fear.  Thus would seem to suggest that fathers but not mothers had elevated fear and that only fathers needed to change. As both fathers and mothers genetically contribute to child anxiety the fact that only fathers had elevated fear required an explanation.  Mothers may have under reported their own fears as they did not want to be blamed for causing any maladjustment in their children. Also, children of anxious fathers may be at greater risk for anxiety as they grow older.  As children grow older, fathers function as models for transactions outside of the family. This was one of the few studies that included fathers, and underscored the importance of the father's role in the family and with the child.

Consistent with treatment goals both parents reported less overprotective rearing and fathers less rejection. A decrease in these attitudes may have been a result in the reduction of parental anxiety.  Parental anxiety makes parents more irritable and changes in parental rearing result from decreases in child anxiety.  Parents respond to their child's chronic anxiety with anxiety, rejection and control.  Children reported improvement in family relationships. It was speculated by the authors that the improvement in these family relationship reflected changes in parental rearing behaviors.

This study implied that, First, fathers can and should be included in treatment. Second, Family Cognitive Behavioral Therapy appeared to be a good alternative for Child Cognitive Behavioral Therapy. Third, the further improvement of families after treatment supported the author's clinical impressions that ending family treatment, even after a limited number of sessions, important, even if there is little improvement.