Cognitive Behavioral Therapy For Generalized Anxiety in A 6-Year-Old

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

Kristen G. Anderson
Clinical Case Studies 2004; 3; 216
DOI: 10.1177/1534650103259632
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CLINICAL
10.1177/1534650103259632
Anderson
/ CBT
CASE
FOR
STUDIES
GAD IN
/ July
A 6-YEAR-OLD
2004
Cognitive Behavioral Therapy for

Generalized Anxiety in a 6-Year-Old
KRISTEN G. ANDERSON
University of California, San Diego
Abstract: Cognitive-behavioral treatment has been identified as a probably efficacious

treatment for anxiety disorders in children. In the treatment of generalized anxiety disorder
in childhood, two cognitive-behavioral treatments have received the most empirical attention, Kendalls Coping Cat program and Silverman and Kurtiness transfer-of-control
approach. The following case study involves the use of the transfer-of-control approach and
medication in the treatment of a 6-year-old with generalized anxiety disorder. At the onset
of treatment, this child was unable to engage in age-appropriate social activities, eat in public, and be separated from his parents. In addition, he had lost 10 pounds and was having
significant difficulties sleeping. At 3-month follow-up, he was reengaged with his peers, separating from his parents, and had returned to his normal weight.
Keywords: cognitive-behavioral therapy, generalized anxiety disorder, transfer-of-control
THEORETICAL AND RESEARCH BASIS
Prevalence rates for generalized anxiety disorder (GAD) in children range from
3% to 6% (Moore & Carr, 2000). Previously identified as Overanxious Disorder of
Childhood (Diagnostic and Statistical Manual of Mental Disorders [3rd ed., rev.]
[DSM-III-R], American Psychiatric Association, 1987), this disorder was subsumed
under the diagnosis of GAD in DSM-IV (American Psychiatric Association, 1994).
GAD is associated with excessive anxiety and worry about a wide range of activities or
events causing clinically significant impairment and distress. In addition to being unable
to control their anxiety, children must also have one of the following symptoms: restlessness, fatigue, concentration difficulties, irritability, muscle tension, and disturbed sleep.
In childhood, these concerns often center on performance or competence in school
(DSM-IV) . Considered a chronic disorder (Ollendick & King, 1994), the mean age of
onset of GAD in childhood has been identified as 8.8 years of age (Wagner, 2001).
AUTHORS NOTE: The author wishes to thank Richard Milich, Ph.D., for his guidance on this case and support in the
preparation of this article. Correspondence concerning this article should be addressed to Kristen G. Anderson, Ph.D.,
University of California, San Diego, Brown Lab, McGill Hall, 9500 Gilman Drive, M/C 0109, La Jolla, CA 92093-0109.
CLINICAL CASE STUDIES, Vol. 3 No. 3, July 2004 216-233
DOI: 10.1177/1534650103259632
2004 Sage Publications
216

Anderson / CBT FOR GAD IN A 6-YEAR-OLD
217
The role of familial factors in the development and maintenance of generalized

anxiety disorder have been mixed (American Psychiatric Association, 1994; SouthamGerow, Kendall, & Weersing, 2001; Wagner, 2001). In a review of the literature on
GAD, Wagner (2001) suggests that children of parents with an anxiety disorder have
more than a fivefold chance of manifesting an anxiety disorder. In addition, she cites
research (Kendler, Neale, Kessler, Heath, & Eaves, 1992) suggesting that heritability
estimates for GAD are about 30% for shared genetic factors.
Treatments for GAD in children range from cognitive-behavioral treatments to
psychodynamic approaches to pharmacotherapy (Moore & Carr, 2000; Wagner, 2001).
Cognitive-behavioral treatment (CBT) with or without a family-based component has
been identified as a probably efficacious treatment for anxiety disorders in childhood
based on the guidelines set for empirically supported treatments by the APA Task Force
(Ollendick & King, 1998). Moore and Carr (2000) identify this type of treatment as the
treatment of choice for GAD. Kendalls (1994) Coping Cat program and Silverman
and Kurtiness (1996a, 1996b) CBT programs have been the focus of a number of empirical investigations (Berman, Weems, Silverman, & Kurtines, 2000; Moore & Carr,
2000; Silverman, Kurtines, Ginsberg, Weems, Rabian, et al., 1999; Southam-Gerow et
al., 2001). This case study involves the use of Silverman and Kurtiness (1996) transfer-ofcontrol approach in the treatment of a 6-year-old with generalized anxiety. This cognitivebehavioral treatment integrates parents into the treatment of a childs anxiety disorder,
transferring the control of treatment as it progresses.
The transfer-of-control approach is based on the idea that effective long-term
child psychotherapeutic change involves a gradual transfer of control where the
sequence is generally from therapist to parent to child (Silverman & Kurtines, 1996a,
p. 58). In this model of treatment, the therapist functions as a consultant, providing parents and child with the skills necessary to facilitate behavioral change and to maintain
treatment gains. The focus is on the control of anxiety and the use of exposure as the
main mechanism for change. Exposure, both in vivo and imaginal, is used to reduce the
anxiety experienced by children by providing them with the experience of conquering
their fears. Contingency management, through use of contracts, and self-control training are used to facilitate the childs progress through the exposure experiences. The reinforcement provided through the contracts allows the child to develop approach behaviors to previously avoided stimuli. It also allows parents to become central agents in
changing their childs behavior. Training for both parents and child in self-control techniques provides skills in cognitive restructuring and reward, fostering approach behaviors in the child and self-reliance for maintenance of treatment gains within the family
(Silverman & Kurtines, 1996a).
The basic structure is a 10- to 12-week treatment program involving both individual sessions with the parents, individual sessions with the child, and a joint session, totaling 80 minutes. Included are an education phase, an implementation phase, and a
relapse prevention phase. The education phase involves orientation of the family to the

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CLINICAL CASE STUDIES / July 2004
treatment approach, providing an understanding and rationale for the mechanisms for
change in the program (exposure, fear hierarchies), introduction to contingency management and self-control skills, and the strategies used in implementing the treatment
program (in- and out-of-session activities). In this phase, a fear hierarchy, the basis for
exposure tasks, is developed. Specifying the treatment program to a particular anxiety
disorder is attained through formulation of the fear hierarchy and treatment goals; the
hierarchy is based on anxiety-provoking situations for the particular child, reflecting his
or her particular disorder (Silverman & Kurtines, 1996a).
The implementation phase focuses on changing the childs behavior. During this
phase, the child engages in gradually more fear-inducing tasks on the hierarchy, supported by behavioral contacts with rewards and self-control strategies. The therapist
works with the family to monitor the childs progress through the hierarchy, problemsolve any issues that might arise, and support continued learning and use of skills. The
final phase of treatment involves relapse prevention, including a review of progress and
skill development, how to interpret slips, and strategies for handling issues in the future
(Silverman & Kurtines, 1996a).
Empirical support has been shown for this type of treatment for anxiety disorders.
Silverman, Kurtines, Ginsberg, Weems, Rabian, et al. (1999) examined efficacy of contingency management, self-control training, and educational support in the treatment of
childhood phobias (simple phobias, agoraphobia, and social phobia). They found that
all three were effective in generating clinically significant change in phobic symptoms
across time. However, they did find evidence that contingency management and selfcontrol training were more effective than educational support on some outcome measures. In an investigation of the effectiveness of the transfer-of-control approach in a
group-administered format, Silverman, Kurtines, Ginsberg, Weems, Lumpkin, et al.
(1999) found significant improvement in treatment groups over wait-list controls, with
treatment gains being maintained 12 months postimplementation.
Berman et al. (2000) investigated factors associated with treatment outcome in a
sample of children 6 to 17 years of age using this approach in individual and group settings. Predictors of treatment success, defined as either no longer meeting DSM criteria
for their primary diagnosis or showing a major reduction of symptom severity, were
examined. It was found that comorbid diagnoses of depression, trait anxiety, parental
symptoms of depression, fear, and paranoia predicted poor treatment outcome. However, age, ethnicity, and family income were not related to treatment outcome. No differences were found between treatment success and failures for type of primary diagnosis,
number of concurrent diagnoses, or severity of the disorder (Berman et al., 2000). These
findings, in conjunction with more general findings as to the efficacy of CBT (Ollendick
& King, 1998) in the treatment of child anxiety, provide support for use of Silverman and
Kurtiness (1996a) approach to treating child anxiety.

219
CASE INTRODUCTION
Steven M., a 6-year-old White boy, was seen at an outpatient mental health center
in a large, midwestern city. All names within this case study have been changed and nonessential information regarding his treatment was modified to protect the identity of his
family.
PRESENTING COMPLAINTS
His mother had contacted the clinic for an evaluation of Stevens current level of
cognitive abilities because of his complaints of being bored in school. Mrs. M also
expressed concerns that Steven may be suffering from some form of anxiety related to his
school experience. She reported that his teacher was concerned that he refused to eat at
school and seemed very anxious. In tandem with Stevens lack of eating at school, Mrs.
M reported that Steven had begun to resist going to school, stating that it was boring
and that she was concerned that anxiety may be playing a role in both of these behaviors.
When the evaluator suggested that a more in-depth evaluation might be needed, Mrs. M
asked that an intellectual assessment be performed first to rule out boredom as the cause
of his resistance to attending school.
HISTORY
Steven was the only child of upper-middle-class, professional parents. Both parents
were employed outside the home and dedicated a large amount of their nonwork time to
Steven. Mrs. M reported that Stevens pre- and postnatal development was typical, and
that he had not suffered from any major illnesses or injuries. Both parents reported that
Steven had been an irritable and challenging infant. He had been difficult to soothe
as an infant and required a large amount of attention. In toddlerhood, Steven had demonstrated excessive control of his bowel movements. At one time, he required medical
treatment owing to his refusal to go to the bathroom. Approximately 2 years before seeking treatment, Steven had gone through a period of compulsive hand washing that had
spontaneously remitted. Stevens parents and teacher indicated that his school transition
had been traumatic (crying, screaming, etc.). It had taken him months to transition
into kindergarten, but he had less difficulty with the first-grade transition because of the
presence of the same teacher and classmates.
Approximately 6 months before coming to the clinic, Steven had begun to demonstrate increasing levels of fear. These included significant difficulties leaving his mother

220
to go play with friends or allowing her to be away from him, refusing to attend Sunday
School, and difficulties in separating from his parents to stay with other family members
(with whom he had stayed with many times previously). In addition, his parents also
reported that he had fears of people being away from him, fears of getting sick when eating in public, and a preoccupation with being embarrassed. It was reported that he
seemed tense and nervous and consistently ground his teeth while sleeping. Significantly impairing checking behaviors (needing to know where his parents were within
the home at all times and checking to see if they were where they said they would be) and
needing the objects in his room in order were reported. Although the severity of these
behaviors had increased over time, many of these behaviors had been reported, at a lesser
severity, for years.
In a phone interview with Stevens first-grade teacher, he was described as a very
bright and well-liked boy. Mrs. Smith indicated that he was a model student in kindergarten but almost overly so. In first grade, he occasionally talked to his friends while
she was speaking and might speak without raising his hand, behaviors more normative
for his age. Socially, Mrs. Smith described Steven as well liked and appropriate. However, she reported that he seemed to be more fearful than the average child.
Mrs. Smith also reported that Steven had significant difficulties with changes in
routine in the classroom. She reported that he had severe problems with fire drills and
that during his first fire drill, he had cried and displayed extreme fear. Mrs. Smith also
indicated that Steven seemed fearful during schoolwide assemblies and would sit on her
lap or right next to her during them. She spontaneously described similar checking
behavior as his parents. Mrs. Smith reported that he wanted to know where she was when
he was out of the classroom and where her aide was if he could not see her. The teacher
reported an incident where Steven became very agitated and upset when the teachers
aide was out owing to illness.
Steven had seen his pediatrician 1 month before seeking an assessment. Mrs. M
had expressed her concerns to the doctor about Stevens refusal to eat in school and in
public. Despite his recent 10-pound weight loss, the doctor had indicated that because
Steven continued to grow, she was not especially concerned about the eating difficulties.
Stevens mother indicated that Steven had weighed more than his age mates so that his
weight loss put him closer to the norm.
Stevens parents also reported that there was a family history of anxiety and depression on both sides of their family. Stevens father had suffered from panic disorder in the
past and was on maintenance medication. His grandfather had also suffered from
untreated bipolar depression. On his maternal side, it was reported that a number of
members of his mothers family had sought treatment for internalizing disorders.

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ASSESSMENT
Given his mothers request that Steven be administered an intellectual assessment

first, he was given the Wechsler Intelligence Scale for ChildrenThird Edition (WISCIII; Wechsler, 1991). After this was completed, Stevens parents agreed to return to the
clinic to provide information regarding his symptoms of anxiety.
BEHAVIORAL OBSERVATIONS
Steven was an attractive little boy who dressed neatly. He was very nervous at the
beginning of the assessment. He reported that he enjoyed school, especially playing
dodge ball at recess and spelling. He indicated that he attended an after-school program
at his school that he enjoyed. Steven said that he had friends both at school and at home.
He indicated that he spent a lot of time with his best friend, playing after school and on
weekends. Steven also reported enjoying playing soccer on a team and playing
videogames. He denied concerns about going to school or eating lunch there.
Steven refused to wait in the waiting room or in the room next door to the examination room while the examiner spoke with his mother. After negotiation, Steven allowed
his mother to be interviewed alone with the agreement that he could stay next door if the
door to the examination room were left open. Afterwards, Steven readily agreed to stay
with the examiner for testing and quickly developed rapport with the examiner. He was
open and pleasant throughout the testing session.
During the test administration, Steven was highly motivated to perform and
seemed concerned about doing well. He often commented that particular items were
getting hard. He explained to the examiner that he liked testing because It keeps
changing. It isnt boring because were not doing the same thing over and over. Steven
seemed frustrated at times when the examiner was required to repeat directions for a task.
He said that he knew how to do the tasks after the directions had been explained once.
TESTING RESULTS AND INTERPRETATION
On the WISC-III, Steven obtained a Full Scale IQ of 128 (CI = 122-132; 97th percentile), placing him within the Superior range of intellectual ability. Both his Verbal IQ
and Performance IQ scores were 126, falling within the Superior range. Steven obtained
a score of 130 on the Verbal Comprehension Index, placing him in the Very Superior
range. On the Perceptual Organization Index, Steven obtained a score of 123, placing
him in the Superior range. Steven obtained a score of 115 on the Freedom from
Distractibility factor, placing him in the High Average range for his age. The Freedom

222
from Distractibility Index taps attention, concentration, and the ability to work with
information in short-term memory. Compared to his performance on the other indices,
this is an area of relative weakness for Steven. On the Processing Speed Index, Steven
received a score of 119, placing him within the High Average range.
CLINICAL EVALUATION
Mr. and Mrs. M returned to the clinic to complete a diagnostic interview (Parent
VersionChildrens Interview of Psychiatric Symptoms; Weller, Weller, Fristad, &
Rooney, 1999) at the examiners request. They reported significant difficulties in getting
to the clinic due to an outburst by Steven prior to their leaving. Mr. and Mrs. M indicated
that although they had attempted to prepare him for their departure, he had misunderstood and believed that Mr. M would be staying home with him. Instead, he was to stay at
his grandmothers home while they attended the meeting. They reported that Steven
lost control and that it was always stressful for them to leave him. Mr. and Mrs. M
stated that he becomes stressed in these situations (scowling face, punching the air in
their direction, kicking at objects, saying something nasty). Mrs. M stated that he
becomes so keyed up in these situations that he is unable to stop this type of acting-out
behavior. Because of these outbursts, it seemed the family was limited in their options for
child care. As a result, either Mr. or Mrs. M stayed home with Steven when necessary.
Stevens parents reported that he was experiencing overwhelming anxiety, manifested through symptoms of separation anxiety and obsessive-compulsive characteristics.
It also seems apparent that this anxiety was setting the stage for explosive reactions to
overstimulation and a loss of control. Although Steven met full criteria for separation
anxiety disorder, generalized anxiety disorder, and oppositional defiant disorder, it
seemed apparent that his oppositional behavior was an outgrowth of an inability to cope
with his symptoms of anxiety. It appeared that Stevens obsessive and oppositional behavior were manifested when he has lost control of his environment through
overstimulation or an unexpected change in routine.
On the basis of parent and teacher interviews (see Section 4), Steven seemed to be
facing significant impairments in functioning, as indicated by his high levels of anxiety.
Such anxiety seemed to be manifested in clinically significant separation anxiety and
multiple symptoms of obsessive-compulsive disorder. Stevens oppositional-defiant
behavior appeared to be evident in the home environment as a manifestation of his
attempts to cope with overwhelming anxiety and loss of control. Mrs. M reported feeling
like Steven saved up his agitation and aggression until he got home from school.
Greene (1998) described children with these levels of inflexibility and anxiety as putting
so much energy into maintaining control during the school day that they melt down
when they get home from school (p. 58).

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DIAGNOSIS
Although Steven exhibited significant strengths in the area of intellectual abilities,

he was demonstrating clinically significant impairments in his ability to cope with anxiety. At the time of his evaluation, he met criteria for separation anxiety disorder, generalized anxiety disorder, and oppositional defiant disorder. In addition, he demonstrated
some features of obsessive-compulsive disorder that might have been additional attempts
to modulate his anxiety.
CASE CONCEPTUALIZATION
Given Stevens family history of internalizing disorders, it is possible that genetic

factors and learning factors played a role in the manifestation of his disorder. Mr. Ms history of panic disorder could have affected Steven either through direct transmission of
risk or through modeling of anxious reactions to environmental stimuli. Past research
has suggested that children of parents with panic disorder are more likely to have children who are behaviorally inhibited or fearful (Rosenbaum et al., 1988). Although there
is some evidence to suggest that temperamental characteristics might have a genetic
loading (Plomin & Stocker, 1994), other research suggests that parental anxiety might
also shape child behavior through the modeling of anxious reactions or parenting style
(Barrios & ODell, 1998).
Steven seemed to demonstrate high levels of behavior inhibition in novel situations. From his parents description of his behavior in early childhood, Steven seemed to
have difficulty self-regulating his emotional and physical states as well as having a low
tolerance for excess stimulation. These temperamental characteristics, or behavioral
style, are consistent with Thomas and Chesss (1977) conception of a difficult child.
Past research has suggested that behavioral inhibition, sometimes seen as associated with
the difficult temperamental style (Rothbart, 1991), has been linked to the development
of later anxiety disorders (Caspi, 2000; Muris, Mercklebach, Wessel, & van de Ven,
1999; Rosenbaum, Biederman, & Gersten, 1991). On the basis of Stevens family history, it was unsurprising that he was faced with an internalizing disorder.
COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS
During the feedback session, it was recommended to Stevens parents that they see
a child psychiatrist, well versed in the treatment of anxiety disorders, to provide them
with information about options for pharmacological treatment. Given his high levels of
anxiety, his ability to learn from psychosocial interventions seemed in doubt. His parents

224
were also referred to parent training to learn strategies to manage Stevens oppositional
behavior. Although his parents were willing to seek a referral and parent training, they
asked if it was possible for Steven to have individual therapy in addition to their own. It
was agreed that the family would begin treatment after they had sought consultation
with a child psychiatrist.
To select a treatment program that best met the needs of Stevens family, a review of
the literature on the treatment of child anxiety and consultation with other professionals
was completed. The transfer-of-control approach seemed to best match the treatment
needs of this family; its integration of individual sessions with the child, parents, and the
family, the presentation of behavior modification training that could be used across
domains by his parents, and training in the use of coping skills seemed most appropriate.
Given the high level of motivation demonstrated by Stevens parents and Steven, this
program seemed an optimal way to meet the familys needs.
SESSION 1
The first session was scheduled 6 weeks after the completion of the assessment
because of a holiday hiatus. Prior to this meeting, Steven had seen a child psychiatrist
who had prescribed Prozac 5 mg per day for his anxiety. At the time of the initial session,
he had been on the medication for almost 5 weeks. Mr. and Mrs. M reported satisfaction
with the psychiatrist they had seen and reported some improvement on the medication.
For example, Steven was able to play outside for 30 to 40 minutes without checking on
them. However, he continued to demonstrate significant difficulties with separation and
had difficulties returning to school after the recent holiday. Mrs. M was particularly concerned by a recent comment by Steven that he was tired of being scared and wanting
help.
In this meeting, Steven reported that he was having difficulties eating in the morning before school and at lunch (during his assessment, he had denied these difficulties).
He stated that he felt very hungry in the morning but was afraid that he would get sick or
vomit if he ate in school. When asked if he had ever been sick in school, Steven said no.
However, he did tell a story of an incident where he had been sick after eating in a restaurant with his parents. Mr. and Mrs. M verified this story and said that he had come down
with the flu a few months before. After eating at a restaurant, he had vomited when they
had gotten home. Steven said he worried about being sick at school all of the time. He
acknowledged that he was also worried that his parents would not pick him up from
school. When asked if they had ever left him at school, Steven said no.
The majority of this session was spent outlining the treatment program and
transfer-of-control approach. The treatment plan outlined was composed of 10 to 12
treatment sessions consisting of 50-minute sessions (for modification of session length,
see Silverman & Kurtines, 1996a, 1996b). It was agreed that these sessions would
include individual meetings with Steven, parent meetings, and meetings as a family. In

225
four sessions, it was agreed to discuss the progress of treatment and to reevaluate the treatment plan.
SESSIONS 2-4
These sessions were dedicated to the education phase of the treatment program.
Stevens parents were provided with information on exposure, learning theory, contingency management programs, and relaxation skills. Individually, Steven was taught
relaxation breathing whereas his parents were provided with information on how to
guide Steven through the use of these strategies. Both individually with Steven and
jointly with his parents, a fear hierarchy was developed and refined. At the top of his hierarchy was being in a noisy place, followed by spending the night at someones house and
other activities requiring being away from his parents or eating in public. Steven was
allowed to set the behaviors and ratings of fears on his hierarchy. In the following session,
the family met to discuss these activities and negotiated to add other activities to the list
that also were the source of anxiety. In addition, an awards menu was developed to serve
as reinforcers for Stevens successful engagement in activities on his fear hierarchy. In his
first menu, activities were chosen that were naturally reinforcing for Steven (e.g., 30 minutes of his fathers time playing a game of his choice or baking cookies with his mother)
and were not generally available to him.
Beginning in Session 3, homework assignments and contracts were implemented.
The first contract was designed to provide Steven with success on his first attempt. An
activity was chosen for his homework that did not induce fear but had been the source of
conflict and defiant behavior from Steven. Tension between Steven and Mr. M had
been building over their weekly trip to martial arts class. They attended together and
seemed to enjoy the activity, but preparation for leaving had become a source of conflict.
Steven would begin to become agitated when asked to prepare his bag to leave and
would argue with his father about going. Steven denied feelings of anxiety about the
activity or leaving home, but seemed to be facing difficulties with the transition. A contract was drawn between Steven and his father stating that Steven would attend class and
get ready for class without argument.
Session 4 began to set the pattern for the rest of therapy. Steven and his parents
would meet briefly with the therapist to review his progress on his homework assignment
and what he had chosen from his awards menu. Praise and encouragement were provided to the family for their accomplishments of the previous week. The therapist would
then meet with Steven and his parents individually. Prior to the end of session, the family
would meet again to set the new contract for next weeks homework.
This session, Stevens parents reported that Steven had eaten twice at school and at
his after-school program the previous week, a small candy bar on one occasion and a
piece of cake and juice on another. When asked how he was able to eat, Steven said that
I just did it and that he did not feel scared anymore. This led to a modification of his

226
hierarchy, dropping eating at school to a less feared task. Stevens parents also reported
that they had seen the child psychiatrist that week. The doctor had decided to increase
Stevens dose of Prozac to 10 mg daily because of a leveling off of treatment gains from
the medication.
With the aim of increasing the difficulty of the homework assignments, the therapist introduced tokens into the contingency program. Steven would earn one ticket for
each aspect of the contract he was able to complete. This would allow the activity to be
broken down into smaller units, providing Steven with the opportunity for success
within each homework assignment even if he was unable to complete an entire exposure. It was agreed that Steven had to spend the tickets he earned before the next therapy session because Stevens father had expressed concerns that Steven tended to hoard
money and suggested that Steven needed to use his tickets weekly. Given Stevens spontaneous eating at school, continuing his progress in this arena was targeted. His homework was to eat at least one bite of food or drink one juice box at school 3 out of 5 days. For
each successful day, Steven would earn a ticket. Completion of this task would be
verified by self-report and teacher report.
During this period, the therapist had the opportunity to consult with the child psychiatrist on the case. The doctor was very supportive of the cognitive-behavioral treatment being conducted with Steven and was very happy with Stevens progress. He
expressed his appreciation of Mr. and Mrs. Ms dedication to their sons treatment and
their compliance with recommendations. Given the family history of anxiety and Stevens history of behavioral inhibition, he felt that medication treatment in tandem with
exposure and skills-based training seemed an optimal treatment strategy.
SESSIONS 5 AND 6
Steven successfully completed his homework assignment of eating at school and

earned all of his tickets. In Session 5, relaxation training was reviewed and practiced. Stevens parents expressed concerns about potential side effects from the medication and
discussed the progress of treatment with the therapist. They expressed concerns that the
medication might be leading to hyperactive behavior in Steven. The therapist suggested
they speak to their psychiatrist about these concerns. Despite these issues, Mr. and Mrs.
M expressed satisfaction with the treatment gains so far. Steven and his parents continued to seem motivated for treatment and followed the treatment program. His next
homework increased the quantity and frequency of his eating required to earn his
reinforcers.
Session 6 began with Stevens report that he had eaten at his friends house the past
weekend. He seemed very excited and proud that he had done so. He discussed what had
made it easy or hard for him and what he had done to face his fear. Steven indicated that
he did not think eating at school or in his after-school program was a problem now. After
demonstrating his ability to eat at a friends house, it was decided to begin the process of

227
working on his separation fears. During this session, Steven and the therapist identified
his fears about being away from his parents using a thought bubble technique. Steven
was asked to draw a self-portrait. On a separate sheet of paper, the therapist had drawn a
thought bubble like those used in cartoons. Steven was asked what he thought about
when he thought about being away from his parents. These thoughts were then written
in the bubble. Examples of these thoughts included, The person I will stay with will be
mean and I will get sick while my parents are gone. The therapist then guided Steven
through a thought challenge procedure where Steven would generate alternative
hypotheses of what could happen in these situations (e.g., The person I would stay with
could be fun and play games with me.).
SESSIONS 7-10
These sessions targeted Stevens fears of separation using in vivo exposure. In the
first of these sessions, Steven was able to earn tickets for successive steps involved in being
separated from his parents at home. In Session 7, an exposure task was developed where
Steven had the opportunity to earn one ticket for behaving appropriately when his father
left home (saying Goodbye, Dad and waving as his father left), the second for doing the
same when his mother left 2 minutes later, and the third for completing thought bubbles
about the experience with his therapist while his parents were away. Steven did not evidence fear until it was time for his mother to leave. At that time, he seemed nervous but
was able to complete his assigned task. He indicated that he felt a little scared when she
left. Steven successfully earned all three tickets and said that the experience was fun at
the end of the session.
In the second in vivo session, Steven completed the same process but increased the
length of time away from his parents. During this session, he was introduced to the
thought-stopping and self-praise aspects of self-control training. In the Stop Signal
task, Steven was taught how to identify that he was afraid (by identifying physiological
fear cues), identifying the thoughts associated with his fear, generating alternative
thoughts about the event, and praising himself for completing the task. Steven quickly
understood the procedure. He completed the stop signal assignment and earned all
three of his tickets. During the exposure, he neither reported nor displayed any fear.
After the exposure was over, his parents expressed concerns that Stevens trust of
the therapist had limited the fear he had experienced during the exposure. The gradual
nature of exposure was reiterated and plans were made to meet at their home the following week to introduce a stranger into the exposure task.
In Session 9, the therapist arrived at the session with a therapist from the clinic who
was unknown to Steven. The goal of this session was for Steven to be faced with staying
alone with a stranger. The contract afforded Steven the opportunity to earn one ticket
each for appropriately saying goodbye to his parents, saying goodbye to his therapist a few
minutes later, and then playing with the stranger for 30 minutes until the therapist and

228
then his parents returned. Steven earned all three tickets during the exposure task
without much difficulty.
When meeting with his parents, Mrs. M reported that Steven had gone out to dinner the previous weekend with their neighbors. She stated that he had seemed hesitant
to accept the invitation at first but without prompting had decided to go. Steven said that
he had a good time and seemed proud of his ability to go out with his friend. Mrs. M also
reported that Mrs. Smith had commented on a change in his behavior at school. The
teacher had remarked that Steven was being more social in the classroom and seemed
happier. Mrs. M stated that she felt his demeanor had changed in the last few months.
She also felt he seemed more gregarious and lighthearted. Given his progress in separating from his parents, it was decided that Steven was ready to try to stay with a
babysitter. A homework contract was drawn in which Steven could earn his tickets by
staying with a babysitter for 2 hours.
Session 10 took place in the clinic with Steven and his father (his mother was ill). It
was reported that Steven had successfully earned his tickets for staying with his
babysitters. In the individual meeting with the therapist, Steven stated I have done
everything on my list! He was able to articulate what he had accomplished on his hierarchy, and described the skills and strategies he had learned in treatment, but indicated
that he hadnt really needed to use them. After reviewing Stevens treatment gains with
his father, including his spontaneous activities of dining out with neighbors and eating at
school, it was decided to meet in 2 weeks. Steven drew up a contract with his father to
engage in three completed activities from his hierarchy (staying at a friends house, staying with a babysitter, or eating in public with someone other than his parents) in the next
2 weeks.
SESSIONS 11 AND 12
Session 11 began the relapse prevention portion of the program. Stevens last
homework assignment and the treatment plan were discussed. Steven had successfully
completed his last homework assignment and had earned his reward. He had also joined
a friend on a trip to the zoo 2 hours away, gone out to dinner, and a movie with friends,
and had attended a sleepover next door. Mrs. M indicated that Steven had stated that he
felt he did not need to come to the clinic anymore because Im not scared anymore.
She also reported that Steven had regained the 10 pounds he had lost before coming to
treatment and was sleeping much better. In discussing his treatment plan, it became
obvious that Steven had been able to complete all of the tasks in his hierarchy and had
met his treatment goals. It was decided that the family would meet with the therapist in 1
months time for a booster session and then decide if termination was appropriate.
During the booster session, Mr. and Mrs. M reported that Steven continued to
show improvement. His parents had been able to successfully implement a contingency

229
program on their own to reduce Stevens use of a security blanket. They had concerns
that Steven continued to bring the blanket to school in his backpack and had wanted to
see if he could learn to attend school without it. Steven reported that it had been hard
at first but that he did not even think about it now. The family seemed excited by their
vacation plans for the summer, including trips for the family as a whole and for Steven
without his parents. Although his parents were gratified by the progress that had been
made, they asked to have one more session prior to the beginning of the next school year
to assist in any potential transitioning issues. After a discussion of the handling of slips
and continued use of skills to face potential problems that could arise during the summer, it was agreed to meet in 2-3 months time for a follow-up meeting.
COMPLICATING FACTORS
The greatest challenge in working with Steven was to remember that he was only 6
years old and thus tailor the intervention to his level of emotional development. Given
his high level of verbal ability, it was easy to begin speaking with him as if he were an adolescent or adult. However, Stevens emotional development was clearly that of a 6-yearold boy. Although he could clearly articulate that something was bothering him or was
difficult, Steven lacked the ability to identify his emotions and describe the specific
nature of his fears. These issues became apparent when working through the cognitive
aspect of the program, especially during the stop signal task. Initially, it was very difficult
for him to identify why he was scared and identify the thoughts associated with his feelings of fear. Developmentally, it seemed that his lack of self-awareness, appropriate for
his age, made this aspect of the training more difficult.
An additional complicating factor was Mr. Ms own history with psychological
treatment. Although Mr. M was very receptive to therapist recommendations and participated wholeheartedly in the treatment process, he seemed to have doubts regarding the
efficacy of psychological treatment to help Steven. Mr. M had reported that psychotherapy had not been effective for his panic disorder and that his own recovery had been
based on pharmacological interventions alone. At times, some reiteration of the goals
and support for the treatment approach was necessary. Finally, although the family did
allow for some contact between the therapist and the school for assessment purposes,
they were hesitant for Steven to be identified as seeking psychological treatment. For
that reason, the therapist was unable to use in vivo exposures in school or work directly
with school staff to provide interventions surrounding his school-based fears. Although
the lack of this contact did not seem to hinder Stevens overall progress, the ability work
with school personnel could have provided support for Stevens use of relaxation
strategies and cognitive challenging in the classroom if difficulties arose in the future.

230
FOLLOW-UP
The family returned to the clinic 3 months later for a termination session. Steven
excitedly described his trip to stay with an aunt in another state without his parents. He
enjoyed the adventure with his cousins, and his parents reported no difficulties with
the separation. In addition, he had gone on a number of overnights with friends and had
no difficulties eating in public. Mr. and Mrs. M indicated that there had been an
increase in Stevens anxiety within the last few weeks over the beginning of the new
school year. Steven was being advanced to a combined 2-3 classroom and would have a
new teacher. However, that evening they had attended an open house at the school. Mrs.
M reported that Steven had used his relaxation breathing in the car on the way to the
school and after meeting his new teacher seemed much more relaxed. When asked how
he felt about going to school, Steven indicated that he felt much better after meeting the
teacher and thought that going to school would be fun. When asked about the use of his
skills in the car, Steven said I dont think those skills help very much . . . they just make
me not pay attention to being nervous!
Mr. and Mrs. M reported that they were very pleased with Stevens progress and felt
that his treatment had been very effective. He had gained 13 pounds since the onset of
treatment and was behaving more like other children his age. They reported that they
had seen Stevens psychiatrist over the summer, who continued him on the same dose of
medication. The therapist talked with them alone about the possibility of removing Steven from medication, under the supervision of his psychiatrist, in the future. Reiteration
of the risks of slips in the future and strategies to handle them were reviewed. The therapist offered to be a resource for consultation or treatment in the future if need arose.
10
TREATMENT IMPLICATIONS OF THE CASE
There was a confluence of factors that contributed to the rapid treatment gains in
this case. Most notable was the high level of motivation and treatment adherence by Steven and his family. They immediately responded to recommendations by the therapist,
including seeking outside consultation with a psychiatrist and implementing the contingency management program. Their high level of motivation and willingness to try different things made working with them very pleasurable.
In addition, there were a number of characteristics of Steven and his parents that
lent themselves to treatment success. They were very intelligent, well-educated, and
articulate individuals. As parents, they quickly understood the purpose and outline of the
program, enabling them to implement it effectively. Stevens verbal and intellectual
ability made it easier for him to understand what was expected of him and to articulate
his feelings about his experiences.

231
Although there was not consistent contact between the therapist and the child psychiatrist, the willingness of the therapist and the psychiatrist to consult and their agreement on how to proceed with the case was extremely helpful. Because rapport was developed between the family and both practitioners, Stevens family was able to feel secure in
the course of treatment. For the therapist, the ability to consult with another professional
involved with the family who respected and supported the psychosocial intervention was
invaluable.
This case underscores the usefulness of integrated treatment using psychotherapy
approaches supported by empirical investigation and pharmacotherapy. Although use of
CBT for anxiety disorders does not necessitate the use of medication, medication can be
a useful tool to support psychosocial treatment. In addition, use of a treatment manual
based on empirical findings in the literature allows the therapist the knowledge that he
or she is working with a protocol that has been used successfully in the past.
11
RECOMMENDATIONS TO CLINICIANS AND STUDENTS
Cognitive-behavioral therapy is the current state-of-the-art treatment for anxiety

and phobic disorders in childhood. Knowledge of the available research on treatment
outcomes and periodic review of alternative strategies for meeting treatment goals provide clinicians and students with innovative ways to best meet the needs of clients. The
use of empirically validated treatments allows therapists to feel confident that the interventions they use have scientific support. Although the use of a manualized treatment
protocol is not the panacea for all forms of psychological distress, the ability to rely on
strategies that have been validated on individuals with specific disorders is extremely
helpful.
The specific benefit of Silverman and Kurtiness (1996a, 1996b) approach is that
the structure provides flexibility for clinicians to tailor the treatment to the specific needs
of the client. Within the framework of behavior modification, exposure, and cognitive
strategies, the clinician has immense freedom to target specific characteristics of familial
interaction, environmental contingencies, and irrational beliefs that contribute to the
distress the child and family is facing. Through the integration of family and individual
treatment, a holistic approach to the treatment of anxiety disorders in childhood is
available.
REFERENCES
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American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.).
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Barrios, B. A., & ODell, S. L. (1998). Fears and anxieties. In E. J. Mash & R. A. Barkley (Eds.), Treatment of
childhood disorders (2nd ed., pp. 249-337). New York: Guilford.
Berman, S. L., Weems, C. F., Silverman, W. K., & Kurtines, W. M. (2000). Predictors of outcome in exposurebased cognitive and behavioral treatments for phobic and anxiety disorders in children. Behavior Therapy, 31, 713-731.
Caspi, A. (2000). The child is the father of man: Personality continues from childhood to adulthood. Journal
of Personality and Social Psychology, 78(1), 158-172.
Greene, R. W. (1998). The explosive child. New York: HarperCollins.
Kendall, P. C. (1994). Treating anxiety disorders in children: Results of a randomized clinical trail. Journal of
Consulting and Clinical Psychology, 62, 100-110.
Kendler, K. S., Neale, M. C., Kessler, R. C., Heath, A. C., & Eaves, L. J. (1992). Generalized anxiety disorder
in women. Archives of General Psychiatry, 49, 267-272.
Moore, M., & Carr, A. (2000). Anxiety disorders. In A. Carr (Ed.), What works with children and adolescents?
A critical review of psychological interventions with children, adolescents and their families (pp. 178-202).
Florence, KY: Taylor & Francis/Routledge.
Muris, P., Mercklebach, H., Wessel, I., & van de Ven, M. (1999). Pathological correlates of self-reported
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Ollendick, T. H., & King, N. J. (1994). Diagnosis, assessment, and treatment of internalizing problems in
children: The role of longitudinal data. Journal of Consulting and Clinical Psychology, 62(5), 918-927.
Ollendick, T. H., & King, N. J. (1998). Empirically supported treatments for children with anxiety and phobic disorders. Journal of Clinical Child Psychology, 27, 156-167.
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on behavioral inhibition (pp. 219-240). Chicago: University of Chicago Press.
Rosenbaum, J. F., Biederman, J., & Gersten, M. (1991). Anxiety disorders and behavioral inhibition. In J. S.
Resnick (Ed.), Perspectives on behavioral inhibition (pp. 255-270). Chicago: University of Chicago Press.
Rosenbaum, J. F., Biederman, J., Gersten, M., Hirshfeld, D. R., Meminger, S. R., & Herman, J. B. (1988).
Behavioral inhibition in children of parents with panic disorder and agoraphobia: A controlled study.
Archives of General Psychiatry, 45, 463-470.
Rothbart, M. K. (1991). Temperament: A developmental framework. In J. Strelau & A. Angleitner (Eds.),
Explorations in temperament: International perspectives on theory and measurement (pp. 61-75). New
York: Plenum.
Silverman, W. K., & Kurtines, W. M. (1996a). Anxiety and phobic disorders: A pragmatic approach. New
York: Plenum.
Silverman, W. K., & Kurtines, W. M. (1996b). Transfer of control: A psychosocial intervention model for
internalizing disorders in youth. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child
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American Psychiatric Association.
Silverman, W. K., Kurtines, W. M., Ginsberg, G. S., Weems, C. F., Lumpkin, P. W., & Carmichael, D. H.
(1999). Treating anxiety disorders in children with group cognitive behavioral therapy: A randomized
clinical trial. Journal of Consulting and Clinical Psychology, 76(6), 995-1003.
Silverman, W. K., Kurtines, W. M., Ginsberg, G. S., Weems, C. F., Rabian, B., & Serafini, L. T. (1999). Contingency management, self-control, and education support in the treatment of childhood phobic disorders: A randomized clinical trial. Journal of Consulting and Clinical Psychology, 67(5), 675-687.
Southam-Gerow, M. A., Kendall, P. C., & Weersing, V. R. (2001). Examining outcome variability: Correlates of treatment response in a child and adolescent anxiety clinic. Journal of Consulting and Clinical
Psychology, 30(3), 442-436.
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Kristen G. Anderson, M.Ed., Ph.D. is a NIAAA Postdoctoral Research Fellow at the University of California, San Diego, Department of Psychiatry. Dr. Andersons primary area of research is the developmental
psychopathology of addictive behaviors in children and adolescence. She has also published in the areas of
affective and eating disorders, the treatment of childhood behavioral disorders and gender bias in diagnosis.


Cognitive Behavioral Therapy For Generalized Anxiety in A 6-Year-Old

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Clinical Case Studies

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

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Cognitive Behavioral Therapy for

University of California, San Diego

Abstract: Cognitive-behavioral treatment has been identified as a probably efficacious

THEORETICAL AND RESEARCH BASIS

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

The role of familial factors in the development and maintenance of generalized

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CLINICAL CASE STUDIES / July 2004

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

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CLINICAL CASE STUDIES / July 2004

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

Given his mothers request that Steven be administered an intellectual assessment

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CLINICAL CASE STUDIES / July 2004

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

Although Steven exhibited significant strengths in the area of intellectual abilities,

Given Stevens family history of internalizing disorders, it is possible that genetic

COURSE OF TREATMENT AND ASSESSMENT OF PROGRESS

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CLINICAL CASE STUDIES / July 2004

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

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CLINICAL CASE STUDIES / July 2004

Steven successfully completed his homework assignment of eating at school and

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

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CLINICAL CASE STUDIES / July 2004

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

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CLINICAL CASE STUDIES / July 2004

TREATMENT IMPLICATIONS OF THE CASE

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

RECOMMENDATIONS TO CLINICIANS AND STUDENTS

Cognitive-behavioral therapy is the current state-of-the-art treatment for anxiety

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CLINICAL CASE STUDIES / July 2004

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

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