Treatment Modifications Based on Childhood Anxiety Diagnosis: Demonstrating the Flexibility in Manualized Treatment
Grover, Rachel L., Hughes, Alicia A., Bergman, R. Lindsey, Kingery, Julie Newman, Journal of Cognitive Psychotherapy
The current article presents suggestions for modifications to common manualized treatments to tailor the interventions to specific anxiety diagnoses and common comorbid diagnoses. The authors utilize one cognitive-behavioral treatment manual (Coping Cat; Kendall, 2000) to demonstrate appropriate clinical accommodations. As the majority of cognitive-behavioral treatment manuals contain both skill (e.g., relaxation training, cognitive restructuring, problem solving) and exposure components, suggestions for accommodations are grouped into relevant skill or exposure sections. Recommended modifications include a focus on imaginai exposure for generalized anxiety disorder, involvement of parents in the treatment of separation anxiety disorder, completion of a variety of in vivo exposures for social phobia, and involvement of school personnel in the treatment of selective mutism. Brief recommendations are also included for common comorbid symptoms of depression and attention-deficit/hyperactivity disorder.
Keywords: child anxiety; Coping Cat; cognitive-behavioral therapy; manualized treatment
The last decade has seen significant improvement in the treatment of anxiety disorders in children and adolescents, in part due to the efficacy and widespread availability of empirically supported manualized treatments (e.g., Coping Koala, Barrett, Dadds, & Rapee, 1991; FRIENDS, Barrett, Lowry-Webster, & Turner, 2000; Coping Cat, Kendall, 2000). Cognitive-behavioral manual-based treatments for childhood anxiety, whether group or individual modalities, typically include similar components. One commonly used manual-based program is the Coping Cat (or C.A.T. Project for adolescents), a package that includes a therapist manual and child and adolescent versions of ancillary workbooks (Kendall, 2000). The treatment program is composed of two main phases, the first focusing on skill development (e.g., introduction of relaxation techniques, cognitive restructuring, problem solving) and the second targeting graded exposure to fearful situations. Although helpful, the majority of existing treatment manuals were designed to be flexibly applied to a range of anxiety disorders. Typically, the clinician is challenged with the task of individualizing the treatment by making modifications based on a child's age, developmental level, and diagnostic status. To aid clinicians in the adaptation of the common treatment manuals for child anxiety, we suggest potential accommodations appropriate for several anxiety and anxiety-related diagnoses (i.e., generalized anxiety disorder [GAD], separation anxiety disorder [SAD], social phobia, selective mutism) as well as frequently comorbid diagnoses (depression, attention-deficit/hyperactivity disorder [ADHD]).
TREATMENT MODIFICATIONS FOR GENERALIZED ANXIETY DISORDER
The predominant features of GAD are uncontrollable worry about a number of events or activities and accompanying physical symptoms of anxiety (e.g., muscle tension, sleep difficulties, restlessness, difficulty concentrating). Children with GAD commonly report worries about school, family, friends, performance, and health. Often described as "worriers" by family members, GAD children frequently require extensive reassurance regarding their anxious concerns. In order to meet diagnostic criteria, the worry or accompanying physical symptoms must occur more days than not for a minimum of 6 months and cause significant distress or impairment in important areas of functioning (e.g., school, home, peer relationships; American Psychiatric Association, 1994). Given that the core symptoms of GAD in children and adolescents include uncontrollable worry and physical signs of anxiety, treatment manual modifications should target these features.
Adapted Skill Components
Children with GAD may report experiencing a number of different physical symptoms when worrying, such as muscle tension, difficulty falling asleep, headaches, and stomachaches. …