Wow! eBook
Parent-Led CBT for Child Anxiety: Helping Parents Help Their Kids
Author(s): Cathy Creswell (Author), Monika Parkinson (Author), Kerstin Thirlwall (Author), Lucy Willetts (Author)
- Publisher: Guilford Press
- Publication Date: 18 Jun. 2019
- Edition: 1st
- Language: English
- Print length: 210 pages
- ISBN-10: 1462540805
- ISBN-13: 9781462540808
Book Description
Parents can play a strong role in helping their children overcome anxiety disorders–given the right tools. This innovative, research-based book shows clinicians how to teach parents cognitive-behavioral therapy (CBT) techniques to use with their 5- to 12-year-old. Session-by-session guidelines are provided for giving parents the skills to promote children’s flexible thinking and independent problem solving, help them face specific fears, and tackle accompanying difficulties, such as sleep problems and school refusal. User-friendly features include illustrative case studies, sample scripts, advice on combining face-to-face sessions with telephone support, and pointers for overcoming roadblocks. Several parent handouts can be downloaded and printed in a convenient 8 1/2″ x 11″ size.
Editorial Reviews
Review
“Creswell et al. have harnessed their collective talent and considerable clinical experience in this eminently readable, highly useful guide. Unlike most treatments for anxious children–which are directed primarily, if not exclusively, to the children themselves–this approach is oriented toward the parents. By actively and collaboratively engaging the parents, the clinician can bypass many barriers to effective treatment with children. The approach is developmentally sensitive, contextually informed, evidence based, and low intensity (four of the eight sessions can be conducted by telephone). This is an impressive book with considerable potential.”–Thomas H. Ollendick, PhD, ABPP, University Distinguished Professor, Department of Psychology, Virginia Tech
“This book fills an important gap by helping therapists to empower parents with the skills and confidence to help their anxious child. Creswell and her coauthors give us a science-based, engaging, extremely practical book that is underpinned by years of experience. Detailed exercises and case examples ensure that any therapist will deliver consistent results. The strategies in this book will change the lives of children with anxiety disorders and their families.”–Ronald M. Rapee, PhD, Distinguished Professor of Psychology and founding director, Center for Emotional Health, Macquarie University, Australia
“Creswell and colleagues present an efficient and effective CBT-based program that enables parents to help their children overcome the distress and functional impairment associated with problematic anxiety. Clearly written and well organized, this book guides providers at all levels through each step of the treatment process, from the initial assessment through relapse prevention. It contains a multitude of useful charts, figures, and case examples.”–John C. Piacentini, PhD, ABPP, Director, Childhood OCD, Anxiety, and Tic Disorders Program, UCLA Semel Institute for Neuroscience and Human Behavior
“A succinct, incredibly practical, and well-written book. Therapists get knowledge and tools for working effectively with parents of children struggling with anxiety. I hope that many parents have the opportunity to experience this empowering approach.”–Wendy K. Silverman, PhD, ABPP, Alfred A. Messer Professor of Child Psychiatry and Director, Anxiety and Mood Disorders Program, Child Study Center, Yale University School of Medicine
“I can’t wait to use this book in my practice with parents! The authors present a clear, step-by-step, evidence-based guide for therapists. With this book, practitioners can teach parents (who often believe erroneously that reassuring their anxious child will help) to foster their child’s independence, ‘curiosity’ about his or her worries, and testing of possible solutions. Parents will see their children gain perspective, mastery, and confidence as their fears decrease.”–Cynthia G. Whitham, MSW, LCSW, private practice, Los Angeles, and Director, UCLA Parenting and Children’s Friendship Program, University of California, Los Angeles –
“This book fills an important gap by helping therapists to empower parents with the skills and confidence to help their anxious child. Creswell and her coauthors give us a science-based, engaging, extremely practical book that is underpinned by years of experience. Detailed exercises and case examples ensure that any therapist will deliver consistent results. The strategies in this book will change the lives of children with anxiety disorders and their families.”–Ronald M. Rapee, PhD, Distinguished Professor of Psychology and founding director, Center for Emotional Health, Macquarie University, Australia
“Creswell et al. have harnessed their collective talent and considerable clinical experience in this eminently readable, highly useful guide. Unlike most treatments for anxious children–which are directed primarily, if not exclusively, to the children themselves–this approach is oriented toward the parents. By actively and collaboratively engaging the parents, the clinician can bypass many barriers to effective treatment with children. The approach is developmentally sensitive, contextually informed, evidence based, and low intensity (four of the eight sessions can be conducted by telephone). This is an impressive book with considerable potential.”–Thomas H. Ollendick, PhD, ABPP, University Distinguished Professor, Department of Psychology, Virginia Tech
“Creswell and colleagues present an efficient and effective CBT-based program that enables parents to help their children overcome the distress and functional impairment associated with problematic anxiety. Clearly written and well organized, this book guides providers at all levels through each step of the treatment process, from the initial assessment through relapse prevention. It contains a multitude of useful charts, figures, and case examples.”–John C. Piacentini, PhD, ABPP, Director, Childhood OCD, Anxiety, and Tic Disorders Program, UCLA Semel Institute for Neuroscience and Human Behavior
“A succinct, incredibly practical, and well-written book. Therapists get knowledge and tools for working effectively with parents of children struggling with anxiety. I hope that many parents have the opportunity to experience this empowering approach.”–Wendy K. Silverman, PhD, ABPP, Alfred A. Messer Professor of Child Psychiatry and Director, Anxiety and Mood Disorders Program, Child Study Center, Yale University School of Medicine
“When I teach Introduction to Child and Family Therapy, one of the first questions that comes up is how to work with parents. This book is the best resource for students seeking answers to this question. It is so clear, scientifically grounded, and clinically useful that I strongly recommend it as a supplemental text and a resource for clinicians at all levels. Teaching parents how to implement the skills that therapists have been studying for years will expand the reach of our efforts with anxious children, and, most probably, will improve our outcomes.”–Eduardo L. Bunge, PhD, Clinical Psychology PhD Program, Palo Alto University
“I can’t wait to use this book in my practice with parents! The authors present a clear, step-by-step, evidence-based guide for therapists. With this book, practitioners can teach parents (who often believe erroneously that reassuring their anxious child will help) to foster their child’s independence, ‘curiosity’ about his or her worries, and testing of possible solutions. Parents will see their children gain perspective, mastery, and confidence as their fears decrease.”–Cynthia G. Whitham, MSW, LCSW, private practice, Los Angeles, and Director, UCLA Parenting and Children’s Friendship Program, University of California, Los Angeles –
About the Author
Cathy Creswell, DClinPsy, PhD, is Professor of Developmental Clinical Psychology in the School of Psychology and Clinical Language Sciences at the University of Reading, United Kingdom. She is also Honorary Consultant Clinical Psychologist and Joint Director of the University of Reading Anxiety and Depression in Young People clinical research unit. Dr. Creswell’s research and clinical interests focus on the development and treatment of anxiety disorders in children and adolescents. In addition to numerous academic publications, she is coauthor (with Lucy Willetts) of two self-help books for parents of children with anxiety disorders.
Monika Parkinson, DClinPsy, is a clinical psychologist and Clinical Research Fellow at the University of Reading, United Kingdom. She has worked clinically for the U.K. National Health Service and on several large treatment trials at the University of Reading, as well as running her own private practice. Dr. Parkinson’s interests focus on identifying effective components of treatments for youth and finding cost-effective ways of supporting families and parents of youth with mental health difficulties. She is coauthor (with Shirley Reynolds) of two self-help books on teenage depression.
Kerstin Thirlwall, DClinPsy, PhD, is a chartered clinical psychologist and Honorary Fellow at the University of Reading, United Kingdom. She led a treatment trial funded by the U.K. Medical Research Council that assessed the effectiveness of a guided parent-delivered cognitive-behavioral therapy approach for childhood anxiety disorders. Dr. Thirlwallcontinues to have a special interest in evidence-based treatments for childhood anxiety disorders, with a particular focus on parent-led approaches;delivers teaching and training to mental health professionals; and provides treatment for children and their families.
Lucy Willetts, DClinPsy, PhD, is a chartered clinical psychologist and accredited cognitive-behavioral therapist. She worked as a clinical psychologist within the U.K. National Health Service for nearly 20 years and most recently was Clinical Director of the Berkshire Child Anxiety Clinic. Dr. Willetts now works in private practice and is Visiting Fellow at the University of Reading. She is coauthor of several books on childhood anxiety.
Excerpt. © Reprinted by permission. All rights reserved.
Parent-Led CBT for Child Anxiety
Helping Parents Help Their Kids
By Cathy Creswell, Monika Parkinson, Kerstin Thirlwall, Lucy Willetts
The Guilford Press
Copyright © 2017 The Guilford Press
All rights reserved.
ISBN: 978-1-4625-4080-8
Contents
CHAPTER 1. Introduction 1,
CHAPTER 2. Conducting a Comprehensive Assessment and Establishing Treatment Goals, 13,
CHAPTER 3. Psychoeducation and Individualizing the Treatment Model, 39,
CHAPTER 4. Promoting Independence in Day-to-Day Life, 65,
CHAPTER 5. Helping Parents to Promote Flexible Thinking and a “Have a Go” Attitude, 80,
CHAPTER 6. Helping Parents Support Their Child in Facing Fears, 98,
CHAPTER 7. Helping Parents Promote Independent Problem Solving, 119,
CHAPTER 8. Keeping Things Going, 137,
CHAPTER 9. Tackling Sleep Problems, 144,
CHAPTER 10. Tackling School Refusal, 159,
CHAPTER 11. Treating Child Anxiety within Challenging Contexts, 175,
References, 187,
Index, 203,
CHAPTER 1
Introduction
Together we have worked with hundreds of parents of children with anxiety disorders, supervised and trained hundreds of clinicians in a range of settings, and conducted research in this area. Our intention in writing this book is to bring together our shared knowledge and experience to guide therapists in working with parents of children with anxiety disorders. All the case studies in the book are based on composites across many cases. The aim of this first chapter is to introduce the background and philosophy of our overall approach. We appreciate that it might be tempting to skip straight to the practical sections, but we encourage you to stick with us so that you have a good understanding of why we do what we do, and ultimately, why we are suggesting that you do the same!
Treatment for Childhood Anxiety Disorders: How Is This Approach Different?
It is now well known that anxiety disorders are among the most common mental health difficulties and that they typically first occur in childhood or adolescence (Kessler et al., 2005). Indeed worldwide prevalence rates suggest that about 6.5% of children are likely to meet diagnostic criteria for an anxiety disorder at any one time (Polanczyk, Salum, Sugaya, Caye, & Rohde, 2015), presenting those children with an increased risk of ongoing anxiety problems as well as other health and social difficulties, most notably, depression (Essau & Gabbidon, 2013).
Both psychological and pharmacological treatments have been evaluated for children with anxiety disorders; however, due to their lower likelihood of side effects, psychological treatments have been recommended as a first line of treatment for preadolescent children (Rynn et al., 2015). The psychological treatments that have been evaluated to date almost all follow a cognitive-behavioral therapy (CBT) approach, which typically involves a therapist working with the child to address anxious thoughts and avoidant behaviors and to develop coping skills. Most of the CBT-based treatments that are available follow, or are based on, the highly influential Coping Cat program, which was developed by Philip Kendall and his colleagues from Temple University, Philadelphia, and was first evaluated in 1994 (Kendall, 1994). There have now been a large number of trials to evaluate these treatments, with, on average, 60% of children being free of their anxiety disorder by the end of treatment (James, James, Cowdrey, Soler, & Choke, 2013). On the whole, the inclusion of parents within or alongside the children’s CBT sessions has not been found to improve children’s treatment outcomes (e.g., Reynolds, Wilson, Austin, & Hooper, 2012); however, the extent and way in which parents have been involved in treatments have varied substantially across these trials. A more nuanced analysis, in which the extent and manner of parental involvement have been taken into account, has led to the suggestion that actively including parents in treatment, incorporating a specific focus on helping parents reinforce children’s brave behaviors (see Chapter 6), and gradually shifting control of the program from the therapist to the parent are associated with significantly better outcomes for children when assessed a year after treatment (with 82% free of their anxiety diagnosis compared to 53–65% following treatments either with limited parental involvement or without an active focus on contingency management and transfer of control; Manassis et al., 2014).
So, we have CBT treatments that work for many children with anxiety disorders, and it appears that involving parents in particular ways can improve children’s outcomes over the medium to long term. However, these treatments are often intensive, involving approximately 14–16 hours of face-to-face child–therapist (and parent–therapist) contact, which presents a challenge for many health care systems. Indeed in the United Kingdom it has been suggested that only a quarter of children with a mental health problem will see a mental health professional (Layard, 2008), and of those that do, many do not access practitioners who are suitably trained or confident in delivering CBT (Stallard, Udwin, Goddard, & Hibbert, 2007). It is essential, therefore, that we find ways to deliver treatments efficiently, while making sure that children continue to have good outcomes from treatment. One way in which to do this is to capitalize on the importance of helping parents feel more empowered to deal with their children’s difficulties and to work primarily with parents or carers (hereafter, “parents”) to help them help their children overcome their difficulties with anxiety. In our view, this approach brings many advantages:
It reduces the burden on children of attending therapy appointments, including missing school and age-appropriate activities and the perceived stigma of attending mental health services.
It reduces the overall amount of therapy time because
[??] There is not the same need for activities and games to increase child engagement and motivation (with working directly with parents, we can often “cut to the chase”).
[??] Parents can implement CBT strategies within their children’s day-to-day life.
Concerns about longer-term difficulties may make parents more motivated to engage in treatment than children, who may be reluctant to attend.
Parents are more likely (than therapists) to be present at times when children need to put strategies in place between sessions and help them generalize principles in day-to-day life.
Parents may be in a better position (than children or therapists) to create opportunities to implement strategies and promote their repetition and generalization between sessions.
Parents are generally in a better position (than children) to liaise with schools or other agencies to encourage the implementation of useful strategies (while retaining control of this within the family rather than it being taken over by the therapist).
Treatment provides the opportunity to address any parenting practices that may be inadvertently maintaining child anxiety (see Chapter 2) and, instead, empowers parents to help their children overcome their difficulties.
Parents can apply the principles and strategies on a familywide basis, potentially helping other children within the family and possibly themselves.
Parents are more likely (than children) to recall and put strategies in to place if problems recur in the months/years following treatment.
Parents’ lives can be significantly affected by having a child who suffers with anxiety, and treatment provides opportunity for them to gain support.
Parents are the most important agent for change that we can access in helping children to overcome difficulties with anxiety. It is essential that we value parents and help them feel skilled and confident in managing their children’s difficulties.
Parent-Led Treatment for Childhood Anxiety Disorders: Does It Work?
As noted above, the majority of treatment trials that have evaluated psychological treatments for children with anxiety disorders have typically involved direct therapeutic work with children, with or without additional input for or from parents. However, in recent years a number of trials have reported positive outcomes for children when the intervention is focused exclusively on parents. This approach was first evaluated in Australia, with the specific aim of supporting families in rural communities who were unable to easily access child mental health services (Rapee, Abbott, & Lyneham, 2006; Lyneham & Rapee, 2006). In these studies, parents of 6- to 12-year-old children were given a book to guide them in how to help their child. Giving the parents the book on its own was associated with a modest impact on children’s anxiety problems: 26% of children were free of their anxiety disorder compared to 7% among those who received no treatment. However, the book-based intervention was not as effective as standard group CBT involving children and parents (61% diagnosis free). In a subsequent trial, supplementing the book for parents with therapist support (provided over the telephone) was associated with extremely positive outcomes, with 79% of children being free of their anxiety disorder. Later U.K.-based trials have also demonstrated that children can achieve good outcomes when parent-only treatment is delivered in a group (57% diagnosis free; Cartwright-Hatton et al., 2011) or in a brief format involving only about 5 hours of therapist input (50% diagnosis free; Thirlwall et al., 2013). Of particular note, two trials that have directly compared parent-only treatment to parent and child treatment found no significant differences between treatments in terms of child outcomes, despite the fact that the parent + child treatment involved at least twice the amount of therapist input to deliver parallel parent and child sessions (Waters, Ford, Wharton, & Cobham, 2009; Cobham, 2012; Creswell, Hentges, et al., 2010). Specifically in the Cobham study, a remarkable 95% of children (7–14 years old) were free of all their anxiety disorders after the parents received a brief intervention comprising a 2-hour parent group followed by six phone calls delivered over 2-week intervals to guide the parent through a workbook, compared to 78.3% of children who received a 12-session family-focused CBT treatment and 0% in the wait-list control condition. Although this is still an emerging area for research, it is clear that taking a parent-led approach to treatment can provide an efficient means of bringing about excellent outcomes for children with anxiety disorders.
Guiding parents to put CBT principles into practice in their children’s day-to-day life is a brief and effective treatment approach for childhood anxiety disorders.
For Whom Is This Book Intended?
We have written this book for clinicians who work with children with anxiety disorders to provide an overview and a framework for also working with the parents of these children. Although we are assuming a general background in child mental health treatment, we have not assumed any prior knowledge of CBT because we have found that novices in CBT can successfully implement the parent-led treatment approach that we are describing (after brief training and with ongoing supervision; Thirlwall et al., 2013). Furthermore, we have examined the feasibility of this approach within a U.K. primary care mental health service with mental health workers with a broad range of backgrounds (including psychology, social work, nursing and home health visiting) and have found that (again, following brief training and with ongoing supervision) the mental health workers delivered the treatment well and achieved good outcomes (Creswell, Hentges, et al., 2010). However, whether you are a novice or experienced therapist, we strongly recommend that you access regular clinical supervision, which will be essential in supporting the work you do with families.
With Whom Can This Approach Be Used?
Age of the Child
Parent-led approaches to treatment for childhood anxiety disorders have been evaluated with children in ages ranging from 2 years, 7 months (Cartwright-Hatton et al., 2011), up to 14 years (Cobham, 2012), but the majority of study participants have been between 6 or 7 and 12 years of age. Although we have anecdotal reports of the approach being used successfully with both younger and older children (with some adaptations), we do not yet have a firm evidence base on which to recommend the approach, but we would welcome feedback based on your own experiences. Similarly, we have heard anecdotal reports of the approach being used successfully with children with developmental delay and autism spectrum disorders (ASD) (where it might be argued that the increased repetition that comes from working with parents may be particularly useful in promoting generalization; Puleo & Kendall, 2011); however, as yet we have no solid evidence on which to base recommendations. Finally, the studies of this approach to date have included fairly homogeneous groups in terms of social, economic, cultural, and ethnic backgrounds, and the extent to which the approach is appropriate, acceptable, and effective across, for example, different cultures remains unclear. We would very much welcome any feedback from your experiences of applying the approach in more diverse settings.
Participating Adults
Our preference is to invite the child’s primary caregivers in to treatment, so when there is more than one key carer, we encourage them both/all to attend treatment. It may not always be practical for more than one parent to attend every session. Sessions conducted over the telephone may also present challenges when more than one parent is involved, so we ask parents to nominate one of them to be the main point of contact, to commit to attending every session, and to provide feedback to another parent if he or she is not able to join a particular session. If parents are willing, audio recordings of sessions could be shared with a parent who is unable to attend. Of course, it is also sometimes the case that children live with different parents at different times, and that parents do not feel able to come together for their children’s treatment. Our view is that the critical factors in deciding who participates in treatment is that (1) the participating parent is able to commit to attending the sessions and (2) is in a position to consistently make relevant changes in their child’s life. For example, if a child lives with one parent during the week and another at weekends, and all of the difficulties relate to attending school, it would be critical to have the parent who has to manage those weekday difficulties involved in treatment. The participating parent also needs to be motivated to bring about changes in his or her child’s life. For example, from time to time we have worked with families in which one parent is very concerned about the child’s anxiety, but the other parent does not share these concerns. As we discuss in Chapter 2, it is obviously important to ascertain each parent’s view of the child’s difficulties independently, because it is possible that one parent has a particular perception of the other parent’s view — for example, that he or she is disinterested or unsupportive — but this may not accurately reflect the other parent’s perspective. On the other hand, if it becomes clear that a parent does not consider his or her child to have a problem with anxiety, that parent is unlikely to be motivated to attend therapy sessions focused on helping the child overcome these difficulties. We discuss general considerations for engaging parents and maximizing their motivation throughout the book.
What Does the Treatment Involve?
Fundamental Principles
The overall aim of the treatment is to work collaboratively with parents to help them develop the skills and confidence to support their children in overcoming difficulties with anxiety. In creating an individualized treatment plan, the therapist role is to work with parents to bring together therapist knowledge about the maintenance and treatment of childhood anxiety disorders with the parental knowledge of the child and how that child responds to challenges. Therapists also encourage parents in continuing to work through the program and help them (1) rehearse key skills, (2) recognize their own skills and positive progress, and (3) problem-solve any challenges that might arise. In order for this intervention to be successful, it is critical that parents feel engaged in the treatment process and empowered to make changes in their children’s lives.
Content of Sessions
The actual content of the treatment is not dissimilar to other CBT programs for child anxiety disorders, and involves the following elements:
Establishing clear, achievable treatment goals (Chapter 2).
Providing psychoeducation and individualizing the treatment model (Chapter 3).
Promoting independence in day-to-day life (Chapter 4).
Helping parents promote flexible thinking and a “have a go” attitude (Chapter 5).
Helping parents support their children in facing their fears (Chapter 6).
Helping parents promote independent problem solving (Chapter 7).
Keeping progress going (Chapter 8).
The main differences from other child- and/or parent-focused treatments in terms of the content result from our emphasis on working jointly with parents. For example, to promote parental engagement and empowerment, it is critical that parents have good background information about the treatment program to equip them to identify anxiety appropriately in their children, to feel hopeful about their children’s outcomes, to understand the rationale for each element of the treatment program, and to relate these directly to their children’s particular difficulties. Because many parents embark on treatment feeling concerned that they have caused their children’s difficulties in some way (or that the therapist may think that they have), it is essential that the therapist be explicit about the underlying treatment model and how parents’ responses fit in to that. As we discuss further in Chapter 3, although the treatment does set out, when appropriate, to alter parental responses that may inadvertently maintain anxiety, this is not to suggest that parents are to blame. Instead we recognize (1) that parents’ responses are largely a response to their children’s anxiety, and (2) that highly anxious children may be more susceptible to influence from particular parental responses than their less anxious peers or siblings. Parents may also express concerns that they are not the “right person for the job” of putting CBT principles and strategies in place, for example, because they are not the “expert,” or they feel that their child is more likely to “open up” to a therapist. For these reasons, as well as providing clear information about the treatment model, it is also essential that the therapy process encourage parental empowerment from start to finish. Beyond these specific aspects of the content, the strategies used are typically from child-focused CBT approaches, adapted in ways that parents can apply in their day-to-day lives.
(Continues…)Excerpted from Parent-Led CBT for Child Anxiety by Cathy Creswell, Monika Parkinson, Kerstin Thirlwall, Lucy Willetts. Copyright © 2017 The Guilford Press. Excerpted by permission of The Guilford Press.
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