Anxiety disorders are among the most common psychiatric problems experienced by children [1
]. Related functional impairments can include school refusal, failure to make and keep friends, and family conflict [2
]. If left untreated, child anxiety disorders can be pernicious as they often do not remit over time [4
]. The presence of anxiety disorders in childhood is linked with the development of depression and substance use [5
]. Given the potential for negative long-term outcomes, psychosocial treatments that produce lasting changes in child anxiety may serve an important preventive function affecting the course of later mental health and functioning [6
]. Toward this end, it is important to know whether treatments produce lasting reductions over time [7
Reviews of the child and adolescent psychotherapy literature consistently identify cognitive-behavioral therapy (CBT) as an efficacious intervention for child anxiety [8
]. A typical CBT program involves anxiety management skills training (e.g., psychoeducation, relaxation, cognitive skills) and exposure interventions. Both family-focused (FCBT) and child-focused (CCBT) approaches have received extensive empirical support, with neither approach consistently outperforming the other at posttreatment [9
]. Moreover, evidence suggests that treatment-generated effects produced by CCBT and FCBT are maintained at 1 year [10
] and 6- to 7.4-year follow-ups [11
]. Both approaches therefore appear to produce lasting reductions in child anxiety. The few clinical trials that have compared CCBT and FCBT and presented follow-up data have generated inconsistent results, with most findings suggesting nonsignificant group differences [10
]. Questions therefore remain about the relative long-term benefit of FCBT and CCBT for child anxiety.
In the present study, we investigate the relative long-term efficacy of FCBT versus CCBT. The FCBT program, Building Confidence [16
] outperformed a CCBT program at posttreatment on diagnostician’s ratings of anxiety severity and clinical global impressions, as well as a parent report measure of anxiety, though not on child-reported anxiety or diagnostic status [17
]. This FCBT program (a) involves parents as co-clients rather than merely supports for the child’s coping skills and (b) targets parental intrusiveness, a parenting behavior theorized to maintain child anxiety [18
]. Thus, the Building Confidence program is characterized by features that might enhance the impact of parental involvement on outcomes in CBT for child anxiety.
A unique feature of the Building Confidence program is that it targets parental intrusiveness. Parents who act intrusively tend to take over tasks that children are (or could be) doing independently and impose an immature level of functioning on their children [20
]. Whereas a low level of parental intrusiveness is hypothesized to foster children’s perceptions of control and mastery [22
], heightened intrusiveness is hypothesized to maintain elevated levels of child anxiety [23
]. Developmentally, the impact of intrusive parental behaviors may be most pronounced during the transition into adolescence. In early adolescence, autonomy becomes an increasingly important need [25
] and parental behavior that restricts autonomy can be particularly salient. The benefit of reducing intrusive parenting may therefore be most significant in early adolescence.
This pattern of findings has led experts to speculate that parental involvement in CBT may be important for child outcomes only under certain conditions [6
]. Relevant parameters include the amount and type of parental involvement, the child’s level of development, and the extent to which interventions target parental behaviors that maintain child anxiety [9
]. However, though these parameters might affect the impact parental involvement has on clinical outcomes, more empirical evidence is needed. Relatively little is yet known about the mediators and moderators of CBT treatment among children with anxiety disorders [27
]. Although reductions in self-reported anxious self-talk have been found to mediate reductions in self-reported anxiety symptoms in CCBT [28
], parenting has not been tested as a mediator of treatment effects in FCBT. Moderators of treatment effects in CCBT and FCBT have been studied on an exploratory basis, with preliminary evidence suggesting that an FCBT program focusing on parent anxiety management, coparenting, and child management parenting skills may have been more effective than CCBT for younger children (7–10 years old) but not older children (11–14 years old) [10
]. On the whole, little is known about the factors that produce change in treatment or for whom CCBT and FCBT are most effective [27
The principle goal of this study was to compare the relative efficacy of FCBT and CCBT for children at a 1-year follow-up assessment. A secondary aim was to test hypotheses about the mechanisms that might account for differential effects. Specifically, it was hypothesized that FCBT might be superior to CCBT for early adolescents rather than for younger children. An exploratory test was conducted examining the role of changes in intrusiveness as a mediator of treatment effects. Because of the relatively small sample employed in this study, these secondary analyses were considered as a hypothesis-generating mechanism to guide future research, not as definitive tests of moderation and mediation.