افشای پریشانی در میان اضطراب مختل جوانان: تفاوت در نتیجه درمان

The present study evaluated treatment outcome differences in anxiety-disordered youth who differed in their disclosure of internal distress as measured in a structured diagnostic interview. One hundred and seventy-one clinic-referred, anxiety-disordered children served as participants. Participants’ primary diagnoses were one of three anxiety disorders: separation anxiety, generalized anxiety/overanxious, or social phobia/avoidance. At a pretreatment assessment, children and their parents were interviewed separately using the Anxiety Disorders Interview Schedule (ADIS) to determine the child’s diagnosis. The child’s status as a discloser of high distress or discloser of low distress was determined by the parents’ endorsement of an anxiety disorder and the child’s endorsement or lack of endorsement of an anxiety disorder, respectively. Parents, teachers, and children also completed measures assessing the child’s psychopathology (e.g., Revised Children’s Manifest Anxiety Scale, Child Behavior Checklist). In general, findings indicated that the level of distress reported by the children moderated treatment outcome. Although both groups benefited from treatment, the children disclosing high distress experienced greater treatment gains than the children disclosing low distress.

Internalizing disorders in childhood may be difficult to recognize as they reflect the emotional states of the child, and are less readily identifiable in observations of overt behavior. Moreover, children with internalizing disorders exhibit a variety of patterns regarding sharing information about their distress. Although some children talk openly about their emotional states and internal concerns, others have difficulty sharing their distress. Children who are willing to talk openly about their emotions can be seen as disclosers of high distress, whereas those who have difficulty in this area can be seen as disclosers of low or no distress (hereafter, this type of child will be referred to as a discloser of low distress). Disclosure in therapy is a topic that is almost exclusively discussed in the adult literature (see Kelly, 2000 for a review; see also Arkin & Hermann, 2000; Hill, Gelso, & Mohr, 2000; Mayo, 1968; McDaniel, Stiles, & McGaughey, 1981; Rippere, 1977; Stiles, Shuster, & Harrigan, 1992). Much of the research has focused on whether self-disclosure or openness (i.e., sharing personal information and reactions) in therapy is associated with more or less favorable outcomes. In a review of the adult psychotherapy literature, Kelly (2000) suggested that psychotherapy is a self-presentational process in which, over the course of therapy, clients learn to withhold personal information, thoughts, and reactions in therapy to present a more favorable impression to the therapist. Symptom reduction results from the concealment of negative information (i.e., reduction in sharing of symptoms), that in turn elicits positive responses from the therapist. Others support the opposite view and maintain that disclosure reduces psychological distress through catharsis and promotion of self-understanding (e.g., Jourard, 1964, Jourard, 1971, Stiles, 1987 and Stiles et al., 1992). Although the question of whether disclosure is associated with better or worse therapy outcome continues to be debated in the adult literature, the issue of self-disclosure among children remains largely ignored. Issues of disclosure in the childhood literature primarily focus on the disclosure of abuse or other upsetting/traumatic events in the child’s life (e.g., DeVoe & Faller, 1999; Joyce, 1997). This type of self-disclosure involves the sharing of personal information, perhaps within a treatment context, but the role of disclosure has not been examined in relation to outcome of treatment. Given the developmental differences in cognition and psychosocial processes between children and adults, it would be inappropriate to generalize adult findings to children and adolescents. The literature on parent–child agreement among anxiety-disordered children on ratings of child anxiety may well be relevant to disclosure as defined here. Children may be considered disclosers of high distress when they agree with parents on the presence of a childhood anxiety disorder and disclosers of low distress when parents report the presence of a childhood anxiety disorder and they do not. Thus, a child’s status as discloser of high or low distress is heavily determined by the degree of child–parent agreement. The reader should note that when determining a diagnosis, teachers’ reports, clinical observation and judgement, as well as child and parent reports should be taken into account. In the examination of ratings and diagnoses of anxiety in children, current thinking indicates that an approach using multiple informants (e.g., parents, children, teachers) is critical in obtaining a full understanding of the child and his/her difficulties (Kazdin & Weisz, 1998; Kendall, Chu, Pimentel, & Choudhury, 2000). However, utilizing these varied sources creates the possibility of disagreement between sources or “informant variance” (Choudhury, Pimentel, & Kendall, 2003; Kashani, Orvaschel, Burk, & Reid, 1985). A majority of those studies that used multiple informants to measure and diagnose anxiety have, in fact, found minimal agreement between raters, particularly between parents and children (e.g., Edelbrock, Costello, Dulcan, Conover, & Kalas, 1986; Engel, Rodrique, & Gefken, 1994; Grills & Ollendick, 2003; Hodges, Gordon, & Lennon, 1990; Kashani et al., 1985; Sylvester, Hyde, & Reichler, 1987). Parents’ ratings of their children demonstrate more anxiety symptoms (DiBartolo, Albano, Barlow, & Heimberg, 1998; Grills & Ollendick, 2003; Rapee, Barrett, Dadds, & Evans, 1994 [in children under 10 years of age]; Schniering, Hudson, & Rapee, 2000) and greater general psychopathology (Treiber & Mabe, 1987) than children’s own reports. Correspondingly, children report less distress and fewer or no symptoms as compared to their parents (Rapee et al., 1994 [in children under 10 years of age]; Schniering et al., 2000; Schwab-Stone, Fallon, Briggs, & Crowther, 1994; [for exceptions see Bird, Gould, & Staghezza, 1992; Edelbrock et al., 1986; Herjanic & Reich, 1982]). Furthermore, anxious children have shown concerns regarding their self-presentation, wanting to present themselves in a positive light (Kendall & Chansky, 1991; Silverman & Rabian, 1995), and therefore, may report in a socially desirable manner (DiBartolo et al., 1998). This concern about self-presentation can be, understandably, pronounced in children with social phobia. Choudhury et al. (2003) found that while parent–child agreement was low for all anxiety disorders, it was lowest for social phobia, with parents reporting the presence of social phobia twice as frequently as children. Conversely, Grills and Ollendick (2003) found that children who scored higher on the RCMAS lie scale (with items such as “I like everyone I know” that assess social desirability) had better agreement with parent ratings of anxiety. They believe that this is because the “lie” items may tap into the perfectionistic and overly compliant nature of anxious children and not necessarily their willingness to disclose less socially desirable information (Grills & Ollendick, 2003). Although some researchers suggest that the low parent–child agreement does not necessarily imply that the children are unreliable reporters of their internalized distress (Silverman & Eisen, 1992), others suggest that a reliance on child self-reports as accurate indices of distress may be unwise. Schniering et al. (2000) reported that children, particularly those under age 12, show poor retest reliability, calling into question the accuracy of their reports. Similarly, they reported a trend for children to have more difficulty with complex details such as the duration and onset of their symptoms. Other studies have found similar results, reporting that children and even adolescents have difficulty thinking retrospectively and answering questions that require the most meta-cognition (i.e., internalizing questions reflecting an awareness of their thought processes) (Perez, Ascaso, Massons, & Chaparro, 1998). This appears to be a developmental issue in the assessment of children in general, not just for those with anxiety disorders, as similar findings are found in assessments of externalizing disorders (Reitman, Hummel, Franz, & Gross, 1998). These are areas (e.g., reporting of complex details, meta-cognition) that are less problematic for parents, and as such, parents appear to be less susceptible to factors that could influence reliability. In fact, research suggests that parents can be very astute observers and reliable reporters of their children’s distress (DiBartolo et al., 1998). DiBartolo et al. (1998) asked both socially phobic youth and their parents to rate the youth’s fear and avoidance of certain situations. A significant correlation was found between children’s ratings of their own fears and parents’ ratings of their children’s avoidance. Mean parent ratings of social avoidance also emerged as a significant predictor of clinician ratings of severity of social phobia based on interviews with the children and the parents. In a study by Grills and Ollendick (2003), graduate-level clinicians who conducted semi-structured diagnostic interviews with both parents and children appeared to rely more heavily on parent information when making their clinical judgment of diagnosis. This indicates that while child self-report is important, parents provide a unique and invaluable source of information. In the evaluation and treatment of anxiety-disordered children, two groups of children seem to emerge: (a) children who openly disclose their anxiety and distress, similar to their parents’ reports, and (b) children who report little or no distress, dissimilar to their parents’ reports. This division between children disclosing high and low internal distress may have implications for the effectiveness of treatment. That is, disclosure of distress may be a moderator of treatment outcome. We believe this to be especially true because our treatment modality, cognitive-behavioral therapy, is action-oriented; therefore, it is important that the therapist know the specific problems that he/she is targeting. This targeting can serve several purposes—first, it helps to develop a meaningful hierarchy of fears that is an actual representation of the child’s fears. Second, it may help the child hear and accept the information better and feel more invested in the treatment if the therapist is addressing the specific problems that the child is facing. Children may be more likely to actively engage in therapeutic techniques that are applied to self-identified problems. Furthermore, children who disclose more may feel that the therapist understands them better, enhancing therapist–client rapport, and thereby increasing treatment gains. The present study evaluated treatment outcome differences in anxiety-disordered youth who were categorized as disclosing high or low levels of internal distress. It was hypothesized that children who disclosed high distress would not differ from children who disclosed low distress on pretreatment characteristics. However, it was hypothesized that although both groups would benefit from treatment, the children who disclosed high distress would benefit more than those who did not.