مربیگری رفتار رویکردی و رهبری توسط مدل سازی: منطق، اصول و شرح جلسه به جلسه از برنامه CALM برای اضطراب اولیه دوران کودکی

Whereas the cognitive-behavioral treatment of childhood anxiety has been well-researched and empirically supported over the last 20 years, interventions for anxiety in young children (ages 7 and below) have garnered little attention. Because young children generally lack the required developmental skills to effectively engage in cognitive-behavioral treatment, a simple downward extension of treatments used for older children is inappropriate. The CALM program (Coaching Approach behavior and Leading by Modeling) was developed as a developmentally compatible intervention to treat anxiety disorders in young children ages 3 to 7. The CALM program is an adaptation of Parent-Child Interaction Therapy (PCIT), and an extension of Pincus, Eyberg, and Choate's (2000) adaptation of PCIT for young children with separation anxiety disorder. It is a parent-focused treatment that teaches parents skills to effectively reinforce their children's brave behavior and coaches the use of these skills during in-session parent-child interactions. The treatment emphasizes live, bug-in-the-ear coaching of parents during in vivo exposure sessions. This article describes the CALM program in detail.

Childhood anxiety disorders constitute a serious public health concern, affecting up to 10% of children and adolescents (Costello et al., 2003 and Merikangas et al., 2010). Children suffering from anxiety disorders frequently experience significant impairment in academic, social, and family functioning (Grills and Ollendick, 2002 and Hughes et al., 2008). Moreover, when left untreated, childhood anxiety disorders often persist and are associated with depression and substance abuse in adolescence (e.g., Buckner et al., 2008, Kaplow et al., 2001, Kendall et al., 2004 and Lewinsohn et al., 2008), as well as occupational impairments and reduced quality of life in adulthood (Comer et al., 2011 and Merikangas et al., 2007). Over the last 20 years, cognitive-behavioral treatment (CBT) has garnered strong empirical support in the treatment of childhood anxiety in children ages 7 and above (see Kendall et al., 2010 and Silverman et al., 2008). Whereas specific treatment programs for child anxiety vary, well-supported protocols share a number of core components, including (a) psychoeducation about anxiety; (b) instruction in and practice of anxiety management skills such as relaxation training or cognitive restructuring; and (c) gradual exposure to feared situations. These strategies allow a child to reframe the internal experience of anxiety and to re-estimate threat in the environment. But what if an anxious child lacks key developmental skills required to productively engage in well-supported treatments? How best to treat anxious children below the age of 7, who typically have a limited ability to accurately report on his or her thoughts, to think about alternative ways to perceive anxiety-provoking situations, to consider how anxious he or she may be in an imagined scenario, or to delay the reward of anxiety relief in an exposure situation? The treatments that have been empirically supported for youth with anxiety disorders require a set of developmental abilities that younger children typically do not fully possess. Treated children are expected to describe their internal thoughts and feeling states in treatment. They are further required to sustain attention toward goal-directed behaviors and to hold previously learned concepts in mind within and across treatment sessions. Exposure-based interventions require a child to suppress dominant attentional and behavioral responses, and to plan and delay rewards. The aforementioned metacognitive (Flavell et al., 2001 and Schneider, 2008) and executive functioning (Garon, Bryson, & Smith, 2008) skills are generally limited in young children and continue to develop throughout childhood. Consequently, the optimal course of treatment for anxiety in young children is considerably less clear. This dilemma becomes most concerning when considering that as many as 9% of preschoolers suffer from an anxiety disorder (Egger & Angold, 2006), and the median age of anxiety disorder onset is 6 years (Merikangas et al., 2010). The presence of anxiety at a young age predicts anxiety presence later in childhood and even in adulthood, and earlier onset is associated with more intractable course of illness (Kessler et al., 2005). Clearly, the identification of developmentally appropriate treatment options for young children constitutes a vital public health agenda. If anxiety can be effectively treated in young children, then the development of additional disorders through adolescence and young adulthood may be delayed or prevented. Although the treatment of child anxiety disorders presenting in children below 7 years has historically been neglected by research, a handful of research groups working with anxious preschoolers have recently begun to show support for the use of developmentally sensitive downward extensions of child anxiety treatments (Cartwright-Hatton et al., 2011, Freeman et al., 2008, Hirshfeld-Becker et al., 2010, Kennedy et al., 2009 and Waters et al., 2009). Kennedy et al. (2009) developed an 8-session parent-based intervention for children ages 3 to 4 exhibiting high behavioral inhibition and who had at least one parent with a diagnosed anxiety disorder. This intervention was associated with greater reduction in anxiety symptoms and in behavioral inhibition compared to a waitlist control at 6-month follow-up. Hirshfeld-Becker et al. (2010) adapted Kendall's Coping Cat treatment for children ages 4 to 7. Their treatment, known as the Being Brave program, consisted of 20 weekly sessions; Sessions 1 to 6 and 20 were conducted with parents, and Sessions 7 to 19 were conducted with both parent and child. In a randomized trial, the Being Brave program was associated with a 69% response rate on the Clinical Global Impression Scale for Anxiety compared to a 32% response rate for waitlist control participants. Compared to controls, participants receiving the Being Brave treatment also exhibited greater reduction in anxiety symptoms and increased parent coping at posttreatment. Results were maintained at 1-year follow-up. Waters et al. (2009) compared a group cognitive-behavioral treatment for child anxiety—the Take Action Program—conducted with parents and children to a version of the treatment conducted with parents only. Sixty participants ages 4 to 8 were randomized to the parent and child group, the parent-only group, or a waitlist control. Both treatment programs lasted for 10 sessions and involved psychoeducation, training in relaxation, cognitive restructuring, social skills, and graded exposure. Both active treatments outperformed the waitlist control, with 55.3% of children in the parent-only group and 54.8% in the parent-and-child group no longer meeting diagnosis for an anxiety disorder. Results were maintained at 1-year follow up. Cartwright-Hatton et al. (2011) completed a randomized clinical trial comparing a group-based treatment, the Timid to Tiger program, for parents of 74 anxious children up to age 9 to waitlist control. All children either met criteria for an anxiety disorder or exceeded the cutoff scale for internalizing problems on either the Child Behavior Checklist or the Preschool Behavior Checklist. Group treatment consisted of ten 2-hour sessions and provided psychoeduction about anxiety while teaching parents to use positive attending, active ignoring, reward systems, limit setting, and time-out procedures to reinforce exposure to feared situations and extinguish avoidance behavior. Fifty-seven percent of children whose parents participated in the Timid to Tiger program no longer met criteria at posttreatment, compared to 15% of children of waitlist-control parents, and these results were maintained at 12-month follow-up. The programs outlined by Kennedy et al. (2009), Hirshfeld-Becker et al. (2010), Waters et al. (2009), and Cartwright-Hatton et al. (2011) include important developmental adaptations, with the most salient adaptation being a greater emphasis on parental involvement. Increasing the role of parents in the treatment of anxiety in young children makes good clinical sense given that certain parenting behaviors, such as overprotection, high control, and accommodation of children's anxiety-related avoidance, have been associated with heightened childhood anxiety (Hudson et al., 2008, McLeod et al., 2007, Moore et al., 2004, Rapee, 1997, Siqueland et al., 1996 and Wood et al., 2003). Given relationships between parenting behaviors and childhood anxiety, as well as noted limitations that established child anxiety treatments may hold for young children, interventions focusing primarily on parents instead of children, and modifying parenting behavior, may be most particularly well-suited in the successful treatment of early childhood anxiety. One particularly promising model for parent-based treatment of early childhood psychopathology, generally used in the treatment of children with disruptive behavior disorders, is Parent-Child Interaction Therapy (PCIT; McNeil & Hembree-Kigin, 2010). PCIT was originally developed to treat young children with disruptive behavior problems (McNeil & Hembree-Kigin, 2010). It is a directive, short-term treatment that entails (a) teaching parents skills to more effectively manage their child's problematic behavior, and (b) live coaching of these skills while the parent and child interact during the session. Traditional PCIT consists of two main treatment phases. First, parents learn and practice using child-directed interaction (CDI) skills, including giving positive attention to appropriate behavior and actively ignoring undesired attention-seeking behaviors. The CDI phase of treatment is intended to teach children that positive parental attention is contingent upon appropriate behavior. After parents demonstrate sufficient use of CDI skills, they learn and practice parent-directed interaction (PDI) skills, including the use of effective commands and consequences (e.g., time-out) for noncompliance or misbehavior. Thus, the antecedents and consequences of a child's behavior are modified in a way that shapes the child to act more appropriately. In the novel format of PCIT, the therapist is unobtrusively situated in an adjacent monitoring room, observing the parent-child interactions and delivering live parent training via a bug-in-the-ear receiver worn by the parent. In initial case reports and a recently completed clinical trial, Pincus and colleagues modified PCIT to treat separation anxiety in young children (Choate et al., 2005, Pincus et al., 2010, November and Pincus et al., 2005). As in standard PCIT, their model taught CDI and PDI to parents and coached these skills in session, but also included a Bravery-Directed Interaction, or BDI, component, in which parents were taught to promote and respond positively to their children encountering feared situations. Parents are encouraged to guide their children through feared situations out of session, although the treatment does not involve in-session exposures to feared situations. Results from a controlled evaluation of their program showed significant reductions in young children's separation anxiety symptoms. However, this pioneering work of Pincus and colleagues has been exclusively focused on children presenting with separation anxiety—only one of several anxiety disorders that often develops in early childhood. Informed by this promising work supporting extensions of PCIT for separation anxiety disorder, our group has developed a PCIT modification designed to target the range of common anxiety disorders affecting children below the age of 7, including social phobia, generalized anxiety disorder, separation anxiety disorder, and specific phobias. Specifically, we developed the CALM program (Coaching Approach behavior and Leading by Modeling), which combines the format and many core concepts of PCIT with an exposure-based treatment to target anxiety. Parents treated in the CALM program learn to positively attend to their child when he or she approaches feared situations and to actively ignore anxiety-related avoidance. During in-session exposures, parents are live-coached to model and reinforce their child's approach behavior in feared situations. Previous treatments targeting anxiety in young children have also focused on modifying parent behavior (e.g., Cartwright-Hatton et al., 2011, Choate et al., 2005, Hirshfeld-Becker et al., 2010 and Kennedy et al., 2009). Pincus’ adaptation of PCIT for separation anxiety disorder and Cartwright-Hatton's Timid to Tiger programs, in particular, are similar to the CALM program in its primary emphasis on positive attending, active ignoring, and use of effective commands to reinforce “brave” behavior. However, the CALM program is the first protocol for early-onset child anxiety to incorporate live parental coaching during in-session exposure tasks. An initial pilot evaluation of the CALM program recruited nine children, ages 4 to 8, with anxiety disorder diagnoses and their parents. All families received the CALM treatment in a multiple baseline design. Of the nine families enrolled in the study, seven completed treatment and approximately 80% of participants completed all treatment sessions. Of treatment completers, all but one child was free of all anxiety disorder diagnoses and demonstrated functional improvement at posttreatment. Additional details from this study are reported elsewhere (Comer et al., 2012). Below we present a detailed session-by-session description of the CALM program, along with scripts illustrating the treatment's implementation.