رفتار درمانی شناختی و خانواده مبتنی بر دلبستگی برای نوجوانان دچار اضطراب: فاز اول و دوم مطالعات

The goals of these two studies were to assess the acceptability and feasibility as well as to gather preliminary efficacy data on a modified combination cognitive behavioral (CBT) and attachment based family therapy (ABFT) for adolescents (ages 12–18), with the primary diagnosis of generalized (GAD), social phobia (SP), and separation (SAD) anxiety disorders. In Phase I, CBT was modified for an adolescent population and ABFT was modified for working with anxious adolescents in combination with CBT. Therapists were trained for both conditions and eight patients were treated as an open trial pilot of combined CBT-ABFT with positive results. In Phase II, 11 adolescents were randomly assigned to CBT alone or CBT and family based treatment (CBT-ABFT). Participants were evaluated at pre, post, and 6–9 months follow-up assessing diagnosis, psychiatric symptoms and family functioning. Results indicated significant decreases in anxiety and depressive symptoms by both clinical evaluator and self-reports with no significant differences by treatment. Sixty-seven percent of adolescents in CBT no longer met criteria for their primary diagnosis at post treatment as compared to 40% in CBT-ABFT with continued improvement of 100 and 80% at follow-up with no significant differences between treatments. Both CBT and CBT-ABFT appear to be promising treatments for anxious adolescents and more treatment development and evaluation is needed.

Anxiety disorders are among the most common diagnoses reported in childhood and adolescent epidemiological studies (Costello, 1989; Lewinsohn, Hops, Roberts, Seeley, & Andrews, 1993; McGee, Feehan, Williams, & Partridge, 1990). Many children with anxiety disorders struggle with low self-esteem, social isolation and inadequate social skills, impairment in academic work, and physical problems (e.g., headaches and stomachaches) (Dweck & Wortman, 1982; Livingston, Taylor, & Crawford, 1988; Strauss, 1988). In addition, there is growing evidence that anxiety disorders and symptoms persist over time (Beidel, Fink, & Turner, 1996; Cantwell & Baker, 1989; Keller et al., 1992; Last, Perrin, Hersen, & Kazdin, 1996). Fortunately, a number of well-controlled clinical trials have demonstrated that 10–16 weeks CBT treatments combined with in vivo exposure significantly reduce anxiety in 50–80% of treated children with generalized anxiety disorder, separation anxiety or social phobia (Barrett, Dadds, Rapee, & Ryan 1996a; Cobham, Dadds, & Spence, 1998; Kendall, 1994 and Kendall et al., 1997; Last, Hansen, & Franco, 1998; Silverman et al., 1999a and Silverman et al., 1999b). However, since 20–50% of children in CBT treatment remain symptomatic after treatment, it is clear that psychosocial treatments could be improved. The last few years have also shown promising developments in pharmacological treatments for anxious adolescents (e.g., Pediatric Psychopharmacology Anxiety Study Group, 2001; Rynn, Siqueland, & Rickels, 2001; Birmaher et al., 2003), but more studies are needed before this approach can be considered first line treatment. There is limited to no information about the long term outcome and effect of psychopharmacological treatment. Research on family factors has suggested that particular family characteristics and interactional patterns may have a role in the development and/or maintenance of childhood anxiety. Children with anxiety disorders describe their family environments as more controlling, less cohesive and supportive, and more conflictual than children of control families (Stark, Humphrey, Crook, & Lewis, 1990; Stark, Humphrey, Laurent, Livingston, & Christopher, 1993). Parental overcontrol, defined as intrusive parenting or limiting of autonomy (e.g. McClure, Brennan, Hammen, & Le Brocque, 2001) and overprotection (e.g., Merikangas, Avenevoli, Dierker, & Grillon, 1999) were found to be positively related to child anxiety. These self-report findings have been corroborated in the few studies available that employed direct observation of family interaction (Dumas, LaFreniere, & Serketich, 1995; Krohne & Hock, 1991; Siqueland, Kendall, & Steinberg, 1996). Finally, observational studies have found that in many families of anxious children, there is modeling of anxious interpretation of ambiguous situations and encouragement or tolerance of avoidance behavior (Barrett, Rapee, Dadds, & Ryan, 1996b; Chorpita, Albano, & Barlow, 1996; Dadds, Barrett, Rapee, & Ryan, 1996). These findings suggest specific areas of family interactions to target or to utilize parent based approaches (for review, see Ginsburg & Schlossberg, 2002). A number of studies have shown that family based interventions seem to improve outcome on both anxiety and other externalizing symptoms, as well as overall functioning (Barrett, 1998 and Barrett et al., 1996a). Barrett et al. (1996a) compared individual CBT treatment with CBT plus a behavioral family intervention for children ages 7–14. The combined family treatment included teaching parents: to reward coping behavior and to extinguish excessive anxious behavior, to manage their own anxiety with CBT techniques, and to develop new family communication and problem-solving skills. Both individual and group formats with the combination of CBT with family intervention showed advantages on anxiety diagnosis, family related measures, avoidant behavior, and generalization of parenting skills to other behavioral domains at post-treatment and follow-up (Barrett, 1998 and Barrett et al., 1996a). However, in a separate study, Cobham et al. (1998) found that children (ages 7–14), whose parents did not have anxiety did equally well in the CBT treatment and the combined family treatment, while children whose parents did have anxiety did poorly in the child CBT treatment but did well in the combined treatment. The individual CBT and combined CBT and family based approaches reviewed above have focused thus far on middle childhood (7–14 years). We have little evidence of the efficacy of CBT treatment for anxious adolescents specifically in the age range of 14–17. Two small studies assessing group CBT approaches for socially anxious adolescents in the school setting have reported significant decreases in symptoms and diagnosis relative to wait list control (Hayward et al., 2000, Masia et al., 2001). None of the family treatment studies has included children over 14 years of age, and family based treatment was most effective with younger children and females (Barrett et al., 1996a). The family based model (ABFT) used in this study has a different emphasis than the Barrett et al. (1996a) model, which focuses on modeling and rewarding of anxious behavior and targeting parental anxiety. ABFT attempts to address additional aspects of family interaction that have been associated with childhood anxiety disorders reviewed above: parental beliefs about anxiety, overprotection, and psychological control. This family therapy model shares a similar theoretical foundation and structure to ABFT for depression (Diamond, Reis, Siqueland, Diamond, & Issac, 2002; Diamond, Siqueland, & Diamond, 2003) in terms of types of sessions and specific therapeutic goals and tasks to address the needs of adolescents. While the primary interpersonal goals of ABFT for depressed adolescents focus on repairing the attachment bond (i.e., rebuilding trust and security), ABFT for anxiety focuses on making overly rigid attachment bonds more flexible. In general, therapists help parents promote adolescent autonomy by being less overprotective and controlling. The purpose of this treatment development study was to modify and tailor CBT and family therapy to the specific needs of anxious adolescents. Specifically, for CBT we sought to examine how therapeutic approaches and techniques might need to be modified from the original Kendall (1994) manual designed for children ages 8–13. For ABFT, originally developed for depressed adolescents, we sought to better target core family processes associated with anxiety, and to combine it with CBT hoping to maximize treatment efficacy. Phase I focused on manual development, therapist training, and an open trial pilot to explore treatment feasibility and acceptability for the combined condition. Phase II used a randomized design to assess the feasibility of implementing both individual CBT and a combined CBT plus ABFT. Preliminary efficacy data was collected as well.