Cognitive and Behavioral Interventions

, Rebecca B. Skolnick7 and Kristin P. Wyatt7



(7)
Department of Psychology, Hofstra University, Hempstead, NY, USA

 



Description


Hierarchy development is an integral component of graded exposure therapy for anxiety disorders. A hierarchy, often referred to as a “fear ladder” (e.g., Kendall & Hedtke, 2006), is a list of anxiety-provoking situations, or stimuli that a child avoids, organized in order of increasing difficulty. Hierarchies can take numerous forms, such as a written list, drawing of a ladder (e.g., Kendall & Hedtke, 2006), picture of a pyramid, or a map of different sized “islands” based on the level of anxiety provoked by each situation (e.g., March & Mulle, 1998). The hierarchy is developed in the beginning sessions of therapy and is used as an assessment tool to aid in case conceptualization and treatment planning. Hierarchies are also guides for determining graduated exposure or desensitization exercises to conduct in therapy.


Theoretical and Research Underpinnings


The concept of a fear hierarchy can be found in literature as early as the famous Little Albert study, (Watson & Raynor, 1920) during which a child conditioned to a white rat also demonstrated various levels of conditioned anxiety to other animals and objects that shared characteristics of the rat. This led to the conceptualization of the anxiety hierarchy as a key component of Wolpe (1958) model of systematic desensitization , one of the first comprehensive scientifically derived, evidence-based models of behavior therapy. In the initiation of systematic desensitization, Wolpe (1990) advocated that hierarchy construction and relaxation training occur at the beginning of therapy. He then had patients relax and imagine increasingly anxiety-provoking situations from the hierarchy (in a step-wise fashion) until the stimuli became associated with a relaxed state and no longer evoked substantial anxiety. Regardless of what CBT protocols are used, a hierarchy-based exposure is often part of the procedure for the treatment of childhood anxiety (see Table 13.3).

Hierarchy development functions to combat anxiety from the start, as discussing anxiety-provoking situations (i.e., conditioned stimuli) can be a form of informal exposure in itself if the child becomes anxious in session. Creating a hierarchy may also begin to provide distance between the child and his/her anxiety, which will facilitate the ability to externalize the disorder during treatment (March & Mulle, 1998). Hierarchy construction can also be used to build rapport (e.g., by making it game-like) so that the child stays in treatment. Once the hierarchy is developed, the therapist is encouraged to work collaboratively with the child to negotiate and plan the order, sequence, and difficulty level of exposure exercises, thus increasing self-efficacy (Kendall et al., 2005).


Mechanics


Hierarchy construction involves a number of steps to ensure accurate assessment of the child’s fears in order to develop a thorough treatment plan (see Table 13.1). Depending on the child’s developmental level, caretakers can be an important source of information as well. Table 13.2 provides an example of a hierarchy for a child with school refusal behavior.


Table 13.1
Steps for developing a hierarchy





































Step

Brief description

1. Interview child

Explore presenting problem, related issues, hypothesized issues, parent(s) may be included dependent upon age/maturity

2. Select and administer appropriate assessment instruments to child and parent

Utilize general and specific self-report and observational measures of fears/anxiety

3. Provide rationale for hierarchy

Psychoeducation about anxiety/avoidance, discuss how hierarchy will be used to guide exposures or “therapy experiments”

4. Explain SUDs rating procedure

Can take many forms, such as fear ladder, and may range from 0 to 8, 0 to 10, or 0 to 100

5. Offer stimuli and obtain SUDs ratings

Present in random order; anchor high and low points near beginning of process; assess presented items and hypothesized cues. Can use post-it or index card methods.

6. Obtain parent ratings and elicit other potential stimuli

Depending on developmental level, parent(s) may be involved in hierarchy construction

7. Check parent contribution with child

If additional information is received from parent, obtain SUDs ratings from child

8. Organize list from highest to lowest intensity

Collaboratively select items to go on hierarchy, and write it out for child. This may take different forms, such as fear ladder, island drawings, or a pyramid. If there are multiple themes, may create more than one hierarchy.

9. Reassess hierarchy throughout treatment

This may be done weekly, bi-weekly, at therapist’s discretion



Table 13.2
Example of school refusal hierarchy








































Situations or places that scare me

SUDs rating (0–10)

Taking math test (hardest class) where I don’t understand material because I missed so much school and other kids are laughing at me

10

Taking math test where I don’t understand material but no one notices

9

Peer girls asking why I missed so much school

9

Peer boys asking why I missed so much school

8

Taking social studies test

7

Attending full day of school without tests

6

Attending school basketball game as spectator

5

Walking into school during the day alone

4

Walking into school during the day with therapist

3

Walking into school at night with parent (no one else is around)

2

Hierarchy development begins with an interview exploring the nature of the presenting problem, issues related to the problem, hypothesized cues, and other concerns stated by the child. It is important to ascertain what the child thinks will happen when faced with the feared situation. Depending upon the child’s developmental level, parent(s) may be involved in this stage. Standardized self-report and behavioral assessment instruments can aid in determining potential stimuli for the hierarchy. The therapist must select anxiety assessment measures that are relevant to the presenting problem. Instruments can include general anxiety measures, such as the Fear Survey Schedule for Children-II (FSSC-II; Gullone & King, 1992), and specific measures, such as the Spider Phobia Questionnaire for Children ( SPQ-C; Kindt, Brosschot, & Muris, 1996) or the children’s Yale-Brown Obsessive-Compulsive Scale (CY-BOCS; Scahill et al., 1997). Behavioral avoidance tests can also be used to assess anxiety symptoms and determine stimuli for the hierarchy.

Following assessment, the rationale for hierarchy development should be provided. This includes psychoeducation about anxiety and avoidance and a discussion of how the hierarchy will be used to guide exposures or “therapy experiments.” Specifically, examples of the thoughts, feelings, and behaviors associated with anxiety can be elicited. This may involve drawings of the child’s body, circling areas of the body where the child feels anxiety, and/or completing drawings of people with thought bubbles (e.g., Kendall & Hedtke, 2006; Chorpita, 2007). Anxiety can be explained as an alarm (Chorpita, 2007) that is tested by putting oneself in the avoided situation and seeing if the “fear comes true.” Metaphors can also be used to enhance the child’s comprehension of anxiety and avoidance. For example, an analogy of developing a hierarchy to climbing a ladder or mountain can be used to clarify the process (e.g., Kendall & Hedtke, 2006). Further, hierarchy development can be explained as a tool to help the therapist get to know the child better and aid the child in understanding his/her anxiety so that it can be conquered, thus building rapport. Parents, teachers, etc. need to be aware of this process as well.

Once the rationale is understood, a subjective units of distress (SUDs; Wolpe, 1969) rating procedure for anxiety-provoking situations is introduced. This involves a Likert-type scale ranging from 0 to 100 (0 = no distress and 100 = highest level of distress), 0 to 10 (e.g., Wolpe, 1990), or 0 to 8 (e.g., Kendall & Hedtke, 2006; Kearny & Albano, 2007). For younger children, a visual analogue scale, such as coloring in a picture of a fear ladder , may be more useful.

The rating procedure is then applied to a range of potential feared stimuli offered by the therapist. Present the stimuli in random order (not as they might fall on the hierarchy) and anchor high and low points at the beginning of the process. Different hierarchies can be created for distinct “themes” or fears, and it is recommended to work on one at a time. Stimuli can be situations, cues, sensations, obsessions, or thoughts. The therapist should try to obtain specific items at different levels and elaborate on stimuli using descriptors or adjectives (e.g., tiny vs. big spider). The stimuli offered should be based both on what the child states and on hypothesized cues (i.e., related stimuli or thoughts not explicitly stated).

A number of researchers suggest that stimuli can be written on index cards or Post-its (Chorpita, 2007; Kearney & Albano, 2007; Kendall & Hedtke, 2006) to make an interactive, game-like task. Once there are at least ten items, record SUDs rating for each stimulus and make sure that almost every level of anxiety is represented. These will be ordered later with the child. The goal is to have a range of items with different intensity levels. Praise the child for hard work and doing well on an important task. For older children, the therapist may just solicit the items, obtain ratings, and organize them on a piece of paper.

Depending on the child’s developmental level, it is often useful to meet with the parent(s) alone to obtain information about the child’s feared stimuli (Chorpita, 2007; Kearney & Albano, 2007). During this meeting, ensure that the parents understand the SUDs rating procedure, and get their ratings of the stimuli offered by the child (without telling them the child’s ratings). Then ask if there are any other feared stimuli that have been omitted, and obtain ratings for these as well. If the parent(s) has provided additional information, meet with the child and parent(s) together, and obtain the child’s SUDs ratings for the new items.

Using all of the information obtained, collaboratively select the hierarchy items that will be used to guide subsequent exposure exercises. The items should then be organized from highest to lowest intensity. Chorpita (2007) suggests making a copy of the hierarchy for both the child and the parent(s). At the end of the session, praise the child again and thank the parents. If time permits, end the session on a positive note, such as a game.

As treatment progresses, the ratings of items on the hierarchy will diminish; thus it is important for the therapist to keep checking in with the child and parent(s) regarding ratings for items. This can be done by distributing an unrated copy of the hierarchy to the parent(s) and child as frequently as the therapist deems appropriate and asking for current SUDs. This way, the hierarchy can also be used to assess treatment progress.


Research Support


Hierarchies are key components in many controlled studies of successful anxiety treatment for children (see Table 13.3). For example, hierarchies have been used as part of individual cognitive-behavioral therapy (CBT), group CBT, family CBT, multiple session treatments, and one-session treatments for children with a range of specific phobias, obsessive compulsive disorder, separation anxiety disorder, and/or generalized anxiety disorder. These treatments have demonstrated significantly greater improvements in anxiety disorder symptoms when compared to control groups.


Table 13.3
Examples of controlled research studies that used a hierarchy as part of successful anxiety treatment for children



































































Researchers

Sample

Primary outcome measures

Treatment conditions

Results

Follow-up data

Barrett (1998)

60 children (ages 7–14) with separation anxiety, overanxious disorder, or social phobia

1. ADIS-C and ADIS-P (Silverman and Nells, 1988)

2. Diagnostic interview

3. Fear Survey Schedule for Children-Revised (FSSC-R; Ollendick, 1983);

4. Child Behavior Checklist (CBCL; Achenbach and Edelbrock, 1991)

1. Group cognitive-behavioral therapy (CBT)

2. Group CBT with family management

3. Waitlist

64.8 % of children no longer met diagnostic criteria for an anxiety disorder (compared to 25.2 % on waitlist)

At 12-month follow-up, 64.5 % in Group-CBT and 84.8 % in Group CBT with family management did not meet diagnostic criteria for an anxiety disorder

The Pediatric OCD Treatment Study Team (POTS; 2004)

112 patients (ages 7–17) with primary OCD diagnoses

1. CY-BOCS (Scahill et al., 1997)

1. CBT alone

2. Sertraline alone

3. CBT and sertraline

4. Pill placebo

Remission rates of 53.6 % for combined treatment, 39.3 % for CBT alone, 21.4 % for sertraline alone, and 3.6 % of placebo. Remission rate for combined treatment was not significantly different from that of CBT alone, but was significantly greater than sertraline alone and placebo.
 

Walkup et al. (2008)

488 children (ages 7–17) with primary diagnoses of separation anxiety disorder, generalized anxiety disorder (GAD), or social phobia

1. Clinician Global Impression-Improvement Scale (National Institute of Mental Health, 1970)

2. Pediatric Anxiety Rating Scale (Research Unit on Pediatric Psychopharmacology Anxiety Study Group, 2002)

1. CBT alone

2. Sertraline alone

3. CBT and sertraline

4. Pill placebo

At 12 weeks, 80.7 % in the combination group, 59.7 % in the CBT group, 54.9 % in the sertraline group, and 23.7 % in placebo group were rated as much or very much improved. Results on the Pediatric Anxiety Rating Scale yielded similar outcomes.
 

Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg (2008)

161 children (ages 7–14) with primary diagnoses of separation anxiety disorder, social phobia, or GAD

1. ADIS-C/P (Silverman and Albano, 1996)

1. Individual CBT

2. Family CBT

3. Family-based control group

Diagnoses were no longer present for 57 % of those in individual CBT, 55 % in family CBT, and 37 % in control group

At 1-year follow-up, 61 %, 58 %, and 44 % of principal diagnoses for individual CBT, family CBT, and control group, respectively, continued to be absent, with no significant differences across conditions

Hudson et al. (2009)

112 children (ages 7–16) with principal anxiety disorder

1. ADIS-IV-C/P

2. Structured interviews

1. Group CBT

2. Group control

At post-treatment, a significantly higher proportion of those in CBT group compared to the control group no longer met anxiety disorder diagnostic criteria

At 6-month follow-up, 68.6 % in CBT and 45.5 % in control group no longer met diagnostic criteria for their principal anxiety disorder

Ollendick et al. (2009)

196 children (ages 7–16) with various specific phobias

1. ADIS-C/P including clinician severity rating (CSR)

2. Behavioral Approach Tests (BATs)

3. Treatment satisfaction survey

1. One-session exposure treatment (OST)

2. Education support treatment (EST)

3. Waitlist control (WLC)

At post-treatment, those in OST and EST had significantly lower CSRs and percentages of phobic-free participants than did those in WLC. The OST was superior to EST on CSR, percentage of phobic-free participants, child ratings of anxiety before BAT, and treatment satisfaction.

At 6-month follow-up, OST continued to demonstrate better CSRs and percentage of phobic-free participants than did the EST condition. However, there were no significant differences on other variables.

Kerns, Read, Klugman, & Kendall (2013)

91 children (ages 8–14) with primary diagnoses of social phobia, GAD, or separation anxiety disorder (SAD)

1. ADIS-C/P (Silverman and Albano, 1996) including CSR

1. CBT (Coping Cat; Kendall and Hedtke, 2006)

2. Waitlist control

Those in CBT condition demonstrated significant improvement in anxiety symptoms from pretreatment to post-treatment. Those with social anxiety had significantly higher anxiety levels at pretreatment and post-treatment.

At 1-year follow-up, those in CBT condition continued to improve. At 7.4-year follow-up, those with social anxiety symptoms were significantly less improved than were others.



Exposure Therapy: Application to Childhood Anxiety



Mitchell L. Schare, Kristin P. Wyatt8 and Rebecca B. Skolnick8


(8)
Department of Psychology, Hofstra University, Hempstead, NY, USA

 


Description


Exposure therapy is a most efficacious procedure to treat anxiety disorders in children ranging from specific phobias to complex issues involving school refusal, obsessive compulsive disorder, and posttraumatic stress reactions. It entails systematic exposure to a feared stimulus or a representation of that stimulus, repeatedly over a prolonged time period to elicit anxiety, with the ultimate goal of decreasing the anxiety and related avoidance behaviors. Stimuli may be presented in a graduated or non-graduated manner (e.g., flooding ), using imagery or in vivo experiences to facilitate exposure to the stimulus without allowing avoidance or escape behaviors (i.e., response prevention ) which maintain problematic behavior.

Exposure therapy for children and adolescents is described as the key element of cognitive-behavioral treatment (CBT) for childhood anxiety (Foa, Chrestman, & Gilboa-Schechtman, 2008; Kazdin & Weisz, 1998) yet is often applied in the context of a multicomponent CBT package, such as the widely utilized Coping Cat (Kendall, 2000). Components may include awareness of physiological signs of anxiety, cognitive restructuring, and relaxation (Chorpita, 1998; Kendall et al., 2005; Kingery et al., 2006). Exposure is also used with mindfulness-based approaches for teens and children (Greco & Hayes, 2008), including dialectical behavior therapy (Miller, Rathus, & Linehan, 2007; Perepletchikova et al., 2011).


Theoretical and Research Underpinnings


The earliest uses of exposure-like procedures with children are initially found in the pioneering work of Mary Cover Jones (1924). Animal models of anxiety induction (Estes & Skinner, 1941) and subsequent extinction (Page & Hall, 1953; Solomon, Kamin, & Wynne, 1953) demonstrated procedures which were later applied to humans experiencing serious phobias (e.g., Malleson, 1959). Mowrer (1947, 1960) contributed a two-factor theoretical model explaining the acquisition (fear is established via classical conditioning) and maintenance of anxiety (instrumentally through negative reinforcement of escape and avoidance responses), which was subsequently extrapolated into procedures for its treatment. Modern exposure therapy grew out of implosive therapy (Stampfl, 1961), flooding (Rachman, 1966), and response prevention (Baum, 1970).


Mechanics


Effective implementation of exposure involves several phases: assessment, preparation for exposure, exposure, and postexposure processing. Each phase may require tailoring to a child’s individual developmental level, and a greater emphasis should be placed on making sessions appealing or fun (while not avoiding) to enhance treatment engagement for younger children (Bouchard, Mendlowitz, Coles, & Franklin, 2004).


Assessment


Thorough conceptualization of childhood anxiety consists of a functional assessment of the anxious behaviors, which may be conducted through clinical interviews of the child and parent, in a structured or unstructured format. The use of additional assessment tools such as multi-rater rating scales (e.g., Multidimensional Anxiety Scale for Children ; March, Parker, Sullivan, Stallings, & Conners, 1997) and diagnosis-specific inventories (e.g., Social Phobia and Anxiety Inventory for Children; Beidel, Turner, & Morris, 1995; Revised Children’s Manifest Anxiety Scale, 2nd ed ; Reynolds & Richmond, 2008) is encouraged.

Brief problem history as well as a thorough functional analysis of the anxiety and associated avoidance and/or escape behaviors needs to occur. Identification of the initial triggering events for the fear (e.g., for dog phobia: child chased by German Shepherd) is helpful but not imperative. A detailed evaluation of fear-inducing stimuli (and variations) is particularly helpful for exposure. Introduction of subjective ratings of distress (SUDs; Wolpe, 1969) during assessment is beneficial for case conceptualization and use during exposure, although a visual or truncated scale, such as 8- or 10-point scale is suggested. The same scale may be used as a treatment process measure, which will be discussed later. An anxiety hierarchy may be constructed to guide exposures but is not necessary.

The pattern of overt escape and avoidance behaviors warrants particular focus as these behaviors will be targeted during exposure. When parents’ or other significant persons’ (e.g., teacher, peer) behavior inadvertently maintains anxiety, training is required to inhibit presentation of escape and avoidance opportunities to the child.


Preparing for Exposure


Preparation for exposure includes psychoeducation , rationale for exposure, and motivational components. Explanations of anxiety, avoidance, and exposure will vary based on the child’s cognitive (reasoning skills) and emotional development (e.g., emotion understanding, regulation). Younger children will benefit from the use of simpler phrasing (e.g., “Not facing things which scare us makes them seem even worse. We have to face the things that scare us”). Adolescents may feel more respected with more complex explanations using scientific terminology (e.g., extinction, habituation), which may help foster rapport and treatment compliance (Kendall et al., 2005). Comparing exposure to other experiences that are initially scary, difficult or improve with practice and time is often helpful as well (e.g., watching a scary scene in a movie; getting into a cold swimming pool). Younger children may benefit from identifying imaginary characters or superheroes to help them cope with the anxiety during an exposure (Bouchard et al., 2004).

Motivation is important to elicit from children to help them tolerate exposures. A good starting point is, “What is your anxiety keeping you from doing that you want to do?” For example, if a child is afraid to get on an airplane but it is stopping them from going to Disney World, the ultimate goal of getting to Disney is worth enduring flight exposures. Tangible motivation through positive reinforcement for engaging in exposures (i.e., rewards for effort) both in and out of session is encouraged by some protocols (Bouchard et al., 2004; Chorpita, 1998; Kendall, 2000) and may be especially helpful when working with younger children. Rewards should be meaningful and presented immediately after the exposure. Lastly, exposure tasks work best when they are collaboratively chosen and planned (Bouchard et al., 2004), using stimuli that evoke an optimal level of anxiety. For cases in which imaginal exposure is utilized, assessment of imagery skills and subsequent imagery training may be conducted as needed.


Exposure


Based on the nature of the stimulus (e.g., accessibility, practicality) and patient factors (e.g., ability to immersively imagine, willingness to confront fear in vivo), a modality of exposure must be chosen to represent the targeted feared stimuli. Ultimately, all forms of exposure immerse the client in the feared situation using multiple sensations, real or generated environmental contexts, and assess for anxiety (SUDs), feelings, thoughts, and physiological responses throughout.

In virtual reality and in vivo environments, the presentation of the stimulus in context requires little effort from the therapist. In these exposures, the therapist must guide the child’s attention, using verbal cues, to relevant aspects of the environment (e.g., “look at the yellow flowers and listen to the buzzing sounds of the bee”). During imaginal exposure , the therapist is completely responsible for generating relevant cues through words and thus must present a cohesive scene that incorporates the feared cues in a way that is relatable to the child or adolescent. As such, the therapist must build all sensory aspects of the scene to make it feel real (i.e., simulate in vivo) by drawing the child’s attention beyond visual cues to include auditory, olfactory, tactile and even gustatory cues to aid immersion. It is important that verbal construction of imagery is paced slowly to allow the patient to process the information. Younger children may have more difficulty with imaginal exposure (Davis, Whiting, & May, 2012); thus tangible elements may be helpful, such as using props to act out aspects of the fear (Kendall et al., 2005) or writing a story of the feared event with the child. Kendall (2000) suggests that imaginal exposure may be utilized to prepare for subsequent in vivo exposures.



Table 13.4
Steps for conducting exposure






















Step

Brief description

Assessment

– Interview the child and parent(s)

– Administer structured assessment tools

– Conduct thorough functional assessment of anxiety and related behaviors for hierarchical conceptualization and, if desired, hierarchy construction

Prepare for exposure

– Psychoeducation

– Exposure rationale

– Motivation: discuss reasons to conquer fear, possible behavior plan

Exposure

– Choose modality (e.g., imaginal or in vivo)

– Add elements to personalize scene/environment

– Assess for and reflect feelings, physiological response, thoughts, and SUDs back to the patient

Postexposure processing

– Summarize experience and emphasize changes in anxiety and fulfillment of feared consequences

– Normalize possible memory recall and sensitization

– Homework exercises

Once in contact with the stimulus in vivo, in imagery or in virtual reality, the therapist’s role is to continue the client’s engagement with the scene and to personalize it with aspects of their patient’s experience. As such, level of anxiety (using SUDs), thoughts, feelings, bodily responses, and behaviors should be intermittently assessed and reflected to the child (e.g., “That’s right. Your heart is beating very quickly, and you’re afraid the spider will bite you.”). Check-in questions should be paced at a frequency at which they do not detract from immersion and should be phrased in a developmentally appropriate manner. For example, an adolescent may be able to answer questions about physiological signs of anxiety and consequential thinking, while a young child may require questioning about how parts of his or her body feels and what kind of worry thoughts he or she is having. During exposure, it is crucial that escape (i.e., safety) behaviors be attended to through response prevention. A child in vivo is not allowed to look away or turn from feared stimuli. Likewise during imaginal exposure, opening one’s eyes is a typical way to avoid concentrating on fearful imagery and is therefore not allowed.

While the length of exposure sessions varies, longer sessions allow for greater in-session habituation and are preferred (Bouchard et al., 2004), with some treatment manuals claiming a 50 % decrease in SUDs reports (Davis, Ollendick, & Öst, 2009; Kendall, 2000). In a single-session protocol, Davis et al. (2009) recommend a 3-h massed session. On the other end of the spectrum, some multiple-session exposure protocols recommend a maximum of 30 min (Chorpita, 1998) or as few as 10 min or less procedures (Hedtke, Kendall, & Tiwari, 2009; Tiwari, Kendall, Hoff, Harrison, & Fizur, 2013) (Table 13.4).


Postexposure Processing


Following exposure , the child should receive verbal praise from the therapist and a reinforcer if a behavior plan is in place. The child’s attention is directed to relevant aspects of the experience regarding their emotional reactions. It may be helpful to visually display within and across-session changes in SUDs on a graph to increase progress tangibility and be reinforcing to both child and parents. In addition, it is important to revisit what the child thought would happen and if it did or did not occur.

It is important to discuss and normalize what may happen between sessions. They may find themselves thinking about their fear more or remembering related past experiences. In exposure therapy, this is reframed as a continuation of the work from the session which should be attended to in addition to any other exposure exercises agreed upon. Over the course of treatment, the last three steps, preexposure preparation, exposure, and postexposure, are repeated until sufficient extinction in the anxiety response has occurred (e.g., as indicated by SUDs ratings or approach behaviors) (Table 13.4).


Research Support


Numerous studies show support for exposure-based treatments with children (cf. Davis, May & Whiting, 2011; Reynolds, Wilson, Austin, & Hooper, 2012 for reviews), though few studies examine exposure therapy alone (e.g., Bolton & Perrin, 2008; Sreenivasan, Manocha, & Jain 1979).

Recent exposure-related research includes dismantling studies of multicomponent treatments. Kendall’s Coping Cat protocol (2000) serves as the gold standard for the treatment of children’s anxiety disorders. In this 16–20 session protocol, exposure is introduced around session 7. Research finds that when exposure is introduced earlier, shorter treatment length and greater effect size are found compared to the Coping Cat model (Gryczkowski et al., 2013; Vande Voort, Svecova, Brown Jacobsen, & Whiteside, 2010). Others, using a modular therapeutic approach, which allowed exposure to be introduced earlier, also found efficacy for doing so (Chorpita, 1998; Chorpita, Taylor, Francis, Moffitt, & Austin, 2004).

Davis, Whiting, and May (2012) suggest that in vivo may be better than imaginal exposure for children, because of developmental maturity. Alternatively, virtual reality exposure shows promise for treatment of childhood phobias (Bouchard, 2011; St-Jacques, Bouchard, & Bélanger, 2010). Tiwari et al. (2013) examined the impact of preexposure preparation and postexposure tasks on treatment response, as both are advocated for, but without empirical basis. Postexposure processing, rewards, and homework assignment were associated with improved outcomes while preparation for exposure was not.


Assertion Training for Youth



Mark Terjesen


(9)
Department of Psychology, St. John’s University, Jamaica, NY, USA

 

Childhood and adolescence involves a complex interplay between the development of social relationships, the pressure toward conformity (Coleman, 1980), and the achievement of one’s unique social identity (Wise, Bundy, Bundy, & Wise, 1991). Children are constantly faced with challenging interpersonal situations such as refusing the requests of others, giving and receiving compliments, making friends, coping with criticism, and managing stress. Children who are socially skilled in solving these problems are likely to be “well adjusted in many areas of their life, particularly at school” (Rotheram-Borus, 1988, p. 83). Conversely, children who have interpersonal difficulties or exhibit few assertive behaviors are more likely to be bullied, develop aggressive tendencies, and demonstrate lower academic achievement (Malecki & Elliott, 2002; Sarkova et al., 2013). This chapter will review the definition of assertiveness, describe pre-intervention considerations and social skills assessments, and suggest programs that can be carried out with treatment integrity in the school setting.


Conceptual Model of Assertiveness Skill Development


Assertive behavior is the appropriate, respectful expression of feelings (Alberti & Emmons, 1995; Masters & Rimm, 1987). Assertive behavior typically involves making requests of others as well as refusing requests that are deemed unreasonable (Duckworth, 2009). Assertive behavior allows for the expression of strong feelings and opinions, and it can be further conceptualized as a “middle ground” between passivity and aggression, emphasizing self-expression in socially acceptable ways.

Within a cognitive-behavioral framework, passivity and aggression can be described behaviorally as “learned behaviors” subject to reinforcement principles and result from specific cognitive evaluations. Similarly, assertive behaviors are often maintained by reinforcers, are subject to the motivational and affective states of the student, and may develop as a result from these cognitive-evaluative factors. Both nonassertive and assertive behaviors are learned through rewards or punishment, and how the students think about these behaviors influences their motivation to engage in them.

Consideration of history may be important as behaviors that have been regularly reinforced from an early age may be more resistant to change. Moreover, these behaviors are most likely also maintained in the child’s current setting. It is beneficial for the clinician to identify reinforcers for nonassertive behaviors prior to implementing an assertion skills training program and be aware that these reinforcers may be covert or overt. As many events occur within a social setting, discerning through observation which ones may be reinforcing the behavior may be challenged. Consultation with parents and teachers may help to reduce the influence of the reinforcers that maintain undesirable behaviors.

A lack of assertive behavior has been linked to the motivational and affective states of the student (Alberti & Emmons, 1995; Duckworth, 2009). The motivational state of the student that may lead him/her to engage in passive or aggressive behaviors (and not assertive behaviors) may be driven by reinforcement expectancies, which can in turn interfere with the student’s motivation to learn these new assertive behaviors. For some children, a successful outcome following assertive behavior is likely a receipt of the preferred outcome, with the child getting what he or she wants. To promote the development of assertive behavior, it may be important for the clinician to reframe success to reflect the notion that assertive behavior reflects more personal control and respect (Duckworth, 2009). Schab (2009) refers to this as the “Golden Rule” in that we seek to educate students that they should treat others like they want to be treated themselves. Appropriately asserting oneself is both respect for the individual they are communicating with as well as respect for themselves for demonstrating control in their interaction and not behaving passively or aggressively. In contrast, students may have the false belief that after the training, the act of engaging in the appropriate assertive behavior will consistently lead to the desired outcome. For example, if a child is upset because they are not asked to participate in a game, we may work with them on a good example of something assertive that they may say (e.g., “I do not like when you don’t ask me to play with you. I feel unhappy when this happens. I would like to play with you.”) but also would want to work with the student on understanding that because they make the request it does not mean that they will get the desired outcome (i.e., getting asked to play with them). Promoting persistence in assertion is a way to increase the likelihood of the receipt of their desired goal can be explained to students through the use of both personal examples and anecdotes. A clinician may point out that the first time the student tried to do a specific mathematical multiplication computation, it may not have been met with success. The only way the student eventually acquired the ability to do multiplication was through practice and persistence. The same would hold true for assertive behavior.

The affective states influencing assertive behaviors involve emotional and physiological experiences that the student may have in relation to the idea of behaving in an assertive manner. If these experiences are heightened, there may be negative impact on behavior, making them less likely to interact assertively with others, because the decrease in unpleasant emotions following non-assertion is reinforcing.


Pre-Intervention Considerations


Assertiveness training has garnered some empirical support in working with anxious/avoidant youth and for delinquency and disruptive behaviors (American Academy of Pediatrics, 2014). However, in reviewing the research, assertiveness training is very often a part of a multicomponent intervention, such as social skills training. Yet, the skills developed during assertiveness training assume the existence of adequate social skills (Duckworth, 2009). Gresham and Elliott (1990) define social skills as “socially acceptable learned behaviors that enable a person to interact effectively with others and to avoid socially unacceptable responses” (p. 1). Malecki and Elliot (2002) highlight that assertion is one of these key skills. Effective assertive behaviors involve nonverbal and verbal components. Among the nonverbal behaviors the clinician may wish to consider are eye contact, posture, facial expressions, and body movements (Rotheram-Borus, 1988). Poor and inconsistent eye contact and a more rigid posture might convey disinterest or anxiety. Facial expressions may also convey a message that is not consistent with the desired assertive behavior. Affective displays may reflect anxiety or anger. Some body movements may be interpreted as tentativeness in making the assertive request. Last, inappropriate regard or awareness of other’s “personal space” may also impact how the assertive behavior is received (Duckworth, 2009). Therefore, clinicians may wish to give feedback about the child’s nonverbal behavior and use of personal space and to build these skills via practice.

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Jun 29, 2017 | Posted by in PSYCHOLOGY | Comments Off on Cognitive and Behavioral Interventions

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