Engaging parents in cognitive behavioral treatment for children with anxiety disorders

COGNITIVE AND BEHAVIORAL PRACTICE 5 , 81-102, 1998

Engaging Parents in Cognitive Behavioral Treatment for Children With Anxiety Disorders

Lynne Siqueland Guy S. Diamond University of Pennsylvania Medical School Children's Hospital of Philadelphia

The involvement of parents in individual child-focused treatment is a complex issue that needs to be treated as a therapeutic target in its own right. A number of manuals and protocols articulate interventions with parents, but do not describe how to implement them or what to do when parents do not comply. This paper provides a rationale for the inclusion of parents into the treatment of childhood anxiety disorders and describes approaches to engage parents. Discussion is organized around the assessment and intervention in three domains of functioning that might impede progress in individual child cognitive behavioral treatment: parents' beliefs about parenting and their role as parents, family dynamics or interactional styles, and parental psychopathology. This article identifies some of the difficulties inherent in involving parents and offers some treatment goals and procedures, illustrated through clinical vignettes, for involving parents.

In general, there are two problems with many cognitive behavioral (CBT) child-focused treatments regarding parental involvement. First, parents are often

not included, or, at a m i n i m u m , therapists involve parents only in the assess- men t and treatment p lann ing phase. A n u m b e r of approaches suggest that therapists also educate parents about the t rea tment model being used with their child. Second, when a manua l does describe t reatment goals or interventions for parents (e.g., not rewarding anxious or avoidant behavior), it rarely tells therapists how to implement these interventions, or what to do when parents

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82 SIQUELAND & DIAMOND

do not comply. Instead, it appears that therapists just tell parents to encourage competent behavior and not to reward anxious behavior. However, implemen- tation of these interventions is not so easy. Parental involvement in treatment is a complex issue that needs to be treated as a therapeutic target in its own right. Therapists need to know how to engage parents and work with them as they interact with their children to manage anxiety and other emotional challenges. This paper provides a rationale for the inclusion of parents into the treatment of childhood anxiety disorders, identifies some of the difficulties inherent in involving parents, and offers some treatment goals and procedures, illustrated through clinical vignettes, for involving parents.

Rationale for Parental Involvement

Incorporating parents into their child's treatment is important for a number of reasons. First, parents can help their child practice the skills taught them in CBT treatment and generalize learning to other contexts. While the therapist can create some in vivo experiences in or near the office, many anxiety- provoking situations happen only in the home (e.g., leaving for school or going to bed without an adult) or with peers (e.g., sports, parties). Maintenance of gains made in CBT will depend on the child's continuing ability to use these coping skills on new challenges and opportunities. Second, parents' beliefs and attitudes about their child's abilities, their own abilities to cope, and the safety of the world may impede progress. Third, changes in their child may threaten parents by destabilizing familiar, although uncomfortable, family dynamics. Parents rarely articulate this, but often the child's new-found independence may provoke fear or uncertainty in parents.

Research on Parental Involvement in Individual-Focused CBT for Children

Little research exists on the role of parents or family interaction in childhood anxiety disorders. Only one study has tested the effectiveness of adding a behavioral family intervention to an individual CBT treatment (Barrett, Dadds, & Rapee, 1996). Barrett et al's family intervention involved parent training in rewarding courageous and coping behavior and extinguishing excessive anxious behavior. In addition, parents learned coping skills for their own anxiety as well as parent-child communication and problem-solving skills. At the end of treatment, 84% of children in the combined treatment no longer met DSM- III-R diagnosis, compared to 57 % of the children treated with CBT alone (based on Kendall, Kane, Howard, & Siqueland, 1990). The combined treatment con- tinued to show superior outcome at 6-month (84% vs. 71%) and 12-month follow- up (96% vs. 70%). The combined treatment was especially effective with fe- male and younger children. Using a behavioral observation task after the family treatment, Barrett and colleagues were also able to directly assess and docu-

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ment specific changes in the way parents interacted with their children as the children interpreted and responded to threats. After treatment, parents were less likely to interpret situations as threatening to their children and to suggest avoidant solutions.

A few treatment protocols for obsessive-compulsive disorder (OCD; March, Mulle, & Herbel, 1994) and social phobia (Albano, 1995) have included parental involvement. Data are not yet available on the influence of parental involvement with these protocols, but a National Institute of Mental Health-funded clinical trial by Albano & Barlow currently underway compares group cognitive behavioral treatment for social phobia with and without parental involvement. In addition, a multiple baseline study of 6 children who participated in a family-based modification of individual CBT treatment for anxiety disorders showed promising results (Howard & Kendall, 1996). Finally, Kendall (1994) and Kendall et al. (1997) looked at global therapist's ratings of degree of beneficial parental involvement, degree of parental interference, and amount of contact with parent(s). None of the factors was a significant predictor of change, but beneficial parental involvement was correlated with treatment gains and maintenance of gains (Kendall et al.).

C u r r e n t M a n u a l s or P r o t o c o l s

Some cognitive behavioral manuals and books (e.g. Albano, 1995; Eisen & Kearney, 1995) both articulate the desired parental behavior to potentiate treatment and describe possible intervention techniques to achieve it. For example, these authors (Albano; Eisen & Kearney) describe educating the parents about the disorder, teaching the parents the same cognitive-behavioral skills taught to the child, and involving them in establishing the anxiety hierarchy and im- plementing in vivos. In addition, Albano describes one session in which the family discusses the adolescent's in vivo exposure task, and the therapist suggests ways the parents might modify their behavior. Ginsburg, Silverman, and Kurtines (1995) provide an excellent review of family factors in childhood anxiety disorders. In their article, the authors describe their use of the transfer of control theory, which involves a shifting of the power for change from the therapist to the parent and then to the child. The authors also outline a dyadic treatment approach, based on this theory, that can be used when both a parent and child present with an anxiety disorder. In this model, the identified parent and child have sessions together, and both are taught cognitive and behavioral skills to manage anxiety. Then, if there is evidence of problematic parent-child interaction (e.g., modeling or reinforcement of anxious behavior, or communication or problem-solving deficits), additional interventions are added in a pragmatic approach, or as needed. There is some evidence that parental involvement in child-focused treatment may be helpful, though the empirical work in this area is still in its infancy. In addition, many cognitive behavioral teachers


and clinicians talk about the usefulness of involving parents in treatment and in articulating treatment goals. However, little information is available on how to actually accomplish these goals and how difficult it can be.

Developing a Rationale and Motivation for Parental Involvement

Engaging parents in treatment begins with the first contact, where the therapist tries to develop a rationale and to motivate parents to become involved in treatment. Many families of anxious children have an avoidant style and are concerned about how they present themselves and their families to people outside the family. The therapist needs to provide a safe context for parents to discuss their concerns. Often it takes a number of sessions until the parents begin to trust the therapist enough to talk about how they may feel about their child's behavior, family difficulties, or disagreements. Therapists need to express their interest in and concern about the parents as individual people, not just as parents. The therapist must be seen to be willing to be an advocate for both the child and parents. Two of the best ways to begin to build this alliance is to empathize with the difficulties parents face and to help the parents articulate what impact having a child with anxiety disorder has had on them and the family as a whole.

Many parents describe the difficulty they experience figuring out how to parent their child, especially if they have another child who has an "easier" or different temperament than the anxious child. Often what works with one child is useless with the other. Parents with anxious children usually resonate to the description of the struggle of trying to find the right balance between challenging and comforting or promoting independence and helping. Clearly, living with a child with an anxiety disorder can be taxing and frustrating at times. It is helpful to acknowledge this with parents, to normalize these feelings, and, perhaps, even to share experiences of other parents of anxious children. This approach may help parents to feel more comfortable about acknowledging nega- tive feelings.

Awareness of child temperament is very important in treating children with anxiety disorders. It is difficult to figure out how to parent a child who may have demonstrated a temperamental style of high autonomic arousal, behavioral inhibition, and passivity since infancy (Kagan, Reznick, & Snidman, 1987). In this vein, parents have found two well-written books helpful: Raising Your Spirited Child by Mary Sheedy Kurcinka (1991) and The D~ul t Child by Stanley Turecki (1989). These books provide, in an accessible format, important information on temperament and offer suggestions on how parents can work with, rather than against, a child's temperament in day-to-day activities (the examples are most appropriate for children under 12). The therapist can help the family to identify the impact an anxious child has had on the family and their lifestyle. Sometimes the impact of the child's anxious behavior on the family is clear,

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and may even be one of the reasons the family has sought treatment. In these cases, this topic naturally arises in the intake interview or in the first few sessions. In these first sessions, parents often describe their concerns for their child and the stress they are under. Parents describe shopping experiences as a night- mare because their child cries, agonizes over, or can't make a decision about such simple tasks as which book bag to buy. An invitation to a party, rather than a cause for celebration, can lead to their child's outright refusal to go, weeks of questioning and worry, and tears or tantrums on the day of the party. The anxious child's refusal or hesitancy to participate in activities can inhibit the family's social life, limiting spontaneity and other family members ' involvement and enjoyment. Anxious children's discomfort or refusal to be left alone or with a sitter limits parents ' time alone together. In one of the early sessions, the therapist can ask parents to describe changes they would like to see in their child and in their family if their child's anxiety were not interfering. Some- times these discussions alone lead parents to begin to consider challenging the status quo.

Assessment of Problem Areas a nd D o m a i n s for Intervention

No one pattern characterizes all families with an anxious child. M a n y families of anxiety-disordered children have just "gotten off track" or need some parent ing suggestions on how best to manage their child's anxious behavior. Developmental transitions (i.e., entering adolescence or attending a new school) may cause more conflict or distress, but in the main, these families easily accept guidance and flexibly respond to their child's needs. With some minimal suggestions and support, these families implement strategies suggested by the therapist or easily collaborate with the therapist in designing a t reatment plan.

For many of the families, the work is not that simple. Not because the families are difficult or resistant ( though some are). When working with these more complex families, we suggest therapists assess and target three domains of functioning: parents' beliefs about parent ing and their role as parents, family dynamics or interactional styles, and parental psychopathology. Not all these domains are relevant to all families. Therefore, the outline below serves as a guideline and provides suggestions for the therapist on how to assess the im- portance of these issues with the particular family. Actually, these three domains often blend into one another. For example, treatment always benefits from a discussion of what parent ing strategies parents have tried and why. This discussion gives the therapist some information about parent ing beliefs and often alerts the therapist to areas of parental conflict or disagreement and family interactional cycles that may perpetuate the child's anxious style. In the course of these conversations, many parents also bring up the impact their own anxiety and depression may be having on their ability to help their child. At other times, these issues don't become apparent until t reatment progresses.


More Formal Assessment of Family Interaction Styles and Parental Psychopathology

In addition to the clinical interview techniques described above, the clinician can also use self-report measures to assess the parents' and child's perception of family functioning. Some possible instruments to use include the Moos Family Environment Scale (Moos & Moos, 1981), the Cohesion and Conflict Scale (Bloom, 1985) or the full Bloom Family Functioning Scale (Bloom; a measure designed from the most reliable items from a number of family functioning scales), and the Children's Report of Parenting Behavior Inventory (CRPBI; Schludermann & Schludermann, 1970). These measures, especially the Cohe- sion and Conflict Scale, the Bloom Family Functioning Scale, and the CRPBI, may capture dimensions that are particularly relevant to anxiety disorders. Parental psychopathology can be assessed rather simply by routinely asking parents to fill out such measures as the Beck Depression Inventory (Beck, Steer, & Garbin, 1988), Speilberger's Trait Anxiety measure (Spielberger, Gorsuch, & Lushene, 1970), Symptom Checklist (SCL-90R; Derogatis, 1983), or Brief Symptom Inventory (Derogatis, 1992). Given the literature on concordance of parent and child diagnosis (for review, see Ginsburg et al., 1995), parents of anxiety-disordered children will likely be struggling primarily with anxiety and depressive symptoms.

Most parents welcome these assessments; however, if parents resist, much of the needed information arises from clinical observation of in-session inter- actions. The therapist can set up a specific interaction task for the family to discuss a conflictual topic or discuss how to manage the child's anxiety. The therapist can also note the parents' reaction when their child is describing a recent anxiety-provoking event, or if the child gets upset or anxious in the office. Many of the issues arise most clearly when the therapist tries to move on to the in vivo or exposure stage of treatment. For all families, the cognitive behavioral therapist might begin with a relatively straightforward introduction to the CBT model and a review of the skills taught to the child. The therapist can suggest modifications in the parents' own behavior that would facilitate the effectiveness of these approaches. The overall goals would be those outlined by a number of theorists: contingency management and rewarding of independent behaviors, ignoring assurance-seeking or somatic complaints, limiting anxious interpretation of events, and setting up and following through with in vivo or exposure exercises (e.g., Eisen & Kearney, 1995). However, if parents are unable or have difficulty with these suggestions, additional discussions or interventions may be helpful. Sometimes the therapist knows even before he or she finishes explaining the desired changes that there will be problems, because the parent expresses concern or disagrees with the therapist's suggestions as soon as they are offered.

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Parental Beliefs About Parenting

In the next sections, we will highlight some of the literature on parents' beliefs about parenting, family dynamics, and parental psychopathology. We will discuss how to assess, through discussion with parents, self-report measures, and observation of family interaction, whether problems in these domains are inhibiting treatment progress. Finally, using excerpts from sessions, we will describe how these issues arise and suggest ways to talk to parents about both the expected changes in their behavior and their concerns about these changes.

Parents' Beliefs About Parenting: Empirical Studies and Interventions Empirical studies. There is quite an extensive literature on parental beliefs

(e.g., attributions) and parenting behaviors. However, we are addressing parenting philosophy rather than behavior (see Darling & Steinberg, 1993, for a discussion of the distinction). Parenting philosophy is the parents' definition of what a good parent is and what a good parent does. It is unclear from the research available what relationship there is between philosophy and actual parenting behavior. There is no direct empirical work investigating the role of parenting philosophy in child anxiety disorders.

However, there are two studies from research in developmental psychology that may be informative for understanding the relationship between parental beliefs and the treatment of childhood anxiety disorders. First, Rubin and colleagues have written extensively on anxious-withdrawn children in non-clinic settings (Rubin & Mills, 1991). Rubin and Mills (1990) found that mothers of anxious-withdrawn children were more likely than mothers of control children to believe that social skills were trait-based and should be taught in a directive manner, including telling the child what to do or taking over for the child. In addition, these mothers were more likely to blame themselves for their children's unskilled social behaviors and to report feeling more angry, disappointed, guilty and embarassed by their child's deficits than control mothers. Whether ' these patterns hold in families of children with diagnosed anxiety disorders needs to be investigated. Second, Got tman and his colleagues have been studying parents' theory about emotions and emotional processing and its relation to child functioning (Gottman, Katz, & Hooven, 1996). Got tman and colleagues are particularly interested in parents' thoughts, feelings, and attitudes about their own and their child's experience of sadness and anger. These researchers are interested in articulating parents' "philosophy of emotional expression and control;' or their metaemotion theory (p. 244), and using this information to teach emotion coaching skills. Based on our and others' clinical experience with families with children with anxiety disorders (reviewed below), parents' philosophy and beliefs about the acceptability of expression of emotions is a pivotal issue in some families of anxiety-disordered children.

Intervention. If the parent intervenes for the child in an age-inappropriate


manner, has concerns about asking the child to take on tasks, or seems extremely distressed when the child is upset, it would be helpful to talk to parents about their views of parenting. The therapist should ask parents directly about their beliefs and their parenting philosophy, where that philosophy came from, and how the parents arrived at their decisions about how to parent. These beliefs are often based in each parent's personal history. A number of parents report how their own parents served as important role models, and that they would like to emulate them. The therapist often learns that some parents struggled with the same difficulties as their children when they were growing up, and hears the parents' impressions of how their own parents handled their difficulties. This can be very informative because some parents feel that their own parents did not teach them how to cope with strong emotions or how to do things independently. Instead, their parents were very protective, limiting their involvement with things or people outside the family. Some parents report that they wished their parents had toughened them up a little instead of taking over for them or doing things for them.

In addition, many parents of anxious children grew up in families where the world was portrayed as a dangerous and unsafe place, and the only safe place was the home. These parents have usually brought these messages into their own families, even if their behavior is different than their parents'. Other parents won't push their children at all because they felt pressured by their own parents. We have worked with a number of parents who are hesitant to exert any control over, provide limits for, or show anger towards their child, because their own parents were out of control, psychologically or physically, in their expression of anger. Independent of their own background, we find that quite a number of the parents' children with anxiety disorders report that they should never make their child upset or angry with them, because they cannot tolerate these feelings. Whatever the experiences reported by the parents, the therapist's awareness of these beliefs and the parents' rationale for these beliefs provide crucial information for designing an intervention strategy.

Articulate the message parents are sending their children. The therapist can talk to parents about their choices to intervene on behalf of their child. The therapist can discuss how parents may be sending the message that the child cannot tolerate anxiety or distress. Unfortunately, parents' excessive "helping" sends messages to the child that he or she is incapable of managing normal situations without the parents' assistance. It also teaches children that distress, pain, and anxiety are dangerous and to be avoided at all costs.

However, a therapist can work with the parents, suggesting that parents do want to teach their children to have a sense of mastery, control, and the ability to soothe themselves when distressed. The therapist states that the interventions suggested will always have the goal of providing the child with a sense of competence and confidence. In addition, therapists can point out how the

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parents ' tendency to take over for the child does not give the child a chance to practice crucial psychological or interpersonal tasks.

Clarifying and modifying parents' expectations. Because of their concerns about up- setting their child, parents of anxious children are often unsure of what they can ask or expect of their child. This is one of the first and most powerful intervention points. Again, the therapist empathizes with the parents over how hard it is to figure out how to be helpful to their child given the child's anxious style. Parents have a hard time finding that balance between protecting and encourag- ing/challenging their child. Because their children may become easily upset in many situations, parents often say that they do not want to be the ones to provoke their child's distress. Of course, all parents wish to reduce their child's distress; however, this stance becomes detrimental if it gets in the way of having appropriate developmental expectations for the child.

In general, we tell parents that they should have the same expectations for their child with an anxiety disorder that they would have with any child. There- fore, parents should expect their child to attend school, to participate in social activities, to address problems with peers, and to be able to cope with uncertainty and ambiguity. Parents are often surprised, but relieved, upon hearing this recommendation. These parents need to know that these expectations should be made explicit and that children feel "safer and more secure" when parents provide structure and limits.

In general, these issues come up when the therapist tries to make recom- mendat ions about how the parents should change their parenting related to their child's anxious behavior. For example, this is often how a conversation around limiting reassurance-seeking might proceed:

Parent: He keeps coming to us about 10 to 20 times a day to ask us if it is alright to do this or say that. We tell him it is okay and not worry about it. Then he seems to calm down, but it starts up again.

Therapist: Repeated reassurance-seeking is very confusing. Kids and parents think it helps to talk it out, but actually it doesn't. The calm doesn't last and he keeps coming back. Sometimes it actually keeps the worry going. So we need to think of a way to limit your response to him to show him that he can get by without your reassurance.

Parent: You're right, it doesn't help for long, but I don't know what to do.

[Here the therapist outlines the goal of mastery and self-soothing.]

Therapist: Well, we want to teach him how to reassure himself rather than coming to you for that kind of help, but we have to move in steps. He seems mostly concerned


about his thoughts and feelings being wrong. Now you've told him all feelings and thoughts are okay, which was great. So when he comes up to you, r emind him that he can say that to himself and to you. You can help h im by r emind ing h im of what he can say to himself, but r emind h im ra the r than answering his questions.

Parent: You mean I shouldn't answer his questions? But he is real ly upset about all this and I want h im to feel he can ask questions.

Therapis t : It sounds like you feel that you will be a hurtful or uncar ing pa ren t not answering these questions.

Parent: Always before he would never talk to us about things. He real ly kept to h imself and he's jus t s tar t ing to open up. I am concerned it will shut h im down.

Therapis t : But these questions are not helpful to him and he a l ready knows the answer, right. The tr icky things with these kids is what is the best way to help. Most ly you want to let h im know that you believe he can handle these si tuations, that he is s t rong and competent , and to teach h im to comfort and reassure himself. Tha t is the reason I am asking you to do t h i s - - so he gets that message. I believe if you are willing to give it a try, you will see that he will calm down if you help h im not to ask the questions.

All good cogni t ive-behavioral and behavioral therapists are well aware that with their clients it is helpful to break tasks down into smaller, more manageab le steps. Somet imes it may be impor tan t to base the scope of the task on parent needs and abilities ra ther than the child's. The parent , enjoying success in m a n a g i n g a tolerable level of his or her own anxiety, will consequent ly make it more likely that the child will also have a mas te ry experience. We often use a pr ivate- t ime task descr ibed below. It serves two purposes for the parents: to make them more will ing to not reassure; and to have a special es tabl ished t ime for them to talk and be engaged with the child. For the child, it also provides individual at tention from the parent (that may be part of the goal of reassurance- seeking) and gives the child a sense of control over the worry by demons t ra t ing that the child can delay or stop the worry. Both the child and parents often feel the child has no control over this behavior (this is s imilar to techniques used with adults with general ized anxiety disorder, suggested by Borkovec and Matthews, 1998).

Therapis t : One th ing that works really well for this is set- t ing up a "private time." Tha t is, a special t ime for the child to be alone with you for 15 minutes sometime during


the day. I want you to tell him about this private time first, when it will be, and explain that "private time" is when you will answer his questions. Start the private time tonight. Then when he comes to ask you for reassurance, remind him to tell himself "all thoughts and feelings are okay:' Tell him to remember his questions and you will talk about them at private time.

Parent: I know he'll say he won't remember them and then he'll worry about remembering.

Therapist: You are probably right about that. But you can tell him that if the questions are really important, he will remember. And you need to know that if they disappear by private time they were not very important, but were a way to get reassurance from you. Why don't you try it for a day or two, and I will call you tomorrow to see how it is going. Then we can talk if it's not working. However, it takes some time to work, so try to stick with it. When you change your behavior, he may react strongly at first and ask you even harder to get you to react in the old way he knows. Tell him about the private time before you stop reassuring, but then stick with the plan.

Family Interaction: Empirical Studies and Interventions

Empirical Studies Both the clinical experience of therapists working with families with anxious

children and beginning empirical investigation shed light on possible family interaction patterns and possible intervention targets. Stark and colleagues (Stark, Humphrey, Crook, & Lewis, 1990; Stark, Humphrey, Laurent, Livingston, & Christopher, 1993) have attempted to describe and differentiate the family environments of children with anxiety disorders only, depressive disorders only, and mixed anxiety and depression. Compared to control families, the children with either psychological disorder described their families as higher in conflict, more enmeshed, less supportive and cohesive, and less democratic in their decision-making. The only significant differences between the disordered groups was more enmeshment and conflict in the anxious and depressed group compared to the other two clinical groups.

The first author's own work (Siqueland, Kendall, & Steinberg, 1996), developed out of clinical experience treating anxiety-disordered children in a cognitive behavioral format, has corroborated the findings of the studies described above using both self-report and behavioral observation. On self-report measures, children with anxiety disorders rated their parents as significantly less


accepting than the control children rated their parents. The majority of families with the highest ratings of psychological control and lowest ratings on warmth/ acceptance (using the CRPBI measure) were from the anxiety-disordered group. In addition, trained raters, observing families discussing a topic of conflict, rated parents of children with an anxiety disorder as significantly lower than control families on psychological autonomy granting. Psychological autonomy granting behavior was defined by the presence of the following behaviors during the problem discussion task: the parent (a) solicits child's opinion, not simply a reaffirmation of parents' opinion; (b) tolerates differences of opinion; (c) acknowledges and demonstrates respect for child's views; (d) avoids judgmental or dismissive reactions to child's views; (e) encourages child to think independently; and (f) uses explanation and other inductive techniques.

Dadds (1995) suggests that there is only limited evidence of a general family interaction style in the families of children with anxiety disorders; however, he has documented a particular interactional pattern regarding how families of anxious children handle anxiety-provoking or ambiguous situations (FEAR effect; Barrett, Rapee, Dadds, & Ryan, 1996). These researchers have developed very interesting paradigms to document this interactional process by eliciting the child's responses to ambiguous situations and then seeing how these responses change after discussing the situations with their parents. Barrett et al. found that both children diagnosed with anxiety disorders and their parents perceived more threat and generated more avoidant responses in ambiguous situations. More importantly, anxious interpretation increased in clinically anxious children following discussion of the situations with their parents (Barrett et al.). Chorpita, Albano, and Barlow (1996) found similar results to Barrett et al. examining parents' transmission to their children of particular cognitive biases associated with danger during discussion of ambiguous situations.

More generally, we find that many parents have developed their own way of coping with their emotions and the world that is congruent with their child's avoidant behavior. A number of parents have an anxious or avoidant style of coping themselves. I f the parents are fearful about their own safety or view the world as a frightening place, independent of actual parental psychopathology, it is hard not to pass this view on to their children. Some parents have difficulty tolerating strong emotions of any kind, such as sadness or anger, and, therefore, may have difficulty tolerating their expression by their children. Or parents may have explicit beliefs or rules about whether these emotions should be ex- pressed, even if they are felt (similar to Gottman's meta-einotion theory; Gottman et al., 1996). Their children may learn to not express these strong emotions directly; but anxiety may be an alternative "emotion" that the family can tolerate. Finally, if parents are uncomfortable with and try to minimize interpersonal conflict, it may be very difficult to let their children know that it is okay to disagree or be autonomous.

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In tervent ions T h e therapis t shows the parent how to give suppor t to their child and solicit

the child's input and problem-solv ing skills, ra ther than al lowing avoidance, t ak ing over for the child, or overly d i rec t ing the child. The therapis t can ac- compl ish this most directly in the therapy room.

Intervention 1." Using CBT skills. C B T therapis ts can use cogni t ive-behavioral skills as a guide to model a different way for the parents to interact with the child when anxious. The therapis t will often notice that if the child starts to get upset or nervous about t ry ing something new, parents will often try to reassure the child, promise that it will be all right, or even quickly wi thdraw their request . The therapis t can block the parents from doing this and can model ta lking with the child about coping with the anxie ty that the child is experi- encing despite the child's distress. I f the paren t has been taught the same steps for coping that the child has learned in sessions, the parents can use these steps to in teract with their child. The therapis t reminds the parent that the goal is to empower the child so that the child has an experience of mas te ry coping

with s t rong affect. The therapis t can show the paren t how to ask for informat ion and input

from the child. The paren t can ask the child for details about the par t icu- lar concerns for that si tuation, and then th ink aloud, with the child, of ways to address these th rough either cognitive or behavioral strategies ("What do you th ink you could do or say that would help you feel calmer?"). Therapis t s can model for parents how to tell their chi ldren that the parents will wait and "sit with them" if the child is too upset or d is t raught to talk or problem-solve at the moment . Often the therapis t may have to engage the pa ren t in conver- sat ion in order to help the paren t tolerate their child's distress. The therapis t models how a parent can stay present for and engaged with the child but not intervene. The therapist demons t ra tes a "faith" in the child's own abi l i ty to calm himself or herself and re turn to the discussion. The therapis t also requires that the pa ren t continue the discussion ra ther than "drop the subject" or avoid the

distress. T h e child has a l ready learned some coping skills and is likely s tar t ing to

feel confident that he or she can do something, other than avoid the si tuation, if r eminded about these skills. I t is often helpful for the therapis t to meet alone with the child and walk the child th rough the use of the coping skills before mee t ing with the parents. Then the child can assume the expert role and present his or her own plan to the parents for dea l ing with an anxie ty-provoking situa- tion. Again, this bui lds a sense of mas te ry and competence for the child. I t is in teres t ing to note that parents often quest ion the child's p lan because of their own fears or concerns about what could go wrong. However, parents also see that their chi ldren can be r emarkab ly creative, when given the chance, to provide ideas about what they could do themselves when anxious.

Intervention 2: Different ways of "helping." M a n y parents of anxious children have


gotten used to intervening on behalf of their child or feeling they have to help or make it better when their child is distressed. Children can provide suggestions about how their parents could specifically help to make the difficult situa- tion more manageable. Interestingly, children often tell their parents that they can "help" by helping less. It is useful for the child to tell the parents how much help they want, or if they need any help at all. Many children, when they begin to try to cope with their anxiety, ask their parents not to ask if they are anxious or if they need help. Instead, they prefer to tell their parent if they need help; and, otherwise, the parent should assume they are okay. Families can also develop a system of defining levels of help: "I want to do this alone;' "Stay around in case I need your help" or "Come help me now." Chansky (1996), in her work with children with OCD, described the child's use of a stoplight cue to signal levels of parental help: red (I'm okay), yellow (Stand by, I might need you), and green (Come help now).

When asked first, children often offer more reasonable solutions and ask for more limited involvement or help from their parents than their parents assume they want or need. The child will offer a strategy that would be a new step or challenge, even though it might be only an approximation of the final goal. For example, a child who fears going to a party might suggest that the parent could accompany the child to the party and stay in the kitchen for the first 15 minutes to see if they are okay, then leave. In contrast, parents will suggest that they attend the whole party before the child would agree to go. It can be very helpful for the parents to see their child upset when discussing events, even become teary, and still be competent and capable of talking through options and suggesting solutions.

Intervention 3: Family discomfort with emotional expression or autonomy. At times, the family interactional style can pervade areas other than managing the child's anxious behavior. It can include a broader difficulty or discomfort with the expression of different viewpoints, feelings, and experiences within the family. For some families, there is extreme discomfort around the expression of nega- tive feelings of anger and sadness. The therapist can address and elucidate family members' concerns about the consequence of expressing differences or strong feelings. Often these concerns about feelings and autonomy focus around separation and loss. Fears of irreparable damage to relationships leads to avoidance rather than open discussion of emotions or differences. As Minuchin, Rosman, and Baker (1978) have suggested, "loyalty is valued over autonomy and approval is valued over competence" (p. 56). The therapist will often have to support family members to tolerate differences and to disagree without being disconnected. Sometimes this work can be done with the whole family together, but it often may require separate meetings with the parents to discuss their concerns about emotional expression. Children, as they begin to cope better, feel more confident, and ask for more autonomy, may push the family towards discussing differences and negotiating.


Intervention 4: Addressing parental conflict. Often in two-parent families, the mother and father have different views about what the child needs that prevents them from taking a clear, uni ted stand with their child. One paren t may be more cautious by nature, and overly concerned about upset t ing the child. This paren t may overidentify with the child, "certain" of what the child is feeling. This may be because the parent has, or had, s imilar experiences. Often it is difficult for the pa ren t to conceive that the child might not feel the same as the parent does. It can be very informative to have the paren t ask the child to describe his or her experience ra ther than have the paren t assume how difficult si tuations are for the child. If the paren t struggles with anxie ty and is avoidant, he or she may feel that it is dangerous , unfair, or even cruel to challenge the child. In contrast , the other paren t instead expresses concern about the child's development , and wants to encourage the child to develop appropr ia te skills. This can lead to anger between parents, with each paren t viewing the other as not under- s tanding the needs of the child. A process of doing and undoing is often played out, result ing in the child feeling confused about expectat ions and consequences of his or her behavior. Parents can get polar ized into a more ext reme posi t ion than they actually hold because of the perceived extreme posit ion of their spouse. I f this difficulty is identif ied and parents are given the chance to discuss their different views, they can often compromise on a consistent approach to paren t ing the child. Again this may require the therapis t meet ing with the parents separa te from the child. I f these d isagreements cause a lot of distress or conflict, or pa ren ta l differences expand into o ther areas of the parents ' relat ionship, a referral for couples therapy may be needed.

The following discussion il lustrates both a par t icu la r family interact ion style of hand l ing emot ional upset as well as d i sagreement between spouses about pa ren t ing practices. In the following si tuation, a father cont inual ly r eminded his son about gett ing ready in the morn ing despite his son's request that he could handle it h imself and some beg inn ing demons t ra t ion of his abil i ty to do so. However, the son had been refusing to go to school in the mornings at intake a few months earlier.

[Meeting alone with the parents. ]

Therapis t : So your son tells me that you are cont inuing to remind h im about get t ing ready in the morning, even though he wants to do it himself.

Father: I know we talked about that but he dawdles so much that I don't see how he is ever going to get ready.

Therapis t : But I thought ear l ier this week he made it out on t ime by himself.

Father: That ' s because his mothe r was a round and she jus t tells him that he needs to be ready because the school bus will be coming in 15 minutes and then walks away.


Mother: If you leave him alone, he takes care of it somehow. And, anyway, if he doesn't, he doesn't.

Therap i s t [to father]: But tak ing that view is ha rd for you, to have h im be responsible for gett ing himself ready.

Father: Yes, because I even have to tell h im to get out of the shower or he's in there forever.

Therapis t : Do you feel that your son can't handle or isn't capable of t ak ing a shower by himself?. Because I am worr ied that that is the message you are sending to him: that he will begin to think that he can't handle these things. O r at the least, he'll think, M y dad thinks I can't handle myself. W h e n actually we know he can because he does it when M o m is around. But maybe he knows when you are a round that he can let someone else take care of it. I th ink you want him to know that you expect he should and can handle these things on his own and that he is capable.

Mother : The p rob lem is I tell h im if he is not ready and misses the bus that I am not going to drive him. But then he runs late and his dad takes h im anyway.

Therapist : So it is difficult for the two of you to take a uni ted s tand with him. You may be undoing each other 's work and sending h im confusing messages.

Mother : Yeah, I want to teach h im to do it himself. Therap i s t [to father]: A n d that 's ha rd for you to do. Father: Because what if he misses the bus, and we don't

drive him, then he misses school. Therapis t : I don't think that will happen , but you would

have to be p repa red for that possibility. W h a t would be so bad about him missing a day of school if it also showed h im that he has to be responsible for himself.

Father: I f he misses school we would be back to square one.

Therapis t : I think we are in a very different place now than when you came for t reatment . He has been going to school and tak ing on more for qui te a while. But what you imagine is that he will get worse.

Father: I t was jus t so terr ible fighting and dragging him and he was so depressed, I really worry about him falling apart .

Therapis t : You still have an image of him of be ing really a mess and unable to take care of himself.

Father: Yes, I real ly worry if he is going to be okay or keep


having these problems forever and what will that mean for him.

Therapist: The thing I am concerned about is that you are sending that message to your son. He is looking to you for information on whether you think he can do things himself and he is picking up on your worries or belief that he can't. In that way your trying to help may not be helping but getting in the way of his getting better.

In the case example above, the therapist has already brought to the family's awareness the role the parents' behavior may be having on the child's anxiety disorder. The therapist points out that the parent still has an image of the child as unable to function despite significant changes in the child's behavior. This view is driven more by the father's anxiety than by his softs anxiety. In addition, the parent is sending messages to the child that he is not competent to handle routine tasks. This child had also reported that his father was always looking at him and asking if he was okay even when the child was doing fine. The son was able to tell his father that this behavior made him more anxious and self- conscious. Sometimes parents are able to recognize the impact of their behavior, to utilize their available resources, and to change their parenting behavior with their child with some support and guidance. We take this approach first, working with the parent on parenting their child differently. For example, with the case above, we might suggest that the father could let the mother handle the morning routine for a week so that he could feel more confident that his son would likely not miss school. Then the father could try again to interact differently with his son the following week. If the parent is unable to make these changes or has a disorder that is interfering with his or her ability to change parenting behavior, wewill begin to speak about the need for individual treatment for the parent. Often parents will be more cooperative if the therapist takes the focused parenting approach first, and then, if that does not succeed, recom- mend a referral for individual treatment.

Parental Psychopathology: Empirical Studies and Interventions

Empirical Studies Research suggests that children are at increased risk to develop anxiety dis-

orders if their parents have an anxiety or depressive disorder. These children are 7 times more likely to develop an anxiety disorder than children of unaffected parents (see Turner, Beidel, & Costello, 1987; Weissman, Leckman, Merikangas, Gammon, & Prusoff, 1984). Silverman, Cerny, and Nelles (1988) found that 81% of children of agorophobics, 75% of children of mixed phobics, and 29% of children of GAD patients met criteria for an anxiety diagnosis. Interestingly, within the anxiety disorder diagnosis, it is the level of parental avoidance that


seems to affect the family more than the severity of the disorder. I f children of anxiety-disordered parents receive a diagnosis, they tend to receive an anxiety disorder diagnosis (Silverman et al.); however, if the parents have mixed anxiety and depression, the children tend to show risk of anxiety and/or depressive disorders (Weissman, Leckman, Merikangas, Gammon , & Prusoff, 1984). From the other direction, mothers of children with diagnosed anxiety disorders have also demonstrated a higher lifetime (83% vs. 40%) and current rate (57% vs. 20%) of anxiety disorders themselves than mothers of controls (Last, Strauss, Hersen, Francis, & Grubb, 1987). Clinicians should be aware of these concordance rates because it is likely that a child referred to them with an anxiety disorder may have a parent who is also struggling with anxiety and/or depression.

Intervention. The therapist should identify and discuss, if relevant, how the parent 's own anxiety or depressive symptoms may be affecting the way they view their child and their child's treatment. As they feel stronger, some children are able to tell their parents themselves that their parents ' anxiety is making it difficult for them to get better for a number of reasons. Some children report that they worry about their parent "being okay," and suggest that they stay close to the parent because of fear that the parent will become upset or sick. At times, parents have made statements to their children that perpetuate these fears. These messages need to be elucidated and discussed. If the parent really has an illness (either psychological or physical), we have found children to be greatly com- forted by information about what they should do in case of an emergency rather than global reassurances not to worry. Many children we have worked with have told their parents that it is hard that the parent is always watching them or asking them if they are nervous or okay.

We have found that some parents who struggle with anxiety or depressive disorders can challenge and support the progress of their children despite their own difficulties. Other parents may decide to pursue treatment to address their own fears, not for themselves, but out of their commitment as a parent. Pa- rental love and caring for the well being and future of their child can be a powerful motivator for many parents who have been reluctant to seek treatment for themselves. While support ing the parents' concern for the child, we also use our alliance with the parents to encourage self-care for the parents themselves. However, if the parent is not able to continue the work outside of sessions because of his or her own difficulties, a therapist will have to be clear with a parent that the therapist is concerned about how much the child can benefit from treatment. An example of this type of discussion follows in a continuation of the same family presented in the section on family interaction.

Therapist: So how did it go this week? Did you [mother] handle the morn ing routine?

Mother: Yes, it went pretty well. He made it every morning.


He bare ly made it one day but I r eminded h im of not dr iv ing h im and he got out to the bus in 15 minutes.

Therapis t : That ' s great, glad to hea r it. [To father] How are you feeling about this? Were you able to stay clear of r emind ing him?

Father: Well, I t r ied to stay in the bedroom. Mother : I t was really hard , he kept coming out to check

and he was a wreck. Father: I was kind of a wreck. I don't relax until he's out

the door. Therapis t : So even though your son is doing fine, you are

still really worr ied and distressed. I am concerned what toll this is tak ing on you.

Father: No, I am fine. Mother : I am not so sure you are fine, you have been

seeming real ly down and stressed out at work too. Therapis t : You know your son said to me that he feels he

is gett ing bet ter but he is worr ied that you are gett ing worse. I think he is concerned about you. We have talked before about you gett ing some help with this anxiety.

Father: No, I don't believe in all that therapy and stuff, going over my past.

Therapis t : Tha t surprises me because you have been very support ive of your son's work here, and this is therapy. M a n y therapies focus on helping people cope with their current problems.

Father: I don't think I am up for it. I can control my behavior bet ter with him.

Therapis t : Well, why don't we see how this goes for another week or two. Let's see first if you can let your wife handle the morn ing and you can jus t suppor t her. Then we can see if you are able to interact with your son differently yourself. However, if this is too difficult or painful, I think we need to discuss it further. I feel your son's long- te rm progress depends on your abi l i ty as parents to cont inue to support and encourage his independence.

Father: Well, that 's impor t an t but I think I can change. Therapis t : I hope that you would do this for your son. But

more, I hope you would do it for yourself. I t seems like you are really suffering and there are a number of things that could help. I see your dedica t ion to and car ing for your son, and that is special. You can model for h im how to take care of yourself by gett ing help from others.

1 0 0 SIQUELAND & DIAMOND

You don't have to be going through what you are, and I hope you will let your wife and me help you. Will you think about it?

Father: I've seen what a difference this has made for my son. I'll think about it.

Since parents come seeking treatment for their child, we first suggest parents seek treatment themselves for the sake of their children. Often it is easier to go for help for their child. However, we also focus on the parents caring for themselves and addressing their own needs as another way to model this behavior for their child. Sometimes their child's improvement gives parents new hope that therapy can help with their own problems that they have accepted as inevitable or "just how it is." Many times one spouse can help support and show their concern for the other spouse. Finally, as kids get better and feel more comfortable, like this child, they will often tell their parent that they are worried, or that the parent should get help. Children have an understanding of the sys- temic view that sometimes if one person starts getting better, another family member has more difficulty or has to change as well.

Understanding and empathy for parents' dilemmas are crucial for this work. Sometimes child therapists have entered this specialty because they don't particularly like working with parents. Their discomfort and lack of skills or experience in this area can become apparent, even though they may be wonderful in working with children. We believe both skills are required to motivate, support, and elicit cooperation from parents to assist in their child's treatment. Not all parents seeking treatment for their children require this level of intervention; however, we find that most families need to know that they are heard and that their values are understood before they are willing to do what the therapist says. Addressing these issues meaningfully for families is clinical work that is more than just teaching the parents certain ways to handle anxiety, com- municate, and handle conflict. Providing a clear rationale for the changes the therapist is asking the parents to make, and respecting the parents' needs and values, makes it more likely that parents will implement the therapist's suggestions. We have found that the therapist's skill in addressing parents' beliefs, family interaction styles, and parental psychopathology leads to better maintenance of gains that the child makes in the primarily individual treatment. It is also likely that the family as a whole will function better in new and different challenges that arise in the future.

However, future empirical work will be needed to evaluate the effect of parental involvement. The authors are embarking on a comparison of CBT alone and CBT plus a family relationship intervention for adolescents with generalized or separation anxiety disorder. The family relationship intervention focuses on (1) parents' support of child's mastery and independence rather than taking over or helping; (2) clarifying and modifying parents' expectations

ENGAGING PARENTS 101

of child 's abi l i ty to func t ion independen t ly ; (3) ident i fy ing the role of the paren t ' s

own anx i e ty or depress ive symptoms ; (4) e n c o u r a g i n g inc reased to le rance for

the expression of different viewpoints , feelings, and experiences wi th in the family;

(5) focus ing on p rob l em-so lv ing and open nego t i a t ion of confl ict r a the r t h a n

avo idance ; and (6) address ing mar i t a l confl ict in pa ren t ing . We will assess the

effect o f the family and C B T in t e rven t ion on chi ld and fami ly func t i on ing u s ing

m e a s u r e s o f skill bu i l d ing and re la t ionsh ip change . F u r t h e r studies m i g h t com-

pa re a fami ly re la t ionship t r e a t m e n t to C B T t r ea tmen t .

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Preparation of this article was funded in part by NIMH grants R21-MH52920 and N I M H Clinical Research Center P30-MH-45178. Address correspondence to Lynne Siqueland, Ph.D., 3600 Market St., 7th floor, Philadelphia, PA 19104-2648; e-mail: [email protected]

RECEIVED: June 10, 1997 ACCEPTED: December 30, 1998

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Engaging parents in cognitive behavioral treatment for children with anxiety disorders