Download Failures in Cognitive-Behavior Therapy for Children

Failures in Cognitive-Behavior Therapy for Children
Yasmin Rey, Carla E. Marin, and Wendy K. Silverman
Florida International University
This article discusses treatment failures in child therapy, specifically cognitive-behavioral therapy (CBT) for anxiety and its disorders. The
theoretical foundations and principles of CBT are discussed first, followed by a summary of the treatment outcome literature. Also
discussed is how treatment failure is defined and gauged in CBT, as well as factors implicated in treatment failure. A case illustration
highlights these factors, which resulted in the child not advancing positively in treatment. The article concludes with key practice
recommendations. © 2011 Wiley Periodicals, Inc. J Clin Psychol: In Session 67:1140-1150, 2011.
Keywords: Adolescent; Anxiety; CBT; Child; Psychotherapy; Treatment failure
Correspondence concerning this article should be addressed to: Wendy K. Silverman, Department of Psychology, Florida International
University, 11200 S.W. 8th Street, Miami, Florida, 33199; e-mail: [email protected]
JOURNAL OF CLINICAL PSYCHOLOGY: IN SESSION, Vol. 67(11), 1 140-1 150 (2011) © 2011 Wiley Periodicals, Inc.
Published online in Wiley Online Library (wileyonlinelibrary.com/journal/jclp). DOI: 10.1002/jclp.20848
Clinical disorders of childhood and adolescence are highly prevalent, afflicting approximately 10% to 20% of youth in the United States
(La Greca, Silverman, & Lochman, 2009). About 70% of these youth do not receive treatment services to alleviate the distress and
impairment resulting from these disorders (U.S. Department of Health and Human Services, 1999). Further, many of the youth receiving
treatment are not receiving treatments that have been empirically found ‘‘to work’’ (Silverman & Hinshaw, 2008). More importantly, and
especially pertinent to this Journal issue, even if a child or adolescent receives an evidence-based treatment, it cannot be assumed that
positive treatment response will ensue. A substantial portion (e.g., 20% to 40% of anxious youth) who receive evidence-based
treatments fail to respond positively (McKay & Storch, 2009).
In this article, we discuss treatment failure in child cognitive-behavior therapy. Given the broadness of ‘‘child therapy,’’ we focus our
discussion in our area of specialization: anxiety and its disorders. As will be apparent, many of the principles we discuss are applicable to
other disorders of childhood and adolescence. This is because these disorders, like anxiety, can be reduced with cognitive-behavioral
treatment (CBT).
CBT for Youth
When working with children and adolescents with anxiety disorders, a key CBT procedure is exposure (Silverman & Kurtines, 1996).
Exposure involves the individual confronting fear or anxiety provoking objects or situations in a gradual fashion, either live (i.e., in vivo) or
in imagination. Gradual exposures are typically implemented along a fear hierarchy. A fear hierarchy lists items that represent the
specific feared objects or situations, ranked from least to most fearful. Each item on the fear hierarchy is then used in-sessions and
out-of-sessions as an exposure task. Typically, exposures begin with low fearful items and over treatment the exposures focus on the
more fearful items.
The precise mechanism by which exposure works to reduce anxiety is unclear. However, all explanations involve modification of
behavioral, cognitive, and affective processes. For example, exposure to anxiety-provoking situations or objects may lead to anxiety
reduction by extinguishing (or removing) the physiological arousal associated with the feared object or situation. Alternatively, exposure
may allow the youth to receive incompatible information that perceived catastrophic consequences associated with anxious stimuli do
not occur.
To facilitate youths’ learning during exposures, cognitive strategies are used. Most common is self-control strategies, which rely on
self-observation, self-modification, self-evaluation, and self-reward. In our work, we teach youth to use the acronym STOP during in and
out of session exposures (Silverman & Kurtines, 1996). Youth learn to first identify when they are feeling anxious or Scared (S), then to
identify their anxious Thoughts (T). Then they learn to modify or restructure their anxious thoughts by generating other alternative coping
thoughts and behaviors (O). Finally, youth learn to evaluate their performance in confronting their fears during exposure tasks, and to
reward or Praise themselves for confronting their fears (P). To help modify irrational thoughts (or change Ts’’ to O’s), youth are taught to
look for evidence for their anxious thoughts and to then identify a more realistic thought based on the evidence or lack of evidence.
Parental Involvement
When parents appear to be maintaining their child’s anxiety problems, especially avoidant behaviors, it may be helpful to get parents
involved in their child’s treatment. To help parents learn how to decrease their child’s avoidant behaviors, a common behavioral
procedure used is contingency management. Contingency management emphasizes training parents in the appropriate use of
contingencies by contracting. In contingency contracting, the therapist helps the child and parent devise weekly contracts. The contracts
specify the details of the exposure task the child is to perform in the coming week and the specific reward the parent is to provide to the
child contingent on the child’s completion of the exposure. To further assist parents, parents are trained in reinforcement and extinction.
Using these skills, parents are encouraged to provide positive consequences (praise, tangible rewards) following their child’s efforts in
facing the anxiety-provoking situations. Parents also are encouraged not to allow (or to extinguish) their child’s avoidance of the anxiety
provoking objects or situations.
Outcome Research
A large research literature has accumulated that provides strong and consistent evidence for the efficacy of CBT to reduce anxiety and
its disorders in youth (Silverman, Pina, & Viswesvaran, 2008). CBT is efficacious in reducing anxiety disorders whether delivered to the
child individually, to the child and parent together, and in a group format. Most of the RCTs involve random assignment of youth
participants to a CBT condition versus a waitlist control. A smaller number of studies have randomized youth to CBT versus an active,
credible comparison control condition. These studies involve multimethod-multisource assessment procedures to evaluate treatment
outcome.
Most studies report recovery rates ranging from about 60% to 80% of youth no longer meeting diagnostic criteria for their targeted
anxiety diagnosis at post-treatment (Silverman et al., 2008). Most studies also report statistically significant reductions in youth and
parent anxiety symptom ratings. A smaller number of studies also have reported statistically significant reductions in teacher ratings, as
well as in behavioral observation ratings of the youths’ anxiety.
Defining and Gauging Failure in CBT
Despite the generally positive outcomes of CBT for youth anxiety disorders, a significant portion of youth fails to respond to treatment:
About 20% to 40% of youth continue to meet diagnostic criteria for their anxiety disorder at the conclusion of treatment (Silverman et al.,
2008). These youth also fail to show significant reductions in clinician ratings of disorder severity and youth and parent anxiety symptom
ratings. They also are likely not to be viewed as significantly improved by teachers and behavioral observations from pre to
post-treatment.
As in almost all youth randomized clinical trials, youth anxiety trials use multimethod- multisource assessment to gauge treatment
response and treatment failure. To gauge whether the child or adolescent continues to meet diagnoses, diagnostic interview schedules
are typically employed.
In the anxiety area, the Anxiety Disorders Interview Schedule for DSM-IV: Child and Parent Versions (ADIS-IV: C/P) is the most widely
used interview. The ADIS-IV: C/P also contains a Severity Rating Scale, which allows for a global assessment of severity of interference
or impairment associated with the youth’s anxiety diagnoses. Ratings on the Severity Rating Scale can range from 0 to 8. After
treatment, higher ratings (i.e., four or greater) reflects treatment failure because the child’s diagnoses are still resulting in high
interference.
Treatment success and failure also is typically gauged using youth-completed and parent- completed symptom rating scales (Silverman
& Ollendick, 2005). The most widely used youth symptom rating scales are the Revised Children’s Manifest Anxiety Scale and
Multidimensional Anxiety Scale for Children. The most widely used parent symptom rating scale is the Child Behavior Checklist,
specifically, the Internalizing Broadband Scale and/or the Anxious/Depressed Narrowband Scale. A companion teacher version, the
Teacher Report Form, also has been used.
Factors Implicated in CBT Failure in Youth
Below we summarize what is known about treatment failure in CBT among youth suffering from anxiety disorders (see McKay & Storch,
2009; Silverman & Hinshaw, 2008).
Symptom Severity
Severity of youths’ symptoms before treatment has been implicated in CBT failure among youth with anxiety disorders (Silverman et al.,
2008). For example, youth who retained their primary anxiety diagnoses following CBT had higher pretreatment levels of self-rated trait
anxiety and self-rated depressive symptoms than youth who were free of their primary anxiety diagnosis at post-treatment. High
pretreatment child rated trait anxiety also was associated with high clinician severity ratings of interference of the youth’s primary anxiety
diagnoses at post-treatment. Also implicated is high mother ratings of their child’s social withdrawal symptoms, as well as teacher ratings
of the child’s anxious/depressed symptoms (Southam- Gerow, Kendall, & Weersing, 2001).
Cognitive Factors
Youths’ self-statements or self-talk prior to treatment also have been implicated in CBT failure (McKay & Storch, 2009). For example,
youths’ anxious self statements, such as ‘‘I am very nervous’’ and ‘‘I am going to make a fool of myself,’’ were associated with less
pretreatment to post-treatment reductions in youth self ratings of fear, anxiety, and depressive symptoms. Further, youth with more
anxious pretreatment self statements than positive self statements (e.g., ‘‘I am a winner,’’ ‘‘I feel good about myself’’) were associated
with less pre to posttreatment reductions in youth self ratings of anxiety symptoms.
Comorbidity
Pretreatment comorbidity is also probably involved in CBT failure among youth (Liber et al., 2010; McKay & Storch, 2009). Youth with a
comorbid diagnosis of depression, for example, were more likely to retain their primary anxiety diagnosis following CBT than youth
without a comorbid depression diagnosis. Additionally, youth with any type of comorbid diagnoses (e.g., anxiety, depressive, disruptive)
were more likely to retain an anxiety diagnosis at posttreatment (Liber et al., 2010). However, some studies have not been able to show
that pretreatment comorbidity is implicated in youth anxiety CBT outcome (McKay & Storch, 2009).
Parent Psychopathology
The presence of anxiety disorders in the mothers and fathers of child patients increases the risk of treatment failure (Bodden et al., 2008;
Cresswell, Willetts, Murray, Singhal, & Cooper, 2008; Gar & Hudson, 2009). Additionally, depression symptoms in mothers and fathers
have been implicated (Liber et al., 2008; McKay & Storch, 2009). Some studies, however, have not found an association between
parental depression symptoms and treatment failure (Crawford & Mannassis, 2001; Southam-Gerow, Kendall, & Weersing, 2001).
Parenting Behaviors and Other Family Factors
Maternal over involvement has also been shown to contribute to CBT failure among youth with anxiety disorders. Mothers’ expressions
of fear, such as being stiff, tense, and fidgety, have been identified in CBT failure (Cresswell et al., 2008). Fathers’ reports of rejecting
their child and children rating their mothers as low in warmth also have been shown as significant predictors of CBT failure (Liber et al.,
2008). Mothers, fathers, and youth who report high family dysfunction and mothers who report high parenting stress tend to predict, and
probably contribute to, CBT failure.
Treatment Processes
Several treatment processes, defined in different ways across studies, predict lower rates of positive response in CBT. For example, the
quality of the therapeutic relationship, defined as the perceived bond between therapist and youth client, predicted higher failure rates
(McKay & Storch, 2009). Lower client involvement in CBT, defined as youths’ willingness to participate in treatment aspects such as
self-disclosure and engagement, has been implicated as well (McKay & Storch, 2009). Specifically, minimal youth involvement at mid
treatment, prior to their participation in exposure tasks, predicted higher clinician severity ratings at posttreatment. Decreases in the
youth therapist alliance, defined as both the quality of the therapeutic relationship and the degree of youths’ willingness to participate in
treatment, also have been implicated in anxiety treatment failure (Chiu, McLeod, Har, & Wood, 2008).
Case Illustration
Presenting Problem and Client Description
Juan, an 8-year-old Hispanic boy in second grade, was referred to our clinic by his school counselor. He lives with both biological parents
and his 5-year-old sister. Juan’s mother telephoned the clinic because he had missed about 30 days of school due to his fear of harm
befalling himself and his mother when they are not together. Juan’s separation anxiety was so severe that he could never be left alone
anywhere in the house. He also could not sleep by himself at night in his own bed. Juan’s school counselor recommended the family
seek help because Juan’s grades had severely declined and he was currently not attending school. Juan was at risk of being expelled
from school because of his excessive absenteeism.
Juan’s mother reported that, since the first day of the school year, Juan cried excessively and had temper tantrums every morning she
tried bringing him to school. Juan’s crying and tantruming were so severe that his mother sometimes turned around and went home with
Juan instead of dropping him off at school, or she picked him up early from school. Juan told his mother he was afraid she would not
come back to pick him up at the end of the school day. Mother reported that ever since Juan stopped attending school, he appeared
sadder and to have lost interest in activities he used to enjoy.
Juan had difficulties being away from his mother since age 2. Mother described him as ‘‘clingy,’’ and even as a toddler, he showed much
anxiety about being in new situations. Juan’s mother provided many examples of how he became highly distressed when she left him
with her mother (Juan’s grandmother) so that she could run errands. He cried, threw tantrums, and begged his mother not leave him.
Juan’s mother responded by not running her errands; instead, she stayed home to allay Juan’s separation protests. Mother reported,
‘‘Juan is so worried I will leave and never come back that he does not want me to ever leave his side.’’ She also indicated that her son
has been sleeping with her and her husband since toddlerhood. Whenever she tried to get him to sleep in his own bed, he would cry and
throw tantrums; she thus ‘‘gives in.’’
Mother also reported that Juan showed difficulties attending and staying in school since he began kindergarten. Juan’s mother was a
stay at home mom from the time of Juan’s birth until the start of kindergarten. She noted that Juan had difficulty in making the transition
from being home all day with her to having to be away from her for the school day. During the first two weeks of kindergarten, mother
reported that Juan cried incessantly and pleaded with her not to leave him. His anxiety about separation from her would not subside
despite her reassurances that she will definitely return, on time, to pick him up at the end of the school day.
When Juan first began kindergarten, his mother reported that she walked her son to his classroom and she stayed in the room with him
for the duration of the school day. After two weeks, however, the vice principal no longer allowed her to stay in the classroom. Thereafter,
his mother had to drop him off at the classroom door. Mother reported that when she left him, ‘‘His screams could be heard all over the
school.’’ Juan’s fussing and protesting about going to school and the amount of time it took to soothe him subsided after the first month of
kindergarten. After the first month, Juan was able to attend and stay in kindergarten with no subsequent significant difficulties for the
remainder of the school year.
Upon entering first grade, Juan again experienced difficulties attending school in the mornings at the start of the school year. Again,
however, Juan’s difficulties subsided after the first month of first grade. Currently, in the second grade, Juan’s difficulties in attending
school were substantially worse than the previous school years. After about a month and a half from the first day of the second grade,
Juan refused going to school altogether. His refusal to attend school has persisted for a month and was still ongoing at the time he
presented to our clinic.
Juan’s mother further reported that this year also was different than past years because he was ‘‘down and upset.’’ When Juan learned
he was failing all his classes he told his mother, ‘‘I can’t do anything right.’’ According to Juan’s mother, hardly anything ‘‘brought him
joy.’’
Juan’s mother reported that her son reached all his developmental milestones ‘‘more or less’’ on time. He learned to walk when he was
1-year-old, and he was toilet trained by age 3. He had no significant delays in speech. There was no history of abuse or neglect. Juan’s
mother further reported she never sought treatment for Juan’s difficulties separating from her before.
In terms of family history, Juan’s mother reported that she suffered her whole life with major depressive disorder and an anxiety disorder.
When she presented to our clinic, she had recently begun taking medication for her depressive and anxiety symptoms. She noted that
previous treatments did not help her. Mother also reported that she felt somewhat better, though she still had ‘‘good days and bad days.’’
She also reported there were conflicts between herself and her husband about Juan’s difficulties. She believed her husband ‘‘simply did
not understand,’’ and she disagreed with him that she ‘‘babied’’ her son.
Assessment
Juan and his mother were administered the ADIS-IV: C/P, child and parent versions, respectively. Juan’s mother responded affirmatively
to the presence of four symptoms of separation anxiety disorder from the Separation Anxiety Disorder module. When asked to give an
interference rating using the Severity Rating Scale, Juan’s mother gave a rating of seven (on the 0- to 8-point scale). Based on Juan’s
mother’s interview, Juan met the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, diagnostic criteria for separation
anxiety disorder.
Juan’s mother also responded affirmatively to the presence of six symptoms of major depressive disorder. She related that ever since
Juan stopped attending school he felt ‘‘down and irritable’’ almost every day and no longer had interest in things he previously enjoyed,
such as attending play dates with friends even if his mother went with him.
Juan’s mother further reported that Juan sleeps a great deal and complains of feeling tired all the time, and that he has feelings of guilt
over ‘‘causing so many problems at home.’’ When asked to give an interference rating using the Severity Rating Scale, Juan’s mother
gave a rating of five. Based on the mother’s interview, Juan also met the diagnostic criteria for major depressive disorder.
Before it was even possible to interview Juan, accommodations had to be made so that his mother was in close proximity to him. Juan
was reassured that he could check in on his mother (who was now sitting right outside the interview room); he did so several times during
the interview. While being administered the ADIS-IV: C interview, Juan appeared nervous and withdrawn as evident by his shaky posture
and his lack of eye contact. He also displayed flat affect throughout the interview.
Juan’s interview report on the Separation Anxiety Disorder module corresponded closely with his mother’s report. The main difference
was that Juan responded affirmatively to the presence of two additional symptoms of separation anxiety disorder: frequent worries that
something bad may happen to him when they are not together and frequent nightmares about harm befalling his mother. When asked to
give an interference rating using the Severity Rating Scale, Juan gave a rating of eight. He therefore met diagnostic criteria for
separation anxiety disorder.
Juan’s interview report on the Major Depressive Disorder module also corresponded closely with his mother’s report. The main
difference was that Juan responded affirmatively to the presence of one additional symptom of major depressive disorder: Difficulty
concentrating. Juan gave an interference rating of six on the Severity Rating Scale. He therefore also met diagnostic criteria for major
depressive disorder.
The Revised Children’s Manifest Anxiety Scale and the Multidimensional Anxiety Scale for Children were also administered to Juan; the
Child Behavior Checklist was administered to Juan’s mother; and the Teacher Report Form was administered to Juan’s homeroom
teacher. Juan’s pretreatment score on the Revised Children’s Manifest Anxiety Scale was 27 and his score on the Multidimensional
Anxiety Scale for Children was 87, both indicative of high anxiety. Scores on the Internalizing and Anxious/Depressed Scales of the Child
Behavior Checklist and Teacher Report Forms also were high and in the clinical range.
Case Formulation
Juan’s primary difficulties attending school were related to his fears about being away from his mother. These separation concerns not
only prevented Juan from being able to stay in school, but also prevented Juan from going to friends’ houses and sleeping alone. These
separation concerns led to high interference in terms of academic failure, deterioration of peer and family relationships, as well as
leading to significant personal distress. In addition, Juan experienced secondary difficulties associated with feelings of depression,
mostly due to his inability to attend school.
The case formulation was based largely on the environmental factors, particularly the maternal behaviors that were inadvertently
maintaining separation anxiety and his avoidant behaviors, and secondarily on genetic factors that led to a biological vulnerability to
anxiety and depression. By giving up her day job to stay at home with her son, by picking him up early from school, and by allowing Juan
to sleep with her and her husband at night, Juan’s separation anxiety was being reinforced. He also was not being provided with
opportunities to learn what might happen if in fact he was separated from his mother. Also, based on what Juan and his mother
described during their interviews, it was apparent that Juan engaged in high amounts of anxious self-statements of catastrophic events
that would occur if he were to be separated from his mother (e.g., mother would die in a car accident). Such anxious self-statements
contributed to maintaining his anxious avoidant behaviors because he had no reason to believe that these self statements or thoughts
lacked evidence (i.e., had low probability of occurring).
Given the large body of evidence for its efficacy, CBT was recommended to alleviate Juan’s anxiety about separating from his mother.
Exposure was used to help Juan gradually face his fears in situations where separation from his mother occurred. Self-control training
was used to help Juan learn how to manage his anxious self-statements regarding harm befalling his mother. Contingency management
was also used to help Juan’s mother learn how to help Juan face his fears and reduce his anxious and avoidant behaviors.
Course of Treatment
Juan’s mother enrolled Juan in CBT at our clinic. The treatment comprised 14 weekly sessions of approximately one hour each session.
Because Juan’s mother appeared to be inadvertently maintaining Juan's anxious and avoidant behaviors, we decided to involve her in
her son's treatment. What follows is a description of the course of treatment with this severe and complex case of separation anxiety
disorder with school refusal behavior and comorbid major depressive disorder.
Sessions one to three: Rapport building, psychoeducation, and the fear hierarchy. The first three treatment sessions comprised rapport
building and strengthening the therapeutic relationship with Juan and his mother. These initial sessions also entailed having a discussion
about the etiology of anxiety disorders and the rationale and goals of treatment. The role of avoidant behavior was also emphasized
because it was important for Juan and his mother to understand how avoiding school and other separation anxiety provoking situations
that Juan avoided maintained Juan's separation anxiety problems. We also devised a fear hierarchy, as shown in Table 1.
Juan's mother wanted Juan to return to school as soon as possible and to stay at school full time by the end of treatment. Juan, on the
other hand, was reluctant to return to school. He was not as engaged in treatment as his mother, evident by his flat affect and minimal
participation (e.g., he said few words in these early sessions). Juan’s therapist explained that for Juan to return to school full time, he
would be asked to gradually go to school during the course of treatment. Juan immediately began to cry and scream inconsolably when
he heard this and indicated he was never returning to treatment. All he wanted was to be ‘‘near mommy.'' The therapist expressed
empathy and explained that because it is difficult for most ‘‘kids to face their fears,'' in this treatment we ask children to face their fears
step by step. This explanation appeared to alleviate some of Juan's concerns.
[begin table]
[ATAC editor’s note: This table has been linearized for easier reading]
Table 1 Fear Hierarchy
o Feared situation
o Most Fearful

Stay at school all day


Stay at school for 5 and a half hours


Fear rating (0-8): 4
Stay at school for 2 and a half hours


Fear rating (0-8): 4
Stay at school for 3 hours


Fear rating (0-8): 5
Stay at school for 3 and a half hours


Fear rating (0-8): 5
Stay at school for 4 hours


Fear rating (0-8): 6
Stay at school for 4 and a half hours


Fear rating (0-8): 7
Stay at school for 5 hours


Fear rating (0-8): 8
Fear rating (0-8): 4
Stay at school for 2 hours each day

Fear rating (0-8): 3
o Least Fearful

Get dressed in the mornings as if you were going to go to school, and have mom drive you around the school for 10
minutes.

Fear rating (0-8): 2
Note. Youths’ fear ratings are based on the Severity Rating Scale, which also assesses for severity of fear related to anxiety-provoking
situations.
[end table]
Sessions four to six:
Graded exposures tasks, contingency management, and self-control. The initial exposures involved having Juan gradually start
attending school again. To help accomplish this, Juan's mother contacted the school principal, the school counselor, and the teacher to
explain how Juan would be trying to attend school in a gradual fashion (e.g., on the first day back, he would stay for the first two hours of
the school day).
The school personnel agreed to accommodate and agreed to allow Juan to finish his classroom assignments at home. Juan’s mother
corresponded weekly with Juan’s teacher to coordinate classroom and homework assignments.
The treatment plan was for Juan to gain confidence and mastery over the exposure task; thus, the therapist assigned a relatively easy
first out of session exposure task (the first step of the fear hierarchy): Getting dressed in the mornings as if he was going to go to school,
and driving around the school for 10 minutes (Table 1). Juan was asked to complete this task at least three times during the week. If
Juan completed this task without fussing, whining, or throwing a tantrum, then mother was asked to reward him with an extra half hour
TV time at night. Juan did not have any difficulties driving around the school in the mornings, or getting dressed, but problems soon
arose after Juan’s first exposure task at school.
When mother drove up to the front of the school, Juan began crying and screaming that he did not want to stay because she would not
return to pick him up. Juan’s mother began to experience anxiety at this point of separation, and began to waiver in terms of whether she
should insist that Juan leave her. Fortunately, the school counselor had agreed to walk Juan to his classroom and so she was waiting for
Juan and his mother at the car pool lane. The school counselor was successful in pulling Juan and his mother apart and, after much
reassurance, Juan walked with the school counselor to his classroom. Unfortunately, one hour later, Juan’s mother reported she could
not stand the idea of Juan being so miserable, and she felt terribly anxious that Juan would not be able to handle being at school for 2
hours. Thus, she decided on her own to go back to the school and bring Juan home.
In addition to exposure, we developed a parent-child contingency contract each week, which included clear and specific instructions
about the exposure task Juan needed to perform each week. It included the reward mother was to give her son contingent on his
completion of the exposure task. Additionally, Juan’s mother was taught behavioral principles such as positive and negative
reinforcement and extinction. She was instructed to provide Juan with a positive consequence after he tried to attend school. She was
instructed not to allow Juan to avoid situations where separation between he and her occurred, and to not respond to his anxious and
avoidant behaviors (e.g., fussing, whining, tantruming).
Two things went wrong with the contingency management. First, as described above, when mother decided on her own to pick up Juan
early from school, she argued that ‘‘it was a rough day for the two of them’’ and thus decided that the two of them ‘‘deserved a nice
lunch.’’ From this (and other examples throughout treatment), it was clear that mother had difficulties implementing behavioral
contingencies. Second, it was difficult to even identify positive activities that were motivating or rewarding to Juan. Perhaps Juan’s lack
of interest in rewards was related to Juan’s comorbid depressive disorder: He had lost interest in almost all things that used to give him
pleasure.
Self-control training was employed to help Juan modify his fearful self-talk into coping self talk and to develop plans for coping with his
anxiety more effectively. To facilitate Juan’s recall of this method, we introduced the acronym STOP (S for scared; T for thoughts; O for
other thoughts; P for praise). Using STOP effectively proved challenging with Juan. A main challenge was that because mother was in
fact usually not allowing the exposures to occur (because she would pick him up and thus not allow the separation exposures to occur),
Juan did not gain opportunities to learn that there was little, if any evidence, that harm would not befall his mother if they were apart.
Sessions 7-10:
Continued exposure tasks and addressing parental concerns. The second half of treatment focused on continuing to help Juan complete
his exposure tasks at school. Again, Juan’s mother was inconsistent in assisting in Juan’s completion of his assigned exposures. Despite
the parent training and contingency management explanations, Juan’s mother ‘‘gave in’’ to her son’s tantrums and excessive separation
protesting behaviors. She acknowledged in treatment that she found it difficult to allow her son to be in distress and, as a mother, it was
‘‘her job to protect her son.’’
In speaking further with Juan’s mother, it became apparent that her own anxiety was a contributing factor. She was feeling increasingly
anxious at the sight of her son’s struggle when she would try to take him to school in the mornings. Mother was feeling guilty asking her
son to do something that was so clearly hard for him to do. She noted that her husband’s lack of empathy and support contributed and
thought that her husband was too harsh and rejecting towards Juan.
At the end of session 10, Juan had yet to complete most of his exposure tasks. He still did not stay in school for a full day. He had
remained in school for only 2 hours each day at this juncture, the second step of the hierarchy, which he rated 3 on the 0- to 8-point scale
(see Table 1).
Sessions 11-14:
Addressing factors interfering with progress. The final phase of CBT typically entails teaching the child and parent relapse prevention
strategies. Given only the slight gains made by Juan, we chose not to emphasize relapse prevention. Instead, we emphasized factors
that were interfering with Juan’s success in the treatment. For example, the therapist recommended that Juan’s parents seek marital
therapy to address their conflicts and their argument regarding Juan’s disorders. It was apparent that marital therapy would likely help
them resolve other conflictual issues beyond Juan.
The therapist worked more closely with Juan’s mother to reduce her own anxiety when it came to assisting Juan with exposure tasks.
The therapist encouraged Juan’s mother to apply similar self-control strategies that were being taught to Juan and to model these
self-control skills in Juan’s presence so he could observe her coping more effectively. Juan’s mother also received additional training in
contingency management skills. The therapist helped Juan’s mother generate alternative ways to respond to Juan’s avoidant behaviors
rather than giving in to his separation protests (e.g., Juan’s mother would instruct Juan ‘‘use what you are learning in the treatment’’
when he was protesting separation at home and then she walked away).
Finally, to address Juan’s comorbid diagnosis of major depressive disorder, the therapist recommended that Juan schedule activities
that he found pleasurable. For example, play dates with Juan and his school friends. If necessary, mother was instructed to stay with her
son during the play dates if it was too anxiety provoking for Juan to be there without his mother.
Outcome and Prognosis
At the end of the treatment (session 14), Juan remained in school for 3 hours each day, which was only the fourth step of the fear
hierarchy. He experienced less distress staying home when his mother left to run errands compared with the start of treatment. Juan also
spent more time playing with his friends rather than staying home all the time, even though he still needed his mother to be with him
when he was at friends’ houses. Despite these advances, Juan was still unable to stay in school for a full day. He also continued to have
difficulties sleeping alone in his room at night.
Juan’s continued separation anxiety and major depressive disorder were further evidenced by the results of the post-treatment
assessments. According to Juan’s mother’s report on the ADIS-IV: P, Juan continued to meet diagnostic criteria for separation anxiety
disorder. However, her rating on the Severity Rating Scale now dropped from seven to five. Similarly, although Juan continued to meet
diagnostic criteria for major depressive disorder according to his mother’s report, her rating dropped from five to four. According to Juan’s
report on the ADIS-IV: C, he also continued to meet diagnostic criteria for separation anxiety disorder. His rating on the Severity Rating
Scale, however, dropped from eight to six. He also continued to meet diagnostic criteria for major depressive disorder, but his rating
dropped too from 6 to 4.
Juan’s score on the Revised Children’s Manifest Anxiety Scale dropped from 27 to 24 at post-treatment and his score on the
Multidimensional Anxiety Scale for Children dropped from 87 to 82. Despite these symptom reductions over the course of CBT, the
post-treatment scores still indicated high levels of anxiety.
This was true as well for the Internalizing and Anxious/Depressed Scale scores on the Child Behavior Checklist and Teacher Report
Forms, which both continued to be in the clinical range at post-treatment.
Juan’s full recovery following treatment will probably depend on several factors. First, it will be important for Juan to continue his
exposure tasks. To facilitate Juan’s implementation of the exposure tasks after treatment, Juan, his mother, and his counselor devised a
plan where Juan would continue to increase the amount of time he stayed in school until he stayed the full day. A plan also was devised
to help Juan gradually go to sleep by himself in his own bed, once he stayed in school the full day. Second, Juan’s mother will need to
continue to model self control skills in Juan’s presence and practice contingency management skills. It will also probably prove useful for
Juan’s mother to continue to schedule pleasurable activities with the goal of eventually having mother drop Juan off at his friends’
houses instead of her staying with him.
Clinical Practice and Summary
Juan is an example of an anxious youth who failed to show significant improvement after being treated with a research-supported CBT.
Juan’s failure to respond to CBT was likely because of, in part, the presence of several factors that have been implicated in treatment
failure: the high severity of his symptoms, comorbidity with depression, parental psychopathology, marital conflict, and minimal
engagement in, and commitment to, the treatment.
How might such failures be reduced in the future? We recommend that clinicians working with severe cases of youth anxiety identify
those factors that have been implicated in treatment failure and attend to them during the course of treatment. It may be necessary, as it
was in the case of Juan, to address some of these factors to help the youth move forward in treatment. For example, it might be helpful to
recommend that parents seek marital therapy to reduce their conflicts, especially conflicts centering on their child’s difficulties. When one
or both parents have anxiety or depression, it also might be helpful for the parent(s) to receive individual therapist attention so that the
parent(s) can learn anxiety reduction procedures. We also have often worked with the child and parent together in treatment and have
targeted simultaneously the child and parent anxiety problems (e.g., ask the dyad to complete an out- of-session exposure task
together). For anxious youth with comorbid diagnoses such as depression, it also can be useful to ask the youth to practice similar
strategies, such as obtaining the evidence, not just in situations that elicit anxious reactions but also depressive reactions.
Although we identified factors that may have contributed to Juan’s treatment failure and addressed these factors during the course of
treatment, it is possible that Juan would have shown more improvement if his treatment was of a longer duration than 14 sessions.
Additional sessions could have provided Juan and his mother with more opportunity to practice the skills they learned in the treatment. In
addition, given the evidence for the efficacy of combined CBT and pharmacotherapy to reduce anxiety in youth (Walkup et al., 2009),
another possibility to reduce treatment failure could have been to recommend continued CBT and use of selective serotonin reuptake
inhibitors. Both possibilities, however, await further empirical verification because to date, there is no evidence that ‘‘more treatment’’
means ‘‘more improvement.” There also is no evidence that following unsuccessful CBT with medication can help rectify the previous
unsuccessful CBT course. Further research is needed on these and other issues to draw firm conclusions about preventing treatment
failure of CBT in the future.
Acknowledgments
This article was supported in part by grants from the National Institute of Mental Health (R01MH079943, K24MH73696).
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