Cheng-Fang Yen Yu-Min Chen Jen-Wen Cheng Tai-Ling Liu Tzu-Yu Huang Peng-Wei Wang Pinchen Yang Wen-Jiun Chou

Child Psychiatry Hum Dev (2014) 45:338 347 DOI 10.1007/s10578-013-0403-9 ORIGINAL ARTICLE Effects of Cognitive-Behavioral Theray on Imroving Anxiety Symtoms, Behavioral Problems and Parenting Stress in Taiwanese Children with Anxiety Disorders and Their Mothers Cheng-Fang Yen Yu-Min Chen Jen-Wen Cheng Tai-Ling Liu Tzu-Yu Huang Peng-Wei Wang Pinchen Yang Wen-Jiun Chou Published online: 4 Setember 2013 Ó Sringer Science+Business Media New York 2013 Abstract The aims of this intervention study were to examine the s of individual cognitive-behavioral theray (CBT) based on the modified Coing Cat Program on imroving anxiety symtoms and behavioral roblems in Taiwanese children with anxiety disorders and arenting stress erceived by their mothers. A total of 24 children with anxiety disorders in the treatment grou comleted the 17-session individual CBT based on the modified Coing Cat Program, and 26 children in the control grou received the treatment as usual intervention. The Taiwanese version of the MASC (MASC-T), the Child Behavior Checklist for Ages 6 18 (CBCL/6-18) and the Chinese version of the C.-F. Yen Y.-M. Chen T.-L. Liu P.-W. Wang P. Yang Deartment of Psychiatry, Faculty of Medicine, Kaohsiung Medical University Hosital, Kaohsiung Medical University, Kaohsiung, Taiwan C.-F. Yen Y.-M. Chen T.-L. Liu P.-W. Wang (&) P. Yang Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, No. 100, Tzyou 1st Road, Kaohsiung 807, Taiwan e-mail: wistar.huang@gmail.com J.-W. Cheng Deartment of Psychiatry, Kaohsiung Veterans General Hosital, Kaohsiung, Taiwan T.-Y. Huang Deartment of Psychology, College of Humanities and Social Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan W.-J. Chou (&) Deartment of Child and Adolescent Psychiatry, Chang Gung Memorial Hosital, Kaohsiung Medical Center and College of Medicine, Chang Gung University,, Ta-Pei Rd., Niao-Sung Hsiang, Kaohsiung 83342, Taiwan e-mail: wjchou@adm.cgmh.org.tw Parenting Stress Index (C-PSI) were alied to assess the severities of anxiety symtoms, behavioral roblems and arenting stress, resectively. The s of CBT on imroving anxiety symtoms, behavioral roblems and arenting stress were examined by using linear mixed model with maximum likelihood estimation. The results indicated that the CBT significantly imroved the severities of MASC-T Physical Symtoms and Social Anxiety subscales, CBCL/6-18 DSM-oriented Anxiety Problem subscale, and C-PSI Child domains Mood and Adatability subscales. Individual CBT based on the modified Coing Cat Program can otentially imrove anxiety symtoms in Taiwanese children with anxiety disorders and some child domains of arenting stress erceived by their mothers. Keywords Anxiety disorder Children Cognitivebehavioral theray Parenting stress Introduction Anxiety disorders in children and adolescents are characterized as having high revalences [1] and chronic courses [2]. Anxiety disorders may result in debilitating consequences in children and adolescents [3]. For examle, anxiety disorders may comromise youths self-esteem, social relationshis and academic erformance [4]. Anxiety disorders in children and adolescents may also redict the occurrence of anxiety disorders in adulthood [5] and increase the risk of other sychiatric disorders [6]. A 5-year follow-u study has found that childhood searation anxiety disorder significantly increases the risk for the subsequent develoment of secific hobia, agorahobia, anic disorder, and major deression [7]. A review study

Child Psychiatry Hum Dev (2014) 45:338 347 339 has summarized that early anxiety symtoms or disorders, whether found in clinical, community, eidemiologic, or offsring-at-risk samles, significantly increase the risk of meeting criteria for anxiety disorders later in life [8]. Early detection and intervention for anxiety disorders may reduce the damage to individuals functional imairment and the risk of ersisting into adulthood [9]. Exosure-based cognitive-behavioral theray (CBT) is the sychotheray model that has been found to be ive in imroving anxiety symtoms among children and adolescents [10, 11]. The Coing Cat Program develoed by Kendall and Hedtke [12] is one of the most commonly used CBT rograms for children with generalized anxiety disorder, social hobia, or searation anxiety disorder. The targets of the Coing Cat Program are to hel children recognize and analyze anxious feelings and develo strategies to coe with anxiety-rovoking situations. The rogram focuses on four related comonents: (1) recognizing anxious feelings and hysical reactions to anxiety; (2) clarifying feelings in anxiety-rovoking situations; (3) develoing a coing lan (for examle, modifying anxious self-talk into coing self-talk, or determining what coing actions might be ive); and (4) evaluating erformance and administering self-reinforcement [12]. Previous studies have suorted the iveness of the Coing Cat Program for anxious children and adolescents [13, 14]. Meanwhile, follow-u studies also indicated that the s of the Coing Cat Program for anxious children can ersist for a long eriod [15 17]. There are, however, several issues regarding the s of CBT based on the Coing Cat Program in children with anxiety disorders that require further study. First, most of the revious studies on the s of the CBT were conducted in Western countries, and very few studies have examined the of CBT for anxious children in Asia. Research has found significant differences in the levels of anxiety symtoms on the Multidimensional Anxiety Scale for Children (MASC) between Taiwanese and American children and adolescents [18], as well as between Chinese and American adolescents [19]. The authors attributed the differences in anxiety symtoms to the differences in culture, background and arent rearing behaviors between Asian and American societies [18, 19]. For examle, Taiwanese and Chinese adolescents had higher scores on the social anxiety scale than the American adolescents [18, 19]. One exlanation is that Chinese culture based on Confucianism is more collectivistic-orientated than Western culture, and the difference in value orientation makes adolescents in Chinese culture-based society lace greater imortance on social relationshis than American adolescents [19]. Whether the difference in value orientation has any influence on the of CBT on childhood anxiety in Asian countries needs further examination. To the best of our knowledge, only one study in Hong Kong [20] and one in Jaan [21] have examined the of CBT on childhood anxiety in Asian countries, and both reorted ositive s on imroving anxiety symtoms. Further study is needed to confirm the of CBT in Asian children with anxiety disorders as seen in Western countries. Another issue that requires further examination is the of CBT on imroving arenting stress among arents of children with anxiety disorders. Parenting stress is the ressure exerienced by arents rooted in their interactions with their children [22]. Research has found that mothers of children with anxiety disorders exerience significant stress when managing their children s anxious feelings and behaviors [23]. Parents may modify their request, exectation and arenting behaviors to reduce arenting stress; however, the modification may further maintain children s anxiety and avoidance behaviors [24]. On the other hand, arenting stress has also been considered a redictor of anxiety symtoms in children [25] and may have negative imacts on family interaction [26]. A recent study has found that child-focused anxiety treatments can result in imrovements in arental sychological distress, trait anxiety, and arent-reorted family dysfunction for arents of children who were rated as treatment resonders [27]. Further study is needed to examine whether CBT can imrove the severity of arenting stress exerienced by the mothers of children with anxiety disorders. The third issue requiring further study is whether CBT for anxious children can imrove their externalizing behavior roblems in Asian children. Research has found that externalizing symtoms often co-occur with anxiety symtoms and may be articularly manifest in anxietyrovoking contexts [28]. It raises the ossibility that for some children with anxiety disorders externalizing behaviors may imrove when their anxiety disorders subside. A revious study has found that the externalizing behavioral roblems of children with anxiety disorders did imrove in the course of CBT, and thus measurements of externalizing behaviors were suggested to be included when evaluating the of CBT for children with anxiety disorders [29]. However, comared with the targeted anxiety symtoms, the changes in externalizing behavioral roblems have been measured much less often in revious studies on the of CBT for children with anxiety disorders. In the revious two studies examining the s of CBT on imroving children s anxiety symtoms in Asia, the study of Ishikawa and colleagues [21] did not include the control grou, and both the studies of Ishikawa et al. [21] and Lau et al. [20] did not examine the s of CBT on imroving children s behavioral roblems other than anxiety symtoms and arents erceived arenting stress. There has been no study examining the s of CBT on imroving children s anxiety symtoms, behavioral

340 Child Psychiatry Hum Dev (2014) 45:338 347 roblems and arenting stress in Taiwanese children with anxiety disorders. The aims of this study were to examine the s of individual CBT based on the modified Coing Cat Program on imroving anxiety symtoms and behavioral roblems in Taiwanese children with anxiety disorders. This study also aimed to examine the of individual CBT on imroving arenting stress exerienced by the mothers of Taiwanese children with anxiety disorders. We hyothesized that the individual CBT based on the modified Coing Cat Program can imrove the severities of anxiety symtoms, internalizing and externalizing behavioral roblems and arenting stress in Taiwanese children with anxiety disorders and their mothers. Methods Particiants Particiants of the treatment and control grous in this study were recruited from the child sychiatric outatient clinics of two teaching hositals in southern Taiwan. All articiants visited outatient clinics for anxiety-related roblems. A total of 30 children with anxiety disorders according to the diagnostic criteria in the Diagnostic and statistical manual of mental disorders-iv text revision (DSM-IV-TR) [30] were invited to receive CBT based on the Coing Cat Program. The diagnoses of anxiety disorders were made by three child sychiatrists based on the results of clinician interview and history rovided by the arents. Of them, 24 children (12 girls and 12 boys, mean age of 9.1 years, standard deviation [SD]: 1.8 years, range 7 12 years) comleted the full 17-session CBT and all assessments, and they were classified as the treatment grou. Of the 6 children who did not receive the full 17-session CBT, 3 children droed out of treatment before comleting the first eight sessions of CBT due to ersonal reasons. The other 3 children started to receive medication for their anxiety symtoms during their first eight sessions of CBT. Because all of them did not comlete the later eight sessions using exosure tasks, we did not include these 6 children into analysis because exosure is the core concet of the Coing Cat Program. No difference in sex ( of Fisher s exact test [0.05), age ( of Mann Whitney U test [0.05) or mother s educational level ( of Mann Whitney U test [0.05) was found between the treatment comleters and the non-comleters. Another 20 children with anxiety disorders who exressed the consent to receive CBT but no theraist available immediately were ut on the waiting list for CBT. Meanwhile, 12 children with anxiety disorders refused to articiate in this treatment rogram. Thus a total of 32 children with anxiety disorders were recruited into the control grou. A total of 26 children (14 girls and 12 boys, mean age: 9.5 years, SD: 1.6 years, range 7 12 years) received the re-treatment and ost-treatment assessments, and they were classified as the control grou. Although articiants in the control grou were not matched with those in the treatment grou on sex, age or mother s education level, there was no difference in sex (v 2 = 0.238, [ 0.05), age (t = 0.881, [ 0.05) or mother s educational level (t = 0.648, [ 0.05) between the treatment and control grous. All articiants of the treatment and control grous had intact arental marriage status. Regarding the diagnoses of anxiety disorders, 18 and 20 articiants in the treatment and control grous had generalized anxiety disorder, resectively, 10 and 11 articiants in the treatment and control grous had social hobia, resectively, and 2 and 2 articiants in the treatment and control grous had searation anxiety disorder, resectively. A total of 6 and 7 in the treatment and control grous had dual diagnoses of anxiety disorders, resectively. The Institutional Review Board (IRB) of Kaohsiung Medical University aroved the study. The Modified Coing Cat Program The 16-session Coing Cat Program develoed by Kendall and Hedtke [12] is one of the commonly used manualized CBT rograms for children with searation anxiety disorder, generalized anxiety disorder, and social hobia. The original Coing Cat Program was comosed of three arts of individual treatment: (1) 7 sessions (Sessions 1 3 and 5 8) for skill introduction and training, including building raort and treatment orientation, identifying anxious feelings, identifying somatic resonses to anxiety, relaxation training, identifying anxious self-talk and learning to challenge, develoing roblem solving skills, and introducing self-evaluation and self-reward, (2) 7 sessions (Sessions 10 16) for skill racticing in low, moderate and high anxiety-rovoking situations using exosure tasks, and (3) 2 sessions (Sessions 4 and 9) for meeting with arents to teach the skills that the arents could use to hel their children to coe with anxiety [12]. In the ilot study alying the Coing Cat Program, we found that arents might not understand the core sirit of the Coing Cat Program in the first three sessions and had difficulties in heling their children to ractice the skills learned, and thus the ossibility of droing out of the Coing Cat Program during the first three sessions increased. Thus, we added one session (the first session) for meeting with mothers to introduce the treatment rogram and to teach the basic skills that the mothers could use to hel their children to coe with anxiety during the first 1 month of treatment. Meanwhile, we modified the terms, ictures in the working manual and anxiety-rovoking situations used

Child Psychiatry Hum Dev (2014) 45:338 347 341 in the treatment based on the local conditions in Taiwan to hel the children and their mothers to understand the concets of treatment. For examle, in the original Coing Cat Program the abbreviation F-E-A-R (Feeling Frightened-Execting bad things to haen-attitudes and Actions that can hel-results and Rewards) was used to reresent the four core concets of CBT. In the modified Coing Cat Program we used four written Chinese characters ( Xin-Xiang-Shi-Cheng ) to reresent the four concets reresented by F-E-A-R, resectively. Because Xin-Xiang-Shi-Cheng is a common term used in the Taiwanese society, the transformation can hel the articiants with learning the four core concets of the Coing Cat Program. Three sychologists erformed individual treatment at the frequency of one session er week. All sychologists had received a comrehensive training course for CBT, including reading and conducting the modified Coing Cat Program for three children with anxiety disorders under individual suervision in their master s degree rogram. The contents of intervention for each articiant were discussed in the weekly research meeting to make sure theraists adherence to the manual-guided CBT. Assessment The severities of anxiety symtoms and behavioral roblems of the children and the arenting stress of their mothers were assessed before the start of the treatment rogram (re-treatment) and after comleting the seventeenth session (ost-treatment) in the treatment grou. The re-treatment and ost-treatment severities of anxiety symtoms, behavioral roblems and arenting stress in the control grou were assessed in the same 17-week eriod. Children comleted the Taiwanese version of the MASC (MASC-T) to assess the severity of the children s selfreorted anxiety symtoms. The MASC-T is comosed of 39 items answered on a Likert 4-oint scale, with 0 indicating never true about me, 1 indicating rarely true about me, 2 indicating sometimes true about me, and 3 indicating often true about me [31, 32]. The MASC-T contained four subscales: Physical Symtoms, Harm Avoidance, Social Anxiety, and Searation/Panic. Meanwhile, the MASC-T contained the Anxiety Disorder Index (ADI) indicating the tendency to have anxiety disorders on the DSM [30]. The higher scores indicated more severe anxiety symtoms. The sychometrics of the MASC-T have been reorted elsewhere [32]. In brief, the internalconsistency reliability (Cronbach s a coefficients) of the total score on the MASC-T ranged from.871 to.895, indicating good internal consistency. The 1-month test retest reliability of the MASC-T was in the satisfactory to excellent range, with single intraclass correlation coefficients (ICC) ranging from.727 to.897, and the average ICC ranged from.842 to.946 ( \ 0.001). Children and adolescents with any anxiety disorder had higher scores on the total MASC-T than those without any anxiety disorder (t =-4.205, \ 0.001), which suorted the discriminant validity of the total MASC-T for any anxiety disorder [32]. Mothers of the children were invited to comlete the Child Behavior Checklist for Ages 6 18 (CBCL/6-18) [33, 34] to assess the children s behavioral roblems. The CBCL/6-18 consists of behavior/emotional items that are scored 0 if not true, 1 if somewhat true or sometimes true, and 2 if very true or often true. The CBCL/6-18 is comosed of Anxious/Deressed, Withdrawn/Deressed, Somatic Comlaints, Social Problems, Thought Problems, Attention Problems, Rule-Breaking Behavior and Aggressive Behavior syndrome subscales. The first three syndrome subscales comrised the Internalizing Problems syndrome, and the last two comrised the Externalizing Problems syndrome. The higher scores indicated more severe behavioral roblems. A revious study found that the internal consistency and 1-month test retest reliability of the CBCL were satisfactory for Taiwanese adolescents [35]. The CBCL/6-18 also ossesses DSM-Oriented Scales, including Anxiety Problems, Affective Problems, Somatic Problems, Attention Deficit/Hyeractivity Problems, Oositional Defiant Problems and Conduct Problems, constructed through exert clinical judgment to match selected categories for behavioral/emotional roblems as described in the DSM-IV [30]. The mothers of the children also comleted the Chinese version of the Parenting Stress Index (C-PSI) [36, 37] to assess child and maternal sychosocial roblems related to arenting stress. The C-PSI consists of a child domain and a arent domain. The child domain score reflects arental stress associated with the child s individual characteristics as measured on 6 subscales: Distractibility/Hyeractivity, Adatability, Reinforces Parent, Demandingness, Mood, and Accetability. The arent domain reflects arental stress associated with the arental role and is measured on 7 subscales: Cometence, Isolation, Attachment, Health, Role Restriction, Deression, and Souse. Mothers rated their level of agreement with the items on a 5-oint Likert scale. Higher scores indicate more arenting stress. Procedures and Statistics The articiants in the treatment grou received the 17-session CBT based on the modified Coing Cat Program manual. The articiants and their mothers in the control grou received the treatment as usual (TAU) intervention, including sycho-education for knowledge of anxiety disorders, basic muscle relaxation skills, and

342 Child Psychiatry Hum Dev (2014) 45:338 347 individual suortive counseling. The 20-min TAU intervention was conducted every 2 weeks in the 17-week eriod. There were 3 children starting to receive CBT and 3 starting to receive medication for their anxiety symtoms before ost-treatment assessment. These 6 children were removed from the control grou. Particiants in the treatment and control grous were assessed on the MASC-T before and after intervention during the same 17-week eriod. Their mothers comleted the CBCL/6-18 and C-PSI at the same time. In this study we used the linear mixed- model with maximum likelihood estimation to examine the s of the CBT on imroving the scores on the MASC-T, CBCL/6-18 and C-PSI. In the linear mixed- model grou (0: control; 1: treatment) was included as the between subjectfactor, time (0: retreatment; 1: osttreatment) as the within-subject factor, and their interaction (grou 9 time) as the treatment. Meanwhile, sex and age were included to control their s. A two-tailed value of less than 0.05 was considered statistically significant. Results Pre-treatment and ost-treatment MASC-T anxiety symtoms, CBCL/6-18 behavioral roblems and C-PSI arenting stress in the treatment and control grous are shown in Table 1. At the retreatment assessment, the treatment grou had higher scores on the CBCL/6-18 Anxious/ Deressed Syndrome subscale (t =-2.427, = 0.019), CBCL/6-18 DSM-Oriented Anxiety Problems subscale (t =-3.087, = 0.003) and C-PSI Child domain Adatability subscale (t =-2.447, = 0.018) than the control grou. The control grou had a higher score on the CBCL/ 6-18 DSM-Oriented Attention Deficit/Hyeractivity Problems subscale (t = 3.284, = 0.002) than the treatment grou. No significant differences in the other domains or subscales were found between the treatment and control grous. The results of examining the of CBT on the MASC-T anxiety symtoms in the eriod of treatment are shown in Table 2. The results indicated that CBT significantly imroved the severities of the MASC-T Physical Symtoms and Social Anxiety subscales, ADI and total MASC-T anxiety symtoms. The results of examining the of CBT on the CBCL/6-18 behavioral roblems in the eriod of treatment are shown in Table 3. The results indicated that CBT significantly imroved the severities of the DSM-oriented Anxiety Problems subscale. Although CBT tended to imrove the CBCL/6-18 Anxious/Deressed ( = 0.077) and Internalizing Problems syndrome subscales ( = 0.056), the values did not reach statistically significant level. CBT did not significantly imrove the severities of other behavioral roblems on the CBCL/6-18. The results of examining the of CBT on the C-PSI arenting stress in the eriod of treatment are shown in Table 4. The results indicated that CBT significantly imroved the severities of arenting stress on the mood and adatability subscales of the C-PSI Child domains. However, CBT did not significantly imrove the severities of arenting stress on the C-PSI Parent domains. Discussion The first main finding of this study was that CBT based on the modified Coing Cat Program can significantly imrove both child-reorted and mother-reorted anxiety symtoms. The results confirmed that although Taiwanese children may have different levels of anxiety symtoms comared with American children [18], CBT focusing on teaching the nature of and coing skills for anxiety symtoms, cognitive restructuring and exosure in real situations can imrove the severity of anxiety symtoms for children in a non-western cultural context. An eidemiological study found that 9.2 % of students at grade 7 in Taiwan had any anxiety disorder [38]. Effective treatment rograms for Taiwanese children and adolescents with anxiety disorders are imortant. Further study is needed to examine whether the mechanisms of change in CBT vary across cultures. For examle, research has found that CBT can hel children to use active coing strategies for anxiety symtoms in American children [39]. Further study is needed to examine whether it works the same in non- American children. Meanwhile, although we modified the terms, ictures and exosure tasks in the Coing Cat Program based on the local conditions in Taiwan, we did not modify the CBT based on the differences between Chinese and American cultures, for examle, the collectivistic value orientation, that may account for the differences in the severities of anxiety symtoms between Taiwanese and American adolescents. Further study is needed to develo the culture-orientated CBT model for children with anxiety disorders. Further study is also needed to comare the sizes between the studies of the Coing Cat Program in Asian and Western cultures. This study found that CBT for children with anxiety disorders can significantly imrove arenting stress on the Mood and Adatability subscales of the C-PSI Child domains. The imrovement of Child domain arenting stress may be due to fewer arent child conflicts after the imrovement of children s mood and adatability after CBT. Meanwhile, research has found that after CBT, mothers reorted significant increases in their likely use of ositive reinforcement, modeling and reassurance when

Child Psychiatry Hum Dev (2014) 45:338 347 343 Table 1 Pre-treatment and ost-treatment MASC-T anxiety symtoms, CBCL/6-18 behavioral roblems and C-PSI arenting stress in the treatment and control grous AD/H attention deficit/ hyeractivity, CBCL/6 18 child behavior checklist for ages 6 18, C-PSI Chinese version of the arenting stress index, MASC-T Taiwanese version of the Multidimensional Anxiety Scale for Children, SD standard deviation Treatment grou Pre-treatment mean (SD) Post-treatment mean (SD) Control grou Pre-treatment mean (SD) Post-treatment mean (SD) MASC-T anxiety symtoms Physical symtoms 10.1 (6.5) 5.9 (5.9) 6.2 (5.7) 5.8 (5.4) Harm avoidance 15.2 (5.3) 14.2 (4.3) 12.8 (6.4) 14.0 (4.9) Social anxiety 13.9 (7.3) 9.3 (7.0) 13.3 (6.2) 12.5 (7.6) Searation/anic 13.2 (5.1) 11.5 (6.1) 11.3 (6.6) 10.6 (6.3) Anxiety disorder index 14.2 (5.1) 11.2 (4.6) 11.9 (4.8) 11.8 (5.1) Total MASC-T 52.5 (16.7) 40.9 (16.2) 43.6 (15.3) 42.8 (16.3) CBCL/6-18 syndrome subscale Anxious/deressed 11.4 (6.1) 7.8 (5.0) 7.8 (5.0) 6.5 (4.8) Withdrawn/deressed 4.4 (3.0) 2.9 (2.7) 3.6 (2.8) 3.2 (2.6) Somatic comlaints 4.1 (3.6) 2.8 (3.0) 3.9 (3.5) 3.3 (2.5) Internalizing roblems 19.8 (10.1) 13.4 (9.2) 15.4 (9.5) 13.0 (8.1) Rule-breaking behavior 3.8 (3.6) 2.5 (2.9) 5.4 (4.3) 4.2 (2.5) Aggressive behavior 10.6 (7.1) 7.3 (6.5) 11.3 (7.3) 8.5 (5.0) Externalizing roblems 14.4 (10.1) 9.8 (9.0) 16.7 (10.9) 12.7 (7.0) Social roblems 6.6 (4.2) 4.9 (4.3) 7.4 (4.2) 6.3 (4.0) Thought roblems 5.8 (4.4) 4.2 (4.6) 5.2 (4.2) 4.4 (3.7) Attention roblems 7.6 (4.7) 6.2 (4.9) 11.4 (4.4) 11.0 (4.8) CBCL/6-18 DSM-oriented subscale Anxiety roblems 6.9 (3.3) 4.7 (2.8) 4.2 (2.7) 3.6 (2.5) Affective roblems 6.2 (4.3) 3.9 (3.6) 5.4 (3.3) 4.5 (3.2) Somatic roblems 1.8 (2.3) 1.1 (1.8) 2.0 (2.6) 1.6 (1.8) ADH roblems 5.8 (3.2) 4.6 (3.5) 9.1 (3.3) 8.3 (3.2) Oositional defiant roblems 4.5 (2.5) 3.6 (2.4) 4.9 (2.8) 4.2 (2.3) Conduct roblems 3.3 (4.1) 2.0 (2.7) 5.5 (5.0) 3.8 (2.7) C-PSI arent domain Total 138.6 (18.8) 134.5 (22.3) 135.7 (23.8) 128.2 (23.6) Cometence 29.2 (5.8) 27.1 (5.2) 28.9 (6.7) 27.7 (5.3) Attachment 13.7 (3.7) 13.6 (3.1) 14.4 (3.5) 13.2 (3.8) Role restriction 20.0 (5.8) 19.8 (5.9) 18.5 (5.8) 17.3 (4.9) Deression 25.5 (4.7) 24.8 (4.6) 25.0 (5.7) 23.3 (6.4) Souse 21.9 (4.3) 22.1 (4.5) 21.2 (4.7) 20.9 (5.3) Isolation 16.7 (4.0) 16.2 (3.7) 17.6 (7.7) 15.3 (4.4) Health 11.6 (3.5) 10.9 (3.0) 11.2 (2.9) 10.5 (3.0) C-PSI child domain Total 124.1 (24.7) 109.5 (25.5) 119.7 (24.4) 113.4 (24.1) Distractibility/hyeractivity 18.7 (6.6) 17.7 (6.4) 22.1 (6.1) 20.7 (5.9) Reinforces arent 10.1 (3.0) 9.4 (2.4) 10.1 (2.8) 9.3 (2.4) Mood 15.5 (4.1) 12.6 (3.8) 13.8 (5.2) 12.9 (4.4) Accetability 18.5 (5.7) 16.3 (5.0) 21.3 (13.1) 19.2 (5.2) Adatability 33.6 (7.7) 29.4 (6.7) 28.6 (6.3) 27.5 (6.4) Demandingness 26.8 (6.2) 24.1 (7.0) 26.2 (5.3) 23.9 (5.2) dealing with children s exressions of anxiety; meanwhile, mothers also reorted a significant decrease in their likely use of arenting strategies that reinforce children s deendency [29]. Research also found that interventions aimed at reducing symtoms of child s anxiety can also result in a decrease of maternal criticism and emotional over-involvement toward children [40]. These changes in the use of arenting skills may artially account for the imrovement of arenting stress found in this study. One issue that requires further examination is the role of

344 Child Psychiatry Hum Dev (2014) 45:338 347 Table 2 Effect of cognitive-behavioral theray on the MASC-T anxiety symtoms in the eriod of treatment Physical symtoms Harm avoidance Social anxiety Searation/anic Anxiety disorder index Total MASC Grou (0: control; 1: 7.508.007 4.165.122 5.192.080 1.776.511 4.928.031 18.642.009 treatment) Time (0: retreatment; -.423.651 1.269.195 -.846.366 -.769.364 -.115.882 -.769.729 1: osttreatment) Sex (0: girl; 1: boy) -1.607.381-1.750.289.284.897-1.933.343-1.301.393-5.007.333 Age.827.080.570.175 1.588.006 -.572.271.827.036 2.414.070 Grou 9 Time -3.863.008-2.222.131-3.773.009 -.945.456-2.837.018-10.802.002 MASC-T Taiwanese version of the Multidimensional Anxiety Scale for Children arental involvement in CBT for the imrovement of arenting stress. Given that arenting factors (i.e., intrusiveness, negativity, distorted cognitions) contribute to the develoment and maintenance of childhood anxiety [24], it is reasonable to hyothesize that adding a arental comonent may enhance the treatment of CBT [41]. However, research has not shown unequivocal suort for the of adding a arental comonent into traditional CBT [42]. Different to the original Coing Cat Program, however, we added one session for mothers at the beginning of CBT to introduce the treatment rogram and to teach the basic skills that the mothers could use to hel their children to coe with anxiety in this study. Whether adding a beginning session for arents has additional s on reducing the severity of arenting stress needs further study. This study found that mother-reorted externalizing behavioral roblems of the children did not imrove during the eriod of CBT. This result was not in line with those of revious studies, in which imrovements of arent-reorted externalizing behavioral roblems were found during CBT for children with anxiety disorders [10, 43, 44]. Researchers have hyothesized that the anxiety-disordered child may become distressed and act in an externalizing behavior attern when he/she is made to face fear by his/ her arents [44]. CBT may hel anxious youths to engage less in dysregulated methods of emotion management in resonse to rovocative situations, and thus imrove the severity of externalizing behaviors. However, the results of this study did not suort the of CBT on externalizing behavioral roblems in children with anxiety disorders. A revious study found that youths with anxiety disorders demonstrated imroved coing and less emotional dysregulation with worry but not with anger, which suggests that the gains made in worry regulation do not generalize to other emotions that are not secifically targeted within the CBT rotocol [45]. There are several limitations of this study that need to be addressed. First, the small samle size of the treatment and control grous limited the ossibility of examining the moderating s of demograhic characteristics and the diagnoses of anxiety disorders on the of CBT. Some demograhic characteristics that may influence the of CBT, such as family income and arental anxiety were not collected in this study. This study also did not examine the ossible mechanisms accounting for the s of CBT. This study did not follow-u and could not calculate how long the s of CBT ersisted. Because of the limitations of case resources, this study did not adot a randomized research design. While the treatment grou had higher severities of baseline anxiety symtoms and arenting stress on the Child Adatability domain than the control grou, the control grou had a higher baseline attention deficit/hyeractivity severity than the treatment grou. In this study the CBT condition involved theraist client contact weekly for 17 weeks, whereas the control condition involved client contact only once every 2 weeks. Internal validity was comromised by differences in the frequency of client contact across conditions. We did not have mid-treatment assessment and can not figure out when the CBT treatment rogram begins to be ive. No inter-rater reliability was examined among the three child sychiatrists making the diagnoses of anxiety disorders in this study. Meanwhile, we did not examine whether the articiants still have anxiety disorders at ost-treatment assessment or not. Summary This study found that individual CBT based on the modified Coing Cat Program could otentially imrove childreorted and mother-reorted anxiety symtoms in Taiwanese children with anxiety disorders, as well as arenting stress in the child mood and adatability domains erceived by their mothers. However, CBT for children with anxiety disorders did not significantly imrove

Child Psychiatry Hum Dev (2014) 45:338 347 345 Table 3 Effect of cognitive-behavioral theray on the CBCL/6-18 behavioral roblems in the eriod of treatment Anxious/ deressed Withdrawn/ deressed Somatic comlaints Internalizing roblems Rule-breaking Behavior Aggressive behavior Externalizing roblems Social roblem Thought roblems Attention roblems Syndrome subscale Grou 5.659.025 2.152.132.756.629 8.567.046 -.920.583.631.832 -.289.946.044.979 1.795.349-1.689.438 Time -1.308.125 -.385.467 -.654.244-2.346.095-1.231.040-2.769.007-4.000.006-1.077.009 -.885.155 -.423.564 Sex -.591.730.185.824.364.717 -.043.989 1.292.241 2.085.332 3.377.275.416.775.991.480 2.811.067 Age.156.720.384.075 -.343.182.197.801.029.916 -.024.964.005.995.124.736.261.464.071.852 Grou 9 time -2.264.077-1.139.153 -.632.449-4.035.056 -.103.907 -.469.749 -.571.783 -.590.321 -.687.457 -.958.384 Anxiety Affective Somatic Attention deficit/hyeractivity Oositional defiant Conduct roblems DSM-oriented subscale Grou 4.216.002 2.744.122 -.028.981-1.666.238.455.691-2.004.277 Time -.615.180 -.885.152 -.462.308 -.769.097 -.769.051-1.769.007 Sex -.008.993.779.508.286.657 2.834.008 1.703.036 1.271.305 Age.060.800.262.381 -.279.093 -.115.656 -.091.651.131.675 Grou 9 time -1.527.029-1.449.118 -.253.708 -.469.493 -.183.751.388.683 CBCL/6-18 Child behavior checklist for ages 6 18

346 Child Psychiatry Hum Dev (2014) 45:338 347 Table 4 Effect of cognitive-behavioral theray on the arenting stress in the eriod of treatment Total Cometence Attachment Role restriction Deression Souse Isolation Health C-PSI arent domain Grou -1.887.860 1.604.599 -.428.785 -.203.938 -.943.697-1.039.678-2.735.342 -.278.864 Time -7.538.043-1.192.289-1.154.039-1.231.169-1.769.021 -.385.681-2.346.033 -.615.311 Sex -2.718.712.632.732 2.841.009-1.445.431 -.483.795-2.415.100.086.958-1.599.094 Age -.317.865.189.687.259.329 -.048.918 -.281.554 -.292.427.107.799 -.179.454 Grou 9 time 3.491.522 -.903.590 1.059.198 1.040.434 1.055.344.575.682 1.870.248 -.051.955 Total Distractibility/hyeractivity Reinforces arent Mood Accetability Adatability Demandingness C-PSI child domain Grou 16.886.103-1.638.577.027.983 3.844.054-1.828.702 9.445.002.607.823 Time -6.231.036-1.385.185 -.846.067 -.885.150-2.038.279-1.154.239-2.346.010 Sex 8.114.336 4.887.013 -.040.963.542.719 1.762.469 2.834.208 -.939.634 Age 1.507.481.370.446.227.300 -.053.889.282.648.392.490.138.784 Grou 9 time -8.388.059.432.780.084.901-1.973.034 -.104.970-3.084.039 -.368.780 C-PSI Chinese version of the arenting stress index externalizing behavioral roblems. The results of this study suorted the s of the CBT for anxious children living in a non-western cultural context. It is of clinical benefit to identify children with anxiety disorders and refer them for CBT. Acknowledgments This study was suorted by Grants NSC 98-2410-H-037-005-MY3 awarded by the National Science Council, Taiwan (ROC) and grant KMUH 100-0R48 awarded by Kaohsiung Medical University Hosital. References 1. Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A (2003) Prevalence and develoment of sychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 60:837 844 2. Yonkers KA, Warshaw MR, Maisson AO, Keller MB (1996) Phenomenology and course of generalized anxiety disorder. Br J Psychiatry 168:308 313 3. Albano AM, Chorita BF, Barlow DH (2003) Childhood anxiety disorders. In: Mash EJ, Barkley RA (eds) Child sychoathology, 2nd edn. Guilford Press, New York, 279 329 4. Klein RG, Last CG (1989) Anxiety disorders in children. Sage, Newbury Park 5. Hudson JL, Dodd HF (2012) Informing early intervention: reschool redictors of anxiety disorders in middle childhood. PLoS ONE 7:e42359 6. Pine DS, Cohen P, Gurley D, Brook J, Ma Y (1998) The risk for early-adulthood anxiety and deressive disorders in adolescents with anxiety and deressive disorders. Arch Gen Psychiatry 55:56 64 7. Biederman J, Petty CR, Hirshfeld-Becker DR, Henin A, Faraone SV, Fraire M et al (2007) Develomental trajectories of anxiety disorders in offsring at high risk for anic disorder and major deression. Psychiatry Res 153:245 252 8. Hirshfeld-Becker DR, Micco JA, Simoes NA, Henin A (2008) High risk studies and develomental antecedents of anxiety disorders. Am J Med Genet C Semin Med Genet 148C:99 117 9. Connolly SD, Bernstein GA, the Work Grou on Quality Issues (2007) Practice arameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 46:267 283 10. Ollendick TH, King NJ (1998) Emirically suorted treatments for children with hobic and anxiety disorders: current status. J Clin Child Psychol 27:156 167 11. Reynolds S, Wilson C, Austin J, Hooer L (2012) Effects of sychotheray for anxiety in children and adolescents: a metaanalytic review. Clin Psychol Rev 32:251 262 12. Kendall PC, Hedtke KA (2006) Cognitive-behavioral theray for anxious children: theraist manual (3rd ed). Philadelhia, PA, Temle University, Child and Adolescent Anxiety Disorders Clinic 13. Kendall PC (1994) Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol 62:100 110 14. Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM, Southam-Gerow M, Henin A, Warman M (1997) Theray for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol 65:366 380 15. Kendall PC, Safford S, Flannery-Schroeder E, Webb A (2004) Child anxiety treatment: outcomes in adolescence and imact on substance use and deression at 7.4-year follow-u. J Consult Clin Psychol 72:276 287 16. Kendall PC, Southam-Gerow MA (1996) Long-term follow-u of cognitive-behavioral theray for anxiety disordered youth. J Consult Clin Psychol 64:724 730

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