Evidence-based psychotherapies for children and adolescents by Weisz and Kazdin (third edition) – Chapter 2 summary

Anxiety disorders are common in youth with a prevalence rate of 10% to 20%. It is associated with difficulties in academic achievement, social and peer relations and future emotional health. It is a risk factor for comorbidity and comorbidity is also very common.

Anxiety consists of a behavioural (1), physiological (2) and cognitive component (3). Anxiety is part of normal development (i.e. it cautions one against danger) and can bolster performance (e.g. tests). However, too much anxiety can quickly become distressing. Youth with anxiety view the world as dangerous (1), experience physical complaints (2) and avoid certain situations (3). Avoidance reinforces feelings of anxiety and avoidance behaviours.

Coping Cat is a treatment for anxiety disorders for children from the age of 7 to 13. This treatment targets all aspects of anxiety (i.e. tripartite model). It includes psychoeducation (1), somatic management skills (2), cognitive restructuring (3), gradual exposure to feared situations (4) and relapse prevention plans (5). Affective awareness is increased during the early stages of treatment and corrective information about anxiety is provided (e.g. normalization of feelings of anxiety). Somatic management techniques are introduced as adaptive responses. Cognitive restructuring focuses on challenging maladaptive thoughts and shifting to coping-focused thinking. The C.A.T. project is a treatment for anxiety disorders for adolescents. CBT may also be useful.

The goal of the Coping Cat treatment is to teach youth to recognize signs of anxiety and implement strategies to better cope with the distress rather than completely eliminate anxiety. There is typically an individual meeting with the child for several weeks and two meetings with the parents. Coping Cat mainly focuses on practicing the application of anxiety management strategies in real, anxiety-provoking situations.

In the first half of the treatment, children are being taught a four-step FEAR plan to organize the psychoeducational content into problem-solving steps:

1. Feeling frightened?
   Children ask themselves whether they feel frightened in this step to help them identify the physical symptoms associated with anxious arousal. This is a cue to address the anxiety (e.g. relaxation). They are being taught coping mechanisms, such as relaxation or deep breathing.
2. Expecting bad things to happen?
   Children ask themselves whether they expect bad things to happen. Expectations are first identified and then challenged to reduce faulty beliefs. The therapist helps with identification and changing the beliefs and then new beliefs are being established using coping self-talk. The therapist may use balloons as youth typically do not tell what they are thinking. Thoughts are first identified for neutral or ambiguous situations and alter for anxiety-provoking situations from low to high anxiety-provoking situations. Modelling and role play helps youth develop and practice these skills. The emphasis is on identifying and reducing negative self-talk.
3. Attitudes and actions that might help
   Children are being taught that it is useful to take action that will help change an anxious situation or a reaction to it. The child is taught to not rely on initial reactions but to define the problem and generate solutions for it without initial evaluation. Each solution is then evaluated for possible outcomes and one is selected. The therapist models problem solving although teens can be granted more autonomy. It is practiced in gradually increasing anxiety-provoking situations and as part of homework assignments. The goal is to develop confidence in one’s ability to meet daily challenges.
4. Results and rewards
   In this step, approach behaviour is strengthened and anxious behaviour is reduced through shaping and positive rewards. Effort is rewarded. Self-rating is introduced and a reward refers to how glad others are with the work for young children and how satisfied one is for teens. The idea is that a child rewards themselves for effort and thus requires self-monitoring. The therapist uses coping modelling and role play to demonstrate self-rating and self-reward and provides opportunities to practice it.
   This step is based on self-monitoring and contingent reinforcement.

The second half of the treatment is devoted to the application of the FEAR plan within exposure to increasingly anxiety-provoking situations. Near the end of the treatment, the youth creates a product summarizing experiences that can help other youth manage anxiety, giving youth a chance to become expert by experience.

Parental involvement is part of the Coping Cat treatment. Parents are used as consultants (1), collaborators (2) or co-clients (3). Therapists meet the parents individually (i.e. without the child) for two sessions to collaborate on treatment plans, maintain cooperation and discuss concerns. Parents are told how they can foster positive outcomes and parent techniques are discussed (e.g. maintaining anxiety through modelling). One session is during the skill-building phase and one before exposure.  

The Coping Cat treatment can be flexible as it is driven by techniques and not by session-per-session topics. The Coping Cat treatment is efficacious.

RCTs has shown that the Coping Cat treatment reduces anxiety compared to a waiting list and gains were maintained for over a year. Combined treatment with medication may be even more effective though this is not entirely sure.

A family-based Coping Cat increases parental involvement and uses the same protocol but the parents are included at all sessions. Individual Coping Cat outperformed family-based Coping Cat for teacher reports of anxiety. However, family-based Coping Cat was more effective than individual Coping Cat when both parents had an anxiety disorder. Group-based Coping Cat was effective but not for self-reports of anxiety. Emotion-based Coping Cat seems effective and also reduces emotional inflexibility and improves emotion regulation. A brief version of Coping Cat seems to be effective. Computed-based Coping Cat is also a feasible alternative.

There are several variables which may affect treatment outcome:

1. Demographic variables
   Non-completers of treatment are more likely to live in a single-parent household (1), be members of an ethnic-minority group (2) and have less anxious symptomatology (3).
2. Symptom severity
   Children with higher anxiety severity at pre-treatment experience similar gain although they may have higher anxiety at post-treatment. Youth with higher levels of pre-treatment social anxiety may experience greater post-treatment reductions.
3. Comorbidity
   Comorbid non-anxiety disorders have higher anxiety at post-treatment. Anxious youth with higher autism spectrum symptoms are less engaged in individual Coping Cat. Certain comorbid disorders may require family involvement (e.g. autism). Comorbid ADHD may lead to reduced maintenance of treatment gains.
4. Parental involvement
   The added benefit of parental involvement may depend on whether specific parental factors that contribute to or maintain the child’s anxiety are targeted.
5. Parental psychopathology
   Children with parents with an anxiety disorder may benefit more because it may directly address factors that maintain the child’s anxiety. The effect of parental psychopathology may depend on the child’s developmental stage although results are mixed.
6. Family factors
   Family dysfunction, parental frustration and parenting stress predicts reduced treatment response although it is not clear whether this holds for individual and family Coping Cat.
7. In-session variables
   Therapeutic alliance (1), youth involvement (2), youth engagement (3) is associated with better outcomes. Youth safety-seeking and youth avoidance of therapy tasks and topics have less robust outcomes. Changes in negative self-talk mediates the relationship between treatment and anxiety reduction.