International Review of Psychiatry (2002), 14, 143–154
Family-based treatment of childhood anxiety disorders
GOLDA S. GINSBURG & MARGARET C. SCHLOSSBERG
Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
Summary
Recently attention has turned to family involvement in the treatment of childhood anxiety disorders. Theoretical models and research
on parenting behaviour have identified specific targets for family intervention. A growing number of family-based treatment studies
targeting these parenting behaviours and interactions suggest that this approach is effective. A review of the targets of treatment and
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intervention strategies are described in detail.
Introduction
Anxiety disorders are among the most prevalent
childhood psychiatric disorders, with prevalence
rates ranging between 3 and 15% (Costello &
Angold, 1995). More importantly, these disorders
severely impair the daily functioning of children and
their families. For instance, many children with
anxiety disorders have difficulty attending and
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performing in school, struggle with making and
maintaining friendships, have high levels of family
conflict, and experience significant personal distress
(see Silverman & Ginsburg, 1998, for a review).
Anxiety disorders in childhood often continue into
adulthood. A recent longitudinal study found that
children with anxiety disorders faced a two- to four-
fold increased risk for having an adult anxiety
disorder (Pine et al., 1998). Taken together, these
facts suggest that an anxiety disorder in childhood
confers significant short- and long-term risks. Thus,
the need for effective treatment is great.
As reviewed in this issue (Albano & Kendall), sev-
eral well-controlled clinical trials have demonstrated
that a short-term (10–16 weeks) course of cognitive
behavioural therapy (CBT) significantly reduces
anxiety in 50–80% of children (Barrett et al., 1996a;
Cobham et al., 1998; Kendall, 1994; Kendall et al.,
1997; Last et al., 1998; Silverman et al., 1999a;
Silverman et al., 1999b). However, current methods
of CBT, which tend to be individual and child-
focused, are not effective for all children, as
approximately 20–50% remain symptomatic after
treatment. Consequently, attention has turned to
ways of improving these interventions.
In this article, we advocate a family-based CBT
treatment model. Family-based treatments are
defined as those that incorporate teaching parents
specific strategies for reducing anxiety in their
Correspondence to: Golda S. Ginsburg, PhD, Johns Hopkins University, Division of Child & Adolescent Psychiatry,
600 North Wolfe Street/CMSC 312, Baltimore, MD 21287, USA.
ISSN 0954–0261 print/ISSN 1369–1627 online/02/020143–12
DOI: 10.1080/0954026022013266 2
children. Our rationale for advocating a family-based
treatment model is based on several converging
bodies of literature, including: (1) family studies of
anxiety; (2) etiological models of anxiety disorders in
children; (3) research on parenting behaviours and
aspects of the family environment associated with
child anxiety; (4) family-based treatment efficacy
studies. Taken together, this growing body of
literature suggests that parents play an important
role in the development and/or maintenance of child
anxiety and may also have an impact on treatment
outcome. Later, we briefly summarize each of these
areas of research. In addition, a description of the
specific CBT treatment strategies used in existing
family-based interventions is presented.
Family studies
Family aggregate studies, using ‘top down’ and
‘bottom up’ methodologies with predominately
clinic samples, indicate that anxiety disorders run in
families. Findings from top down studies generally
reveal that among anxious parents, up to 60% of
their children (with a greater risk for girls than boys)
meet criteria for an anxiety disorder (e.g. Berg, 1976;
Capps, et al., 1996; Fyer et al., 1990; Merikangas
et al., 1998; Silverman et al., 1988; Turner et al.,
1987; Weissman et al., 1984). For example, Beidel &
Turner (1997) using a top down approach examined
129 children (ages 7–12) of parents with an anxiety
disorder, major depression, both anxiety and
depression, and normal controls. Findings indicated
that children of anxious parents were five times more
likely to meet DSM criteria for an anxiety disorder
compared to the children of parents who had no
clinical disorder. Specifically, 33% of children whose
parents had an anxiety disorder only, compared with
Institute of Psychiatry
 144 Golda S. Ginsburg & Margaret C. Schlossberg
9% of the children of normal controls, were
diagnosed with an anxiety disorder. Similar rates of
anxiety disorders in children were found among the
offspring of depressed only (21%), and anxious/
depressed (33%) parents.
In contrast to top down studies, bottom up studies
examine the rates of disorder in the parents of
affected children. Among children with anxiety
disorders, up to 80% of their parents have been found
to have an anxiety disorder (e.g. Berg et al., 1974;
Bernstein & Garfinkel, 1988; Kashani et al., 1990;
Last et al., 1987; Last et al., 1991; Last et al., 1987;
Livingston et al., 1985; Rosenbaum et al., 1992). A
recent example of a study using this bottom up
method (Martin et al., 1999) found that among
parents of children with anxiety-based school refusal,
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78% of mothers (n = 51) and 54% of fathers (n = 45)
met criteria for a lifetime diagnosis of an anxiety
disorder.
Although family aggregate studies suggest that
anxiety runs in families, the specific mechanisms of
transmission are unknown. However, these mecha-
nisms are likely to be both genetic and environmental.
Some of these environmental factors, such as
parenting behaviour, may be amenable to treatment.
Etiological models address their specific role in
the development of child anxiety disorders. These
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models are presented below.
Etiological models of child anxiety disorders
Existing theoretical models for understanding the
development of childhood anxiety disorders stress
the reciprocal relation between parent and child
factors, in the context of environmental stressors
Figure 1. Developmental Model of Childhood Anxiety
(Chorpita & Barlow, 1998; Chorpita et al., 1998;
Manassis & Bradley, 1994; Rapee, 1997; Rubin &
Mills, 1991; Warren et al., 1997). Our develop-
mental model, adapted from Manassis & Bradley
(1994) and Rubin & Mills (1991) is depicted in
Figure 1. Although many elements of this model
have not been empirically tested, it has heuristic
value in highlighting the implications of parental
behaviour in both the etiology and treatment of
child anxiety. Focusing on the parent side, certain
parental temperaments and an insecure attachment
history are hypothesized to predispose parents to
psychological/psychiatric symptoms in general, and
anxiety in particular. High levels of anxiety in the
parent likely interfere with the development of the
parents adaptive coping skills and lead to specific
‘anxiety-enhancing’ parenting behaviours. These
parenting behaviours, in turn, are hypothesized to
increase their child’s vulnerability to developing
an anxiety disorder. Parenting behaviours and
psychiatric symptoms are also influenced by envi-
ronmental stressors (e.g. unemployment, death of
loved one), lack of social support and social isola-
tion, and marital discord (Manassis & Bradley,
1994).
Taken together, this model suggests that parents
who engage in ‘anxiety-enhancing’ parenting behav-
iours—either due to their own anxiety or in response
to child factors—may be less likely to assist in their
children’s adaptive cognitive, social, and emotional
development. In this connection, maladaptive
parenting and family behaviours may moderate or
mediate the development of anxiety disorders in
youth. Interventions that target these behaviours
may enhance the treatments for child anxiety and are
discussed later.
 Family-based treatment 145

Parenting and family variables associated with
child anxiety disorders
The last 15 years have witnessed a remarkable accel-
eration in the empirical investigation of parenting
and family variables in connection with childhood
anxiety (for review see Rapee, 1997). Researchers
have examined both broad dimensions of parenting
styles and family functioning/environment as well as
specific parenting behaviours and parent–child
interactions. These studies have been extraordinarily
diverse with respect to methodologies, definitions,
measures, and sample characteristics. For instance,
there are methodological variations in the specific
population studied (community versus clinical), the
specific range of problems examined (samples with a
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in the etiology and/or maintenance of child anxiety.
Interventions targeting these behaviours by using a
family-based model may enhance current treatment
approaches.
In an effort to synthesize this literature, we first
identified studies in which children were diagnosed
with an anxiety disorder (excluding post-traumatic
stress disorder (PTSD)), and some aspect of
parenting or the family relationship was measured.
A total of 20 studies were identified. We then exam-
ined the types of parenting or family variables
examined (some studies examined more than one
type of family variable) and grouped them into the
following nine categories: (1) overcontrol; (2)
overprotection; (3) modelling or reinforcing anx-
ious and/or avoidant behaviour; (4) negative beliefs

single diagnosis versus samples with a spectrum of
anxiety diagnoses), the specific measure of parenting
or family relationships used, and whose perspective
of parenting behaviour or family relationships were
assessed (parent, child, observer). In addition,
similar parenting behaviours have been defined using
different terms. As one example, parents who use
excessive caution and restrict and/or protect their
children in the absence of a cause or reason may be
described as overprotective, overcontrolling (behav-
ioural and/or psychological), intrusive, and/or not
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and expectations about the child; (5) emotional
warmth/positive affect; (6) rejection/criticism; (7)
conflict; (8) family environment; (9) parenting
style. Later, we briefly review the findings regarding
each parenting and family variable category (see
Table 1).
Overcontrol
A total of five studies examined parental overcontrol.

granting of autonomy, depending on the study.
Finally, the findings from these studies do not
address whether there is specificity in the relation
between parenting behaviours and child anxiety—
either across psychiatric disorders (anxiety versus
depression) or among the anxiety disorders (social
phobia versus separation anxiety). Research disen-
tangling the specific effects of these variables is
needed. Despite these variations, accumulating
research does implicate specific parenting behaviours
Two studies were based on an observational method
(Dumas et al., 1995; Siqueland et al., 1996), one was
based on child- and parent-report (Fristrad & Cray-
ton, 1991), and two were based on child-report only
(Leib et al., 2000; McClure et al., 2001). Across
these studies, parental overcontrol was defined as
intrusive behaviour, granting minimal autonomy to
their child, constraining their child’s individuality,
use of excessive commands or instructions, and
restriction of their child’s behaviour during a task. Of

Table 1. Evidence of parenting and family variables associated with childhood anxiety disorders
Total number of Number of
Parent & family variables studies studies/method Findings
Overcontrol 5 1 Child- & parent-report 2 Support
2 Child-report 2 No support
2 Observational-report 1 Mixed
Overprotection 3 1 Child- & parent-report 2 Support
2 Child-report 1 No support
Modelling anxiety/reinforcing avoidance 4 1 Child- & parent-report 4 Support
3 Observational-report
Negative beliefs & expectations about child 1 1 Observational- & parent-report 1 Support
Rejection/criticism 4 1 Child-report 4 Support
3 Observational-report
Emotional warmth/positivity 5 2 Child-report 2 Support
3 Observational-report 3 No support
Conflict 5 2 Parent- & child-report 1 Support
2 Child-report 3 No support
1 Observational-report
Family environment 11 2 Parent- & child-report 6 Support
4 Child-report 5 No support
4 Parent-report
1 Observational-report
Parenting styles 2 1 Parent- & child-report 1 Support
1 Child-report 1 No support
 146 Golda S. Ginsburg & Margaret C. Schlossberg
the five studies, two found that higher levels of
parental control were associated with higher levels of
anxiety in children (Dumas et al., 1995; Siqueland et
al., 1996), and one found mixed results (i.e. support
for parental psychological control but no support for
parental behavioural control; McClure et al., 2001).
As an example, Siqueland and colleagues (1996)
compared 17 clinically anxious children (ages 9–12
years) and their families with 27 control children
(ages 9–12 years) and their families. Each family par-
ticipated in four 6-minute ‘revealed differences’ tasks
that were videotaped and coded by blind observers.
This task involved discussing topics that typically
produced conflict or differences between family
members. Observers found that parents of children
with anxiety disorders granted less autonomy and
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exerted more control in dialogues with their children
than parents in the control group. Additionally, chil-
dren with anxiety disorders, compared to their non-
ill peers, rated their mothers as more controlling.
Overprotection
Three studies examined parental overprotection.
Two studies used child-report (Leib et al., 2000;
Merikangas et al., 1999), and one study used parent
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report (Last & Strauss, 1990). In these studies,
parental overprotection was defined as using
excessive caution and restrictive and/or protective
behaviours in the absence of a cause or reason. Two
of the three studies found that higher levels of
overprotection were associated with higher levels of
child anxiety (Last & Strauss, 1990; Leib et al.,
2000). For example, Leib et al. (2000) used
child reports to determine the association between
perceived parental overprotection and social phobia
in adolescents. In this study, 1,047 adolescents (ages
14–17) completed the Questionnaire of Recalled
Parental Rearing Behaviour (QRPRB), which
assesses three dimensions of parenting behaviours
including parental overprotection. Adolescents with
social phobia were more likely to perceive their
parents as overprotective compared to adolescents
without social phobia.
Model anxiety and reinforce avoidant behaviour
Four studies examined modelling and/or reinforce-
ment of anxious/avoidant behaviour. Three studies
were based on observational methods (Barrett et al.,
1996b; Chorpita et al., 1996; Dadds et al., 1996) and
one study was based on child- and parent-report
(Muris et al., 1996). In these studies, parents who
model anxiety were those who exhibited avoidance
and anxious behaviours in the presence of their child
while parents who reinforced avoidant behaviour
tended to pay attention to, agree with, tolerate, and/
or reciprocate their child’s anxious avoidance.
Despite methodological differences among studies,
all four found that parents’ modelling anxiety and/or
reinforcing avoidance was higher in children with
anxiety disorders compared to their non-anxious
peers. For example, Dadds and colleagues (1996)
compared interactions between 66 clinically anxious
children and their mothers with the interactions of 18
non-anxious children and their mothers using an
ambiguous situation task. Ambiguous situations
comprised of a variety of scenes depicting potentially
threatening or non-threatening situations, such as
hearing a noise in the hallway from bed at night.
Children were asked to list possible interpretations of
the situation and a list of plans for how to react to the
situation. Once complete, children were asked to
discuss two of the ambiguous situations with their
parents, and then provide a final interpretation and
plan. Findings indicated that parents of anxious
children were more likely to agree with and support
anxious interpretations and avoidant strategies
suggested by children than parents of non-anxious
controls.
Negative beliefs/expectations about child
Although researchers have suggested that parental
beliefs and expectations play an important role in
the etiology of child anxiety, only one study has
examined these variables in a clinically anxious
sample (Kortlander et al., 1997). Kortlander and
colleagues compared maternal expectations and
attributions regarding their child’s ability to cope
with a stressful situation (giving a 5-minute video-
taped speech about themselves) with mothers of 40
clinically anxious children (ages 9–13) and mothers
of 40 normal controls (ages 8–14). Results indicated
that, compared to mothers of non-anxious children,
mothers of the clinically anxious children expected
their offspring to be more upset, less able to cope,
and were less confident in the children’s ability to
perform the task. In addition, mothers of normal
and anxious children differed in their attributions for
coping ability. Specifically, mothers of anxious
children tended to use fewer explanations for their
child’s inability to cope (anxiety level, difficult task)
compared to mothers of non-anxious children. This
finding suggests that mothers of anxious children
may hold more fixed ideas about their child that may
maintain their anxiety and avoidance.
Emotional warmth/positivity
Five studies examined parental warmth/positivity in
association with child anxiety. Three of these were
based on observational methods (Dadds et al., 1996;
Dumas et al., 1995; Siqueland et al., 1996) and two
were based on child-report (Leib et al., 2000;
McClure et al., 2001). In general, emotional warmth
and positivity were defined as positive affect,

expressing affection, showing positive regard, recog-
nition of feelings, and laughing and smiling with the
child. Only two of the five studies found that high
degrees of warmth and positivity were associated
with lower levels of anxiety in children (Dadds et al.,
1996; Dumas et al., 1995). In the Dadds’ study
described earlier, researchers found that parents of
non-anxious children communicated happier affect
compared with parents of clinically anxious
children.
Rejection/criticism
Four studies examined parental rejection/criticism
in relation to child anxiety. Two studies used
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observational methods (Dumas et al., 1995; Hibbs
et al., 1991), one study used child-report (Leib et al.,
2000), and one study used parent report (Hibbs
et al., 1993). In these studies, rejection/criticism was
defined as disapproving, judgmental, dismissive, and
critical (including expressed emotion) behaviour on
the part of the parent. All four studies found that
higher levels of parental rejection/criticism were
associated with higher levels of child anxiety (Dumas
et al., 1995; Hibbs et al., 1991; Hibbs et al., 1993;
Leib et al., 2000). Hibbs et al. (1991) compared
levels of expressed emotion (measured using the
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5-minute speech sample) among parents of youth
with obsessive compulsive disorder (OCD) (n = 39),
disruptive behavioural disorders (n = 34), and
normal controls (n = 45). Findings revealed that,
compared to normal controls, expressed emotion
was higher in the OCD group. No differences were
found between the two clinical groups.
Conflict
Five studies examined family conflict in association
with child anxiety. Two studies used child- and
parent-reports (Kashani et al., 1990; Stark et al.,
1990), two used child-report only (Manassis &
Hood, 1998; Stark et al., 1993), and one used
parent-report only (Siqueland et al., 1996). Conflict
was defined as disagreements among family
members, fighting, arguing, disharmony, and verbal
or physical aggression. Only two of the five studies
found that high degrees of family conflict were
associated with high levels of anxiety (Kashani et al.,
1990; Stark et al., 1990). For example, Stark and
his colleagues (1990) examined the perceived
environments among families with a depressed,
depressed and anxious, anxious only, or non-ill child
(ages 9–14 years). Relevant here, parents completed
the conflict subscale of the Self-Report Measure
of Family Functioning (SRMFF; Bloom, 1985).
Findings indicated that anxious children reported
more conflict than non-ill controls, however, no
differences were found between anxious and
depressed children.
Family-based treatment 147
Family environment
Eleven studies have examined some aspect of the
family environment such as overall family function-
ing, enmeshment, cohesion, adaptability, religious/
moral values, problem solving, family sociability,
locus of control, family structure and organization.
Four of these studies used child-report only (Kashani
et al., 1999; Leib et al., 2000; Merikangas et al.,
1999; Stark et al., 1993), four used parent-reports
(Fristrad & Crayton, 1991; Hibbs et al., 1993;
Kashani et al., 1990; Thomsen, 1994) and two used
both child- and parent-report (Messer & Biedel,
1994; Stark et al., 1990). Five of the ten studies
found a significant association between at least one
aspect of the family environment and anxiety in chil-
dren (Hibbs et al., 1993; Kashani et al., 1999; Stark
et al., 1990; Stark et al., 1993; Thomsen, 1994). For
example, Kashani and colleagues (1999) interviewed
100 inpatient children and adolescents to obtain a
sample of 21 children diagnosed with depression
(mean age = 14) and 18 children diagnosed with
anxiety (mean age = 11). These researchers com-
pared anxious and depressed children’s responses on
the Family Adaptability and Cohesion Scale (i.e.
adaptability and cohesion) and Family Strengths
Questionnaire (a measure of positive attributes such
as trust, loyalty, respect, and competency). Findings
revealed that, compared to depressed children,
anxious children described their families as more
adaptable to the demands of the environment, and
had more trust, loyalty, and respect for their families.
Parenting styles
Two studies have specifically examined parenting
styles, based on child-reports, in families with clini-
cally anxious children (Stark et al., 1990; Stark et al.,
1993). Both studies defined parenting styles using
Baumrind’s (1968) three parenting styles: authoritar-
ian, authoritative/democratic, and permissive/laisse-
faire, which are characterized by how much demand-
ingness and responsiveness parents employ. The
authoritarian parent directs their child’s behaviour
using strict control, limits their child’s autonomy and
freedom, and demands obedience. The authoritative/
democratic parent also attempts to direct their child’s
behaviour, but tends to encourage the child’s verbal
give and take, shares the rationale for rules, and values
independence. The permissive parent places few
demands on their child, avoids attempts to control
their child’s behaviour, and encourages their children
to regulate themselves as much as possible (Baumrind,
1968). In both studies authoritative/democratic
parenting style was associated with lower anxiety.
Summary
Evident from the above review, a variety of parental
behaviours have been found to be associated with
 148 Golda S. Ginsburg & Margaret C. Schlossberg

higher levels of child anxiety. Interventions that
target these behaviours may enhance treatment
gains.
Studies of family-based treatments for child
anxiety
The advantages of parental involvement in CBT
treatments for child anxiety have only been recently
discussed (e.g. Barrett et al., 1996a; Barrett et al.,
1996b; Barrett, 1998; Ginsburg et al., 1995;
Mendlowitz et al., 1999; Spence et al., 2000). To
date, there have been seven published studies that
have evaluated a family-based treatment for child-
hood anxiety using a controlled design. Table 2
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As can be seen from Table 2, the majority of studies
(6/7) have been tested on children with a broad range
of anxiety disorders or symptoms in the same study,
including overanxious disorder (OAD)/generalized
anxiety disorder (GAD), separation anxiety disorder
(SAD), social phobia (SOP), and simple/specific
phobia (SP). Only one study focused exclusively on
a single anxiety disorder, i.e. SOP (Spence et al.,
2000). The age ranges were also broad, both within
and across each study, ranging from ages 6–16. With
respect to number of sessions, most family-based
interventions were short term, ranging from 4 to 12
parent sessions and all were implemented in
conjunction with 10–12 sessions of individual child
CBT. With only one exception (Barrett et al.,
1996a), the parent interventions were delivered in a

presents the key characteristics of these studies. group format.

Table 2. Controlled family-based treatment studies for childhood anxiety disorders

Number of parent
Study Diagnoses N/ages sessions/format Treatment components
Barrett et al., 1996 OAD 79/7–14 12/child & parent conjoint Expert team
SOP Psychoeducation
GAD Contingency management
Parent anxiety management
Parent modelling of coping
Problem-solving
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Communication
Barrett, 1998 OAD 60/7–14 12/parent and child Expert team
conjoint group
SA Psychoeducation
SOP Contingency management
Parent anxiety management
Parent modelling of coping
Problem-solving
Communication
Cobham et al., 1998 GAD 67/7–14 4/group Parent anxiety management:
SOP Psychoeducation
OAD Contingency management
SP Relaxation
SAD Cognitive restructuring
Parent modelling of coping
Mendlowitz et al., 1999 Anxiety symptoms 62/7–12 12/group Psychoeducation
Contingency management
Systematic desensitization
Cognitive distortions
Relaxation
Improve family interactions
Shortt et al., 2001 SAD 71/6–10 10/group Reduce parent anxiety
GAD Contingency management
SOP Cognitive restructuring
Communication
Problem solving
Partner support training
Build support among parents
Silverman et al., 1999 SOP 56/6–16 12/group & conjoint group Psychoeducation
GAD Contingency management
OAD
AVD
Spence et al., 2000 SOP 50/7–14 12/group Psychoeducation
Model & prompt coping skills
Ignore kids social anxious behavior
Encourage increased activity
Support and encourage HW
completion
Model social activity

The content of the parent interventions was
somewhat consistent across studies. All included a
cognitive behavioural conceptualization of childhood
anxiety and its treatment (i.e. psychoeducation),
contingency management (i.e. rewarding ‘brave’
behaviour and using extinction procedures for
reducing anxious and avoidant behaviours), and
emphasized parents modeling non-anxious, coping
behaviours for their children. In addition, parents
were viewed as important treatment ‘team members’
who encouraged homework completion, provided
support, and facilitated child exposures. Four studies
taught parents strategies to recognize and reduce
their own anxiety levels (Barrett, 1998; Barrett et al.,
1996; Cobham et al., 1998; Shortt et al., 2001). Four
studies (Barrett et al., 1996a; Barrett, 1998;
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Mendlowitz et al., 1999; Shortt et al., 2001) also
included specific skills training in family problem-
solving and communication. Two studies specifically
incorporated cognitive restructuring for parents
(Cobham et al., 1998; Shortt et al., 2001).
Finally, only one of the interventions articulated a
theoretical model that guided the selection and
sequence of treatment strategies (Silverman et al.,
1999a). In this model, referred to as the ‘transfer of
control model’, the therapist is viewed as an expert
consultant who possesses knowledge of the skills
For personal use only.
and methods necessary to produce long-term child
therapeutic change. Briefly, the model stipulates that
effective change involves a gradual transfer of the
knowledge, skills, and methods, where the sequence
is generally from therapist to parent to child. Thus,
while both parents and youth are taught anxiety-
reducing strategies, parents begin to implement
these strategies first (via contingency management).
Once parents master these skills, the child increases
their use of cognitive self-control strategies and
parents gradually fade their use of anxiety reduction
strategies. This sequence is explicitly described to
parents and children to convey that success
ultimately rests upon children learning to cope with
and manage their anxiety/fear ‘on their own’. The
transfer of control model is based on the premise that
treatment effectiveness is maximized by the use of
clear and direct pathways of transfer of control.
Thus, additional strategies are used, as needed, to
‘unblock’ pathways between child and parent that
may interfere with treatment success (Ginsburg
et al., 1995; Silverman & Kurtines, 1996).
With respect to child outcomes, findings from
these treatment studies suggest that family-based
CBT is either as effective, or more effective, than
individual CBT. Specifically, between 60–90% of
children who received the family-based CBT
treatment no longer met criteria for an anxiety
disorder at post-treatment. There is also some
evidence that a family-based treatment may be more
effective for children whose parents have an anxiety
disorder. Cobham et al. (1998) compared individual
versus family-based CBT among anxious children
Family-based treatment 149
with and without anxious parents. Among children
with anxious parents, response rates (i.e. percent
without diagnosis) at post-treatment were 39% and
77% for the individual and family-based CBT,
respectively. Similarly, at the 1-year follow-up
assessment, children of anxious parents who received
the family-based CBT had higher response rates
(71%) compared to the individual CBT (59%),
though this difference did not reach statistical
significance.
Despite the excitement about family-based treat-
ments for child anxiety, many questions remain about
the efficacy of family-based treatments. For instance,
few studies measure changes in parenting skill from
pre- to post-treatment to assess whether changes
actually occurred in parenting behaviours, and the
extent to which changes in parenting skills are related
to changes in child anxiety. Moreover, it is unknown
for whom this modality would be most effective. It is
also unclear whether current family-based CBT
interventions are sufficiently potent; one would
expect family CBT to be far superior to individual
child CBT. The use of a parent group (as used in all
but one of these studies) may not be as effective as
treatment done with each family individually. Finally,
it is not clear that the family-based treatments address
each of the parenting and family behaviours found
to be associated with increased levels of anxiety
described above. Future research is needed to address
these and related questions.
Therapeutic components of family-based CBT
interventions
Several therapeutic strategies directed toward parents
appear consistently across family-based interventions
for child anxiety. The strategies directed toward
parents include: (a) psychoeducation; (b) contin-
gency management; (c) reducing parental anxiety;
(d) cognitive restructuring; (e) improving the parent–
child relationship; (f) relapse prevention. In the next
section, we present a description of how to implement
these treatment strategies. This description is
designed to provide practical information to clinicians
in how to incorporate parents more centrally in their
work with anxious youth. A general overview of our
approach to family-based treatment is presented first.
Overview of treatment
Although most of the family CBT interventions
provide instruction to parents separately (e.g. in a
parents group) as an adjunctive component to child
CBT, we recommend including parents more
centrally in therapy by conducting treatment with
both the parent and child together. This conjoint
format allows parents and children to practice their
new skills in the session with the benefit of therapist’s
 150 Golda S. Ginsburg & Margaret C. Schlossberg
corrective feedback, allows parents to gain important
information about their child’s progress, and enables
the therapist to have access to ‘live’ parent–child
interactions that might limit treatment success.
Treatment generally lasts between 10 and 16
weeks, with initial sessions occurring weekly and
later sessions spaced out over several weeks. This
time frame allows adequate time for learning,
practicing, and applying new skills. Treatment
length and duration may vary based on the individual
needs of families. The format of each treatment
session is somewhat flexible, but generally includes
establishing an agenda, wherein parents can identify
issues and incidents they want to discuss in
treatment, a review of homework, and teaching or
practicing new skills. Sessions end with an agreed
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upon homework assignment that helps parents and
children practice or experiment with what they
learned in session. The therapist is directive and
active, using questions, providing instruction, and
giving feedback. Therapy sessions are generally
present-focused and solution-oriented.
We emphasize stressing to parents that treatment
is based on a team approach that requires parents to
assist in their child’s treatment as well as examine,
and if necessary, change their own behaviour/
thoughts. Thus, family-based CBT involves applying
For personal use only.
CBT principles to the parents themselves (e.g. to
reduce their own anxiety or distorted beliefs about
their children), and addressing problems in parent–
child or parent–parent relationship as needed.
Psychoeducation
Psychoeducation involves teaching the cognitive-
behavioural conceptualization of anxiety and its
treatment. It often begins with a discussion and
explanation of the manifestations of anxiety. For
instance, the therapist may explain that anxiety
manifests in three primary ways: (1) physically, such
as stomach aches, headaches, and a racing heartbeat;
(2) cognitively or in negative or distorted thoughts,
such as ‘I am going to choke and die if I eat this’ ‘No
one will like me if I make a mistake’, or ‘ Someone is
going to kidnap me’; (3) behaviourally, such as
avoiding school or parties, tantruming, crying, or
acting aggressively. Socratic questioning is used to
illicit symptoms that are specific to each child and
parent.
An explanation of the CBT treatment model
involves learning strategies to address each of these
three manifestations of anxiety. Thus, parents and
children are taught the importance of being able to
recognize somatic or physical symptoms and the
value of using relaxation exercises to reduce
somatic distress. To address negative or distorted
thinking, the therapist will teach parent and child
how to identify ‘scary’ thoughts, evaluate their
accuracy, and change or substitute them with more
realistic or helpful (i.e. coping) thoughts. Finally, to
address avoidant and anxious behaviour, the
concept of ‘exposure’ or ‘facing one’s fears’ is
described as an essential therapeutic ingredient.
Specifically, because continued avoidance main-
tains anxiety, prevents mastery over the situation,
and limits the development of new skills, facing
one’s fears has numerous benefits and is a focus of
treatment. Thus, treatment requires the child to
gradually approach situations in which s/he feels
afraid. Toward this end, a fear hierarchy is
developed to establish the situations in which the
child feels afraid (ranging from minimal anxiety to
extreme anxiety). We ask both parents and children
to complete a fear hierarchy, as parents can often
identify situations that might be omitted by the
child.
Contingency management (CM)
CM strategies are designed to help parents manage
and reduce their child’s anxious behaviour. Teaching
CM involves explaining that anxious and avoidant
behaviours are, in part, learned and can thus be
‘unlearned’ using basic learning principles and
behaviour modification. In this connection, we
provide explanations for such concepts as positive
and negative reinforcement, consequences, shaping,
and extinction. We often show parents how they
shape a child’s behaviour by giving contingent
rewards, such as praise for doing a good job, for
successive approximations toward the desired behav-
iour. With parents and children together, we identify
several types of reinforcements (social, activities,
tangible, tokens) that they can use to reward their
child’s coping responses (e.g. facing their fears).
These reinforcements are provided subsequent to
‘brave’ or coping behaviour (i.e. exposures).
The use of ‘extinction’, or the removal of uninten-
tional reinforcers, such as parental attention, for
anxious behaviours is stressed as well. This usually
leads to a discussion of how family members may
accommodate the child’s anxiety by allowing them to
avoid certain situations (e.g. not joining a club for a
child with SOP; sleeping in parents room because of
fears of the dark or SAD) because it causes distress
for the child or parents feel the child can not
successfully ‘handle’ the situation on their own.
The concepts of contingency management are also
made explicit and concrete through the use of
contingency contracts, i.e. written documents that
detail the child’s exposure task (e.g. attending a
party) and the specific reward to be given by the
parent (going for ice cream). Written contracts,
when sufficiently detailed, can reduce power
struggles between parent and child and serve as a
reminder of each family member’s role in the
practice task. It also serves as a formal record of what
the child has accomplished.

Reducing parental anxiety
As noted earlier, top down and bottom up studies
indicate that children with anxiety disorders are
likely to have a parent who is also struggling with
anxiety (and other psychopathology) and modelling
of anxiety was associated with increased levels of
child anxiety. Thus, targeting parental anxiety is an
important aspect of family-based treatment. During
the initial psychoeducation sessions we help parents
identify their own anxiety symptoms and discuss
specific ways that parents may be modelling anxiety.
For example, parents may refuse to drive at night
because of fears of something bad happening or may
forecast a terrible natural disaster and begin to show
anxiety when they hear that a storm coming. To
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address parental anxiety, we apply the same CBT
strategies (i.e. exposure, cognitive restructuring) that
are used in treating their child’s anxiety as part of
the family treatment, including gradual exposure.
Parents who need additional interventions (e.g.
medications) are encouraged to seek individual
treatment.
Cognitive restructuring
Related to parental anxiety, parents’ thoughts and
For personal use only.
expectations about their child (e.g. their compe-
tence) or the world in general are important to
address in family-based treatment. It is not
uncommon for parents to express their beliefs that
their child ‘can’t handle the situation’ or ‘is too
sensitive’. Parent’s ‘distorted’ cognitions about their
child might limit their ability to support their child
and interfere with treatment. To address this
problem, we teach parents how to identify their
automatic thoughts and cognitive distortions about
their anxious child. Then, using similar strategies
taught to children, we have parents evaluate the
reality and usefulness of these thoughts in a
systematic fashion. We then work with parents to
replace negative thoughts with more realistic and
encouraging ones about their child and their
behaviour (‘John did well at the party by himself, he
will probably be fine this time too’ or ‘Even if I’m not
100% sure Suzy will succeed at softball, it’s important
for her to try so she can learn to face her fears and
develop new skills’). Similarly, a parent’s protective
questioning or constant reassurance may draw the
child’s attention to something worrisome and inad-
vertently increase their anxiety/fear. The presence of
these behaviours in parents and other family
members is discussed candidly and alternatives are
generated and practiced.
Parent–child relationship
Enhancing the parent–child relationship focuses on
reducing parent–child conflict, improving family
Family-based treatment 151
communication, and increasing parents’ positive
commitment and attachment to their children.
Toward this end, several skills are introduced includ-
ing communication, problem-solving, and conflict
resolution. With respect to communication skills,
emphasis is placed on educating parents about
negative communication patterns such as interrupt-
ing, blaming, criticizing, etc. Alternative, and more
positive, communication styles are then taught and
practiced with children and their parents (including
complimenting, smiling and laughing). Key elements
include both verbal and non-verbal communication
such as active listening (e.g. head nodding, restating
and clarifying, etc.) and having the family structure a
specific time each day to practice these skills.
Family problem-solving focuses on teaching and
training parents and children an effective step-by-
step method for solving problems in general, as
well as those associated with the child’s anxious and
avoidant behaviour. Key elements of this training
include mutually identifying the problem, brain-
storming a list of alternative solutions, evaluating
each potential solution, selecting a solution that has
the most potential for success, and assessing how
well the solution worked (D’Zurilla & Goldfried,
1971).
With respect to conflict resolution, it is useful to
provide parents and children with information about
how high levels of conflict (between family members
as well as between parents) can increase their child’s
anxiety. We then discuss with the family each
member’s role in conflict situations. Parents are also
encouraged to identify specific conflicts related to
co-parenting their anxious child (e.g. one parent
believes the child can not face their fears while the
other encourages the child to do so).Problem-solving
and communication strategies can then be used to
address these issues. Conflict resolution also involves
teaching parents strategies to de-escalate and reduce
conflict at home. This involves helping parents
identify triggers and ways to reduce their own and
their child’s anger and frustration (e.g. a brief respite,
time alone, scheduled times to discuss ‘hot’ topics).
Additionally, we help parents identify negative
thoughts prior to and during conflict that may fuel
their anger and interfere with problem-solving. We
teach parents skills to challenge their unhelpful and
negative thoughts and strategies to reduce power
struggles. This may involve being proactive in
planning ahead during difficult transitions of the day,
maintaining clear and realistic expectations, and
providing more global monitoring and supervision in
regard to high conflict task demands.
We also provide opportunities for parents to
identify family accomplishments, positive family
traits, and effective parenting strategies. We discuss
ways of increasing quality time, family rituals, and
family traditions that enhance family commitment
and attachment.
 152 Golda S. Ginsburg & Margaret C. Schlossberg
Relapse prevention
Although concepts related to relapse prevention are
emphasized throughout the treatment (via practice),
specific relapse prevention strategies must be
explicitly incorporated into treatment. Most CBT
programmes begin by defining and providing
information about what a relapse or ‘slip’, means.
For instance, slips are explained as times when the
child feels excessively anxious or fearful and begins
to avoid certain anxiety provoking situations.
As part of the education we provide about
relapse, we inform parents and children that slips
are common, that most children will experience a
slip, and that such experiences provide children
and families an opportunity to practice what they
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have learned. This ‘normalizes’ and prepares
families for relapse while empowering them to be
proactive rather than reactive. In this connection,
it is critical to explain to parents (and children)
that having a slip does not mean they are back
where they started prior to treatment. Both parents
and children have learned the skills required for
reducing anxiety.
In addition to preparing children and families
psychologically for a relapse, it is important to
prepare them with some concrete triggers of relapse
and an action plan to manage the relapse. Thus, a
For personal use only.
discussion of potential stressors or triggers for
relapse, as well as strategies that will help prevent
slips (i.e. practice using CBT strategies and engaging
in exposure) is conducted with both parents and
children. These potential stressors and coping
strategies can be recorded on a ‘planning ahead’
handout. Finally, one of the most important
strategies for relapse prevention is ensuring that
parents do not despair and react as if their child is
‘back at square one’. Parents must be aware that to
the extent that they feel that their child has ‘failed’
because of the slip, so too will the child. Conversely,
to the extent that they feel confident that the child’s
slip is merely that—a slip, that can be readily
overcome, so too will the child. Thus, parental
responses to slips are critical and must be explicitly
discussed.
Conclusions
Anxiety disorders in children have been identified as
a significant problem. Converging areas of research
suggest that parents play an important role in the
development and maintenance of child anxiety.
Treatment outcome studies using a CBT family-
based approach appear effective for reducing child
anxiety. Specific treatment components of these
interventions include psychoeducation, contingency
management, cognitive restructuring, reducing
parental anxiety, improving the parent–child rela-
tionship, and relapse prevention. Despite the appeal
of family-based treatments, many questions remain
unaddressed and await future research.
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