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CCSXXX10.1177/1534650116668046Clinical Case StudiesKolomeyer and Renk

Article
Clinical Case Studies
2016, Vol. 15(6) 443­–458
Family-Based Cognitive–behavioral © The Author(s) 2016
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DOI: 10.1177/1534650116668046
Elementary School-Aged Child ccs.sagepub.com

With Generalized Anxiety Disorder

Ellen Kolomeyer1 and Kimberly Renk1

Abstract
This case study follows an 8-year-old Caucasian female who presented with symptoms of
Generalized Anxiety Disorder (GAD). Given this child’s age but advanced cognitive skills, careful
selection of an appropriate treatment was made. In the current case study, a family-based
cognitive–behavioral therapy intervention (Wood & McLeod, 2008) was implemented to treat
this child’s symptoms of GAD. Following completion of the intervention, the child demonstrated
significant decreases in her symptoms. In addition, she demonstrated a thorough understanding
of coping skills, successfully applied and generalized her skills to a variety of situations, and
took pride in teaching her skills to others. This child showed quantitative improvements on
objective self-report measures as well as qualitative improvements in her overall emotional
and behavioral functioning. This case study suggested that cognitive–behavioral therapy
interventions, particularly when used in a family-based approach, are effective for children with
symptoms of GAD.

Keywords
generalized anxiety disorder, school-aged, family-based intervention, cognitive–behavioral
therapy

1 Theoretical and Research Basis for Treatment


The distress that stems from Generalized Anxiety Disorder (GAD) is an individual, subjective
experience; however, impairment is an objective, observable experience and a cause for concern
for many parents of children diagnosed with GAD. Children who exhibit visible impairment
frequently are struggling with the intolerable weight of multiple, intense worries. Given that such
worries require higher level cognitive functioning, GAD typically does not develop until later
childhood, when children begin to think more abstractly about themselves and the future (Wood
& McLeod, 2008). Unfortunately, the course of childhood anxiety disorders is relatively chronic.
That is, anxiety disorders tend to persist over time, showing a relatively stable nature (Cantwell
& Baker, 1989) and often persisting into adulthood (Wood & McLeod, 2008).

1University of Central Florida, Orlando, FL, USA

Corresponding Author:
Kimberly Renk, Department of Psychology, University of Central Florida, 4000 Central Florida Blvd., Orlando, FL
32816, USA.
Email: Kimberly.Renk@ucf.edu

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444 Clinical Case Studies 15(6)

Current theories regarding the causes of anxiety implicate a combination of biological and
environmental influences (Vasey & Dadds, 2001). Certainly, susceptibility to anxiety can be
inherited through biological traits (Silverman, Cerny, Nelles, & Burke, 1988), with this predispo-
sition then being triggered in particular situations. Thus, it is important to select an intervention
that takes both biological and environmental influences into account. Furthermore, particular
attention should be given to involving caregivers in the intervention given children’s reliance on
their caregivers for shaping the surrounding environment (Wood & McLeod, 2008). Specifically,
caregivers must be considered allies when providing intervention services to children given care-
givers’ inarguable impact on children’s developmental pathways.
Moreover, the most effective interventions for childhood anxiety disorders are cognitive–
behavioral in nature (Barrett, Dadds, & Rapee, 1996; Kendall, 1994; Kendall et al., 1997), with
a variety of such child-focused interventions being available. In fact, cognitive–behavioral inter-
ventions for childhood anxiety disorders have been researched widely and garnered vast empiri-
cal support (Kendall, Aschenbrand, & Hudson, 2003; Silverman & Berman, 2001). Despite the
success of these interventions in remediating many children’s symptoms of anxiety, many chil-
dren continue to experience impairing symptoms post-intervention (Wood & McLeod, 2008). As
a result, the idea of more intensive family participation in interventions for children has been
considered (Silverman & Berman, 2001). Findings are favorable in that family-based cognitive–
behavioral interventions for childhood anxiety disorders were found to be highly effective and to
outperform child-focused cognitive–behavioral interventions alone (Wood & McLeod, 2008).
In addition, psychopharmacology often is recommended for individuals whose anxiety symp-
toms are too impairing to engage in effective interventions (RUPP Anxiety Group, 2001).
Specifically, selective serotonin reuptake inhibitors (SSRIs) are recommended for children with
anxiety disorders based on a study conducted by the RUPP Anxiety Group (2001). Furthermore,
research continues to corroborate the usefulness of SSRIs in the short- and long-term treatment
of childhood anxiety disorders (Clark et al., 2005). Nonetheless, others find that SSRIs alone are
not as effective as a combination of an SSRI with cognitive–behavioral intervention (Walkup
et al., 2009). Continued research on the use of psychopharmacology in treating childhood anxiety
disorders is necessary to determine the optimal duration and sequencing of medication regimens
(Silverman & Field, 2011).
The intervention selected for the child featured in this case study, Wood and McLeod’s (2008)
Building Confidence intervention, involves caregivers and specifically addresses parent–child
communication and family relationships as part of the intervention (Wood, McLeod, Sigman,
Hwang, & Chu, 2003). Compared with traditional, child-focused, cognitive–behavioral interven-
tions, the Building Confidence intervention shows benefits above and beyond those of traditional
therapy (Wood, Piacentini, Southam-Gerow, Chu, & Sigman, 2006). Such findings build on the
results of other case studies that describe successful outcomes when involving caregivers in the
treatment of childhood anxiety problems (e.g., Anderson, 2004; Krain, Hudson, Coles, & Kendall,
2002; Michael, Payne, & Albright, 2012; Siddaway, Wood, & Cartwright-Hatton, 2014); how-
ever, descriptions of the Building Confidence intervention and its outcomes are rarer in the
literature.
Notably, the Building Confidence intervention upholds the standards formulated by its prede-
cessors and follows an acronym model (i.e., KICK) to depict the cognitive and behavioral strate-
gies associated with the intervention. Specifically, the Building Confidence intervention begins
by promoting a child’s identification of the physical cues for their anxiety so that they can better
recognize when coping skills are needed. Next, one of the main goals of this intervention is to
alter inaccurate schemas that trigger anxiety reactions in the child by acknowledging maladaptive
thoughts and facilitating the child’s development of more realistic cognitions. This goal is accom-
plished by encouraging the child to conceptualize situations from a different, calmer viewpoint
than he or she had previously, such that more realistic beliefs begin to overshadow and replace

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Kolomeyer and Renk 445

cognitive distortions (Wood & McLeod, 2008). Also known as cognitive restructuring, the goals
of this process are to generate awareness about the harmfulness of existing cognitions and create
new beliefs that, with practice, can be recalled during future difficult experiences (Brewin, 2006).
A major component of cognitive–behavioral interventions that helps to facilitate reduction of
anxiety is exposure. Considered the “behavioral” portion of cognitive–behavioral intervention,
exposure allows the child to confront anxiety-provoking situations and habituate to them. The
Building Confidence intervention encourages the child to become exposed gradually to anxiety-
provoking situations by developing a hierarchy of these situations to determine the difficulty
level of each event. Given that these situations understandably can cause the child much distress,
positive reinforcement is utilized throughout the Building Confidence intervention to promote
motivation. Thus, caregivers become important figures in the child’s successful completion of
this intervention by providing the child with appropriate, repeated exposure opportunities, by
implementing a motivating reward system outside of the intervention sessions, and by promoting
the child’s courage and autonomy. Overall, cognitive–behavioral intervention is a powerful tool
for alleviating symptoms of childhood anxiety disorders, with even greater results when willing
caregivers are involved in the intervention process.

2 Case Introduction
Jane Smith (pseudonym) was an 8-year-old Caucasian female whose mother brought her to a
university clinic to seek treatment for her generalized anxiety and panic symptoms. Jane resided
with her biological mother and father and her older brother (who was 11-years-old) during the
course of her treatment. Jane’s anxiety-related symptoms (e.g., excessive worrying about the
future, somatic complaints, self-consciousness, contamination) and panic-related symptoms
(e.g., shaking, heart palpitations) began after she contracted a stomach virus when she was
5-years-old. In addition, Jane was diagnosed with Irritable Bowel Syndrome (IBS) at that time
and underwent a colonoscopy and endoscopy to determine whether she was experiencing irregu-
lar inflammation due to her stomach virus. Her panic-related symptoms only were present when
she began to worry about contracting another virus and/or about vomiting as a result of a virus.
Jane was enrolled in the second grade at the time of her treatment and was experiencing psycho-
social impairment at home and in the classroom. A doctoral student in clinical psychology com-
pleted all intake interviews and assessments and subsequently conducted all intervention sessions
under the supervision of a licensed clinical psychologist.
Jane’s case enhances the existing literature regarding treatment of GAD in school-aged chil-
dren. Specifically, Jane’s case is relatively novel in that it offers mental health care providers an
example of a family-based cognitive–behavioral intervention for children who otherwise are
developing typically, have no comorbid psychological diagnoses, and who possess advanced
cognitive thinking skills (with the presence of such skills adding to the complexity of implement-
ing cognitive restructuring and other intervention components). Furthermore, Jane’s case high-
lights the imperativeness of positive caregiver involvement in cognitive–behavioral interventions,
particularly with the Building Confidence intervention that has not yet been discussed commonly
in the literature.

3 Presenting Complaints
Jane was experiencing panic-like symptoms at the start of her intervention services. In particular,
Jane would become cold, chatter her teeth, tremble, and experience heart palpitations. These
symptoms recurred approximately 3 times per week in response to worries about vomiting. Thus,
there was a clear indicator (i.e., specific worry about vomiting) that triggered her panic-like
symptoms, and these symptoms were not unexpected or uncued.

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446 Clinical Case Studies 15(6)

Furthermore, Jane worried excessively about a variety of topics, including her performance in
school and in other activities. For example, Jane worried about her competence. In particular,
Jane became overly worried when she received constructive criticism on any academic or leisure
activity and could become pre-occupied with achieving perfection on her assignments. Next,
Jane worried about becoming sick from contaminated food. Specifically, she worried about
expired food as well as about her food touching a contaminated surface. In relation to her worries
about becoming sick, Jane complained of stomachaches several times per week.
In addition, Jane worried about her appearance, particularly about whether others were judg-
ing her appearance negatively. Jane also worried about being punctual and about leaving her
classroom during times of active instruction, indicating that she was afraid to miss something
important and to be judged by her peers upon her return. Moreover, Jane sought reassurance from
her parents and teachers excessively regarding her performance and her appearance. Finally, Jane
was often restless, was fatigued easily despite sleeping well through the night and being well-
rested in the morning, was irritable 2 to 3 times per week, and became markedly tense before bed,
exhibiting an inability to relax due to worry-centered thoughts. At bedtime, Jane sometimes indi-
cated that her “mind [wouldn’t] shut off.” Jane enjoyed drawing or listening to an audio book to
help her relax before bed.

4 History
Jane was born following an uncomplicated pregnancy and delivery. Jane was alert and easily
soothed, bonded well with her caregivers, maintained appropriate eye contact, and demonstrated
appropriate social interactions as an infant. Overall, Jane was happy, social, and easygoing and
achieved her developmental milestones within normal limits.
Jane experienced repeated instances of Otitis Media starting when she was 4-months-old.
Once Jane entered the school setting, her ear infections occurred every few months and were
treated successfully with antibiotics. Jane’s infections subsided by the time that she was 5-years-
old. Although Jane acquired language within the expected age range, Ms. Smith sought a speech
and language evaluation when Jane was 36-months-old to determine whether Jane’s language
development was delayed given her history of ear infections. Jane was diagnosed with Speech-
Language Impairment, and it was recommended that she receive Speech and Language Therapy.
Furthermore, Jane was diagnosed with Developmental Delay, resulting in Occupational Therapy
being recommended for remediation of hypotonia and fine motor skill difficulties. Finally, Jane
already had been prescribed Zoloft (20 mg/daily) by a psychiatrist prior to the start of the inter-
vention services described in this case study.

5 Assessment
Jane’s assessment for the course of intervention described in this case study consisted of a diag-
nostic interview, parent- and teacher-report measures, and self-report measures. An intellectual
assessment also was administered to Jane following the completion of intervention as Ms. Smith
requested that Jane be evaluated for giftedness.

Diagnostic Interview
The Kiddie Schedule for Affective Disorders and Schizophrenia–Present and Lifetime Version
(K-SADS; Kaufman & Schweder, 2004) was administered to Ms. Smith. It should be noted that
criteria from the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5;
American Psychiatric Association [APA], 2013) were considered, rather than just criteria from
the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; DSM-IV-TR; APA,

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Kolomeyer and Renk 447

Table 1.  CBCL and TRF Ratings (T-Scores).

Pre-treatment Pre-treatment Pre-treatment Time 2 Post-treatment


(teacher) (father) (mother) (mother) (mother)
Broad-band scales
  Internalizing problems 67a 67a 67a 69a 73a
  Externalizing problems 57 34 41 47 53
  Total problems 59 55 57 59 61a
Narrow-band scales
 Anxious/depressed 71a 68a 78a 74a 82a
 Withdrawn/depressed 53 56 52 50 50
  Somatic complaints 57 66a 53 68a 70a
  Social problems 54 57 64 59 64
  Thought problems 65a 58 54 54 50
  Attention problems 53 55 55 55 53
  Rule-breaking behavior 50 50 50 50 50
  Aggressive behavior 58 50 50 51 56
DSM-oriented scales
  Affective problems 55 60 60 63 63
  Anxiety problems 67a 70a 73a 70a 72a
  Somatic problems 57 64 50 64 64
  Attention deficit/ 55 51 52 51 50
hyperactivity
problems
  Oppositional defiant 50 50 50 51 55
problems
  Conduct problems 50 50 50 50 50

Note. CBCL = Child Behavior Checklist; TRF = teacher’s report form; DSM = diagnostic and statistical manual of
mental disorders.
aClinically meaningful scores.

2000). This interview confirmed a history of panic and anxiety symptoms. Diagnoses are dis-
cussed below.

Measures of Emotional and Behavioral Problems


Parent report.  Mr. and Ms. Smith completed the Child Behavior Checklist (CBCL) for ages 6 to
18 (Achenbach & Rescorla, 2001) as a measure of Jane’s emotional and behavioral functioning
at home. Mr. Smith completed the CBCL once prior to Jane’s participation in the intervention,
whereas Ms. Smith completed the CBCL 3 times (i.e., pre-, during, and post-intervention). This
measure provides both broad-band and narrow-band scores regarding the emotional and behav-
ioral functioning of children. T scores on these scales have a mean of 50 and a standard deviation
of 10. For the broad-band scales, scores that fall at 60 or higher can be considered clinically
noteworthy. For the narrow-band and DSM-oriented scales, scores that fall at 65 or higher can be
considered clinically noteworthy. Pre- and post-intervention scores for narrow-band and broad-
band scales can be found in Table 1.

Teacher report.  Jane’s second-grade teacher completed the Teacher’s Report Form (TRF; Achen-
bach & Rescorla, 2001) as a measure of Jane’s functioning in the classroom. Similar to the
CBCL, the TRF provides both broad-band and narrow-band scores regarding the emotional and

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448 Clinical Case Studies 15(6)

Table 2.  MASC-2 Self-Report Ratings (T-Scores).

Time 1 Time 2 Time 3 Time 4


Separation anxiety/phobias 48 41 48 40
GAD index 70a 63 55 40
Humiliation/rejection 67a 48 55 43
Performance fears 40 40 40 40
Social anxiety total 57 43 47 40
Obsessions and compulsions 66a 56 51 40
Panic 62 45 45 45
Tense/restless 52 61 55 49
Physical symptoms total 58 53 50 46
Harm avoidance 43 48 41 40
MASC-2 total score 60 50 47 40

Note. MASC-2 = Multidimensional Anxiety Scale for Children–Second edition; GAD = generalized anxiety disorder.
aClinically meaningful scores.

behavioral functioning of children. T scores on these scales have a mean of 50 and a standard
deviation of 10. For the broad-band scales, scores that fall at 60 or higher can be considered clini-
cally noteworthy. For the narrow-band and DSM-oriented scales, scores that fall at 65 or higher
can be considered clinically noteworthy. Jane’s classroom teacher completed a TRF prior to
Jane’s participation in the intervention. Pre-intervention scores for narrow-band and broad-band
scales can be found in Table 1. Post-intervention scores were unable to be obtained given that the
intervention was completed during the summer break.

Self-report.  To track Jane’s anxiety symptoms across the intervention, Jane was asked to complete
the Multidimensional Anxiety Scale for Children–Second edition (MASC-2; March, 2012). The
MASC-2 was selected given its wide recognition as a normed and psychometrically sound instru-
ment that assesses broad-band child anxiety symptoms (March, Parker, Sullivan, Stallings, &
Conners, 1997; March, Sullivan, & Parker, 1999) across the Diagnostic and Statistical Manual
of Mental Disorders (4th ed.; DSM-IV; APA, 1994) and DSM-5. This self-report measure pro-
vides specific index scores regarding the symptoms of anxiety that children and adolescents may
experience as well as a Total composite score. T scores on these scales have a mean of 50 and a
standard deviation of 10. Scores that fall at 65 or higher can be considered clinically noteworthy.
Higher scores indicate more problematic anxiety symptoms. Pre-, during, and post-intervention
scores can be found in Table 2.

Intelligence Testing
Ms. Smith requested that Jane’s intellectual functioning be assessed following completion of her
intervention services. To measure Jane’s current intellectual functioning, she was administered
the Wechsler Intelligence Scale for Children–Fourth edition (WISC-IV; Wechsler, 2003), a com-
prehensive clinical instrument for assessing the intellectual functioning of children and adoles-
cents who are between the ages of 6 and 16 years. The WISC-IV provides an overall measure of
intellectual functioning, the Full Scale Score. It also provides measures of specific intellectual
abilities (i.e., Index scores) based on the different types of subscales administered. These scores
have a mean of 100 and a standard deviation of 15.
Jane exhibited discrepancies in her performance across the WISC-IV factor indices. Thus,
Jane’s Full Scale score (113) was likely not a representative estimate of her intellectual abilities.

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Kolomeyer and Renk 449

In particular, Jane’s Verbal Comprehension Index score (128) was significantly higher than her
Perceptual Reasoning (117), Working Memory (94), and Processing Speed (91) Index scores.
Jane’s Perceptual Reasoning Index score also was significantly higher than her Working Memory
and Processing Speed Index scores. In addition to the typical scores that are derived commonly
for the WISC-IV, a General Ability Index (GAI) also was considered. The GAI is a score that
considers an individual’s performance on verbal comprehension and perceptual reasoning tasks
without the influence of working memory and processing speed and has been shown to be useful
in determining Giftedness. Jane’s GAI (126) suggested that Jane was likely to perform extremely
well in academic settings from a verbal and performance perspective and that she would benefit
greatly from advanced learning opportunities.

Client Observations
Jane was of average height based on her age and of average weight for her height. She was
dressed casually and groomed appropriately for all assessment and intervention sessions. Jane
was friendly, respectful, and inquisitive; engaged in spontaneous conversation; and appeared
forthcoming in sharing her thoughts and responses during all sessions. Overall, Jane put forth
commendable effort during the assessment and intervention process.

6 Case Conceptualization
Jane’s difficulties were examined via the diagnostic interview; parent-, teacher-, and self-report
measures; and behavioral observations at the clinic. Jane’s diagnosis is outlined below.

GAD
The information gathered (as discussed above) suggested that Jane met diagnostic criteria for
GAD based on DSM-5 criteria. Given that Jane had been exhibiting excessive anxiety and worry,
restlessness, muscle tension, irritability, and fatigue that was interfering with her psychosocial
functioning in the classroom and with family members and given that these symptoms had been
present since Jane was 5 years of age, she met criteria for GAD at the time that she was presented
for services.
Given that GAD typically develops in later childhood due to the level of higher cognitive
processes required to conceive excessive worries (Wood & McLeod, 2008), developmental level
must be considered when diagnosing GAD. The extent to which a child may experience the cog-
nitive symptoms of GAD relates to the child’s level of insight and understanding of emotion
(Dadds, James, Barrett, & Verhulst, 2004) and requires advanced language development and
comprehension to interpret and understand emotions (Schniering, Hudson, & Rapee, 2000) and
internal processes (Sattler, 2001). Ms. Smith’s report as well as observations of Jane in session
suggested that Jane demonstrated an advanced level of maturity and insight with regard to her
own and others’ emotions and internal states. In addition, Jane’s Superior score on the Verbal
Comprehension Index of the WISC-IV later confirmed that she possessed the language capability
and comprehension skills necessary to formulate and understand her worries and to describe her
experiences subjectively.

7 Course of Treatment and Assessment of Progress


Based on the case conceptualization and related empirical literature, it became evident that Jane
would benefit from a cognitive–behavioral intervention (Kendall et al., 2003; Kendall et al.,
1997; Wood et al., 2006). Specifically, Jane’s identified intervention needed to include the

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450 Clinical Case Studies 15(6)

identification of physiological signs of anxiety, identification of thoughts that provoke anxiety,


development of a plan for coping skills that involved changing thoughts and actions into positive
self-talk and practice, and a self-evaluation of performance (Wood & McLeod, 2008). These
skills would prepare Jane for planning an exposure hierarchy and participating in exposure tasks,
the goal of which was to alleviate her anxiety by repeated exposure to feared, albeit innocuous,
situations to reduce her symptoms (Rachman, 1990). According to Ollendick, Vasey, and King
(2001), exposure is the mechanism of action responsible for the reduction of anxiety and fear in
cognitive–behavioral interventions (Wood & McLeod, 2008). In addition, research suggested
that familial involvement in interventions for children’s anxiety may improve success and facili-
tate maintenance of gains (Barrett & Shortt, 2003). Thus, Wood and McLeod’s (2008) Building
Confidence intervention was selected for Jane.
Specifically, the Building Confidence intervention utilizes the acronym KICK to teach children
the core strategies needed for cognitive and behavioral change. First, emotion education must occur
for children to learn to recognize the physiological cues associated with their anxiety (i.e., K =
Knowing I’m Nervous) and become more aware of the situations in which they become anxious.
Next, children identify their maladaptive schemas by learning to identify the beliefs that they have
about anxiety-provoking situations (i.e., I = Identify Icky Thoughts). Then, cognitive restructuring
occurs as children identify calmer ways to think about these situations (i.e., C = Calm Your Thoughts).
Finally, children are reminded to continue facing their fears repeatedly through exposure so that they
can habituate to these situations and learn how to manage their worries (i.e., K = Keep Practicing).
Following assessment, Jane participated in the cognitive–behavioral Building Confidence
intervention (Wood & McLeod, 2008) for her symptoms of GAD. Throughout intervention, the
Building Confidence manual was followed closely. Jane was asked to complete the MASC-2
periodically throughout the course of the intervention. Specifically, Jane completed the MASC-2
once at baseline, every 12 weeks throughout the intervention, and once at post-intervention, for
a total of four completions. The 12-week time frame was chosen based on Jane’s progression
through the situations on her exposure hierarchy. In addition, Mr. and Ms. Smith completed the
CBCL at baseline, and Ms. Smith completed the CBCL at post-intervention and follow-up. Ms.
Smith also reported qualitative improvements that occurred throughout intervention. Homework
was assigned after each session so that Jane could continue practicing the skills learned in inter-
vention sessions and building on intervention progress. Family involvement was essential to
Jane’s intervention plan for the purposes of coordinating exposure opportunities outside of the
clinic setting, facilitating practice of coping skills, and offering positive reinforcement. Thus, Ms.
Smith was consulted and was provided with session details during every session. Jane’s interven-
tion is detailed below. Also see Table 3 for a summary of sessions.

Session 1 (60 Min)


Following two assessment sessions, the purpose of the first intervention session was to establish
rapport with Jane and to obtain Jane’s own description about her feelings of anxiety. Jane was
highly attentive, poised, and engaged in appropriate conversation. She reported having many
worries and indicated that she wanted to work on not feeling as worried overall.

Session 2 (60 Min)


The purpose of Session 2 was to introduce Jane and Ms. Smith to the goals of the Building
Confidence intervention. Specifically, the process of overcoming Jane’s worries through chal-
lenge exercises and positive reinforcement for completing challenges was discussed. In addition,
Ms. Smith was provided with handouts summarizing the Building Confidence intervention and
instructions to complete a Behavior Record Form for Jane’s anxious behaviors.

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Kolomeyer and Renk 451

Table 3.  Summary of Sessions.


Session 1 Establish rapport and obtain description of anxiety symptoms from Jane
Session 2 Introduction to Building Confidence intervention, challenge exercises, and
a reward system
Session 3 Introduction to K step of KICK plan
Session 4 Introduction to I step of KICK plan
Session 5 Introduction to C step of KICK plan
Session 6 Administration of MASC-2 at baseline
Session 7 Development exposure hierarchy
Session 8 Introduction to K step of KICK plan, exposure to being late
Session 9 Distress tolerance skills, exposure to being late and losing
Session 10 Distress tolerance skills, exposure to being late
Session 11 Distress tolerance skills, exposure to being late
Session 12 Distress tolerance skills, exposure to being late
Session 13 Distress tolerance skills, exposure to being late
Session 14 Distress tolerance skills, exposure to being late
Session 15 Administration of MASC-2
Session 16 Re-evaluation of exposure hierarchy
Session 17 Progressive muscle relaxation skills
Session 18 Assertiveness skills
Session 19 Exposure to embarrassment
Session 20 Exposure to embarrassment
Session 21 Exposure to embarrassment
Session 22 Exposure to embarrassment
Session 23 Exposure to embarrassment
Session 24 Exposure to embarrassment
Session 25 Administration of MASC-2
Session 26 Updated exposure hierarchy related to food contamination
Session 27 Exposure to food contamination worries
Session 28 Exposure to food contamination worries
Session 29 Exposure to worries about getting sick
Session 30 Exposure to worries about getting sick
Session 31 Conclusion of therapy, administration of MASC-2
Session 32 Gifted evaluation requested by Ms. Smith
Session 33 Booster session

Note. K = Knowing I’m Nervous; I = Identify Icky Thoughts; C = Calm Your Thoughts; K = Keep Practicing;
MASC-2 = Multidimensional Anxiety Scale for Children–Second edition.

Sessions 3 Through 5 (60 Min)


The purpose of Session 3 was to introduce Jane to the K step of the KICK plan (i.e., to identify
her physiological cues of anxiety). In addition, Ms. Smith had completed the Behavior Record
Form and was provided with parent handouts regarding Common Patterns of Child Anxiety and
more information about the Building Confidence intervention. Session 4 focused on the I step of
the KICK plan, which connected anxious feelings to anxiety or “icky” thoughts. During this ses-
sion, Ms. Smith was provided with handouts regarding encouraging independent self-help skills
in Jane. The purpose of Session 5 was to introduce Jane to the C step of the KICK plan. In addi-
tion, Ms. Smith had begun encouraging Jane to utilize more independent self-help skills at home,
including the selection of her own outfits for school, bathing herself, and organizing her play
activities. Next, this session focused on introducing Jane to the concept of identifying calm
thoughts to replace previously identified anxious thoughts for the characters presented in her

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452 Clinical Case Studies 15(6)

handouts. Ms. Smith was provided with a handout aimed at helping Jane cope with her anxiety
using the CALM strategy (i.e., Catch your breath, Accept negative feelings, Label emotions, and
Model coping skills). In addition, Ms. Smith was provided with a handout detailing selective
attention in an effort to decrease the attention that Ms. Smith offered Jane when Jane became
upset in anxiety-provoking situations.

Sessions 6, 15, 25, and 31 (60 Min)


Jane completed a baseline MASC-2 in Session 6, prior to discussing her exposure hierarchy in
the next session. Additional administrations of the MASC-2 were completed with Jane every
twelve weeks throughout the intervention (i.e., in Sessions 15 and 25) and finally at post-inter-
vention in Session 31.

Sessions 7, 16, and 26 (60 Min)


The purpose of Session 7 was to develop Jane’s exposure hierarchy. Jane listed anxiety-provok-
ing situations and rated each on a scale of 0 to 10, with 10 signifying the highest difficulty level.
Jane took the initiative to label the emotions that each step of her hierarchy elicited. By Session
16, Jane believed that she had already “KICKed” many of the worries on her initial exposure
hierarchy. Therefore, Jane’s exposure hierarchy was re-evaluated and updated in Session 16.
Following implementation of distress tolerance skills and exposure opportunities for many of
Jane’s other worries, a final exposure hierarchy was developed during Session 26 related specifi-
cally to food contamination and getting sick.

Session 8 (60 Min)


Session 8 focused on presenting the second K of the KICK plan to Jane as a reminder to keep
practicing coping skills and exposure tasks (starting with the next session). This information was
discussed in the context of building Jane’s confidence in anxiety-provoking situations. In addi-
tion, a motivating reward system for Jane’s completion of exposure tasks was discussed with Ms.
Smith, who agreed to participate actively in facilitating exposure opportunities for Jane outside
of sessions.

Sessions 9 Through 14 (60 Min)


Sessions 9 through 14 focused on exposure to being late. Jane was provided with distress
tolerance and problem-solving skills, and Ms. Smith facilitated exposures outside of ses-
sions. Between Sessions 13 and 14, Ms. Smith reported that Jane’s Zoloft dosage was
increased from 20 to 25 mg/daily. Across Sessions 13 and 14, Jane had begun creating her
own distress tolerance skills that she could use in addition to the skills that she was learning
in session.

Sessions 17 and 18 (60 Min)


Sessions 17 and 18 focused on providing Jane with additional distress tolerance skills. For exam-
ple, in Session 17, Jane learned progressive muscle relaxation skills via a child-oriented script to
address her continued feelings of restlessness and muscle tension. Session 18 focused on asser-
tiveness skills, as Jane had indicated previously that she wished to learn how to stand up for
herself in a confident manner without hurting anyone’s feelings.

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Kolomeyer and Renk 453

Sessions 19 Through 24 (60 Min)


The purpose of Sessions 19 through 24 was for Jane to complete in-session exposure exercises
related to feeling embarrassment. Jane often became upset upon learning what exposure oppor-
tunities would be completed in session, exhibiting physiological symptoms of anxiety and pro-
testing verbally. Nonetheless, Jane was able to utilize her distress tolerance skills in addition to
preparing for each exposure with individualized KICK plans. Ultimately, Jane participated in
each in-session exposure exercise. Throughout these sessions, Ms. Smith facilitated opportuni-
ties for Jane to practice exposures outside of session.

Sessions 27 Through 30 (60 Min)


Sessions 27 through 30 focused on the most difficult level of Jane’s exposure hierarchy, getting
sick from food contamination. Jane created a KICK plan for this trigger and strategized distress
tolerance skills to generalize to broader situations so that she could examine food independently
without having to seek reassurance about the safety of food from others. In between Sessions 27
and 28, Ms. Smith contacted the doctoral student clinician to report that Jane had been success-
fully using her independent food examination skills and had not asked anyone questions related
to food contamination. Finally, Jane’s vomiting-related fears were discussed in Sessions 29 and
30. Given that Jane frequently vocalized worries about vomiting and often asked her parents
whether she was going to vomit, a list of body signals was created to provide Jane with opportu-
nities to perform a mental independent body scan to determine whether she was going to vomit.
The next session was scheduled for approximately 1 month later to provide Jane an opportunity
to practice all of her skills independently.

Session 31 (90 Min)


The purpose of the final session was to check in with Jane regarding her worries about getting
sick and vomiting, to review all of her skills, and to conclude intervention services. Jane and Ms.
Smith both indicated that, at this point, Jane had been using her distress tolerance skills and
KICK plans and that she was no longer worried about vomiting. A final MASC-2 was adminis-
tered during this session. Finally, all of Jane’s skills were reviewed and independent implementa-
tion of these skills in the future was discussed.

Session 32 (120 Min)


Session 32 focused on administering the WISC-IV to Jane as part of a gifted evaluation requested
by Ms. Smith. Jane exhibited high motivation and compliance during the assessment; however,
she experienced low frustration tolerance and symptoms of anxiety (e.g., hands shaking, rapid
breathing) during difficult tasks. Jane was able to independently implement her distress tolerance
skills throughout the evaluation to regulate her physiological symptoms.

Session 33 (60 Min)


Approximately 7 months following the conclusion of Jane’s intervention services, Ms. Smith
contacted the graduate student clinician to discuss Jane’s challenges with upcoming standardized
testing at school. Consequently, Jane attended a booster session so that she could participate in a
refresher of her skills prior to the standardized testing. During the session, Jane created a KICK
plan for the testing and developed several “calm thoughts” to combat her “icky thoughts” regard-
ing testing. In addition, Jane reviewed the distress tolerance skills that she would implement

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454 Clinical Case Studies 15(6)

during testing. Finally, Ms. Smith reported that Jane had been doing very well throughout the
school year overall with regard to managing worries that arose throughout the year. No further
cognitive–behavioral intervention was sought.

8 Complicating Factors
During the course of Jane’s intervention, her older brother began experiencing heightened anxi-
ety and panic attacks and also began receiving intervention services in the same university clinic
from a different doctoral student in clinical psychology. Given that Jane’s brother shared his wor-
ries in Jane’s presence, Jane occasionally adopted her brother’s worries and presented new wor-
ries that she had not experienced previously, including worries that were focused on possible
events in the distant future (i.e., middle school). This presentation would be consistent with the
fact that anxiety symptoms may heighten in the siblings of anxious children (Poirier, Brendgen,
Vitaro, Dionne, & Boivin, 2016). Nonetheless, the Building Confidence intervention was effec-
tive in managing Jane’s anxiety symptoms, particularly given her willingness to participate and
given the support received from her family throughout services and beyond.

9 Access and Barriers to Care


Minimal barriers to care existed in this particular case; however, several barriers could hinder
intervention. Specifically, intervention often can be costly and time intensive. Furthermore, it
was critical for Jane’s parents to be willing participants in the completion of the Building
Confidence intervention. The participation of Jane’s parents (particularly her mother) allowed for
Jane to receive consistent service and desirable rewards and for Jane to participate in exposure
opportunities outside of session. Without this level of parent participation, families may experi-
ence other barriers, such as parents having difficulty when they experience their own anxiety,
when they become intrusive in or avoidant of their child’s participation in the intervention, and/
or when they fail to promote their child’s courageous behavior in the face of anxiety-provoking
triggers.

10 Follow-Up
Given that low remission rates are common with GAD (APA, 2013; Bruce et al., 2005), it is not
necessarily the goal of interventions to eliminate anxiety. Rather, the goal should be to alleviate
the daily challenges associated with anxiety symptoms and to provide appropriate skills for doing
so. To monitor Jane’s progress in managing her anxiety, Ms. Smith completed the CBCL 3 times
to provide information about Jane’s emotional and behavioral functioning. Overall, the trends of
scores on the CBCL were relatively similar across time points. In contrast, Jane’s self-report rat-
ings on the MASC-2 decreased significantly across the four time points at which she completed
the measure. The considerable decrease in Jane’s self-report scores suggested that, despite con-
tinuing to experience some symptoms of anxiety (as reported by Ms. Smith), Jane was no longer
experiencing her symptoms in a debilitating way that was detrimental to her overall functioning.
Certainly, based on available cross-informant literature (e.g., Achenbach, McConaughy, &
Howell, 1987), it would not be unexpected for parents’ ratings of their child’s behavior to differ
from those provided by the child him- or herself. Nonetheless, the impact of intervention in this
case must be interpreted conservatively, and interpretations should not rely on one measure.
Furthermore, qualitative reports from Ms. Smith and Jane throughout the intervention indi-
cated that the severity of Jane’s symptoms improved greatly. Specifically, Jane’s continued
practice of distress tolerance skills and KICK plans through contrived exposure opportunities
and organic daily challenges facilitated Jane’s confidence in managing her symptoms. In

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Kolomeyer and Renk 455

addition, through repeated exposure, many of Jane’s worries subsided after she recognized
the actual safety of previously feared situations, restructured her cognitions successfully, and
implemented effective, rather than maladaptive, behaviors. In fact, at Jane’s 1-month follow-
up appointment, Jane and Ms. Smith reported that Jane had not been mentioning her worries
and had been implementing her distress tolerance skills and KICK plans when new worries
arose.
Finally, Jane returned for a booster session 7 months following her last appointment given
new, relevant challenges that she was experiencing with regard to standardized testing at
school. Although Jane continued to implement her skills over the course of her current aca-
demic year, she believed that she would benefit from refreshing her skills in session prior to
her testing at school. Jane sought guidance in developing a KICK plan and choosing appropri-
ate distress tolerance skills to use. After Jane’s standardized testing was complete, Ms. Smith
reported that Jane had done great and did not experience any further problems.

11 Treatment Implications of the Case


This case demonstrated the effectiveness of an empirically supported, family-based cogni-
tive–behavioral Building Confidence intervention for an intelligent, elementary school-aged
child. Given the low remission rates for GAD, this intervention is particularly important for
helping children to foster the skills necessary to manage their anxiety from an early age and
to prepare them for future challenges throughout their lives. Moreover, this intervention
exemplified the importance of families’ roles in children’s treatment. The support provided
by Jane’s parents was vital to the evolution of Jane’s independent and courageous behavior
in battling her worries. Jane’s parents played the beneficial role of providing her with expo-
sure opportunities, promoting her use of the skills that she learned in session, reducing their
own unintentional involvement in avoidant or maladaptive behaviors, and encouraging Jane
to successfully develop a sense of confidence that naturally reduced her anxiety and fostered
effective behavior (Wood & McLeod, 2008). This particular case was relatively novel in the
existing literature given its demonstration of the appropriate balance of caregiver involve-
ment in the cognitive–behavioral Building Confidence intervention. In other words, the
importance of positive, developmentally appropriate familial inclusion cannot be stressed
enough with regard to successful cognitive–behavioral intervention in children with
anxiety.
Another important consideration for effective cognitive–behavioral intervention for child-
hood GAD is the adaptability of cognitive restructuring and behavioral strategies. Although com-
mitment to the structure of any manualized intervention is necessary, this structure often requires
modification to suit the needs of each individual. In particular, Jane’s intervention extended lon-
ger than the number of sessions originally described in the Building Confidence manual. Although
several of Jane’s worries could be subsumed into one type of exposure task that required few
sessions in some instances, other feared situations took Jane longer to habituate to, particularly at
the beginning of her course of intervention.
In addition, given Jane’s insight to label the emotions that she felt in each of her feared situa-
tions, several worries on her exposure hierarchy could be addressed through one type of exposure
situation. Finally, Jane’s own willingness to participate is noteworthy. Jane’s advanced language
skills, thought processes, and emotional maturity benefitted her greatly over the course of inter-
vention and facilitated her motivation to practice the skills learned in session, create new skills
on her own, and engage in exposure exercises. Overall, supportive and effective family involve-
ment as well as individualized, core cognitive–behavioral strategies were beneficial to Jane in
developing the courage needed to confront her anxiety.

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456 Clinical Case Studies 15(6)

12 Recommendations to Clinicians and Students


Providing effective intervention services for a child diagnosed with GAD can be challenging.
Various treatment options exist, and it is necessary to deliver an intervention that suits each indi-
vidual child and his or her family. The therapeutic alliance with the child in treatment and the
child’s family is of vital importance to effective intervention. Of course, intervention effective-
ness for children with GAD relies heavily on the child’s participation; however, the impact of the
ability and willingness of clinicians and caregivers to work together cannot be underestimated.
In addition, it is essential to maintain fidelity to the intervention manual while balancing the
structure of the actual intervention with an individual child’s struggles, progress, and fluctuating
needs. For example, clinical judgment based on client observations may need to be used to deter-
mine whether a child attributed the appropriate difficulty level to each situation. Furthermore, it
is important to consider the specific age and developmental level of the child when selecting and
implementing an appropriate intervention. The Building Confidence intervention was chosen for
this case partly based on its appropriateness for school-aged children. Particularly, this interven-
tion’s use of cartoons showing school-aged characters in commonly feared situations resonates
with similar-aged children in identifying and restructuring maladaptive thinking. For example,
children can focus initially on cartoon characters’ thought processes without having to emphasize
their own anxiety at first (Wood & McLeod, 2008).
Moreover, some children may require pharmacotherapy, such as antidepressant medications
(RUPP Anxiety Group, 2001). Certainly, having pharmacotherapy implemented concurrently
with a psychological intervention may increase difficulty in determining the impact of either
intervention alone. Nonetheless, if anxiety symptoms are too impairing for children and prevent
them from engaging in cognitive–behavioral interventions, pharmacotherapy may be a necessary
addition (Wood & McLeod, 2008). Providers should use previous research and their clinical
judgment in determining whether a child needs to be referred to a physician for pharmacotherpay
when participating in psychotherapeutic intervention. Initial, short-term relief may be necessary
for some children to learn the psychotherapeutic skills that will allow for an eventual reduction
or discontinuation of medication (Wood & McLeod, 2008).
Finally, clinicians, patients, and families alike need not be discouraged if a child’s struggles
with anxiety persist following the completion of a cognitive–behavioral intervention. Rarely
does GAD remit fully. Rather, it can be an enduring experience that may arise in a variety of
future situations over the course of many years. This course does not need to imply bleak out-
comes, however. On the contrary, family-based, cognitive–behavioral interventions offer an
effective, head on, response to addressing difficulties with childhood anxiety and provide the
lifelong skills necessary to continue facing challenging situations for years to come.

Declaration of Conflicting Interests


The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

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Author Biographies
Ellen Kolomeyer, MS, is a doctoral student at the University of Central Florida. Her work focuses on dif-
ficult experiences in early childhood, particularly on decreasing young children’s emotional and behavioral
dysregulation and fostering the parent–young child relationship in families who were affected by adverse
experiences.
Kimberly Renk, PhD, is currently an associate professor of clinical psychology at the University of Central
Florida and a licensed psychologist in the state of Florida. Inspired by her completion of Infant Mental Health
fellowship training while completing her pre-doctoral internship at the Louisiana State University Health
Sciences Center, the majority of her research has examined the needs of young children who are experiencing
emotional and behavioral problems in the context of significant family stressors (e.g., trauma, abuse, neglect).
Throughout her graduate studies and her postdoctoral work, she has worked with traumatized young children
in a variety of clinical settings. Most recently, she has been working with Neil W. Boris, MD, to integrate
evidence-based parenting interventions into the child welfare system in Central Florida.

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