Child Psychiatry & Human Development

, Volume 45, Issue 3, pp 338–347 | Cite as

Effects of Cognitive-Behavioral Therapy on Improving Anxiety Symptoms, Behavioral Problems and Parenting Stress in Taiwanese Children with Anxiety Disorders and Their Mothers

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


The aims of this intervention study were to examine the effects of individual cognitive-behavioral therapy (CBT) based on the modified Coping Cat Program on improving anxiety symptoms and behavioral problems in Taiwanese children with anxiety disorders and parenting stress perceived by their mothers. A total of 24 children with anxiety disorders in the treatment group completed the 17-session individual CBT based on the modified Coping Cat Program, and 26 children in the control group received the treatment as usual intervention. The Taiwanese version of the MASC (MASC-T), the Child Behavior Checklist for Ages 6–18 (CBCL/6-18) and the Chinese version of the Parenting Stress Index (C-PSI) were applied to assess the severities of anxiety symptoms, behavioral problems and parenting stress, respectively. The effects of CBT on improving anxiety symptoms, behavioral problems and parenting stress were examined by using linear mixed-effect model with maximum likelihood estimation. The results indicated that the CBT significantly improved the severities of MASC-T Physical Symptoms and Social Anxiety subscales, CBCL/6-18 DSM-oriented Anxiety Problem subscale, and C-PSI Child domains Mood and Adaptability subscales. Individual CBT based on the modified Coping Cat Program can potentially improve anxiety symptoms in Taiwanese children with anxiety disorders and some child domains of parenting stress perceived by their mothers.


Anxiety disorder Children Cognitive-behavioral therapy Parenting stress 



This study was supported by Grants NSC 98-2410-H-037-005-MY3 awarded by the National Science Council, Taiwan (ROC) and grant KMUH 100-0R48 awarded by Kaohsiung Medical University Hospital.


  1. 1.
    Costello EJ, Mustillo S, Erkanli A, Keeler G, Angold A (2003) Prevalence and development of psychiatric disorders in childhood and adolescence. Arch Gen Psychiatry 60:837–844PubMedCrossRefGoogle Scholar
  2. 2.
    Yonkers KA, Warshaw MR, Maisson AO, Keller MB (1996) Phenomenology and course of generalized anxiety disorder. Br J Psychiatry 168:308–313PubMedCrossRefGoogle Scholar
  3. 3.
    Albano AM, Chorpita BF, Barlow DH (2003) Childhood anxiety disorders. In: Mash EJ, Barkley RA (eds) Child psychopathology, 2nd edn. Guilford Press, New York, pp 279–329Google Scholar
  4. 4.
    Klein RG, Last CG (1989) Anxiety disorders in children. Sage, Newbury ParkGoogle Scholar
  5. 5.
    Hudson JL, Dodd HF (2012) Informing early intervention: preschool predictors of anxiety disorders in middle childhood. PLoS ONE 7:e42359PubMedCentralPubMedCrossRefGoogle Scholar
  6. 6.
    Pine DS, Cohen P, Gurley D, Brook J, Ma Y (1998) The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Arch Gen Psychiatry 55:56–64PubMedCrossRefGoogle Scholar
  7. 7.
    Biederman J, Petty CR, Hirshfeld-Becker DR, Henin A, Faraone SV, Fraire M et al (2007) Developmental trajectories of anxiety disorders in offspring at high risk for panic disorder and major depression. Psychiatry Res 153:245–252PubMedCentralPubMedCrossRefGoogle Scholar
  8. 8.
    Hirshfeld-Becker DR, Micco JA, Simoes NA, Henin A (2008) High risk studies and developmental antecedents of anxiety disorders. Am J Med Genet C Semin Med Genet 148C:99–117PubMedCrossRefGoogle Scholar
  9. 9.
    Connolly SD, Bernstein GA, the Work Group on Quality Issues (2007) Practice parameter for the assessment and treatment of children and adolescents with anxiety disorders. J Am Acad Child Adolesc Psychiatry 46:267–283CrossRefGoogle Scholar
  10. 10.
    Ollendick TH, King NJ (1998) Empirically supported treatments for children with phobic and anxiety disorders: current status. J Clin Child Psychol 27:156–167PubMedCrossRefGoogle Scholar
  11. 11.
    Reynolds S, Wilson C, Austin J, Hooper L (2012) Effects of psychotherapy for anxiety in children and adolescents: a meta-analytic review. Clin Psychol Rev 32:251–262PubMedCrossRefGoogle Scholar
  12. 12.
    Kendall PC, Hedtke KA (2006) Cognitive-behavioral therapy for anxious children: therapist manual (3rd ed). Philadelphia, PA, Temple University, Child and Adolescent Anxiety Disorders ClinicGoogle Scholar
  13. 13.
    Kendall PC (1994) Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin Psychol 62:100–110PubMedCrossRefGoogle Scholar
  14. 14.
    Kendall PC, Flannery-Schroeder E, Panichelli-Mindel SM, Southam-Gerow M, Henin A, Warman M (1997) Therapy for youths with anxiety disorders: a second randomized clinical trial. J Consult Clin Psychol 65:366–380PubMedCrossRefGoogle Scholar
  15. 15.
    Kendall PC, Safford S, Flannery-Schroeder E, Webb A (2004) Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4-year follow-up. J Consult Clin Psychol 72:276–287PubMedCrossRefGoogle Scholar
  16. 16.
    Kendall PC, Southam-Gerow MA (1996) Long-term follow-up of cognitive-behavioral therapy for anxiety disordered youth. J Consult Clin Psychol 64:724–730PubMedCrossRefGoogle Scholar
  17. 17.
    Benjamin CL, Harrison JP, Settipani CA, Brodman DM, Kendall PC (2013) Anxiety and related outcomes in young adults 7–19 years after receiving treatment for child anxiety. J Consult Clin Psychol (in press)Google Scholar
  18. 18.
    Yen CF, Ko CH, Wu YY, Yen JY, Hsu FC, Yang P (2010) Normative data on anxiety symptoms on the Multidimensional Anxiety Scale for Children in Taiwanese children and adolescents: differences in sex, age, and residence and comparison with an American sample. Child Psychiatry Hum Dev 41:614–623PubMedCrossRefGoogle Scholar
  19. 19.
    Yao S, Zou T, Zhu X, Abela JRZ, Auerbach RP, Tong X (2007) Reliability and validity of the Chinese version of the Multidimensional Anxiety Scale for Children among Chinese secondary school students. Child Psychiatry Hum Dev 38:1–16PubMedCrossRefGoogle Scholar
  20. 20.
    Lau WY, Chan CK, Li JC, Au TK (2010) Effectiveness of group cognitive-behavioral treatment for childhood anxiety in community clinics. Behav Res Ther 48:1067–1077PubMedCrossRefGoogle Scholar
  21. 21.
    Ishikawa S, Motomura N, Kawabata Y, Tanaka H, Shimotsu S, Sato Y et al (2012) Cognitive behavioural therapy for Japanese children and adolescents with anxiety disorders: a pilot study. Behav Cogn Psychother 40:271–285PubMedCrossRefGoogle Scholar
  22. 22.
    Abidin RR (1990) Introduction to the special issue: the stresses of parenting. J Clin Child Psychol 19:298–301CrossRefGoogle Scholar
  23. 23.
    Anthony LG, Anthony BJ, Glanville DN, Naiman DQ, Waanders C, Shaffer S (2005) The relationships between parenting stress, parenting behaviour and preschoolers’ social competence and behavior problems in the classroom. Infant Child Dev 14:133–154CrossRefGoogle Scholar
  24. 24.
    Ollendick TH, Horsch LM (2007) Fears in clinic-referred children: relations with child anxiety sensitivity, maternal over-control, and maternal phobic anxiety. Behav Ther 38:402–411PubMedCrossRefGoogle Scholar
  25. 25.
    Ashford J, Smit F, Van Lier PAC, Cuijpers P, Koot HM (2008) Early risk indicators of internalizing problems in late childhood: a 9-year longitudinal study. J Child Psychol Psychiatry 49:774–780PubMedCrossRefGoogle Scholar
  26. 26.
    Onatsu-Arvilommi T, Nurmi JE, Aunola K (1998) Mothers’ and fathers’ well-being, parenting styles, and their children’s cognitive and behavioural strategies at primary school. Eur J Psychol Educ 13:543–556CrossRefGoogle Scholar
  27. 27.
    Keeton CP, Ginsburg GS, Drake KL, Sakolsky D, Kendall PC, Birmaher B et al (2013) Benefits of child-focused anxiety treatments for parents and family functioning. Depress Anxiety. doi: 10.1002/da.22055 Google Scholar
  28. 28.
    Rockhill C, Kodish I, DiBattisto C, Macias M, Varley C, Ryan S (2010) Anxiety disorders in children and adolescents. Curr Probl Pediatr Adolesc Health Care 40:66–99PubMedCrossRefGoogle Scholar
  29. 29.
    van der Sluis CM, van der Bruggen CO, Brechman-Toussaint ML, Thissen MA, Bögels SM (2012) Parent-directed cognitive behavioral therapy for young anxious children: a pilot study. Behav Ther 43:583–592PubMedCrossRefGoogle Scholar
  30. 30.
    American Psychiatric Association (2000) Diagnostic and statistical manual of mental disorders (4th ed. text revision). Washington, American Psychiatric AssociationGoogle Scholar
  31. 31.
    March JS, Parker JD, Sullivan K, Stallings P, Conners CK (1997) The ultidimensional Anxiety Scale for Children (MASC): factor structure, reliability, and validity. J Am Acad Child Adolesc Psychiatry 36:554–565PubMedCrossRefGoogle Scholar
  32. 32.
    Yen CF, Yang P, Wu YY, Hsu FC, Cheng CP (2010) Factor structure, reliability and validity of the Taiwanese version of the Multidimensional Anxiety Scale for Children. Child Psychiatry Hum Dev 41:342–352PubMedCrossRefGoogle Scholar
  33. 33.
    Chen IC, Huang HL, Chao CC (2009) The Chinese version of the achenbach system of empirically based assessment. Psychological Publishing Co, TaipeiGoogle Scholar
  34. 34.
    Achenbach TM, Rescorla LA (2007) Multicultural supplement to manual for the ASEBA School-age forms and profiles. Burlington, VT, University of Vermont, Research Center for Children, Youth, and FamiliesGoogle Scholar
  35. 35.
    Yang HJ, Soong WT, Chiang CN, Chen WJ (2000) Competence and behavioral/emotional problems among Taiwanese adolescents as reported by parents and teachers. J Am Acad Child Adolesc Psychiatry 39:232–239PubMedCrossRefGoogle Scholar
  36. 36.
    Abidin RR (1997) The parenting Stress Index: a measure of the parent-child system. In: Zalaquett CP, Wood RJ (eds) Evaluating stress: a book of resources. University Press of America, LathanGoogle Scholar
  37. 37.
    Weng YS (2003) Parenting Stress Index. Psychological Publishing Co, TaipeiGoogle Scholar
  38. 38.
    Gau SSF, Chong MY, Chen THH, Cheng ATA (2005) A 3-year panel study of mental disorders among adolescents in Taiwan. Am J Psychiatry 162:1344–1350PubMedCrossRefGoogle Scholar
  39. 39.
    Mendlowitz SL, Manassis K, Bradley S, Scapillato D, Miezitis S, Shaw BF (1999) Cognitive-behavioral group treatments in childhood anxiety disorders: the role of parental involvement. J Am Acad Child Adolesc Psychiatry 38:1223–1229PubMedCrossRefGoogle Scholar
  40. 40.
    Gar NS, Hudson JL (2009) Changes in maternal expressed emotion toward clinically anxious children following cognitive behavioral therapy. J Exp Child Psychol 104:346–352PubMedCrossRefGoogle Scholar
  41. 41.
    Barmish AJ, Kendall PC (2005) Should parents be co-clients in cognitive-behavioral therapy for anxious youth? J Clin Child Adolesc Psychol 34:569–581PubMedCrossRefGoogle Scholar
  42. 42.
    Breinholst S, Esbjørn BH, Reinholdt-Dunne ML, Stallard P (2012) CBT for the treatment of child anxiety disorders: a review of why parental involvement has not enhanced outcomes. J Anxiety Disord 26:416–424PubMedCrossRefGoogle Scholar
  43. 43.
    Barrett PM (1998) Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol 27:459–468PubMedCrossRefGoogle Scholar
  44. 44.
    Suveg C, Hudson JL, Brewer G, Flannery-Schroeder E, Gosch E, Kendall PC (2009) Cognitive-behavioral therapy for anxiety-disordered youth: secondary outcomes from a randomized clinical trial evaluating child and family modalities. J Anxiety Disord 23:341–349PubMedCrossRefGoogle Scholar
  45. 45.
    Suveg C, Sood E, Comer JS, Kendall PC (2009) Changes in emotion regulation following cognitive-behavioral therapy for anxious youth. J Clin Child Adolesc Psychol 38:390–401PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Cheng-Fang Yen
    • 1
    • 2
  • Yu-Min Chen
    • 1
    • 2
  • Jen-Wen Cheng
    • 3
  • Tai-Ling Liu
    • 1
    • 2
  • Tzu-Yu Huang
    • 4
  • Peng-Wei Wang
    • 1
    • 2
  • Pinchen Yang
    • 1
    • 2
  • Wen-Jiun Chou
    • 5
  1. 1.Department of Psychiatry, Faculty of Medicine, Kaohsiung Medical University HospitalKaohsiung Medical UniversityKaohsiungTaiwan
  2. 2.Graduate Institute of Medicine, College of MedicineKaohsiung Medical UniversityKaohsiungTaiwan
  3. 3.Department of PsychiatryKaohsiung Veterans General HospitalKaohsiungTaiwan
  4. 4.Department of Psychology, College of Humanities and Social SciencesKaohsiung Medical UniversityKaohsiungTaiwan
  5. 5.Department of Child and Adolescent Psychiatry, Chang Gung Memorial Hospital, Kaohsiung Medical Center and College of MedicineChang Gung UniversityKaohsiungTaiwan

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