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Very early family-based intervention for anxiety: two case studies with toddlers
  1. Dina R Hirshfeld-Becker1,2,
  2. Aude Henin1,2,
  3. Stephanie J Rapoport1,
  4. Timothy E Wilens2,3 and
  5. Alice S Carter4
  1. 1 Child CBT Program, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2 Department of Psychiatry, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Division of Child and Adolescent Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
  4. 4 Department of Psychology, University of Massachusetts Boston, Boston, Massachusetts, USA
  1. Correspondence to Dr Dina R Hirshfeld-Becker; dhirshfeld{at}


Anxiety disorders represent the most common category of psychiatric disorder in children and adolescents and contribute to distress, impairment and dysfunction. Anxiety disorders or their temperamental precursors are often evident in early childhood, and anxiety can impair functioning, even during preschool age and in toddlerhood. A growing number of investigators have shown that anxiety in preschoolers can be treated efficaciously using cognitive–behavioural therapy (CBT) administered either by training the parents to apply CBT strategies with their children or through direct intervention with parents and children. To date, most investigators have drawn the line at offering direct CBT to children under the age of 4. However, since toddlers can also present with impairing symptoms, and since behaviour strategies can be applied in older preschoolers with poor language ability successfully, it ought to be possible to apply CBT for anxiety to younger children as well. We therefore present two cases of very young children with impairing anxiety (ages 26 and 35 months) and illustrate the combination of parent-only and parent–child CBT sessions that comprised their treatment. The treatment was well tolerated by parents and children and showed promise for reducing anxiety symptoms and improving coping skills.

  • childhood anxiety disorders
  • toddlers
  • preschoolers
  • cognitive behavioural therapy
  • parents

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  • Contributors DRHB designed the study with input from ASC, AH and TEW. DRHB developed the intervention and treated the cases, and DRHB, SJR and AH collected, scored, analysed and tabulated the data. DRHB wrote the first draft of the manuscript, SJR drafted parts of the Results section, and AH made significant additions to the Discussion section. AH, ASC and TEW revised the manuscript critically for important intellectual content. DRHB incorporated all of their edits and finalised the document. All authors approved the final version and are accountable for ensuring accuracy and integrity of the work.

  • Funding This work was supported by a private philanthropic donation by Mrs. Eleanor Spencer.

  • Competing interests DRHB and AH receive or have received research funding from the National Institutes of Health (NIH). ASC reports receipt of royalties from MAPI Research Trust on the sale of the ITSEA, one of the instruments included in the manuscript. TEW receives or has received grant support from the NIH (NIDA), and is or has been a consultant for Alcobra, Neurovance/Otsuka, Ironshore and KemPharm. TEW has published a book, Straight Talk About Psychiatric Medications for Kids (Guilford Press); and co/edited books: ADHD in Adults and Children (Cambridge University Press), Massachusetts General Hospital Comprehensive Clinical Psychiatry (Elsevier), and Massachusetts General Hospital Psychopharmacology and Neurotherapeutics (Elsevier). TEW is co/owner of a copyrighted diagnostic questionnaire (Before School Functioning Questionnaire), and has a licensing agreement with Ironshore (BSFQ Questionnaire). TEW is Chief of the Division of Child and Adolescent Psychiatry, and (Co)Director of the Center for Addiction Medicine at Massachusetts General Hospital. He serves as a clinical consultant to the US National Football League (ERM Associates), US Minor/Major League Baseball, Phoenix House/Gavin Foundation and Bay Cove Human Services.

  • Patient consent for publication Parental/guardian consent obtained.

  • Ethics approval All procedures were approved by our hospital’s institutional review board (Partners Human Research Committee, 2018P000376), and parents provided informed consent for themselves and their child.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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