Table 1

Application of treatment protocol with both participants

CBT strategyParticipant 1 (‘J’)Participant 2 (‘K’)
Length of treatment6 parent-only sessions and 5 parent–child sessions at ages 36–39 months. Sessions included the mother only.7 parent-only sessions and 3 child–parent sessions delivered at ages 26–29 months. Sessions included both parents.
Identification of treatment goalsTo improve J’s ability to walk up the steps alone, tolerate her mother being in a separate room, sleep in her own bed, stay in her car seat for more than 15 min, stay with her father while her mother went out and cope with doctors’ visits.To improve K’s ability to tolerate his mother being in a separate room, mother leaving the house, mother dropping him off at day care and the drop-in centre at the gym, saying ‘goodbye’ to mother (instead of her slipping out unnoticed), and toys being put back in new places.
Psychoeducation about CBT modelConducted in first parent-only session.Conducted in first parent-only session.
Cognitive restructuringMother learnt to distinguish her anxious thoughts from appropriate concerns about medical issues. For child, staying in the car seat was reframed as “the car seat hugs me to keep me safe.” Coping with medical procedures was reframed as (for ear exam) “it tickles and then it’s all done”; (for taking oral medicine) “it’s yukky, but then we get juice”; and (for injections) “1-2-3-it hurts and then it’s all done and we get a Band-Aid.”For the child, coping with frightening situations was reframed as ‘games’: being in a separate room from his mother to hunt for toys was ‘the hiding game’; practising saying goodbye to her mother was ‘the goodbye game’; and putting objects in new places was ‘the silly game’.
Modelling coping plans: coping includes recognising one’s fear and anxious cognitions, making a plan to cope with them, and then feeling rewarded.To cope with being in the car seat, J’s mother would act out a princess doll having to go into the car seat in her carriage: “she feels scared (feeling), it’s too tight (thought), but she can remember that the car seat hugs her to keep her safe (helpful thought) and she can look out the window and play ‘I Spy’ (coping action) and then it doesn’t feel so bad (reward).”To cope with waking in the night, the therapist used an in-session role play with Mr Potato Head figures to demonstrate the baby Potato waking in the night and feeling scared (feeling), singing ‘Twinkle Twinkle’, his usual bedtime song (coping action), and going back to sleep, and then earning a sticker the next morning (reward).
Non-directive 1:1 play*Reviewed but not emphasised in session. Mother was already playing in a similar way with J.Role-played in session with both parents and implemented 3×/week each with each parent. This increased K’s enjoyment of playing 1:1 with his father.
RelaxationBecause J had physical tension at bedtime, her mother expressed interest in using relaxation with her. She guided J in tensing and relaxing muscles as a game, and J ultimately was able to use it to relax before bedtime.Included in parent workbook, but not emphasised in session.
Exposure hierarchies: these were planned in session with the therapist, and implemented in the office and at home. To cope with going up stairs, J’s mother or sisters would place a desired toy on a step slightly out of J’s reach, and encourage J to go up and get it, progressing to higher and higher (or for going down, lower and lower) steps.
To cope with the car seat, J’s mother practised having her ride for progressively longer durations, while redirecting her with games or activities (eg, putting stickers on the back of the seat in front of her, playing ‘I Spy’).
To cope with separation, J’s mother would leave the room while J counted (first to 10 and then higher) or sang (shorter and then longer) songs, to accustom her to ‘being brave’ apart from her mother for longer and longer intervals. J could decide in advance for how long her mother would stay out. Exposures progressed from having the door cracked to having it open, to having J play a game with a family member while her mother was behind a closed door. J’s mother also stopped having her father allow her to ‘face-time’ with her mother when out, and this enabled J to tolerate being apart from her better (because her intermittent anxiety was not reinforced).
To cope with medical visits, the therapist used imaginal exposure, involving doll play and role plays with a toy medical kit to enact ear exams, taking oral medicine and shots, using coping plans and reinforcement.
To cope with separations, K’s mother played a ‘hiding’ game, where she would enter a room separate from K to hide stuffed toys, and then send K in alone to find them. K practised saying ‘goodbye’ to his mother as she sat on higher and higher steps in the playroom while he played with his father (‘the goodbye game’). In the office K chose which person (mother, father or therapist) and then which two people left the room. Parents used similar strategies in getting him used to the drop-in centre at their gym.
To address sleep , K’s parents helped him learn progressively to go to sleep independently at the start of the night so that he could be supported in doing so if he roused in the night (eg, placing him in his crib and singing his last bedtime song with him awake). They used the same plan if he roused in the night and stopped allowing him to come into their bed at night. Once K was coping better with night awakenings, a reward was offered in the morning for sleeping through the night.
To practise putting things in the wrong place (deviations from routine), the therapist modelled and then had K try ‘putting things in a silly place’: for example, the wrong colour caps on markers, the markers in unusual places (eg, in the tissue box) and putting Mr Potato Head parts in the wrong openings. This game continued at home, including going on ‘silly’ paths for K’s walk.
Completion of treatment goalsJ learnt to walk the stairs without anxiety, tolerate long rides in the car seat with redirection, and better tolerate separations from her mother (eg, allowing her mother to go to the bathroom, staying with her father while her mother went out, and performing in her gymnastics show independently). Her sleep was still being medically evaluated, so it was not worked on fully during the treatment.K learnt to tolerate goodbyes from his mother in all settings, could easily play downstairs with his father while his mother was on a separate floor, could go to the drop-off centre at the gym and alone on outings alone with his father, and needed parental attention in the middle of the night less than once per month. He was starting to do better with deviations from routine.
Relapse prevention: parent meeting about keeping the work going.Discussed how to cope with upcoming family stressors.Discussed how to cope with upcoming transition to a toddler bed and giving up pacifier at night.
  • *This common component of many parent–child interventions (for example31) involves having the parent spend 5 min per day following the child’s lead in play, narrating the child’s actions, mirroring comments, praising specific behaviours, and refraining from giving instructions, criticisms or questions.

  • CBT, cognitive–behavioural therapy.