Western Consortium for Public Health Essay.

 

Ever since Hazan and Shaver (1987) showed that it is possible to use a self-report questionnaire to measure adolescent and adult romantic-attachment orientations (secure, anxious, and avoidant–the three patterns identified by Ainsworth, Blehar, Waters, and Wall, 1978, in their studies of infant-caregiver attachment), a steady stream of variants and extensions of their questionnaire have been proposed. The resulting diversity often arouses frustration and confusion in newcomers to the field who wonder which of the many measures to use. The three of us are probably typical of attachment researchers in receiving as many as five telephone calls, letters, and e-mail messages a week from researchers who want to know either “Has anything happened since 1987?” or “Which measure is the best?” In the present chapter we attempt to solve this problem by creating an all-purpose reply to future attachment researchers who wish to use self-report measures. Interview measures have also been proposed, but we will say little about them here. Attachment interviews are powerful and perhaps uniquely revealing, but they are also impractical for most researchers. (See Bartholomew & Horowitz, 1991; Bartholomew & Shaver, this volume; Main, Kaplan, & Cassidy, 1985; Scharfe & Bartholomew, 1994; and van IJzendoorn, 1995, for discussions of attachment interview measures, not all of which measure the same constructs.)

Hazan and Shaver (1987, 1990) asked research participants to indicate which of three attachment-style prototypes (shown here in Table 1) best characterized their feelings and behavior in romantic relationships. These authors naively took for granted that Ainsworth et al. (1978) were correct in thinking of attachment patterns (usually called “attachment styles” by social psychologists) as categories or types. In retrospect, it is evident that Hazan and Shaver should have paid attention to Ainsworth et al.’s Figure 10 (p. 102), which summarized the results of a discriminant analysis predicting infant attachment type (secure, anxious, or avoidant) from the continuous rating scales used by coders to characterize the infants’ behavior in a laboratory “Strange Situation.” Our Figure 1 reproduces the essential features of the Ainsworth et al. figure and also includes our names for the two discriminant functions: Avoidance and Anxiety.Western Consortium for Public Health Essay.

The coding scales that correlated most highly with the avoidance dimension (Function 1) were: (1) avoiding mother during episodes 5 and 8 of the Strange Situation (the two reunion episodes), (2) not maintaining contact with mother during episode 8, (3) not seeking proximity during episode 8, and (4) engaging in more exploratory behavior and more distance interaction (communication with a stranger while mother was absent) in episode 7 of the Strange Situation. All of these scales indicate avoidance of mother, lack of closeness to mother, and less distress during mother’s absence (in the presence of an adult stranger). The coding scales that correlated most highly with the anxiety dimension (Function 2) were: (1) crying (all through episodes, 2-8, but especially episode 6, when the infant was left alone for 3 minutes), (2) greater angry resistance to mother during episodes 5 and 8 (the reunions), (3) greater angry resistance to the stranger during episodes 3, 4, and 7 (when the stranger tried to comfort or play with the infant), and (4) reduced exploration in episode 7, when the solitary infant was joined by a stranger.Western Consortium for Public Health Essay.

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Insert Table 1 and Figure 1 about here

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Figure 1 indicates that, right from the start, Ainsworth’s three major attachment “types” could be conceptualized as regions in a two-dimensional space, the dimensions being Avoidance (discomfort with closeness and dependency) and Anxiety (crying, failing to explore confidently in the absence of mother, and angry protest directed at mother during reunions after what was probably experienced as abandonment). When Levy and Davis (1988) first asked adult subjects to rate how well each of Hazan and Shaver’s (1987) romantic attachment prototypes described them, it was revealed that the three ratings could be reduced to two dimensions, one corresponding to Avoidance (discomfort with closeness and dependency) and the other to Anxiety (about abandonment).Western Consortium for Public Health Essay.

In subsequent studies, Simpson (1990) and Collins and Read (1990) broke Hazan and Shaver’s multi-sentence attachment-style prototypes into separate propositions with which subjects could agree or disagree to varying extents. When these Likert-type items were factor analyzed, a two-factor (Simpson) or three-factor (Collins & Read) solution was obtained. In the case of the three-factor solution, two of the factors (discomfort with closeness and discomfort with dependence on romantic partners) were significantly correlated (r = .38). Simpson and his colleagues (e.g., Simpson, Rholes, & Nelligan, 1992) called their two dimensions “security vs. avoidance” and “anxiety” (about abandonment). Collins and Read (1990) called their three dimensions “close,” “depend,” and “anxiety” (about abandonment). If we interpret the close and depend dimensions as facets of avoidance (the term facets being borrowed from Costa & McCrae, 1992), all of the early analyses of the structure of Hazan and Shaver’s measure are compatible with the interpretation that adult attachment measures, like Ainsworth et al.’s coding scales for the Strange Situation, primarily assess avoidance and attachment-related anxiety.

The two-dimensional empirical and conceptual structure underlying attachment orientations was articulated more completely when researchers who study infant-caregiver attachment and those who study adolescent and adult romantic attachment realized that a two-dimensional space makes room for four, rather than three, quadrants or conceptual patterns. Crittenden (1988) and others who focused on infant-caregiver attachment in abusive and troubled families noted a mixed avoidant/anxious type. Main and Solomon (1990) identified a somewhat similar pattern, called “disorganized, disoriented” attachment. A diagram of the four infant types organized by the Avoidance and Anxiety dimensions is shown in Figure 2.Western Consortium for Public Health Essay.

In the area of adult attachment, Bartholomew (1990), who had noticed that Hazan and Shaver’s (1987, 1990) avoidant type and Main et al.’s (1985) dismissing (avoidant) type differed in the degree to which they exhibited anxious as well as avoidant qualities, proposed the now-familiar two-dimensional, four-category conceptual scheme shown in Figure 3. The parallels between Figures 2 and 3 are obvious. In both diagrams the upper left-hand quadrant represents securely attached individuals–infants and adults who are neither anxious about abandonment nor avoidant in their behavior. The upper right-hand quadrant of both diagrams represents anxious or preoccupied attachment, defined as a mixture of anxiety and interpersonal approach (nonavoidance). The lower left-hand quadrant represents dismissingly avoidant attachment, a combination of avoidant behavior and apparent lack of anxiety about abandonment. The lower right-hand quadrant represents fearfully avoidant attachment, which combines anxiety about abandonment with avoidant behavior.Western Consortium for Public Health Essay.

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How effective is Cognitive Behavioural Therapy Essay.

 

Cognitive Behavioural Therapy, also referred to as CBT is an approach that “focuses on thought processes and how these might be maladaptive” (Sanders P 2009 p 58). The following literature review will explore and summarise four selected pieces of research that look at the use of CBT in the treatment of childhood anxiety and how effective it is. The term childhood in this case is referred to as children aged between 4 and 7 years. The term anxiety as referred to in the Diagnostic and Statistical Manual of Mental Disorders is an Anxiety Disorder which is a psychological condition (DSM-IV 2010). It manifests itself as unusual or abnormal behavior such as; Panic attacks, Agoraphobia or Obsessive – Compulsive Disorder amongst others. (DSM-IV 2010)How effective is Cognitive Behavioural Therapy Essay.

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Search Strategy

An online search was conducted using the University of Salford’s research data base SOLAR. This is accessed online via the University of Salford’s Blackboard. In SOLAR you opt for the ‘ find databases’ search area. This area then enables you to access online research specific to the school or area of study, in this case Health and Social Care and then the subject area, Counselling and Psychotherapy. Solar then gives the option of a more specific database search engine such as EBSCO the academic search premier database (EBSCO 2011). EBSCO gives you the option to use keywords to help you find a specific researched area.How effective is Cognitive Behavioural Therapy Essay.

Keywords where picked with the literature review question in mind. The keywords used where; Cognitive Behavioural Therapy, CBT and child anxiety. Between each keyword a Boolean (EBSCO 2011) word can be used e.g. and, or, not. You are also able to select where you would like the keywords to be i.e. in the title (TI) in the text (TX) etc. The use of a question mark inside the spelling of behavio?r would also assist the search by checking all the variations of spellings i.e. behavioral/behavioural. The use of a truncation (*) next to the word child* will check all the synonyms of a word i.e. child, children, childhood (EBSCO 2011). To refine the search further limiters such as ‘only scholarly (peer reviewed) articles’ in the ‘full text’ version produced a more manageable result.How effective is Cognitive Behavioural Therapy Essay.

See fig 1 below for a step by step guide to the sequence of keyword and phrases used in the search.

From the results found, each title was reviewed and the titles that contained all the relevant keywords were placed in a folder for closer review. Any papers that contained variants to the topic such as, teenagers, adolescents or youth where discarded. By doing this a thematic review could be constructed to ‘identify distinct key issues or questions throughout the area of research’ (McLeod 2003, p 19).

One of the selected research articles was a summary of an original paper written in Brown University letter (2010). To obtain the full pdf version of Hirschfield-Becker’s team’s (2010) research article, EBSCO presented a ‘find it’ search tool which enables a search in other databases such as OVID SP (2011). The full paper was found for use in OVID SP (2011). A recent journal article written in 2011 was found but was only available as an abstract (Van der Leeden et al 2011). The full electronic version was available to purchase at other Universities or by post which can take up to 3 weeks to deliver. Unfortunately this option did not allow enough time for this essay, but it would be an option to bear in mind for future research projects such as a dissertation.How effective is Cognitive Behavioural Therapy Essay.

Summary

Having read the four chosen research papers the following thematic literature review should aim to address the question of the effectiveness of CBT in childhood anxiety and highlight similarities or conflicts between the selected researches (McLeod 2003). On reading the articles in detail it became apparent that CBT was proven to be 83% effective in the treatment of anxiety in children aged 4 onwards after a 1 year follow up1 (Hirshfield-Becker 2010). It was based on the collaboration of numerous factors that ordained a successful outcome (Hirshfield-Becker 2010, Gosh 2006, Monga 2009, Surveg 2006). Factors such as parental involvement (Surveg 2006) the competence of the therapist (Gosh 2006) and variations to the methods used. (Gosh 2006, Monga 2009, Hirshfield- Becker 2010)

The methodologies used in Cognitive Behavioral Therapy included a method known as the Coping Cat Program (Kendall et al 1992). The Coping Cat Program incorporates skill building and relaxation techniques to help soothe the anxious child. This method was used in all the chosen research articles and was concluded as successful (Surveg 2006, Gosh 2006, Monga 2009 & Hirshfield-Becker 2010). The ultimate goal of CBT with anxious youth is for the child to gain a sense of mastery over his/her anxiety (Kendall & Hedtke 2006) and the Coping Cat program assists with this. Hirshfield-Beckers (2010) team adapted Kendall’s (2006) method slightly, for its use with younger children. They included games and immediate positive reinforcement and greater parental involvement to reinforce coping strategies.

Through parent/therapist only sessions questionnaires where offered to evaluate the child’s condition and also increase awareness of the symptoms of anxiety disorders (Surveg 2006, Gosh 2006, Monga 2009, and Hirshfield-Becker 2010). Techniques for relieving stress where also discussed as tools for themselves and the anxious child (Hirshfield-Becker 2010). The families chosen for the research all tend to be from middle class, semi-professional or professional two parent families (Surveg 2006, Gosh 2006, Monga 2009 and Hirshfield-Becker 2010). This raises the question whether anxious children who are from a less fortunate background may or may not benefit from CBT? (Dodd 2011). Dodd (2011) later reviews Hirshfield-Beckers (2010) research and look into the limitations of the results when CBT is applied to lower income and less well-educated participants.How effective is Cognitive Behavioural Therapy Essay.

Other areas in the research looked at the importance of the therapeutic relationship. Different combinations of parent/child/therapist participation where experienced. For example a group of 5-8 children with their parent or parents and a therapist or a child, the parents and a therapist (Monga 2009) It was not entirely clear from Monga’s team (2009) which combination was more effective, we can only assume from the positive outcome that all variations where effective for some anxiety disorders (Gosh 2006).

Serveg (2006) looked at the benefits and barriers in parental involvement and the team highlighted the importance of parent/therapist rapport which would enable a deeper understanding for all regarding the child’s anxiety. Parental involvement would offer the therapist feedback regarding the home, school and social environment of the child and also offer a gauge in the progression of treatment (Surveg 2006). The therapist is then able to tailor the treatment to address the specific needs of the child (Surveg 2006). Another advantage to parental participation is the interpretation of the child’s choice of language when talking about their anxieties or recalling a feeling (Surveg 2006).How effective is Cognitive Behavioural Therapy Essay.

A child’s response to a therapists question could be questionable as a child of four may not be able to interpret their true feelings about a situation. This may result in the child becoming disengaged in therapy or avoid-ant in social circumstances or other relationships (Gosh 2006). A parent’s interpretation and insight can often assist the therapist in deciphering the child’s message. This is not always the case though and a parent could also hinder the process of change. For example a parent could feel the need to ‘rescue’ the child or the parent might themselves be depressed, this may impact greatly on the child’s behaviour (Surveg 2006). Hirshfield -Becker (2010) addressed this issue by creating a play exercise that enabled the child space and re-educated the parents perception of what is real danger and what could be their own fear. The parents could project their own anxieties about a situation which could if turn exasperate the child’s anxiety or create a new one.

Conclusion

Child anxiety is among the most common of mental health disorders and if left untreated could have a worsening effect later on in adolescence and throughout adult hood (Gosh 2006). Childhood anxiety is often left undiagnosed and those fortunate to receive therapy such as CBT have a greater chance to resolve anxieties such as Obsessive Compulsive Disorder and Panic Attacks among others noted in the DSM-IV (2010). It became obvious throughout the reviewed research that parental involvement hugely effects a positive outcome. Points to consider for further research could include the question ‘Is CBT effective without parental involvement?’

Most agree that further research should be considered to evaluate the efficiency and effectiveness of further interventions (Surveg 2006, Monga 2009,Hirshfield-Becker 2010). If parental involvement facilitates treatment then the parents involvement in the origins of the anxiety disorder should also be considered, it is often said that in the illness lies the cure. To explore child anxiety further It would be beneficial research to look at the parental involvement in the child’s anxiety this could be addressed through a more long term therapy program such as the Person Centred Therapy approach (Rogers 1951) or Transactional Analysis (Berne 1961). CBT seems to offer a quick solution to alleviate symptoms, but to get to the route of the anxiety and arrest it completely other modalities of psychotherapy could be considered.How effective is Cognitive Behavioural Therapy Essay.

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