Chronis-Tuscano et al 2015 Turtle R34

Journal of Consulting and Clinical Psychology Preliminary Evaluation of a Multimodal Early Intervention Program for Behaviorally Inhibited Preschoolers Andrea Chronis-Tuscano, Kenneth H. Rubin, Kelly A. O’Brien, Robert J. Coplan, Sharon Renee Thomas, Lea R. Dougherty, Charissa S. L. Cheah, Katie Watts, Sara Heverly-Fitt, Suzanne L. Huggins, Melissa Menzer, Annie Schulz Begle, and Maureen Wimsatt Online First Publication, March 23, 2015. http://dx.doi.org/10.1037/a0039043 CITATION Chronis-Tuscano, A., Rubin, K. H., O’Brien, K. A., Coplan, R. J., Thomas, S. R., Dougherty, L. R., Cheah, C. S. L., Watts, K., Heverly-Fitt, S., Huggins, S. L., Menzer, M., Begle, A. S., & Wimsatt, M. (2015, March 23). Preliminary Evaluation of a Multimodal Early Intervention Program for Behaviorally Inhibited Preschoolers. Journal of Consulting and Clinical Psychology. Advance online publication. http://dx.doi.org/10.1037/a0039043 Journal of Consulting and Clinical Psychology 2015, Vol. 83, No. 2, 000 © 2015 American Psychological Association 0022-006X/15/$12.00 http://dx.doi.org/10.1037/a0039043 Preliminary Evaluation of a Multimodal Early Intervention Program for Behaviorally Inhibited Preschoolers Andrea Chronis-Tuscano, Kenneth H. Rubin, and Kelly A. O’Brien Robert J. Coplan Carleton University This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. University of Maryland, College Park Sharon Renee Thomas and Lea R. Dougherty Charissa S. L. Cheah University of Maryland, College Park University of Maryland, Baltimore County Katie Watts, Sara Heverly-Fitt, Suzanne L. Huggins, Melissa Menzer, Annie Schulz Begle, and Maureen Wimsatt University of Maryland, College Park Objective: Approximately 15%–20% of young children can be classified as having a behaviorally inhibited (BI) temperament. Stable BI predicts the development of later anxiety disorders (particularly social anxiety), but not all inhibited children develop anxiety. Parenting characterized by inappropriate warmth/sensitivity and/or intrusive control predicts the stability of BI and moderates risk for anxiety among high-BI children. For these reasons, we developed and examined the preliminary efficacy of the Turtle Program: a multimodal early intervention for inhibited preschool-age children. Method: Forty inhibited children between the ages of 42– 60 months and their parent(s) were randomized to either the Turtle Program (n ⫽ 18) or a waitlist control (WLC; n ⫽ 22) condition. Participants randomized to the Turtle Program condition received 8 weeks of concurrent parent and child group treatment. Participants were assessed at baseline and posttreatment with multisource assessments, including parent and teacher report measures of child anxiety, diagnostic interviews, and observations of parenting behavior. Results: The Turtle Program resulted in significant beneficial effects relative to the WLC condition on maternal-reported anxiety symptoms of medium to large magnitude; large effects on parent-reported BI; medium to large effects on teacher-rated school anxiety symptoms; and medium effects on observed maternal positive affect/sensitivity. Conclusions: This study provides encouraging preliminary support for the Turtle Program for young behaviorally inhibited children. Effects of the Turtle Program generalized to the school setting. Future studies should examine whether this early intervention program improves long-term developmental outcomes for this at-risk group. What is the public health significance of this article? This study provides encouraging preliminary support for the Turtle Program for behaviorally inhibited preschool-age children. The Turtle Program improved child anxiety symptoms across home and school settings, and increased observed maternal positive affect and sensitivity. Keywords: behavioral inhibition, anxiety, parenting, early intervention Fifteen to 20% of young children can be classified as behaviorally inhibited (BI) during infancy, and roughly half continue to display socially reticent behaviors throughout childhood (Degnan & Fox, 2007). Prospective studies demonstrate that stable BI across infancy and early childhood is associated with the development of later anxiety, particularly social anxiety disorder (SAD; Chronis-Tuscano et al., 2009)—suggesting a need for early intervention. Andrea Chronis-Tuscano, Kenneth H. Rubin, Kelly A. O’Brien, Sharon Renee Thomas, Lea R. Dougherty, Katie Watts, Sara Heverly-Fitt, Suzanne L. Huggins, Melissa Menzer, Annie Schulz Begle, and Maureen Wimsatt, Department of Psychology, University of Maryland, College Park; Robert J. Coplan, Department of Psychology, Carleton University; Charissa S. L. Cheah, Department of Psychology, University of Maryland, Baltimore County. This research was funded by National Institutes of Health Grant R34 MH083832-01. We thank Donna Pincus and Dina Hirshfeld-Becker for their contributions to the development of the parent group manual. Correspondence concerning this article should be addressed to Andrea Chronis-Tuscano, Department of Psychology, University of Maryland, College Park, MD 20742. E-mail: achronis@umd.edu 1 CHRONIS-TUSCANO ET AL. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 2 Parenting characterized by inappropriate warmth, a lack of responsive supportiveness, and high levels of control, intrusiveness, and overprotection predicts both the stability of BI over time (e.g., Rubin, Burgess, & Hastings, 2002) and the development of later anxiety (McLeod, Wood, & Weisz, 2007). Moreover, maternal overcontrol moderates risk for anxiety, such that children with stable BI who also experience maternal intrusive control and a lack of responsiveness are at greatest risk for adolescent social anxiety (Lewis-Morrarty et al., 2012). Within our theoretical model (Rubin, Coplan, & Bowker, 2009), parents of children high in BI perceive them as vulnerable and, thus, respond to them in an unresponsive, unsupportive, and intrusive manner. Over time, these children become increasingly dependent on their parents and come to believe they are unequipped to deal with anxiety-provoking situations on their own. When parents respond to inhibited preschoolers with appropriate warmth and sensitivity, their children follow a healthier developmental trajectory (e.g., Hane, Cheah, Rubin, & Fox, 2008). Following from this transactional model, we developed an early intervention program for preschoolers displaying high BI and their parents. Unlike other programs for inhibited children (Rapee, Kennedy, Ingram, Edwards, & Sweeney, 2010), the “Turtle Program” targeted parent and child behavior. The Turtle Program parent component was derived from adaptations of Parent–Child Interaction Therapy (PCIT), an evidencebased treatment for externalizing disorders in young children that uses in vivo coaching to teach parents skills to enhance the parent– child relationship and implement effective discipline (Eyberg, Nelson, & Boggs, 2008). Adapted PCIT may also be an effective treatment for anxiety. Pincus, Eyberg, and Choate (2005) adapted PCIT for separation anxiety disorder by including a Bravery-Directed Interaction (BDI) module. A more recent adaptation, Coaching Approach Behavior and Leading by Modeling (CALM), was developed to treat 3- to 8-year-olds with anxiety disorders (Comer et al., 2012). These PCIT adaptations appear promising, on the basis of a preliminary randomized controlled trial (RCT; Puliafico, Comer, & Pincus, 2012) and open trial (PCIT-CALM; Comer et al., 2012), but have not been tested specifically with inhibited children. We report results of an RCT examining preliminary effects of the Turtle Program compared to a waitlist control (WLC) condition. Although other groups have developed early intervention programs for young children with inhibition and/or anxiety disorders (Hirshfeld-Becker et al., 2010; Kennedy, Rapee, & Edwards, 2009; Rapee et al., 2010), our study builds on previous studies by also incorporating in vivo parent coaching and reporting observational and teacher-report outcomes. Also, unlike other PCIT adaptations for anxious children, the Turtle Program allows for in vivo parent coaching within the peer group context.1 Method Participants were recruited from local preschools, daycares, pediatricians, and media advertisements. Inclusion criteria included child age of 42– 60 months and a Behavioral Inhibition Questionnaire (BIQ) score ⱖ132 (Bishop, Spence, & McDonald, 2003). Exclusion criteria included a Social Communication Questionnaire (SCQ; Berument, Rutter, Lord, Pickles, & Bailey, 1999) score ⬎15 to rule out autism.2 Prospective participants who met basic entry criteria on a telephone screen attended a clinic visit at which informed consent was obtained. Interviewers uninformed of group membership administered the Preschool Age Psychiatric Assessment (PAPA; Egger, Ascher, & Angold, 1999) to parents.3 Mothers completed the BIQ (␣ ⫽ .89 in this sample), Child Behavior Checklist (CBCL; Achenbach & Rescorla, 2000), and Preschool Anxiety Scale (PAS; Spence, Rapee, McDonald, & Ingram, 2001) total (␣ ⫽ .72) and social (␣ ⫽ .69) anxiety subscales. Teachers completed the School Anxiety Scale (Lyneham, Street, Abbott, & Rapee, 2008) total (␣ ⫽ .92) and social anxiety (␣ ⫽ .93) subscales. An observational taxonomy was used to assess Positive Affect/ Sensitivity (i.e., the parent’s ability to respond to the child’s verbal and nonverbal requests for attention or assistance with warmth and positive enjoyment of the child) and Negative Control (i.e., parental behavior that is ill-timed, excessive, or inappropriately controlling relative to what the child is doing) during free play and Lego model building (Rubin, Cheah, & Fox, 2001).4 Cohen’s kappas ranged from .80 to .83 for Positive Affect/Sensitivity and Negative Control. Three cohorts, each consisting of 5– 6 families, were randomly assigned to the Turtle Program (n ⫽ 18) or WLC (n ⫽ 22). The Turtle Program included 8 weekly, 90-min concurrent parent and child group sessions, each led by two therapists.5 Posttreatment assessments included the PAPA anxiety module, parenting observation, and parent and teacher questionnaires. WLC families received a 6-week parent psychoeducation program after posttreatment assessments were completed. There were no significant differences between families who did and did not complete posttreatment assessments (see Figure 1). “The Turtle Program: Helping Shy Preschoolers Come Out of Their Shells” Parent component. The parent group manual was modeled after PCIT for separation anxiety disorder (Puliafico et al., 2012) with two primary exceptions: (a) exposures occurred within the clinic so that parents could be coached in the moment and (b) group (rather than individual) format. Children were pulled from the child group for dyadic parent– child coaching, while other parents observed for the purpose of vicarious learning. Session content is presented in Table 1. 1 Although CALM involves in-session exposures, peers are typically unavailable for in vivo social exposures because the program is delivered individually. 2 None of the participants were prescribed psychiatric medication or excluded on the basis of SCQ scores. 3 For the treatment group, the PAPA informants were as follows: 89% mothers and 11% both mothers and fathers at baseline; 88% mothers and 12% both mothers and fathers at posttreatment. For the WLC, the PAPA informants were as follows: 85% mothers, 5% grandparent, and 10% both mothers and fathers at baseline; 78% mothers, 7% fathers, 7% grandmothers, and 7% both mothers and fathers at postassessment. 4 During free play (15 min), the child was free to play with anything in the room. During the Lego task (15 min), mothers were asked to guide and teach the child to create a Lego structure to match a model, while refraining from building the model for the child and from touching the materials. 5 Mothers were the primary participants in treatment. In 44% of the families, fathers attended at least one session. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. EARLY INTERVENTION FOR INHIBITED PRESCHOOLERS Figure 1. 3 CONSORT diagram. See the online article for the color version of this figure. Session 1 (psychoeducation) was modeled after Being Brave: A Program for Coping With Anxiety for Young Children and Their Parents (Hirshfeld-Becker et al., 2010) and described our theoretical model. During Child-Directed Interaction (CDI), parents were coached to stay “a step behind” (as opposed to adopting a controlling or intrusive style) and provide labeled praise for child behaviors such as independence, sharing his or her own ideas, and appropriate social behaviors. During BDI, parents learned to apply CDI skills in the context of anxiety-provoking situations (e.g., asking another child to play, participating in “Show and Tell”) and were coached to remove attention for avoidant or clingy behaviors while praising social approach behaviors. Parents were also instructed in planning and implementing out-of-session exposures. During Parent-Directed Interaction, parents learned to distinguish anxious and oppositional behaviors, and to implement discipline strategies for the latter. In the final session, a “graduation party” was held, which also served as an exposure task in which parents were coached to use their acquired skills. Table 1 Turtle Program Session Content Session and parent group 1: Psychoeducation 2: CDI teach 3: CDI coach 4: BDI teach 5: BDI Coach 1 6: BDI Coach 2 7: PDI teach 8: PDI check-in and wrap-up Child group Learning to introduce yourself Making eye contact Relaxation (Balloon Breathing) Communicating to keep friends Facing your fears (Lizzy the Lamb book; Schleffler, 2011)a Expressing emotions Group activity: Sharing about oneself game during snacktime Dealing with disappointment Group activity: Show & Tell Working together Group activity: Scavenger Hunt Group activity: Graduation party Coachinga Coaching during separation and pick-up Coaching during separation and pick-up Individual CDI coaching Coaching during separation and pick-up Individual BDI coaching: Bravery challenge Individual BDI coaching: Show and tell Coaching during separation and pick-up Coaching during graduation party Note. CDI ⫽ Child-Directed Interaction; BDI ⫽ Bravery-Directed Interaction; PDI ⫽ Parent-Directed Interaction. a The amount of coaching depended on the number of families per group (5– 6, with 1–2 parents attending). Coaching was done in Sessions 1–2 (separation), 3 (CDI), 5– 6 (BDI), and 8. CHRONIS-TUSCANO ET AL. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 4 Child component. The child group was adapted from Social Skills Facilitated Play (SSFP; Coplan, Schneider, Matheson, & Graham, 2010), which uses social skills training in a manner that is developmentally appropriate for preschool children. The didactic portion was brief, with sensitivity to the attention span of young children, and incorporated puppets and games as age-appropriate ways of conveying content. After the didactic portion, children engaged in free play and group activities, during which SSFP leaders used systematic modeling, guided participation, and reinforcement of relevant social skills, as well as facilitation of social interaction and social problem solving. Activities were incorporated to allow for exposure to feared social situations (see Table 1). Children were praised for approach behaviors and discretely encouraged to use SSFP skills as appropriate. Analytic Plan Generalized estimating equations (GEE; Hardin & Hilbe, 2003) was used to examine treatment effects on outcomes. GEE is an extension of the generalized linear model that allows for the analysis of correlated observations in repeated measures designs. Users can specify model distributions, the structure of correlated data over time using working correlation matrices, and conduct full factorial models using categorical and continuous predictors. GEE is robust to small sample sizes and missing data. In this study, unstructured correlation matrices were selected for each parameter based on the lowest quasilikelihood under independence model criterion (QIC) value and a priori hypotheses. To examine change in anxiety diagnoses, binomial distributions and independent or exchangeable correlation matrices were specified. Gamma distributions with logit link functions were specified for observed parenting and other nonnormally distributed outcome variables, and identity link functions were used with normally distributed outcome variables. For each outcome, main effects of time, treatment group, and the interaction effect of Time ⫻ Treatment Group were estimated. To control familywise error, estimated marginal means were calculated using simple and pairwise comparisons for main and interaction effects. Hedges’ g (Hedges, 1981) was calculated as an indicator of the magnitude of Time ⫻ Treatment Group effects.6 Results Baseline group differences were examined in preliminary analyses (see Table 2 for participant characteristics at baseline). Seventy-seven percent of children in the treatment group met Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) criteria for an anxiety disorder relative to 47.6% of children in the WLC group; however, this difference was not significant, ␹2(1) ⫽ 3.73, p ⫽ .054. Similarly, the two groups did not differ on baseline BIQ scores, t(35) ⫽ ⫺1.012, p ⫽ .319, or PAPA total anxiety symptoms, t(37) ⫽ .0682, p ⫽ .135. No other significant baseline differences between groups were observed. Descriptive statistics for all outcome measures are presented in Table 3. On the PAPA, significant Time ⫻ Group interactions of large magnitude were found favoring the Turtle Program on total anxiety symptoms (see Table 4). Treatment effects on social anxiety symptoms and diagnoses were marginally significant and of me- Table 2 Individual and Family Characteristics at Baseline Assessment Characteristic Child’s age in months, M (SD) Child’s gender, n (% male) Maternal age, M (SD) Race, n (%) Caucasian African American Other Education, n (%) High school or less Some college Bachelor’s degree Master’s degree Doctorate Marital status, n (%) Never married Married Separated/divorced/widowed Child baseline diagnoses, n (%)a Social phobia Any anxiety disorder Selective mutism Specific phobia Separation anxiety Major depressive disorder ADHD Oppositional defiant disorder Annual family income M (SD) Treatment (n ⫽ 18) Waitlist (n ⫽ 22) 50.81 (9.37) 9 (50) 35.56 (4.72) 54.27 (10.19) 8 (36) 38.47 (4.12) 10 (55.6) 2 (11.1) 5 (17.8) 11 (50.0) 5 (22.7) 2 (9.0) 1 (5.6) 1 (5.6) 3 (16.7) 9 (50.0) 4 (22.2) 0 1 (4.5) 7 (31.8) 5 (22.7) 5 (22.7) 0 17 (94.4) 1 (5.6) 2 (9.1) 16 (72.7) 0 13 (72.2) 14 (77.8) 2 (11.1) 1 (5.5) 3 (16.7) 2 (11.1) 1 (5.5) 1 (5.5) 115,118 (56,227) 10 (45.5) 10 (45.5) 0 1 (4.5) 1 (4.5) 1 (4.5) 0 0 137,733 (67,832) Note. ADHD ⫽ attention-deficit/hyperactivity disorder. Current ⫽ symptoms present in past 3 months. a dium magnitude (.55 and .62, respectively). Significant Time ⫻ Group interactions also were found on the BIQ, CBCL Internalizing Problems, and PAS social anxiety subscale, such that children in the treatment group demonstrated greater improvements from pretreatment to posttreatment in parent-rated BI, internalizing problems, and social anxiety symptoms relative to WLC children; these effects were large in magnitude, ranging from .84 to 1.06 (see Table 4). Teachers similarly reported significant pre–post treatment reductions in total and generalized anxiety of medium to large magnitude for Turtle Program, relative to WLC, participants. A significant Time ⫻ Group interaction on maternal positive affect/sensitivity during free play of medium magnitude was found, also favoring the treatment group. No treatment effects on maternal negative control were observed. Discussion This small RCT is, to our knowledge, the first study of an early intervention program targeting children on the basis of early BI which included concurrent parent and child groups and which also measured treatment effects across parent ratings, teacher ratings, 6 Hedges’ g, recommended by the What Works Clearinghouse (Seftor et al., 2011), represents an effect size comparable to Cohen’s d, except that Cohen’s d uses the sample standard deviation while Hedges’ g uses the population standard deviation (Rosenthal & Rosnow, 2008). An absolute value of Hedges’ g of 0.2, 0.5, and 0.8 correspond to small, medium, and large effects, respectively. EARLY INTERVENTION FOR INHIBITED PRESCHOOLERS 5 Table 3 Descriptive Statistics This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Treatment (n ⫽ 18) Waitlist (n ⫽ 22) Measure Baseline Posttreatment Baseline Posttreatment Diagnostic interview PAPA SAD symptoms, M (SD) SAD diagnosis, n (%) Total anxiety symptoms, M (SD) Any anxiety diagnosis, n (%) Parent report BIQ, M (SD) CBCL Internalizing, M (SD) Preschool Anxiety Scale, M (SD) Social Anxiety subscale, M (SD) Teacher report School Anxiety Scale, M (SD) Social Anxiety subscale, M (SD) Generalized Anxiety, M (SD) Observed parenting Positive Affect/sensitivity—free play, M (SD) Positive Affect/sensitivity—Lego, M (SD) Negative control—free play, M (SD) Negative control—Lego, M (SD) (n ⫽ 18) (n ⫽ 17) (n ⫽ 22) (n ⫽ 17) 2.61 (0.78) 13 (72.2) 32.28 (10.53) 14 (77.8) (n ⫽ 18) 169.50 (3.71) 60.83 (1.19) 63.94 (2.31) 19.84 (1.07) (n ⫽ 15) 12.91 (1.95) 8.57 (1.50) 4.34 (0.59) (n ⫽ 18) 1.0 (1.37) 5 (27.8) 14.76 (10.12) 7 (38.9) (n ⫽ 17) 144.79 (4.14) 51.02 (2.19) 45.00 (4.04) 14.30 (1.33) (n ⫽ 16) 10.97 (1.88) 8.16 (1.45) 2.81 (0.55) (n ⫽ 17) 2.1 (1.1) 10 (45.5) 26.48 (12.81) 10 (45.5) (n ⫽ 22) 163.46 (3.81) 58.71 (2.10) 60.64 (3.91) 17.52 (1.16) (n ⫽ 21) 14.09 (2.11) 8.80 (1.21) 5.06 (1.17) (n ⫽ 22) 1.64 (1.45) 7 (31.8) 22.29 (14.07) 7 (31.8) (n ⫽ 17) 159.76 (6.30) 58.05 (2.25) 52.85 (4.49) 17.20 (1.26) (n ⫽ 18) 17.67 (2.80) 9.59 (1.43) 7.90 (1.69) (n ⫽ 17) 1.45 (0.18) 1.49 (0.22) 1.45 (0.16) 1.35 (0.17) 1.46 (0.29) 1.02 (0.03) 1.00 (0.13) 1.53 (0.3) 1.01 (0.01) 0.96 (0.18) 1.51 (0.24) 1.03 (0.05) 1.03 (0.13) 1.43 (0.29) 1.02 (0.04) 1.01 (0.14) Note. PAPA ⫽ Preschool Age Psychiatric Assessment; SAD ⫽ social anxiety disorder; BIQ ⫽ Behavioral Inhibition Questionnaire; CBCL ⫽ Child Behavior Checklist. and observed parenting. Our novel, theoretically and developmentally grounded treatment approach, adapted from PCIT and SSFP, involved in vivo coaching of parents in the use of behavioral strategies as their inhibited children participated in a peer group. Results suggest that the Turtle Program holds great potential to improve child anxiety symptoms across home and school settings, and importantly, to increase observed maternal positive affect and sensitivity. The treatment group demonstrated significant pre–post treatment improvement relative to the WLC on maternal-reported anxiety symptoms and diagnoses, of medium to large magnitude. Table 4 Results of Generalized Estimating Equations Analyses Measure Diagnostic interview SAD symptoms SAD diagnosis Any anxiety symptoms Any anxiety diagnosis Parent report BIQ CBCL Internalizing Preschool Anxiety Scale Social Anxiety Subscale Teacher report School Anxiety Scale Social Subscale Generalized Subscale Observed parenting Positive Affect/Sensitivity Free play Lego Negative control Free play Lego B SE ⫺0.71 0.41 0.97 0.21 0.96 ⫺0.59 OR 1.91 1.68 p ga 0.09 3.81 0.18 3.57 .081 .050 .005 .081 0.55 0.62 0.88 0.55 95% CI 95% CI 1.52 0.003 0.99 0.21 ⫺21.019 ⫺9.15 ⫺11.15 ⫺5.22 7.14 2.72 6.21 1.97 ⫺35.01 ⫺14.71 ⫺23.32 ⫺9.09 ⫺7.03 ⫺3.82 1.01 ⫺1.35 .003 .001 .072 .008 0.93 1.06 0.57 0.84 ⫺5.52 ⫺1.204 ⫺4.37 2.76 1.59 1.52 ⫺10.92 ⫺4.33 ⫺7.35 ⫺0.11 1.92 ⫺1.38 .045 .450 .004 0.63 0.24 0.91 0.14 0.09 0.06 0.07 0.018 0.047 0.25 0.23 .024 .196 0.73 0.40 0.016 0.07 0.04 0.16 0.02 0.10 .447 .660 0.23 0.13 ⫺0.01 ⫺0.03 Note. SAD ⫽ social anxiety disorder; BIQ ⫽ Behavioral Inhibition Questionnaire; CBCL ⫽ Child Behavior Checklist; OR ⫽ odds ratio; CI ⫽ confidence interval; g ⫽ Hedges’ g. a Values of 0.2 correspond to small effects, values of 0.5 correspond to medium effects, and values of 0.8 correspond to large effects. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 6 CHRONIS-TUSCANO ET AL. Consistent with other studies finding effects on parent-reported (Kennedy et al., 2009) and laboratory-observed BI symptoms (Kennedy et al., 2009; Hirshfeld-Becker et al., 2010), we found large effects of treatment on parent-reported BI. This is particularly promising, given that baseline BI negatively predicted treatment response to Hirshfeld-Becker’s (2010) Being Brave intervention for 4- to 7-year-olds with anxiety disorders. Thus, we selected a very challenging population and yet demonstrated change on both inhibition and anxiety. As an index of generalization, teachers reported improvements in school anxiety symptoms for children in the treatment group relative to the WLC. This was encouraging, given that no intervention took place in the school and teachers were uninvolved in treatment. Given that researchers who have completed intervention studies of young children with BI or anxiety disorders have rarely, if ever, collected teacher questionnaires, it has been unclear whether these earlier interventions decreased anxious behavior in the school setting. Given the social nature of BI and demonstrated associations with later social anxiety, it is critical that effects of early interventions designed for inhibited young children are demonstrated at school. We were also encouraged by the significant treatment effects on observed maternal positive affect/sensitivity. Given that maternal warmth and sensitivity both predict the discontinuity of BI over time and protect against future maladjustment in at-risk children (Coplan, Arbeau, & Armer, 2008; Degnan & Fox, 2007; Hane et al., 2008), this finding was particularly noteworthy. Observational measures are often considered the gold standard in treatment research, given the potential for parent reports to be biased and influenced by expectations that treatment will work. This may be particularly the case when parents are involved in treatment and the comparison condition does not receive active treatment, as was the case in our study and other studies of young children with high BI and/or anxiety (Hirshfeld-Becker et al., 2010; Rapee et al., 2010). We were surprised by the lack of treatment effects on negative/ intrusive control. In contrast with studies showing that parents of inhibited and/or anxious children tend to engage in negative control (Hudson & Rapee, 2000), few mothers in this study demonstrated negative control at baseline. Characteristics of our sample or observational context may have contributed to this finding. This study was limited by a small sample size and WLC (rather than active comparison) condition. We also did not observe child social behavior in the laboratory for both conditions at pre- and posttreatment. Finally, the BIQ was used both as a selection and outcome variable. Despite these limitations, the findings were encouraging in that the Turtle Program demonstrated effects on parent and teacher ratings of anxiety, as well as observed maternal positive affect/sensitivity, supporting the need for further evaluation. Future studies should include larger samples that are block randomized on the basis of the presence of baseline anxiety disorders. Future studies should also include observations of child behavior and follow-up assessments to better characterize the effects of early intervention on the trajectory of anxiety in this at-risk group. A larger, socioeconomically diverse sample and multiple assessment points during the course of treatment will allow for an examination of mediators (e.g., parenting, social skills) and moderators (e.g., baseline anxiety severity, culture, physiological reactivity, socioeconomic status) of treatment ef- fects. Future studies may also examine single and additive effects of various treatment components (e.g., in vivo coaching, parent- or child-only group), given that studies have reported effects of a parent-only intervention on diagnostic outcomes (Rapee et al., 2010) and no differences between parent– child and parent-only interventions (Waters, Ford, Wharton, & Cobham, 2009). References Achenbach, T. M., & Rescorla, L. A. (2000). Manual for the ASEBA Preschool Forms & Profiles. 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