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.As in the Obler and Terwilliger[91] study, significant changes in dark tolerance were evinced for thereinforced practice group only; changes were not evident in the controlgroup.266 __________________________________________________________________________________________ PHOBIASSheslow et al.[93] provided yet another demonstration of the effective-ness of reinforced practice.This study compared reinforced practice(labelled graduated exposure by the authors), verbal coping skills andtheir combination in treating fear of the dark in 32 young children (4 to 5years old).The children were randomly assigned to one of the threetreatment conditions or to a control group condition.Reinforced practiceconsisted of graduated exposure to dark stimuli accompanied by reinforce-ment.Verbal coping skills consisted of teaching children a set of self-instructions that would assist them in coping with, and handling, their fears while in the dark.Graduated exposure was not used in this condition.In the combined group, verbal coping skills were practised while graduatedexposure occurred.Results indicated that the reinforced practice group and the combined verbal self-instruction plus reinforced practice groupdemonstrated significant changes on the behavioural avoidance task; suchchanges were not evinced for the verbal-coping-only group or the controlgroup.Similarly, positive support for the effectiveness of reinforced practice was found in a study conducted by Menzies and Clarke [28].They examined therelative effectiveness of reinforced practice and modelling in reducingchildren’s phobic anxiety and avoidance of water.Forty-eight water-phobicchildren between the ages of 3 and 8 years were randomly assigned to oneof four groups: (a) reinforced practice, (b) live (therapist) modelling, (c) reinforced practice plus live modelling and (d) assessment-only control.At the conclusion of treatment, the reinforced practice condition had produced statistically and clinically significant gains that had generalized to other water-related activities.In contrast, the live modelling condition did not lead to greater treatment benefits than those observed in the controlchildren.Moreover, modelling did not appear to enhance the effects ofreinforced practice, as was anticipated.This combined condition was nomore effective than the reinforced-practice-alone condition.Thus, on the basis of these four randomized control studies, it can beconcluded that reinforced practice has also earned well-established status: it has been shown to be more effective than no-treatment control conditions in two studies [91,92] and to be superior to two other treatment modalities,verbal coping skills [93] and live (adult) modelling [28,36], both of which have been shown to be more effective than no treatment.Cognitive-Behavioural ProceduresCognitive-behavioural procedures include a variety of strategies designedto alter perceptions, thoughts, images and beliefs of phobic children bymanipulating and restructuring their distorted, maladaptive cognitions.PHOBIAS IN CHILDREN AND ADOLESCENTS: A REVIEW _________________________ 267Because these maladaptive cognitions are assumed to lead to maladaptivebehaviour (e.g.phobic avoidance), it is asserted that cognitive changes will produce behaviour changes.In support of this underlying hypothesis, alimited amount of research has confirmed the presence of maladaptivethoughts and beliefs in phobic and anxious children.During testingsituations, for example, test-phobic children frequently report having more off-task thoughts, more negative self-evaluations and fewer positive self-evaluations [94,95].Verbal self-instruction procedures are used to teachphobic children how to generate positive self-statements using cognitivemodelling, rehearsal and social reinforcement.Positive self-statements typically include instructions to aid the child in developing a plan to deal with the feared situation, coping with the anxiety experienced by using relaxation or other problem-solving strategies, and evaluating ongoing performance.Support for the ‘‘probably efficacious’’ status for cognitive-behaviouralprocedures (as defined above) is available.Kanfer et al.[96] firstdemonstrated the potential utility of this approach.They randomlyassigned 45 children, 5 to 6 years of age, who demonstrated ‘‘strong fearof the dark’’ to one of three experimental groups which varied in the verbal self-instructions used during treatment: (a) competence group, in which the children were taught to say such phrases as ‘‘I am a brave boy (girl).I can take care of myself in the dark’’, (b) stimulus control group, in which the children were instructed to say such words as ‘‘The dark is a fun place to be.There are many good things in the dark’’, and (c) neutral group, in whichthe children simply rehearsed nursery rhymes.Results revealed that the‘‘competence’’ group was superior to the ‘‘stimulus’’ and ‘‘neutral’’ groups on fear of dark measures.In a clinical outcome trial, Graziano and Mooney [97] randomly assigned33 children, 6 to 13 years of age, with severe night-time fears of longduration (over 2 years) and their families to a verbal self-instruction group or a waiting list control group.In the self-instruction group, children were taught a series of exercises to use on a nightly basis and parents wereinstructed in how to supervise, monitor and reward their children withpraise and ‘‘bravery’’ tokens.Nightly exercises included muscle relaxation, imagining a pleasant scene and reciting ‘‘brave’’ statements.After training, the self-instruction group had significantly less night-time fear than did the control group.Following the clinical trial, the waiting list group was also provided treatment.At 6- and 12-month follow-up, the treated childrenrevealed maintenance of and steady improvement in night-time fearlessbehaviour.Subsequent to this report, Graziano and Mooney [98] conducteda 2.5- to 3-year follow-up of these children.Gains persisted over thisextended period of time, and no new problems were reported.In a recent study, Silverman et al.[23] examined the benefits of anoperant-based contingency management treatment and a cognitive-based268 __________________________________________________________________________________________ PHOBIASself-control treatment to an education support control group in thetreatment of phobias.Graduated in vivo exposure was used in both theself-control and the contingency management conditions and, althoughgraduated in vivo exposure was not prescribed for the education/supportcondition, it was not specifically proscribed.In the study, 81 phobicchildren between 6 and 16 years of age and their parents were evaluatedusing child, parent and clinician measures.The children were assignedrandomly to one of the three 10-week manualized treatment conditions (i.e.self-control, contingency management or education support)
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