Cognitive-behavioural treatment (CBT) that combines anxiety management training with enactive exposure has been studied most in relation to anxious children. Its brevity and re-producibility (through the use of standardized manuals) facilitate outcome studies. Three groups of investigators have conducted randomized trials in mixed anxious samples. Kendall and others used the "coping cat" individual treatment model for children aged 9 to 13 years in 2 such trials with waiting-list control subjects. Treated children fared significantly better, with most returning to subclinical levels of anxiety and maintaining their gains at I year after treatment. A subgroup (82% of original sample), studied at 3 years after treatment, continued to show improvement.
Using the same treatment model adapted for groups, Mend-lowitz and others also showed treatment-related reductions in self-reported anxiety and depression. In this trial, families were randomized to child group only, parent group only, or combined treatment with child and parent groups, with a waiting-list control condition. Relative to the other treatments, combined treatment showed more benefits in fostering children's use of more adaptive coping strategies.
The importance of parental involvement was further examined by Barrett and others, who found no benefit from adding family management to child CBT when the child was evaluated immediately after treatment, but found a significantly greater remission from anxiety disorders at I year after treatment. Interestingly, they then related parental anxiety level to treatment differences. Remission from anxiety disorder in the child was greater for the combined treatment only if the parent reported a high level of anxiety him- or herself, suggesting that anxious parents have particular difficulty helping their children cope with anxiety. Treatment participation is therefore especially important in this group. These investigators also demonstrated the effectiveness of group CBT in a randomized trial.
A recent study of CBT for school phobia, however, found no differences in school return between CBT and traditional interventions, with both treatments reducing self-reported anxious and depressive symptoms. This finding highlights the need to determine which components of CBT are most effective in various disorders. For example, in phobic disorders, exposure may be key to therapeutic change, with other anxiety-management strategies being less crucial in determining outcome.
The long-term effects of CBT on developmental outcomes in anxious children also remain to be elucidated, since most studies follow children for I year or less. Further, the treatment's high reliance on verbal ability limits its utility in less verbal children, and the transportability of CBT from academic centres to the community has not yet been demonstrated.
School-based interventions using cognitive techniques with parental involvement have recently been found to reduce "anxiety problems," and prevent the onset of new anxiety disorders in randomized trials. Prevention of anxiety disorders is certainly a laudable aim, but caution is warranted in interpreting these results--these children were not clinically identified. While subclinical levels of anxiety may be amenable to school-based interventions, it is unrealistic to expect school personnel to address the needs of children with severe anxiety disorders. Preventive intervention involving parent and child has also been used to increase social competence (relative to a control group) in preschoolers who appeared anxious and withdrawn. A small open study of students identified as anxious by teachers found a reduction in self-reported anxiety with electromyograph biofeedback and thermal (finger temperature) biofeedback. Students learned to relax their muscles and increase peripheral circulation using these techniques.
Comorbidity and Treatment
Comorbidity among childhood anxiety disorders and between anxiety disorders and other psychopathology is highly prevalent. Comorbid depression has been studied most, and various explanatory models exist for the co-occurrence of mood and anxiety disorders in children. A recent study of twins found that most of the covariation between mother-rated anxiety and depressive symptoms could be explained by a common set of genes, with some covariation explained by nonshared environmental influences. After examining studies of environmental influences, Brady and Kendall suggested a temporal progression with severe, impairing anxiety predisposing to later depression. Last and others identified depression as a poor prognostic indicator. Indeed, the early treatment of anxiety-related impairment may help prevent depression.
Other comorbidities occurring at rates that exceed chance include attention-deficit hyperactivity disorder (ADHD), oppositional defiant disorder, alcohol abuse, and learning disabilities. Probing for these comorbidities is an important aspect of assessing anxious children, since their presence can influence treatment decisions. For example, comorbid ADHD may suggest an initial trial of stimulants rather than SSRIs--the overall functioning of many of these children improves with stimulants, whereas SSRI treatment risks behavioural activation. Clinicians may also need to modify some aspects of CBT that require sustained attention. Covert alcohol abuse increases the risks of pharmacotherapy. Undiagnosed learning disabilities can contribute to school-related anxiety, and anxiety-related worries can interfere with cognitive processes. In children with multiple comorbidities, the most disabling symptoms must be prioritized, and families require encouragement to persevere with treatment until the child is returned to age-appropriate functioning in most areas. Etiologic factors underlying each of these comorbidities are currently being studied.
An empirically based understanding of childhood anxiety disorders is now beginning to develop. CBT and pharmacotherapy have been shown to reduce anxiety symptoms, but interventions that address child impairment (social, academic, behavioural), concurrent depression, parental anxiety, and family conflict are also likely to affect long-term prognosis. Research is needed to elucidate the neural substrates of anxious children's cognitive characteristics (selective attention and memory for threat, anxiety sensitivity, coping deficits), to integrate developmental and neurophysiological theories of anxiety to clarify the etiology of specific disorders, and to locate specific genes that contribute to childhood anxiety disorders. New measures of anxiety must capture child impairment as well as anxiety symptoms and use multiple informants. Randomized controlled trials are needed to evaluate the effectiveness of current pharmacological treatments, particularly SSRIs. The further development of CBT holds some challenges: adapting CBT to children with cognitive limitations (either due to youth or learning impairment), discerning the most effective components of CBT for specific disorders, improving the transportability of CBT to nonacademic settings, and including systematic treatment for parent child interactions that can perpetuate anxiety. Finally, the most effective combinations of psychological and pharmacological treatments for specific disorders must be determined.
- Manassis, Katharina, Canadian Journal of Psychiatry, Oct2000.
The article above contains foundational information. Articles below contain optional updates.
Reflection Exercise #3
The preceding section contained information
about childhood anxiety disorders. Write
three case study examples regarding how you might use the content of this section
in your practice.
Online Continuing Education
What have school-based interventions using cognitive techniques with parental involvement been found to reduce? Record the letter of the correct answer