Program

Sep 22, 2014

OVERVIEW

Three random-assignment studies investigated the impact of 12 weeks of cognitive behavioral therapy (CBT) for children diagnosed with an anxiety disorder.  In the first evaluation, children assigned to receive individualized CBT were compared to those who received group CBT.  Children in the individualized CBT group had significantly larger anxiety symptom improvements post-intervention. Children in both groups experienced significant gains in terms of anxiety symptoms and adaptive functioning, there were no significant group differences post-intervention or at a one-year follow-up. The second evaluation assigned children with social phobia to receive CBT, CBT with parent involvement, or no treatment.  Compared to children in the control group, children in both treatment groups experienced a reduction in the severity of their social phobia, were significantly less likely to meet diagnostic criteria for a social phobia diagnosis, and had significantly  improved social skills at immediate follow-up.  There were no group differences for CBT versus CBT with parent involvement post-intervention or at a 6-month follow-up.  In the last evaluation, children were assigned to receive CBT or treatment as usual without CBT components.  Children in both groups had significant improvements in global functioning and symptoms of comorbid disorders, and significantly fewer children in both groups met criteria for their primary anxiety disorder post-intervention and at a one-month follow-up.  However, children who received CBT did not have significantly better outcomes than their peers in the treatment as usual group.  improvements.

DESCRIPTION OF PROGRAM

Target population: Children with anxiety disorders

Children diagnosed with an anxiety disorder and their parents receive twelve weekly cognitive behavioral therapy sessions . Sessions last 1.5 hours and cover material from the Coping Bear Workbook in the child sessions and material from Keys to Parenting Your Anxious Child in the parent sessions. Outcomes are assessed through multiple questionnaires completed by children, parents, and clinicians.

EVALUATION OF PROGRAM

Manassis, K., Mendlowitz, S. L., Scapillate, D., Avery, D., Fiksenbaum, L., Freire, M.,… Owens, M. (2002). Group and individual cognitive-behavioral therapy for childhood anxiety disorders: A randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 1423-1430.

Evaluated population: A total of 78 children (42 males and 36 females) between the ages of eight and twelve participated in the evaluation.  At least one parent participated with each child. The sample was primarily white (85 percent), with a small proportion (15 percent) being either African-American or Asian. In order to be eligible to participate, children had to have been diagnosed with an Axis I anxiety disorder. Children’s primary diagnoses included generalized anxiety disorder (60 percent), separation anxiety disorder (26 percent), simple phobia (6 percent), social phobia (6 percent), and panic disorder (1 percent).

Approach: Before the intervention began, participants (children and parents) were administered a semi-structured diagnostic interview. Once a clinical diagnosis was confirmed, children were randomly assigned to either an individualized or a group-based cognitive-behavior therapy (CBT) intervention. The individualized and group-based CBT interventions were of equal length and covered the same material. Both treatments were given over 12 weekly sessions that lasted 1.5 hours. The individualized condition consisted of weekly sessions in which the therapist spent 45 minutes with the child and 45 minutes with the parent. Group sessions consisted of parent and child groups that participated in concurrent sessions and lasted 1.5 hours. Therapy for all children was based on the Coping Bear Workbook (available from the first author, see information below). The parent sessions were based on the book Keys to Parenting Your Anxious Child (also available from the first author).

Parents provided demographic information and child developmental and medical history. Questionnaires about the children’s mental health were given to children and parents before and after treatment. Parents, children, and clinicians completed a questionnaire that assessed children’s current condition in comparison with their condition prior to treatment. Clinicians, those who were involved with the child as well as three clinicians not involved in the intervention, also rated the children’s adaptive functioning during the previous month before and after treatment. In addition to clinician reports, children completed questionnaires that assessed a broad spectrum of anxiety symptoms, including anxiety in relation to peers and social situations. They also completed a questionnaire to assess depressive symptoms during the previous two weeks. Parents also rated children’s anxiety symptoms, as well as externalizing and internalizing symptoms.

The thirty two families seen in the first year of the study were contacted a year after treatment to verify whether improvement was maintained.

Results: When analyzing results for all participants, child and parent reported symptoms of anxiety decreased over time, and clinicians’ rating of children’s use of skills they had learned to help them cope with anxiety increased over time. Global improvement as rated by clinicians, children, and parents did not differ by treatment condition. There were no significant further gains a year after the intervention. Results revealed no differences across gender.

Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (2000). The treatment of childhood social phobia: The effectiveness of a social skills training-based, cognitive-behavioral intervention, with and without parental involvement. Journal of Child Psychology and Psychiatry, 41(6), 713-726.

Evaluated population: The evaluation included50 children and adolescents ages 7 to 14 in Australia diagnosed with social phobia.

Approach: Participants were assigned to cognitive-behavioral therapy (CBT), CBT with parent involvement, or a waitlist control group. Twelve weekly sessions were provided, along with homework and booster sessions at 3 and 6 months (a detailed outline of the program is available[1]). The parent-involvement condition included a parent-training component to help parents model and reinforce skills and ignore anxious and avoidant behaviors.

Results: Both the CBT and CBT with parent involvement treatments had significantly fewer children retain their diagnosis of social phobia than the control group. Both treatment groups also had significant and large reductions in social and general anxiety, along with an increase in parent ratings of social skills compared with the control group. At the 12-month follow-up, these improvements were retained. There were no significant differences in self-report anxiety or parental ratings between the two treatment groups, though there was a non-significant trend for children in the parent-involvement condition to be less likely to have a clinical diagnosis of social phobia.

Ginsburg, G. S., Becker, K. D., Drazdowski, T. K., & Tein, J. Y. (2012, February). Treating anxiety disorders in inner city schools: Results from a pilot randomized controlled trial comparing CBT and usual care. In Child & youth care forum (Vol. 41, No. 1, pp. 1-19). Springer US.

Evaluated population: A total of 32 children with generalized (GAD), social (SOD), separation

(SAD), specific (SP), or anxiety not otherwise specified (ANOS) anxiety disorder were recruited from mental health clinics in 14 public schools in Baltimore.

While all children in the study had a diagnosis of some anxiety disorder, sixty-three percent of children  had a co-occurring disorder as well; 25 percent had a secondary diagnosis of GAD, 25 percent of SOP, 22 percent of SP, 13 of SAD, 3 percent of major depressive disorder, 3 percent of oppositional defiant disorder, and 3 percent of enuresis.

Children in the treatment group were significantly older (mean age 11) than their peers in the control group (mean age 9), but there were no other group statistically significant differences for demographic information.

In the treatment group, 71 percent of the children were female, 88 percent were African American, 31 percent had parents who were married, and the average family income was $26,700.  In the control group, 53 percent of the children were female, 15 percent had parents who were married, and the average family income was $46,200; however, none of these differences between groups were found to be significant.  For the treatment group, the primary anxiety disorder diagnosis was GAD for 35 percent of children, SOP for 29 percent of children, SAD for 24 percent of children, SP for 6 percent of children, and ANOS for 6 percent of children.  For the control group, the primary anxiety disorder diagnosis was GAD for 53 percent of children, SOP for 20 percent of children, and SAD for 27 percent of children. Again, these group differences were not found to be significant.

Approach: Participants were randomly assigned to either a control group (n=15) in which they received usual care from a clinician without explicit components of CBT or a treatment group (n=17) in which they received CBT therapy.  There were no significant baseline differences between groups for the outcomes of interest.

Therapy sessions were 30-45 minutes long and all 12 sessions were held during school time by school clinicians.  The CBT treatment used in the study was adapted from anxiety CBT manuals into eight modules, including psychoeducation, exposure, rewards, cognitive restructuring, problem solving, relaxation, and relapse prevention, which could largely be delivered in a variable order.  Clinicians were encouraged to involve parents in three sessions.

A number of measures were assessedat baseline, immediately post-intervention, and at a one-month follow-up.  Independent evaluators conducted semi-structured diagnostic interviews with all children to assess whether they met diagnostic criteria for an anxiety disorder as their primary diagnosis. These clinicians also provided ratings to assess the severity of children’s anxiety and the degree of children’s global impairment and functioning.  Children completed a questionnaire to assess maladaptive cognitions involving social threat, physical threat, personal failure, and hostility and parents completed a questionnaire to assess children’s symptoms of co-occurring disorder(s).  Both parents and children also completed a questionnaire to assess children’s anxiety symptoms.

In addition, independent evaluators’ ratings post-intervention and at one-month follow-up were used to assess whether the child’s anxiety severity was at a level that suggested they were responding to treatment.

Results:  There were no significant differences between the intervention and treatment as usual groups for the percent of children categorized as responding to treatment or between the groups for the severity of children’s anxiety or the amount of maladaptive cognitions they experienced after treatment.  Similarly, there were no significant differences in the percent of children who no longer met diagnostic criteria for a primary anxiety disorder diagnosis or for children’s anxiety symptoms after treatment when comparing the intervention and treatment as usual groups. There were also no significant group differences for children’s global functioning or co-occurring disorder symptoms after treatment.  While there was also no significant program impacts identified in the study, children in both the intervention and treatment as usual groups made significant gains over time in all four areas.

SOURCES FOR MORE INFORMATION

References

Manassis, K., Mendlowitz, S. L., Scapillate, D., Avery, D., Fiksenbaum, L., Freire, M.,… Owens, M. (2002). Group and individual cognitive-behavioral therapy for childhood anxiety disorders: A randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 41, 1423-1430.

Spence, S. H., Donovan, C., & Brechman-Toussaint, M. (2000). The treatment of childhood social phobia: The effectiveness of a social skills training-based, cognitive-behavioral intervention, with and without parental involvement. Journal of Child Psychology and Psychiatry, 41(6), 713-726.

Ginsburg, G. S., Becker, K. D., Drazdowski, T. K., & Tein, J. Y. (2012, February). Treating anxiety disorders in inner city schools: Results from a pilot randomized controlled trial comparing CBT and usual care. In Child & youth care forum (Vol. 41, No. 1, pp. 1-19). Springer US.

Contact Information

 Manuals used during treatment (Coping Bear Workbook for children and Keys to Parenting Your Anxious Child for parents) are available from the first author, K. Manassis.

Contact Info:

Katherine Manassis

Department of Psychiatry

Hospital for Sick Children

555 University Avenue

Toronto, Ontario, Canada    M5G 1X8

kmanas@sickkids.on.ca

KEYWORDS:  Children (3-11), Adolescents (12-17), Males and Females (Co-ed), Clinic/Provider-based, Manual is available, Counseling/Therapy, Parent or family component, Parent training/education, Anxiety disorders/symptoms, Other Mental Health

Program information last updated 9/22/2014

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