Elizabeth A. Gosch

Cognitive-behavioral therapy for anxiety disordered youth: a randomized clinical trial evaluating child and family modalities.

This randomized clinical trial compared the relative efficacy of individual (child) cognitive-behavioral therapy (ICBT), family cognitive-behavioral therapy (FCBT), and a family-based education/support/ attention (FESA) active control for treating anxiety disordered youth ages 7-14 years (M = 10.27). Youth (N = 161; 44% female; 85% Caucasian, 9% African American, 3% Hispanic, 3% other/mixed) with a principal diagnosis of separation anxiety disorder, social phobia, or generalized anxiety disorder and their parents participated. Outcome analyses were conducted using hierarchical linear models on the intent-to-treat sample at posttreatment and 1-year follow-up using diagnostic severity, child self-reports, parent reports, and teacher reports. Chi-square analyses were also conducted on diagnostic status at post and 1-year follow-up. Children evidenced treatment gains in all conditions, although FCBT and ICBT were superior to FESA in reducing the presence and principality of the principal anxiety disorder, and ICBT outperformed FCBT and FESA on teacher reports of child anxiety. Treatment gains, when found, were maintained at 1-year follow-up. FCBT outperformed ICBT when both parents had an anxiety disorder. Implications for treatment and suggestions for research are discussed.

Quality of life: expanding the scope of clinical significance.

Clinical researchers have turned their attention to quality of life assessment as a means of broadening the evaluation of treatment outcomes. This article examines conceptual and methodological issues related to the use of quality of life measures in mental health. These include the lack of a good operational definition of the construct, the use of subjective versus objective quality of life indicators, and the nature of the relationship between symptoms and quality of life judgments. Of special concern is the ability of quality of life measures to detect treatment-related changes. The authors review the application of quality of life assessment across diverse patient groups and therapies and provide recommendations for developing comprehensive, psychometrically sophisticated quality of life measures.

Clinical characteristics of anxiety disordered youth.

Reports the characteristics of a large, representative sample of treatment-seeking anxious youth (N=488). Participants, aged 7-17 years (mean 10.7 years), had a principal DSM-IV diagnosis of separation anxiety disorder (SAD), generalized anxiety disorder (GAD), or social phobia (SP). Although youth with a co-primary diagnosis for which a different disorder-specific treatment would be indicated (e.g., major depressive disorder, substance abuse) were not included, there were few other exclusion criteria. Participants and their parent/guardian underwent an extensive baseline assessment using a broad array of measures capturing diagnostic status, anxiety symptoms and severity, and areas of functional impairment. Means and standard deviations of the measures of psychopathology and data on diagnostic status are provided. The sample had moderate to severe anxiety disorder and was highly comorbid, with 55.3% of participants meeting criteria for at least one non-targeted DSM-IV disorder. Anxiety disorders in youth often do not present as a single/focused disorder: such disorders in youth overlap in symptoms and are highly comorbid among themselves.

Considering CBT with Anxious Youth? Think Exposures

Following a historical precis regarding exposure and a brief description of a representative cognitive-behavioral therapy (CBT) program for anxiety disorders in youth, we discuss several factors related to conducting exposure tasks in youth. Topics include assessing anxious situations, creating a hierarchy, and using imaginal, as well as in vivo and in- and out-of-session exposure tasks. We also describe and discuss the posture of the therapist with regard to the development and maintenance of rapport, the process of consulting with the child, the use of shaping and rewarding effort, the restraining from reinforcing avoidance, modeling for parents, and how to deal with the occasional less-than-successful exposure task. Developmental level of the child and contextual factors are examined as they might influence the design and implementation of exposure tasks. Last, we consider professional practice issues of liability, applications in private practice, and the challenges that face new therapists undertaking exposures. Examples and illustrations from actual clinical cases are included throughout.

Cognitive-behavioral interventions

Anxiety has long been a central issue in the field of psychology, having played a key role in the development of several theories, the assessment of psychological constructs, and the evaluation of forms of psychological treatment. More recently, the formal diagnostic categories of anxiety disorders have been empirically investigated, and the treatment of anxiety disorders (primarily focused on behavioral and cognitive interventions with adult populations) has received meaningful research endorsement (e.g., Barlow, Cohen, Waddell, Vermilyea, Klosko, Blanchard, & Di Nardo, 1984; Butler, Cullington, Munby, Amies, & Gelder, 1984; Clark, 1986). Taking into account childhood developmental concerns, a promising therapeutic intervention for children with anxiety disorders is emerging (e.g., Kane & Kendall, 1989; Kendall et al., 1992).

24- and 36-Week Outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS)

OBJECTIVE We report active treatment group differences on response and remission rates and changes in anxiety severity at weeks 24 and 36 for the Child/Adolescent Anxiety Multimodal Study (CAMS). METHOD CAMS youth (N = 488; 74% ≤ 12 years of age) with DSM-IV separation, generalized, or social anxiety disorder were randomized to 12 weeks of cognitive-behavioral therapy (CBT), sertraline (SRT), CBT+SRT (COMB), or medication management/pill placebo (PBO). Responders attended 6 monthly booster sessions in their assigned treatment arm; youth in COMB and SRT continued on their medication throughout this period. Efficacy of COMB, SRT, and CBT (n = 412) was assessed at 24 and 36 weeks postrandomization. Youth randomized to PBO (n = 76) were offered active CAMS treatment if nonresponsive at week 12 or over follow-up and were not included here. Independent evaluators blind to study condition assessed anxiety severity, functioning, and treatment response. Concomitant treatments were allowed but monitored over follow-up. RESULTS The majority (>80%) of acute responders maintained positive response at both weeks 24 and 36. Consistent with acute outcomes, COMB maintained advantage over CBT and SRT, which did not differ, on dimensional outcomes; the 3 treatments did not differ on most categorical outcomes over follow-up. Compared to COMB and CBT, youth in SRT obtained more concomitant psychosocial treatments, whereas those in SRT and CBT obtained more concomitant combined (medication plus psychosocial) treatment. CONCLUSIONS COMB maintained advantage over CBT and SRT on some measures over follow-up, whereas the 2 monotherapies remained indistinguishable. The observed convergence of COMB and monotherapy may be related to greater use of concomitant treatment during follow-up among youth receiving the monotherapies, although other explanations are possible. Although outcomes were variable, most CAMS-treated youth experienced sustained treatment benefit. Clinical trial registration information-Child and Adolescent Anxiety Disorders (CAMS); URL: http://clinicaltrials.gov. Unique identifier: NCT00052078.

Principles of Cognitive-Behavioral Therapy for Anxiety Disorders in Children

This article elucidates the theoretical underpinnings of cognitive-behavior therapy (CBT) as applied to the treatment of anxiety disorders in children, focusing on social phobia, generalized anxiety disorder, and separation anxiety disorder. It reviews behavioral and cognitive theories that have influenced this approach. We argue that it is necessary to understand the essential components of this approach in the context of these theories in order to provide effective, clinically sensitive, and child-focused treatment. Components discussed include assessment, psychoeducation, affective education, self-instruction training, cognitive restructuring, problem solving, relaxation training, modeling, contingency management, and exposure procedures. Hypothesized key processes, such as the need to be experiential in treatment, are presented for consideration. Keywords: anxiety; children; cognitive behavior therapy; theory Anxiety disorders are among the most common mental health disorders in youth with prevalence rates ranging from 12% to 20% (Achenbrach, Howell, McConaughy, & Stanger, 1995; Velting, Setzer, & Albano, 2004). Left untreated, these disorders tend to have long-term effects on social and emotional development. Negative consequences associated with anxiety disorders in youth include lower levels of social supports, academic underachievement, underemployment, substance use, and high comorbidity with other psychiatric disorders (Velting, Setzer, & Albano, 2004). Moreover, evidence suggests that these disorders demonstrate a chronic course, often persisting into adulthood (Rapee & Barlow, 1993). Despite these costs, only a small percentage of children with anxiety disorders receive treatment. This group may be underserved for a number of reasons including the covert nature of their symptoms. However, there is also a shortage of treatment providers trained to recognize and provide effective treatment for these children. The American Psychological Association has urged the dissemination of empirically supported treatments. Numerous clinical trials have demonstrated the efficacy of CBT for treating anxiety disorders in children (Dadds, Spence, Holland, Barrett, & Laurens, 1997; Kendall, 1994; Kendall et al., 1997; Short, Barrett, & Fox, 2001; Silverman et al., 1999). The CBT approach tends to be multifaceted, incorporating a variety of cognitive and behavioral techniques. Although early efforts focused primarily on the child in treatment, more recent studies support incorporating the anxious childs social context, particularly the parents and school, into CBT treatment. A number of treatment manuals that share many common elements have been developed for this population, perhaps best known being the Coping Cat program (Kendall, 2000). Manuals provide greater opportunity for training, help ensure treatment integrity, and lend themselves to dissemination. However, caution must be exercised when disseminating a treatment manual. We can anticipate the problems that can be encountered when therapists attempt to implement manualized procedures without understanding the theoretical principles that guide them. Such a lack of knowledge leads to overly rigid implementation of procedures and, at times, using the procedures in a manner that violates the principles upon which they are based. For example, to increase participation in out-of-session exposure assignments that promote generalization of treatment gains, a manual may call for delivery of stickers for completion of homework and the earning of a prize when a certain number of stickers have been earned. This may sound like a straightforward procedure; however, the delivery of this system is informed by our knowledge of reinforcement principles. Certain children may require a more or less frequent reinforcement schedule; others may find the therapists encouragement more rewarding than a tangible prize while others may find the delivery of stickers aversive or lacking in reinforcement value. …

Cognitive-behavioral therapy for anxiety-disordered youth : Secondary outcomes from a randomized clinical trial evaluating child and family modalities

This study examined secondary outcomes of a randomized clinical trial that evaluated an individual cognitive-behavioral (ICBT), family-based cognitive-behavioral (FCBT), and family-based education, support and attention (FESA) treatment for anxious youth. Participants (161) were between 7 and 14 years (M=10.27) of age and had a principal diagnosis of separation anxiety disorder, social phobia, and/or generalized anxiety disorder. Hierarchical linear modeling examined youth-reported depressive symptomatology and parent- and teacher-reported externalizing behavior and adaptive functioning at pretreatment, posttreatment, and 1-year follow-up. In general, youth in all treatments evidenced improvements in most domains, with improvements maintained at follow-up. Overall, gender and age did not moderate treatment outcomes. The results suggest that both child and family cognitive-behavioral therapy, and the family-based supportive approach used in this study, can be effective in addressing some of the associated symptoms and adaptive functioning deficits typically linked to anxiety in youth.

Trajectories of Change in Youth Anxiety during Cognitive Behavior Therapy

OBJECTIVE To evaluate changes in the trajectory of youth anxiety following the introduction of specific cognitive-behavior therapy (CBT) components: relaxation training, cognitive restructuring, and exposure tasks. METHOD Four hundred eighty-eight youths ages 7-17 years (50% female; 74% ≤ 12 years) were randomly assigned to receive either CBT, sertraline (SRT), their combination (COMB), or pill placebo (PBO) as part of their participation in the Child/Adolescent Anxiety Multimodal Study (CAMS). Youths in the CBT conditions were evaluated weekly by therapists using the Clinical Global Impression Scale-Severity (CGI-S; Guy, 1976) and the Childrens Global Assessment Scale (CGAS; Shaffer et al., 1983) and every 4 weeks by blind independent evaluators (IEs) using the Pediatric Anxiety Ratings Scale (PARS; RUPP Anxiety Study Group, 2002). Youths in SRT and PBO were included as controls. RESULTS Longitudinal discontinuity analyses indicated that the introduction of both cognitive restructuring (e.g., changing self-talk) and exposure tasks significantly accelerated the rate of progress on measures of symptom severity and global functioning moving forward in treatment; the introduction of relaxation training had limited impact. Counter to expectations, no strategy altered the rate of progress in the specific domain of anxiety that it was intended to target (i.e., somatic symptoms, anxious self-talk, avoidance behavior). CONCLUSIONS Findings support CBT theory and suggest that cognitive restructuring and exposure tasks each make substantial contributions to improvement in youth anxiety. Implications for future research are discussed. (PsycINFO Database Record

Defining Treatment Response and Remission in Child Anxiety: Signal Detection Analysis Using the Pediatric Anxiety Rating Scale

OBJECTIVE To determine optimal Pediatric Anxiety Rating Scale (PARS) percent reduction and raw score cut-offs for predicting treatment response and remission among children and adolescents with anxiety disorders. METHOD Data were from a subset of youth (N = 438; 7-17 years of age) who participated in the Child/Adolescent Anxiety Multimodal Study (CAMS), a multi-site, randomized controlled trial that examined the relative efficacy of cognitive-behavioral therapy (CBT; Coping Cat), medication (sertraline [SRT]), their combination, and pill placebo for the treatment of separation anxiety disorder, generalized anxiety disorder, and social phobia. The clinician-rated PARS was administered pre- and posttreatment (delivered over 12 weeks). Quality receiver operating characteristic methods assessed the performance of various PARS percent reductions and absolute cut-off scores in predicting treatment response and remission, as determined by posttreatment ratings on the Clinical Global Impression scales and the Anxiety Disorders Interview Schedule for DSM-IV. Corresponding change in impairment was evaluated using the Child Anxiety Impact Scale. RESULTS Reductions of 35% and 50% on the six-item PARS optimally predicted treatment response and remission, respectively. Post-treatment PARS raw scores of 8 to 10 optimally predicted remission. Anxiety improved as a function of PARS-defined treatment response and remission. CONCLUSIONS Results serve as guidelines for operationalizing treatment response and remission in future research and in making cross-study comparisons. These guidelines can facilitate translation of research findings into clinical practice.