Developing an Effective Treatment Protocol

Anxiety disorders are the most prevalent disorders among children and adolescents in both community and clinical settings. The high prevalence of anxiety disorders in children and adolescents leads to increased interest in the development and implementation of effective treatments. Anxiety disorders in children and adolescents are often associated with significant psychosocial impairments (eg, poor social relationships, decrease in academic performance, low self-esteem), and untreated anxiety tends to persist through adulthood.^1,2

An effective treatment for anxiety disorders in children is cognitive-behavioral therapy (CBT).³ However, some children with anxiety disorders demonstrate minimal response to CBT alone. When children and adolescents show minimal response to a trial of CBT, psychotropic medications are often added for a multi- modal treatment approach.⁴ SSRIs are documented to be effective in the treatment of anxiety disorders in children.⁵ Most studies reviewed in this article include participants in whom generalized anxiety disorder, social phobia, or separation anxiety disorder was diagnosed.

CBT has been shown to be effective in the treatment of childhood anxiety disorders when used in individual, group, family, and school-based settings. Six essential components of CBT have been identified for the treatment of anxiety disorders in children: psychoeducation, somatic management, cognitive restructuring, problem solving, exposure, and relapse prevention.⁶

• Psychoeducation provides families and children with information on anxiety disorders.
• Somatic management techniques (eg, diaphragmatic breathing, progressive muscle relaxation) increase awareness and management of autonomic and physiological symptoms related to anxiety.
• Cognitive restructuring strategies require that the child monitor his or her thought processes to recognize maladaptive, irrational thoughts and that these thoughts be replaced with more adaptive, rational thoughts.
• Problem-solving methods are taught to the child so that he can identify coping strategies to manage anxiety-provoking situations.
• Exposure exercises include hierarchical and systematic exposures to feared stimuli, which provide the child with practice in managing associated anxiety symptoms.
• Relapse prevention (eg, decreasing session frequency while scheduling follow-up or booster sessions) is an important component of CBT because it encourages the child to take more control over his anxiety and to rely less on the therapist.

Individual and group CBT were shown to be consistently superior to a wait-list control condition (ie, no treatment) in children with anxiety disorders.^7-9 Longitudinal research studies have shown that treatment gains with individual CBT were maintained and enhanced at 3- and 7.5-year follow-up.^10,11 Flannery-Schroeder and Kendall⁹ compared individual CBT with group CBT and found that the interventions were equally effective and treatment gains were maintained after a 1-year period in children with anxiety.¹²

Furthermore, group CBT has been successfully used in school-based settings as a preventive and early intervention effort to target children with anxiety symptoms.^8,13 Outcomes from these studies showed a decrease in anxiety symptoms or remission of anxiety in children who received school-based group CBT intervention compared with children who did not.

Studies have shown mixed results when a parent-training component is added to CBT. Some studies have shown no added benefits when parents were involved in their children's anxiety treatment^14,15; however, other studies found some favorable outcomes when a parent component was added to the traditional child CBT model.¹³

In one study, children who participated in school-based group CBT or school-based group CBT with parent training were rated as having significantly less anxiety at posttreatment compared with children in the no-treatment control group.¹³ The parent component of the intervention included information on the following topics: the 6 components of CBT⁶ (described earlier), parental anxiety and stress management, the impact the child's anxiety had on family relationships, and implementation of behavioral contracting.

Further benefits were found in children whose parents participated in a parent-training component. On 2 outcome measures, the Clinical Global Impression (CGI)-Improvement Scale and the parent version of the Multidimensional Anxiety Scale for Children, significant benefits were found for children in the CBT with parent-training group compared with no-treatment controls but not for children in CBT alone compared with no-treatment controls. These results suggest that the inclusion of a parent-training component may provide added benefits to children with anxiety who receive group CBT.

Wood and colleagues¹⁶ developed a family component that specifically targets parental intrusiveness and lack of child autonomy, since these factors are shown to play a central role in the maintenance of childhood anxiety disorders.^17,18 The parent-training sessions encouraged parents to provide choices for their anxious child when he is indecisive, allow their child to learn through mistakes rather than taking over to protect him, validate their child's emotional responses, and support their child's development of self-help skills.¹⁶

A family CBT program was compared with a child CBT program with limited parental involvement. The child CBT program was composed of individual sessions with the child, and the family CBT program was composed of sessions that consisted of time with the child alone, parents alone, and parents and child together. Children in the family CBT group demonstrated a greater decrease in anxiety severity at a faster rate compared with children in the child CBT group.¹⁶ Previous parent programs strove to train parents to support CBT skills at home and manage parental anxiety¹³; however, it may be important for parents to learn specific parenting strategies to aid in the reduction of the child's anxiety (eg, decrease parental intrusiveness, increase child autonomy seeking).

A recent study by Victor and colleagues¹⁹ examined the relationships among family functioning, parenting stress, parental psychopathology, and treatment outcome in anxious children. Results showed that a higher level of family cohesion before participating in group CBT was associated with a significantly greater decrease in child anxiety posttreatment. Parenting stress and parental psychopathology were not directly related to treatment outcome; however, parents from families with low cohesion endorsed significantly greater levels of parenting stress and parental psychopathology (ie, depression, anxiety, global severity) when compared with families high in cohesion. Thus, family cohesion may function as a mediator when there are high levels of parenting stress and parental psychopathology. Furthermore, these findings provide additional support for including a parent or family component in the treatment of children with anxiety.

Psychopharmacological treatment is often considered for the treatment of anxiety disorders in children when symptoms are severe and significantly interfere with daily functioning (eg, school refusal, difficulty with participating in social activities) and children are exhibiting a minimal response to CBT. SSRIs are the first-choice medications for treating anxiety disorders in children and adolescents.⁴ Several randomized clinical trials (RCTs) support the efficacy of SSRIs in decreasing anxiety symptoms and in the short-term safety of SSRIs in youths.^5,20-22

When examining pharmacological treatment effects in children who are anxious, RCTs often include children with generalized anxiety disorder, separation anxiety disorder, or social phobia. A multicenter study examined outcome following 8 weeks of treatment with fluvoxamine(Drug information on fluvoxamine) versus placebo and found that fluvoxamine had a significantly greater impact on reducing anxiety symptoms.⁵ Birmaher and colleagues²⁰ completed a 12-week RCT comparing the effects of fluoxetine(Drug information on fluoxetine) and placebo on children with anxiety. Results showed that children who received fluoxetine were more likely to be rated as much or very much improved on the CGI compared with children who received placebo. These studies provide support for the efficacy of SSRIs as treatment for anxiety disorders in children.