Treatment and prevention of childhood anxiety

Chapter 8

Treatment and Prevention of Childhood Anxiety

Introduction In the case of Little Hans, the therapist, Sigmund Freud himself, had only one therapeutic session with the anxious boy (Gay, 1988). After this single session, Hans's fear of horses quickly disappeared, and this is why many have questioned whether the boy really suffered from a phobia and argued that Hans just displayed the signs of a normal developmental fear (see Chapter 6). However, advocates of psychodynamic therapy have pointed out that it was Freud's intervention that was highly effective. For example, in his biography of Freud, Jones (1955) states that the "brilliant success of child analysis" (p.289) was "indeed inaugurated by the study of this very case" (p.292; see Wolpe & Rachman, 1960). This claim seems to be supported by a review of 352 records from the Anna Freud center of children who were, retrospectively, diagnosed with DSM-III-R (American Psychiatric Association, 1987) disorders, and in particular anxiety disorders and depression. All these children underwent psychoanalysis or psychodynamic therapy, and the results indicated that 72% of the youngsters displayed improvement in adaptation (see Bernstein & Kinlan, 1997). Although it has been concluded that this therapeutic approach may be useful in the treatment of childhood anxiety disorders (American Academy of Child and Adolescent Psychiatry, 1997), there are few controlled therapy outcome studies, which means that the empirical status of this type of intervention is meagre (see for an exception, Muratori, Picchi, Apicella et al., 2005). A completely different picture emerges when considering the effectiveness of cognitivebehavioral and pharmacological treatments of anxiety disorders in children and adolescents. In the past decades, a host of controlled therapy outcome studies has appeared examining the efficacy of these interventions. In this chapter, the results of this research are summarized. First, the focus will be on the cognitive-behavioral treatment of phobias and anxiety disorders in children and adolescents. The content of an exposure therapy for phobias and a cognitive-behavioral intervention protocol for more generalized anxiety problems will be described, and studies demonstrating their short-term and long-term effectiveness are discussed. Second, the issue will be addressed of whether the effectiveness of a cognitivebehavioral intervention can be enhanced by including the family in this type of treatment. Third, other psychological approaches for treating phobias and anxiety disorders in youths are discussed. Fourth, an overview of the psychopharmacological treatment of childhood anxiety problems will be provided, and empirical trials evaluating their effectiveness are presented. Finally, the current status of the psychological and pharmacological treatment of

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childhood anxiety disorders will be critically discussed, developmental issues will be addressed, and an attempt will be made to link both types of intervention to the multifactorial, aetiological model that was described earlier (see Chapter 6).

Cognitive-Behavioral Treatment of Childhood Anxiety Cognitive-behavior treatment (CBT) essentially represents a fusion of behavior therapy and cognitive interventions (Kendall & Panichelli-Mindel, 1995). The behavior therapy component has evolved within learning theory and is based on the assumption that behavior, which has been acquired via classical and/or operant conditioning, can be corrected and changed (e.g., Wolpe, 1958). The cognitive component is grounded on the increasingly accepted notion that all normal and abnormal human behavior is mediated by cognitive processes (Beck, 1995). The two components are often combined in treatment, and differences between behavior and cognitive therapists simply seem to pertain to the strategy that is initially chosen to deal with the problematic behavior. That is, behavior therapists work with patients to change behaviors and thereby reduce distressing feelings and thoughts, whereas cognitive therapists first try to change thoughts and feelings, with improvements in functional behavior following in turn (see Compton, March, Brent et al., 2004). In order to get an impression of CBT interventions with youths, two examples of such treatments are given in the following paragraphs. The first example is an exposure-based therapy for childhood phobias. This one-session therapy was developed by Ost (1989) and essentially consists of a series of behavioral exercises, during which the child or adolescent is instructed to approach the phobic stimulus (see Table 8.1). The exposure is gradual in two respects. First, the child starts with a phobic stimulus that elicits relatively low levels of fear and anxiety, and ends up with the stimulus that is feared most. Second, each stimulus is approached in a stepwise manner: The child first carefully observes the phobic object and then gets closer to the stimulus, touches it indirectly with another object (for example, a pencil or a long stick), and eventually makes direct physical contact. During the exposure, the therapist continuously monitors the child's subjective anxiety level, and the rule of thumb is that before one proceeds to the next step

Table 8.1 Possible hierarchy for a one-session exposure in vivo therapy of spider phobia Exposure-exercises

Possible steps within each exercise

1. 2. 3. 4. 5. 6.

1. 2. 3. 4. 5. 6.

Pictures of spiders Toy spider Small spider Medium-size spider Large house spider Tarantula

Watch the spider from a distance Gradually approach the spider Touch the spider with a pencil Touch the spider with a finger Let the spider walk on the hand Catch a spider

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or stimulus, there should be at least a 50% decline in anxiety level. The therapist first demonstrates each step (modeling) and then encourages the child to perform the exercise. A one-session exposure therapy can best be viewed as an example of behavior therapy. No active cognitive therapy is carried out during the treatment session, although the therapy aims at correcting the false beliefs that a child has in regard to the phobic stimulus (e.g., in case of a spider phobia, the belief that the spider will approach and attack). In other words, "The hallmark, then, of one-session treatment is a graduated, systematic, prolonged exposure to the phobic stimulus combined with the active dissuading and repair of faulty cognitions" (Ollendick, Davis, & Muris, 2004; p.293). The second example is the "Coping Koala (Cat)," a CBT program for anxiety disordered children and adolescents (Kendall, 1990, 2000), of which many variants have appeared (e.g., "Coping Koala," Heard, Dadds, & Rapee, 1991; "Friends," Barrett, Lowry-Webster, & Turner, 2000; "Cool Kids," Rapee, Wignall, Hudson, & Schniering, 2000). The basic elements of this program are shown in Table 8.2. As can be seen, the core feature of the program is the so-called FEAR-plan which helps the child or adolescent (1) to recognize anxious feelings and the physical symptoms of fear and anxiety, (2) to identify anxious thoughts and self-talk in potentially threatening situations, (3) to think up a plan to deal with threatening events, and (4) to evaluate one's behavior and to reinforce oneself for coping effectively with fear- and anxiety-provoking stimuli and situations. Obviously, the active correction of negative cognition clearly is an important component of the "Coping Koala (Cat)" program, and as such this type of treatment can certainly be regarded as cognitively oriented (Hudson, Hughes, & Kendall, 2004). Nevertheless, it is important to note that exposure exercises are also a very important component of this treatment. In sessions 9 through 11, the child or adolescent is encouraged to apply his/her newly acquired skills in real-life threatening situations. In addition, the "Coping Koala (Cat)" also contains a number of other therapeutic elements that may help to reduce fear and anxiety, including psychoeducation and relaxation training. Taken together, the "Coping Koala (Cat)" contains a mixture of cognitive-behavioral strategies, which make it possible to use this program with a variety of childhood phobias and anxiety disorders.

Effectiveness of CBT in Childhood Phobias and Anxiety Disorders From early on, CBT has been strongly embedded in research tradition. This explains why CBT probably is the best evaluated treatment approach for psychological disorders. The same conclusion can be drawn regarding the treatment of childhood phobias and anxiety disorders. As soon as clinicians and researchers started to realize that these disorders should be regarded as serious clinical problems, a host of controlled treatment outcome studies have appeared investigating the effectiveness of exposure programs, CBT protocols, and other cognitive-behavioral interventions in phobic and anxiety disordered youths.

Exposure-Based Treatment of Phobias While exposure is assumed to be an essential element of an intervention for almost every anxiety disorder, it is generally regarded as the treatment of choice for phobias. In Antony

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Table 8.2 The 12 sessions of the "Coping Koala" (the Australian version of the "Coping Koala (Cat)"), a cognitive-behavioral program for children with anxiety disorders Session

Title in workbook

1

Introduction

2

Recognizing feelings

3 4

How does my body react? Relax!

5

What do I think?

6

What can I do?

7

How am I doing?

8

The FEAR-plan

9

Start to exercise

10

It's getting more difficult Look what I am doing! You did it!

11 12

Main content Acquaintance and providing an overview of the treatment. To help the child to identify anxious and worried feelings and to differentiate these from other feelings. To identify the physical symptoms that accompany fear and anxiety. To introduce relaxation training and to teach the child to use it as a strategy for controlling the physical symptoms that are associated with fear and anxiety. To explain the function of personal thoughts and their impact on the child's behavior. To teach the child to recognize anxious self-talk in (potentially) threatening situations. To teach the child to change anxious self-talk into coping self-talk and to alter fearful into brave behavior. To teach the child to evaluate his/her behavior and to rate and reward performance. To introduce the FEAR-plan, which integrates the elements that were learned in previous sessions. The FEAR-plan is a 4-step approach for dealing with fear- and anxiety-provoking situations: 1. Feeling frightened? (awareness of physical symptoms of anxiety); 2. Expecting bad things to happen? (recognition of anxious self-talk); 3. Attitudes and actions that will help (problemsolving and coping); and 4. Results and rewards (self-evaluation and self-reward for effort). To apply the FEAR-plan in mildly threatening situations. To apply the FEAR-plan in moderately threatening situations. To apply the FEAR-plan in highly threatening situations. Closure and award of the anxiety certificate.

Based on: Heard, Dadds, & Rapee (1991).

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and Barlow's (2002) words: "Almost all experts agree that exposure to feared objects and situations is both necessary and sufficient for treating the vast majority of the patients with this condition" (p.408). Although this statement was made with regard to the treatment of phobias in adults, there is no reason to assume that this is not true for childhood phobias (King, Heyne, & Ollendick, 2005; King, Muris, & Ollendick, 2005; King, Muris, Ollendick, & Gullone, 2005; Ollendick, Davis, & Muris, 2004). In fact, the literature contains many case studies that describe exposure as an important element in the treatment of phobic children (e.g., Nelissen, Muris, & Merckelbach, 1995; Nock, 2002; Saavedra & Silverman, 2002; Sturges & Sturges, 1998). Moreover, controlled treatment outcome research has indicated that exposure-based treatments are indeed effective in reducing fear and anxiety in phobic youths. Exposure treatment of childhood phobias has been conducted in many ways. Based on the idea that two emotional states cannot occur simultaneously, Wolpe (1958) developed the treatment approach named "systematic desensitization," during which fear and anxiety elicited by a phobic stimulus are terminated by a previously learned relaxation response. Briefly, Wolpe assumed that a response antagonistic to anxiety (e.g., physiological relaxation) inhibits the emotional fear response (a phenomenon known as "reciprocal inhibition"). Various studies have demonstrated that systematic desensitization yields positive effects when treating phobic youths, and this is especially true when real-life exposure to the phobic stimulus is used to provoke fear and anxiety during the therapeutic procedure. For example, Ultee, Griffoen, and Schellekens (1982) divided 24 water phobic children aged between 5 and 10 years in three groups: (1) an in vitro desensitization group in which children received gradual imaginal exposure to fear-evoking stimuli plus relaxation, (2) an in vivo desensitization group in which children were treated with gradual real-life exposure in combination with relaxation, and (3) a no-treatment control group. The results of behavioral observation tests and reports by the swimming teachers indicated that both desensitization procedures were effective in reducing children' s fear of water, whereas no such effect could be observed in the no-treatment condition. Further, evidence was found showing that the in vivo exposure procedure yielded better treatment effects than the in vitro exposure procedure. In spite of the fact that various other studies have documented positive effects of systematic desensitization in the treatment of childhood phobias (e.g., Miller, Barrett, Hampe, & Noble, 1972), this type of intervention seems somewhat outdated. This is because research has demonstrated that Wolpe's (1958) basic ideas about the underlying mechanism of systematic desensitization are not correct. In fact, there is clear evidence showing that the relaxation component of this treatment is not necessary to achieve the positive effects of the intervention (see Emmelkamp, 1982). Although the therapeutic procedure of systematic desensitization is less frequently employed nowadays, it is of interest to note that there is an age-downward variant that may still be feasible to apply, in particular when working with younger children. This technique has been described as "emotive imagery," and was first defined by Lazarus and Abrahamson (1962) as "those classes of imagery which are assumed to arouse feelings of self-assertion, pride, affection, mirth, and similar anxiety-inhibiting responses" (p.191). An important feature of the emotive imagery procedure is that the child identifies himself with a "personal hero" (usually a person or cartoon character seen on television) and then makes up a narrative, in which the phobic stimulus is gradually introduced (see for an example,

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Table 8.3 Transcript from an emotive imagery therapy session with a 5-year-old boy who had a phobia of darkness

Therapist

Child Therapist Child Therapist Child Therapist

ChiM Therapist

Child

Close your eyes. Now I want you to imagine that you are sitting in the lounge room watching TV with your family. You are dressed for bed and the last program before bedtime has finished. Your mother tells you that it is time for bed, but just then Batman appears out of nowhere and sits down next to you. Think about it as best as you can. Can you see Batman in your head? Yes. Can you tell me what Batman is wearing? What color are his clothes? He's got black and red clothes, big shoes, and a gun. Oh, you can see him with a gun? Yeah, he needs it for the Joker. That's terrific! Now I want you to imagine that Batman tells you he needs you on his mission to catch robbers and other bad people, and he has appointed you as his special agent. However, he needs you to get your sleep in your bedroom, and he will call on you when he needs you. You are so lucky to have been chosen to help him. Yes. Now your mother puts you in bed and leaves a small light on. Batman is also there, looking as strong as he always does. Think about it as clearly as you can. Can you see it? Yes. I can see Mummy and Batman in my room.

From: King, Molloy, Heyne et al. (1998).

Table 8.3). After the imaginal exposure, during which the child--supported by the personal hero--effectively deals with the phobic stimulus, he/she is encouraged to apply these newly learned skills in real-life situations (King, Heyne, Gullone, & Molloy, 2001; King, Molloy, Heyne, Murphy, & Ollendick, 1998). In an attempt to examine the effectiveness of emotive imagery, King, Cranstoun, and Josephs (1989) treated three children (aged 6, 8, and 11 years old) with nighttime fears in a multiple baseline design. All three children showed marked improvements on a behavioral test for darkness toleration. Further, parents observed fewer nighttime disturbances for two of the children and reported to be satisfied with emotive imagery as a fear-reduction procedure. More systematic research was conducted by Cornwall, Spence, and Schotte (1996) who assigned 24 clinically referred 7- to 10-yearold children with a severe darkness phobia to either emotive imagery treatment or a waitinglist control condition. The results demonstrated that children in the emotive imagery group showed significant reductions in darkness fear and anxiety and clear improvement on a darkness tolerance test, whereas no such effects were observed in the waiting-list control group (see Figure 8.1). Another way to conduct an exposure treatment in phobic youths is "reinforced practice," which is also known as "contingency management." In line with his operant conditioning

Treatment and Prevention of Childhood Anxiety

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Fear of darkness --0

0

Pretreatment

[~

Posttreatment

Follow-up (3 months)

Emotive imagery - 0 - Waiting-list I Darkness tolerance

180 160 140 120 100 80

.I--0

60

• r~

40 20 0

0

Pretreatment

Posttreatment

Follow-up

Figure 8.1" Mean scores on a self-report questionnaire (fear of darkness) and a behavioral test (darkness tolerance) in the emotive imagery and the waiting-list control groups at pretreatment, posttreatment, and 3-month follow-up. Based on: Cornwall, Spence, & Schotte (1996).

theory, Skinner (1988) assumed that a phobia essentially is "a reduced probability of moving toward a feared object and a heightened probability of moving away from it" (p. 172). During reinforced practice, an attempt is made to weaken the negative associations with the phobic stimulus that results in avoidance behavior by strengthening positive associations through reinforcement of approach behavior. This is achieved via exposure exercises during which successful approaches of the phobic stimulus are reinforced by means of rewards. There is ample evidence supporting the efficacy of reinforced practice in treating phobic children and adolescents. For example, Silverman, Kurtiness, Ginsburg et al. (1999) treated 33 6- to 16-year-old youths with either specific phobia, social phobia, or agoraphobia by means of a reinforced practice program during which children had to perform increasingly difficult exposure tasks that were reinforced by their parents every time they completed a task successfully. Results revealed that this treatment program was equally effective in reducing fear and anxiety levels as a cognitive-behavioral intervention. Further, it was found that the positive treatment effects of reinforcement practice were largely maintained at a one-year

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Normal and Abnormal Fear and Anxiety in Children and Adolescents

follow-up. In terms of clinical significant improvement, it was found that more than half of the youths (55%) no longer met the diagnostic criteria of a phobic disorder after the completion of the treatment. Yet another option is to make children observe a nonphobic person who approaches the phobic stimulus and successfully copes with it without displaying fear. This procedure of modeling, which has also been described as vicarious learning (Bandura, 1969), can be employed in various ways. The first way is filmed modeling, during which the child watches a film in which a model interacts with the phobic stimulus. The second way is live modeling: The phobic child observes a real model interacting and dealing with the phobic stimulus. Finally, during participant modeling, the child and the model work together: The model demonstrates how to approach and deal with the phobic stimulus, and then instructs the child to imitate this behavior. Research has indicated that participant modeling clearly is more effective than the other modeling variants (Ollendick et al., 2004). For example, Menzies and Clarke (1993) assigned 3- to 8-year-old children with water phobia to various interventions involving exposure, live modeling, or a combination of these two procedures. Most important, this study demonstrated that modeling merely yielded significant treatment effects when combined with exposure exercises. Clearly, this finding can be taken as support for the notion that participant modeling is far more effective than live modeling only. A final exposure-based approach that can be chosen to treat childhood phobias is the aforementioned one-session therapy (Ost, 1989). A number of studies can be found in the literature demonstrating that this type of intervention is particularly effective for reducing phobic complaints in youths. A first study by Muris, Merckelbach, Van Haaften, and Mayer (1997) compared the efficacy of one-session therapy with that of eye-movement desensitization and reprocessing (EMDR, Shapiro, 1995; see Box 8.1) in the treatment of 22 spiderphobic girls aged 9 to 14 years. A crossover design was used in which half of the children were first treated with exposure and then with EMDR, whereas the other half received the

Box 8.1

Eye-movement desensitization and reprocessing

Eye-movement desensitization and reprocessing (EMDR) is a therapeutic technique that has been proposed as a treatment for posttraumatic stress disorder (PTSD; Shapiro, 1995). During EMDR, the therapist induces rapid, lateral eye movements while the patient imaginally exposes him- or herself to aversive memories. After each set of eye movements, the patient briefly reports his or her images, feelings, and/or thoughts. This procedure is repeated until the negative affect associated with the traumatic or aversive memory habituates. Furthermore, the therapist encourages cognitive restructuring. That is, the patient is prompted to change negative cognitions about him- or herself or about the traumatic event into more functional cognitions. While the EMDR-procedure in itself is unique (because of the employment of the eye movements), it is clear that this treatment is essentially based on the key elements of cognitive-behavioral therapy (i.e., exposure and cognitive restructuring). Based on: Muris & Merckelbach (1999b).

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treatments in reversed order. Treatment outcome was evaluated by means of self-report questionnaires and a behavioral approach test (during which children had to approach a real-life house spider in a stepwise manner), which were administered before treatment, after treatment 1, and after treatment 2. The results indicated that one-session therapy was superior to EMDR. More precisely, the one-session therapy yielded a significant reduction of subjective fear and a clear improvement on the behavioral approach test, whereas the EMDR intervention only produced some positive effects on the self-report scales. Similar findings were obtained in a follow-up study by Muris, Merckelbach, Holdrinet, and Sijsenaar (1998), who compared the effects of one-session therapy, EMDR, and computerized exposure in 26 8- to 17-year-old girls with a spider phobia. The one-session therapy resulted in significant improvements on all outcome measures, EMDR only yielded a significant improvement on self-reported spider fear, whereas computerized exposure did not produce any improvement. Further research by ~)st, Svensson, Hellstr6m, and Lindwall (2001) tested the effectiveness of one-session therapy in a large sample of children and adolescents (N = 60) with various types of specific phobias. For this purpose, youths were randomly assigned to (1) regular one-session therapy, (2) one-session therapy with one of the child's parents present, or (3) a waiting-list control group. Various outcome measures were used including self-report inventories, independent assessor ratings, a behavioral approach test, and physiological indexes (e.g., blood pressure, heart rate), most of which were obtained at pretreatment, posttreatment, and one-year follow-up. The results consistently showed that one-session therapy produced significantly better results than the waiting-list control condition. Further, both variants of the one-session therapy did equally well on most outcome measures, indicating that the presence of a parent did neither promote nor hinder the treatment effects. Finally, the treatment effects of one-session therapy were maintained at a follow-up of one year (see Figure 8.2). Altogether, this type of intervention seems highly effective for treating phobias in children and adolescents. In sum, then, exposure-based interventions have shown to be effective for treating phobias in children and adolescents. In their systematic review article, Ollendick and King (1998) provide an overview of the empirical status of treatments for youths with phobias, thereby using the guidelines as provided by the American Psychological Association (Task Force on Promotion and Dissemination of Psychological Procedures, 1995; see Chambless & Ollendick, 2001). With regard to the treatment of phobias in youths, these authors conclude that "participant modeling and reinforced practice enjoy a well-established status" (p.162), which implies that multiple studies have shown that these interventions are more effective than other treatments. A more recent review by Davis and Ollendick (2005) has indicated that one-session therapy by now also meets the criteria for a well-established treatment. These interventions all share that they try to enhance approach behavior to reallife phobic stimuli, which seems to be an essential element for the treatment of (childhood) phobias (Muris, 2005). As a final note it should be mentioned that CBT programs like the "Coping Koala (Cat)" have also been successfully employed to treat phobias in children and adolescents (see Silverman et al., 1999). However, this type of intervention seems more suitable for treating those childhood anxiety disorders (e.g., separation anxiety disorder, generalized anxiety disorder, and social phobia) in which dysfunctional cognitions play a more prominent role. In the next section, empirical evidence on the effectiveness of CBT programs for anxietydisordered youths will be discussed in detail.

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Severity of phobia

--0-- Waiting-list -Q-- One-session therapy + parent --0-- One-session therapy

w

Pretreatment Posttreatment

Follow-up

Figure 8.2: Severity of phobia scores as rated by independent assessors for youths in the one-session therapy groups and the waiting-list control group. Based on: Ost, Svensson, Hellstr6m, & Lindwall (2001).

CBT Programs for Childhood Anxiety Disorders Since the introduction of the "Coping Koala (Cat)," a series of studies has appeared that examined the effectiveness of such CBT programs for treating anxiety disorders in children and adolescents. In a multiple-baseline evaluation of four 9- to 13-year old children diagnosed with generalized anxiety disorder, Kane and Kendall (1989) were among the first to demonstrate that this CBT program has potential for treating anxious youths. Kendall (1994) then performed the first randomized clinical trial to evaluate the effectiveness of the "Coping Koala (Cat)" program more systematically. In this study, 47 children with anxiety disorders (i.e., generalized anxiety disorder, separation anxiety disorder, and social phobia) were assigned to the CBT intervention or a waiting-list control condition. Outcome was evaluated using child self-report, parent report, teacher report, and behavioral observation. The results of a number of these outcome measures are displayed in Figure 8.3. As can be seen, there were significant pre- to posttreatment changes in the CBT intervention group, whereas the waiting-list control group remained relatively unchanged. More precisely, the CBT intervention resulted in substantial reductions of self-reported anxiety symptoms, parent-reported internalizing symptoms, and observable anxious behavior, as well as significant improvement of self-rated coping abilities. Furthermore, it is important to note that these positive effects of CBT were retained at a one-year follow-up assessment. Finally, many of the treated children (64%) no longer met the diagnostic criteria for an anxiety disorder at posttreatment, which indicated that the observed treatment effects were also clinically significant. In a following study (Kendall, Flannery-Schroeder, Panichelli-Mindel et al., 1997) with 94 anxiety-disordered children, these results were largely replicated. Again, the CBT intervention resulted in substantial improvements at posttreatment, whereas no such effects occurred in the waiting-list control condition. Due to treatment, anxiety levels of the majority of children returned within nondeviant limits, and this was still the case at a one-year follow-up.

Self-reported anxiety 60 55 50 CBT - - 0 - Waiting-list

45 40 35 30 Pretreatment Posttreatment

Follow-up

Parent-reported internalizing symptoms 75 70 65 60 v

55 Pretreatment Posttreatment

Follow-up

Observation of anxious behavior 1,5 1,3 1,1 0,9 0,7 0,5

Pretreatment Posttreatment

Follow-up

Self-reported coping

Pretreatment

Posttreatment

Follow-up

Figure 8.3: Changes on various outcome measures for children treated with the CBT program and children in the waiting-list control group. Based on: Kendall (1994).

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Further research has been conducted to examine whether these CBT programs yield equally positive results when administered in a group format. For example, Silverman, Kurtiness, Ginsburg et al. (1999) evaluated the therapeutic efficacy of a group CBT in 56 children and adolescents (aged between 6 and 16 years) with social phobia, generalized anxiety disorder, or separation anxiety disorder. Results showed that group CBT was very effective in reducing anxiety symptoms. That is, youths treated with group CBT showed significant improvement from pre- to posttreatment on all outcome measures, and these effects were largely maintained at 3-, 6-, and 12-months follow-up (see also Lumpkin, Silverman, Weems, Markham, & Kurtines, 2002). About 75% of the children and adolescents did no longer fulfill the diagnostic criteria of the anxiety disorder for which they had received the treatment. In contrast, children and adolescents in a waiting-list condition did not show any improvement: These youths did not show spontaneous recovery and remained highly anxious. Although this study suggests that group CBT is also effective for treating youths with anxiety disorders, it should be noted that this intervention was supported by a parent intervention. More precisely, parents were instructed to encourage and reinforce the exposure exercises of their children. In other words, it is not clear to what extent the positive effects observed in the treated youths were caused by the group CBT program or by the parent intervention. A more clear-cut picture on the effects of group CBT was provided by Hayward, Varady, Albano et al. (2000), who randomly assigned 35 female adolescents to a treatment or a notreatment control group. The treatment group received group CBT without any parental involvement. All participants were assessed at pretreatment, posttreatment, and one-year follow-up by means of standardized self-report questionnaires and a structured diagnostic interview. The results showed that the group CBT intervention resulted in a significant decline of social phobia symptoms, whereas no such effect was observed in the no-treatment control group. At posttreatment, a substantial proportion of the treated adolescents (i.e., 55%) still met the criteria of social phobia, although this percentage was substantially lower than in the control group (96%). At the one-year follow-up, the differences between adolescents who had received group CBT and those who were untreated seemed to disappear: In the treatment condition 40% continued to have social phobia, whereas in the no-treatment condition this percentage was 56%. However, this state of affairs changed when comorbid depression was taken into account. As noted by Hayward et al. (2000), "Much of the improvement in the group CBT compared to the untreated group was maintained when social phobia and major depression were combined as the outcome" (p.724; (see Figure 8.4)). Taken together, although the group CBT yielded positive results, the effects seemed somewhat less impressive than those observed in previous studies by Kendall and colleagues (1994, 1997). However, it should be kept in mind that the youths in the Hayward et al. (2000) study were substantially older, and so it may well be the case that the anxiety problems were simply more chronic and severe than those of the younger children in Kendall et al.'s studies. Of course, only a direct comparison between individual and group CBT programs can provide an answer to the question of whether both types of treatment are equally effective in reducing anxiety symptoms in youths. Flannery-Schroeder and Kendall (2000) carried out an investigation in which this issue was addressed. Thirty-seven anxiety disordered children were randomly assigned to three conditions: individual CBT, group CBT, and waiting-list

Treatment and Prevention of Childhood Anxiety

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100 80 60 • Group CBT [] No treatment

40 20

Pretreatment

Posttreatment

Follow-up

Figure 8.4" Percentage of female adolescents with either social phobia or depression in the group CBT and the no-treatment control condition at pretreatment, posttreatment, and 1-year follow-up. Based on: Hayward, Varady, Albano et al. (2000).

control. Results showed that individual and group CBT were equally effective and superior to the waiting-list control condition. For example, after treatment, percentages of diagnosisfree children were 73% in the individual CBT condition, 50% in the group CBT condition versus only 8% in the waiting-list control condition. However, it is important to note that in both CBT interventions, several sessions with parents were included in order to enhance therapeutic effects. Thus, although the results of the Flannery-Schroeder and Kendall (2000) study seem to indicate that the effects of individual CBT and group CBT are comparable, it may well be the case that the parental involvement in both interventions has overshadowed differential treatment effects. A similar remark can also be made with regard to a study by Manassis, Mendlowitz, Scapillato et al. (2002). These researchers compared the effectiveness of individual and group CBT, both with parental involvement, in treating 78 anxiety disordered children aged 8 to 12 years. Both treatment formats yielded significant and largely comparable treatment gains. Nevertheless, some indications were found showing that high socially anxious children responded more favorably to the individual treatment format. A final investigation by Muris, Mayer, Bartelds, Tierney, and Bogie (2001) also made a comparison of the effects of individual and group CBT in a nonreferred sample of 36 8- to 13-year-old school children who fulfilled the diagnostic criteria of social phobia, generalized anxiety disorder, and/or separation anxiety disorder. Treatment was solely targeted at the children, which makes it possible to compare the "pure" effects of individual and group CBT. No differences were observed between both treatment formats--that is, levels of anxiety disorder symptoms were relatively stable from baseline to pretreatment (i.e., waiting-list period) but substantially decreased from pre- to posttreatment, and this pattern was identical for both CBT formats (see Figure 8.5). Altogether, it can be concluded that CBT programs have proven to be very successful in treating youths with anxiety disorders (see Dadds & Barrett, 2001). Further, research seems to suggest that a group format CBT is just as effective as an individual CBT intervention (James, Soler, & Weatherall, 2005). This finding seems to warrant the conclusion that the

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Self-reported anxiety symptoms 80 70

O-A w

60

--0-Individual CBT

50

- O - Group CBT

40 30 Baseline

Pretreatment Posttreatment

Figure 8.5" Mean levels of anxiety disorders symptoms in the individual CBT and the group CBT conditions at the baseline (6 months before the intervention), pretreatment, and posttreatment assessments. Based on: Muris, Mayer, Bartelds, Tierney, & Bogie (2001).

group treatment format is preferable simply because it is more cost- and time-efficient. However, the results of the aforementioned study by Manassis et al. (2002) seem to suggest that individual treatment may still be necessary for some children. For instance, children with extremely high levels of social phobia may profit little from a group CBT simply because it is too difficult for them to participate adequately in the group sessions. As another example, severely traumatized youths may find it difficult to discuss their experiences, fears, and anxieties in front of other children. Finally, the individual format also seems to be preferable for children suffering from comorbid ADHD. Although children with ADHD may certainly profit from a group CBT intervention, it has also been observed that these children regularly disturb the group interactions with their hyperactive and impulsive behaviors (Muris et al., 2001; see Manassis & Monga, 2001).

Combining CBT with a Family Intervention Based on the observation that family factors play a role in the aetiology and maintenance of childhood anxiety disorders (see Chapter 3), many clinicians are convinced that it is important to involve parents in the CBT intervention (e.g., Kendall, MacDonald, & Treadwell, 1995). One of the first studies that examined whether family CBT yields positive effects in the treatment of youths with anxiety disorders was carried out by Howard and Kendall (1996). In a multiple-baseline design, six children aged 9 to 13 years who were diagnosed with an anxiety disorder received a CBT treatment in which at least one of the parents was present during the sessions. Besides the normal child-focused protocol, parents were encouraged to gain better understanding of their children's anxiety symptoms and the role of the family in these problems, and to help and support their offspring to carry out the homework exposure exercises. Results clearly revealed changes on various types of outcome measures indicating meaningful treatment-related improvements. In the FRIENDS program, Barrett and co-workers (2000) have worked out a more systematic plan for helping parents to deal effectively with their anxious offspring. Besides the

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CBT sessions for the children, this program incorporates a parent component that consists of four 1½-hour sessions (that can eventually be split up into multiple sessions of shorter duration) during which parents are taught to recognize and deal with their own anxiety, to reinforce their child's courageous behavior, to help their children employ cognitive techniques in order to challenge dysfunctional thoughts, and to communicate effectively and to support each other within the family (see Table 8.4). Shortt, Barrett, and Fox (2001) evaluated the efficacy of this family group CBT program. Seventy-one anxiety disordered

Table 8.4 Session

Content of the parent sessions of the FRIENDS program Aim General introduction of the program. Normalize the emotion of anxiety during childhood. Introduce Step 1 (Feeling worried?) and Step 2 (Relax and feel good). Introduce Step 3 (Inner thoughts) and Step 4 (Explore plans).

Introduce Step 5 (Nice work, so reward yourselP.) Teach parents operant conditioning principles to reinforce desirable behaviors. Introduce Step 6 (Don't forget to practice) and Step 7 (Stay calm). Promote positive family skills and outline strategies to maintain gains.

Based on: Shortt, Barrett, & Fox (2001).

Main content Psychoeducation about anxiety. Explanation of the rationale behind the program. Parents are taught to identify (their child's) physical symptoms of anxiety and how to employ progressive muscle relaxation to deal with these symptoms. Parents are taught to identify dysfunctional thoughts of themselves and their children. Parents are taught how to combat such dysfunctional thinking and how to assist their child in doing so. Parents are taught how to apply a problem-solving plan and to employ this to help their children to solve problems. Parents are informed about the main learning principles (observation, reinforcement). Parents are taught to behave as a positive role model for their child and to praise and reward for (partial) successful behavior of their child in difficult situations. Parents are taught how they can support each other and encouraged to plan family activities. Parents are instructed to engage other persons (e.g., teachers) to deal more effectively with child's anxiety. Strategies for maintaining gains and potential future difficulties are discussed, and plans for continuation of the FRIENDS program are made.

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children aged between 6 and 10 years were assigned to the FRIENDS treatment or a waiting list. Results showed that 69% of the children who had received the FRIENDS program were anxiety disorder-free after treatment as compared to only 6% in the waiting-list control condition. The positive effects of the intervention were maintained over a longer time period with 68% of the treated children being still diagnosis-free at a one-year follow-up. Similar findings were reported in a recent study by B6gels and Siqueland (2006), who also treated children and adolescents with a family CBT program. It was found that this intervention was more effective than a waiting-list period: That is, none of the youths improved during the waiting period, whereas of the treated children and adolescents 41% were free of diagnosis at posttreatment, 57% at three-month follow-up, and 71% at one-year follow-up. Altogether, these findings indicate that family CBT is an effective treatment for youths with anxiety disorders (see also King, Tonge, Heyne et al., 1998; Siqueland, Rynn, & Diamond, 2005; Thienemann, Moore, & Tompkins, 2006). A number of controlled therapy outcome studies have been conducted to examine whether a CBT plus family intervention is more effective than a CBT intervention that is only targeted at the child. A first study was conducted by Barrett, Dadds, and Rapee (1996), who randomly allocated 79 anxiety disordered children aged between 7 and 14 years to three treatment conditions: (1) regular CBT: Children were treated with a 12-session Australian variant of Kendall's (1990) program (i.e., the "Coping Koala (Cat)"), (2) CBT plus family management, in which the child's CBT session was shortened and combined with a family anxiety management session. During these family sessions, the parents were trained to reward courageous behavior and to extinguish the anxiety of their child, to communicate in a more optimal way, and to deal with their own emotions and model problem-solving responses in potentially fearful situations, or (3) a waiting-list control condition. The effectiveness of the interventions was assessed at posttreatment and at 6- and 12-month follow-up. Results first of all indicated that treatments produced better outcome than the waiting list. For example, of the children who had received CBT or family CBT, 70% no longer fulfilled the diagnostic criteria for an anxiety disorder, compared with 26% of the children in the waiting-list control condition. Most important, indications were found that demonstrated that family CBT was somewhat more effective than regular CBT: At a 12-month follow-up, 96% of the children in the family CBT group appeared diagnosis-free versus 70% in the child-alone CBT group. The added benefits of family CBT were also found when other therapy evaluation measures (i.e., self-report scales and clinician ratings) were employed. Further research was conducted by Barrett (1998), who evaluated the effectiveness of a group CBT intervention plus family management. In this study, 60 children aged between 7 and 14 years with generalized anxiety disorder, separation anxiety disorder, and social phobia were allocated to three treatment conditions: (1) group CBT, (2) group CBT plus family management, or (3) a waiting-list control condition. The effectiveness of the interventions was examined at posttreatment and 12-month follow-up. Results indicated that at posttreatment 56% of the children in the group CBT and 71% in the group CBT plus family management no longer met the criteria for an anxiety disorder as compared with 25% in the waiting-list control condition. At the 12-month follow-up, 65% of the children in the group CBT and 85% of youths in the group CBT plus family management were anxiety disorder-free. Although these figures seem to indicate an advantage for the group CBT plus family intervention, statistical tests could not substantiate this impression.

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Various other studies have compared the effectiveness of CBT programs with or without parental involvement. Mendlowitz, Manassis, Bradley et al. (1999) randomly assigned 7- to 12-year-old children to one of three group CBT conditions: a combined parent-child intervention, a child-only intervention, and a parent-only intervention. Compared to a waitinglist control condition, all CBT variants produced significant treatment gains. Some indications were found indicating that children in the combined parent-child intervention profited somewhat more from treatment. More specifically, at posttreatment, children in this treatment condition used more active coping strategies and (according to their parents) displayed greater improvement in emotional well-being than children in the other two conditions. A similar result was obtained by Wood, Piacentini, Southam-Gerow, Chu, and Sigman (2006), who also compared the effectiveness of a family- and a child-focused CBT intervention in 40 clinically anxious youths aged 6 to 13 years. Although both interventions were found to be effective in reducing children's anxiety symptomatology, "family CBT was associated with greater improvement on independent evaluators' ratings and parent reports of child anxiety [and thus] may provide additional benefit over and above child-focused CBT" (Wood et al., 2006; p.314). A study by Spence, Donovan, and Brechman-Toussaint (2000) randomly distributed 50 7- to 14-year-old youths with social phobia across child-focused CBT, CBT plus parent involvement, and a waiting-list control condition. CBT interventions were a combination of social skills training, graded exposure, and cognitive restructuring. The results demonstrated that both treatment groups displayed a significantly greater decrease of self-reported social anxiety and an increase of parent-rated social skills as compared to the control group, and these positive effects of CBT were retained at a one-year follow-up. Further, although CBT plus parental involvement produced somewhat better results than child-focused CBT, this difference did not reach statistical significance. Further research by Heyne, King, Tonge et al. (2002) evaluated the relative effectiveness of child CBT, caregiver (i.e., parent/teacher) CBT, and the combination of these two interventions in 61 children and adolescents aged 7 to 14 years who displayed anxiety-based school refusal (see King, Tonge, Heyne, & Ollendick, 2000). All youths were assessed at pretreatment, posttreatment, and four-month follow-up by means of school attendance records, self-report, parent, and clinicianratings. All interventions yielded statistically and clinically significant treatment results. At posttreatment, child-focused CBT was somewhat less effective in increasing school attendance as compared to the other two interventions. However, at the follow-up assessment, this difference had disappeared, and data essentially showed that all interventions were equally effective. Finally, Nauta, Scholing, Emmelkamp, and Minderaa (2003) also evaluated the effectiveness of a CBT program for children and adolescents with anxiety disorders and the additional value of a cognitive parent training program, addressing the parents' behavior and thoughts regarding their anxious child. Children and adolescents aged 7 to 18 years were randomly assigned to a CBT intervention or a waiting-list control condition. In half of the youths who received active treatment, the cognitive parent training was added to the intervention. The results indicated that CBT was more effective in reducing anxiety symptoms than the waiting-list condition. Further, in contrast with previous research (Barrett et al., 1996; Mendlowitz et al., 1999; Wood et al., 2006), no differences in outcome were observed between the two CBT treatment conditions. That is, all children improved equally whether or not additional parent training was offered.

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Taken together, a number of randomized control trials have sought to examine whether the effects of a CBT intervention can be enhanced by an adjunctive parent component. In a review of this research, Barmish and Kendall (2005) conclude that although the effect sizes of CBT plus parent interventions seem somewhat larger than those reported for childfocused CBT, this research is far from conclusive. To begin with, these authors note that there has been quite some variability across the content and number of the parent sessions that were added to the CBT protocol, which of course make it difficult to make a good comparison across the effectiveness of the treatments provided in various studies. Further, the children treated in various studies vary considerably with respect to age, and there are some indications that the inclusion of a parent component may be more useful in younger children than in adolescents (Barrett et al., 1996; see also Barrett, 2000, 2001). Finally, the measures that have been used to evaluate treatment outcome are also important in this regard. That is, some studies have documented fairly large effect sizes on parent report measures in the case of family CBT. Of course, such a finding may simply reflect demand m that is, parents who were actively involved in the treatment reported that their children did well after this intervention. Interestingly, the results of a study by Cobham, Dadds, and Spence (1998) have suggested that it may be useful to add a parent component to a CBT intervention but only in the case that parents suffer from anxiety problems themselves. In this study, 67 children aged 7 to 14 years who fulfilled the criteria for an anxiety disorder were assigned to two treatment conditions: child-focused CBT or child-focused CBT plus parental anxiety management. As can be seen in Figure 8.6, the effectiveness of the interventions at posttreatment was dependent on the anxiety status of the parents. In children of whom the parents did not display anxiety problems, child-focused CBT was equally effective as child-focused CBT

90 80 70 60 50

• CBT

[] CBT + PAM

40 30

20 10

Child anxiety only

Child + parental anxiety

Figure 8.6: Percentage of youths who were anxiety disorder-flee after being treated with either child-focused CBT or child-focused CBT plus parental anxiety management (PAM). Based on: Cobham, Dadds, & Spence (1998).

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plus parental anxiety management. However, in children who had one or more anxious parents, child-focused CBT clearly yielded less favorable results than the CBT plus parental anxiety management intervention (see also Toren, Wolmer, Rosental et al., 2000). Thus, although it intuitively makes sense to include the parents of youths with anxiety disorders in the treatment, more evidence is needed to substantiate this intervention strategy. A recent meta-analysis by In-Albon and Schneider (2006), including 24 therapy outcome studies, clearly indicated that "the active treatment condition was cognitive-behavioral" and "that no differences in outcome were observed between child- and family-focused treatments" (p.15). Based on this observation and the results of her own randomized clinical trial, B6gels (2006) concludes that given the extra time and therapeutic effort that is invested in a CBT plus family/parent component intervention, a child-focused CBT is even preferable in terms of cost-effectiveness.

Long-Term Effectiveness of CBT Interventions CBT interventions have proven to be highly effective in the short term (see reviews by Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004; Compton et al., 2004; Dadds & Barrett, 2001; Hudson, 2005; James et al., 2005). Most studies evaluating the effectiveness of CBT with anxiety disordered youths have included follow-up assessments until one year after treatment, and these data have shown that the positive effects of CBT are largely maintained over such a time period (e.g., Barrett, 1998; Kendall, 1994). The question is whether effects of CBT are preserved over longer intervals of time. So far, a number of studies have addressed this issue. A first investigation by Kendall and SouthamGerow (1996) reexamined 36 of the 47 children who were treated in Kendall's (1994) original study between two and five years after they had finished treatment. On all outcome measures, the treatment gains obtained at the one-year follow-up were continued, with no observable deterioration. A further study by Barrett, Duffy, Dadds, and Rapee (2001) also evaluated the long-term effectiveness of CBT for childhood anxiety disorders. Fifty-two participants (aged between 14 and 21 years) who had completed treatment on average more than six years earlier were reassessed using diagnostic interviews, clinician ratings, and self- and parent-report questionnaires. Results demonstrated that 86% of the participants were still anxiety disorder-free. On most of the other outcome measures, immediate treatment effects were maintained at the long-term follow-up. Interestingly, the data also showed that child-directed CBT and CBT plus family anxiety management were equally effective (see Figure 8.7), which substantiates the earlier formulated conclusion that an additional focus on the anxious child's family is not really necessary to achieve positive treatment results. Another investigation by Garcia-Lopez, Olivares, Beidel et al. (2005) obtained longterm (i.e., five-year) follow-up data for a group of adolescents who were treated with three types of CBT-based interventions that all included social skills training and exposure, potentially supplemented with cognitive restructuring. All treatment conditions produced significant reductions in social anxiety. Most importantly to the present discussion, these positive treatment effects were still present at the five-year follow-up. Similar positive longterm effects were documented by King, Tonge, Heyne et al. (2001), who followed a sample of youths that had received CBT for anxiety-based school refusal. Their findings indicated

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Self-reported anxiety 16 14 12 10

Pretreatment

1-year follow-up

6-year follow-up

Self-reported fear 140 130120- o - CBT - o - CBT+ FAM

11010090 80 Pretreatment

1-year follow-up

6-year follow-up

Parent-reported internalizing 75 70 65 60 55 J

50

A v

45 40 Pretreatment

1-year follow-up

6-year follow-up

Figure 8.7" Long-term changes on a number of outcome measures in youths who had been treated with child-focused CBT or CBT with family anxiety management. Based on: Barrett, Duffy, Dadds, & Rapee (2001).

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that 3 to 5 years after termination of treatment, children still showed maintenance of the improvements in school attendance and school adjustment that were observed just after the intervention. A final study on the long-term effects of CBT for anxiety disorders in youths was conducted by Kendall, Safford, Flannery-Schroeder, and Webb (2004). Children and adolescents who had received a 16-week CBT intervention for an anxiety disorder were examined after a mean follow-up period of 7.4 years (range: 5.5 to 9.3 years). The assessments showed that for the majority of the participants, the significant improvements in anxiety symptoms were retained at the long-term follow-up. Further, the data also indicated that positive responders to the CBT intervention had a reduced risk for developing substance use problems (i.e., the regular use of alcohol, cigarettes, and drugs) than less positive responders. Finally, a substantial proportion of the participants in this study (50%) had received additional treatment after the CBT program, including outpatient therapy, hospitalization (a very small percentage), or medication (see also Manassis, Avery, Butalia, & Mendlowitz, 2004). This indicates that some youths with anxiety disorders clearly need more intensive treatment and/or booster sessions in order to achieve and/or retain the desired treatment goals. Obviously, this issue is related to the observation that 30% to 40% of the anxious youths do not respond very well to a CBT protocol. In order to optimize the treatment of these children and adolescents, it is important to study the characteristics of these "nonresponders," which is a topic that will be addressed in following section.

Predictors of Outcome in CBTfor Anxious Youths Various factors have been put forward as relevant for predicting the outcome of a CBT intervention in children and adolescents with anxiety disorders. Several child and family characteristics have been studied in this context. For example, in an early study on this topic, Treadwell, Flannery-Schroeder, and Kendall (1995) examined sensitivity to a CBT intervention across gender and ethnicity (i.e., European American versus African American) in 81 children aged 9 to 13 years with anxiety disorders. These researchers observed that the CBT intervention produced similar reductions in anxiety symptoms and the presence of anxiety disorders irrespective of gender and ethnic background. A similar conclusion was reached by Pina, Silverman, Fuentes, Kurtines, and Weems (2003), who compared the CBT outcome of 131 Hispanic/Latino and European-American youths aged 6 to 16 years. Results indicated that Hispanic/Latino and European-American children and adolescents responded similarly to the CBT intervention, and this was still the case at a one-year follow-up. Both studies seem to indicate that demographic variables such as gender and ethnicity are not very important predictors of treatment outcome in anxiety-disordered youths. Comorbidity is another factor that has been related to CBT outcome. Anxiety disorders are highly comorbid with other disorders including depression and disruptive behavior disorders (see Chapter 1) and one might expect that such concurrent psychopathology influences the ability of children and adolescents to gain from treatment of their anxiety disorder. However, there is very little empirical evidence for this notion. For instance, Kendall, Brady, and Verduin (2001) treated 165 children aged between 8 and 13 years with a standardized CBT protocol. Twenty-one percent of the children were diagnosed with only one anxiety disorder, while other children either suffered from multiple anxiety disorders (52%) or an

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anxiety disorder plus a comorbid externalizing disorder. Pretreatment comorbidity was not found to be associated with differences in treatment outcome. That is, 65% of the noncomorbid children were free of their primary anxiety disorder versus 71% in the comorbid group. Further, no differences were observed between children with a comorbid anxiety disorder or a comorbid externalizing disorder. This led Kendall et al. (2001) to the conclusion that "the cognitive-behavioral treatment program was similarly effective in anxious children with and without comorbid disorders" (p.787; see also Flannery-Schroeder, Suveg, Safford, Kendall, & Webb, 2004; Rapee, 2003). Further research has indicated that a number of child and family characteristics do matter when studying responsiveness to CBT interventions. Southam-Gerow, Kendall, and Weersing (2001) classified a large sample of 7- to 15-year-old children and adolescents who had completed a CBT for their anxiety problems in one of two groups: poor treatment responders and good treatment responders. By means of a discriminant function analysis, a wide range of child- and family-variables were evaluated as possible predictors of group status. The results indicated that higher levels of internalizing symptoms at pretreatment, an older age of the child, and higher levels of maternal depression were associated with poor treatment outcome. In other words, when a child's problems are severe and perhaps may have become more chronic and if the mother of the child has serious problems of her own, response to a CBT intervention for childhood anxiety disorders seems to be less favorable (see also Berman, Weems, Silverman, & Kurtiness, 2000; Crawford & Manassis, 2001). Altogether, it can be concluded that, although some relevant factors have been identified, research on the determinants of responsiveness to CBT interventions for anxiety disorders in youths has generally yielded disappointing results. This means that it is still largely unknown what factors predict poor or good response to this type of treatment. In a discussion of this topic, Pina, Silverman, Weems, Kurtiness, and Goldman (2003) note that investigators need to move beyond the types of sociodemographic and clinical variables that were studied so far in this type of research. In their words, "Although these variables were reasonable ones to initially select, especially given that the first generation of child clinical trials was designed mainly to evaluate whether positive outcome could be produced, the next generation of clinical trials is well posed to evaluate other [variables] . . . . These variables include stressors and obstacles that compete with treatment attendance, treatment demands and issues, perceived relevance of treatment, relationship with the therapist, time and effort concern" (p.703). Interestingly, in recent years, a number of studies have begun to examine such factors. For example, Creed and Kendall (2003) explored the specific behaviors of the therapists who delivered the CBT intervention to anxious youths, and the contribution of such behaviors to children's perception of the therapeutic alliance (which has been shown to be a significant predictor of therapy outcome; e.g., Shirk & Karver, 2003). It was found that "collaboration" (i.e., the therapist presents the treatment as a team effort and builds a sense of togetherness with words like "we," "us," and "let's") and "not being overly formal" (i.e., the therapist makes the relationship with the child relaxed and comfortable) contributed positively to the building of a therapeutic alliance, whereas "pushing the child to talk" (i.e., the therapist too strongly pressures the child to talk about his/her anxiety) and "finding common ground" (i.e., things that the therapist does to make the child feel special and connected to the therapist, which may be perceived by the child as insincere especially in the beginning of the therapy) were negatively associ-

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ated with the formation of an alliance between child and therapist. A further study by Chu and Kendall (2004) examined whether children's involvement in the CBT program is associated with therapy outcome. Independent coders viewed a number of audiotaped therapy sessions and then completed a rating scale for measuring children's involvement in therapy (e.g., "Does the child initiate discussion or introduce new topics?," "Does the child demonstrate enthusiasm in therapy-related tasks?"). Results indicated that child involvement was significantly associated with therapy gains: Higher levels of involvement, measured at midtreatment (just prior to the exposure exercises), were predictive of treatment outcome. More precisely, children who had shown a substantial increase of involvement by midtreatment were likely to have a more than four times greater chance of being anxiety disorderfree at posttreatment. These findings are promising, and it may be interesting to study whether similar findings can be obtained when assessing involvement in later therapy sessions when children have to do homework assignments during which they expose themselves to increasingly threatening situations (Hudson & Kendall, 2002). Finally, Panichelli-Mindel, Flannery-Schroeder, Kendall, and Angelosante (2005) examined whether the degree to which children disclose distress during therapy has influence on the effectiveness of a CBT intervention. The idea was that children who are "open" to the therapist about their problems, fears, and anxieties will eventually profit more from CBT. The findings indeed demonstrated that the level of disclosure moderated therapy outcome. That is, children high on distress disclosure profited more from treatment than children low on distress disclosure. Clearly, more of these types of studies are needed to further explore the issue of predicting responsiveness to CBT for anxiety-disordered youths.

CBT for Specific Anxiety Disorders A CBT protocol like Kendall's (1990) "Coping Koala (Cat)" program contains a variety of cognitive-behavioral elements (e.g., exposure, cognitive restructuring, psychoeducation, relaxation), and as such it is not surprising that this type of intervention is suitable for treating various types of childhood anxiety disorders. However, a number of anxiety disorders have such unique features that it may be advisable or even necessary to apply a more specific therapeutic approach.

Obsessive-Compulsive Disorder. As described in Chapter 1, obsessive-compulsive disorder (OCD) in effect consists of two components: obsessions, which refer to intrusive anxiety- or distress-provoking thoughts or impulses, and compulsions, which pertain to the repetitive behaviors or mental acts that are conducted in order to prevent or reduce distress and anxiety. According to the cognitive-behavioral perspective, compulsions play a prominent role in the continuation of OCD as they result in an immediate reduction of anxiety and distress, thereby negatively reinforcing these ritualistic behaviors, which increasingly interfere with the patient's daily routine (see Salkovskis, 1985). As such, it is clear that response prevention, which intends to block any type of compulsive behavior, is regarded as an important ingredient of a CBT intervention for OCD (e.g., Salkovskis, 1999). March and Mulle (1998) were the first to systematically apply this knowledge to the treatment of OCD in youth populations. These authors developed a detailed 20-sessions

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Table 8.5

Session

3-18 18-19 20

Summary of a CBT program for treating childhood OCD Aims To provide general information on OCD. To explain to the child the basic principles of cognitive theory of OCD. To clarify what the OCD of this particular child looks like. To teach the child some techniques to apply cognitive restructuring. To teach the child "exposure plus response prevention." To advise the child on relapse prevention and to close the treatment. Booster session: To check how the child is doing some 4 weeks after the end of treatment.

Note. Parent sessions can be added to the program, in particular in the beginning and at the end of treatment and during the "exposure plus response prevention" sessions when parents may be needed as cotherapists. Based on: March & Mulle (1998).

CBT protocol for treating children and adolescents with OCD. As shown in Table 8.5, a substantial proportion of this intervention consist of "exposure plus response prevention" (sessions 3 through 18): Children expose themselves to stimuli and situations that elicit the obsessional thoughts, and then try to prevent the occurrence of the compulsive behavior (or when this is too difficult, to delay, shorten, or modify the ritual). In the beginning of the treatment, the therapist or parents may help the child to expose himself to the anxietyprovoking stimuli and situations and to provide support in preventing the compulsions from occurrence. Eventually, the child has to learn to apply "exposure plus response prevention" on his own and to employ this technique to cope with the OCD in real life. Several studies have demonstrated that a CBT protocol incorporating "exposure plus response prevention" is successful in treating childhood OCD. For example, a number of open trials have shown that such a CBT intervention either provided individually or in a group format yields clinically significant improvement in 25% to 70% of the cases (Fischer, Himle, & Hanna, 1998; Franklin, Kozak, Cashman et al., 1998; Knox, Albano, & Barlow, 1996; March, Mulle, & Herbel, 1994; Martin & Thienemann, 2005; Piacentini, Bergman, Jacobs, McCracken, & Kretchman, 2002; Piacentini, Gitow, Jaffer, Graae, & Whitaker, 1994; Scahill, Vitulano, Brenner, Lynch, & King, 1996; Valderhaug, Larsson, G6testam, & Piacentini, 2007; Waters, Barrett, & March, 2001; Wever & Rey, 1997). More recently, a number of controlled treatment outcome studies have also appeared. De Haan, Hoogduin, Buitelaar, and Keij sers (1998) randomly assigned 22 children and adolescents (aged between 8 and 18 years) to CBT or drug treatment (clomipramine; see following). Significant improvement was obtained with both types of interventions, although on some of the outcome measures CBT produced better a outcome than drug treatment. The largest controlled trial on the effectiveness of CBT in youths with OCD has been conducted by Barrett, Healy-Farrell, and March (2004). Seventy-seven youths aged between 7 and 17 years were randomly distributed across three conditions: individual CBT, group CBT, or a waiting-list control condition. Treatment outcome was evaluated by means of diagnostic interviews and standardized rating scales. Outcome data showed that both CBT interventions were highly

Treatment and Prevention of Childhood Anxiety

Severity

249

of OCD-symptoms

10 _

_

--o--

Waiting-list

Individual CBT 4

Group CBT

-

_

Pretreatment Posttreatment 12-month follow-up

18-month follow-up

Figure 8.8: Mean clinician-rated severity of OCD-symptoms in the two CBT groups and the waiting-list control condition. Based on: Barrett, Healy-Farrell, & March (2004) and Barrett, Farrell, Dadds, & Boulter (2005).

effective in eliminating OCD symptomatology as compared to the waiting-list control condition for which symptoms remained fairly stable (see Figure 8.8). Follow-up assessments indicated that the treatment gains of the CBT interventions were maintained up to 18 months after treatment (Barrett, Farrell, Dadds, & Boulter, 2005). These positive results were also clinically significant. Directly after treatment, 88% of the youths in the individual CBT condition and 76% in the group CBT condition were without a diagnosis of OCD versus 0% in the waiting-list control condition. At 18-months follow-up, 78% of the youths treated with one of the two CBT interventions were still diagnosis-free. Altogether, these results have provided further support for the notion that CBT is a highly recommended intervention for OCD in children and adolescents (March, Frances, Carpenter, & Kahn, 1997). Posttraumatic Stress Disorder. In posttraumatic stress disorder (PTSD), traumatic experiences play a central role. Although some clinicians fear the use of CBT, because during this treatment youths are repeatedly re-exposed to the trauma (see King, Tonge, Mullen et al., 1999), available evidence suggests that children and adolescents benefit remarkably from such an intervention. More precisely, there are a number of randomized clinical trials which have demonstrated that CBT is effective for treating traumatized youths. For example, Deblinger and colleagues (Deblinger, Lippmann, & Steer, 1996; Deblinger, Steer, & Lippmann, 1999) assigned 100 sexually abused children aged 7 to 13 years, of whom threequarters fulfilled the criteria of PTSD, to four treatment conditions: child CBT, mother CBT, child plus mother CBT, and a community control condition. Symptoms of PTSD and other emotional and behavioral problems were assessed at pretreatment, posttreatment, and various follow-up moments until two years after termination of treatment. As shown in Figure 8.9, while PTSD symptoms decreased in all groups, it is clear that the CBT groups showed greater reductions of such symptoms. Initially, somewhat greater reductions in

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PTSD symptoms 12 10 ---o-- Child CBT

8

--o-- Mother CBT

6

Child + mother CBT 4-

Community control

20 Pretreatment Posttreatment

3-month follow-up

6-month follow-up

1-year follow-up

2-year follow-up

Figure 8.9: Mean combined child/parent ratings of PTSD symptoms of sexually abused children in the four treatment conditions. Based on: Deblinger, Steer, & Lippmann (1999).

symptoms were achieved in the CBT conditions that incorporated child participation (i.e., the child CBT and the child plus mother CBT groups; Deblinger et al., 1996). However, these effects disappeared during the (long-term) follow-up assessments. King, Tonge, Mullen et al. (2000) also evaluated the efficacy of CBT for sexually abused children and adolescents (aged 5 to 17 years). These researchers randomly distributed 36 youths over a child-alone CBT condition, a family CBT condition, and a waiting-list control condition. Results demonstrated that both CBT interventions produced significant improvement in caregiver-reported PTSD symptoms and self-reported fear and anxiety as compared to the waiting-list control condition. Child-focused and family CBT were equally effective, which indicated that parental involvement did not improve the efficacy of the CBT intervention. Further research, also involving sexually abused youths, has been conducted by Cohen, Mannarino, and colleagues. Interestingly, this research group carried out a set of randomized controlled trials in which the effects of CBT were compared with those of an alternative intervention--namely, nondirective supportive therapy, which was mainly based on clientcentered principles (Cohen & Mannarino, 1996; Cohen, Deblinger, Mannarino, & Steer, 2004). The results consistently showed that the CBT intervention resulted in significantly more improvement with regard to PTSD, depression, behavior problems, and abuse-related attributions than nondirected supportive therapy, and these differences in outcome were still present at a one-year follow-up (Cohen & Mannarino, 1997; Cohen, Mannarino, & Knudsen, 2005). To get an impression of the specific content of a CBT intervention for traumatized youths, Table 8.6 displays the Multi-Modality Trauma Treatment protocol as described by March, Amaya-Jackson, Murray, and Schulte (1998). Notice that there is clear overlap with the regular CBT protocol for childhood anxiety disorders (Kendall, 1990) but that there is also a clear focus on the trauma. March et al. (1998) evaluated the effectiveness of this protocol in a small sample of 10- to 15-year-old children and adolescents who had been exposed to a single stressor (e.g., car accident, gunshot injury, fire). Clear reductions of PTSD symptoms were observed in the youths that were treated with this CBT program, with, respectively, 57% and 86% being free of diagnosis at posttreatment and a 6-month follow-up.

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Table 8.6

Session

251

An outline of a CBT group protocol for traumatized youths Main content

1-2

Introduction

3-5

Anxiety management training

6-7

Anger coping

8-9 10-15

Cognitive training Exposure

16

Right beliefs

17-18

Closure

To provide an overview of treatment, to give information on PTSD, to map the symptoms of the children, to define rules for the group. To learn progressive muscle relaxation and to employ this technique when experiencing trauma-related distress. To teach children to cope with feelings of anger by means of interpersonal problem solving. To help children to develop positive self-talk. To provide the rationale for exposure, to construct a hierarchy of trauma-related stimuli and situations, and to gradually expose children to these stimuli by means of narrative exposure or exposure in vivo while applying the techniques learned in the earlier sessions. To correct PTSD-induced dysfunctional beliefs or schemas. To advise children on relapse prevention and to close the treatment.

Based on: March, Amaya-Jackson, Murray, & Schulte (1998).

A final note on the cognitive-behavioral treatment of PTSD is devoted to EMDR (see Box 8.1). EMDR has been primarily developed for treating adults with PTSD and other trauma-related anxiety problems. Although EMDR has been criticized because of its weak empirical foundation (e.g., McNally, 1999), randomized clinical trials have demonstrated that, at least in adults with PTSD, this type of intervention clearly yields positive effects. For example, on the basis of a meta-analysis of studies examining the effects of EMDR, Davidson and Parker (2001) conclude that this treatment, when applied to PTSD or traumatic memories, produces significant effects on various outcome measures (e.g., subjective, behavioral, physiological). However, these authors also noted that EMDR was not significantly better than regular exposure techniques, which is not surprising, given the observation that the incremental therapeutic effect of the eye movements is nil (Muris & Merckelbach, 1999a). Nevertheless, various studies have shown that EMDR can be applied to youths with PTSD symptoms (e.g., Chemtob, Nakashima, & Carlson, 2002; Jaberghaderi, Greenwald, Rubin, Oliaee Zand, & Dolatabadi, 2004; Muris & De Jongh, 1996; Tufnell, 2005), but clearly more controlled outcome research is necessary to demonstrate whether this exposure-based intervention has any additional value in the treatment of traumatized children and adolescents. Altogether, research in the past 10 to 15 years has yielded indisputable evidence indicating that CBT interventions are effective in treating phobias and anxiety disorders in children

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Effect size (Cohen's d)

CBT pre- to posttreatment

Waiting-list control

CBT short-term CBT long-term follow-up follow-up

Figure 8.10: Mean pre- to posttreatment, short-term (<1 year) and long-term (>3 years), follow-up effect sizes for CBT with anxious youths. Mean effect sizes for waiting-list control conditions are added for reasons of comparison. Based on: In-Albon & Schneider (2006).

and adolescents (Velting, Setzer, & Albano, 2004). The meta-analysis by In-Albon and Schneider (2006) on controlled treatment outcome studies of childhood anxiety disorders revealed a mean effect size of .86, indicating a large treatment effect. Follow-up data demonstrated that these treatment gains were maintained at short-term (mean effect size = 1.36) and long-term (mean effect size = .92) follow-up (see Figure 8.10). In terms of clinical significance, 69% of all children and adolescents who completed treatment showed recovery and hence no longer met the criteria of their principal pretreatment anxiety disorder. When applying more stringent criteria (i.e., taking into account dropouts), it can be concluded that 55% of those who start with a CBT eventually will recover (see also Cartwright-Hatton et al., 2004). When comparing these figures to those of general child and adolescent psychotherapy (Weisz, Weiss, Han, Granger, & Morton, 1995), it can be concluded that the effects of CBT for anxious youths are quite favorable (see Butler, Chapman, Forman, & Beck, 2006 who draw a similar conclusion for the efficacy of CBT in anxious adults). A number of comments can be made regarding the treatment of childhood anxiety disorders with CBT. First of all, it should be mentioned that most CBT interventions for anxious youths contain a variety of behavioral and cognitive therapeutic techniques such as cognitive restructuring, coping self-talk, in vivo exposure, modeling, role-play, and relaxation training. In their review article on the current status of treatments for anxiety disordered children, Ollendick and King (1998) rightly pointed out that an important avenue for future research will be dismantling studies in which the critical components of CBT-based treatment packages are established. Although some preliminary attempts have been made in this direction (Muris, Meesters, & Gobel, 2002), more studies should be conducted to compare the unique effects of the separate components of CBT interventions. Such research may have to take into account that childhood anxiety disorders differ in terms of their symptomatology and that it may be important to tune the intervention to the specific expression of the disorder.

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For example, anxious children and adolescents who clearly report somatic symptoms may profit more from relaxation training, whereas anxious youths with prominent faulty cognition may benefit more from cognitive restructuring (e.g., Eisen & Silverman, 1998). In a similar vein, it may be useful to address specific features of various anxiety disorders during the CBT intervention. For example, recent attempts have been made to target specific cognitive features of generalized anxiety disorder (i.e., intolerance of uncertainty; L6ger, Ladouceur, Dugas, & Freeston, 2003) and obsessive-compulsive disorder (i.e., metacognition; Simons, Schneider, & Herpertz-Dahlmann, in press), but it remains to be established whether such a focused CBT intervention is more effective than regular CBT. A second and related issue pertains to the fact that the precise working mechanism of CBT is still largely unknown. In other words, it is unclear what factors change as a result of the CBT intervention and ultimately produce the symptomatic improvement (e.g., Ollendick & King, 1998). Prins and Ollendick (2003) have suggested two factors that may be important in this respect. Briefly, they assume that CBT may correct faulty cognition and/or enhance nonavoidant coping, but they note that more research is necessary to evaluate the mediational role of these variables in treatment gains observed in CBT. A third point is that so far CBT for anxiety disordered youths has been mainly compared to waiting-list control conditions. Although this research has shown that CBT is clearly more effective than no treatment (see also Figure 8.10), more studies should compare the effects of CBT with those of other interventions. Notably, studies that made such a comparison have yielded rather mixed results. Some studies have shown that CBT is no more active than an attention-placebo control condition (Last, Hansen, & Franco, 1998; Silverman et al., 1999), whereas other investigations have indicated that CBT is far more effective than emotional disclosure (Muris, Meesters, & Van Melick, 2002), bibliotherapy (Rapee, Abbott, & Lyneham, 2006), or another active but nonspecific intervention (Beidel, Turner, & Morris, 2000). More research is needed to understand why "placebo" interventions sometimes yield such positive treatment results. It may be the case that when delivered with a strong and straightforward rationale, even a nondirective placebo intervention may produce positive therapeutic change. Furthermore, it seems also important to compare CBT to other psychological interventions (e.g., psychodynamic therapy, non-cognitive-behavioral family therapy) and psychopharmacologic therapy (see following). A fourth issue is concerned with developmental considerations regarding CBT for childhood anxiety disorders. The treatment of fear and anxiety in very young children may require specific therapeutic techniques. Besides the aforementioned procedure of emotive imagery, other therapeutic aids may be viable. For example, Muris, Verweij, and Meesters (2003) employed an "antimonster letter" (see Box 8.2) to help 4- to 6-year-old children overcome their nighttime fears. Further, at least some degree of cognitive maturation must be present before children are able to use cognitive restructuring techniques for combating negative cognitions. This means that in children of a younger age, behavioral strategies (in particular exposure) are more appropriate, whereas in older children cognitive techniques may be increasingly added to the intervention (Barrett, 2000). Developmental level may also be an important determinant of the type of parental involvement in a CBT intervention of anxious youths. For example, in younger children, parents need to provide a secure environment in which youths can form a secure attachment relationship and gain a proper sense of control over the environment. However, in older youths, parents not only need to

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Box 8.2 The "antimonster letter," which can be used to help young children with nighttime fears Dear monsters, ghosts, witches, and other beasts. Please read this message at the very least. With this "antimonster letter," I am feeling good and even better. And I will use this letter for ever and ever so that I am not afraid of you spooky thing, never and never! Based on: Muris, Verweij, & Meesters (2003).

provide support to their offspring but also should encourage autonomy and independence (Dadds & Barrett, 2001). Future research should take such developmental differences into account when delivering CBT interventions to anxious youths of various ages. A fifth point is concerned with the dissemination of CBT programs that are developed in a research clinic to practitioners working in regular health service (see Kendall & Southam-Gerow, 1995). Research has shown that youths with anxiety disorders who were treated in a community clinic were quite different from youths with anxiety disorders treated in a university research setting. That is, anxious children and adolescents who apply for treatment in a community clinic generally display more comorbid externalizing problems and more frequently come from low-income and single parent families (Southam-Gerow, Weisz, & Kendall, 2003). Yet, it should be mentioned that CBT protocols allow therapists to be quite flexible in their application of the treatment manual (Kendall & Chu, 2000), which may help to employ this type of intervention with multiproblem youths. As such it is not surprising that CBT has been found to be just as effective for treating anxiety disorders of youths in a community clinic as for treating youths in a university research setting (Barrington, Prior, Richardson, & Allen, 2005). More effort should be put in the transportation of CBT protocols to community settings, so that more children and adolescents with phobias and anxiety disorders will profit from these effective interventions (Collins, Westra, Dozois, & Bums, 2004). Many youths are still treated with traditional forms of psychotherapy, which have not demonstrated to be very effective (Weiss, Catron, Harris, & Phung, 1999). A sixth and final issue has to do with the fact that although anxiety disorders are highly prevalent among youths, these problems often remain unrecognized and untreated (e.g., Chavira, Stein, Bailey, & Stein, 2005). In order to circumvent barriers to treatment, researchers have begun to transport CBT interventions for childhood anxiety disorders into schools (see Spence, 2001; Spence & Dadds, 1996). In a first study, Dadds, Spence, Holland, Barrett, and Laurens (1997) screened a total of 1786 7- to 14-year-olds for anxiety problems using teacher nominations and children's self-report. After this recruitment, high-risk children were randomly assigned to a 10-week school-based CBT intervention (plus parental anxiety management) or a monitoring condition. The results indicated that immediately after the intervention/monitoring period, anxiety problems significantly improved in both conditions. However, at a 6-month follow-up, this improvement was only maintained in the CBT inter-

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255

Children with an anxiety disorder 100 80 60

• CBT

[] Monitoring

40 20

Pre

Post

6-month follow-up

Children at risk but no anxiety disorder 100 80 60

• CBT

[] Monitoring

40 20

Pre

Post

6-month follow-up

Figure 8.11: Percentages of children with an anxiety disorder diagnosis at pretreatment, posttreatment, and 6-month follow-up in the CBT intervention and the monitoring groups. The top panel displays the children who at study onset already met the criteria for an anxiety disorder, the bottom panel displays at-risk children who at the beginning of the study did not meet the full criteria of an anxiety disorder. Based on: Dadds, Spence, Holland, Barrett, & Laurens (1997).

vention condition: These children still displayed reduced rates of anxiety disorders and also developed less new anxiety problems (see Figure 8.11). These and other findings (Masia, Klein, Storch, & Corda, 2001; Masia-Wamer, Klein, Dent et al., 2005; Mifsud & Rapee, 2005) make clear that it is feasible and useful to implement CBT protocols into school programs as they may help youths with anxiety problems and prevent the development of new disorders (Spence & Dadds, 1996). As a final note, while implementation in schools may be a viable approach, Rapee, Kennedy, Ingram, Edwards, and Sweeney (2005) developed an intervention program for even younger children. Based on research showing that behavioral inhibition is one of the best predictors of later anxiety problems, these researchers selected withdrawn/inhibited children in preschool (aged 3 to 5 years) and provided the parents of these youngsters with a brief six-session parent intervention program (see also

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Box 8.3 Some basic knowledge for understanding the working mechanisms of psychopharmacologic drugs

In the brain, information is passed from one neuron (nerve cell) to another via a synapse, which is a small gap between the cells. The neuron that sends the information releases neurotransmitters (such as norepinephrine, dopamine, and serotonin) into that gap. The neurotransmitters are then recognized and received by receptors on the surface of the postsynaptic cell, which upon this stimulation, in turn, relays the signal. After this action has taken place, a substantial proportion of the neurotransmitters is released from the receptors and taken up again by the presynaptic cell, a process called reuptake. Psychopharmacologic medication is thought to influence this process of physiological information-processing in various ways. For example, these drugs can (1) increase the amount of neurotransmitters in the synaptic cleft by stimulating the production of certain neurotransmitters, preventing their destruction, or blocking their reuptake; (2) diminish the amount of neurotransmitters via similar but reversed ways; (3) directly bind to the postsynaptic receptors, thereby stimulating the cell to pass on the signal. Based on: Information from Wikipedia, the free encyclopedia (www.wikepedia.org).

Rapee, 2002). This intervention appeared to produce a significant reduction of children's anxiety problems, and thus seems to indicate that prevention programs for childhood anxiety disorders can start at a very early age.

Pharmacological Treatment o f Childhood Anxiety Disorders Almost a decade ago, researchers and clinicians were rather reserved to use drugs for treating anxiety disorders in children and adolescents (see Bernstein & Kinlan, 1997). The most important reason for this reluctance was that solid scientific evidence for the employment of medication in this type of psychopathology was still lacking (e.g., Kearney & Silverman, 1998). In their review published in 1999, Labellarte, Ginsburg, Walkup, and Riddle conclude, "Several controlled studies of cognitive-behavioral therapy (CBT) demonstrate efficacy for paediatric anxiety disorders. In contrast, no controlled psychopharmacology studies have demonstrated efficacy in children and adolescents with anxiety disorders, except obsessive-compulsive disorder" (p. 1567), which nicely illustrates the prevailing view at that point-in-time. However, this state of affairs has gradually changed since the appearance of a number of large, methodologically sound treatment outcome trials evaluating the effects of psychopharmacologic drugs in youths with anxiety disorders. This section contains a comprehensive review of the effects of pharmacotherapy in anxiety disordered youths, but first an overview of various psychopharmacologic drugs and their supposed working mechanisms is provided (see also Box 8.3).

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Anxiolytic Drugs Various types of psychopharmacologic drugs have an anxiolytic effect and can be applied to treat anxiety disorders in children and adolescents. These include benzodiazepines, buspirone, tricyclic antidepressants (TCAs), and selective serotonin-reuptake inhibitors (SSRIs; see Velosa & Riddle, 2000). Table 8.7 summarizes a number of important features for each of these drug categories. Benzodiazepines (also known as minor tranquilizers) bind at benzodiazepine or gammaaminobutyric acid (GABA) receptor membrane chloride channel complexes, which are mainly situated in the cortex and the limbic system. Through this action, these drugs enhance and facilitate the transmission of GABA, which is the most important inhibitory neurotransmitter in the brain. The net effect is that the general neuronal activity of the brain is dampened. Because they work quickly, benzodiazepines are often used for short-term relief of severe disabling anxiety. Main side effects of these drugs are sedation and concentration and memory problems. Further, benzodiazepines are considered to be moderately to highly addictive, which explains why prolonged use of these drugs is usually discouraged. Buspirone is a nonbenzodiazepine anxiolytic, which is thought to act by binding to serotonin (5HTIA) receptors in the brain. As a result, there would be less spontaneous firing of serotonergic neurons in subcortical brain regions, which would be the basis for the anxiolytic effect of this drug. It takes some time before the anxiety-reducing effects of buspirone become visible. This medication has no sedative effects and does not cause dependence, but it has a number of physical side effects, including dizziness, headaches, sleeping problems, and gastrointestinal troubles. Beta-blockers hinder the action of endogenous cathecholamines, in particular adrenaline (epinephrine) and noradrenaline (norepinephrine), on I]-adrenergic receptors, which are part of the peripheral sympathetic nervous system and are an important mediator of the fightflight response. The blocking of these receptors in the heart, lungs, muscles, and so on directly inhibits the physiological symptoms of anxiety (e.g., palpitations, increased respiration, trembling) and secondarily also reduces subjective and cognitive symptoms. It is generally thought that TCAs work because they inhibit the reuptake of noradrenaline, dopamine, and serotonin by the presynaptic cells, causing these neurotransmitters to stay longer in the synaptic cleft, which enhances the chance that they will be received by the postsynaptic cell, which can eventually be fully stimulated. In this way, the activity of the brain systems involving these neurotransmitters will be normalized, resulting in a decrease of all kinds of psychopathological symptoms, including anxiety. TCAs also block cholinergic, histaminic, and adrenergic receptors, which explains their massive side effects, including a dry mouth, blurred vision, nausea, dizziness, weight gain, and even cardiac problems (in some youths, TCAs may even cause sudden death; see Riddle, Geller, & Ryan, 1993). SSRIs are an improvement in this respect: These drugs selectively inhibit the reuptake of serotonin, which leads to an increase of this neurotransmitter in the synaptic cleft and eventually results in a normalization of the serotonergic neurotransmission. Because SSRIs have little impact on other neurotransmitter systems, they have fewer and weaker side effects and are considered as safer than TCAs (although some have observed that these drugs may enhance suicidal ideation; Labellarte, Walkup, & Riddle, 1998).

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Treatment and Prevention of Childhood Anxiety

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Effectiveness of Pharmacologic Treatment of Anxious Youths This section summarizes the empirical evidence that has accumulated on the efficacy of pharmacotherapy in children and adolescents with anxiety disorders (see for reviews, Walkup, Labellarte, & Ginsburg, 2002; Waslick, 2006). First, studies on the pharmacologic treatment of OCD will be summarized. Then, research on this type of intervention with other childhood anxiety disorders will be reviewed. It should be mentioned that the effects of benzodiazepines, buspirone, and beta-blockers are seriously understudied in youth populations (see Walkup et al., 2002). Most controlled outcome studies in this relatively young research area are concerned with TCAs and SSRIs, and therefore the focus will be on these two psychopharmacologic drugs.

OCD OCD is the anxiety disorder that has received most attention from investigators seeking efficacious pharmacologic treatment in children and adolescents. This research started in the 1980s with studies evaluating the effects of TCAs in youths with this anxiety disorder. For example, Leonard, Swedo, Rapoport et al. (1989) compared the effects of clomipramine and desipramine (both are TCAs, but the former is thought to have more potential for blocking the reuptake of serotonin) using a double-blind crossover design in 45 children and adolescents (aged 7 to 19 years) with severe OCD. Results indicated that in particular clomipramine was effective in reducing OCD symptoms, suggesting that in particular TCAs with a serotonergic effect are suitable for this type of anxiety disorder. The positive effects of clomipramine for treating OCD in youths were also documented by DeVaugh-Geiss, Moroz, Biederman et al. (1992), who conducted a double-blind multi-center trial to compare the effects of clomipramine versus placebo in a sample of 54 10- to 17-year-olds with OCD. Outcome was measured with an age-downward version of the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS; Goodman, Price, Rasmussen et al., 1989a). At the end of the eight-week treatment period, youths treated with clomipramine displayed a mean reduction of 37% on the Y-BOCS, whereas those in the placebo condition only showed an improvement of 8%. However, these studies have also demonstrated that youths suffer from substantial side effects that are typical for this type of medication. As such it is not surprising that more recent studies have mainly concentrated on studying the effects of SSRI in youths with OCD because this type of drug is safer and has considerably less adverse side effects. In one of the first studies evaluating this intervention in youths with OCD, Riddle, Scahill, King et al. (1992) treated 14 children and adolescents aged 8 to 15 years with fluoxetine in a 20-week randomized, double-blind, placebo-controlled trial. The results showed that fluoxetine was well tolerated by the youths and significantly reduced the severity of OCD symptoms. A similar conclusion was reached in a clinical trial conducted by Geller, Hoog, Heiligenstein et al. (2001), who assigned 103 patients aged 7 to 17 years to a fluoxetine or placebo condition. Treatment outcome was evaluated with the child version of the Y-BOCS and various other self-report, parent, and clinician rating scales. Results indicated that across various outcome measures fluoxetine yielded significantly greater reductions in OCD symptoms than the placebo control intervention (see also Liebowitz, Turner, Piacentini et al., 2002).

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Normal and Abnormal Fear and Anxiety in Children and Adolescents

Paroxetine 0

Sertraline ~

Fluvoxamine

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-10 Figure 8.12: Mean short-term decline in self-reported OCD symptoms (as indexed by the Children's Yale-Brown Obsessive-Compulsive Scale) after being treated with various types of selective serotonin reuptake inhibitors (SSRIs) or a placebo intervention. * Mean decrease across various studies; in all cases, significantly smaller than the effect of the SSRI. Based on: Geller, Hoog, Heiligenstein et al. (2001); Geller, Wagner, Emslie et al. (2004); March, Biederman, Wolkow et al. (1998); Riddle, Reeve, Yaryura-Tobias et al. (2001).

Other types of SSRIs such as paroxetine, sertraline, and fluvoxamine have yielded highly comparable findings. These drugs not only produced a statistically significant decline of OCD symptoms within a time frame of 8 to 12 weeks (see Figure 8.12) but also yielded clinically significant improvement in about half of the youths treated for this anxiety disorder (e.g., Geller, Wagner, Emslie et al., 2004; March, Biederman, Wolkow et al., 1998; Riddle, Reeve, Yaryura-Tobias et al., 2001). Interestingly, a study by Cook, Wagner, March et al. (2001), who evaluated the safety and long-term effectiveness of sertraline in 132 children and adolescents with OCD, indicated that youths further improved when the administration of this SSRI was continued for 1 year: 67% showed clinically significant improvement at the end point of treatment, with no differences being observed between children (aged 6 to 12 years) and adolescents (aged 13 to 18 years).

Other Anxiety Disorders

After the positive effects ofpharmacotherapy in childhood OCD, researchers have a renewed interest in examining whether drugs can be a useful intervention for other anxiety disorders as well. However, the first controlled trial for treating childhood anxiety problems with a TCA was already published more than three decades ago, when Gittelman-Klein and Klein (1971) randomly assigned 6- to 14-year-old children and young adolescents with a school phobia to two treatment conditions: an imipramine plus CBT intervention and a placebo plus CBT intervention. Results demonstrated that the imipramine plus CBT intervention yielded significantly better results than the placebo plus CBT intervention. For example,

Treatment and Prevention of Childhood Anxiety

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81% of the youths in the imipramine condition returned to school within six weeks after the beginning of treatment versus only 47% of the youths in the placebo condition. Two further studies have made an attempt to replicate these promising findings. In a first replication study by Klein, Koplewicz, and Kanner (1992), no evidence was obtained showing that imipramine was better than placebo in a relatively small sample of 6- to 15-year-olds with separation anxiety disorder. In contrast, a more recent investigation by Bernstein, Borchardt, Perwien et al. (2000) again provided support for the efficacy of imipramine in youths with anxiety problems. More specifically, these researchers compared the effects of imipramine plus CBT versus placebo plus CBT in the treatment of school-refusing adolescents with comorbid anxiety and depressive disorders. Like in the Gittelman-Klein and Klein (1971) study, imipramine plus CBT produced a better outcome than the placebo plus CBT intervention, with mean school attendance rates of respectively 70% versus 28% during the last week of treatment. However, follow-up data of this sample (Bernstein, Hektner, Borchardt, & McMillan, 2001) showed that one year after treatment, many of the youths again met the criteria of an anxiety disorder or a depression (respectively, 64% and 33%), indicating relapse in a substantial proportion. Thus, while initially promising, evidence on the effectiveness of TCAs for treating anxiety disorders in youths is still meagre, as studies have generally yielded mixed results. Given the fact that SSRIs are safer than TCAs and have been found to produce better effects in childhood mood disorders (e.g., Keller, Ryan, Strober et al., 2001), researchers and clinicians have shifted toward SSRIs as the primary medication for childhood anxiety disorders (see Seidel & Walkup, 2006). Besides a number of open trials that explored the potential effectiveness of SSRIs in youths with non-OCD anxiety disorders (e.g., Birmaher, Waterman, Ryan et al., 1994; Chavira & Stein, 2002; Compton, Grant, Chrisman et al., 2001; Dummit, Klein, Tancer, Asche, & Martin, 1996; RUPP Anxiety Study Group, 2002), a number of randomized placebo-controlled studies have emerged. In an early study, Black and Uhde (1994) evaluated the efficacy of treatment with fluoxetine in reducing symptoms associated with selective mutism. Sixteen patients aged 5 to 16 years were treated with placebo for 2 weeks. The 15 placebo nonresponders were then assigned to a double-blind treatment with fluoxetine or continued placebo for an additional 12 weeks. Significant improvements in clinician, parent, and teacher ratings of symptoms were observed in both fluoxetine- and placebotreated youths. However, the parental measures indicated that children treated with fluoxetine were significantly more improved than the placebo-treated controls. In a placebo-controlled trial by the RUPP Anxiety Study Group (2001), 128 children and adolescents (aged between 6 and 17 years) with separation anxiety disorder, generalized anxiety disorder, and/or social phobia were randomly allocated to a treatment with fluvoxamine or placebo for 8 weeks. Outcome was evaluated using clinician ratings of anxiety symptoms and global improvement. Results indicated that the decline in anxiety symptoms was more than three times larger in the fluvoxamine treatment group as compared to the placebo group. In addition, in the fluvoxamine group 76% of the youths responded favorable to the intervention versus 29% in the placebo group. Finally, it is worthy of note that the fluvoxamine was tolerated rather well: Only 8% of the children and adolescents discontinued treatment because of adverse side-effects (as compared to 2% in the placebo group). Rynn, Siqueland, and Rickels (2001) compared the efficacy of sertraline versus placebo in the treatment of a small sample of 5- to 17-year-old children and adolescents (N = 22)

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with generalized anxiety disorder. On the main outcome measure, the Hamilton Anxiety Scale (completed by children and parents), the results clearly indicated that the sertraline treatment was superior in reducing anxiety symptoms as compared to the placebo intervention. A multi-center, randomized, double-blind, placebo-controlled trial by Wagner, Berard, Stein et al. (2004) evaluated the effectiveness of paroxetine in 319 youths aged 8 to 17 years with social phobia. After 16 weeks of treatment, clinicians observed significantly greater improvement in the youths treated with paroxetine (78%) than in youths who received the placebo (38%). The difference in improvement between the two groups was confirmed by self-reports of social anxiety as completed by the children and adolescents. A final randomized study was carried out by Birmaher, Axelson, Monk et al. (2003) who compared the effects of fluoxetine versus placebo in 7- to 17-year-old children and adolescents with separation anxiety disorder, generalized anxiety disorder, and social phobia. Results indicated that fluoxetine was more effective in reducing anxiety symptoms and improving general functioning than placebo. For example, on self- and parent-report measures of anxiety symptoms, fluoxetine-treated youths displayed larger reductions than their placebo-treated counterparts. Further, 61% of the children and adolescents taking fluoxetine showed much to very much improvement versus only 35% of the youths taking placebo. Interestingly, the participants of this study were followed for one year in an open trial (Clark, Birmaher, Axelson et al., 2005). During this open trial, four groups were studied: (1) youths who had received fluoxetine during the randomized trial who continued to take this medication, (2) youths who had received fluoxetine during the randomized trial and stopped taking this medication, (3) youths who had received placebo during the randomized trial and now received fluoxetine, and (4) youths who had received placebo during the randomized trial and still did not receive any medication. The results of the study are shown in Figure 8.13, which displays the mean change in clinician-rated severity of anxiety disorders symptoms for each of the four groups. As can be seen, the largest reduction in severity was observed

FluoxetineRCT/Fluoxetine

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0,4 0,20-~ -0,2 -0,4 -0,6 -0,8 -1 -1,2

Figure 8.13" Mean change in clinician-rated severity of anxiety disorders symptoms in the four treatment groups. RCT = Randomized Controlled Trial. Based on: Clark, Birmaher, Axelson et al. (2005).

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in the group who had received placebo during the randomized trial followed by fluoxetine in the follow-up period. A substantial reduction was also observed for the group who continued the fluoxetine medication during the follow-up period. The groups who received no medication during the follow-up year did not display noteworthy change: The group receiving placebo during the randomized trial followed by no medication during the follow-up period even showed a slight increase in symptom severity. In conclusion, then, pharmacotherapy is increasingly accepted as a viable treatment of childhood anxiety disorders. The review above indicates that in particular SSRIs yield positive effects in treating OCD and other anxiety disorders in youths. As noted by Seidel and Walkup (2006), SSRIs have become "the pharmacologic treatment of choice for paediatric anxiety disorders" (p.171). These drugs have clear-cut anxiolytic effects and are welltolerated by most children and adolescents. Although there is a small but significant increased risk for suicide, the magnitude of the improvement produced by the SSRIs in anxietydisordered youths makes the benefit/risk ratio is acceptable. A number of remarks can be made with regard to the pharmacologic treatment of childhood anxiety disorders. First of all, most randomized placebo-controlled trials have focused on OCD, separation anxiety disorder, generalized anxiety disorder, and social phobia. While it is clear that psychopharmacologic drugs are not really an option in the case of specific phobias (Stein & Seedat, 2004), SSRIs may be useful in the treatment of panic disorder and PTSD, and it is clear that this issue needs proper investigation (Waslick, 2006). Second, 50% to 70% of the children and adolescents appear to respond favorably to an SSRI (Scott, Mughelli, & Daes, 2005): These youths display a reduction of anxiety symptomatology and show a significant improvement of general functioning. In terms of effect size, the effects produced by SSRIs in anxious youths are quite robust. For example, in the randomized controlled trials on SSRIs in non-OCD anxiety disorders (see supra), effect sizes across various outcome measures ranged between 1.45 and 2.68, indicating large treatment effects. Third, it is important to get insight in the factors that either moderate or mediate the outcome of pharmacotherapy in anxious youths. A preliminary study of the RUPP Anxiety Study Group (2003) showed that severity of the anxiety disorder and the presence of a social phobia (and possibly a behaviorally inhibited temperament) were predictive of a less favorable outcome, but it is clear that this issue requires more research. Fourth, the administration of a placebo in the randomized controlled trials was also frequently accompanied by substantial decreases of anxiety symptoms and improvement in functioning. This underlines that nonspecific therapeutic effects (e.g., attention from a clinician, belief that the treatment works) are important determinants of the outcome of any treatment, including medicationbased interventions. Recently, Olfson, Marcus, Weissman, and Jensen (2002) described trends in the use of psychotropic medications by children and adolescents in the United States. These researchers did not specify the medication use for anxiety disorders but noted that the use of antidepressants, which are commonly employed for this type of problem, had clearly increased between 1987 and 1996. More precisely, in the age categories 6 to 14 years and 15 to 18 years, the use of these drugs had grown from, respectively, .30 and .50 per 100 children in 1987 to 1.06 and 2.12 per 100 children in 1996. While there seems to be increasing support for this type of intervention, it should be borne in mind that research so far has only demonstrated short-term efficacy of pharmacotherapy in childhood anxiety disorders. More

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research is required to study the long-term effects and the consequences of prolonged use of these drugs in youth populations (Seidel & Walkup, 2006).

Conclusion The past decade has seen a steady increase of methodologically sound (see Kendall & Flannery-Schroeder, 1998) treatment outcome studies evaluating the effectiveness of psychological and biological interventions for youths with phobias and anxiety disorders. This research has demonstrated that CBT and pharmacotherapy are effective in reducing anxiety symptoms in children and adolescents of various ages. Given that the empirical evidence for CBT is more substantial than that for pharmacotherapy, cognitive-behavioral therapy should still be regarded as the treatment of choice for childhood anxiety disorders. However, pharmacotherapy (in particular SSRIs) can be employed during the acute phase of treatment (when symptoms are very severe) or when children or adolescents do not respond adequately to a CBT intervention (see also American Academy of Child and Adolescent Psychiatry, 1997). Such treatment algorithm is nicely in keeping with parents' perception of the most optimal treatment for their anxious child. More precisely, Brown, Deacon, Abramowitz, Dammann, and Whiteside (2007) recently found that although CBT and pharmacotherapy are both viewed as acceptable interventions for childhood anxiety disorders, most parents rate CBT as more acceptable, believable, and effective than a pharmacologic intervention (see also Young, Beidel, Turner et al., 2006). Meanwhile, it is of interest to note that a randomized control trial (Pediatric OCD Treatment Study (POTS) Team, 2004) has indicated that the combination of CBT and medication may yield the most optimal treatment outcome. In that study, children and adolescents with OCD from various academic treatment centers (N= 112) were randomly assigned to receive CBT alone, sertraline alone, combined CBT and sertraline, or a placebo. As shown in Figure 8.14, the CBT alone and sertraline

25-

Sertraline ----o- CBT

20 Sertraline +

CBT ---0-- Placebo

15

10 Pretreatment

Posttreatment

Figure 8.14" Mean OCD-symptoms scores for youths in various intervention groups before and after the 12-week treatment period. Based on: Pediatric OCD Treatment Study (POTS) Team (2004).

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alone treatments were significantly better than the placebo intervention in reducing youths' symptoms of OCD, but it is also clear that the combined CBT and sertraline treatment produced the most optimal effects. These findings are interesting and need further replication, especially in other types of childhood anxiety disorders. A number of developmental issues are relevant for the treatment of anxiety disorders in children and adolescents. As mentioned earlier, the precise content of a CBT intervention may depend on the developmental level of the child. In their interesting review article, Dadds and Barrett (2001) have pointed out that each developmental stage has its own characteristics and poses the child for new risks and challenges, which have implications for the content of a CBT intervention (see also Hudson, Kendall, Coles, Robin, & Webb, 2002). During infancy, the main focus should be on training the parents to be responsive to their child in order to foster a secure attachment relationship and a predictable/controllable environment. As children grow older, problem-solving training, exposure, and cognitive strategies become the main targets of the child-based CBT intervention. During early and middle childhood, parents should be trained to model effective cognitive and behavioral coping to their child and to manage behavior avoidance. Finally, during adolescence, the approach of the child largely remains the same, although it may be useful to focus more on the interaction with peers during treatment. Parent training during this stage is more concerned with finding a balance between autonomy/independence and family support. In the case of pharmacotherapy, development and age seem less important as most studies have demonstrated equal responsiveness to drug treatment for children and adolescents (e.g., RUPP Anxiety Study Group, 2003; Wagner et al., 2004). However, it should be borne in mind that the use of such medication on a younger age may have consequences for the maturation of the brain. For example, animal studies have demonstrated detrimental effects of chronic use of SSRIs on the development of frontal and subcortical brain areas (e.g., Norrholm & Ouimet, 2001; Wegerer, Moll, Bagli et al., 1999). These observations have made some authors reserved about the (chronic) employment of SSRIs and other anxiolytic medication in young children (Pine, 2002). The theoretical basis for CBT and pharmacotherapy seems sound, although a lot of research is still necessary to reveal the precise working mechanisms of both types of intervention. In terms of the multifactorial aetiological model that was described in Chapter 6, it can be argued that both types of interventions aim at decreasing children's vulnerability. For example, any CBT interventions contains elements of emotion regulation (SouthamGerow & Kendall, 2002), which seem to target soothing the reactive temperament/personality factor of neuroticism. However, it is equally plausible to assume that these programs promote protective factors of children. More precisely, during a typical CBT program, youths are prompted to carefully analyze the stimuli and situations that cause their anxious feelings, to think about what is going on in their head, and to eventually choose a more adaptive behavioral response instead of avoidance. In other words, CBT teaches children to inhibit their maladaptive behaviors and to regulate their attention, thereby improving their effortful control (Muris & Ollendick, 2005). A similar line of reasoning can be made regarding the presumed working mechanism of pharmacologic interventions. On the one hand, these drugs decrease the activity and arousability of subcortical brain circuits, which would directly reduce feelings of fear and anxiety. On the other hand, this medication may ameliorate the regulative function of the frontal lobes, so that children and adolescents are better

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able to control too intense manifestations of these emotions. Interestingly, some authors have suggested that CBT and pharmacotherapy result in comparable modifications of brain processes, suggesting that the effects produced by both therapeutic approaches are not as dissimilar as previously thought (Linden, 2006; O'Neill & Schwartz, 2004; Schwartz, 1999). In conclusion, the information in this final chapter shows that research has not only made considerable progress in the study of the aetiology and maintenance of childhood anxiety disorders but also indicates clear advances in the treatment of this type of psychopathology in youths. This is certainly positive news for children and adolescents who, just like Little Hans, are in need of an intervention for their anxiety problems.