Diagnosis Of Separation Anxiety Disorder Research Articles

Separation Anxiety: The Core of Attachment and Separation-Individuation

ABSTRACT This paper, written in honor of Anni Bergman, focuses on the concept of separation anxiety as it was conceptualized and developed in attachment theory by Bowlby and in separation-individuation theory by Mahler and colleagues. The focus is on how separation anxiety manifests differentially in individuals with secure versus insecure attachment and in different subphases of the separation-individuation process, with emphasis on the areas of overlap and divergence in the two traditions. The paper then reviews recent research that has focused on how separation anxiety has provided a transdiagnostic risk factor for psychopathology, including anxiety, depression, and PTSD, complicating the treatment course of individuals with these disorders. These findings have contributed to the delineation of the DSM-5 diagnosis of Separation Anxiety Disorder (SAD) and to the development of new assessment instruments to measure it. We consider how separation anxiety has been assessed in several treatment studies of these disorders and how it is related to other factors such as insecure attachment and reflective function (RF, mentalization in attachment relationships). The ways in which recent research on separation anxiety in individuals with psychopathology, including depression and PTSD, has affirmed and expanded the original formulations of Bowlby and Bergman and her colleagues is also discussed.

Maternal Labor Force Participation During the Child's First Year and Later Separation Anxiety Symptoms.

Separation anxiety symptoms are frequent among preschool-aged children, but it is also a possible gateway for diagnosis of separation anxiety disorder. Early maternal employment after childbirth can increase the risk for the development of separation anxiety symptoms. From an economic perspective, however, securing employment is one effective strategy to ensure child well-being. This study investigated how mothers' participation in the labor force (vs. maternal leave) and the financial state of families when the child was 5 months old was prospectively associated with separation anxiety symptoms. This study is based on 1,295 Canadian families with children assessed longitudinally from 17 months to age 6 on their levels of separation anxiety. Separation anxiety was measured during face-to-face interviews with the mothers. Maternal labor force participation, financial status, and risk factors were measured at 5 months. Results adjusted for propensity scores and for sample weight revealed that children of working mothers, despite having sufficient income (n = 245, 18.9%), were at higher risk of separation anxiety during early childhood. In contrast, maternity leave was most beneficial for children's separation anxiety, whether they were in a family with sufficient income (n = 950, 73.4%) or temporary low income (n = 100, 7.7%). Children of mothers in maternity leave were at risk of heightened separation anxiety only if they experienced chronic economic hardship. Therefore, maternity leave uptake could help prevent the development of separation anxiety. Providing families with opportunity to care for the baby as their main occupation during this sensitive developmental period could help improve children's mental health.

Separation anxiety disorder among outpatients with major depressive disorder: Prevalence and clinical correlates

Prior studies have reported that separation anxiety disorder (SEPAD) can continue into or may begin in adulthood. Association of SEPAD with other psychiatric disorders has been frequently examined, and high rates of comorbidities have been found. The aim of this study was to investigate the prevalence and clinical correlation of SEPAD in adult patients undergoing treatment for major depressive disorder (MDD). The study sample was comprised of 100 outpatients. Participants underwent a DSM-5-based comprehensive assessment. Purposefully-designed semi-structured sociodemographic information and illness history forms were filled out by the researchers, and diagnoses of SEPAD were made using the Structured Clinical Interview for Separation Anxiety Symptoms, Separation Anxiety Symptom Inventory and Adult Separation Anxiety Survey. The frequency of SEPAD was 41% in patients with MDD, three-quarters of whom were adult onset. The use of new-generation antidepressants, adjunctive medications and comorbidity of other anxiety disorders were higher in patients with SEPAD (p < 0.05). SEPAD was highly prevalent, with a majority of cases starting in adulthood among patients with MDD, while SEPAD comorbidity was associated with high levels of anxiety and an increased likelihood of suboptimal response to usual depression treatment. Further studies are required to define the relevance and pathological basis for the comorbidity of SEPAD in people with MDD.

Separation Anxiety Symptom Profiles and Parental Accommodation Across Pediatric Anxiety Disorders.

Parental accommodation refers to ways in which caregivers modify their behavior to decrease child distress in the short-term. Accommodation is prevalent among anxious youth and related to decreased treatment and functional outcomes. Although separation anxiety disorder (SAD) is associated with increased accommodation, SAD is not a predictor of treatment response, suggesting that a diagnosis of SAD alone may not be enough to clarify the relationship between accommodation and separation anxiety symptoms within a clinical context. Participants were youth with a primary anxiety disorder (N = 186; aged 7-17) enrolled in an outpatient anxiety clinic. Latent class analysis was used to extract profiles from parent-reported SAD symptoms using the Anxiety Disorders Interview Schedule for DSM-IV/5. Profiles were compared on pre-treatment accommodation. Low, moderate, and interfering SAD classes emerged. Interfering SAD was associated with high accommodation. Results help to clarify the association between SAD and accommodation and has implications for personalized intervention.

Predicting outcomes for anxious children receiving group cognitive‐behavioural therapy: Does the type of anxiety diagnosis make a difference?

BackgroundCognitive‐behavioural therapy (CBT) is an efficacious treatment for anxiety disorders in children and adolescents, yet not all young people improve. Understanding predictors of treatment response can inform treatment improvements in order to enhance outcomes.AimThe purpose of this study was to compare treatment outcomes following group‐based CBT for children with different anxiety disorders (social phobia (SocP), separation anxiety disorder (SAD), generalised anxiety disorder (GAD), specific phobia (SP)) to determine whether differential outcomes from group‐based CBT are related to type of diagnosis.MethodParticipants were 205 clinically anxious children between 4 and 12 years of age. Treatment outcomes were assessed using clinician‐rated diagnostic interviews, parent‐report, and child‐report symptom measures. Ninety‐seven children completed a long‐term follow‐up assessment 6 or 12 months after treatment.ResultsChildren with a principal diagnosis of SocP and GAD had a poorer post‐treatment outcome compared to children with a principal diagnosis of SP and SAD. Poorer outcomes persisted in children with a principal diagnosis of SocP by the follow‐up assessment compared to children with the other anxiety disorders.ConclusionsThese findings are consistent with recent studies that have found poorer outcomes from CBT for youth and adults with SocP, and emphasise the need for further research into treatments that target specific factors that could improve outcomes.

Predictors of long-term outcome of CBT for youth with anxiety disorders treated in community clinics

Cognitive behavioral therapy (CBT) has proven long-term effects in youth with anxiety disorders. However, only a few studies have examined predictors of long-term outcomes of CBT treatment. The present study investigated possible predictors of long-term treatment outcomes in youth with mixed anxiety disorders treated in community mental health clinics. A total of 139 youth (mean age at assessment 15.5 years, range 11–21 years) with a principal diagnosis of separation anxiety disorder, social anxiety disorder, and/or generalized anxiety disorder were evaluated a mean of 3.9 years post-treatment (range 2.2–5.9 years). Outcomes were loss of all inclusion anxiety diagnoses, loss of the principal inclusion anxiety diagnosis, and changes in youth- and parent-rated youth anxiety symptoms. Predictors encompassed youth, parent and demographic factors, and post-treatment recovery. The most consistent finding was that low family social class predicted poorer outcomes. Higher treatment motivation was associated with better outcome whereas a diagnosis of social anxiety was associated with poorer outcome. Identified predictors extend on previous findings from efficacy trials, and the results indicate a need for more specific treatment protocols.

Help me Feel Better! Ecological Momentary Assessment of Anxious Youths' Emotion Regulation with Parents and Peers.

Anxious youth often have trouble regulating negative affect (NA) and tend to over-rely on parents when faced with challenges. It is unclear how social interactions with parents or peers actually helps or hinders anxious youths' success in regulating NA. The aim of this study was to examine whether the success of anxious youths' emotion regulation strategies differed according to social context. We compared the effectiveness of co-ruminating, co-problem solving and co-distracting with parents/peers for regulating anxious youth's NA in response to stress in their daily lives. We also examined the benefit of attempting each strategy socially vs. non-socially (e.g., co-ruminating vs. ruminating). One-hundred-seventeen youth (9-14) with a current diagnosis of Separation Anxiety Disorder, Generalized Anxiety Disorder, and/or Social Phobia completed an ecological momentary assessment (14 calls over 5days), reporting on recent stressors, their affective state, presence of others, and emotion regulation strategies within the prior hour. Mixed linear models revealed that co-distracting was the most effective social strategy for reducing NA, but only for boys. Co-rumination was the least effective social strategy for regulating NA. Regarding social context, only co-distracting was more effective for regulating NA over distracting alone, but only among anxious boys. Results suggest that co-rumination is an ineffective use of social support for regulating NA. Anxious boys may benefit from social support by co-distracting with parents/peers, but improper use may reflect avoidance and contribute to long-term anxiety maintenance. Results extend research on gender differences in interpersonal relationships and emotion regulation.

Long-term effectiveness of cognitive behavioral therapy for youth with anxiety disorders

Cognitive behavioral therapy (CBT) has demonstrated favorable long-term outcomes in youth with anxiety disorders in efficacy trials. However, long-term outcomes of CBT delivered in a community setting are uncertain. This study examined the long-term outcomes of individual (ICBT) and group CBT (GCBT) in youth with anxiety disorders treated in community mental health clinics. A total of 139 youth (mean age at assessment 15.5 years, range 11–21 years) with a principal diagnosis of separation anxiety disorder (SAD), social anxiety disorder (SOP), and/or generalized anxiety disorder (GAD) were evaluated, on average, 3.9 years post-treatment (range 2.2–5.9 years). Outcomes included loss of all inclusion anxiety diagnoses, loss of the principal anxiety diagnosis and changes in youth- and parent-rated youth anxiety symptoms. At long-term follow-up, there was loss of all inclusion anxiety diagnoses in 53%, loss of the principal anxiety diagnosis in 63% of participants as well as significant reductions in all anxiety symptom measures. No statistical significant differences in outcome were obtained between ICBT and GCBT. Participants with a principal diagnosis of SOP had lower odds for recovery, compared to those with a principal diagnosis of SAD or GAD. In conclusion, outcomes of CBT for youth anxiety disorders delivered in community mental health clinics were improved at nearly 4 years post-treatment, and recovery rates at long-term follow-up were similar to efficacy trials.

Emotion-Focused Cognitive-Behavioral Therapy for Youth with Anxiety Disorders: A Randomized Trial.

Difficulties with emotion regulation are a core feature of anxiety disorders (ADs) in children and adults. Interventions with a specific focus on emotion regulation are gaining empirical support. Yet, no studies to date have compared the relative efficacy of such interventions to existing evidence-based treatments. Such comparisons are necessary to determine whether emotion-focused treatments might be more effective for youth exhibiting broad emotion-regulation difficulties at pretreatment. This study examined an emotion-focused cognitive-behavioral therapy (ECBT) protocol in comparison to traditional cognitive-behavioral therapy (CBT) in a sample of children with a primary anxiety disorder diagnosis. Moderation analyses examined whether children with higher levels of emotion dysregulation at pretreatment would show greater levels of improvement in ECBT than CBT. Ninety-two youth ages 7 to 12years (58% male) with a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia were included. Participants were randomly assigned to ECBT or CBT. Results showed that youth in both conditions demonstrated similar improvements in emotion regulation and that pretreatment levels of emotion dysregulation did not moderate treatment outcomes. Additional analyses showed that ECBT and CBT were similarly effective on diagnostic, severity, and improvement measures. Future work is needed to further explore the ways that emotion regulation is related to treatment outcome for anxious youth.

Child and Adolescent Adherence With Cognitive Behavioral Therapy for Anxiety: Predictors and Associations With Outcomes

Cognitive behavioral therapy (CBT) for anxiety disorders is effective, but nonadherence with treatment may reduce the benefits of CBT. This study examined (a) four baseline domains (i.e., demographic, youth clinical characteristics, therapy related, family/parent factors) as predictors of youth adherence with treatment and (b) the associations between youth adherence and treatment outcomes. Data were from 279 youth (7–17 years of age, 51.6% female; 79.6% White, 9% African American), with Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.) diagnoses of separation anxiety disorder, generalized anxiety disorder, and/or social phobia, who participated in CBT in the Child/Adolescent Anxiety Multimodal Study. Adherence was defined in three ways (session attendance, therapist-rated compliance, and homework completion). Multiple regressions revealed several significant predictors of youth adherence with CBT, but predictors varied according to the definition of adherence. The most robust predictors of greater adherence were living with both parents and fewer youth comorbid externalizing disorders. With respect to outcomes, therapist ratings of higher youth compliance with CBT predicted several indices of favorable outcome: lower anxiety severity, higher global functioning, and treatment responder status after 12 weeks of CBT. Number of sessions attended and homework completion did not predict treatment outcomes. Findings provide information about risks for youth nonadherence, which can inform treatment and highlight the importance of youth compliance with participating in therapy activities, rather than just attending sessions or completing homework assignments.

Brief Behavioral Therapy for Pediatric Anxiety and Depression in Primary Care

Anxiety and depression affect 30% of youth but are markedly undertreated compared with other mental disorders, especially in Hispanic populations. To examine whether a pediatrics-based behavioral intervention targeting anxiety and depression improves clinical outcome compared with referral to outpatient community mental health care. This 2-center randomized clinical trial with masked outcome assessment conducted between brief behavioral therapy (BBT) and assisted referral to care (ARC) studied 185 youths (aged 8.0-16.9 years) from 9 pediatric clinics in San Diego, California, and Pittsburgh, Pennsylvania, recruited from October 6, 2010, through December 5, 2014. Youths who met DSM-IV criteria for full or probable diagnoses of separation anxiety disorder, generalized anxiety disorder, social phobia, major depression, dysthymic disorder, and/or minor depression; lived with a consenting legal guardian for at least 6 months; and spoke English were included in the study. Exclusions included receipt of alternate treatment for anxiety or depression, presence of a suicidal plan, bipolar disorder, psychosis, posttraumatic stress disorder, substance dependence, current abuse, intellectual disability, or unstable serious physical illness. The BBT consisted of 8 to 12 weekly 45-minute sessions of behavioral therapy delivered in pediatric clinics by master's-level clinicians. The ARC families received personalized referrals to mental health care and check-in calls to support accessing care from master's-level coordinators. The primary outcome was clinically significant improvement on the Clinical Global Impression-Improvement scale (score ≤2). Secondary outcomes included the Pediatric Anxiety Rating Scale, Children's Depression Rating Scale-Revised, and functioning. A total of 185 patients were enrolled in the study (mean [SD] age, 11.3 [2.6] years; 107 [57.8%] female; 144 [77.8%] white; and 38 [20.7%] Hispanic). Youths in the BBT group (n = 95), compared with those in the ARC group (n = 90), had significantly higher rates of clinical improvement (56.8% vs 28.2%; χ21 = 13.09, P < .001; number needed to treat, 4), greater reductions in symptoms (F2,146 = 5.72; P = .004; Cohen f = 0.28), and better functioning (mean [SD], 68.5 [10.7] vs 61.9 [11.9]; t156 = 3.64; P < .001; Cohen d = 0.58). Ethnicity moderated outcomes, with Hispanic youth having substantially stronger response to BBT (76.5%) than ARC (7.1%) (χ21 = 14.90; P < .001; number needed to treat, 2). Effects were robust across sites. A pediatric-based brief behavioral intervention for anxiety and depression is associated with benefits superior to those of assisted referral to outpatient mental health care. Effects were especially strong for Hispanic participants, suggesting that the protocol may be a useful tool in addressing ethnic disparities in care. clinicaltrials.gov Identifier: NCT01147614.

Infant stranger fear trajectories predict anxious behaviors and diurnal cortisol rhythm during childhood.

Although a robust literature has linked stable, high levels of fear across childhood to increased risk for anxiety problems, less is known about alternative pathways to anxiety. We tested two putatively normative developmental pathways of early fearfulness for their distinct associations with behavioral (anxiety-related behaviors and symptoms) and biological (diurnal cortisol) markers of anxiety risk in middle childhood in a community-based sample (n = 107). Steeper increases in fear from 6 to 36 months predicted more parent-reported anxiety symptoms at age 8 years. In addition, children who exhibited steep increases in fear during infancy were overrepresented among children with diagnoses of separation anxiety disorder at age 8 years. Finally, we showed that steeper increases in fearfulness in infancy predicted flatter slopes of diurnal cortisol at age 8 years for girls. Thus, differences in stranger fear across infancy may indicate varying degrees of risk for anxious behaviors in later childhood.

Separation Anxiety Disorder in School-Age Children: What Health Care Providers Should Know

Separation anxiety disorder (SAD) is the most common childhood anxiety disorder, and it has many consequences, particularly for school-age children. These consequences include excessive worry, sleep problems, distress in social and academic settings, and a variety of physical symptoms that, left untreated, can cause social and academic decline. Pediatric providers routinely see children in the primary care office and have the unique opportunity to diagnose, treat, and manage children with SAD. Despite this, SAD continues to be underdiagnosed and undertreated because of a gap in the literature regarding evidence-based practice guidelines for pediatric providers. The purpose of this article is to discuss the diagnosis and management of SAD in school-age children and highlight the role of pediatric providers in managing separation anxiety.

Spanish Validation of the Separation Anxiety Assessment Scale.

The aim of this study was to investigate the factorial structure and psychometric properties of the Separation Anxiety Assessment Scale (SAAS) with Spanish schoolchildren. The participants in Study 1 were 1281 children aged 8-11. Exploratory factor analysis identified four factors: worry about calamitous events, fear of abandonment, fear of being alone, and fear of physical illness, which explained 47.77% of the variance. The participants of Study 2 were 4628 schoolchildren aged 8-11. The four related factors model was validated by confirmatory factor analysis. The internal consistency (α=.84) and temporal stability (r=.77) were good. The convergent validity was evident from the pattern of correlations with the measures of separation anxiety, sensitivity to anxiety and school fears. The sensitivity of the scale was 83%, and its specificity, 93%. The complementary subscales predicted the diagnosis of separation anxiety disorder. The results support the reliability, validity and clinical utility of the SAAS.

Convergent and divergent validity of K-SADS-PL anxiety and attention deficit hyperactivity disorder diagnoses in a clinical sample of school-aged children

Background The Schedule for Affective Disorders and Schizophrenia for School Age Children, Present and Lifetime Version (K-SADS-PL) is a commonly used diagnostic interview both in research and clinical settings, yet published data on the psychometric properties of the interview generated diagnoses are scarce. Aims To examine the convergent and divergent validity of the Norwegian version of the K-SADS-PL current diagnoses of anxiety disorders and attention deficit hyperactivity disorder (ADHD). Method Participants were 105 children aged 7–13 years referred for treatment at child mental health clinics and 36 controls. Diagnostic status was determined based on K-SADS-PL interviews with the mothers. Child and mother reported child symptoms of anxiety on the Multidimensional Anxiety Scale for Children and teachers reported anxiety symptoms on the Teacher Report Form. Mother and teacher reported on symptoms of ADHD on the Disruptive Behavior Rating Scale. Results Rating scale data from multiple informants in a clinical sample and healthy controls supported the convergent and divergent validity of K-SADS-PL anxiety diagnoses combined, and, specifically, the diagnoses of separation anxiety disorder, social phobia, and specific phobia. Support was also observed for convergent and divergent validity of ADHD diagnoses, including the predominately inattentive subtype. Conclusion The K-SADS-PL generates valid diagnoses of anxiety disorders and ADHD.

Separation Anxiety Disorder Presenting with Pseudo-Convulsive Episodes: A Case Study

A 13-year-old female presented with symptoms resemblingseizures. After several neurologic and psychiatric assessments, a final diagnosis of separation anxiety disorder (SAD) was made.Our case report briefly explains the pathophysiology and clinical presentation of SAD, and how a physician can be fooled by and a typical presentation.

A model-based cluster analysis of social experiences in clinically anxious youth: links to emotional functioning

Social difficulties are commonly associated with anxiety disorders in youth, yet are not well specified in the literature. The aim of this study was to identify patterns of social experiences in clinically anxious children and examine the associations with indices of emotional functioning. A model-based cluster analysis was conducted on parent-, teacher-, and child-reports of social experiences with 64 children, ages 7–12 years (M = 8.86 years, SD = 1.59 years; 60.3% boys; 85.7% Caucasian) with a primary diagnosis of separation anxiety disorder, social phobia, and/or generalized anxiety disorder. Follow-up analyses examined cluster differences on indices of emotional functioning. Findings yielded three clusters of social experiences that were unrelated to diagnosis: (1) Unaware Children (elevated scores on parent- and teacher-reports of social difficulties but relatively low scores on child-reports, n = 12), (2) Average Functioning (relatively average scores across all informants, n = 44), and (3) Victimized and Lonely (elevated child-reports of overt and relational victimization and loneliness and relatively low scores on parent- and teacher-reports of social difficulties, n = 8). Youth in the Unaware Children cluster were rated as more emotionally dysregulated by teachers and had a greater number of diagnoses than youth in the Average Functioning group. In contrast, the Victimized and Lonely group self-reported greater frequency of negative affect and reluctance to share emotional experiences than the Average Functioning cluster. Overall, this study demonstrates that social maladjustment in clinically anxious children can manifest in a variety of ways and assessment should include multiple informants and methods.

Predictors and moderators of treatment response in childhood anxiety disorders: Results from the CAMS trial.

We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS). Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures. Three baseline variables predicted better outcomes (independent of treatment condition) on the PARS, including low anxiety severity (as measured by parents and independent evaluators) and caregiver strain. No baseline variables were found to predict Week 12 responder status (CGI-I). Participants' principal diagnosis moderated treatment outcomes but only on the PARS. No baseline variables were found to moderate treatment outcomes on Week 12 responder status (CGI-I). Overall, anxious children responded favorably to CAMS treatments. However, having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcomes. Clinical implications of these findings are discussed.

The Separation Anxiety Hypothesis of Panic Disorder Revisited: A Meta-Analysis

Evidence suggests that childhood separation anxiety disorder may be associated with a heightened risk for the development of other disorders in adulthood. The authors conducted a meta-analysis to examine the relationship between childhood separation anxiety disorder and future psychopathology. PubMed, PsycINFO, and Embase were searched for studies published through December 2011. Case-control, prospective, and retrospective cohort studies comparing children with and without separation anxiety disorder with regard to future panic disorder, major depressive disorder, any anxiety disorder, and substance use disorders were included in the analysis. Effects were summarized as pooled odds ratios in a random-effects model. Twenty-five studies met all inclusion criteria (14,855 participants). A meta-analysis of 20 studies indicated that children with separation anxiety disorder were more likely to develop panic disorder later on (odds ratio=3.45; 95% CI=2.37-5.03). Five studies suggested that a childhood diagnosis of separation anxiety disorder increases the risk of future anxiety (odds ratio=2.19; 95% CI=1.40-3.42). After adjusting for publication bias, the results of 14 studies indicated that childhood separation anxiety disorder does not increase the risk of future depression (odds ratio=1.06; 95% CI=0.78-1.45). Five studies indicated that childhood separation anxiety disorder does not increase the risk of substance use disorders (odds ratio=1.27; 95% CI=0.80-2.03). Of the subgroup analyses performed, differences in comparison groups and sample type significantly affected odds ratio sizes. A childhood diagnosis of separation anxiety disorder significantly increases the risk of panic disorder and any anxiety disorder. These results support a developmental psychopathology conceptualization of anxiety disorders.

3008 – Effectiveness of cognitive-behavioral anxiety treatments for children and adolescents

There is substantial evidence that cognitive behavioral therapy (CBT) works for child anxiety disorders, but this evidence-base mainly rests on efficacy trials with rigorous scientific control conducted in University-clinics. Are results transferable to ordinary clinics? To a large extent, the answer seems to be yes. This presentation will review the state-of-the-art of effectiveness trials for child anxiety disorders. Additionally, data will be presented from a large ongoing randomized controlled trial (RCT) for child anxiety disorders conducted in community child and adolescent mental health clinics in Norway. This is the child part of the Assessment and Treatment - Anxiety in Children and Adults (ATACA) trial, PI's Heiervang and Havik. Children aged 8 to 15 years (N = 182) with a primary diagnosis of separation anxiety disorder, social phobia, or generalized anxiety disorder were included and randomized to group CBT (GCBT), individual CBT (ICBT) or a waitlist condition (WLC). The treatment program was Barrett's Friends for life manual. CBT outperformed WLC, with no major difference between GCBT and ICBT. Although overall symptom reduction was comparable to previous effectiveness trials, the full remission rates were somewhat lower than in previous trials. The possible reasons behind this will be discussed, and there will be an emphasis on how process factors such as pretreatment motivation, perceived treatment credibility, and the therapeutic alliance, which were all assessed in the RCT, may play a part to influence treatment results.