Therapy For Childhood Anxiety Disorders Research Articles

Parent-coached exposure therapy versus cognitive behavior therapy for childhood anxiety disorders

Cognitive-behavioral therapy (CBT) is the strongest evidenced-based therapy for childhood anxiety disorders (CADs). However, CBT’s impact is limited by its lack of clear superiority over treatment as usual, excessive length, and greater than 50% of patients remaining symptomatic. Parent-coached exposure therapy (PCET) is designed to treat CADs more effectively and efficiently through a focus on exposure and working with parents and youth together. In a randomized controlled trial, 78 patients (78% female) aged 7 to 17 with CADs were assigned to PCET or the gold-standard CBT. The primary outcome was independent evaluator ratings of anxiety severity at mid- and post-treatment. Secondary outcomes were parent- and child-reported symptoms. Patients receiving PCET had significantly lower mean scores than those receiving CBT on the primary outcome measure at mid-treatment (3.03 ± 0.14, 95% CI, 2.75–3.32 vs. 3.77 ± 0.16 95% CI, 3.45–4.08, p = 0.0010) and post-treatment (2.79 ± 0.14, 95% CI, 2.50–3.07 vs. 3.33 ± 0.16, 95% CI, 2.02–3.64, p = 0.0153). Similar significant results were found with the secondary parent- and child-reported outcomes. These superior results were achieved in PCET with fewer sessions (6.62, SD = 2.8) than those in CBT (8.00, SD = 3.1), p = 0.041. The superior effectiveness and efficiency of PCET likely results from the greater focus on implementing exposure exercises compared to traditional CBT.

The Importance of Practicing at Home During and Following Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Conceptual Review and New Directions to Enhance Homework Using Mhealth Technology

Practicing newly acquired skills in different contexts is considered a crucial aspect of Cognitive Behavioral Therapy (CBT) for anxiety disorders (Peris et al. J Am Acad Child Adolesc Psychiatry 56:1043–1052, 2017; Stewart et al. Prof Psychol Res Pract 47:303–311, 2016). Learning to cope with feared stimuli in different situations allows for generalization of learned skills, and experiencing non-occurrence of the feared outcome helps in developing non-catastrophic associations that may enhance treatment outcomes (Bandarian-Balooch et al. J Behav Ther Exp Psychiatry 47:138–144, 2015; Cammin-Nowak et al. J Clin Psychol 69:616–629, 2013; Kendall et al. Cogn Behav Pract 12:136–148, 2005; Tiwari et al. J Clin Child Adolesc Psychol 42:34–43, 2013). To optimize treatment outcome, homework is often integrated into CBT protocols for childhood anxiety disorders during and following treatment. Nevertheless, practicing at home can be challenging, with low motivation, lack of time, and insufficient self-guidance often listed as reasons for low adherence (Tang and Kreindler, JMIR Mental Health 4:e20, 2017). This conceptual review provides an overview of (1) how existing CBT childhood programs incorporate homework, and empirical evidence for the importance of homework practice, (2) evidence-based key elements of practice, and (3) how mHealth apps could potentially enhance practice at home, including an example of the development and application of such an app. This review therefore sets the stage for new directions in developing more effective and engaging CBT-based homework programs for childhood anxiety disorders.

A Self-Efficacy Measure for Use During Exposure in CBT Therapy for Childhood Anxiety Disorders

ABSTRACT Cognitive-behavioral therapy (CBT) with exposure is an effective treatment for childhood anxiety disorders; however, by nature it may involve much discomfort, often rendering engagement during exposure a challenge. An examination of factors related to engagement during exposure in CBT for anxiety is needed; yet, a search of the extant literature found few appropriate assessment tools. Thus, the current study focuses on developing and testing a measure of self-efficacy specific to exposure tasks, a construct likely to contribute to engagement during exposures. Twenty-four parent-child dyads were recruited, and parent, child, and clinician assessments were completed. Analyses revealed significant increases in self-efficacy in tandem with reductions in anxiety symptoms and increases in social and family functioning. Internal consistency was acceptable to excellent across time. Observed effect sizes were promising, warranting greater investigation of the self-efficacy measure. Further investigation into factors contributing to child engagement during exposure in CBT for anxiety is needed.

Using Technology to Promote Therapist Use of Exposure Therapy for Childhood Anxiety Disorders: A Randomized Pilot Study

Increasing the use of exposure by community therapists during the treatment of childhood anxiety disorders is critical to improving the quality of available treatment. The aim of the current study was to investigate whether a brief training in the delivery of an exposure-focused and technology-assisted treatment protocol increased community therapist openness to exposure therapy, use of exposure in treatment, and improvement in patient symptoms. Participants were 17 therapists recruited from a large health system to provide outpatient therapy to 32 youth ages 8–18 (M = 12.13, 78.1% girls) with treatment as usual or with the Anxiety Coach application (AC-app). Consistent with two of three hypotheses, therapists in the AC-app condition increased their openness to, and use of, exposure—however, these changes did not translate into improved therapeutic outcomes. Comparisons to benchmark studies suggest that the community therapists did not implement enough in vivo exposure of sufficient intensity or include parents enough to improve outcome. Results support the ability of exposure-focused treatment protocols to increase community therapists’ use of evidence-based treatment and suggest that future efforts should focus on improving the quality, in addition to quantity, of therapist-delivered exposure.

Parents’ Perspectives on Guided Parent-Delivered Cognitive Behavioral Therapy for Childhood Anxiety Disorders: A Qualitative Study

Cognitive behavioral therapy (CBT) is an effective treatment for child anxiety disorders. Low-intensity forms of CBT, such as guided parent-delivered CBT (GPD-CBT), have been developed to increase access; however, it is unclear why some children benefit from this treatment and others do not. This qualitative study aimed to increase understanding of parents’ experiences of GPD-CBT and what facilitates and creates barriers to good outcomes. The sample was derived from a sample of families who took part in long-term follow-up assessments (reported in). Data were analyzed using thematic analysis. Two themes containing five subthemes were developed from the data. Theme 1 described factors influencing the experience of GPD-CBT. Theme 2 described perceived outcomes in the child and wider changes within the family. The identification of facilitators and barriers to the success of GPD-CBT could inform and improve future treatment delivery.

Community Therapist Response to Technology-Assisted Training in Exposure Therapy for Childhood Anxiety Disorders.

Despite the efficacy of exposure for childhood anxiety disorders (CADs), dissemination has been unsuccessful. The current study examined community-therapist response to a brief (90-minutes) training in technology-assisted exposure therapy for CADs. The results indicated that therapists found the training in the therapy approach and technology acceptable, despite endorsing mainly non-exposure-based practice prior to the training. Training also increased positive beliefs about exposure, t (23) = 4.32, p < .000, that persisted 6 months later, t (23) = 4.56, p < .000. In addition, the number of therapists reporting an intention to implement exposure increased substantially from baseline (41.7%) to post-training (83.3%), with many therapists (70.8%) reporting use of exposure within the 6 months following training. However, automatically recorded data indicated little use of the technology. Results suggest that a dissemination message focusing on exposure is acceptable and has the potential to increase the use of this central treatment component.

Therapists’ characteristics associated with the (non-)use of exposure in the treatment of anxiety disorders in youth: A survey among Dutch-speaking mental health practitioners

IntroductionAlthough there is consensus that exposure is the key ingredient in treating childhood anxiety disorders, several studies in the USA suggest exposure to be underused in clinical practice. Previous research pointed to therapists’ beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists’ own anxiety as important factors in the underusage of exposure in the treatment of adult anxiety disorders. This study examined what therapist characteristics may be involved in the (non-)use of exposure in treating childhood anxiety disorders. MethodsAn internet-based survey among 207 youth mental health care professionals in the Netherlands and Belgium was conducted to assess therapists’ beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists’ own anxiety, depression and stress. ResultsThe current survey showed that therapists used exposure in about half of their cases of childhood anxiety and that the non-use was independently associated with the relatively strong negative beliefs about exposure, therapists’ age, and non-CBT orientation. DiscussionFindings point to the importance of addressing negative beliefs about exposure in therapists’ training and supervision to resolve therapy drift away from exposure, and consequently improve utilization and delivery of exposure-based therapy for childhood anxiety disorders.

Using a Smartphone App and Clinician Portal to Enhance Brief Cognitive Behavioral Therapy for Childhood Anxiety Disorders

Cognitive behavioral therapy (CBT) is an efficacious treatment for child anxiety disorders, but 40%–50% of youth do not respond fully to treatment, and time commitments for standard CBT can be prohibitive for some families and lead to long waiting lists for trained CBT therapists in the community. SmartCAT 2.0 is an adjunctive mobile health program designed to improve and shorten CBT treatment for anxiety disorders in youth by providing them with the opportunity to practice CBT skills outside of session using an interactive and gamified interface. It consists of an app and an integrated clinician portal connected to the app for secure 2-way communication with the therapist. The goal of the present study was to evaluate SmartCAT 2.0 in an open trial to establish usability, feasibility, acceptability, and preliminary efficacy of brief (8 sessions) CBT combined with SmartCAT. We also explored changes in CBT skills targeted by the app. Participants were 34 youth (ages 9–14) who met DSM-5 criteria for generalized, separation, and/or social anxiety disorder. Results demonstrated strong feasibility and usability of the app/portal and high satisfaction with the intervention. Youth used the app an average of 12 times between each therapy session (M = 5.8 mins per day). At posttreatment, 67% of youth no longer met diagnostic criteria for an anxiety disorder, with this percentage increasing to 86% at 2-month follow-up. Youth showed reduced symptom severity over time across raters and also improved from pre- to posttreatment in CBT skills targeted by the app, demonstrating better emotion identification and thought challenging and reductions in avoidance. Findings support the feasibility of combining brief CBT with SmartCAT. Although not a controlled trial, when benchmarked against the literature, the current findings suggest that SmartCAT may enhance the utility of brief CBT for childhood anxiety disorders.

Cognitive Behavioral Therapy for Childhood Anxiety Disorders: a Review of Recent Advances.

We review recent research validating cognitive behavioral therapy (CBT) as a first-line intervention for childhood anxiety disorders. We also review recent research aimed at enhancing exposure-based CBT components and adapting CBT to work with specific populations. Exposure-based CBT is a well-established intervention. Different research groups have found positive evidence to augment CBT by evaluating inhibitory learning principles, the role of parents in child treatment, an individualized case formulation, computer and online forms of CBT, and virtual and augmented reality systems for exposure practice. Specific programs have been developed to meet specific needs of preschoolers, adolescents, and children with comorbid autism spectrum disorder and anxiety. Successful adaptations to CBT exist and the field should continue to improve the generalizability, feasibility, and expected benefit of CBT to improve its effectiveness.

Using Motion Tracking to Measure Avoidance in Children and Adults: Psychometric Properties, Associations With Clinical Characteristics, and Treatment-Related Change

Avoidance is implicated in many areas of psychopathology, particularly anxiety and its disorders. Accurate, reliable, valid, and objective measurement of avoidance behavior poses methodological challenges. Two key technological advances, increased computing power and the advent of motion-tracking technology, offer novel solutions to these challenges. We describe a series of three studies using a novel motion-tracking system to measure avoidance in children and adults. The first study examined behavioral avoidance of spider stimuli in large samples of children and adults (N = 200 each; the adults were the mothers of the children). Behavioral avoidance was associated with self-rated fear of spiders and increased state anxiety from before to after the task. The second study examined avoidance of threat faces in children and adults (N = 35 each; the adults were the mothers of the children) and test-retest reliability in the adults. Avoidance of threat faces was associated with broadband anxiety symptom severity. Test-retest correlations in behavioral avoidance measured 6 weeks apart was high and significant. The third study examined behavioral avoidance of spiders in clinically anxious children (N = 25) before and after cognitive-behavioral therapy for childhood anxiety disorders. Behavioral avoidance was significantly reduced following cognitive-behavioral therapy and reduction in behavioral avoidance correlated significantly with improvement in child-rated anxiety symptoms. Taken together, these studies provide strong support for the promise of motion-tracking technology to enable a new phase of behavioral avoidance research with sensitive, valid, reliable, and cost- and time-effective measurement of behavioral avoidance across the lifespan.

Increasing Availability of Exposure Therapy Through Intensive Group Treatment for Childhood Anxiety and OCD.

Archival data were used to examine the feasibility of a 5-day, clinic-based, intensive exposure-based cognitive-behavioral group therapy for childhood anxiety disorders (CADs) and obsessive-compulsive disorder (OCD). Participants were 143 children (82 girls) aged 6 to 19 years ( M = 13.93 years, SD = 2.9 years) with CADs or OCD (or both) in 28 consecutive groups. Repeated-measures ANOVA in the subsample ( n = 57) with complete treatment data indicated positive change on all variables from pretreatment to posttreatment with few differences between CADs and OCD patients. Effect sizes were moderate to large for anxiety symptoms (parent reported = 0.74, child reported = 0.65) and impairment (parent reported = 1.02, child reported = 0.69). The intensive group protocol required fewer sessions and 36% fewer therapist-hours per patient than the individually administered protocol. The program increased treatment availability for families from diverse geographic areas ( M distance traveled to clinic = 407 miles, SD = 786.4 miles). These findings support further, well-controlled examination of the 5-day intensive group treatment protocol's efficacy and potential to increase availability of evidence-based exposure therapy.

Long-term outcomes and predictors of internet-delivered cognitive behavioral therapy for childhood anxiety disorders

ObjectiveThis study investigated the long-term outcomes of internet-delivered cognitive behavior therapy (ICBT) for children with anxiety disorders, and potential pre-treatment predictors of treatment outcome. MethodThe sample included eighty-four children (8–12 years old) with anxiety disorders, from both a treatment group and a waitlist control (after participants had crossed over to treatment) of a previous randomized controlled study. Participants were assessed at post-treatment and three- and twelve-months after treatment using a semi-structured interview and parent ratings. Pre-treatment data were used to investigate predictors of treatment outcome at three-month follow-up. ResultsIntention-to-treat analysis showed that treatment gains were maintained at twelve-month follow-up, including clinician rated severity of the principal anxiety disorder, parent rated anxiety symptoms and global functioning, with mainly large effect sizes (Cohen's d = 0.63–2.35). Completer analyses showed that suspected autism spectrum disorder was associated with less change in symptom severity. No other pre-treatment measures significantly predicted treatment outcome. ConclusionThis study suggests that internet-delivered CBT can have long-term beneficial effects for children with anxiety disorders. Predictors of treatment outcome need to be evaluated further. Trial registrationClinicaltrials.gov; NCT01533402.

Factors associated with practitioners’ use of exposure therapy for childhood anxiety disorders

The current study examines factors related to use of exposure therapy by clinicians who treat children with anxiety disorders. A sample of 331 therapists from a variety of backgrounds (i.e., social workers, doctoral psychologists, masters level counselors, and marriage and family therapists) completed a survey regarding use of exposure and other treatment techniques for childhood anxiety disorders, as well as beliefs about exposure and child resiliency. Although the majority of therapists endorsed a CBT orientation (81%) and use of CBT techniques, exposure therapy was rarely endorsed. Holding a PhD in psychology as well as more positive beliefs about exposure and child resiliency were associated with greater use of exposure. The results suggest that exposure-based therapy is rarely offered in community settings and that dissemination should focus on individual evidence-based principles and correcting therapist misconceptions.

Ethical Considerations in Exposure Therapy With Children

Despite the abundance of research that supports the efficacy of exposure therapy for childhood anxiety disorders and OCD, negative views and myths about the harmfulness of this treatment are prevalent. These beliefs contribute to the underutilization of this treatment and less robust effectiveness in community settings compared to randomized clinical trials. Although research confirms that exposure therapy is efficacious, safe, tolerable, and bears minimal risk when implemented correctly, there are unique ethical considerations in exposure therapy, especially with children. Developing ethical parameters around exposure therapy for youth is an important and highly relevant area that may assist with the effective generalization of these principles. The current paper reviews ethical issues and considerations relevant to exposure therapy for children and provides suggestions for the ethical use of this treatment.

Change in disgust reactions following cognitive-behavioral therapy for childhood anxiety disorders

Disgust, in addition to fear, is a prominent emotional state associated with avoidance of distressing stimuli. While most of the research in disgust has been conducted in relation to Obsessive-Compulsive Disorder (OCD), recent data has also implicated disgust in the etiology of anxiety disorders in general. Studies have shown that decreases in disgust are key to symptom reduction in individuals with OCD. However, there has been little empirical work exploring whether these interventions are efficacious for childhood anxiety disorders that present with prominent disgust components. This study examined how disgust propensity in children with anxiety disorders responds to cognitive-behavioral therapy (CBT) with an emphasis on exposure. Forty-one children, ages 7 to 17, with anxiety disorders were evaluated for disgust propensity and were treated with intensive, weekly, CBT. It was found that disgust levels decreased following treatment across all anxiety disorder diagnoses, where children with primary OCD exhibited significantly greater reductions. Clinical implications and suggestions for further research of the treatment of disgust in relation to childhood anxiety disorders are discussed.

Alltagswirksamkeit kognitiver Verhaltenstherapie bei Kindern und Jugendlichen mit Angststörungen in einer Ausbildungsambulanz

Only few studies have examined whether the efficacy of cognitive-behavioral therapy for childhood anxiety disorders as demonstrated in randomized controlled trials (RCTs) generalizes to clinical practice. This study examines the effectiveness of cognitive-behavioral therapy for juvenile anxiety disorders under routine care conditions in a university-based psychiatric outpatient clinic. 92 children and adolescents with parent-ratings regarding anxiety and comorbid symptoms and 61 children and adolescents with self-ratings regarding anxiety and comorbid symptoms were treated with cognitive-behavioral interventions. Pre/post mean comparisons, effect sizes, and the clinical significance of changes in symptoms were examined. The effect size for reduction of anxiety symptoms was .81 for children whose parents had completed the rating scale and .79 for children who had filled in a self-rating scale. Effect sizes for reduction of comorbid symptoms varied between .37 and .84 for parent ratings and between .21 and .62 for self-ratings. The percentage of children and adolescents who achieved clinically significant improvements in anxiety symptoms was 55.1 % according to the parent ratings and 65.7 % according to the children's self-ratings. More than 50 % of parents and children reported clinically significant improvements in comorbid symptoms. Significant reductions in both anxiety and comorbid symptoms were demonstrated over the course of cognitive-behavioral therapy of juvenile anxiety disorders in a university psychiatric outpatient clinic. The effect sizes for anxiety symptoms were found to be comparable to the effect sizes reported in RCTs. Similarly, clinically significant improvements were as frequent as the rates of remission of anxiety symptoms reported in RCTs.

A Randomized Controlled Trial of the Child Anxiety Multi-Day Program (CAMP) for Separation Anxiety Disorder

While the efficacy of cognitive behavior therapy for childhood anxiety disorders, including separation anxiety disorder (SAD), has been established, tailoring such treatments to particular interests and needs may enhance uptake of evidence-based interventions. The current investigation evaluates the feasibility and preliminary efficacy of an intensive, cognitive-behavioral intervention for girls with SAD provided within the novel context of a 1-week camp-like setting, the Child Anxiety Multi-Day Program (CAMP). Twenty-nine female children aged 7-12 with a principal diagnosis of SAD were randomized to immediate CAMP treatment (n = 15) or waitlist (i.e., delayed treatment; n = 14) condition during the course of this randomized controlled trial. Children in the immediate treatment group evidenced significant reductions in SAD severity, functional impairment, and parent report of child anxiety symptoms relative to the waitlist condition. The intervention's positive therapeutic response suggests one possible delivery model for surmounting difficulties faced in the dissemination of weekly treatments for SAD.

P01-294 - Evaluation of response to cognitive-behavior therapy for childhood anxiety disorders: preliminary results

IntroductionAnxiety disorders are prevalent in childhood and can cause significant impairment in adulthood. Although cognitive-behavior therapy (CBT) show evidence of response in children with anxiety disorders, some questions remain open.ObjectiveTo evaluate the response of an adapted protocol of group CBT for anxiety disorders in childhood.MethodThis is a non-controlled clinical trial of 14 sessions of 90 minutes for children 10 to 13 years. Patients were selected from public schools diagnosed with Anxiety Disorder in Childhood, according to KDSADS. The protocol used was based on manual Cognitive-Behavioral Therapy for Anxious Children: Therapist Manual for Group Treatment of Flannery-Schroeder and Kendall (2006), the Coping Cat Workbook and on clinical experience of therapists. Improvement was evaluated by Clinical Global Impression scale (CGI).ResultsTo date 20 patients completed the 14 sessions of group CBT. There was a predominance of females (n = 15; 75%), mean age 11.6 ± 0.68 years. The most frequent diagnosis was Generalized Anxiety Disorder (n = 14; 70%) and 14 patients had at least one anxiety disorder and comorbidity (70%). Regarding the response to therapy, there was a significant decrease in symptoms (p &lt; 0.001) assessed by the CGI (mean and standard deviation) before (4.15 ± 0.93) and after (2.95 ± 1.05) in the CBT group. Higher CGI at baseline was a predictor of poor response (4.67 ± 0.65 vs. 0.74 ± 3:38; p = 0.001).ConclusionPartial results of this study show that the protocol used for group CBT is effective in improving clinical patients with anxiety disorders in childhood.

Treating Selective Mutism Using Modular CBT for Child Anxiety: A Case Study

Selective mutism is a rare, debilitating condition usually seen in children. Unfortunately, there is little research examining effective treatments for this disorder, and designing an evidence-based treatment plan can be difficult. This case study presents the evidence-based treatment of an 8-year-old Caucasian boy with selective mutism using an established treatment for anxiety—Modular Cognitive-Behavioral Therapy for Childhood Anxiety Disorders (Chorpita, 2007). The treatment consisted of 21 sessions and included modules on psychoeducation, exposure, cognitive restructuring, social skills, and maintenance and relapse prevention. The client's symptoms were greatly improved by the end of treatment based on fear hierarchy ratings, self-report and parent-report questionnaires, and child and parent clinical interviews. In addition, at discharge the client no longer met criteria for selective mutism. Improvements were maintained when the client was reassessed at 1-month and 6-month follow-up appointments.

The Relation of Severity and Comorbidity to Treatment Outcome with Cognitive Behavioral Therapy for Childhood Anxiety Disorders

The present study investigated the impact of comorbidity over and above the impact of symptom severity on treatment outcome of Cognitive Behavioral Therapy for children with anxiety disorders. Children (aged 8–12, n = 124) diagnosed with an anxiety disorder were treated with a short-term CBT protocol. Severity was assessed with a composite measure of parent-reported behavior problems. Two approaches to comorbidity were examined; “total comorbidity” which differentiated anxiety disordered children with (n = 69) or without (n = 55) a co-occurring disorder and “non-anxiety comorbidity’ which differentiated anxious children with (n = 22) or without a non-anxiety comorbid disorder (n = 102). Treatment outcome was assessed in terms of Recovery, represented by post-treatment diagnostic status, and Reliable Change, a score reflecting changes in pre- to post-treatment symptom levels. Severity contributed to the prediction of (no) Recovery and (more) Reliable Change in parent-reported internalizing and externalizing symptoms and self-reported depressive symptoms. Total and non-anxiety comorbidity added to the prediction of diagnostic recovery. Non-anxiety comorbidity added to the prediction of Reliable Change in parent reported measures by acting as a suppressor variable. Non-anxiety comorbidity operated as a strong predictor that explained all of the variance associated with severity for self-reported depressive symptoms. The results support the need for further research on mechanisms by which treatment gains in children with higher symptom severity and non-anxiety comorbidity can be achieved.