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Pooled Effect Size and Quality of Evidence for Treatment Response and Remission
Source publication
Importance
Childhood anxiety is common. Multiple treatment options are available, but existing guidelines provide inconsistent advice on which treatment to use.
Objectives
To evaluate the comparative effectiveness and adverse events of cognitive behavioral therapy (CBT) and pharmacotherapy for childhood anxiety disorders.
Data Sources
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Context in source publication
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Citations
... Guidelines for formulating homework exercises explicitly include personalizing the exposure exercises to ensure that the exercises match the skill-level and personal characteristics of the child (see Tompkins, 2002, for guidelines). Personalizing exposure exercises acknowledges the heterogeneity of each anxiety disorder and each child (Peterman et al., 2015;Wang et al., 2017) and the large variety of anxious expectations children with anxiety disorders present with during treatment. For example, not all children with a social anxiety disorder fear negative evaluation by adults (APA, 2013). ...
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.
... Using this information, the clinician searches for a potential meta-analysis on Google Scholar using the following search terms: Generalized anxiety disorder, African American adolescents, cognitive-behavioral therapy, and metaanalysis. The initial search revealed four potential meta-analysis based on title and abstract review, including the one that will be used in this example, Wang et al. (2017). This meta-analysis was selected from the four because, although not perfect, it most closely matched the clinical question and addressed most of the presenting clinical problems (i.e., GAD, adolescents, cognitive behavioral therapy; p. 1050). ...
... In the next phase of the process, the quality of the meta-analysis was examined. Wang et al. (2017) provided sufficient information in their Methods section (pp. 1050-1051) and in the online supplement to evaluate all three of the criteria listed in Section B of the worksheet. ...
... 1052). Taken together, the Wang et al.'s (2017) meta-analysis does appear to be a reasonable, though perhaps not perfect, metaanalysis for determining if CBT is effective for GAD in adolescents. ...
Despite efforts to incorporate evidence-based practice into mental health settings, there has been inconsistent success doing so. Several barriers to the implementation of evidence-based practice have been identified, including limitations in time and statistical training. One promising approach to further bridge the science-practice gap is the greater use of meta-analytic studies to clarify the magnitude of treatment effects and to understand components of treatments that are more effective within specific populations. Although several articles have been published to help mental health trainees and providers understand and interpret meta-analyses, they may not be sufficient without extensive training in statistical techniques. The purpose of this article is to provide and explain the use of the Meta-Analysis Application Worksheet as a means by which mental health providers at all professional levels can use meta-analytic findings to make clinical judgments regarding treatment approaches in the context of ongoing or new cases. A case example is provided to illustrate the use of the worksheet in clinical decision making.
... Most CBT protocols for childhood anxiety emphasize the number of treatment sessions on exposures, which have been linked to positive treatment outcomes [5,6]. Exposure-based CBT has demonstrated considerable efficacy [7][8][9][10] and effectiveness [11] for reducing anxiety symptom severity and impairment. While pharmacotherapy has also been shown to be efficacious [12], exposure-based CBT is often recommended as the front-line treatment for anxiety disorders in youth [13]. ...
Exposure-based cognitive behavior therapy (CBT) has demonstrated efficacy and is recommended as a front-line treatment for childhood anxiety. Unfortunately, challenges exist that impact the effective implementation of exposure-based CBT in clinical practice. One of the primary challenges is the accessibility and availability of exposure stimuli (e.g., spiders, storms, heights) in CBT sessions. Immersive virtual reality (VR) has shown promise as a scalable and sustainable solution to address this clinical need, but remains largely untested in youth with anxiety disorders. Here, we examine the use of VR exposures in the treatment of youth with an anxiety disorder (i.e., specific phobias). We aimed to investigate: (1) the feasibility and clinical benefit of VR exposures; (2) whether VR exposures elicit changes in physiological arousal and/or subjective distress; and (3) whether habituation serves as a mechanism across physiological and subjective outcomes for VR exposures. Three youth and their parents completed a clinical evaluation, which was followed by a one session treatment (OST) with VR exposures. Afterward, youth and parents completed clinical assessments one-week and 1-month after treatment. Immersive VR exposures were found to be feasible and demonstrated clinical benefit for reducing anxiety severity. Additionally, VR exposures elicited changes in both physiological and subjective outcomes. Finally, physiological habituation to VR exposures was observed among participants who exhibited treatment response at follow-up. Collectively, these findings demonstrate preliminary evidence that VR exposures are feasible, tolerable, and show some therapeutic benefit for treating youth with anxiety.
... Anxiety disorders are one of the most common mental health diagnoses in childhood, tend to persist over time, and lead to impairment and additional psychopathology [1][2][3]. Cognitive behavioral therapy (CBT) is the most well-supported treatment for childhood anxiety disorders (CADs; [4]), with growing evidence and expert consensus that exposure is the most essential active ingredient of treatment [5][6][7]. Unfortunately, most community-based clinicians do not provide exposure when working with CADS [8][9][10] even in response to direct training. ...
Although community therapists rarely use exposure when treating youth with anxiety disorders, they are more likely to endorse the use of imaginal exposure, relative to in vivo or interoceptive exposure. Such use of imaginal exposure could reflect a sub-optimal replacement for in vivo exposure or a targeted intervention to address anxiety-provoking thoughts, such as in generalized anxiety disorder. The current study used the survey responses of 178 community-based clinicians to examine these competing hypotheses. The results indicated that therapist endorsement of more clearly defined imaginal exposure was significantly lower than other techniques such as cognitive restructuring, and that imaginal exposure was most often used instead of more intensive forms of exposures. In addition, most of the endorsed interventions were targeted at helping youth cope with anxiety rather than corrective learning. Alternatively, there was no observed association between imaginal exposure and treatment of general anxiety. These finding suggest that community therapist use of imaginal exposure is suboptimal and unlikely to improve treatment outcomes.
... Effective treatment protocols for anxiety and depression have been developed [10][11][12][13], but they have limitations. Longitudinal studies have shown high relapse rates and a high number of chronically ill patients, even with protocoldriven treatment [14,15]. ...
The present study aimed to assess the efficacy of a group-based, brief transdiagnostic cognitive-behavioral therapy (CBT) program for adolescents with internalizing problems, such as anxiety and depressive disorders, seeking help in a primary health care clinic in Iceland. The group-based CBT program consisted of eight weekly 110-min sessions covering psychoeducation, cognitive restructuring, behavioral activation, exposure, problem-solving, social skills, and mindfulness. The study recruited 53 participants, who were randomly assigned to either receive the group treatment or be placed on a wait-list for monitoring purposes. Measures were taken at baseline, during treatment (week 4), at posttreatment (week 8), and at 2-, 4-month, and 1-year follow-ups. The primary outcome measures were the self-reported total scores of total anxiety and depression using the Revised Children's Anxiety and Depression Scale (RCADS). The study found a significant effect of time and time * treatment interaction on the depression and anxiety total scores. The secondary outcome measures, RCADS parent-rated depression and anxiety total scores, did not show significant effects of time * treatment interaction. However, during naturalistic follow-up, a significant reduction in parent-reported depression and anxiety total scores was observed. The study also observed good treatment adherence, as well as high satisfaction among parents and youth. The results suggest that this group-based, brief transdiagnostic CBT group treatment is feasible and effective in reducing depressive and anxiety symptoms in adolescents with internalizing problems and highlights the importance of addressing comorbidity in treatment.
... Previous reviews have found psychosocial interventions to be efficacious in the treatment of children and adolescents with anxiety disorders (Crowe & McKay (2017); Sigurvinsdóttir et al., 2020;Wang et al., 2017;Zhang et al., 2017). This is particularly the case for clinical trials that compare cognitivebehavioral therapy (CBT) to non-intervention control groups (e.g., Crowe and McKay (2017); Sigurvinsdóttir et al., 2020;Wang et al., 2017). ...
... Previous reviews have found psychosocial interventions to be efficacious in the treatment of children and adolescents with anxiety disorders (Crowe & McKay (2017); Sigurvinsdóttir et al., 2020;Wang et al., 2017;Zhang et al., 2017). This is particularly the case for clinical trials that compare cognitivebehavioral therapy (CBT) to non-intervention control groups (e.g., Crowe and McKay (2017); Sigurvinsdóttir et al., 2020;Wang et al., 2017). Based on meta-analytic reviews, CBT has been found to be to be as effective as antidepressants (Wang et al., 2017), and initial findings indicate that both CBT and behavioral interventions are effective in the treatment of anxiety in children younger than the age of seven (Zhang et al., 2017). ...
... This is particularly the case for clinical trials that compare cognitivebehavioral therapy (CBT) to non-intervention control groups (e.g., Crowe and McKay (2017); Sigurvinsdóttir et al., 2020;Wang et al., 2017). Based on meta-analytic reviews, CBT has been found to be to be as effective as antidepressants (Wang et al., 2017), and initial findings indicate that both CBT and behavioral interventions are effective in the treatment of anxiety in children younger than the age of seven (Zhang et al., 2017). It is noteworthy that CBT appears to be the most commonly utilized treatment approach for child and adolescent anxiety; however, emerging models, including parentchild interaction therapy (PCIT) (Phillips & Mychailyszyn, 2021) and emotion-focused therapy (Edrissi et al., 2019) also show promise. ...
Anxiety symptoms and disorders are prevalent and impairing in young children and these symptoms often persist and worsen over time, indicating the need for efficacious interventions for this age group. The purpose of this study was to evaluate the effectiveness of psychosocial interventions targeting anxiety in younger children and to assess the potential moderators of outcome. The effect sizes from 24 trials were assessed based on a random effect model. The mean weighted effect size was found to be significant and moderate in magnitude. Moderators, including level of intervention, intervention approach, rater, and level of training of the provider/program facilitator, are assessed and discussed. Overall, the findings indicate that anxiety interventions are effective in reducing anxiety in young children, and targeted trials show particularly strong promise.
... [30][31][32][33][34][35][36][37] The combination of CBT with an SSRI may have more benefit than either treatment alone. 38,39 Discussion about treatment benefits and risks is an important element of quality care. 25,26 Close follow-up, including side effect monitoring, is also recommended. ...
Background and objectives:
Primary care pediatricians (PCP) are often called on to manage child and adolescent anxiety and depression. The objective of this study was to describe PCP care practices around prescription of selective serotonin reuptake inhibitors (SSRI) for patients with anxiety and/or depression by using medical record review.
Methods:
We identified 1685 patients who had at least 1 visit with a diagnosis of anxiety and/or depression in a large primary care network and were prescribed an SSRI by a network PCP. We randomly selected 110 for chart review. We reviewed the visit when the SSRI was first prescribed (medication visit), immediately previous visit, and immediately subsequent visit. We abstracted rationale for prescribing medication, subspecialist involvement, referral for psychotherapy, and medication monitoring practices.
Results:
At the medication visit, in 82% (n = 90) of cases, PCPs documented reasons for starting an SSRI, most commonly clinical change (57%, n = 63). Thirty percent (n = 33) of patients had documented involvement of developmental-behavioral pediatrics or psychiatry subspecialists at 1 of the 3 visits reviewed. Thirty-three percent (n = 37) were referred to unspecified psychotherapy; 4% (n = 4) were referred specifically for cognitive behavioral therapy. Of 69 patients with a subsequent visit, 48% (n = 33) had documentation of monitoring for side effects.
Conclusions:
When prescribing SSRIs for children with anxiety and/or depression, PCPs in this network documented appropriate indications for starting medication and prescribed without subspecialist involvement. Continuing medical education for PCPs who care for children with these conditions should include information about evidence-based psychotherapy and strategies for monitoring potential side effects.
... When present during childhood and adolescence, these disorders are associated with adverse outcomes in adulthood, including mood disorders, substance use, and unemployment (Essau, Lewinsohn, Olaya, & Seeley, 2014;Swan & Kendall, 2016). Fortunately, interventions such as cognitive behavioral therapy (CBT) and/or pharmacotherapy [i.e., selective serotonin reuptake inhibitors (SSRIs)] are effective for many youth (Higa-McMillan, Francis, Rith-Najarian, & Chorpita, 2016;Wang et al., 2017). In a landmark randomized controlled trial (RCT) of interventions for anxiety disorders, Child/Adolescent Anxiety Multimodal Treatment Study (CAMS; Walkup et al., 2008), 59.7% of those treated with CBT (Coping Cat; Kendall & Hedtke, 2006), 54.9% of those treated with an SSRI (sertraline; SRT), and 80.7% of those who received a combination of both (i.e., COMB) were rated as treatment responders and >80% maintained these gains over a 6-month followup . ...
Objective
The current study examined trajectories of anxiety during (a) acute treatment and (b) extended follow‐up to better characterize the long‐term symptom trajectories of youth who received evidence‐based intervention for anxiety disorders using a person‐centered approach.
Method
Participants were 319 youth (age 7–17 years at enrollment), who participated in a multicenter randomized controlled trial for the treatment of pediatric anxiety disorders, Child/Adolescent Anxiety Multimodal Study, and a 4‐year naturalistic follow‐up, Child/Adolescent Anxiety Multimodal Extended Long‐term Study, an average of 6.5 years later. Using growth mixture modeling, the study identified distinct trajectories of anxiety across acute treatment (Weeks 0–12), posttreatment (Weeks 12–36), and the 4‐year‐long follow‐up, and identified baseline predictors of these trajectories.
Results
Three nonlinear anxiety trajectories emerged: “short‐term responders” who showed rapid treatment response but had higher levels of anxiety during the extended follow‐up; “durable responders” who sustained treatment gains; and “delayed remitters” who did not show an initial response to treatment, but showed low levels of anxiety during the maintenance and extended follow‐up periods. Worse anxiety severity and better family functioning at baseline predicted membership in the delayed remitters group. Caregiver strain differentiated short‐term responders from durable responders.
Conclusions
Findings suggest that initial response to treatment does not guarantee sustained treatment gains over time for some youth. Future follow‐up studies that track treated youth across key developmental transitions and in the context of changing social environments are needed to inform best practices for the long‐term management of anxiety.
... Le traitement de première ligne recommandé en cas de troubles anxieux chez les enfants et les adolescents est la psychothérapie avec un thérapeute formé (19). De nombreux types de psychothérapie peuvent soutenir les familles, y compris l'entrevue motivationnelle, la thérapie axée sur les émotions et les thérapies de pleine conscience et d'acceptation, mais la TCC est le traitement fondé sur des données probantes le plus fréquent en cas de troubles anxieux (15). ...
... Plusieurs médicaments sont utilisés pour le traitement de l'anxiété, les plus efficaces étant les inhibiteurs sélectifs de la recapture de la sérotonine (ISRS) (19,32). Selon des lignes directrices fondées sur des données probantes avalisées par l'American Academy of Child and Adolescent Psychiatry, les ISRS sont les médicaments de première intention pour le traitement des troubles anxieux chez les enfants et les adolescents de six à 18 ans (33). ...
... Selon des lignes directrices fondées sur des données probantes avalisées par l'American Academy of Child and Adolescent Psychiatry, les ISRS sont les médicaments de première intention pour le traitement des troubles anxieux chez les enfants et les adolescents de six à 18 ans (33). Il est possible d'envisager les inhibiteurs sélectifs de la recapture de la sérotonine et de la noradrénaline (ISRN) pour le traitement de l'anxiété sociale, de l'anxiété généralisée, de l'anxiété de séparation ou du trouble panique (19). Les ISRS et les ISRN peuvent atténuer les symptômes d'anxiété, améliorer le fonctionnement global et contribuer à une rémission (19). ...
Les troubles anxieux sont les problèmes de santé mentale les plus courants chez les enfants et les adolescents canadiens. La Société canadienne de pédiatrie a préparé deux documents de principes qui résument les données probantes à jour sur leur diagnostic et leur prise en charge. Ces documents contiennent des conseils fondés sur des données probantes afin d’aider les professionnels de la santé à prendre des décisions à l’égard des soins aux enfants et aux adolescents atteints de ces troubles. La deuxième partie, qui porte sur la prise en charge, vise à 1) passer en revue les données probantes et le contexte de diverses approches cliniques qui combinent des interventions comportementales et pharmacologiques pour traiter les atteintes de façon appropriée; 2) décrire le rôle de l’éducation et de la psychothérapie pour la prévention et le traitement des troubles anxieux; 3) décrire l’utilisation de la pharmacothérapie, y compris les effets secondaires et les risques qui s’y rapportent. Les recommandations sur la prise en charge de l’anxiété reposent sur les lignes directrices à jour, une analyse bibliographique et un consensus d’experts. Il est à souligner que, dans le présent document, le terme « parent » (au singulier ou au pluriel) inclut les personnes qui s’occupent principalement de l’enfant et toutes les configurations familiales.
... Psychotherapy with a trained therapist is recommended as the first line treatment for anxiety disorders in children and adolescents (19). While there are many types of psychotherapy that can be used to support families, including motivational interviewing, emotion focused therapy, and mindfulness and acceptance-based therapies, CBT is the most common evidence-based treatment modality for anxiety disorders (15). ...
... • Being assertive rather than aggressive (18). (19,32). Evidence-based guidelines endorsed by the American Academy of Child and Adolescent Psychiatry recommend SSRIs as the medication of choice for treating anxiety disorders in children and adolescents aged 6 to 18 years old (33). ...
... Evidence-based guidelines endorsed by the American Academy of Child and Adolescent Psychiatry recommend SSRIs as the medication of choice for treating anxiety disorders in children and adolescents aged 6 to 18 years old (33). Selective norepinephrine reuptake inhibitors (SNRIs) can be considered for treatment of social anxiety, generalized anxiety, separation anxiety, or panic disorder (19). SSRIs and SNRIs can improve anxiety symptoms and global functioning and help achieve remission (19). ...
Anxiety disorders are the most common mental health concerns affecting Canadian children and adolescents. The Canadian Paediatric Society has developed two position statements that summarize current evidence regarding the diagnosis and management of anxiety disorders. Both statements offer evidence-informed guidance to support paediatric health care providers (HCPs) making decisions around the care of children and adolescents with these conditions. The objectives of Part 2, which focuses on management, are to: (1) review the evidence and context for a range of clinical approaches that combine behavioural and pharmacological interventions to effectively address impairment, (2) describe the roles of education and psychotherapy in the prevention and treatment of anxiety disorders, and (3) outline the use of pharmacotherapy, with side effects and risks. Recommendations for managing anxiety are based on current guidelines, review of the literature, and expert consensus. Note that when the word 'parent' (singular or plural) is used, it includes any primary caregiver and every configuration of family.
