Anxiety Disorders

Considerable evidence has accumulated demonstrating the efficacy of individual child cognitive behavior therapy (CBT) for reducing anxiety disorders in children (see Silverman and Berman 2001, for review). In consideration of the accumulating evidence (summarized above), highlighting the importance of the familial context in the development and maintenance of anxiety disorders, early twenty-first century clinical research was directed toward evaluating whether CBT, when used with anxious children, also is efficacious when family parenting variables are targeted in the treatment program. Such work also is a response to increasing interest among practitioners in having available alternative treatment approaches that draw on supplementary therapeutic resources, especially when individual child therapy does not seem sufficient.

As a result, empirical evidence from clinical trials as well as single case study designs suggests that childhood anxiety disorders can be reduced when exposure-based cognitive behavioral treatments target family/parent variables. For example, in a sample of seventy-nine children (ages seven to fourteen years old) and their parents, Paula Barrett, Mark Dadds, and Ronald Rapee (1996) demonstrated that individual cognitive behavioral treatment (ICBT) might be enhanced by parental involvement in the treatment of childhood anxiety disorders when compared to a wait-list comparison group. Results indicated that a large percentage (69.8%) of children who received ICBT, either with or without a parenting component, no longer met diagnostic criteria for an anxiety disorder. Moreover, children who received ICBT with a parenting component had significantly higher treatment success rates (84%) than children who received ICBT without the parenting component (57.1%). Improvement also was evident on child and parent rating scales, though statistically significant differences between the treatment conditions (i.e., ICBT with parent involvement vs. ICBT without parent involvement) were not as apparent on these measures. An interesting age/treatment interaction was observed in that younger children showed more improvement in ICBT with the parenting component than older children who received ICBT without the parenting component.

Barrett and colleagues (2001) reported long-term (five to seven years post-treatment) maintenance of treatment gains from Barrett, Dadds, and Rapee's (1996) study. For both treatment conditions (i.e., ICBT with parental involvement vs. ICBT without parental involvement), treatment gains were maintained for this period as shown by continued absence of the targeted anxiety disorder diagnosis as reported by the child, and on all the child and parent rating scales. The only exception was levels of self-rated fear: children who received ICBT with parental involvement rated significantly less fear at long-term follow-up in comparison to children who received ICBT without parental involvement.

Findings from Vanessa Cobham, Mark Dadds, and Susan Spence (1998) provide additional evidence for ICBT as well as for the involvement of parents in intervention. In this study parental involvement included not only parental management of the child's anxiety, but also parental management of their own anxiety. Children (N=67; ages seven to fourteen years old) with anxiety disorders were assigned to conditions according to whether parents were anxious or not. Treatment success rates for ICBT among children with nonanxious parents were similar to those children with anxious parents who received ICBT plus a parental anxiety management component. Thus, the addition of a parent anxiety management component to ICBT was important for diagnostic recovery for those children with anxious parents.

Barrett (1998) evaluated the effectiveness of including a family component to group CBT. Participants consisted of sixty children (ages seven to fourteen years old) and their parents. Treatment conditions were: (1) child group CBT, (2) child group CBT plus a family management component, and (3) a wait-list control condition. The family management component consisted of parent training of contingency management techniques for their child's anxiety and for any anxiety that parents may experience themselves. Results indicated that children in both group CBT and group CBT plus the family component showed positive treatment in comparison to the wait-list condition. However, children in the group CBT plus family component condition showed somewhat better improvement than children in the group CBT condition as evident in less family disruption, greater parental perception of ability to deal with child's behaviors, and lower child's reports of fear. At one-year follow-up, children in the group CBT plus family maintained lower scores for internalizing and externalizing behaviors as reported by parents. Overall, however, both treatment conditions produced significant change in terms of successful treatment outcome relative to the waitlist condition.

Sandra Mendlowitz and colleagues (1999) conducted a clinical trial examining group CBT for anxiety in children (N=68; ages seven to twelve years old). Three conditions were compared: (1) group CBT for children only, (2) group CBT for children and parents, and (3) group CBT for parents only. A wait-list control condition also was included. Improvement was noted for all treatment conditions in terms of reduction in anxiety symptoms; however, children in the group CBT for children and parents condition showed significantly greater improvement in their coping strategies relative to children in the other conditions.

Susan Spence, Caroline Donovan, and Margaret Brechman-Toussaint (2000) conducted a clinical trial for children with social phobia (N=50; ages seven to fourteen years old) in which group CBT was compared to group CBT with parental involvement, and a wait-list control. Parental involvement consisted mainly of enhanced contingency management techniques taught to parents during therapy sessions. Results indicated that both treatment conditions (i.e., ICBT and ICBT with the parental component) showed significant improvements at post-treatment and twelve-month follow-up when compared to the wait-list condition. It is interesting, however, that comparisons between the two treatment conditions did not show statistically significant differences, suggesting both conditions were efficacious in reducing symptoms of social phobia.

Two late-twentieth-century studies reported on parent and family factors that may be related to treatment success or failure (Berman et al. 2000). Steven L. Berman and his colleagues (2000) found that child symptoms of depression as well as parent self-reported symptoms of depression, fear, hostility, and/or paranoia were predictive of treatment failure. Melissa Crawford and Katharina Manassis (2001) found that child, maternal, and paternal reports of family dysfunction and maternal frustration were significant predictors of a less favorable outcome in child's anxiety and overall functioning. Also, paternal reports of multiple physiological symptoms for which no medical cause was evident were predictive of a less favorable outcome in terms of overall child functioning.

In sum, there is strong and consistent evidence showing a familial influence in the development and maintenance of anxiety disorders. This evidence supports both a biological and psychosocial influence. The intervention research literature further suggests strong evidence for the efficacy of ICBT for reducing anxiety disorders in children. Although the effects might be enhanced when including a family component to the intervention, further research on this issue is needed.