Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review

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Abstract

This paper provides a comprehensive quantitative review of high quality randomized controlled trials of psychological therapies for anxiety disorders in children and young people. Using a systematic search for randomized controlled trials which included a control condition and reported data suitable for meta-analysis, 55 studies were included. Eligible studies were rated for methodological quality and outcome data were extracted and analyzed using standard methods. Trial quality was variable, many studies were underpowered and adverse effects were rarely assessed; however, quality ratings were higher for more recently published studies. Most trials evaluated cognitive behavior therapy or behavior therapy and most recruited both children and adolescents. Psychological therapy for anxiety in children and young people was moderately effective overall, but effect sizes were small to medium when psychological therapy was compared to an active control condition. The effect size for non-CBT interventions was not significant. Parental involvement in therapy was not associated with differential effectiveness. Treatment targeted at specific anxiety disorders, individual psychotherapy, and psychotherapy with older children and adolescents had effect sizes which were larger than effect sizes for treatments targeting a range of anxiety disorders, group psychotherapy, and psychotherapy with younger children. Few studies included an effective follow-up. Future studies should follow CONSORT reporting standards, be adequately powered, and assess follow-up. Research trials are unlikely to address all important clinical questions around treatment delivery. Thus, careful assessment and formulation will remain an essential part of successful psychological treatment for anxiety in children and young people.

Highlights

► Meta-analysis of 55 RCTS of psychotherapy for child anxiety disorders. ► Treatment effect size was moderate overall, small to medium with active control. ► Therapy for specific disorders had larger effects than generic therapy. ► Individual therapy had larger effects than group therapy. ► Studies need effective follow up, cost effectiveness analysis and more power.

Introduction

The cumulative prevalence of anxiety disorders in children is around 10% by the age of 16 years (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003). For a large proportion of children anxiety problems are long lasting and interfere with their development and functioning (Langley, Bergman, McCracken, & Piacentini, 2004). Thus, significant attention has been given to the development and evaluation of psychological and pharmacological therapies. Currently the dominant psychological treatment is cognitive behavior therapy (CBT), and in recent years there have been a number of systematic reviews and meta-analyses of CBT for anxiety in children and adolescents (e.g. Cartwright-Hatton et al., 2004, Compton et al., 2004, Davis et al., 2011, In-Albon and Schnieder, 2006, Ishikawa et al., 2007, James et al., 2005, Silverman et al., 2008). These reviews have concluded that effect sizes are moderate. For example, James et al. (2005) calculated effect sizes of −.55 to −.58 depending on the outcome measure used.

The field has continued to develop rapidly, both in terms of numbers of trials and in the quality of reporting, and to date no meta-analysis has included all childhood anxiety disorders and all psychological therapies. For example, many of the meta-analyses above were restricted to certain anxiety disorders, with many excluding OCD and PTSD and several excluding specific phobias. However, there are strong arguments to suggest that all anxiety disorders should be included. Firstly, selective exclusion does not allow us to fully explore whether psychotherapy is effective for anxiety disorders in children and adolescents. Secondly, there is a great deal of co-morbidity among anxiety disorders (Costello et al., 2005, Storch et al., 2008). Thirdly, having wider inclusion criteria means that fewer trials must be excluded (e.g. because they had some children with OCD or PTSD in the study). Finally, there are many similarities in underlying theories of these anxiety disorders. For example, the perseveration seen in OCD can also be seen in pathological worry; the panic response in specific phobias can be seen in social anxiety and separation anxiety.

CBT for children and adults has developed in parallel (Benjamin et al., 2011). Unlike CBT for adults with anxiety disorders, where there has been a proliferation of specific treatment models for different anxiety disorders, treatment of child anxiety includes programs which are aimed at a range of anxiety disorders as well as disorder specific treatment. For example, the most widely disseminated treatment protocol ‘Coping Cat’ (Kendall, 1990, Kendall and Hedtke, 2006) is a structured CBT program which uses the same anxiety treatment strategies with children who have a range of disorders including separation anxiety, social anxiety, specific phobias, OCD, and GAD, and who typically present with a number of co-morbid anxiety problems.

Disorder-specific CBT protocols for children and young people have been developed for OCD (Derisley et al., 2008, March and Mulle, 1998), PTSD, (Cohen et al., 2000, ⁎Smith et al., 2007), social phobia (Fisher, Masia-Warner, & Klein, 2004) and specific phobias (Davis, Ollendick, & Ost, 2009). There are some reviews of specific anxiety disorder treatments (e.g. OCD; Watson & Rees, 2008); however, it is unclear if these disorder-specific treatments are more effective than generic treatment for anxiety in children and young people. Thus one aim of this meta-analysis is to calculate effect sizes obtained from trials which have used general or ‘omnibus’ treatments of anxiety, and effect sizes from trials which have examined focused treatments for specific anxiety disorders.

Although CBT is emerging as the dominant treatment method for anxiety disorders in children and adolescents, other models of psychotherapy have been developed and evaluated in formal randomized trials. Previous meta-analyses have either specifically excluded non-CBT trials (Ishikawa et al., 2007, James et al., 2005), or have failed to identify any non-CBT trials (In-Albon & Schneider, 2006). Given that other models of psychotherapy have the potential to influence clinical practice and service development a key aim of this review is to provide an overview of any psychological treatments for which evidence is available. The combination of including all anxiety disorders and including all psychotherapies allows this analysis.

In addition to direct questions of effectiveness of treatments for child and adolescent anxiety disorders we also wish to address a number of supplementary questions relating to predictors or moderators of treatment outcome. Some of these questions relate to basic questions about methods of treatment delivery and have implications for service development; for example, what is the effect size for individual treatment and what is the effect size for group treatment? Similarly, is the number of treatment sessions associated with outcome from psychological therapy?

Other questions have broader and more theoretically interesting implications which are specifically related to the fact that treatments for children and adults have significant points of differences which are, in part, related to the specific developmental needs of children and young people. The most obvious point of difference relates to the fact that children and adolescents are less cognitively mature than adults. This has several consequences. First there is an on-going debate about the extent to which cognitive maturity is required for successful engagement in cognitive behavioral treatment (e.g. Cartwright-Hatton et al., 2004, Grave and Blissett, 2004). Some clinicians and researchers argue that cognitively based interventions are not accessible to children and young people because they lack the cognitive maturity to engage adequately (e.g. Barrett, 2000). A typical response to this concern has been to target interventions on behavioral rather than cognitive components of treatment (Stallard, 2002). Other clinicians and researchers have argued that children's cognitive development is more flexible and variable, and that with adequate adaptations and support many young children can demonstrate the ability to engage in the cognitive elements of cognitive behavior therapy (Quakley, Reynolds, & Coker, 2004) and can benefit from cognitive behavioral treatment (Monga, Young, & Owens, 2009). However, there is limited treatment effectiveness research with younger children (Cartwright-Hatton et al., 2004), and the question has not been resolved. Therefore one aim of this review will be to compare effect sizes associated with cognitive behavioral treatment of anxiety for older and younger children.

Psychological therapies with children and young people also vary in the extent to which they are intended to work with or through parents. Some individual trials comparing individual child CBT with CBT which involves family members suggest that parental involvement is beneficial (e.g. Wood, Piacentini, Southam-Gerow, Chu, & Sigman, 2006), and other studies show that parental involvement is not helpful (e.g. Bodden et al., 2008). Recent meta-analyses of CBT for child anxiety have found no differences in effect sizes in trials which included and excluded parents from treatment (In-Albon and Schnieder, 2006, Ishikawa et al., 2007, James et al., 2005, Silverman et al., 2008), and Barmish and Kendall (2005) concluded that further research is required before this question can be answered.

In contrast, a general meta-analysis of the involvement of parents in child psychotherapy more generally (Dowell & Ogles, 2010) concluded that parent participation was beneficial. However, they found that the added benefit of involving parents was smaller in therapies that were cognitive–behavioral in orientation. Dowell and Ogles (2010) included psychotherapy for all disorders, and the finding cannot be specifically generalized to the treatment of anxiety disorders in children and young people. In the absence of conclusive evidence it is sometimes assumed that treating children with the close involvement of their parents is beneficial to treatment outcome (e.g. OCD treatment guidelines, National Institute for Health and Clinical Excellence, 2005). In this meta-analysis we will examine effect sizes for treatment which involves parents and effect sizes for treatments which focus primarily or exclusively on working with the child or young person without their parent involved.

This meta-analysis therefore has four main aims. The first is to provide an up to date and comprehensive meta-analytic review of high quality randomized controlled trials of psychological treatments for a range of anxiety disorders in children and adolescents. Within this we will examine the effect size of cognitive behavioral treatments and other psychological treatments. Second, we will compare the effectiveness of generic anxiety treatments with disorder-specific treatments for anxiety disorders. Third, we will examine the effect of child age on effectiveness of treatment. Finally, we will assess the effect of treatment delivery (group vs. individual, individual vs. family, number of sessions) on outcome.

Section snippets

Method

For the purposes of this meta-analysis we defined psychotherapy for anxiety as an intervention designed to alleviate the symptoms of diagnosed anxiety disorders or elevated anxiety levels. A psychological intervention could take the form of a structured or unstructured interaction with a trained professional or a specially designed treatment program. Parent administered treatment programs were also included in the analysis when parents were given appropriate clinical supervision.

Published

Criteria for study inclusion, and resulting pool of studies

For inclusion in the meta-analysis all studies had to meet the following criteria:

  • a)

    participants selected because of elevated anxiety levels, or a formal diagnosis of any anxiety disorder (including PTSD, OCD, social anxiety);

  • b)

    randomized allocation of participants into a minimum of one treatment condition and one control condition.

  • c)

    all participants in the study were less than 19 years old;

  • d)

    treatment interventions were specifically designed to reduce symptoms of anxiety;

  • e)

    means and standard deviations

Results

We identified 55 randomized controlled trials in which children and/or adolescents with anxiety were treated using a psychological therapy (see Table 1). Across all studies 2434 children and young people were included in the treatment group, and 1824 children and young people were included in the control group. The majority of studies (n = 33) recruited children and young people with a specific anxiety disorder (16 PTSD, 7 social phobia, 5 OCD, 3 specific phobias and 2 school anxiety), with the

Discussion

This meta-analysis provides an overview of randomized controlled trials of psychological therapies for children and adolescents with anxiety disorders. This is a changing field with new methods of delivery (e.g. internet, bibliotherapy, email) being developed to meet the needs of different populations and client groups (e.g. young people with an autistic spectrum disorder). To our knowledge it is the first quantitative review which includes all anxiety disorders and which includes a range of

Conclusions

Anxiety disorders in children can be treated effectively and there is sufficient evidence to recommend psychological therapy, specifically behavioral or cognitive behavioral therapy. The current evidence is adequate to provide broad guidance for service development and service delivery as well as in guiding parents and young people themselves. However the moderate effect sizes derived from treatment studies mean that there is considerable room for improvement in treatment outcomes.

The

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    1

    Tel.: + 44 1603 693312; fax: + 44 1603 593312.

    2

    Now at the School of Psychology, Trinity College, Dublin, Ireland.

    3

    References marked with an asterisk indicate studies included in the meta-analysis.

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