Nothing new since «Little Hans» and «Little Peter»? Psychotherapy for anxiety disorders in childhood and adolescence

Anxiety disorders are among the most frequent psychological disorders in childhood and adolescence. They are characterized by early onset, tend to remain stable over time, and act as a significant risk factor for developing a psychological disorder in adulthood. Over the last few years, research has shown that anxiety disorders in children and adolescents can be treated effectively. However, to date only cognitive behavioral therapy (CBT) has received convincing empirical support as an effective psychotherapeutic treatment. Evidence for the effectiveness of other psychotherapeutic treatments such as nonbehavioral family therapy or psychodynamic interventions is rather scant. Recent randomized controlled trials (RCT) proved CBT to be effective from preschool age onwards. Contrary to long-held beliefs, however, the involvement of parents in a treatment program does not appear to be crucial to therapeutic outcome. Issues regarding the effectiveness of disorder-specific treatments and the combination of psychotherapeutic treatments with the application of selective serotonin reuptake inhibitors (SSRIs) are increasingly being taken up in recent studies. In addition to ?classic? cognitive behavioural treatment programs there are some promising suggestions for the effectiveness of novel treatment methods such as attention bias modification or computer-assisted behavioral therapy.     

Texas Children's Medication Algorithm Project: update from Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder

OBJECTIVE: To revise and update consensus guidelines for medication treatment algorithms for childhood major depressive disorder based on new scientific evidence and expert clinical consensus when evidence is lacking. METHOD: A consensus conference was held January 13-14, 2005, that included academic clinicians and researchers, practicing clinicians, administrators, consumers, and families. The focus was to review, update, and incorporate the most current data to inform and recommend specific pharmacological approaches and clinical guidance for treatment of major depressive disorder in children and adolescents. RESULTS: Consensually agreed on medication algorithms for major depression (with and without psychosis) and comorbid attention-deficit disorders were updated. These revised algorithms also incorporated approaches to address issues of suicidality, aggression, and irritability. Stages 1, 2, and 3 of the algorithm consist of selective serotonin reuptake inhibitor and norepinephrine serotonin reuptake inhibitor medications whose use is supported by controlled, acute clinical trials and clinical experience. Recent studies provide support that selective serotonin reuptake inhibitors in addition to fluoxetine are still encouraged as first-line interventions. The need for additional assessments, precautions, and monitoring is emphasized, as well as continuation and maintenance treatment. CONCLUSIONS: Evidence and expert clinical consensus support the use of selected antidepressants in the treatment of depression in youths. The use of the recommended antidepressant medications requires appropriate monitoring of suicidality and potential adverse effects and consideration of other evidence-based treatment alternatives such as cognitive behavioral therapies.     

Recent developments in child and adolescent social phobia

The following article discusses research trends in childhood and adolescent social phobia during the past year. Of particular importance are findings regarding prevalence rates, cognitive variables and social skills deficits, temperamental influences, and the use of selective serotonin reuptake inhibitors (SSRIs). Recent prevalence rates of social anxiety disorder in children and adolescents range from 0.5% to 4.0%. Findings regarding the role of cognitive processes and social skills deficits in childhood social phobia are supported. Recent longitudinal data investigating the stability of extremes of behavioral inhibition have found that it persists from childhood into adolescence. Initial data regarding the use of SSRIs suggest that they may be a promising treatment option.     

Pharmacologic treatment of anxiety disorders in children and adolescents

This article reviews the pharmacologic treatment of anxiety disorders in children and adolescents. These disorders are quite common and can be considered a "silent epidemic" because they are more often reported by the children and adolescents than by their parents. Tricyclic antidepressants (TCAs), benzodiazepines, buspirone, and selective serotonin reuptake inhibitors (SSRIs) have been used to treat anxiety disorders in children and adolescents with varying degrees of success. Considering safety and efficacy, the SSRIs appear to be the first-line treatment for anxiety disorders in youth, but more studies are needed to confirm preliminary results. Tricyclic antidepressants and benzodiazepines may be considered when the child has not responded to SSRIs or when adverse effects have exceeded benefits. Although nonpharmacologic approaches for the treatment of anxiety in children and adolescents are beyond the scope of this article, their importance is to be underscored and they should be considered as part of the treatment plan. Over the next decade, research data will be generated regarding the treatment of anxiety disorders in youth. Ongoing research studies include the use of fluoxetine (B. Birmaher, personal communication, 1999) and fluvoxamine (J. Walkup, personal communication, 1999) for the treatment of generalized anxiety disorder, separation anxiety disorder, or social phobia; and buspirone for generalized anxiety disorder in children. Despite these efforts, there is a need for more studies to examine the safety and efficacy of different pharmacologic treatments, as well as longitudinal studies to monitor for long-term tolerability and side effects. Pharmacokinetic studies for children and adolescents will provide information on the metabolism and absorption of these medications and delineate the developmental differences between children and adolescents when compared to adults. Finally, and perhaps most importantly, studies that compare medication, psychosocial treatments, and their combination are needed.     

Social anxiety disorder: recent findings in the areas of epidemiology, etiology, and treatment

Social anxiety disorder is a common and chronic disorder that leads to substantial psychosocial impairment. The disorder occurs early in childhood, and is frequently comorbid with a variety of other psychiatric diagnoses like depression, other anxiety disorders, substance abuse, and eating disorders. Given these serious implications of social anxiety disorder, early effective treatment is extremely important. Pharmacotherapy, with a selective serotonin reuptake inhibitor, and cognitive behavioral therapy are the first choice of treatments for social anxiety disorder. This paper reviews recent findings on the epidemiology, etiology, and treatment for social anxiety disorder, and highlights areas where future research should be directed.     

Management of panic disorder

Selective serotonin reuptake inhibitors are the first-line treatment for panic disorder. They are effective and well tolerated. Although tricyclic antidepressants are equally effective, they are less well tolerated than the selective serotonin reuptake inhibitors. Monoamine oxidase inhibitors can be efficacious but have a range of unwanted effects that preclude their use as first-line treatments. Benzodiazepines should be reserved for short-term use and for treatment-resistant patients who do not have a history of dependence and tolerance. Also, they can be combined with selective serotonin reuptake inhibitors in the first weeks of treatment to tide the patient over before the onset of the response. Cognitive behavioral therapy is the psychologic treatment of first choice. The methods of combining drug and nondrug treatments need careful and thorough exploration.     

Psychopharmacologic treatment of children and adolescents with anxiety disorders

Over the last decade, psychopharmacologic treatments for pediatric anxiety disorders have been developed and increasingly subjected to randomized, controlled trials. The authors summarize the data concerning the use of tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), atypical anxiolytics, and benzodiazepines. The extant data suggest that SSRIs--both as monotherapy and when combined with psychotherapy--are effective in the treatment of pediatric anxiety disorders. In addition, some TCAs and SNRIs are effective. However, randomized controlled trials do not suggest efficacy for benzodiazepines or the atypical anxiolytic, buspirone, for children and adolescents with anxiety disorders.     

Establishing the neurobiologic basis of treatment in children and adolescents with generalized anxiety disorder

Generalized anxiety disorder (GAD) is associated with significant morbidity in children and adolescents, yet only recently have the neuropharmacology and neurophysiology of this condition been studied in youth. Accumulating data suggest structural and functional abnormalities within the brain's fear networks in youth with GAD. Additionally, seven studies examined the efficacy of medications that modulate this system and, in some cases, the direct effects of these medications on structures within these networks (e.g. amygdala, ventrolateral prefrontal cortex [VLPFC]). In this review, we summarize the extant functional, functional connectivity, and structural neuroimaging data in children and adolescents with GAD. In addition, data concerning selective serotonin reuptake inhibitors (SSRIs), selective serotonin norepinephrine reuptake inhibitors (SSNRIs), atypical anxiolytics, benzodiazepines, and psychotherapy are reviewed in the context of the neurophysiology of pediatric GAD. The existing data suggest abnormal activity within the amygdala, VLPFC, and anterior cingulate cortex, as well as the possibility of impaired connectivity among these brain regions. In addition to numerous cognitive behavioral therapy (CBT) trials, five randomized, controlled psychopharmacologic trials primarily in youth with GAD suggest that SSRIs and SSNRIs are effective for this condition. These findings also raise the possibility that functional activity within the amygdala and VLPFC may be altered following successful treatment.     

Deliberate self-harm in children and adolescents: a research update

PURPOSE OF REVIEW: We outline research developments in 2004 and early 2005 published in English language journals on deliberate self-harm among children and adolescents up to the age of 18 years. RECENT FINDINGS: The main issue of concern in recent times has been the risk/benefit profile of using antidepressants, especially selective serotonin reuptake inhibitors, in depressed children and adolescents. Other important topics include treatment approaches, particularly cognitive behaviour therapy, dialectical behaviour therapy and multisystemic therapy, barriers to help seeking, the Internet and prevention. SUMMARY: Rates of deliberate self-harm appear to be rising among young people. Risk factors associated with deliberate self-harm are becoming clearer and the evaluation of treatments is progressing. However, the recent conflicting evidence and guidelines regarding selective serotonin reuptake inhibitors and suicidality are presenting major difficulties for clinicians. The role of the Internet and initiatives to prevent suicidal behaviour in adolescents require further research.     

SSRI and SNRI treatment in children and adolescents. Current views of the benefits and risks

The risk of suicidal thoughts and behaviours in the treatment of depressive children and adolescents with selective serotonin reuptake inhibitors (SSRI) and selective noradrenalin reuptake inhibitors (SNRI) is slightly but significantly elevated. These treatments in underage patients with anxiety or obsessive-compulsive disorders are however not related to a higher risk of suicidality. Effect sizes of SSRI/SNRI treatment in children and adolescents are medium to high in anxiety disorders (0.69), medium in obsessive-compulsive disorders (0.48), and low in depressive disorders (0.25). Nevertheless, the benefit:risk ratio is still positive in all three disorders.     

Use of selective serotonin reuptake inhibitors for the treatment of childhood panic disorder: a pilot study.

This preliminary study examines the effectiveness and safety of selective serotonin reuptake inhibitors (SSRIs) for the treatment of panic disorder in children and adolescents. In a prospective open label study, 12 children and adolescents with panic disorder were treated with SSRIs, and if necessary, with benzodiazepines, for a period of 6-8 weeks and were followed for approximately 6 months. During the trial, clinician-based and self-report rating scales for anxiety and depression, functioning, and side effects, were administered. Using the Clinical Global Impression Scale (CGIS) 75% of patients showed much to very much improvement with SSRIs without experiencing significant side effects. After controlling for changes in depressive symptoms, self-report and clinician-based anxiety scales also showed significant improvement. At the end of the trial, 67% of patients no longer fulfilled criteria for panic disorder and 4 patients remained with significant residual symptoms. In conclusion, SSRIs appear to be a safe and promising for the treatment of children and adolescents with panic disorder, however, randomized controlled trials evaluating the effects of SSRIs and other interventions (e.g., cognitive therapy) for treating panic disorder in children and adolescents are warranted. It appears that until the SSRIs begin to exert their effects, a benzodiazepine adjunct treatment might be helpful for patients with severe panic disorder.     

An emerging role for escitalopram in the treatment of obsessive-compulsive disorder

Obsessive-compulsive disorder (OCD) is a common and severe neuropsychiatric disorder treated by both behavioral and pharmacologic techniques. Despite the availability of treatments for OCD, including the selective serotonin reuptake inhibitors (SSRIs), many OCD patients have an inadequate response to current treatments. As such, additional approaches to the management of OCD are required. A potential but little studied treatment for OCD is the SSRI escitalopram. Escitalopram is the S-enantiomer of citalopram, the preparation containing both S and R enantiomers of citalopram. Not only is escitalopram the most selective of the SSRIs, it is also devoid of R-citalopram, which may interfere with the effects of the S enantiomer. Escitalopram appears to be effective in depression and several anxiety disorders, including social anxiety disorder and generalized anxiety disorder, conditions in which it also appears reasonably well tolerated. Enantiomeric specificity, high serotonin reuptake selectivity, comparatively good tolerability and favorable pharmacokinetics, and preliminary evidence of efficacy in OCD suggest a potential role for the use of escitalopram in the treatment of OCD. Nevertheless, additional work including evaluating the use of escitalopram with behavioral interventions and in long-term treatment of OCD is needed to clarify its overall role in managing OCD.     

Current research highlights in child and adolescent psychopharmacology

Recent efforts to stimulate research in pediatric psychopharmacology have resulted in increased interest in the effects of psychotropic medications in children and adolescents. This interest is reflected in the number of studies that have been reported or initiated during the past year. As a means of providing a brief update on the progress of child psychopharmacology, research reports either published or presented at national meetings in 1999 are selectively reviewed here. Relevant initiatives recently started under the sponsorship of the National Institute of Mental Health (NIMH) are also reviewed. Most studies have been directed at testing treatments of attention deficit hyperactivity disorder (ADHD), but also studies of the selective serotonin reuptake inhibitors in patients with obsessive compulsive disorder, depression, and anxiety disorders are well represented. The efforts of NIMH to focus on effectiveness research and direct comparisons of pharmacologic, psychosocial, and combined treatment modalities are apparent in recent initiatives in ADHD and depression. Research of treatments for youths with bipolar disorder, schizophrenia, autism, and eating disorders is still scanty and in urgent need of expansion.     

Pharmacotherapy of social anxiety disorder.

Over the last few years, a number of medications have demonstrated their efficacy in the acute treatment of social anxiety disorder. At present, selective serotonin reuptake inhibitors probably constitute the first line treatment, based on their safety, tolerability, and efficacy in the treatment of social anxiety disorder and common comorbid conditions. Data from single trials suggest that clonazepam, bromazepam, and gabapentin may have efficacy similar to the serotonin reuptake inhibitors, but further studies are needed to confirm these findings. The monoamine oxidase inhibitor phenelzine appears to be at least as efficacious as these other agents, but should be reserved for cases that fail to respond to these safer medications. Among the reversible inhibitors of monoamine oxidase A, brofaromine may also be an effective drug, while moclobemide appears to be less potent.Future research directions should include delineating ways to achieve remission (as opposed to response); developing strategies for augmenting partial responders and treating nonresponders to first line approaches; studying the long-term response to medication and prevention of relapse when medication is discontinued; clarifying ways to integrate psychosocial and pharmacological treatment approaches; developing predictors of which patients do best with which treatments; and the treatment of social anxiety disorder in children and adolescents.     

SNRIs Pharmacological Alternatives for the Treatment of Obsessive Compulsive Disorder?

Obsessive compulsive disorder can be a challenging psychiatric phenomenon to diagnose and treat. At the present time, recommended treatment strategies include cognitive behavioral therapy (e.g., exposure and response prevention) and pharmacotherapy (e.g., selective serotonin reuptake inhibitors and clomipramine). Unfortunately, even with adequate pharmacotherapy, only 70 percent of patients improve, indicating the clinical need for pharmacological alternatives. Such alternatives may presently exist in the group of antidepressants classified as serotonin-norepinephrine reuptake inhibitors. Although large, double-blind, placebo-controlled studies are lacking, preliminary evidence through case reports and small studies suggests potential efficacy for three currently available serotonin-norepinephrine reuptake inhibitors (e.g., venlafaxine, duloxetine, milnacipran). If genuinely efficacious, serotonin-norepinephrine reuptake inhibitors would be likely to have fewer side effects than clomipramine and might be a reasonable second-line alternative to selective serotonin reuptake inhibitors. Only further research will clarify the role of serotonin-norepinephrine reuptake inhibitors in the treatment of obsessive compulsive disorder.     

Diagnosis and treatment of body dysmorphic disorder in adolescents

Body dysmorphic disorder (BDD) is an underrecognized and underdiagnosed problem that is relatively common among adolescents. Although the onset of the disorder occurs in adolescence, BDD research in child and adolescent psychiatry is relatively limited. Body dysmorphic disorder has a high rate of co-morbidity with depression and suicide, which indicates important implications for prompt diagnosis and treatment in adolescents with BDD. Effective treatment options include cognitive behavioral therapy (CBT) and pharmacotherapy with serotonin reuptake inhibitors (SRIs). This paper provides a brief overview of BDD in adolescents, presents and evaluates the most recent literature on approaches to diagnosis and treatment, and highlights some of the characteristics that distinguish BDD from other disorders such as obsessive-compulsive disorder, social phobia, depression, and eating disorders.     

Major depressive disorder in adolescence: a brief review of the recent treatment literature.

OBJECTIVE: Treating adolescents with depression remains a major clinical and public health challenge. Because of the serious morbidity and mortality associated with adolescent major depressive disorder (MDD), there is a need to review the published literature on treatment efficacy to establish effective treatment choices for these adolescents. METHOD: We reviewed the recent literature on the treatment of MDD in adolescents using the Medline and PsycINFO computerized databases. RESULTS: Results of open studies of MDD treatment in adolescents suggested therapeutic efficacy; however, later, better-controlled studies are more difficult to interpret, owing to the high rate of improvement with placebo. Currently, there is limited evidence of robust, effective therapeutic interventions in children and in adolescent depressive disorders. CONCLUSIONS: Despite limitations, current findings from studies investigating selective serotonin reuptake inhibitors (SSRIs), cognitive-behavioural therapy, and interpersonal therapy generally support these treatments as safe and effective for adolescent MDD. Still, further investigations into these treatments for adolescent depression are warranted.     

Child and adolescent depression: short-term treatment effectiveness and long-term opportunities

As with adult major depressive disorder (MDD), child and adolescent MDD is characterized as a common, chronic and recurrent disorder. It is also associated with short- and long-term functional impairment, morbidity, and mortality. Effective treatments, both psychotherapeutic and pharmacotherapeutic, are available for the short-term treatment and management of youth with MDD. However, to date, there are no data on the long-term treatment and management of children and adolescents with MDD and how long-term treatment may affect the outcomes of either high-risk or already affected youth. Understanding the long-term consequences of MDD during youth is as important as understanding how to treat a single episode of depression. Available data on the pharmacotherapeutic and psychotherapeutic options are discussed. In general, tricyclic antidepressants (TCAs) are not as effective for the treatment of youth with MDD as adults with MDD. The selective serotonin reuptake inhibitors (SSRIs) have been shown to be effective in children and adolescents with MDD and non-obsessive compulsive anxiety disorders. The serotonin and norepinephrine reuptake inhibitor (SNRI), venlafaxine XR, has been shown to be effective for the treatment of generalized anxiety disorder in children and adolescents. Understanding the long-term clinical consequences of depressive disorders in youth may provide opportunities for better intervention across the clinical course of illness. Early recognition, diagnosis and adequate treatment of 'high-risk' youth with subsyndromal depressive symptoms, treatment of acute episodes of depression to prevent 'kindling', and aggressive prophylaxis have the potential to improve the mental health of youth throughout their lives.     

When attention-deficit/hyperactivity disorder co-occurs with anxiety disorders: effects on treatment

Anxiety disorders (ANX) and attention-deficit/hyperactivity disorder (ADHD) commonly co-occur; this comorbidity is associated with a high degree of impairment and a poor long-term prognosis. In this review, the nature of this comorbidity and its treatment will be described, and an approach to treating children with ANX + ADHD will be presented. The etiology of ANX + ADHD is controversial, with biological, developmental, environmental and cognitive factors examined in various studies. There is increasing evidence that ANX + ADHD may be distinct from each separate disorder, and may represent a neuropsychiatric condition that involves dysregulation in both anxiety and ADHD domains. Treatment usually requires a combination of medication and psychotherapeutic intervention. Stimulant medications have been found most helpful so far compared with other medications, although atomoxetine is also being studied. There is limited evidence for selective serotonin reuptake inhibitors, and their potential for behavioral activation may be problematic in these children. Intensive behavior modification was shown to be beneficial in conjunction with medication for ANX + ADHD in a multimodal treatment study of children with ADHD. Cognitive-behavioral therapy has been used to address anxiety symptoms, but may need to be individualized in ANX + ADHD as cognitive limitations and ADHD behaviors may otherwise interfere. Parental anxious or ADHD traits and the child's developmental level must also be considered to optimize treatment.     

Assessment and Treatment of Anxiety Disorders in Children and Adolescents

This article reviews the current screening and assessment tools for anxiety disorders in children and adolescents, as well as evidence-based treatment interventions for these disorders. The following anxiety disorders are discussed: separation anxiety disorder, generalized anxiety disorder, specific phobia, panic disorder, social anxiety disorder (social phobia), and selective mutism. There are several well-studied screening and assessment tools to identify childhood anxiety disorders early and differentiate the various anxiety disorders. Evaluations of baseline somatic symptoms, severity, and impairment ratings of the anxiety disorders, and collecting ratings from several sources is clinically helpful in assessment and treatment follow-up. Cognitive-behavioral therapy (CBT) has been extensively studied and has shown good efficacy in treatment of childhood anxiety disorders. A combination of CBT and medication may be required for moderate to severely impairing anxiety disorders and may improve functioning better than either intervention alone. Selective serotonin reuptake inhibitors are currently the only medications that have consistently shown efficacy in treatment of anxiety disorders in children and adolescents. Despite proven efficacy, the availability of CBT in the community is limited. Current research is focusing on early identification of anxiety disorders in community settings, increasing the availability of evidence-based interventions, and modification of interventions for specific populations.