Costs and cost-effectiveness of family CBT versus individual CBT in clinically anxious children

The objective of this study was to investigate the cost-effectiveness of family cognitive-behavioral therapy (CBT) compared with individual CBT in children with anxiety disorders. Clinically anxious children (aged 8-18 years) referred for treatment were randomly assigned to family or individual CBT and were assessed pre-treatment, post treatment, and at 3 months and 1 year after treatment. Cost-effectiveness ratios were calculated expressing the incremental costs per anxiety-free child and the incremental costs per Quality Adjusted Life Year (QALY) for the referred child. Neither societal costs nor effectiveness were significantly different between individual and family CBT. However, the point estimates of the cost-effectiveness ratios resulted in dominance for individual CBT, indicating that individual CBT is more effective and less costly than family CBT. These results were confirmed by bootstrap analyses and cost-effectiveness acceptability curves. Several secondary and sensitivity analyses showed that the results were robust. It can be concluded that family CBT is not a cost-effective treatment for clinically anxious children, compared with individual CBT.     

Intensive Cognitive Behavioral Therapy for Anxiety Disorders in School-aged Children with Autism: A Preliminary Comparison with Treatment-as-Usual

Children with autism spectrum disorders (ASDs) frequently present with a comorbid anxiety disorder that can cause significant functional impairment, particularly at school. An intensive modular cognitive behavioral treatment (CBT) program was delivered to address anxiety, self-regulation, and social engagement in school and in the community. A particular emphasis was placed on increasing generalizability of coping skills and positive social behavior by involving school personnel in the treatment process. Children (7–11 years old) were randomly assigned to an immediate treatment condition (IT) that included 32 sessions of CBT (n = 7) or a 16-week treatment-as-usual (TAU) condition (n = 5). The CBT sessions emphasized behavioral experimentation and emotion regulation training as well as social coaching on increasing positive peer interactions. School observations and consultations were included in the treatment model. Independent evaluators blind to treatment condition conducted structured diagnostic interviews at baseline and post-IT/post-TAU. Post-treatment analyses showed that 71.4 % of the IT group had remitted from their primary anxiety disorder diagnosis as compared with none of the TAU group. In addition, an ANCOVA analysis conducted with baseline anxiety scores included as a covariate revealed a statistically significant difference by treatment group in anxiety severity favoring the IT group at post-treatment. The 32-session CBT program is an intensive approach for children with ASD and moderate-to-severe anxiety disorders that appears to yield a clinically significant impact on anxiety symptoms. The generalizability of coping skills may be enhanced by the inclusion of school-based treatment components due to the consistency of supports this permits across the child’s daily settings.     

Impact of Cognitive Behavioral Therapy on Observed Autism Symptom Severity During School Recess: A Preliminary Randomized,Controlled Trial

This study compared cognitive behavioral therapy (CBT) and treatment-as-usual (TAU) in terms of effects on observed social communication-related autism symptom severity during unstructured play time at school for children with autism spectrum disorders (ASD). Thirteen children with ASD (7–11 years old) were randomly assigned to 32 sessions of CBT or community-based psychosocial treatment (TAU) for 16 weeks. The CBT program is based on the memory retrieval competition model and emphasizes the development of perspective-taking through guided behavioral experimentation supplemented with reflective Socratic discussion and supported by parent training and school consultation to promote generalization of social communication and emotion regulation skills. Trained observers blind to treatment condition observed each child during recess on two separate days at baseline and again at posttreatment, using a structured behavioral observation system that generates frequency scores for observed social communication-related autism symptoms. CBT outperformed TAU at posttreatment on the frequency of self-isolation, the proportion of time spent with peers, the frequency of positive or appropriate interaction with peers, and the frequency of positive or appropriate peer responses to the target child (d effect size range 1.34–1.62). On average, children in CBT were engaged in positive or appropriate social interaction with peers in 68.6 % of observed intervals at posttreatment, compared to 25 % of intervals for children in TAU. Further investigation of this intervention modality with larger samples and follow-up assessments is warranted.     

Predictors of Treatment Effectiveness for Youth with ASD and Comorbid Anxiety Disorders: It all Depends on the Family?

The study aimed to explore predictors of treatment effectiveness in a sample of 79 children with ASD who received cognitive behavioral therapy (CBT) for their anxiety disorders. Severity of anxiety disorders and anxiety symptoms were used to measure treatment effectiveness and was assessed pre-treatment, post-treatment, 3 months-, 1 and 2 years after CBT. Child characteristics and maternal anxiety did not predict treatment effect. Children with anxious fathers and children in ‘un-involved’ families had less anxiety symptoms at pre-treatment and displayed a less steep decline. Children from ‘authoritarian’ families showed higher pre-treatment anxiety levels but responded quite well to treatment. Findings stress the importance of parent (father) and family factors in the treatment of anxiety disorders in youth with ASD.     

Effects of Cognitive Behavioral Therapy on Daily Living Skills in Children with High-Functioning Autism and Concurrent Anxiety Disorders

CBT is a promising treatment for children with autism spectrum disorders (ASD) and focuses, in part, on children’s independence and self-help skills. In a trial of CBT for anxiety in ASD (Wood et al. in J Child Psychol Psychiatry 50:224–234, 2009), children’s daily living skills and related parental intrusiveness were assessed. Forty children with ASD (7–11 years) and their primary caregiver were randomly assigned to an immediate treatment (IT; n = 17) or 3-month waitlist (WL; n = 23) condition. In comparison to WL, IT parents reported increases in children’s total and personal daily living skills, and reduced involvement in their children’s private daily routines. Reductions correlated with reduced anxiety severity. These results provide preliminary evidence that CBT may yield increased independence and daily living skills among children with ASD.     

Child versus family cognitive-behavioral therapy in clinically anxious youth: an efficacy and partial effectiveness study

ObjectiveThe efficacy and partial effectiveness of child-focused versus family-focused cognitive-behavioral therapy (CBT) for clinically anxious youths was evaluated, in particular in relation to parental anxiety disorders and child's age.MethodClinically referred children with anxiety disorders (N = 128) and their parents were randomly assigned to child or family CBT and evaluated at pretreatment, posttreatment, and 3-month follow-up. Twenty-five families were measured before and after a 2- to 3-month waitlist period.ResultsNone of the waitlisted children recovered from their anxiety disorders. In contrast, 41% of the treated children no longer met criteria for any anxiety disorder after CBT, and 52% demonstrated continued improvement at the 3-month follow-up. Significantly more children were free of anxiety disorders (53%) in the child CBT condition compared with family CBT condition (28%) at posttreatment, whereas at 3-month follow-up, the superior effect of child CBT was no longer significant. Similar results were obtained from the questionnaire measures. Both child and family CBT were less effective if parents had an anxiety disorder themselves. On some of the measures, child CBT was superior if parents had anxiety disorders themselves, whereas family CBT was superior if parents had no anxiety disorders. Finally, younger children had better outcomes than older children, regardless of the treatment condition.ConclusionsOverall, child CBT seems slightly more beneficial than family CBT. Because this study was conducted in a clinical setting with clinically referred children, results indicate partial effectiveness for child CBT.     

Maternal anxiety predicts favourable treatment outcomes in anxiety-disordered adolescents

Objective: To determine the differential impact of maternal and paternal internalizing psychopathology on cognitive‐behavioural treatment (CBT) outcome of anxiety‐disordered children and adolescents. Method: Participants consisted of 127 children and 51 adolescents with a primary anxiety diagnosis. Children were randomly assigned to a standardized group CBT or individual CBT; adolescents received individual CBT. Parents received four training sessions. Participants were evaluated at pre‐ and post‐treatment with a clinical interview and with self‐ and parent‐reported questionnaires. Lifetime anxiety and mood disorders in parents were obtained with a clinical interview. Results: For children, no associations were found between maternal and paternal anxiety or mood disorders and treatment outcome. For adolescents, however, maternal lifetime anxiety disorders were positively associated with pre‐post‐treatment improvement in clinician severity ratings and with treatment success. Conclusion: Lifetime maternal anxiety disorders were significantly associated with favourable treatment outcomes in adolescents. Paternal disorders were not associated with treatment response.     

Motivational interviewing and cognitive behaviour therapy for anxiety following traumatic brain injury: A pilot randomised controlled trial

Although cognitive-behavioural therapy (CBT) is the treatment of choice for anxiety, its delivery needs to be adapted for individuals with traumatic brain injury (TBI). It also requires clients' active engagement for maximum benefit. This study was a pilot randomised controlled trial involving an anxiety treatment programme adapted for people with TBI, based on CBT and motivational interviewing (MI). Twenty-seven participants with moderate/severe TBI (aged 21–73 years, 78% males) recruited from a brain injury rehabilitation hospital were randomly allocated to receive MI?+?CBT (n?=?9), non-directive counselling (NDC)?+?CBT (n?=?10) and treatment-as-usual (TAU) (n?=?8). CBT and MI were manualised and delivered in 12 weekly individual sessions. Primary outcome was self-reported anxiety symptoms assessed at baseline, at the end of NDC/MI and immediately following CBT. Assessment was conducted by assessors blinded to group assignment. Intention-to-treat analyses showed that the two active treatment groups demonstrated significantly greater anxiety reduction than TAU. Participants receiving MI showed greater response to CBT, in terms of reduction in anxiety, stress and non-productive coping, compared to participants who received NDC. The results provided preliminary support for the adapted CBT programme, and the potential utility of MI as treatment prelude. Longer follow-up data are required to evaluate the maintenance of treatment effects.     

Group and individual cognitive-behavioral therapy for childhood anxiety disorders: a randomized trial

OBJECTIVE: To compare the efficacy of group and individual cognitive-behavioral therapy (CBT) in children with Axis I anxiety disorders. It was hypothesized that certain subgroups would respond preferentially to one modality. METHOD: Seventy-eight children aged 8-12 years with diagnosed anxiety disorders were randomly assigned to a 12-week, manual-based program of group or individual CBT, both with parental involvement. Outcomes included child anxiety (child and parent report) and global functioning as estimated by clinicians. Repeated-measures analyses of variance (ANOVAs) were done. The sample was then dichotomized by self-reported social anxiety (high/low) and parent-reported hyperactivity (high/low) using median splits, and diagnostically by generalized anxiety disorder versus phobic disorders. ANOVAs were repeated. RESULTS: Children and parents reported significantly decreased anxiety and clinicians reported significantly improved global functioning regardless of treatment modality. Children reporting high social anxiety reported greater gains in individual treatment than in group treatment (p <.01). Parent reports of hyperactivity and diagnostic differences were not associated with differential treatment response by modality. CONCLUSIONS: Children with anxiety disorders appear to improve with CBT, whether administered in a group or individual format. A subgroup of children reporting high social anxiety may respond preferentially to individual treatment. Replication of these findings is indicated.     

A Cost of Illness Study of Children with High-Functioning Autism Spectrum Disorders and Comorbid Anxiety Disorders as Compared to Clinically Anxious and Typically Developing Children

The study’s aim was to estimate the societal costs of children with high-functioning ASD and comorbid anxiety disorder(s) (ASD + AD-group; n = 73), and to compare these costs to children with anxiety disorders (AD-group; n = 34), and typically developing children (controls; n = 87). Mean total costs for the ASD + AD-group amounted €17,380 per year. Societal costs were estimated at almost 142 million euro per year. Costs in the ASD + AD-group were four times higher compared to the AD-group, and 27 times higher compared to controls. ASD-related costs were higher in the ASD + AD-group; anxiety-related costs did not differ between the ASD + AD- and AD-group; costs due to physical or other reasons did not differ across groups. The findings suggest that costs can be decreased if effective treatment options for treating anxiety in ASD are established, however, the remaining costs associated with ASD would still be large. A limitation of the study is that a group of children with ASD without anxiety disorders is lacking.     

Efficacy of a computer-assisted cognitive-behavior therapy program for treating youth with anxiety and co-occurring autism spectrum disorder: Camp Cope-A-Lot

BackgroundIn a crossover design the current study describes the efficacy of a computer-assisted intervention program for youth with autism spectrum disorder (ASD) who also experience co-occurring anxiety.MethodsThe computer-assisted cognitive behavior therapy (CBT) program for treating anxiety, Camp Cope-A-Lot (CCAL) was compared to control intervention, another computer-assisted program, The Social Express (TSE), that does not employ CBT nor is targeted for the treatment of anxiety. TSE is designed to improve social skills in youth with ASD. Participants had a principal anxiety disorder and a current diagnosis of ASD. Participants received 12-sessions of CCAL or 12-sessions of TSE. Outcome measures were obtained at intake, upon completion of the first intervention of the trial and upon completion of the second intervention of the trial.ResultsCCAL was efficacious for treating anxiety. Participants who completed CCAL demonstrated significant and clinical reductions in anxiety when compared to participants who completed TSE. Both interventions, CCAL and TSE, resulted in some limited improvement in social skills.ConclusionsThe current study showed that anxiety symptoms in youth with ASD and co-occurring anxiety disorders can benefit from computer-assisted CBT employing CCAL. This expands previous literature employing computer-assisted CBT interventions in youth, and more specifically, youth with ASD.     

Treatment of childhood anxiety disorders: a preliminary comparison between cognitive-behavioral group therapy and a psychological placebo intervention

The present study examined the efficacy of group cognitive-behavioral therapy (CBT) in the treatment of childhood anxiety disorders. Thirty high-anxious children (aged 9-12 years) were assigned to either (a) group CBT (n = 10), (b) a psychological placebo intervention (i.e., emotional disclosure [ED]; n = 10), or (c) a no-treatment control condition (n = 10). Therapy outcome measures (i.e., children's self-report of anxiety disorders symptoms, depression, and trait anxiety) were obtained three months before treatment, at pretreatment, and at posttreatment. Results showed that levels of psychopathological symptoms remained relatively stable during the three months preceding treatment. Most importantly, pretreatment-posttreatment comparisons indicated that CBT was superior to ED and the no-treatment control condition. That is, only in the CBT condition significant reductions of anxiety disorders symptoms, trait anxiety, and depression were observed. These findings can be taken as further evidence for the efficacy of CBT in the treatment of childhood anxiety disorders.     

Motivational interviewing and cognitive behaviour therapy for anxiety following traumatic brain injury: A pilot randomised controlled trial

Although cognitive-behavioural therapy (CBT) is the treatment of choice for anxiety, its delivery needs to be adapted for individuals with traumatic brain injury (TBI). It also requires clients' active engagement for maximum benefit. This study was a pilot randomised controlled trial involving an anxiety treatment programme adapted for people with TBI, based on CBT and motivational interviewing (MI). Twenty-seven participants with moderate/severe TBI (aged 21-73 years, 78% males) recruited from a brain injury rehabilitation hospital were randomly allocated to receive MI?+?CBT (n?=?9), non-directive counselling (NDC)?+?CBT (n?=?10) and treatment-as-usual (TAU) (n?=?8). CBT and MI were manualised and delivered in 12 weekly individual sessions. Primary outcome was self-reported anxiety symptoms assessed at baseline, at the end of NDC/MI and immediately following CBT. Assessment was conducted by assessors blinded to group assignment. Intention-to-treat analyses showed that the two active treatment groups demonstrated significantly greater anxiety reduction than TAU. Participants receiving MI showed greater response to CBT, in terms of reduction in anxiety, stress and non-productive coping, compared to participants who received NDC. The results provided preliminary support for the adapted CBT programme, and the potential utility of MI as treatment prelude. Longer follow-up data are required to evaluate the maintenance of treatment effects.     

Evaluating a cognitive behavioral therapy group program for anxious five to seven year old children: a pilot study

Background: Cognitive Behavioral Therapy (CBT) has demonstrated benefits for anxious school‐aged children and adolescents; however, treatment programs have not been developed to teach CBT strategies to children under the age of eight. This pilot study examined a novel treatment program for children aged 5–7 years with anxiety disorders. Methods: Thirty‐two children (19 females) aged 5–7 years (mean age=6.51 years) with DSM‐IV anxiety disorders and their families completed a 12‐week, manualized CBT group program. Parent and child groups (5–8 children per group) were held separately but concurrently. Multiple measures of anxiety (Screen for Child Anxiety Related Emotional Disorders, Anxiety Disorders Interview Schedule for DSM‐IV—Parent Version, and clinician Children's Global Assessment Scale ratings) were completed pre and post each treatment series. A subset of participants (n=11; 8 females; mean age=6.34 years) completed an initial assessment followed by a wait period of approximately 3.5 months (range 2.5–5 months) with a second assessment just before treatment start. No treatment was received during this wait time. Results: With treatment, 43.8% of children no longer met criteria for any Axis 1 anxiety disorders whereas 71.9% had at least one anxiety disorder resolve. A series of paired, two‐tailed t‐tests revealed significant reduction in anxiety symptoms on standardized measures. Children who waited for treatment showed no significant change in anxiety symptoms during nontreatment but demonstrated improvement after program attendance. Conclusions: This pilot study suggests that CBT can be used effectively to treat anxious children as young as 5 years of age. Further research is warranted. Depression and Anxiety, 2009. © 2009 Wiley‐Liss, Inc.     

Cognitive-Behavioral Treatment Versus an Active Control for Children and Adolescents With Anxiety Disorders: A Randomized Trial

ObjectivesThe current trial examined whether a specific cognitive-behavioral treatment package was more efficacious in treating childhood anxiety disorders than a nonspecific support package.MethodOne hundred twelve children (aged 7-16 years) with a principal anxiety disorder were randomly allocated to either a group cognitive-behavioral treatment (CBT) program or a control condition (group support and attention [GSA]).ResultsOverall, results showed that CBT was significantly more efficacious compared with the GSA condition: 68.6% of children in the CBT condition did not meet diagnostic criteria for their principal anxiety diagnosis at 6-month follow-up compared with 45.5% of the children in the GSA condition. The results of the child- and parent-completed measures indicated that, although mothers of CBT children reported significantly greater treatment gains than mothers of GSA children, children reported similar improvements across conditions.ConclusionsSpecific delivery of cognitive-behavioral skills is more efficacious in the treatment of childhood anxiety than a treatment that includes only nonspecific therapy factors.     

Family cognitive behavioral therapy for child anxiety disorders

OBJECTIVE: This study compared family-focused cognitive behavioral therapy (CBT; the Building Confidence Program) with traditional child-focused CBT with minimal family involvement for children with anxiety disorders. METHOD: Forty clinically anxious youth (6-13 years old) were randomly assigned to a family- or child-focused cognitive-behavioral therapy (CBT). Conditions were matched for therapist contact time. Both interventions included coping skills training and in vivo exposure, but the family CBT intervention also included parent communication training. Independent evaluator, parent, and child report measures with demonstrated validity and reliability were used to assess child anxiety symptom outcomes at pre- and posttreatment. The data analytic strategy involved an evaluable patient analysis. RESULTS: Compared with child-focused CBT, family CBT was associated with greater improvement on independent evaluators' ratings and parent reports of child anxiety--but not children's self-reports--at posttreatment. CONCLUSIONS: Both treatment groups showed improvement on all outcome measures, but family CBT may provide additional benefit over and above child-focused CBT. These findings provide preliminary support for the efficacy of the "Building Confidence" program and encourage further research in parental participation in treatment for childhood anxiety.     

One year follow-up to modular cognitive behavioral therapy for the treatment of pediatric anxiety disorders in an elementary school setting

The current study sought to evaluate the relative long-term efficacy of a modularized cognitive behavioral therapy (CBT) program for children with anxiety disorders. Twenty four children (5–12 years old) randomly assigned to modular CBT or a 3-month waitlist participated in a 1-year follow-up assessment. Independent evaluators blind to treatment condition conducted structured diagnostic interviews, and caregivers and children completed symptom checklists at pre- and post-, and 1 year follow-up assessments. Analyses revealed that 71.4% of children who received CBT demonstrated a positive treatment response 1 year following treatment, and 83.3% were free of any anxiety diagnosis at 1 year follow-up. Analyses further revealed robust effects of intervention on diagnostic outcomes, caregiver- and child-report measures of anxiety at 1 year follow-up. Results provide evidence of an ongoing advantage on anxiety-specific outcomes for this modularized school-based CBT program 1 year post-treatment.     

Anxiety problems in young people with autism spectrum disorder: a case series

It is now well established that the prevalence of mental health difficulties in individuals with autism spectrum disorders (ASD) is considerably higher than in the general population. With recent estimates of the prevalence of autism spectrum disorders being as high as one percent, increasing numbers of children and young people are presenting to local and specialist services with mental health problems in addition to a diagnosis of ASD. Many families report that the impact of the mental health problems can be as or more impairing than the autism spectrum difficulties themselves. Clinical services are frequently called upon to treat these difficulties; however, there is limited evidence for the effectiveness of treatments in this population. This paper reports a case series of children and adolescents with ASD and an anxiety disorder who were treated with a standard cognitive behaviour therapy (CBT) rationale adapted to take account of the neuropsychological features of ASD. Common features of the presentation of the disorders and also treatment processes are discussed.     

Anxiety Disorders in Typically Developing Youth: Autism Spectrum Symptoms as a Predictor of Cognitive-Behavioral Treatment

Symptoms of autism spectrum disorder (ASD) were assessed (Social Responsiveness Scale-Parent (SRS-P); coded in-session behavior) in typically-developing, anxiety-disordered children (N = 50) treated with cognitive-behavioral therapy (CBT). Study 1: children with moderate autistic symptomology (per SRS-P) were significantly more likely to improve from family CBT (FCBT) than individual CBT (ICBT; OR = 8.67). Coded behavior did not predict outcome. Study 2: CBT components were compared by treatment and ASD symptom status. At-home exposure completion was greater in FCBT and there was an interaction in child involvement for treatment and ASD status. Though both treatments reduced anxiety, FCBT outperformed ICBT for children with moderate ASD symptoms, a benefit potentially linked to more at-home exposures and greater child involvement in FCBT.     

School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups

ObjectiveTo follow 61 participants (7–11 years old) from a study that compared three school-based interventions for anxious children: group cognitive-behavioral therapy (CBT) for children, group CBT for children plus parent training, and no-treatment control to determine whether posttreatment benefits are sustained longitudinally.MethodParent, child, and clinician report measures of child anxiety were completed at 3,6, and 12 months posttreatment. Semistructured diagnostic interviews were administered at 6- and 12-month follow-ups. For initial analyses, the group CBT and group CBT plus parent training conditions were collapsed into one group and compared to control. When significant results were found, each active treatment group was compared to control.ResultsAcross several measures, the collapsed CBT group sustained significant improvement in anxiety severity and impairment across a 12-month period compared to control. There were no significant differences between the three groups on remission of baseline anxiety disorders or incidence of new anxiety disorders during the follow-up. Several parent-report measures at 3 and 6 months posttreatment suggested that group CBT for children plus parent training provided additional benefit over the group CBT for children when each was compared to the control group.ConclusionsSchool-based CBT appears effective in decreasing anxiety symptoms up to 12 months posttreatment for anxious children. J. Am. Acad. Child Adolesc. Psychiatry, 2008; 47(9): 1039–1047.