Naturalistic Follow-up of Youths Treated for Pediatric Anxiety Disorders

JAMA Psychiatry (Impact Factor: 12.01). 01/2014; 71(3). DOI: 10.1001/jamapsychiatry.2013.4186
Source: PubMed


Pediatric anxiety disorders are highly prevalent and impairing and are considered gateway disorders in that they predict adult psychiatric problems. Although they can be effectively treated in the short term, data are limited on the long-term outcomes in treated children and adolescents, particularly those treated with medication.Objective
To determine whether acute clinical improvement and treatment type (ie, cognitive behavioral therapy, medication, or their combination) predicted remission of anxiety and improvement in global functioning at a mean of 6 years after randomization and to examine predictors of outcomes at follow-up.Design, Setting, and Participants
This naturalistic follow-up study, as part of the Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS), was conducted at 6 academic sites in the United States and included 288 youths (age range, 11-26 years; mean age, 17 years). Youths were randomized to 1 of 4 interventions (cognitive behavioral therapy, medication, combination, or pill placebo) in the Child/Adolescent Anxiety Multimodal Study (CAMS) and were evaluated a mean of 6 years after randomization. Participants in this study constituted 59.0% of the original CAMS sample.Exposures
Participants were assessed by independent evaluators using a semistructured diagnostic interview to determine the presence of anxiety disorders, the severity of anxiety, and global functioning. Participants and their parents completed questionnaires about mental health symptoms, family functioning, life events, and mental health service use.Main Outcomes and Measures
Remission, defined as the absence of all study entry anxiety disorders.Results
Almost half of the sample (46.5%) were in remission a mean of 6 years after randomization. Responders to acute treatment were significantly more likely to be in remission (odds ratio, 1.83; 95% CI, 1.08-3.09) and had less severe anxiety symptoms and higher functioning; the assigned treatment arm was unrelated to outcomes. Several predictors of remission and functioning were identified.Conclusions and Relevance
Youths rated as responders during the acute treatment phase of CAMS were more likely to be in remission a mean of 6 years after randomization, although the effect size was small. Relapse occurred in almost half (48%) of acute responders, suggesting the need for more intensive or continued treatment for a sizable proportion of youths with anxiety disorders.Trial Registration Identifier: NCT00052078

Download full-text


Available from: Courtney Pierce Keeton, Aug 26, 2014
  • Source
    • "For example, higher pretreatment severity (of OCD) and higher family dysfunction predicted poorer outcomes at 12- and 18-month follow-up (Barrett, Farrell, Dadds, & Boulter, 2005). Anxiety severity and family functioning (e.g., clear family rules; high-quality family interactions; trust) was also predictive in a 4-to 10-year follow-up of 288 participants treated for anxiety between the ages of 7 and 17: Youth with lower pretreatment anxiety severity and better family functioning were more likely to maintain gains over time (be in remission; defined as loss of all study entry anxiety disorder diagnoses) an average of 6 years later (Ginsburg et al., 2014). With regard to OCD and anxiety in youth, directly targeting these variables may enhance the maintenance of gains over time. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Stokes and Osnes (1989) outlined three principles to facilitate the generalization and maintenance of therapeutic gains. Use of functional contingencies, training diversely, and incorporating functional mediators were recommended. Our review, with most illustrations from studies of youth, updates Stokes and Osnes’s original paper with a focus on evidence-based strategies to increase generalization of therapeutic gains across settings, stimuli, and time. Research since 1989 indicates that training for generalization by increasing the frequency of naturally occurring reinforcers for positive behaviors, and altering maladaptive contingencies that inadvertently reinforce problem behaviors are associated with favorable treatment outcomes. Training diversely by practicing therapy skills across contexts and in response to varying stimuli is also implicated in clinical outcomes for internalizing, externalizing, and neurodevelopmental disorders. Preliminary research recommends the use of internal (e.g., emotion identification) and external (e.g., coping cards) functional mediators to prompt effective coping in session and at home. Strategies for increasing generalization, including the use of technology, are examined and future research directions are identified.
    Full-text · Article · Dec 2015
  • Source
    • "Our study is unique because we were able to follow untreated anxious children as compared to treated children over an average of 8 years in a naturalistic fashion utilizing existing data and infrastructure. Our findings, that show approximately 50% of anxious children remit over time, are consistent with previous LTFU findings, which followed only treated children (Ginsburg et al. 2014; James et al. 2013). Contrary to previous belief, CBT did not appear to enhance remission rates relative to our non-CBT control condition. "
    [Show abstract] [Hide abstract]
    ABSTRACT: Background Anxiety disorders are the most common psychiatric disorders of childhood, generate significant distress, are considered precursors to diverse psychiatric disorders, and lead to poor social and employment outcomes in adulthood. Although childhood anxiety has a significant impact on a child's developmental trajectory, only a handful of studies examined the long-term impact of treatment and none included a control group. The aim of this study was to conduct a long-term follow-up (LTFU) of anxious children who were treated with Cognitive–Behavioral Therapy (CBT) compared to a matched group of children who were not.Methods Subjects comprised 120 children: a treatment group which included the first 60 consecutive consenting children who were diagnosed with an anxiety disorder and treated with CBT between the years 1997 and 2003 and a control group, 60 matched children who were assessed but not treated with CBT. An “ex-post-facto” design was used to compare the two groups.ResultsChildren showed lower rates of anxiety diagnosis (about 50% for both groups) and significantly improved functioning at LTFU (time effect P < 0.0001; no group difference). Anxiety levels were significantly lower in the nontreatment group at LTFU as compared to initial assessment (P = 0.02), but not in the treatment group, and a significant between-group difference was found (P = 0.01) according to child. An inverse relationship was found between self-efficacy/self-esteem and anxiety outcome ([P = 0.0008] and [P = 0.04], respectively).Conclusions This study supports the assumption that childhood anxiety disorders may improve without treatment and highlights self-efficacy/self-esteem as potential factors in recovery.
    Full-text · Article · Sep 2014 · Brain and Behavior
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Introduction: Anxiety disorders are relatively common psychiatric illnesses in children and adolescents. In young people, such disorders are likely to show severe outcomes and adversely impact on multiple aspects of personality and social integration. Area covered: This article aims to analyze systematically the efficacy of both old- and new-generation antidepressants in children and adolescents diagnosed with non-obsessive–compulsive disorder anxiety disorders. Expert opinion: Reviewed data demonstrate that social phobia is the only pediatric anxiety disorder whose response to antidepressant medications has been investigated in an adequate number of studies. In this clinical condition, venlafaxine and fluoxetine (and fluvoxamine as second choice) are the only antidepressants that have shown convincing reports on efficacy. In contrast, apart from preliminary observations suggesting the efficacy of sertraline in pediatric generalized anxiety disorder, no evidence-based information definitively supports the use of antidepressants for managing other juvenile anxiety disorders.
    Full-text · Article · May 2014 · Expert Opinion on Drug Safety
Show more