Psychotherapy of Childhood Anxiety Disorders: A Meta-Analysis

Department of Clinical Child and Adolescent Psychology, University of Basel, Basel, Switzerland.
Psychotherapy and Psychosomatics (Impact Factor: 9.2). 02/2007; 76(1):15-24. DOI: 10.1159/000096361
Source: PubMed
ABSTRACT
The present study compared the efficacy of psychotherapy for childhood anxiety disorders (excluding trials solely treating post-traumatic stress disorder or obsessive-compulsive disorder).
The meta-analysis included studies that met the basic CONSORT (consolidated standards of reporting trials) criteria. Several outcome variables (e.g. effect sizes, percentage of recovery) were analyzed using completer and intent-to-treat analyses during post-treatment and follow-up assessment. Twenty-four studies published by March 2005 were included in this meta-analysis.
In all the included studies, the active treatment condition was cognitive-behavioral. The overall mean effect of treatment was 0.86. No differences in outcome were found between individual and group treatments or child- and family-focused treatments. Follow-up data demonstrated that treatment gains were maintained up to several years after treatment.
These findings provide evidence that anxiety disorders in children can be treated efficaciously. The gathered data support the clinical utility of cognitive-behavioral therapy in this regard. Randomized controlled trial studies investigating treatments other than cognitive-behavioral therapy are missing.

Full-text

Available from: Tina In-Albon
Fax +41 61 306 12 34
E-Mail karger@karger.ch
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Special Article
Psychother Psychosom 2007;76:15–24
DOI: 10.1159/000096361
Psychotherapy of Childhood Anxiety
Disorders: A Meta-Analysis
Tina In-Albon Silvia Schneider
Department of Clinical Child and Adolescent Psychology, University of Basel, Basel , Switzerland
Introduction
Anxiety disorders are the most prevalent mental dis-
orders not only of adulthood but also of childhood and
adolescence [1, 2] . Trait anxiety seems to have increased
greatly [3] and new research shows that childhood anxiety
disorders are important risk factors for the development
of mental disorders in adulthood, including anxiety dis-
orders, depression and substance abuse [4–6] . The devel-
opment and dissemination of effi cacious treatments are,
therefore, essential.
Clinical research on psychotherapy for anxiety disor-
ders in children has advanced considerably in recent
years. Different research groups have conducted several
randomized controlled trials (RCTs) and substantial
progress has been made in treating anxiety disorders in
children and adolescents. However, these studies need to
be summarized and discussed.
Meta-analyses represent an empirical approach to
evaluating psychotherapy research. For a review of
strengths and limitations of meta-analyses, see Sensky [7] .
First meta-analyses have been published examining the
effi cacy of child and adolescent psychotherapies in gen-
eral; yet further specifi c analyses of anxiety disorders were
not the aim of these studies. Casey and Berman [8] re-
ported an overall outcome effect size of 0.74 for child
psychotherapy (n = 75; studies published from 1952 to
1983) and an average treatment versus control effect size
of 1.16 for phobias (n = 9 studies). Weisz et al. [9]
aggre-
Key Words
Child psychotherapy evaluation Childhood anxiety
disorders Treatment evaluation
Abstract
Background: The present study compared the effi cacy of
psychotherapy for childhood anxiety disorders (exclud-
ing trials solely treating post-traumatic stress disorder
or obsessive-compulsive disorder). Methods: The meta-
analysis included studies that met the basic CONSORT
(consolidated standards of reporting trials) criteria. Sev-
eral outcome variables (e.g. effect sizes, percentage of
recovery) were analyzed using completer and intent-to-
treat analyses during post-treatment and follow-up as-
sessment. Twenty-four studies published by March 2005
were included in this meta-analysis. Results: In all the
included studies, the active treatment condition was cog-
nitive-behavioral. The overall mean effect of treatment
was 0.86. No differences in outcome were found be-
tween individual and group treatments or child- and fam-
ily-focused treatments. Follow-up data demonstrated
that treatment gains were maintained up to several years
after treatment. Conclusions : These fi ndings provide ev-
idence that anxiety disorders in children can be treated
effi caciously. The gathered data support the clinical util-
ity of cognitive-behavioral therapy in this regard. Ran-
domized controlled trial studies investigating treatments
other than cognitive-behavioral therapy are missing.
Copyright © 2007 S. Karger AG, Basel
Silvia Schneider, PhD
Universität Basel, Institut für Psychologie
Abteilung Klinische Kinder- und Jugendpsychologie
Missionsstrasse 60/62, CH–4055 Basel (Switzerland)
Tel. +41 61 267 06 50, Fax +41 61 267 06 48, E-Mail silvia.schneider@unibas.ch
© 2007 S. Karger AG, Basel
0033–3190/07/0761–0015$23.50/0
Accessible online at:
www.karger.com/pps
Page 1
In-Albon/Schneider
Psychother Psychosom 2007;76:15–24
16
gated the effects of 39 treatment-control comparisons and
reported a mean overall effect size of 0.79 for child psy-
chotherapy (n = 163; studies published from 1958 to
1984) and a mean effect size of 0.74 for phobias and anx-
iety.
A meta-analysis by Weisz et al. [10] produced an effect
size of 0.60 (n = 16 studies) for phobias and anxiety and
an overall effect size of 0.54 (n = 150; studies published
from 1967 to 1993). An examination of the different types
of therapies used in these studies showed that most were
behavioral therapies. In addition, effects were more ro-
bust for behavioral than nonbehavioral treatments.
A major limitation of previously published meta-anal-
yses is the inclusion of studies which did not require the
establishment of diagnoses on the basis of DSM or ICD
criteria. Furthermore, these meta-analyses did not in-
clude studies published after 1993. However, in the last
10 years, substantial progress has been made regarding
psychotherapy research in the area of childhood anxiety
disorders.
In order to improve the quality of reports using RCTs
and to comprehend the results of RCTs, the consolidat-
ed standards of reporting trials (CONSORT) were de-
veloped. The CONSORT criteria checklist contains
recommendations for four stages of a trial (enrolment,
intervention allocation, follow-up, and analysis). Ac-
cording to current guidelines [11, 12] (http://www.con-
sort-statement.org) and the fact that in recent years, sev-
eral methodologically rigorous child and adolescent anx-
iety treatment outcome studies have been completed,
the purpose of this paper was to provide a comprehen-
sive meta-analysis of child and adolescent psychothera-
py outcomes for anxiety disorders, including only stud-
ies that meet basic methodological criteria. Just recent-
ly, an extensive review by Compton et al. [13] summarized
RCTs on anxiety and depression and concluded that
cognitive-behavioral therapy (CBT) is currently the
treatment of choice for anxiety and depression in chil-
dren and adolescents [see also 14] . However, this review
did not include any statistical analyses summarizing the
results of these studies and did not analyze different
treatment settings, which could be relevant regarding
treatment outcome. Therefore, the present study means
to close this gap and summarize the overall effect sizes
of recently published RCTs, including analyses of dif-
ferent treatment settings in regard to treatment out-
come. The data are aggregated from published studies
in the fi eld and multiple outcome variables are reported
including effect sizes of several treatment settings (e.g.
individual vs. group treatment or child- vs. family-fo-
cused treatment), recovery rates (both completer and
intent-to-treat), sustained recovery rates and the results
of follow-up assessments.
Method
Literature Search
In this meta-analysis, we included only published, peer-re-
viewed psychotherapy outcome studies in English and German.
The literature search was conducted in PsycINFO and Medline
(= PubMed) using the following key words: ‘childhood’, ‘children’,
‘anxiety disorders’, ‘specifi c phobia’, ‘simple phobia’, ‘social pho-
bia’, ‘panic disorder’, ‘separation anxiety disorder’, ‘generalized
anxiety disorder’, ‘overanxious disorder’, ‘avoidant disorder’, ‘ther-
apy’, ‘outcome’, and ‘treatment’. We also included psychotherapy
studies that were listed in the reference sections of the papers we
collected after the initial computer search and conducted an Inter-
net search. This literature search produced a total of 36 treatment
studies. Obsessive-compulsive disorder (OCD) and post-traumatic
stress disorder (PTSD) will not be addressed in this meta-analysis
because both basic research and psychotherapy research of these
two disorders differ substantially from childhood anxiety disorders
mentioned above. In this regard, there is an ongoing discussion
whether OCD should even be assigned to anxiety disorders (see
ICD-10). For separate reviews of psychotherapy research in OCD
and PTSD, see Cartwright-Hatton et al. [14] , Cohen et al. [15] ,
Franklin et al. [16] and Simons et al. [70] .
Inclusion Criteria
All studies included in this meta-analysis were required to have
investigated the effi cacy of a specifi c treatment for anxiety disor-
ders in children against a control condition or alternative credible
psychotherapeutic treatment. Participants (i.e., the children who
were treated) had to have met DSM or ICD diagnostic criteria for
a principal anxiety disorder, and participants had to have been
randomly assigned to either treatment or control conditions (i.e.,
an RCT). In accordance with the CONSORT guidelines, the au-
thors of the studies were required to have written a standard treat-
ment protocol. In order to facilitate computation of effect sizes,
studies were included only if they reported means and standard
deviations of the outcome measures as well as sample sizes at each
assessment time point. We excluded studies in which treatment
groups had fewer than 10 patients (lack of power), single case stud-
ies, subclinical cases and psychopharmacological studies. Studies
had to have been published by March 2005. All decisions were
made a priori, before examining any individual studies. These sev-
eral steps produced a pool of 24 studies for further analyses. An
overview of all the studies is in Appendix 1. The treatment orien-
tation of the excluded studies was primarily CBT, except the chart
review of Target and Fonagy [18] , which involved a psychody-
namic approach.
Effect Size
The effect size (Cohen’s d) is an index of the size and direction
of treatment effects. Cohen [19] suggests that an effect size of 0.20
may be considered a small effect, 0.50 a medium effect, and 0.80
a large effect.
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Effi cacy of Psychotherapy for Childhood
Anxiety
Psychother Psychosom 2007;76:15–24
17
We computed different effect sizes for both treatment and con-
trol conditions including a global effect size and separate effect
sizes for the three most commonly used outcome measures (see
below). Effect sizes were calculated for pre-/post-treatment and for
pre-follow-up assessments. Within each study, effect size values
were averaged across all outcome variables to an overall effect size
(one effect size per study). In a second step, these effect sizes were
averaged across all studies (global effect size). Specifi c effect sizes
were calculated separately for the most commonly used measure-
ments, i.e. Revised Children’s Manifest Anxiety Scale (RCMAS),
Fear Survey Schedule for Children-Revised (FSSC-R), and Chil-
dren’s Depression Inventory (CDI) within each study and then av-
eraged across all studies. In addition, 95% confi dence intervals were
computed for the effect sizes of each category. When the associated
confi dence intervals do not include 0, this indicates that the aver-
age effect size is signifi cantly greater than zero at p ! 0.05. Q sta-
tistic was calculated to determine whether the effect size data from
the studies are homogeneous. If the studies share a common effect
size, the value of Q will be nonsignifi cant. Fail-safe number statis-
tics were calculated to check the robustness of the fi ndings and
whether signifi cant mean effect sizes might have been infl ated by a
publication bias [20] . The fail-safe number informs about the num-
ber of fi le drawer studies required to bring the mean effect size down
to a defi ned level. Orwin [21] adopted Rosenthal’s formula for
probabilities to effect sizes d: n
fs
= [n
total
(mean
d
– d
crit
)]/d
crit
.
In additional analyses, we distinguished between child- and
family-focused treatments. Child-focused treatment was defi ned as
the treatment which focuses on the children and in which the par-
ents are either not included at all or minimally involved (i.e., in
three sessions or fewer). Family-focused treatment was defi ned as
the treatment in which parents are actively involved in the treat-
ment process for more than three sessions, the nature and extent of
parental involvement being clearly described in the treatment pro-
cedure section of the study.
Recovery
Percent recovered is an essential index of a clinically signifi cant
change. However, most of the studies reported recovery rates based
on the percentage recovered compared to those who completed
treatment rather than those who entered treatment (i.e., intent-to-
treat). Intent-to-treat analyses produce a more conservative esti-
mate of recovery by answering the question: ‘Of those patients who
entered in and began treatment, what percentage is likely to re-
cover?’ We will report recovery rates for both completer and intent-
to-treat analyses.
Follow-Up Data
Follow-up data provide an accurate picture of the effi cacy of
treatment and its lasting effects.
Measures
In order to establish diagnoses before and after treatment and
at follow-up and to determine diagnostic recovery, most studies
used the Anxiety Disorders Interview Schedule for Children (ADIS)
[22] . The ADIS is a structured diagnostic interview consistent with
the DSM-IV criteria. It assesses child functioning (anxiety, mood,
and externalizing disorders) in separate interviews: one with the
child and one with the parents. The ADIS contains a Clinician Se-
verity Rating, a scale ranging from 0 (absent) to 8 (very severe) that
represents the degree of symptom severity and interference of di-
agnosis assigned by the interviewer based on clinical information
provided by the interview. The interview has good interrater reli-
ability for the child and the parent interview, adequate test-retest
reliability [23] , and is sensitive to treatment effects in studies with
youths with anxiety disorders [24] .
Child Measures
The RCMAS [25] measures chronic anxiety and is one of the
most frequently used anxiety self-report measures for children. The
RCMAS consists of 37 items, each one rated as true or false. There
has been extensive work supporting the RCMAS’s validity and re-
liability [25] . Signifi cant correlations have been found between
RCMAS scores and other self-report measures of anxiety and re-
lated constructs such as depression [26] .
The FSSC-R consists of 80 items and assesses specifi c fears in
children [27] . The child rates his or her level of fear on a three-point
Likert scale. Ollendick [27] reported solid internal consistency and
adequate test-retest reliability.
The CDI consists of 27 items and assesses cognitive, affective,
and behavioral symptoms of depression. For each item, children
are given three choices from which they select the one which best
describes themselves over the past 2 weeks. The CDI has good in-
ternal consistency, moderate test-retest reliability [28] and corre-
lates in the expected direction with measures of related constructs
such as self-esteem, negative cognitive attributes, and hopelessness
[29] .
Procedure
We assessed the following major variables from each study:
sample size, means and standard deviations of outcome measures,
percentage of children who completed treatment, pre-/post-treat-
ment and treatment-control effect sizes, and percentage of children
who recovered after treatment, both for those who entered (intent-
to-treat) and for those who completed treatment. For follow-up, we
assessed the same variables provided that such data were avail-
able.
Effect Size Calculation
The pre-/post-treatment and pre-follow-up effect sizes were cal-
culated as follows:

12
22
112 2
12
11
2
tt
ttt t
tt
MM
NSDNSD
NN
es
d
where M is the mean of the measurement, t1 represents the pretreat-
ment assessment, t2 represents the post-treatment or follow-up as-
sessment, N is the sample size, and SD the standard deviation
[30] .
To investigate the treatment-control effect size we used the fol-
lowing formula:

TGpost CGpost TGpre CGpre
es
pooledpre pooledpre
MM MM
d
SD SD
¯¯

¡°¡°
¡°¡°
¡°¡°
¢±¢±
where M is the mean of the measurement, TG represents the treat-
ment group, CG represents the control group, and SD
pooledpre
is the
pooled within-group standard deviation.
Page 3
In-Albon/Schneider
Psychother Psychosom 2007;76:15–24
18
Results
Data from 24 clinical trials were included in this meta-
analysis. In all 24 studies, the active treatment condition
was cognitive-behavioral. Twelve studies included indi-
vidual treatment and fi fteen included group therapy.
Seventeen studies included child-focused treatment and
14 included family-focused treatment. Sixteen studies
had a waiting list control condition; the remaining in-
cluded an alternative therapy as a control condition. The
length of treatment ranged from 3 to 18 sessions, with an
average length of 12.3 sessions. The total number of pa-
tients across all studies was 1,275, and the mean age of
participants was 10.9 years (range: 6–18 years). The vast
majority of studies evaluated the effi cacy of psychother-
apy in children with anxiety disorders. Only the study of
Ginsburg and Drake [31] examined the feasibility and
effectiveness of a school-based group CBT for anxiety
disorders with low-income African-American adoles-
cents. The study conducted by Baer and Garland [32]
evaluated a CBT program in a community psychiatric
setting.
Interventions Used by the Studies
Most programs were designed to target the child’s anx-
iety using a mixture of exposure techniques (90.5%), cog-
nitive restructuring strategies (66.7%), relaxation tech-
niques (52.4%), and positive self-talk (38.1%). In regard
to parents, the majority of family-focused treatment stud-
ies used the following interventions: teaching parents to
deal and cope with child anxiety and its related behaviors,
teaching communication and problem-solving skills, and
managing the parents’ own anxiety. Interventions used in
the attention placebo control condition were designed to
provide the child and the parents with a broad range of
information about anxiety (education support), but no
encouragement or instructions were offered to confront
feared situations [33–36] .
Exclusion Criteria Used by the Studies
1
Many studies excluded children with psychotic symp-
toms (72.2%) and mental retardation (50%). Most studies
(77.8%) excluded children who were currently involved
in psychosocial or psychopharmacological treatment.
However, more recent studies [32, 37–39] did include
children who were on psychopharmacological medica-
tion, as long as they maintained a constant dosage on the
same medication throughout the duration of the study.
Completion Rates
Most children who entered treatment (n = 1,275) com-
pleted it (n = 1,080; 84.7%). Completion rates were 85.8%
for group treatment, 84.9% for individual therapy, 82.9%
for family-focused treatment, and 84.9% for child-fo-
cused treatment. Thus, very similar completion rates
were found across all modes of treatment.
Effect Sizes
Active Treatment vs. Waiting List (Global and
Specifi c Effect Sizes)
The mean overall pre-/post-treatment effect size across
all treatments was d = 0.86 (95% CI = 0.69–1.03; n = 24),
whereas the effect size for the waiting list control group
was d = 0.13 (95% CI = 0.03–0.24; n = 16). The specifi c
effect sizes for the three most common treatment out-
come measurements (RCMAS, FSSC-R, and CDI) were
as follows: pre-/post-treatment effect size in the treatment
condition was 0.83 (95% CI = 0.64–1.02) for trait anxiety
(RCMAS) and 0.85 (95% CI = 0.45–1.24) for phobic anx-
iety (FSSC-R). In the control condition, effect sizes were
0.22 (95% CI = 0.08–0.35; RCMAS) and 0.32 (95% CI =
0.11–0.54; FSSC-R). Furthermore, symptoms of depres-
sion (CDI) improved signifi cantly (d = 0.70; 95% CI =
0.54–0.86) in the treatment condition compared to the
waitlist control condition (d = 0.20; 95% CI = 0.07–0.33).
The mean overall treatment versus control effect size
across all active treatments averaged 0.66 (95% CI =
0.36–0.96) at the post-treatment assessment. The t test
with independent samples revealed a signifi cant differ-
ence between treatment versus control effect size [t(37) =
6.92, p = 0.00].
Homogeneity of effect sizes for post-test data was test-
ed. The resulting
2
value was nonsignifi cant [
2
(24) =
25.08, p = 0.20], indicating that the assumption of homo-
geneity for the post-test effect sizes cannot be rejected.
The fail-safe number of this study suggests that 79 fi le
drawer studies with effect sizes of zero are necessary to
reduce the effect size of 0.86 to a mean effect size of 0.20.
To reduce the effect size of 0.86 to a mean effect size of
0.50, 17 studies of zero effect would be necessary.
Follow-Up
Of the 24 outcome studies, 16 reported short-term fol-
low-up assessment data. On average, short-term follow-
up assessments occurred 10.4 months after the end of
treatment. The effect size for pre-follow-up was 1.36 (95%
1
The exclusion criteria for each study included in this meta-analysis can be
requested from the authors.
Page 4
Effi cacy of Psychotherapy for Childhood
Anxiety
Psychother Psychosom 2007;76:15–24
19
CI = 0.78–1.94; n = 16). There are 3 long-term follow-up
studies: the 6-year follow-up study by Barrett et al. [40] ,
the 3.4-year study by Kendall and Southam-Gerow [41]
and the 7.4-year study by Kendall et al. [42] . The long-
term effect size for the study by Kendall and Southam-
Gerow [41] was 0.61. The effect size for the 6-year follow-
up study of Barrett et al. [40] was 0.82. Finally, the effect
size for the 7.4-year follow-up study by Kendall et al. [42]
was 1.13 for child report and 1.54 for parent report.
Treatment Setting (Global Effect Sizes)
Table 1 displays the mean overall pre-/post-treatment
and pre-follow-up effect sizes for the outcome studies by
treatment type. Group and individual treatments were
equally effective in reducing children’s symptoms. The
mean overall treatment versus control pre-/post-treat-
ment effect sizes were 0.52 (95% CI = 0.04–0.99) for in-
dividual therapy and 0.61 (95% CI = 0.44–0.79) for group
therapy. The t test with independent samples revealed a
nonsignifi cant difference [t(11) = 0.33, p = 0.75].
As shown in table 1 , the pre-/post-treatment effect size
for child-focused treatments was similar to the effect size
of treatments involving parents. The mean overall treat-
ment versus control pre-/post-treatment effect sizes were
0.53 (95% CI = 0.30–0.77) for child-focused therapy and
0.63 (95% CI = 1.3–0.58) for family-focused therapy. This
difference was not signifi cant [t(21) = 0.26, p = 0.79].
Placebo Condition vs. Waiting List (Global Effect
Sizes)
We compared waiting list control conditions with ac-
tive, nonspecifi c control conditions, and the pre-/post-
treatment effect sizes were 0.13 (95% CI = 0.03–0.24;
n = 16) for waiting list and 0.58 (95% CI = –1.6 to 1.3;
n = 4) for attention placebo control.
Percent Recovered
Table 2 displays the percentage of patients who recov-
ered from those who completed and those who entered
treatment. Across all active treatments, 68.9% of children
who completed therapy no longer met the diagnostic cri-
teria for their principal pretreatment anxiety disorder
compared to only 12.9% of children who were assigned
to a waiting list. The t test with independent samples re-
Pre-/
post-treatment
95% CI Follow-up 95% CI
Individual therapy 1.00 (n = 6) 0.80–1.21 1.04 (n = 5) 0.61–1.47
Group therapy 0.97 (n = 10) 0.62–1.32 1.64 (n = 4) –0.84 to 4.11
Child-focused therapy 0.91 (n = 16) 0.73–1.1 1.30 (n = 10) 0.75–1.85
Family-focused therapy 0.83 (n = 10) 0.42–1.25 1.38 (n = 9) 0.44–2.3
Some studies investigated more than one treatment setting.
Table 1. Pre-/post-treatment and follow-up
effect sizes (d) and 95% confi dence
intervals for individual vs. group therapy
and for child-focused vs. family-focused
therapy
Percent recovered of
completed
Percent recovered of
entered (intent-to-treat)
mean 8 SD n mean 8 SD n
Individual treatment 72.1814.48 11 57.3817.42 7
Group treatment 6688.84 12 53.287.36 6
Child-focused treatment 64.1810.46 12 54.4812.95 11
Family-focused treatment 76.987.88 10 65.2814.76 9
All active treatments 68.9811.75 21 55.4813.43 13
Waiting list control group 12.989.8 15
There is a signifi cant difference between the treatment and waiting list control
groups.
Table 2. Percentage of patients who
recovered of those who completed or
entered treatment
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Psychother Psychosom 2007;76:15–24
20
vealed a signifi cant difference between treatment versus
control group after treatment with respect to children
without anxiety diagnosis [t(34) = 15.06, p ! 0.00]. At the
follow-up assessment, the recovery rate of children who
completed treatment increased slightly to 72%.
Individual and group therapies showed comparable
recovery rates of 72.1% and 66%, respectively. For the
intent-to-treat sample, the overall recovery rate after
treatment was 55.4%. Intent-to-treat recovery rates were
similar for individual (57.3%) and group (53.2%) therapy.
Child- and family-focused treatment showed recovery
rates of 64.1% and 76.9%, respectively. For the intent-to-
treat sample, the recovery rate after treatment for child-
focused treatment was 54.4% and 65.2% for family-fo-
cused treatment. Because of a lack of the majority of treat-
ment studies to report the number of dropouts in the
waiting list conditions, the intent-to-treat recovery rate
could not be investigated.
Discussion
In the present study, we examined 24 RCTs out of a
pool of 36 treatment outcome studies on anxiety disor-
ders in children and adolescents. The results of the pres-
ent study indicate that treatment produces acute effects,
which refl ect substantial symptom improvement. The
current fi ndings are consistent with previous meta-analy-
ses and provide convergent evidence that CBT is effective
for children with anxiety disorders.
The robust effects of therapy are refl ected in the pre-/
post-treatment effect sizes of 0.86 in the treatment and
0.13 in the waiting list control conditions. Of the children
included in our study who completed treatment, 68.9%
recovered to the extent that they no longer met criteria
for their principal pretreatment anxiety diagnosis. In
comparison, only 12.9% of waiting list participants recov-
ered. Furthermore, the fail-safe number statistic shows
that 79 fi le drawer studies with effect sizes of zero are
needed to reduce this effect size to a mean effect size of
0.20.
Symptom improvements following treatment occurred
not only for anxiety but also for depression. The treat-
ment versus control effect size was 0.66. Previous meta-
analytic estimates reported similar [10] or higher pre-/
post-treatment effect sizes [8, 9] in general child and ado-
lescent psychotherapy.
Interestingly, the attention placebo control condition
reached a pre/post-treatment effect size of 0.58 (n = 4).
Compared to the overall pre-/post-treatment effect size
of the active treatment condition (0.86), the effect size for
the active control condition is quite high. Four studies
included in our meta-analysis compared their active in-
terventions with an attention placebo control condition
[33–36] . However, only the study of Beidel et al. [33] and
Muris et al. [36] used a strict placebo condition consisting
of study skills, test-taking strategies and emotional disclo-
sure, which led to a signifi cant treatment vs. placebo ef-
fect. The two other studies included psychoeducation on
anxiety comparable to information given in CBT pro-
grams, which were equally effective as the active treat-
ments. Thus, these results could imply that improvement
in childhood anxiety disorder can be achieved purely with
psychoeducation on anxiety, without explicit instructions
for exposures. This interesting issue requires further in-
vestigation.
Treatment outcome studies comparing the effi cacy of
child-alone therapy to interventions involving both chil-
dren and parents have found confl icting results. As in the
meta-analysis of Casey and Berman [8] , we did not fi nd
a difference between the two types of treatment. The
mean treatment versus control effect size was 0.53 for
child-focused therapy and 0.63 for family-focused treat-
ment. To date, there is no clear empirical evidence indi-
cating who might benefi t more from one type of therapy
over the other. Some data suggest that younger children
and children with parents who have an anxiety disorder
themselves may benefi t more from a combined child and
parent treatment than from a child-alone therapy [43,
44] . However, in the study by Barrett et al. [43] , the rela-
tive superiority of CBT plus family anxiety management
condition compared to CBT alone at the 12-month post-
treatment assessment disappeared at the 6-year follow-up
assessment [40] . Likewise, the results of other studies
[45–47] suggest that for some children, a child-alone ap-
proach may be suffi cient for anxiety symptom reduction.
Further research must examine the role of parental in-
volvement in treatment for children with different anxi-
ety disorders and identify child and family characteristics
that will enable clinicians to assign anxious children to
either a child-alone intervention or a combined parent-
child intervention.
While earlier studies established the effi cacy of indi-
vidual therapy in treating child anxiety disorders, the re-
sults of a number of recent trials suggest that group treat-
ment may be equally effi cacious [38, 48] . In the present
study, the mean effect sizes for group and individual ther-
apy were comparable. These results should nevertheless
be interpreted with caution. A number of group treatment
studies in our meta-analysis included family-focused in-
Page 6
Effi cacy of Psychotherapy for Childhood
Anxiety
Psychother Psychosom 2007;76:15–24
21
terventions (n = 7), making it diffi cult to disentangle the
effects of group therapy and family involvement. Though
Muris et al. [38] have recently demonstrated the similar-
ity in outcomes of group and individual treatment with-
out parental involvement in either condition, future re-
search should continue to investigate this question while
controlling the overlap of family-focused and group treat-
ment settings.
Weisz et al. [9, 10] and Kazdin et al. [49] reported in
their meta-analyses that only around one third of all pub-
lished treatment outcome studies reported data from fol-
low-up assessments. Recently published studies seem to
have improved in this regard, as 16 (66.7%) of the 24 out-
come studies included in our meta-analysis reported fol-
low-up data. In our meta-analysis, the mean pre-follow-
up effect size was 1.36, suggesting that treatment gains
were well maintained. Furthermore, 72% of the children
did not meet the criteria for their principal pretreatment
diagnosis at follow-up. These results are consistent with
three long-term follow-up studies [40–42] , which have
demonstrated that the effects of child anxiety treatments
are relatively stable and long-lasting (up to 7.4 years).
With the exception of fi ve studies that investigated the
effi cacy of psychotherapy for social phobia [32, 33, 46,
50, 51] , none of the other treatment studies differentiated
between the different types of anxiety disorders. In fact,
these studies tested general treatments for anxiety disor-
ders in groups of children with different anxiety disorders
(separation anxiety disorder, generalized anxiety disor-
der, specifi c phobia, social phobia). However, RCT stud-
ies with a focus on specifi c anxiety disorders, in particular
separation anxiety disorder, generalized anxiety disorder
and specifi c phobia, are needed to complement the previ-
ous global approaches.
All studies included in the meta-analysis investigated
the effi cacy of CBT. Thus, non-CBT outcome studies that
fulfi ll the methodological criteria required by CONSORT
are still missing. In the literature search for the present
study, we found a chart review of child psychoanalysis
and psychotherapy of children with emotional disorders
[18] , which reported an improvement rate of 47.2% in a
large child sample (n = 352). However, this study did not
meet the inclusion criteria for our meta-analysis (see Ap-
pendix 2).
It has to be considered that the studies included in this
meta-analysis demonstrate effi cacy of psychotherapy for
anxious children; however, effectiveness has to be prov-
en. Therefore, now that CBT trials are found to be suc-
cessful, it is important to extend studies to the clinical
settings. Baer and Garland [32] investigated a pilot study
of community-based cognitive-behavioral group therapy
for adolescents with social phobia. Although the sample
size (n = 12) was small, the study provides support for the
use of simplifi ed cognitive-behavioral interventions in
community psychiatric settings. Similar conclusions can
be drawn from the study of Ginsburg and Drake [31] that
evaluated the feasibility and effectiveness of a school-
based group treatment for anxiety disorders with African-
American adolescents. For the evaluation of the present-
ed results, general limitations regarding meta-analyses
have to be considered. The reported effect sizes only pro-
vide information about how much the patients improved
after therapy compared to their values before therapy.
Thus, the effect sizes do not provide information regard-
ing symptom severity and functional level after therapy
compared to healthy control participants.
Reported effect sizes are based entirely on self-report
measures, due to the fact that parent and teacher reports
were not regularly assessed. However, the gold standard
in assessing effi cacy of psychotherapy in children and ad-
olescents should be the inclusion of self-reports as well as
parent and teacher reports [71] . Further psychotherapy
research should take this into consideration in order to
get a sound and accurate description of therapy out-
come.
Knowing how to treat childhood anxiety disorders is
important. Such knowledge both helps ease the suffering
of children and contributes to the reduction and preven-
tion of future suffering as adults. As we work toward im-
proving psychotherapy for childhood anxiety disorders,
we must especially focus on helping those children for
whom existing therapies continue to produce less than
optimal outcomes.
Acknowledgements
This research was supported by a Swiss National Science Foun-
dation scholarship to Tina In-Albon (PBBS1-102350) and by a
grant of the Swiss National Science Foundation to Silvia Schneider
(SNF PP001-68701). The authors thank David A. Moscovitch, Mi-
chael K. Suvak, Department of Psychology, Boston University, and
Andrea H. Meyer, University of Basel.
Page 7
In-Albon/Schneider
Psychother Psychosom 2007;76:15–24
22
Appendix 1
Studies Included in the Meta-Analysis
Study n Age Mode Diagnosis Weeks Com-
pleted, %
FU Pre-/post-treatment effect size (d)
per treatment condition
4
Baer and Garland
[32] 12 13–18 Gr
1
SoP 12 36 SPAI: 1.20
Barrett et al. [43]
79 7–14 Ind
1, 2
SAD, OAD, SoP 12 94 6, 12 months; Barrett
et al. [40]: 6 years
CBT: 0.59, CBT+Fam: 0.89
Barrett [48]
60 7–14 Gr
1, 2
SAD, OAD, SoP 12 83 12 months FSSC-R Ch: 1.54, FSSC-R Fam:
2.37
Beidel et al. [33]
67 8–12 Gr
1, 3
SoP 12 75 6 months SPAI: 1.21; SPAI Tb: 0.18
Cobham et al. [44]
67 7–14 Ind,
act tx
1, 2
SAD, OAD, GAD, SPP, SoP 10 91 6, 12 months CBT Ch anx: 0.77, CBT+PAM Ch
anx: 0.49, CBT+PAM Ch+Pa anx:
0.40, CBT Ch+Pa anx: 0.66
Flannery-Schröder
et al. [52] 37 8–14 Ind+Gr
1
GAD, SAD, SoP 18 76 3 months Ind: 1.26, Gr: 0.73
Gallagher et al. [51]
23 8–11 Gr
1
SoP 3 50 3 weeks 0.36
Ginsburg et al. [31]
12 14–17 Gr
1
GAD, SPP, AG, SoP 10 75 SCARED: 0.27
Hayward et al. [50]
35 14–18 Gr
1
SoP 16 81 12 months SPAI: 1.10
Heyne et al. [45]
61 7–14 Ind, act tx
1, 2
SAD, SoP, GAD, PD, OCD,
CD
8 4.5 months Ch: 0.51, Pa+Te: 1.58, Ch+Pa+Te:
0.78
Kendall [53]
47 9–13 Ind
1
SAD, OAD, AD 16 78 12 months; Kendall
and Southam-Gerow
[41]: 3.4 years
1.32
Kendall et al. [54]
94 9–13 Ind
1
SAD, OAD, AD 16 80 12 months; Kendall
et al. [42]: 7 years
1.08
King et al. [55]
34 5–15 Ind
2
SAD, OAD, SoP, SPP, CD 4 100 3 months 1.37
Last et al. [34]
56 6–17 Ind
2, 3
Schoolpho
4
12 73 1 month STAIC-T CBT: 0.57, STAIC-T ES:
1.33
Manassis et al. [37]
78 8–12 Ind+Gr
2
GAD, SAD, SPP, SoP, PD 12 SASC Gr: 0.21, SASC Ind: 0.43
Mendlowitz et al.
[39] 62 7–12 Gr, act tx
1, 2
12 91 Ch: 0.26, Pa: 0, Ch+Pa: 0.33
Muris et al. [38]
36 8–13 Gr+Ind
1
GAD, SAD, SoP 12 100 STAIC Ind: 0.82, STAIC Gr: 1.08
Muris et al. [36]
30 9–12 Gr
1, 3
GAD, SAD, SoP 12 80 STAIC: 1.38
Nauta et al. [47]
79 7–18 Ind
1, 2
SAD, SoP, GAD, PD 12 96 3 months SCAS Ch: 1.13, SCAS Pa: 0.65
Rapee [56]
95 7–16 Gr
2
SAD, GAD, SoP 12 12 months 0.81
Silverman et al. [69]
56 6–16 Gr
2
OAD, SoP, GAD 73 3, 6, 12 months 0.64
Silverman et al. [35]
81 6–16 Ind
2, 3
SPP, SoP, AG 10 78 3, 6, 12 months SC: 0.91, CM: 0.57, ES: 0.27
Spence et al. [46]
50 7–14 Gr, act tx
1, 2
SoP 6, 12 months Ch: 0.97, Ch+Pa: 0.75
Toren et al. [57]
24 6–13 Gr
2
SAD, OAD 10 12, 36 months 0.58
SAD = Separation anxiety disorder; GAD = generalized anxiety disorder; OAD = overanxiety disorder; SoP = social phobia; SPP = specifi c phobia; PD =
panic disorder; AG = agoraphobia; CD = conduct disorder; Schoolpho = school refusal; Gr = group treatment; Ind = individual treatment; act tx = active pla-
cebo treatment; SPAI = Social Phobia and Anxiety Inventory; SCARED = Screen for Childhood Anxiety Related Emotional Disorders; SCAS = Spence Child
Anxiety Scale; STAIC-T = State-Trait Anxiety Inventory for Children; SASC = Social Anxiety Scale for Children; ES = education support; SC = exposure-based
cognitive self-control; CM = exposure-based contingency management; PAM = parental anxiety management; Tb = testbuster.
1
Child-focused treatment.
2
Family-focused treatment.
3
Attention-placebo control group.
4
Effect sizes are indicated for outcome measure RCMAS, when not otherwise specifi ed.
Page 8
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Anxiety
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23
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  • Source
    • "Another meta-analysis of psychotherapy for anxiety disorders based on 24 randomized controlled trials (all CBT treatment ) found a recovery rate of 68.9 %, and an effect size of .82 [26]. A review of the current treatment of pediatric depression (both psychotherapy and pharmacotherapy) estimated remission rates of depression to be 60 % within 6 months [40]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: To examine demographic and clinical characteristics as potential predictors of change for children and youth with emotional disorders treated at two child and adolescent mental health outpatient services (CAMHS) in Norway. Methods: The study was of naturalistic observational type with "treatment as usual" (TAU). The sample consisted of 84 children and youth with emotional disorders. The Health of the Nation Outcome Scale (HONOSCA), and the Children's Global Assessment Scale (CGAS) were administered at intake (T0), during the assessment (T1) and approximately six months after assessment (T2). Change was analysed by means of the linear mixed models procedure. Results: For the HONOSCA total score, youths with a diagnosis of depression had statistically higher symptom severity levels at baseline and significantly lower change rates as compared to youths with an anxiety disorder. Conclusions: The current study adds to the limited knowledge of predictors of rate of change for children and adolescents with emotional disorders treated within CAMHS. Our results point to a special need to improve clinical care for depressed children and adolescents. Important limitations comprising the external validity of the study concern missing data, a small study sample, and lack of information regarding the content and extent of the service provided.
    Full-text · Article · Dec 2016 · Child and Adolescent Psychiatry and Mental Health
  • Source
    • "Some studies show no superiority of family-based treatment (e.g. [48, 49]), Table 4. Hierarchical prediction of adaptive child ER-S by maternal ER-S and age (including first order as well as interaction terms). 2: Predicting adaptive child ER-S (R 2 = .193*) "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Social anxiety is thought to be strongly related to maladaptive emotion regulation (ER). As social anxiety symptoms accumulate in families, we hypothesize that maladaptive ER is also more prevalent in families with anxious children. Thus, we analyze differences in emotion regulation of both child and mother in relation to social anxiety, as well as both their ER strategies in dealing with anxiety. Further, a positive relation between child and maternal ER strategies is assumed. Method: Children (aged 9 to 13 years) with social, anxiety disorder (SAD; n = 25) and healthy controls (HC, n = 26) as well as their mothers completed several measures of social anxiety and trait ER strategies towards anxiety. As ER of children is still in development, age is considered as covariate. Results: SAD children and their mothers reported more maladaptive ER strategies than HC dyads. Maternal maladaptive ER was related negatively to child adaptive ER which was further moderated by the child's age. Discussion: Maladaptive ER strategies seem to contribute to the exacerbation of social anxiety in both mother and child. Mothers reporting maladaptive ER may have difficulties supporting their child in coping with social anxiety while simultaneously also experiencing heightened levels of anxiety. Deeper understanding of interactional processes between mothers and children during development can assist the comprehension of factors maintaining SAD. Implications for future research and possible consequences for interventions are discussed.
    Full-text · Article · Apr 2016 · PLoS ONE
    • "Undetected or undertreated, these disorders present significant future risk for adult anxiety disorders, educational underachievement, suicidality, depression, substance abuse and future hospitalization5671516171819. Cognitive behavioral therapy (CBT) as a first-line treatment for anxiety disorders in children and adolescents is well established [20,21,22] and supported by meta-analytic work [23,24,25]. CBT combines systematic exposure to feared situations with skills training and the learning of activities to help replace anxious thoughts about feared situations with more adaptive thoughts [20,21]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: There is a demand to make first-line treatments, including cognitive behavioural therapy (CBT) for adolescent anxiety disorders, more widely available. Internet-based CBT is proposed to circumvent access and availability barriers and reduce health care system costs. Recent reviews suggest more evidence is needed to establish the treatment effects of Internet-based CBT in children and adolescents and to determine related economic impacts. Objective: This pilot trial aims to collect the necessary data to inform the planning of a full-scale RCT to test the effectiveness of the Internet-based CBT program Breathe (Being Real, Easing Anxiety: Tools Helping Electronically). Methods: We are conducting a 27-month, 2-arm parallel-group, pilot randomized controlled trial (RCT). Outcomes will inform the planning of a full-scale RCT aimed to test the effectiveness of Internet-based CBT with a population of adolescents with moderate to mild anxiety problems. In the pilot RCT we will: (1) define a minimal clinically important difference (MCID) for the primary outcome measure (total anxiety score using the Multidimensional Anxiety Scale for Children); (2) determine a sample size for the full-scale RCT; (3) estimate recruitment and retention rates; (4) measure intervention acceptability to inform critical intervention changes; (5) determine the use of co-interventions; and (6) conduct a cost-consequence analysis to inform a cost-effectiveness analysis in the full-scale RCT. Adolescents aged 13-17 years seeking care for an anxiety complaint from a participating emergency department, mobile or school-based crisis team, or primary care clinic are being screened for interest and eligibility. Enrolled adolescents are being randomly allocated to either 8 weeks of Internet-based CBT with limited telephone and e-mail support, or a control group with access to a static webpage listing anxiety resources. Adolescents are randomly assigned using a computer generated allocation sequence. Data are being collected at baseline, treatment completion, and at a 3-month follow-up. Results: Currently, adolescents are being enrolled in the study. Enrolment is taking place between March 2014 and February 2016; data collection will conclude May 2016. We expect that analysis and results will be available by August 2016. Conclusions: In many communities, the resources available for front-line anxiety treatment are outweighed by the need for care. This pilot RCT is an essential step to designing a robust RCT to evaluate the effectiveness of an Internet-based CBT program for adolescents with moderate to mild anxiety problems. Trial registration: Clinicaltrials.gov NCT02059226; http://clinicaltrials.gov/ct2/show/NCT02059226 (Archived by WebCite at http://www.webcitation.org/6epF8v7k4).
    No preview · Article · Jan 2016
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