I’m going to do a couple of blog posts examining the treatment of anxiety disorders in children and youth. While these posts may not seem terribly relevant to serving kids in church environments, pastors and church leaders are looked to as resources by families when their children are in need of help.
In general, the most effective approach to treating kids with significant anxiety is a combination of medication and a very specific counseling approach referred to as cognitive-behavioral therapy (CBT). While combination therapy may work best, not every child needs medication at the outset of treatment. The severity of the child’s anxiety and the degree to which anxiety interferes with the child’s day to day functioning usually determines the approach to treatment. Kids with milder forms of anxiety will typically try counseling before medication. Kids most likely to require a trial of medication are those with moderate to severe anxiety, those with other psychiatric or emotional disorders in conjunction with anxiety and kids who have not responded or responded incompletely to an appropriate trial of cognitive-behavioral therapy.
The most comprehensive study to date examining treatment of anxiety in children and teens was the Child and Adolescent Multimodal Treatment (CAMS) study. In this study, 488 children between the ages of 7-17 diagnosed with separation anxiety disorder, social anxiety disorder or generalized anxiety disorder were randomly assigned to groups treated with sertraline (brand name: Zoloft) for twelve weeks, 14 sessions of CBT, medication plus CBT, or placebo pills. Response rates were as follows:
From a statistical standpoint, the combination of CBT and medication was significantly more effective than therapy alone or medication alone. CBT and medication were equally effective, and both treatments were more effective than placebo pills.
What’s so unique about cognitive-behavioral therapy (CBT)?
CBT is the counseling approach with the most research support for effectiveness in the treatment of kids with anxiety disorders.
In CBT, children learn coping skills to develop a sense of mastery over anxiety symptoms or situations associated with significant distress. CBT approaches used to treat children with anxiety include educating the child and their parents about the anxiety disorder and the purpose of therapy, equipping them with relaxation techniques to help moderate physical symptoms associated with anxiety, addressing misperceptions that lead to negative expectations and negative self-image, exposing the child to situations, real or imagined, associated with anxiety symptoms, and development of strategies to help prevent the relapse of symptoms. Behavioral interventions are designed to help positively reinforce the child’s willingness to expose themselves to anxiety-provoking situations. Parents are taught the various interventions and strategies so they can serve as coaches, helping their children to practice the strategies at home.
The component of the counseling found to be most impactful in the CAMS study was exposure. Exposure usually occurs later in the course of treatment and occurs when the child is deliberately placed in a situation that would usually provoke great anxiety, after having been equipped with coping strategies for managing their response to the situation. For example, a child unwilling to go outside because of a fear of being stung by bees might go to a park in the middle of summer with their therapist for a picnic lunch.
Specific CBT interventions are tailored to the nature of the child’s anxiety symptoms. Children with phobias may benefit from graded exposure to the object or situation that triggers fear. They may benefit from observing their therapist or parents as they approach the object or situation they fear. Social skill training may be incorporated into treatment of children with social anxiety.
Two studies demonstrated that educating kids about the nature, causes and course of anxiety disorders without teaching other CBT techniques was of benefit in reducing anxiety symptoms. Presumably, educational interventions along with supportive counseling result in kids becoming more comfortable with exposing themselves to anxiety-provoking situations.
Are other approaches to counseling or therapy helpful to kids with anxiety disorders?
While a great deal of case experience is reported using traditional psychodynamic psychotherapy to treat anxiety disorders in children, there is very little research support for such treatment approaches.
Several studies have examined family-based treatment approaches to the child with anxiety. The CAMS study included two visits specifically to train parents in the use of CBT techniques. Other studies have shown benefit from addition of a parental component to treatment in situations when one or both parents are anxious.
What are the limitations of talk therapy for kids with anxiety?
Not every child is going to respond to cognitive-behavioral therapy. In the CAMS study, 40% of kids who received CBT alone hadn’t experienced a significantly positive response after twelve weeks of treatment with the best therapy protocols conducted by expert clinicians at prestigious academic medical centers. Twelve weeks may feel like a lifetime to the child experiencing acute anxiety as well as to the parent who has to cope with feelings of helplessness watching their child suffer. The benefits of talk therapy in the CAMS study only became significant by the ninth week of the study. Kids don’t immediately become proficient in the anxiety management skills learned in therapy sessions.
A very significant limitation of talk therapy is the degree to which success of the treatment is dependent upon the level of skill of the child’s therapist. Most clinicians will have had some lecture and class discussion of the principles of cognitive-behavioral therapy. Fewer will have had specific training or supervision in CBT. Fewer still will have had training or supervision in implementing CBT with children as opposed to adults. In many parts of the U.S. families may not have access to adequately trained clinicians. The most competent clinicians often choose not to accept the highly discounted rates of payment offered by insurance companies.
Wednesday: The role of medication for kids with anxiety