Success in treating childhood anxiety

Posted: October 31, 2008

More than 80 percent of children suffering from the most common psychiatric disorders - anxieties and phobias that can make them fear the future and avoid trick-or-treating - dramatically improved on a combination of medication and 12 weeks of therapy, researchers reported yesterday in the biggest study of its kind.

Nearly 60 percent were helped by either the antidepressant alone or the cognitive behavioral therapy program that was developed by a Temple University psychologist two decades ago and is now used around the world.

The Coping Cat program - aka Coping Bear in Canada and Coping Koala in Australia - encourages children to recognize, experience and then master their fears.

"You'll still feel them, but instead of, 'Oh my god, my heart's racing,' " said Philip C. Kendall, director of Temple's Child & Adolescent Anxiety Disorders Clinic, "you'll know what to do."

"You start out as a scaredy cat or a fraidy cat and you become a coping cat."

Estimates of the number of children with debilitating anxieties or social phobias vary wildly. Many experts think it is about 10 percent of American children and adolescents.

"These are common conditions, and families and practitioners need to look for them," said John T. Walkup, associate professor of psychiatry and behavioral sciences at Johns Hopkins, "because the treatments are pretty good."

Walkup, the lead author of the new study, presented the findings at the American Academy of Child & Adolescent Psychiatry meeting in Chicago. They were simultaneously published online by the New England Journal of Medicine.

Medication and cognitive behavioral therapy are the two main treatments for childhood anxiety disorders, but they had never been directly compared before.

Four study groups

The study, funded by the National Institute of Mental Health, followed 488 children between the ages of 7 and 17 at six U.S. centers, including Temple, who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder or social phobia. They were randomly placed in four groups:

One group received 14 sessions of therapy over 12 weeks and up to 200mg a day of the antidepressant sertraline, also sold under the brand name Zoloft.

A second got therapy alone.

A third got only the drug, a form of selective serotonin reuptake inhibitor (SSRI). It is approved by the Food and Drug Administration to treat children as young as 6 for obsessive compulsive disorder.

A fourth group got a placebo drug.

More than four-fifths of the children in the combination group improved on various measures. Cognitive behavioral therapy was second, but the difference between that group and the drug group - 60 percent succeeded in the therapy group v. 55 percent on sertraline - was not statistically significant. One quarter improved on placebo.

No serious adverse events were linked to any of the treatments. Minor reactions such as headaches were also uncommon, although more likely in the drug groups.

At least half of children typically don't respond to one treatment or the other, and both parents and children may have preferences, researchers said.

"What's significant about this study is we are able to talk now with data behind us that there are these three options," said Anne Marie Albano, associate professor of clinical psychology at Columbia University Medical Center and a study author.

Children with these disorders experience a range of fears and anxieties that may cause them to insist on sleeping in their parents' bed or not talking with peers. Left untreated, they are more likely to become depressed or abuse substances as adults.

'Not normal'

They take a big toll on families, who sometimes turn the house upside down to accommodate them.

Often, like obesity, they are considered normal, said Walkup. "But obesity is not normal. The same thing with anxiety disorders."

In the form of cognitive behavioral therapy practiced at the Temple University clinic, children first work with a therapist to identify the physical symptoms of their anxieties, such as butterflies in the stomach, and what situations trigger them.

Then they practice techniques - in the clinic, and then in the real world - that will help them get past their fears.

The clinic's staff of more than a dozen, mostly doctoral students in psychology, provides treatment mainly as part of ongoing research with outside funding, so the sessions are often free for families. A small outpatient clinic also takes children not in research studies on what Kendall called a "generous sliding scale."

Although the findings presented yesterday covered just 12 weeks, another phase is continuing. And previous research has found that it made a difference years later.

Kendall's Coping Cat program was the first structured approach to use cognitive behavioral therapy to treat children with anxiety disorders, other researchers said. Versions of it are used around the world, and virtually all other cognitive behavioral therapies for these disorders developed since then use it as a model, they said.

"It really is hard to find a CBT program that doesn't have Dr. Kendall's stamp on it," said Albano, who developed a program of her own at Columbia.

Is Your Child Overly Anxious?

All children experience anxiety. But about one in 10 suffer from an anxiety disorder that causes significant distress and seriously interferes with the child's life.

Children with serious anxiety typically exhibit at least two

of the following:

Physical symptoms such as headaches, stomachaches, etc.

Withdrawing from or avoiding various situations

such as trick-or-treating or eating in the cafeteria.

Self-consciousness, self-criticism, or perfectionism.

Difficulty attending school or separating from parents.

Excessive concern about future and past events.

SOURCE: Temple University Child & Adolescent Anxiety Disorders Clinic

Links to information about the Temple clinic and the Coping Cat program, including independent research and an animated demonstration of how kids learn to deal with their fears:

Contact staff writer Don Sapatkin at 215-854-2617 or

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