Components of CBT Related to Outcome in Childhood Anxiety Disorders Chelsea M. Ale, Ph.D. Ale, C. M., McCarthy, D. M., Rothschild, L. M., & Whiteside,  S. P. H. (2015). Components of Cognitive Behavioral Therapy Related to Outcome in Childhood Anxiety Disorders. Clinical Child & Family Psychology Review, 18 (3), 240-251. test

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Cognitive Behavioral Therapy (CBT) “probably efficacious” for Childhood Anxiety Disorders (CADs) Chambless & Ollendick (2001) 93% of studies follow an Anxiety Management Strategies + Exposure model (AMS + EX) Reynolds, Wilson, Austin, & Hooper (2012) 6-9 weekly sessions of anxiety management strategies (AMS) Emotion identification Relaxation Problem solving 6-8 weekly sessions of exposure (Ex) Facing the feared stimuli Parents involved at the end of each meeting and in two parent-only sessions

How well does it work? Efficacy studies: Effectiveness studies: small effect: < 0.5 medium effect: 0.5 - 0.7 large effect: 0.8+ Cohen (1988) Efficacy studies: AMS+Ex moderately effective = 0.53 Reynolds, Wilson, Austin, & Hooper (2012) Clinical improvement rates: Placebo, 24% < Sertraline, 55% = AMS+Ex model, 60% < Med+CBT, 81% Walkup, Albano, Piacentini, et al. (2008) Remission rates < 50% Ginsburg GS, Kendall PC, Sakolsky, et al. (2011) Effectiveness studies: ASM+Ex studies 0 - detrimental Weisz, Kuppens, Eckshtain, Ugueto, Hawley, & Jensen-Doss (2013) Large effects for adult anxiety (0.82 - 1.46), childhood specific phobias (1.40 - 1.91), & pediatric OCD (0.99 - 2.20) Abramowitz, Whiteside, & Deacon (2005); Davis, Ollendick, & Ost, (2009); Mitte (2005); van Balkom, et al. (1994); van Etten & Taylor (1998)

Break it down? Dismantling studies called for repeatedly since the early 1990s Anxiety Management Strategies = Emotional disclosure = Waitlist Muris P, Meesters (2002); Muris, Meesters, & van Melick (2002) Symptom improvement does not begin until exposure implemented mid- treatment Kendall, et al. (1997); Ollendick (1995); Ollendick, Hagopian, & Huntzinger (1991) More exposure links to greater effects e.g., Shilpee, Kendall, Hoff, Harrison, & Fizur (2013)

Method 43 published randomized controlled trials (RCTs) for CADs 33 excluded studies: Other anxiety disorder or problem (specific phobia, school refusal, PTSD, and Autism spectrum disorder) Unique treatment delivery methods (e.g., not face-to-face) RCT authors unable to provide protocol information or raw outcome data 35 RCT for CAD and 8 RCT for OCD included: Community (42.9%), Specialty clinics (40.5%), and Both settings (16.7%) For CAD RCTs: 20 Mixed CADs (i.e., social, generalized, or separation), 9 social anxiety only, 5 undiagnosed elevated anxiety.

Method 95 experimental conditions Child Anxiety Disorders (CADs) studies 44 AMS+Ex CBT conditions 11 Attention-placebo conditions 25 Waitlist conditions Within the OCD studies 9 Exposure w/ Response Prevention (ERP) conditions Attention placebo = 5 education and support, 2 treatment as usual, 1 pill placebo, 1 emotional writing, 1 rwading an adventure story, 1 study skills

Method Compared average effect size between AMS+Ex CBT vs. Attention Placebo vs. Waitlist

Method Compared average effect size between AMS+Ex CBT vs. Attention Placebo vs. Waitlist Examined the relation of treatment condition effect size to treatment components: Relaxation, Exposure, and Parent Involvement. Compared effect sizes for AMS+Ex CBT for CADs vs. ERP CBT for OCD

Results Outcomes for Clinic-based CBT for CADs   k a Mean ES SE 95% CI Experimental Conditions Anxiety Management Strategies + Exposure (AMS+Ex) 25 1.26b 0.17 0.93 - 1.58 Attention Placebo (e.g., supportive listening) 7 1.12 0.32 0.50 - 1.74 Waitlist 13 0.18 0.23 -0.27 - 0.63 a Number of effect sizes b Differs from WL, p < .05., * p < .05. t p = .05.

Results Outcomes for Clinic-based CBT for CADs   k a Mean ES SE 95% CI Experimental Conditions Anxiety Management Strategies + Exposure (AMS+Ex) 25 1.26b 0.17 0.93 - 1.58 Attention Placebo (e.g., supportive listening) 7 1.12 0.32 0.50 - 1.74 Waitlist 13 0.18 0.23 -0.27 - 0.63 Relaxation Skills Yes 17 1.00* 0.20 0.62 - 1.40 No 8 1.83 0.30 1.24 - 2.42 a Number of effect sizes b Differs from WL, p < .05., * p < .05. t p = .05.

Results Effect Sizes by Experimental Condition AMS+Ex for CADs 29 1.18   k Mean ES SE 95% CI AMS+Ex for CADs 29 1.18 0.14 0.85 - 1.39 Attention Placebo for CADs 7 1.16 0.29 0.55 - 1.68 Waitlist for CADs 17 0.19 * 0.18 -0.15 - 0.55 Exposure w/ Response Prevention for OCD 2.09 * 0.30 1.51 - 2.68 * Means differ significantly from AMS+Ex for CADs, p < .05.

Results Effect Sizes by Experimental Condition AMS+Ex for CADs 29 1.18   k Mean ES SE 95% CI AMS+Ex for CADs 29 1.18 0.14 0.85 - 1.39 Attention Placebo for CADs 7 1.16 0.29 0.55 - 1.68 Waitlist for CADs 17 0.19 * 0.18 -0.15 - 0.55 Exposure w/ Response Prevention for OCD 2.09 * 0.30 1.51 - 2.68 * Means differ significantly from AMS+Ex for CADs, p < .05.

Results Effect Sizes by Experimental Condition AMS+Ex for CADs 29 1.18   k Mean ES SE 95% CI AMS+Ex for CADs 29 1.18 0.14 0.85 - 1.39 Attention Placebo for CADs 7 1.16 0.29 0.55 - 1.68 Waitlist for CADs 17 0.19 * 0.18 -0.15 - 0.55 Exposure w/ Response Prevention for OCD 2.09 * 0.30 1.51 - 2.68 * Means differ significantly from AMS+Ex for CADs, p < .05.

Childhood anxiety disorders (CADs) Safety behaviors Reassurance seeking Distraction? Relaxation?

Summary of Findings: Not good evidence to support the use of Anxiety Management (Emotion Recognition, Relaxation, Problem Solving) + Exposure (Facing Fears) model of CBT for CADs. Waitlist < AMS+Ex CBT = attention placebo Symptom changes with AMS+Ex CBT for CAD are significantly less than with similar interventions (i.e., ERP for OCD) Relaxation should not be included in treatment of CADs Insufficient emphasis on exposure likely contributes to the underperformance of CBT for CADs Multiple baseline designs and other component-focused experimental trials needed