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Is it effective to use parent–child cognitive behavioural therapy (CBT) for anxiety disorders in children between 4 and 7 years of age?
64 children (average age of 5.4 years) with current Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) anxiety disorder diagnosis (based on Schedule for Affective disorder and Schizophrenia for School Age Children, Epidemiologic version, K-SADS-E). Among the participants 77% had more than one DSM-IV anxiety disorder, and the rates of the individuals disorders were as follows: 44% had separation anxiety disorder, 67% had social anxiety disorder, 44% had generalised anxiety disorder (GAD), 36% had agoraphobia and 48% had specific phobia. For 73% of the children at least one parent had a lifetime history of major anxiety disorder (panic disorder, agoraphobia, social phobia, GAD and/or obsessive compulsive disorder) and 44% had at least one parent with a current major anxiety disorder. Exclusions: parent with current psychosis, substance abuse or suicidality; children with mental retardation, prescribed psychiatric treatment, previous CBT or judged by two clinicians to be either too uncooperative or distractible to take part in the trial or too severely symptomatic to wait 6 months for treatment.
Oupatient research clinic at a general hospital, USA; recruitment February 2001 to January 2004.
Parent–child CBT or waiting list control for 6 months. CBT involved 20 sessions, either with parent and child (13 sessions) or with the parent only (7 sessions). CBT used a manual called Being Brave: A Program for Coping with Anxiety for Young Children and Their Parents, which was specially modified for use with younger children.
Response (much or very much improved on the Clinical Global Impression Scale for Anxiety); no longer meeting DSM-IV diagnosis of anxiety disorder.
89.1% at 6 months, 100% included in intention-to-treat (ITT) analysis. Only the CBT group was followed up at 1 year (85.3% follow-up).
Randomised controlled trial.
Single blind (outcome assessors blinded).
1 year (post-treatment).
Parent–child CBT significantly increased the proportion of children who responded compared with waiting list control at the end of treatment (completer analysis: 69% with CBT vs 32% with control, p<0.01; ITT analysis: 59% with CBT vs 30% with control, p=0.016). Parent–child CBT also significantly increased the proportion of children who were free from anxiety disorders post-treatment (completer analysis: 59% with CBT vs 18% with control, p<0.01; ITT analysis: 50% with CBT vs 16.7% with control p<0.01). One year after CBT completion, 83% of treatment completers were rated as responders (very much or much improved from baseline) and none were unchanged or worse compared to baseline. In addition, 59% of CBT completers were free from all anxiety diagnoses at 1-year follow-up (no ITT analysis presented).
A 6-month programme of parent–child CBT for young children (age 4–7 years) with anxiety disorders increases response and reduces the proportion of children having anxiety disorder diagnoses at the end of treatment compared with a waiting list control. The improvement in those treated with CBT persists over at least a year.
In the ITT analyses non-completers were assumed to be non-responders and to still have an anxiety disorder diagnosis.
Preschool children experience anxiety disorders similar to those seen in older children. Yet, cognitive behavioural therapy (CBT) programmes are typically designed for children over the age of seven. This paper is the first randomised controlled trial of CBT for mixed anxiety disorders in preschool children.
This landmark study has several strengths: the CBT programme was adapted specifically for preschool children from a well-established protocol; the authors conducted comprehensive, multi-method assessments at baseline, including maternal anxiety and child behavioural inhibition; participants were assessed post-treatment and at 1-year follow-up; a meticulous methodology was employed including reliable diagnosticians unaware of treatment condition.
Overall, the findings suggest that significant improvements in day-to-day functioning can be achieved for carefully diagnosed anxiety in preschool children using CBT. Particularly promising are the number of participants who no longer met criteria for any anxiety diagnoses at the end of treatment. These gains were maintained over 1-year follow-up, although the control participants were not assessed at this stage.
While these results are certainly positive, there are a number of points that need to be considered with regards the generalisability of the findings and the feasibility of administering this programme in clinical practice. First, participating families were largely middle class, with well-educated parents and children of above average intelligence. It is not clear how well the findings will generalise to lower income and less well-educated participants. Second, the treatment protocol requires up to 20 sessions. This is a significant time commitment and is notably longer than other programmes for preschool children cited in the paper. The authors comment that they are working on a shorter version and this is to be encouraged if the protocol is to have maximum impact in clinical settings. Related to this, it may be of interest for future research to assess parenting behaviour and parental anxiety before and after treatment to evaluate the importance of the parent-only sessions. A final point for consideration is that less positive outcomes were found for children classified as behaviourally inhibited. This may indicate that alterations to the programme for behaviourally inhibited children, or treatment protocols designed specifically for these children, are required.
Source of funding National Institutes of Health.
Competing interests None.
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