Treating Anxiety in Youth: CBT, Medication or Both?

anxious teenAnxiety disorders in youth are common; between one fourth and one third of teens develop one by the end of adolescence. Examining treatment issues with this population, the landmark Child/Adolescent Anxiety Multimodal Study (CAMS) just published its 24 and 36 week outcomes (i.e., article dated 3/2014). This multisite study, that included 488 children aged 7 to 17 (average age of 10), compared cognitive behavioral therapy (CBT; a talking therapy) to sertraline (SRT; an SSRI medication), to both together (COMB), to pill placebo in the treatment of Generalized Anxiety Disorder, Social Phobia and Separation Anxiety Disorder. (Youth with other anxiety disorders, or with co-occurring problems such as depression or pervasive developmental disorders, were not included.) I will first review some key findings and then suggest some take home points for clinical practice.

• At 12 weeks, or the immediate conclusion of the study, this is the percentage of children who were rated to have a positive treatment response across the four conditions: COMB: 81%, CBT: 60%, SRT: 55% and pill placebo: 28%. At that point in time the combined treatment was determined to be moderately superior to the other three conditions.

• At no point in the study were there statistically significant differences between the CBT and medication treatment conditions.

• At week 24, the superiority of combined condition over medication alone and anxious childCBT shrank (COMB: 81%, CBT: 69% and SRT: 68%).

• At week 36, the superiority of the combined condition over medication alone and CBT shrank further (COMB: 83%, CBT: 72% and SRT: 70%).

• For both of the preceding two points, the magnitude of the differences at week 36 varied across the various outcome measurements.

• Quoting the authors: “…only 5% of youth receiving COMB and only 15% to 16% of those receiving monotherapy failed to achieve responder status at any point during study participation.” And, “although COMB appears best for prompt benefit, all 3 treatment conditions appear beneficial at 6 months.”

Take home points for clinical practice

therapy etchingThese results support what I, and many of my child clinician colleagues, have tended to recommend in the treatment of youth suffering from one of the aforementioned anxiety disorders. These recommendations are as follows:

• If wanting the most aggressive approach, consider medication therapy and CBT.

• If concerned about adding a psychoactive agent to a developing brain when there may be viable alternatives, consider starting with CBT alone unless the anxiety symptoms are in a severe range (e.g,, a child cannot get to school), to see if the talking treatment will be sufficiently effective.

• If a child is taking a medication, consult with the prescriber about the possibility of tapering off the medication once the CBT skills have been learned.

• It would usually not make clinical sense to treat a child with medication alone, though unusual circumstances could suggest otherwise (e.g., CBT is refused or not available).

• The CBT protocol used in this study was the “Coping Cat” program. However, other established CBT programs for children would likely also have value.

• The authors note that their results are similar to the results found in treatment therapy with teenstudies of juvenile depression. This suggests that similar clinical guidelines may also apply in the treatment of youth suffering from juvenile depression.

To read the abstract for this study, click here.

For a referral for mental health care, click here.

For an article on affording mental health care, click here.

I’d like to offer a closing thought for those parents who have a child or teen suffering from an anxiety disorder: in my clinical experience this is one of the most treatable kinds of problems that a kid can have. So, I strongly encourage you to take your child or teen to a mental health professional who can delivery quality care (for a more thorough review of what good mental health care looks like, please see Chapter 10 of my parenting book). After all, why have your baby suffer needlessly?

Tune in next week when I will post an article that describes cognitive behavioral therapy.

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