Professional Documents
Culture Documents
net/publication/322499001
CITATION READS
1 1,215
4 authors, including:
SEE PROFILE
Some of the authors of this publication are also working on these related projects:
All content following this page was uploaded by Evan Alvarez on 15 January 2018.
Psychotherapy for anxiety disorders in children and adolescents
Authors: Evan Alvarez, MA, Anthony Puliafico, PhD, Kimberly Glazier, PhD, Ann Marie Albano, PhD, ABPP
Section Editor: David Brent, MD
Deputy Editor: Richard Hermann, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2016. | This topic last updated: Aug 23, 2016.
INTRODUCTION — Anxiety disorders are the most common psychiatric disorders diagnosed in childhood and
adolescence [1,2]. Anxiety disorders that may begin in childhood include generalized anxiety disorder, social
anxiety disorder, and separation anxiety disorder (collectively known as the “child anxiety triad”), in addition to
selective mutism, panic disorder, agoraphobia, and specific phobia.
Pediatric anxiety disorders are associated with functional difficulty in childhood and tend to persist into adulthood,
where they are associated with functional impairment and cooccurring psychiatric disorders. The development
and testing of psychotherapies for pediatric anxiety disorders has largely been limited to cognitivebehavioral
therapy and more recent advances in parentchild therapy in very young children.
This topic describes psychotherapy for anxiety disorders in children and adolescents. The epidemiology,
pathogenesis, clinical manifestations, course, assessment and diagnosis of anxiety disorders in children and
adolescents are described separately. Pharmacotherapy for anxiety disorders in children and adolescents is also
described separately. Psychosocial treatment for obsessive compulsive disorder and posttraumatic stress
disorder in children is also discussed separately. (See "Anxiety disorders in children and adolescents:
Epidemiology, pathogenesis, clinical manifestations, and course" and "Anxiety disorders in children: Assessment
and diagnosis" and "Pharmacotherapy for anxiety disorders in children and adolescents" and "Psychosocial
treatment of posttraumatic stress disorder in children and adolescents" and "Treatment of obsessivecompulsive
disorder in children and adolescents".)
COGNITIVEBEHAVIORAL THERAPY — Cognitivebehavioral therapy (CBT) focuses on the interplay between
cognitions, behaviors and emotions, helping patients to recognize and modify maladaptive anxietyprovoking
thoughts and to change patterns of avoidance. The content of CBT programs can vary but typically includes
psychoeducation and exposure to anxiety producing stimuli and situations, couched within an active and
collaborative patienttherapist relationship, and reinforced by the use of patientcentered homework assignments.
Exposure treatment is central to all efficacious CBT for pediatric anxiety disorders; this involves the child
gradually but repeatedly experiencing the feared situation with the intent of reducing the associated anxiety, or
learning to tolerate and manage normal, expected levels of anxiety.
There are multiple semistructured, manualized CBT programs for pediatric anxiety disorders that have been
found to be efficacious when delivered by a trained clinician [3].
The most wellresearched and prominently used program for treating anxiety is the Coping Cat program was
developed for children ages 7 to 13 diagnosed with generalized anxiety disorder, social anxiety disorder, or
separation anxiety disorder [4]. The C.A.T. Project [5] adapts the program for use with adolescents ages 14 to 17
the same disorders.
● Psychoeducation to the child/adolescent and caretakers
● Somatic management skills
● Cognitive restructuring techniques
● Problemsolving skills
Once these skills are taught, treatment focuses on gradual exposure to feared situations.
Indications — CBT is indicated for all of the childhood anxiety disorders, including separation anxiety disorder,
generalized anxiety disorder, social anxiety disorder, and specific phobia in adolescents and children age seven
and older [3,6,7].
Children younger than seven typically do not possess the developmental abilities needed to understand and
apply cognitivebehavioral strategies to their symptoms, but CBT has been adapted for delivery to parents of
children with anxiety disorders, or to parents and children together [812]. (See 'Adaptations for young children'
below.)
Conceptualization and components — CBT conceptualizes anxiety as a tripartite construct that involves
interaction between physiological, cognitive, and behavioral components. Change in one of these three
components sets up a process of change in one or more of the other two. CBT includes several key treatment
components, such as psychoeducation, somatic management skills, cognitive restructuring, exposure to feared
situations, and relapse prevention. Each component targets mechanisms that are believed to maintain
maladaptive anxiety.
Psychoeducation — Psychoeducation involves teaching children and caregivers about their anxiety
symptoms and providing an overview and rationale for CBT. Emphasis is placed on:
● Normalizing anxiety symptoms.
● The relationship between anxiety and avoidance; the role of avoidance in maintaining anxiety.
● The process of exposure treatment.
● Creating a detailed list of situations the patient avoids due to anxiety and behaviors the child or caregivers
enact to reduce anxiety (eg, providing reassurance).
Patients learn, for example, that the experience and sensations of anxiety are normal, but that maladaptive levels
of anxiety interfere with their functioning (eg, leading to poor grades at school, few friendships, or poor work
performance). Through selfmonitoring of their daily lives and reactions, patients learn to recognize their
individual patterns of responding to anxietyprovoking events and triggers with avoidance, increased negative
thinking, and greater subjective feelings of distress.
Selfmonitoring may be in the form of paperandpencil diary forms or through commercially available software
applications (eg, MindShift) [13].
Somatic management skills — Somatic management skills, including diaphragmatic breathing and
progressive muscle relaxation, are intended to teach the patient to identify and effectively manage physical
symptoms of anxiety.
Diaphragmatic breathing involves breathing slowly and deeply from the diaphragm, and is intended to facilitate a
parasympathetic response. Progressive muscle relaxation involves systematically tensing and relaxing muscles
throughout the body to relieve muscle tension associated with anxiety. Patients are encouraged to use these
strategies when facing anxietyprovoking situations.
Software applications such as MindShift and various computerbased programs, such as Camp CopeALot [14],
reinforce the teaching of these skills to children and teens.
Cognitive restructuring — Cognitive restructuring is a process of logically identifying and challenging
maladaptive thoughts (eg, cognitive distortions) that may be contributing to or perpetuating anxiety. Common
cognitive distortions, often labeled as “thinking traps,” are reviewed with patients; they include:
● Fortune telling – Predicting that negative events will occur in the future
● Mind reading – Assuming that others are thinking negatively about you
● Catastrophizing – Believing that a terrible event is likely to occur
Cognitions serve the same function across the anxiety disorders, to increase anxiety while prompting the child to
avoid a situation or to act out with much distress. The focus of the thought varies according to the nature of the
anxiety (social fears, general worries, separation concerns, fear of body sensations in panic), yet the process of
restructuring these thoughts are the same across the disorders.
Patients are taught to identify these distortions and challenge them with alternative, copingfocused thoughts,
such as:
● “What is the worst thing that can happen, and can I handle that?”
● “What are the chances my fear will come true?”
● “I have handled this situation before and I can do it again.”
These strategies can be modified for each specific anxiety disorder and to match the age and developmental
level of the child. As an example, a therapist may help a child with social anxiety disorder identify his thought, that
no one will talk to him at an upcoming party, as “fortune telling” and help him identify a more adaptive alternate
thought, such as, “If I’m invited, someone wants me there, and I might end up with a new friend.”
A child with separation anxiety typically thinks the parent will not make it home from an evening out due to a
catastrophe. The child is taught to address his or her inner thoughts with realistic challenges, “How many times
has Mom gone out at night and not come home? She’s always returned! I can go to sleep and she’ll be happy to
see me at breakfast!”
Exposure — Exposure to feared situations identified by the patient is considered to be a core component of
effective CBT for pediatric anxiety [15,16].
Exposure directly targets the mechanism of avoidance, which allows symptoms of anxiety to perpetuate and
often worsen. Through exposure, patients are guided in repetitions of facing anxietyprovoking situations, which
typically causes the anxiety to diminish and in some cases remit. As an example, initial exposure treatment for a
child with a specific phobia of dogs might begin with looking at pictures of dogs. Exposure proceeds to being
physically near a dog, and then to petting a dog. Of note, exposure treatment of specific phobias is effective in
one session, usually two to three hours in length.
For some youth and situations, the goal of exposure would be learning to tolerate the associated anxiety as
opposed to the goal of extinguishing it [17]. This would be for situations where anxiety is typical and normal in
magnitude, eg, when the child gives an oral report in class or asks someone on a date.
Patients typically complete exposures in session with the therapist, and are then encouraged to complete
exposures regularly between treatment sessions. The process of exposure is very similar across pediatric anxiety
disorders, with only the content of exposures changing based on the child’s fears.
For younger children, it is typically helpful to involve caregivers during insession exposures so that they can lead
their children in exposures at home. Older children and adolescents are often more able to complete exposures
independently and may not want their caregivers’ involvement.
Relapse prevention — Relapse prevention helps to sustain the effects of treatment by working with the
patient to establish a contingency plan in the event that symptoms or functioning worsen after termination. The
return of symptoms can be due to a setback, to external events (such as a return to school), or to taking on new,
challenging developmental tasks. Further treatment might involve additional “booster sessions” of CBT, checkin
calls, or other types of intervention.
Efficacy — Randomized clinical trials have established the efficacy of individual CBT to treat separation anxiety
disorder, social anxiety disorder, and generalized anxiety disorder in children as young as seven years. CBT for
panic disorder has empirical support in adolescence [3,18]. Single, small trials suggest that CBT may be
efficacious for selective mutism and separation anxiety disorder. There are no randomized trials of CBT for
agoraphobia in children/adolescents.
Social anxiety disorder — Clinical trials have found CBT to be efficacious for pediatric social anxiety disorder
[1921]. As an example, a clinical trial randomly assigned 50 youths (ages 7 to 14) to 12 weeks of childfocused
CBT, CBT plus parent involvement, or to a waitlist condition [19]. At the end of the treatment period, patients
assigned to each of the CBT groups experienced higher remission rates compared with the control group (58 and
87.5 versus 7 percent). At 12month followup, treatment gains were maintained for both CBT groups. A
statistically insignificant trend found a trend toward greater efficacy for the combination of CBT plus parent
involvement compared with CBT alone (81 versus 53 percent).
Selective mutism — A small trial suggests that exposure therapy may be more effective than contingency
management for pediatric anxiety disorders [22]. A trial randomly assigned nine children ages four to nine years
with selective mutism to treatment with either exposurebased therapy or parentfocused contingency
management, with treatment duration ranging from 8 to 32 sessions. The exposurebased therapy was more
effective than the parentfocused contingency management in overall rating score and in the number of words
participants spoke per day (62.8 versus 44.2). Eight of the nine participants no longer met diagnostic criteria for
selective mutism posttreatment and at threemonth followup.
Specific phobia — Clinical trials have found a onesession CBT treatment in children diagnosed with specific
phobia reduced phobic and anxious symptoms [23,24]. This treatment comprises primarily of continued graded
exposure to the feared object over the course of several hours.
Panic disorder — A clinical trial [25] randomly assigned 26 adolescents ages 14 to 17 and diagnosed with
panic disorder to receive 11 weeks of panic control treatment for adolescents (PCTA), which is a downward
extension of panic control treatment [26] or to a control condition involving selfmonitoring panic symptoms and
meeting with a therapist every two weeks to review monitoring. At posttreatment, the PCTA group was found to
have a greater reduction of panic symptoms compared with the control condition.
Multiple anxiety disorders — Several clinical trials found CBT to be effective in children/adolescents with
multiple anxiety disorders [4,15,2731]. As an example, a 16week trial randomly assigned 47 participants ages 9
to 13 with either separation anxiety disorder, DSMIII avoidant disorder, or DSMIII overanxious disorder to
receive CBT or to a waitlist control group [27]. Based on serial assessments with the Anxiety Disorders Interview
Schedule for Children and Parents, participants assigned to the CBT group were much more likely to meet
criteria for remittance rate of the anxiety disorder at the completion of treatment compared with the control group
(64 versus 5 percent). Symptom improvement gains were also maintained by participants receiving CBT
compared with waitlist controls at followup after one year. Several subsequent studies have also found CBT
superior to waitlist or active control conditions [15,2831].
A modular approach to treatment of childhood anxiety disorders may be superior to standard treatment protocols.
In a modular approach, the clinician is instructed to apply specific treatment modules, such as cognitive
restructuring, exposure, or parenting strategies, based on child and parent feedback and clinician judgment.
When children present with multiple problems requiring more than one treatment, the modular approach provides
guidance with sequencing treatments [32]. A modular approach may be particularly helpful for children exhibiting
anxiety disorders and comorbid depression or disruptive behavior disorders.
Moderators of treatment outcome — Certain factors have been found to moderate treatment outcome in CBT
for childhood anxiety disorders:
● Familybased treatment may be superior for younger children [29] and when both parents also had an
anxiety disorder [28].
● Low anxiety sensitivity and high caregiver burden were predictors of poorer response to treatment [33].
● Children diagnosed with social anxiety disorder responded more poorly to CBT compared with children with
generalized anxiety disorder or separation anxiety disorder [33].
Administration — Child and adolescent patients in these clinical trials typically received CBT over 12 to 20
weekly sessions of 45 to 60minute sessions. The majority of trials involved individual treatment rather than
groups. Groupbased treatment CBT has been found to be effective in social anxiety disorder, but has not been
compared to individual CBT [34].
Additional information about empirically supported treatments for pediatric anxiety disorders can be found at the
following websites:
● www.effectivechildtherapy.com
● www.childanxietysig.com
Adaptations for young children — A growing body of research suggests that clinical interventions with parents
or parent and child may be efficacious for treating anxiety disorders in children [31,3537] and for children with
separation disorder [38], both between age four and seven. These treatments are primarily adaptions of
cognitivebehavioral treatment strategies applied to older children and adolescents, but with greater parental
involvement.
As an example, a clinical trial randomly assigned 64 children ages four to seven years with an anxiety disorder to
receive a parentchild CBT intervention (up to 20 sessions over six months) or a sixmonth waitlist condition [31].
After six months, children assigned to active treatment were more likely to experience reduced anxiety compared
with the control group (59 versus 30 percent). Gains were maintained at oneyear followup.
Separation anxiety disorder — Parentchild interaction therapy (PCIT), a behavioral treatment originally
developed to treat disruptive behavior disorders in young children, was adapted to treat separation anxiety
disorder. In PCIT, therapists teach caregivers strategies to reinforce desired behaviors and extinguish unwanted
behaviors, and coach them to apply them while interacting with their child.
A randomized trial comparing an adaptation of PCIT with a waitlist control for children ages four to seven with
separation anxiety disorder found that a greater proportion of children receiving PCIT no longer met criteria for an
anxiety disorder compared with the control group (73 versus 0 percent) [38].
OTHER PSYCHOTHERAPIES — Psychotherapies for pediatric anxiety disorder other than cognitivebehavioral
therapy based therapies have not been tested in clinical trials.
COMPARING MEDICATION AND PSYCHOTHERAPY — Clinical trials comparing the efficacy of serotonin
reuptake inhibitor medication versus cognitivebehavioral therapy (CBT) for anxiety disorders in children have
had mixed results:
● Social effectiveness therapy for children (SETC), a behavioral therapy, was found in a clinical trial to be
superior to fluoxetine for social anxiety disorder [39]. The 12week trial randomly assigned 122 children with
social anxiety disorder (ages 7 to 17) to fluoxetine, SETC, or pill placebo. At the end of 12 weeks, a greater
proportion of participants receiving SETC no longer met diagnostic criteria for social anxiety disorder
compared with patients receiving fluoxetine or placebo (53 versus 21.2 or 3.1 percent). SETC was superior
to fluoxetine; both were superior to placebo in reducing social distress and behavioral avoidance, and
increasing general functioning.
● A clinical trial randomly assigned 488 children (ages 7 to 17) with a primary diagnosis of social anxiety
disorder, generalized anxiety disorder, or separation anxiety disorder to receive CBT, sertraline, combined
CBTsertraline, or a drug placebo [33]. A greater proportion of patients assigned to receive CBT alone or
sertraline alone experienced a symptom reduction compared with patients assigned to placebo, with no
significant difference between groups receiving active treatments (59.7 and 54.9 versus 23.7 percent).
Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than
in the placebo group.
COMBINING MEDICATION AND PSYCHOTHERAPY — A clinical trial found that the combination of cognitive
behavioral therapy (CBT) and a selective serotonin reuptake inhibitor (SSRI) was more efficacious compared with
the individual modalities [33]. In the trial (described above) of 488 children with social anxiety disorder,
generalized anxiety disorder, or separation anxiety disorder, a greater proportion of participants who received
combined CBTsertraline were rated as “much improved” or “very much improved” on the Clinician Global
ImpressionImprovement scale compared with patients who received either CBT or sertraline as monotherapy
(80.7 versus 59.7 or 54.9 percent).
Combined SSRI/CBT strategies have not been tested for specific phobia, panic disorder, selective mutism, or
agoraphobia. A clinical trial found similar results for combined treatment in a related condition, school refusal [40].
The trial randomly assigned 63 children (ages 12 to 18) with school refusal to receive either the combination of
CBT and imipramine or imipramine and placebo, finding that CBT/imipramine led to greater improvement in
school attendance compared with the tricyclic medication alone.
TREATMENT SELECTION
Firstline treatment
● Mild to moderate anxiety disorder – We suggest cognitivebehavioral therapy (CBT) as a firstline
treatment of children with an anxiety disorder of mild to moderate severity rather than an SSRI or other
treatment. Clinical trials comparing CBT with selective serotonin reuptake inhibitors (SSRI) treatment for
pediatric anxiety disorders are mixed, with the larger trial finding no difference in remission rates between
groups and another finding CBT to be superior to sertraline. Selection between these modalities may also be
influenced by availability of CBT and by child/parent preferences. (See 'Comparing medication and
psychotherapy' above.)
● Severe anxiety disorder – For children with a severe pediatric anxiety disorder, we suggest firstline
treatment with a combination of CBT and an SSRI. Combined CBTSSRI treatment performed better than
either modality individually in clinical trials of children with social phobia, generalized anxiety disorder, or
separation anxiety disorder [33], as well as in a trial of a related childhood condition, school refusal [40].
● Cooccurring anxiety disorder and major depression – A combination of CBT and SSRI medication may
be beneficial for children with an anxiety disorder and comorbid major depression, although this treatment
combination has not been tested directly in clinical trials.
There is an absence of strong evidence or clear consensus on treatment approaches for children and
adolescents whose anxiety symptoms do not improve after receiving CBT and/or SSRI medication [41].
SUMMARY AND RECOMMENDATIONS — Cognitive and behavioralbased therapies are the only
psychotherapies that have been tested in randomized clinical trials in children and adolescents. (See 'Cognitive
behavioral therapy' above and 'Other psychotherapies' above.)
● Cognitivebehavioral therapy (CBT) focuses on the interplay between cognitions, behaviors and emotions,
helping patients to recognize and modify maladaptive anxietyprovoking thoughts and to change patterns of
avoidance. The content of CBT programs can vary but typically includes psychoeducation and exposure to
anxiety producing stimuli and situations, couched within an active and collaborative patienttherapist
relationship, and reinforced by the use of patientcentered homework assignments. (See 'Cognitive
behavioral therapy' above.)
● Exposure treatment is central to all efficacious CBT for pediatric anxiety disorders; this involves the child
gradually but repeatedly experiencing the feared situation with the intent of reducing the associated anxiety,
or learning to tolerate and manage normal, expected levels of anxiety. (See 'Cognitivebehavioral therapy'
above.)
● Randomized clinical trials have established the efficacy of individual CBT to treat separation anxiety disorder,
social anxiety disorder, and generalized anxiety disorder in children as young as seven years. CBT for panic
disorder has empirical support in adolescence. Smaller trials suggest that CBT may be efficacious for
selective mutism and separation anxiety disorder. (See 'Efficacy' above.)
● A growing body of research suggests that clinical interventions with parents or parent and child may be
efficacious for treating anxiety disorders in children and for children with separation disorder, both between
age four and seven. These treatments are primarily adaptions of CBT strategies applied to older children and
adolescents, but with greater parental involvement. (See 'Adaptations for young children' above.)
● We suggest CBT as a firstline treatment of children with an anxiety disorder of mild to moderate severity
rather than an SSRI or other treatment (Grade 2C). (See 'Comparing medication and psychotherapy' above.)
● For children with a severe pediatric anxiety disorder, we suggest firstline treatment with a combination of
CBT and an SSRI (Grade 2B). (See 'Combining medication and psychotherapy' above.)
Use of UpToDate is subject to the Subscription and License Agreement.
REFERENCES
1. Costello EJ, Mustillo S, Erkanli A, et al. Prevalence and development of psychiatric disorders in childhood
and adolescence. Arch Gen Psychiatry 2003; 60:837.
2. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents:
results from the National Comorbidity Survey ReplicationAdolescent Supplement (NCSA). J Am Acad
Child Adolesc Psychiatry 2010; 49:980.
3. Silverman WK, Pina AA, Viswesvaran C. Evidencebased psychosocial treatments for phobic and anxiety
disorders in children and adolescents. J Clin Child Adolesc Psychol 2008; 37:105.
4. Kendall PC, Hedtke KA. Cognitivebehavioral Therapy for Anxious Children: Therapist manual, 3rd ed,
Workbook Publishing, Ardmore, PA 2006.
5. Kendall PC, Choudhury M, Hudson J, Webb A. “The C.A.T. Project” Manual for the CognitiveBehavioral
Treatment of Anxious Adolescents, Workbook Publishing, Admore 2002.
6. Kendall PC, Furr JM, Podell JL. Childfocused treatment of anxiety.. In: Evidencebased psychotherapies
for children and adolescents., Weisz JR, Kazdin AE. (Eds), Guilford, New York 2003. p.45.
7. Ollendick TH, King NJ. Empirically supported treatments for children with phobic and anxiety disorders:
current status. J Clin Child Psychol 1998; 27:156.
8. Flavell JH, Miller PH, Miller SA. Cognitive Development, 4th ed, Prentice Hall, New York 2001.
9. Zhang WW, Zhang J. The development of children’s social perspective taking and the differences between
perspective taking subtypes. Psychol Sci 1999; 22:116.
10. Shaw P, Eckstrand K, Sharp W, et al. Attentiondeficit/hyperactivity disorder is characterized by a delay in
cortical maturation. Proc Natl Acad Sci U S A 2007; 104:19649.
11. Pincus DB, Santucci LC, Ehrenreich JT, et al. The implementation of modified parentchild interaction
therapy for youth with separation anxiety disorder. Cogn Behav Pract 2008; 15:118.
12. Comer JS, Puliafico AC, Aschenbrand SG, et al. A pilot feasibility evaluation of the CALM Program for
anxiety disorders in early childhood. J Anxiety Disord 2012; 26:40.
13. http://www.adaa.org/findinghelp/mobileapps (Accessed on August 24, 2016).
14. http://copealot.com (Accessed on August 24, 2016).
15. Kendall PC, FlannerySchroeder E, PanichelliMindel SM, et al. Therapy for youths with anxiety disorders: a
second randomized clinical trial. J Consult Clin Psychol 1997; 65:366.
16. Chu BC, Skriner LC, Zandberg LJ. Shape of change in cognitive behavioral therapy for youth anxiety:
symptom trajectory and predictors of change. J Consult Clin Psychol 2013; 81:573.
17. Craske MG, Liao B, Brown L, Veryliet B. Role of inhibition in exposure therapy. J Exp Psychopathol 2012;
3:322.
18. HigaMcMillan CK, Francis SE, RithNajarian L, Chorpita BF. Evidence Base Update: 50 Years of Research
on Treatment for Child and Adolescent Anxiety. J Clin Child Adolesc Psychol 2016; 45:91.
19. Spence SH, Donovan C, BrechmanToussaint M. The treatment of childhood social phobia: the
effectiveness of a social skills trainingbased, cognitivebehavioural intervention, with and without parental
involvement. J Child Psychol Psychiatry 2000; 41:713.
20. Beidel DC, Turner SM, Morris TL. Behavioral treatment of childhood social phobia. J Consult Clin Psychol
2000; 68:1072.
21. Hayward C, Varady S, Albano AM, et al. Cognitivebehavioral group therapy for social phobia in female
adolescents: results of a pilot study. J Am Acad Child Adolesc Psychiatry 2000; 39:721.
22. Vecchio J, Kearney CA. Treating youths with selective mutism with an alternating design of exposurebased
practice and contingency management. Behav Ther 2009; 40:380.
23. Ollendick TH, Ost LG, Reuterskiöld L, et al. Onesession treatment of specific phobias in youth: a
randomized clinical trial in the United States and Sweden. J Consult Clin Psychol 2009; 77:504.
24. Ost LG, Svensson L, Hellström K, Lindwall R. OneSession treatment of specific phobias in youths: a
randomized clinical trial. J Consult Clin Psychol 2001; 69:814.
25. Pincus DB, May JE, Whitton SW, et al. Cognitivebehavioral treatment of panic disorder in adolescence. J
Clin Child Adolesc Psychol 2010; 39:638.
26. Barlow, D, Craske, M. Mastery of your anxiety and panic, 4th ed, Oxford University Press, New York 2006.
27. Kendall PC. Treating anxiety disorders in children: results of a randomized clinical trial. J Consult Clin
Psychol 1994; 62:100.
28. Kendall PC, Hudson JL, Gosch E, et al. Cognitivebehavioral therapy for anxiety disordered youth: a
randomized clinical trial evaluating child and family modalities. J Consult Clin Psychol 2008; 76:282.
29. Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin
Psychol 1996; 64:333.
30. Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitivebehavioral treatment of anxiety disorders in
children: longterm (6year) followup. J Consult Clin Psychol 2001; 69:135.
31. HirshfeldBecker DR, Masek B, Henin A, et al. Cognitive behavioral therapy for 4 to 7yearold children with
anxiety disorders: a randomized clinical trial. J Consult Clin Psychol 2010; 78:498.
32. Weisz JR, Chorpita BF, Palinkas LA, et al. Testing standard and modular designs for psychotherapy treating
depression, anxiety, and conduct problems in youth: a randomized effectiveness trial. Arch Gen Psychiatry
2012; 69:274.
33. Ginsburg GS, Kendall PC, Sakolsky D, et al. Remission after acute treatment in children and adolescents
with anxiety disorders: findings from the CAMS. J Consult Clin Psychol 2011; 79:806.
34. Albano AM, Marten PA, Holt CS, et al. Cognitivebehavioral group treatment for social phobia in
adolescents. A preliminary study. J Nerv Ment Dis 1995; 183:649.
35. CartwrightHatton S, McNally D, Field AP, et al. A new parentingbased group intervention for young
anxious children: results of a randomized controlled trial. J Am Acad Child Adolesc Psychiatry 2011; 50:242.
36. Kennedy SJ, Rapee RM, Edwards SL. A selective intervention program for inhibited preschoolaged
children of parents with an anxiety disorder: effects on current anxiety disorders and temperament. J Am
Acad Child Adolesc Psychiatry 2009; 48:602.
37. Waters AM, Ford LA, Wharton TA, Cobham VE. Cognitivebehavioural therapy for young children with
anxiety disorders: Comparison of a Child + Parent condition versus a Parent Only condition. Behav Res
Ther 2009; 47:654.
38. Pincus DB, Chase R, Chow CW, et al. Efficacy of modified ParentChild Interaction Therapy for young
children with separation anxiety disorder. Paper presented at the the 44th annual meeting of the Association
for Behavioral and Cognitive Therapies, San Francisco 2010.
39. Beidel DC, Turner SM, Sallee FR, et al. SETC versus fluoxetine in the treatment of childhood social phobia.
J Am Acad Child Adolesc Psychiatry 2007; 46:1622.
40. Bernstein GA, Borchardt CM, Perwien AR, et al. Imipramine plus cognitivebehavioral therapy in the
treatment of school refusal. J Am Acad Child Adolesc Psychiatry 2000; 39:276.
41. Ginsburg GS, Becker EM, Keeton CP, et al. Naturalistic followup of youths treated for pediatric anxiety
disorders. JAMA Psychiatry 2014; 71:310.
Topic 15927 Version 1.0
Contributor Disclosures
Evan Alvarez, MA Nothing to disclose Anthony Puliafico, PhD Nothing to disclose Kimberly Glazier,
PhD Nothing to disclose Ann Marie Albano, PhD, ABPP Nothing to disclose David Brent,
MD Grant/Research/Clinical Trial Support: NIMH [Child & Adolescent Psychiatry]; AFSP [Suicide prevention].
Consultant/Advisory Boards: Healthwise [Consumer health education (Child Psychiatry)]; Klingenstein Third
Generation Foundation [Postdoctoral fellowships]. Patent Holder: Guilford Press [Psychology (Treating
depressed and suicidal adolescents)]; ERT Inc [Cloud platform solution (C-SSRS)]. Richard Hermann,
MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform to
UpToDate standards of evidence.