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Rabner J, Olino TM, Albano AM, Keeton CP, Sakolsky D, Birmaher B, Piacentini J, Peris TS, Compton SN, Gosch E, Ginsburg GS, Pinney EL, Kendall PC. Substance use outcomes from the Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS). J Child Psychol Psychiatry 2024. [PMID: 38217328 DOI: 10.1111/jcpp.13926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND Substance use problems and anxiety disorders are both highly prevalent and frequently cooccur in youth. The present study examined the benefits of successful anxiety treatment at 3-12 years after treatment completion on substance use outcomes (i.e. diagnoses and lifetime expected use). METHODS The sample was from the Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS), a naturalistic follow-up study to the Child/Adolescent Anxiety Multimodal Study (CAMS) which randomized youth to cognitive behavioral therapy (CBT; Coping cat), medication (sertraline), their combination, or pill placebo. The first CAMELS visit occurred an average of 6.5 years following CAMS randomization. Participants were 319 youth (65.4% of the CAMS sample), aged 7-17 years at CAMS baseline assessment with a mean age of 17.6 years (range: 11-26 years) at the time of the first CAMELS follow-up. Substance use outcomes included diagnoses as well as lifetime substance use (i.e. alcohol and tobacco use). RESULTS Eleven of 319 (3.4%) CAMELS participants were diagnosed with a substance use disorder at the initial follow-up visit. When compared to the population lifetime rate of 11.4%, the rate of diagnoses in the posttreated sample was significantly lower. Additionally, rates of lifetime alcohol use were lower than population rates at the initial and final follow-up visits. Rates of lifetime tobacco use were similarly lower than lifetime population rates at the initial visit (driven by significantly lower rates in the CBT treatment condition), but higher by the final visit. Furthermore, treatment remission (but not treatment response) was associated with a lower rate of substance use diagnoses at the initial follow-up visit, although rates of lifetime alcohol and tobacco use did not differ by treatment outcome. CONCLUSIONS Anxiety treatments confer a beneficial impact on problematic substance use (i.e. diagnoses) as well as on expected substance use (i.e. alcohol and tobacco use) for on average, a period of 6.5 years.
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Affiliation(s)
- Jonathan Rabner
- Department of Psychology and Neuorscience, Temple University, Philadelphia, PA, USA
| | - Thomas M Olino
- Department of Psychology and Neuorscience, Temple University, Philadelphia, PA, USA
| | - Anne Marie Albano
- Department of Psychiatry, New York State Psychiatric Institute, Columbia University Medical Center, New York, NY, USA
| | - Courtney P Keeton
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dara Sakolsky
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
- Western Psychiatric Institute & Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Boris Birmaher
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
- Western Psychiatric Institute & Clinic, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - John Piacentini
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles School of Medicine, Los Angeles, CA, USA
| | - Tara S Peris
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles School of Medicine, Los Angeles, CA, USA
| | - Scott N Compton
- Department of Psychiatry, Duke University Medical Center, Durham, NC, USA
| | - Elizabeth Gosch
- Department of Psychology, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Golda S Ginsburg
- Department of Psychiatry, University of Connecticut Health Center, Farmington, CT, USA
| | | | - Philip C Kendall
- Department of Psychology and Neuorscience, Temple University, Philadelphia, PA, USA
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Bai S, Rolon-Arroyo B, Walkup JT, Kendall PC, Ginsburg GS, Keeton CP, Albano AM, Compton SN, Sakolsky D, Piacentini J, Peris TS. Anxiety symptom trajectories from treatment to 5- to 12-year follow-up across childhood and adolescence. J Child Psychol Psychiatry 2023. [PMID: 37005705 DOI: 10.1111/jcpp.13796] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2023] [Indexed: 04/04/2023]
Abstract
OBJECTIVE The current study examined trajectories of anxiety during (a) acute treatment and (b) extended follow-up to better characterize the long-term symptom trajectories of youth who received evidence-based intervention for anxiety disorders using a person-centered approach. METHOD Participants were 319 youth (age 7-17 years at enrollment), who participated in a multicenter randomized controlled trial for the treatment of pediatric anxiety disorders, Child/Adolescent Anxiety Multimodal Study, and a 4-year naturalistic follow-up, Child/Adolescent Anxiety Multimodal Extended Long-term Study, an average of 6.5 years later. Using growth mixture modeling, the study identified distinct trajectories of anxiety across acute treatment (Weeks 0-12), posttreatment (Weeks 12-36), and the 4-year-long follow-up, and identified baseline predictors of these trajectories. RESULTS Three nonlinear anxiety trajectories emerged: "short-term responders" who showed rapid treatment response but had higher levels of anxiety during the extended follow-up; "durable responders" who sustained treatment gains; and "delayed remitters" who did not show an initial response to treatment, but showed low levels of anxiety during the maintenance and extended follow-up periods. Worse anxiety severity and better family functioning at baseline predicted membership in the delayed remitters group. Caregiver strain differentiated short-term responders from durable responders. CONCLUSIONS Findings suggest that initial response to treatment does not guarantee sustained treatment gains over time for some youth. Future follow-up studies that track treated youth across key developmental transitions and in the context of changing social environments are needed to inform best practices for the long-term management of anxiety.
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Affiliation(s)
- Sunhye Bai
- Department of Human Development and Family Studies, The Pennsylvania State University, University Park, PA, USA
| | | | - John T Walkup
- Department of Psychiatry and Behavioral Sciences, Northwestern University, Evanston, IL, USA
| | - Philip C Kendall
- Department of Psychology, Temple University, Philadelphia, PA, USA
| | - Golda S Ginsburg
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Courtney P Keeton
- Department of Psychiatry and Behavioral Services, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Dara Sakolsky
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
| | - John Piacentini
- Division of Child and Adolescent Psychiatry, University of California Los Angeles, Los Angeles, CA, USA
| | - Tara S Peris
- Division of Child and Adolescent Psychiatry, University of California Los Angeles, Los Angeles, CA, USA
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Bai S, Ricketts EJ, Thamrin H, Piacentini J, Albano AM, Compton SN, Ginsburg GS, Sakolsky D, Keeton CP, Kendall PC, Peris TS. Longitudinal Study of Sleep and Internalizing Problems in Youth Treated for Pediatric Anxiety Disorders. Res Child Adolesc Psychopathol 2021; 48:67-77. [PMID: 31506757 DOI: 10.1007/s10802-019-00582-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The current study examined prospective bidirectional links between dysregulated sleep, and anxiety and depression severity across 4 years, among youth with a history of anxiety disorder. Participants were 319 youth (age 11-26 years), who previously participated in a large multisite randomized controlled trial for the treatment of pediatric anxiety disorders, Child/Adolescent Anxiety Multimodal Study (CAMS), and subsequently enrolled in a naturalistic follow-up, Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS), an average of 6.5 years later. They participated in four annual visits that included self-report items of dysregulated sleep and semi-structured multi-informant interviews of anxiety and depression. Dysregulated sleep was bidirectionally associated with clinician-rated anxiety and depression symptom severity across adolescence and young adulthood. However, these bidirectional relationships were attributable to youth mean levels of dysregulated sleep, and anxiety and depression severity over the 4 years. Elevations in dysregulated sleep at each visit, relative to mean levels, did not predict worse anxiety or depression severity 1 year later. Likewise visit-specific elevations in anxiety and depression severity, as opposed to average levels, did not predict higher levels of dysregulated sleep at the next visit. Having higher levels of dysregulated sleep or more severe internalizing problems across the four-year period, as opposed to reporting a relative increase in symptom severity at a particular visit, posed greater risk for poor mental health. Interventions should continue to assess and treat persistent sleep problems alongside anxiety and depression.
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Affiliation(s)
- Sunhye Bai
- Human Development and Family Studies, The Pennsylvania State University, 216 Health and Human Development, University Park, PA, 16802, USA. .,Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA.
| | - Emily J Ricketts
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
| | - Hardian Thamrin
- Department of Psychology, Arizona State University, Tempe, AZ, USA
| | - John Piacentini
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
| | | | - Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
| | - Golda S Ginsburg
- Department of Psychiatry, University of Connecticut School of Medicine, Farmington, CT, USA
| | - Dara Sakolsky
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Courtney P Keeton
- Department of Psychiatry and Behavioral Services, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Philip C Kendall
- Department of Psychology, Temple University, Philadelphia, PA, USA
| | - Tara S Peris
- Division of Child and Adolescent Psychiatry, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, CA, USA
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Keeton CP, Caporino NE, Kendall PC, Iyengar S, Lee P, Peris T, Sakolsky D, Piacentini J, Compton SN, Albano AM, Birmaher B, Ginsburg GS. Mood and suicidality outcomes 3-11 years following pediatric anxiety disorder treatment. Depress Anxiety 2019; 36:930-940. [PMID: 31356713 DOI: 10.1002/da.22944] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2018] [Revised: 06/06/2019] [Accepted: 06/15/2019] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Youth anxiety interventions have potential to reduce risk for depression and suicidality. METHODS This naturalistic follow-up of the multi-site, comparative treatment trial, inking and behavior, and depressive symptoms 3-11 years (mean 6.25 years) following 12-week evidence-based youth anxiety treatment. Participants (N = 319; 10-26 years, mean 17 years) completed semiannual questionnaires and annual diagnostic interviews for 4 years. RESULTS One-fifth (20.4%) of the sample met DSM-IV criteria for a mood disorder, 32.1% endorsed suicidal ideation, and 8.2% reported suicidal behavior. Latent class growth analysis yielded two linear trajectories of depressive symptoms, and 85% of the sample demonstrated a persistent low-symptom course over seven assessments. Child/Adolescent Anxiety Multimodal Study (CAMS) 12-week treatment outcome (positive response, remission) and treatment condition (cognitive behavior therapy [CBT], medication, CBT + medication, pill placebo) were not associated with subsequent mood disorder or suicidal thinking. CAMS remission predicted absence of suicidal behavior, and treatment response and remission predicted low depressive symptom trajectory. Greater baseline self-reported depressive symptoms predicted all long-term mood outcomes, and more negative life events predicted subsequent mood disorder, depressive symptom trajectory, and suicidal ideation. CONCLUSIONS Effective early treatment of youth anxiety, including CBT, medication, or CBT + medication, reduces risk for subsequent chronic depressive symptoms and suicidal behavior. Attention to (sub)clinical depressive symptoms and management of negative life events may reduce odds of developing a mood disorder, chronic depressive symptoms, and suicidality. Findings contribute to evidence that early intervention for a primary disorder can serve as secondary prevention.
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Affiliation(s)
- Courtney P Keeton
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Philip C Kendall
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | - Satish Iyengar
- Department of Statistics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Phyllis Lee
- Department of Psychological Science, Eastern Connecticut State University, Willimantic, Connecticut
| | - Tara Peris
- Department of Psychiatry, University of California, Los Angeles, California
| | - Dara Sakolsky
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburg, Pennsylvania
| | - John Piacentini
- Department of Psychiatry, University of California, Los Angeles, California
| | - Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University School of Medicine, Durham, North Carolina.,Department of Psychology & Neuroscience, Duke University, Durham, North Carolina
| | - Anne Marie Albano
- Department of Psychiatry, New York State Psychiatric Institute, New York, New York
| | - Boris Birmaher
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburg, Pennsylvania
| | - Golda S Ginsburg
- Department of Psychiatry, University of Connecticut School of Medicine, West Hartford, Connecticut
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Keeton CP, Teetsel RN, Dull NMS, Ginsburg GS. Parent Psychopathology and Children's Psychological Health: Moderation by Sibling Relationship Dimensions. J Abnorm Child Psychol 2015; 43:1333-42. [PMID: 25896728 PMCID: PMC6013740 DOI: 10.1007/s10802-015-0013-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Offspring of anxious adults are at heightened risk for psychological maladjustment; however factors that protect youth in the context of this risk have been rarely explored. Supported by literature showing the meaningful role of sibling relationships for children's psychological outcomes, this study examined the protective role of the sibling relationship for children in the context of risk for psychological maladjustment due to having a parent with a clinical anxiety disorder. Participants were 81 children ages 7 to 12 years (58% female; 82 % Caucasian), and their parents. Parents met DSM-IV-TR diagnostic criteria for a primary anxiety disorder, and youth did not meet diagnostic criteria for any psychiatric disorder. Parents completed questionnaires on their own psychological distress and use of parenting behaviors, and on their children's psychological adjustment. Children self-reported on the quality of their sibling relationship based on their closest-age sibling. Parenting behaviors were also coded based on a parent-child interaction task. Results of hierarchical regression models demonstrated that sibling relationship quality moderated the relation between parental psychological distress and child adjustment. Post-hoc simple slopes analyses showed that parental distress was significantly positively associated with greater child psychological problems only for children reporting low sibling companionship or high sibling conflict. Aspects of the sibling relationship did not moderate the association between self-rated or observer-rated parenting behaviors and child anxiety symptoms. Findings are consistent with developmental models and empirical literature emphasizing the protective role of sibling relationships for youth's psychological outcomes. Sibling relationships may be a salient target for youth psychological preventive or treatment interventions.
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Affiliation(s)
- Courtney P Keeton
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA,
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Peris TS, Compton SN, Kendall PC, Birmaher B, Sherrill J, March J, Gosch E, Ginsburg G, Rynn M, McCracken JT, Keeton CP, Sakolsky D, Suveg C, Aschenbrand S, Almirall D, Iyengar S, Walkup JT, Albano AM, Piacentini J. Trajectories of change in youth anxiety during cognitive-behavior therapy. J Consult Clin Psychol 2014; 83:239-52. [PMID: 25486372 DOI: 10.1037/a0038402] [Citation(s) in RCA: 105] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate changes in the trajectory of youth anxiety following the introduction of specific cognitive-behavior therapy (CBT) components: relaxation training, cognitive restructuring, and exposure tasks. METHOD Four hundred eighty-eight youths ages 7-17 years (50% female; 74% ≤ 12 years) were randomly assigned to receive either CBT, sertraline (SRT), their combination (COMB), or pill placebo (PBO) as part of their participation in the Child/Adolescent Anxiety Multimodal Study (CAMS). Youths in the CBT conditions were evaluated weekly by therapists using the Clinical Global Impression Scale-Severity (CGI-S; Guy, 1976) and the Children's Global Assessment Scale (CGAS; Shaffer et al., 1983) and every 4 weeks by blind independent evaluators (IEs) using the Pediatric Anxiety Ratings Scale (PARS; RUPP Anxiety Study Group, 2002). Youths in SRT and PBO were included as controls. RESULTS Longitudinal discontinuity analyses indicated that the introduction of both cognitive restructuring (e.g., changing self-talk) and exposure tasks significantly accelerated the rate of progress on measures of symptom severity and global functioning moving forward in treatment; the introduction of relaxation training had limited impact. Counter to expectations, no strategy altered the rate of progress in the specific domain of anxiety that it was intended to target (i.e., somatic symptoms, anxious self-talk, avoidance behavior). CONCLUSIONS Findings support CBT theory and suggest that cognitive restructuring and exposure tasks each make substantial contributions to improvement in youth anxiety. Implications for future research are discussed. (PsycINFO Database Record
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Affiliation(s)
- Tara S Peris
- Semel Institute for Neuroscience and Human Behavior University of California, Los Angeles
| | - Scott N Compton
- Department of Psychology and Behavioral Sciences, Duke University Medical Center
| | | | - Boris Birmaher
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center
| | - Joel Sherrill
- Division of Services and Intervention Research, National Institute of Mental Health
| | - John March
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Elizabeth Gosch
- Department of Psychology, Philadelphia College of Osteopathic Medicine
| | - Golda Ginsburg
- Division of Child and Adolescent Psychiatry, Johns Hopkins Medical Institutions
| | - Moira Rynn
- New York State Psychiatric Institute-Columbia University Medical Center
| | - James T McCracken
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Courtney P Keeton
- Division of Child and Adolescent Psychiatry, Johns Hopkins Medical Institutions
| | - Dara Sakolsky
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center
| | | | - Sasha Aschenbrand
- New York State Psychiatric Institute-Columbia University Medical Center
| | | | - Satish Iyengar
- Western Psychiatric Institute and Clinic-University of Pittsburgh Medical Center
| | - John T Walkup
- Division of Child and Adolescent Psychiatry, Weill Cornell Medical College
| | - Anne Marie Albano
- New York State Psychiatric Institute-Columbia University Medical Center
| | - John Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
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Schleider JL, Ginsburg GS, Keeton CP, Weisz JR, Birmaher B, Kendall PC, Piacentini J, Sherrill J, Walkup JT. Parental psychopathology and treatment outcome for anxious youth: roles of family functioning and caregiver strain. J Consult Clin Psychol 2014; 83:213-24. [PMID: 25222799 DOI: 10.1037/a0037935] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Research has examined the effects of parental psychopathology, family functioning, and caregiver strain on treatment response in anxious youths. Although these variables have shown individual links to youth treatment response, theoretical models for their combined effects remain unexplored. This study tested the hypothesis that improvements in family functioning and reductions in caregiver strain explained the effects of parental psychopathology on youth treatment outcome in an anxiety treatment trial. METHOD A multiple mediation technique was used to test the proposed model across independent evaluator (IE), parent, and youth informants in 488 youths, aged 7-17 years (50% female; mean age = 10.7) meeting Diagnostic and Statistical Manual of Mental Disorders criteria for social phobia, separation anxiety, and/or generalized anxiety disorder. Youths were randomized to receive 12 weeks of cognitive-behavioral treatment (Coping Cat), medication (sertraline), their combination, or a pill placebo. At pre- and posttreatment, parents completed self-report measures of global psychopathology symptoms, family functioning, and caregiver strain; parents, youths, and IEs rated youths' anxiety symptom severity. RESULTS Changes in family functioning and caregiver strain jointly explained relations between parental psychopathology and reductions in youth anxiety. Specifically, across IE and parent informants, families with higher pretreatment parental psychopathology showed more improvement in family functioning and caregiver strain, which in turn predicted greater youth anxiety reductions. Further, higher pretreatment parental psychopathology predicted greater caregiver strain reductions and, in turn, greater youth anxiety reductions, based on youths' reports of their own anxiety. CONCLUSIONS Findings suggest that improvements in family functioning and reductions in caregiver strain can influence treatment outcomes for anxious youths, especially among youths with more distressed parents.
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Affiliation(s)
| | - Golda S Ginsburg
- Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine
| | - Courtney P Keeton
- Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine
| | | | | | | | - John Piacentini
- Division of Child and Adolescent Psychiatry, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Joel Sherrill
- Division of Services and Intervention Research, National Institute of Mental Health
| | - John T Walkup
- Department of Psychiatry, Weill Cornell Medical College
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Ginsburg GS, Becker EM, Keeton CP, Sakolsky D, Piacentini J, Albano AM, Compton SN, Iyengar S, Sullivan K, Caporino N, Peris T, Birmaher B, Rynn M, March J, Kendall PC. Naturalistic follow-up of youths treated for pediatric anxiety disorders. JAMA Psychiatry 2014; 71:310-8. [PMID: 24477837 PMCID: PMC3969570 DOI: 10.1001/jamapsychiatry.2013.4186] [Citation(s) in RCA: 152] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Pediatric anxiety disorders are highly prevalent and impairing and are considered gateway disorders in that they predict adult psychiatric problems. Although they can be effectively treated in the short term, data are limited on the long-term outcomes in treated children and adolescents, particularly those treated with medication. OBJECTIVE To determine whether acute clinical improvement and treatment type (i.e., cognitive behavioral therapy, medication, or their combination) predicted remission of anxiety and improvement in global functioning at a mean of 6 years after randomization and to examine predictors of outcomes at follow-up. DESIGN, SETTING, AND PARTICIPANTS This naturalistic follow-up study, as part of the Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS), was conducted at 6 academic sites in the United States and included 288 youths (age range, 11-26 years; mean age, 17 years). Youths were randomized to 1 of 4 interventions (cognitive behavioral therapy, medication, combination, or pill placebo) in the Child/Adolescent Anxiety Multimodal Study (CAMS) and were evaluated a mean of 6 years after randomization. Participants in this study constituted 59.0% of the original CAMS sample. EXPOSURES Participants were assessed by independent evaluators using a semistructured diagnostic interview to determine the presence of anxiety disorders, the severity of anxiety, and global functioning. Participants and their parents completed questionnaires about mental health symptoms, family functioning, life events, and mental health service use. MAIN OUTCOMES AND MEASURES Remission, defined as the absence of all study entry anxiety disorders. RESULTS Almost half of the sample (46.5%) were in remission a mean of 6 years after randomization. Responders to acute treatment were significantly more likely to be in remission (odds ratio, 1.83; 95% CI, 1.08-3.09) and had less severe anxiety symptoms and higher functioning; the assigned treatment arm was unrelated to outcomes. Several predictors of remission and functioning were identified. CONCLUSIONS AND RELEVANCE Youths rated as responders during the acute treatment phase of CAMS were more likely to be in remission a mean of 6 years after randomization, although the effect size was small. Relapse occurred in almost half (48%) of acute responders, suggesting the need for more intensive or continued treatment for a sizable proportion of youths with anxiety disorders. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00052078.
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Affiliation(s)
- Golda S. Ginsburg
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Emily M. Becker
- Department of Psychology, University of Miami, Coral Gables, Florida
| | - Courtney P. Keeton
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dara Sakolsky
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - John Piacentini
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - Anne Marie Albano
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, Columbia University Medical Center, New York, New York
| | - Scott N. Compton
- Department of Psychiatry and Biobehavioral Sciences, Duke University, Durham, North Carolina
| | - Satish Iyengar
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevin Sullivan
- Department of Psychiatry and Biobehavioral Sciences, Duke University, Durham, North Carolina
| | - Nicole Caporino
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | - Tara Peris
- Department of Psychiatry and Biobehavioral Sciences, UCLA Semel Institute for Neuroscience and Human Behavior, Los Angeles, California
| | - Boris Birmaher
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Moira Rynn
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, Columbia University Medical Center, New York, New York
| | - John March
- Department of Psychiatry and Biobehavioral Sciences, Duke University, Durham, North Carolina
| | - Philip C. Kendall
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
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Compton SN, Peris TS, Almirall D, Birmaher B, Sherrill J, Kendall PC, March JS, Gosch EA, Ginsburg GS, Rynn MA, Piacentini JC, McCracken JT, Keeton CP, Suveg CM, Aschenbrand SG, Sakolsky D, Iyengar S, Walkup JT, Albano AM. Predictors and moderators of treatment response in childhood anxiety disorders: results from the CAMS trial. J Consult Clin Psychol 2014; 82:212-24. [PMID: 24417601 DOI: 10.1037/a0035458] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE We sought to examine predictors and moderators of treatment outcomes among 488 youths ages 7-17 years (50% female; 74% ≤ 12 years) meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed., text rev.; American Psychiatric Association, 2000) criteria for diagnoses of separation anxiety disorder, social phobia, or generalized anxiety disorder who were randomly assigned to receive either cognitive behavioral therapy (CBT), sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) in the Child/Adolescent Anxiety Multimodal Study (CAMS). METHOD Six classes of predictor and moderator variables (22 variables) were identified from the literature and examined using continuous (Pediatric Anxiety Ratings Scale; PARS) and categorical (Clinical Global Impression Scale-Improvement; CGI-I) outcome measures. RESULTS Three baseline variables predicted better outcomes (independent of treatment condition) on the PARS, including low anxiety severity (as measured by parents and independent evaluators) and caregiver strain. No baseline variables were found to predict Week 12 responder status (CGI-I). Participants' principal diagnosis moderated treatment outcomes but only on the PARS. No baseline variables were found to moderate treatment outcomes on Week 12 responder status (CGI-I). DISCUSSION Overall, anxious children responded favorably to CAMS treatments. However, having more severe and impairing anxiety, greater caregiver strain, and a principal diagnosis of social phobia were associated with less favorable outcomes. Clinical implications of these findings are discussed.
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Affiliation(s)
- Scott N Compton
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Tara S Peris
- Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Daniel Almirall
- Survey Research Center, Institute for Social Research, University of Michigan
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - Joel Sherrill
- Division of Services and Intervention Research, National Institute of Mental Health
| | | | - John S March
- Department of Psychiatry and Behavioral Sciences, Duke University Medical Center
| | - Elizabeth A Gosch
- Department of Psychology, Philadelphia College of Osteopathic Medicine
| | - Golda S Ginsburg
- Division of Child and Adolescent Psychiatry, The Johns Hopkins Hospital
| | - Moira A Rynn
- Department of Child Psychiatry, Columbia University Medical Center
| | - John C Piacentini
- John C. Piacentini and James T. McCracken, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - James T McCracken
- John C. Piacentini and James T. McCracken, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Courtney P Keeton
- Division of Child and Adolescent Psychiatry, The Johns Hopkins Hospital
| | | | | | - Dara Sakolsky
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - Satish Iyengar
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center
| | - John T Walkup
- Division of Child and Adolescent Psychiatry, Weill Cornell Medical College
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10
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Beidas RS, Lindhiem O, Brodman DM, Swan A, Carper M, Cummings C, Kendall PC, Albano AM, Rynn M, Piacentini J, McCracken J, Compton SN, March J, Walkup J, Ginsburg G, Keeton CP, Birmaher B, Sakolsky D, Sherrill J. A probabilistic and individualized approach for predicting treatment gains: an extension and application to anxiety disordered youth. Behav Ther 2014; 45:126-36. [PMID: 24411120 PMCID: PMC3893713 DOI: 10.1016/j.beth.2013.05.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2013] [Revised: 04/28/2013] [Accepted: 05/05/2013] [Indexed: 11/15/2022]
Abstract
The objective of this study was to extend the probability of treatment benefit method by adding treatment condition as a stratifying variable, and illustrate this extension of the methodology using the Child and Adolescent Anxiety Multimodal Study data. The probability of treatment benefit method produces a simple and practical way to predict individualized treatment benefit based on pretreatment patient characteristics. Two pretreatment patient characteristics were selected in the production of the probability of treatment benefit charts: baseline anxiety severity, measured by the Pediatric Anxiety Rating Scale, and treatment condition (cognitive-behavioral therapy, sertraline, their combination, and placebo). We produced two charts as exemplars which provide individualized and probabilistic information for treatment response and outcome to treatments for child anxiety. We discuss the implications of the use of the probability of treatment benefit method, particularly with regard to patient-centered outcomes and individualized decision-making in psychology and psychiatry.
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11
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Keeton CP, Ginsburg GS, Drake KL, Sakolsky D, Kendall PC, Birmaher B, Albano AM, March JS, Rynn M, Piacentini J, Walkup JT. Benefits of child-focused anxiety treatments for parents and family functioning. Depress Anxiety 2013; 30:865-72. [PMID: 23390005 PMCID: PMC4144828 DOI: 10.1002/da.22055] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 12/12/2012] [Accepted: 12/16/2012] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND To examine (1) changes in parent (global psychological distress, trait anxiety) and family (dysfunction, burden) functioning following 12 weeks of child-focused anxiety treatment, and (2) whether changes in these parent and family factors were associated with child's treatment condition and response. METHODS Participants were 488 youth ages 7-17 years (50% female; mean age 10.7 years) who met DSM-IV-TR criteria for social phobia, separation anxiety, and/or generalized anxiety disorder, and their parents. Youth were randomly assigned to 12 weeks of "Coping Cat" individual cognitive-behavioral therapy (CBT), medication management with sertraline (SRT), their combination (COMB), or medication management with pill placebo (PBO) within the multisite Child/Adolescent Anxiety Multimodal Study (CAMS). At pre- and posttreatment, parents completed measures of trait anxiety, psychological distress, family functioning, and burden of child illness; children completed a measure of family functioning. Blinded independent evaluators rated child's response to treatment using the Clinical Global Impression-Improvement Scale at posttreatment. RESULTS Analyses of covariance revealed that parental psychological distress and trait anxiety, and parent-reported family dysfunction improved only for parents of children who were rated as treatment responders, and these changes were unrelated to treatment condition. Family burden and child-reported family dysfunction improved significantly from pre- to posttreatment regardless of treatment condition or response. CONCLUSIONS Findings suggest that child-focused anxiety treatments, regardless of intervention condition, can result in improvements in nontargeted parent symptoms and family functioning particularly when children respond successfully to the treatment.
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Affiliation(s)
- Courtney P. Keeton
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, Maryland,Correspondence to: Courtney P. Keeton, Division of Child & Adolescent Psychiatry, The Johns Hopkins University School of Medicine, 550 N. Broadway, Suite 201A, Baltimore, MD 21205.
| | - Golda S. Ginsburg
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Kelly L. Drake
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Dara Sakolsky
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Philip C. Kendall
- Department of Psychology, Temple University, Philadelphia, Pennsylvania
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Anne Marie Albano
- Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - John S. March
- Department of Psychiatry and Behavioral Services, Duke University Medical Center, Durham, North Carolina
| | - Moira Rynn
- Department of Psychiatry, Columbia University Medical Center, New York, New York
| | - John Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California Los Angeles, Los Angeles, California
| | - John T. Walkup
- Division of Child and Adolescent Psychiatry, Weill Cornell Medical College and New York-Presbyterian Hospital, New York, New York
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12
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Podell JL, Kendall PC, Gosch EA, Compton SN, March JS, Albano AM, Rynn MA, Walkup JT, Sherrill JT, Ginsburg GS, Keeton CP, Birmaher B, Piacentini JC. Therapist Factors and Outcomes in CBT for Anxiety in Youth. ACTA ACUST UNITED AC 2013; 44:89-98. [PMID: 25419042 DOI: 10.1037/a0031700] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
This study examined the relationship between therapist factors and child outcomes in anxious youth who received cognitive-behavioral therapy (CBT) as part of the Child-Adolescent Anxiety Multimodal Study (CAMS). Of the 488 youth who participated in the CAMS project, 279 were randomly assigned to one of the CBT conditions (CBT only or CBT plus sertraline). Participants included youth (ages 7-17; M = 10.76) who met criteria for a principal anxiety disorder. Therapists included 38 cognitive-behavioral therapists. Therapist style, treatment integrity, and therapist experience were examined in relation to child outcome. Child outcome was measured via child, parent, and independent evaluator report. Therapists who were more collaborative and empathic, followed the treatment manual, and implemented it in a developmentally appropriate way had youth with better treatment outcomes. Therapist "coach" style was a significant predictor of child-reported outcome, with the collaborative "coach" style predicting fewer child-reported symptoms. Higher levels of therapist prior clinical experience and lower levels of prior anxiety-specific experience were significant predictors of better treatment outcome. Findings suggest that although all therapists used the same manual-guided treatment, therapist style, experience, and clinical skills were related to differences in child outcome. Clinical implications and recommendations for future research are discussed.
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13
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Blossom JB, Ginsburg GS, Birmaher B, Walkup JT, Kendall PC, Keeton CP, Langley AK, Piacentini JC, Sakolsky D, Albano AM. Parental and Family Factors as Predictors of Threat Bias in Anxious Youth. Cognit Ther Res 2013; 37:812-819. [PMID: 25328258 DOI: 10.1007/s10608-012-9513-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
The present study examined the relative predictive value of parental anxiety, parents' expectation of child threat bias, and family dysfunction on child's threat bias in a clinical sample of anxious youth. Participants (N = 488) were part of the Child/Adolescent Anxiety Multi-modal study (CAMS), ages 7-17 years (M = 10.69; SD = 2.80). Children met diagnostic criteria for generalized anxiety disorder, separation anxiety and/or social phobia. Children and caregivers completed questionnaires assessing child threat bias, child anxiety, parent anxiety and family functioning. Child age, child anxiety, parental anxiety, parents' expectation of child's threat bias and child-reported family dysfunction were significantly associated with child threat bias. Controlling for child's age and anxiety, regression analyses indicated that parents' expectation of child's threat bias and child-reported family dysfunction were significant positive predictors of child's self-reported threat bias. Findings build on previous literature by clarifying parent and family factors that appear to play a role in the development or maintenance of threat bias and may inform etiological models of child anxiety.
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Affiliation(s)
- Jennifer B Blossom
- Nemours Pediatrics, Thomas Jefferson University Hospital, 833 Chestnut Street, Ste 1210, Philadelphia, PA 19107, USA
| | - Golda S Ginsburg
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Boris Birmaher
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John T Walkup
- Division of Child and Adolescent Psychiatry, Weill Cornell Medical College, New York, NY, USA
| | - Philip C Kendall
- Department of Psychology, Temple University, Philadelphia, PA, USA
| | - Courtney P Keeton
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Audra K Langley
- Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, CA, USA
| | - John C Piacentini
- Semel Institute for Neuroscience and Human Behavior, University of California at Los Angeles, Los Angeles, CA, USA
| | - Dara Sakolsky
- Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Anne Marie Albano
- New York State Psychiatric Institute, Columbia University Medical Center, New York, NY, USA
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14
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Abstract
Social phobia (SOP) and selective mutism (SM) are related anxiety disorders characterized by distress and dysfunction in social situations. SOP typically onsets in adolescence and affects about 8% of the general population, whereas SM onsets before age 5 and is prevalent in up to 2% of youth. Prognosis includes a chronic course that confers risk for other disorders or ongoing social disability, but more favorable outcomes may be associated with young age and low symptom severity. SOP treatments are relatively more established, whereas dissemination of promising and innovative SM-treatment strategies is needed.
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Affiliation(s)
- Courtney P Keeton
- Department of Psychiatry, Johns Hopkins University School of Medicine, 550 North Broadway/Suite 201, Baltimore, MD 21205, USA.
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15
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Ginsburg GS, Kendall PC, Sakolsky D, Compton SN, Piacentini J, Albano AM, Walkup JT, Sherrill J, Coffey KA, Rynn MA, Keeton CP, McCracken JT, Bergman L, Iyengar S, Birmaher B, March J. Remission after acute treatment in children and adolescents with anxiety disorders: findings from the CAMS. J Consult Clin Psychol 2012; 79:806-13. [PMID: 22122292 DOI: 10.1037/a0025933] [Citation(s) in RCA: 200] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To report on remission rates in anxious youth who participated in the Child/Adolescent Anxiety Multimodal Study (CAMS). The CAMS, a multisite clinical trial, randomized 488 children and adolescents (ages 7-17 years; 79% Caucasian; 50% female) with separation, social, and/or generalized anxiety disorder to a 12-week treatment of sertraline (SRT), cognitive behavioral therapy (CBT), their combination (COMB), or clinical management with pill placebo (PBO). METHOD The primary definition of remission was loss of all study-entry anxiety disorder diagnoses; additional definitions of remission were used. All outcomes were rated by independent evaluators blind to treatment assignment. Predictors of remission were also examined. RESULTS Remission rates after 12 weeks of treatment ranged from 46% to 68% for COMB, 34% to 46% for SRT, 20% to 46% for CBT, and 15% to 27% for PBO. Rates of remission (i.e., achieving a nearly symptom-free state) were significantly lower than rates of response (i.e., achieving a clinically meaningful improvement relative to baseline) for the entire sample. Youth who received COMB had significantly higher rates of remission compared to all other treatment groups. Both monotherapies had higher remission rates compared to PBO, but rates were not different from each other. Predictors of remission were younger age, nonminority status, lower baseline anxiety severity, absence of other internalizing disorders (e.g., anxiety, depression), and absence of social phobia. CONCLUSIONS For the majority of children, some symptoms of anxiety persisted, even among those showing improvement after 12 weeks of treatment, suggesting a need to augment or extend current treatments for some children.
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Affiliation(s)
- Golda S Ginsburg
- Division of Child and Adolescent Psychiatry, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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16
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Abstract
Despite the absence of data on the efficacy of combination therapy (i.e., psychosocial and medication) for the treatment of anxiety disorders in youths, clinicians in clinical practice often utilize this treatment approach. This paper discusses issues related to sequencing, combining, and integrating cognitive behavioural and pharmacological interventions for anxiety disorders in children and adolescents. We briefly summarize the empirical evidence for mono and combination therapy and raise a variety of issues that should be considered when making treatment decisions. Finally, we present an integrated treatment model to facilitate the delivery of a comprehensive treatment approach across care providers. These suggestions are geared toward optimizing clinical outcomes for anxious youths.
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Affiliation(s)
- Courtney P Keeton
- Division of Child and Adolescent Psychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD 21287-3325, USA.
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