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clear. Research has also focused on the ways in which anxious children process threatening information (Muris & Field, 2013). As has been shown in adults, anxious children have both a bias in attention toward threat and a bias to interpret ambiguous information in a threat-consistent manner. Some research has shown that these biases decrease with successful treatment. TREATMENT Psychopharmacology Pharmacological management of anxiety in children has typically focussed on the use of selective serotonin reuptake inhibitors (SSRIs). Several studies have demonstrated significant efficacy of SSRIs such as fluoxetine and sertraline in the management of broad-based anxiety disorders, although most studies have primarily focussed on treatment of OCD (Ipser et al, 2009). Little difference has been shown between specific agents, although paroxetine is not recommended in this age group and there is some suggestion that Venlafaxine has lower efficacy and acceptability (Uthman 2010). Treatment has generally lasted 10-15 weeks. Outcome results indicate that 50% to 60% of children are considered treatment-responders at the end of treatment compared with around 30% of those on placebo. Unfortunately, the longer-term maintenance of gains has rarely been investigated, but there is Click on the picture to hear Eli R Lebowitz PhD talk about CBT for childhood anxiety disorders (13:14 minutes) Anxiety disorders F.1 12 IACAPAP Textbook of Child and Adolescent Mental Health some hint in the literature that medication effects may level off after around 8 weeks (Ipser et al, 2009). Adverse medication events are relatively infrequent but do occur and up to 7% of anxious children on SSRIs discontinue due to side effects. Suicidality needs to be monitored in all young people taking an SSRI (for more details on pharmacological treatment see Chapter A.8 and Table A.8.1). Skills-based programs Most evidence-based psychological treatment for childhood anxiety falls under the broad category of cognitive-behavioural or skills-based treatment. The fundamental basis is teaching the child (and sometimes the parents) specific skills to help manage the child’s anxiety. Most treatments consist of comprehensive packages or combinations of techniques. Specific treatment techniques include: • Psychoeducation • Relaxation • In vivo exposure • Contingency management • Parent training • Cognitive restructuring • Social skills and assertiveness training Treatment programs typically last 8-15 weeks of around 1-2 hours per session and have been delivered in either group format or individually. Results indicate that 50% to 60% of children are considered diagnosis-free at the end of treatment (James et al, 2015) and this figure typically increases to 70%-80% up to 12 months following the end of treatment. A few studies have indicated maintenance of treatment gains up to 6-8 years following treatment (e.g., Kendall et al, 2004). A number of studies have tried to identify factors that may influence treatment efficacy. There is some evidence that individual treatment delivery may produce slightly larger effects than treatment delivered in a group (Reynolds et al, 2012). A more important issue that has received some attention is the extent to which it is necessary to include parents in treatment and to teach them specific skills. Evidence on this issue is mixed but generally indicates few benefits of including parents as active participants in the treatment (Reynolds et al, 2012). However, studies that have addressed this issue have rarely taken the age of the child into account. More importantly, studies differ widely in the ways in which parents have been included in treatment programs and this has rarely been considered in reviews of the literature. In one large reanalysis of data, teaching parents specific skills in parenting or methods to help their child outside therapy, led to significantly better outcomes three months following the end of treatment than other parental inclusion (Manassis et al, 2014). Another relevant question is the influence of comorbid diagnoses on treatment effects. Surprisingly, the majority of research to date has failed to show that treatment response is worse for anxious children with comorbid disorders. In other words, anxious children seem to respond equally well to skills-based treatment packages even if they have additional difficulties with anxiety, depression, or externalising problems (Ollendick et al, 2008). Having said that, there is mixed evidence for depression; a few studies have suggested that comorbid depression may reduce treatment response (Rapee et al, 2009). A recent study from our own clinic has shed a little more light on this issue. Based on our data, it appears that having a comorbid disorder does not influence the degree of change across treatment but does influence the endpoint. Because children with comorbid disorders (especially comorbid externalising disorders and depression) typically have more severe Results indicate that 50% to 60% of children are considered diagnosis-free at the end of treatment (skillsbased or CBT programs) and this figure typically increases to 70%-80% up to 12 months following the end of treatment Anxiety disorders F.1 13 IACAPAP Textbook of Child and Adolescent Mental Health anxiety to begin with, the point they reach at the end of treatment is
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