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generally not as good as children without comorbid disorders, although the rate of change across treatment is very similar. Some research has also begun to show that children with high functioning autism and comorbid anxiety also respond very well to the treatment of their anxiety (Moree & Davis, 2010). Few other predictors of treatment response have been found. There have been hints that parent psychopathology – both parent anxiety and depression – predicts worse outcome, but some studies have failed to show this effect. Other factors such as marital status, parent education, and family size appear to have little effect. Some intriguing research has shown that genetic status might predict treatment response. Children with short alleles on the 5HTTLPR gene showed a better response to treatment at follow-up than did children with two long alleles (Eley et al, 2012). However, a later study failed to replicate this effect (Lester et al, 2016). Finally, consistent evidence has emerged that children with social anxiety disorder show poorer response to treatment than children with other anxiety disorders (Hudson et al, 2015). The reasons for this difference are not clear but it is possible that social anxiety will require additional treatment elements. Low intensity interventions A growing body of work is demonstrating the efficacy of treating anxious children using methods that require considerably fewer therapist resources than traditional face-to-face treatment (Rooksby et al, 2015). This form of treatment, often referred to as low intensity, is usually delivered either by written material or over the internet. Programs of this type usually follow skills-based principles, but the information is delivered to either the parent (for children) or to the young person directly (for adolescents) via printed or electronic means. Most programs include some support from a therapist, often over the telephone, and this has been shown to produce larger effects than pure self-help. A program example: Cool Kids There are several skills-based treatment packages for the management of anxiety disorders in young people and most contain very similar components. Sessions and components of the Cool Kids program. Session Coverage - Child Coverage - Parents 1 Psychoeducation Psychoeducation and treatment rationale 2 Cognitive restructuring Cognitive restructuring for both parent and child 3 Cognitive restructuring practice Cognitive restructuring practice Child management skills 4 In vivo exposure and development of hierarchies In vivo exposure and development of hierarchies 5 Dealing with difficulties in exposure Dealing with difficulties in exposure 6 Practice exposure and cognitive restructuring Practice exposure, cognitive restructuring and child management 7 Introduce assertiveness and social skills Ways to increase assertiveness and social skills 8 Teasing and bullying Teasing and bullying 9 Practice and review Practice and review 10 Practice, review and relapse prevention Practice, review and relapse prevention Anxiety disorders F.1 14 IACAPAP Textbook of Child and Adolescent Mental Health an example, I will describe our own program, Cool Kids. Cool Kids is a manualised treatment program for anxious young people aged 7 to 17 years. There is a detailed set of guidelines for therapists that is supported by workbooks for the parents and the young person. Different workbooks and a slightly different structure are used for children (7-12) and adolescents (13-17). There are also modified versions for use with children with autism, children who are chronically victimised, for adolescents with comorbid anxiety and depression, for children and adolescents with unexplained medical symptoms, and for families who are unable to attend a clinic for face-to-face treatment (low intensity). Treatment using Cool Kids typically comprises 10 sessions over 12 weeks. Parents are an integral component and are seen at all sessions when treatment is for children but have a reduced involvement when treatment is for adolescents. The program can be delivered in either a group or individual format. Sessions typically last 60 minutes when delivered individually and 120 minutes when delivered as a group. There are separate components covered with children and parents. The sessions and components of Cool Kids are shown in Table F.1.2. Overall efficacy for Cool Kids is good (Mychailyszyn, 2017). We generally include any child with an anxiety disorder as their principal (most interfering) Table F.1.3 Treating childhood anxiety disorders in practice • First line treatment: Low-intensity treatment – including use of books (bibliotherapy), CD’s or internet programs (e-therapy). May not be recommended in cases of highly urgent need (e.g., chronic school refusal) or high risk (e.g., suicidal ideation), or in cases of especially poor parent-child relationships • If unwilling to attempt low intensity – then low-intensity is not recommended – or patient does not improve with low-intensity treatment, suggest traditional CBT or skills-based treatment with a qualified practitioner in all cases, with the exception of patients who refuse skills-based treatment or CBT is not available • If a patient does not improve after a treatment program delivered by a skilful clinician for long enough (12-20 weeks), refuses skills-based treatment or CBT is not available, consider medication • When patients are
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