Abstracts
Objective
To conduct a systematic review about the long-term response to cognitive-behavioral therapy (CBT) for anxiety disorders (ADs) in children and adolescents.
Methods
The PubMed and ISI Web of Science databases were consulted. Search in the databases was performed in November 2012 and included cohort studies after CBT for ADs in children and adolescents with a follow-up period over 12 months.
Results
A total of 10 papers met the inclusion criteria. The follow-up period ranged from 12 months to 13 years and the results generally showed maintenance of the short-term benefits with CBT. However, the studies presented limitations, especially regarding methods, such as lack of a control group and losses to follow-up.
Conclusion
The long-term benefits of CBT were identified, however it would be interesting to conduct other studies with more frequent assessment periods, in order to minimize losses to follow-up, in addition to evaluating children and adolescents in the various stages of their development.
Cognitive-behavioral therapy; anxiety disorders in children and adolescents; follow-up studies
Objetivo
Realizar uma revisão sistemática sobre a resposta em longo prazo à terapia cognitivo-comportamental (TCC) para transtornos de ansiedade (TAs) em crianças e adolescentes.
Métodos
Foram consultadas as bases PubMed e ISI Web of Science. A pesquisa nas bases de dados foi realizada em novembro de 2012 e incluíram-se estudos de coorte após TCC para TAs na infância e adolescência com período de seguimento superior a 12 meses.
Resultados
Um total de 10 artigos preencheu os critérios de inclusão. O período de seguimento variou entre 12 meses e 13 anos e, em geral, os resultados indicaram a manutenção dos ganhos com a TCC em curto prazo. No entanto, os estudos apresentaram limitações, principalmente em relação ao método, como ausência de grupo controle e perdas de seguimento.
Conclusão
Foram identificados os benefícios da TCC em longo prazo, porém seria interessante a realização de outros estudos que mantivessem períodos de avaliação mais frequentes a fim de minimizar perdas de seguimento, além de avaliar a criança e o adolescente nas diferentes etapas de seu desenvolvimento.
Terapia cognitivo-comportamental; transtornos de ansiedade na infância e adolescência; estudos de seguimento
INTRODUCTION
Anxiety and fear are emotions inherent to human nature, which become pathological when they are disproportionate to the stimulus or qualitatively differ from that which is observed in a given age group11 Nevo GA, Manassis K. Outcomes for treated anxious children: a critical review of Long-Term-Follow-Up studies. Depress Anxiety. 2009;26(7):650-60., characterizing anxiety disorders (ADs). These disorders are currently classified as: separation anxiety disorder (SepAD), panic disorder (PD), social anxiety disorder or social phobia (SAD), generalized anxiety disorder (GAD), specific phobia (SP), post-traumatic stress disorder (PTSD) and obsessive-compulsive disorder (OCD)22 American Psychiatric Association e Manual Diagnóstico e Estatístico de Transtornos Mentais: revisão. 4.ed. Porto Alegre: APA; 2000.. A recent study observed that ADs are among the major disorders affecting children and adolescents, and up to 24.9% of them could experience these disorders over the course of their life33 Kessler RC, Avenevoli S, Costello EJ, Georgiades K, Green JG, Gruber MJ, et al. Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. 2012;69(4):372-80., with symptoms impairing their academic and social performance44 Duchesne S, Vitaro F, Larose S, Tremblay RE. Trajectories of anxiety during elementary-school years and the prediction of high school noncompletion. J Youth Adolesc. 2008;37(9):1134-46..
Retrospective55 Pollack MH, Otto MW, Sabatino S, Majcher D, Worthington JJ, McArdle
ET, et al. Relationship of childhood anxiety to adult panic disorder: Correlates
and influence on course. Am J Psychiatry. 1996;153(3):376-81. and prospective
studies66 Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, et al.
Incidence of social anxiety disorder and the consistent risk for secondary
depression in the first three decades of life. Arch Gen Psychiatry.
2007;64(8):903-12.
7 Bittner A, Egger HL, Erkanli A, Costello J, Foley DL, Angold A. What
do childhood anxiety disorders predict? J Child Psychol Psychiatry.
2007;48(12):1174-83.-88 Moffitt TE, Harrington H, Caspi A, Kim-Cohen J, Goldberg D, Gregory
AM, et al. Depression and generalized anxiety disorder: cumulative and
sequential comorbidity in a birth cohort followed prospectively to age 32 years.
Arch Gen Psychiatry. 2007;64(6):651-60. show that ADs in childhood and
adolescence are chronic conditions that do not spontaneously present remission over
time. If these disorders are not treated in their early stages, they increase the
risk of school dropout or predict significant setbacks in academic life44 Duchesne S, Vitaro F, Larose S, Tremblay RE. Trajectories of anxiety
during elementary-school years and the prediction of high school noncompletion.
J Youth Adolesc. 2008;37(9):1134-46., as well as psychopathologies in
adulthood, such as depression66 Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, et al.
Incidence of social anxiety disorder and the consistent risk for secondary
depression in the first three decades of life. Arch Gen Psychiatry.
2007;64(8):903-12.
7 Bittner A, Egger HL, Erkanli A, Costello J, Foley DL, Angold A. What
do childhood anxiety disorders predict? J Child Psychol Psychiatry.
2007;48(12):1174-83.
8 Moffitt TE, Harrington H, Caspi A, Kim-Cohen J, Goldberg D, Gregory
AM, et al. Depression and generalized anxiety disorder: cumulative and
sequential comorbidity in a birth cohort followed prospectively to age 32 years.
Arch Gen Psychiatry. 2007;64(6):651-60.
9 Flannery-Schroeder EC. Reducing anxiety to prevent depression. Am J
Prev Medicine. 2006;31(6):136-42.
10 Copeland WE, Shanahan L, Costello J, Angold A. Childhood and
adolescent psychiatric disorders as predictors of young adult disorders. Arch
Gen Psychiatry. 2009;66(7):764-72.-1111 Beesdo K, Pine DS, Lieb R, Wittchen HU. Incidence and risk patterns
of anxiety and depressive disorders and categorization of generalized anxiety
disorder. Arch Gen Psychiatry. 2010;67(1):47-57. and substance abuse1212 Kendall PC, Kessler RC. The impact of childhood psychopathology
interventions on subsequent substance abuse: Policy comments, and
recommendations. J Consult Clin Psychol. 2002;70(6):1303-6..
Despite its high prevalence and substantial associated morbidity, ADs in children and adolescents are still underdiagnosed and undertreated, even though there is evidence of effective treatment, such as pharmacotherapy1313 Walkup JD, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT, et al. Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England J Medicine. 2008;359(26):2753-66. and cognitive-behavioral therapy (CBT)1414 In-Albon T, Schneider S. Psychotherapy of childhood anxiety disorders: a meta-analysis. Psychother Psychosom. 2007;76(1):15-24.,1515 Silverman WK, Pina AA, Viswesvaran C. Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. J Clin Child Adolesc Psychol. 2008;37(1):105-30.. In a meta-analysis involving 10 randomized controlled trials that compared CBT for ADs in childhood and adolescence with a waiting list, the remission rate in the CBT group was 56.5% versus 34.8% in the control group, suggesting a clinically significant benefit associated with the treatment1616 Cartwright-Hatton S, Roberts C, Chitsabesan P, Fothergill C, Harrington R. Systematic review of the efficacy of cognitive behavior therapies for childhood and adolescent anxiety disorders. British J Clin Psychol. 2004;43(4):421-36.. In another meta-analysis, with 13 randomized clinical trials (498 patients and 311 controls), the response to CBT for any AD was 56%, compared to 28.2% in the control group (RR: 0.6; CI 95%: 0.53-0.69), with a number needed to treat (NNT) of 3 (CI 95%: 2.5-4.5)1717 James A, Soler A, Weatherall R. Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database Syst Rev. 2009;19(4)..
Follow-up studies evaluating long-term response to CBT are considerably more scarce when compared to studies evaluating short-term response. A recent review study about ADs showed that the short-term benefits of CBT are extended into late adolescence11 Nevo GA, Manassis K. Outcomes for treated anxious children: a critical review of Long-Term-Follow-Up studies. Depress Anxiety. 2009;26(7):650-60.. However, the authors suggest that more follow-up studies are needed in order to confirm the predictors of long-term results.
Considering these gaps, which are still observed in the literature, this study aims to carry out a systematic review of follow-up studies assessing CBT for ADs in children and adolescents.
METHODS
This is a systematic review, with queries to the PubMed and ISI Web of Science databases. As inclusion criteria, researchers looked for cohort studies after CBT for ADs in childhood and adolescence; in English, Spanish or Portuguese languages. There was no limitation regarding ADs types and publication date. Studies with a follow-up period under one year were excluded. The following search terms were used: “childhood”; “anxiety or anxiety disorders”; “cognitive behavioral therapy”; “follow-up”.
Research in the databases and selection of the articles were conducted separately by two researchers. Studies mentioned in more than one database were computed only once. The abstracts of all the articles found in the search were preliminarily read; upon meeting the inclusion criteria, the entire article was read prior to its final inclusion.
In order to present the studys’ findings, results with p < 0.05 were considered as significant. Due to the heterogeneity of study designs (CBT format – individual or group; with or without parents) and variables (follow-up time), it was not feasible to conduct a meta-analysis of the studies included.
RESULTS
Search in the databases was conducted in November 2012 and 72 abstracts were found: 34 in PubMed (with eight selected to be read in full) and 38 in ISI Web of Science (with four selected to be read in full). A total of 10 articles met the inclusion criteria (Figure 1). Most studies that were excluded used follow-up periods of 3 to 6 months after CBT to reassess patients.
The characteristics and demographics of the studies included are shown in table 1. It can be observed that the follow-up
period in the study ranged from 12 months to 13 years after CBT. Patients were
diagnosed through instruments and 9 studies used the Anxiety Disorders Interview
Schedule: Child Version (ADIS-C), which follows the criteria of the Diagnostic and
Statistical Manual of Mental Disorders (DSM)1818 Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood
anxiety: a controlled trial. J Consult Clin Psychol.
1996;64(2):333-42.
19 Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the
treatment of childhood anxiety. J Consult Clin Psychol.
1998;66(6):893-905.
20 Barrett PM. Evaluation of cognitive-behavioral group treatments for
childhood anxiety disorders. J Clin Child Psychol.
1998;27(4):459-68.
21 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral
treatment of anxiety disorders in children: Long-term (6 year) follow-up. J
Consult Clin Psychol. 2001;69(1):135-41.
22 O’leary EMM, Barrett PM, Fjermestad KW. Cognitive-behavioral family
treatment for childhood obsessive-compulsive disorder: a 7-year follow-up study.
J Anxiety Disorders. 2009;23(7):973-8.
23 Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive
behavioral treatment for childhood anxiety disorders: long-term effects on
anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry.
2010;51(8):924-34.-2424 Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child anxiety
treatment: outcomes in adolescence and impact on substance use and depression at
7.4 year follow- up. J Consult Clin Psychol. 2004;72(2):276-87.,2626 Bernstein GA, Bernat DH, Victor AM, Layne AE. School-based
interventions for anxious children: 3-, 6-, and 12-month follow-ups. J Am Acad
Child Adolesc Psychiatry. 2008;47(9):1039-47.,2727 Cobham VE, Dadds MR, Spence SH, McDermott B. Parental anxiety in the
treatment of childhood anxiety: a different story three years later. J Clin
Child Adolesc Psychology. 2010;39(3):410-20.. In addition to the ADIS, 7 articles used Child
Behavior Checklist (CBCL) completed by parents1818 Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood
anxiety: a controlled trial. J Consult Clin Psychol.
1996;64(2):333-42.
19 Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the
treatment of childhood anxiety. J Consult Clin Psychol.
1998;66(6):893-905.
20 Barrett PM. Evaluation of cognitive-behavioral group treatments for
childhood anxiety disorders. J Clin Child Psychol.
1998;27(4):459-68.-2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral
treatment of anxiety disorders in children: Long-term (6 year) follow-up. J
Consult Clin Psychol. 2001;69(1):135-41.,2323 Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive
behavioral treatment for childhood anxiety disorders: long-term effects on
anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry.
2010;51(8):924-34.,2424 Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child anxiety
treatment: outcomes in adolescence and impact on substance use and depression at
7.4 year follow- up. J Consult Clin Psychol. 2004;72(2):276-87.,2727 Cobham VE, Dadds MR, Spence SH, McDermott B. Parental anxiety in the
treatment of childhood anxiety: a different story three years later. J Clin
Child Adolesc Psychology. 2010;39(3):410-20.. The four oldest studies were based on DSM-III1818 Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood
anxiety: a controlled trial. J Consult Clin Psychol.
1996;64(2):333-42.
19 Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the
treatment of childhood anxiety. J Consult Clin Psychol.
1998;66(6):893-905.
20 Barrett PM. Evaluation of cognitive-behavioral group treatments for
childhood anxiety disorders. J Clin Child Psychol.
1998;27(4):459-68.-2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral
treatment of anxiety disorders in children: Long-term (6 year) follow-up. J
Consult Clin Psychol. 2001;69(1):135-41..
Among the scales used to assess the anxiety and depression symptoms, the most commonly used were the Revised-Children Manifest Anxiety Scale (R-CMAS), the Multidimensional Anxiety Scale for Children (MASC) and the Children’s Depression Inventory (CDI). Most follow-up interviews were conducted in person, but some took place by telephone or email. Patients were generally evaluated at the baseline (before starting CBT), after completing the sessions, within 3-6 months, and at the follow-up point, which ranged from 12 months to 13 years.
Regarding the format of the intervention, two studies compared individual CBT versus group CBT2222 O’leary EMM, Barrett PM, Fjermestad KW. Cognitive-behavioral family treatment for childhood obsessive-compulsive disorder: a 7-year follow-up study. J Anxiety Disorders. 2009;23(7):973-8.,2323 Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive behavioral treatment for childhood anxiety disorders: long-term effects on anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry. 2010;51(8):924-34.. The remaining studies analyzed group CBT versus CBT including the family, with or without a waiting list. In the study of CBT for OCD, researchers compared individual CBT + family counseling to group CBT + family counseling2222 O’leary EMM, Barrett PM, Fjermestad KW. Cognitive-behavioral family treatment for childhood obsessive-compulsive disorder: a 7-year follow-up study. J Anxiety Disorders. 2009;23(7):973-8..
Three studies describe offering a reward in exchange for cooperation in the
follow-up; in two studies this reward was monetary2323 Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive
behavioral treatment for childhood anxiety disorders: long-term effects on
anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry.
2010;51(8):924-34.,2424 Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child anxiety
treatment: outcomes in adolescence and impact on substance use and depression at
7.4 year follow- up. J Consult Clin Psychol. 2004;72(2):276-87. and, in another study, the reward consisted of movie
tickets2020 Barrett PM. Evaluation of cognitive-behavioral group treatments for
childhood anxiety disorders. J Clin Child Psychol.
1998;27(4):459-68.. Additional
treatment was after CBT deemed necessary in four studies2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral
treatment of anxiety disorders in children: Long-term (6 year) follow-up. J
Consult Clin Psychol. 2001;69(1):135-41.
22 O’leary EMM, Barrett PM, Fjermestad KW. Cognitive-behavioral family
treatment for childhood obsessive-compulsive disorder: a 7-year follow-up study.
J Anxiety Disorders. 2009;23(7):973-8.
23 Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive
behavioral treatment for childhood anxiety disorders: long-term effects on
anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry.
2010;51(8):924-34.
24 Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child anxiety
treatment: outcomes in adolescence and impact on substance use and depression at
7.4 year follow- up. J Consult Clin Psychol. 2004;72(2):276-87.-2525 Manassis K, Avery D, Butalia S, Mendlowitz S. Cognitive-behavioral
therapy in childhood anxiety disorders: functioning in adolescence. Depress
Anxiety. 2004;19(4):209-16., taking place on an outpatient basis or even with
hospitalization, and also with medication. Only in one study the participants who
received additional therapy were excluded from the follow-up evaluation2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral
treatment of anxiety disorders in children: Long-term (6 year) follow-up. J
Consult Clin Psychol. 2001;69(1):135-41..
The results of the follow-up studies after CBT regarding symptoms and diagnosis are presented in table 2. It is observed that, in most studies, the benefits of therapy regarding anxiety and depression symptoms were maintained over time; in three of them, improvement was greater at the follow-up1818 Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64(2):333-42.,2020 Barrett PM. Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol. 1998;27(4):459-68.,2323 Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive behavioral treatment for childhood anxiety disorders: long-term effects on anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry. 2010;51(8):924-34., in five there was an improvement compared to the baseline, but no significant difference regarding the evaluation after the end of the sessions1919 Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consult Clin Psychol. 1998;66(6):893-905.,2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6 year) follow-up. J Consult Clin Psychol. 2001;69(1):135-41.,2424 Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4 year follow- up. J Consult Clin Psychol. 2004;72(2):276-87.,2626 Bernstein GA, Bernat DH, Victor AM, Layne AE. School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1039-47.,2727 Cobham VE, Dadds MR, Spence SH, McDermott B. Parental anxiety in the treatment of childhood anxiety: a different story three years later. J Clin Child Adolesc Psychology. 2010;39(3):410-20., and in two studies no difference in the anxiety symptoms was observed at the follow-up2222 O’leary EMM, Barrett PM, Fjermestad KW. Cognitive-behavioral family treatment for childhood obsessive-compulsive disorder: a 7-year follow-up study. J Anxiety Disorders. 2009;23(7):973-8.,2525 Manassis K, Avery D, Butalia S, Mendlowitz S. Cognitive-behavioral therapy in childhood anxiety disorders: functioning in adolescence. Depress Anxiety. 2004;19(4):209-16..
It was also found that CBT can have a positive impact on the diagnosis of ADs over time, i.e., in eight of the studies, most patients no longer met the diagnostic criteria for the ADs, except in two studies, in which no significant difference was found2525 Manassis K, Avery D, Butalia S, Mendlowitz S. Cognitive-behavioral therapy in childhood anxiety disorders: functioning in adolescence. Depress Anxiety. 2004;19(4):209-16.,2626 Bernstein GA, Bernat DH, Victor AM, Layne AE. School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1039-47..
Out of the seven studies that included the family in therapy, four found significantly better results for CBT + family when compared to CBT only for the patients1818 Barrett PM, Dadds MR, Rapee RM. Family treatment of childhood anxiety: a controlled trial. J Consult Clin Psychol. 1996;64(2):333-42.,2020 Barrett PM. Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol. 1998;27(4):459-68.,2626 Bernstein GA, Bernat DH, Victor AM, Layne AE. School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1039-47.,2727 Cobham VE, Dadds MR, Spence SH, McDermott B. Parental anxiety in the treatment of childhood anxiety: a different story three years later. J Clin Child Adolesc Psychology. 2010;39(3):410-20. and in three of the studies the no difference was found in the results1919 Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consult Clin Psychol. 1998;66(6):893-905.,2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6 year) follow-up. J Consult Clin Psychol. 2001;69(1):135-41.,2525 Manassis K, Avery D, Butalia S, Mendlowitz S. Cognitive-behavioral therapy in childhood anxiety disorders: functioning in adolescence. Depress Anxiety. 2004;19(4):209-16..
These studies presented limitations, primarily in terms of method. For instance, most of them lacked a control group. Furthermore, the waiting list ended up receiving treatment, which rendered it useless as a control. Out of the ten studies, only one had a waiting list that was not treated; this was the only clinical trial with a controlled follow-up2626 Bernstein GA, Bernat DH, Victor AM, Layne AE. School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1039-47.. The lack of control for variables, such as the use of additional therapies, was also observed, which may indicate a bias in the interpretation of results.
Only one study describes the use of additional therapies as an exclusion criterion2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6 year) follow-up. J Consult Clin Psychol. 2001;69(1):135-41.. Three other studies have described the use of additional therapies, but maintained the patients in the follow-up evaluation2020 Barrett PM. Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol. 1998;27(4):459-68.,2424 Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4 year follow- up. J Consult Clin Psychol. 2004;72(2):276-87.,2525 Manassis K, Avery D, Butalia S, Mendlowitz S. Cognitive-behavioral therapy in childhood anxiety disorders: functioning in adolescence. Depress Anxiety. 2004;19(4):209-16..
DISCUSSION
This review was conducted with scientific rigor and it has confirmed that there are very few follow-up studies of CBT for ADs in children and adolescents covering a period over 12 months. The main finding of the studies included is that the benefits of therapy are maintained over time, even for the cases in which the difference was in relation to the baseline1919 Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consult Clin Psychol. 1998;66(6):893-905.,2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6 year) follow-up. J Consult Clin Psychol. 2001;69(1):135-41.,2424 Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4 year follow- up. J Consult Clin Psychol. 2004;72(2):276-87.,2626 Bernstein GA, Bernat DH, Victor AM, Layne AE. School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1039-47.,2727 Cobham VE, Dadds MR, Spence SH, McDermott B. Parental anxiety in the treatment of childhood anxiety: a different story three years later. J Clin Child Adolesc Psychology. 2010;39(3):410-20..
Among the studies that compared CBT + Family and CBT only with the children, the results of more recent studies found that interventions including the family were more favorable2626 Bernstein GA, Bernat DH, Victor AM, Layne AE. School-based interventions for anxious children: 3-, 6-, and 12-month follow-ups. J Am Acad Child Adolesc Psychiatry. 2008;47(9):1039-47.,2727 Cobham VE, Dadds MR, Spence SH, McDermott B. Parental anxiety in the treatment of childhood anxiety: a different story three years later. J Clin Child Adolesc Psychology. 2010;39(3):410-20.. On the other hand, in two studies, no differences was found between the groups, even though these are older studies1919 Cobham VE, Dadds MR, Spence SH. The role of parental anxiety in the treatment of childhood anxiety. J Consult Clin Psychol. 1998;66(6):893-905.,2121 Barrett PM, Duffy AL, Dadds MR, Rapee RM. Cognitive-behavioral treatment of anxiety disorders in children: Long-term (6 year) follow-up. J Consult Clin Psychol. 2001;69(1):135-41..
Losses to follow-up studies are another common limitation that may somehow compromise the results. This confirms the need for evaluations with shorter intervals and for the consideration of rewarding participants, as three studies in this review have done2020 Barrett PM. Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. J Clin Child Psychol. 1998;27(4):459-68.,2323 Saavedra LM, Silverman WK, Morgan-Lopez AA, Kurtines WM. Cognitive behavioral treatment for childhood anxiety disorders: long-term effects on anxiety and secondary disorders in young adulthood. J Child Psychol Psychiatry. 2010;51(8):924-34.,2424 Kendall PC, Safford S, Flannery-Schroeder E, Webb A. Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4 year follow- up. J Consult Clin Psychol. 2004;72(2):276-87..
In all the studies, there was a clear focus on clinical outcomes, such as the severity of symptoms and the maintenance of the diagnosis of AD at follow-up. Therefore, studies that focus on evaluating psychosocial aspects, such as school performance and quality of life over time, still need to be conducted. These other parameters say much about the functioning of children and adolescents, including the way they feel about themselves, the environments to which they are exposed and how satisfied they are with their lives. Also, considering that one of the goals of AD treatment is to reduce the risk of psychopathology in adulthood, follow-up studies to define response predictors are yet to be developed11 Nevo GA, Manassis K. Outcomes for treated anxious children: a critical review of Long-Term-Follow-Up studies. Depress Anxiety. 2009;26(7):650-60..
Some limitations of this study must be considered. The search was carried out on only two databases, and might, therefore, have left some studies aside, leading to more limited conclusions. Besides, the lack of long term follow-up studies makes it difficult to establish comparisons.
CONCLUSIONS
Despite these limitations, the long-term benefits of CBT were identified, regardless of whether the format was individual or in group, with or without the inclusion of the family. It would be interesting to conduct further studies that used more frequent evaluation intervals, in order to minimize losses to follow-up, in addition to evaluating children and adolescents in the different stages of their development.
ACKNOWLEDGEMENTS
Hospital de Clínicas de Porto Alegre (HCPA), where the Program of Anxiety Disorders in Childhood and Adolescence (PROTAIA) is developed and where the design and development of studies like this one takes place; the Federal University of Rio Grande do Sul (UFRGS), institution of origin of the authors.
REFERENCES
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1Nevo GA, Manassis K. Outcomes for treated anxious children: a critical review of Long-Term-Follow-Up studies. Depress Anxiety. 2009;26(7):650-60.
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2American Psychiatric Association e Manual Diagnóstico e Estatístico de Transtornos Mentais: revisão. 4.ed. Porto Alegre: APA; 2000.
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3Kessler RC, Avenevoli S, Costello EJ, Georgiades K, Green JG, Gruber MJ, et al. Prevalence, persistence, and sociodemographic correlates of DSM-IV disorders in the National Comorbidity Survey Replication Adolescent Supplement. Arch Gen Psychiatry. 2012;69(4):372-80.
-
4Duchesne S, Vitaro F, Larose S, Tremblay RE. Trajectories of anxiety during elementary-school years and the prediction of high school noncompletion. J Youth Adolesc. 2008;37(9):1134-46.
-
5Pollack MH, Otto MW, Sabatino S, Majcher D, Worthington JJ, McArdle ET, et al. Relationship of childhood anxiety to adult panic disorder: Correlates and influence on course. Am J Psychiatry. 1996;153(3):376-81.
-
6Beesdo K, Bittner A, Pine DS, Stein MB, Höfler M, Lieb R, et al. Incidence of social anxiety disorder and the consistent risk for secondary depression in the first three decades of life. Arch Gen Psychiatry. 2007;64(8):903-12.
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Publication Dates
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Publication in this collection
Oct-Dec 2014
History
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Received
19 Feb 2014 -
Accepted
31 Oct 2014