Parent-Delivered CBT Reduces Kids' Anxiety
Deborah Brauser
January 22, 2014

Parent-delivered cognitive-behavioral therapy (CBT) guided by therapists is effective in treating child anxiety disorders, new research suggests.

A randomized study of almost 200 children between the ages of 7 and 12 years in the United Kingdom showed that 50% of those in the full guided group recovered from their clinically diagnosed anxiety disorder after treatment vs 39% of those in the brief guided group.

The full guided group was also 85% more likely to recover than those assigned to a treatment wait list, suggesting that it is "an effective and inexpensive first-line treatment for child anxiety," write the investigators.

"We were really pleased to see that a large proportion of children benefited," coinvestigator Cathy Creswell, DClinPsy, PhD, principal research fellow and clinical psychologist at the University of Reading, UK, told Medscape Medical News.

However, Dr. Creswell noted that she was a little surprised that outcomes did not differ according to the background, experience, or training level of the therapists who guided the parents.

"This finding was encouraging, as it suggests that this intervention can be delivered well by nonspecialists," she said.

The study was published in the December issue of the British Journal of Psychiatry.

Stepped Care Approach

According to the investigators, 5% to 10% of all children are affected by anxiety disorders; and these can increase the risk for later problems, including mood disorders and substance abuse.

Although CBT has been recommended as first-line treatment for child anxiety, the researchers note that it is a resource-intensive intervention and not readily accessed.
Dr. Cathy Creswell

"We were keen to develop an intervention that could be delivered quickly and efficiently so that, ultimately, more children could access treatment. Working with parents, who are in a position to put procedures into place in their children's day-to-day lives, is an ideal way to do this," added Dr. Creswell.

Past research has shown that therapist-guided parent-delivered CBT, which is considered a low-intensity treatment, reduces child anxiety. However, "the degree of guidance necessary remains unclear."

For the study, investigators enrolled 194 children who had been referred to the Berkshire Child Anxiety Clinic in the UK. All were randomly assigned to receive full guided parent-delivered CBT (n = 64, 53% boys) or brief guided parent-delivered CBT (n = 61, 51% boys) for 12 weeks, or they were assigned to a wait-list control group (n = 69, 51% boys).

Families of those in the first 2 groups were sent a self-help book and were assigned to 1 of 19 available therapists.

For the full guided group, parents (and/or caretakers) participated in 4 face-to-face sessions and 4 telephone sessions with therapists during a period of 8 weeks (for a rough total of 5 hours, 20 minutes) to discuss the self-help book, rehearse skills, discuss problems, and provide support. The parents of the brief guided group received 2 face-to-face sessions and 2 telephone sessions (for a rough total of 2 hours, 40 minutes).

The therapists were categorized as having either "some clinical experience" (n = 10) or as being "novices" (n = 9). Those with some experience included clinical psychology trainees, a trainee CBT therapist, and a psychiatrist. The novice group included assistant psychologists and postgraduate students.

All of the therapists underwent a 1-day training session and received an implementation manual, as well as supervision and weekly 2-hour group sessions with a clinical psychologist.

Results

The Anxiety Disorders Interview Schedule (ADIS), child/parent version, was used to assess the presence and severity of a primary anxiety disorder, the Clinical Global Impression–Improvement (CGI-I) scale was used to measure overall improvement, and the parent- and child-reported Spence Children's Anxiety Scales and parent-reported Child Anxiety Impact scale were used to measure symptom changes.

The wait-list control group was asked to refrain from participating in any child anxiety intervention during the 12-week study period. But after their final assessments, they were offered guided parent-delivered CBT.

Results showed that significantly more of the children in the full guided parent-delivered CBT group recovered from their initial primary diagnosis after treatment than those in the wait-list control group (50% vs 25%, respectively; relative risk [RR], 1.85; 95% confidence interval [CI], 1.14 - 2.99; P = .013).

A total of 39% of the children in the brief guided group recovered from their initial primary diagnosis (RR, 1.56; 95% CI, 0.89 - 2.74).

The full guided group was also more likely to have recovered from any ADIS anxiety diagnosis than those in the wait-list group (RR, 3.13; P = .006). A total of 34% of those in the full guided group recovered vs 11% of the wait list group vs 15% of the brief guided group.

The CGI-I showed that 76% of the children in the full guided CBT group were rated "much" or "very much" improved at their post-treatment assessment vs 25% of those in the wait-list group (RR, 2.64; P < .0001). Although the CGI-I effect was smaller in the brief guided group (54%), it was significantly superior to the wait list (RR, 1.89; P = .01).

At the 6-month post-treatment assessment, 76% of the full guided CBT group and 71% of the brief guided group no longer met diagnostic criteria for their primary anxiety disorder. And the ADIS showed that 53% and 55%, respectively, no longer met criteria for any anxiety disorder at the 6-month follow-up.

In addition, 76% of the full guided and 79% of the brief guided group were rated "much" or "very much" improved on the CGI-I at 6 months post-treatment; 60% and 53% of each group, respectively, who had not shown this improvement level immediately after treatment did so at the 6-month point.

Therapist Experience Not a Factor

The parent-reported Child Anxiety Impact scale showed a significant post-treatment reduction in anxiety scores from baseline for the full guided group compared with the wait-list group (P = .0045) but not for the brief guided group.

Neither the parent- nor child-reported Spence Children's Anxiety Scales showed any significant between-group differences.

A total of 66% of the parents in the full guided CBT group met with a therapist who had some clinical experience, as did 71% of those in the brief guided group. The others met with novice therapists.

The proportion of children who were in the full guided group and who recovered from their primary diagnosis at the post-treatment assessment did not change on the basis of the experience level of their assigned therapist (RR, 1.0; 95% CI, 0.55 - 1.81).

Although those in the brief guided group showed "a somewhat larger proportion" of recovery for those treated by an experienced therapist, the difference was not deemed significant.

Dr. Creswell noted that the findings support the use of this intervention within a stepped care approach to treatment. In other words, a brief intervention would be delivered first by nonspecialists, and then "only those who require further input go on to more specialist services."

"Working directly with parents of children with anxiety disorder can be an effective and efficient way to help families overcome their children's difficulties," she said.

Case for Treatment Is Clear

In an accompanying editorial, Sam Cartwright-Hatton, ClinPsyD, from the School of Psychology at the University of Sussex, UK, writes that the study's finding that more than 70% of the children receiving CBT were free of their primary anxiety disorder 6 months later was impressive.

"Despite the gaps in our knowledge, the case for treatment is pretty clear," writes Dr. Cartwright-Hatton.

The investigators showed that "a fairly light-touch intervention" produced outcomes equivalent to those reported by a recent systematic review, she adds.

"Moreover, this interesting study produces some engaging evidence that therapists need not be highly skilled or experienced to achieve these results," Dr. Cartwright-Hatton writes, although she notes that the therapists were well supervised.

"There are a lot of children with anxiety disorders out there, and while they are not being treated, they are storing up a lot of trouble for the future. We have the means to help them, and we should be doing so."

Cr. Creswell and another study author have reported receiving royalties as authors of the self-help book used in this study for the parent-delivered CBT. The other 4 study authors and Dr. Cartwright-Hatton have reported no relevant financial relationships.

Br J Psychiatry. 2013;203:436-444, 401-402. Full article, Editorial