Shorter communicationParents’ perceptions of pharmacological and cognitive-behavioral treatments for childhood anxiety disorders
Introduction
Randomized controlled trials have increasingly established the efficacy of two distinct treatment modalities for childhood anxiety disorders: pharmacotherapy and cognitive-behavioral psychotherapy (CBT; Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004; Pediatric OCD Treatment Study Team, 2004; The Research Unit on Pediatric Psychopharmacology Anxiety Study Group, 2001). While both are effective, these modalities involve dissimilar approaches to conceptualization and treatment. While pharmacotherapy is most consistent with biological models that implicate neurotransmitter dysregulation, CBT is derived from cognitive (e.g., Beck, Emery, & Greenberg, 1985) and learning (e.g., Mowrer, 1960) models that emphasize the role of conditioning experiences, avoidance behaviors, and inaccurate appraisals of threat. Understandably, these two modalities also make for very different therapeutic experiences for children and their parents. The present study is concerned with how parents of children with an anxiety disorder view various aspects of these two treatments.
Recent trends in health care have highlighted the need to understand patients’ and parents’ perspectives of treatment. To begin with, respect for patients’ preferences has been highlighted by the president of the American Psychological Association as an important area of assessment (American Psychological Association, 2005). When treating children, this concern extends to parents who are increasingly encouraged to play an active role in making decisions about their child's healthcare (Breeding & Baughman, 2003). In fact, the effectiveness of care may be positively affected by assessing parent preference. Research with depressed adolescents suggests that treatment outcome may be enhanced when parents positively perceive their child's treatment (e.g., Brent et al., 1997). In addition, many have argued that treatment adherence and maintenance of behavior change is improved when parents consider the treatment acceptable for their child (Frentz & Kelley, 1986; Miller & Kelley, 1992). Although the use of pharmacotherapy among child populations continues to rise (Zito et al., 2003), little empirical information about parents’ perceptions of pharmacotherapy exists. Unfortunately, the increase in pharmacotherapy may have little to do with parents’ preference for pharmacotherapy, but rather be related to parents’ reported pressure to comply with medication recommendations for their child (Hearn, 2004) and the outpouring of advertisements for pharmacotherapy from various media sources. Thus, a clearer understanding of how parents perceive the different approaches to conceptualizing and treating their anxious child's symptoms may improve the clinical management of these problems.
To date, most studies examining treatment perceptions and preference in the area of child and adolescent psychopathology have focused on various disruptive behavior problem populations (e.g., ADHD, externalizing problems; Kazdin, 1980; Rostain, Power, & Atkins, 1993), and less is known about treatment perceptions for internalizing disorders, particularly anxiety. Studies of parents who have children with externalizing disorders (e.g., oppositional defiant disorder, conduct disorder) have generally found a greater acceptance of CBT than medication to treat disruptive behaviors (Kazdin, 1984; Miller & Kelley, 1992). In one study that compared parents’ rankings of several child behavior management strategies, medication was ranked similarly to spanking with both considered significantly less acceptable than reinforcement-based interventions (e.g., positive reinforcements, time out; Miller & Kelley, 1992). Studies of parents who have children with ADHD found that a child's history of medication use was related to a greater likelihood to pursue medication, and a history of counseling was slightly related to a greater likelihood to pursue both medication and counseling (Rostain et al., 1993).
In concert with the externalizing literature, the few studies on treatment perceptions and preferences of parents of children with internalizing disorders have demonstrated that parents tend to endorse more positive perceptions of, and a preference for, CBT compared to medication (Dudley, Melvin, Williams, Tonge, & King, 2005; Tarnowski, Simonian, Bekeny, & Park, 1992). Only one study has investigated treatment perceptions of parents whose children have an anxiety disorder. In that investigation, Chavira, Stein, Bailey, and Stein (2003) focused solely on parents’ perceptions of treatment for socially anxious children who were recruited from a pediatric primary care setting. Findings revealed that parents reported favorable attitudes toward CBT and neutral beliefs about medication. Examining the moderating effect of child treatment history, researchers found that parents whose children had used medication in the past, or were using it at present, reported more favorable attitudes toward medication for treating their child's social anxiety. Further, parents whose children had a history of CBT reported more favorable attitudes toward both CBT and medication use. Interestingly, greater severity of the child's social anxiety did not significantly relate to parents’ treatment acceptance of either medication or CBT. While this study provides a helpful initial investigation into treatment perceptions of parents with anxious children, it is limited by its exclusion of other anxiety disorders (e.g., OCD, GAD) and by the fact that it was conducted in a non-mental health facility.
In summary, despite a growing body of literature in this area, much remains to be understood about parents’ treatment perceptions and preferences. To this point, we know that parents tend to endorse greater acceptance and a preference for CBT as compared to medication for both externalizing and internalizing disorders; however, variables such as children's treatment history appear to influence parents’ perceptions. Little is known about perceptions other than parental acceptance of CBT and medication; other important parameters (e.g., perceived believability and effectiveness) that have received attention in adult literature (Deacon & Abramowitz, 2005; Walker, Vincent, Furer, Cox, & Kjernisted, 1999) have not been studied. Existing literature examining specific perceptions of parents of children with anxiety disorders is particularly sparse. To address limitations of previous research, the present study investigated parents’ perceptions of and preferences for pharmacotherapy and CBT for childhood anxiety. On the basis of previous research, we hypothesized that parents would perceive CBT more favorably than medication, and would prefer CBT as the treatment of choice for their child. We also explored the moderating effects of their child having participated in pharmacotherapy and psychotherapy on perceptions of these treatments. Lastly, we explored associations between parents’ treatment perceptions and other potentially related variables (i.e., child age, anxiety severity level, and parent-reported level of interference caused by child's anxiety).
Section snippets
Participants
Seventy-one parents, mainly mothers (78%), of children being evaluated in a Child & Adolescent Anxiety Disorders Clinic in a large midwestern medical center participated in the present study. All children presented with an anxiety disorder as their principal diagnosis. Twenty-seven (38.0%) had a principal diagnosis of OCD, 10 (14.1%) had GAD, 9 (12.7%) had separation anxiety disorder, 7 (9.9%) had social phobia, 4 (5.6%) had specific phobia, 1 (1.4%) had panic disorder, and 13 (18.3%) had other
Preliminary analyses
We examined the interrelationships between the TPQ-P items to determine the extent to which they assessed separate dimensions of treatment perceptions. The four CBT items were significantly related to each other, with correlations ranging from .66 (acceptability and short-term effectiveness) to .90 (acceptability and believability). Similar results were found for the four medication treatment items, with correlations ranging from .71 (believability and short-term effectiveness) to .83
Discussion
The present study investigated how parents seeking treatment for their child's anxiety disorder view the two most well-established treatments for their child's condition. This study addressed gaps in the existing literature by being the first to assess treatment perceptions of parents of clinically referred anxious children and including children with a variety of anxiety disorders. Previous research had also neglected to assess multiple parameters of treatment preference (i.e., acceptance,
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