Evidence-based treatment of anxiety and phobia in children and adolescents: Current status and effects on the emotional response

Abstract

Research on treatments for childhood anxiety disorders has increased greatly in recent decades. As a result, it has become increasingly necessary to synthesize the findings of these treatment studies into reviews in order to draw wider conclusions on the efficacy of treatments for childhood anxiety. Previous reviews of this literature have used varying criteria to determine the evidence base. For the current review, stricter criteria consistent with the original Task Force (1995) guidelines were used to select and evaluate studies. Studies were divided by anxiety disorder; however, many studies combine various anxiety disorders in their samples. As a result, these were included in a combined anxiety disorder group. Using more traditional guidelines, studies were assigned a status of well-established, probably efficacious, or experimental based on the available literature and the quality of the studies. While some treatments do meet the criteria for well-established status, it is clear from this examination that gaps remain and replication is necessary to establish many of these treatments as efficacious. In addition, there still appears to be a lack of research on the effects of treatment on the physiological and cognitive aspects of fear and anxiety.

Introduction

Anxiety and fear are normal responses to emotional events and do not require clinical intervention unless the fear is of unusual duration, intensity, content, or frequency (DSM-IV-TR; American Psychiatric Association, 2000). Normal childhood fears typically resolve themselves with age and fear at any age can be healthy and adaptive. Fear and anxiety that linger and are clinically significant, however, are excessive in duration and intensity and interfere with daily life. Attempting to take these developmental issues into account, the DSM-IV-TR incorporates the adjusted duration criteria for children: for childhood anxiety disorders, symptoms must be present for one to sixth months, varying by disorder. However, a key ongoing debate in the literature remains: for childhood worries and fears that are clinically significant, what are the “best” treatments, and how does one even define “best”?

Anxiety disorders are among the most prevalent disorders in children and adolescents, with estimates ranging between 5 and 10% (Anderson et al., 1987, Costello et al., 1996, Klein and Pine, 2002). Early onset of these disorders can lead to either a fluctuating or chronic course into adulthood (Achenbach et al., 1995, Pine et al., 1998). The median age of onset for anxiety disorders is 11 years-old. Lifetime prevalence for anxiety disorders is 28.8% with each anxiety disorder occurring as follows: specific phobia — 12.5%, social phobia — 12.1%, generalized anxiety disorder — 5.7%, posttraumatic stress disorder — 6.8%, obsessive–compulsive disorder — 1.6%, separation anxiety disorder — 5.2%, panic disorder — 4.7%, and agoraphobia without panic — 1.4% (Kessler et al., 2005). Anxiety disorders often go undetected and untreated, and can cause significant impairment in social, academic, occupational, and familial functioning. The need to identify and disseminate efficacious and effective treatments for these prevalent disorders to practitioners and the public is obvious.

As a result, the purpose for this review is twofold. First, there is currently a divide between research and clinical practice. It is necessary to summarize and evaluate the results of treatment studies so that clinicians can have a clear, comprehensive guide on where the evidence for efficacious treatments stands. Second, reviews of this type help the field as a whole focus further research, minimizing redundancy and filling gaps where needed. Currently the standard for evaluating what is efficacious is ill-defined, or better stated multiply-defined depending on which summary methodology one prefers. Given this, a return to the original evidence-based descriptions is endorsed, albeit with further description of a treatment's efficacy at alleviating specific components of fear or anxiety (Davis, 2009, Davis and Ollendick, 2005). It is asserted that the research community must consistently apply rigorous standards to review past treatments and set a bar for future studies in order for the science of clinical child psychology to progress.