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Effect of Comorbidity on Treatment of Anxious Children and Adolescents: Results From a Large, Combined Sample

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Abstract

Objective

The purpose of the present study was to evaluate the influence of comorbid disorders on the degree of change and the endpoint of cognitive-behavioral treatment in anxious young people.

Method

Data on 750 children 6 to 18 years old were compiled from different samples within one clinic. All children had a primary anxiety disorder and were engaged in a manual-based, 10-session, cognitive-behavioral treatment program. Outcome was determined according to diagnostic status and continuous symptom measurements. Analyses compared results among four groups: no comorbidity, comorbid anxiety disorders, comorbid externalizing disorders, comorbid mood disorders. All analyses were intent-to-treat analyses.

Results

Children with comorbid depression were the least likely to be free of their primary anxiety diagnosis at the end of treatment and follow-up. According to child and maternal reports, symptoms of anxiety decreased similarly over time in all groups, but children with comorbid mood disorders scored significantly highest at all time points. Examining the effects of anxiety treatment on comorbid disorders showed that comorbid mood disorders, but not externalizing disorders, decreased significantly over time.

Conclusions

The existence of comorbid disorders does not appear to affect the rate or extent of response to cognitive-behavioral treatment for child anxiety. However, comorbidity has a marked influence on the endpoint of treatment. Children with nonanxiety comorbidity and especially with comorbid mood disorders exhibit greater severity at the outset and remain worse after treatment. On the positive side, treatment for anxiety disorders appears to decrease comorbid mood disorders, although it has less effect on comorbid externalizing disorders.

Section snippets

Participants

Eligible participants for the study were 866 children and adolescents 6 to 18 years old (plus their parents) who were treated using a standard structured treatment program at the Centre for Emotional Health at Macquarie University from 2000 through 2011. Approximately 69% of the children participated in randomized clinical trials,15, 16 and the remainder were treated in ongoing clinical services between trials. All participants in the authors’ service were told that they were receiving

Treatment Attendance and Missing Data

The total number of sessions attended by families did not differ significantly between groups (F3,642 = 0.3, p = .799). Means are presented in Table 1.

After treatment, 14.0% of the total sample failed to return data and there was a significant difference among groups (n = 750, χ23 = 12.83, p = .005): no comorbidity, 19.7%; anxiety only, 13.4%; externalizing, 6.7%; and mood disorders, 21.1%. At follow-up, 30.4% of participants failed to return data, and the difference among groups was no longer

Discussion

An interpretation of the present results needs to be qualified depending on the perspective from which they are viewed. The rate at which children improve is directly relevant to theory and clinical process. Most previous research has indicated that comorbid disorders do not adversely affect the rate of response to CBT in anxious children.4, 7, 9 Consistent with previous research, the results of the present study clearly fail to indicate that the existence of comorbid anxiety, mood, or

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    Drs. Rapee, Lyneham, Hudson, Kangas, Wuthrich, and Schniering are with the Centre for Emotional Health, Macquarie University, Sydney.

    This research was supported by different granting bodies, including the National Health and Medical Research Council, the Australian Research Council, and Australian Rotary Health.

    Disclosure: Drs. Rapee, Lyneham, Hudson, Kangas, Wuthrich, and Schniering report no biomedical financial interests or potential conflicts of interest.

    This article can be used to obtain continuing medical education (CME) at www.jaacap.org.

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