TREATMENT OF CHILDHOOD ANXIETY DISORDERS USING BEHAVIOUR THERAPY AND PHARMACOTHERAPY Neville J. King, Bruce J. Tonge
Although the treatment of childhood anxiety disorderscan beapproachedfrom numeroustheoretical perspectives,the concentration of research has been on the efficacy of behaviour therapy. Behaviour therapy procedures are briefly described and evaluated, including systematic desensitisation, flooding, modelling, reinforcement and cognitive procedures. We also review research findings on pharmacotherapy, focusing on benzodiazepine and antidepressant usage. Finally, several conclusions are drawn concerning the scientific and clinical status of these treatment approaches for childhood anxiety disorders. Australian and New Zealand Journal of Psychiatry 1992; 26:644-651 Whilst there has been much research on the treatment of anxiety disorders in adults, considerably less work has been undertaken on the treatment of childhood anxiety disorders. The comparative neglect of childhood anxiety disorders is unfortunate in several ways. As numerous authorities [ 1,2] have explained. anxiety can manifest itself cognitively (e.g. negative self-evaluation and expectations), physiologically (e.g. autonomic changes such as palpitations and sweating), and motorically (e.g. escape and avoidance). These changes are both distressing and debilitating to the child and family. Further, it cannot be assumed that childhood anxiety disorders are transient and have no bearing on long-term adjustment in adult years. The histories of adult patients with anxiety disorders often contain descriptions of
Faculty of Education, School of Graduate Studies, Monash University, Clayton, Victoria Neville J. King BA, Dip Ed, PhD, MAPsS Monash Medical Centre, Monash University, Clayton, Victoria Bruce J . Tonge MBBS. MD, DPM. MRCPsych. FRANZCP, Cert. Child Psych RANZCP
anxiety-related problems in childhood or adolescence. For example, adults with agoraphobic and panic disorder frequently report a childhood history involving marked separation anxiety and difficulty in adjusting to school [3,4]. Also, the prevalence of childhood anxiety disorders in the general population of children and adolescents has been documented in recent epidemiological studies [5,6]. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [7,8] identifies three anxiety disorders of childhood: separation anxiety disorder, avoidant disorder of childhood, and overanxious disorder. In addition, children can present with simple and. social phobias, as well as anxiety disorders more typical of adults. Of considerable clinical importance, childhood anxiety disorders are not mutually exclusive and other psychiatric disturbance (particularly depression) may be present as well [9,lo]. Although the treatment of childhood anxiety and phobic disorders can be approached from numerous theoretical perspectives, the concentration of research has been on the effectiveness of behaviour therapy and pharmacotherapy. We now review the
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scientific and clinical status of these treatment approaches.
Behaviour therapy Ollendick 11 I ] has observed that behaviour therapy is characterised by (a) the principles of behavioural psychology, most notably principles of learning, and (b) a commitment to strategies or procedures that are methodologically sound and empirically validated. From a behaviour therapy perspective, childhood anxiety disorders and phobias can be treated via systematic desensitisation, flooding, modelling and reinforcement. Cognitive procedures are also utilised in contemporary behaviour therapy. Although much research has been conducted on children with mild fears and anxieties (sometimes referred to as “analogue” studies), we concentrate on those investigations that have involved clinic-referred children.
Systematic desensitisation Pioneered by Wolpe [ 121, systematic desensitisation is often the preferred treatment strategy for children exhibiting specific phobic reactions and anxieties. In this paradigm, fears and phobias are viewed as classically conditioned responses that can be unlearned through specific counterconditioning procedures. In counterconditioning, the fear-producing stimuli are presented (either imaginally or in vivo) in the presence of stimuli which elicit responses incompatible with fear. Systematic desensitisation has primarily relied on the relaxation response as the competing, inhibiting response. Therefore, systematic desensitisation consists of three basic steps: (a) progressive relaxation training, (b) development of a fear-producing stimulus hierarchy, and (c) the systematic, graduated pairing of items in the hierarchy with relaxation. Typically, the fear-producing stimuli are presented imaginally (in order of least to most fear producing) while the individual is deeply relaxed. Whilst there has been much controversy regarding the underlying mechanism, there is little doubt that systematic desensitisation is frequently used with fearful children [ 131. However, in its traditional form systematic desensitisation can present difficulties for children. In particular, training in relaxation can be fairly demanding and tedious for children. Also the evocation and control of images as required in desensitisation can present further difficulties for them. Consequently,
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variants of systematic desensitisation have been applied to children. Illustrative of these variants is emotive imagery as shown in treatment of a 5-year-old child with extreme fears of darkness, noises and shadows [ 141. Having determined that the child was fond of the comic character Batman, the therapists created a fear hierarchy and then asked the child to imagine that “he and Batman had joined forces and that he was appointed as a special agent”. Next he was asked to close his eyes and to imagine the fear-producing stimuli in a graduated fashion. while accompanied by Batman. After only four sessions of emotive imagery, the child showed considerable improvements. Recently, King, Cranstoun and Josephs [ IS 1 evaluated the efficacy of emotive imagery using a multiple baseline design across subjects. Three clinic-referred children (6, 8 and 1 1 years old) with night-time fears participated in the study. These children also slept with their parents at night as a means of coping with their fear. Following emotive imagery, two of the children showed marked behavioural improvements and were able to sleep by themselves at night. Other uncontrolled and controlled case studies have illustrated the potential efficacy of systematic desensitisation and its variants in the treatment of a variety of childhood fears (e.g. dogs, dark. dentists, water, school, bees and loud noises). In one particularly interesting and well-controlled study, Van Hasselt and colleagues treated an 1 1 -year-old multiphobic child (blood, heights and test-taking) with standard systematic desensitisation procedures in a multiplebaseline fashion [ 161. Fear of heights was treated first, followed by fear of blood, and then fear of taking tests. Measures of motoric, cognitive and physiological measures were obtained for each of these fears. Results indicated that relaxation alone had little or no effect on the three response modes; however, the pdiring of items in the graduated hierarchy with relaxation led to a significant reduction in both the motoric and cognitive aspects of the anxiety but not the physiological ones. These changes occurred for each fear only when systematic desensitisation was applied specifically to that fear. Such results affirm the controlling effects of the desensitisation procedure. Only one group outcome study has been conducted with clinically anxious children and adolescents. Miller, Barret. Hampe and Noble [ 171 compared imaginal desensitisation, psychotherapy, and waiting list control conditions in the treatment of a variety of fears: school, dark, dogs, storms, heights, germs, physical
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injury, elevators, nakedness and deep water. The children were 6 to 15 years old. The only major methodological weakness in this otherwise well-controlled study was that parents in both treatment groups received intensive parent counselling based on operant principles (parents in both groups were instructed to remove any secondary gains the child might be receiving at home as a consequence of his or her phobia), and the children in both groups received “behavioural strategies for coping with stress.” Thus, the potential for determining the differential efficacy of these procedures was clouded by the similarity in parental intervention and child instructions. Perhaps these confounds were responsible for the findings. Essentially, Miller et al. [ 171 reported significant improvement on parental report measures for the two treatment conditions, but not for the waiting list condition. However, the two treatment groups did not differ with respect to their relative efficacy. Successfully treated children tended to remain symptom free at 1- and 2-year follow-ups [ 181. Unfortunately, behavioural observation of the children in the setting in which they were anxious and self-report measures of anxiety were not obtained in this study. Whether differences would have been obtained on these measures is unknown. Whilst systematic desensitisation is a clinically useful procedure for anxiety disordered children, well controlled evaluations are required to establish its efficacy.
Flooding In contrast to the graduated approach of systematic desensitisation and its variants, flooding is an alternative treatment approach that involves prolonged exposure, either in vivo or imaginally, to the most fear-producing stimuli. Essentially, the conditioned fear stimuli are presented repeatedly in the absence of the original unconditioned stimuli. The latter point is especially important for the procedure to be effective. For example, for a child with a simple phobic reaction towards dogs being treated in vivo, it would be essential to ensure that the dog not actually bite or attack the child [13]. Such an occurrence would undoubtedly occasion renewed conditioning, and the child would continue to avoid dogs and evince even greater fear. Despite the concerns of parents and children about this particular behavioural procedure [ 191, a number of uncontrolled case studies attest to the usefulness of flooding [20,21].
Flooding has been especially influential in the treatment of school phobia. Numerous authorities have argued that school phobic children should undergo a rapid re-entry to school in order to avoid the complications of prolonged absenteeism, particularly secondary gain. In an uncontrolled investigation, Kennedy [22] successfully treated 50 school phobic children using a rapid school return program. Parents were required to escort their child to school, and ignore illness complaints and tantrums. More recently, Blagg and Yule [23] examined the relative efficacies of behavioural treatment (n = 30), hospitalisation (n = 16),and home tuition plus psychotherapy (n = 20). The emphasis of behavioural treatment was on rapid school re-entry. A child was judged a treatment “success” if he returned to full-time schooling without any further problem; one attendance breakdown was allowed provided that the child quickly responded to booster treatment. After 1 year of treatment, 93% of the behavioural group were judged to be successful compared with 37% of the hospitalisation group and 10% of the home tuition plus psychotherapy group. Also the behavioural treatment approach was the most economical in terms of duration and cost of intervention. However, subjects were not randomly assigned to the various treatment groups and a no-treatment control condition was not included. Moreover, it would be an oversimplification to regard rapid school return programs as “pure” flooding. Typically, rapid school return programs have elements of classical, operant and vicarious conditioning, and might best be regarded as comprehensive behavioural treatment [ 131. In summary, flooding has been subjected to little controlled investigation despite its frequent use in the treatment of childhood anxiety disorders.
Modelling and reinforcement Consistent with the principles of vicarious conditioning, modelling entails demonstrating nonfearful behaviour in the anxiety-producing situation and showing the child an appropriate response for handling the feared stimuli [24]. Because the difficulties of the child may be a function of excessive anxiety and not knowing what specific behaviours are required, modelling services a crucial function. Many clinicians and researchers favour participant modelling which requires the child to observe another person interacting fearlessly with the anxiety-producing object or situation, and then perform the appropriate behaviour with
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the physical and psychological support of the therapist. Illustrative of these procedures, Ross, Ross and Evans [25] used modelling to treat a 6-year old boy whose fear and avoidance of interactions with agemates was so extreme that he actively avoided peers and refused to even watch filmed presentations featuring young children. Treatment consisted of establishing generalised imitation, participant modelling, and social reinforcement. Following treatment, the child was observed to interact positively with his peers and to display few avoidant behaviours. On follow-up. two months after cessation of treatment, he was observed to ‘‘join ongoing play groups, initiate verbal contacts, and sustain effective social interactions, all with children who were complete strangers to him”. Clearly, significant clinical improvement was noted in this case study. Matson [26] has reported some interesting findings on the use of participant modelling in overcoming the long standing social fears of three girls with moderate mental retardation. These girls had refused to talk with, or be in, the same general vicinity of adults other than their parents, a few close family members and, to a lesser degree, their teacher. Dependent measures included approaching and talking to strange adults, as well as child ratings of overall fear. A noteworthy aspect of this study concerned the use of a specific criterion to establish the clinical significance of the treatment effects. Participants were matched on age, sex, and level of mental retardation, with children having “normal” amounts of fear. Participant modelling was given by the mother who also provided a sufficient amount of physical and verbal prompts to ensure appropriate greetings and so forth. These prompts were gradually faded out as treatment progressed. As the training was conducted in a mental health clinic, generalisation to the home settings was assessed at various stages of the investigation. Given in a multiple baseline format across subjects, the treatment proved effective, and gains in the reduction of fears were maintained at a six-month follow-up. Changes in the desired directions were rapid and put the children in the normal range based on the response of their matched peers. Whilst modelling-based procedures show considerable promise, the efficacy of these procedures with clinically referred youngsters needs additional empirical support.
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Cognitivebased procedures With the more cognitive-based procedures, an attempt is made to modify faulty or dysfunctional cognitions in order to effect constructive behaviour change. Typically, cognitive procedures are used in conjunction with behavioural strategies. The usefulness of cognitive-behavioural procedures has been shown in a number of uncontrolled case reports. For example, Barlow and Seidner 1271 report a study on three adolescents with agoraphobia. Similar to the treatment of adult agoraphobics, therapy consisted of self-initiated exposure, panic management, and cognitive restructuring. The latter involved an explanation of their agoraphobia condition and physical symptoms of anxiety, as well as focusing on the irrational nature of their fears of dying or injury. On individualised measures of fear and avoidance, two of the three adolescents showed improvements that were maintained at 1 month and 3 month follow-ups. The adolescents and mothers provided very similar ratings on the changes in phobic behaviour. More recently, Mansdorf and Lukens [28] were successful in their use of cognitive-behavioural procedures with two children who exhibited separation anxiety and school refusal. As well as therapy being directed at the children, cognitive restructuring was carried out with the parents so that they could more readily deal with school-refusing behaviour. In a multiple baseline design across subjects, Kane and Kendall [29] have illustrated the utility of cognitive-behaviour therapy for children with overanxious disorder. Four children were treated individually over 16 to 20 sessions. Treatment focused on the identification of somatic reactions and cognitions in anxietyprovoking situations and the development of coping skills aimed at modifying anxious self-talk. The children also evaluated the success of their coping strategies and applied self-reinforcement as appropriate. Behavioural procedures such as in viva exposure, relaxation training, role play and contingent reinforcement were incorporated. All children showed improvement on parent and independent clinician’s ratings, as well as on self-report. Further, these gains were maintained at 3 to 6 month foilow-up. Graziano and his colleagues have reported an evaluation of cognitive-behavioural procedures for clinically anxious children using a group comparisons design [30].Forty children between 6 and 13 years of age were treated. The children were severely night-
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time fearful. displaying panic behaviours (e.g. frequent crying and frightened calling out to the parents) that had disrupted the families nearly every night for a mean of five years. Children were randomly assigned to a treatment or waiting-list control group. Treatment involved teaching relaxation and verbal coping skills to the children to counter any feelings of being afraid through the night. Over the three week program, parents played an important role in monitoring home practice and rewarding children for their progress. The children received “bravery tokens” that were exchanged for backup reinforcement (party). Results clearly attested to the efficacy fo the cognitive-behavioural treatment. Significant changes were noted for the treatment group on a host of variables including number of minutes to get in bed and time to fall asleep, self-reported willingness to go to sleep, and proportion of days that delay tactics (e.g. asking for water, light on) were used. Following treatment the waiting-list group was also treated. In total, 39 of 40 children showed significant change in behaviour as judged against a strict criterion: ten consecutive nights of fearless night-time behaviours. Long-term follow-up information was obtained two to three years after treatment from 34 of the 40 families by means of a mail questionnaire and extensive telephone contacts. Maintenance of improvement was noted for 31 of the 34 children [311. In general, cognitive and behavioural approaches are acceptable ways of treating childhood anxiety disorders, as judged by children andcaregivers in bothcommunity survey andclinical studies [ 15,191.
Pharmacotherapy Pharmacotherapy often plays an important adjunctive role in the treatment of childhood anxiety disorders. The anxiolytics and antidepressants appear to be the most frequently used pharmacological agents. In relation to the anxiolytics, benzodiazepines are well known for their anti-anxiety properties in adults. The possible efficacy of benzodiazepines in children is suggested by their usefulness as pre-anaesthetic compounds in reducing situational or anticipatory anxiety [32]. However, direct empirical evaluations concerning their effectiveness and safety in anxiety disordered children are lacking. although some data have emerged in recent years. Biederman [33] has reported the successful use of clonazepam in the treatment of three prepubertal children (2 boys and 1 girl) whose clinical presentation was consistent with separation
anxiety disorder and/or overanxious disorder. In addition, their symptoms were compatible with the diagnosis of adult-type panic disorder ( t w o with agoraphobia, one without agoraphobia). The daily doses ranged from 0.5 to 3 mg, and no adverse effects were observed. The children were symptom-free at follow-up, which ranged from 5 months to 3 years. However, as well as being uncontrolled case reports, assessment was restricted to clinical impressions. Nonetheless, the study illustrates the possible utility of clonazepam. Simeon and Ferguson [34] studied the effects of alprazolam in 12 children aged between 7 and 17 years who met DSM-I11 criteria for overanxious or avoidant disorder. Following a baseline placebo period ( 1 week), the patients underwent alprazolam therapy (4 weeks), a drug tapering period ( 1 week) and also a drug-free follow-up approximately four weeks after termination of the study. Dosages were individually adjusted with the daily maximum ranging from 0.5 mg to 1.5 mg. In this single blind investigation, children, parents and teachers were blind as to which medication (alprazolam or placebo) was administered. Alprazolam therapy produced marked or moderate clinical global improvement in 7 out of the 12 patients. Clinician ratings indicated significant improvements of anxiety, depression and psychomotor excitation. Parent questionnaires indicated significant improvements of anxiety and hyperactivity, while teacher questionnaires showed significant improvements of an anxious-passive factor. Despite improvements on these measures, the children’s self-ratings of anxiety were insensitive to alprazolam therapy. The evaluation of adverse effects was difficult since the children reported a variety of somatic symptoms at screening and on placebo. The most common adverse effects were lethargy, agitation, headaches, and nausea. These side effects were considered to be mild and transient and in no case was medication discontinued because of these problems. Also there were no significant changes in EKG measures, blood pressure or pulse rate while the patients were taking alprazolam. Not unexpectedly, parents reported an improvement in sleep problems in the children. Importantly, alprazolam therapy did not adversely affect performance on cognitive tests nor did teachers report any impairment of school performance. Clearly these findings indicate that controlled double blind studies should be undertaken on alprazolam in the treatment of childhood anxiety disorder.
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It appears likely that short term use of benzodiazepines reduces acute anxiety in children with separation anxiety and generalised anxiety [35], and in children facing stressful painful procedures or illness such as cancers [36]. However, these drugs may be used more widely and for too long in young children than our knowledge of their action and efficacy would justify. A Canadian study in Saskatchewan demonstrated that minor tranquillisers were the most commonly prescribed psychotropic medication. At the time of the study they were given to 1.5% of children under 4 years. to about 0.9% of children between 5 to 15 years, and to 2.2% of adolescents between 15 and 19 years [37]. These drugs are not without side effects. They tend to disinhibit some children, causing restlessness and agitation, and with increasing dose may also cause neurological disturbance such as ataxia and diplopia. Longer term treatment is associated with dependence and withdrawal problems such as seizures [381. As a proportion of school refusers exhibit depressive symptoms, antidepressant medication (e.g. imipramine) is sometimes prescribed for the child or adolescent. Gittelman-Klein and Klein [39] have reported a double-blind placebo controlled study on the efficacy of imipramine in the treatment of school refusers. The patients, aged 6 to 14, had been absent from school for at least 2 weeks or had been attending intermittently under extreme distress. Initially, 42 children were randomly assigned to either an imipramine group or placebo group for a 6 week period. However, seven children dropped out of the study leaving 16 in the imipramine group and 19 in the placebo group. The dosage was fixed for the first 2 weeks. and adjusted weekly thereafter with a maximum of 200 mg/day being set. Medication was administered in the morning and in the evening. At the end of the study, the dosage ranged from 100 mg to 200 mg/day (mean = 152 mg/day). Over this time the child and family were seen weekly, using persuasion and desensitisation techniques consistent with behavioural principles. Families were instructed to maintain a firm attitude with respect to school attendance and in most cases a family member was advised to accompany the child to school. Treatment recommendations varied according to the severity of the child’s anticipatory anxiety and the mother’s ability to set and enforce limits. After 6 weeks of treatment, 47% of the placebo group and 8 I % of the imipramine group were attending school regularly. Self-ratings of improve-
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ment were much higher for the children on imipramine than placebo treated children. With the exception of one case of orthostatic hypotension, side effects disappeared without dose alterations. In contrast to these findings, which are quite striking, Berney and colleagues failed to demonstrate any significant short-term effects over a 12-week doubleblind trial comparing another antidepressant (clomipramine) and placebo conditions in the treatment of school refusers [40]. However, it should be noted that less than half the amount of medication was used than in the Gittelman-Klein and Klein [39] study, and individual psychotherapy and parent counselling were instituted instead of behavioural treatment. Bemstein and her colleagues have also reported a double blind evaluation comparing imipramine, alprazolam and placebo in the treatment of school refusal [41]. For the imipramine group the maximum dosage ranged from 150 to 200 mg/day (mean = 164.29 mg/day). For the alprazolam group, the maximum dosage ranged from 1.0 to 3.0 mg/day (mean = 1.82). All subjects received psychosocial therapy in addition to medication ( N = 24). There were no significant differences between the medication and nonmedication groups on changes in measures of anxiety and depression. Also there were negligible differences between the groups regarding school attendance after treatment. The researchers noted that sample sizes were probably too small to detect anything except a profound medication effect. However, at the moment, the findings of Gittelman-Klein and Klein [39] have not been replicated in the treatment of school refusal. The adverse effects of imipramine and other cyclic antidepressants have been emphasised by numerous authorities [38,42,43]. Cardiotoxicity and death have been reported with antidepressants in the absence of untoward effects which might prompt close reduction. Therefore, initial and follow-up electrocardiograph monitoring during treatment is indicated, particularly when doses of imipramine of 5 mg/kg per day or greater are used [38]. Common autononomic side effects include dry mouth, anorexia, nausea, constipation, dizziness, insomnia, drowsiness, increased heart rate and increased diastolic blood pressure. These are frequently transient and disappear with dose reduction. [44]. Behavioural toxicity may include irritability, agitation and worsening of psychosis. Fear of side effects is probably responsible for the negative perceptions of caregivers towards pharmacotherdpy in the treatment of childhood anxiety disorders [ 191.
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Conclusions Unfortunately, it is difficult to draw any firm conclusions about the efficacy of behaviour therapy and pharmacotherapy in the treatment of childhood anxiety disorders. Claims for the effectiveness of these treatments are tempered by a number of methodological limitations. Firstly, greater attention must be given to diagnostic issues. Many studies were reviewed in which subjects were not diagnosed on DSM-III/DSM111-Rcriteria. Therefore, at this stage, little is known about treatment outcomes for the specific types of childhood anxiety disorders and phobias. Secondly, a number of investigations, particularly behaviour therapy evaluations, lacked attention-placebo controls. Thus the influence of factors such as expectancy of improvement and having the support of a therapist are unknown. Thirdly, inadequate measures often leave open the question of treatment effectiveness, and whether significant real life changes have occurred for children [45]. Limited data attests to the complexity of treatment outcomes and the desynchrony of cognitive, behavioural and physiological changes [ 161. Fourthly, the long-term effectiveness of behavioural and pharmacological treatments has not been adequately evaluated. Comprehensive follow-up assessment would be extremely valuable in determining the durability of therapeutic results, and what factors are associated with set-backs and relapses. Finally, few studies have examined the efficacy of combined behavioural and pharmacological treatments. As a component analysis has yet to be camed out, it is not clear as to whether a combination of behaviour therapy and pharmacotherapy is more effective than these treatments alone.
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27. Barlow DH. Seidner AL. Treatment of adolescent agoraphobics: Effects on parent-adolescent relations. Behaviour Research & Therapy 1983; 2 I :5 19-526. 28. Mansdorf IJ, Lukens E. Cognitive-behavioral psychotherapy for separation anxious children exhibiting school phobia. Journal of the American Academy of Child and Adolescent Psychiatry 1987;m 2 2 - 2 2 5 . 29. Kane MT, Kendall PC. Anxiety disorders in children: A multiple-baseline evaluation of a cognitive-behavioral treatment. Behavior Therapy 1989; 20:499-508. 30. Graziano AM, Mooney KC, Huber C, Ignasiak D. Self-control instructions for children’s fear reduction. Journal of Behavior Therapy and Experimental Psychiatry 1979; 10:221-227. 31. Graziano AM, Mooney KC. Behavioral treatment of “nightfears” in children: maintenance of improvement at 2 to 3year follow-up. Journal of Consulting & Clinical Psychology 1982; 50598-599. 32. Gittelman R, Koplewicz HS. Pharmacotherapy of childhood anxiety disorders. In: Gittelman R, ed. Anxiety disorders of childhood. New York: Guilford Press, 1986, 188-203. 33. Biederman J. Clonazepam in the treatment of prepubertal children with panic-like symptoms. Journal of Clinical Psychiatry 1987; 48:38-41. 34. Simeon IG. Ferguson HB. Alprazolam effects in children with anxiety disorders. Canadian Journal of Psychiatry 1987; 32570574. 35. Campbell M. Anderson LT. Green WH. Behavior-disordered and aggressive children: New advances in pharmacotherapy. Developmental Behavioral Pediatrics 1983; 4:265-27 I . 36. Pfefferbaum B, Overall JE, Boren HA, Frankel CS, Sullivan MP. Johnson K. Alprazolam in the treatment of anticipatory and acute situational anxiety in children with cancer. Journal of the American Academy of Child and Adolescent Psychiatry 1987; 2632-535.
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37. Quinn DMP. Prevalence of psychoactive medication in childhood. Canadian Journal of Psychiatry 1986; 31575-535. 38. Waters B. Pharmacological and other physical treatments. In: Tonge BJ, Burrows GD, Weny JS, eds. Handbook of studies on child psychiatry. Amsterdam: Elseview 1990:387-402. 39. Gittelman-Klein R, Klein DF. Controlled imipramine treatment of school phobia. Archives of General Psychiatry 1971; 25:204207. 40. Berney T, Kolvin I, Bhate SR, Garside RF, Jeans J, Kay B, Scarth L. School phobia: A therapeutic trial with clomipramine and short-term outcome. British Journal of Psychiatry 198 I ; 138:110-118. 41. Bernstein GA, Garfinkel BD, Borchardt CM. Comparative studies of pharmacotherapy for school refusal. Journal of the American Academy of Child & Adolescent Psychiatry 1990; 29:773-781. 42. Biederman J. Sudden death in children treated with a tricyclic antidepressant. Journal of the American Academy of Child and Adolescent Psychiatry 1991; 30495-498. 43. Kutcher SP, Reiter S, Gardner DM. Klein RG. The pharmacotherapy of anxiety disorders in children and adolescents. In: Shaffer D. ed. The psychiatric clinics of North American: Pediatric psychopharmacology. Philadelphia: Saunders 1992:4167. 44. Campbell M,Green WH, Deutsch SI. Child and adolescent psychopharmacology. Beverly Hills, CA: Sage, 1985. 45. Ollendick TH. Fear reduction techniques with children. In: Hersen M, Eisler RM, Miller PM, eds. Progress in behavior modification (Vol8). New York: Academic Press 1979:127-168.
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Although the treatment of childhood anxiety disorderscan beapproachedfrom numeroustheoretical perspectives,the concentration of research has been on the efficacy of behaviour therapy. Behaviour therapy procedures are briefly described and evaluated, including systematic desensitisation, flooding, modelling, reinforcement and cognitive procedures. We also review research findings on pharmacotherapy, focusing on benzodiazepine and antidepressant usage. Finally, several conclusions are drawn concerning the scientific and clinical status of these treatment approaches for childhood anxiety disorders. Australian and New Zealand Journal of Psychiatry 1992; 26:644-651 Whilst there has been much research on the treatment of anxiety disorders in adults, considerably less work has been undertaken on the treatment of childhood anxiety disorders. The comparative neglect of childhood anxiety disorders is unfortunate in several ways. As numerous authorities [ 1,2] have explained. anxiety can manifest itself cognitively (e.g. negative self-evaluation and expectations), physiologically (e.g. autonomic changes such as palpitations and sweating), and motorically (e.g. escape and avoidance). These changes are both distressing and debilitating to the child and family. Further, it cannot be assumed that childhood anxiety disorders are transient and have no bearing on long-term adjustment in adult years. The histories of adult patients with anxiety disorders often contain descriptions of
Faculty of Education, School of Graduate Studies, Monash University, Clayton, Victoria Neville J. King BA, Dip Ed, PhD, MAPsS Monash Medical Centre, Monash University, Clayton, Victoria Bruce J . Tonge MBBS. MD, DPM. MRCPsych. FRANZCP, Cert. Child Psych RANZCP
anxiety-related problems in childhood or adolescence. For example, adults with agoraphobic and panic disorder frequently report a childhood history involving marked separation anxiety and difficulty in adjusting to school [3,4]. Also, the prevalence of childhood anxiety disorders in the general population of children and adolescents has been documented in recent epidemiological studies [5,6]. The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders [7,8] identifies three anxiety disorders of childhood: separation anxiety disorder, avoidant disorder of childhood, and overanxious disorder. In addition, children can present with simple and. social phobias, as well as anxiety disorders more typical of adults. Of considerable clinical importance, childhood anxiety disorders are not mutually exclusive and other psychiatric disturbance (particularly depression) may be present as well [9,lo]. Although the treatment of childhood anxiety and phobic disorders can be approached from numerous theoretical perspectives, the concentration of research has been on the effectiveness of behaviour therapy and pharmacotherapy. We now review the
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scientific and clinical status of these treatment approaches.
Behaviour therapy Ollendick 11 I ] has observed that behaviour therapy is characterised by (a) the principles of behavioural psychology, most notably principles of learning, and (b) a commitment to strategies or procedures that are methodologically sound and empirically validated. From a behaviour therapy perspective, childhood anxiety disorders and phobias can be treated via systematic desensitisation, flooding, modelling and reinforcement. Cognitive procedures are also utilised in contemporary behaviour therapy. Although much research has been conducted on children with mild fears and anxieties (sometimes referred to as “analogue” studies), we concentrate on those investigations that have involved clinic-referred children.
Systematic desensitisation Pioneered by Wolpe [ 121, systematic desensitisation is often the preferred treatment strategy for children exhibiting specific phobic reactions and anxieties. In this paradigm, fears and phobias are viewed as classically conditioned responses that can be unlearned through specific counterconditioning procedures. In counterconditioning, the fear-producing stimuli are presented (either imaginally or in vivo) in the presence of stimuli which elicit responses incompatible with fear. Systematic desensitisation has primarily relied on the relaxation response as the competing, inhibiting response. Therefore, systematic desensitisation consists of three basic steps: (a) progressive relaxation training, (b) development of a fear-producing stimulus hierarchy, and (c) the systematic, graduated pairing of items in the hierarchy with relaxation. Typically, the fear-producing stimuli are presented imaginally (in order of least to most fear producing) while the individual is deeply relaxed. Whilst there has been much controversy regarding the underlying mechanism, there is little doubt that systematic desensitisation is frequently used with fearful children [ 131. However, in its traditional form systematic desensitisation can present difficulties for children. In particular, training in relaxation can be fairly demanding and tedious for children. Also the evocation and control of images as required in desensitisation can present further difficulties for them. Consequently,
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variants of systematic desensitisation have been applied to children. Illustrative of these variants is emotive imagery as shown in treatment of a 5-year-old child with extreme fears of darkness, noises and shadows [ 141. Having determined that the child was fond of the comic character Batman, the therapists created a fear hierarchy and then asked the child to imagine that “he and Batman had joined forces and that he was appointed as a special agent”. Next he was asked to close his eyes and to imagine the fear-producing stimuli in a graduated fashion. while accompanied by Batman. After only four sessions of emotive imagery, the child showed considerable improvements. Recently, King, Cranstoun and Josephs [ IS 1 evaluated the efficacy of emotive imagery using a multiple baseline design across subjects. Three clinic-referred children (6, 8 and 1 1 years old) with night-time fears participated in the study. These children also slept with their parents at night as a means of coping with their fear. Following emotive imagery, two of the children showed marked behavioural improvements and were able to sleep by themselves at night. Other uncontrolled and controlled case studies have illustrated the potential efficacy of systematic desensitisation and its variants in the treatment of a variety of childhood fears (e.g. dogs, dark. dentists, water, school, bees and loud noises). In one particularly interesting and well-controlled study, Van Hasselt and colleagues treated an 1 1 -year-old multiphobic child (blood, heights and test-taking) with standard systematic desensitisation procedures in a multiplebaseline fashion [ 161. Fear of heights was treated first, followed by fear of blood, and then fear of taking tests. Measures of motoric, cognitive and physiological measures were obtained for each of these fears. Results indicated that relaxation alone had little or no effect on the three response modes; however, the pdiring of items in the graduated hierarchy with relaxation led to a significant reduction in both the motoric and cognitive aspects of the anxiety but not the physiological ones. These changes occurred for each fear only when systematic desensitisation was applied specifically to that fear. Such results affirm the controlling effects of the desensitisation procedure. Only one group outcome study has been conducted with clinically anxious children and adolescents. Miller, Barret. Hampe and Noble [ 171 compared imaginal desensitisation, psychotherapy, and waiting list control conditions in the treatment of a variety of fears: school, dark, dogs, storms, heights, germs, physical
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injury, elevators, nakedness and deep water. The children were 6 to 15 years old. The only major methodological weakness in this otherwise well-controlled study was that parents in both treatment groups received intensive parent counselling based on operant principles (parents in both groups were instructed to remove any secondary gains the child might be receiving at home as a consequence of his or her phobia), and the children in both groups received “behavioural strategies for coping with stress.” Thus, the potential for determining the differential efficacy of these procedures was clouded by the similarity in parental intervention and child instructions. Perhaps these confounds were responsible for the findings. Essentially, Miller et al. [ 171 reported significant improvement on parental report measures for the two treatment conditions, but not for the waiting list condition. However, the two treatment groups did not differ with respect to their relative efficacy. Successfully treated children tended to remain symptom free at 1- and 2-year follow-ups [ 181. Unfortunately, behavioural observation of the children in the setting in which they were anxious and self-report measures of anxiety were not obtained in this study. Whether differences would have been obtained on these measures is unknown. Whilst systematic desensitisation is a clinically useful procedure for anxiety disordered children, well controlled evaluations are required to establish its efficacy.
Flooding In contrast to the graduated approach of systematic desensitisation and its variants, flooding is an alternative treatment approach that involves prolonged exposure, either in vivo or imaginally, to the most fear-producing stimuli. Essentially, the conditioned fear stimuli are presented repeatedly in the absence of the original unconditioned stimuli. The latter point is especially important for the procedure to be effective. For example, for a child with a simple phobic reaction towards dogs being treated in vivo, it would be essential to ensure that the dog not actually bite or attack the child [13]. Such an occurrence would undoubtedly occasion renewed conditioning, and the child would continue to avoid dogs and evince even greater fear. Despite the concerns of parents and children about this particular behavioural procedure [ 191, a number of uncontrolled case studies attest to the usefulness of flooding [20,21].
Flooding has been especially influential in the treatment of school phobia. Numerous authorities have argued that school phobic children should undergo a rapid re-entry to school in order to avoid the complications of prolonged absenteeism, particularly secondary gain. In an uncontrolled investigation, Kennedy [22] successfully treated 50 school phobic children using a rapid school return program. Parents were required to escort their child to school, and ignore illness complaints and tantrums. More recently, Blagg and Yule [23] examined the relative efficacies of behavioural treatment (n = 30), hospitalisation (n = 16),and home tuition plus psychotherapy (n = 20). The emphasis of behavioural treatment was on rapid school re-entry. A child was judged a treatment “success” if he returned to full-time schooling without any further problem; one attendance breakdown was allowed provided that the child quickly responded to booster treatment. After 1 year of treatment, 93% of the behavioural group were judged to be successful compared with 37% of the hospitalisation group and 10% of the home tuition plus psychotherapy group. Also the behavioural treatment approach was the most economical in terms of duration and cost of intervention. However, subjects were not randomly assigned to the various treatment groups and a no-treatment control condition was not included. Moreover, it would be an oversimplification to regard rapid school return programs as “pure” flooding. Typically, rapid school return programs have elements of classical, operant and vicarious conditioning, and might best be regarded as comprehensive behavioural treatment [ 131. In summary, flooding has been subjected to little controlled investigation despite its frequent use in the treatment of childhood anxiety disorders.
Modelling and reinforcement Consistent with the principles of vicarious conditioning, modelling entails demonstrating nonfearful behaviour in the anxiety-producing situation and showing the child an appropriate response for handling the feared stimuli [24]. Because the difficulties of the child may be a function of excessive anxiety and not knowing what specific behaviours are required, modelling services a crucial function. Many clinicians and researchers favour participant modelling which requires the child to observe another person interacting fearlessly with the anxiety-producing object or situation, and then perform the appropriate behaviour with
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the physical and psychological support of the therapist. Illustrative of these procedures, Ross, Ross and Evans [25] used modelling to treat a 6-year old boy whose fear and avoidance of interactions with agemates was so extreme that he actively avoided peers and refused to even watch filmed presentations featuring young children. Treatment consisted of establishing generalised imitation, participant modelling, and social reinforcement. Following treatment, the child was observed to interact positively with his peers and to display few avoidant behaviours. On follow-up. two months after cessation of treatment, he was observed to ‘‘join ongoing play groups, initiate verbal contacts, and sustain effective social interactions, all with children who were complete strangers to him”. Clearly, significant clinical improvement was noted in this case study. Matson [26] has reported some interesting findings on the use of participant modelling in overcoming the long standing social fears of three girls with moderate mental retardation. These girls had refused to talk with, or be in, the same general vicinity of adults other than their parents, a few close family members and, to a lesser degree, their teacher. Dependent measures included approaching and talking to strange adults, as well as child ratings of overall fear. A noteworthy aspect of this study concerned the use of a specific criterion to establish the clinical significance of the treatment effects. Participants were matched on age, sex, and level of mental retardation, with children having “normal” amounts of fear. Participant modelling was given by the mother who also provided a sufficient amount of physical and verbal prompts to ensure appropriate greetings and so forth. These prompts were gradually faded out as treatment progressed. As the training was conducted in a mental health clinic, generalisation to the home settings was assessed at various stages of the investigation. Given in a multiple baseline format across subjects, the treatment proved effective, and gains in the reduction of fears were maintained at a six-month follow-up. Changes in the desired directions were rapid and put the children in the normal range based on the response of their matched peers. Whilst modelling-based procedures show considerable promise, the efficacy of these procedures with clinically referred youngsters needs additional empirical support.
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Cognitivebased procedures With the more cognitive-based procedures, an attempt is made to modify faulty or dysfunctional cognitions in order to effect constructive behaviour change. Typically, cognitive procedures are used in conjunction with behavioural strategies. The usefulness of cognitive-behavioural procedures has been shown in a number of uncontrolled case reports. For example, Barlow and Seidner 1271 report a study on three adolescents with agoraphobia. Similar to the treatment of adult agoraphobics, therapy consisted of self-initiated exposure, panic management, and cognitive restructuring. The latter involved an explanation of their agoraphobia condition and physical symptoms of anxiety, as well as focusing on the irrational nature of their fears of dying or injury. On individualised measures of fear and avoidance, two of the three adolescents showed improvements that were maintained at 1 month and 3 month follow-ups. The adolescents and mothers provided very similar ratings on the changes in phobic behaviour. More recently, Mansdorf and Lukens [28] were successful in their use of cognitive-behavioural procedures with two children who exhibited separation anxiety and school refusal. As well as therapy being directed at the children, cognitive restructuring was carried out with the parents so that they could more readily deal with school-refusing behaviour. In a multiple baseline design across subjects, Kane and Kendall [29] have illustrated the utility of cognitive-behaviour therapy for children with overanxious disorder. Four children were treated individually over 16 to 20 sessions. Treatment focused on the identification of somatic reactions and cognitions in anxietyprovoking situations and the development of coping skills aimed at modifying anxious self-talk. The children also evaluated the success of their coping strategies and applied self-reinforcement as appropriate. Behavioural procedures such as in viva exposure, relaxation training, role play and contingent reinforcement were incorporated. All children showed improvement on parent and independent clinician’s ratings, as well as on self-report. Further, these gains were maintained at 3 to 6 month foilow-up. Graziano and his colleagues have reported an evaluation of cognitive-behavioural procedures for clinically anxious children using a group comparisons design [30].Forty children between 6 and 13 years of age were treated. The children were severely night-
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time fearful. displaying panic behaviours (e.g. frequent crying and frightened calling out to the parents) that had disrupted the families nearly every night for a mean of five years. Children were randomly assigned to a treatment or waiting-list control group. Treatment involved teaching relaxation and verbal coping skills to the children to counter any feelings of being afraid through the night. Over the three week program, parents played an important role in monitoring home practice and rewarding children for their progress. The children received “bravery tokens” that were exchanged for backup reinforcement (party). Results clearly attested to the efficacy fo the cognitive-behavioural treatment. Significant changes were noted for the treatment group on a host of variables including number of minutes to get in bed and time to fall asleep, self-reported willingness to go to sleep, and proportion of days that delay tactics (e.g. asking for water, light on) were used. Following treatment the waiting-list group was also treated. In total, 39 of 40 children showed significant change in behaviour as judged against a strict criterion: ten consecutive nights of fearless night-time behaviours. Long-term follow-up information was obtained two to three years after treatment from 34 of the 40 families by means of a mail questionnaire and extensive telephone contacts. Maintenance of improvement was noted for 31 of the 34 children [311. In general, cognitive and behavioural approaches are acceptable ways of treating childhood anxiety disorders, as judged by children andcaregivers in bothcommunity survey andclinical studies [ 15,191.
Pharmacotherapy Pharmacotherapy often plays an important adjunctive role in the treatment of childhood anxiety disorders. The anxiolytics and antidepressants appear to be the most frequently used pharmacological agents. In relation to the anxiolytics, benzodiazepines are well known for their anti-anxiety properties in adults. The possible efficacy of benzodiazepines in children is suggested by their usefulness as pre-anaesthetic compounds in reducing situational or anticipatory anxiety [32]. However, direct empirical evaluations concerning their effectiveness and safety in anxiety disordered children are lacking. although some data have emerged in recent years. Biederman [33] has reported the successful use of clonazepam in the treatment of three prepubertal children (2 boys and 1 girl) whose clinical presentation was consistent with separation
anxiety disorder and/or overanxious disorder. In addition, their symptoms were compatible with the diagnosis of adult-type panic disorder ( t w o with agoraphobia, one without agoraphobia). The daily doses ranged from 0.5 to 3 mg, and no adverse effects were observed. The children were symptom-free at follow-up, which ranged from 5 months to 3 years. However, as well as being uncontrolled case reports, assessment was restricted to clinical impressions. Nonetheless, the study illustrates the possible utility of clonazepam. Simeon and Ferguson [34] studied the effects of alprazolam in 12 children aged between 7 and 17 years who met DSM-I11 criteria for overanxious or avoidant disorder. Following a baseline placebo period ( 1 week), the patients underwent alprazolam therapy (4 weeks), a drug tapering period ( 1 week) and also a drug-free follow-up approximately four weeks after termination of the study. Dosages were individually adjusted with the daily maximum ranging from 0.5 mg to 1.5 mg. In this single blind investigation, children, parents and teachers were blind as to which medication (alprazolam or placebo) was administered. Alprazolam therapy produced marked or moderate clinical global improvement in 7 out of the 12 patients. Clinician ratings indicated significant improvements of anxiety, depression and psychomotor excitation. Parent questionnaires indicated significant improvements of anxiety and hyperactivity, while teacher questionnaires showed significant improvements of an anxious-passive factor. Despite improvements on these measures, the children’s self-ratings of anxiety were insensitive to alprazolam therapy. The evaluation of adverse effects was difficult since the children reported a variety of somatic symptoms at screening and on placebo. The most common adverse effects were lethargy, agitation, headaches, and nausea. These side effects were considered to be mild and transient and in no case was medication discontinued because of these problems. Also there were no significant changes in EKG measures, blood pressure or pulse rate while the patients were taking alprazolam. Not unexpectedly, parents reported an improvement in sleep problems in the children. Importantly, alprazolam therapy did not adversely affect performance on cognitive tests nor did teachers report any impairment of school performance. Clearly these findings indicate that controlled double blind studies should be undertaken on alprazolam in the treatment of childhood anxiety disorder.
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It appears likely that short term use of benzodiazepines reduces acute anxiety in children with separation anxiety and generalised anxiety [35], and in children facing stressful painful procedures or illness such as cancers [36]. However, these drugs may be used more widely and for too long in young children than our knowledge of their action and efficacy would justify. A Canadian study in Saskatchewan demonstrated that minor tranquillisers were the most commonly prescribed psychotropic medication. At the time of the study they were given to 1.5% of children under 4 years. to about 0.9% of children between 5 to 15 years, and to 2.2% of adolescents between 15 and 19 years [37]. These drugs are not without side effects. They tend to disinhibit some children, causing restlessness and agitation, and with increasing dose may also cause neurological disturbance such as ataxia and diplopia. Longer term treatment is associated with dependence and withdrawal problems such as seizures [381. As a proportion of school refusers exhibit depressive symptoms, antidepressant medication (e.g. imipramine) is sometimes prescribed for the child or adolescent. Gittelman-Klein and Klein [39] have reported a double-blind placebo controlled study on the efficacy of imipramine in the treatment of school refusers. The patients, aged 6 to 14, had been absent from school for at least 2 weeks or had been attending intermittently under extreme distress. Initially, 42 children were randomly assigned to either an imipramine group or placebo group for a 6 week period. However, seven children dropped out of the study leaving 16 in the imipramine group and 19 in the placebo group. The dosage was fixed for the first 2 weeks. and adjusted weekly thereafter with a maximum of 200 mg/day being set. Medication was administered in the morning and in the evening. At the end of the study, the dosage ranged from 100 mg to 200 mg/day (mean = 152 mg/day). Over this time the child and family were seen weekly, using persuasion and desensitisation techniques consistent with behavioural principles. Families were instructed to maintain a firm attitude with respect to school attendance and in most cases a family member was advised to accompany the child to school. Treatment recommendations varied according to the severity of the child’s anticipatory anxiety and the mother’s ability to set and enforce limits. After 6 weeks of treatment, 47% of the placebo group and 8 I % of the imipramine group were attending school regularly. Self-ratings of improve-
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ment were much higher for the children on imipramine than placebo treated children. With the exception of one case of orthostatic hypotension, side effects disappeared without dose alterations. In contrast to these findings, which are quite striking, Berney and colleagues failed to demonstrate any significant short-term effects over a 12-week doubleblind trial comparing another antidepressant (clomipramine) and placebo conditions in the treatment of school refusers [40]. However, it should be noted that less than half the amount of medication was used than in the Gittelman-Klein and Klein [39] study, and individual psychotherapy and parent counselling were instituted instead of behavioural treatment. Bemstein and her colleagues have also reported a double blind evaluation comparing imipramine, alprazolam and placebo in the treatment of school refusal [41]. For the imipramine group the maximum dosage ranged from 150 to 200 mg/day (mean = 164.29 mg/day). For the alprazolam group, the maximum dosage ranged from 1.0 to 3.0 mg/day (mean = 1.82). All subjects received psychosocial therapy in addition to medication ( N = 24). There were no significant differences between the medication and nonmedication groups on changes in measures of anxiety and depression. Also there were negligible differences between the groups regarding school attendance after treatment. The researchers noted that sample sizes were probably too small to detect anything except a profound medication effect. However, at the moment, the findings of Gittelman-Klein and Klein [39] have not been replicated in the treatment of school refusal. The adverse effects of imipramine and other cyclic antidepressants have been emphasised by numerous authorities [38,42,43]. Cardiotoxicity and death have been reported with antidepressants in the absence of untoward effects which might prompt close reduction. Therefore, initial and follow-up electrocardiograph monitoring during treatment is indicated, particularly when doses of imipramine of 5 mg/kg per day or greater are used [38]. Common autononomic side effects include dry mouth, anorexia, nausea, constipation, dizziness, insomnia, drowsiness, increased heart rate and increased diastolic blood pressure. These are frequently transient and disappear with dose reduction. [44]. Behavioural toxicity may include irritability, agitation and worsening of psychosis. Fear of side effects is probably responsible for the negative perceptions of caregivers towards pharmacotherdpy in the treatment of childhood anxiety disorders [ 191.
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Conclusions Unfortunately, it is difficult to draw any firm conclusions about the efficacy of behaviour therapy and pharmacotherapy in the treatment of childhood anxiety disorders. Claims for the effectiveness of these treatments are tempered by a number of methodological limitations. Firstly, greater attention must be given to diagnostic issues. Many studies were reviewed in which subjects were not diagnosed on DSM-III/DSM111-Rcriteria. Therefore, at this stage, little is known about treatment outcomes for the specific types of childhood anxiety disorders and phobias. Secondly, a number of investigations, particularly behaviour therapy evaluations, lacked attention-placebo controls. Thus the influence of factors such as expectancy of improvement and having the support of a therapist are unknown. Thirdly, inadequate measures often leave open the question of treatment effectiveness, and whether significant real life changes have occurred for children [45]. Limited data attests to the complexity of treatment outcomes and the desynchrony of cognitive, behavioural and physiological changes [ 161. Fourthly, the long-term effectiveness of behavioural and pharmacological treatments has not been adequately evaluated. Comprehensive follow-up assessment would be extremely valuable in determining the durability of therapeutic results, and what factors are associated with set-backs and relapses. Finally, few studies have examined the efficacy of combined behavioural and pharmacological treatments. As a component analysis has yet to be camed out, it is not clear as to whether a combination of behaviour therapy and pharmacotherapy is more effective than these treatments alone.
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