درمان اختلالات اضطرابی دوران کودکی: مقایسه اولیه بین رفتاردرمانی شناختی گروهی و مداخله دارونمای روانشناختی

The present study examined the efficacy of group cognitive-behavioral therapy (CBT) in the treatment of childhood anxiety disorders. Thirty high-anxious children (aged 9–12 years) were assigned to either (a) group CBT (n=10), (b) a psychological placebo intervention (i.e., emotional disclosure [ED]; n=10), or (c) a no-treatment control condition (n=10). Therapy outcome measures (i.e., children's self-report of anxiety disorders symptoms, depression, and trait anxiety) were obtained three months before treatment, at pretreatment, and at posttreatment. Results showed that levels of psychopathological symptoms remained relatively stable during the three months preceding treatment. Most importantly, pretreatment–posttreatment comparisons indicated that CBT was superior to ED and the no-treatment control condition. That is, only in the CBT condition significant reductions of anxiety disorders symptoms, trait anxiety, and depression were observed. These findings can be taken as further evidence for the efficacy of CBT in the treatment of childhood anxiety disorders.

Anxiety disorders are among the most prevalent psychopathological problems in children and adolescents. Epidemiological studies have shown that between 8% and 12% of the youths suffer from some type of anxiety disorder that is sufficiently severe to interfere with daily functioning (see for a review, Bernstein, Borchardt, & Perwien, 1996). During the past decade, researchers and clinicians in the field of child psychopathology have reached consensus on the various types of anxiety disorders that may occur in children and adolescents (American Academy of Child and Adolescent Psychiatry, 1997). According to the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association [APA], 2000), the following anxiety disorders can be distinguished: separation anxiety disorder, generalized anxiety disorder, social phobia, panic disorder, agoraphobia, obsessive-compulsive disorder, specific phobia, acute and posttraumatic stress disorder, anxiety disorder due to a general medical condition, substance-induced anxiety disorder, and anxiety disorder not otherwise specified. Treatment of childhood anxiety disorders is considered to be important for several reasons. To begin with, although many childhood anxiety disorders remit spontaneously within 3–4 years (Last, Perrin, Hersen, & Kazdin, 1996), a substantial proportion of these disorders have a chronic course and even persist into adulthood (e.g., Keller, Lavori, Wunder, Beardslee, & Schwartz, 1992). Further, anxiety disorders often interfere significantly with children and adolescents’ adaptive functioning in a wide range of domains (e.g., McGee & Stanton, 1990; Strauss, Frame, & Forehand, 1987). Finally, anxiety disorders have considerable potential to increase the risk for other disorders, in particular depression (e.g., Cole, Peeke, Martin, Truglio, & Seroczynski, 1998). During the past decade, progress has been made with the psychological treatment of anxiety disorders in children and adolescents. In particular, cognitive-behavioral therapy (CBT) has received considerable research attention. During CBT, cognitive strategies are employed to assist the child to recognize anxious cognitions, to use awareness of these cognitions as cues for managing their anxiety, and to help them cope more effectively with anxiety-provoking situations. In addition, behavioral strategies such as modeling, in vivo exposure, role-play, relaxation training, and reinforced practice are used. In the first controlled outcome study (Kendall, 1994), 47 9- to 13-year-old children with anxiety disorders (i.e., generalized anxiety disorder, separation anxiety disorder, and social phobia) were assigned to either a CBT condition or a waiting-list control condition. Treatment outcome was evaluated using children's self-report, parent report, teacher report, and behavioral observations. Pretreatment–posttreatment comparisons showed significant improvements of the CBT treated children over the waiting-list control children on all measures. Most importantly, results indicated that many treated children did no longer fulfill criteria for an anxiety disorder at posttreatment and scored within the normal range on most anxiety measures. Highly similar results were obtained in a second randomized trial (Kendall et al., 1997) in which CBT was compared with a waiting-list control condition in a larger group of anxiety disordered children (N=94). Other studies have also reported positive effects of CBT in the treatment of children and adolescents with anxiety disorders. Taken together, the findings of these investigations can be catalogued as follows. First, a number of controlled trials have shown that group-based CBT is equally effective as individual CBT (Barrett, 1998; Dadds, Spence, Holland, Barrett, & Laurens, 1997; Flannery-Schroeder & Kendall, 2000; Mendlowitz et al., 1999; Muris, Mayer, Bartelds, Tierney, & Bogie, 2001; Silverman et al., 1999). For instance, Flannery-Schroeder and Kendall (2000) assigned 37 anxiety disordered children to one of three conditions: individual CBT, group CBT, and waiting-list control. Results showed that individual CBT and group CBT were equally effective and superior to the waiting-list control condition. Second, several studies have examined whether the effectiveness of CBT can be enhanced by incorporating parent training (Barrett, Dadds, & Rapee, 1996; Mendlowitz et al., 1999; Spence, Donovan, & Brechman-Toussaint, 2000). An exemplary study in this regard is that by Barrett and colleagues (1996) who allocated 79 7- to 14-year-old children who met criteria for generalized anxiety disorder, separation anxiety disorder, or social phobia to three treatment conditions: CBT, CBT plus parent training, and a waiting-list control condition. The effectiveness of the interventions was evaluated at posttreatment and at 6 and 12 months follow-up. Results showed favorable treatment outcome for both CBT conditions over the waiting-list control condition. In addition, some support was found for the notion that CBT plus family training was more effective than CBT alone. For example, at the 12-month follow-up, 95.6% of the children in the CBT plus family training condition did no longer meet criteria for an anxiety disorder versus 70.3% of the children in the regular CBT condition. A further study by Cobham, Dadds, and Spence (1998) showed that in particular children with anxious parents seem to profit from a CBT plus family intervention. Third and finally, follow-up studies have indicated that the positive effects of CBT are maintained for long time periods (Kendall & Southam-Gerow, 1996), even periods of 6 years (Barrett, Duffy, Dadds, & Rapee, 2001). Based on available evidence and using the guidelines for well-established, probably efficacious, and experimental treatments as put forward by the American Psychological Association's Division 12 (Clinical Psychology) Task Force on Promotion and Dissemination of Psychological Procedures (1995), it can be concluded that CBT should be considered as a ‘probably efficacious’ intervention for childhood anxiety disorders (Ollendick & King, 1998). That is to say, a substantial number of studies (see supra) have shown that various forms of CBT (i.e., individual CBT, group CBT, CBT with or without parent training) are more effective than a waiting-list control condition. However, as Ollendick and King (1998, p. 164) rightly remarked “no studies have shown it [CBT] to be more effective (i.e., superior) than psychological placebo or another treatment.” The present study was a first attempt to address this issue. Twenty 9- to 12-year-old primary school children with anxiety disorders were randomly assigned to either a group CBT or an Emotional Disclosure (ED) intervention in which children were invited to write about their fears and anxious experiences. The ED intervention is based on the theoretical notions of Pennebaker (1993) who believes that the inhibition of negative emotions as elicited by stressful or traumatic events has the effect of suppressing the immune function, with consequent adverse effects on physical and psychological health, and that disclosure overcomes this inhibition. A recent study of Reynolds, Brewin, and Saxton (2000) has indicated that ED yielded significant reductions of mental health problems, physical symptoms, and psychosocial difficulties in a sample of 8- to 13-year-old school children. Because ED usually targets at stressful and traumatic experiences, we considered this intervention as a psychological placebo treatment for childhood anxiety disorders against which to compare the effects of group CBT.