MIAMI — A cognitive-behavioral therapy program designed for children aged 4–7 years significantly improves anxiety symptoms over 6 months, according to a randomized, controlled trial.
Many pediatric cognitive-behavioral therapy (CBT) programs are geared toward older children and teenagers. The typical age range is between 8 and 14 years, for example. “But anxiety disorders have an earlier onset than age 8,” Dina R. Hirshfeld-Becker, Ph.D., said in an interview at her poster at the annual conference of the Anxiety Disorders Association of America.
“People thought for a while that CBT was not suitable for younger children. They thought kids did not have enough perception into their cognition and would not be compliant enough with their homework,” said Dr. Hirshfeld-Becker, director of anxiety research in the pediatric psychopharmacology program at Massachusetts General Hospital, Boston.
However, the findings of this study counter that perception. Dr. Hirshfeld-Becker and her associates assessed 65 children. All but one had a DSM-IV anxiety disorder; the other child was at high risk for anxiety. A total of 71% had multiple anxiety diagnoses. More than half of the children had a parent with an anxiety disorder, and 20% had comorbid oppositional defiant disorder. Mean age was 5 years, 54% were female, 80% were white, and 88% came from intact families.
The researchers randomized 35 participants to CBT treatment—up to 20 sessions over 6 months—and an additional 30 to a monitoring-only group as a control. The CBT protocol is called “Being Brave: A Program for Coping With Anxiety,” adapted from the Coping Cat program for children aged 8–13 years developed by Philip C. Kendall, Ph.D., at Temple University in Philadelphia. The first six sessions are a parent-only module, in which parents learn anxiety management and how to coach their children to cope in feared situations. A child-parent module for an additional 8–13 sessions incorporates effective techniques for preschoolers with phobia analogs, in vivo exposure, modeling, and reinforced practice. A final session for parents is designed to maintain gains and continue progress.
“We teach relaxation exercises and coping self-statements like, 'I'm a brave boy,' and that can help,” Dr. Hirshfeld-Becker said. All attempts at success are rewarded, for example, with stickers or extra time with the parent. “We do graded exposure therapy, but we make it fun.”
A total of 58 children completed the study. At 6 months, a blinded clinician rated 70% of the 30 CBT completers as having much or maximal improvement on global ratings of improvement for anxiety compared with 32% of the 28 control group completers. An intent-to-treat analysis yielded similar findings: 60% achievement with CBT, vs. 30% for controls.
“I was happy the improvement rates they showed were comparable to CBT protocols in older kids,” Dr. Hirshfeld-Becker said.
Initially, parents were concerned with the graded exposure, Dr. Hirshfeld-Becker said. “Parents might expect the kid will suffer, but they come to respect their children when they show resiliency.” The protocol helped parents too, she added. “The parents tended to benefit as well as the child.”