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Book Forum: Child/Adolescent Psychiatry   |    
Treating Anxious Children and Adolescents: An Evidence-Based Approach
ESTHER SOMERFELD-ZISKIND, M.D., M.A.
Am J Psychiatry 2002;159:886-a-887. doi:10.1176/appi.ajp.159.5.886-a
View Author and Article Information
Los Angeles, Calif.

By Ronald M. Rapee, Ph.D., Ann Wignall, M. Psych., Jennifer L. Hudson, and Carolyn A. Schniering. Oakland, Calif., New Harbinger Publications, 2000, 195 pp., $49.95.

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For several years, the authors have been running anxiety disorder clinics for children ages 7 to 16 at the University of Queensland. Success rates with cognitive behavior therapy have been promising, with maintenance of moderate to marked improvements in 75% of the children for a year or more.

This is dramatic news from psychologists. Medical methods do not top this success rate. Antianxiety agents such as benzodiazepines are excellent for acute relief of intense anxiety, but they can be habit forming, requiring larger and larger doses in a small minority of users. Cognitive behavior therapy usually requires eight to 12 weekly sessions. After that the family and patient ("client") must continue to reinforce the therapy, often for several years or more.

Anxiety disorders last a lifetime and are contagious. Anxious children usually come from anxious families. Dr. Rapee and his colleagues warn mothers to be less protective, less invasive. The mothers and fathers are required to take part in the treatment. These authors feel that group therapy is just as effective as individual and, of course, cheaper.

Generalized anxiety disorder and panic disorder were seldom seen in the children who came to the authors’ clinic. Specific phobias, such as separation anxiety, were prevalent in the younger children. Social phobia and school phobia were prevalent in adolescents, and occasional cases of obsessive-compulsive disorder (OCD) were seen at all ages. The psychiatrist is likely to try clomipramine for OCD and gabapentin for severe social phobia. Dr. Rapee and his colleagues claim that they rarely have to refer a child or adolescent for pharmacology. Psychiatrists usually find it more efficient to use an antidepressant for major help and add cognitive behavior therapy if available. The authors also address social skills training and assertiveness training.

According to the authors,

A negative life event may precipitate anxiety, but that anxiety can be exacerbated by the reaction to life events in someone who is temperamentally emotional.

The anxious parent is likely to respond to a vulnerable child with excessive control and protections.

Overprotection provided by the parent increases the child’s tendency to perceive danger and to believe that he or she has no control over danger.

The use of exposure is aimed at getting the child to approach feared situations and thereby learn to cope.

Teaching the child to think more realistically can reverse the natural tendency to interpret situations as threatening.

Relaxation techniques can reduce excessive arousal.

If you have been wondering what cognitive therapy is, in this book you have it in a nutshell. It is an excellent "cookbook" that can teach the psychiatrist step-by-step how to employ cognitive behavior therapy. I predict that most psychiatrists would not use this detailed method, were they to take the trouble to learn it, after practicing other forms of psychotherapy. Soon there will be better medication to calm pathological anxiety. Some medical schools are teaching cognitive behavior therapy to students, and some psychiatric residencies offer training in cognitive behavior therapy. There is talk of dopamine deficiency in anxiety, and the role of amygdala function in anxiety disorders is under exploration. In the meantime, some of us will refer patients with anxiety disorder patients to friendly psychologists with extensive experience in cognitive behavior therapy. Fluvoxamine has been approved by the Food and Drug Administration for anxiety disorders in children. The combination of cognitive behavior therapy with psychopharmacology has not been sufficiently researched. It may be a step forward.

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