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Treatment of Anxiety & Related Disorders
in Children & Adolescents
Martin E. Franklin, Ph.D.
Associate Professor of Psychiatry & Director,
Child/Adolescent OCD, Tics, Trich, & Anxiety
Group (COTTAGe)
University of Pennsylvania School of Medicine
Anxiety Disorders in Youth
• What do they have in common?
» Intense anxiety resulting in distress and/or functional impairment
• What are the different anxiety disorders?
» Specific (Simple) Phobia
» Social Anxiety Disorder (Social Phobia) & Selective Mutism
» Separation Anxiety Disorder
» Generalized Anxiety Disorder (GAD)
» Panic Disorder
» Obsessive-Compulsive Disorder (OCD)
» Posttraumatic Stress Disorder (PTSD)
• Why should I care?
The NEW ENGLAND JOURNAL of MEDICINE
EDITORIALS
Pediatric Anxiety — Underrecognized and Undertreated
Graham J. Emslie, M.D.
Generalized anxiety disorder, separation anxiety
disorder, and social phobia are relatively prevalent disorders that affect 6 to 20% of children
and adolescents.1 However, these disorders frequently go unrecognized by medical professionals. This is a critical problem, since a younger
age of onset and severity of illness result in poor
outcomes in adolescents and adults. Furthermore,
the failure to identify these disorders early in life
leads to increased rates of anxiety disorders, depression, and substance abuse later in life, as
well as to educational underachievement.2 In
this issue of the Journal, the report by Walkup et
al. on the Child-Adolescent Anxiety Multimodal
Study (CAMS)3 addresses the need of early treatment for these disorders.
It is important to understand that clinicians
did not always consider anxiety disorders among
children to be related to adult anxiety disorders.
Once similar diagnostic criteria for anxiety disorders were developed for children and adults
with the publication of the Diagnostic and Statistical
Manual of Mental Disorders, fourth edition (DSM-IV),4
it was recognized that adult anxiety disorders
often have their origins in childhood. For example, “overanxious disorder of childhood,” once
considered an age-bound condition, was then
understood as part of a continuum of generalized anxiety disorder that began in childhood.
After generalized anxiety disorder and social
phobia were labeled with DSM-IV criteria consistent across the life span, it was clear that early
onset, particularly in preadolescents, was an indicator of poor prognosis. In all, the changes in
diagnostic categories that stemmed from the
DSM-IV criteria have led to increasing awareness
of the longitudinal effect of anxiety disorders and
have permitted extrapolation of treatments from
research in adults to children.
Anxiety disorders may go unrecognized in the
pediatric population for several reasons. For one
thing, fears and worries are common in healthy
children. Normal, developmentally appropriate
worries, fears, and shyness can be difficult to
distinguish from anxiety disorders. For diagnosis, worries and fears must persist and must lead
to impaired functioning. However, even distressing and dysfunctional symptoms are frequently
unrecognized because children with anxiety disorders often report only physical symptoms (e.g.,
headache and stomachache) and are unable to
verbalize their internalized symptoms of “worry”
or “fear.” Furthermore, such reported symptoms
are often accommodated by family or school,
and the affected child may simply avoid anxietyprovoking situations (avoidant coping). Such overaccommodation strategies may minimize the
immediate symptoms yet often lead to increased
difficulty in coping with these anxieties later.
For example, a child with marked social anxiety
may well have substantial difficulties transitioning from elementary school to junior high school
if the problem is not addressed. Furthermore, a
child with severe social anxiety may have less
opportunity to develop the necessary social skills
for success later in life because of avoidant coping. Thus, recognizing anxiety disorders in children is the necessary first step in providing treatment that would facilitate learning healthier
coping skills.
These issues are central to the CAMS study.
Although early randomized, controlled trials demonstrated the effectiveness of the individual treatments (antidepressant medications and cognitive
behavioral therapy) used in this study, CAMS
compares the two monotherapies, examines their
combination, and reveals several interesting findings. First, the two monotherapies were equally
n engl j med 359;26 www.nejm.org december 25, 2008
Downloaded from www.nejm.org at PRINCETON UNIVERSITY on January 6, 2009 . Copyright © 2008 Massachusetts
Medical Society. All rights reserved.
Why Pay So Much Attention to Anxiety?
• Up to 20% of school age children have clinical anxiety
• Negative impact in multiple domains
• “Derailing” from achievement of important developmental
milestones (e.g., development of dating skills)
• Educational underachievement (e.g., Woodward & Fergusson,
2001)
• Associated with depression & suicidal ideation
• Predicts substance abuse problems & adult anxiety disorders
Treatment Efficacy: Overall Effects
Evidence from RCTs support the efficacy of:
• Cognitive-behavioral therapy (CBT)
• Pharmacological interventions (e.g., SSRIs)
• Combined CBT + SSRIs
CBT for Pediatric Anxiety Disorders:
Theoretical & Practical Considerations
Emotional Processing Theory & Treatment of
Anxiety Disorders (Foa & Kozak, 1985, 1986)
• Exposure is designed to activate fear network
• Need to “match” exposures to the fear network
• Prevention of avoidance is necessary because it
disrupts the natural process of habituation and
hence interferes with cognitive change
• Exposure provides “corrective information”
CBT Interventions for Pediatric Anxiety
Typically Include:
• 10 -12 + sessions delivered by trained/supervised therapists
• Psychoeducation re: nature of anxiety
• Identifying & dealing with anxiety-relevant cognitions
• Hierarchy development & selection of treatment targets
• Some form of behavioral exposure to feared
thoughts & situations
• Relapse prevention
CBT for Pediatric Anxiety Disorders:
Short Version
“Blah, blah, blah…do the thing you’re afraid of…
Blah, blah, blah…the more you do it, the easier it gets.”
Gwen Franklin, age 6
Specific Example:
March & Mulle’s (1998) CBT Protocol
for Pediatric OCD
• Psychoeducation
• Cognitive Training
• Mapping OCD: Development of Treatment Hierarchies
• Exposure and Response Prevention (EX/RP)
• Relapse Prevention
POTS I & II:
CBT Protocol
Obsessive Compulsive Cycle
Obsessions
Distress
Repetitive negative,
images or impulses
Anxiety, fear, disgust or
shame
Relief
Compulsions
Distress subsides
temporarily
Repetitive thoughts
images or actions
X
Negative Reinforcement
Pediatric OCD Treatment Study:
Penn, Duke, & Brown
Study Design:
CBT
SER
n = 28
n = 28
CBT +
SER
n = 28
PBO
n = 28
Phase l: 12 Week Acute Treatment
Phase ll: 16 Week Follow-up for Treatment Responders
POTS I CY-BOCS ITT Outcomes
COMB > CBT = SER > PBO
CY-BOCS TOTAL
30
25
20
PBO
SER
CBT
COMB
15
10
5
0
Week 0
Pediatric OCD Study Team (2004) JAMA.
Week 12
Stages of Treatment Model
• Initial treatment(s)
• Maintenance treatment(s)
• Clinical management of partial response
• Clinical management of non-response
Evans D. et al., (2004). Treating and preventing adolescent mental health disorders:
What we know and what we don’t know. New York: Oxford U Press.
Annenberg Foundation Trust at Sunnylands’ Adolescent Mental Health Initiative
POTS II Collaborative Study Group
PIs: M. Franklin, J. Freeman, J. March, H. Leonard
POTS II methods paper published in:
Freeman J., et al. (2009). Child & Adolescent
Psychiatry & Mental Health, 3:4.
POTS II primary outcome paper published in:
Franklin M, et al. (2011). Journal of the American
Medical Association, 306, 1224-32.
POTS II:
Design
POTS II:
Penn, Duke & Brown
Study Design:
MM+CBT
MM+I-CBT
MM
n = 42
n = 40
n = 42
12 Week Treatment Phase
3 & 6 month naturalistic follow-up for all participants
POTS II: Demographics
• Gender:
54% female
• Mean age:
13.6 years (2.8)
• Age range:
7-17
• % of sample < 11 yrs.:
32%
• Ethnicity/race:
96% Caucasian
Comorbidity
• 60% had at least one comorbid disorder:
- 44% had an anxiety or mood disorder
- 22% had comorbid ADD/ADHD
- 15% had a comorbid tic disorder
CYBOCS By Visit Week
Franklin et al. (2011) JAMA.
Conclusions
• Augmenting medication maintenance (MM) with CBT
results in symptom improvement compared to MM alone
• Adding a brief form of CBT as a component of routine
MM offers only modest benefit
• From a public health perspective, both POTS I and POTS
II argue forcefully for a strong CBT dissemination effort
POTS Junior:
Treatment of Very Young Children
w/ OCD
Family Based CBT program
(Freeman & Garcia, 2008)
• Psychoeducation for parents and children
• Child Tools
• Parent Tools
• Family Process Issues
Family-Based Treatment of OCD in
Very Young Children
CBT
REL
N = 62
N = 62
14 Week Treatment Phase
• REL participants receive open CBT
• Transfer of control model for youth ages 5 - 8
Study recruitment recently completed @ Penn, Duke, & Brown
Pediatric Trichotillomania (TTM)
DSM IV Definition of
Trichotillomania (TTM)
A. Recurrent hairpulling with noticeable hair loss
B. Tension before pulling or when attempting to resist
C. Pleasure, gratification, or relief when pulling
D. Not better accounted for by another disorder and
not due to a general medical condition
E. Clinically significant distress/functional impairment
Franklin & Tolin’s TTM Protocol
(2007):
Core Elements
• Psychoeducation
• Self-monitoring/awareness training
• Stimulus control
• Competing response/habit reversal
Habit Reversal Training
• First increase awareness of pulling behaviors
• Engage in competing behavior for 1 minute
• Use competing behavior at progressively earlier stages
in the pulling cycle
• Formally similar to what our group and others
researchers have studied in the treatment of Tourette
Syndrome (Franklin et al., 2011; Piacentini et al., 2010)
RCT for Pediatric TTM: Design
CBT
MAC
N = 12
N = 12
8 Week Treatment Phase
• MAC participants receive open CBT
• 8 week maintenance phase for CBT participants
6 month Naturalistic Follow-up Phase
RCT Sample Description (N=24)
Age in years:
12.5 (2.7)
Age of onset:
8.9 (3.2)
% Adolescents:
67%
% Female:
67%
% Caucasian:
75%
RCT Pulling Sites (% Endorsing)
Scalp
79%
Eyelashes
42%
Eyebrows
25%
Pubic
8%
Arm/Leg
4%
% Multiple sites
33%
Comorbidity
• 46% had at least one comorbid disorder
• 33% had at least one anxiety disorder (e.g., GAD)
• 13% had at least one comorbid externalizing disorder
(e.g., ADD/ADHD, ODD, conduct disorder)
• 13% had a comorbid mood disorder
• 4% had comorbid OCD
14
BT and MAC Outcomes
(LOCF on Week 40)
12
NIMH-TSS
10
8
BT (n = 12)
MAC (n = 12)
6
4
2
0
Wk 0
Wk 8
Wk 16
Wk 40
Franklin et al.
(2011). JAACAP.
But Was Running Against
MAC Really a Fair Test?
BT for Pediatric TTM: Ongoing R01
CBT
N = 30
SC
N = 30
8 Week Treatment Phase
• SC participants receive open CBT
• 8 week maintenance phase for CBT participants
6 month Naturalistic Follow-up Phase
Habit Reversal Training
for Tics
Douglas W. Woods
August 4, 2006
Philadelphia, PA
Common Features of
Tic Disorders
• Tics can be simple or complex
• Tics wax & wane
• Occur in bouts of bouts of bouts
• Topography changes
• Motor tics typically develop from head down
• Frequency, intensity, severity often follow a
developmental pattern
• Usually preceded by premonitory urge
Changing Internal Contingencies
Premonitory
Urge
Tic
X
Relief
Creates habituation to Premonitory Urge
Negative Reinforcement
Steps of CR Training
• Introduce CR
• Choose CR

Incompatible w/ tic

Mutual decision b/w patient and therapist
• Therapist simulates correct implementation
• Client is taught to do & practice CR in session
CR Caveats
• CR need not be physically incompatible to be
effective, but it makes more intuitive sense to start
with an incompatible response
• CR should be done contingent on tic or warning
sign to be maximally effective
• CR is held for 1 minute or until the premonitory
urge goes away (whichever is longer)
• CR tends to fade as the tic fades
Comprehensive Behavioral Intervention for
Tics Study (CBITS)
Two parallel studies comparing behavior therapy to ST
Child Study: 120 children (ages 9-17) with TS/CTD
Adult Study: 120 children and adults (ages 16+) with TS/CTD
8 session treatments over 10 weeks
Comprehensive assessment at BL, 5 wks, 10 wks (post treatment), 3 & 6 month
follow-ups
Participating Sites (40 at each of 3 sites)






UCLA (Child)
Johns Hopkins University (Child)
University of Wisconsin – Milwaukee (Child)
Mass General Hospital/Harvard (Adult)
Yale Child Study Center (Adult)
U. of Texas Health Sciences Center (Adult)
Funded by NIMH through two different mechanisms (R01 to TSA; Child study,
and Collaborative R01s to Yale, Harvard, and UTHSC)
Study Treatments
CBIT
Components
• Psychoeducation
Psychoed/SC
Components
• Phenomenology of TS
• Prevalence of TS
• Habit Reversal Therapy
• Natural History of TS
• Functional Intervention
• Common Comorbidities
• Reward System
• Relaxation Training
• Causes of TS
• Psychosocial Impairments
• Nonspecific Support
YGTSS
CBITS Results (Piacentini et al., 2010
• More children in the
control group were
rated as improved/ very
much improved on CGI
• Gains were maintained
for at least 6 months
Habit Reversal Training and ACT for Chronic Tic
Disorders (TSA-Sponsored)
• 7 participants ages 14 – 25 (3 @ Penn, 4 @ Duke)
received standard HRT treatment for tics
• Data from this phase used to inform HRT+ACT manual
• HRT+ACT provided to 6 additional participants (3/site)
• ACT did not appear to enhance HRT outcomes, perhaps
because of a floor effect in HRT
• Franklin et al. (2011). Journal of Developmental and
Physical Disabilities
Mean tic severity (YGTSS) scores over time for
HRT (n = 7) versus HRT+ACT (n = 6)
Treatments for Pediatric Anxiety
& Related Disorders:
What Do the Efficacy Data Tell Us?
• CBT is efficacious, both alone and in COMB with meds
• COMB might have some advantages over both monotherapies,
but optimal sequencing yet to be established
• CBT appears to be applicable to very young children
• Treatments are neither universally nor completely effective, so
there is treatment development work to be done
Pediatric Anxiety & Related Disorders:
What’s Next ?
• Moderator
analyses to examine which kids need COMB
• Mediator analyses to examine mechanisms of action
• Therapist effects
• Transportability to community clinical settings
• Novel approaches to promote dissemination (e.g., web-based
training & treatments, CD-ROMs)
• Protective factors: What prevents kids with behaviorally inhibited
temperaments at risk for anxiety from developing anxiety disorders?