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Wang Z, Whiteside S, Sim L, et al. Anxiety in Children [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2017 Aug. (Comparative Effectiveness Reviews, No. 192.)

Cover of Anxiety in Children

Anxiety in Children [Internet].

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Introduction

Background

Childhood anxiety disorders are very common, affecting one in eight children.1 The National Institute of Mental Health estimates a prevalence between the ages 13 and 18 years of 25.1 percent and a lifetime prevalence of 5.9 percent for severe anxiety disorder.2 Anxiety disorders in childhood generally follow an impairing course leading to additional psychopathology and often interfere with social, emotional, and academic development.3, 4

Multiple treatment options are available, including psychotherapy, pharmacotherapy, and combined treatment approaches. Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitor (SSRIs) are considered by many to be first line treatments.59 CBT is generally recommended as the first-line treatment by World Health Organization (WHO), National Institute for Health and Care Excellence (NICE), and British Columbia Medical Services Commission.1012 In addition to CBT, other psychotherapy approaches include: psychoanalysis, family therapy, and education support. Pharmacotherapy is also widely used, including SSRIs, serotonin–norepinephrine reuptake inhibitors (SNRIs), benzodiazepines, and others. Pharmacotherapy is commonly used when psychotherapy is not available, does not lead to adequate response, or for moderate or severe symptoms at initial presentation.

There is a great deal of uncertainty regarding comparative effectiveness and safety of all treatments for childhood anxiety disorders. The potential advantage of psychotherapy is related to being safe and noninvasive.5, 6 The potential disadvantages are that it has limited availability,13 requires multiple appointments,14 and requires behavioral changes by children and families. The potential disadvantages of pharmacotherapy are that it has unknown effect on brain chemistry, has the potential for adverse events (AEs),15, 16 and that its benefits may not persist after treatment has been discontinued.17, 18 Currently, existing treatment guidelines provide inconsistent and at times conflicting advice.10, 11, 19 Regarding SSRIs, one guideline specifically recommends that SSRIs should not be used in children,11 while another recommends they be used if CBT is not sufficient,10 and the third recommends their use for more severe presentations or if CBT is not available.19 Furthermore, despite the fact that all guidelines recommended CBT as a first line treatment, the components that comprise CBT differ between guidelines. In addition, one guideline suggested mild severity be treated with general health promotion,10 another recommended CBT regardless of severity,11 and the third recommended CBT as a sole intervention only for mild to moderate symptoms.19 Regarding other behavioral interventions, one organization specifically recommended that they should not be used,11 another did not comment,10 and the third recommended that multiple different interventions be considered including modalities that were later in the guidelines described as having little to no empirical support.19 In addition, there were inconsistency between several recommendations and the supporting data, particularly when discussing the role of symptom severity in treatment decisions, the comparative effectiveness of different SSRIs, the use of SSRIs in preschool age youth, and the use of non-SSRIs medications.2022 Finally, additional inconsistencies exists between guidelines, such as the level of empirical support ascribed to an intervention, the relative value of different treatment modalities, or the specifics of treatment protocols.

Many factors have been proposed to interfere with participation or adherence to treatment and/or response to treatments, including severity of illness, comorbid conditions, family socioeconomic status (SES), externalizing symptoms, patient age, family dysfunction or stressor, and others. For example, treatment for children under six usually involves primarily parent training/behavior management interventions; while treatment with children 6 and up is more likely to involve working directly with children. Evidence reviews and randomized controlled trials (RCTs) reported conflicting results regarding differential response rates by age groups.23 Severity of symptoms is generally believed to be associated with worse outcomes and guidelines suggest a different treatment approach for these children.11, 19 Despite many available treatments, the majority of children with anxiety disorders do not receive treatment.24

The objectives of this systematic review are to evaluate the comparative effectiveness of psychotherapy and pharmacotherapy for childhood anxiety disorders and to evaluate the harms and safety concerns associated with these treatments.

Based on the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), we plan to study the following types of anxiety: panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, and separation anxiety. Obsessive compulsive disorder (OCD) and post-traumatic stress disorder will be excluded as their treatment approaches are generally different from other types of anxiety.

Scope and Key Questions

Scope of the Review

This systematic review addresses the comparative effectiveness and harms of commonly used types of psychotherapy and pharmacotherapy as listed in Tables 1 and 2.

Table 1. Psychotherapy used to treat childhood anxiety.

Table 1

Psychotherapy used to treat childhood anxiety.

Table 2. Medications used to treat childhood anxiety.

Table 2

Medications used to treat childhood anxiety.

Key Questions

The following Key Questions (KQs) were determined based on input from multiple key informants and members of a Technical Expert Panel. The related PICOTS (population, interventions, comparisons, outcomes, timing, and setting) are listed in Table 3.

Table 3. PICOTS (population, interventions, comparisons, outcomes, timing, and setting).

Table 3

PICOTS (population, interventions, comparisons, outcomes, timing, and setting).

KQ 1.

What is the comparative effectiveness of the available treatments for childhood anxiety disorders, including panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, and separation anxiety?

  1. What is the evidence for the comparative effectiveness of psychotherapy, pharmacotherapy, and combined treatment approaches for childhood anxiety disorders?
  2. What is the evidence of differential effectiveness of different classes of medication, and for different medications within classes?
  3. What is the evidence of differential effectiveness of different psychotherapy approaches, delivery mode, and components of psychotherapy for childhood anxiety disorders that are necessary and sufficient for improvement (including number of treatments and intensity of psychotherapy)?
  4. How does comparative effectiveness of interventions vary according to child/family characteristics, and disease characteristics, including age, sex, race, ethnicity, SES, diagnosis, child maltreatment, parent/family comorbidity, duration, maltreatment?
  5. How does comparative effectiveness of interventions vary according to child comorbid conditions, including attention deficit hyperactivity disorder (ADHD), depression, substance abuse, autism spectrum disorder, behavioral disorders, and somatic medical conditions?
  6. What are the treatment burdens (for patients, providers, and health systems) and contextual factors (patient/family preference, time associated with psychotherapy) that influence treatment choices for childhood anxiety disorders?
KQ 2.

What are the comparative harms and safety concerns regarding the available treatments for childhood anxiety disorders, including panic disorder, social anxiety disorder, specific phobias, generalized anxiety disorder, and separation anxiety?

  1. What is the evidence for short-term and long-term patient experienced harms associated with treatments for childhood anxiety disorders?

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