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Cognitive behavioural therapy for anxiety disorders in children and adolescents

  • Review
  • Intervention

Authors


Abstract

Background

Childhood and adolescent anxiety disorders are relatively common, occurring in between 5-18% of all children and adolescents. They are associated with significant morbidity and impairment in social and academic functioning, and when persistent, there is a risk of depression, suicide attempts and substance abuse in adulthood. There is accumulating evidence for the efficacy of cognitive behavioural therapy (CBT), with a number of randomised controlled trials (RCTs) suggesting benefit.

Objectives

To determine whether CBT is an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or attention controls.

Search methods

Search of the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register, which includes relevant randomised controlled trials from the bibliographic databases - The Cochrane Library ( to January 2004), EMBASE, (1970-2004) MEDLINE (1970-2004) and PsycINFO (1970-2004). We also searched the references of all included studies and relevant textbooks, and contacted authors in order to identify further trials.

Selection criteria

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Each identified study was assessed for possible inclusion by two reviewers independently.
Inclusion criteria consisted of randomised controlled trials of CBT versus waiting list/attention controls in children (more than six years of age) and adolescents (under the age of 19 years) with a DSM (Diagnostic Statistical Manual) or ICD (International Classification of Diseases) anxiety diagnosis; and excluding simple phobia, obsessive compulsive disorder and post-traumatic stress disorder. Each study was required to conform to the principles of CBT through use of a protocol and comprising at least eight sessions of CBT.

Data collection and analysis

The methodological quality of included trials was assessed by two reviewers independently. The dichotomous outcome of remission of anxiety diagnosis was pooled using relative risk (RR) with 95% confidence intervals. Means and standard deviations of anxiety symptom continuous scores were pooled using the standardised mean difference (SMD). Heterogeneity was assessed and intention-to-treat (ITT) analyses undertaken. The presence of publication bias was assessed using funnel plots.

Main results

Thirteen studies with 498 subjects and 311 controls met the inclusion criteria and were included in the analyses. The studies involved community or outpatient subjects only, with anxiety of only mild to moderate severity. ITT analyses showed a response rate for remission of any anxiety diagnosis of 56% for CBT versus 28.2% for controls (RR 0.58,95%CI 0.50 to 0.67), with no evidence of heterogeneity. The number needed to treat (NNT) was 3.0 (95%CI 2.5 to 4.5). For reduction in anxiety symptoms, the SMD was -0.58 (95% CI -0.76 to -0.40) with no significant heterogeneity indicated. Post hoc analyses suggest that individual, group and family/parental formats of CBT produced fairly similar outcomes.

Authors' conclusions

Cognitive behavioural therapy appears an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or attention control. There was no evidence for a difference between an individual, group or parental/family format. CBT can be recommended for the treatment of childhood and anxiety disorders, although with only just over half improving, there is a need for further therapeutic developments.

摘要

背景

以認知行為治療兒童與青少年的焦慮症

焦慮症在兒童與青少年的人口中約有5 – 18%,是相當常見的疾病。他們與顯著的發病率及社會學業功能損害有關,當情況持續下去,在成人期可能會演變成憂鬱,企圖自殺及物質濫用。有越來越多累積的證據顯示認知行為治療(CBT)是有效的,而多數的隨機對照試驗(RCTs)也提出了其效益。

目標

以等候名單或注意力控制做為對照組,評估CBT是否為治療兒童與青少年焦慮症的有效治療方式。

搜尋策略

搜尋登錄在Cochrane憂鬱、焦慮、精神官能症團體,以及的臨床試驗研究,這些研究是從書目資料庫考科藍圖書館(到2004年1月),EBMASE(1970 – 2004),MEDLINE(1970 – 2004),以及PsycINFO(1970 – 2004)找出相關的臨床試驗研究。我們也搜尋了所有研究的文獻、相關的教科書,並聯繫這些作者以確認進一步的試驗。

選擇標準

由兩位審查者分別評估每一個可以納入的研究。納入的標準包涵了(六歲以上的)兒童及(19歲以下)青少年,在DSM或ICD診斷為焦慮症,採用CBT的隨機對照研究,與等候名單/注意力控制組相對照,排除特定對象恐懼症,強迫症與創傷後壓力疾患。每項研究必須透過使用CBT的標準手冊以符合執行原則,並且持續至少8次CBT治療。

資料收集與分析

由兩名審查者獨立評估納入研究的研究方法的品質。焦慮診斷的緩解結果為二分資料集中以相對危險值(RR)處理,並計算出95%信賴區間。焦慮症狀是連續性分數,其平均值與標準差以離均差(SMD)集中處理。進行異質性語意向性治療的評估。出版偏誤的存在以漏斗圖進行評估。

主要結論

有13研究包含了498名個案,及311的控制對象符合納入標準,並列入了分析。這些研究包含了社區或門診的焦慮個案,只有嚴重度只有輕到中度的焦慮。意向性治療分析顯示焦慮診斷的緩解反應比率,CBT有56%,對照組有28.2%(RR = 0.58,95%CI 0.50 to 0.67),沒有異質性。益一需治數(NNT)是3.0 (95%CI 2.5 to 4.5)。對於減少焦慮症狀的離均差(SMD)是−0.58(95%CI = −0.76 to −0.40),沒有顯著的異質性。事後分析顯示,個別、團體和家庭/父母等CBT的形式有相當類似的結果。

作者結論

相較於等候治療或注意力控制組,以認知行為治療兒童和青少年的焦慮症是有效的。在個別治療、團體治療,或父母/家庭等形式方面並沒有顯著的差異。CBT被推薦可以治療兒童和焦慮症,雖然有超過一半的人可改善,仍需要更進一步的治療發展。

翻譯人

本摘要由彰化基督教醫院陳美貴翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

相較於等候治療或注意力控制組,以認知行為治療兒童和青少年的焦慮症是有效的。認知行為療法已被認為適合治療六歲以上有焦慮症的兒童與青少年。這種心理治療可以採用各種形式:個人,團體和家庭/父母。認知行為治療在超過50%以上的病例是有效的。在各種形式上並沒有差別。

Plain language summary

Cognitive behavioural therapy compared to waiting list or an attention control for child and adolescent anxiety disorders

Cognitive behavioural therapy has been adapted for the treatment of anxiety disorders in adolescents and children over the age of six years. This psychological treatment can be delivered in various formats: individual, group and family /parent. Cognitive behavioural therapy appears effective in just over 50% of cases. There is no difference between formats.

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