New research about treatments for pediatric anxiety

Happy Summer!

I hope you all are getting outside and despite the abundance of summer activities in the midwest, also finding ways to slow down and schedule less (I know in the chaos of modern life that may feel like a pipedream, but I feel it is worth creating some intention around).

I’m popping into your inbox to share a research update on treatment for pediatric anxiety. This study is exciting for several reasons:

First, the sample is more representative of what clinicians, particularly pediatricians see (in comparison to ivory tower clinical trials). By that I mean the sample endorsed higher levels of anxiety and economic hardship as well as co-occurring depression than previous research samples. This means the sample is closer to what occurs in “real-world” settings, meaning the findings may be more generalizable. 

Interestingly, the authors hypothesized that fluoxetine would outperform other treatments. This surprised me at first, but is due partly to the large presence of comorbid depression in this sample (67%) and we wouldn’t necessarily expect exposure-based CBT for anxiety to target depression. The other reason the authors leaned this way with their hypotheses was based on the assumption that community therapists delivering CBT may not be as adept at this form of treatment (again compared to CBT clinicians in academic medical centers where clinical trials tend to occur).

Notably, the CBT focused on psychoeducation and coping for the first 6 sessions and then moved to exposures. Similarly, the fluoxetine dosing moved at a relatively quick rate with the recommendation that the dosage be increased if the child was not yet in remission and absent significant side effects. This study had a level 2 optimization phase where CBT focused on more challenging exposures and medication dosage increased.

A decision point for families and clinicians is whether to begin with medication or CBT first. This study was designed to test the effectiveness of various sequences of treatment. This study also addresses the question of how to optimize treatment if improvement is not seen after 12 weeks.

Youth with OCD or PTSD were excluded. Instead the sample had social anxiety, generalized anxiety, panic, or separation anxiety. In addition to depression, ADHD was present in 46% of the sample. The age range of the sample was relatively young with a mean age of 13 (age range 8-17). 83% of sessions were conducted via telehealth (both CBT and med management). 

Yes I did sift through the 80 pages of supplementary materials! 

Here are my takeaways: 

1. All treatments (medication only, CBT only, CBT+med) reduced symptoms.
2. We need to take clinical anxiety in children seriously. And if minimal improvement is seen at 12 weeks, it makes sense to talk about adding another treatment modality to move things along. *caveat, overall findings did not differentiate here, but this comes from the sequencing findings versus a main effect. 
3. The secondary racial/ethnicity findings are really interesting to me having done some previous research on this. On secondary outcome measures (parent reported anxiety and impairment), non-Hispanic White youth benefited most from starting with fluoxetine (prozac) and staying on it, whereas minority youth seemed to benefit from starting with CBT and then adding medication. 
4. Number of sessions conducted via telehealth versus in person did not seem to change results. Average percent of CBT sessions conducted via telehealth in this sample was 83%. 
5. The number of kids who met criteria for full remission from clinical anxiety at 24 weeks was low (6%). 
6. Patient preferences and practical considerations such as treatment availability and cost matter, particularly when exposure-based CBT is difficult to access and requires significant effort (hard work!). 

TLDR: Any treatment reduces anxiety - treatment works! The rest is nuance for people like me to think about and inform you of so you and your family can make educated decisions. 

Links if you want to read more: paper or news 

I hope passing this research along is helpful to you.

Dr. Rachel and the Well Brain Team



➤ Reminder that we have a back-to-school anxiety worksheet you can use this month if worries start to creep into summer.

What We’re Listening To: 

How the adolescent brain works, discussions with cognitive neuroscientists: 

Episode 1

Episode 2

If you’re going to be getting info from social media my friend and colleague Dr. Natania Crane has started posting about adolescent brain development, particularly as it relates to substance use. Another great resource is my colleague Dr. Zia Lakdawalla who shares parenting anxious kids tips including her experience parenting her own kids. 

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