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Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety
Open accessAbstract
BACKGROUND: Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy. METHODS: In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12. RESULTS: The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline. CONCLUSIONS: Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.)
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“While psychological and pharmacological interventions are mainstays of treatment for anxiety and depressive disorders in children and adolescents (James 2020;Walkup 2008;Wang 2017), alternative and adjunct treatment options are available, including exercise.”
From Exercise for the treatment of anxiety in children and adolescents (2022) · cites this paper as Walkup 2008
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“Randomization will be stratified by study site, age group [8–17], and baseline symptom severity (dichotomizing SCARED-41 scores as ≤33 or > 33, based on the median SCARED-41 score for participants having scores ≥25 in the CAMS [49] and LAMS [163] studies).”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [49]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“In CAMS, this was “designed to reflect how the … treatment would be delivered in clinical settings” over an extended care time frame and focused on exposure practice and coping skills review, without the addition of other new material [49].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [49]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“in a relevant prior study [49], 139 children were randomized to 12 weeks of Coping Cat treatment, and none of those children withdrew from treatment during the entire 12 weeks (though 6 (4.3%) were lost to the study).”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [49]
Experimental — accuracy not yet measuredThe source backs part of the claim, not all of it — or backs it for a different population, condition or comparison.
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“For example, the duration of CAMS trial, which compared CBT with medication and the combination, was only 12 weeks long.”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [49]
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“Very few studies have compared combined therapy to either treatment alone [47–49].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [49]
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“In the CAMS study, combined CBT + sertraline improved clinical response more than either modality alone [49], but primarily in those with severe anxiety [50], and not in long-term follow-up [29].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [49]
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“First, medication in the CAMS study exhibited a small, non-significant advantage over CBT on ratings from the Pediatric Anxiety Rating Scale [49].”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [49]
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“Coping Cat training has demonstrated effectiveness with clinicians ranging from graduate students [180, 181] to experienced psychotherapists [49], with strong treatment effects in each case.”
From A Sequential Multiple Assignment Randomized Trial (SMART) study of medication and CBT sequencing in the treatment of pediatric anxiety disorders (2021) · cites this paper as [49]
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In the citing paper
“Conversely, FGID symptoms have been reported in 30% to 70% of children with anxiety disorders3,5 as compared to 6% to 25% of children from the general population.6”
From Provider Communication Regarding Psychosocial Factors Predicts Pain Beliefs in Parent and Child (2016) · cites this paper as [6]
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Citations
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Harnessing neuroplasticity for clinical applications
Cramer, S. C., Sur, M., Dobkin, B. H., O'Brien, C., Sanger, T. D., Trojanowski, J. Q., Rumsey, J. M., Hicks, R., Cameron, J., Chen, D., et al. (2011) · Brain · doi:10.1093/brain/awr039 · Cited by 1,259
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Metadata
- Authors
- Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., Ginsburg, G. S., Rynn, M. A., McCracken, J., Waslick, B., Iyengar, S., March, J. S., & Kendall, P. C.
- Affiliations
- Johns Hopkins University (US)
- Columbia University Irving Medical Center (US)
- University of California, Los Angeles (US)
- University of Pittsburgh Medical Center (US)
- Duke Medical Center (US)
- National Institute of Mental Health (US)
- Baystate Medical Center (US)
- Temple University (US)
- ORCID
- Venue
- New England Journal of Medicine
- Publisher
- Massachusetts Medical Society
- Published
- 2008-12-25
- Volume
- 359
- Issue
- 26
- Pages
- 2753-2766
- ISSN
- 0028-4793 (ISSN-L)
- 1533-4406
- PMC
- PMC2702984
- OpenAlex
- W2131873172
- Semantic Scholar
- a41b3bc19195f9eba51187a6e1119eeb1b17a808
- Cited by
- 1,442
- References
- 30
- Citations by year
- 2026: 46 · 2025: 46 · 2024: 64 · 2023: 63 · 2022: 92 · 2021: 97 · 2020: 85 · 2019: 91 · 2018: 93 · 2017: 89 · 2016: 85 · 2015: 109 · 2014: 88 · 2013: 100 · 2012: 82
- FWCI
- 95.27
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- New England Journal of Medicine (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health (U01MH64088, U01MH64107, U01MH64003, U01MH064088, U01MH064107, U01MH64092, U01MH064089, U01MH064092, U01MH63747, U01MH064003, U01MH063747, L40 MH072315, K23MH075843)
- Topics
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Keywords
- childhood anxiety disorders, cognitive behavioral therapy, sertraline, selective serotonin reuptake inhibitors, combination therapy, separation anxiety disorder, generalized anxiety disorder, social anxiety disorder, treatment efficacy, adverse events, suicidal ideation, insomnia
- MeSH terms
- Adolescent, Anxiety Disorders, Child, Combined Modality Therapy, Female, Humans, Male, Cognitive Behavioral Therapy, Treatment Outcome, Selective Serotonin Reuptake Inhibitors, Sertraline
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