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Cited by 63Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesChild and Adolescent Psychosocial and Emotional DevelopmentPsychotherapy Techniques and Applications

Monotherapy Insufficient in Severe Anxiety? Predictors and Moderators in the Child/Adolescent Anxiety Multimodal Study

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Taylor, Jerome H., Lebowitz, Eli R., Jakubovski, Ewgeni, Coughlin, Catherine G., Silverman, Wendy K., Bloch, Michael H.·2018·Journal of Clinical Child & Adolescent Psychology
DOI 10.1080/15374416.2017.1371028PMC PMC6191182
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Abstract

This secondary analysis of the Child/Adolescent Anxiety Multimodal Study (CAMS) used baseline patient characteristics to identify prognostic subgroups of children based on likelihood of remission. We also investigated predictors and moderators of outcome. CAMS randomized 488 youths with generalized, social, and separation anxiety disorders to cognitive behavioral therapy (CBT), sertraline, both, or pill placebo. Outcomes were Week 12 child, parent, and independent evaluator (IE) ratings of child anxiety. We used receiver operating characteristics analysis and stepwise regression to identify predictors and moderators of outcome. Severe anxiety, lower socioeconomic status, and comorbid obsessive-compulsive disorder predicted higher IE-rated anxiety posttreatment; child-rated social anxiety predicted poorer outcomes reported by all informants. Regarding moderators, Hispanic ethnicity predicted higher IE-rated anxiety after CBT and higher parent-rated anxiety after sertraline. In youths with severe anxiety (Pediatric Anxiety Rating Scale ≥ 20, n = 220), combination treatment increased remission (relative risk [RR] = 2.85, p < .001), 95% confidence interval (CI) [1.51, 5.39], whereas CBT (RR = 1.55, p = .20), 95% CI [0.77, 3.10], and sertraline (RR = 1.27, p = .53), 95% CI [0.59, 2.73], did not significantly increase remission relative to placebo. These are the first findings demonstrating that a combination of CBT and a selective serotonin reuptake inhibitor, not monotherapy, is likely key for achieving remission in severe anxiety. CAMS was not powered to detect treatment efficacy after stratification by anxiety severity, so further research is needed regarding effective treatments in severe anxiety. Our main effect findings suggest youth with severe anxiety (especially social phobia), low socioeconomic status and obsessive-compulsive disorder benefit less from current first-line treatments relative to other anxious youth. ClinicalTrials.gov: NCT00052078.

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  • SSRIs and SNRIs have been found to be more effective than waiting lists or placebo controls in reducing the severity of anxiety symptoms, including those associated with SAD.

    “SSRIs and SNRIs have been found to be more effective than waiting lists or placebo controls in reducing the severity of anxiety symptoms, including those associated with SAD [35,56,57].”

    From The risks versus the benefits of pharmacological intervention in social anxiety disorder in children (2025) · cites this paper as [56]

    The Introduction reports that sertraline, an SSRI, outperformed pill placebo in a trial including youths with separation anxiety disorder (SAD). It does not establish an SAD-specific reduction in symptom severity, and the paper provides no evidence here for SNRIs or waiting-list comparisons. The Abstract Results also report that sertraline did not significantly improve remission over placebo among youths with severe anxiety. Page numbers were not provided in our copy. (LLM, conf=0.88)

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  • In the CAMS study, combined CBT + sertraline improved clinical response more than either modality alone, but primarily in those with severe anxiety, and not in long-term follow-up.

    “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 [50]

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Research works printed but not linked: 6

  1. Birmaher B, Axelson DA, Monk K, Kalas C, Clark DB, Ehmann M,... Brent DA (2003b). Fluoxetine for the treatment of childhood anxiety disorders. Journal of the American Academy of Child and Adolescent Psychiatry, 42(4), 415– 423. 12649628
  2. Birmaher B, Brent DA, Chiappetta L, Bridge J, Monga S, & Baugher M (1999b). Psychometric properties of the Screen for Child Anxiety Related Emotional Disorders (SCARED): a replication study. Journal of the American Academy of Child and Adolescent Psychiatry, 38(10), 1230– 1236. doi: 10.1097/00004583-199910000-00011 10517055 · DOI · Paper page
  3. Kendall PC, & Hedtke KA (2006). Cognitive-behavioral therapy for anxious children: therapist manual (3rd ed.). Ardmore, PA: Workbook Publishing.
  4. NICE. (2013). Department of Health, United Kingdom. National Institute for Health and Care Excellence (NICE). Social anxiety disorder: recognition, assessment and treatment 31869048
  5. Silverman WK, & Albano AM (1996). Anxiety Disorders Interview Schedule for DSM-IV.: Child and Parent Interview Schedules (Vol. 1): Oxford University Press.
  6. Southam-Gerow MA, Kendall PC, & Weersing VR (2001b). Examining outcome variability: correlates of treatment response in a child and adolescent anxiety clinic. Journal of Clinical Child Psychology, 30(3), 422– 436. doi: 10.1207/S15374424JCCP3003_13 11501258 · DOI

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Authors
Taylor, J. H., Lebowitz, E. R., Jakubovski, E., Coughlin, C. G., Silverman, W. K., & Bloch, M. H.
Affiliations
Yale University (US)
Corresponding author
Taylor, Jerome H.
ORCID
Venue
Journal of Clinical Child & Adolescent Psychology
Publisher
Informa UK Limited
Published
2017-09-28
Volume
47
Issue
2
Pages
266-281
ISSN
  • 1537-4416 (ISSN-L)
  • 1537-4424
DOI
10.1080/15374416.2017.1371028
PMC
PMC6191182
OpenAlex
W2758939645
Cited by
63
References
68
Citations by year
2026: 5 · 2025: 6 · 2024: 5 · 2023: 7 · 2022: 5 · 2021: 8 · 2020: 12 · 2019: 8 · 2018: 5 · 2017: 2
FWCI
9.55
Type
journal article
Language
en
Open access
Locations
  • Journal of Clinical Child & Adolescent Psychology (publishedVersion)
  • PubMed (publishedVersion)
  • Europe PMC (PubMed Central) (acceptedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • Brain and Behavior Research Foundation (NARSAD)
  • National Institute of Mental Health (1K23MH091240, 1K23MH103555, 5T32MH018268, 5T32MH019112)
  • Robert E. Leet and Clara Guthrie Patterson Trust
  • Substance Abuse and Mental Health Services Administration (Minority Fellowship Program)
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
child and adolescent anxiety, severe anxiety, generalized anxiety disorder, social anxiety disorder, separation anxiety disorder, cognitive behavioral therapy, sertraline, selective serotonin reuptake inhibitors, combination therapy, monotherapy, treatment moderators, predictors of treatment outcome, anxiety remission, socioeconomic status, obsessive-compulsive disorder comorbidity, Hispanic origin
MeSH terms
Adolescent, Anxiety Disorders, Child, Female, Humans, Male, Prognosis

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