Childhood Anxiety Disorders: Developmental Risk Factors and Predictors of Treatment Response

Abstract

Cognitive Behavioral Therapy (CBT) is the evidence-based treatment of choice for childhood anxiety disorders. Its blend of cognitive and behavioral coping strategies for anxiety management has more empirical support than any other intervention approach. Yet even after receiving CBT, more than 40% of anxious children still meet criteria for their anxiety disorder. Research is needed to identify factors associated with treatment response and non-response, and ultimately to inform treatment improvement. Three studies, reflecting this broad objective, focus on factors that may relate to child treatment response—environmental, biological, and cognitive factors suggested by theoretical models of anxiety and potentially relevant to treatment effectiveness research. Study 1 examined whether parental anxiety is a negative predictor, and child perception of control a positive predictor, of treatment outcome in CBT within a randomized controlled trial for childhood anxiety disorders. We found that parental anxiety and child perception of control were not associated with treatment outcomes in the CBT or Usual Care treatment conditions with the exception of child perceived social control. In addition, parental anxiety levels did not change from pre- to post-treatment but child perceived control increased from pre- to post-treatment in response to both CBT and Usual Care. Study 2 examined biological stress response in the context of exposure, the treatment component widely regarded as the heart of CBT for anxiety. Analyses of salivary analytes focused on activation of biological systems implicated in the social stress response (i.e., the hypothalamic-pituitary-adrenal axis and the autonomic nervous system) in children with Social Anxiety Disorder and age-matched non-anxious controls, and we found that socially anxious children do not exhibit abnormally elevated biological reactivity. The study also tested whether heightened physiological arousal facilitates habituation and fear extinction, and we found that children who experienced greater biological activation over the course of a graduated exposure intervention appeared to benefit most. Finally, we found that subjective reports of heightened anxiety did not correspond to objective levels of biological arousal, suggesting that social anxiety may be associated with excessive self-monitoring and hypersensitivity to normative physiological response to stress and anxiety rather than biological dysregulation. Study 3 examined whether socially anxious children exhibit social skills deficits and/or negative cognitive appraisal biases in a social-evaluative speech task. We found that socially anxious children did not exhibit negative cognitive appraisal biases, but they did exhibit specific social skills deficits in comparison to age-matched non-anxious peers. Taken together, these studies shed light on child and parent characteristics that are positively and negatively associated with youth anxiety treatment outcome from a biopsychosocial perspective.