Prepared for Child and Youth Mental Health Services - British Columbia Ministry of Children and Family Development

Welcome
Summer 2007 Children's Emotional Wellbeing
Welcome to the Summer 2007 issue of the Childrens Mental Health Research Quarterly, produced by the
Childrens Health Policy Centre at Simon Fraser University. The Quarterly provides updates on the best
currently available research evidence in childrens mental health. The theme for this issue is childrens
emotional wellbeing. This theme was chosen in consultation with Child and Youth Mental Health (CYMH)
staff at BCs Ministry of Children and Family Development (MCFD).
In addition to our regular features, in this issue we:
Spotlight long-term outcomes of cognitive-behavioural therapy for treating anxiety disorders
Highlight a review on including parents in treatment
Present a review on effective treatments for obsessive-compulsive disorder
Discuss using research evidence in clinical practice with Jane Garland, a child psychiatrist
We hope you find this issue both enjoyable and useful. Please email us with your questions, comments and
suggestions for future topics.
Next Issue
The theme for our Fall 2007 Quarterly will be helping children cope at school, highlighting the assessment
and treatment of attention-deficit/hyperactivity disorder (ADHD).

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

The Quarterly is prepared by an interdisciplinary team at the Childrens Health Policy Centre.
EDITOR
Erika Harrison, MA
WRITER
Christine Schwartz, MA, PhD, RPsych
SCIENTIFIC EDITOR
Charlotte Waddell, MSc, MD, CCFP, FRCPC
RESEARCH ASSISTANTS
Orion Garland, BA; Larry Nightingale, LibTech; Jenn Dixon, BScHP

We welcome people to use The Quarterly as a reference source (for example, in preparing educational
materials for parents or community groups). Please cite our work as:
Schwartz C, Waddell C, Harrison E, Garland O, Nightingale L, & Dixon J. 2007. Childrens Mental Health Research Quarterly:
Summer Issue Childrens Emotional Wellbeing. Vancouver, BC: Childrens Health Policy Centre, Faculty of Health Sciences,
Simon Fraser University.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

Current Articles
IN COMMENTARY
Fears and worries: The typical and the concerning
We respond to questions from policy-makers, practitioners and parents about the distinction between
common childhood worries and clinical anxiety disorders. We then discuss factors that influence the
development of anxiety problems. We also look at the importance of preventing and treating anxiety
problems early in life, and the costs to children if we do not.
IN REVIEW
Promoting emotional wellbeing, addressing childhood anxiety
We present findings from the latest high-quality research evidence on interventions for preventing and
treating anxiety problems in children. To highlight the most effective programs, we examine newly
published research findings and recap results from our previous anxiety disorders review. We then
suggest recommendations for policy and practice based on this evidence.
IN FOCUS
Treating Obsessive-Compulsive Disorder
We summarize a recent high-quality systematic review on treating obsessive-compulsive disorder in
children. We present well-conducted research that continues to accumulate on the effectiveness of
exposure and response prevention, a form of cognitive-behavioural therapy.
IN PRACTICE
Out of the journals and into childrens lives
Jane Garland is a child psychiatrist, clinical professor at the University of British Columbia (UBC) and head
of the Mood and Anxiety Disorders Clinic at BC Childrens Hospital. She is also the co-author of Taming
Worry Dragons, a book designed to help children combat problematic worry.We spoke to Jane about her
experiences taking the research evidence into her practice and programs.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

IN COMMENTARY
Fears and worries: The typical and the concerning
Here we respond to questions from policy-makers, practitioners and parents.
What is normal anxiety in children?
Anxiety is a normal part of childhood. Certain fears and worries are typical and
may be expected at any given developmental stage. For example, it is common for
toddlers to fear the dark, for school-aged children to fear animals and for
teenagers to worry about relationships with peers. These typical anxiety
experiences do not usually interfere with childrens development and functioning.
They also usually diminish with time.
When does anxiety become a problem?
Anxiety disorders are distinguished from more typical worries in that they have a significant negative
impact, causing children distress and impairing childrens functioning at home, at school or in the
community. When fears start to interfere with daily living, for example, causing difficulties such as the
inability to attend school or to enjoy friendships, there may be a clinically significant anxiety disorder.

What are the types of anxiety disorders in children?

There are several different types of anxiety disorders. All
involve excessive fears and all cause serious impairment
for affected children. Many of these disorders present

Fears of various kinds can be

typical to a childs
developmental stage

early in life, between ages seven and 11 years. The table

below details specific types of anxiety disorders commonly found in children.
Types of Anxiety Disorders in Children1
Anxiety Disorder

Description

Specific phobia

Excessive fear of an object or situation such as water or an animal

Social phobia

Severe and persistent fears of interacting with others such as meeting new people

Separation anxiety

Excessive worry about separation from important individuals such as parents or

caregivers

Generalized anxiety

Various severe worries associated with physical symptoms and difficult to control

Posttraumatic stress disorder &

Acute stress disorder

Characteristic physical and psychological anxiety responses to a traumatic event such as

severe maltreatment or a serious accident

Panic disorder

Frequent disabling anxiety attacks occurring with or without obvious triggers

Obsessive-compulsive disorder

Intrusive thoughts and repetitive behaviours causing severe distress such as a

compulsion to wash excessively because of a fear of germs

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

How common are anxiety disorders?

Anxiety disorders are the most common mental health problems in children (and adults). Approximately
6.4% of children (or six in 100) have severe problems with worries and fears warranting a clinical
diagnosis.2 Obsessive-compulsive disorder (OCD) is typically distinguished from other anxiety disorders and
affects an estimated 0.2% of children (or two in 1,000).2 This means that at any given time over 42,000
children in BC and over 338,000 children in Canada may experience some type of anxiety disorder.3 If
milder forms of anxiety are considered, many more children are likely affected. Strikingly, the majority of
these children (over 75%) do not get the help they need in childhood.2
How do anxiety disorders develop?
Like many mental health problems, anxiety disorders
likely arise through the interaction between genes and
environment, particularly as children experience adversity

Anxiety disorders are the most

common mental health problems
in children

over time.4 Mental disorders such as anxiety emerge

differently during different developmental periods.5 Many factors increase the likelihood of such problems
occurring.6 Being female is a risk factor, as is having a parent with an anxiety disorder. 7 Parenting styles
can affect the development of anxiety problems, such as when parents inadvertently encourage fears by
allowing children to avoid uncomfortable situations. 8 Being temperamentally cautious during the preschool
years is also a risk factor.5 The experience of extremely negative or stressful events, beyond the typical
adversities most children experience, can promote anxiety problems. Examples of extreme adversities
include being physically or sexually abused, witnessing violence, being bullied, experiencing a serious
accident, having numerous changes in caregivers or losing an important adult such as a parent or
caregiver.4 For OCD, research suggests biological factors are particularly important given the development
of some cases after streptococcal infections9 and noted differences in specific brain regions.10
The risk of developing a mental disorder after experiencing a single risk factor is quite low. Anxiety
disorders, like other mental health problems, typically occur when children are exposed to multiple severe
adversities.11 It is therefore crucial to ensure children are protected from unnecessary and preventable
negative experiences impeding healthy development such as maltreatment.
What factors can protect children from developing
anxiety problems?
When the prevention of anxiety problems has not been
possible, it is vital to target interventions at adversities or

Anxiety problems typically occur

when children are exposed to
multiple severe adversities

risk factors that can be changed. Building on protective

factors is also critical. Active coping strategies, such as focusing on solving problems rather than avoiding
them, have been specifically identified as protective factors for childhood anxiety. 7 More generally, several
protective factors are associated with positive mental health, including freedom from anxiety. These
include: a positive relationship with at least one adult; positive relationships with peers; good learning
abilities; a cohesive community and a sense of greater purpose.12 It is a given that all children need
stability, safety and supportive adults in their lives to encourage their healthy development.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

Why dont more children with anxiety receive the help they need?
Anxiety problems often go undetected or mistaken for another problem resulting in children not receiving
the help they need.7 Children with anxiety are often quiet and do not come to adults attention the same
way children with behaviour problems do. Anxiety problems can also present in other ways, for example, as
irritability or anger or learning difficulties when children are confronted with situations that overwhelm
them. All these factors make it especially likely that serious anxiety problems may go undetected or get
mislabeled, for example, when people mistake anxiety for attention or learning problems. This also means
the underlying causes of the anxiety often go undetected.
What are the costs of anxiety disorders for children
and for society?
Childhood anxiety disorders are associated with a number
of negative outcomes. Children with anxiety disorders
often have difficulties with academic work and periods of

Prevention and early

intervention enhance the
wellbeing of children, families
and communities

inability to attend school.8 Difficulties in social

relationships commonly result from low self-esteem, social isolation and challenges with social skills. 8
Physical symptoms, including headaches and stomachaches, are common.8 Childhood anxiety disorders
have also been associated with thoughts of suicide and suicide attempts.13 Finally, children with anxiety
disorders are at risk of developing additional mental disorders including other anxiety disorders, depression
and substance abuse.7 When anxiety problems are treated or prevented altogether, children can avoid such
adverse outcomes and experience a healthier development.
If not successfully prevented, or detected and treated early, childhood anxiety disorders typically have a
chronic course and worsen over time.13 These disorders then often persist (unnecessarily) into adulthood.14
Anxiety disorders are the most common mental health problems for adults as well.15 These difficulties have
enormous individual and social costs. In Canada, the total economic costs of mental disorders exceed an
estimated $14 billion dollars annually. 16 (In our next article we highlight successful prevention and
treatment programs for childhood anxiety disorders). Intervening early not only reduces suffering for
children and families, but also enhances the emotional wellbeing of the whole population. 17

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

MCFD staff can access original articles cited in the Quarterly from the Health and Human Services Library.
References:
1.

American Psychiatric Association. 2000. Diagnostic and statistical manual of mental disorders: DSM-IV-TR (4th Ed.).
Washington: American Psychiatric Association.

2.

Waddell et al. 2005. A public health strategy to improve the mental health of Canadian children. Canadian Journal of
Psychiatry; 50: 226-233.

3.

Waddell et al. 2007. Developing a research-policy partnership to improve childrens mental health in British Columbia. In
LeClair & Foster (Eds.), Contemporary Issues in Mental Health: Concepts, Policy, and Practice. Canadian Western
Geographical Series; 41 (pp. 183-198). Victoria: Western Geographical Press.

4.

Rutter et al. 2006. Gene-environment interplay and psychopathology: Multiple varieties but real effects. Journal of Child
Psychology and Psychiatry and Allied Disciplines; 47: 226-261.

5.

Essex et al. 2006. Exploring risk factors for the emergence of childrens mental health problems. Archives of General
Psychiatry; 63: 1246-1256.

6.

Kazdin et al (Eds.). 2003. Evidence-based psychotherapies for children and adolescents. New York: The Guildford Press.

7.

Connolly et al. 2007. Practice parameter for the assessment and treatment of children and adolescents with anxiety
disorders. Journal of the American Academy of Child and Adolescent Psychiatry; 46: 267-283.

8.

Siqueland et al. 2005. Cognitive behavioral and attachment based family therapy for anxious adolescents: Phase I and II
studies. Journal of Anxiety Disorders; 19: 361-381.

9.

Leonard & Swedo. 2001. Paediatric autoimmune neuropsychiatric disorders associated with streptococcal infection
(PANDAS). International Journal of Neuropsychopharmacology; 4: 191-198.

10.

Lopez-Ibor & Lopez-Ibor. 2003. Research on obsessive-compulsive disorder. Current Opinion in Psychiatry; 16: 85S-91S.

11.

Rutter. 2000. Resilience reconsidered: Conceptual consideration, empirical findings and policy implication. In J. P. Shonkoff
& S. J. Meisels (Eds.), Handbook of Early Childhood Intervention (2nd ed., pp 651-682) Cambridge: Cambridge University
Press.

12.

Werner & Smith. 2001. Journeys from childhood to midlife: risk, resilience, and recovery. Ithaca: Cornell University Press.

13.

Kendall et al. 2004. Child anxiety treatment: Outcomes in adolescence and impact on substance use and depression at
7.4-year follow-up. Journal of Consulting and Clinical Psychology; 72: 276-287.

14.

Kendall et al. 1997. Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and
Clinical Psychology; 65: 366-380.

15.

Kessler et al. 2005. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the national comorbidity
survey replication. Archives of General Psychiatry; 62: 593-602.

16.

Stephens & Joubert. 2001. The economic burden of mental health problems in Canada. Chronic Diseases in Canada; 22:
18-23.

17.

Farrell & Barrett. 2007. Prevention of childhood emotional disorders: Reducing the burden of suffering associated with
anxiety and depression. Child and Adolescent Mental Health; 12: 58-65.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

IN REVIEW
Promoting emotional wellbeing, addressing childhood anxiety
A comprehensive strategy is required to promote childrens emotional wellbeing
and avoid the distress and impairment associated with childhood anxiety
problems. In our 2004 report, Preventing and Treating Anxiety Disorders in
Children and Youth, we identified three universal and two targeted prevention
programs that were effective at reducing anxiety symptoms.1 All but one program
used cognitive-behavioural techniques to teach children to manage worries and
anxiety. The universal Friends program notably reduced new cases of anxiety
disorders by 8% for program participants overall and 54% for at-risk children.2
(See the first issue of the Quarterly where we highlighted outcomes of the Friends program and described
its implementation in BC schools.)
The six effective treatment programs identified in our previous report also used cognitive-behavioural
therapy (CBT) or behavioural therapy (BT). Individual CBT and BT along with group CBT (with and without
family involvement) were highly effective in treating a variety of anxiety disorders. A seven-year follow-up
to one of these original studies was recently conducted. We summarize this study in the highlight below.
Since our 2004 report, new research on childhood anxiety disorders has accumulated. We reviewed this
recently published high-quality evidence on preventing and treating anxiety.
How we reviewed the research
Our research team conducted a systematic review of randomized-controlled trials (RCTs) on interventions
for preventing and treating anxiety disorders. We searched the databases Medline, PsycINFO, CINAHL,
CENTRAL and EMBASE for RCTs published between 2004-2007 (the time period since our previous review
on anxiety). We accepted RCTs that included a comparison group consisting of children being placed on a
waitlist or receiving treatment as usual or another form of treatment. (See the first issue of the Quarterly
for a description of our standard methodology.)
What we learned
Of the 73 articles we identified and assessed, seven articles describing five RCTs met our inclusion criteria.
One addressed prevention. The four treatment RCTs all addressed psychosocial interventions for a variety of
anxiety disorders. All interventions were CBT-based and typically had components including education,
managing physical signs of anxiety (e.g., relaxation and breathing exercises), challenging inaccurate
thinking styles (e.g., disputing negative self-talk) and exposure exercises. Most programs took place in
settings natural to children such as their homes or schools, rather than in clinics or hospitals.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

Highlight
Treating childhood anxiety disorders: Long-term outcomes
In our 2004 report, Preventing and Treating Anxiety Disorders in Children and Youth,
we presented findings from a number of CBT treatment programs.1 In one of the featured
studies, Kendall and his colleagues found 57% of children no longer had their primary anxiety
disorder at the end of their CBT treatment.2 At one-year follow-up, children maintained these
gains.
Seven years later, the same research team collected outcome data on 91% of the original child
participants*. Kendall found that children treated with individual CBT continued to maintain and
build on their successes with 81% of the children being free from their primary diagnosis at long-term follow-up.3
Children's treatment gains related to their anxiety disorders also appeared to be associated with future substance use.
Children meeting diagnostic criteria for their primary anxiety disorder at the end of treatment were significantly more likely to
use marijuana, use drugs in larger amounts, drink more days of the month, experience more unwanted consequences from
drug use and have more unsuccessful attempts to control drug use. However, post-treatment diagnostic status was not
predictive of actual rates of substance use disorders or depression.
The outcomes of this follow-up study should be considered preliminary given the study design. Because there were no
comparison groups used in the long-term follow-up, we cannot know if the natural effects of time and maturation contributed
to the positive outcomes. As well, 50% of children received additional treatment after leaving the study suggesting other
possible reasons for noted gains. Accordingly, further long-term research using appropriate control groups is needed before
we can say with greater certainty that successful treatment can lead to long-term gains in both anxiety symptoms and other
areas of functioning.
* This follow-up study was not included in our own review because it lacked a comparison group.
MCFD staff can access original articles cited in the Quarterly from the Health and Human Services Library.
References:
1. Waddell et al. 2004. Preventing and treating anxiety disorders in children and youth. Vancouver, BC: UBC.
2. Kendall et al. 1997. Therapy for youths with anxiety disorders: A second randomized clinical trial. Journal of Consulting and Clinical
Psychology; 65: 366-380.
3. Kendall et al. 2004. Child anxiety treatment: Outcomes in adolescence and impact on substance use and depression at 7.4-year
follow-up. Journal of Consulting and Clinical Psychology; 72: 276-287.

The table below shows program and participant

characteristics along with outcomes. We reported
symptom measure outcomes only for those studies not
including diagnostic measures. For all studies, reported
findings include the final data collection point ranging from

CBT can effectively prevent and

treat a wide variety of anxiety
disorders

three months to one year after the end of treatment

(post-test). We also reported outcomes at post-test for the two studies not retaining their waitlist control
group at follow-up.3-5

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

CBT-Based Anxiety Disorder Prevention and Treatment Programs

Intervention Description

Participant
Characteristics

Findings

Ages: 9-10
Gender: 59% female
Target population:
Economically
disadvantaged children
with high anxiety levels

At 4-mo follow-up, CBT produced

significant improvements over controls
on:

Ages: 6-12
Gender: 40% female
Diagnosesi: GAD,
Social Phobia, SAD,
Specific Phobia, OCD
&/or PD

At post-test, Bibliotherapy & Group CBT

produced significant improvements over
controls on:

Prevention Programs
Cool Kids Program: School Version:6
8 weekly group child sessions & 2 group parent
information sessions
Delivered by school counsellors & mental health
workers in Australian middle schools

2/3 symptom measures

Comparison Group: Waitlist

Treatment Programs
Parent-led Bibliotherapy:5
3 month self-paced program
Delivered without practitioner assistance in rural
Australian homes
Comparison Groups: Waitlist (at post-test only) &
Group CBT
Group CBT: iii
18 weekly group child sessions & several parent
education sessions
3,4

Delivered by graduate students in American

outpatient clinics

Ages: 8-14
Gender: 49% female
Diagnosesi: GAD, SAD
&/or Social Phobia

Delivered by therapists in American outpatient clinics

At 3-mo follow-up, Bibliotherapy &

Group CBT maintained improvements
on both diagnostic measures
At post-test, Individual & Group CBT
produced significant improvements over
controls on:
2/2 diagnostic measures
At 12-mo follow-up, Individual & Group
CBT maintained improvements on both
diagnostic measures

Comparison Groups: Waitlist (at post-test only) &

Individual CBT
Trauma-focused CBT (TF-CBT):7,8
12 weekly individual child & parent sessions (3
sessions include joint component)

2/2 diagnostic measuresii

Ages: 8-14
Gender: 79% female
Diagnosis: PSTD
related to contact
sexual abuse

At 12-mo follow-up, TF-CBT produced

significant improvements over
child-centred therapy on:

Ages: 14-16
Gender: 83% female
Diagnosisi: SAD

At 6-mo follow-up, SASS produced

significant improvements over controls
on:

2/10 symptom measures

Comparison Group: Child-centred therapy

Skills for Social and Academic Success (SASS):7,8
12 weekly group sessions (+ 2 booster sessions); 4
social events; 2 individual meetings; 2 parent &
teacher educational meetings
Delivered by psychologist & graduate student in
American high schools

2/2 diagnostic measures

Comparison Group: Attention control

GAD = Generalized Anxiety Disorder

SAD = Social Anxiety Disorder

OCD = Obsessive-Compulsive Disorder

PD = Panic Disorder

PTSD = Posttraumatic Stress Disorder

Diagnoses listed in descending frequency with many children having at least one comorbid diagnosis

ii

Group CBT produced significantly greater improvements than Bibliotherapy

iii

a follow-up study to an RCT featured in our original 2004 report

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

Highlight
Involving parents in treating childhood anxiety disorders
Involving parents in CBT for treating childhood anxiety disorders was recently addressed in a
well-conducted research review. Barmish and Kendall examined data from nine RCTs that
included parents as active participants in treatment.1 Most studies had 10 to 12 sessions with
parents, although one had as few as four. Parental involvement typically consisted of teaching
parents to model appropriate behaviour by managing their own anxiety, reducing family
conflict and helping parents learn not to reinforce anxious behaviour in their children.
The authors compared effect sizes of CBT programs with and without parental involvement.
Post-treatment effect sizes for CBT without parent involvement ranged from small to medium
for child-reported measures to large for parent-reported measures. For programs with parents
actively involved, effect sizes ranged from small to large for child-reported measures to large
for parent and practitioner reports. The authors concluded that although treatments with
parental involvement seemed to have larger effect sizes, there was not enough evidence to conclude that involving parents in
treatment is uniformly superior. This tentative finding is consistent with our own review noting that including a family
component did not uniformly improve outcomes and that initial improvements were not always maintained long-term.2
The value of parents participating in CBT for childhood anxiety disorders may vary based on factors such as the childs age
and the parents' mental health issues. Specifically, including parents in treatment may be particularly beneficial for younger
children.1 There may also be added benefits to including parents in treatment when they too experience significant anxiety.1
Further research is needed to better understand when it is most important to include parents in treatment to improve
outcomes.
MCFD staff can access original articles cited in the Quarterly from the Health and Human Services Library.
References:
1. Barmish et al. 2005. Should parents be co-clients in cognitive-behavioural therapy for anxious youth? Journal of Clinical Child and
Adolescent Psychology, 34: 569-581.
2. Waddell et al. 2004. Preventing and treating anxiety disorders in children and youth. Vancouver, BC: UBC.

All interventions produced significant improvements including decreases in at least two anxiety symptom
measures, or decreases in the number of children meeting diagnostic criteria for an anxiety disorder. These
gains were made in comparison to another form of treatment (child-centred therapy) or in comparison to
control groups. However, because two studies did not include control groups at follow-up (Group CBT and
Parent-led Bibliotherapy), we cannot be certain the long-term gains for these two interventions were due to
the treatment received rather than other factors such as time or maturation.
The reported improvements were both statistically and clinically significant with up to 81% of children being
diagnosis-free at one-year follow-up.4 For example, 59% of children in the school-based SASS group no
longer met criteria for SAD compared to no students in the attention control group. Although parent-led
home-based bibliotherapy was more successful than a waitlist control (e.g., 18% versus 6% diagnosis free
at post-test), standard group CBT resulted in greater change by both practitioner and parent reports (e.g.,
49% diagnosis free at post-test). Additionally, treatments were effective in natural settings such as homes
and schools.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

What we recommend
Any comprehensive public health strategy to address childrens emotional wellbeing needs to include
attention to prevention, to treatment and to addressing underlying causes. High-quality research evidence
shows that many cases of childhood anxiety can be prevented through CBT-oriented programs such as the
Cool Kids Program and Friends. Importantly, these short-term programs have been effectively implemented
in schools natural settings where large populations of children can be easily reached. In addition to
preventing anxiety problems, school-based programs promote emotional resilience in large numbers of
children.10 These programs, together with evaluations of their impact on BC children, are therefore highly
recommended.
To best meet childrens needs, the focus should be on preventing problems before they arise, as well as on
providing treatment for those with disorders. Where prevention is not possible, it is vital to use the most
effective treatments. Consistent with findings from a well-established practice parameter noting the
substantial empirical support for CBT in treating anxiety disorders, the evidence regarding the long-term
utility of CBT continues to accumulate.11
In the highlight above, we summarize new research
suggesting that CBT can effectively treat a wide variety of
anxiety disorders both within traditional clinic settings and
in the community including in schools and homes.
Although home-based bibliotherapy produced less robust

Successful interventions for

anxiety problems can be used in
homes and schools

results than group CBT, emerging evidence suggests

better results for bibliotherapy when parents are supported by practitioner phone contact.12 Overall,
community settings for mental health interventions have a strong advantage because they reach children
who may not, or cannot, access treatment otherwise. Such settings may also help reduce stigma and
encourage children to use effective strategies in their natural environments. CBT, in its various formats,
remains the standard of care for treating most types of anxiety problems. Medications, including the SSRI
fluoxetine, should only be used for the most severe situations and be carefully monitored when they are
used. Overall, investments in effective prevention and treatment programs for anxiety disorders in children
are highly recommended.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

MCFD staff can access original articles cited in the Quarterly from the Health and Human Services Library.
References:
1.

Waddell et al. 2004. Preventing and treating anxiety disorders in children and youth. Vancouver, BC: UBC.

2.

Waddell et al. 2007. Preventing mental disorders in children: A systematic review to inform policy-making. Canadian Journal
of Public Health; 98: 166-173

3.

Flannery-Schroeder & Kendall. 2000. Group and individual cognitive-behavioural treatments for youth with anxiety
disorders: A randomized clinical trial. Cognitive Therapy and Research; 24: 251-278.

4.

Flannery-Schroeder et al. 2005. Group and individual cognitive-behavioral treatments for youth with anxiety disorders:
1-year follow-up. Cognitive Therapy and Research; 29: 253-259.

5.

Rapee et al. 2006. Bibliotherapy for children with anxiety disorders using written materials for parents: A randomized
controlled trial. Journal of Consulting and Clinical Psychology; 74: 436-444.

6.

Mifsud & Rapee. 2005. Early intervention for childhood anxiety in a school setting: Outcomes for an economically
disadvantaged population. Journal of the American Academy of Child and Adolescent Psychiatry; 44: 996-1004.

7.

Cohen et al. 2004. A multisite, randomized controlled trial for children with sexual abuse-related PTSD symptoms. Journal of
the American Academy of Child and Adolescent Psychiatry; 43: 393-402.

8.

Deblinger et al. 2006. A follow-up study of a multisite, randomized, controlled trial for children with sexual abuse-related
PTSD symptoms. Journal of the American Academy of Child and Adolescent Psychiatry; 45: 1474-1484.

9.

Masia Warner et al. In Press. Treating adolescents with social anxiety disorder in school: An attention control. Journal of
Child Psychology and Psychiatry and Allied Disciplines.

10.

Farrell & Barrett. 2007. Prevention of childhood emotional disorders: Reducing the burden of suffering associated with
anxiety and depression. Child and Adolescent Mental Health; 12: 58-65.

11.

Connolly et al. 2007. Practice parameter for the assessment and treatment of children and adolescents with anxiety
disorders. Journal of the American Academy of Child and Adolescent Psychiatry; 46: 267-283.

12.

Lyneham & Rapee. 2006. Evaluation of therapist-supported parent-implemented CBT for anxiety disorders in rural children.
Behaviour Research and Therapy; 22: 1287-1300.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

IN FOCUS
Treating Obsessive-Compulsive Disorder (OCD)
What is OCD?
To be diagnosed with OCD, a child must experience clinically significant obsessions
and/or compulsions. Obsessions are unwanted recurring thoughts or images
causing significant anxiety. The most common obsessions are fears of
contamination.1 Worries about personal safety and the safety of family members
are also frequent.1 Compulsions are repetitive behaviours or mental acts a child
feels compelled to do either to prevent or reduce anxiety. The most common
compulsions include excessive washing, cleaning and confirming actions (e.g., checking that doors are
locked).2 These repetitive behaviours are quite time consuming and are often kept hidden from others due
to embarrassment.
Helping children overcome fearful situations
Exposure and Response Prevention (E/RP) is a specific form of CBT developed to treat OCD. E/RP involves
gradually exposing a child to a feared situation while the child practices not engaging in anxiety reducing
behaviours or rituals. For example, a child who washes compulsively would be gradually exposed to
challenging situations such as touching a dirty object, without engaging in ritualized washing or other
cleaning behaviours.
Children are encouraged to take an active role in choosing
and sequencing their exposures to feared situations. E/RP
is typically used with other CBT techniques including
education, cognitive exercises and relaxation training.
Reviewing the research evidence

Exposure and Response

Prevention, a form of CBT, is a
highly effective treatment for
OCD

OKearney, Anstey and von Sanden recently published a

systematic review of treatments for OCD.3 Applying rigorous (Cochrane) methodological standards, the
authors accepted four RCTs in their review.* All studies examined the effectiveness of E/RP with all but one
(Neziroglu) including additional educational and cognitive components in their treatment protocol. Gender
distribution was equal for all studies. The table below shows additional participant and study characteristics.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

Characteristics of Study Participants and Interventions

Study

Nationality

Number of
Participants

Age range
(in yrs)

E/RP
duration
(in hrs)

Medication
Comparison

Placebo
Control

De Haan 1998

Dutch

23

7 to 18

12

Clomipramine

n/a

POTS 2004

American

112

7 to 18

14

Sertraline

Pill placebo

Barrett 2004

Australian

77

10 to 13

21

n/a

Waitlist

Neziroglu 2000

American

10

10 to 17

30

Fluvoxamine

n/a

* Three of the studies used were included in our previous review, Treating Obsessive-Compulsive Disorder in Children4

E/RP produced positive outcomes

The findings demonstrate E/RP is an effective treatment of childhood OCD. E/RP produced better
post-treatment functioning than control groups (pill placebo or waitlist). Pooled data from two studies
showed no significant difference in outcomes between E/RP and medication treatments. There was evidence
that combining E/RP and medication was beneficial compared to medication alone, but not relative to E/RP
alone. The authors concluded that E/RP is a promising treatment for childhood OCD.
Putting research into policy and practice
These review findings supporting the effectiveness of E/RP are consistent with our previously published
report Preventing and Treating Obsessive Compulsive Disorder in Children and Youth and a
well-regarded practice parameter.4,5 In our report we recommended medication only be used for the most
severe OCD cases due to safety concerns. Despite the strong evidence in favour of using E/RP, there are
ongoing issues regarding the availability of treatment for children in need. A barrier to successful use of
E/RP is the lack of adequately trained practitioners.6 Training practitioners to use this effective treatment is
necessary to best help children meet their full potential. In BC, the Child and Youth Mental Health Plan
gives a framework to provide practitioners with CBT training.
MCFD staff can access original articles cited in the Quarterly from the Health and Human Services Library.
References:
1.

DellOsso et al. 2007. Diagnosis and treatment of obsessive-compulsive disorder and related disorders. International Journal
of Clinical Practice; 61: 98-104.

2.

Rapoport et al. 2000. Practitioner review: Treatment of obsessive-compulsive disorder in children and adolescents. Journal
of Child Psychology and Psychiatry; 41: 419-431.

3.

OKearney et al. 2006. Behavioural and cognitive behavioural therapy for obseesive compulsive disorder in children and
adolescents. Cochrane Database of Systematic Reviews.

4.

Waddell et al. 2005. Treating obsessive compulsive disorder in children. Vancouver, BC: UBC.

5.

King et al. 1998. Practice parameters for the assessment and treatment of children and adolescents with
obsessive-compulsive disorder. Journal of the American Academy of Child and Adolescent Psychiatry; 37: 27S-45S.

6.

Abramowitz et al. 2005. The effectiveness of treatment for pediatric obsessive-compulsive disorder: A meta-analysis.
Behavior Therapy; 36: 55-63.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

IN PRACTICE
Out of the journals and into childrens lives
We recently spoke with child psychiatrist, Jane Garland, about her experiences
using evidence-informed practices with children experiencing anxiety problems.
Jane is a clinical professor at the University of British Columbia and the clinic head
of the Mood and Anxiety Disorders Clinic at British Columbias Childrens Hospital.
She is the co-author of the book Taming Worry Dragons designed to help children
combat problematic worry.
Jane Garland
Child Psychiatrist

Here we describe Jane's strategies and successes in managing some typical

obstacles faced in using CBT for treating childhood anxiety disorders. Many

children with anxiety problems have learned to avoid those situations that trigger their fears. Some children
also resist using CBT strategies such as exposure to fear provoking stimuli. Jane described techniques she
has successfully used to help overcome resistance.
Beginning with assessment and understanding
Jane noted the importance of starting with a therapeutic assessment. She uses CBT-informed language
during the process to reframe childrens experiences and perspectives on anxiety. Excessive fears can be
transformed into a talent for creative worrying and an amazing imagination. This shift helps to increase
childrens willingness to discuss their concerns and their interest in treatment. A successful interview also
provides an opportunity for practitioners to teach children important information about the nature of
anxiety. Jane uses the analogy of an overly sensitive car alarm that goes off when the wind blows. This
metaphor helps children understand the importance of their own alarm system which can be miss-set to
ring even when the child is just a bit nervous. Jane discussed how a successful therapeutic assessment can
set the stage for useful interventions.
Making therapy fun
Using childrens own creativity is a technique Jane
stressed as useful in overcoming resistance to treatment.
Jane uses metaphors to make therapy fun and appealing.
For example, to highlight the concept of thought
stopping, Jane often uses the analogy of pulling the plug
on a computer. She also described having children view

Excessive fears can be

transformed into a talent for
creative worrying and an
amazing imagination.

themselves as heroes in a battle against worry dragons.

To help children stop listening to their fears, they are encouraged to write down or draw their worries and
place them in a dragon trapping jar. Jane uses the same metaphor to encourage positive lifestyle habits.
Children are reminded of the importance of good sleep and eating habits in order to stay in shape to fight
dragons.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

Support from family and community

Jane spoke about the importance of including significant adults to help children overcome their fears and
worries. Parents are encouraged to support and instruct their children as they face their anxieties rather
than trying to rescue children from fear provoking situations. Siblings can be supportive by helping
children take time away from worrying by engaging in positive activities. Finally, school staff can be part of
the problem solving process by assisting childrens efforts in their CBT program. By focusing on the
strengths of children, families and communities, adaptive functioning can be achieved and sustained.
Fighting their fears
To see an example of the personal impact of anxiety disorders in children, see the Knowledge Network
documentary, Fighting Their Fears: Child and Youth Anxiety. Marleys Story demonstrates how CBT
techniques helped her overcome what began as separation anxiety and progressed into social anxiety.
Alanas Story provides another example of positive outcomes using coping strategies and Jasons Story
shows his struggles and successes with OCD.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University

Making Research Work for Children

About the Childrens Health Policy Centre
We are an interdisciplinary research group in the Faculty of Health Sciences at Simon Fraser University. Our
work focuses on integrating research and policy to improve childrens social and emotional wellbeing, or
childrens mental health. We promote a public health strategy for children's health. Our work complements
the mission of the Faculty of Health Sciences at Simon Fraser University to integrate research and policy for
population and public health locally, nationally and globally.
Public Health Strategy for Childrens Mental Health

About The Quarterly

The Quarterly is an electronic publication prepared for Child and Youth Mental Health Services with British
Columbias Ministry of Children and Family Development. It provides updates on the best currently available
research evidence in childrens mental health for policy-makers, practitioners, families and the public.
Please visit www.childhealthpolicy.sfu.ca to learn more about our ongoing work integrating research and
policy to improve children's social and emotional wellbeing.

www.childhealthpolicy.sfu.ca | Copyright 2007 Simon Fraser University