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ANXIETY 26:243250 (2009)

Research Article
Suneeta Monga, M.D, Arlene Young, Ph.D, and Mary Owens, M.B., Ch.B

Background: Cognitive Behavioral Therapy (CBT) has demonstrated benefits

for anxious school-aged children and adolescents; however, treatment programs
have not been developed to teach CBT strategies to children under the age of
eight. This pilot study examined a novel treatment program for children aged
57 years with anxiety disorders. Methods: Thirty-two children (19 females)
aged 57 years (mean age 5 6.51 years) with DSM-IV anxiety disorders and
their families completed a 12-week, manualized CBT group program. Parent
and child groups (58 children per group) were held separately but concurrently.
Multiple measures of anxiety (Screen for Child Anxiety Related Emotional
Disorders, Anxiety Disorders Interview Schedule for DSM-IVParent Version,
and clinician Childrens Global Assessment Scale ratings) were completed pre
and post each treatment series. A subset of participants (n 5 11; 8 females; mean
age 5 6.34 years) completed an initial assessment followed by a wait period of
approximately 3.5 months (range 2.55 months) with a second assessment just
before treatment start. No treatment was received during this wait time.
Results: With treatment, 43.8% of children no longer met criteria for any Axis
1 anxiety disorders whereas 71.9% had at least one anxiety disorder resolve. A
series of paired, two-tailed t-tests revealed significant reduction in anxiety
symptoms on standardized measures. Children who waited for treatment showed
no significant change in anxiety symptoms during nontreatment but demonstrated improvement after program attendance. Conclusions: This pilot study
suggests that CBT can be used effectively to treat anxious children as young as 5
years of age. Further research is warranted. Depression and Anxiety
26:243250, 2009.
r 2009 Wiley-Liss, Inc.
Key words: cognitive behavioral therapy (CBT); young children; anxiety
disorders; group therapy
Anxiety Disorders Program, Division of Child Psychiatry,
University of Toronto, Toronto, Ontario, Canada


nxiety disorders are one of the most prevalent

psychiatric conditions in childhood affecting 1520%
of children and adolescents.[1] Anxious children and
adolescents as a group, however, are often undiagnosed
or misdiagnosed.[2,3] Co-morbidity among the anxiety
disorders and between anxiety disorders and other
psychiatric conditions, such as Oppositional Defiant
Disorder (ODD), Mood Disorder, Attention Deficit
Hyperactivity Disorder (ADHD), and adolescent
r 2009 Wiley-Liss, Inc.

Contract grant sponsor: Department of Psychiatry, Hospital for

Sick Children.
Correspondence to: Suneeta Monga, Department of Psychiatry,
The Hospital for Sick Children, 555 University Avenue, Toronto,
Ontario, Canada M5G 1X8. E-mail:

Received for publication 31 July 2008; Revised 22 December 2008;

Accepted 28 December 2008
Dr. Arlene Youngs current address is Department of Psychology,
Simon Fraser University, Burnaby, Canada
DOI 10.1002/da.20551
Published online 11 February 2009 in Wiley InterScience (www.


Monga et al.

substance abuse,[3,4] contributes to this difficulty in

diagnosis and treatment. Parents and teachers often do
not recognize the quiet, internal distress experienced
by anxious children or the anxiety is misperceived as
behavioral issues due to the tendency of many young
children to exhibit their anxiety as acting out
behaviors.[2,5] Despite the difficulty in diagnosis, there
is evidence that anxiety disorders have a very early
onset and that anxiety disorders are common in young
children[6] with many of them requiring treatment.
Once an anxiety disorder develops, it can be very
debilitating, affecting all aspects of a childs life
including social adjustment, academic achievement,[7,8]
and family life.[9] Without treatment, anxiety disorders
are unlikely to remit[10,11] and even with remittance,
children have high rates of recurrence[12,13] or the
development of new anxiety or mood disorders over
time.[14,15] Early age of onset,[16] older age at intake,[13]
and severe baseline symptoms[16,17] are all associated
with low remittance.
Cognitive Behavioral Therapy (CBT) is currently the
treatment of choice for anxiety disorders in children
and adolescents.[6,18,19] Several studies have compared
individual CBT to group CBT[20,21,22] in children
older than 8 years of age with both individual and
group therapies appearing effective in the treatment of
anxiety disorders although in one study[21] socially
anxious children responded better to individual treatment rather than group treatment. It is important to
note, however, that whether individual or group CBT
is a better treatment modality is a relatively underresearched area and results to date are far from
conclusive. Given the clear economic advantages in
terms of therapist and facility utilization[16,19,23] further
research into the effectiveness of group treatment
programs in different age groups are critical.
Despite evidence that anxiety disorders begin at a
young age,[6] general treatment programs have not
been developed specifically for anxious children under
the age of 8 years. Programs for specific phobias have
been the main stay of treatment with young children.[24] The FRIENDS Program[25] (mean
age 5 7.85), although used with younger children, is a
family based CBT group program based on the Coping
Koala Group Workbook.[26] This latter program is an
adaptation of Kendalls Coping Cat Workbook,[27]
which was developed for school-aged children. In part
the lack of research in CBT for children under the age
of 8 years old reflects a belief that the cognitive and
linguistic demands of CBT are too difficult for these
children. Preschoolers, however, have the cognitive
Depression and Anxiety

ability to understand complex problems, which can

then be further enhanced by providing concrete
examples and avoiding the use of open-ended
Experienced cognitive behavioral therapists developed a manual for child and parent groups, Taming
Sneaky Fears: Child Treatment Manual[29] and Parent
Treatment Manual.[30] The Child Manual is not a
modification of other manuals and is a unique approach
to CBT that was developed specifically with the
anxious 57-year-old child in mind. In particular, the
manual utilized stories, games, and activities designed
to be intrinsically appealing to young children to
enhance the learning of cognitive behavioral strategies.
Early child sessions focus on helping children
recognize and label various feeling states. Relaxation
strategies such as muscle tension relaxation, deep
breathing, and imagery are taught in session four.
Cognitive strategies such as talking and labeling your
feeling states to adults when anxious, ignoring the scary
thoughts, and thinking of alternative or brave
thoughts when feeling anxious are taught in later
sessions. Each weekly session starts with a review of key
concepts learnt in previous sessions thus providing
necessary reinforcement to solidify previously presented concepts. Strengths of the child program
include the use of puppets, crafts, games, and stories,
which make learning difficult concepts more engaging.
The goal of the parent program is to teach parents
cognitive behavioral strategies to use with their
children. The initial focus of the parent program is
psycho-education and the teaching of parent management and behavioral strategies to support parents as
they begin to distinguish anxiety symptoms from more
general behavioral issues. Later parents are taught
relaxation exercises and desensitization strategies to
help their child confront rather than avoid their fears.
Key elements of the parent program are the parental
support obtained from sessions and the experiences of
group problem solving.
Fourteen children and their parents participated in a
trial of the manual and using parent and therapist
feedback, elicited through structured questionnaires
and interviews, revisions were made before this pilot
study. In the manual development stage parents were
interviewed at the start and conclusion of the group
program and completed the Screen for Child Anxiety
Related Emotional Disorders (SCARED: Parent Version),[31] pre- and postgroup. At postgroup interview
parents reported positively on the content of the parent
and child groups; felt more aware of the role anxiety
played in their childs behavior; found their child more
cooperative and easier to manage. In addition, child
anxiety as measured by the SCARED: Parent Version
improved postgroup. Therapists also noted an improvement in the childrens abilities to recognize and

Research Article: Cognitive Behavioral Therapy Group Program

verbalize their anxiety over the course of the group as

measured by therapist ratings of childrens understanding of concepts after each group session and
improvement using a modified Clinical Global Impression Scale.[32]
This revised manualized child and parent CBT
group program was used in this pilot study with a
new sample of children. This pilot study was designed
to examine the effects and feasibility of implementing a
novel, CBT group intervention program for various
DSM-IV anxiety disorders in children aged 57 years.


Physicians and mental health professionals referred the families for
treatment to the Anxiety Disorders clinic of a large childrens
hospital. All children were between the ages of 5 and 7 and met
criteria for at least one DSM-IV anxiety disorder based on clinical
interview and semi-structured interview utilizing the Anxiety
Disorders Interview Schedule for DSM-IV Parent Version
(ADIS-P).[33] Co-morbid ODD and ADHD were not exclusionary
criteria as long as anxiety was the main and most impairing clinical
condition. Although children on psychotropic medications were not
excluded from the program, only one child in the pilot study was on
Fluoxetine, which had been started several months before the start of
the study. No adjustments to the dose of Fluoxetine were made for 3
months before the start of the group therapy program and there were
no dosage adjustments during the course of the treatment program.
Children who had a psychotic disorder, pervasive developmental
disorder, a medical condition that would interfere with treatment, or
who were not proficient in the English language were excluded from
participation. Children who had significant learning problems that
would interfere with the understanding and participation in treatment (based on school information and clinician judgment) were also
excluded from participation.
Thirty-two children (13 males and 19 females) aged 57 years (mean
age 5 6.51 years) and their parents completed the pilot program. At
least one parent was required to attend the parent group in order for
the child to be enrolled in the child group. Although 34 children
entered the program, two boys and their families dropped out of the
program (both at session three) in different groups because of
scheduling conflicts. Primary diagnoses included: Social Anxiety
Disorder (37.5%), Separation Anxiety disorder (21.9%), Generalized
Anxiety Disorder (21.9%), and Selective Mutism (18.7%). Comorbidity among the anxiety disorders was common with 20 children
(62.5%) having two or more anxiety disorders whereas 12 children
(37.5%) had only one anxiety disorder. Six of the 32 children (18.7%)
had co-morbid ODD whereas 43.8% had identified temperamental
difficulties based on parental completion of the Behavioral Style
Questionnaire (BSQ).[34] The majority (84.4%; n 5 27) of the sample
was Caucasian whereas 12.5% (n 5 4) were Asian, and 3.1% (n 5 1)
were of African descent.

The SCARED Parent Version (SCARED):[31] A 41-item instrument
for parents that elicits anxiety symptoms rated on a 3-point scale. Five
factors screen for School Refusal and DSM-IV diagnostic categories of
Generalized Anxiety Disorder, Separation Anxiety Disorder, Panic
Disorder, and Social Anxiety Disorder. The SCARED demonstrates
good internal consistency and testretest reliability.[31,35] It discrimi-


nates among anxiety disorders, between anxiety and disruptive

disorders;[31,35] and between anxiety and mood disorders.[36]
Anxiety Disorders Interview Schedule for DSM-IV: Parent Version
(ADIS-P):[33] A semi-structured interview that generates DSM-IV
diagnoses for child anxiety disorders, mood disorders and externalizing
disorders. Testretest reliability ranges from good to excellent.[37,38]
The ADIS-P Clinical Severity Rating (CSR) provides an estimate of the
degree of functional impairment and distress engendered by the
disorder based on an 8-point scale.[33] A score of 4 or greater is
necessary for diagnosis.
Childrens Global Assessment Scale (CGAS):[39] A clinician rating of
adaptive functioning during the previous month for children aged
416 years. It is rated on a 100-point scale with 1 being most
impaired and 100 being least impaired with descriptors for each 10point interval. A CGAS Score of 4150 indicates a moderate degree
of interference in functioning in most social areas or severe
impairment of functioning in one area whereas a score of 5160
indicates variable functioning with sporadic difficulties or symptoms.
Revised Connors Parent Rating Scale: Long Version (CPRS-R:L):[40]
An 80-item instrument that screens for behavioral difficulties. It has
good testretest reliability;[41] and inter-rater reliability;[42] and has
been shown to reliably discriminate normal children from behaviorally disordered children.[43] Three of the seven factors or subscales
were utilized in the study: Oppositional Subscale (A); Anxious/Shy
Subscale (D); and Psychosomatic Subscale (G).
Behavioral Style Questionnaire (BSQ):[34] a 100-item instrument
rated on a 6-point scale of frequency that measures child temperament characteristics. It has good internal consistency and excellent
testretest reliability.[34] This instrument was used to assess each
childs temperament. Although temperament is known to be a stable
trait;[44] it has been identified to be a risk factor in the development of
anxiety in children[44,45] and thus hypothesized to have a possible
effect on treatment outcome.

Pre-group assessment. Children between the ages of 5 and
7 years inclusive who were seen for clinical assessment by a child and
adolescent psychiatrist and diagnosed with a primary anxiety disorder
according to DSM-IV criteria[46] were invited to participate in the
pilot study. All invited families agreed to participate in the treatment
phase of the pilot study and provided parental consent and child
assent before study enrollment.
A pre-group assessment occurred 12 weeks before the start of
each group treatment series. At the time of the pre-group assessment,
a child psychiatrist trained in the ADIS-P completed the ADIS-P
with the parent(s). Primary and co-morbid diagnoses were based on
clinical interview and ADIS-P interview. A consensus CGAS rating of
the child was completed by an independent group of experienced
clinicians within the Anxiety Disorders Treatment team in which the
study was based. The CGAS ratings were based on case descriptions
from the clinical and ADIS-P interviews. Parents also completed
standardized child report measures describing their childs anxiety
symptoms (SCARED) and behaviors (CPRS-R:L) and their childs
temperament (BSQ) as part of the pregroup assessment. In this pilot
study, children did not complete any self-report measures although
they were seen in a clinical interview with their parents before
enrollment in the program.
Group treatment program. The group program consisted
of twelve weekly, 1 hour sessions. Only parents attended the first week
thus allowing for discussion of any separation or other anxiety-related
concerns parents had about their children. The second group session
began with both parents and children together in one room for a
portion of the session to allow children to familiarize themselves with
Depression and Anxiety


Monga et al.

the therapists. All other group sessions were held for parents and
children separately but concurrently. A child therapist joined the
parent group for the last few minutes of each session to review with
the parents the material their children had learnt. At the mid-point of
the group program, an interview with each parent was conducted by a
child therapist to review each childs progress.
A total of five group programs made up the pilot study with 58
children per group. Overall attendance was very good (range
83100%) with no family missing more than two sessions in total.
If a session was missed, a child therapist contacted the parent to
review general themes before the next session.
Wait time for treatment. Most children in the pilot study
were assessed just a few weeks before a treatment group starting.
However, a small subset of our sample (n 5 11; 3 males, 8 females;
mean age 5 6.34) was assessed at a time when the wait for the next
group was between 2.55 months. This longer delay between
assessment and group was necessitated because groups were only
run twice a year in the fall (SeptemberDecember) and in the spring
(March to June). Children were assessed based on their referral date
rather than the immediate availability of treatment groups. As there
were no significant differences between the sub-set and the full
sample we decided to compare children who needed to wait for
treatment with those who received treatment shortly after their initial
assessment as this may provide further information on the effect of
the treatment. Children in the longer wait condition had two research
assessments (ADIS-P and questionnaires) before the start of the
treatment group: one shortly after the initial clinical assessment; and
the other occurring 12 weeks before the commencement of the
treatment group. CGAS ratings were determined for both assessment
time points. Wait times for treatment varied from 2.5 to 5 months
(mean wait time 5 3.5 months) and during this time the children and
their families did not receive treatment of any kind. For this subset it
was possible to determine whether the passage of time alone, without
active treatment intervention, had any effect on symptom change.
Postgroup assessment. Within 2 weeks of the completion
of the group program, parents were brought in for a postgroup visit.
Parents completed the SCARED and the CPRS-R:L and the pretreatment child psychiatrist completed a short clinical interview and
re-administered the ADIS-P. As all children and parents who
participated in this pilot study were treated with the same program,
the psychiatrist completing the ADIS-P was not blind to treatment.
Experienced clinicians completed a consensus CGAS based on
postgroup ADIS-P and parent postgroup clinical interview.

Data was evaluated using the Statistical Package for the Social
Sciences (SPSS Version 13.0). Questionnaires with multiple missing
responses were considered invalid and were not used (3 for SCARED
data; 2 for CPRS-R:L data). Given that we are reporting on multiple
comparisons, the probability of a type 1 error is increased therefore
we report the actual P values and interpret the results as significant at
an a level of .01 rather than the .05 level.
To test for treatment effect, paired two-tailed t-tests were
performed on pre- and postgroup parent ratings on the SCARED
(total score and each of the five factors); the parent ratings on the
CPRS-R:L subscales Oppositional (A), Anxious/Shy (D), and
Psychosomatic (G); on the CGAS and the ADIS-P Primary Diagnosis
CSR using time as the dependent variable. Effect size was calculated
using Cohens d.[47]
Repeated measures ANOVAs were used to test for possible
interactions and main effects of variables that may potentially
influence treatment outcome such as gender, age, and temperament.
No significant interaction or effect on treatment was observed for
either gender (male versus female) or age (o6.5 years versus Z6.5
Depression and Anxiety

years) or temperament (presence or absence of temperament


Child anxiety, as measured by parent reports on the
SCARED are presented in Table 1. Parent SCARED
total ratings were significantly decreased from pre- to
postgroup as were parent scores on four of the five
factors of the SCARED (generalized anxiety factor 2,
separation anxiety factor 3, social anxiety factor 4, and
school refusal factor 5).
Parent ratings on the CPRS-R:L as presented in
Table 1 significantly declined from pre- to postgroup
on the Anxious/shy subscale (D) and a large treatment
effect (d 5 0.82) was demonstrated while a small effect
size (d 5 0.42) was seen on the Psychosomatic subscale
(G). Despite a specific focus on behavioral strategies to
deal with oppositional behavior covered within the
parent groups, no significant change was noted on
posttreatment parent ratings on the Oppositional
subscale (A), t 5 1.423 (1,29), P 5.166. In addition,
when a sub-sample of children who met criteria for
ODD pretreatment (n 5 6) were examined independently, no significant change in ratings of on the
Oppositional subscale (A) t 5 2.753 (1,4) P 5.051, was
Paired two-tailed t-tests were performed on pre- and
posttreatment CSR for the primary ADIS:P diagnosis.
Postgroup mean CSR (3.1 SD 5 2.2) was below the
clinically significant level (CSR 5 4.0) for ADIS:P
diagnosis and was significantly lower than the mean
pregroup CSR (5.6 SD 5 0.98) t 5 6.82 (1,31), P 5.001.
A large effect size (d 5 1.48) was obtained on the
change in number of anxiety disorders.
Furthermore, as presented in Figure 1, 20 of the 32
children in our sample had two or more anxiety
disorders pretreatment and only five continued to have
two or more anxiety disorders posttreatment. 71.9% of
the children (n 5 23) had at least one anxiety disorder
resolve posttreatment whereas fourteen children
(43.8%) no longer met criteria for any major DSMIV anxiety disorders posttreatment as diagnosed by the
ADIS-P. Remission rates in children with only one
anxiety disorder were higher (66.7%) compared to
remission rates in those children with two or more
anxiety disorders (30%).
Paired two-tailed t-tests were also performed on
childrens adaptive functioning as measured by clinician
pre- and postgroup CGAS ratings presented in
Figure 2. In the full sample, mean CGAS improved

Research Article: Cognitive Behavioral Therapy Group Program


TABLE 1. Pregroup versus Postgroup outcome measures

SCARED n 5 29
Factor 1
Factor 2
(Gen. Anx.)
Factor 3
(Sep. Anx.)
Factor 4
(Soc. Anx.)
Factor 5
(School refusal)
Total score
t-score (n 5 30)
Subscale A
Subscale D
Subscale G





P value

Effect size (Cohens d)











































significant at P 5 0.01; SCAREDScreen for Child Anxiety Related Emotional Disorders; CPRS-R:LRevised Connors Parenting Rating

Scale: Long Version.

Figure 2. Mean CGAS change.

Figure 1. Pretreatment versus posttreatment number of ADIS
anxiety diagnoses.

from 45.9 pretreatment to 57.1 posttreatment,

t 5 8.14 (1,31), P 5.001 with a large effect size
(d 5 1.5) demonstrated. A small subset of the total
sample (n 5 11) who inadvertently were required to
wait for treatment were analyzed with repeated
measures ANOVAs using Helmert planned contrasts
to compare three time points: initial assessment,
pretreatment, and posttreatment to determine whether
there was any change in anxiety during the wait time of
no treatment. During the time period from initial
assessment to pretreatment, (no treatment phase), the
mean CGAS (initial mean CGAS 5 49.1, SD 5 8.72;

pretreatment mean CGAS 5 46.2, SD 5 4.45) demonstrated a trend toward deterioration F(1, 10) 5 6.51,
P 5.029.
SD 5 10.31) scores in this subgroup improved significantly F(1, 10) 5 30.94, Po.001 as compared with
pretreatment mean CGAS scores. These results suggest that treatment rather than time had an effect on
improving CGAS scores over the three time points.

The major focus of this study was to pilot a cognitive
behavioral treatment program developed specifically
for children aged 57 years with DSM-IV anxiety
Depression and Anxiety


Monga et al.

disorders and their families and to assess the effectiveness of such an intervention program. Results from this
pilot study suggest that young children aged 57 years
of age can benefit from CBT when taught in an
innovative, age-appropriate manner. Over 40% of
anxious children in this pilot study no longer met
criteria for any anxiety disorder according to a
structured diagnostic assessment following treatment
and 71.9% had at least one anxiety disorder resolve
with treatment. Furthermore, children posttreatment
were seen as demonstrating only sporadic difficulties in
functioning on clinician rated CGAS scores. These
results are comparable to a recent review by Cartwright-Hatton et al.,[6] indicating that older children
and adolescents show overall remission rates of 56.5%
with CBT. Although the effects of co-morbidity were
not specifically examined in this study, children in this
study with only one anxiety disorder had better
remission rates (67%) compared with children with
two or more anxiety disorders (30%).
Parent ratings of the most common forms of
childhood anxiety, such as separation anxiety, generalized anxiety, social anxiety, and school refusal
(SCARED Factors 25) all improved significantly with
treatment. There however, was no significant change
post-treatment on Factor 1 of the SCARED, which
measures somatic or panic symptoms such as My child
feels dizzy. It is interesting to note that this somatic/
panic factor was also the only factor that was not
elevated within the clinical range before treatment.
Thus, the lack of improvement may reflect the
relatively low initial scores on this factor.
In the sample as a whole, parent ratings for
oppositional behavior also did not change with treatment even though there was a behavioral management
component to the parent sessions. This lack of change
may reflect the relatively small sub-sample of anxious
children who also met criteria for ODD (n 5 6) in our
sample. Future studies with larger samples of comorbid ODD will need to be conducted.
One significant limitation of this pilot study is the
lack of a randomized control comparison group. We
however, were able to take advantage of the inadvertent
wait time that some children experienced to examine
the possibility that time alone would be sufficient to
ameliorate symptoms. This subset (11 of 32 children)
who waited for treatment did not demonstrate any
change in anxiety as measured by CGAS scores, while
waiting for active treatment to start and in fact a trend
toward deterioration was noted during this wait time.
This same subset then went on to attend the treatment
group and demonstrated significant improvement with
treatment. Although only a small number of our sample
experienced a wait time, these observations are a
promising indication that improvement of child CGAS
scores was due to the effect of the group treatment
rather than the process of time alone. Future research
will have to further assess the effect of wait time and/or
include an appropriate control group.
Depression and Anxiety

Subsequent studies will also benefit from assessing

whether such a parent child program provides any
added benefit to a parent only program which to date
has been the general mode of treatment for young
children with anxiety disorders. Although it would be
ideal for children to report on their anxiety symptoms
there is a general lack of suitable, reliable, valid selfreport instruments for young children to report anxiety
symptoms. Future studies would benefit from child
self-report as an additional measure of anxiety. As well,
an exploration of contextual and family variables, such
as measures of parental anxiety and family functioning,
that may influence therapy outcomes in this age group
are important factors to include in future studies. And
finally, it will be important to follow these young
children over the course of time to determine the longterm effects of such a group intervention.

CBT has clinically demonstrated effectiveness in the
treatment of anxiety disorders in adolescents and
school-aged children. Young children aged 57 years
develop major DSM-IV anxiety disorders, but to date
there is little in the way of evidence-based treatments
developed specifically for this age group. Anxious
children aged 57 years who participated in this novel,
group CBT program improved with treatment on
several anxiety measures. This pilot study suggests that
CBT can be used effectively to treat anxious children as
young as 5 years of age. Further studies in this area are
necessary to extend these findings.
Acknowledgments. An Endowment Fund Grant
from the Department of Psychiatry, The Hospital for
Sick Children provided funding for this pilot study.
The authors thank Dr. Annie Dupuis for her statistical
support and our co-therapists, Maryanne Shaw and
Veronica Romano for their help in conducting this

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