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Cognitive-Behavioral Group Therapy for


Youths with Anxiety Disorders in the
Community: Effectiveness in Low and
Middle Income Countries

ARTICLE in BEHAVIOURAL AND COGNITIVE PSYCHOTHERAPY FEBRUARY 2013

Impact Factor: 1.69 DOI: 10.1017/S1352465813000015 Source: PubMed

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Giovanni Abraho Salum

Universidade Federal do Rio Gran

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Gisele G Manfro

Universidade Federal do Rio Gran

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Available from: Giovanni Abraho Salum Retrieved on: 14 March 2016

Cognitive Behaviouraland

CognitiveBehavioralGroupTherapyforYouthswith
AnxietyDisordersintheCommunity:EffectivenessinLow
andMiddleIncomeCountries

MariaAugustaMansurdeSouza,GiovanniA.Salum,RafaelaBehsJarros,LucianoIsolan,
RobertaDavis,DanielaKnijnik,GiseleGusManfroandElizethHeldt

FederalUniversityofRioGrandedoSul(UFRGS),Brazil

Background:Althoughcognitivebehavioraltherapy(CBT)isestablishedasafirstlinetreatmentfor
anxietydisordersinchildrenandadolescents,thereislittleevidenceabouttheeffectivenessofCBT
protocolsincasesidentifiedinthecommunityinlowandmiddleincomecountries(LaMICs).Aims:
ToevaluatetheeffectivenessofgroupCBTprotocolforyouthswithanxietydisordersidentifiedina
communitysampleinLaMICs.Method:Atotalof14sessionsofgroupCBTforyouthsand2
concurrentsessionsforparentsbasedonKendallsCopingCatprogramwereoffered.Participants
wereselectedfromacrosssectionalcommunitystudy;45subjectsfulfilledinclusioncriteriaand28
agreedtoparticipateintheopenclinicaltrial.Treatmenteffectivenesswasevaluatedwithstandard
clinical,selfandparentratedmeasuresofanxiety,depression,externalizingsymptomsandqualityof
life(QoL).Results:Twentyyouthscompletedtheprotocol.Allscalesshowedanimprovementof
anxietyandreductioninexternalizingsymptomsovertime,withamoderatetolargeeffectsize(d=
0.59to2.06;p<.05),butnotindepressivesymptomsorQoL.Conclusions:Consistentwithprevious
evidence,groupCBTiseffectiveintreatinganxietydisordersinyouths.Resultsencouragefurther
randomizedclinicaltrialsusingCBTprotocolsadaptedanddevelopedtobeusedinLaMICs.

Keywords:Cognitivebehavioraltherapy,anxietydisorders,youth,grouptherapy.

Introduction

Anxietydisordersareamongthemostcommonpsychiatricdisordersinchildrenand
adolescents(Beesdo,KnappeandPine,2009;Merikangasetal.,2010).Epidemiological
studiesdescribeprevalenceratesrangingfrom2to4%forcurrentor3monthpediatric
anxietydisorders,and6to12monthprevalenceratesvarybetween10and20%(Costello,
EggerandAngold,2005).Inadditiontosignificantnegativeimpactonsocialandemotional
developmentofchildren(Kessleretal.,2005),anxietydisorderstendtofollowachronic
andfluctuatingcourseinadulthood(Merikangasetal.,2010).Thereforeearlyidentification
andeffectivetreatmentcanreducetheimpactofdiseaseonsocialandacademicfunctioning

ReprintrequeststoMariaMansurdeSouza,UFRGS,LucasdeOliveira,2776/202PortoAlegre,RioGrandedo
Sul90460000,Brazil.Email:ma.mansur@terra.com.br

BritishAssociationforBehaviouralandCognitivePsychotherapies2013

M.A.MansurdeSouzaetal.

(Kendall,Khanna,Edson,CummingsandHarris,2011;Klein,2009)andondevelopmentof
psychiatricdisordersinadulthood(Connolly,BernsteinandIssues,2007).

Anxietydisordertreatmenthasbeenthefocusofseveralstudieswithimportantadvancesinthe
last20years(March,2011).SelectiveSerotoninReuptakeInhibitors(SSRIs)andCognitive
BehavioralTherapy(CBT)arebothconsideredfirstlinetreatmentsforanxietydisorders(Rynn
etal.,2011;Walkupetal.,2008).Arecentreviewofcontrolledtrialsshowedaremissionrateof
around56%forCBTusingconservativeintentiontotreatcriteriaversus28.2%forcontrols
(James,SolerandWeatherall,2007).However,themajorityofstudieswereconductedin
specificresearchcentersinhighincomecountries(Connollyetal.,2007).

Althoughfirstlineoptionsareeasilyaccessiblearoundtheworld,inlowandmiddleincome
countries(LaMICs)suchasBrazil,CBTisusuallylimitedtoresearchcentersandspecialized
care.WebelievethatthesmallnumberofqualifiedtherapistsandthelackofCBTprotocols
designedforthesespecificpopulationsmaycontributetoitsunderutilization.Disseminationof
effectivetechniquesisanimportantnewresearchfieldandadequateprotocolsareastarting
pointforthis(Kendalletal.,2011;McLeanandFoa,2011).

CBTprotocolshavebeendevelopedinBrazilandshowntobeeffectivewithadultswithanxiety
disordersintheshort(Heldtetal.,2003;Cordiolietal.,2003)andlongerterm(Braga,Manfro,
NiederauerandCordioli,2010;Heldtetal.,2011).However,CBTprogrammesforyouthwith
anxietydisordershavenotbeentestedinBrazilandthereisanotablelackofqualifiedhealth
professionalscapableofconductingCBTwithchildrenandadolescents

TheCBTgroupprogrammeusedinthisstudywasbasedonarecognizedCBTprotocolfor
anxiouschildren:theCopingCatprogram(KendallandHedtke,2006a,b).Thisstudyisnota
crossculturaladaptationofamanual,butratheritusespreviouslyvalidatedCBTtechniquesto
developafeasibleprotocoladaptedtoBraziliansocioeconomicandculturalreality,focusingon
anxiety,withevidenceofsimilarresponsestotreatmentforseparationanxietydisorder(SeAD),
socialanxietydisorder(SoAD),panicdisorder(PD),andgeneralizedanxietydisorder(GAD)in
youths.OurobjectiveistoevaluatetheeffectivenessofgroupCBTprotocolforyouthswith
anxietydisordersidentifiedinacommunitysampleinLaMICs.

Method

ThisisanopenclinicaltrialdesignedtoevaluatetheeffectivenessofgroupCBTforanxiety
disordersinyouthandwasundertakenfrom2009to2010.Thestudywasapprovedbythe

ResearchandEthicsCommitteeofHospitaldeClnicasdePortoAlegre(n 08450).
Primarycaretakersandyouthssignedwritteninformedconsentstoparticipate.

Participants

Thisstudyispartofacommunitycrosssectionstudythatscreenedatotalof2457subjects
from10to17yearsoldforanxietydisordersinthecommunitywiththeScreenforChild
andAdolescentsRelatedEmotionalDisorders(Isolan,Salum,Osowski,AmaroandManfro,
2011).Asubsampleof242subjectswerefurtherevaluatedwiththeScheduleforAffective
DisordersandSchizophreniaforSchoolAgeChildrenPresentandLifetimeVersion(K
SADSPL)(Kaufmanetal.,1997),performedbyindependentchildandadolescent
psychiatristsorpsychiatricresidentsreceivingsupervision(Salumetal.,2011).Fromthose
atotalof138(5.6%)werediagnosedwithatleastoneanxietydisorder.

Cognitivebehavioralgrouptherapyforyouths
3

Children and adolescents diagnosed with Anxiety Disorders (K-SADS-PL) in the community phase

Eligible for Group CBT n=45

Pilot group
recru
itmen
t

Pilot group n= 4

Enrol
lment

n=138

of
subje
cts

Exclusion criteria for the


CBT trial (n=93)

- Age above 13 years (n=55)


- Therapy or pharmacotherapy
(n=6) - Without indication of
CBT (n= 32)

Clinical trial

I
n
v
i
t
e
d

Refused participation

f
o
r
p
a
r
t
i
c
i
p
a
t
i
o
n

n=13(32%)

n
=
4
1

Reasons: Nobody able to

motivation or previous

b
r
i
n
g
t
o
t
r
e
a
t
m
e
n
t,
l
a
c
k
o
f

n= 28(68%)

commitments

E
n
t
e
r
e
d

Completed treatment

n
=
2
0
(
7
1
%
)

Figure1.Flowchartofthestudy

InordertoparticipateintheCBTtrial,youthshadtobebetween10to13
yearsold,notreceivingpsychotherapyorpsychopharmacologicaltreatment
atthetimeofrecruitment,andbeavailabletoparticipateingroupCBTfor
14weeks.Theexclusioncriteriainclude:severecomorbiditiesthat
demandedimmediatetreatment,maindiagnosisofPTSD,OCD,psychotic
disordersorpervasivedevelopmentaldisorder,andmentalretardationor
cognitivedysfunction.

Fortyfivesubjectsmetinclusioncriteria;4participatedinapilotgroup,
withtheremaining41beinginvitedtoparticipateinthemaintrial.Ofthese,
28consentedtotakepartintheresearch(seeFigure1).

M.A.MansurdeSouzaetal.

Intervention

TheinterventionwasbasedonarecognizedCBTprotocolforanxiouschildren,theCoping
CatprogramCognitiveBehavioralTherapyforAnxiousChildren:therapistmanualfor
grouptreatment(KendallandHedtke,2006a),andTheCopingCatWorkbook(Kendalland
Hedtke,2006b).

Theinterventionconsistedof14weekly90minutesessions.Twomoreconcurrentsessions
withparents,oneintheseventhandanotheratthelastsessionoftreatment,wereincluded.
CBTwasconductedbytwoclinicalpsychologists,supervisedbyresearcherswithmore
than10yearsofexperienceingroupCBT.Beforestartingtheopentrialweundertooka
pilotgroup(n=4)toassesssuitabilityforaBrazilianpopulationandthetimerequiredto
delivertheprogramme.

Thegroupinterventionaimedto:increaserecognitionandanalysisofdistortedthinking
patternsthatcontributetoanxietysymptoms;developcopingstrategiestodealwithanxiety
provokingsituations;recognizesignsofanxietyasasignaltousethecopingstrategiesand
todecreaseoreliminateavoidancethatmaintainsanxiety(Kendalletal.,1997;Kendalland
Hedtke,2006a,b).

Studyprocedures

AfterthepilotCBTgroupwascompleted,41youthswereinvitedtoparticipateinthetrialand
wereassessedbychildandadolescentpsychiatristsandthroughselfreportquestionnaires
describedbelow.Theseevaluationswereconductedatthreedifferenttimepoints:beforestarting
treatment(baseline),inthemiddle(session7),andattheendoftreatment(session14).

Primaryoutcomes

TheClinicalGlobalImpression(CGI)ratingscalewasusedastheprimarydichotomous
outcome.CGIisaclinicianratingscaleofseveritythatrangesfrom1(normal)to7
(extremelyill),withlowerscoresindicatinggreaterimprovement,ascomparedwith
baseline(Guy,1976).RemissionratesweredefinedbyaCGI2inthepreviousmonth.

ThePediatricAnxietyRatingScale(PARS)wasusedastheprimarycontinuousoutcome.
Withthisscale,theclinicianusesachecklistofquestionsregardingthesymptomsof
anxietyduringthepastweektoelicitresponsesfromparentsandyouthsagedbetween617
years.Aftercompletingthischecklist,theclinicianratesfivegeneralitems:theseverityof
thechildsdistressduetoanxiety,thefrequencyofanxiety,thedegreetowhichthechild
avoidedanxietyprovokingsituations,andthedegreetowhichtheanxietylimitedthe
childsparticipationintypicaldailyactivitiesbothathomeandinotherenvironments,such
asschool.Totalscoresonthisscalerangefrom0to30,withscoresabove13indicating
clinicallymeaningfulanxiety.Symptomswereconfirmedthroughintegrationofbothyouth
andparentinformation,ratedbytheevaluator(TheResearchUnitsonPediatric
PsychopharmacologyAnxietyStudyGroup,2002).

Secondaryoutcomes

TheScreenforChildAnxietyRelatedEmotionalDisorders(SCARED;Birmaheretal.,1997)is
achildandparentselfreportmeasurewith41itemsthatassessDSMIVsymptomsof

Cognitivebehavioralgrouptherapyforyouths
5

SeAD,GAD,SoAD,PD,andschoolphobia.Thetwoversionsareforthechild(SCARED
C)andparents(SCAREDP)respectively.Thetotalscoreandeachofthefivefactorsofthe
SCAREDBrazilianPortugueseversionshowedgoodinternalconsistency,testretestand
constructvalidity(Isolanetal.,2011).

TheChildrensGlobalAssessmentScale(CGAS)providesaglobalimpairmentmeasureand
functioningoverthepreviousmonth.Thescalerangesfrom1(lowest)to100(highest)and
scoresof60orlowerareconsideredtoindicateaneedfortreatment(Shafferetal.,1983).

TheChildrensDepressionInventory(CDI)isa27itemselfreportmeasureassessing
cognitiveandsomaticsymptomsassociatedwithdepressioninpeopleagedfrom7to17
yearsold(GolfetoandDOliveira,2004).Itemsareratedona3pointscale,rangingfrom0
to2,reflectingthedegreeofparticulardepressivesymptomsoverthepast2weeks.With
thesumofthescoresofallitems,weobtainedatotalscorefrom0to54.

YouthQualityofLifeInstrumentResearchVersion(YQOLR)isaselfreportquestionnaireof
49perceptualitemsusedtoperformamultidimensionalassessmentofthegenericqualityoflife
(QoL)(Edwards,Huebner,ConnellandPatrick,2002;Patrick,EdwardsandTopolski,2002).A
conceptualmodelwasusedtoorganizeQoLitemsforeachdomainandtheirassociatedfacets,in
an11pointscalewithanchorsof0(Notatall)and10(Agreatdealorcompletely).TheYQOL
Risconsideredayouthcenteredquestionnaire,focusesonpositiveaspectsofhealthand
perceptions,andallowscrossculturalcomparisons.

TheSNAPIVwastheversionusedinaMultimodalityTreatmentStudy,whichincludes26
itemscorrespondingtoAttentionDeficitDisorderHyperactivity(ADHD),andsymptomsof
OppositionalDefiantDisorder(ODD).The4pointresponseisscoredfrom03,subscale
scoresfortheADHDandODDarecalculatedbysummingthescoresontheitemsinthe
specificsubset(e.g.Inattention)anddividingbythenumberofitemsinthesubset(Serra
Pinheiro,MattosandAnglica,2008).

Statisticalanalysis

Dataweredescribedascountandpercent(%),meanandstandarddeviations(SD).A
GeneralizedEstimatingEquations(GEE)modelwasperformedtakingintoconsideration
theindividualandtherapygrouplevelstestingtimeeffectintherepeatedmeasuresat
baseline,midpointandendpointevaluations.Anunstructuredcorrelationmatrixwasused
asarobustestimator.SequentialBonferroniadjustmentformultiplecomparisonswasused
tocomparetimepoints.Allcomparisonswereadjustedforageandgender.Thesetestswere

complementedbypresentationofwithingroupeffectsizes(Cohensd

=
M
1

M
2

/
SD2

SD2
2rSD1SD2).Testsweretwotailed,withasignificancelevelof.05and

performedwithSPSS17.0.

Results

Atotalof28(68%)patientswereincludedinoneofthefourgroups,withdemographic
characteristicsanddiagnosisbeingsummarizedinTable1.Twentypatients(71%)completedthe
interventionwith9(45%)meetingcriteriaforremission(CGI2).Allclinician,selfratedand
parentratedscalesshowedanimprovementovertime,withamoderatetolargeeffect(Cohens
drangingfrom=0.59to2.09).Inaddition,therewasasignificant

M.A.MansurdeSouzaetal.

Table1.Descriptivesamplecharacteristics(n=28)

Age(years)
12
SD=0,77

Gender(female)
22
79%

Anxietydisorders:

PD
3
11%

SeAD
13

46%

SoAD
11
39%

GAD
23
82%

Presentcomorbidities:

ADHD
8
29%

ODD
4
14%

Pastcomorbidities:

Enuresis
4
14%

Depression
6
21%

Anxietydisorderscomorbidities:

1
6
21%
2
12
43%
3
9
32%
4
1
4%

Notes:Dataarepresentedasn(%)andmeanandStandardDeviation(SD)

Abbreviations:ADHD=AttentionDeficit/HyperactivityDisorder;ODD=OppositionalDefiant
Disorder;PD=PanicDisorder;SeAD=SeparationAnxietyDisorder;SoAD=SocialAnxiety
Disorder;GAD= GeneralizedAnxietyDisorders.

Relativefrequencysuperiorto10%

improvementinsymptomsofexternalizingdisorders,butnotindepressivesymptomsover
time.NosignificantchangewasfoundinQoLscores(seeTable2).

Discussion

ThisstudywasafirstattempttoclinicallytestaCBTprotocolforanxietydisordersin
Brazilianyouth(Kendalletal.,1997;KendallandHedtke,2006a,b).Ourfindingssuggest
thatgroupCBTisaneffectiveinterventionforyouthwithanxietydisordersinaLaMIC.

Interestingly,CBTproducedsubstantialtreatmenteffectsforanxietysymptomsmeasured
byPARSandSCARED,althoughitdidnotresultinasignificantdecreaseindepressive
symptomsnoranimprovementinqualityoflife.Thereisevidencethatdepressionis
frequentlyaconsequenceofhighlevelsofanxietyandsomethingthatstartsinchildhood
(Merikangasetal.,2010;Roza,Hofstra,VanDerEndeandVerhulst,2003).Themeanage
ofoursampleisaround12yearsoldandthemeanofdepressivesymptomswaslow,as
verifiedbyCDI,suggestingthatperhapswedidnothaveenoughpowertoshowmild
differencesindepressionscores(Kendall,Safford,FlannerySchroederandWebb,2004).

Anotherinterestingresultwasthesignificantdecreaseinexternalizingsymptomsmeasuredby
theSNAPIVafterthetreatment.Withregardtothisfinding,around30%ofthesample

Cognitivebehavioralgrouptherapyforyouths

Table2.Estimatedmarginalmeansofeachoutcomeoverthecourseoftreatment

Baseline

Week7

Week14

GEEtime
Effect

EMM
CI95%

EMM
CI95%

EMM
CI95%

effect
Size

Clinicianrated:

PARS
13.8a
12.7
14.9

10.8b
9.6
11.9

7.2c
5.6
8.7

<0.001

1.57

CGI
4.1a
3.8
4.4

3.5b
3.2
3.9

2.7c
2.2
3.1

<0.001
2.06

CGAS
55.9a
52.9
58.9

62.2b
59.2

65.2

69.8c
65.3
74.4

<0.001
1.93

Selfrated:

SCAREDC
28.2a
23.8
32.6

25.0a,b
21.3
28.8

21.6b
18.2
25.1

0.012
0.66

Parentrated:

SCAREDP
29.2a
24.4
34.1

28.2a,b
23.1
33.4

23.0b
18.1
27.9

<0.001
0.67

Comorbid

symptoms:

CDI
5.4
3.4
7.5
4.2
2.5
5.9
4.0
2.0
6.0

0.080

SNAP
27.7a

23.3
32.1

26.0a
19.0
32.9

21.7b
15.7
27.7

0.003
0.59

QualityofLife:

YQOL
82.1
74.9
89.4
83.5
77.7
89.3
83.5
77.7
89.3
0.602

Notes:Differentletters(a,b,c)indicatestatisticalsignificantresultsat0.05levelofsignificantin
sequentialBonferronimultiplecomparisonadjustment.

Effectsize(Cohensformula)betweenbaselineandthe14weekassessment.

Abbreviations:EEM,EstimatedMarginalMeans;CI95%,95%ConfidenceInterval;GEE,
GeneralizedEstimatingEquations;PARS,PediatricAnxietyRatingScale;CGI,ClinicalGlobal
Impressions;CGAS,ChildrensGlobalAssessmentScale;SCAREDC,ScreenforChildAnxiety
RelatedDisordersChildVersion;SCAREDP,ScreenforChildAnxietyRelatedDisordersParent
Version;CDI,ChildhoodDepressionInventory;YQOL,YouthQualityofLifeInstrument.

hadADHDcomorbidity(Kendall,BradyandVerduin,2001).Furthermore,improvementof
anxietysymptomsmayhavecontributedtothepositiveeffectsonexternalizingsymptoms
(Beidas,Benjamin,Puleo,EdmundsandKendall,2010).

Intermsofinterventiondeliveryourexperiencesuggeststhatthepresenceofacotherapist
inallsessionswasessential.Intermsoftime,nosessionexceeded90minutes,withgroup

sizebeinglimitedtosixduetoindividualproblemsofparticipants(shyness,anxiety).
Accordingtofamilyreport,thetwosessionsdesignedforfamilymemberswerevery
importantinunderstandingthedisorder,learninghowtodealwiththechildsanxietyand
cooperatingwiththechildshomework.

Ourstudyhaslimitationsthatshouldbetakenintoconsideration.Thelackofacontrolgroup,the
absenceofafollowupandthesmallsamplesizelimitthegeneralizationofourfindings.
Similarly,only50%ofthosewhowereeligibleactuallycompletedthetreatment.Inspiteofthis,
theeffectsizeofinterventionsgreatlyencouragesfurtherresearch.Theyouthssufferedfrom
differentkindsofanxietydisordersand,asthesamplewastoosmall,itremainsunclearwhether
ornotaspecificanxietydisorderdemonstratedabetterresponsetogroupCBT.Ontheother
hand,thiswasasampledirectlyselectedfromthecommunityandnotatreatmentseekingone.
Giventhehighprevalenceandsubstantialmorbidityassociatedwithanxietydisordersin
childhoodandadolescence,disseminationofCBTfromresearchtoclinicalpracticeshouldbea
priority(Beidasetal.,2010;Kendalletal.,2011;March,

M.A.MansurdeSouzaetal.

2011;McLeanandFoa,2011).However,animportantbarrieristhelackofCBT
practitionersadequatelytrainedinempiricallysupportedtreatments(Kendalletal.,2011).
TheuseofagroupCBTprotocolaidedtheabilityofclinicianstoprovideaneffective
manualdriventreatment.Further,randomizedcontrolledtrialsareneededtoconfirmour
findingswithanappropriatefollowuptoevaluatewhethergainsaremaintainedovertime.

Acknowledgements

FinancingwasprojectlinkedfromUniversalEdictCNPq2007(Number:483032/20077),
FIPEHCPAandCAPESProf.

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