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Background Anxiety disorders are common psychiatric conditions affecting children and adolescents. Although cognitive behavioral therapy and selective serotonin-reuptake inhibitors have shown efficacy in treating these disorders, little is known about their relative or combined efficacy. Methods In this randomized, controlled trial, we assigned 488 children between the ages of 7 and 17 years who had a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia to receive 14 sessions of cognitive behavioral therapy, sertraline (at a dose of up to 200 mg per day), a combination of sertraline and cognitive behavioral therapy, or a placebo drug for 12 weeks in a 2:2:2:1 ratio. We administered categorical and dimensional ratings of anxiety severity and impairment at baseline and at weeks 4, 8, and 12. Results The percentages of children who were rated as very much or much improved on the Clinician Global Impression-Improvement scale were 80.7% for combination therapy (P<0.001), 59.7% for cognitive behavioral therapy (P<0.001), and 54.9% for sertraline (P<0.001); all therapies were superior to placebo (23.7%). Combination therapy was superior to both monotherapies (P<0.001). Results on the Pediatric Anxiety Rating Scale documented a similar magnitude and pattern of response; combination therapy had a greater response than cognitive behavioral therapy, which was equivalent to sertraline, and all therapies were superior to placebo. Adverse events, including suicidal and homicidal ideation, were no more frequent in the sertraline group than in the placebo group. No child attempted suicide. There was less insomnia, fatigue, sedation, and restlessness associated with cognitive behavioral therapy than with sertraline. Conclusions Both cognitive behavioral therapy and sertraline reduced the severity of anxiety in children with anxiety disorders; a combination of the two therapies had a superior response rate. (ClinicalTrials.gov number, NCT00052078.)

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Objective: To review the literature on the cognitive-behavioral treatment of children and adolescents with anxiety and depressive disorders within the conceptual framework of evidence-based medicine. Method: The psychiatric and psychological literature was systematically searched for controlled trials applying cognitive-behavioral treatment to pediatric anxiety and depressive disorders. Results: For both anxiety and depression, substantial evidence supports the efficacy of problem-specific cognitive-behavioral interventions. Comparisons with wait-list, inactive control, and active control conditions suggest medium to large effects for symptom reduction in primary outcome domains. Conclusions:From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders in children and adolescents. Future research in this area will need to focus on comparing cognitivebehavioral psychotherapy with other treatments, component analyses, and the application of exportable protocol-driven treatments to divergent settings and patient populations. J. Am. Acad. Child Adolesc. Psychiatry, 2004;43(8):930-959.Key Words: outcome studies, children and adolescents with major depression and dysthymic disorder, children and adolescents with anxiety disorder, literature review.

Objective: To evaluate the relative efficacy of (1) individual cognitive-behavioral family-based therapy (CBFT); (2) group CBFT; and (3) a waitlist control group in the treatment of childhood obsessive-compulsive disorder (OCD). Method: This study, conducted at a university clinic in Brisbane, Australia, involved 77 children and adolescents with OCD who were randomized to individual CBFT, group CBFT, or a 4-to 6-week waitlist control condition. Children were assessed before and after treatment and at 3 months and 6 months following the completion of treatment using diagnostic interviews, symptom severity interviews, and self-report measures. Parental distress, family functioning, sibling distress, and levels of accommodation to OCD demands were also assessed. Active treatment involved a manualized 14-week cognitivebehavioral protocol, with parental and sibling components. Results: By an evaluable patient analysis, statistically and clinically significant pretreatment-to-posttreatment change occurred in OCD diagnostic status and severity across both individual and group CBFT, with no significant differences in improvement ratings between these conditions. There were no significant changes across measures for the waitlist condition. Treatment gains were maintained up to 6 months of follow-up. Conclusions: Contrary to previous findings and expectations, group CBFT is as effective in reducing OCD symptoms for children and adolescents as individual treatment. Findings support the efficacy and durability of CBFT in treating childhood OCD.