Mediators of Treatment Outcomes for Anxious Children and Adolescents: The Role of Somatic Symptoms

Abstract

Cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors are effective treatments for pediatric anxiety disorders. However, the mechanisms of these treatments are unknown. Previous research indicated that somatic symptoms are reduced following treatment, but it is unclear if their reductions are merely a consequence of treatment gains. This study examined reductions in somatic symptoms as a potential mediator of the relationship between treatment and anxiety outcomes. Participants were 488 anxious youth ages 7-17 (M = 10.7), 50.4% male, 78.9% Caucasian, enrolled in Child/Adolescent Anxiety Multimodal Study, a large randomized control trial comparing 12-week treatments of CBT, sertraline, a combination of CBT and sertraline, and a pill placebo. Causal mediation models were tested in R using data from baseline, 8-, and 12-week evaluations. Somatic symptoms were assessed using the Panic/Somatic subscale from the Screen for Child Anxiety Related Emotional Disorders. Youth outcomes were assessed using the Pediatric Anxiety Rating Scale and Children's Global Assessment Scale. Reductions in somatic symptoms mediated improvement in anxiety symptoms and global functioning for those in the sertraline-only condition based on parent report. Conditions involving CBT and data based on child reported somatic symptoms did not show a mediation effect. Findings indicate that reductions in somatic symptoms may be a mediator of improvements for treatments including pharmacotherapy and not CBT. Although the overall efficacy of sertraline and CBT for anxiety may be similar, the treatments appear to function via different mechanisms.

Group- Versus Parent-Involvement CBT for Childhood Anxiety Disorders: Treatment Specificity and Long-Term Recovery Mediation

“…Research on treatment mediation is rare, including in youth anxiety, despite calls for such research (e.g., Kazdin et al, 1990; La Greca et al, 2009; Weersing & Weisz, 2002; Weisz et al, 2017). Most trials focus on a single variable; in youth anxiety studies, cognitive variables are most often examined as mediators (Peris et al, 2015; Treadwell & Kendall, 1996), although a recent study examined somatic symptoms (Hale et al, 2018). Further, most studies focus on pre- to posttreatment analysis only.…”

Symptom‐specific effects of cognitive‐behavioral therapy, sertraline, and their combination in a large randomized controlled trial of pediatric anxiety disorders

“…Given its low overall network influence, it may not be a considered a central treatment target, which is in line with evidence suggesting that targeting physical symptoms (e.g., relaxation) are not key to improving CBT outcomes (Peris et al., ). However, a recent study found that reduction of physical symptoms mediated treatment outcome for CAMS participants in the sertraline condition (Hale et al., ). Taken together, the role of physical symptoms in pediatric anxiety and its treatment warrants further research.…”

“…A solid edge between the treatment node and a symptom domain node indicates a positive association (i.e., the active treatment is associated with more severe symptoms within that symptom domain). A dashed edge indicates a negative association (i.e., the active treatment is associated with less severe symptoms within that symptom domain) treatment outcome for CAMS participants in the sertraline condition (Hale et al, 2018). Taken together, the role of physical symptoms in pediatric anxiety and its treatment warrants further research.…”

Research Review: Pediatric anxiety disorders – what have we learnt in the last 10 years?

“…However, relatively few studies have explored the differential effects of pharmacotherapy and psychotherapy on specific symptoms in pediatric anxiety disorders. Recently, however, Hale et al (2018) used causal mediation models to evaluate somatic symptoms in CAMS. Somatic symptom improvement was mediated by improvement in anxiety and global function in sertraline-treated patients, but a similar relationship was not observed in youth receiving CBT or CBT + sertraline (Hale et al, 2018).…”

“…Recently, however, Hale et al (2018) used causal mediation models to evaluate somatic symptoms in CAMS. Somatic symptom improvement was mediated by improvement in anxiety and global function in sertraline-treated patients, but a similar relationship was not observed in youth receiving CBT or CBT + sertraline (Hale et al, 2018).…”