Kathleen Louden

April 02, 2014

CHICAGO — Approximately 25% of youth with an anxiety disorder and comorbid externalizing symptoms, including aggression, hyperactivity, and conduct problems, experience exacerbation of such symptoms following effective treatment for anxiety, new research shows.

The latest results from the Child/Adolescent Anxiety Multimodal Study (CAMS) suggest that this phenomenon may result from a decrease in young patients' inhibitions due to an effective reduction of internalizing symptoms.

The finding has implications for mental health providers treating children and teenagers who have anxiety disorders, said lead author Courtney Keeton, PhD, a psychologist with Johns Hopkins Medicine, Baltimore, Maryland.

"Although it is more likely that these symptoms will not change or will improve, clinicians will need to monitor the possibility for this increase in externalizing symptoms," Dr. Keeton told Medscape Medical News. "And they will need to offer treatment strategies that specifically target [these symptoms], which can be different than strategies used to target internalizing symptoms."

The findings were presented here at the Anxiety and Depression Association of America (ADAA) Conference 2014.

Different Treatment Approach

Dr. Keeton's research used the full 488-patient cohort from the CAMS. The randomized, controlled trial originally found that combined cognitive behavioral therapy and sertraline (Zoloft, Pfizer Inc) therapy during a 12-week period resulted in a superior treatment response compared with either treatment alone or with a placebo pill in children aged 7 to 17 years ( N Engl J Med. 2008;359:2753-2766). All patients of CAMS had separation anxiety, social phobia, and/or generalized anxiety.

In the current analysis, the majority of study participants (n = 363) did not have comorbid externalizing symptoms during or after treatment. However, 125 participants did, as shown by a T score of 60 or higher on the Child Behavior Checklist.

This parent-reported questionnaire assesses a child's internalizing symptoms, such as anxiety and depression, as well as externalizing symptoms, including aggression, hyperactivity, bullying, conduct problems, defiance, and violence.

The group with comorbid externalizing symptoms differed significantly from the other group in several ways (all P< .001), Dr. Keeton reported. Differences for the group with externalizing symptoms included the following:

  • Slightly younger mean age

  • Higher parent-reported anxiety severity on the Screen for Childhood Anxiety Related Emotional Disorders

  • Higher anxiety impact using the Child Anxiety Impact Scale

  • Lower social competence on a subscale of the Child Behavior Checklist

  • Higher family burden, as reported on the Burden Assessment Scale

Consistent with the authors' hypothesis, the data show that children with worsening externalizing symptoms were more likely to respond to treatment [t(75) = −2.57; P = .001], with two thirds of the youth demonstrating improved externalizing symptoms.

However, the finding that 25% of all youth had worsening externalizing symptoms was a concern.

"Our findings support some changes in how we conceptualize symptoms," said Dr. Keeton.

"The symptoms don't always fit so nicely into distinct categories — for example, anxiety disorder or attention-deficit/hyperactivity disorder — but they share underlying etiologies or mechanisms, and those factors, rather than diagnoses, should drive treatment decision making," she added.

Although the researchers have not yet analyzed the data to determine whether there is any association between worsening externalizing symptoms and anxiety type, treatment type, or child characteristics, Dr. Keeton said they plan to do so.

Study limitations, said Dr. Keeton, included a small sample size, a sample of primarily white patients, exclusion of youth with major depressive disorder, and lack of exploration of other comorbid conditions.

Need for More Active Parenting?

Commenting on the study as a discussant was CAMS investigator John Walkup, MD, a psychiatrist at New York–Presbyterian Weill Cornell Medical Center, New York City. Dr. Walkup, who did not participate in this secondary analysis, questioned the cause of the worsening externalizing symptoms in a subset of the youth.

"The question is, are they really worse, or do they need more active parenting when they have more energy after treatment? Parents need help to manage these changes in their children, yet there was no parent training for management of disruptive behavior in CAMS," he told conference delegates.

Dr. Walkup agreed with Dr. Keeton's proposal that parental training be a component of anxiety treatment.

It is also possible, he suggested, that an externalizing disorder such as oppositional defiant disorder is slightly more difficult to manage when coexisting with anxiety, at least in this sample.

Dr. Walkup praised the work of Dr. Keeton's group and others performing studies to improve results of treatment in children with anxiety.

"These treatments, when they work, can have spectacular results," he said. "Now we're really trying to understand why poor outcomes may occur."

The National Institute of Mental Health helped fund the original Child/Adolescent Anxiety Multimodal Study (CAMS). Dr. Keeton disclosed no relevant financial relationships. Dr. Walkup reported that, as a CAMS investigator, he received free sertraline (Zoloft) and placebo from Pfizer during that study. He reported no other relevant financial relationships.

Anxiety and Depression Association of America (ADAA) Conference 2014. Abstract 329R. Presented March 28, 2014.


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