Professor Ron Rapee Hi there, and welcome back  to those of you who saw the first part of this   series, or welcome to anyone who’s joining in  the middle here. I’m talking about the nature   and treatment of anxiety disorders in children and  adolescents, and this is part two, where I’m going   to give a broad overview of the treatment  of children and adolescents with anxiety. When we’re talking about evidence-based treatment,  so that is treatments for which there is good   scientific evidence for their efficacy,  and I’m talking here about several studies,   not just a one-off, there’s really two  types of treatments that have shown – that   have been shown to work with children and  young people with anxiety disorders. First   and foremost are the – are what’s referred to as  cognitive behaviour therapy. That is skills-based   teaching or training of strategies, and  there’s – that’s got, by far and away,   the most evidence. There’s a large number  of research trials showing that cognitive   behaviour therapy works for children and anxi  – and adolescents with anxiety disorders. When we think about cognitive behaviour  therapy, the traditional way in which   that’s done is – naturally, it’s with  a parent and child perhaps going to see   a Therapist in an office and sitting down in  chairs, face-to-face, facing each other, and   going through session after session in that way,  that’s the traditional treatment. More recently,   Researchers have started to develop what are often  referred to as low-intensity treatments. That is,   treatments that require less input, less time from  a Therapist, and can be delivered more easily and   more broadly and disseminated more broadly,  and many of these are run on the internet,   that is, online treatments. And so, I  put those there as a separate group,   but they’re still cognitive behaviour therapy.  So, the evidence – there’s evidence that both   traditional and online cognitive behaviour therapy  work for the treatment of anxiety disorders. Another form of treatment is medication. Within  the medication trials, there’s far fewer trials   of medication for children and adolescents  and it’s a far less popular treatment,   but there is certainly very clear evidence that  medication works, and it works about as well,   pretty much equivalent, to cognitive behaviour  therapy. Among the medication trials,   the most commonly evaluated form of medication  are the selective serotonin reuptake inhibitors,   referred to as the SSRIs. These are often  referred to colloquially as anti-depressants,   but of course, they’re not just anti-depressants.  They work well for anxiety, and as I said,   there’s good evidence that they work  for the treatment of young people. Now, I’m going to go on to talk in a  little bit more detail about treatment,   but I’m not going to talk any more about  medication, that’s not my field, and so,   I’m going to talk primarily about cognitive  behaviour therapy treatments. So, to give you an   example of a type of cognitive behaviour therapy  treatment is our own treatment, Cool Kids. Now,   I make a disclaimer here to say I’m not in  any way saying that Cool Kids is the best,   or it is different to any other cognitive  behavioural treatment. I’m giving it   purely as an example of one type of cognitive  behaviour therapy package, because obviously,   it’s the one that I know best. It comes  from our clinic at Macquarie University. Cool Kids has – is a structured, manualised  treatment. It provides very clear indication   for the Therapist about – guidance for  the Therapist about how to do treatment,   and – although there’s flexibility, of  course, in how the Therapist applies   that. But it’s one of several programmes around  the world that have that same sort of structure   and guidance for Therapists. This particular  programme, the main programme covers manuals   for children from seven to 17. There’s separate  manuals for children, which is – in Australia,   it’s primary school, so it’s, like, seven to  12-ish years of age. And there’s a different   manual for adolescents, who’d be in high  school in Australia, which is, like,   12 up to 17. We also do have a preschool version  of the programme, and so, this pretty much,   characterises the research across the world in  most forms of treatment for anxiety, which is   that there’s treatments – good evidence that you  can treat children all the way from preschool,   through to the end of high school, using  these sorts of manualised programmes. Cool Kids can be delivered either in group or  individual face-to-face sessions, and again,   that’s typical of the world. Most programmes  are delivered either group or individually,   and both group and individual treatment have  been shown to work. This particular programme   is delivered – the main programme is delivered in  ten sessions over 12 weeks. We allow flexibility   within our programme so that if the child is  not better after ten sessions, the Therapist   can choose to go longer, but the main programme,  the evaluated, scientific programme, is typically   ten sessions over 12 weeks. And again, that’s  very common, very typical of most programmes   in the world. Most of the CBT programmes tend to  be between about eight to 15 sessions in length. In the Cool Kids programme, we include the  parents in all our versions, but they vary – their   inclusion varies depending on the age of the  child. So, the preschool programme is entirely   a parent-delivered programme. For the child  programme, we include parents in every session,   in every step of the way, and for the adolescent  programme, parents become less and less involved   as their teenager gets – is older. Again, this is  not uncommon in other programmes around the world,   but this is one area in which the programmes do  differ a bit. Some programmes tend to have very   little parent involvement, and some programmes,  like Cool Kids, are very heavily parent inclusive,   and they just vary. The evidence doesn’t suggest  a lot of difference between parent-delivered   versus – or parent-included – inclusive versus  not inclusive programmes. Both seem to work well. The programme, Cool Kids, teaches very practical  skills and strategies, which is the hallmark of   cognitive behaviour therapy, and in Cool  Kids, as well as in all other programmes,   cognitive behavioural programmes, there is  extensive between-session homework. In terms of   the content of Cool Kids, again, not – very, very  similar to most other programmes around the world.   As I’ve mentioned, it’s a skill-based programme,  so the idea is that it’s teaching new skills, new   strategies to the parents and the children to help  the children manage their anxiety independently.   Specific components include, firstly,  psychoeducation, and you’ll find psychoeducation,   that is information about the nature and  the causes and the treatment of anxiety,   general information like that is a component of  pretty much all cognitive behavioural programmes.  Cognitive restructuring is included in Cool  Kids. It is in some but not all pro – other   programmes. We refer to that as ‘Detective  thinking’ where we talk to the children,   but it’s really teaching the children different  ways of looking at the world, different ways of   using information and evidence to try to change  their beliefs and their expectations. We teach   the parents child management strategies. That is,  we teach the parents different ways of interacting   with their child, and in particular, we focus  very strongly on parent overprotection. So, we   teach the parents to gradually pull away from and  allow their child greater and greater autonomy. Most importantly, the core component of Cool Kids  is in vivo exposure. That is, getting the child   in a structured, systematic way, to approach and  engage with the situations that they are currently   avoiding. Reducing that avoidance behaviour is  the core component of all cognitive behavioural   programmes, and it is the major – the lion’s  share of the treatment programme within Cool   Kids. We then supplement that with a variety of  skills training, teaching kids social skills or   assertiveness, or how to deal with bullying, where  it’s needed, only – that’s a more flexible part of   the programme, where and if needed. And throughout  the whole programme, there’s an emphasis on   real-life applications through continued homework  practice and putting everything into practice. So, let’s then – having gone through the nature  of the treatment, let’s talk a little bit about   some of the scientific evidence that’s around, and  again, I’ll use examples largely from Cool Kids,   but it’s just examples of the scientic – it’s  the scientific evidence that’s around for all   different forms of CBT treatments. Firstly,  talking broadly across the research – across   the literature, there was a Cochrane Review,  that is the pinnacle meta-analytic review of   any treatment, a Cochrane Review of CBT treatments  for child anxiety done by James and colleagues. The most recent one for this talk – recent to  this talk is – was in 2020, and what they showed   in 2020 was when you look at all the cognitive  behavioural treatment studies around the world,   you find at the end of treatment, that just about  50% of children at the end of treatment are free   of their main presenting anxiety disorder. So,  if a child presents with social anxiety disorder,   there’s a 50% chance that they will be free  of that disorder at the end of treatment,   if they present with generalised anxiety disorder  and so on. So, across all anxiety disorders,   about half the kids are free of their  main disorder at the end of all these   treatments. Compared to control treatment, all  the different control treatments, around about   17% of children are free of their disorder  at the end of all the comparison treatments. So, you can see, you don’t need statistics  to tell you that that is a clear difference,   and CBT treatments work and they work  very well. There’s still a long way to   go. 50% means that 50% of kids are not free of  their disorder at the end of treatment. What   the James – what the Cochrane Review didn’t  look at, but we do know from other reviews,   is that improvement continues after treatment.  So, we typically find another ten to 20% of young   people will be free of their primary disorder  in the next three months to 12 months beyond   the end of treatment. So, that’s the good  news, is that when they keep putting these   strategies into practice, they will continue  to get better, but still, we end up, still,   with about 30/40% of kids at any stage,  even well beyond treatment, who will still   maintain their anxiety disorder. We still have  a long way to go to improve these treatments. Let me give you an example of just one study, just  to show you a part – a specific research study.   This is a Cool Kids study that we did many years  ago, where we wanted to compare our low-intensity   treatment, in that case it was a bibliotherapy  treatment. So, we gave parents a book and told   them to help their child. We wanted to compare  that against our standard Cool Kids treatment. So,   we had about 200 children in this study. They  were all children, in this case, aged seven   to 11 years, they were randomly allocated to  either get the standard Cool Kids treatment.   They had ten sessions delivered over 12 weeks,  as I described earlier. This particular study,   it was – included group delivery, so this was  group treatment of ten sessions over 12 weeks. We compared that against a waitlist, that is, kids  who got no treatment at all and were told to wait   for 12 weeks, and we compared that against  a pure bibliotherapy condition. That is, a   condition where the parent was given a commercial  book about anxiety disorders, they were told to   follow the book and to help their child using the  book, and we didn’t see them again for 12 weeks. And here’s the results. This is the number  of young people – number of children who   are free of their primary anxiety disorder  after treatment. You can see first of all,   on the waitlist, very few. About 7% of children  lost their anxiety disorder over the 12 weeks.   Here’s the more important results for this talk,  which is at the end of treatment with Cool Kids,   60% of children were free of their primary  anxiety disorder, and over the next three   months that continued to increase, up to  about 75%/73%, something like that. So,   you can see, after three months after  treatment, about 73% of kids are free   of their main presenting problem in  Cool Kids and in many other treatments. Interestingly, just as an aside, when you look at  the book treatment, that is, giving parents a book   alone, they actually do pretty well. About 25% of  those kids are free of their anxiety disorder just   by having a parent book – go through strategies  with them, following a manual, a book. And that   dropped a little bit in the next three months,  but it’s still much, much better than waitlist. Just to point out, then, some other research  showing that not only do we get good results   when we run these very carefully controlled  trial – scientific trials in university clinics,   but here’s some research from a group in Denmark,  Jónsson and colleagues, in 2015, who looked at the   use of Cool Kids in community outpatient clinics.  These were general community clinics using regular   Community Therapists, and they looked – it  wasn’t a controlled trial, but they looked   at how these kids changed over time, and here  first of all, are the results for the symptoms. This is the SCAS, which is the Spence Children’s  Anxiety Scale. It’s a measure of anxiety symptoms,   and their symptoms reported,  firstly by the child themself,   and secondly by the parent about the child. And  you can see in both cases that there is lovely,   large changes over time. That is, running  the treatment – Cool Kids treatment in a   community setting, these kids are improving  dramatically from pre to post-treatment,   and they showed continued improvement  over the next several months. This next slide is looking at life interference.  So, the CALIS is a measure of the impact on the   child’s life of the anxiety symptoms  according to the child’s own report,   and according to the parent’s report, and again,  you can see nice changes across time. A little   bit less when you look at the child’s own report,  but when you look at the parent’s report as well,   very, very large and dramatic improvements across  time, post-treatment, and into follow-up, showing   that you can run these sorts of treatments  in regular external community practice. And what about the online, the low-intensity  internet treatments? I hadn’t mentioned   earlier that the Cool Kids – we also have  online versions of Cool Kids, where we run   treatments via the internet, both for children,  a child version, and an adolescent version, which   we call Chilled Out. And so, here’s some data,  again done from Denmark, the Danish groups are   fabulous at running Cool Kids and running great  research. This is a Danish group looking – in   2019 – looking at the impact of Chilled Out, our  adolescent version of Cool Kids online treatment. In this study they had 70 adolescents aged 13  to 17 years. Those of you who work with young   people know that’s a pretty tough time to be  treating kids, an average of 15 years of age,   so this was a difficult group of kids. 80% were  female, and in this particular study they gave   this online treatment, which has regular  delivered sessions that are done online,   and together with this, they also – these  Researchers had telephone calls with the   young person for 20 minutes at a time, every  week. Now, that’s a relatively heavy amount   of Therapist input in this case, compared to  some online treatments, but it’s still much,   much less than you would find in traditional  face-to-face treatments. They’re still a very   low-intensity treatment, and they also  had a booster call three months later. And this is the percentage who were free of  their presenting anxiety disorder at the end   of treatment. You can see, even with this  low-intensity treatment, online treatment   with just 20-minute Therapist phone calls, 40%  of these teenagers were free of their primary   disorder at the end of treatment, compared  to only about 15% of those in the waitlist.   And three months later, that was more or less  maintained, a little bit – a slight drop-off,   but still about 35% free of their primary  disorder, with this relatively low-intensity   treatment. And as I mentioned earlier, it’s not  just this programme, but there are many other   online treatments, and in general, the research  shows these programmes work and they work well. So, let me, then, just get onto some broader  comments of interest to Therapists and   Researchers, which is, firstly, what are some  of the moderators of treatment? What are some   of the factors that we need to consider that  will impact the efficacy of treatment? Firstly,   the severity of anxiety. We know that  more – kids who start out more severe,   will finish more severe. They actually  show equivalent improvement over time. So,   kids – severity of anxiety doesn’t seem to  moderate the effects of treatment, but it   does affe – obviously moderate the endpoint,  because these kids start out more severe,   at the end of 12 weeks of treatment, ten sessions,  12 weeks, they are still more severe. So,   if you need to treat a child with greater severity  anxiety, you might need to continue for longer. Social anxiety disorder is a big one. We know  from study after study after study from all   around the world, that the kids who have social  anxiety disorder, either as their main presenting   disorder or as an additional disorder, those  kids don’t do as well in treatment. There are   a number of theories around this, about why,  but we don’t know exactly what the reason is,   but we do find consistent evidence that  the young people with an – social anxiety   disorder tend to have worse outcome at the  end of treatment. They don’t respond as well. Comorbid disorders, kids who have other comorbid  disorders, such as externalising disorders or mood   disorders, also don’t seem to do as well. Again,  the evidence suggests that these kids actually do   respond to treatment as well as kids without these  extern – these other disorders. In other words,   they change at the same, sort of, rate,  but again, like the severity issue,   kids with comorbid problems, particularly  those kids with ext – with depression,   comorbid depression, they start out a lot worse  at the beginning of treatment, and therefore, even   though they improve over time, they still finish  a lot worse. And they need something – either   something additional, or they need more  sessions, because at the end of ten sessions,   they have not remitted nearly as much as kids who  don’t have these additional comorbid problems. We also know that parent emotional disorder, that  is, parents who have anxiety or mood disorders,   their children don’t tend to respond quite  as well. And that’s possibly partly due to   the extra genetic loading, or it might be  due to the way in which these parents are   engaging with their child. But for whatever  the reason, we don’t know the exact reason,   those kids – parent emotional disorder also  appears to impact treatment, so those kids   don’t do quite as well as the kids of parents  who don’t have anxiety or mood disorders. That’s the bad news. What about the good news?  What are some of the moder – potential moderators   that actually don’t moderate, actually don’t  make a lot of difference to treatment? Firstly,   the group versus individual treatment, I mentioned  this point earlier. It doesn’t seem to make a   difference to outcome whether you treat kids –  anxious kids as a group, or whether you treat   them individually, one-on-one. The outcomes  appear to be much the same. So, that’s good   news. You can – the Therapist can choose how they  want to run treatments. It might be more efficient   to run it as a group, but it’s also sometimes a  little harder to arrange, and so, it’s different   Therapists will run it in different ways, and it  doesn’t seem to make any difference to outcome. Girls versus boys also doesn’t seem to  make a lot of difference. There’s perhaps   a little bit of – maybe some hints in the  research, a little bit of suggestion that   boys do a little better than girls at  the end of treatment, but in general,   no significant difference, and overall,  there doesn’t seem to be much difference. So,   you can treat girls and boys much the  same, and outcomes will be much the same. Similarly, children versus adolescents. There  are a few little hints in the literature that   adolescents perhaps are harder to treat and  don’t do quite as well in outcome. There’s no   doubt that most Therapists who work with  children and adolescents will admit that   adolescents are a little bit harder to engage in  treatment, and they have more autonomy of course,   so engagement is more important.  But overall, the research shows   that children and adolescents at the end of  treatment appear to do very similarly well,   and there doesn’t seem to be any major or obvious  difference between the ages in terms of outcome. Therapist contact time I put under this  list, but it’s a little bit more confusing,   a little bit more mixed than that. Overall,  Therapist contact time doesn’t make a big   difference when you get to the higher level.  So, there’s some evidence that when you’re doing   traditional face-to-face treatment, when  you have very little – very few sessions,   and very little Therapist time, such as two  or three or five sessions, they don’t – kids   in those programmes don’t do quite as well as  kids that might get eight or more sessions.   But the evidence suggests that once you have  more than about eight sessions face-to-face,   it makes no difference how many sessions  you have, the outcomes are much the same. We also know, as I’ve shown before, that  online treatments, low-intensity treatments,   also show very good effects, and that’s  with very, very minimal Therapist time. So,   Therapist contact time is a slightly mixed  question. It’s not true that it makes no   difference, but in general, it doesn’t  seem to make a huge amount of difference,   particularly if you have  the right form of treatment. Type of anxiety disorder also makes very little  difference, apart from the comment I made earlier   about social anxiety disorder. As we know, kids  with social anxiety disorder tend to do much worse   than kids with other disorders, but kids with  the other forms of anxiety disorder do very,   very similarly at the end of treatment, and  that includes obsessive compulsive disorder. So,   kids who have obsessive compulsive disorder,  separation anxiety disorder, specific phobias,   or generalised anxiety disorder, all seem  to have very, very similar outcomes at the   end of treatment. It’s only social anxiety  disorder that seems to do a little worse. And finally, the very good news for those who  are working with autism spectrum disorder,   the – having autism spectrum disorder appears  to make no difference at all to outcome. And   there’s now some very good meta-analyses showing  that you can treat the anxiety component among   kids with autism spectrum disorder, and the  outcomes for anxiety are just as good as you   get for anxiety disorders for kids without  autism spectrum disorder. There are specific   treatments we – for Cool Kids, for example, we  have a specific separate version of Cool Kids   specifically designed for kids who have autism  spectrum disorder, and there’s similar specific   programmes in other parts of the world for  kids with the comorbid problems. So, a slightly   different programme is used, but the good news  is that the anxiety component of that is treated   equally as well, whether or not kids are on the  spectrum and so, they get equally good results. Thank you very much for listening.  I hope this was useful to you,   and I wish you all the very best  in your research and your practice.