Academic journal article Canadian Psychology

The Management of Childhood Anxiety Disorders in Ontario's Public Mental Health System

Academic journal article Canadian Psychology

The Management of Childhood Anxiety Disorders in Ontario's Public Mental Health System

Article excerpt

Substantial empirical data support the use of cognitivebe- havioural therapy (CBT) and pharmacotherapy with selective serotonin reuptake inhibitors (SSRIs) in the treatment of child- hood anxiety disorders (Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004; Ipser, Stein, Hawkridge, & Hoppe, 2009; Ishikawa, Okajima, Matsuoka, & Sakano, 2007; James, Soler, & Weatherall, 2005; Kodish, Rockhill, & Varley, 2011; Reinblatt & Riddle, 2007; Silverman, Pina, & Viswesvaran, 2008; Walkup et al., 2008). Some evidence suggests that their combina- tion may be most effective, with results from a randomized control trial showing that combined CBT and SSRI (Sertraline) treatment was superior to either monotherapy (Walkup et al., 2008). Based on research evidence, several professional organisations have de- veloped practice guidelines. For instance, the American Aca- demy of Child and Adolescent Psychiatry (AACAP; Connolly, Bernstein, & Work Group on Quality Issues, 2007) issued practice parameters for the treatment of childhood anxiety advocating for the use of combined treatment with SSRIs and psychotherapy, such as CBT, for moderate to severe anxiety in children. The Society of Clinical Child and Adolescent Psychotherapy (Division 53, American Psychological Association) also provides web-based information on Evidence-Based Treatments or EBTs (http://www .effectivechildtherapy.com) based on the current state of scientific knowledge. Individual, group, and family CBT are recommended in the treatment of anxiety based on meta-analyses (Silverman et al., 2008).

Recently, there have been several national efforts to increase the use of EBTs for mental health disorders in Canada, with the Canadian Psychological Association (CPA) releasing a task force report on evidence-based psychological treatments to support and guide practice, as well as to inform stakeholders (CPA, 2012; Dozois, 2013). The Mental Health Commission of Canada also released the Evergreen: Child and Youth Framework for Canada report (Kutcher & McLuckie, 2010), in which using the "best available evidence" to inform treatments was identified as a core value in the reform of Canada's publicly funded children's mental health care system.

Although "best available evidence" supports the use of CBT and SSRIs for the treatment of childhood anxiety, it is not clear how childhood anxiety is typically managed in clinical settings and whether patients can access EBTs. There is often a gap between research evidence and what constitutes usual care (UC) in clinical settings for these disorders (Hoagwood & Olin, 2002), with the implementation of EBTs affected by clinicians' attitudes toward the adoption of such interventions, the institutional context, the availability of treatment manuals, appropriate training and ongoing supervision in EBTs, financial factors, and consumer demand (e.g., see Aarons, 2004; Salloum, Sulkowski, Sirrine, & Storch, 2009; Torrey et al., 2001). Given the researchpractice gap, knowledge of UC is important to guide efforts to improve mental health interventions.

Usual Care

In their review of UC, Garland, Bickman, and Chorpita (2010) indicated that therapists generally identified themselves as using an "eclectic" approach, incorporating interventions from several different theoretical models. Although they found that elements of EBTs occurred frequently in UC, other common elements of EBTs appeared to be employed less frequently or with less intensity or depth by practitioners. UC has also been found to include practice elements not typically included in the EBTs for that particular problem area (e.g., see Daleiden, Lee, & Tolman, 2004). Even practitioners who use EBTs may not incorporate all of the sup- ported treatment ingredients, which might lower overall efficacy. For example, Freiheit, Vye, Swan, and Cady (2004) found that the majority of psychologists (88%) surveyed in Minnesota reported using CBT techniques to treat anxiety disorders. …

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