Child Psychiatry & Human Development

, Volume 50, Issue 6, pp 940–949 | Cite as

The Effects of Youth Anxiety Treatment on School Impairment: Differential Outcomes Across CBT, Sertraline, and their Combination

  • Amanda L. SanchezEmail author
  • Jonathan S. Comer
  • Stefany Coxe
  • Anne Marie Albano
  • John Piacentini
  • Scott N. Compton
  • Golda S. Ginsburg
  • Moira A. Rynn
  • John T. Walkup
  • Dara J. Sakolsky
  • Boris Birmaher
  • Philip C. Kendall
Original Article


Youth anxiety disorders are highly prevalent and are associated with considerable school impairment. Despite the identification of well-supported strategies for treating youth anxiety, research has yet to evaluate the differential effects of these treatments on anxiety-related school impairment. The present study leveraged data from the Child/Adolescent Anxiety Multimodal Study to examine differential treatment effects of CBT, sertraline, and their combination (COMB), relative to placebo (PBO), on anxiety-related school impairment among youth (N = 488). Latent growth modeling revealed that all three active treatments demonstrated superiority over PBO in reducing anxiety-related school impairment over time, with COMB showing the most robust effects. According to parent report, medication strategies may have stronger effects on anxiety-related school impairment among males than among females. Results were discrepant across parents and youth. Findings are discussed in terms of clinical implications for anxious youth and the need for continued research to examine treatment effects on anxiety-related school impairment.


Child Adolescent Anxiety School impairment CAMS CBT Sertraline 



This research was supported by NIMH Grants U01 MH64088, U01 MH064003, U01 MH63747, U01 MH64003, U01 MH64092, U01 MH64107, U01 MH064089, and K23 MH090247. Sertraline and matching placebo were supplied free of charge by Pfizer.

Compliance with Ethical Standards

Conflict of interest

Ms. Sanchez reports nothing to disclose. Dr. Comer reports Grant Support from NIMH, NICHD, NSF, PCORI, the Charles H. Hood Foundation, the Andrew Kukes Foundation for Social Anxiety, and the International Obsessive–Compulsive Disorder Foundation, as well as personal fees from Oxford University Press and Worth Publishing/Macmillan Learning. Dr. Albano reports royalties from Oxford University Press and has received honorarium from American Psychological Association. Dr. Piacentini reports grant support from NIMH, Tourette Association of America, TLC Foundation for BFRBs, Pettit Family Foundation, and Pfizer Pharmaceuticals. He reports royalties from Guilford Press and Oxford University Press and has received honorarium and travel support from the Tourette Association of America, and the International OCD Foundation. Dr. Compton reports research support from NIMH and has served as a consultant to Shire Pharmaceuticals. He has received honoraria from the Nordic Long-Term Obsessive–Compulsive Disorder (OCD)-Treatment Study Research Group and Journal of Consulting and Clinical Psychology (JCCP). He has provided expert testimony at Duke Forensic Group. Dr. Walkup reports grant support from the Hartwell Foundation and the Tourette Syndrome Association. He has served on the advisory board and speaker’s bureau of the Tourette Syndrome Association. He reports royalties from Guilford Press and Oxford University Press and has received honorarium and travel support from the Tourette Syndrome Association. He is an unpaid member of the Scientific Advisory Board of the Trichotillomania Learning Center, the Scientific Council of the Anxiety and Depression Association of America, and a Scientific Advisor to the American Foundation of Suicide Prevention. Dr. Ginsburg reports research support from NIMH and DOE. Dr. Rynn research support from NIMH, personal fees from Oxford University Press, and royalties from UpToDate. Dr. Birmaher reports grant support from NIMH and personal fees from Random House, Inc., Lippincott Williams and Wilkins, and UpToDate. Dr. Kendall reports grant support from NIMH and NICHD, as well as personal fees from Oxford University Press, Guilford Press, Ericsson, and Workbook Publishing. Dr. Kendall receives royalties from the sales of materials related to the treatment of anxiety in youth, such as the materials used in the CAMS report.


  1. 1.
    Merikangas KR, He JP, Burstein M, Swanson SA, Avenevoli S, Cui L et al (2010) Lifetime prevalence of mental disorders in US adolescents: results from the National Comorbidity Survey Replication-Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry 49:980–989. CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Comer JS, Blanc C, Grant B, Hasin D, Liu SM, Turner JB, Olfson M (2011) Health-related quality of life across the anxiety disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions. J Clin Psychiatry 72:43–50. CrossRefPubMedGoogle Scholar
  3. 3.
    Comer JS, Olfson M (2010) The epidemiology of anxiety disorders. In: Simpson HB, Schneier F, Neria Y, Lewis-Fernandez R (eds) Anxiety disorders. Theory, research, and clinical perspectives. Cambridge University Press, New York, pp 6–19. CrossRefGoogle Scholar
  4. 4.
    Lyneham HJ, Sburlati ES, Abbott MJ, Rapee RM, Hudson JL, Tolin DF et al (2013) Psychometric properties of the Child Anxiety Life Interference Scale (CALIS). J Anxiety Disord 27:711–719. CrossRefPubMedGoogle Scholar
  5. 5.
    Bittner A, Egger HL, Erkanli A, Costello EJ, Foley DL, Angold A (2007) What do childhood anxiety disorders predict? J Child Psychol Psychiatry 48:1174–1183. CrossRefPubMedGoogle Scholar
  6. 6.
    Cornacchio D, Crum KI, Coxe S, Pincus DB, Comer JS (2016) Irritability and severity of anxious symptomatology among youth with anxiety disorders. J Am Acad Child Adolesc Psychiatry 55:54–61. CrossRefPubMedGoogle Scholar
  7. 7.
    Cummings CM, Caporino NE, Kendall PC (2014) Comorbidity of anxiety and depression in children and adolescents: 20 years after. Psychol Bull 140:816–845. CrossRefPubMedGoogle Scholar
  8. 8.
    Duperrouzel J, Hawes S, Lopez-Quintero C, Pacheco-Colon I, Comer JS, Gonzalez R (2017) The relationships between adolescent cannabis use and anxiety: a parallel process analysis. Addict Behav 78:107–113. CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Poznanski B, Cornacchio D, Coxe S, Pincus DB, McMakin DL, Comer JS (2018) The link between anxiety severity and irritability among anxious youth: evaluating the mediating role of sleep problems. Child Psychiatry Hum Dev 49:352–359. CrossRefPubMedGoogle Scholar
  10. 10.
    Wu P, Goodwin R, Comer JS, Hoven C, Cohen P (2010) The relationship between anxiety disorders and substance use among adolescents in the community: specificity and gender differences. J Youth Adolesc 39:177–188. CrossRefPubMedGoogle Scholar
  11. 11.
    Copeland WE, Angold A, Shanahan L, Costello EJ (2014) Longitudinal patterns of anxiety from childhood to adulthood: the great smoky mountains study. J Am Acad Child Adolesc Psychiatry 53:21–33. CrossRefPubMedGoogle Scholar
  12. 12.
    Green JG, Comer JS, Donaldson AR, Elkins RM, Nadeau MS, Reid G, Pincus D (2017) School functioning and use of school-based accommodations by treatment-seeking anxious children. J Emot Behav Disord 25:220–232. CrossRefGoogle Scholar
  13. 13.
    Mychailyszyn MP, Mendez JL, Kendall PC (2010) School functioning in youth with and without anxiety disorders: comparisons by diagnosis and comorbidity. Sch Psychol Rev 39:106–121Google Scholar
  14. 14.
    Swan AJ, Kendall PC (2016) Fear and missing out: youth anxiety and functional outcomes. Clin Psychol Sci Pract 23:417–435. CrossRefGoogle Scholar
  15. 15.
    Woodward LJ, Fergusson DM (2001) Life course outcomes of young people with anxiety disorders in adolescence. J Am Acad Child Adolesc Psychiatry 40:1086–1093. CrossRefPubMedGoogle Scholar
  16. 16.
    Kessler RC, Foster CL, Saunders WB, Stang PE (1995) Social consequences of psychiatric disorders, I: educational attainment. Am J Psychiatry 152:1026–1032. CrossRefPubMedGoogle Scholar
  17. 17.
    Kessler RC, Greenberg PE (2002) The economic burden of anxiety and stress disorders. Neuropsychopharmacology 67:981–992Google Scholar
  18. 18.
    Albano AM, Comer JS, Compton SN, Piacentini J, Kendall PC, Birmaher B et al (2018) Secondary outcomes from the child/adolescent anxiety multimodal study: Implications for clinical practice. Evid Based Pract Child Adolesc Ment Health 3:30–41. CrossRefPubMedGoogle Scholar
  19. 19.
    Walkup JT, Albano AM, Piacentini J, Birmaher B, Compton SN, Sherrill JT et al (2008) Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. N Engl J Med 359:2753–2766. CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Kendall PC, Safford S, Flannery-Schroeder E, Web A (2004) Child anxiety treatment: outcomes in adolescence and impact on substance use and depression at 7.4-year follow-up. J Consult Clin Psychol 72:276–287. CrossRefPubMedGoogle Scholar
  21. 21.
    Peris TS, Compton SN, Kendall PC, Birmaher B, Sherrill J, March J et al (2015) Trajectories of change in youth anxiety during cognitive-behavior therapy. J Consult Clin Psychol 83:239–252. CrossRefPubMedGoogle Scholar
  22. 22.
    Peterman JS, Carper MM, Elkins RM, Comer JS, Pincus DB, Kendall PC (2016) The effects of cognitive behavioral therapy for youth anxiety on sleep problems. J Anxiety Disord 37:78–88. CrossRefPubMedGoogle Scholar
  23. 23.
    Beidel DC, Turner SM, Morris TL (1999) Psychopathology of childhood social phobia. J Am Acad Child Adolesc Psychiatry 38:643–650. CrossRefPubMedGoogle Scholar
  24. 24.
    Silverman WK, La Greca AM, Wasserstein S (1995) What do children worry about? Worries and their relation to anxiety. Child Dev 66:671–686. CrossRefPubMedGoogle Scholar
  25. 25.
    Weems CF, Silverman WK, La Greca AM (2000) What do youth referred for anxiety problems worry about? Worry and its relation to anxiety and anxiety disorders in children and adolescents. J Abnorm Child Psychol 28:63–72. CrossRefPubMedGoogle Scholar
  26. 26.
    Wood J (2006) Effect of anxiety reduction on children’s school performance and social adjustment. Dev Psychol 42:345–349. CrossRefPubMedGoogle Scholar
  27. 27.
    Nail JE, Cristofferson J, Ginsburg GS, Drake K, Kendall PC, McCracken JT et al (2015) Academic impairment and impact of treatments among youth with anxiety disorders. Child Youth Care Forum 44:327–342. CrossRefGoogle Scholar
  28. 28.
    Gallo KP, Cooper-Vince CE, Hardway C, Pincus DB, Comer JS (2014) Trajectories of change across outcomes in intensive treatment for adolescent panic disorder and agoraphobia. J Clin Child Adolesc Psychol 43:742–750. CrossRefPubMedGoogle Scholar
  29. 29.
    Chu BC, Skriner LC, Zandberg LJ (2013) Shape of change in cognitive behavioral therapy for youth anxiety: symptom trajectory and predictors of change. J Consult Clin Psychol 81:573–587. CrossRefPubMedGoogle Scholar
  30. 30.
    Craske MG (1999) Anxiety disorders: psychological approaches to theory and treatment. Westview Press, BoulderGoogle Scholar
  31. 31.
    McLean CP, Asnaani A, Litz BT, Hofmann SG (2011) Gender differences in anxiety disorders: prevalence, course of illness, comorbidity and burden of illness. J Psychiatr Res 45:1027–1035. CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Derdikman-Eiron R, Indredavik MS, Bakken IJ, Bratberg GH, Hjemdal O, Colton M (2012) Gender differences in psychosocial functioning of adolescents with symptoms of anxiety and depression: longitudinal finding from the Nord-Trondelag Health Study. Soc Psychiatry Psychiatr Epidemiol 47:1855–1863. CrossRefPubMedGoogle Scholar
  33. 33.
    Langley AK, Bergman R, McCracken J, Piacentini JC (2004) Impairment in childhood anxiety disorders: preliminary examination of the Child Anxiety Impact Scale-Parent Version. J Child Adolesc Psychopharmacol 14:105–114. CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Compton SN, Walkup JT, Albano AM, Piacentini JC, Birmaher B, Sherrill JT et al (2010) Child/Adolescent Anxiety Multimodal Study (CAMS): rationale, design, and methods. Child Adolesc Psychiatry Ment Health 4:1–15. CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Kendall PC, Compton SN, Walkup JT, Birmaher B, Albano AM, Sherrill J et al (2010) Clinical characteristics of anxiety disordered youth. J Anxiety Disord 24:360–365. CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Muthén LK, Muthén BO (1998–2015) Mplus User’s Guide. Seventh Edn. Muthén & Muthén, Los AngelesGoogle Scholar
  37. 37.
    Widaman KF, Ferrer E, Conger RD (2010) Factorial invariance within longitudinal structural equation models: measuring the same construct across time. Child Dev Perspect 4:10–18. CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Brown AM, Deacon BJ, Abramowitz JS, Dammann J, Whiteside SP (2007) Parents’ perceptions of pharmacological and cognitive-behavioral treatments for childhood anxiety disorders. Behav Res Ther 45:819–828. CrossRefPubMedGoogle Scholar
  39. 39.
    Prins MA, Verhaak PF, Bensing JM, van der Meer K (2008) Health beliefs and perceived need for mental health care of anxiety and depression—the patients’ perspective explored. Clin Psychol Rev 28:1038–1058. CrossRefPubMedGoogle Scholar
  40. 40.
    Jick H, Kaye JA, Jick SS (2004) Antidepressants and the risk of suicidal behaviors. JAMA 292:338–343. CrossRefPubMedGoogle Scholar
  41. 41.
    Rynn M, Walkup JT, Compton SN, Sakolsky DJ, Sherrill JT, Shen S et al (2015) Child/Adolescent anxiety multimodal study: evaluating safety. J Am Acad Child Adolesc Psychiatry 54:180–190. CrossRefPubMedGoogle Scholar
  42. 42.
    Comer JS, Kendall PC (2004) A symptom-level examination of parent-child agreement in the diagnosis of anxious youths. J Am Acad Child Adolesc Psychiatry 43:878–886. CrossRefPubMedGoogle Scholar
  43. 43.
    De Los Reyes A, Kazdin AE (2005) Informant discrepancies in the assessment of childhood psychopathology: a critical review, theoretical framework, and recommendations for further study. Psychol Bull 131:483. CrossRefGoogle Scholar
  44. 44.
    Kendall PC, Hudson JL, Gosch E, Flannery-Schroeder E, Suveg C (2008) Cognitive-behavioral therapy for anxiety disordered youth: a randomized clinical trial evaluating child and family modalities. J Consult Clin Psychol 76:282–297. CrossRefPubMedGoogle Scholar
  45. 45.
    Sanchez AL, Cornacchio D, Poznanski B, Golik AM, Chou T, Comer JS (2018) The effectiveness of school-based mental health services for elementary-aged children: a meta-analysis. J Am Acad Child Adolesc Psychiatry 57:153–165. CrossRefPubMedGoogle Scholar
  46. 46.
    Atkins MS, Cappella E, Shernoff ES, Mehta TG, Gustafson EL (2017) Schooling and children’s mental health: realigning resources to reduce disparities and advance public health. Annu Rev Clin Psychol 13:123–147. CrossRefPubMedGoogle Scholar
  47. 47.
    Ginsburg GS, Drake KL (2002) School-based treatment for anxious African-American adolescents: a controlled pilot study. J Am Acad Child Adolesc Psychiatry 41:768–775. CrossRefPubMedGoogle Scholar
  48. 48.
    Ginsburg GS, Becker KD, Drazdowski TK, Tein JY (2012) Treating anxiety disorders in inner city schools: results from a pilot randomized controlled trial comparing CBT and usual care. Child Youth Care Forum 41:1–19. CrossRefPubMedPubMedCentralGoogle Scholar
  49. 49.
    Masia Warner C, Colognori D, Brice C, Herzig K, Mufson L, Lynch C et al (2016) Can school counselors deliver cognitive-behavioral treatment for social anxiety effectively? A randomized controlled trial. J Child Psychol Psychiatry 57:1229–1238. CrossRefPubMedGoogle Scholar
  50. 50.
    Simon NM, Zalta AK, Worthington Iii JJ, Hoge EA, Christian KM, Stevens JC et al (2006) Preliminary support for gender differences in response to fluoxetine for generalized anxiety disorder. Depress Anxiety 23:373–376. CrossRefPubMedGoogle Scholar
  51. 51.
    Ginsburg GS, Kendall PC, Sakolsky D, Compton SN, Piacentini J, Albano AM et al (2011) Remission after acute treatment in children and adolescents with anxiety disorders: findings from the CAMS. J Consult Clin Psychol 79:806. CrossRefPubMedPubMedCentralGoogle Scholar
  52. 52.
    Ginsburg GS, Becker-Haimes EM, Keeton C, Kendall PC, Iyengar S, Sakolsky D et al (2018) Results from the Child/Adolescent Anxiety Extended Long-Term Study (CAMELS): primary anxiety outcomes. J Am Acad Child Adolesc Psychiatry 57:471. CrossRefPubMedGoogle Scholar
  53. 53.
    Piacentini J, Bennett S, Compton S, Kendall PC, Birmaher B, Albano AM et al (2014) 24- and 36-week outcomes for the Child/Adolescent Anxiety Multimodal Study (CAMS). J Am Acad Child Adolesc Psychiatry 53:297–310. CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2019

Authors and Affiliations

  • Amanda L. Sanchez
    • 1
    Email author
  • Jonathan S. Comer
    • 1
  • Stefany Coxe
    • 1
  • Anne Marie Albano
    • 2
  • John Piacentini
    • 3
  • Scott N. Compton
    • 4
  • Golda S. Ginsburg
    • 5
  • Moira A. Rynn
    • 4
  • John T. Walkup
    • 6
  • Dara J. Sakolsky
    • 7
  • Boris Birmaher
    • 7
  • Philip C. Kendall
    • 8
  1. 1.Center for Children and Families and Department of PsychologyFlorida International UniversityMiamiUSA
  2. 2.Division of Child & Adolescent Psychiatry, Department of PsychiatryColumbia University Medical Center, New York State Psychiatric InstituteNew YorkUSA
  3. 3.Department of Psychiatry and Biobehavioral SciencesUCLA Semel Institute for Neuroscience and Human BehaviorLos AngelesUSA
  4. 4.Department of Psychiatry and Biobehavioral SciencesDuke UniversityDurhamUSA
  5. 5.Department of PsychiatryUniversity of Connecticut School of MedicineFarmingtonUSA
  6. 6.Anne and Robert H. Lurie Children’s Hospital of ChicagoChicagoUSA
  7. 7.Western Psychiatric Institute and Clinic—University of Pittsburgh Medical CenterPittsburghUSA
  8. 8.Department of PsychologyTemple UniversityPhiladelphiaUSA

Personalised recommendations