5findings suggest that the association is more complex compared to what has been

previously assumed (Fjermestad et al., 2016; Marker et al., 2013).

The current study has a number of notable strengths, including the use of treatment-as-usual as active control treatment, clinicians’ treatment of children in mental health clinical practice, the use of mother- and child-reported outcomes, and long term follow-up assessments. Some limitations should also be considered when interpreting the findings. First, the diagnostic assessment of DSM-IV diagnoses was conducted by agency clinicians after an extensive diagnostic process that was usual in the agencies, but this was not done in a standardized manner such as with diagnostic interviews. Further research would benefit from assessment based on diagnostic interviews. Second, by actively screening children in primary schools, we probably included children who would not have sought or received treatment without recruitment in the current study. Thus, the sample was a mix of children with a clinical anxiety disorder referred for treatment and children who were in need for treatment but would otherwise not have received it. Although mean baseline anxiety scores reported by mother and child were comparable to those in other clinical trials (Bodden, Bögels, & Muris, 2009; Muris & Steerneman, 2001), some caution is warranted to generalize the findings to clinical samples from routine child mental health services.

Third, we were unable to include the number of children we anticipated (Janssen et al., 2012). Thus, the analyses were underpowered. More research with bigger sample sizes is needed.

Conclusions and Implications

Although this study has some limitations, it supports previous findings, which suggested that manualized CBT does not outperform usual treatment in routine clinical practice. Treatment-as-usual was even superior to CBT in some instances.

Since treatment-as-usual in the participating Dutch agencies consisted of CBT components, the study adds to the growing literature that supports the efficacy of CBT for children with an anxiety disorder. Moreover, findings seem to suggest that CBT can be effective in a shorter and more flexible manner than prescribed by manualized CBT programs. However, treatment predictors and moderators still need to be assessed to determine which children benefit from which treatment.

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CHAPTER 6