Introduces topic (1), cites article to be appraised, and appraisal tool utilized (1), provides 2-3 sentences summarizing the overarching strengths and weaknesses of the article (2), and includes summary statement that indicates that the article was “include”, “seek further information” or “exclude” (1)
Chooses 2 criteria from the assigned appraisal tool that were found to be weaknesses or that introduced bias into the study. In a sentence state what the 2 criteria are that you will be expanding upon
1. Explains each of the 2 criteria and why it is important 2. States whether and how the article meets the desired level of quality for the criteria 3. Cites the article, the appraisal tool, and other resources as necessary for explanation.
Article is CAMELS and appriasal tool is CASP both attached below.
CASP Randomised Controlled Trial Standard Checklist:
11 questions to help you make sense of a randomised controlled trial (RCT)
Main issues for consideration: Several aspects need to be considered when appraising a
randomised controlled trial:
Is the basic study design valid for a randomised
controlled trial? (Section A)
Was the study methodologically sound? (Section B)
What are the results? (Section C)
Will the results help locally? (Section D)
The 11 questions in the checklist are designed to help you think about these aspects
systematically.
How to use this appraisal tool: The first three questions (Section A) are screening questions
about the validity of the basic study design and can be answered quickly. If, in light of your
responses to Section A, you think the study design is valid, continue to Section B to assess
whether the study was methodologically sound and if it is worth continuing with the appraisal by
answering the remaining questions in Sections C and D.
Record ‘Yes’, ‘No’ or ‘Can’t tell’ in response to the questions. Prompts below all but one of the
questions highlight the issues it is important to consider. Record the reasons for your answers
in the space provided. As CASP checklists were designed to be used as educational/teaching
tools in a workshop setting, we do not recommend using a scoring system.
About CASP Checklists: The CASP RCT checklist was originally based on JAMA Users’ guides to the
medical literature 1994 (adapted from Guyatt GH, Sackett DL and Cook DJ), and piloted with
healthcare practitioners. This version has been updated taking into account the CONSORT 2010
guideline (http://www.consort-statement.org/consort-2010, accessed 16 September 2020).
Citation: CASP recommends using the Harvard style, i.e. Critical Appraisal Skills Programme
(2020). CASP (insert name of checklist i.e. Randomised Controlled Trial) Checklist. [online]
Available at: insert URL. Accessed: insert date accessed.
©CASP this work is licensed under the Creative Commons Attribution – Non-Commercial- Share
A like. To view a copy of this licence, visit https://creativecommons.org/licenses/by-sa/4.0/
Critical Appraisal Skills Programme (CASP) part of Oxford Centre for Triple Value Healthcare Ltd www.casp-uk.net
2
…………………………………………………………………………………………………………
Section A: Is the basic study design valid for a randomised controlled trial?
1. Did the study address a clearly focused
research question?
CONSIDER:
Was the study designed to assess the outcomes
of an intervention?
Is the research question ‘focused’ in terms of:
• Population studied
• Intervention given
• Comparator chosen
• Outcomes measured?
Yes No Can’t tell
o o
2. Was the assignment of participants to
interventions randomised?
CONSIDER:
• How was randomisation carried out? Was
the method appropriate?
• Was randomisation sufficient to eliminate
systematic bias?
• Was the allocation sequence concealed
from investigators and participants?
Yes No Can’t tell
o o o
3. Were all participants who entered the study
accounted for at its conclusion?
CONSIDER:
• Were losses to follow-up and exclusions
after randomisation accounted for?
• Were participants analysed in the study
groups to which they were randomised
(intention-to-treat analysis)?
• Was the study stopped early? If so, what
was the reason?
Yes No Can’t tell
o o o
Section B: Was the study methodologically sound?
4.
• Were the participants ‘blind’ to
intervention they were given?
• Were the investigators ‘blind’ to the
intervention they were giving to
participants?
• Were the people assessing/analysing
outcome/s ‘blinded’?
Yes No Can’t tell
o o o
o o
o o o
5. Were the study groups similar at the start of
the randomised controlled trial?
CONSIDER:
• Were the baseline characteristics of each
study group (e.g. age, sex, socio-economic
group) clearly set out?
• Were there any differences between the
study groups that could affect the
outcome/s?
Yes No Can’t tell
o o o
3
6. Apart from the experimental intervention, did
each study group receive the same level of
care (that is, were they treated equally)?
CONSIDER:
• Was there a clearly defined study protocol?
• If any additional interventions were given
(e.g. tests or treatments), were they similar
between the study groups?
• Were the follow-up intervals the same for
each study group?
Yes No Can’t tell
o o o
Section C: What are the results?
7. Were the effects of intervention reported
comprehensively?
CONSIDER:
•
• What outcomes were measured, and were
they clearly specified?
• How were the results expressed? For
binary outcomes, were relative and
absolute effects reported?
• Were the results reported for each
outcome in each study group at each
follow-up interval?
• Was there any missing or incomplete data?
• Was there differential drop-out between the
study groups that could affect the results?
• Were potential sources of bias identified?
• Which statistical tests were used?
• Were p values reported?
Yes No Can’t tell
o o o
8. Was the precision of the estimate of the
intervention or treatment effect reported?
CONSIDER:
• Were confidence intervals (CIs) reported?
Yes No Can’t tell
o o o
9. Do the benefits of the experimental
intervention outweigh the harms and costs?
CONSIDER:
• What was the size of the intervention or
treatment effect?
• Were harms or unintended effects
reported for each study group?
• Was a cost-effectiveness analysis
undertaken? (Cost-effectiveness analysis
allows a comparison to be made between
different interventions used in the care of
the same condition or problem.)
Yes No Can’t tell
o o o
Was a power calculation undertaken?
4
Section D: Will the results help locally?
10. Can the results be applied to your local
population/in your context?
CONSIDER:
• Are the study participants similar to the
people in your care?
• Would any differences between your
population and the study participants alter
the outcomes reported in the study?
• Are the outcomes important to your
population?
• Are there any outcomes you would have
wanted information on that have not been
studied or reported?
• Are there any limitations of the study that
would affect your decision?
Yes No Can’t tell
o o o
11. Would the experimental intervention provide
greater value to the people in your care than
any of the existing interventions?
CONSIDER:
• What resources are needed to introduce
this intervention taking into account time,
finances, and skills development or training
needs?
• Are you able to disinvest resources in one
or more existing interventions in order to
be able to re-invest in the new
intervention?
Yes No Can’t tell
o o o
Record key points from your critical appraisal in this box. What is your
conclusion about the paper? Would you use it to change your practice or to recommend changes to
care/interventions used by your organisation? Could you judiciously implement this intervention
without delay?
- Study and citation:
- Section D Will the results help locally:
- Check Box2: Off
- Q:
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- Check Box1: Off
- Check Box4: Off
- Check Box5: Off
- Check Box6: Off
- Check Box7: Off
- Check Box9: Off
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- Check Box40: Off
1 consideration answers:
2 consideration answers:
3 consideration answers:
5 consideration answers:
6 consideration answers:
7 consideration answers:
8 consideration answers:
9 consideration answers:
10 consideration answers:
11 consideration answers:
APPRAISAL SUMMARY:
NEW RESEARCH
Results From the Child/Adolescent Anxiety
Multimodal Extended Long-Term Study (CAMELS):
Primary Anxiety Outcomes
Golda S. Ginsburg, PhD, Emily M. Becker-Haimes, PhD, Courtney Keeton, PhD, Philip C.
Kendall, PhD, ABPP, Satish Iyengar, PhD, Dara Sakolsky, MD, Anne Marie Albano, PhD,
Tara Peris, PhD, Scott N. Compton, PhD, John Piacentini, PhD, ABP
P
Objective: To report anxiety outcomes from the multisite Child/Adolescent Anxiety Multimodal Extended Long-term Study (CAMELS). Rates of
stable anxiety remission (defined rigorously as the absence of all DSM-IV TR anxiety disorders across all follow-up years) and predictors of anxiety
remission across a 4-year period, beginning 4 to 12 years after randomization to 12 weeks of medication, cognitive-behavioral therapy (CBT), their
combination, or pill placebo were examined. Examined predictors of remission included acute treatment response, treatment assignment, baseline child
and family variables, and interim negative life events.
Method: Data were from 319 youths (age range 10.9�25.2 years; mean age 17.12 years) originally diagnosed with separation, social, and/or
generalized anxiety disorders and enrolled in the multi-site Child/Adolescent Anxiety Multimodal Study (CAMS). Participants were assessed annually by
independent evaluators using the age-appropriate version of the Anxiety Disorders Interview Schedule and completed questionnaires (eg, about family
functioning, life events, and mental health service use).
Results: Almost 22% of youth were in stable remission, 30% were chronically ill, and 48% were relapsers. Acute treatment responders were less likely
to be in the chronically ill group (odds ratio ¼ 2.73; confidence interval ¼ 1.14�6.54; p < .02); treatment type was not associated with remission status
across the follow-up. Several variables (eg, male gender) predicted stable remission from anxiety disorders.
Conclusion: Findings suggest that acute positive response to anxiety treatment may reduce risk for chronic anxiety disability; identified predictors can
help tailor treatments to youth at greatest risk for chronic illness.
Clinical Trial Registration Information: Child and Adolescent Anxiety Disorders (CAMS). http://clinicaltrials.gov/; NCT00052078.
Key words: anxiety, treatment, follow-up, cognitive-behavior therapy, sertraline
J Am Acad Child Adolesc Psychiatry 2018;57(7):471–480.
P
Journal of t
Volume 57
ediatric anxiety disorders are highly prevalent, are
associated with severe disability, and confer high
personal and economic costs.1-3 These illnesses
are chronic, as data from retrospective and prospective
studies show high degrees of continuity for anxiety disorders
as children reach adolescence and adulthood.4-6 Conse-
quently, identifying factors that interrupt the progression or
persistence of these illnesses is paramount. One key factor
may be early and effective treatment. Two evidenced-based
treatments, cognitive-behavioral therapy (CBT) and selec-
tive serotonin reuptake inhibitor (SSRI) use, have been
shown to reduce anxiety and related impairment in the
short term.7 However, data on whether an acute positive
response to these treatments reduces risk of anxiety
disability years later are limited. A recent review of studies
examining the long-term benefits of treatments for pediatric
anxiety disorders concluded that the majority of youths
he American Academy of Child & Adolescent Psychiatry
/ Number 7 / July 2018
receiving cognitive-behavioral treatment no longer meet
diagnostic criteria for their initial anxiety diagnosis at an
average of 5.85 years after treatment.8 However, studies in
this review were cross-sectional (ie, a one-time assessment at
follow-up) and consequently may over- or underestimate
the long-term benefits of treatment. Follow-up studies of
medication or combination treatment are lacking.
Our study, called the Child/Adolescent Anxiety Multi-
modal Extended Long-term Study (CAMELS),9 was
designed to address this issue by examining the long-term
outcomes of anxious youth across 4 consecutive years1 who
were initially randomized in the landmark Child/Adolescent
Anxiety Multimodal Study (CAMS)7 to 1 of 4 treatment
conditions (ie, CBT, SSRI, combination of SSRI and CBT,
or pill placebo). Youth entered the CAMELS study between
4
and 12 years after their initial randomization in the CAMS.
After study entry, participants were expected to be assessed
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http://crossmark.crossref.org/dialog/?doi=10.1016/j.jaac.2018.03.017&domain=pdf
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GINSBURG et al.
annually over 5 consecutive years. Specifically, each year
participants were asked to complete one “long” and “short”
visit. During each long visit, a diagnostic evaluation was
completed, along with several self- and parent-report ques-
tionnaires. During the “short” visits, study staff conducted
telephone interviews to complete questions about mental
health symptoms and service use. Data presented in this
article were obtained during long visits only that were
completed over 4 consecutive years. The current study
examined the following: (1) rates of stable anxiety disorder
remission (as well as relapse and chronicity), and (2) pre-
dictors of stable remission across the follow-up period.
Examined predictors included the following: acute treatment
response (ie, clinically meaningful improvement measured 12
weeks after randomization) to one of the CAMS treatments;
the CAMS treatment assignment (sertraline, CBT, their
combination, or pill placebo); the CAMS baseline child and
family variables (ie, demographics, child clinical characteris-
tics, presence of study entry diagnoses, family/parent func-
tioning); and interim negative life events between the CAMS
and this follow-up study. Data examining the long-term
outcomes of treated youth can provide important informa-
tion about downstream anxiety disability and estimates and
expectations for prognosis to families. These data can also
inform possible preventive efforts. Examining predictors of
youth outcomes over time can help identify needed modifi-
cations for subgroups of anxious youth, regardless of treat-
ment type, to enhance maintenance of treatment gains and to
reduce relapse. Moreover, the specific predictors examined in
this study were selected in light of literature indicating their
relation to acute and/or long-term anxiety treatment
response.10 Based on the recent review of long-term treat-
ment outcomes for anxious youth,8 we hypothesized that
approximately 60% of youth would be in stable remission.
With respect to predictors, we hypothesized that the CAMS
treatment responders (compared to nonresponders), regard-
less of treatment type, would more likely be in remission.
Given that youth who received combination treatment were
more likely to be acute treatment responders, we hypothe-
sized that they would be more likely to be in stable remission
at the follow-up.
METHOD
Participants
Participants were 319 volunteer families previously enrolled
in the CAMS (representing 65.3% of the original sample of
488). All youth in the CAMS at baseline were between 7
and 17 years of age and met criteria for social, generalized,
and/or separation anxiety disorder according to the Diag-
nostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision (DSM-IV TR). The average age range
472 www.jaacap.org
of these youth at the time of their first CAMELS follow-up
assessment was 17.12 years (range ¼ 10.9�25.2 years).
Average length of time since initial randomization to a
CAMS treatment condition and the first CAMELS follow-
up assessment was 6.51 years (SD ¼ 1.65). The length of
time varied by participant based on enrollment date in the
CAMS and recruitment date into CAMELS. Table 1 dis-
plays the demographic and clinical characteristics of those
enrolled in CAMELS (n ¼ 319) and those CAMS partici-
pants who did not participate in CAMELS (n ¼ 169).
Measures
Anxiety Disorders. Presence of current anxiety disorder was
assessed annually at each long visit using the age-appropriate
version of the Anxiety Disorders Interview Schedule for DSM-
IV (ADIS).11,12 The ADIS interviews are the gold standard
assessment tools for determining anxiety disorders, were
used in the CAMS, and have been well validated. In the
current study, interrater diagnostic agreement (ie, k values)
were all greater than 0.90 for anxiety diagnoses based on a
randomly selected sample (n ¼ 90; 28%) of ADIS ad-
ministrations. Diagnostic agreement was defined as
matching on the presence or absence of a disorder and a
Clinical Severity Rating within one point. Within-person
trajectories of anxiety disorders over the follow-up period
were assessed by creating three groups of youths who
completed three or more annual ADIS assessments: (1) re-
mitters, defined rigorously as youth who did not meet
diagnostic criteria for any anxiety disorder (defined as any
DSM-IV TR anxiety disorder, including post-traumatic
stress disorder and obsessive-compulsive disorder) at any
follow-up visit; (2) chronic, defined as youth who met
diagnostic criteria for one or more anxiety disorder at every
follow-up visit; and (3) relapsers, youth who were anxiety
diagnosis free during at least one follow-up visit and met
diagnostic criteria for one or more anxiety disorders at
another follow-up visit.
This definition of remission was selected over a less
rigorous criterion, such as absence of all three of the CAMS
entry disorders (generalized, social, and separation anxiety) or
absence of a primary disorder only because numerous studies
have demonstrated that pediatric anxiety disorders are highly
comorbid (at both the symptom and disorder level) and
manifest differently over the course of development (eg,
separation anxiety disorder predicts later panic disorder).
Thus, an overly narrow definition may confound conclusions
about the long-term outcomes following anxiety treatment.
Predictor Variables
CAMS Treatments. As noted, eligible youth were random-
ized to 12 weeks of one of the following treatments (described
Journal of the American Academy of Child & Adolescent Psychiatry
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TABLE 1 Comparisons Between the Child/Adolescent Anxiety Multimodal Study (CAMS) and the Child/Adolescent Anxiety
Multimodal Extended Long-term Study (CAMELS) Sample
All CAMELS Participants vs. Nonparticipants
Participated in 1�2 Assessment
Time Points vs. 3þ Time Points
Non
participants
(n ¼ 169)
CAMELS
Participants
(n ¼ 319) Statistic
1�2 Time
Points Only
(n ¼ 95)
3þ Time
Points
(n ¼ 224) Statistic
% % % %
Female gender 39.1 55.2 11.48**a 52.6 56.3 .35a
Ethnicity, Hispanic 19.5 8.2 13.45***a 9.5 7.6 .32a
Racial minority 26.0 18.5 3.78a 20.0 17.9 .20a
Tx condition 0.86a 1.71a
Combination 28.4 28.8 33.7 26.8
Sertraline 25.4 28.2 26.3 29.
0
CBT 29.0 28.2 27.8 28.6
Placebo 17.2 14.7 12.6 15.6
CAMS Responseb 60.9 66.4 1.28a 75.9 62.8 4.60*a
Mean SD Mean SD Mean SD Mean SD
Baseline age 10.81 2.81 10.69 2.80 0.67c 10.82 2.72 10.55 2.83 0.78c
Hollingshead SES 44.45 12.07 49.70 10.99 L4.85***c 47.27 12.53 50.72 10.13 L2.59*c
Baseline CGI-S 5.05 0.76 5.01 0.71 0.59c 5.05 .74 5.00 0.70 0.66c
Baseline CGAS 51.21 6.99 50.45 7.17 1.13c 50.93 7.26 50.24 7.13 0.78c
Baseline # Dx 2.89 1.28 3.00 1.19 L0.92c 3.02 1.25 2.99 1.17 0.21c
Baseline
Parent BFAM
11.11 5.75 10.95 5.12 0.30c 11.61 4.76 10.69 5.24 1.40c
Parent BSI 0.50 0.46 0.47 0.40 0.76c 0.49 0.42 0.46 0.39 0.52c
Years since
Randomizationd
— — — — — 7.29 1.94 6.19 1.39 5.69***
Note: BFAM ¼ Brief Family Assessment of Functioning Measure; BSI ¼ Brief Symptom Inventory; CBT ¼ cognitive-behavioral therapy; CGAS ¼
Children’s Global Assessment of Functioning Scale; CGI-S ¼ Clinical Global Impression�Severity Scale; Dx ¼ diagnosis; SES ¼ socioeconomic status.
aFrom c2 test.
bData presented on the CAMS posttreatment response status represent available data only. It should be noted that 31 youth who did not participate in
CAMELS and 18 youth who did participate in CAMELS were missing data for their 12-week outcome assessment and were not included in this
comparison. If the last observation carried forward (LOCF) data imputation method is used for this variable, then youth in the CAMELS are more likely
to have been CAMS treatment responders than youth who did not participate in the CAMELS.
cFrom t test.
dNot applicable for non-CAMELS participants.
*p < .05; **p < .01; ***p < .001.
LONG-TERM OUTCOMES FOR ANXIOUS YOUTH
in detailed elsewhere7): (1) CBT: CBT consisted of the age-
appropriate versions of the Coping Cat protocol: Coping
Cat for children and C.A.T. Project for Adolescents13,14.
Both protocols included 12 individual child sessions (
60
minutes each) and 2 parent-only sessions scheduled over 12
weeks. (2) Sertraline (SRT): SRT treatment consisted of eight
30- to 60-minute in-person sessions involving discussing
anxiety symptoms, functioning, and adverse events within
supportive clinical care. Medication was administered using a
“fixed-flexible” dosing strategy that was linked to clinical
response and side effects. In general, participants’ medication
dose was adjusted upward in 50-mg/d increments if anxiety
levels were moderate to high. The dose was held stable, or
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 7 / July 2018
adjusted downward, if the participant had few anxiety
symptoms or if there were impairing side effects. (3) Com-
bination treatment (COMB): COMB consisted of both CBT
and SRT. (4) Pill placebo (PBO): PBO consisted of a double-
blinded treatment that paralleled SRT. Youth assigned to
PBO who were considered “nonresponders” to treatment
were offered the CAMS CBT and/or medication.
CAMS Treatment Responder Status. CAMS treatment
responder was defined using the Clinical Global
Impression�Improvement Scale (CGI-I)15 assigned at
posttreatment (ie, 12 weeks after randomization). The CGI-
I is a 7-point scale (1 ¼ very much improved, 7 ¼ very
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GINSBURG et al.
much worse) completed by the independent evaluator.
Youth with CGI-I scores of 1 (very much improved) or 2
(much improved) were categorized as treatment responders.
Negative Life Events. Negative life events were assessed at
each completed CAMELS visit using the Life Events Scale
(LES),16 which is a 35-item parent-report measure of
exposure to a broad range of stressful events that cut across
family, school, and social domains. Examples include death
of a parent, change in income, school failure, illness, and
moving. A total score was calculated reflecting the aggregate
number of endorsed negative life events since CAMS and
over the follow-up period.
CAMS Baseline Demographic Variables. Demographic
variables included child age, gender, race/ethnicity (minor-
ity versus nonminority), and socioeconomic status as
measured by the Hollingshead Index,17 all reported by the
participating parent.
CAMS Baseline Child Clinical Variables. Child clinical
variables included a) anxiety symptom severity as measured
by the Clinical Global Impression�Severity Scale (CGI-S).15
The CGI-S is a well-established measure that yields a global
rating of anxiety severity ranging from 1 (not at all ill) to 7
(extremely ill) and b) comorbid disorders (internalizing and
externalizing) based on the age-appropriate version of the
ADIS. Internalizing disorders included any non�study entry
anxiety or depressive disorder. Externalizing disorders
included disruptive behavior disorders (eg, oppositional
defiant disorder, attention-deficit/hyperactivity disorder).
CAMS Baseline Family/Parent Variables.. Brief Family
Assessment Measure (BFAM)18 The BFAM is a 14-item
measure completed by parents to assess overall family func-
tioning (eg, “We take the time to listen to each other”). A total
score was used, with higher scores indicating more family
dysfunction (Cronbach’s a at the CAMS baseline was 0.84).
Brief Symptom Inventory (BSI)19 The BSI is a widely
used 53-item parent-report measure of global psychiatric
symptomatology (Cronbach’s a at the CAMS baseline was
0.95). For the present analyses, the Global Severity Index
(BSI-GSI) provided a single composite score of current
symptoms of somatization, obsessive-compulsive disorder,
interpersonal sensitivity, depression, anxiety, hostility,
phobic anxiety, paranoid ideation, and psychosis. Higher
scores suggest greater severity of psychological distress.
Burden Assessment Scale (BAS)20 The BAS is a 21-item
parent completed measure that assesses caregiver burden
associated with having a child with a mental health disorder.
Parents indicated how much the child’s anxiety disrupts
family life, emotions, and routines on a scale ranging from
474 www.jaacap.org
1 (not at all) to 5 (very much). A total score was used, with
higher score reflecting greater burden. Cronbach’s a at the
CAMS baseline sample was 0.91.
Additional Control Variables
To reduce bias associated with interim mental health service
use, the Supplemental Services Form of the ADIS (SSF),
assessed at each CAMELS long and short visit, was entered as
a control variable in all analyses. The SSF was administered by
a research assistant at each follow-up visit and assessed the use
of a broad range of mental health services since the CAMS.
Examples of these services include psychiatric hospitalization,
psychotropic medication, and various kinds of psychotherapy
(eg, family, supportive, psychodynamic). A dichotomous
score (ie, yes/no for any use across all SSF items) was calcu-
lated over the entire follow-up period; 238 youth (74.6%)
reported receiving some sort of mental health service use over
the follow-up. Additional control variables included treat-
ment site (collected at the CAMS baseline) and time since the
CAMS randomization (in years).
Procedures
This was a naturalistic follow-up study conducted at six sites
in the United States (Johns Hopkins University, University
of California Los Angeles, University of Pittsburgh, Temple
University, Duke University, and Columbia University) and
approved by the respective institutional review boards. Prior
to enrollment, and after complete description of the study,
parents/guardians provided written informed consent and
children provided assent. Recruitment for CAMELS began in
2011 and ended in 2015. Recruitment for the original
treatment study, the CAMS, occurred between 2002 and
2007. In the CAMS, eligible youth were randomized into one
of four treatment conditions: CBT only, SRT (sertraline
medication) only, COMB (combination CBT and SRT), or
PBO (placebo). At posttreatment (12 weeks after randomi-
zation), youth were evaluated by independent evaluators who
determined treatment response status. Youth assigned to pill
placebo who were determined to be “nonresponders” were
offered any active CAMS treatments. Receipt of subsequent
treatment for anxiety was documented on the SSF and
statistically controlled for in the current study.
The proposed CAMELS grant was a 5-year study.
However, because of variations in study start-up and end
dates at each recruitment site, sample sizes varied across the
5 years and resulted in a significantly lower sample size of
participants completing all five annual assessments. 319
youth completed their first long CAMELS visit. The sample
size of youth who completed their subsequent long visits
were: year 2 ¼ 239, year 3 ¼ 220, year 4 ¼ 209; year 5 ¼
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 7 / July 2018
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LONG-TERM OUTCOMES FOR ANXIOUS YOUTH
91; only 61 youth participated in all 5 long visits. Because
of the low year 5 enrollment, the current study included
only data obtained across 4 years.
Potentially eligible families for the current study were
contacted via letter, social media outlets, and phone. Fam-
ilies expressing interest provided written informed consent
and then were expected to complete a maximum of five
annual in-person evaluations, depending on when the
family was enrolled. During these “long” evaluations,
measures described above (and several others) were
collected. Between each long visit (mid-way at 6 months), a
phone evaluation was planned (referred to as a “short” visit),
during which time only questionnaire data were collected.
During the long visits, a trained independent evaluator
administered the age-appropriate diagnostic interview and
other measures used in this study. Short visits were con-
ducted by research assistants. Each family was reimbursed
$130 for completion of each long visit and $50 for each
FIGURE 1 Child/Adolescent Anxiety Multimodal Extended Long-
488 Enrolled in
140 Assigned
to receive
sertraline and
CBT
133 Assigned
to receive
sertraline
alone
319 Enrolled in
CAMELS
92 (66% of
140)
Received
sertraline
and CBT
90 (68% of
133)
Received
sertraline
alone
90 (65% of
139)
Received
CBT alone
47 (62% of
76)
Received
placebo
1 CAMELS visit:
n = 18
2 CAMELS visits:
n = 13
3 CAMELS visits:
n = 8
4 CAMELS visits:
n = 33
5 CAMELS visits:
n =
20
1 CAMELS visit:
n = 10
2 CAMELS visits:
n = 13
3 CAMELS visits:
n = 11
4 CAMELS visits:
n = 37
5 CAMELS visits:
n = 19
1 CAMELS visit:
n = 9
2 CAMELS visits:
n = 15
3 CAMELS visits:
n = 15
4 CAMELS visits:
n = 35
5 CAMELS visits:
n = 16
Note: CAMS ¼ Child/Adolescent Anxiety Multimodal Study; CBT ¼ cognitive-behavio
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 7 / July 2018
short visit. Figure 1 provides the Consolidated Standards Of
Reporting Trials (CONSORT) diagram.
Data Analysis
Analyses included all youth enrolled in CAMELS, regardless
of their original CAMS treatment assignment. Descriptive
analyses determined rates of remission across each year in
this follow-up study. Acute treatment response and initial
treatment assignment were examined as predictors of
remission in each year using logistic regressions, controlling
for treatment site, supplemental service use, and baseline
anxiety severity. To determine predictors of the course of
anxiety disorders within youth over time, participants with
three or more long follow-up visits (n ¼ 224) were classified
into one of the three groups defined earlier (ie, remitters,
chronically ill, relapsers). Multinomial regression analyses
examined predictors of group membership (remitter,
chronic, relapse). Predictor analyses included the following
term Study (CAMELS) Participant Flow
the CAMS
139 Assigned
to receive CBT
alone
76 Assigned to
receive placebo
169 Did not
Participate
146 Could not
contact/ were
not interested
23 Declined
further
contact
during
the CAMS
1 CAMELS visit:
n = 3
2 CAMELS visits:
n = 6
3 CAMELS visits:
n = 10
4 CAMELS visits:
n = 22
5 CAMELS visits:
n = 6
ral therapy.
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GINSBURG et al.
covariates: study site, the CAMS baseline anxiety severity
(CGI-S), time since the CAMS randomization (in years),
and mental health service use (using the SSF dichotomous
variable) since the CAMS. These predictors were analyzed
across a series of 5 models: demographic predictors (model
1), baseline clinical predictors (model 2), presence/absence
of study entry diagnoses at the CAMS baseline (model 3),
parent and family predictors (model 4), and life events
(model 5). Missing data analysis for this subgroup of 224
participants revealed that no predictor had more than 2%
missing data and was therefore handled via listwise deletion.
RESULTS
CAMS and CAMELS Sample Comparisons
Table 1 displays the demographic and clinical characteristics
between those enrolled in CAMELS (n ¼ 319) and those not
enrolled in CAMELS (n ¼ 169) as well as between those who
completed three or more, versus less than three CAMELS
annuallong-visitassessments.Youthwhodidnotparticipatein
CAMELS did not differ significantly from CAMELS partici-
pants on baseline anxiety severity, number of disorders, or
percent of the CAMS treatment responders (all p values >.05).
However, CAMELS participants were more likely to be fe-
male, of non-Hispanic ethnicity, and to families from higher
socioeconomic (SES) backgrounds than non-CAMELS par-
ticipants. CAMELS youth who completed three or more
annual long study visits were less likely to have been the CAMS
treatment responders and were of lower SES backgrounds
compared to those who completed only one to twostudy visits.
Primary Analyses: Anxiety Remission Rates
Figure 2 displays the raw data on anxiety disorder
remission rates for the total CAMELS sample and by
FIGURE 2 Remission Rates Across Follow-up Assessment
Time Points
0
10
20
30
40
50
60
CAMELS Y1 CAMELS Y2 CAMELS Y3 CAMELS Y4
Total Sample CAMS Responder CAMS Nonresponder
* *
*
Note: Child/Adolescent Anxiety Multimodal Study (CAMS) Responder status
associated with increased likelihood of remission. CAMELS ¼ Child/Adolescent
Anxiety Multimodal Extended Long-Term Study. Please note color figures are
available online.
*p < .05.
476 www.jaacap.org
treatment responder status across each of the 4 years in
the follow-up study. For the total sample, remission rates
ranged from 42% to 48.8% across years 1 to 4. When
rates of remission were examined within person across all
4 years, results indicated that 21.7% were in stable
remission, 30% were chronically ill, and 48% were
relapsers (Figure 3). Rates of remission in each year by
treatment group ranged from 40% to 60% in CBT, 40%
to 52% in SRT, 41% to 49% in COMB, and 25% to
47% in PBO.
Predictors of Remission
Results from logistic regression analyses examining pre-
dictors of remission at each follow-up year indicated that the
CAMS treatment responders were more likely to be in
remission at each time point, with the exception of year 4
(year 1: OR ¼ 1.81, 95% CI ¼ 1.07�3.07, p ¼ .03; year
2: OR ¼ 2.23, 95% CI ¼ 1.24�4.01, p ¼ .007; year 3:
OR ¼ 1.92, 95% CI ¼ 1.04�3.53, p ¼ .04; year 4: OR ¼
1.26, 95% CI ¼ 0.69�2.31, p ¼ .45). Logistic regressions
examining whether treatment assignment was a predictor of
remission at any year revealed no association.
Results from multinomial regression analyses predicting
group membership (remitters, relapsers, or chronically ill)
indicated that the CAMS treatment responders were more
likely to be in the remitter group relative to the chronic
group (OR ¼ 2.73, 95% CI ¼ 1.14�6.54, p ¼ .02). The
CAMS treatment assignment was not associated with
remission status (all p values >.05). Several factors predicted
group membership (Table 2): specifically, male gender
(OR ¼ 3.85, 95% CI ¼ 1.59�9.35), younger age (OR ¼
0.82, 95% CI ¼ 0.69�0.98]), youth without social phobia
anywhere in their diagnostic profile (OR ¼ 0.36, 95%
FIGURE 3 Percent Remitters, Chronic, and Relapsers Across
Follow-up Period
0
10
20
30
40
50
60
Consistent Remitters Relapsers Chronic
Total Sample CAMS Responders CAMS NonResponders
*
Note: Child/Adolescent Anxiety Multimodal Study (CAMS) Responder status asso-
ciated with increased likelihood of group membership. Please note color figures
are available online.
*p < .05.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 7 / July 2018
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TABLE 2 Predictors of Remission Groups in the Multisite Child/Adolescent Anxiety Multimodal Extended Long-term Study
(CAMELS) from Multinomial Regression Analysis
Predictor
Chronic vs. Remissiona Relapsers vs. Remissionb
OR CI p OR CI p
CAMS Response 2.73 (1.14e6.54) .02 1.05 (0.47e2.33) .59
CAMS Treatment Conditionc
Combination 1.47 (0.41e5.33) .56 0.99 (0.29e3.40) .99
Sertraline only 1.74 (0.49e6.14) .39 0.95 (0.29e3.14) .93
CBT only 2.26 (0.63e8.12) .21 1.02 (0.31e3.38) .98
Demographic Predictors
Age 0.82 (0.69e0.98) .03 0.89 (0.76e1.05) .17
Male gender 3.85 (1.59e9.35) .003 4.51 (2.03e10.04) <.001
Minority status 0.86 (0.26e2.90) .81 1.03 (0.34e3.12) .96
SES 1.17 (0.68e1.99) .58 1.07 (0.66e1.74) .89
Baseline Clinical Predictors
Anxiety severity (CGI-S) .80 (0.37e1.72) .57 0.81 (0.41e1.60) .55
Overall functioning (CGAS) 1.09 (1.01e1.19) .03 1.03 (0.97e1.10) .33
Comorbid internalizing 0.59 (0.24e1.46) .26 0.96 (0.35e2.58) .93
Comorbid externalizing 0.74 (0.25e2.17) .59 0.77 (0.35e1.73) .53
Presence of Baseline Study Entry Diagnoses
Separation anxiety 0.99 (0.44e2.26) .98 0.58 (0.28e1.19) .14
Social phobia 0.36 (0.13e0.96) .04 0.39 (0.17e0.88) .02
Generalized Anxiety 1.61 (0.54e4.76) .39 0.99 (0.38e2.66) .99
Parent and Family Predictors
Parental global distress (BSI) 1.86 (0.58e5.99) .30 1.47 (0.51e4.23) .48
Family functioning (BFAM) 0.94 (0.90e0.98) .006 0.99 (0.96e1.02) .56
Caregiver strain (BAS) 0.99 (0.96e1.03) .73 0.99 (0.96e1.02) .22
Negative Life Events 0.37 (0.19e0.69) .002 0.62 (0.36e1.08) .09
Note: All analyses controlled for baseline anxiety severity, treatment site, years since Child/Adolescent Anxiety Multimodal Study (CAMS) randomi-
zation, and supplemental service use over the follow-up period. BAS ¼ Burden Assessment Scale; BFAM ¼ Brief Family Assessment of Functioning
Measure; BSI ¼ Brief Symptom Inventory; CBT ¼ cognitive-behavioral therapy; CGAS ¼ Children’s Global Assessment of Functioning Scale; CGI-S ¼
Clinical Global Impression�Severity Scale; OR ¼ odds ratio; SES ¼ socioeconomic status.
aOdds ratios represent the odds of being in the remission group relative to the chronic group.
bOdds ratios represent the odds of being in the remission group relative to the relapse group.
cResults show results of active treatment compared to placebo intervention.
LONG-TERM OUTCOMES FOR ANXIOUS YOUTH
CI ¼ 0.13�0.96]), higher global functioning (OR ¼ 1.09,
95% CI ¼ 1.01�1.19), and better family functioning
(OR ¼ 0.94, 95% CI ¼ 0.90�0.98; all measured pre-
treatment) and fewer interim negative life events
(OR ¼ 0.37, 95% CI ¼ 0.19�0.69]) were all associated
with belonging to the stable remission group relative to the
chronically ill group (all p values <.05). Youth without
social phobia at baseline (OR ¼ 0.39, 95% CI ¼
0.17�0.88) and male gender (OR ¼ 4.51, 95% CI ¼
2.03�10.04) were also associated with increased likelihood
of being in the remission group relative to the relapser group
(p vallues <.05). Minority status, SES, baseline anxiety
severity (CGI-S scores), diagnostic comorbidity, parental
psychopathology, and caregiver strain at the CAMS baseline
were not associated with group membership across the
follow-up period.
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 7 / July 2018
Post Hoc Analyses
Given the number of significant predictors found across the
five models, we ran an additional multivariate model
including all the significant predictors outlined above in
addition to the established covariates (treatment site, sup-
plemental service use, baseline anxiety severity, and years
since randomization) to determine which predictors
remained after controlling for the other significant
predictors. Most predictors remained significant, with
male gender (OR ¼ 3.01, 95% CI ¼ 1.16�7.79),
absence of baseline social phobia (OR ¼ 0.32, 95%
CI ¼ 0.10�0.98]), better baseline family functioning
(OR ¼ 0.95, 95% CI ¼0.91�0.99), and fewer negative life
events (OR ¼ 0.35, 95% CI ¼ 0.18�0.70) associated with
increased likelihood of belonging to the remission group
relative to the chronic group; youth age and baseline
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GINSBURG et al.
functioning were no longer significant. Only male gender
remained a predictor of remission group membership rela-
tive to the relapser group (OR ¼ 3.90, 95% CI ¼
1.69�9.00); social phobia diagnosis at baseline was reduced
to a trend (OR ¼ 0.40, 95% CI ¼ 0.16�1.03).
Finally, because of the potential confounding effects of
interim mental health service use, we also examined patterns
of services use across treatment condition and remission
status groups, controlling for treatment site. Rates of sup-
plemental service use ranged from 69% (CBT) to 83%
(placebo). Logistic regression analyses showed no differences
in the percentage of youth receiving interim mental health
services based on original treatment condition relative to
placebo (combination: OR ¼ 1.17, 95% CI ¼ 0.36�3.44;
CBT: OR ¼ 0.48, 95% CI ¼ 0.17�1.36; sertraline: OR ¼
0.73, 95% CI ¼ 0.25�2.10). Rates of supplemental service
use based on remission status across the follow up were 63%
(remission group), 74% (relapse group), and 90% (chronic
group). Multinomial regressions indicated that youth who
did not receive supplemental services were more likely to be
in the remission group relative to the chronic group (OR ¼
4.14, 95% CI ¼ 1.56�10.97) and the relapse group
(OR ¼ 2.26, 95% CI ¼ 1.10�4.66).
DISCUSSION
The present study provides rarely obtained multiyear pro-
spective data on the long-term outcomes for a large sample of
youth with anxiety disorders who were treated in the context
of a randomized controlled multisite trial comparing sertra-
line, cognitive-behavioral therapy, their combination, and a
pill placebo. In contrast to cross-sectional follow-up studies
and our initial hypothesis, findings revealed that despite
receiving high-quality evidenced-based treatments for 12
weeks, less than half of the sample met the rigorous criteria for
stable remission (ie, no longer met diagnostic criteria for any
anxiety disorder across the follow-up years), revealing the
chronic nature of pediatric anxiety disorders for a large
portion of anxious youth and the need for enhanced treat-
ment and relapse prevention strategies. Indeed, only 21.7%
youth were consistently “anxiety free” (absence of all anxiety
disorders) over the course of the follow-up, whereas the
remainder of youth showed a pattern of relapse or chronic
illness. Few studies have followed youth for multiple years,
and these data suggest that cross-sectional snapshots may
overestimate the durability of treatments’ success. Our find-
ings also send a clear and disquieting message that some
anxious youth are in need of longer or better treatments to
reduce the burden of these illnesses over time.
Fortunately, youths who made significant clinical
improvement after 12 weeks of treatment, regardless of
treatment type, were more likely to be in stable remission
478 www.jaacap.org
(versus chronically ill), suggesting there are long-term ben-
efits to getting good treatment early in the course of these
disorders. However, the magnitude of this benefit over time
was modest, indicating room for improvements in the short-
term efficacy even for our best evidenced-based treatments.
With respect to the relative benefits of one specific treat-
ment type (ie, cognitive-behavioral therapy, sertraline, or
their combination), findings revealed no association be-
tween type of treatment assigned and remission status over
time, suggesting that enhancing access to any effective
treatment may have comparable long-term benefits. Of
note, youth originally assigned to the pill placebo condition
faired similarly to those assigned to an active CAMS treat-
ment. One reason may be that the CAMS participants who
were assigned to the pill placebo condition and were
deemed nonresponders at week 12 (ie, posttreatment) were
offered their choice of the CAMS treatment after the
posttreatment assessment. Indeed, the vast majority (86%)
of those assigned to pill placebo reported receiving an active
treatment at CAMELS Visit 1,9 which likely accounts for
the similarities in outcomes at the long-term follow-up.
Identifying predictors of long-term outcomes can help
determine which youths are most at risk for poor outcomes,
increase the use of assessment tools to identify those at
higher risk for poor outcomes, lead to the development of
new treatments for these subgroups of individuals, and
provide helpful prognostic data for patients. Specifically, our
data indicate that youth who were younger at the start of
treatment were more likely to be in stable remission
(compared to chronically ill youth) over the course of the
follow-up study. It may be that older youth had experienced
anxiety for longer periods of time prior to seeking treatment
and that their anxiety may be more recalcitrant to treat-
ment, emphasizing the value of intervening early. Older
youth had higher anxiety severity at the CAMS baseline,21
also suggesting these youth may have had more severe and
less malleable anxiety. Alternatively, it may be that parents
of younger participants were more involved in treatment,
provided more supervision and support, and facilitated
completing treatment requirements such as taking medica-
tion regularly or completing therapy assignments compared
to older youth who have greater autonomy about whether
or how much to engage in treatment. Males were also more
likely to be in stable remission over the 4 years of the follow-
up study, although they did not show lower levels of anxiety
at baseline. The elevated risk for females has been reported
in long-term follow-up studies of adolescent depression22
and suggests that greater screening and gender-specific in-
terventions may be needed to help young women benefit
more from anxiety treatment. We note, however, that there
were relatively fewer males than females in the CAMELS
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Volume 57 / Number 7 / July 2018
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LONG-TERM OUTCOMES FOR ANXIOUS YOUTH
sample, which may have influenced our findings showing
poorer overall outcomes for females.
Several pretreatment child clinical factors also predicted
stable remission, such as youth with higher general func-
tioning as well as participants whose parents endorsed more
positive family interactions such as open communication, a
sense of trust, and fair punishments, suggesting that such
family factors may have a long-term impact on anxiety
remission. In addition, youth with social anxiety disorder at
baseline (not only as primary anxiety disorder) were less
likely to be in stable remission. The relation between social
anxiety disorder and poorer long-term outcomes has been
reported elsewhere.23 The relation between social anxiety
disorder and poorer outcomes may be a result of the
developmental timing of CAMELS assessments. The ma-
jority of youth in the CAMS at baseline were young (mean
age, 7 years), whereas the average age in CAMELS at visit 1
was 17 years—a particularly vulnerable time socially. Thus,
youth with social anxiety disorder at baseline may be more
vulnerable to the social stressors, demands, and transitions
associated with adolescence and emerging adulthood—the
time period captured during CAMELS assessments.
Finally, youth who experienced fewer negative life
events in the time period between the original treatment
study and the follow-up were more likely to be in stable
remission across the follow-up period. A substantial litera-
ture has documented the relation between stressful life
events and pediatric anxiety disorders.24,25 Future studies
are needed to examine the types and timing of these events
to better characterize their impact on long-term outcomes.
Clinically, the assessment of such events should be con-
ducted at regular intervals to address their negative effects.
Assessments of negative life events seems particularly
important for females, as females reported more exposure to
negative life events in this sample than males and females
were less likely to be in stable remission.
Results from this naturalistic follow-up may be
confounded by numerous threats to internal validity (eg,
maturation, history effects), and causal relations cannot be
claimed. The unique characteristics of the sample restricts to
whom results can be generalized. Moreover, the retention rate
of original participants of the CAMS was only 65%, raising
questions about the generalizability of findings and potential
bias (either over- or underestimating remission rates, for
instance). In addition, although there were few differences in
baseline clinical variables (eg, baseline anxiety severity) be-
tween the CAMS and CAMELS samples, those enrolled in
CAMELS were different demographically (eg, less likely to be
female and from ethnic minorities), again raising potential
concerns about generalizability. Despite these limitations,
CAMELS represents the largest sample of anxious youth to be
Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 7 / July 2018
followed over time in the United States, and the retention
rate is similar to those reported in other multi-site trials.22
In sum, findings from this study may be used to inform
clinical research and practice by providing patients with
estimates of prognosis. Conclusions suggest there may be
long-term benefits from early effective treatment with ser-
traline, cognitive-behavioral therapy, and/or their combi-
nation, for anxiety. However, for the majority of pediatric
patients, anxiety disorders are chronic, and additional
treatment and relapse prevention approaches appear war-
ranted. This follow-up study represents a unique and rich
opportunity to gain insight into the natural trajectories of
anxiety disorders following acute treatment. Further in-
depth analyses of these data will follow for years to come,
providing additional insights into how we can improve the
long-term outcomes for anxious youth.
Accepted May 3, 2018.
Dr. Ginsburg is with the University of Connecticut School of Medicine, West
Hartford. Dr. Becker-Haimes is with the University of Pennsylvania, Philadel-
phia. Dr. Keeton is with Johns Hopkins University, Baltimore, MD. Dr. Kendall is
with Temple University, Philadelphia, PA. Drs. Iyengar and Sakolsky are with the
University of Pittsburgh, PA. Dr. Albano is with Columbia University, NY. Drs.
Peris and Piacentini are with the University of California, Los Angeles. Dr.
Compton is with Duke University, Durham, NC.
This research was supported by the National Institute of Mental Health (NIMH)
grants MH064089 to Dr. Ginsburg, MH064003 to Dr. Sakolsky, MH64088 to
Dr. Piacentini, MH64092 to Dr. Albano, MH64107 to Dr. Compton, and
MH063747 to Dr. Kendall. The funding source had no role in the design and
conduct of the study; collection, management, analysis, and interpretation of
the data; preparation, review, or approval of the manuscript; and decision to
submit the manuscript for publication.
Dr. Becker-Haimes served as the statistical expert for this research.
The authors thank the following individuals who worked so diligently to
complete this study: Columbia University Medical Center: M. Rynn, MD, A.
Sarubbi, PsyD, J. Guerry, PhD, O. Jablonka, MA, K. Camacho, MA, A. Rapp,
MA, C. Heleniak, BA, M. Goldfine PhD, and E. Alvarez, MA; Duke University:
J. Curry, PhD, D. Hood, BA, B. Glass-Thomas, BA, C. Mauro, PhD, N. Heilbron,
PhD, J. Sapyta, PhD, R, Dingfelder, PhD, J. Compton, PhD, and P. Cuper, PhD;
The Johns Hopkins University School of Medicine: B. Gibby, MA, J. Walkup,
MD, M. Crosby-Budinger, MA, N. Affrunti, PhD, K. Drake, PhD, T. Drazdowski,
PhD, J. Christofferson, MA, S. Makhzoumi, MA, R. Teetsel, MA, E. Santana, MA,
R. Boyer, MA, N. Marie Dull, MA, A. Gorden-Hollingsworth, PhD, F. Ba’th, MA,
and R. Bloom, MA; Temple University: C. Settipani, PhD, C. Wei, PhD,
D. Brodman, BA, J. Peterman, BA, H. Makover, PhD, and J. Edmunds, BA;
UCLA Semel Institute for Neuroscience and Human Behavior: J. McCracken,
MD, S. Chang, PhD, J. Podell, PhD, R. Vivrette, MD, PhD, D. Solis, BA, M. Wu,
PhD, E. Ricketts, PhD, S. Bai, PhD, MPH, and N. Abrahami, LCSW; Western
Psychiatric Institute and Clinic: B. Birmaher, MD, N. Curcio, MS, J. Bender,
MSW, H. Kumar, MS, and K. Monk, BSN.
Disclosure: Dr. Ginsburg has received support from NIMH and from the US
Department of Education/Institute of Education Sciences. Dr. Becker-Haimes
has received support from NIMH. Dr. Keeton has received support from
NIMH. Dr. Kendall has received support from NIMH and the Eunice Kennedy
Shriver National Institute of Child Health and Human Development (NICHD).
He has received royalties from the sales of materials related to the treatment of
anxiety disorders in youth (eg, Guilford Press; Workbook Publishing; Gyldendal
Norsk; Gyldendal Akademisk). Dr. Iyengar has received support from NIMH.
Dr. Sakolsky has received support from NIMH and NARSAD. She has served as
a consultant for LEK Consulting Inc. Dr. Albano has received royalties from
Oxford University Press for the Anxiety Disorders Interview Schedule, Child and
Parent Versions. She has received an editor’s honorarium from the American
Psychological Association. Dr. Peris has received support from NIMH, the
Society for Clinical Child and Adolescent Psychology, and the TLC Foundation
for Repetitive Behavior Disorders. She has received royalties from Oxford
University Press. Dr. Compton has received support from NIMH, NC
www.jaacap.org 479
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4
GINSBURG et al.
GlaxoSmithKline Foundation, Pfizer, Neurocrine Biosciences, and Mursion, Inc.
He has served as a consultant for Shire and Mursion, Inc. He has received
honoraria from the Nordic Long-Term OCD Treatment Study Research Group
and the Centre for Child and Adolescent Mental Health, Eastern and Southern
Norway. He has served on the scientific advisory board of Tourette Association
of America, Anxiety and Depression Association of America, and Mursion, Inc.
He has presented expert testimony for Duke University. Dr. Piacentini has
received support from NIMH, the TLC Foundation for Body-Focused Repeti-
tive Behaviors, the Tourette Association of America, the Pettit Family Foun-
dation, and Pfizer Pharmaceuticals through the Duke University Clinical
Research Institute Network. He is a co-author of the Child OCD Impact Scale
�Revised (COIS-R), the Child Anxiety Impact Scale�Revised (CAIS-R), the
Parent Tic Questionnaire (PTQ), and the Premonitory Urge for Tics Scale (PUTS)
80 www.jaacap.org
assessment tools, all of which are in the public domain therefore no royalties
are received. He has received royalties from Guilford Press and Oxford Uni-
versity Press. He has served on the speakers’ bureau of the Tourette Associ-
ation of America, the International Obsessive-Compulsive Disorder
Foundation, and the TLC Foundation for Body-Focused Repetitive Behaviors.
Correspondence to Golda S. Ginsburg, PhD, Department of Psychiatry, Uni-
versity of Connecticut School of Medicine, 65 Kane Street Room 2033 West
Hartford, CT 06119; e-mail: Gginsburg@uchc.edu
0890-8567/$36.00/ª2018 American Academy of Child and Adolescent
Psychiatry
https://doi.org/10.1016/j.jaac.2018.03.017
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Journal of the American Academy of Child & Adolescent Psychiatry
Volume 57 / Number 7 / July 2018
mailto:Gginsburg@uchc.edu
https://doi.org/10.1016/j.jaac.2018.03.017
http://www.jaacap.org
- Results From the Child/Adolescent Anxiety Multimodal Extended Long-Term Study (CAMELS): Primary Anxiety Outcomes
Method
Participants
Measures
Anxiety Disorders
Predictor Variables
CAMS Treatments
CAMS Treatment Responder Status
Negative Life Events
CAMS Baseline Demographic Variables
CAMS Baseline Child Clinical Variables
CAMS Baseline Family/Parent Variables
Brief Family Assessment Measure (BFAM)18
Brief Symptom Inventory (BSI)19
Burden Assessment Scale (BAS)20
Additional Control Variables
Procedures
Data Analysis
Results
CAMS and CAMELS Sample Comparisons
Primary Analyses: Anxiety Remission Rates
Predictors of Remission
Post Hoc Analyses
Discussion
References
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Title Page
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