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Anxiety disorders are among the most prevalent pediatric behavioral health conditions, affecting roughly 32% of youths prior to adulthood, and associated with impaired functioning that can continue into adulthood and increase in severity.1,2 In this issue of JAMA Pediatrics, Wang et al3 report an updated meta-analysis evaluating the comparative efficacy of cognitive behavioral therapy (CBT) and pharmacotherapy for pediatric anxiety disorders. Results supported the efficacy of CBT, selective serotonin reuptake inhibitors (SSRIs), and their combination; limited support was provided for serotoninnorepinephrine reuptake inhibitors (SNRIs). We briefly review the evidence followed by implementation issues. Resultsofthemeta-analysisindicatethatCBTandSSRIswere each more likely to result in diagnostic remission/treatment response compared with wait list/no treatment and pill placebo, respectively. Combined CBT and medication led to greater improvements in anxiety symptoms compared with CBT alone (2 studies) or medication alone (1 study). Comparison of CBT and SSRIs (2 studies) indicated greater declines in anxiety (symptoms and diagnostic remission) among CBT-treated vs SSRI-treated children.4,5 Some, but less, support was found for SNRIs on a few outcomes in some trials; there was no support for tricyclic medications, benzodiazpines, or buspirone. Adverse events and treatment dropout were more common during pharmacotherapy compared with CBT, although SSRIs and pill placebo did not statistically differ in dropout rates, dropout due to adverse events, or any specific adverse events. With regard to psychiatric adverse events, no suicide deaths or attempts were reported in any study andsuicidalbehaviorappearedtobelessthanindepressionstudies. Behavioral activation, which is sometimes confused with mania, is a psychiatric adverse event especially noteworthy in children younger than 12 years.6 Fromaclinicalperspective,thekeyissuesarehowmanychildren will recover, how much recovery is expected, and how rapidlywillrecoveryoccur.FindingsfromtheChild/AdolescentAnxietyMultimodalStudy,5 thelargestandmostrigorousrandomized clinical trial included in the meta-analysis, provide a relatively clear answer to these questions. Focusing on children ages 7 to 17 years with primary diagnoses of separation anxiety, generalized anxiety, or social phobia, roughly 81% of youths receiving combined SSRI (sertraline) and CBT had shown “much or very much” clinical improvement compared with 55% for SSRI only, 60% for CBT only, and 24% for pill placebo following 12 weeks of treatment. Remission, defined by the loss of all targeted anxiety diagnoses, was observed in 68%, 46%, 46%, and 24% of youths receiving combined SSRI plus CBT, SSRI only, CBT only, and placebotreatment,respectively,at12weeks.7 Childrenreceivingcombined SSRI plus CBT and those receiving SSRI only began to improve earlier, separating from placebo by 4 weeks. At 12 weeks, theCBT-onlyandSSRI-onlygroupsshowedsimilarimprovements with each group improving more relative to pill placebo. Therefore, current evidence indicates that treatments with demonstrated efficacy in the reviewed trials can yield substantial improvements in anxiety symptoms within a relatively brief period. Despite the large number of included studies and novel information presented, the review is constrained by the limitations of the existing evidence base and meta-analytic methods. The meta-analysis and many of the included studies omit analyses of functional outcomes. Anxious children often show school refusal and avoidance behavior that interferes with optimal development. While it is important to know whether anxiety symptoms and global anxiety decline, it is equally and arguably more important to consider treatment effects on school and social functioning. Results varied by informant, with the strongest evidence emerging for clinician reports, compared with parent report, and relatively weak support based solely on child self-report. Only 1 study conducted a head-to-head comparison of CBT, pharmacotherapy, and their combination.5 The meta-analysis was not restricted to randomized clinical trials and included less rigorous nonrandomized comparative studies. The results provide minimal data on which drugs are most effective. Ironically, the best-researched medications are offlabel for childhood anxiety treatment (excluding obsessivecompulsive disorder) with US Food and Drug Administration approval only for duloxetine. Relatively few studies conducted longer-term follow-ups to assess durability of improvements. This important limitation is underscored by Child/Adolescent Anxiety Multimodal Study findings that approximately half of youth receiving gold-standard CBT, SSRI, or CBT plus SSRI treatments experienced diagnostic recurrence within roughly 6 years of initial treatment.8 These data suggest that anxiety disorders may be best viewed as conditions that can be effectively treated in the short term, but characterized by continuing longer-term risk. Future research is needed to evaluate strategies for longerterm monitoring and preventive care after acute treatment. Meta-analytic methods also have their weaknesses, requiring cautious interpretation. By combining results across trials, statistical power is enhanced, improving the ability to Related article Opinion