Cognitive Behavioral Therapy for Childhood Anxiety

Anxiety is quite common in children. In fact, it is the most commonly diagnosed childhood-onset psychiatric disorder in children. At any given time 10-20% of kids are affected by some type of anxiety.

The CAMS Study

A recent study published in the Journal of the American Academy of Child and Adolescent Psychiatry provided helpful and hopeful information about the treatment of childhood anxiety.  The Child/Adolescent Anxiety Multimodal Study (CAMS) was a randomized, placebo controlled study of 412 children, 7-17 years old, with a number of anxiety disorders (separation anxiety, generalized anxiety, and social phobia). Children were randomized into four treatment groups:

1. Sertraline alone

2. 14 sessions of Cognitive Behavioral Therapy (CBT)

3. A combination of sertraline and CBT

4. Placebo

Sertraline, brand name Zoloft, is a selective serotonin reuptake inhibitor (SSRI), which is commonly used for the treatment of anxiety and depression in adults.  Because of the potential side effects, sertraline is less well studied in children.

The good news is that treatment was very effective across the board.  At 12 weeks the number of children in the four groups that reached “improved” or “very much improved” on the Clinician Global Impression scale were:

  • 80.7% of children in the combination treatment (CBT and sertraline)

  • 59.7% for CBT alone

  • 54.9% for sertraline alone

  • 23.7% for placebo

These are reassuring results that show that treatment works for childhood anxiety.  The study then had follow ups at 24 and 36 weeks, which continued to show hopeful results. Most of the children in the study continued past the original 12 week study to 24 and 36 week follow up assessments.  During this additional time children continued their original treatment plan. This means they received monthly CBT booster sessions, continued sertraline, or both, depending on the group to which they were originally assigned.

At the 12 and 36 week follow up assessments, the combination treatment group maintained their 12 week response rates at 80%, and did not improve further.  However, the children in the CBT and sertraline alone groups continued to improve.  Both groups reached a response rate of 70% at 36 weeks.

Cognitive Behavioral Therapy (CBT) for Children:

In the CAMS study children received 14 sessions of 60 minute CBT based on the “Coping Cat” program. In the study parents met with the child’s therapist for a brief check in at the end of every session.

The five main components of CBT for child anxiety include:

1. Psychoeducation

Both parents and children learn about the signs and triggers of anxiety.  While for some people receiving a diagnosis is an upsetting experience, for others it is a great relief. They know what they are dealing with, and that they are not alone.  Understanding the cycle of anxious thoughts, negative emotions and avoidance behaviors helps children start to see how anxiety is getting in the way of their lives.  Parents can also learn to understand the experience of their child and how they can support their child in the process of overcoming anxiety.

2. Somatic Management Skills Training

Before the cognitive and exposure components of CBT, children need to learn coping skills and relaxation strategies.  Having a good foundation of coping skills supports the next two phases of treatment.  Children learn essential skills such as breathing, relaxation training, and self monitoring.  A variety of mind-body techniques such as breathing, yoga, biofeedback, mindfulness, and guided imagery may also be very useful in learning to manage the physical and psychological symptoms of anxiety.

Diaphragmatic breathing is a particular kind of breathing that involves taking slow breaths into the belly- it is easy to learn and practice, and once learned is always available.

  • Younger children can learn diaphragmatic breathing by placing a stuffed animal on the belly and making the animal float up, or imagining a balloon in their belly, which they fill up with breath.

  • Older children and adolescents can learn diaphragmatic breathing by placing one hand on the belly and focusing their attention on the breath- taking slow deep breaths and breathing so that the hand on the belly rises and falls with each breath

3. Relaxation Training

Relaxation training is personalized for each child. Together provider and patient find strategies that allow for unwinding on daily basis, and techniques that are accessible in crisis situations to manage stress.  Relaxation strategies can be as simple as going for a walk or listening to music, and sometimes the right strategy may involve additional specialized training.  The use of mindfulness and meditation in children is growing in both popularity and evidence base, with studies documenting that children can learn mindfulness techniques and benefit from them

4. Cognitive Restructuring

Anxiety often involves negative thought patterns.  Learning to detect and modify these harmful patterns takes time and effort, yet is ultimately empowering and helpful.  With guidance, children can learn to detect their own negative thought patterns. Some examples of these thought patterns are: negative expectations, focusing on negative events and ignoring positive ones, catastrophizing, negative mind reading, and black and white thinking.

5. Exposure

Exposure involves facing the feared idea or situation either in imagination or in reality.  With exposure children learn that they can handle any anxiety that may come up, and that the anxiety will eventually decrease.  For example, a teenager who may be anxious about talking to other teens would first imagine these interactions, and eventually begin to engage in such interactions in increasingly more challenging situations.

The CAMS study also addressed relapse prevention. It showed that monthly booster sessions of CBT not only maintained the gains from the initial 14 sessions of therapy, but actually allowed for further improvement.  The ongoing maintenance of the skills learned in therapy is essential for protecting from a relapse of symptoms. While some children may need ongoing booster therapy sessions, other children may be able to maintain their learning with the help of parents, teachers and other supportive adults.

What This Study Shows Us

  • Treatment works! The majority of children with anxiety can get better.

  • More intensive treatment, such as a combination of therapy and medication, with more contact with clinicians is more effective and faster.

  • Less intensive treatment such as therapy alone or medication alone takes more time, yet is also effective.

  • Therapy alone and medication alone are equally effective treatments.

  • 14 CBT sessions followed by monthly booster sessions are an effective dose of therapy.

The use of medications in children is a complicated issue.  While the CAMS study shows that medications can be useful for the treatment of childhood anxiety, medications may also carry the risk of side effects.  We do not have long term studies on the safety of these medications in children.  Therefore, parents and clinicians are often cautious about prescribing these medications to children.  The CAMS study shows that while the combination treatment of therapy and medication works faster for a greater number of children, therapy alone works well too.  This is great news for those who would like to minimize the use of medications in children.

At this time we have limited research evidence for the use of alternative and complementary treatments for childhood anxiety.  A 2008 review study noted that a number of treatments such as bibliotherapy, massage, melatonin and relaxation training may reduce anxiety in children, yet concluded that more research is needed. The American As of Child and Adolescent Psychiatry practice guidelines give an overview of the approach and research on the evaluation and treatment of childhood anxiety. They call for a thorough evaluation of childhood anxiety, and a comprehensive treatment approach.

Anxiety can be harmful and disruptive to children’s and their families life. Addressing anxiety symptoms early can protect children from unnecessary suffering and from disruptions in the normal development. Luckily, there are methods of treating anxiety in children that work!