Cochrane review: Cognitive behavioural therapy for anxiety disorders in children and adolescents

Abstract

BackgroundChildhood and adolescent anxiety disorders are relatively common, occurring in between 5‐18% of all children and adolescents. They are associated with significant morbidity and impairment in social and academic functioning, and when persistent, there is a risk of depression, suicide attempts and substance abuse in adulthood. There is accumulating evidence for the efficacy of cognitive behavioural therapy (CBT), with a number of randomised controlled trials (RCTs) suggesting benefit.ObjectivesTo determine whether CBT is an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or attention controls.Search strategySearch of the Cochrane Register of Controlled Trials and the Cochrane Depression, Anxiety and Neurosis Group Register, which includes relevant randomised controlled trials from the bibliographic databases ‐ The Cochrane Library ( to January 2004), EMBASE, (1970‐2004) MEDLINE (1970‐2004) and PsycINFO (1970‐2004). We also searched the references of all included studies and relevant textbooks, and contacted authors in order to identify further trials.Selection criteriaEach identified study was assessed for possible inclusion by two reviewers independently.Inclusion criteria consisted of randomised controlled trials of CBT versus waiting list/attention controls in children (more than six years of age) and adolescents (under the age of 19 years) with a DSM (Diagnostic Statistical Manual) or ICD (International Classification of Diseases) anxiety diagnosis; and excluding simple phobia, obsessive compulsive disorder and post‐traumatic stress disorder. Each study was required to conform to the principles of CBT through use of a protocol and comprising at least eight sessions of CBT.Data collection and analysisThe methodological quality of included trials was assessed by two reviewers independently. The dichotomous outcome of remission of anxiety diagnosis was pooled using relative risk (RR) with 95% confidence intervals. Means and standard deviations of anxiety symptom continuous scores were pooled using the standardised mean difference (SMD). Heterogeneity was assessed and intention‐to‐treat (ITT) analyses undertaken. The presence of publication bias was assessed using funnel plots.Main resultsThirteen studies with 498 subjects and 311 controls met the inclusion criteria and were included in the analyses. The studies involved community or outpatient subjects only, with anxiety of only mild to moderate severity. ITT analyses showed a response rate for remission of any anxiety diagnosis of 56% for CBT versus 28.2% for controls (RR 0.58,95%CI 0.50 to 0.67), with no evidence of heterogeneity. The number needed to treat (NNT) was 3.0 (95%CI 2.5 to 4.5). For reduction in anxiety symptoms, the SMD was ‐0.58 (95% CI ‐0.76 to ‐0.40) with no significant heterogeneity indicated. Post hoc analyses suggest that individual, group and family/parental formats of CBT produced fairly similar outcomes.Authors' conclusionsCognitive behavioural therapy appears an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or attention control. There was no evidence for a difference between an individual, group or parental/family format. CBT can be recommended for the treatment of childhood and anxiety disorders, although with only just over half improving, there is a need for further therapeutic developments.Plain language summaryCognitive behavioural therapy appears an effective treatment for childhood and adolescent anxiety disorders in comparison to waiting list or an attention control.Cognitive behavioural therapy has been adapted for the treatment of anxiety disorders in adolescents and children over the age of six years. This psychological treatment can be delivered in various formats: individual, group and family /parent. Cognitive behavioural therapy appears effective in just over 50% of cases. There is no difference between formats.

Components of Cognitive Behavioral Therapy Related to Outcome in Childhood Anxiety Disorders

“…They cause substantial impairment across a variety of domains of functioning (e.g., academic, social, familial); are highly comorbid with other psychiatric disorders; and often persist into adulthood (Anderson 1994;Biggs et al 2011;Chorpita and Southam-Gerow 2006;Mendlowicz and Stein 2000;Merikangas and Avenevoli 2002;Mychailyszyn et al 2010;Quilty et al 2003). Fortunately, multiple literature reviews have concluded that cognitive behavioral therapy (CBT) is ''probably efficacious'' for childhood anxiety disorders (CADs; defined here as social phobia, generalized anxiety disorder, and separation anxiety disorder 1 ; Chambless and Ollendick 2001;Chorpita et al 2011;James et al 2005Kendall et al 2012Manassis et al 2010;Ollendick and King 1998;Reynolds et al 2012;Seligman and Ollendick 2011;Silverman et al 2008).…”

Direction of attention bias to threat relates to differences in fear acquisition and extinction in anxious children

“…Treatment outcome studies have shown that exposure-based CBT, in both individual and group format, is effective in eliminating anxiety disorders in approximately 50e85% of anxious children (Barrett, Dadds, & Rapee, 1996;Cobham, Dadds, & Spence, 1998;In-Albon & Schneider, 2007;Kendall, 1994;Lyneham & Rapee, 2005;Saavedra et al, 2010;Silverman, Pina, & Viswesvaran, 2008;Waters, Ford, Wharton, & Cobham, 2009) with large scale reviews concluding that about 60% of anxious children will experience significant reductions in anxiety symptoms (James, Soler, & Weatherall, 2007). These rates highlight the need for further research into the underlying mechanisms of anxiety disorders in children and how such mechanisms influence treatment outcomes following exposure-based CBT.…”

Is e-health the answer to gaps in adolescent mental health service provision?

“…Symptoms of depression and anxiety in adolescence may mark the development of a mental illness, as up to 75% emerge before the age of 25 [4]. Early intervention is critical to prevent chronic impairment [5], with a number of evidence-based treatments available to prevent and reduce symptoms of anxiety and depression [6][7][8]. However, many adolescents do not seek help for mental health problems from professional services.…”