Cognitive Behavior Therapy for Anxious Adolescents: Developmental Influences on Treatment Design and Delivery

Anxiety disorders in adolescence are common and disruptive, pointing to a need for effective treatments for this age group. Cognitive behavior therapy (CBT) is one of the most popular interventions for adolescent anxiety, and there is empirical support for its application. However, a significant proportion of adolescent clients continue to report anxiety symptoms post-treatment. This paper underscores the need to attend to the unique developmental characteristics of the adolescent period when designing and delivering treatment, in an effort to enhance treatment effectiveness. Informed by the literature from developmental psychology, developmental psychopathology, and clinical child and adolescent psychology, we review the ‘why’ and the ‘how’ of developmentally appropriate CBT for anxious adolescents. ‘Why’ it is important to consider developmental factors in designing and delivering CBT for anxious adolescents is addressed by examining the age-related findings of treatment outcome studies and exploring the influence of developmental factors, including cognitive capacities, on engagement in CBT. ‘How’ clinicians can developmentally tailor CBT for anxious adolescents in six key domains of treatment design and delivery is illustrated with suggestions drawn from both clinically and research-oriented literature. Finally, recommendations are made for research into developmentally appropriate CBT for anxious adolescents.     

Children’s Perspectives of an Enhanced Cognitive-Behavioral Treatment for Child–Parent Dyads With Anxiety Disorders

Prior research has extensively evaluated the efficacy of cognitive-behavioral therapy (CBT) for child anxiety disorders—however, few studies have investigated anxious children’s perspectives and experiences of participating in CBT. This qualitative study explored children’s acceptability of a newly developed enhanced CBT intervention, designed specifically for the treatment of anxiety disorders in children with a clinically anxious parent. The study also explored children’s perceptions and experiences of individual (child only) and joint observational (child–parent) exposure activities that were key to the intervention. Ten children (age range 6–11, M = 8.5 years) and their mothers (age range 34–45, M = 39.5 years) completed in-depth semistructured interviews to investigate child participants’ anticipated and experiential acceptability of the enhanced CBT intervention. Thematic analysis revealed seven major themes broadly reflecting the acceptability, appropriateness, and perceived benefit of the intervention elements, with particular value credited to exposure tasks and the dyadic nature of the intervention. Findings suggest that future experimental evaluation of the enhanced intervention is warranted. Further, the study highlights that CBT for child anxiety disorders, where exposure work is a feature, is acceptable and perceived to be effective by its intended treatment recipients. Trial prospectively registered, preresults, ANZCTR1261900033410.     

A Meta-Analysis on the Efficacy of Technology Mediated CBT for Anxious Children and Adolescents

Several meta-analyses indicate that cognitive-behavioral therapy (CBT) via electronic/technological devices or applications (i.e., eCBT) is an effective alternative to standard therapist-delivered CBT for anxious adults. However, we know little about the efficacy of eCBT interventions for anxious children and adolescents. The present meta-analysis set out to investigate the efficacy of eCBT in comparison to standard CBT or waitlist control for anxious children and adolescents. Eight randomized controlled studies (N = 404 participants) that targeted anxiety at post-intervention and follow-up were included in the analysis. The results indicated that eCBT was as effective as standard CBT (g = .295) and more effective than waitlist (g = 1.410) in reducing anxiety symptoms. Moderation analyses revealed that anxious children and adolescents benefited the most from eCBT in the minimal therapist involvement condition (g = 2.682) in contrast to the significant therapist involvement group (g = .326). Furthermore, older participants seemed to extract greater clinical benefits from eCBT in contrast to younger participants (slope = .514). Current eCBT interventions for anxious children and adolescents appear to be promising, but require further investigation.     

Computer-Assisted CBT for Child Anxiety: The Coping Cat CD-ROM

Empirical data support the efficacy of cognitive-behavioral therapy (CBT) for child anxiety, but there is need and merit in the development and evaluation of cost-effective and transportable CBT approaches. Relatedly, a widely endorsed goal is the dissemination of evidence-based treatments from research clinics to community settings. Computer-based and computer-assisted treatment programs may provide a cost-effective and efficient way to increase the accessibility of CBT treatment strategies to anxious youth. In this research update, we introduce the Coping Cat CD-ROM, a computer-assisted CBT for the treatment of anxiety disorders in youth ages 7 to 13, in its initial phases of development and evaluation.     

Direction of threat attention bias predicts treatment outcome in anxious children receiving cognitive-behavioural therapy

BackgroundA bias to selectively direct attention to threat stimuli is a cognitive characteristic of anxiety disorders. Recent studies indicate that individual differences in pre-treatment threat attention bias predict treatment outcomes from cognitive-behavioural therapy (CBT) in anxious individuals. However, there have been inconsistent findings regarding whether attention bias towards threat predicts better or poorer treatment outcome.MethodThis longitudinal study examined treatment outcomes in 35 clinically-anxious children following a 10-week, group-based CBT program, as a function of whether children showed a pre-treatment attention bias towards or away from threat stimuli. The effect of CBT on attention bias was also assessed.ResultsBoth groups showed significant improvement after receiving CBT. However, anxious children with a pre-treatment attention bias towards threat showed greater reductions not only in anxiety symptom severity, but also in the likelihood of meeting diagnostic criteria for anxiety disorders at post-treatment assessment, in comparison with anxious children who showed a pre-treatment attention bias away from threat. Children who had a pre-treatment bias away from threat showed a reduction in this bias over the course of CBT.ConclusionsFindings suggest that pre-existing differences in the direction of attention towards versus away from threat could have important implications for the treatment of anxious children.     

The Role of Emotion Regulation in the Treatment of Child Anxiety Disorders

In this review, we examine the role of emotion regulation in the treatment of children with anxiety disorders. Cognitive-behavioral therapy (CBT) has been shown to “work” for children with anxiety disorders and it has been categorized as an evidence-based treatment. However, most studies have shown that the treatment is effective for about 60–70% of children, leaving the remaining children symptomatic and oftentimes with persisting psychological disorders. Of importance, it has also been shown that many children with anxiety disorders demonstrate poor emotion regulation skills. Despite these findings, little attention has been directed toward incorporating emotion regulation strategies into these relatively effective cognitive-behavioral treatments. It is possible that CBT programs do not work as well for a portion of children because their emotion regulation deficits, if present, are not being targeted sufficiently. In this review, it is suggested that adding an emotion regulation component could increase treatment efficacy. In addition, strategies aimed at improving emotion regulation at the individual level and at the family level are introduced. Details of how improved emotion regulation skills could be beneficial in bringing about change are discussed. Finally, issues of measurement and the clinical implications for research and practice are considered.     

Emotion-Focused Cognitive-Behavioral Therapy for Youth with Anxiety Disorders: A Randomized Trial

Difficulties with emotion regulation are a core feature of anxiety disorders (ADs) in children and adults. Interventions with a specific focus on emotion regulation are gaining empirical support. Yet, no studies to date have compared the relative efficacy of such interventions to existing evidence-based treatments. Such comparisons are necessary to determine whether emotion-focused treatments might be more effective for youth exhibiting broad emotion-regulation difficulties at pretreatment. This study examined an emotion-focused cognitive-behavioral therapy (ECBT) protocol in comparison to traditional cognitive-behavioral therapy (CBT) in a sample of children with a primary anxiety disorder diagnosis. Moderation analyses examined whether children with higher levels of emotion dysregulation at pretreatment would show greater levels of improvement in ECBT than CBT. Ninety-two youth ages 7 to 12 years (58% male) with a primary diagnosis of separation anxiety disorder, generalized anxiety disorder, or social phobia were included. Participants were randomly assigned to ECBT or CBT. Results showed that youth in both conditions demonstrated similar improvements in emotion regulation and that pretreatment levels of emotion dysregulation did not moderate treatment outcomes. Additional analyses showed that ECBT and CBT were similarly effective on diagnostic, severity, and improvement measures. Future work is needed to further explore the ways that emotion regulation is related to treatment outcome for anxious youth.     

A randomized pilot study of motivation enhancement therapy to increase utilization of cognitive–behavioral therapy for social anxiety

Despite the efficacy of cognitive–behavioral therapy (CBT), most socially anxious individuals do not seek treatment or seek treatment only after many years of suffering. This study evaluated the efficacy of a three-session motivation enhancement therapy (MET) designed to increase CBT utilization among socially anxious individuals. Twenty-seven non-treatment-seeking socially anxious individuals (92.6% met current DSM-IV criteria for social anxiety disorder) were randomly assigned to either MET for CBT (n = 12) or a control condition (n = 15). The primary outcome was attendance at first CBT appointment. Secondary outcomes included openness to therapist contact and willingness to schedule a CBT appointment. After the intervention, seven of the 12 (58.3%) participants in the MET condition attended a CBT appointment compared to two of 15 (13.3%) control participants. Eight of 11 (72.7%) participants in the MET condition indicated they would like a CBT therapist to contact them compared to four of 12 (33.3%) controls. Further, willingness to schedule a CBT appointment increased at a significantly greater rate in the MET condition. Results suggest MET for CBT may be a time-efficient means to increase CBT utilization among socially anxious individuals.     

The Emerging Role of Technology in Cognitive–Behavioral Therapy for Anxious Youth: A Review

Research documents the application of cognitive–behavioral therapy (CBT) with technology either as therapeutic adjuncts or stand-alone interventions. The literature evaluating the feasibility and efficacy of using technology with CBT for youth experiencing internalizing disorders is small though steadily emerging. Technological approaches offer cost-effective and efficient service to an increased number of anxious youth for whom a CBT treatment would be otherwise unavailable. The present article aims to review the use of two broad types of technology in CBT for anxious children and adolescents: computer- and internet-based CBT and mobile mental health applications (i.e., mobile phone, smartphone, and tablet technology). Within each section, we provide an overview of the advantages and general principles of each type of technology, and review evidence for the use of each type of technology along with examples of current applications. Finally, we discuss ethical issues, barriers, and future directions for the use of technology in facilitating dissemination of effective treatments.     

Commentary: Expanding the Research Agenda on Interventions for Child and Adolescent Anxiety Disorders

The articles in this series describe complementary programs of research and innovative approaches to extend evidence-based interventions for youth with anxiety in several important directions: to extend the target age range [Pincus, D. B., Santucci, L. C., Ehrenreich, J. T., & Eyberg, S. M. (2008-this issue). Treating separation anxiety disorder in young children: Exploring the additive impact of exposure on PCIT treatment outcome. Cognitive and Behavioral Practice, 15]; to extend interventions to more broadly defined target populations, including youth with co-occurring psychiatric symptoms [Weersing, V. R., Gonzalez, A., Campo, J. V., & Lucas, A. N. (2008-this issue). Brief CBT for pediatric anxiety and depression: Piloting an integrated treatment approach. Cognitive and Behavioral Practice, 15] and somatic symptoms [Reigada, L. C., Fisher, P. H., Cutler, C., & Masia Warner, C. (2008-this issue). An innovative treatment approach for children with anxiety disorders and medically unexplained somatic complaints. Cognitive and Behavioral Practice, 15]; to extend access in specific community-practice settings [Ginsburg, G. S., Becker, K., Kingery, J., & Nichols, T. (2008-this issue). Transporting CBT for childhood anxiety disorders into inner city school-based mental health clinics. Cognitive and Behavioral Practice, 15; Reigada, L. C., Fisher, P. H., Cutler, C., & Masia Warner, C. (2008-this issue). An innovative treatment approach for children with anxiety disorders and medically unexplained somatic complaints. Cognitive and Behavioral Practice, 15; Weersing, V. R., Gonzalez, A., Campo, J. V., & Lucas, A. N. (2008-this issue). Brief CBT for pediatric anxiety and depression: Piloting an integrated treatment approach. Cognitive and Behavioral Practice, 15]; and to extend access to these evidence-based approaches, in general [Khanna, M. S., & Kendall, P. C. (2008-this issue). Computer assisted CBT for child anxiety: The Coping Cat CD. Cognitive and Behavioral Practice, 15]. This commentary addresses how, collectively, these programs of research illustrate promising approaches to intervention adaptation and testing. The discussion also explores potential directions that might facilitate future research, including potential directions for broadening the interventions research agenda to help ensure that high-quality, evidence-based interventions are ultimately available to children and adolescents with anxiety.     

Cognitive Behavioral Treatment of Comorbid Anxiety Disorders and Social Difficulties in Children with High-Functioning Autism: A Case Report

A substantial proportion of children with high-functioning autism (HFA) or Asperger syndrome (AS) have one or more comorbid anxiety disorders. Because anxiety disorders exacerbate the social difficulties and other functional impairments caused by an autism spectrum disorder (ASD), there is a need for efficacious treatments to address the clinical needs of youth with this comorbid presentation. This article describes an evidence-based cognitive behavioral therapy (CBT) treatment manual enhanced to address the unique characteristics and clinical needs of children with ASD. A case study is presented in which CBT was utilized in the successful treatment of an 11-year-old girl with HFA. The intervention was effective in reducing anxiety and improving social and adaptive functioning. These findings suggest that an enhanced CBT approach may be a viable intervention for children with comorbid HFA and anxiety disorders that should be further evaluated.     

Increasing access to low‐intensity interventions for childhood anxiety: A pilot study of a guided self‐help program for Scandinavian parents

Cognitive Behavior Therapy (CBT) is an effective treatment for child anxiety. However, access to treatment is limited. It has been suggested that low‐intensity formats of parent‐delivered CBT may improve access to treatment. Our aim was to develop and pilot‐test the acceptability and effect of a low‐intensity therapist‐guided parent‐delivered group program for anxious children (age 7–12 years) adjusted to the Scandinavian culture. The program required 1.5 hours of therapist‐time per family. Mothers, fathers and children reported on revised child anxiety and depression scale (RCADS) at referral, pre‐ and post‐treatment. Mothers and fathers also gave a qualitative account of their experiences. Thirty‐one families were enrolled and only one family dropped out. Mean age of the children was 9 years. Intent‐to‐treat analyses revealed significant reductions in anxiety and depressive symptoms from pre‐ to post‐treatment for all informants. Large effect sizes were found for child anxiety symptoms as reported by mothers and fathers, and for child depressive symptoms as reported by mothers. Medium to large effect sizes was found for the self‐reported anxiety symptoms by the children, and for depressive symptoms reported by both children and fathers. More than 93% of the parents would recommend the program. Results suggest that our program may provide a new approach to improve access to treatment for anxious children in Scandinavia; however, further research must be conducted before firm conclusions can be drawn.     

Cognitive change and enhanced coping: missing mediational links in cognitive behavior therapy with anxiety-disordered children

In this review, we examine the recent cognitive behavior therapy (CBT) outcome literature with anxiety-disordered children and, specifically, explore the status of cognitive change and increased coping ability as (1) specific treatment effects, and (2) possible mediators of the efficacy of CBT. In the past decade, the number of controlled CBT studies with clinically diagnosed anxiety-disordered children has increased substantially. CBT aims to restructure distorted or maladaptive cognitions and teach the anxious child to effectively use diverse coping strategies. Our review shows that in recent CBT research with anxiety-disordered children the use of domain-specific measures like cognitive and coping measures is, unfortunately, not common practice. Furthermore, only one study examined the issue of treatment mediation. Generally, recent CBT research has not been designed to test mediational issues and does not clarify whether cognitive change and enhanced coping—the presumed central components of CBT—are in fact responsible for its efficacy. Implications for the direction of future CBT research with anxiety-disordered children are discussed.     

Social anxiety in children: social skills deficit, or cognitive distortion?

BACKGROUND: Treatments for childhood social anxiety have traditionally employed social skills training, based on the assumption that effected children have social skills deficits. Recent conceptualisations of social anxiety in adults have questioned this assumption, and have suggested that socially anxious individuals merely believe that they have skill deficits. A recent study using children provided preliminary confirmation of this for younger populations, and also suggested that beliefs about appearing nervous are of particular importance. METHODS: Two groups of children, aged 10-11 years (analogue high social anxiety/low social anxiety), participated in a conversation with an unfamiliar adult. They then rated their performance in a number of domains, after which independent observers also rated their performances. RESULTS: Independent observers were unable to distinguish between the low and high social anxiety groups. However, high socially anxious children rated themselves as appearing significantly less skilled than their low socially anxious counterparts. Notably, high socially anxious children rated themselves particularly poorly in terms of how nervous they looked. CONCLUSIONS: Socially anxious children may not necessarily display social skill deficits. However, they may believe that they appear nervous during social encounters. Clinicians should consider using CBT techniques to address these concerns, rather than relying on social skill remediation.     

Improving Treatment Response for Paediatric Anxiety Disorders: An Information-Processing Perspective

Cognitive behavioural therapy (CBT) is considered the treatment of choice for paediatric anxiety disorders, yet there remains substantial room for improvement in treatment outcomes. This paper examines whether theory and research into the role of information-processing in the underlying psychopathology of paediatric anxiety disorders indicate possibilities for improving treatment response. Using a critical review of recent theoretical, empirical and academic literature, the paper examines the role of information-processing biases in paediatric anxiety disorders, the extent to which CBT targets information-processing biases, and possibilities for improving treatment response. The literature reviewed indicates a role for attentional and interpretational biases in anxious psychopathology. While there is theoretical grounding and limited empirical evidence to indicate that CBT ameliorates interpretational biases, evidence regarding the effects of CBT on attentional biases is mixed. Novel treatment methods including attention bias modification training, attention feedback awareness and control training, and mindfulness-based therapy may hold potential in targeting attentional biases, and thereby in improving treatment response. The integration of novel interventions into an existing evidence-based protocol is a complex issue and faces important challenges with regard to determining the optimal treatment package. Novel interventions targeting information-processing biases may hold potential in improving response to CBT for paediatric anxiety disorders. Many important questions remain to be answered.     

Show-That-I-Can (Homework) in Cognitive-Behavioral Therapy for Anxious Youth: Individualizing Homework for Robert

Cognitive-behavioral therapy (CBT) has been reviewed and described as an empirically supported treatment for anxious youth. One component of CBT is the use of out-of-session “Show That I Can” tasks (STIC; i.e., homework tasks). STIC tasks vary in content and are to be completed between sessions. We discuss homework in CBT for Robert, a 13-year-old boy with social anxiety. Robert experienced distressing anxiety participating in and giving presentations at school and was fearful of open-ended questions. Robert had difficulty maintaining conversations with peers and reported being preoccupied with a concern that he would say something “weird” or “stupid.” Robert avoided numerous situations, and his social anxiety affected his grades, social interactions, family, and quality of life. Robert’s initial homework tasks entailed (a) journaling and self-monitoring anxious feelings and thoughts, and (b) practicing relaxation skills. During the second half of treatment, Robert’s STIC assignments were exposure tasks, including (a) opinion discussion assignments, (b) participating in class, and (c) initiating conversations with children at the bus stop. The present discussion focuses on how homework was individualized and presented so that it was palatable and sensitive. Issues regarding out-of-session exposure tasks that elicit sufficient anxiety, resistance to high-level exposure tasks, and parent involvement are explored.     

Challenging anxious cognitions or accepting them? Exploring the efficacy of the cognitive elements of cognitive behaviour therapy and acceptance and commitment therapy in the reduction of children's fear of the dark

Anxiety is highly prevalent in pre-adolescent children. Distorted cognitions are characteristic for dysfunctional levels of anxiety. However, applying cognitive elements in pre-adolescent children cannot be fully ascertained, as it is not until adolescence before children can apply logical and abstract reasoning in a sophisticated manner. Cognitive behaviour therapy (CBT) and acceptance and commitment therapy (ACT) both target distorted cognitions. Whereas CBT encourages children to change the content of negative cognitions by applying cognitive restructuring, ACT stimulates youth to have a more accepting attitude towards these thoughts by applying cognitive defusion. The current study examined the efficacy of applying cognitive elements and compared the cognitive elements of CBT and ACT in pre-adolescent children. We included no behavioural elements to specifically study the developmental appropriateness of the cognitive elements in this age group. Highly anxious children, aged 8–12 years were randomised to a 30-minute cognitive restructuring (n = 21) or cognitive defusion intervention (n = 22). Subjective fear of the dark levels, behavioural darkness toleration, and comprehension and fun associated with the interventions were assessed. Both interventions had a significantly positive impact on children's fear of the dark. Cognitive restructuring led to more favourable results on subjective fear than cognitive defusion, no differences were found for darkness toleration.     

Changes in maternal expressed emotion toward clinically anxious children following cognitive behavioral therapy

The aim of this study was to determine whether maternal expressed emotion (criticism and emotional overinvolvement) decreased across treatment for childhood anxiety. Mothers of 48 clinically anxious children (aged 6-14 years) were rated on levels of criticism (CRIT) and emotional overinvolvement (EOI), as measured by a Five Minute Speech Sample (FMSS) from mothers, prior to and following cognitive behavioral therapy (CBT) for their children’s anxiety. Results showed a significant decrease in the proportion of mothers who expressed high levels of criticism and emotional overinvolvement from pretreatment to posttreatment. This finding suggests that interventions aimed at reducing symptoms of child anxiety can also result in a decrease of maternal expressed emotion (criticism and emotional overinvolvement).     

Parents' perceptions of pharmacological and cognitive-behavioral treatments for childhood anxiety disorders

Cognitive-behavioral therapy (CBT) and pharmacotherapy are the most well-established treatments for childhood anxiety disorders. This study examined how parents (N=71) seeking treatment for their child's anxiety disorder perceive the acceptability, believability, and effectiveness of these treatments. While both treatments were perceived favorably, CBT was rated as more acceptable, believable, and effective in the short- and long-term. Children's treatment history influenced parents' perceptions of pharmacotherapy, with parents of children with no treatment history perceiving medication treatment as less acceptable and believable than parents of children with a history of medication alone or in combination with behavior therapy. No effect of treatment history was found for perceptions of CBT. Significant positive correlations emerged between parents' perceived acceptance and believability for pharmacotherapy and child age and level of dysfunction due to their child's anxiety, respectively. The level of the child's anxiety was not significantly correlated with parents' perceptions of either CBT or pharmacotherapy. Our results suggest that parents of anxious children prefer CBT to medication for the treatment of their child's anxiety disorder. Directions for future research are discussed.     

Development of a Multi-Disciplinary Intervention for the Treatment of Childhood Obesity Based on Cognitive Behavioral Therapy

Along the lines of the evidence-based recommendations, we developed a multi-disciplinary intervention for overweight children 7- to 12-years-old, primarily aiming at helping children to adopt healthier eating habits and a physically active lifestyle. The program combined nutrition intervention, based on a non-dieting approach, with physical activity intervention, implemented through the basic principles of Cognitive Behavioral Therapy (CBT), along with parental support. The program was conducted by dieticians with the collaboration of child psychiatrists and pediatricians. Training and regular supervision upon CBT priniciples application was intended to enhance dieticians' efficiency. The intervention is currently being evaluated to determine its effectiveness in treating childhood obesity.