How is CBT used to treat anxiety in children and adolescents? Does it work for everyone?

This essay will explain how Cognitive Behavioural Therapy (CBT) is used to treat

children and adolescents with anxiety disorders, and whether it is an effective form of

treatment. I will start by looking at what anxiety is (according to the DSM-V) and the

prevalence of specific types of anxiety disorders in children and adolescents. Following this I

will explain what CBT is and how the treatment was formed based on various cognitive

theories. I will then explain how CBT is administered to children and adolescents, and the

different techniques that are used. Lastly, I will look at whether CBT works as a form of

treatment for anxiety in children and adolescents and whether the therapy is effective in

reducing symptoms for everyone who tries it. To do this I will review previous research;

specifically, research that looks at the remission rate of patients who have received CBT as a

treatment. I will also look at why CBT is not 100% effective and what can be done to make it

more effective as a treatment, and what can be done to make sure more people are effectively

treated.

Anxiety, according to the DSM-V (American Psychiatric Association, 2013), can be

defined as the anticipation of threat. An anxiety disorder, therefore, is when a person

experiences feelings of anxiety excessively, for a prolonged period of time (i.e. for at least 6

months), and to the extent where it may interrupt a persons ability to perform day to day tasks

such as going to work. Of all the psychiatric disorders, anxiety disorders are some of the most

common in society, not just in adults (Kessler et al., 2005) but also in children and adolescents.

Cartwright-Hatton, McNicol, and Doubleday (2006) reviewed research into the prevalence of

anxiety disorders and found that generalized anxiety disorder can be found in up to 17.5% of

children from various populations. More specifically, around 0.7% of children aged 5-10 in
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Great Britain will present enough symptoms to be diagnosed with generalized anxiety disorder.

This is a lot of people suffering with similar problems, that not only are distressing to live with

but also make day to day activities extremely difficult; hence such a strong relationship

between anxiety disorders and depression and/or suicidal thoughts and behaviours (Brady &

Kendall, 1992; Nepon, Belik, Bolton, & Sareen, 2010). Therefore, treatments have been

developed in order to decrease the intensity of symptoms, making life more bearable for

sufferers.

Cognitive Behavioural Therapy (CBT) is a commonly used treatment for anxiety

disorders (Clark, 2011). It stems from the cognitive theory of psychological disorders proposed

by Beck (1967) as cited in Jacobs and Joseph (1997). The main component of the theory is the

cognitive triad that looks at the interactions between a persons view of themselves, view of

the world and how they view the future. Jacobs and Joseph (1997) provided real life evidence

that supported that people with higher scores on measures of anxiety have a more negative

view of themselves, the world and the future. They found that 29% of the variance in anxiety

between 218 adolescent individuals was accounted for by scores on a 36-item cognitive triad

inventory (the self, the world, and the future), suggesting that anxiety can be explained by the

cognitive triad. Therefore, a therapeutic technique that targets the faulty aspects of the

cognitive triad may be appropriate as a form of treatment for anxiety disorders.

Beck and Clark (1988; 1997) looked at the different aspects of the cognitive theory that

cause anxiety. They suggested that anxiety was not just a result of the faulty aspects of the

cognitive triad, but also a result of a persons faulty schema-based information processing. In

particular, the differences in how people with and without anxiety problems register

threatening stimuli, and whether this activates primal responses such as autonomic arousal (i.e.

fight or flight). They suggested that not only do people with anxiety process stimuli as more
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threatening in general but also that they have maladaptive schemas that often overrise

functional ones resulting in a fight or flight response to stimuli that people without anxiety

would not consider threatening. CBT aims to target these schemas and alter faulty cognitions

that arise, to try and prevent the autonomic responses to stimuli.

The techniques used in CBT are similar for both adults and children (Stanley et al.,

2009). The differences lie in what techniques are appropriate for what age group. For example,

Kendall (1994) stated that the CBT techniques used for 9-13 year olds with anxiety disorders

included recognizing anxious feelings and personal reactions to anxiety, clarification of the

cognitions involved in the onset of anxious feelings, developing a coping plan using techniques

such as positive self-talk and relaxation, evaluating the effectiveness of these techniques, and

providing self-reinforcement. Whereas, Stanley et al. (2009) administered CBT to 134 older

adults and the therapeutic techniques used involved those used by Kendall (1994), as well as

motivational interviewing and problem solving skills training which are both more complex

therapeutic techniques and therefore are more appropriate for older people than children,

because adults have a more developed brain than children and therefore can deal with more

complex thought processes (Casey, Giedd, & Thomas, 2000).

Following the development of CBT as a form of treatment for anxiety disorders

researchers have studied its effectiveness in terms of reducing symptoms and have found

significant decreases in symptoms of anxiety following a complete course of CBT (Cartwright-

Hatton, Roberts, Chitsabesan, Fothergill, & Harrington, 2004). Reynolds, Wilson, Austin, and

Hooper (2012) reviewed 55 research studies on the effectiveness of CBT as a treatment of

anxiety in children and adolescents. They found that overall psychological therapy was

moderately effective in comparison to no therapy, and that CBT successfully reduced

symptoms of anxiety. More specifically they found that disorder specific CBT (CBT that has
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been altered to target specific aspects of a certain disorder) was more effective that regular

CBT, individual therapy was more effective than group therapy, minimal parental involvement

proved more effective than no parental involvement, and the optimum length of treatment was

between 9 and 16, 1-hour sessions. This not only suggests that CBT is an extremely effective

form of treatment for anxiety, but also provides an insight into what increases the effectiveness

of CBT in reducing symptoms. It suggests that perhaps the involvement of a parent in treatment

increases its effectiveness, possibly due to the increase in familial support and understanding

(Steketee, 1993).

It has also been found that this reduction in anxiety related symptoms due to the use of

CBT is not just a short-term change but a relatively long term one. Research suggests that this

reduction in symptoms can be sustained over the course of a year, and that children aged 9-13,

who were no longer diagnosed with an anxiety disorder following treatment, were still without

a diagnosis 12 months after the completion of CBT (Kendall, 1994). This suggests that it not

only reduces symptoms, but treats the disorder completely in some cases. This may be because

patients were treated at a young age, a time when there is a lot of brain plasticity (Mundkur,

2005), meaning that children may just be easier to treat with CBT and that it will not be as

effective for everyone. However, research does suggest that CBT is an effective treatment for

all ages.

Stanley et al., (2009) found results that were both similar and contrasting to previous

research into the effectiveness of CBT as a treatment. They found that when comparing the use

of CBT for 3 months to regular care and enhanced care in older participants (with a mean age

of 66.9 years), CBT improved both the severity of feelings of worry and depressive symptoms,

suggesting it is still and effective form of treatment. However, unlike when it was used to treat

children, CBT did not reduce the severity of the generalized anxiety disorder (GAD) itself.

This supports the idea that children respond better to CBT due to more brain plasticity, because
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older participants did not respond as well to CBT and research suggests that blain plasticity

decreases with age (Burke & Barnes, 2006).

However, even though CBT has proven to be more effective in treating anxiety

disorders in children and adolescents than treating anxiety in adults, it has still never proven to

be 100% effective in treating everyone with an anxiety disorder. Therefore, there is still room

for improvement to make it a more effective form of treatment for everyone that needs it.

One of the reasons that CBT may not be effective for everyone with an anxiety disorder

is because there may be individual differences in peoples inability to participate fully in

therapeutic sessions. This may be due to certain symptoms that make a person unable to leave

their home and go to a therapy session, such as panic attacks or just anxiety about the therapy

itself. If the intensity of these symptoms could be reduced then people would be able to

participate in therapy sessions. Walkup et al. (2008) did a study that looked at whether CBT

would be more effective if patients were having it in combination with a medication that

reduced the intensity of symptoms. They found that 80.7% of children who had a combination

of CBT and sertraline (Selective Serotonin Reuptake Inhibitor) were rated as very much or

much improved following the course of treatment in comparison to only 59.7% improving with

CBT alone and 54.9% for treatment with just medication. This suggests that the effectiveness

of CBT is enhanced by the use of sertraline and that treatment with sertraline is more effective

when used in combination with CBT. This may be because sertraline reduces certain anxiety

related symptoms that would otherwise hinder the CBT process, meaning the patients can fully

dedicate themselves to the therapy and therefore get more out of it.

It has also been found that there are other factors that influence the ability of CBT to

treat people effectively. For example, CBT has been found to have a high dropout rate. This

can be seen in the study of Bados, Balaguer, & Saldaa (2007) that found that, of the 89 patients
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attending a 13-week course of CBT, most patients dropped out after the first session (28.1%),

with the main reason being a lack of motivation or dissatisfaction with the treatment/therapist;

both of which are individual differences. One person may be satisfied with a therapist and

another may not. Therefore, it can be assumed that the effectiveness of CBT is highly

dependent on the individual themselves.

Another factor that should be considered is that, despite CBT being available on the

NHS in the UK, in other countries people of lower economic groups may not be able to afford

treatment and therefore CBT will not be effective as they cannot access it. Therefore, people

have created forms of CBT that are more accessible and effective for everyone, such as self-

help books and computer based cognitive treatments. Although computer based CBT does not

appear to be as effective as face to face CBT, it is still showing some signs of decreasing certain

symptoms (Gega, Marks, & MataixCols, 2004) and therefore can be developed further to

increase the number of people that can be effectively treated with CBT.

Overall, CBT is a commonly used treatment for anxiety disorders in children and

adolescents, and is somewhat effective in reducing symptoms. However, because it is not 100%

effective and is not an accessible and effective treatment for everyone, researchers are

continuously trying to find ways to increase its effectiveness. It is often used in combination

with medication, which increases its effectiveness by reducing the intensity of symptoms that

hider the ability to participate in therapy. However, due to high drop-out rates for a variety of

reasons, further development also needs to be done to make sure that everyone who needs

treatment, can access it and will participate fully in it, in order for it to treat as many people as

it can and to be as effective as it can be.

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