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Cognitive-behavioral Therapy Treatment Methods for Childhood Anxiety
This paper examines five articles that explore the effectiveness of variations of cognitive-behavioral therapy (CBT) on childhood anxiety disorders and symptoms. The variations explored include family-focused CBT, extra parent training, parent-directed CBT, and parent delivered CBT. Each article explores a different variation and its effectiveness in treating the disorder and decreasing the symptoms of childhood anxiety.
Keywords: anxiety, cognitive-behavioral therapy (CBT), children, childhood,
Cognitive-behavioral Therapy Treatment Methods for Childhood Anxiety
According to de Groot, Cobham, Leong, and McDermott (2007), anxiety disorders are the most common and most significant psychological diagnoses affecting children and adolescents. When left untreated, anxiety disorders can lead to complications in social functioning, development, academic success, and can lead to further complications in later adulthood (de Groot et al., 2007). There are a variety of treatment methods to treat anxiety in children and adolescents. Cognitive-behavioral therapy (CBT) is one method of evidence-based treatment for children and adolescents diagnosed with anxiety disorders. Recent studies have examined the effectiveness of CBT and whether the effectiveness can be increased with variations such as, the focus of the treatment, extra parent training, whether it is child or parent-directed and, who delivers the treatment
In a study by Alder Nevo et al., (2014) the long term effectiveness of CBT was assessed using a long-term follow-up (LTFU) study design. This study compared 120 children between 8-12 years old who were diagnosed with a DSM anxiety disorder. In the original study, 60 of the participants were in the treatment group and were treated with CBT and the other 60 children were in the control group and did not receive CBT treatment. The treatment group received twelve CBT sessions based on the “Coping Bear” manual, which is an adaptation from Kendall’s “Coping Cat” protocol (Alder Nevo et al., 2014). About 8 years after participants were originally evaluated for CBT treatment, anxiety severity was measured again. The measure The Multidimensional Anxiety Scale for Children(MASG) was used to assess anxiety severity for the LTFU study and the initial assessment (Alder Nevo et al., 2014). To analyze the data of the study, a with-in groups comparison of pre and post anxiety severity scores was done using a paired t-test. The results of the LTFU study showed that there was a statistically significant decrease in anxiety for the control group (Alder Nevo et al., 2014). There was also an increase in anxiety in the group that received the treatment, however, the increase was insignificant.
Another study by de Groot, Cobham, Leong, and McDermott (2007) compared the effectiveness of group and individual family-focused CBT. Participants in this study consisted of 29 children between 7-12 years old who all had an anxiety disorder diagnosis. There were 14 children in the individual format CBT group (ICBT) and 15 children in the group format CBT group (GCBT). Participants were assigned randomly to either condition (de Groot et al., 2007). Both the ICBT and GCBT groups used a 12 session CBT treatment program. The 12 sessions were broken into 6 parent-focused sessions based on the Do as I do programme parents workbookand 6 child-based sessions that were based on theFacing your fears programme children’s workbook(de Groot et al., 2007). Pre-treatment diagnostic assessments for participants were performed by postgraduate clinical psychology students. Also, the Spence Children’s Anxiety Scale-Child Version(SCAS) was used as a self-report measure for the child participants and parents of participants completed the Strengths and Difficulties Questionnaire-Extended Version (SDQ)as another self-report measure (de Groot et al., 2007). The SCAS and SDQ were used for pre-treatment, post-treatment, and 3-month and 6-month follow up data. To analyze the data, repeated measures multivariate analysis of variance (MANOVA) was used to assess the differences in the SCAS and SDQ measures (de Groot et al., 2007). After the data was analyzed, the results showed no difference that was significant in the number of participants who no longer had the DSM-IV anxiety diagnosis, based on whether they were in the ICBT group or the GCBT group. In both groups, approximately 50% of participants no longer met the DSM-IV criteria for an anxiety disorder diagnosis at post-treatment, and at 3 and 6-month follow-ups. (de Groot et al., 2007). The study by de Groot et al., (2007) demonstrates that children who participated in family-focused CBT reported improvement in anxiety post-treatment and follow-up.
Nauta, Scholing, Emmelkamp, and Minderaa (2001) assessed if extra cognitive parent training could increase the effects of individual CBT for children. Eighteen children between the ages of 8 and 15 years old who met DSM-IV criteria for an anxiety disorder were participants in the study. All children in the study received 12 weekly sessions of CBT treatment based on the Coping-Cat workbook. This treatment also included two-parent sessions focusing on the treatment for the child (Nauta et al., 2001). Families were assigned to either the extra cognitive parent training condition or the no extra training condition randomly. Families in the extra parent training condition received seven extra sessions of cognitive parent training (CPT) that ran parallel to child CBT sessions. The CPT training revolved around behavior and cognitions brought on by the behavior of the anxious child (Nauta et al., 2001). To gather data for this study, parents and children were interviewed using the Anxiety Disorder Interview Schedule (ADIS C/P)to determine anxiety diagnoses (Nauta et al., 2001). Also, theFear Questionnairewas completed by both parents and children to address the fears of the child and theScale for Worry in Children was also completed by parents and children to assess the distress caused by worry in the child. Self-report measures were also developed to provide parent and child data that would be comparable and would apply to the DSM-IV criteria that applies to anxiety disorders. All measures were performed at pre-treatment, post-treatment, 3-month follow-up, and 15-month follow-up (Nauta et al., 2001). To analyze the data, t-tests were used to evaluate differences between the extra parent training condition and no extra training condition and contrast variables were used to determine the success of CBT treatment. The results demonstrated that by the 3-month follow-up session, 80% of child participants no longer met criteria from the DSM-IV for an anxiety disorder diagnosis. The study did not find any significant impact on effectiveness regarding extra parent training.
Another study assessed whether parent-only CBT would decrease symptoms in children with anxiety disorders. In the study by Salari, Shahrivar, Mahmoudi-Gharaei, Shirazi, and Sepasi (2018) the parents of 42 children who met the DSM-IV-TR criteria for generalized anxiety disorder were randomly assigned to the parent training group or the wait-list control group. Both groups experienced active treatment, the wait-list group received the treatment after the study was completed. The parent-only CBT treatment was based on the FRIENDS for Life program. The treatment consisted of six weekly two-hour sessions (Salari et al., 2018). The children in the study received SSRI medication before pre-treatment assessment and during the study. Measures such as the Revised Children’s Manifest Anxiety (RCMA), Strengths and Difficulties Questionnaire (SDQ), and the Children Global Assessment Scale (CGAS), among others, were completed to assess children’s anxiety symptoms, behavior, and functioning (Salari et al., 2018). Measurements were performed before and after. The results of the study showed the only significant findings were an increase in the CGAS and a decrease in Emotional Symptoms Subscale (Salari et al., 2018). These results show that there was a decrease in children’s emotional problems according to the parent’s report and the child’s functioning and anxiety symptoms improved.
In a long-term follow-up (LTFU) study by Brown, Creswell, Barker, Butler, Cooper, Hobbs, and Thirlwall (2017) a less intensive, brief approach to CBT known as guided parent-delivered CBT (GPD-CBT) was assessed for effectiveness 3-5 years post-treatment. Participants consisted of families who participated in a controlled trial of GD-CBT and had completed 50% of the treatment sessions. The sample consisted of 65 families who had participated in the original controlled trial. In the original trial, parents received a self-help book called Overcoming Your Child’s Fears and Worries and also received either, 4 hour face-to-face sessions and four twenty-minute phone calls which was considered full support, or brief support which was 2 hour face-to-face sessions and two twenty-minute phone calls while working through the treatment (Brown et al., 2017). The treatment also followed a CBT approach. To collect data for the study, the Anxiety Disorders Interview Schedule for DSM-IV: Child and parent versions (ADIS-C/P) was used for diagnosis purposes and also assessed mood, externalizing behavior and other mental health problems (Brown et al., 2017). Another measure used was the Clinical Global Impression-Improvement Scale (CGI-I) which assesses a child’s improvement from baseline. The LTFU assessment was performed between 39 to 61 months after the original trial assessment. Results of the study showed that 11% of participants who still had diagnosis criteria at the last assessment of the original trial, were diagnosis free at the LTFU assessment. Sixty percent of participants who were diagnosis free at the original trial assessment remained diagnosis free at the time of the LTFU assessment (Brown et al., 2017). These results indicate that while GPD-CBT is less constrictive and intensive than traditional CBT, the treatment can influence positive outcomes long-term in children diagnosed with anxiety disorders.
CBT is considered to be an effective evidence-based treatment for childhood anxiety disorders (Alder Nevo et al., 2014; Brown et al., 2017). Recent studies have been performed to assess whether variations of CBT treatment could increase the effectiveness of the treatment. The study by de Groot et al., showed that family-focused CBT treatment showed improvement in anxiety disorders in children. Also, while extra parent training showed no significant impact on the effectiveness of CBT, in the parent-only CBT study children’s emotional problems, functioning, and anxiety symptoms improved (Nauta et al., 2001; Salari et al., 2018). Guided parent-delivered CBT (GPD-CBT) also had a positive impact on children diagnosed with anxiety disorders (Brown et al., 2017). Therefore, variations in CBT treatment, specifically with parent and family involvement can have positive influences on children with anxiety disorders.
However, the implications of these studies still leave the question as to how much parental involvement will be the most effective. To assess for the degree of parental involvement that would be the most effective, another study could be performed. A study consisting of three groups, one group receiving child-only CBT treatment, the second group receiving CBT along with their parents receiving training, and the third group receiving guided parent-delivered CBT could be performed. Participants would consist of children between the ages of 8 and 12 years old who all meet the DSM-IV criteria for an anxiety disorder diagnosis. Participants would be evaluated for DSM-IV anxiety disorder criteria at pre-treatment, post-treatment, 3-month, 6-month, and 15-month follow-ups. Diagnosis criteria from each group would be compared to evaluate which treatment method showed the most success in degreasing anxiety disorder symptoms and diagnosis criteria.
- Adler Nevo, G. W., Avery, D., Fiksenbaum, L., Kiss, A., Mendlowitz, S., Monga, S., & Manassis, K. (2014). Eight years later: Outcomes of CBT-treated versus untreated anxious children. Brain & Behavior, 4(5), 765–774.https://doi.org/10.1002/brb3.274
- Brown, A., Creswell, C., Barker, C., Butler, S., Cooper, P., Hobbs, C., & Thirlwall, K. (2017). Guided parent-delivered cognitive behaviour therapy for children with anxiety disorders: Outcomes at 3- to 5-year follow-up. British Journal of Clinical Psychology, 56(2), 149–159. https://doi.org/10.1111/bjc.12127
- de Groot, J., Cobham, V., Leong, J., & McDermott, B. (2007). Individual versus group family-focused cognitive-behaviour therapy for childhood anxiety: Pilot randomized controlled trial. Australian & New Zealand Journal of Psychiatry, 41(12), 990–997. https://doi.org/10.1080/00048670701689436
- Nauta, M. H., Scholing, A., Emmelkamp, P. M. G., & Minderaa, R. B. (2001). Cognitive-behavioural therapy for anxiety disordered children in a clinical setting: does additional cognitive parent training enhance treatment effectiveness? Clinical Psychology & Psychotherapy, 8(5), 330–340. https://doi.org/10.1002/cpp.314
- Salari, E., Shahrivar, Z., Mahmoudi-Gharaei, J., Shirazi, E., & Sepasi, M. (2018). Parent-only group cognitive behavioral intervention for children with anxiety disorders: A control group study. Journal of the Canadian Academy of Child & Adolescent Psychiatry, 27(2), 130–136. Retrieved from http://search.ebscohost. com/ login.aspx?direct=true&db=a9h&AN=128965947&site=ehost-live&scope=site
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