Cognitive-Behavioral Therapy: A Nonpharmacologic Treatment for Pediatric Anxiety

Media reports on treatment for emotional illnesses in children and adolescents often emphasize the benefits and risks of medication. A recent informative and clearly written article in the Wall Street Journal reported on the effectiveness of cognitive-behavioral therapy (CBT), a nonpharmacologic therapy for anxiety disorders in children.

Obsessive-compulsive disorder (OCD) often is mentioned in clinical discussions of anxiety in children (perhaps because of the dramatic symptoms of OCD), but the most common pediatric anxiety disorders are social anxiety, separation anxiety, and generalized anxiety disorder.

The article makes the following important points about anxiety:

Excessive fears and worries are the hallmark symptoms of anxiety. Many children have fears without an anxiety disorder, and some anxiety is healthy. Anxiety is an illness when it interferes with normal functioning and causes significant emotional or physical distress. Anxiety disorders tend to emerge earlier than other psychological disorders. Treating children with anxiety when they are young might be beneficial because of the plasticity of the developing brain. Further, early treatment might have enduring effects and prevent the development of more-serious illness: Adolescents with social anxiety have a threefold increase in the subsequent onset of depression compared with those without anxiety. A strong evidence base exists for the effectiveness of SSRI medication in children and adolescents with anxiety. For example, in a randomized control trial (RCT) of children aged 7 to 17 years, 61% of fluoxetine recipients showed significant improvement compared with 35% of placebo recipients. However, SSRI medications are associated with side effects (JW Pediatr Adolesc Med Dec 13 2004), and many parents are hesitant to treat their children with these medications.

The article also describes the therapeutic value of CBT:

Exposure therapy is a major component of CBT. As stated in the article, “The goal of CBT is to tutor the brain to restore the fear-management process.” Children learn to anticipate and tolerate uncomfortable feelings as they are deliberately confronted with increasingly difficult situations that cause them anxiety. Age-appropriate rewards are given when children complete tasks, and parents often are enlisted to encourage their children to complete the exposure task. When CBT is used in a standardized way by trained therapists (usually for 14–16 weekly sessions), results in children and adolescents with anxiety disorders are stunning: In RCTs, 70% of children report a significant decrease in anxiety symptoms associated with improved overall function. Limitations of CBT include cost and, in many communities, limited availability of trained therapists. The author provides a resource for parents.