Anxiety Disorders in Children and Adolescents

Cognitive-behavioral therapy

Exposure-based CBT has empirical support from wait-list–controlled studies for the treatment of childhood anxiety disorders and is the psychotherapy of choice for this population.⁸ However, studies that compare CBT with alternative psychotherapies have not been done.

Velting and colleagues9 describe several components of CBT for childhood anxiety disorders as follows:

• Psychoeducation with child and parents about anxiety and CBT for anxiety disorders

• Somatic management skills training: self-monitoring, muscle relaxation, diaphragmatic breathing, relaxing imagery

• Cognitive restructuring: challenging negative thoughts and expectations, learning positive self-talk

• Practicing problem solving: generate several potential solutions for anticipated challenges and generate a realistic action plan ahead of time

• Exposure methods: imaginal and live exposure with gradual desensitization to feared stimuli

• Relapse prevention plans: booster sessions and coordination with parents and school

Along with these components, parents are taught to provide consistent and frequent positive reinforcement for the child’s efforts and successes. This increases the child’s motivation to attempt exposures that initially increase anxiety and discomfort levels. Over the course of treatment, learning to self-reward is emphasized. Parents learn anxiety-management skills so they can function as CBT coaches. Clinicians need to be flexible in considering child and family factors, comorbidity, and psychosocial stressors to achieve treatment success.¹⁰

Children with GAD benefit from CBT strategies that target uncontrollable worry and physical signs of anxiety.¹¹ Relaxation techniques such as diaphragmatic breathing and muscle relaxation target physical symptoms of anxiety. Cognitive restructuring assists children with GAD to identify and challenge persistent worries and anxious thoughts in a range of situations. Practicing problem solving is helpful to children with GAD.

Systematic desensitization for specific phobias involves relaxation, development of a fear hierarchy, and graduated pairing of items in the hierarchy with relaxation. Modifications for children include use of real-life desensitization programs, narrative stories, live modeling (demonstrating adaptive response), participant modeling (the child has physical contact with the model-therapist and the phobic object or situation), and contingency management.¹²

Children with SAD benefit from cognitive restructuring to examine anxious thoughts of bad things happening when they are away from parents and to generate alternative thoughts. Parents and school staff need to take an active role in treatment to forestall the child’s refusal to go to school. Tantrums, irritability, and physical resistance related to anticipation of separation is common in children with SAD, and parents benefit from behavioral strategies to shape and extinguish these responses. Parent training is important to increase the child’s independent functioning.

CBT strategies for children with panic disorder include psychoeducation about physiological processes that lead to physical sensations, progressive muscle relaxation, breathing and relaxation, cognitive coping, and gradual exposure to agoraphobic situations.¹³ Interoceptive exposure can reduce worry about future panic attacks.

Treatment for social phobia has included exposure-based CBT with an emphasis on social skills training and increased social opportunities. One treatment approach added an opportunity to practice skills learned with nonanxious peers in a group activity, with good results.¹⁴

There is good evidence to support behavioral interventions for selective mutism within a multimodal psychosocial treatment approach for social phobia with selective mutism.¹⁵ In addition, addressing comorbid communication deficits, developmental delays, or second-language acquisition is helpful clinically. Other people are encouraged not to speak for the child. Efforts at nonverbal communication (pointing and participation in activities) are positively reinforced and, over time, verbal behaviors (mouthing words, whispering, speaking in a soft voice) are rewarded as the child learns to manage anxiety through standard CBT strategies.

Table 2 gives examples of fear/exposure hierarchies in children for each of the anxiety disorders.

Family interventions

Family interventions that strengthen family problem-solving skills and communication, reduce parental anxiety, and foster parenting skills that decrease avoidant coping and encourage self-efficacy in the child can be helpful for anxious children.² Parental involvement in treatment is critical when the parent is anxious.