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How does CBT for anxious children work?

One of the current challenges for clinical researchers evaluating treatment outcomes is obtaining evidence relating to the mechanisms of action of therapies (process versus outcome). For example, whilst cognitive behavioural (CBT) approaches to anxiety disorders in children have shown considerable efficacy in terms of reducing self-reported anxiety, teacher/parent reported anxiety and observable anxiety symptoms, the question still remains as to what mediates this relationship? Put more simply, what is it that changes in these children that leads them to be less anxious?

CBT for Anxiety – what does it involve?

In my experience, CBT is probably the most talked about and researched of the therapies for anxiety disorders, including anxiety in children and adolescents. There are now multiple “CBT Treatment Protocols” for anxiety disorders in children that guide clinicians on how to do this type of therapy. Fundamentally, the therapy assumes that distorted patterns of thinking and avoidance lead to the development and maintenance of anxiety symptoms. CBT strategies then address these patterns of thinking and avoidance through:

  • cognitive restructuring – identifying and challenging distorted thinking
  • coping self-talk – the addition of more realistic/balanced thinking to self-talk
  • in vivo exposure – confronting objects/ situations that are feared
  • modeling – demonstrating ways of coping in anxiety provoking situations
  • relaxation training – gaining mastery of physical/ emotional symptoms of the fight/flight response

CBT for Anxiety – how does it work?

It is this question that Muris et al (2008) addressed in their small uncontrolled trial of CBT for anxiety disorders in children. Previous research had shown that children and adolescents with anxiety disorders demonstrate biases in information processing and attention, more negative thinking, greater anxious self-statements and lower perceived control. CBT theory suggests that the therapy alters these biases. Muris et al were interested to see if improvements in anxiety symptoms experienced by children receiving CBT treatment were associated with changes in these types of “process” variables. In particular, they were interested in two candidate mediators;

Anxiety-related negative automatic thoughts – automatic thoughts relating to social threat (e.g., “Kids will think that I am stupid”) and physical threat (e.g, “I am going to have an accident”)

Perceived anxiety control – perception of control over negative external and internal threats (e.g., “When something scares me, there is always something I can do’’, ‘‘I can usually stop thinking about things that make me nervous or afraid if I try’’)

What they did

The authors recruited children for their study from 5 regular primary schools in the Netherlands. Children (aged 9-12) were screened using a self-report measure of anxiety and those scoring in the top 10% for social phobia, separation anxiety disorder, and/or generalized anxiety disorder scales were invited into the study. 45 children (permission from parents) agreed to take part in the treatment.

The treatment consisted of the Coping Koala CBT program (Coping Cat, Coping Bear, depending on country). This small group program involves “12 sessions of about 30 min which focus on recognizing anxious feelings and somatic reactions to anxiety, cognitive restructuring in anxiety provoking situations, coping self-talk, exposure to feared stimuli, evaluating performance, and administering self-reinforcement”.

The researchers delivered the program via psychology masters students in small groups of 3-6 children. Measures of anxiety (total, social phobia, generalized anxiety disorder, separation anxiety disorder), negative automatic thoughts and anxiety control were administered prior to and 1-week following the completion of the program. There was no control group.

What they found

Consistent with similar trials, the authors found significant pre- to post reductions in anxiety scores with effect sizes (a rough guide for clinical significance) in the moderate to large range. They also found that over the course of treatment, there was a decrease in negative automatic thoughts and an increase in perceptions of anxiety control.

The authors also found evidence that changes in negative automatic thoughts and anxiety control independently predicted degree of change in anxiety scores. Specifically, changes in negative automatic thoughts accounted for approximately 30% of the variation noted in total anxiety scores. Changes in perceptions of anxiety control were less predictive, although did appear to be related to reductions in specific symptoms of social phobia and generalized anxiety disorder (~17%)

What it means

Muris et al’s study suggests two potential “candidate mediators” for how CBT leads to improvements in anxiey scores in children, namely changes in negative automatic thoughts and perceived anxiety control. In doing so, the study provides useful model-consistent evidence that CBT works through the correction/alteration of condition specific beliefs and cognitions. The amount of variance explained by these two variables though (max 30% of variance in anxiety scores) indicates there are still other factors responsible for the effect of CBT on anxiety outcomes.


The authors readily address the limitations of their study (lack of a control group, only self-report measures used, sample size, non-clinical sample, age of children, treatment integrity and lack of follow-up) as well as the need to conduct appropriate mediation testing. This means there is still considerable work to be done in truly demonstrating theory consistent changes in candidate mediators in CBT for children.

Take Home Message

The take home message from this study (as I see it) is the concerted move from outcome related CBT research (i.e., – does the treatment lead to significant improvements?) to process related research (i.e., how does the treatment work?). This represents a hugely important move in terms of psychological theory as evidence based therapies should be able to demonstrate a) that they work and b) that they work consistent with their theoretical underpinnings. I hope to see more of these kinds of studies over time as we try to unravel how our current arsenal of therapies work.

Muris, P., Mayer, B., Adel, M., Roos, T., Wamelen, J. (2008). Predictors of Change Following Cognitive-Behavioral Treatment of Children with Anxiety Problems: A Preliminary Investigation on Negative Automatic Thoughts and Anxiety Control. Child Psychiatry and Human Development DOI: 10.1007/s10578-008-0116-7


3 Responses

  1. There’s been an anxiety clinic running for young people at Royal North Shore CAMHS for some years and they are currenlty running small groups for young people with anxiety they have also recently started performing MRI’s of the youngsters before they go into the group and hopefully when they finish. This may give some more insights as to how CBT works on the physical structure of the brain.

  2. […] public links >> digest How does CBT for anxious children work? Saved by ahakamada on Sun 28-9-2008 Update from Vegas Saved by BarrettDowell on Sat 27-9-2008 […]

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