Anxiety disorders are highly prevalent among children and adolescents [3, 4], and effective treatments have been identified through extensive research [14]. Studies support cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibi-
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tors (SSRIs) as effective for treating anxiety in children and adolescents [15–17]. In the following sections, we will elaborate on these two interventions, followed by a brief discussion of other approaches that have been studied.
Cognitive Behavioral Therapy (CBT)
CBT is considered, using the criteria of the Division of Clinical Psychology of the American Psychological Association, to be a “well-established” intervention for treating children and adolescents with anxiety [18]. CBT has received much research attention since the initial CBT treatment for child anxiety, the Coping Cat program [19, 20], was developed and received empirical support [21]. Since that time, the specific treatment protocol has been adapted for use with adolescents (the C.A.T. Project) [22] and for use in different countries and languages (e.g., in Norway) [23]. Related adaptations of the protocol have been developed (e.g., Cool Kids) [24], which have similarly demonstrated their efficacy in treating children and adolescents with anxiety [14, 25]. In the largest study to date that has investigated youth anxiety treatment – the Child/Adolescent Anxiety Multimodal Study (CAMS) [17] – 60% of the youth who received CBT (specifically the Coping Cat and C.A.T. Project proto- cols) were rated as “very much improved” or “much improved” by an independent evaluator following treatment. This outcome was a significantly larger percentage than those who had received pill placebo and was comparable to that for those who had received medication (see below for a discussion on medication to treat youth anxiety). Indeed, CBT for youth anxiety consistently outperforms waitlist conditions [26], as well as inactive and active comparison conditions [27, 28].
CBT involves many components, designed to address the physiological, cogni- tive, and behavioral features of anxiety. While there are many CBT protocols for youth anxiety, all tend to include similar elements; typically, CBT involves psycho- education, relaxation training, cognitive restructuring, problem solving, and expo- sure to anxiety-provoking situations. Of note, research indicates that exposure to anxiety-provoking situations is a vital component of CBT for youth anxiety [29, 30]
and should not be omitted. The first phase of treatment typically involves assisting the youth in learning coping strategies that include recognizing when they are anx- ious and then knowing what to do about it [31]. This is followed by the second phase of treatment – the exposures, often referred to as “challenges” with youth – in which the youth apply the skills they have learned in the first part of treatment as they enter anxiety-provoking situations that increase in difficulty. In this way, youth approach the situations that they previously avoided, learning they are able to handle those situations. During this phase of treatment, youth additionally complete similar exposure tasks between sessions as homework [31], often called by a different name to eschew the negative connotations many youth have with the term “homework.”
These out-of-session tasks reinforce what the youth have learned in session and encourage generalization of this learning to the real situations that come up in their lives.
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The Coping Cat program is one of the most (if not the most) widely used proto- cols for youth anxiety treatment and follows this general structure of two phases with the inclusion of homework tasks. As an example of what CBT for youth anxi- ety looks like, we provide a brief summary of the sessions of this treatment.
Throughout this treatment, the therapist works with the child to build a fear hierar- chy, which can be modified as therapy progresses. Additionally throughout the treatment, the therapist assigns Show That I Can (STIC) tasks (i.e., homework) for the youth to practice what has been taught in session. Overall, the program is 16 sessions, which ideally corresponds with 16 weeks.
The initial session is focused heavily on rapport building and orienting the child to the treatment; as youth are often not self-referred and/or may be anxious about the treatment in general, rapport building early on is very important. The second and third sessions focus on building emotional awareness, with the second session dis- cussing physical expressions of a variety of emotions including anxiety, and the third session focused on the child’s own specific somatic reactions to anxiety. In the third session, the therapist also introduces the four-step plan, known as the FEAR plan, to help youth learn to cope with anxiety. In introducing the FEAR plan in ses- sion 3, the therapist teaches the youth the F step: Feeling frightened, which is about the child identifying how he or she is feeling, identifying the bodily cues, and rec- ognizing the level of anxiety he or she is feeling. The fourth session is the first of the two parent sessions, during which the therapist provides the parents with more information on treatment and how they can be involved, discusses their concerns, and learns more about situations in which the child becomes anxious.
The following psychoeducation sessions are focused on skill building. Session 5 is centered on relaxation training, followed by cognitive restructuring in session 6.
Session 6 is also when the child learns the E step of the FEAR plan: Expecting bad things to happen, which is about recognizing the anxious automatic thoughts. In session 7, the client learns problem solving as well as the A step of the FEAR plan:
Attitudes and actions that can help, which helps the child remember to use the tools he or she has learned in the skill building phase to approach the anxiety-provoking situation. In the eighth session, the youth learns about making self-evaluations and rewarding oneself even if he/she does not do a perfect job. Additionally, the youth learns the final step of the FEAR plan, the R step: Results and Rewards. This step is focused on applying self-evaluation and recognizing the rewards of doing some- thing anxiety-provoking. As this is the final session the child has with the therapist before beginning exposures, the therapist reviews the complete FEAR plan with the child, continues work on building the youth’s fear hierarchy, and identifies rewards the child might want to earn for completing challenges (i.e., exposures). The ninth session is the second parent session, during which the therapist prepares the parents for the beginning of exposure tasks in the following session, discusses their role in these exposures and in conducting them at home, and discusses any additions they may have to the fear hierarchy.
Session 10 marks the beginning of the exposure phase in treatment. During this phase of treatment, the STIC tasks assigned are the “challenges” to be completed out of session. In each exposure session (session 10 through session 16), the thera-
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pist and client go through the FEAR plan to prepare for the challenge, complete the challenge, and then process how the challenge went. The challenges in sessions 10 and 11 are low anxiety-provoking situations, those in sessions 12 and 13 are moder- ately anxiety-provoking situations, and those in sessions 14, 15, and 16 are high anxiety-provoking situations. As the treatment program is 16 sessions, in sessions 15 and 16, the therapist discusses the end of treatment, including relapse prevention, with the youth and family. Additionally in session 16, the youth creates a “commer- cial” of some sort to demonstrate what they have learned in treatment, and the thera- pist and client (as well as sometimes the client’s family) celebrate the child’s success. This conclusion of treatment recognizes the child’s accomplishments and encourages them to continue to approach situations so they can continue to over- come fears that arise.
Well-researched and evaluated treatment manuals such as this Coping Cat pro- gram exist and are used by many clinicians when treating anxious youth. As illus- trated above with the Coping Cat program, these provide frameworks by which clinicians can deliver evidence-based therapy to children and adolescents with anxiety disorders. When working with these manuals, it remains essential for cli- nicians to implement them in a flexible way to meet the youth’s needs while remaining adherent to the treatment; indeed the principle of “flexibility within fidelity” has been noted to be of great importance when implementing manualized treatment [32, 33]. Through this approach, the effectiveness of manualized CBT in clinical community centers has been found to be comparable to that in specialty clinics [34].
The majority of the research on CBT has focused on its use with youth ages 7–17; however preliminary research indicates it may be effective for children as young as age 4 [35, 36]. The original format of CBT – individual, youth-focused treatment – has also been modified in various ways that have similarly received empirical support, although they have been studied less often. For instance, CBT has demonstrated efficacy in the group format [34, 37–41] as well as family format, which involves both the youth and the parent or parents in every session [42, 43]. It has also demonstrated efficacy in a brief format [44] or even in as few as one extended session when treating specific phobias [45]. Modifications of the treat- ment to take a more transdiagnostic approach and address the anxiety within the larger context of the youth’s presentation (e.g., comorbid non-anxiety disorders) have additionally demonstrated efficacy for treating anxiety in youth [46, 47].
Research has also evaluated the beneficial role technology may play in treating anxious youth. Findings indicate that computer-assisted CBT (in which some of the treatment is carried out independently via a computer CBT program and some of the treatment is completed with the assistance of a therapist) as well as internet-based CBT programs (in which all sessions are completed online and youth have two brief phone calls with a therapist) yield positive treatment outcomes for anxious youth [48–51]. Thus although the original format of CBT remains the most common when treating youth with anxiety, additional possibilities exist and possess their own benefits.
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Selective Serotonin Reuptake Inhibitors (SSRIs)
CBT is considered the “gold standard” treatment for youth with anxiety, often rec- ommended before the use of medication [52]. However, for youth who do not respond to CBT or continue to experience significant symptoms of anxiety follow- ing a course of CBT, SSRIs have been found to be beneficial [53]. Sertraline, flu- voxamine, fluvoxamine, paroxetine, and venlafaxine are among the SSRIs that have been researched and are prescribed for youth with anxiety. Multiple placebo-con- trolled studies have found SSRIs to be effective for treating children and adoles- cents with anxiety [17, 54–61], with a response rate similar to that of CBT [17].
SSRIs can be used to treat anxious youth alone or in combination with CBT. Research indicates that when youth are treated with the combination of these interventions, the response rate increases from 55% (SSRIs alone) or 60% (CBT alone) to 80%
(SSRIs and CBT combined) [17]. As medication use may have unwanted costs and side effects, and the long-term effects have not been studied in youth, CBT is con- sidered the front-line intervention for anxiety by the American Academy of Child and Adolescent Psychiatry [62], and medication can be added on following a course of CBT if that is deemed appropriate for the individual youth.
Other Interventions
Although research findings consistently support CBT and SSRIs to treat children and adolescents with anxiety, other interventions have been suggested and researched yet to a lesser extent. These include psychosocial treatments as well as additional medication. Among these additional interventions, parent programs (the therapist’s intervention remains youth focused in working with the parents, teaching the par- ents skills to use with their children) and parent therapies (the therapist’s work is not directly focused on the youth and instead centers around the parents’ behaviors) have research support to suggest their efficacy in treating youth with anxiety.
For instance, The Child Anxiety Tales (available at CopingCatParents.com) is an example of a parent program and is based off of the Coping Cat treatment. This par- ent program has demonstrated effectiveness in making parents of children with anxiety feel empowered and more knowledgeable about anxiety in children, as well as informed about strategies that could help [63].
Parent therapies are parent focused, in contrast to CBT, which is youth focused.
In these parent therapies, the therapist works with the parents to change their actions, behaviors, and ways of relating to their child so as to affect change in the youth’s anxiety. Parent-Child Interaction Therapy (PCIT) is one form of parent therapy that has been well researched [64]. PCIT has been adapted from its original version, developed to treat disruptive behavior problems in children, to treat child anxiety [65]. In this therapy, the parent-child interaction is changed in order to improve the child’s behavior. Following pilot studies of PCIT adapted to treat child anxiety [66,
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67], an initial RCT of this adapted PCIT indicated efficacy for treating children ages 4–8 with SepAD [67]. Thus, although more research is clearly needed on this inter- vention, PCIT appears promising as a treatment for young children with anxiety.
Another example of parent therapy is The SPACE Program (Supportive Parenting for Anxious Childhood Emotions) [68]. This approach is a parent-only intervention that targets the accommodating behaviors of the parents that are related to the youth’s anxiety. This treatment does not work to teach parents specific skills to implement, but rather focuses on how the parents are interacting with their child surrounding the child’s anxiety and the relational features of the interactions [68].
Results from a small open trial in youth ages 9–13 provide preliminary support for the efficacy of this parenting skills training program to treat youth anxiety [68]. This approach may be valuable given that some youth may refuse individual treatment, as was the case in the sample of families who participated in this open trial [68]. As is true for PCIT, this intervention requires further investigation to assess its ability to treat youth anxiety.
There are several additional psychosocial interventions that warrant additional study in the treatment of youth anxiety. For instance, acceptance-, mindfulness-, and meditation-based interventions are established treatments for adults. With youth, the findings indicate that these approaches are acceptable and feasible [69–71], yet stud- ies comparing these interventions to treatment-as-usual or to an active control condi- tion have been inconsistent, with some suggesting these approaches to be better than the comparison group [72] and others finding no significant differences [73]. Overall, it has been concluded that more empirical evidence is needed to assess whether or not these treatments can be considered empirically supported [53, 69, 74, 75].
Furthermore, art therapy, music therapy, and play therapy may, in practice, be implemented to treat anxious youth; however, little research has examined these approaches’ efficacy for treating anxiety disorders, and the current research does not support their efficacy [14]. The research that does presently exist has examined changes in anxiety levels from pre- to post-treatment in specialized populations, such as youth with cancer [76], youth who are going to have an operation [77], or youth who have experienced sexual assault [78]. These studies indicate that a course of art therapy or music therapy is associated with decreased self-reported anxiety symptoms [76, 78]; however of note, these studies were not of youth with anxiety disorders. One study evaluated play therapy compared to an active control condition for children with heightened levels of anxiety [79]. In this study, the play therapy group and control group were not themselves comparable, which limits the reported finding that the play therapy group reduced self-reported worry more than the con- trol group. Moreover, the two groups were not found to be significantly different in changes in self-reported physiological anxiety or social anxiety. Thus, while these approaches of art, music, and play therapies may be employed by clinicians to address youth anxiety, the quantity and quality of the research that has been con- ducted on these interventions is not currently sufficient to claim empirical support.
With regard to other medications, research has examined the use of benzodiaze- pines to treat anxiety in children and adolescents: results have been mixed [80]. An open-label trial of 12 adolescents found that 4 weeks of alprazolam led to significant
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improvements in anxiety [81], but placebo-controlled trials of alprazolam [82] and clonazepam [83] found that the benzodiazepines were no more effective than pla- cebo. Additionally, a large majority of the participants reported frequent unwanted side effects from the medication [83]. Beyond the medical side effects, benzodiaz- epine use may also interfere with the benefits of psychotherapy as they have been found to interfere with new learning, a key goal of exposure tasks [84]. As a result of these inconsistent findings as well as the associated side effects, it is suggested that other interventions be implemented first and that benzodiazepines only be pre- scribed to youth in limited situations [85].