Use of CBT to Treat Anxiety in Children and Adolescents
Introduction
There are various treatment modalities for treating different psychological disorders in children and adults. In the same vein, various psychotherapeutic techniques are used to treat anxiety in children and adolescents. The current treatment modalities for treating anxiety in children and youth are behavioural therapy and cognitive behavioural therapy (CBT) in addition to drugs. Worth noting, that experts in psychology have not put forth specific guidelines on the indications for medication versus psychological treatment. However, medications are often preferred as first-line treatment because of the prevalence of such disorders, onset age, and public outlook on the efficacy of psychological treatment.
According to Hirshfeld-Becker, Masek, and Henin (2010) many research studies suggest that childhood anxiety disorders cause familial and academic impairment that are likely to persist if untreated and could predispose children to present anxiety disorder during adolescents and adulthood. Hence, efforts to treat this order at the early stage would benefit the community.
Over the past few decades, psychologists have developed promising cognitive behavioural therapies (CBT) to treat anxiety disorders, such as social phobia, generalized anxiety disorder (GAD), and separation anxiety disorder (Silverman, Pina, & Viswesvaran, 2008). Kendall, Hudson, Gosch, Flannery-Schroeder, and Suveg (2008) concluded that CBT can be effective for anxiety disorders when provided as individual sessions or family sessions.
Cognitive Behavioural Therapy
This essay will discuss the relevance of CBT for treating anxiety in children and youth taking into account the effect of the sufferer’s circumstance on the efficacy of the psychological modality. CBT can be delivered in various formats including individual format, child or teenage format, group format, and parents or family format. For children and adolescents, CBT involves twenty-session therapies. According to Kendall (1994), one of the first manualized CBT programs for children and youth was the Coping Cat. It consisted of education, change of negative cognition, exposure, training for social competence, coping tactics, and self-reinforcing sessions. Other programs include the Cool Kids programme, the Coping Koala programme (Barrett, 1996, cited in James et al., 2015), ACTION (Waters, 2009), Skill for Academic and Social Success [SASS] (Masia-Warner, 2007), the TAPS (Masia-Warner, 2011), Intervention with Adolescents with Social Phobia (IAFS)), and Building Confidence programme. Psychologists have tailored certain programs for children with autism spectrum disorders (ASDs). Such programmes include TAFF, Facing Your Fears [FYF] the Multimodal Anxiety and Social Skills Intervention (MASSI).
How CBT Works
Cognitive Behavioural Therapy (CBT) for anxiety disorders in this group entails assisting the sufferer to do certain tasks (James, James, Cowdery, Soler, & Choke, 2015). The first involves helping the client identify anxious feelings and somantic responses to anxiety. The second task involves helping the child or adolescent clarify thoughts in anxiety-inducing circumstances. The third involves helping the patient develop coping skills and the fourth task involves facilitating the client assesses the outcomes of their efforts. Strategies for behavioural training encompass modelling, reality exposure, role-playing, and relaxation training.
According to James, James, Cowdrey, Soler, and Choke (2015) behavioural treatment relies on the assumption that fears and anxiety are learned responses that can be unlearnt. Silverman (1996) asserts that exposure is the key procedure for CBT. A facet of the treatment called “systematic desensitisation” involves pairing stimuli of anxiety, in vivo or by visualization, in a slowly increasing hierarchy with competing relaxing stimuli including muscle relaxation and pleasant images.
In addition, CBT involves the use of cognitive strategies including self-control strategies that depend on self-observation, self-evaluation, self-correction, and self-reward. This set of tasks corresponds to the STOP acronym (Silverman, 1996) with the letters identifying different tasks. The S signifies children and youth with anxiety disorders learning to identify the manifestation of fear, that is, when they feel Scared (S), after which they identify their own Thoughts (T). After these steps, they learn to alter their thoughts of fear by creating Other (O) alternative behaviours and thoughts for coping. The last steps entail learning to Praise (P) or reward themselves for dealing with their fears.
Based on James et al. (2015), CBT has been modified to incorporate parents and family. The major dimension of CBT parent or family treatment directive involves changing the beliefs of parents regarding helping their child with anxiety disorder and helping parents to react practically to the anxious and avoidant behaviours of their child. Also, it prioritise helping parents handle their own anxiety.
Importantly, having attained a specific level of cognitive development is requisite for the use of CBT on a child sufferer. In this regard, the capacity to measure a thought or belief against the idea of rational standard and the capacity to appreciate that the perception or belief may trigger an individual to behave and feel in a specific way was pivotal to its right application. The question then arises about the age at which a child possesses the cognitive capacities to perform the necessary cognitive tasks. Although positive effects in children aged younger than 6 years have been reported (Hirshfeld-Becker et al., 2010), it is unclear whether children this young can use decentring techniques, including narratives or stories. Consistent with this concern, a recent research study showed that children in their early childhood could be more responsive to the behavioural aspect of the treatment modality than the cognitive (Essau, 2004). Further, Cartwright-Hatton (2011 cited in James et al., 2015) found that the treatment of anxiety disorders in toddlers might be influenced by collaborating with parents alone.
Efficacy of CBT
Different children and adolescents with anxiety disorders respond differently to CBT. The findings from different randomized clinical trials (RCTs) prove the efficacy of CBT in treating this population (Kendall, Hudson, Gosch, Flannery-Schroeder, & Suveg, 2008). Barnish and Kendall (2005 cited in Kendall et al. 2008) reported that CBT for treating anxiety in youth produces medium to large size effects relative to wait-list controls. however, the effect is not the same for the entire population. In this regard, Cartwright-Hatton, Roberts, Chitsabesan, Fothergill and Harrington (2004) showed that 56% of anxious youth recovered after CBT treatment while 63% recovered after 12 months.
Parents play a significant role in the success of therapy for their children with anxiety disorders. Indeed, etiological models underpin the reciprocal relationship between parents and the behavior of children with anxiety disorders (Kendall et al., 2008). The anxiety status of parents can serve to sustain the anxiety and avoidance behaviours of their children. Consistent with this view, earlier research studies showed that parents may facilitate anxiety symptoms such as cognitive biases, and avoidance, through reinforcement and modeling (Barret, Rapee. Dadds, & Ryan, 1996). Crawford and Manassis (2001) proved that acute anxiety caused poorer youth outcomes after treatment with CBT. Such findings suggest the benefit of involving parents in the treatment of their children, because of the ability to reduce parents’ restriction of their children’s activity, overcontrol, and modeling of avoidance and cognitive bias (Kendall et al., 2008).
CBT in Anxiety Disorder Associated with Autism
An estimated 50% of the youth with ASD present clinical anxiety (Ung, Selles, & Small, 2015). Such adolescents are more prone to suffer anxiety symptoms than normal youths because of their communication and social inadequacies associated with problems understanding social cues, problems controling emotions, and hypersensitivity (Ung et al. 2015). CBT has been specially developed to treat anxiety disorders in autistic children and adolescents.
Core components of CBT for the treatment of anxiety symptoms in typically developing youth and youth with high-functioning ASD include, cognitive therapy, creation of the fear hierarchy as well as exposure and prevention of response (Storch, Arnold, Lewin, Nadeau, Jones, De Nadai, 2013). The use of CBT in normal developing youth has been amended to be appropriate for youth with Autism Spectrum Disorder. As a result, CBT protocols have been changing to incorporate social stories that elucidate the feelings and thoughts of others, coaching to increase social skills, as well as visual aids and structured worksheets to adapt components of CBT (Wood, Drahota, Sze, Har, Chiu, Langer, 2009). The efficacy of CBT in typically developing youth and youth with ASD (Storch et al., 2013) has been demonstrated in different research studies. In ASD adolescent, however, the size of effects is more uneven with certain studies finding robust effects (Chalfant, Rapee & Carroll, 2007, cited in Ung et al., 2015) while others have found more modest (Reaven, Blakeley-Smith, Culhane-Shelburne & Hepburn, 2012, cited in Ung et al., 2015) and yet others small effects (Sofronoff, Attwood & Hinton, 2005, cited in Ung et al., 2015).
The duration of CBT session determines the extent to which anxiety patients are cured of the condition. Extended periods of CBT sessions result in a more robust effect of the modality on the symptoms of psychosis than the traditional therapy period of 12 to 16 weeks. Ung and colleagues (2015) suggest that the robust effect may be due to the increased time to practice skills learned in treatment sessions. Nevertheless, researchers have not studied the length of therapy sessions as a moderator of outcomes (Ung et al., 2015).
It has been suggested that the treatment modality (individual versus group sessions with or without parents) and anxiety informant (clinician, parents, and child) influence the magnitude of the therapy outcome (Ung et al., 2015). Conversely, a review of past studies investigating the role of treatment modality and informant play in the effect size showed that these two factors were not significant moderators of treatment effects. The results of this review showed that group or individual sessions regardless of the inclusion of the parents yielded large and moderate effects respectively. The difference in effects of these modalities was not statistically significant, implying that they both have the same efficacy in treating anxiety in ASD. However, group sessions have more benefits to the patient than individual sessions. Such benefits include increasing access to treatments, normalization of anxiety symptoms, social and peer support, heightened motivation, accountability, self-efficacy, and acceptability (Ung et al., 2015). Individual sessions of CBT may also have some advantages such as the capacity to allow for customizing the components of CBT to individual and family needs. Other advantages include an increase in the likelihood and confidentiality of patient disclosure, and individualized exposures and responses that may promote acceptability (Ung et al., 2015).
CBT in Young Children with Anxiety Disorder
Hirshfeld-Becker et al. (2010) examined CBT protocol adapted for young children together with their families in RCT of a sample of children aged between 4 and 7 years suffering from anxiety disorder. The researchers proposed that the treatment elicits significant improvement in anxiety and ability to cope with fear stimuli at the posttreatment than without intervention and benefits will be maintained after one year. Hirshfeld-Becker and colleagues (2010) showed that CBT involving parents of children with anxiety has the potential for alleviating anxiety in children aged between 4 and 7 years. Specifically, this treatment modality should potential to reduce anxiety and enhance coping skills among this population. Importantly, the finding of the study showed that anxiety diagnoses posttreatment reduced to within the range of those reported in CBT trials of older children (Hirshfeld-Becker et al., 2010). The improvement in coping ability was comparable to that reported in studies by Kendall et al. (1997, 2008, cited in Hirshfeld et al., 2010) of older children treated in both individual and family modalities. This study supported the potential of a developmentally modified parent-child CBT approach to treat anxiety in children aged between 4 and 7 years old. However, further studies should be conducted to assess the efficacy and effectiveness of the proposed CBT modality for treating anxiety in young children.
Conclusion
CBT is a psychological intervention that seeks to help sufferers of anxiety disorders learn coping skills by educating them on ways to identify anxiety stimuli. The roles parents play in the success of the treatment have been highlighted especially for younger children. However, results of many studies have shown that CBT does not result in complete recovery of all the patients that received it; just a fraction of children given the therapy recover. Further, the cognitive developmental level of children determines the efficacy of the therapy for children and adolescents with anxiety disorders. Also, longer sessions of the treatment have been shown to be more effective than shorter sessions. Group session of CBT seems slightly more effective than individual sessions, although the difference is not statistically significant.
References
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