Cognitive behavioural therapy for anxiety in children and young people

Why is this review important?

Many children and young people experience problems with anxiety. Children and young people with anxiety disorders are more likely than their peers to have difficulty with friendships, family life, and school, and to develop mental health problems later in life. Therapies such as cognitive behavioural therapy (CBT) can help children and young people to overcome difficulties with anxiety by using new ways of thinking and facing their fears.

Who will be interested in this review?

Parents, children, and young people; people working in education and mental health services for children and young people; and general practitioners.

What questions does this review aim to answer?

This review updates and replaces previous Cochrane Reviews from 2005 and 2015, which showed that CBT is an effective treatment for children and young people with anxiety disorders.

This review aimed to answer the following questions:

• Is CBT more effective than a waiting list or no treatment?

• Is CBT more effective than other treatments and medication?

• Does CBT help to reduce anxiety for children and young people in the longer term?

• Are some types of CBT more effective than others? (e.g. individual versus group therapy)

• Is CBT effective for specific groups? (e.g. children with autism)

Which studies were included in the review?

We searched the databases to find all studies of CBT for anxiety disorders in children and young people published up to October 2019. In order to be included in the review, studies had to be randomised controlled trials (a type of study in which participants are assigned to one of two or more treatment groups using a random method) and had to include young people under 19 years of age with an anxiety disorder diagnosis. We included 87 studies with a total of 5964 participants in the analysis.

What does the evidence from the review tell us?

We rated the overall quality of the evidence as 'moderate’ or 'low'. There is evidence that CBT is more effective than a waiting list or no treatment in reducing anxiety in children and young people, although the findings did vary across studies. There is no clear evidence that CBT is more effective than other treatments. A small number of studies looked at outcomes six months after CBT was given and showed that reductions in anxiety continued. We found no clear evidence that one way of providing CBT is more effective than another (e.g. in a group, longer treatments, with parents) or that CBT is more or less effective for any specific group of children (e.g. children with autism spectrum disorders).

What should happen next?

Future research should compare CBT to alternative treatments and medication; identify who does and does not benefit from CBT and what those who do not benefit need; establish how to make CBT more accessible; and give far more consideration to neglected populations, including children and young people from low- and middle-income countries.

Authors' conclusions: 

CBT is probably more effective in the short-term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.

Read the full abstract...
Background: 

Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up-to-date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer-term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments.

Objectives: 

To examine the effect of CBT for childhood anxiety disorders, in comparison with waitlist/no treatment, treatment as usual (TAU), attention control, alternative treatment, and medication.

Search strategy: 

We searched the Cochrane Common Mental Disorders Controlled Trials Register (all years to 2016), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO (each to October 2019), international trial registries, and conducted grey literature searches.

Selection criteria: 

We included randomised controlled trials of CBT that involved direct contact with the child, parent, or both, and included non-CBT comparators (waitlist/no treatment, treatment as usual, attention control, alternative treatment, medication). Participants were younger than age 19, and met diagnostic criteria for an anxiety disorder diagnosis. Primary outcomes were remission of primary anxiety diagnosis post-treatment, and acceptability (number of participants lost to post-treatment assessment), and secondary outcomes included remission of all anxiety diagnoses, reduction in anxiety symptoms, reduction in depressive symptoms, improvement in global functioning, adverse effects, and longer-term effects.

Data collection and analysis: 

We used standard methodological procedures as recommended by Cochrane. We used GRADE to assess the quality of the evidence.

Main results: 

We included 87 studies and 5964 participants in quantitative analyses.

Compared with waitlist/no treatment, CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45, 95% confidence interval (CI) 3.90 to 7.60; n = 2697, 39 studies, moderate quality); NNTB 3 (95% CI 2.25 to 3.57) and all anxiety diagnoses (OR 4.43, 95% CI 2.89 to 6.78; n = 2075, 28 studies, moderate quality).

Low-quality evidence did not show a difference between CBT and TAU in post-treatment primary anxiety disorder remission (OR 3.19, 95% CI 0.90 to 11.29; n = 487, 8 studies), but did suggest CBT may increase remission from all anxiety disorders compared to TAU (OR 2.74, 95% CI 1.16 to 6.46; n = 203, 5 studies).

Compared with attention control, CBT may increase post-treatment remission of primary anxiety disorders (OR 2.28, 95% CI 1.33 to 3.89; n = 822, 10 studies, low quality) and all anxiety disorders (OR 2.75, 95% CI 1.22 to 6.17; n = 378, 5 studies, low quality).

There was insufficient available data to compare CBT to alternative treatments on post-treatment remission of primary anxiety disorders, and low-quality evidence showed there may be little to no difference between these groups on post-treatment remission of all anxiety disorders (OR 0.89, 95% CI 0.35 to 2.23; n = 401, 4 studies)

Low-quality evidence did not show a difference for acceptability between CBT and waitlist/no treatment (OR 1.09, 95% CI 0.85 to 1.41; n=3158, 45 studies), treatment as usual (OR 1.37, 95% CI 0.73 to 2.56; n = 441, 8 studies), attention control (OR 1.00, 95% CI 0.68 to 1.49; n = 797, 12 studies) and alternative treatment (OR 1.58, 95% CI 0.61 to 4.13; n=515, 7 studies).

No adverse effects were reported across all studies; however, in the small number of studies where any reference was made to adverse effects, it was not clear that these were systematically monitored.

Results from the anxiety symptom outcomes, broader outcomes, longer-term outcomes and subgroup analyses are provided in the text.

We did not find evidence of consistent differences in outcomes according to delivery formats (e.g. individual versus group; amount of therapist contact time) or amongst samples with and without ASD, and no studies included samples of children with intellectual impairments.

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