Cognitive behaviour therapy for children and adolescents with anxiety

Cognitive behaviour therapy is provided by trained people, usually psychologists. To find a local psychologist see: Australian Psychological Association

Cerebral Palsy Alliance offers services to children, adolescents and adults who wish to consider using cognitive behaviour therapy to help with anxiety. Our staff can help you decide if this intervention is a good choice for you and your family.

Find a Cerebral Palsy Alliance service

Fees will apply for assessment and cognitive behaviour therapy with a trained practitioner and will depend on the provider and the number of sessions needed. Check with the practitioner whether fees will also apply for development of a home program, report writing or practitioner travel.

Ask health care providers if you are eligible for funding to assist with fees. People with a disability living in Australia may be eligible for a health care rebate through Medicare or funding from the National Disability Insurance Scheme.

The length of therapy will depend on the needs of the child and their problems. Most children have six to 12 sessions.

Anxiety can be very troubling and interfere with daily life². It comes from having unrealistic or fearful thoughts and beliefs (cognitions) along with avoiding fearful situations or objects (behaviours). Anxiety is very common in children and adolescents.

Cognitive behaviour therapy for anxiety consists of several components³ which usually include:

• Psycho-education - teaches children and adolescents about anxiety, and the differences between helpful and unhelpful fears
• Self-monitoring – children or their parents record the times they are anxious to help understand how different situations, thoughts and behaviours cause anxiety
• Exposure - children and adolescents are carefully helped to face their fears in real life or imagined situations. Prolonged exposure to the situations or events causing anxiety aims to reduce fear and anxiety. Children practice appropriate responses to situations that can cause anxiety, like relaxation techniques, and are rewarded for coping well in situations they find fearful.
• Cognitive restructuring - this teaches a child or adolescent to identify the unhelpful thoughts and feelings that are causing or maintaining their anxiety. Therapists then help children and adolescents to replace them with more helpful thoughts, feelings and actions. Children may learn skills such as managing anger and dealing with bullying.

Educating parents to help their children practise cognitive behaviour therapy is also an important part of this intervention, especially with younger children. Children and their families are asked to do homework between therapy sessions to learn new coping skills and practise what they have learned. The strategies can then be practised after therapy finishes.

Before starting cognitive behaviour therapy, an assessment is completed with a practitioner to identify the type of anxiety the child experiences and its causes. This is important, so that the intervention can be tailored to the child.

During and after therapy, practitioners may ask children and families to fill in questionnaires to measure the impact of cognitive behaviour therapy on the child’s behaviour, emotional distress and coping with everyday life. Self-monitoring can also provide a helpful measure of changes in anxious behaviour.

We searched the psychological, medical and allied health literature to find studies evaluating the outcomes of cognitive behaviour therapy used with children and adolescents with cerebral palsy.

The search aimed to find studies of cognitive behaviour therapy addressing generalised anxiety, specific or social phobias and separation anxiety disorder. No studies of cognitive behaviour therapy used to manage anxiety in children or adolescents with cerebral palsy were found. As a consequence, the search was expanded to include the highest level of evidence (systematic reviews or randomised controlled trials (RCTs)) for cognitive behaviour therapy used to manage anxiety in other groups of children and adolescents.

The best available evidence was a systematic review by Reynolds and colleagues⁴. Reynolds and colleagues identified gaps in the research evidence including evaluation of cognitive behaviour therapy targeting specific anxiety disorders; follow up of outcomes for longer than six months and the effects of computerised cognitive behaviour. Two additional, good quality RCTs^5,6 which had been published since Reynolds and colleagues’ work were also included for review.

High level and good quality evidence indicates that this intervention is effective for reducing anxiety in children and adolescents. This is the case whether therapy is delivered:

• In person, or online
• As a general cognitive behaviour therapy program, or in a form tailored to address a specific type of anxiety disorder
• With parents involved or not.

Cognitive behaviour therapy appears more effective:

• For children aged 11 years old and over
• When more than nine sessions are completed
• Where delivered individually, rather than in a group.

It appears positive results can be retained for at least 12 months. Overall, the evidence for cognitive behaviour therapy for children and adolescents with cerebral palsy is considered to be moderate quality even though it is informed by a good quality systematic review and RCTs. The evidence is rated this way since the research has not been specifically completed with children and adolescents with cerebral palsy. The results, therefore, are expected - rather than proven - to apply to this group. No high level evidence exists evaluating cognitive behaviour therapy for children under 11 years of age and those with a developmental or intellectual disability.

Cognitive behaviour therapy reduced anxiety significantly in children and adolescents

Reynolds and colleagues’⁴ good quality systematic review analysed 48 RCTs of cognitive behaviour therapy for anxiety disorders in children and adolescents. The intervention reduced anxiety significantly more than no treatment at completion of the therapy.

Improvements varied depending on age of children, whether they attended in a group or individually, and the number of sessions

Reynolds and colleagues⁴ reported improvements were larger in adolescents aged 11 years old and over than in younger children, and for children who attended individual sessions rather than group sessions. Finally, Reynolds and colleagues identified that five or more sessions of CBT were effective for reducing anxiety, but the effects were larger when children completed nine or more sessions.

Online cognitive behaviour therapy was effective and accessible

Spence and colleagues’⁶ good quality RCT showed that significantly fewer adolescents had anxiety immediately after receiving online or therapist-delivered cognitive behaviour therapy, when compared with adolescents receiving no treatment. This trend continued after 12 months, with further decreases in adolescents with anxiety in the cognitive behaviour therapy groups, but with no differences between groups. Parents and adolescents rated their satisfaction with online and therapist-delivered cognitive behaviour therapy as moderate to high, suggesting that online cognitive behaviour therapy is effective and acceptable, and potentially accessible to more adolescents.

After six months, cognitive behaviour therapy is as effective as an alternate treatment

Few studies assessed whether improvements were sustained beyond six months. Those which did, compared cognitive behaviour therapy with an alternative treatment, rather than no treatment. This is because it was considered unethical to offer no treatment beyond six months. The improvement found in therapeutic effect for both cognitive behaviour therapy and an alternative treatment are sustained at 12 months.

Parental involvement did not influence the outcome

Cognitive behaviour therapy was effective whether or not parents participated in the intervention⁴.

For children with separation anxiety disorder, a general cognitive behaviour therapy program was as effective as a program specifically developed for the disorder

Schneider and colleagues⁵ compared cognitive behaviour therapy specifically developed for separation anxiety disorder and including parent training, with a general cognitive behaviour therapy program of equal intensity. Twelve months after completing the intervention, over 75 per cent of children in both groups no longer had separation anxiety disorder. Both types of cognitive behaviour therapy were effective for reducing separation anxiety disorder.

Families, caregivers and practitioners are encouraged to carefully consider the unique goals and needs of each child and adolescent with cerebral palsy to determine whether trialling cognitive behaviour therapy is worthwhile.