What is CBT for Youth Anxiety?
Cognitive-behavioral therapy (CBT) for anxiety is an integrative approach founded on the assumption that both cognitive and behavioral processes can cause and maintain anxiety (Brewin, 1996). Although variations in these interventions exist depending on the specific disorder to be treated (e.g., Separation Anxiety, Social Anxiety, Generalized Anxiety Disorder), most CBT protocols aim to teach the child or adolescent new approach behaviors, concrete problem-solving skills, and strategies for challenging maladaptive or unrealistic anxious thoughts and beliefs.
Cognitive distortions are considered to play a key role in the maintenance of youth anxiety as they lead to misinterpretations of environmental threats and undermine the child's coping abilities. Behavioral avoidance is also a primary maintaining factor in anxiety. Avoidant behavior is triggered by a distressing event and then is reinforced by the reduction in distress that follows escape. Continued avoidance perpetuates a cycle of fear, withdrawal, and catastrophic beliefs. CBT aims to alter maladaptive thought processes by highlighting the link between thoughts, feelings, and behaviors and then cultivates new problem-solving and coping skills. CBT uses direct reinforcement, modeling, and in vivo exposures to facilitate safe and adaptive approach behaviors during which children can challenge dysfunctional beliefs. Multiple treatment formats have received empirical support, including single session treatments for specific phobias, week-long intensive formats for Obsessive Compulsive Disorders (OCD) and phobic disorders, and traditional short-term therapy protocols (typically 12-20 weeks). Parents are also frequently involved in treatment to facilitate behavioral practice and help generalize skills to home and school life.
Core Components of the CBT Model for Anxious Youth
CBT uses a variety of strategies to help a child reduce anxiety, challenge anxious thinking, and counter long-standing avoidance behavior, including affective education, behavioral relaxation, cognitive restructuring, imaginal and in-vivo exposure, modeling and rewards, and behavioral parent training. Several of these techniques are outlined as follows:
Emotions Education and Relaxation. Parents and child are taught about the interrelated physiological, cognitive, and behavioral components of anxiety. Activities help demonstrate different emotions, body postures, and cognitive and physiological correlates. Progressive relaxation training helps anxious children develop awareness and control over their own physiological and muscular responses to anxiety.
Cognitive restructuring. Cognitive restructuring helps children identify and replace distorted cognitions with more adaptive beliefs. Basic cognitive strategies include identifying and reducing negative self-talk, generating positive self-statements, thought stopping, thought challenging (weighing evidence for and against), testing both dysfunctional and adaptive beliefs, and creating a coping plan for feared situations.
Imaginal and in-vivo exposure. The goals of exposures are to encourage approach behavior by positioning the child in a previously feared or challenging situation. The child attempts to complete tasks in a graded "fear hierarchy" such that the child experiences early success before attempting greater challenges. During individual exposures, a child is encouraged to use any number of coping skills, including relaxation exercises, coping thoughts (challenging anxious thoughts with more positive, realistic thoughts), concrete problem-solving, or rehearsal of desirable skills.
Parent Interventions. Parents may have their own preconceptions about the threatening nature of anxiety and they may not know how best to encourage a child to cope with anxiety. CBT provides parents education about the risks of continued avoidance and guidance in managing their own anxiety. CBT may also impart basic parenting strategies (e.g., positive/negative reinforcement, planned ignoring, modeling, reward planning) to facilitate the practice of therapy skills in the home.
Exposure and Response Prevention (ERP) for Obsessive Compulsive Disorder. ERP is a variant of traditional exposures wherein exposures target specific obsessions and repetitive compulsions. The child is exposed to a stimulus that triggers anxiety and intrusive thoughts and is helped to resist performing the compulsions meant to relieve the anxiety. Exposures often proceed in a progressive hierarchical gradient but a range of exposure durations and intensities can be successful.
Trauma-Focused CBT (TF-CBT) for Post Traumatic Stress Disorder. TF-CBT is a psychotherapeutic intervention designed to help children, youth, and their parents overcome the negative effects of traumatic life events such as child sexual or physical abuse, traumatic loss of a loved one, domestic, school, or community violence, or exposure to disasters, terrorist attacks, or war trauma. It integrates cognitive and behavioral interventions with traditional child abuse therapies to enhance interpersonal trust and empowerment. More information can be found at: http://tfcbt.musc.edu.
References & Recommended Readings
Barrett, P. M., Farrell, L., Pina, A. A., Peris, T. S., & Piacentini, J. (2008). Evidence-based psychological treatments for child and adolescent obsessive-compulsive disorder. Journal of Clinical Child and Adolescent Psychology, 37, 131-155.
Brewin, C. R. (1996). Theoretical foundations of cognitive-behavioral therapy for anxiety and depression. Annual Review of Psychology, 47, 33-57.
Creswell, C., & Cartwright-Hatton, S. (2007). Family treatment of child anxiety: Outcomes, limitations, and future directions. Clinical Child and Family Psychology, 10, 232-252.
Silverman, W. K., Ortiz, C. D., Viswesvaran, C., Burns, B. J., Kolko, D. J., Putnam, F. W., Amaya-Jackson, L. (2008). Evidence-based psychosocial treatments for children and adolescents exposed to traumatic events. Journal of Clinical Child and Adolescent Psychology, 37, 156-183.
Silverman, W. K., Pina, A. A., & Viswesvaran, C. (2008). Evidence-based psychosocial treatments for phobic and anxiety disorders in children and adolescents. Journal of Clinical Child and Adolescent Psychology, 37, 105-130.
Walkup, J. T., Albano, A. M., Piacentini, J., Birmaher, B., Compton, S. N., Sherrill, J. T., et al. (2008). Cognitive behavioral therapy, sertraline, or a combination in childhood anxiety. New England Journal of Medicine, 359, 2753-2766.
Weissman, A. S., Antinoro, D., & Chu, B. C. (2008). Cognitive-behavioral therapy for anxiety in school settings: Advances and challenges. In M. Mayer, R. Van Acker, J. E. Lochman, & F. M. Gresham (Eds.), Cognitive-behavioral interventions for students with emotional/behavioral disorders (pp. 173-203). New York: Guilford Press.