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International Review of Psychiatry (2002), 14, 129–134
ISSN 0954–0261 print/ISSN 1369–1627 online/02/020129–06 Institute of Psychiatry
DOI: 10.1080/0954026022013264 4
Cognitive behavioural therapy for children and adolescents with anxiety
disorders: clinical research advances
ANNE MARIE ALBANO1 & PHILIP C. KENDALL2
1NYU School of Medicine, New York, USA & 2Temple University, New York, USA
Summary
Cognitive behavioural therapy for children and adolescents with anxiety is based upon both sound theoretical and empirical
underpinnings. This article reviews the empirical support for the efficacy of this treatment as well as its adaptability and transportability
to diverse population of children, to treatment type (e.g. group, individual or family) and treatment se tting (academia, office practice,
schools and communities). A descripti on of the Coping Cat programme provides an example of how manualized cognitive behavioural
therapy programmes can meet the needs of anxious youth.
Introduction
In the past 30 years treatment development research
has focused on treatments that target specific
disorders, and has moved away from applying non-
specific intervention techniques (i.e. treatment-as-
usual model) to the range of clinical problems in
youth (Hibbs & Jensen, 1996; Kazdin, 1997).
Changes in mental health care policy and the focus
on evidenced based treatments contributed in part to
this trend. Consequently, whether considering
psychosocial or pharmacological treatments, a move
towards a disorder-specific, evidenced based treat-
ment management model appears to be the modal
approach to clinical care preferred by clinicians
(March & Ollendick, in press). In this article we
describe the current status of evidence-based psy-
chosocial treatments for anxiety disorders in youth.
First, criteria for determining efficacy are explained.
We then describe the cognitive behavioural model of
psychotherapy for the three most common and co-
existing childhood anxiety disorders, separation
anxiety disorder, social phobia, and generalized anx-
iety disorder. Next, we briefly review the foundations
for empirical support of a manualized, short-term
cognitive behavioural therapy (CBT) for childhood
anxiety. Finally, we provide a critique of the child
CBT literature with directions for future research.
The American psychological association criteria for
empirically supported treatments
During his term as president of the Division of
Clinical Psychology of the American Psychological
Association, David H. Barlow, Ph.D., convened a
task force to develop criteria by which to judge the
empirical support of psychosocial treatments. The
term ‘Empirically-Supported Treatment’ (EST) was
coined to refer to treatments proven effective
through rigorous controlled scientific research. The
Task Force on Promotion and Dissemination of
Psychological Procedures (Chambless et al., 1998a,
1998b), now the Committee on Science and
Practice, set forth the following standards to assign a
designation of EST:
(1) The EST must be compared to a no-treatment
control group, alternative treatment group, or
placebo condition (a) in a randomized control-
led trial, controlled single case experiment or
equivalent time series design, and (b) in which
the treatment under study is statistically signifi-
cantly superior to the comparison condition or
equivalent to an already established EST.
(2) The EST must be conducted with (a) a treatment
manual or equivalent, (b) a population treated
for specified problems, with reliable and valid
inclusion criteria, (c) reliable and valid outcome
measures, and (d) appropriate data analysis.
(3) To be deemed efficacious, the superiority of the
EST must have been demonstrated in at least
two independent research settings. If there is
conflicting evidence, the preponderance of well-
controlled data must support the efficacy of the
treatment in question.
(4) For a designation of probably efficacious, one
study (or research from one center) will suffice in
the absence of conflicting evidence.
(5) For a designation of efficacious and specific, the
treatment must be shown superior to placebo (pill
or psychosocial) or to an alternative treatment in
Correspondence to: Anne Marie Albano, Ph.D., Child Study Center, NYU School of Medicine, 550 First Avenue, New
York, NY 10016, USA. Tel: +1 (212) 263–8661; Fax: +1 (212) 263–8662; E-mail: albana01@popmail.med.nyu.edu
130 Anne Marie Albano & Philip C. Kendall
at least two independent settings. If there is
conflicting evidence, the preponderance of well-
controlled data must support the treatment’s
efficacy and specificity.
The publication of these criteria combined with a list
of treatments for adult disorders meeting the EST
criteria introduced to the US standards for scientific
rigor in psychotherapy studies (Chambless, 2002).
With regards to the anxiety disorders, data from over
60 randomized controlled trials of CBT in adults
with anxiety disorders support the efficacy (see
Gould et al., 1997a, 1997b) and effectiveness (Wade
et al., 1998) of this modality. Although far fewer
controlled trials have focused on the treatment of
anxious youth, the preponderance of evidence
supports CBT for children with anxiety disorders.
Before reviewing the extant literature, we describe
the cognitive behavioural model and approach to
treatment of anxious youth.
Overview of the cognitive behavioural
approach to treatment
The cognitive behavioural model
Treatment from the cognitive behavioural perspec-
tive assumes that anxiety is a normal and expected
emotion comprised of biological, behavioural, and
psychological components. Individual risk for anxiety
disorders vary given an individual’s genetic predispo-
sition, temperament, family history, learning and
environmental experiences, parenting styles, and
other endogenous and exogenous factors. In its
adaptive or ‘normal’ form, anxiety serves a protective
function for the individual to alert him or her to
danger and/or to motivate certain adaptive behav-
iours to avoid stress or negative experiences (e.g. to
study prior to an exam, look both ways before
crossing a street). Anxiety is assumed to be a tripartite
construct involving physiological, cognitive, and
behavioural components (see Barlow, 2002). Physi-
ological arousal occurs in the form of autonomic
nervous system activity. These responses prepare an
individual to respond with appropriate motor
behaviour in stressful situations, such as when the
‘fight or flight’ response is activated. Consider the
child, for example, who while riding his or her bicycle,
suddenly turns a street corner and into the path of an
approaching car. Gasping for breath, tightening of
muscles (e.g. in gripping the handlebars, moving the
legs to peddle faster or stop) are all physiological
responses activated through this system. The cogni-
tive component involves a narrowing of attention
(shift in focus) towards the threat cues in a situation
(or goal, to escape safely) and is accompanied by cer-
tain thoughts and images. Finally, slamming on the
bicycle brakes, turning the handlebars to avoid the
car, and screaming are behavioural reactions that
occur to avoid a catastrophe.
Fears and anxiety in children and adolescent s
Certain fear and anxiety reactions have been well
documented as a normal and expected process
during development, with the focus of anxiety
changing at different ages and cognitive developmen-
tal levels (see Albano et al., 2001, for a review). Thus,
young children are expected to fear the dark, separa-
tion situations, and small animals. Fears of the
dentist and thunderstorms occur in early elementary
school, while a shift to evaluation fears (tests, oral
reports) and social situations occur mostly in
adolescence. Girls often endorse more fears than
boys, and the number and types of fears reported by
youth are fairly consistent across cultures (see Ollen-
dick et al., 1994). Fear or anxiety become
problematic (at the disorder level) when expected
developmental levels are exceeded, resulting in
significant distress and impairment at home, school,
and in social contexts (Albano et al., 1996; Kazdin &
Weisz, 1998; Kendall, 2000). The age of onset of the
anxiety disorders roughly correspond to the ages at
which expected developmental fears occur. Thus,
separation anxiety disorder (SAD) has a fairly early
age of onset (young school-age children, ages 6–9),
generalized anxiety disorder (GAD) most often
onsets by the middle school years (ages 10–12) and
social phobia (SoP) more so in adolescents (12 and
older) (see Albano et al., 1996). As noted in prior
reviews, these three anxiety disorders commonly co-
occur, as the presence of one of the disorders
increases the risk for developing additional anxiety
disorders (e.g. Brady & Kendall, 1992; Kendall &
Brady, 1995; Kendall et al., 2001).
CBT for child and adolescent anxiety disorders
CBT for childhood anxiety disorders has five compo-
nents: psychoeducation, somatic management skills
training, cognitive restructuring, exposure methods,
and relapse prevention plans. Psychoeducation
provides corrective information about anxiety and
feared stimuli. Somatic management techniques
target autonomic arousal and related physiological
responses. Developmentally appropriate, cognitive
restructuring skills are focused on identifying
maladaptive thoughts and teaching realistic, coping-
focused thinking. Exposure techniques involve
graduated, systematic, and controlled exposure to
feared situations and stimuli. Relapse prevention
methods focus on consolidating and generalizing
treatment gains over time.
A manualized CBT protocol for anxiety in youth
Kendall and colleagues were the first to develop and
test the efficacy of a protocol-driven CBT
programme for anxiety disorders in children and
adolescents (Kendall, 1990). We review the
CBT for child and adolescent anxiety 131
empirical support for this protocol below, but first
present an overview of its structure and elements.
Based on experience and extensive evaluation of
manualized treatments, Kendall and colleagues
recommend a flexible, clinically sensitive, and
developmentally appropriate application of CBT for
youth with anxiety disorders (Kendall & Chu, 2000;
Kendall et al., 1998). This flexibility must be driven
by the therapist’s training and expertise in working
with youth of various ages and demographic
backgrounds, and knowledge of child development
and the specific challenges of various developmental
stages. Moreover, a comprehensive understanding of
child psychopathology is essential in the treatment of
youth, as different diagnoses share certain symptoms
(e.g. inability to concentrate in GAD may be
confused with inattention in attention deficit
hyperactivity disorder), and certain symptoms can
manifest differently at various ages. Comorbidity
among the anxiety disorders and other internalizing
and externalizing disorders is also an issue, and the
various comorbid combinations can dictate adapta-
tions to a treatment plan. Finally, a firm foundation
in cognitive behavioural theory and empiricism, and
the principles of applied CBT is essential. CBT is not
simply a ‘toolbox’ of techniques, but involves a
theoretical and empirical approach to understand-
ing, assessing, and treating emotional disorders. A
comprehensive educational and training history,
appropriate continuing education, and adherence to
the CBT model distinguishes the CBT therapist
from those who, through widespread dissemination
of CBT protocols, may haphazardly apply tech-
niques without fully appreciating their bases and
utility (Albano, in press). Thus, the manualization of
CBT allows for adherence to the theoretical model
and effective components of treatment, although
flexibility in the use of manuals has been encouraged
(Dobson & Shaw, 1988) to adapt to the varying
presentation of the patient. Research indicate com-
petent therapists are able to maintain efficacy with
flexible implementation (Kendall & Chu, 2000).
The Coping Cat Programme (Kendall, 1990)
involves roughly 14–18, 60-minute sessions over a
12–16 week period. The first six to eight sessions
focus on teaching new skills to the child, whereas the
second eight sessions provide the child the opportu-
nity to practice newly learned skills (exposure) both
within session and in vivo. The overall goal of CBT
is to teach youth to recognize the signs of unwanted
anxious arousal and to let these signs serve as cues for
the use of anxiety management strategies they are
taught. The main principles of the Coping Cat pro-
tocol are: (1) recognizing anxious feelings and
somatic reactions to anxiety, (2) identifying cogni-
tion in anxiety-provoking situations (i.e. unrealistic
or negative expectations), (3) developing a plan to
cope with the situation (i.e. modifying anxious self-
talk into coping self-talk as well as determining what
coping actions might be effective), (4) behavioural
exposure, and (5) evaluating performance and self-
reinforcement. The treatment uses behavioural
training strategies such as modeling, imaginal and in
vivo exposure, role-play, relaxation training, and
contingent reinforcement. To help reinforce and
generalize the skills, specific homework tasks are
assigned along with specific techniques to enhance
relapse prevention.
Consistent with initial evidence that parent
involvement may improve treatment outcome in
anxious children (Barrett et al., 1996), parent involve-
ment in the child’s treatment occurs on several levels.
Parents’ interactions with the therapist occur regu-
larly (weekly update, scheduling, etc.), and parents
are included in exposure exercises as appropriate.
Parents are engaged as collaborators and consultants
to the child’s treatment, and given a model for assist-
ing with the treatment in the role of the child’s
‘cognitive behavioural coach’. In addition to a regular
10-minute check-in at the start of each session,
parents are scheduled for meetings with the therapist
after the third and eighth sessions, and prior to the
end of treatment. This active involvement of parents
in the child or adolescent’s treatment plan will vary
depending upon a number of factors including degree
of impairment, comorbidity, age and developmental
level of the child (i.e. degree of independent function-
ing). Thus, parents of young separation anxious
youth may be asked to arrange play dates or a sleep-
over at another child’s home. The parents of a child
with GAD could be instructed to desist in providing
reassurance, if the child consistently asks ‘What if’
questions and requires much reassurance about
worries and fears. And, for the social phobic youth,
parents may find themselves arranging small group
gatherings in their home for their child and friends.
However, active involvement of the parents may be
impeded by marital discord, parental psychopathol-
ogy, or other psychosocial stresses such as economic
or environmental problems. Thus, the clinician
will assess each individual situation and ‘dose’ the
parental involvement accordingly.
The foundations of empirical support for CBT
for youth with anxiety disorders
In the first study of the Coping Cat programme
(Kendall, 1994), 47 children ages 8–13 years with
SAD, GAD, and SoP (including the DSM-III
diagnosis of avoidant disorder of childhood) were
randomized to either CBT or a wait-list condition
(Kendall, 1994). Children in the CBT condition
demonstrated significant improvement from pre- to
post-treatment on self- and parent-reported distress
and coping abilities, observation of child behaviour,
and diagnostic status. In total, 66% of treated
children no longer met criteria for their primary anx-
iety diagnosis at post-treatment, based on diagnostic
severity ratings from the Anxiety Disorders Interview
132 Anne Marie Albano & Philip C. Kendall
Schedule for Children (Silverman & Nelles, 1988).
These results were maintained at 1-year follow-up.
In a further follow-up of treated youth, (2–5 year
follow-up, X = 3.5 years; N=36), gains were main-
tained on self-report, parent-report, and diagnostic
interview measures (Kendall & Southam-Gerow,
1996). In a second controlled trial, 94 children ages
9–13 years were randomized to the CBT protocol or
a wait-list condition. Over 50% of treated youth were
free of their primary diagnosis at post-treatment,
with significant reductions in clinical severity for
youth who continued to report anxiety symptoms.
Gains were maintained at 1-year follow-up, with the
majority of youth evidencing greater improvement
over time (Kendall et al., 1997).
Kendall’s programme has earned the distinction of
an empirically supported treatment (EST) through
independent testing in other settings. For example,
the protocol has proven to be both transportable and
adaptable to other cultures such as in Australia (e.g.
Barrett et al., 1996) and Canada (Mendlowitz et al.,
1999). To date, CBT protocols including the
Coping Cat have also been adapted to the group
format and have demonstrated efficacy for a range of
ages and conditions: anxious youth ages 7–14
(Barrett, 1998; Cobham et al., 1998; Flannery-
Schroeder & Kendall, 2000; Silverman et al., 1999a),
school refusal (King et al., 1998), social phobia
in children (Beidel et al., 2000), and adolescents
(Albano et al., 1995; Hayward et al., 2000), and
single-session treatment for specific phobias (Öst
et al., 2001). For complete reviews on the efficacy of
CBT for child anxiety, see Kazdin & Weisz, 1998, or
Ollendick & King, 1998.
Critique of the child CBT literature
The CBT studies described earlier are considered
exemplary in several ways: the inclusion of rigorous
and standardized assessment procedures, compari-
son of the active treatment with a control condition;
clinically meaningful outcome criteria and long-
term follow-up demonstrating maintenance of gains
(Kazdin & Weisz, 1998). However, the results must
be interpreted carefully due to the presence of one
or more methodological issues. Outcomes for CBT
are sometimes cited for study completers, not the
intent-to-treat sample. In the most methodologically
rigorous CBT studies, results reported for the
intent-to-treat sample are more modest. For exam-
ple, Flannery-Schroeder & Kendall (2000) reported
response rates of 50 and 73% for completers of
group and individual CBT, respectively. Using
intent-to-treat analyses the response rates dropped
to 46 and 50%, respectively, indicating that some
children continue to have anxiety symptomatology.
Choosing a control condition for CBT studies is
also an issue. Both wait-list control and educational
support have been criticized as inadequate (Klein,
1997). Wait-list control has been argued to not be
a true comparative treatment or psychotherapy
control. Educational support has been criticized
because it may contain components of active
elements of CBT such as psychoeducation. For
example, two recent studies demonstrated relatively
equivocal effects for CBT as compared to control
conditions, not because of the lack of efficacy of the
active treatment but because of a high response rate
for the educational support control (e.g. Last et al.,
1998; Silverman et al., 1999b). Some CBT studies
include youth with specific phobias as the primary
diagnosis, and this may elevate response rates. In
addition, some CBT studies defined a responder as
one who no longer meets criteria for the primary
anxiety disorder, without taking into account the
continued presence of comorbid anxiety diagnoses,
presence of subsyndromal symptoms of anxiety,
other psychiatric conditions, and global impairment.
Summary and future directions
As noted in articles presented in this special series,
anxiety disorders in children and adolescents are
serious, relatively stable conditions which onset early
in life and run a fluctuating course throughout the
lifespan. Failure to intervene early with effective
treatments may render the child vulnerable to
impairments in a wide range of functioning and result
in deleterious effects on his or her long-term emo-
tional development. Concurrent with the zeitgeist of
developing focused, empirically supported treat-
ments for the range of emotional disorders in
children and adults, CBT for childhood anxiety
disorders has emerged as an efficacious psychosocial
treatment approach. The protocol described in this
article, The Coping Cat, incorporates all the essential
elements of CBT along with allowing for appropriate
flexibility to account for specific child and family
factors that need to be addressed in treatment.
Empirical studies support the efficacy and transport-
ability of this programme, along with its adaptation
to group or family format and diverse cultures. Inves-
tigators are actively adapting and utilizing the firm
foundation of CBT, and the procedures found to be
effective within the Coping Cat programme, to
address a wide range of anxiety and related disorders
in youth. In addition to the development of clinic-
based treatment protocols for these disorders, studies
of the transportability of CBT to non-traditional set-
tings such as schools and primary care are underway
(Masia, personal communication). Among the most
exciting and clinically relevant of current research
programmes in progress is a large study sponsored by
the National Institutes of Mental Health examining
the efficacy of CBT, medication, and their combina-
tion as compared to placebo after acute treatment,
along with examining the long-term benefits of the
active treatment conditions. Overall, these research
CBT for child and adolescent anxiety 133
programmes are geared towards finding the best
solutions for youth who suffer with anxiety disorders
by arming clinicians in both traditional and non-
traditional settings with empirically supported
methods for stopping the progress of anxiety.
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