A REVIEW OF THE ROLE OF COGNITIVE-BEHAVIORAL THERAPY ON ANXIETY DISORDERS OF CHILDREN AND ADOLESCENTS

Nicolae Dumitru Nicoară¹, Paula Marian^2,3*, Alin Ovidiu Petriș³, Cristian Delcea⁴, Felicia Manole^3,5

ABSTRACT

Anxiety disorders are among the most prevalent illnesses in children and adolescents. Children and teens who have these problems perform less well in school, at home, and in social situations. It is crucial to determine the best behavioral and psychiatric therapies for these illnesses. Given the significance of the aforementioned subject, this study looked at how well cognitive-behavioral therapy treats anxiety problems in children and adolescents. Most of the reviewed research contained methodological and theoretical problems. Several challenges included the following: the existence of weaknesses and deficiencies in comparing the results with previous similar studies, the weak explanations provided, the small sample size, and the lack of reference to monitoring methods and advanced formulas of statistics. The majority of the studies under examination did not accurately present and report the data according to the worldwide standard for clinical trials principles and standards. The findings of the studies under review indicate a weak to moderate effectiveness of intervention protocols, but it appears that if the theoretical and methodological issues are resolved, a more precise assessment of the efficacy of cognitive behavioral therapy for anxiety disorders in children and adolescents can be made.

Keywords: Adolescents, Cognitive-behavioral therapy, Children, Anxiety disorders

Introduction

One of the most prevalent psychiatric illnesses in children and adolescents is anxiety disorders, whose prevalence in people under 18 years is between 3 and 27% [1-5]. Anxiety disorders in children are classified as internalizing disorders. Internalizing disorders are maladaptive behavior patterns that cause the child's resentment rather than bothering the people around them [6, 7]. Although a certain amount of anxiety is needed for effective performance, high anxiety causes helplessness and disrupts relationships with friends and family in school assignments [8, 9]. Children with anxiety disorders react strongly to stimuli, which they consider tense states and negative and continuous emotional responses. Since these children have defects in regulating their emotions, this leads to an increase in interpersonal problems between these people. Anxiety disorders have high comorbidity with other disorders, including attention deficit hyperactivity disorder (about 04.04 comorbidity), oppositional defiant disorder (about 43.9), and obsessive-compulsive disorder (about 61.8) [10-12]. According to the chronic course of anxiety disorders in childhood and adolescence and their continuation in the growth path, depending on certain influencing factors such as genetic background, family history, parent's anxiety, type of attachment to the caregiver, learning, experience, and parenting style. It is the cause of disorders in adulthood [13-15].

Considering the importance of the issue, it is necessary to diagnose and treat anxiety disorders in childhood and adolescence. The most common anxiety disorders in this age group are generalized anxiety disorder, separation anxiety disorder, and social anxiety disorder [3, 16]. The main characteristic of generalized anxiety disorder is persistent anxiety and uncontrollable worry that can be seen on most days during 6 months [17, 18]. Symptoms of a generalized anxiety disorder include restlessness, aggression, muscle contraction, fatigue and sleep disturbances, and problems in concentration [19, 20]. This disorder has received a lot of attention in terms of the important role of worry in creating dysfunctional emotional processing. In explaining the etiology of this disorder, Barlow points to two main factors: General Psychological Vulnerability and General Biological Vulnerability [21]. Psychological vulnerability refers to the factor of uncontrollability. The perception of uncontrollability causes the formation of a belief based on the inability to influence events. Such beliefs make people susceptible to anxiety disorders. On the other hand, parents' discordant behavior leads to a decrease in the child's ability to predict the parents' reactions and ultimately leads to children's behavioral inhibition. Failure to control external threats or failure to control internal threats is the main problem during anxiety [22-24]. The classic anxiety disorder of childhood, which is known as separation anxiety disorder or attachment disorder, has a prevalence of about 6-18%. This disorder makes the child prone to anxiety disorder in adolescence and early adulthood [25]. The results of longitudinal studies on separation anxiety in children between 1.5 and 6 years old showed that most children with separation anxiety disorder gradually recover at the age of 4-5 years [26]. But factors such as anxiety and depression of the mother during pregnancy and unemployment of the parents cause the continuation of this disorder, which continues until adulthood if not treated. According to these cases, it is necessary to emphasize preventing the continuation and growth of separation anxiety disorder until preschool age [19]. This disorder, which is often characterized by depression and externalizing disorders and with early onset in childhood, without proper treatment may lead to other anxiety disorders and negative performance in various aspects of adult life over time. Social anxiety disorder starts as early as 8 years old. The clinical manifestations and destructive consequences of this disorder gradually appear in childhood and intensify in early or middle adolescence [27]. Approximately 75% of people experience symptoms between the ages of 8-15 years [28]. The 12-month prevalence of this disorder in children and adolescents, like adults, is about 7% [29]. Social anxiety disorder has high comorbidity with other anxiety and mood disorders, disruptive behaviors, and eating disorders. Research has shown that 81% of people with social anxiety disorder also have another disorder. Depression is one of the most common mental disorders that has a high correlation with social anxiety disorder among teenagers. Therefore, early intervention is necessary to prevent long-term adverse consequences of this disorder [30].

There are many treatment programs for the treatment of children's anxiety disorders, most of which have a cognitive-behavioral basis. In the field of anxiety disorders, especially in the case of children and adolescents, cognitive and behavioral therapy is the chosen and evidence-based treatment in the research literature, and this treatment is also considered here. Cognitive behavioral therapy’s effect on reducing anxiety symptoms in children has been well shown in research [15, 31-33]. Cognitive-behavioral therapies can modify thinking since the fundamental tenet of cognitive-behavioral therapy is that cognition is essentially the source of feelings and behavior [34]. In this treatment, there are two cognitive strategies, such as discovering cognitive distortions and anxiety-provoking thoughts, cognitive reconstruction and strengthening fruitful confrontational self-talk, and behavioral strategies such as role modeling, confrontation, role-playing, muscle relaxation, coping skills training, and increasing self-control and self-efficacy are used [34, 35]. The therapist teaches the child coping skills and creates circumstances for him to practice them, as is indicated in cognitive behavioral therapy. These abilities help youngsters who have anxiety issues. Cognitive behavioral therapy employs a variety of strategies, such as educating the kid and parents about anxiety, progressive muscle relaxation exercises, deep breathing exercises, and challenging thoughts that cause anxiety (cognitive retraining by exposing the child to anxiety), relapse prevention like motivational sessions, and collaboration with parents and school [36, 37]. Treating anxiety in children not only reduces anxiety symptoms but also extends to the treatment of depressive symptoms and externalizing behaviors in the child and thus strengthens the child's adaptive functioning. There are many treatment protocols for the treatment of anxiety disorders. The articles reviewed in this study include some of these protocols, including the confrontational cat protocol [38], group cognitive-behavioral therapy (CBGT) [39], reassurance therapy package, cognitive-behavioral therapy method with a single-process approach [40], and Mykniam's cognitive therapy method [41]. Considering the importance of the mentioned topic, the impact of cognitive-behavioral treatment on anxiety disorders in children and adolescents was studied in this study.

Results and Discussion

In research that looked at how cognitive behavioral therapy affected teenage females with generalized anxiety disorder in terms of anxiety reduction, the findings revealed that following cognitive-behavioral treatment, the anxiety of the experimental group of adolescents dramatically decreased. This demonstrated the efficacy of the therapy [37]. Another study looked at how family-focused cognitive-behavioral treatment affected anxiety in kids with anxiety disorders. Its results indicated that the percentage of recovery for 3 children in one-month follow-up is 86, 41, and 60 [42]. Secondary research compared the efficacy of cognitive-behavioral group therapy (CBT) and emotion-oriented cognitive-behavioral group therapy (ECBT) on children with social anxiety disorder. The results of this study showed that both treatments were effective in reducing the symptoms of social anxiety and dysregulation of sadness in affected children compared to the control group. However, in the scores of grief dysregulation in the follow-up three months later, only emotion-oriented therapy was effective in reducing grief dysregulation compared to the control group; In fact, the effects of change therapy (ECBT) have been stable over time on this variable. Also, in this study, in the variables of inhibition of anger and sadness and effective coping with anger and sadness, only emotion-oriented therapy affected the dependent variable [24].

In a study, it was determined whether cognitive-behavioral group treatment helped generalized anxiety disorder sufferers aged 11 to 13 feel more in control of their anxiety, cognitive-behavioral therapy based on the Coping Cat therapy guide was effective in increasing the perception of emotion and stress control. It was a transition, but it did not have much effect on the threat control. The effect size of treatment on emotion control, threat control, and stress control was 11.25, 0, and 0.29, respectively [11]. In another study, the effectiveness of cognitive-behavioral therapy based on the program (Coping Cat) in reducing the anxiety of 8- to 10-year-old children was investigated. The effect size of the treatment group was 2.3 and the effect size of the waiting group was estimated to be 0.26. Based on these estimates, the changes in 70-80% of subjects were clinically significant [15]. Another research was carried out to see if the confrontational cat therapy program might help youngsters with their anxiety problems. The effect size for the social anxiety variable was 0.33, separation anxiety was 0.33, fear of injury was 0.28, and physical symptoms were 0.32 [36].

The average anxiety score of the control group for boys was 9 when cognitive-behavioral treatment centered on the processing unit (MCBT) was examined to see if it may help children aged 6 and 7 with their separation anxiety symptoms whereas, for cognitive-behavioral therapy with the unit-process approach E is equal to 5.4 and the average score of the control group for girls is 558.10 and for the treatment group is 5.063. Also, the partial coefficient of the eta square was reported as 0.409 [33]. Additionally, when cognitive-behavioral group therapy was tested for its efficacy in treating children with generalized anxiety disorder, the results revealed that it is useful in lowering anxiety, eradicating unhelpful schema, and enhancing family ties [11]. A meta-analysis of psychological interventions for treating children and adolescents with social anxiety disorder showed that the effect size for cognitive-behavioral treatments is 0.24 and the effect size for correcting interpretation biases is 0.48. Therefore, it was concluded that psychological treatments are effective in reducing social anxiety in children and adolescents [30].

In examining the effectiveness of cognitive-behavioral group therapy on anxiety and fatigue in girls with generalized anxiety disorder, the results showed that this treatment had an effect on the anxiety level of the subjects, but did not affect the fatigue component. Also, there was no significant difference in the level of fatigue between the two experimental and control groups in three measurement levels [19]. Also, the results of a study that examined the effectiveness of cognitive-behavioral therapy on social anxiety and blood sugar control in children with type 1 diabetes mellitus showed that cognitive-behavioral therapy according to the average social anxiety components of the experimental group in the post-test Compared to the average of the control group, it has reduced the social anxiety of the experimental group [43]. When evaluating the efficacy of narrative therapy for the anxiety of elementary school girls, it was found that: story therapy was able to significantly reduce generalized anxiety and social anxiety [44]. In research that looked at how group cognitive-behavioral therapy affected female students' social anxiety, the findings confirmed with 99% confidence the hypothesis of the research that group cognitive-behavioral therapy is effective on social anxiety [45]. Additionally, research into group cognitive-behavioral therapy's efficacy for enhancing the quality of life and academic performance of middle school male students with generalized anxiety disorder revealed that this treatment is successful in improving the quality of life and its components. It also had a positive impact on these students' academic performance [46].

Conclusion

Considering the high and stable prevalence of anxiety disorders in childhood and adolescence, their relationship with social and academic performance deficits, effective, timely prevention, and intervention programs for this special group of children are very important. Since one of the important treatment approaches in the field of anxiety disorders is cognitive-behavioral therapy, this study aimed to review the studies conducted in connection with the effect of this treatment on the improvement of anxiety disorders in children and adolescents. The findings of research that looked at how well cognitive-behavioral group therapy treats anxiety disorders and their symptoms are consistent with one another and support the effectiveness of CBT in treating anxiety. In the studies that used individual cognitive-behavioral therapy, half of the studies used the therapy protocol (Coping Cat). All the reviewed studies reported the effectiveness of this treatment and the range of the effect size of most of the studies was in the range of 0.15 to 0.48 and there was no great difference between them.

Acknowledgments: None

Conflict of interest: None

Financial support: None

Ethics statement: None

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