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Running head: EVIDENCE BASED PRACTICES FOR CHILD ANXIETY DISORDERS 1

Evidence Based Practices for Children and Youth with Anxiety Disorders

A Research Paper

Presented to

The Faculty of the Adler Graduate School

___________________________

In Partial Fulfillment of the Requirements for

The degree of Masters of Arts in

Adlerian Counseling and Psychotherapy

_____________________________

By:

Shanelle Wenell

March, 2014

EVIDENCE BASED PRACTICES FOR YOUTH ANXIETY DISORDERS 2

Abstract

In the United States anxiety disorders are highly common and possibly the most wide spread

psychological disorders amongst children and youth (Mychailyszyn, Mendez & Kendall, 2010).

Furthermore, left untreated, anxiety disorders often lead to a host of negative mental health

issues such as substance abuse, depression, lack of healthy developmental experiences, family

dysfunction, and low self-esteem.

Although there is significant evidence of the positive treatment results and efficacy of Evidence

Based Practices (EBPs) when treating anxiety disorders, many clinicians continue to select

treatments that are not empirically supported. These well intending clinicians select treatments

based on clinical intuition, rather than empirical data supporting their treatment selection. As a

result, many youth are improperly treated for anxiety disorders (Muris, Mayer, Adel, Roos &

Wamelen, 2009).

This paper explores the current Evidence Based Practices available for children and youth with

anxiety disorders. Furthermore, given the time sensitive nature and long term negative effects

anxiety disorders can have if they prevail into adulthood, this paper aims to provide support for

utilizing Evidence Based Practices as the first line of treatment.


Dedications and Acknowledgements

I would like to thank my husband for his tireless support and effort, financially,

emotionally, and physically as I completed both my degree and thesis. You have always

encouraged me when I’ve lacked my own courage to move forward. You have been a rock for

me through my own journey of anxiety and finding the professionals that have led me to

recovery, so that I might lead others. Thank you.

Thank you to my mother in law, Cindy Wenell, for your many, many hours watching the

children and offering a helping hand and a listening ear as I worked to finish this degree and be

the best mother to my children at the same time. Without your support this would not have been

possible.

Thank you to my mother for listening to me and providing me with emotional support as

I worked through the emotions of school, motherhood and becoming a therapist. Thank you for

helping with the children and for being an example of education when I was a child.

Thank you to Dr. William Premo for your direct questioning, your sharp focus, your

ability to narrow my approach and your patience with delays, as I balanced being a mom and

finishing this thesis. I would still be stuck on page 1 if it were not for you. Thank you.

Lastly, this paper is dedicated to the many children and youth that have sat across from

me, that have struggled with anxiety disorders, that have fought to make it through another day

of school, that worked up the courage to speak to a new friend, that made the small decisions

every day to work at reclaiming their life. You’ve encouraged me to be the best therapist I can

be, to provide you with the best services you deserve. I hope this paper will serve to guide me

and other clinicians to use the best research available, so that each child we see has the tools they

need to cope with and recover from anxiety.


Table of Contents

Abstract……………………………………………………………………………………2

Dedication & Acknowledgements………………………………………………………...3

Background………………………………………………………………………………..6

Evidence Based Practice…………………………………………………………………..6

Anxiety Disorders…………………………………………………………………………8

Social Anxiety Disorder…………………………………………………………………..9

Separation Anxiety Disorder……………………………………………………………...9

Generalized Anxiety Disorder…………………………………………………………….9

Obsessive Compulsive Disorder………………………………………………………....10

Specific Phobia…………………………………………………………………………..10

Statement of the Problem………………………………………………………………..10

Anxiety Disorders in Children & Youth………………………………………………...10

Social Development and Effects of Anxiety…………………………………………….11

Academics……………………………………………………………………………….11

Peer Relationships……………………………………………………………………….12

Family Relationships…………………………………………………………………….13

Lack of Diagnosis………………………………………………………………………..14

Importance of Early Intervention & Treatment………………………………………….15

Evidence Based Practices for Anxiety Disorders in Children and Youth……………….15

SSRIs & CBT Combined………………………………………………………………..15

SSRIs Risk vs Benefits…………………………………………………………………..16

Cognitive Behavior Therapy……………………………………………………………..17


Automatic Thoughts……………………………………………………………………………...17

Cognitive Behavior Therapy for Children & Adolescents……………………………………...18

Safety Seeking Behaviors………………………………………………………………………..19

Coping Skills…………………………………………………………………………………….20

Deep Breathing………………………………………………………………………………….20

Progressive Muscle Relaxation………………………………………………………………….21

Cognitive Restructuring…………………………………………………………………………21

Exposure Interventions………………………………………………………………………….21

Developmental Concerns for Children & Adolescents Receiving CBT………………………..22

Cognitive Behavior Therapy & Intersections with Adlerian Therapy………………………….23

Implementing Cognitive Behavior Therapy……………………………………………………24

Conclusion……………………………………………………………………………………...25

References……………………………………………………………………………………...26


Evidence Based Practices for Children and Youth with Anxiety Disorders

In the field of psychology, the integration of clinical practice and research has become a

topic of great interest (Cukrowicz et al., 2005). In the 1970s, research revealed that much of what

was done in medicine lacked scientific research, and as a result evidence based practices in

medicine were born (Johnson, 2013).

Today, as the field of psychology receives more validation, support and funding in the

field of healthcare, greater accountability is expected as was with the medical field.

Accountability in the field of psychology has spurred on the interest of utilizing Evidence

Based Practices (EBPs). To many experts in the field, the uses of EBPs are for the benefit of the

overall community. After all, the goal of utilizing EBPs is to improve the overall quality of care,

enhance cost-effectiveness, and provide greater accountability to the field of mental health

(Katsikis, 2014).

Moreover, training and teaching in the field of psychology has begun to emphasize the

use of Evidence Based Practices because they are the most efficient and effective way to reduce

symptoms of certain disorders.

Evidence Based Practice

The American Psychological Association defines Evidence Based Practice as the

“integration of the best available research with clinical expertise for the promotion of efficacious

psychological interventions” (Sburlati, Schniering, Lyneham, Rapee, 2011, p. 89).

Furthermore Evidence Based Practice is a comprehensive practice that incorporates a

wide range of clinical information. This information includes, case conceptualization, therapeutic

alliance, assessments, cultural considerations and integrates this data into the best treatment

available as provided from research evidence.


Some opponents of Evidence Based Practices express concerns that what works in the

medical field does not necessarily work with social science. The reason for this argument is

social science does not contain a strict core of knowledge (Katsikis, 2014).

Furthermore, some clinicians feel the nature of Evidence Based Practices makes

psychology too restrictive and therefore less humane, dampening creativity and thus the

therapeutic relationship (Pagoto, et al., 2007).

However, while clinicians may raise concerns regarding the application of Evidence

Based Practices in social science, the reality is science and research are set up to help control

human error and bias. Scientific research allows for clinicians and practitioners to fairly evaluate

the impact of their psychological interventions regardless of their biases (Duzois, 2013).

Furthermore, for many clinicians and practitioners scientific thinking is unnatural.

Decades of research have shown if practitioners and clinicians rely solely on their intuition, they

will get it wrong more times than they will get it right (Duzois, 2013).

Humans are wired to use their gut, hunches and intuitions in spite of convincing data

(Duzois, 2013). Scientific thinking is unnatural; therefore it is imperative clinicians and

practitioners utilize research and science as a foundation for clinical reasoning and application.

Moreover, “clinicians possess an epistemic duty to rely on the best available scientific evidence

when selecting treatments” (Lilienfeld, et al., 2013, p. 388).

More specifically in a society where anxiety disorders are becoming one of the largest

economic, and social burdens to the U.S. healthcare system, it is imperative mental healthcare

providers learn to work efficiently and effectively in the treatment of mental illness.


Anxiety Disorders

Impact on US Spending

In the United States anxiety disorders are the greatest mental health problem. Millions of

Americans suffer from the symptoms of anxiety beyond a reasonable and healthy amount.

Furthermore, the economic impact of anxiety is significant. Both direct and indirect costs

impact U.S. spending. The estimated annual cost of anxiety in 1990 was 42.3 billion U.S. dollars.

The cost of anxiety disorders is more than that of schizophrenia and the affective disorders

(Clark & Beck, 2010).

In 2003 the sales of pharmacotherapy drugs for antidepressants and mood stabilizers

were an estimated $19.5 billion. While some anxiety is healthy and a normal part of day to day

life, clinical anxiety is increasing rapidly in the United States (Clark & Beck, 2010).

Anxiety Disorder’s Common Thread

Amongst anxiety disorders there are common threads of symptoms pertaining to fear and

heightened anxiety. More specifically, people with an anxiety disorder experience elevated levels

of anxiety and fear in response to cues that signal real or imagined threat. Furthermore these cues

could have formerly signaled a threat, which is no longer existent, yet the cues continue to alert

the individual’s fear response (Craske et al., 2009).

Individuals experiencing anxiety disorders have a heightened level of bias attention to

potentially threating stimuli and contexts. Biologically, there is also a heightened level of

amygdala response to perceived threating stimuli or situations (Craske et al., 2009).

While heighted anxiety and fear response is common amongst the anxiety disorders, each

disorder has a different set of threat related stimuli.


Social Anxiety Disorder

Individuals with social anxiety, experience symptoms of fear and anxiety around social

interactions and performance. This fear may span a variety of social situations including work,

social interactions, and public activities. Social anxiety is marked by disabling anxiety and fear

that is out of proportion to the situation.

Specific to children social anxiety may be represented by excessive crying and tantrums,

physically freezing up or shrinking back from people and or refusing to speak. These reactions

can be in response to both strangers and people the child are familiar with (American Psychiatric

Association, 2013).

Separation Anxiety Disorder

Separation Anxiety is characterized by excessive fear and worry regarding separation

from home or from those the individual is attached to. The length of concern is excessive and

expands a time frame of four or more weeks.

Individuals may experience symptoms of: excessive concern that harm will come to

those they care for while they are away, the fear of being home without an adult or attached

figures present, nightmares surrounding separation and or marked distress with the anticipation

of being away from the ones the individual is attached to (American Psychiatric Association,

2013).

Generalized Anxiety Disorder

Generalized Anxiety Disorder is characterized by chronic excessive worry. The worry

may span several different areas of life, including family, health, school, finances, etc. The worry

is uncontrollable and unreasonable and causes significant impairment and dysfunction to the

individual (American Psychiatric Association, 2013).


Obsessive Compulsive Disorder

Obsessive Compulsive Disorder is characterized by the existence of obsessions and

compulsions that the person realizes is unreasonable or excessive. Individuals with Obsessive

Compulsive Disorder experience intrusive unwanted thoughts that cause marked distress. As an

effort to control these thoughts individuals will often perform mental or physical rituals to

“neutralize” the unwanted obsessions (American Psychiatric Association, 2013).

Specific Phobia

Specific Phobia is an anxiety disorder marked by excessive and unreasonable fear of a

specific object, situation or place. Examples may be fear of blood, body fluids, snakes, driving,

flying, heights etc.

Furthermore exposure to the place, object or situation elicits excessive fear that can result

in great distress causing panic attacks. Often the individual with a specific phobia avoids the

stimulus. The individual realizes their phobia is obsessive and it causes great impairment in

normal day to day functioning (American Psychiatric Association, 2013).

Statement of the Problem

Anxiety Disorders in Children and Youth

An estimated 10-20% of youth have an anxiety disorder (Mychailyszyn, et al., 2011).

Anxiety disorders in youth are highly common, prevalent and impairing. Based on the complex

and pervasive effects of anxiety disorders over a life period, time is of essence when treating

youth suffering from the impairment of one.

Research shows that if left untreated anxiety disorders can persist into adulthood and

greatly affect mental health and overall functioning. Furthermore, anxiety disorders in youth


become open doors for substance abuse, depression and mental, physical and social impairments

in adulthood (Tiwari, et al., 2013).

Youth with an anxiety disorders that is improperly treated have a higher prevalence of

persistent suicidal ideation (Wolk, Kendall & Beidas, 2015) and are six times more likely to be

hospitalized for psychiatric disorders than those who do not suffer from an anxiety disorder.

Moreover youth with anxiety disorders are 8 times more likely to develop depression than those

without anxiety (Muris, Mayer, Adel, Roos & Wamelen, 2009).

In comparison to depression, anxiety disorders are much more persistent and chronic

over one’s life span. Furthermore, unlike other disorders, without treatment remission of an

anxiety disorder is relatively low (Clark & Beck, 2010).

In regards to occupational, academic and social functioning, overall quality of life for

individuals with an anxiety disorder is significantly lower than those without one (Mendlowicz

& Steinm, 2000).

Social and Developmental Effects of Anxiety

Beyond the long-term effects anxiety disorders can have on children and youth, day to

day symptoms of anxiety impair many different domains of functioning. Anxious youth struggle

with academics, peer relationships, personal distress that affects self-image, and family

relationships (Drake & Ginsburg, 2012).

Academics. In the realm of school, one study showed that children and youth with

anxiety disorders were 8 times more likely to fall into the lowest percentage of reading success

and two and a half times more likely to be in the lowest percentage for math success

(Mychailyszyn, Mendez & Kendall, 2010).


Furthermore anxiety symptoms present in children in the first grade were predictive of

prevailing anxiety in the fifth grade, with continued lower academic achievement

(Mychailyszyn, Mendez & Kendall, 2010).

In a study done by (Mychailyszyn, Mendez & Kendall, p. 113, 2010) based on a Likert

scale teachers reported youth without anxiety disorders as “working significantly harder, learning

significantly better, doing significantly better academically, and being significantly happier”

compared to youth with anxiety disorders.

Furthermore school support is not as readily acknowledged or available for children and

youth with anxiety disorders as it is for those suffering from external disorders (Mychailyszyn,

Mendez & Kendall, 2010).

Given the internalizing nature of anxiety disorders, youth experiencing anxiety often go

undiagnosed in a school setting compared to children exhibiting external disorders such as

ADHD and disruptive behavior disorders. This provides an entirely different set of challenges for

youth experiencing anxiety disorders. Teachers may misinterpret their lack of successful

academic performance as laziness or unwillingness to try (Mychailyszyn, Mendez & Kendall,

2010)

Peer relationships. In regards to peer relationships, (Strauss, Frame & Forehand, 1987)

found that students considered highly anxious by their teachers had significantly more trouble

with psychosocial skills than children that were not anxious.

Moreover, compared to children and youth without a psychological disorder those with

anxiety disorders struggled more with emotional regulation. For children with anxiety disorders,

lack of emotional regulation expresses itself as the inability to express culturally appropriate


emotions, which are imperative for social development (Mychailyszyn, Mendez & Kendall,

2010).

Sadly, the impact of anxious children and youth’s behaviors affects their ability to

develop peer relationships. Children and youth, who lack the ability to regulate their emotions,

may be looked at, as socially inept by their peers. Therefore, they are less likely to be considered

popular or confident and are more likely to attract other friends that are socially withdrawn

(Coplan, Girardi, Findlay, & Frohlick, 2007).

The more children and youth lack healthy peer relationships, the greater their inability

becomes to develop socially appropriate relationship skills (Mychailyszyn, Mendez & Kendall,

2010).

Furthermore, a study done by (Suveg, Sood, Comer, & Kendall, 2010), discovered

children and youth with anxiety disorders are less capable of identifying and recognizing facial

expressions. The recognition of facial expressions is also an imperative skill for the development

of social relationships. Therefore, these children with anxiety disorders are more likely to

struggle with interpersonal relationships and encounter more socially awkward experiences,

perpetuating the cycle of anxiety.

Family relationships. In a study done by (Suveg, Sood, Comer & Kendall, 2009)

mothers of children with anxiety disorders, reported their children tend to be less flexible,

negative and easily emotionally impacted compared to children without a psychological disorder.

Unknowingly, parents raising children with anxiety disorders may unintentionally

perpetuate the problem of emotional regulation. Specifically a study by (Hurrell, Hudson &

Schniering, 2015) suggests mothers of children with anxiety respond with less supportive

emotions when dealing with the child’s negative emotional responses. Furthermore research


supports that parental response to children’s emotions plays an important role in the development

of emotional regulation (Hurrell, Hudson & Schniering, 2015).

Anxiety Disorders in Children and Youth go Undiagnosed

In comparison to disorders that present more external symptoms, such as attention-

deficit/hyperactivity disorders or conduct disorders, anxiety disorders receive much less attention

(Mendez, Mychailyszyn, Kendall, 2010). Children and youth with anxiety disorders tend to

present themselves as being shy or possibly quiet, making it sometimes difficult to diagnose their

disorder.

In addition, those with anxiety disorders often misunderstand the physiological symptoms

of anxiety and interpret them as an illness. While children may complain to parents or family

members about their symptoms, they often do not affect members outside of their family with

their difficulties from anxiety. Rather they are avoidant and or ashamed of their symptoms;

therefore they often go undiagnosed (Miller, Short, Garland, Clark, 2010).

Often, by the time a child receives treatment the symptoms of anxiety have already

created detrimental effects to their development in many ways. These effects are typically, lower

self-confidence, frustration, and more or less likely impaired peer relationships (Miller, Short,

Garland, & Clark, 2010).

Youth experiencing the relentless symptoms of anxiety often begin to experience

depression in adolescents as symptoms of anxiety steal away normal developmental activities

such as friendships, academic performance, and achievements along with peer popularity (Miller,

Short, Garland, & Clark, 2010).


Importance of Early Intervention and Treatment

Research shows the higher level of anxiety and the older the child, the less responsive

they become to treatment (Kendall, Settipani, & Cummings, 2012). However, the more likely

children and youth are properly diagnosed and treated for anxiety early on, the less likely they

are to suffer from it in adulthood. Therefore, early diagnosis and proper treatment for these youth

are both imperative and essential for their ongoing and long term health (Mychailyszyn, et al.,

2011).

Evidence Based Treatment for Anxiety Disorders in Children and Youth

Over the past two decades, there has been significant improvement in the understanding

of evidence based treatment interventions for children and adolescents with anxiety disorders

(Muris, Mayer, Adel, Roos & Wamelen, 2009).

Cognitive Behavior Therapy and Selective Reuptake Inhibitors (SSRIs) have a positive

treatment effect on anxiety disorders, both individually and together (Brown University Child &

Adolescent Psychopharmacology, 2014).

However, more specifically, SSRIs in combination with Cognitive Behavior Therapy

have proven most effective for the treatment of anxiety disorders in children and youth (Mohatt,

Bennet & Walkup, 2014).

Under the category of anxiety disorders successfully treated with SSRIs and CBT are:

social anxiety disorder, generalized anxiety, separation anxiety, OCD and specific phobias.

The strongest evidence in research for anxiety disorders supports the use of SSRIs and

CBT in conjunction with one another rather than independent (Mohatt, Bennet & Walkup, 2014).

In the Child/Adolescent Anxiety Multimodal Study (CAMS) a 12 week study of SSRI

therapy, CBT therapy and a combination of the two were assessed at weeks 24 and 36.


488 youth ages 7-17 were randomly assigned to a group. At the 24-week mark 422 of the

youth showed positive response to treatment in all three groups.

However, the youth that were treated with CBT and SSRIs combined had greater

treatment results (80.7 %) than those assigned to the CBT (59.7%) or the SSRI (54.9%) group

alone. All three therapeutic groups succeeded over the placebo group at (28.3%) (Piacentini et

al., 2014).

SSRI Risks VS Benefits

While many parents and practitioners see the benefits of using medication in the

treatment of anxiety disorders, some of the adverse side effects of the medication may cause

parental concern.

Risks for children under the age of 7. In a study completed, 39 children under the age

of 7 with disabling anxiety; received SSRIs for help with the reduction of symptoms. Of the 39

children 40% of them experienced severe to moderate activation of adverse events including:

aggression, risk taking, oppositional behavior, irritability, swearing and increased loud and

jumpy behavior, with an average onset of symptoms at 23 days (Brown University Child &

Adolescent Psychopharmacology, 2007).

Beyond behavioral side effects, parents may worry about additional suicidal ideation or

suicidal behaviors SSRIs may induce. Specifically since the FDA issued a black box warning in

2003-2004 on antidepressants there has been a decline in prescriptions, particularly in relation to

the fear of increased suicidal ideation or behavior (Brent, 2009).

Therefore, in order for families treating youth with anxiety disorders to weigh out the risk

versus benefits of utilizing an SSRI in combination with CBT, it is important for them to know

the statistical data surrounding the risks.


In clinical studies of more than 4,300 youth there have been no actual suicidal attempts

rather an increase in suicidal ideation. Furthermore, studies have shown that increased suicidal

ideation or risk with youth taking medication is .09% rather than the initial 2% reported by the

FDA (Brent, 2009).

While these numbers may seem low, it is at the discretion of family members to decide

the benefits versus the risks of potential adverse events with using SSRIs as a form of treatment

in conjunction with CBT.

Moreover, clinicians utilizing evidence based practices, such as CBT and SSRIs for

children with anxiety disorders, are most likely utilizing systematic assessments to rate and track

their client’s symptoms and behaviors. This added data and systematic approach; may further

help parents feel educated and comfortable with the use of SSRIs (Brent, 2009) in addition to

CBT.

Cognitive Behavior Therapy

Cognitive Behavior Therapy (CBT) is a cognitive model of therapy. The basic model is

founded on how one’s thoughts, and perceptions about a situation influence their emotions and

behaviors. Furthermore once one’s emotions and behaviors are involved there is often a

physiological response (Clark & Beck, 2010).

Often people’s thoughts and perceptions regarding a situation are inaccurate, distorted

and or dysfunctional. Especially if an individual is in a stressful situation, the likely hood of their

thoughts being accurate is slim. Therefore, cognitive behavior therapy helps clients to address

their dysfunctional, automatic thoughts and assess them.

Automatic thoughts. Automatic thoughts are thoughts that occur almost instantly

without much processing of information. These thoughts can present themselves in a form of


mental imagery or verbal information. Once a person is able to capture and identify the

automatic thoughts, they are then able to correct and adjust their thinking to help them more

accurately think about, perceive and respond to a situation (Clark & Beck, 2010).

Moreover addressing automatic thoughts and gaining a more accurate perspective of

one’s situation, decreases client’s level of distress, thus allowing them to behave in a functional

and healthy manner. Furthermore decreasing distress levels and behaving more functionally,

particularly in the case of anxiety, often decreases physiological symptoms as well.

Cognitive Behavior Therapy is also a transdiagnostic form of therapy. Meaning it

is able to target overlapping dysfunctional thinking patterns and processes that are most

commonly prevalent across the various types of anxiety disorders (Clark & Beck, 2010).

Cognitive Behavior Therapy for Children and Adolescents

Cognitive Behavior Therapy is considered the most effective evidence based

psychotherapy treatment for children and adolescents dealing with an anxiety disorder.

Furthermore, it is a therapeutic model that is sufficient without the engagement of

parental involvement in therapeutic sessions and is adaptable to the developmental stages of

children and adolescents.

In a study completed by (Jansen et al., 2012) based on the Cognitive Behavior Therapy

model, children ages 8-17 years old received therapy for a range of anxiety disorders. The

anxiety disorders included SAD, GAD and SP. After the completion of 8 weeks of treatment, at a

3-month post follow up, 56% of children were free of their primary anxiety diagnosis and 41%

no longer met criteria for an anxiety disorder. Furthermore, the results were even more

significant than a group of children receiving Family Based Cognitive Behavior Therapy.


Interestingly enough, developmental and etiological explanations of anxiety offer that

parental influences are important to the ongoing symptomology and structure of childhood

anxiety disorders. However current research does not indicate it has an added benefit. Rather

child focused CBT has proven more viable (Wei & Kendall, 2014).

While further research needs to be done in the area of parental involvement with anxiety

disorders, perhaps one explanation is that Cognitive Behavior Therapy teaches children and

adolescents the skills to begin cognitive restructuring on their own.

Cognitive restructuring allows children more independence in their ability to think

appropriately about anxiety provoking situations without the consistent reliance of outside

influences, to help them feel safe (Jansen et al., 2012).

Often well-intended parents continue the cycle of anxiety by allowing children to overly

rely on them for safety when they feel anxious. While children need the comfort and security of

their parents, when a child becomes overly dependent on a parent for reassurance due to anxiety,

this can become a safety seeking behavior.

Safety seeking behaviors. In short safety seeking behaviors are behaviors intended to

reduce anxiety, but actually perpetuate the cycle. As children utilize safety seeking behaviors to

avoid dealing with anxious feelings and thoughts, they can become dependent on them (Clark &

Beck, 2010). More often than not, safety seeking behaviors help in the short term, but create a

long term problematic pattern, as children learn to avoid fully confronting their fears or worries.

Furthermore, when parents are involved in the continuous engagement of safety seeking

behaviors, children do not learn to independently manage their anxiety. This dependence upon

family members can become tiring and worrisome for any well- intended parent.


For example, a child that has separation anxiety may request a parent to call and check on

them many times throughout the day. While a parent may find this behavior acceptable and

comforting to their child, it teaches the child to avoid feelings of anxiety by continuously

reassuring them through external behaviors.

While parents are encouraged to gain psychoeducation regarding their child’s diagnosis,

and help children with the skills they learn in Cognitive Behavior Therapy, the treatment model

overall teaches children to cope internally with their diagnosis thus increasing their locus of

control.

Through learning to cope with some level of anxiety, restructure thinking patterns and

address their fears, children are able to play a central role in their own recovery.

Through Cognitive Behavior Therapy children learn coping skills such as deep breathing

exercises, and muscle relaxation for heightened anxiety. Furthermore they learn the ability to

restructure their thinking and complete the process of exposure to anxiety provoking situations,

in a slow and progressive format.

Coping Skills

Deep breathing. Deep breathing exercises are often taught to those dealing with stress

and anxiety disorders (Bourne, 2000). It is not unusual for individuals that are dealing with

anxiety to begin breathing at a rapid shallow pace. This training tool is often used for individuals

dealing with panic disorder.

Deep breathing helps increase blood flow and slows down one’s heart rate, presenting the

body with physical cues to relax (Clark & Beck, 2010). This is a quick and easy tool to teach

children and is often one of the first relaxation tools taught in CBT.


Progressive muscle relaxation. Muscle relaxation is a common tool used in CBT to help

children and youth understand when their bodies are starting to feel tense. It was developed by a

Harvard University physiologist, Dr. Edmund Jacobson. Dr. Jacobson discovered that by

squeezing and releasing muscles one could induce deep relaxation.

Clients are instructed to systematically tense and release different parts of their muscle

groups for 5-7 seconds and notice the release of tension (Bernstein & Borkovec, 1973). This

technique is particularly useful in helping clients that are experiencing heightened anxiety

concerning other CBT techniques such as exposure interventions.

Cognitive restructuring. Cognitive restructuring teaches children to develop a new way

of thinking about their anxious concerns and the level of threat they actually present. During

cognitive restructuring the therapist focuses on the most active or recent threat the child or

adolescent is facing. Cognitive restructuring is an important step in helping children and youth

learn to deactivate their brains developed patterns of anxiety (Clark & Beck, 2010).

Some of the techniques children learn during cognitive restructuring are evidence

gathering, decatastrophizing, and generating alternative outcomes.

Exposure interventions. Exposure interventions are a critically important step in treating

anxiety disorders. Most anxiety disorders trigger a fight or flight response which can often end in

avoidance of feared objects, places, thoughts, stimuli, etc. While the initial avoidance provides

the client with some level of comfort and relief, it also teaches them they are safe because of

their avoidance (Beck & Emery, 2005).

Empirical evidence suggests that exposure therapy provides a significant amount of

reduction in anxiety; therefore it plays a critical role in cognitive behavior therapy for anxiety


disorders (Riggs, Cahill, & Foa, 2006). Children and youth learn that it is exposure to the feared

stimuli rather than avoidance that ultimately reduces symptoms of anxiety.

Exposure interventions involve a slow and progressive exposure to fear stimulating,

events, objects, places, thoughts or stimuli. The exposure is progressive in that it starts with the

least anxiety provoking situation and slowly progresses to greater levels of anxiety provoking

stimuli (Clark & Beck, 2010).

Due to the intense amount of anxiety children and adolescents may face when discussing

exposure interventions, it is imperative that parents understand the rationale for treatment and are

provided with the statistical research regarding the benefits of exposure. Furthermore, it is

important the client, parent and therapist are aligned for this portion of therapy and that it is

slow, progressive and consistent.

Developmental Concerns for Children and Adolescents Receiving CBT

A common misperception of Cognitive Behavior Therapy is the notion that children are

unable to follow a cognitive model because of their limited range of thinking. However, mental

health professionals treating children and adolescents are able to adapt Cognitive Behavior

Therapy techniques to the developmental level of children and adolescents that is appropriate for

their age (Melfsen et al., 2011).

Furthermore, the cognitive model allows for the flexibility of mental health professionals

to adapt treatment according to the child’s individual cognitive style. For example therapists may

need to take into consideration whether or not a child is a concrete or abstract thinker. The

therapist is then able to utilize the information and adapt ideas and concepts that are relative to

the child’s worldview and developmental level (Melfsen et al., 2011).


Moreover the use of language is adaptable for children as therapists learn to select words

based on the child’s level of vocabulary. Through the use of hands on demonstrations, pictures,

and examples taken from the child’s day-to-day environment Cognitive Behavior Therapy is

adaptable for children and adolescents at many different levels of development (Melfsen et al.,

2011).

Cognitive Behavior Therapy and Intersections with Adlerian Therapy

Much like Adlerian Therapy, Cognitive Behavior Therapy addresses people’s basic

understanding of themselves, their world, and those around them. Cognitive Behavior Therapy

believes that one’s distorted self-beliefs influence the way they process information about

themselves and the world around them.

In Adlerian terms one’s private logic contributes to the way they interact with their

environment and their beliefs about the world around them. Adler and Dreikurs both realized

positive self-regard and a belief that one is equal with others are key contributors to mental

health and becoming functional individuals.

Furthermore private logic much like distorted self-beliefs in CBT is often faulty and

inaccurate. According to Adlerian Therapy, private logic is developed during the very early years

of development. However, much of what is observed during the early stages of life is

inaccurately interpreted. When gone unchallenged, these inaccurate interpretations can follow

individuals into their adult life often creating unhealthy and dysfunctional patterns of thinking

and behavior.

Adler described private logic as such; “a neurotic person may have an inclination of

normalcy of life around them, however regardless of this inclination his or her behaviors operate


out of a completely different frame of reference. This behavior is not often understood by others

around them, however it makes complete sense to the neurotic person” (Rosenthal, p.6, 1963).

Similarly, Adlerian Therapy and CBT address how an individual’s development

contributes to maladaptive self-beliefs. While Adlerian Therapy commonly utilizes early

recollections to understand an individual’s framework of reference, CBT dissects how life events

and experiences contribute to an individual’s misguided beliefs, dysfunctional thoughts and

unhelpful behavior patterns (Ferguson, 2001, p.326).

Implementing Cognitive Behavior Therapy

Although significant progress has been made in research regarding CBT and its effective

results for children and youth with anxiety disorders, many children still do not receive this

evidence based treatment. This only highlights the need for “improved dissemination and

implementation of these interventions” (Elkins et. al., 2011, p. 161).

As the mental health realm moves diligently towards evidence based practices it is

imperative young graduates and novice therapists begin to become competent in the area of

EBPs. Newly graduated therapists unfamiliar with CBT may have concerns regarding the time it

will take to learn and implement a new theory. However, research shows even novice therapists

trained in CBT are able to show competence and produce positive clinical results with initial

training and supervision (Brown et al., 2013).

Furthermore, the same study showed therapists with greater years of experience predicted

less competence in the delivery CBT even after initial training. These findings suggest the

importance of learning EBPs as a novice therapist and maintaining continued education and

training through supervision.


Conclusion

While anxiety disorders are common amongst the population, their presence wreaks

havoc not only on the individuals that experience them but on society as a whole. Anxiety

disorders affect U.S. spending, are one of the top reasons for disability and affect the overall

health of society as a whole.

For children and youth these disorders steal away success in academics, normative

developmental experiences, affect peer relationships and family relationships. Left untreated

anxiety disorders begin the chain of ongoing social, functional mental impairment and suicidal

ideation.

However, research has proven Cognitive Behavior Therapy combined with SSRIs is an

effective evidence based treatment for the treatment of anxiety disorders.

Given the prevalence of anxiety disorders and the long term negative impacts they can

have on children and youth, when left improperly treated, it is recommended that CBT in

conjunction with SSRIs be utilized as the frontline treatment of choice.


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