EVIDENCE-BASED CHILD HEALTH: A COCHRANE REVIEW JOURNALEvid.-Based Child Health 2: 1278–1281 (2007)Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/ebch.184

Commentary

Commentaries on ‘Cognitive behavioural therapy foranxiety disorders in children and adolescents’, withresponse from the author

Gavin Andrews,1* Alison Mahoney1 and William Turner2†

1Clinical Research Unit for Anxiety and Depression, School of Psychiatry, UNSW at St Vincent’s Hospital, Sydney, Australia2School for Policy Studies, University of Bristol, Bristol, UK

These are commentaries on a Cochrane review, published in this issue of EBCH, first published as: James A,Soler A, Weatherall R. Cognitive behavioural therapy for anxiety disorders in children and adolescents.Cochrane Database of Systematic Reviews 2005, Issue 4. Art. No.: CD004690.DOI: 10.1002/14651858.CD004690.pub2.

Further information for this Cochrane review is available in this issue of EBCH in the accompanying EBCHSummary and Characteristics and Key Findings Tables articles.

Gavin Andrews and Alison Mahoney’sCommentary

Nathan and Gorman (1) edit an industry standard AGuide to Treatments that Work in mental disordersthat is now in its third edition. The chapter onpsychological treatments for panic disorders, phobiasand generalised anxiety disorder reports evidence ofthe efficacy of cognitive behaviour therapy (CBT)against placebo for all disorders, but none of thestudies they quoted included any of the 13 in thisreview. It is as though work in children, unless itrefers to a disorder specific to childhood like conductdisorder or ADHD, goes unnoticed. And therein liesthe problem.

The anxiety disorders are disorders of the young.The median age of onset in two national surveys was11–13 years (25th percentile 6 years) (2,3) and theburden in children and adolescents is certainly no lessthan in any other age group. Anxiety disorders thatpersist into adulthood are associated with incompleteeducation, poor workforce participation rates and bro-ken relationships (4), issues that are more likely to be aconsequence of the anxiety disorder than a cause. Thepresent review is therefore timely and very important.

In the current review, James et al. conducted a verythorough and conservative meta-analysis of CBT pro-grams for anxiety disorders in children aged 7–18.Search strategies were systematic and included per-sonal communications with leading authors in the

*Correspondence to: Gavin Andrews, Clinical Research Unit forAnxiety and Depression, School of Psychiatry, UNSW at St Vincent’sHospital, Sydney, Australia. E-mail: gavina@unsw.edu.au.†Correspondence to: William Turner, School for Policy Studies, Uni-versity of Bristol, Bristol, UK. E-mail: W.Turner@bristol.ac.uk.

field. They identified 13 controlled trials comparingCBT to waitlist and/or attention control. Most studiesstemmed from Kendall’s pioneering work (5).

The sample consisted of 817 children and adoles-cents; 519 in CBT conditions and 298 (6) in thecontrol conditions, although not all participants arerepresented in all analyses. All participants were diag-nosed with an anxiety disorder of mild to moder-ate severity. The sample did not include those withsevere disorders, those on medication, or those withobsessive compulsive disorder, posttraumatic stressdisorder, specific phobias or selective mutism. Co-morbidity was addressed but there is no analysis ofits effect on outcome, an important omission inher-ent in the trial data. Treatment quality and integritywere assured, and all studies employed manualisedCBT conducted by doctoral level psychologists receiv-ing regular supervision. Established semi-structureddiagnostic assessments, self report and parent reportmeasures were used to reflect clinically relevant crite-ria.

Remissions (no longer meeting criteria for diagno-sis) in the intervention groups were double that in thecontrol groups and the number needed to treat was 3.The results appeared to be durable over the first yearfor studies where data is available from both interven-tion and control groups. No between group comparisondata was available at long term follow-up, which isnot surprising given most control groups were ‘wait-listed’ for the intervention. All formats of CBT (i.e.individual, group, family) were effective in reducingsymptom severity and diagnostic status. These lev-els of efficacy are comparable to those in adult trials.There is simply no reason not to implement CBT forchildren with anxiety disorders forthwith, before the

Copyright 2008 John Wiley & Sons, Ltd.

‘Cognitive behavioural therapy for anxiety disorders in children and adolescents’ 1279

children afflicted become educationally and vocation-ally disadvantaged.

Now we know that CBT works for children, whyare we not providing it? The problem is that anxiouschildren are no problem to teachers – ‘be still, bequiet, be docile’ was the title of an early paper onbehaviour therapy – and anxious children are exactlythis. School counsellors and school psychologists havetheir time taken up with children whose behaviour isthe opposite, and there is no imperative for anxiouschildren to receive help. Yet the potential health gainsfrom intervening in this group are considerable and theefficiency in dollars per unit of health gain are likelyto be even more compelling (6). Few jurisdictionshave taken the step to implement CBT programs as aroutine. The school system in British Columbia is oneexception. It has pursued an active policy of trainingchild mental health staff to deliver CBT programs(7). Internet-based programs are another avenue forreaching anxious children and adolescents. They areaccessible for young people, and are time and costeffective for teachers and counsellors. In this treatmentmodality, anxious children and adolescents can be asquiet and still and docile as they like but still receivethe treatment they require. There are few references tosuch programs in the literature, perhaps because suchprograms are still being evaluated (8).

Declarations of Interest

None.

William Turner’s Commentary

Anxiety disorders are among the most prevalent psy-chiatric disorders in children and adolescents (9) caus-ing disruptions in academic, social, family functioning(10), and linked to adult psychopathology (11,12).Cognitive behavioural therapy (CBT) is now seen asthe psychotherapeutic treatment of choice for youthswith internalising disorders (13,14). The cognitivebehaviour model of anxiety disorders offers a logi-cally consistent relation between clinical presentation,the treatment approach, and the specified outcome(s)(15,16).

This Cochrane systematic review includes data fromover 800 youths in 13 randomised controlled trialsof CBT vs waiting list/attention controls. The trialsincluded in the review were graded as moderate qualityin the review. In 12 out of the 13 included studies,details on the process of randomisation and allocationwere unclear or inadequate. As acknowledged by thereviewers, it is not possible in this type of research toblind the subjects. Outcome assessments were carriedout blind, although details of this processing werenot made clear in three trials. Additionally, there wasinadequate reporting of those lost to therapy.

Remission in anxiety diagnosis was the primaryclinically relevant outcome. Reviewers also examinedtwo secondary clinically relevant outcomes; reductionin anxiety symptoms, as measured by a variety of tests,and acceptability, as measured by losses to follow-up.Assessments were based on a range of reliable andvalid measures with good psychometric properties.

In the analyses on remission of any anxiety diag-nosis results clearly favour CBT even when sensi-tivity analysis compared ITT analysis (assuming non-completers in the CBT group were treatment failuresand those lost-to follow-up in the control group weretreatment successes) with completer analysis (includ-ing only those for whom data was available at the endof the study). Using conservative ITT data, for all CBTformats the risk reduction was by about 42% and thenumbers needed to treat (NNT) is 3.0, which meansthat in order for one additional subject to obtain remis-sion from anxiety disorder using CBT, one needs totreat three subjects. The results relating to reduction inanxiety symptom scores were in the moderate range.There was no difference in the rate of those lost tofollow-up between groups indicating a similar degreeof acceptability among intervention and control par-ticipants.

Post-hoc subgroup analysis to examine differencesbetween individual, group and family CBT formatsrevealed similar response rates of remission of anyanxiety diagnosis (individual CBT 54.2%, group CBT56.8%, and family CBT 67%). The finding that fam-ily CBT reduced the risk by about 62% is particularlyimportant considering that research and clinical expe-rience suggest that parents and families may play animportant role in the development and maintenanceof childhood anxiety. Considering the limited num-ber of family CBT studies included in this review,future studies should further examine the benefits ofadding a parental component to standard CBT forchildhood anxiety as well as other interventions tar-geting parents or family. Additionally, considering thevariation in the length of treatments (from 7.5–27 h)noted within the included studies, future updates ofthe review should incorporate further subgroup anal-yses examining this factor as it may have importantimplications for clinical practice.

Although the overall age range of participants wasfrom 6–18 years, reviewers note that older adolescentswere relatively under-represented in the overall sam-ple as nine studies had an upper age limit of 13 or14 years. There are no trials evaluating CBT specifi-cally for very young anxious children considering thatmany anxiety disorders have a very early onset, andthat clinical anxiety is not uncommon in this age group(17). The rather limiting age range is an importantissue with regard to directness (the extent to which thepeople, interventions, and outcome measures are sim-ilar to those of interest). Another issue with regard todirectness is the inclusion of community or outpatientsubjects only. It would be difficult to generalise theconclusions of this review to the most severe cases of

Copyright 2008 John Wiley & Sons, Ltd. Evid.-Based Child Health 2: 1278–1281 (2007)DOI: 10.1002/ebch.184

1280 G. Andrews, A. Mahoney and W. Turner

anxiety disorder, who might have received day patientor inpatient treatment.

Two other reviews (18,19) of the same clinical prob-lem have been published. Both support the efficacyof CBT interventions for anxiety disorders. Despitethe differences in methodological approaches betweenthe three reviews, the consistency in results strength-ens the conclusion of this review favouring CBT inthe treatment of anxiety disorders in children andadolescents. It is important to note that recommenda-tions from all reviews are based on trials of moderatequality.

Considering the complexity involved in judgementsabout evidence and recommendations, the GRADEinstrument (20) has been developed as a system-atic and explicit method for assessing the qualityof evidence and strength of recommendations. Basedon issues of study quality and directness, using theGRADE instrument, there is moderate quality evi-dence for the relative effects of CBT on remissionof anxiety diagnosis and reduction of anxiety symp-toms for mild to moderate anxiety. The overall qualityof evidence is moderate and there appears to be netbenefits for the short-term efficacy of CBT for child-hood and adolescent anxiety. While there seems tobe net benefits, the recommendation to ‘probably’ usecognitive behaviour therapy is warranted, reflectinguncertainty because of the quality of the evidence.Reviewers rightly suggest that future methodologicallyrigorous studies should include more severe cases,should be stratified by age and focus on more specificanxiety disorders rather than grouping them together.Finally, the present recommendation may have beendifferent if evidence had been considered from com-parison studies with other forms of treatment includingpharmacotherapy and combined treatments.

Declarations of Interest

None.

Review Author’s Response to Commentary

Anthony James‡

University of Oxford, Oxford, UK

‡Correspondence to: Dr Anthony James, Universityof Oxford, Oxford, UK. E-mail: anthony.james@psychiatry.oxford.ac.uk.

This paper comes at an apposite time as follow-upto the review by James and Soler is due. Cognitivebehavioural therapy is very active area of researchand the number of practitioners and research centreshas increased considerably. The commentaries addressthe evidence base for the cognitive-behavioural treat-ment of a number of anxiety disorders in youths,

excluding posttraumatic disorder and obsessive com-pulsive disorder. The major point to make is that therewere a number (13) of randomised controlled trials(RCTs) which makes cognitive behavioural therapy(CBT) one of the most researched therapies in childpsychiatry. Generally, the quality of the therapy is ade-quate, although the issue of concealment of allocationis rightly highlighted. All the reviews point to a sim-ilar outcome for CBT– – around 56% improvementas denoted by remission of anxiety diagnoses. In thefield of mental health this is a respectable response,and the more systematic analysis, using the GRADEinstrument, confirms the recommendation of CBT asa treatment for anxiety disorders in children and ado-lescents.

Several questions remain notably the effect ofparental or family involvement. Hopefully, as arguedby the reviewers, larger numbers of studies will allowthis issue to be addressed. The issue of comorbidityneeds further detailed analysis, particularly as the fre-quency of comorbidity is high in this age group. It hasbeen suggested that in the follow-up review a subgroupanalysis is needed to examine the effect of durationof treatment, however, this is by no means straight-forward. The issue is not a simple dose response,as for instance with drug therapies; there are shorterand longer term protocols which could be compareddichotomously. More important is the need to exam-ine the mechanisms by which CBT operate. It couldbe argued that we know CBT works, but how exactly?This is a question for the researchers of CBT. A furtherquestion that comes from the reviews is – how canone improve on the outcome of CBT as 40% remainaffected after treatment. We await the answer.

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Copyright 2008 John Wiley & Sons, Ltd. Evid.-Based Child Health 2: 1278–1281 (2007)DOI: 10.1002/ebch.184