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Meta-Analysis
. 2015 Feb 18;2015(2):CD004690.
doi: 10.1002/14651858.CD004690.pub4.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

Anthony C James  1 , Georgina James, Felicity A Cowdrey, Angela Soler, Aislinn Choke
Affiliations
Meta-Analysis

Cognitive behavioural therapy for anxiety disorders in children and adolescents

Anthony C James et al. Cochrane Database Syst Rev. .

Abstract

Background: A previous Cochrane review (James 2005) showed that cognitive behavioural therapy (CBT) was effective in treating childhood anxiety disorders; however, questions remain regarding (1) the relative efficacy of CBT versus non-CBT active treatments; (2) the relative efficacy of CBT versus medication and the combination of CBT and medication versus placebo; and (3) the long-term effects of CBT.

Objectives: To examine (1) whether CBT is an effective treatment for childhood and adolescent anxiety disorders in comparison with (a) wait-list controls; (b) active non-CBT treatments (i.e. psychological placebo, bibliotherapy and treatment as usual (TAU)); and (c) medication and the combination of medication and CBT versus placebo; and (2) the long-term effects of CBT.

Search methods: Searches for this review included the Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Depression, Anxiety and Neurosis Group Register, which consists of relevant randomised controlled trials from the bibliographic databases－The Cochrane Library (1970 to July 2012), EMBASE, (1970 to July 2012) MEDLINE (1970 to July 2012) and PsycINFO (1970 to July 2012).

Selection criteria: All randomised controlled trials (RCTs) of CBT versus waiting list, active control conditions, TAU or medication were reviewed. All participants must have met the criteria of the Diagnostic and Statistical Manual (DSM) or the International Classification of Diseases (ICD) for an anxiety diagnosis, excluding simple phobia, obsessive-compulsive disorder, post-traumatic stress disorder and elective mutism.

Data collection and analysis: The methodological quality of included trials was assessed by three reviewers independently. For the dichotomous outcome of remission of anxiety diagnosis, the odds ratio (OR) with 95% confidence interval (CI) based on the random-effects model, with pooling of data via the inverse variance method of weighting, was used. Significance was set at P < 0.05. Continuous data on each child's anxiety symptoms were pooled using the standardised mean difference (SMD).

Main results: Forty-one studies consisting of 1806 participants were included in the analyses. The studies involved children and adolescents with anxiety of mild to moderate severity in university and community clinics and school settings. For the primary outcome of remission of any anxiety diagnosis for CBT versus waiting list controls, intention-to-treat (ITT) analyses with 26 studies and 1350 participants showed an OR of 7.85 (95% CI 5.31 to 11.60, Z = 10.26, P < 0.0001), but with evidence of moderate heterogeneity (P = 0.04, I² = 33%). The number needed to treat (NNT) was 6.0 (95% CI 7.5 to 4.6). No difference in outcome was noted between individual, group and family/parental formats. ITT analyses revealed that CBT was no more effective than non-CBT active control treatments (six studies, 426 participants) or TAU in reducing anxiety diagnoses (two studies, 88 participants). The few controlled follow-up studies (n = 4) indicate that treatment gains in the remission of anxiety diagnosis are not statistically significant.

Authors' conclusions: Cognitive behavioural therapy is an effective treatment for childhood and adolescent anxiety disorders; however, the evidence suggesting that CBT is more effective than active controls or TAU or medication at follow-up, is limited and inconclusive.

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Conflict of interest statement

No potential conflicts of interest were reported for any of the review authors.

Figures

1
1
Risk of bias summary: risk of bias item for each included study.
2
2
Risk of bias graph: risk of bias item presented as percentages across all included studies.
3
3
PRISMA Study flow diagram.
4
4
Forest plot of comparison: 1 CBT versus wait‐list, outcome: 1.1 Remission of anxiety diagnoses (ITT analysis).
5
5
Funnel plot of comparison: 1 CBT versus wait‐list, outcome: 1.1 Remission of anxiety diagnoses (ITT analysis).
1.1
1.1. Analysis
Comparison 1: CBT versus wait‐list, Outcome 1: Remission of anxiety diagnoses (ITT analysis)
1.2
1.2. Analysis
Comparison 1: CBT versus wait‐list, Outcome 2: Acceptability ‐participants lost to follow‐up
1.3
1.3. Analysis
Comparison 1: CBT versus wait‐list, Outcome 3: Reduction in anxiety symptoms
1.4
1.4. Analysis
Comparison 1: CBT versus wait‐list, Outcome 4: Remission of anxiety diagnoses: long term follow‐up
1.5
1.5. Analysis
Comparison 1: CBT versus wait‐list, Outcome 5: Reduction in anxiety symptoms: long term follow‐up
1.6
1.6. Analysis
Comparison 1: CBT versus wait‐list, Outcome 6: Sensitivity analysis: Remission of anxiety diagnoses (completers only analysis)
2.1
2.1. Analysis
Comparison 2: CBT versus active controls, Outcome 1: Remission of anxiety diagnoses (ITT analysis)
2.2
2.2. Analysis
Comparison 2: CBT versus active controls, Outcome 2: Acceptability ‐participants lost to follow‐up
2.3
2.3. Analysis
Comparison 2: CBT versus active controls, Outcome 3: Reduction in anxiety symptoms
2.4
2.4. Analysis
Comparison 2: CBT versus active controls, Outcome 4: Remission of anxiety diagnoses: long term follow‐up (ITT analysis)
2.5
2.5. Analysis
Comparison 2: CBT versus active controls, Outcome 5: Reduction in anxiety symptoms: long term follow‐up
2.6
2.6. Analysis
Comparison 2: CBT versus active controls, Outcome 6: Sensitivity analysis: remission of anxiety diagnoses (completers only analysis)
3.1
3.1. Analysis
Comparison 3: CBT versus treatment as usual (TAU), Outcome 1: Remission of anxiety diagnoses (ITT analysis)
3.2
3.2. Analysis
Comparison 3: CBT versus treatment as usual (TAU), Outcome 2: Acceptability ‐participants lost to follow‐up
3.3
3.3. Analysis
Comparison 3: CBT versus treatment as usual (TAU), Outcome 3: Reduction of anxiety symptoms
3.4
3.4. Analysis
Comparison 3: CBT versus treatment as usual (TAU), Outcome 4: Sensitivity analysis: remission of anxiety diagnoses (completers only analysis)
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