Cognitive behavioural therapy for anxiety disorders in children and adolescents

Anthony C James<sup>a</sup>; Georgina James; Felicity A Cowdrey; Angela Soler; Aislinn Choke

doi:10.1002/14651858.CD004690.pub4

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Figure 1

Risk of bias summary: risk of bias item for each included study.

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Figure 2

Risk of bias graph: risk of bias item presented as percentages across all included studies.

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Figure 3

PRISMA Study flow diagram.

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Figure 4

Forest plot of comparison: 1 CBT versus wait‐list, outcome: 1.1 Remission of anxiety diagnoses (ITT analysis).

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Figure 5

Funnel plot of comparison: 1 CBT versus wait‐list, outcome: 1.1 Remission of anxiety diagnoses (ITT analysis).

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Analysis 1.1

Comparison 1: CBT versus wait‐list, Outcome 1: Remission of anxiety diagnoses (ITT analysis)

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Analysis 1.2

Comparison 1: CBT versus wait‐list, Outcome 2: Acceptability ‐participants lost to follow‐up

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Analysis 1.3

Comparison 1: CBT versus wait‐list, Outcome 3: Reduction in anxiety symptoms

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Analysis 1.4

Comparison 1: CBT versus wait‐list, Outcome 4: Remission of anxiety diagnoses: long term follow‐up

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Analysis 1.5

Comparison 1: CBT versus wait‐list, Outcome 5: Reduction in anxiety symptoms: long term follow‐up

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Analysis 1.6

Comparison 1: CBT versus wait‐list, Outcome 6: Sensitivity analysis: Remission of anxiety diagnoses (completers only analysis)

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Analysis 2.1

Comparison 2: CBT versus active controls, Outcome 1: Remission of anxiety diagnoses (ITT analysis)

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Analysis 2.2

Comparison 2: CBT versus active controls, Outcome 2: Acceptability ‐participants lost to follow‐up

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Analysis 2.3

Comparison 2: CBT versus active controls, Outcome 3: Reduction in anxiety symptoms

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Analysis 2.4

Comparison 2: CBT versus active controls, Outcome 4: Remission of anxiety diagnoses: long term follow‐up (ITT analysis)

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Analysis 2.5

Comparison 2: CBT versus active controls, Outcome 5: Reduction in anxiety symptoms: long term follow‐up

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Analysis 2.6

Comparison 2: CBT versus active controls, Outcome 6: Sensitivity analysis: remission of anxiety diagnoses (completers only analysis)

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Analysis 3.1

Comparison 3: CBT versus treatment as usual (TAU), Outcome 1: Remission of anxiety diagnoses (ITT analysis)

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Analysis 3.2

Comparison 3: CBT versus treatment as usual (TAU), Outcome 2: Acceptability ‐participants lost to follow‐up

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Analysis 3.3

Comparison 3: CBT versus treatment as usual (TAU), Outcome 3: Reduction of anxiety symptoms

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Analysis 3.4

Comparison 3: CBT versus treatment as usual (TAU), Outcome 4: Sensitivity analysis: remission of anxiety diagnoses (completers only analysis)

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Summary of findings 1. CBT compared to wait‐list for children and adolescents with anxiety disorders

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
CBT compared to wait‐list for children and adolescents with anxiety disorders
Patient or population: children and adolescents with anxiety disorders Settings: outpatient Intervention: CBT Comparison: wait‐list
	Assumed risk	Corresponding risk
	Wait‐list	CBT
Remission of anxiety diagnoses (ITT analysis) i.e. no longer meeting criteria for DSM or ICD anxiety diagnosis at the end of the trial.	161 per 1000	600 per 1000 (504 to 689)	OR 7.85 (5.31 to 11.6)	1350 (26 studies)	⊕⊕⊕⊝ moderate¹
Participants lost to follow‐up	104 per 1000	97 per 1000 (63 to 148)	OR 0.94 (0.58 to 1.51)	1297 (26 studies)	⊕⊕⊝⊝ low^2,3
Reduction in anxiety symptoms at the end of the trial		The mean reduction in anxiety symptoms in the intervention groups was 0.98 standard deviations lower (1.21 to 0.74 lower)		1394 (30 studies)	⊕⊕⊝⊝ low^2,4	SMD ‐0.98 (‐1.21 to ‐0.74) standardised mean difference. [SMD (difference in means/pooled standard deviation) of 0.2 standard deviation units is to be considered a small difference between intervention groups, 0.5 a moderate difference, and 0.8 a large difference (Cohen 1988).]
Remission of anxiety diagnoses: long‐term follow‐up i.e. no longer meeting criteria for DSM or ICD anxiety diagnosis at the end of the follow‐up study period.	516 per 1000	775 per 1000 (506 to 920)	OR 3.22 (0.96 to 10.75)	124 (3 studies)	⊕⊕⊝⊝ low^1,5
Reduction in anxiety symptoms: long‐term follow‐up, i.e. at the end of the follow‐up study period.		The mean reduction in anxiety symptoms: long‐term follow‐up in the intervention groups was 1.55 standard deviations lower (3.20 lower to 0.10 higher)		186 (4 studies)	⊕⊕⊝⊝ low^2,3,4,5	SMD ‐1.55 (‐3.20 to 0.10)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio.
GRADE Working Group grades of evidence: High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Moderate heterogeneity present. ² Large variation in treatment effects. ³ Very wide confidence intervals. ⁴ Significant heterogeneity present. ⁵ Small sample size.

Summary of findings 1. CBT compared to wait‐list for children and adolescents with anxiety disorders

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Summary of findings 2. CBT compared to active controls for children and adolescents with anxiety disorder

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
CBT compared to active controls for children and adolescents with anxiety disorders
Patient or population: children and adolescents with anxiety disorders Settings: outpatient Intervention: CBT Comparison: active controls
	Assumed risk	Corresponding risk
	Active controls	CBT
Remission of anxiety diagnoses (ITT) analysis i.e. no longer meeting criteria for DSM or ICD anxiety diagnosis at the end of the trial.	372 per 1000	472 per 1000 (313 to 637)	OR 1.51 (0.77 to 2.96)	426 (6 studies)	⊕⊕⊕⊝ moderate¹
Reduction in anxiety symptoms at the end of the trial		The mean reduction in anxiety symptoms in the intervention groups was 0.5 standard deviations lower (1.09 lower to 0.09 higher)		411 (8 studies)	⊕⊕⊕⊝ moderate²	SMD ‐0.5 (‐1.09 to 0.09) standardised mean difference
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio.
GRADE Working Group grades of evidence: High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Widely differing estimates of the treatment effect. ² Significant heterogeneity (introduced by one study).

Summary of findings 2. CBT compared to active controls for children and adolescents with anxiety disorder

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Summary of findings 3. CBT compared to treatment as usual (TAU) for children and adolescents with anxiety disorder

Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No of Participants (studies)	Quality of the evidence (GRADE)	Comments
CBT compared to treatment as usual (TAU) for children and adolescents with anxiety disorders
Patient or population: children and adolescents with anxiety disorders Settings: outpatient Intervention: CBT Comparison: treatment as usual (TAU)
	Assumed risk	Corresponding risk
	Treatment as usual (TAU)	CBT
Remission of anxiety diagnoses (ITT analysis) i.e. no longer meeting criteria for DSM or ICD anxiety diagnosis at the end of the trial.	556 per 1000	398 per 1000 (223 to 610)	OR 0.53 (0.23 to 1.25)	88 (2 studies)	⊕⊕⊕⊝ moderate¹
Reduction of anxiety symptoms at the end of the trial		The mean reduction in anxiety symptoms in the intervention groups was 0.19 standard deviations lower (0.79 lower to 0.4 higher)		98 (3 studies)	⊕⊕⊕⊝ moderate^1,2	SMD ‐0.19 (‐0.79 to 0.4) standardised mean difference
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval; OR: Odds ratio.
GRADE Working Group grades of evidence: High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ Small sample size. ² Moderate heterogeneity present.

Summary of findings 3. CBT compared to treatment as usual (TAU) for children and adolescents with anxiety disorder

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Table 1. Sample sizes

	Number of studies	Mean	Std. Dev.	Min	Max
Individual CBT	7	29.14	15.75	12	60
Individual Controls	7	21.57	10.71	10	43
Group CBT	13	24.77	14.71	6	64
Group Controls	13	21.92	14.41	5	67
Family/Parental CBT	11	25	13.02	6	54
Family/Parental Controls	11	17.18	6.62	5	29

Table 1. Sample sizes

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Comparison 1. CBT versus wait‐list

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1.1 Remission of anxiety diagnoses (ITT analysis) Show forest plot	26	1350	Odds Ratio (IV, Random, 95% CI)	7.85 [5.31, 11.60]

1.1.1 Individual CBT	7	325	Odds Ratio (IV, Random, 95% CI)	7.92 [3.37, 18.63]
1.1.2 Group CBT	13	546	Odds Ratio (IV, Random, 95% CI)	7.86 [3.83, 16.12]
1.1.3 Family/Parental CBT	12	479	Odds Ratio (IV, Random, 95% CI)	8.65 [5.01, 14.92]
1.2 Acceptability ‐participants lost to follow‐up Show forest plot	26	1321	Odds Ratio (IV, Random, 95% CI)	0.94 [0.58, 1.51]

1.3 Reduction in anxiety symptoms Show forest plot	30	1483	Std. Mean Difference (IV, Random, 95% CI)	‐0.98 [‐1.21, ‐0.75]

1.3.1 Individual	8	344	Std. Mean Difference (IV, Random, 95% CI)	‐0.59 [‐0.82, ‐0.36]
1.3.2 Group	15	608	Std. Mean Difference (IV, Random, 95% CI)	‐1.27 [‐1.74, ‐0.80]
1.3.3 Family/Parental	13	531	Std. Mean Difference (IV, Random, 95% CI)	‐0.93 [‐1.29, ‐0.56]
1.4 Remission of anxiety diagnoses: long term follow‐up Show forest plot	3	124	Odds Ratio (IV, Random, 95% CI)	3.22 [0.96, 10.75]

1.5 Reduction in anxiety symptoms: long term follow‐up Show forest plot	4	186	Std. Mean Difference (IV, Random, 95% CI)	‐1.55 [‐3.20, 0.10]

1.6 Sensitivity analysis: Remission of anxiety diagnoses (completers only analysis) Show forest plot	26	1365	Odds Ratio (IV, Random, 95% CI)	11.09 [7.47, 16.45]

1.6.1 Individual CBT	7	325	Odds Ratio (IV, Random, 95% CI)	11.09 [5.46, 22.56]
1.6.2 Group CBT	13	568	Odds Ratio (IV, Random, 95% CI)	11.36 [5.47, 23.59]
1.6.3 Family/Parental CBT	12	472	Odds Ratio (IV, Random, 95% CI)	11.35 [6.36, 20.25]

Comparison 1. CBT versus wait‐list

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Comparison 2. CBT versus active controls

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
2.1 Remission of anxiety diagnoses (ITT analysis) Show forest plot	6	426	Odds Ratio (IV, Random, 95% CI)	1.51 [0.77, 2.96]

2.2 Acceptability ‐participants lost to follow‐up Show forest plot	5	424	Odds Ratio (IV, Random, 95% CI)	0.53 [0.31, 0.91]

2.3 Reduction in anxiety symptoms Show forest plot	8	411	Std. Mean Difference (IV, Random, 95% CI)	‐0.50 [‐1.09, 0.09]

2.4 Remission of anxiety diagnoses: long term follow‐up (ITT analysis) Show forest plot	2	273	Odds Ratio (IV, Random, 95% CI)	2.03 [1.22, 3.36]

2.5 Reduction in anxiety symptoms: long term follow‐up Show forest plot	4	395	Std. Mean Difference (IV, Random, 95% CI)	‐0.91 [‐2.06, 0.24]

2.6 Sensitivity analysis: remission of anxiety diagnoses (completers only analysis) Show forest plot	5	337	Odds Ratio (IV, Random, 95% CI)	2.18 [1.31, 3.64]

Comparison 2. CBT versus active controls

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Comparison 3. CBT versus treatment as usual (TAU)

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
3.1 Remission of anxiety diagnoses (ITT analysis) Show forest plot	2	88	Odds Ratio (IV, Random, 95% CI)	0.53 [0.23, 1.25]

3.2 Acceptability ‐participants lost to follow‐up Show forest plot	2	90	Odds Ratio (IV, Random, 95% CI)	1.01 [0.31, 3.31]

3.3 Reduction of anxiety symptoms Show forest plot	3	98	Std. Mean Difference (IV, Random, 95% CI)	‐0.21 [‐0.77, 0.36]

3.4 Sensitivity analysis: remission of anxiety diagnoses (completers only analysis) Show forest plot	2	78	Odds Ratio (IV, Random, 95% CI)	1.10 [0.45, 2.68]

Comparison 3. CBT versus treatment as usual (TAU)

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