Cognitive Behavioural Therapy, also referred to as CBT is an approach that “focuses on thought processes and how these might be maladaptive” (Sanders P 2009 p 58). The following literature review will explore and summarise four selected pieces of research that look at the use of CBT in the treatment of childhood anxiety and how effective it is. The term childhood in this case is referred to as children aged between 4 and 7 years. The term anxiety as referred to in the Diagnostic and Statistical Manual of Mental Disorders is an Anxiety Disorder which is a psychological condition (DSM-IV 2010).
It manifests itself as unusual or abnormal behavior such as; Panic attacks, Agoraphobia or Obsessive – Compulsive Disorder amongst others. (DSM-IV 2010)
An online search was conducted using the University of Salford’s research data base SOLAR. This is accessed online via the University of Salford’s Blackboard. In SOLAR you opt for the ‘ find databases’ search area. This area then enables you to access online research specific to the school or area of study, in this case Health and Social Care and then the subject area, Counselling and Psychotherapy.
Solar then gives the option of a more specific database search engine such as EBSCO the academic search premier database (EBSCO 2011). EBSCO gives you the option to use keywords to help you find a specific researched area.
Keywords where picked with the literature review question in mind. The keywords used where; Cognitive Behavioural Therapy, CBT and child anxiety. Between each keyword a Boolean (EBSCO 2011) word can be used e.
g. and, or, not. You are also able to select where you would like the keywords to be i.e. in the title (TI) in the text (TX) etc. The use of a question mark inside the spelling of behavio?r would also assist the search by checking all the variations of spellings i.e. behavioral/behavioural. The use of a truncation (*) next to the word child* will check all the synonyms of a word i.e. child, children, childhood (EBSCO 2011). To refine the search further limiters such as ‘only scholarly (peer reviewed) articles’ in the ‘full text’ version produced a more manageable result.
See fig 1 below for a step by step guide to the sequence of keyword and phrases used in the search.
From the results found, each title was reviewed and the titles that contained all the relevant keywords were placed in a folder for closer review. Any papers that contained variants to the topic such as, teenagers, adolescents or youth where discarded. By doing this a thematic review could be constructed to ‘identify distinct key issues or questions throughout the area of research’ (McLeod 2003, p 19).
One of the selected research articles was a summary of an original paper written in Brown University letter (2010). To obtain the full pdf version of Hirschfield-Becker’s team’s (2010) research article, EBSCO presented a ‘find it’ search tool which enables a search in other databases such as OVID SP (2011). The full paper was found for use in OVID SP (2011). A recent journal article written in 2011 was found but was only available as an abstract (Van der Leeden et al 2011). The full electronic version was available to purchase at other Universities or by post which can take up to 3 weeks to deliver. Unfortunately this option did not allow enough time for this essay, but it would be an option to bear in mind for future research projects such as a dissertation.
Having read the four chosen research papers the following thematic literature review should aim to address the question of the effectiveness of CBT in childhood anxiety and highlight similarities or conflicts between the selected researches (McLeod 2003). On reading the articles in detail it became apparent that CBT was proven to be 83% effective in the treatment of anxiety in children aged 4 onwards after a 1 year follow up1 (Hirshfield-Becker 2010). It was based on the collaboration of numerous factors that ordained a successful outcome (Hirshfield-Becker 2010, Gosh 2006, Monga 2009, Surveg 2006). Factors such as parental involvement (Surveg 2006) the competence of the therapist (Gosh 2006) and variations to the methods used. (Gosh 2006, Monga 2009, Hirshfield- Becker 2010)
The methodologies used in Cognitive Behavioral Therapy included a method known as the Coping Cat Program (Kendall et al 1992). The Coping Cat Program incorporates skill building and relaxation techniques to help soothe the anxious child. This method was used in all the chosen research articles and was concluded as successful (Surveg 2006, Gosh 2006, Monga 2009 & Hirshfield-Becker 2010). The ultimate goal of CBT with anxious youth is for the child to gain a sense of mastery over his/her anxiety (Kendall & Hedtke 2006) and the Coping Cat program assists with this. Hirshfield-Beckers (2010) team adapted Kendall’s (2006) method slightly, for its use with younger children. They included games and immediate positive reinforcement and greater parental involvement to reinforce coping strategies.
Through parent/therapist only sessions questionnaires where offered to evaluate the child’s condition and also increase awareness of the symptoms of anxiety disorders (Surveg 2006, Gosh 2006, Monga 2009, and Hirshfield-Becker 2010). Techniques for relieving stress where also discussed as tools for themselves and the anxious child (Hirshfield-Becker 2010). The families chosen for the research all tend to be from middle class, semi-professional or professional two parent families (Surveg 2006, Gosh 2006, Monga 2009 and Hirshfield-Becker 2010). This raises the question whether anxious children who are from a less fortunate background may or may not benefit from CBT? (Dodd 2011). Dodd (2011) later reviews Hirshfield-Beckers (2010) research and look into the limitations of the results when CBT is applied to lower income and less well-educated participants.
Other areas in the research looked at the importance of the therapeutic relationship. Different combinations of parent/child/therapist participation where experienced. For example a group of 5-8 children with their parent or parents and a therapist or a child, the parents and a therapist (Monga 2009) It was not entirely clear from Monga’s team (2009) which combination was more effective, we can only assume from the positive outcome that all variations where effective for some anxiety disorders (Gosh 2006).
Serveg (2006) looked at the benefits and barriers in parental involvement and the team highlighted the importance of parent/therapist rapport which would enable a deeper understanding for all regarding the child’s anxiety. Parental involvement would offer the therapist feedback regarding the home, school and social environment of the child and also offer a gauge in the progression of treatment (Surveg 2006). The therapist is then able to tailor the treatment to address the specific needs of the child (Surveg 2006). Another advantage to parental participation is the interpretation of the child’s choice of language when talking about their anxieties or recalling a feeling (Surveg 2006).
A child’s response to a therapists question could be questionable as a child of four may not be able to interpret their true feelings about a situation. This may result in the child becoming disengaged in therapy or avoid-ant in social circumstances or other relationships (Gosh 2006). A parent’s interpretation and insight can often assist the therapist in deciphering the child’s message. This is not always the case though and a parent could also hinder the process of change. For example a parent could feel the need to ‘rescue’ the child or the parent might themselves be depressed, this may impact greatly on the child’s behaviour (Surveg 2006). Hirshfield -Becker (2010) addressed this issue by creating a play exercise that enabled the child space and re-educated the parents perception of what is real danger and what could be their own fear. The parents could project their own anxieties about a situation which could if turn exasperate the child’s anxiety or create a new one.
Child anxiety is among the most common of mental health disorders and if left untreated could have a worsening effect later on in adolescence and throughout adult hood (Gosh 2006). Childhood anxiety is often left undiagnosed and those fortunate to receive therapy such as CBT have a greater chance to resolve anxieties such as Obsessive Compulsive Disorder and Panic Attacks among others noted in the DSM-IV (2010). It became obvious throughout the reviewed research that parental involvement hugely effects a positive outcome. Points to consider for further research could include the question ‘Is CBT effective without parental involvement?’
Most agree that further research should be considered to evaluate the efficiency and effectiveness of further interventions (Surveg 2006, Monga 2009,Hirshfield-Becker 2010). If parental involvement facilitates treatment then the parents involvement in the origins of the anxiety disorder should also be considered, it is often said that in the illness lies the cure. To explore child anxiety further It would be beneficial research to look at the parental involvement in the child’s anxiety this could be addressed through a more long term therapy program such as the Person Centred Therapy approach (Rogers 1951) or Transactional Analysis (Berne 1961). CBT seems to offer a quick solution to alleviate symptoms, but to get to the route of the anxiety and arrest it completely other modalities of psychotherapy could be considered.