Q: I am a school counselor and noticing a marked increase in the number of students experiencing clinical levels of anxiety. Finding good outside therapists is challenging for families. What do you think are the possibilities and limitations of "teaching" CBT skills broadly in school?

You raise an important point. All young people with anxiety should be able to receive evidence-based care to support their mental health and wellbeing. Unfortunately, there are many challenges facing clinicians and young people that make access to this care difficult – including difficulty accessing therapists and long waitlists. A universal school program is one where all children receive strategies to support their mental health and wellbeing – regardless of their “level” of anxiety. Universal programs have benefits, including that they are 1) easily accessible to a wide range of children, 2) reduce parental strain, 3) reduce stigma, and 4) overcome barriers such as cost, location, and time (Barrett & Pahl, 2006; Masia-Warner et al., 2006). A recent review showed that school-based universal programs have a small but significant effect on depression and anxiety symptoms (see https://www.sciencedirect.com/science/article/pii/S0272735821001227). Targeted anxiety programs (i.e., programs developed to reduce anxiety for young people with elevated symptoms) may be more effective than school-based universal programs in terms of the overall size of the effect. A comprehensive solution to the rising mental health problems we are witnessing in children and youth should include both universal and targeted interventions. In the current climate, parents (and professionals) are faced with the difficult challenge of finding suitable therapists, as well as battling long waitlist times. Digital interventions offer a possible solution to these problems. However, many digital interventions (i.e., “mental health apps”) have not been evaluated, and others have resulted in mixed evidence for efficacy (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439418/). Thus, when making clinical decisions, professionals must first evaluate the evidence and efficacy of the program in question to make an evidence-based decision to improve treatment outcomes for the young person.

Question 1

Are cognitive and behavioral models of specific anxiety disorders different in children?  How? 
For example, in adult OCD, the cognitive model emphasizes metacognitive threat interpretations of normal intrusive thoughts and disfunctional beliefs (thought-action fusion, intolerance of uncertainty, thought control, etc.) as key factors in OCD. However, given cognitive developmental differences in children, how does OCD operate in youth? Are metacognition and OCD beliefs still relevant for understanding childhood OCD or does it operate under different mechanisms?

Jennie Hudson · Accepted Answer

Cognitive-behavioural models of adult anxiety disorders have informed the development of child models of anxiety disorders (e.g., Rapee et al., 2009; Vasey & MacLeod, 2001). Yet it is often the case that the differences in cognitive development between children and adults are not adequately explored or acknowledged. This is crucial, as there is a large body of literature acknowledging differences in cognitive development, and particularly the role of “meta-cognitive beliefs” (e.g., See attached Ellis & Hudson, 2011; White & Hudson, 2016).

Research has shown that children develop meta-cognitive skills around 8 years of age, but the onset of Generalised Anxiety Disorder (GAD) and OCD can develop before 8 years of age. This indicates that meta-cognitive worry is not an essential experience for OCD and GAD. In addition, research has shown that anxious youth report higher metacognitive beliefs compared to non-anxious controls, but no differences in metacognition between the type of emotional problem (e.g., GAD, non-GAD, anxious, anxious/depressed; Ellis & Hudson, 2011).

In the case of GAD, research has also shown that positive beliefs about worry seem to behave differently in children compared to adults – with positive beliefs about worry not associated with anxiety (White & Hudson, 2016). These differences suggest that adult models of anxiety cannot be “cut and paste” and applied to children. Developmental differences in cognition, as well as biological, familial, and social differences, need to be considered.

Question 2

I dont seem to be successful in implementing CBT - young people dismiss my efforts. I have a resource (ThingkGood Feel Good) that talks about implementing Motivational Interviewing to get agreement to participate. Do you see this as essential?

Jennie Hudson · Accepted Answer

Great to see that you’re implementing CBT in your therapy! We know there is good evidence that CBT can improve outcomes and reduce anxiety for young people. We also understand that there are many barriers to implementing CBT – factors such as time, engagement, resources, and motivation can significantly impact implementation and outcomes.

The results on trials with Motivational Interviewing (MI) and CBT have been mixed, and there are very few studies on MI and CBT in young people. There is evidence that MI and CBT result in greater overall anxiety symptom reduction compared to standard CBT alone in adults (Marker et al., 2018). The “dose” of MI did not seem to matter – as little as one session of MI could improve outcomes. Interestingly, there was no difference in dropout rates (which may be an indirect measure of motivation). Other research has shown that MI does not reduce the severity of anxiety disorders for adults (specific to social anxiety disorder in this study; Peters et al., 2019). However, they reported that MI was more effective for adults with significant functional impairments (i.e., difficulties in adaptive/daily living skills). Thus, MI may be a useful adjunct to therapy to reduce anxiety for adults with certain clinical presentations.

Currently, the evidence does not support integrating MI and CBT in therapy to reduce anxiety for young people. Further research is needed to better understand this addition to therapy for young people. Instead, below are some strategies that could be useful to enhance motivation and encourage young people to engage in therapy:

* Acknowledge and validate (rather than dismiss) the young person’s thoughts and experiences. We want to encourage the young person to be curious and challenge their anxious thoughts. Ask questions that encourage the young person to view their thoughts with curiosity. It is crucial that we do not tell a young person that their thoughts are “wrong” and need to be “fixed.”

* Create strong therapeutic alliance and spend time building rapport. This can include understanding the young person’s interests and showing genuine curiosity towards their experiences.

* Collaborate with the young person to identify goals and tasks to achieve their goals. It is also important to focus on goals that are achievable and not too challenging to begin with – we want to allow the young person to experience success and see the benefit of the strategies we are teaching them.

* Implement reward strategies that are delivered immediately and consistently throughout therapy. This might be rephrased as “incentives” or “privileges” for adolescent clients.

* Tailor the therapy to the developmental level of the young person – sometimes adolescents think that they are doing “little kid work,” so we need to ensure the young person is supported and adequately challenged.

Question 3

What are some protective lifestyle factors that can decrease the severity of anxiety disorders in children and young people?

Jennie Hudson · Accepted Answer

There are many factors that cause and maintain anxiety disorders, yet surprisingly little research has been conducted into the protective factors for anxiety disorders. Based on our knowledge so far, the protective lifestyle factors to decrease anxiety and depressive symptoms in young people are listed below (See attached: Sampasa-Kanyinga et al., 2020):

* Sufficient sleep (9 to 11 hours for children; 8-10 hours for adolescents)

* Regular physical activity (> 60 minutes of physical activity)

* Low levels of sedentary behaviour ( < 2 hours recreational screen time)

* Healthy eating patterns and reducing sugar and refined carbohydrates (See attached: Aucoin et al., 2021)

* Reducing caffeinated drinks

* Increasing social connectedness to reduce loneliness (See attached: Wickramaratne et al., 2022)

Question 4

I am a school counselor and noticing a marked increase in the number of students experiencing clinical levels of anxiety. Finding good outside therapists is challenging for families. What do you think are the possibilities and limitations of "teaching" CBT skills broadly in school?

Jennie Hudson · Accepted Answer

You raise an important point. All young people with anxiety should be able to receive evidence-based care to support their mental health and wellbeing. Unfortunately, there are many challenges facing clinicians and young people that make access to this care difficult – including difficulty accessing therapists and long waitlists.

A universal school program is one where all children receive strategies to support their mental health and wellbeing – regardless of their “level” of anxiety. Universal programs have benefits, including that they are 1) easily accessible to a wide range of children, 2) reduce parental strain, 3) reduce stigma, and 4) overcome barriers such as cost, location, and time (Barrett & Pahl, 2006; Masia-Warner et al., 2006). A recent review showed that school-based universal programs have a small but significant effect on depression and anxiety symptoms (see https://www.sciencedirect.com/science/article/pii/S0272735821001227). Targeted anxiety programs (i.e., programs developed to reduce anxiety for young people with elevated symptoms) may be more effective than school-based universal programs in terms of the overall size of the effect. A comprehensive solution to the rising mental health problems we are witnessing in children and youth should include both universal and targeted interventions.

In the current climate, parents (and professionals) are faced with the difficult challenge of finding suitable therapists, as well as battling long waitlist times. Digital interventions offer a possible solution to these problems. However, many digital interventions (i.e., “mental health apps”) have not been evaluated, and others have resulted in mixed evidence for efficacy (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4439418/). Thus, when making clinical decisions, professionals must first evaluate the evidence and efficacy of the program in question to make an evidence-based decision to improve treatment outcomes for the young person.

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