The Role of CBT in Child and Adolescent Mental Health

Understanding Child and Adolescent Mental Health

Mental health difficulties in children and adolescents are an important concern due to the significant long-term impact these challenges can have on their development and overall well-being. According to the Mental Health of Children and Young People in England 2023, published by the NHS, 1 in 5 children and young people, aged 8-25, had a probable mental health disorder in 2023.

The most common mental health conditions in children and adolescents are:

• Anxiety disorders
• Depression
• Obsessive-compulsive disorder (OCD)
• Phobias
• Eating disorders, such as anorexia and bulimia
• Mood disorders, such as bipolar disorder
• Schizophrenia
• Post-traumatic stress disorder (PTSD)
• Behavioural disorders, such as operational defiance disorder (ODD)

Unlike adults, children and adolescents are still in crucial stages of cognitive, emotional and social development. Untreated mental health issues during these formative years can lead to long-lasting consequences that persist into adulthood. Mental health challenges in childhood and adolescence can disrupt critical developmental milestones and result in young people not acquiring the essential skills and coping mechanisms necessary for navigating adulthood successfully. For example, untreated anxiety in adolescence may impair the development of healthy coping strategies and lead to persistent difficulties managing stress and emotions in adulthood.

Children and adolescents experiencing mental health problems may struggle with academic performance, maintaining healthy relationships and overall quality of life. Additionally, untreated mental health issues in youth can increase the risk of developing more severe conditions later in life, including chronic mental health disorders and even physical health problems.

Furthermore, mental health issues during childhood and adolescence can exacerbate social and academic challenges and contribute to issues such as school dropout, substance abuse and involvement in negative or damaging behaviours. Addressing mental health concerns early in life not only prevents immediate distress but also promotes resilience and positive outcomes later on.

Recognising and intervening in mental health issues during these important developmental stages can reduce the long-term negative effects of mental health difficulties.

Foundations of CBT for Youth

Cognitive behavioural therapy (CBT) is a widely used and evidence-based approach for treating mental health issues in people of all ages, including children and adolescents. The principles of CBT revolve around the understanding that thoughts, feelings and behaviours are interconnected and by changing negative or unhelpful thoughts and behaviours, you can reduce your emotional distress and improve overall well-being.

When adapting CBT for children and adolescents, several considerations need to be made to ensure that the therapy is effective and engaging for young people.

• Simplified language
  CBT sessions for children and adolescents often use simplified language to ensure that concepts are easily understood. Therapists may use metaphors, analogies and age-appropriate explanations to explain complex psychological concepts in a way that young people can understand.
• Engagement through activities
  Children and adolescents may have shorter attention spans compared to adults, so CBT sessions often incorporate interactive activities and exercises to keep them engaged. These activities can include drawing, storytelling, role-playing and games, which can help reinforce CBT principles in a fun and relatable manner.
• Concrete examples
  Therapists use concrete examples relevant to the child or adolescent’s experiences to explain key CBT concepts. By connecting abstract ideas to real-life situations, young people can better understand how thoughts, feelings and behaviours interact and influence each other.
• Involvement of parents and caregivers
  In youth-focused CBT, parents and caregivers are actively involved in the therapeutic process. Therapists provide guidance and support to parents, teaching them strategies to reinforce CBT principles at home and create a supportive environment for their child’s progress.
• Skill building
  CBT for youth emphasises skill building to equip children and adolescents with practical tools for managing their emotions and coping with challenges. These skills may include relaxation techniques, problem-solving skills, emotion regulation strategies and effective communication skills.
• Gradual exposure
  When working with children and adolescents facing anxiety disorders, OCD or trauma-related disorders, therapists may use gradual exposure techniques to help them confront feared situations or stimuli in a step-by-step manner. This approach allows young people to gradually build confidence and resilience while managing their anxiety.
• Tailored interventions
  CBT interventions are tailored to the developmental stage, cognitive abilities and individual needs of each child or adolescent. Therapists adapt their approach based on factors such as age, cultural background and personal interests to ensure that therapy is relevant and effective for the young individual.

Overall, youth-focused CBT incorporates a blend of evidence-based techniques, age-appropriate language and interactive activities to engage children and adolescents in the therapeutic process effectively. By providing practical skills and empowering children and adolescents to challenge negative thoughts and behaviours, CBT helps promote resilience and well-being in young people facing mental health difficulties.

Common Mental Health Challenges

Children and adolescents can experience a number of mental health challenges that can significantly impact their well-being and functioning. Some of the most common mental health disorders experienced by young people include:

Anxiety disorders

Anxiety disorders are among the most prevalent mental health issues in children and adolescents. These disorders include:

• Generalised anxiety disorder (GAD)
• Social anxiety disorder
• Specific phobias
• Separation anxiety disorder

Children and adolescents with anxiety disorders experience excessive worry, fear and nervousness that can interfere with daily activities, school performance and social relationships.

Depressive disorders

Depression is another common mental health challenge among young people. Depressive disorders in children and adolescents may manifest as persistent feelings of sadness, hopelessness, irritability or loss of interest in previously enjoyed activities. Depressive symptoms can impact academic performance, social functioning and overall quality of life.

Eating disorders

Record numbers of children and young people in the UK have a diagnosed eating disorder and are receiving treatment. An eating disorder is a serious mental health problem where people control food as a way of coping with their feelings or situations they find difficult. The most common eating disorders are: 

• Bulimia nervosa
• Anorexia nervosa
• Binge-eating disorder

Adolescence is the most common period of onset for eating disorders.

Obsessive-compulsive disorder (OCD)

Obsessive-compulsive disorder is characterised by recurrent obsessions (intrusive, unwanted thoughts) and compulsions (repetitive behaviours or mental acts performed to alleviate anxiety or prevent perceived harm). Children and adolescents with OCD may experience distressing obsessions related to contamination, symmetry or intrusive thoughts. This can lead to ritualistic behaviours that interfere with daily functioning.

Trauma-related disorders

Exposure to traumatic events such as abuse, neglect, accidents, natural disasters or witnessing violence can lead to trauma-related disorders like post-traumatic stress disorder (PTSD) in children and adolescents. Symptoms of PTSD may include flashbacks, nightmares, hypervigilance, avoidance of reminders of the trauma and emotional numbing.

Attention deficit hyperactivity disorder (ADHD)

ADHD is a neurodevelopmental disorder characterised by inattention, hyperactivity and impulsivity. Children and adolescents with attention deficit hyperactivity disorder may struggle with focus, organisation, impulse control and time management, which can affect academic performance, relationships and daily functioning.

Behavioural disorders

Behavioural disorders such as oppositional defiant disorder (ODD) involve persistent patterns of disruptive, defiant or aggressive behaviours. Children and adolescents with behavioural disorders may display behaviours such as temper tantrums, arguing with authority figures, defiance of rules, aggression towards peers or animals and destruction of property.

These common mental health disorders can vary in severity and presentation and some people experience a combination of symptoms from different disorders. Early recognition, intervention and appropriate treatment are essential for addressing these mental health issues and promoting the well-being of children and adolescents.

Assignment and Diagnosis

If your child is experiencing mental health difficulties or you have noticed any symptoms you are concerned about, you should make an appointment with their GP or primary healthcare physician. Their GP will likely ask about their symptoms and may look at your child’s medical history and family history. If they think they may have a mental health condition, your child may be referred for a specialist assessment, most likely with a psychiatrist or other mental health professional.

Mental health professionals play an important role in assessing and diagnosing mental health issues in young people. Their expertise allows them to identify symptoms, patterns and risk factors associated with various mental health disorders in children and adolescents to ensure an accurate diagnosis is made.

A mental health professional will conduct a comprehensive assessment to gather information about your child’s emotional, behavioural and developmental functioning. This assessment typically involves interviews with the child, parents or caregivers and sometimes teachers or other relevant individuals. Standardised assessments, questionnaires and behavioural observations may also be used to gather additional information.

To gain more information about your child’s symptoms, you and your child may be asked about:

• Their symptoms, including the types of symptoms they are experiencing, how frequently they occur and how severe they are.
• When you or your child first noticed symptoms and anything that may have triggered the symptoms.
• Your child’s medical history.
• Whether there is a family history of mental health difficulties.
• How much their symptoms interfere with their day-to-day life, well-being and behaviour.

Following diagnosis, mental health professionals collaborate with the child or adolescent and their family to develop individualised treatment plans. These plans will be tailored to the unique needs and preferences of the child.

Tailored Treatment Plans

Creating individualised treatment plans for children and adolescents is essential to address their mental health needs effectively. When creating a tailored treatment plan, healthcare professionals will need to consider:

• The unique needs of the child
  Every child or adolescent is unique, with their own set of strengths, challenges and circumstances. A one-size-fits-all approach to treatment is unlikely to address the specific needs of each individual. Tailoring treatment plans ensures that interventions are personalised to the child or adolescent’s specific symptoms, preferences and goals.
• Developmental stages
  Children and adolescents undergo rapid changes in their physical, cognitive and emotional development. Treatment plans must consider the child or adolescent’s developmental stage to ensure that interventions are developmentally appropriate and aligned with their capabilities and understanding.
• Family dynamics
  Family plays an important role in a child or adolescent’s life and can significantly influence their mental health and well-being. Understanding and addressing family dynamics, relationships and communication patterns are essential aspects of treatment planning. Involving family members in the treatment process can enhance support, improve outcomes and create positive changes within the family.
• Culture and religion
  Cultural and religious factors, including beliefs, values, traditions and social norms, can impact how mental health issues are perceived, expressed and treated within different communities. Treatment plans should consider the cultural background and preferences of the child or adolescent and their family to ensure that interventions are culturally sensitive and respectful.
• Flexibility and adaptability
  Children and adolescents may respond differently to various treatment modalities and their needs may evolve over time. Treatment plans should be flexible and adaptable, allowing for adjustments based on progress, changing circumstances and feedback from the child or adolescent and their family.

When creating a treatment plan, a collaborative approach is necessary. Collaborating with the child or adolescent, their family and other relevant professionals (e.g. teachers and speech and language therapists) is essential in developing comprehensive and effective treatment plans. Involving families and other professionals in the treatment planning process encourages collaboration and shared decision-making and improves the likelihood of successful outcomes.

A holistic approach to mental health treatment addresses the child or adolescent’s overall well-being, including their physical health, social functioning, academic performance and quality of life. A holistic approach considers multiple areas of functioning to promote more effective improvements in mental health and overall functioning.

Cognitive Restructuring for Youth

CBT helps young people identify and challenge negative thought patterns and cognitive distortions through a structured and evidence-based approach. Some ways that CBT can help children and young people overcome their mental health difficulties include:

• Understanding thought patterns
  CBT begins by helping children and adolescents understand the connection between their thoughts, feelings and behaviours. Therapists teach them that their thoughts can influence how they feel and behave and that not all thoughts are accurate or helpful.
• Identifying negative thought patterns
  Children and adolescents learn to recognise negative thought patterns, such as all-or-nothing thinking, catastrophising, over-generalisation and personalisation. They become aware of how these patterns contribute to feelings of anxiety, sadness or anger.
• Challenging cognitive distortions
  Once negative thought patterns are identified, CBT helps young people challenge and reframe these distortions by examining evidence and considering alternative perspectives. They learn to question the accuracy and helpfulness of their thoughts.

Cognitive restructuring exercises

• Thought diaries
  Children and adolescents can use thought diaries to track their thoughts, emotions and behaviours in specific situations. They can identify the triggering event, record their automatic thoughts and then challenge these thoughts by asking questions such as, ‘Is this thought based on facts or feelings?’ or ‘What would I tell a friend in this situation?’.
• Balanced thinking
  Therapists encourage children and adolescents to generate balanced thoughts by considering both the positive and negative aspects of a situation. For example, if a child receives a lower grade on a test, they might challenge negative thoughts by acknowledging their effort and identifying areas for improvement.
• Reality testing
  Young people are taught to reality-test their thoughts by evaluating evidence and considering alternative explanations. For instance, if a child thinks, ‘Nobody likes me’, they might explore evidence to challenge this belief, such as times when friends have shown kindness or appreciation towards them.
• Cognitive coping cards
  Children and adolescents can create cognitive coping cards containing helpful reminders, affirmations or coping statements to challenge negative thoughts when they occur. These cards can be used as portable tools to support cognitive restructuring in real-life situations.
• Reinforcement and practice
  Cognitive restructuring exercises are reinforced through practice and repetition. Children and adolescents gradually build their skills and confidence in challenging negative thoughts and replacing them with more balanced and positive alternatives.

Cognitive restructuring in CBT empowers young people to take control of their thoughts and emotions and promotes resilience and healthier ways of thinking and coping with life’s challenges. By teaching them to challenge and reframe negative thought patterns, CBT equips children and adolescents with valuable skills for managing their mental health and improving their overall well-being.

Emotion Regulation

CBT equips children and adolescents with a range of strategies for regulating their emotions, managing stress and coping with challenging situations. By targeting thoughts, behaviours and coping mechanisms, CBT helps young people develop effective emotional regulation skills.

Some ways that CBT can teach young people strategies to regulate their emotions include:

• Identifying emotions
  CBT helps children and adolescents recognise and label their emotions accurately. By increasing emotional awareness, young people can better understand the underlying reasons for their feelings and respond to them more effectively.
• Understanding triggers
  CBT teaches children and adolescents to identify triggers or situations that provoke intense emotions. By understanding the relationship between triggers and emotional responses, young people can anticipate and prepare for challenging situations.
• Cognitive restructuring
  As discussed earlier, CBT helps young people challenge and reframe negative thought patterns. By changing their thinking, children and adolescents can influence their emotional responses to events. For example, reframing catastrophic thoughts can help reduce feelings of anxiety.
• Behavioural coping skills
  CBT teaches children and adolescents practical coping skills to manage emotions and reduce stress. These skills may include relaxation techniques (e.g. deep breathing and progressive muscle relaxation), distraction techniques (e.g. engaging in enjoyable activities) and problem-solving strategies (e.g. breaking down problems into manageable steps).

Emotion regulation strategies

CBT helps young people develop specific emotion regulation strategies to control their emotional responses. These strategies may include:

• Mindfulness: CBT incorporates mindfulness techniques to help children and adolescents stay focused on the present and observe their thoughts and emotions without judgement. Mindfulness practices can promote emotional awareness and reduce reactivity.
• Emotion labelling and expression: CBT encourages children and adolescents to express their emotions in healthy ways, such as talking to a trusted adult, journaling or engaging in creative expression (e.g. drawing or painting). By acknowledging and validating their feelings, young people can prevent emotional suppression and build resilience.
• Problem-solving skills: CBT teaches problem-solving skills to help young people effectively address the underlying issues contributing to their emotions. By breaking down problems into smaller, manageable steps and brainstorming potential solutions, children and adolescents learn to approach challenges proactively and assertively.
• Stress management techniques: CBT provides children and adolescents with tools to manage stress effectively. These techniques may include time management skills, organisation strategies and assertiveness training. By learning to prioritise tasks, set boundaries and communicate assertively, young people can reduce stress and maintain a sense of control in their lives.

Parent and Caregiver Involvement

Parent and caregiver involvement plays an important role in supporting CBT for children and adolescents. When parents and caregivers actively participate in the therapeutic process, they can reinforce CBT principles at home and create a supportive environment that enhances the child or adolescent’s progress.

Parents and caregivers can familiarise themselves with the basic principles and techniques of CBT. This understanding enables them to reinforce CBT concepts at home and support their child’s application of skills learned in therapy by incorporating CBT techniques into daily routines. For example, they can encourage their child to practise relaxation exercises before bedtime or use cognitive restructuring techniques to challenge negative thoughts during challenging situations.

Communication between parents/caregivers and the therapist is essential for effective treatment. Parents and caregivers should actively engage with the therapist, share relevant information about their child’s progress and challenges and collaborate on treatment goals and strategies. It is important for parents and caregivers to set realistic expectations for their child’s progress in therapy. CBT is a gradual process and changes may take time to become evident. Encouragement, patience and support are key during the therapeutic journey.

Parents and caregivers are role models to their children and can model healthy coping behaviours. By demonstrating healthy coping behaviours, such as problem-solving, emotion regulation and positive communication, they can teach valuable skills that align with CBT principles.

Creating a safe and supportive home environment is essential for the child or adolescent’s emotional well-being. Parents and caregivers can encourage open communication, active listening and empathy, which allows their child to express thoughts and feelings without fear of judgement or criticism. Consistent routines and structure can help children and adolescents feel secure and grounded. Parents and caregivers can establish predictable routines for meals, bedtime and daily activities, which can promote feelings of stability and reduce stress.

While providing support, parents and caregivers should also encourage their child’s independence and autonomy. Empowering children and adolescents to take ownership of their mental health and problem-solving can improve self-confidence and resilience.

Supporting a child or adolescent in therapy can be challenging and parents and caregivers may benefit from their own support network or professional assistance. Seeking guidance from a therapist, support group or parenting resources can help caregivers navigate their role effectively and manage their own stress.

Effectiveness of CBT for Youth

CBT has been extensively researched and demonstrated to be highly effective in treating a variety of mental health issues in children and adolescents. Some examples are listed below.

Anxiety disorders:

One prominent research study that has demonstrated the effectiveness of cognitive behavioural therapy in treating anxiety disorders in children and adolescents is a meta-analysis conducted by James et al. (2020). The researchers systematically reviewed and synthesised the findings of randomised controlled trials (RCTs) that looked at the effectiveness of CBT interventions for anxiety disorders in children and adolescents. The studies included young people aged 7 to 18 years old who were diagnosed with various anxiety disorders, including generalised anxiety disorder (GAD), social anxiety disorder, separation anxiety disorder and specific phobias.

The results of the meta-analysis indicated that CBT interventions were significantly more effective than no treatment or waitlist controls in reducing symptoms of anxiety in children and adolescents. Additionally, the study found that the effects of CBT for anxiety disorders in young people were maintained at follow-up assessments, suggesting the treatment can be effective over time.

Depression:

A well-known research study examining CBT as a treatment for depression in children and adolescents is the Adolescent Depression Antidepressants and Psychotherapy Trial (ADAPT). The ADAPT study was a large-scale randomised controlled trial conducted in the United States. It aimed to compare the effectiveness of CBT, fluoxetine (an antidepressant medication) and their combination in treating adolescents with moderate to severe depression.

In the ADAPT study, participants aged 12 to 18 years with major depressive disorder (MDD) were randomly assigned to one of four treatment groups: CBT alone, fluoxetine alone, combination therapy (CBT plus fluoxetine) or placebo. The study duration was 36 weeks, with assessments conducted at regular intervals to evaluate changes in depressive symptoms and treatment outcomes.

The results of the ADAPT study showed that all active treatment groups (CBT alone, fluoxetine alone and combination therapy) were more effective than placebo in reducing depressive symptoms in adolescents. Importantly, CBT alone was found to be as effective as fluoxetine alone and combination therapy in treating depression.

Overall, the ADAPT study provided strong evidence for the effectiveness of CBT as a standalone treatment for depression in young people. It highlighted the importance of psychotherapy, particularly CBT, as a safe and effective intervention for addressing depression in children and adolescents, with comparable outcomes to antidepressant medication.

Conclusion

Cognitive behavioural therapy can be highly effective in treating a wide range of mental health difficulties in young people. CBT interventions that are tailored to the unique needs and developmental stages of children and adolescents can significantly reduce symptoms and improve overall functioning. CBT is recognised for its versatility and adaptability in addressing various mental health difficulties faced by young people, including anxiety disorders, depression, OCD, PTSD and eating disorders. CBT interventions can be customised to suit the specific needs, preferences and developmental levels of children and adolescents.

By equipping young people with practical skills and strategies for identifying and challenging negative thought patterns, managing emotions and coping with stressors, CBT encourages empowerment and resilience. CBT interventions empower children and adolescents to take an active role in managing their mental health and building adaptive coping mechanisms for long-term well-being.

By understanding and implementing CBT principles, mental health professionals, educators, parents and caregivers can contribute to the well-being and resilience of young people and can help to improve their mental health, development and long-term outcomes.