CBT, Pharmacotherapy Both Safe, Effective for Childhood Anxiety

Child talking to a therapist
Child talking to a therapist
CBT and pharmacotherapy are effective treatments for anxiety disorders in children and adolescents younger than 18.

A meta-analysis published in JAMA Pediatrics showed that both cognitive behavioral therapy (CBT) and pharmacotherapy are effective treatments for anxiety disorders in children and adolescents younger than 18.

To evaluate the efficacy and safety of CBT and/or pharmacotherapy in children, researchers evaluated the results of 115 studies (n=7719; mean age [range] 9.2 [5.4-16.1]; 55.6% female). A random-effects meta-analysis was used to evaluate the effect of treatments on primary anxiety symptoms (measured by child, parent, or clinician), remission, response, and adverse events.

Primary anxiety symptoms (parent report: standardized mean difference [SMD] −0.61, 95% CI −1.03 to −0.20; clinician report: SMD −0.65; 95% CI, −1.10 to −0.21), remission (relative risk [RR] 2.04, 95% CI 1.37-3.04), and response (RR 1.96; 95% CI 1.60-2.40) were improved by selective serotonin reuptake inhibitors (SSRIs). Clinician-reported primary anxiety symptoms were reduced by serotonin-norepinephrine reuptake inhibitors ([SNRIs] SMD −0.45, 95% CI −0.81 to −0.10). Low quality of evidence revealed that benzodiazepines and tricyclic antidepressants were not significantly associated with changes in primary anxiety symptoms.

Compared with waitlisting or no treatment, CBT significantly improved child-reported (SMD −0.77, 95% CI −1.06 to −0.47), parent-reported (SMD −0.88, 95% CI −1.23 to −0.54), and clinician-reported (SMD −1.38, 95% CI −1.95 to −0.81) primary anxiety symptoms based on moderate quality of evidence. CBT also increased response to treatment (RR 4.72, 95% CI 2.39-9.32) and remission (RR 4.08, 95% CI 1.05-15.80). When compared with fluoxetine and sertraline, CBT improved primary anxiety symptoms and increased remission, respectively.

Compared with either treatment option alone, the combination of sertraline and CBT significantly improved clinician-reported primary anxiety symptoms and treatment response.

Related Articles

Adverse events were common in patients receiving pharmacotherapy but mostly minor, including gastrointestinal symptoms, behavior change, difficulty sleeping, headache, fatigue, and somnolence. Patients receiving CBT were less likely to withdraw from the study compared with patients receiving placebo.

According to Dr Zhen Wang, lead study investigator, the data indicate that “SSRIs, SNRIs and CBT are all effective in reducing anxiety symptoms.” Based on these results, “The choice of treatments [for childhood anxiety disorders] should be based on values, preferences, availability of services, and adverse effect profile.”


Wang Z, Whiteside SPH, Sim L, et al. Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: a systematic review and meta-analysis [published online August 31, 2017]. JAMA Pediatr.  doi:10.1001/jamapediatrics.2017.3036