ORIGINAL PAPER

A Pilot Investigation of Cognitive Therapy for GeneralizedAnxiety Disorder in Children Aged 7–17 Years

Susanna Payne • Derek Bolton • Sean Perrin

Published online: 13 November 2010

� Springer Science+Business Media, LLC 2010

Abstract The development of treatments based on cog-

nitive models of worry has led to improved outcomes for

adults with Generalized Anxiety Disorder (GAD), and

holds out the promise that similar improvements may be

achieved for GAD further down the age range. The aim of

the current study was to evaluate the effect of a GAD-

specific, cognitive treatment in a sample of children and

adolescents with GAD. Sixteen youth (7–17 years of age)

who were consecutive referrals to a specialty anxiety dis-

orders clinic, with a primary diagnosis of DSM-IV GAD,

and who were not undergoing concurrent pharmacological

treatment for anxiety were provided 5 to 15 session

(mean = 9.7) of cognitive therapy aimed at their tolerance

for uncertainty, beliefs about worry, negative problem

orientation, and cognitive avoidance strategies. All partic-

ipants who entered the study completed treatment and 13

(81%) lost their GAD diagnosis (not blindly assessed); two

were improved but still had GAD and one experienced no

improvement at all. Age, gender and number of sessions

received were unrelated to diagnostic outcome but age was

positively correlated (r = 0.6, P \ .01) with pre-to-post

reductions in worry frequency. The uncontrolled effect size

for self-reported worry was 2.0 and for anxiety was 1.4.

Further controlled evaluations of this cognitive treatment

for GAD in children and adolescents are warranted.

Keywords Generalized anxiety disorder �GAD �Anxiety �Cognitive therapy � CBT � Children and adolescents

Introduction

Generalized Anxiety Disorder (GAD) is characterized by

the presence of excessive and uncontrollable worry about a

variety of events, accompanied by at least one somatic

symptom in children (three for adults), and clinically sig-

nificant distress or impaired functioning for no less than

6 months (Diagnostic and Statistical Manual for Mental

Disorders, 4th Edition (DSM-IV), American Psychiatric

Association 1994). Prior to the 1994 DSM revision the

same criteria were also listed in the child section of the

manual under Overanxious Disorder (OAD). Along with

specific phobias, GAD/OAD is the most commonly diag-

nosed anxiety disorder in non-referred youth under

18 years of age (Meltzer et al. 1999; Scheibe and Albus

1992). GAD/OAD is also among the most commonly

occurring comorbid conditions in youth seeking treatment

for separation anxiety, social phobia, panic and obsessive

compulsive disorders (Kendall et al. 2010; Last et al.

1992).

Prospective studies suggest that GAD during childhood

significantly increases the risk of developing other anxiety

disorders and depression during adolescence (Last et al.

1996). When GAD is comorbid with depression in ado-

lescence, it significantly increases the risk in early adult-

hood (18–26 years of age) of self-reported adjustment

problems, being out of school/employment, and health/

mental health utilisation (Last et al. 1997). Research with

adults reports similar findings for GAD: high prevalence

and comorbidity; adolescent onset; negative impact on

functioning; and increased health service utilization

Statement that informed consent has been appropriately obtained.

S. Payne � D. Bolton � S. Perrin (&)

Department of Psychology (PO77), King’s College

London/Institute of Psychiatry, 16 DeCrespigny Park Road,

London SE5 8AF, UK

e-mail: sean.perrin@kcl.ac.uk

123

Cogn Ther Res (2011) 35:171–178

DOI 10.1007/s10608-010-9341-z

(Wittchen and Hoyer 2001; Kessler et al. 2005; Hunt et al.

2002; Maier et al. 2000; Yonkers et al. 1996). With the

obvious long-term consequences associated with childhood

GAD, early identification and treatment are clearly

warranted.

To date cognitive behaviour therapy (CBT), mostly the

Coping CAT protocol (Kendall 1990) aimed at both the

child and the parents, is the only treatment to have been

evaluated for use with GAD in children and adolescents

(for reviews see Silverman et al. 2008). As applied to

children, the evaluated CBT programs are not GAD-spe-

cific but they do overlap with adult treatments that target

the somatic and cognitive components of GAD (Barlow

et al. 1984), and include psycho-education about the tri-

partite model of anxiety, coping skills training (including

relaxation skills, positive self-talk, and thought challeng-

ing), imaginal and in vivo exposure, and relapse preven-

tion. In the 36 open and randomised controlled trials of this

approach to childhood anxiety published to date, children

are recruited (often by newspaper advertisement) because

they have either simple or social phobia, separation anxiety

disorder, or GAD. While a significant percentage (40–50%)

are identified as having GAD as either a primary or sec-

ondary condition in these trials, outcomes for specific

disorders including GAD are not reported.

Our knowledge of how CBT impacts childhood GAD/

OAD specifically comes from four small case series. The

earliest were carried out by Kane and Kendall (1989) and

Eisen and Silverman (1993, 1999) and involved 15–20

sessions of CBT (as described above) delivered in either

prescriptive or non-prescriptive formats, to a total of 12

youth aged 6–15 years with either primary or secondary

diagnoses of GAD/OAD. Treatment brought about signif-

icant symptom reductions with approximately 50% losing

their diagnosis with all gains maintained at 3–6 month

follow-up. More recently Leger et al. (2003) examined the

effect on older adolescents (aged 16–18 years) with a pri-

mary diagnosis of DSM-IV GAD of a treatment based on a

disorder-specific, cognitive model of GAD (Dugas et al.

1998). The model assumes that GAD is maintained by: (1)

a low tolerance for uncertainty; (2) dysfunctional beliefs

about worry; (3) negative problem orientation; and (4)

dysfunctional strategies to reduce distress (i.e., thought/

image suppression, ruminating). These maintaining factors

were targeted via: (1) worry awareness training; (2) worry

interventions (planned exposure to uncertainty; modifica-

tion of dysfunctional beliefs about worry; modified prob-

lem-solving training; imaginal exposure); and (3) relapse

prevention (Dugas et al. 1998). Following an average of 13

sessions, three of the seven participants (42.8%) lost their

GAD diagnosis with gains maintained for two of these at

12-month follow-up. Two participants retained their GAD

diagnosis but experienced moderate declines in symptoms

(maintained at follow-up). One experienced no improve-

ment and one dropped out of treatment. In discussing the

relatively poor response for some participants, the authors

noted that the therapy might be too psycho-educational and

didactic in places and outcomes might be improved by

further adaptation of the worry interventions to more clo-

sely fit the age and maturity of these older adolescents.

They also remark that one of the challenges of future

research is to keep the treatment sufficiently individualised

while using a controlled group design (Leger et al. 2003).

The aims of the current case series study were three-

fold. First, to modify the treatment developed by Dugas

et al. (1998) in ways consistent with recommendations in

Leger et al. (2003) and our own experience of using

explicitly cognitive interventions with children and ado-

lescents. Our modifications were minor (described below)

and emphasized the in-session experiential exercises (over

the psycho-educational and didactic ones) described by

Dugas et al. (1998) but using age-appropriate language and

current worries to elicit the relevant cognitions and

behaviours proposed in the model. Our second aim was to

replicate Leger et al. (2003) in applying this GAD-specific

treatment to adolescents with a GAD. Finally, we aimed to

test the model and treatment in application further down

the age range by including children with a primary diag-

nosis of GAD.

Method

Participants

Participants were six girls and ten boys, aged 7–17 years

(median age = 11) with a primary diagnosis of GAD. All

participants were consecutive referrals to the Anxiety

Disorders Clinic (ADC) based in the Maudsley Hospital.

Referrals to the ADC come from 10 outpatient community

Child and Adolescent Mental Health Services (CAMHS)

within the South London and Maudsley National Health

Service (NHS) Foundation Trust. Assessment and treat-

ment in the NHS is provided free and initiated by a referral

from the GP or school to the local CAMHS. The Trust

serves a catchment area of nearly three million people

living in South East London, representing a very wide

range of socio-economic and ethnic backgrounds. Partici-

pants reflected this diversity with 10 of the 16 self-declared

as White British (62.50%) and 1 each (6.25%) of self-

declared Irish, Columbian, Kurdish, Mixed Black, Paki-

stani/British Pakistani, and White and Asian.

The 10 CAMHS were notified that a pilot investigation

of cognitive therapy for GAD was ongoing and were asked

to refer anyone with a definite or differential diagnosis of

GAD to the ADC. A total of 17 young people were referred

172 Cogn Ther Res (2011) 35:171–178

123

with one child being excluded before trial entry because he

did not have GAD. All children and adolescents who met

the inclusion criteria were invited to participate and all

accepted. Inclusion criteria for the study were: (1) a pri-

mary diagnosis of GAD; (2) no other condition requiring

more immediate treatment; and (3) the absence of marked

intellectual or developmental difficulties (either directly

assessed or assumed from referral information). No other

exclusion criteria (regarding age or medication usage) were

applied. Ten of the 16 participants (62.5%) had undergone

unsuccessful psychological treatment for anxiety as either a

primary or secondary condition prior to study entry

including: school-based counselling/CBT for mixed anxi-

ety/behaviour problems (n = 4); CAMHS based counsel-

ling and family therapy for anxiety (n = 3); specialist CBT

for Separation Anxiety Disorder from the ADC (n = 2);

and specialist family therapy for Anorexia Nervosa and

anxiety (n = 1). Participant 16 who suffered from GAD

and Major Depression at intake to the trial (see Table 1)

was taking Melatonin to improve sleep under the supervi-

sion of the family GP. Otherwise the participants had never

had medication for anxiety, and none were receiving con-

current pharmacotherapy or psychological treatment during

the trial.

Informed Consent and Other Ethical Considerations

The study was approved by the National Health Service

Local Research Ethics Committee (reference number 08/

H0805/12—Bromley). Informed consent was obtained in

writing from the participating child/adolescent and at least

one parent/guardian. The clinical needs of the child over

rode the trial protocol or participation in all stages of the

research.

Measures

The primary outcome measure was diagnostic status

established using the Anxiety Disorders Interview Sche-

dule for DSM-IV, Child and Parent Report Version (ADIS-

C/P, Silverman and Nelles 1998). The ADIS-C/P has

established reliability and validity and is the most fre-

quently used outcome measure in treatment trials of

childhood anxiety disorder (Silverman et al. 2008). All

participants and their parents were interviewed separately

and the information combined to achieve the best-estimate

diagnostic profile. All pre-treatment interviews were car-

ried out in the ADC by clinical psychologists trained to use

the ADIS-C/P and supervised by the second and third

authors. Post-treatment ADIS-C/P interviews were carried

out by the therapist who provided all treatment (the first

author). However, 31% of post-treatment ADIS-C/P

assessments were video-taped and then separately rated

(not blindly) by a clinical psychologist from the ADC who

had extensive experience and training with the ADIS-C/P

and with GAD. Inter-rater reliability for GAD diagnostic

status at post-treatment was 100%.

Secondary outcome measures were: (1) clinician

severity ratings (0–8) from the GAD section of the ADIS-

C/P; (2) total scores on the 11-item version (Muris et al.

2001) of the Penn State Worry Questionnaire for Children

(Chorpita et al. 1997); and (3) age-adjusted, T Score

transformations of the total score on the Multidimensional

Anxiety Scale for Children (MASC) (March et al. 1997).

All three measures have excellent validity and reliability

(Chorpita et al. 1997; March et al. 1997; Muris et al. 2001)

and are regularly used in trials of CBT for anxiety disorders

and GAD specifically. An additional secondary outcome

measure was recovery from secondary (comorbid) disor-

ders assessed using the ADIS-C/P.

Planned Analytic Strategy

All analyses and reporting were planned on the basis of

‘intention-to-treat’ (ITT). Patients who drop out of treat-

ment were to be followed up where possible; if follow-up

assessments were refused, a ‘‘last observation carried for-

ward’’ (LOCF) strategy was to be used. There were no drop

outs. Effects of treatment on the primary outcome measure,

recovery from GAD diagnostic status, were to be reported

as a proportion, as were effects on the secondary outcome

measure of other diagnoses lost. Effects on secondary

outcome continuous variables were to be examined using

paired sample t-tests. Analyses were carried out using the

statistical software package SPPS-17 (SPSS 2008).

Treatment

Treatment proceeds in 6 stages: (1) worry awareness

training; (2) planned exposure to uncertainty; (3) modifi-

cation of dysfunctional beliefs about worry; (4) modified

problem-solving training; (5) imaginal exposure to

unpleasant images or worries; and (6) relapse prevention

(full details can be found in Dugas and Robichaud 2007).

In its original format, each stage involves a psycho-edu-

cational and didactic component where the client is

socialized to the cognitive model before proceeding to

experiential exercises and the planning of homework

linked to that phase of treatment.

Again, we amended the original protocol with a view

towards optimizing therapeutic engagement with the cog-

nitive model bearing in mind that the constructs implicated

in the model are abstract and might be difficult for some

participants to grasp through more didactic methods. In

each stage we moved very quickly from (de-emphasized)

the didactic components to the experiential exercises

Cogn Ther Res (2011) 35:171–178 173

123

described by Dugas and Robichaud (2007): (1) detailed

discussion of current worries to identify common elements

of uncertainty and cognitive avoidance; (2) critical dis-

cussion to distinguish real-life problems from worries; (3)

behavioural experiments to test the validity/utility of any

worry-related beliefs and cognitive strategies (suppression,

ruminating); and (4) imaginal and in vivo exposure to

feared situations. Throughout treatment all cognitive pro-

cesses were described using the language of the child and

linked to a current worry. Homework was given but it was

assumed participants would learn the cognitive model of

GAD by ‘‘doing’’ experiential exercises in session.

By way of example, a young girl (aged 7) was asked in

session to describe in detail her recurrent worry that her

teacher was angry with her and might shout or criticize the

girl in class if she raised her hand. She was asked to

imagine a recent interaction with her teacher and helped to

identify her feelings of physical discomfort when she was

not able to guess with any certainty the mood of her teacher

from her facial expressions, tone of voice, or movements.

The child was asked to consider whether her teacher being

angry was a ‘‘real problem’’ or ‘‘just a worry.’’ An exercise

was then done in which the child agreed to walk through

the clinic with the therapist looking at the faces of the staff

and identifying whom she could approach and ask direc-

tions to the toilet. This triggered repeated requests for

reassurance that particular staff member were ‘‘nice.’’

Reassurance was withheld by the therapist and this trig-

gered a bout of worry about whether a particular staff

member was ‘‘angry’’ at the child for being in the hallway

and looking at them. The child was asked to identify the

effect of this worrying on her arousal and willingness to

approach the staff member. The child was returned to the

therapy room and she was asked to critically evaluate

whether anything untoward would have happened if she

approached that staff member to ask directions to the toilet

or whether this was ‘‘just a worry.’’ The child was then led

through an imaginal exposure where she described in vivid

detail her worst fears about approaching that staff member.

Following this exposure she was able to say that her worst

fears in this case were ‘‘silly’’ and it was useless to try and

guess what others were feeling or thinking all of the time. It

Table 1 Demographic and clinical data for each study participant and group/treatment statistics

Case # Age Sex Pre-treatment Post-treatment

Sessions Primary DX

(CSR)

Secondary

DX

PSWQ-C MASC Primary DX

(CSR)

Secondary

DX

PSWQ-C MASC

1 12 12 F GAD (7) SAD, SOC 28 70 GAD (4) 12 50

2 9 10 M GAD (7) SAD 19 48 13 40

3 10 17 F GAD (8) 28 63 4 36

4 8 10 M GAD (6) SAD 13 78 6 47

5 6 9 M GAD (6) OCD 18 47 2 36

6 15 7 F GAD (8) SAD 32 87 GAD (6) SAD 29 67

7 8 11 M GAD (8) OCD 25 59 7 56

8 14 11 F GAD (8) SAD 26 57 11 43

9 6 11 M GAD (8) 16 58 10 49

10 13 11 F GAD (6) SAD 30 64 9 46

11 15 10 M GAD (8) SAD, PANIC,

DEP

28 76 GAD (8) SAD, PANIC,

DEP

27 76

12 10 13 M GAD (7) 29 66 7 39

13 5 10 F GAD (4) 14 59 7 54

14 6 9 M GAD (5) 15 60 6 43

15 6 10 M GAD (6) 24 61 9 36

16 12 9 M GAD (7) DEP 24 63 8 49

Whole sample

Pre-treatment

M (SD)

Post-treatment

M (SD)

Effect size d

PSWQ-C 23.1 (6.3) 10.4 (7.4) 2.0

MASC 63.5 (10.4) 47.9 (10.8) 1.4

CSR clinician severity rating (ADIS-C/P), GAD generalized anxiety disorder, SAD separation anxiety disorder, SOC social anxiety disorder,

OCD obsessive compulsive disorder, DEP major depression, PSWQ-C Penn State worry questionnaire for children (11-item version, Total

Score), MASC multi-dimensional anxiety scale for children (age-adjusted T score)

174 Cogn Ther Res (2011) 35:171–178

123

was planned that in the next session the child would

accompany the therapist on a walk through the clinic,

trying to ask directions to the toilet from every staff

member they saw (regardless of their facial expression or

general demeanour). In future sessions the child was able to

identify that her worry about getting lost in unfamiliar

places was another manifestation of her ‘‘need for cer-

tainty’’ and how this could trigger worry and upset. Again

these were followed by experiential exercises where the

child confronted her worst fears about approaching an

unfamiliar place using imaginal and in vivo exposure.

Treatment was delivered weekly for 1-h. Parents were

formally included in the first session where the model of

treatment was presented. During this session it was

explained to the parent and child that there would be

occasional homework assignments that would involve

confronting worries and reducing requests for reassurance.

The parents were asked to provide praise (or tangible

rewards) to their child for attempting to complete this

homework. The concept of ‘‘secondary gain’’ was also

introduced, i.e. that avoidance and reassurance could also

result in tangible rewards being delivered by the parents or

others (attempts to calm the child through verbal/physical

reassurance, food, or access to toys/computers/television;

allowing the child to escape from chores and schoolwork).

The parents and their child were encouraged to be aware of

these contingencies and the parents asked to refrain from

providing rewards for avoidance and reassurance seeking.

Thereafter all sessions were one-to-one with the partici-

pants, not all of whom were brought by their parents to the

clinic for every session. When the parent did bring their

child to the clinic, and the child/adolescent was in agree-

ment, and there was sufficient time, the parent was invited

into the last 5–10 min of the session so the child and

therapist could explain any improvements and homework.

If the parents requested advice, they were asked to reward

any attempts by their child to confront worries and to

refrain from rewarding avoidance and reassurance seeking.

Therapy was planned to end when the participant

reported no symptoms of GAD (no worrying, or no

excessive worrying associated with distress or impairment)

for the past week for two consecutive sessions (as mea-

sured using the ADIS-C/P) or when 15 sessions had

elapsed, whichever was earliest. Clinical follow-up and

other treatment (if required) was to be offered per normal

clinical practice.

All treatment was provided by the first author who is a

clinical psychologist, and at the time the trial started was

6 months post-qualification. During her doctoral training

she had two, six-month placements in the ADC providing

CBT under the supervision of the second and third authors.

To help insure the therapist adhered to the treatment, a

manual was developed by the three authors in which the six

core components of Dugas and Robichaud’s (2007) treat-

ment and how they might be applied to younger children

were described. The first author also attended a day-long

workshop by Professor Michel Dugas on the treatment of

GAD and was supervised on a weekly basis by the second

and third authors (the latter also attended the day-long

workshop by Professor Dugas).

Results

Table 1 presents data on each participant in terms of age,

gender and clinical characteristics/outcome. The table also

includes the means and standard deviation for the sample

as a whole on the PSWQ-C (total scores) and MASC

(T Scores), and the estimated (uncontrolled) treatment

effect size. The primary outcome measure was GAD

diagnostic status as assessed by the ADIS-C/P. Thirteen of

the 16 participants (81.25%) lost their GAD diagnosis.

Three retained their GAD diagnosis (18.75%): two with

some improvement (CSR reduction = 2–3 points) and the

third with no improvement (CSR reduction = 0). Ten of

the 16 participants met criteria for a secondary disorder

based on the ADIS-C/P at pre-treatment, usually another

anxiety disorder. Of these, only two (20%) retained their

co-morbid disorders at post-treatment. The one participant

in the study who did not respond to treatment at all

developed Major Depression during treatment and was

treated for this after their 15th session. None of the par-

ticipants developed new disorder during treatment. The

mean number of sessions was 9.7 (SD = 3.5).

On the secondary outcome measures, the paired sample

t-tests revealed significant pre-to-post treatment effects for

self-reported worry (t(15) = 7.12, P \ 0.001) and anxiety

(t(15) = 6.74, P \ 0.001). Inspection of the means indi-

cates that overall participants achieved a 55.1% reduction

in worry as measured by the PSWQ-C and a 23.3%

reduction in anxiety as measured by the MASC during

treatment. We also calculated the percentage of subjects

who achieved reliable change on the self-report measures

using the statistical approach described in Jacobson and

Traux (1991). A reliable change (RC) coefficient was

calculated for each participant using the formula: RC =

X1 - X2/Sdiff where Sdiff = H2(SE)2 and SE = Standard

Deviation at Pre-Treatment H1 - rxx (test–retest reliabil-

ity coefficient for the questionnaire). If the participant’s RC

exceeds 1.96 for the particular questionnaire then it is

highly likely (P \ .05) that the observed changes in self-

reported symptoms as measured by that questionnaire are

reliable.

For the PSWQ-C: pre-treatment SD = 6.3 and test–

retest reliability = 0.92 (Chorpita et al. 1997); thus SE =

1.8 and Sdiff = 2.5. Based on the pre-to-post difference on

Cogn Ther Res (2011) 35:171–178 175

123

the PSWQ-C divided by 2.5 for each participant, 14

(87.5%) achieved an RC in excess of 1.96 (i.e. significant

at P \ .05) for self-reported worry. For the MASC: pre-

treatment SD = 10.4 and test–retest reliability = 0.88

(March et al. 1999); thus SE = 3.6 and Sdiff = 5.1. Using

these figures, 10 (62.5%) of the participants achieved a

reliable change score for self-reported anxiety that excee-

ded 1.96. These robust results for the self-report measures

are consonant with the significant decline in GAD symp-

toms as measured by the therapist using ADIS-C/P.

Table 1 presents the estimated (uncontrolled) effect size

computed as the pre-/post-treatment mean difference

divided by the pre-treatment standard deviation (Cohen

1988). The pre-to-post-treatment mean difference for the

PSWQ-C was 12.63 (95% CI = 8.45–16.40) and for the

MASC was 14.94 (95% CI = 10.21–19.66). The 95%

Confidence Interval for the effect sizes reported in Table 1

were: PSWQ-C = 1.35–2.61; and MASC = 0.98–1.90.

Finally, post-hoc analyses revealed that age was signifi-

cantly correlated with the pre-to-post difference score on

the PSWQ-C (r = .62, P = .011) but not the MASC.

Gender was unrelated to difference scores on the two self-

report measures. Nine of the 10 male participants (90%)

lost their GAD diagnosis compared to only four of the six

females (67.7%), however, this difference was non-signif-

icant. The number of sessions received was unrelated to

difference scores on the PSWQ-C and MASC and GAD

status at post-treatment.

Discussion

A cognitive treatment designed specifically for use with

adults with GAD (Dugas and Robichaud 2007) and previ-

ously tested with older adolescents (aged 16–19) (Leger

et al. 2003) was successfully used with children and ado-

lescents aged 7 to 17 years suffering from a primary

diagnosis of GAD and comorbid disorders. The current

results replicate the findings of Leger et al. (2003) in that a

GAD-specific model and treatment developed for adults

can be used effectively with adolescents. While compari-

son between case series has limited validity, the 81%

remission rate for GAD in the current study compares

favourably with the 43% remission rate obtained by Leger

et al. (2003). We note however, that our findings are con-

sistent with outcomes for the same treatment (70–84%

recovery at post-treatment and follow-up) in the latest

randomised and controlled of adults with a primary diag-

nosis of GAD (Dugas et al. 2010).

The high rate of GAD diagnostic remission observed

here (although not blindly assessed) is supported by the

fact that 87.5% of the participants exceeded the cut off of

1.96 indicating statistically significant and reliable change

(Jacobson and Truax 1991) for self-reported worry and

62.5% for self reported worry. While this is a small study

and uncontrolled, pre-to-post effect sizes on the two sec-

ondary outcome measures were high (2.0 for worry fre-

quency and 1.4 for anxiety). These effect sizes compare

favourably with the average for self-reported anxiety (0.8)

in meta-analyses of CBT for childhood anxiety disorders

(Schneider and In-Albon 2006; Silverman et al. 2008). The

current study also found an 80% reduction in comorbidity

suggesting that the deliberate targeting of cognitive

mechanisms that mediate worry may have beneficial

effects for untreated anxiety disorders.

The third aim of the study was to test the model and

modified treatment in application to children. It turned out

in the course of normal clinical flow that 13 of the 16

participants (81.2%) were between 7 and 11 years of age,

suggesting that a treatment originally developed for use

with adults can be used effectively with children in this age

range. Our experience was that all of the participants in the

study (regardless of age) could engage with the cognitive

model and interventions using the methodology (as

described above) to make the treatment more accessible to

this age range. Three participants did not significantly

improve and we note that the most significant obstacle to

change was the (often acknowledged) secondary gain

obtained from avoidance of worry-related, stressful situa-

tions. This required explicit discussion of environmental

and social contingencies for worry with the child and

parents. However parent work was not a part of the present

treatment. Future studies may need to evaluate whether a

formal parent component would be beneficial in improving

outcomes.

The study has several limitations and extrapolation

regarding this cognitive treatment to the wider population

of children with GAD must be done with a good degree of

caution. The sample is relatively small, no follow-up

assessments were conducted, and there were no control

group. We did not directly measure the proposed cognitive

mediators of treatment including tolerance for uncertainty.

As the therapist was the evaluator of diagnostic status at

treatment outcome, it is possible that the favourable results

obtained for primary and secondary diagnoses were influ-

enced by demand characteristics. Nevertheless, the present

findings, based on patients recruited entirely from standard

clinical referrals, who were unmedicated and the majority

had previous episodes of treatment for anxiety to which

they did not respond or subsequently relapsed, are prom-

ising and warrant moving to the next stage of evaluation.

The authors are presently engaged in a randomized con-

trolled trial of the current treatment using a larger sample

of clinically-referred children and adolescents and com-

paring it to a control condition involving psycho-education

and symptom-monitoring.

176 Cogn Ther Res (2011) 35:171–178

123

Key Points

• Recent developments in cognitive models of worry and

treatments based on the same have led to improved

outcomes for adults with GAD

• Amendment of these cognitive approaches is required

before they can be used with younger children with

GAD

• Present findings suggest that children, as well as

adolescents, can be successfully treated for GAD using

developmentally-adjusted cognitive methods based on

a GAD-specific theoretical model

Acknowledgments The authors gratefully acknowledge the help

generously given by the children, adolescents and parents taking part

in this project. Dr Payne was fully supported and Professor Bolton

and Dr Perrin partly supported by the National Institute for Health

Research’s Biomedical Research Centre for Mental Health at the

South London and Maudsley NHS Foundation Trust and Kings

College London/Institute of Psychiatry.

Conflict of interest No conflicts declared.

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