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Group and individual cognitive behavioral therapy (CBT) for children & adolescents with anxiety

Children's Mental Health: Anxiety
Benefit-cost methods last updated December 2023.  Literature review updated May 2018.
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Cognitive behavioral therapy (CBT) uses cognitive restructuring and self-talk, exposure to feared stimuli, and other strategies to treat mental health conditions, including anxiety. CBT interventions are typically delivered by therapists in individual or group format in an outpatient setting; well-known examples include the Coping Cat and Coping Koala programs. Programs in this analysis served typically or atypically developing children with anxiety disorders. This analysis includes both traditional CBT interventions, which on average provided an estimated 15 hours of therapy over 12 weeks, and brief, intensive CBT interventions, which on average provided an estimated 30 hours of therapy over two weeks.
 
ALL
BENEFIT-COST
META-ANALYSIS
CITATIONS
For an overview of WSIPP's Benefit-Cost Model, please see this guide. The estimates shown are present value, life cycle benefits and costs. All dollars are expressed in the base year chosen for this analysis (2022). The chance the benefits exceed the costs are derived from a Monte Carlo risk analysis. The details on this, as well as the economic discount rates and other relevant parameters are described in our Technical Documentation.
Benefit-Cost Summary Statistics Per Participant
Benefits to:
Taxpayers $4,542 Benefits minus costs $13,423
Participants $7,716 Benefit to cost ratio $27.04
Others $1,242 Chance the program will produce
Indirect $439 benefits greater than the costs 94%
Total benefits $13,939
Net program cost ($516)
Benefits minus cost $13,423

^WSIPP’s benefit-cost model does not monetize this outcome.

^^WSIPP does not include this outcome when conducting benefit-cost analysis for this program.

*The effect size for this outcome indicates percentage change, not a standardized mean difference effect size.

Meta-analysis is a statistical method to combine the results from separate studies on a program, policy, or topic in order to estimate its effect on an outcome. WSIPP systematically evaluates all credible evaluations we can locate on each topic. The outcomes measured are the types of program impacts that were measured in the research literature (for example, crime or educational attainment). Treatment N represents the total number of individuals or units in the treatment group across the included studies.

An effect size (ES) is a standard metric that summarizes the degree to which a program or policy affects a measured outcome. If the effect size is positive, the outcome increases. If the effect size is negative, the outcome decreases. See Estimating Program Effects Using Effect Sizes for additional information.

Adjusted effect sizes are used to calculate the benefits from our benefit cost model. WSIPP may adjust effect sizes based on methodological characteristics of the study. For example, we may adjust effect sizes when a study has a weak research design or when the program developer is involved in the research. The magnitude of these adjustments varies depending on the topic area.

WSIPP may also adjust the second ES measurement. Research shows the magnitude of some effect sizes decrease over time. For those effect sizes, we estimate outcome-based adjustments which we apply between the first time ES is estimated and the second time ES is estimated. We also report the unadjusted effect size to show the effect sizes before any adjustments have been made. More details about these adjustments can be found in our Technical Documentation.

Meta-Analysis of Program Effects
Outcomes measured Treatment age No. of effect sizes Treatment N Adjusted effect sizes(ES) and standard errors(SE) used in the benefit - cost analysis Unadjusted effect size (random effects model)
First time ES is estimated Second time ES is estimated
ES SE Age ES SE Age ES p-value
School attendance^
Number or percentage of school days present in a given enrollment period.
 10 1 24 0.019 0.286 10 n/a n/a n/a 0.019 0.948
Attention-deficit/hyperactivity disorder symptoms
Clinical diagnosis of attention-deficit/hyperactivity disorder (ADHD) or symptoms measured on a validated scale.
10 1 42 -0.683 0.219 10 0.000 0.141 11 -0.683 0.002
Anxiety disorder
Clinical diagnosis of an anxiety disorder (e.g., general anxiety, panic, social anxiety, obsessive compulsive disorder) or symptoms measured on a validated scale.
 10 39 1342 -0.681 0.059 10 -0.269 0.190 11 -0.914 0.001
Major depressive disorder
Clinical diagnosis of major depression or symptoms measured on a validated scale.
 10 14 605 -0.187 0.068 10 0.000 0.310 12 -0.224 0.001
Externalizing behavior symptoms
Symptoms of externalizing behavior (e.g., aggressive, hostile, or disruptive behavior) measured on a validated scale.
 10 9 495 -0.258 0.073 10 -0.142 0.075 13 -0.292 0.001
Global functioning^
How well individuals (typically those who are developmentally disabled or seriously mentally ill) have adapted to activities of daily living.
 10 3 173 0.775 0.307 10 n/a n/a n/a 0.775 0.011
Internalizing symptoms
Symptoms of internalizing behavior (e.g., sadness, anxiety, or withdrawal) measured on a validated scale.
 10 12 600 -0.338 0.065 10 -0.338 0.065 12 -0.379 0.001
Hospitalization (psychiatric)^^
Admission to a psychiatric ward or hospital.
 10 2 182 0.000 0.145 10 n/a n/a n/a 0.000 1.000
Suicide attempts^
An attempt to die by suicide resulting in survival.
 10 2 182 0.000 0.115 10 n/a n/a n/a 0.000 1.000
Suicidal ideation^
Thinking about and/or planning death by suicide.
 10 2 182 0.186 0.145 10 n/a n/a n/a 0.186 0.199
Emergency department visits^^
Whether someone visited the emergency department, or the number of times they visited the emergency department.
10 1 19 0.000 0.457 10 n/a n/a n/a 0.000 1.000
Hospitalization^^
Hospital admission, for any reason.
 10 1 140 -0.082 0.168 10 n/a n/a n/a -0.082 0.627
Health care costs*^^
Percent change in total medical costs.
10 1 24 0.046 79.057 10 n/a n/a n/a 0.046 1.000
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1In addition to the outcomes measured in the meta-analysis table, WSIPP measures benefits and costs estimated from other outcomes associated with those reported in the evaluation literature. For example, empirical research demonstrates that high school graduation leads to reduced crime. These associated measures provide a more complete picture of the detailed costs and benefits of the program.

2“Others” includes benefits to people other than taxpayers and participants. Depending on the program, it could include reductions in crime victimization, the economic benefits from a more educated workforce, and the benefits from employer-paid health insurance.

3“Indirect benefits” includes estimates of the net changes in the value of a statistical life and net changes in the deadweight costs of taxation.
Detailed Monetary Benefit Estimates Per Participant
Affected outcome: Resulting benefits:1 Benefits accrue to:
Taxpayers Participants Others2 Indirect3 Total
Major depressive disorder Mortality associated with depression $0 $0 $0 $0 $0
Anxiety disorder Labor market earnings associated with anxiety disorder $3,149 $7,419 $0 $0 $10,568
Externalizing behavior symptoms Criminal justice system $66 $0 $157 $33 $256
K-12 special education $236 $0 $0 $118 $354
Internalizing symptoms K-12 grade repetition $41 $0 $0 $20 $61
Health care associated with internalizing symptoms $1,051 $297 $1,084 $525 $2,958
Program cost Adjustment for deadweight cost of program $0 $0 $0 ($258) ($258)
Totals $4,542 $7,716 $1,242 $439 $13,939
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Detailed Annual Cost Estimates Per Participant
Annual cost Year dollars Summary
Program costs $1,431 2015 Present value of net program costs (in 2022 dollars) ($516)
Comparison costs $927 2010 Cost range (+ or -) 30%
In studies included in this analysis, participants received an average of 15 hours of therapist time. Per-participant cost estimates are based on weighted average therapist time, as reported in the treatment studies. Hourly therapist cost is based on the actuarial estimates of reimbursement by modality (Mercer. (2016). Mental health and substance use disorder services data book for the state of Washington). For comparison group costs, we use 2010 Washington State DSHS data to estimate the average reimbursement rate for anxiety treatment for children and adolescents.
The figures shown are estimates of the costs to implement programs in Washington. The comparison group costs reflect either no treatment or treatment as usual, depending on how effect sizes were calculated in the meta-analysis. The cost range reported above reflects potential variation or uncertainty in the cost estimate; more detail can be found in our Technical Documentation.
Benefits Minus Costs
Benefits by Perspective
Taxpayer Benefits by Source of Value
Benefits Minus Costs Over Time (Cumulative Discounted Dollars)
The graph above illustrates the estimated cumulative net benefits per-participant for the first fifty years beyond the initial investment in the program. We present these cash flows in discounted dollars. If the dollars are negative (bars below $0 line), the cumulative benefits do not outweigh the cost of the program up to that point in time. The program breaks even when the dollars reach $0. At this point, the total benefits to participants, taxpayers, and others, are equal to the cost of the program. If the dollars are above $0, the benefits of the program exceed the initial investment.

Citations Used in the Meta-Analysis

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Arendt, K., Thastum, M., & Hougaard, E. (2016). Efficacy of a Danish version of the Cool Kids program: A randomized wait‐list controlled trial. Acta Psychiatrica Scandinavica, 133(2), 109-121.

Barrett, P.M. (1998). Evaluation of cognitive-behavioral group treatments for childhood anxiety disorders. Journal of Clinical Child Psychology, 27(4), 459-468.

Barrett, P.M., Dadds, M.R., & Rapee, R.M. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64(2), 333-342.

Bernstein, G.A., Layne, A.E., Egan, E.A., & Tennison, D.M. (2005). School-based interventions for anxious children. Journal of the American Academy of Child & Adolescent Psychiatry, 44(11), 1118-1127.

Chiu, A.W., Langer, D.A., McLeod, B.D., Har, K., Drahota, A., Galla, B.M., . . . Wood, J.J. (2013). Effectiveness of modular CBT for child anxiety in elementary schools. School Psychology Quarterly, 28(2), 141.

Cobham, V.E. (2012). Do anxiety-disordered children need to come into the clinic for efficacious treatment? Journal of Consulting and Clinical Psychology, 80(3), 465.

Conelea, C.A., Selles, R.R., Benito, K.G., Walther, M.M., Machan, J.T., Garcia, A.M., . . . Freeman, J.B. (2017). Secondary outcomes from the pediatric obsessive compulsive disorder treatment study II. Journal of Psychiatric Research, 92, 94-100.

Flannery-Schroeder, E.D., & Kendall, P.C. (2000). Group and individual cognitive-behavioral treatments for youth with anxiety disorders: A randomized clinical trial. Cognitive Therapy and Research, 24(3), 251-278.

Franklin, M.E., Sapyta, J., Freeman, J.B., Khanna, M., Compton, S., Almirall, D., . . . March, J.S. (2011). Cognitive behavior therapy augmentation of pharmacotherapy in pediatric obsessive-compulsive disorder: The Pediatric OCD Treatment Study II (POTS II) randomized controlled trial. JAMA 306(11), 1224-1232.

Gallagher, H.M., Rabian, B.A., & McCloskey, M.S. (2004). A brief group cognitive-behavioral intervention for social phobia in childhood. Journal of Anxiety Disorders, 18(4), 459-479.

Ginsburg, G.S., Becker, K.D., Drazdowski, T.K., & Tein, J.Y. (2012). Treating anxiety disorders in inner city schools: Results from a pilot randomized controlled trial comparing CBT and usual care. Child and Youth Care Forum, 41(1), 1-19.

Ginsburg, G.S., Kendall, P.C., Sakolsky, D., Compton, S.N., Piacentini, J., Albano, A.M., . . . Birmaher, B. (2011). Remission after acute treatment in children and adolescents with anxiety disorders: Findings from the CAMS. Journal of Consulting and Clinical Psychology, 79(6), 806.

Hayward, C., Varady, S., Albano, A.M., Thienemann, M., Henderson, L., & Schatzberg, A.F. (2000). Cognitive-behavioral group therapy for social phobia in female adolescents: Results of a pilot study. Journal of the American Academy of Child and Adolescent Psychiatry, 39(6), 721-726.

Hudson, J.L., Rapee, R.M., Deveney, C., Schniering, C.A., Lyneham, H.J., & Bovopoulos, N. (2009). Cognitive-behavioral treatment versus an active control for children and adolescents with anxiety disorders: A randomized trial. Journal of the American Academy of Child & Adolescent Psychiatry, 48(5), 533-544.

Kendall, P.C., Hudson, J.L., Gosch, E., Flannery-Schroeder, E., & Suveg, C. (2008). Cognitive-behavioral therapy for anxiety disordered youth: A randomized clinical trial evaluating child and family modalities. Journal of Consulting and Clinical Psychology, 76(2), 282-297.

Khanna, M.S., & Kendall, P.C. (2010). Computer-assisted cognitive behavioral therapy for child anxiety: Results of a randomized clinical trial. Journal of Consulting and Clinical Psychology, 78(5), 737-745.

Lau, W.Y., Chan, C.K.Y., Li, J.C.H., & Au, T.K.F. (2010). Effectiveness of group cognitive-behavioral treatment for childhood anxiety in community clinics. Behaviour Research and Therapy, 48(11), 1067-1077.

McNally Keehn, R.H., Lincoln, A.J., Brown, M.Z., & Chavira, D.A. (2013). The Coping Cat program for children with anxiety and autism spectrum disorder: A pilot randomized controlled trial. Journal of Autism and Developmental Disorders, 43(1), 57-67.

Muris, P., Meesters, C., & van Melick, M. (2002). Treatment of childhood anxiety disorders: A preliminary comparison between cognitive-behavioral group therapy and a psychological placebo intervention. Journal of Behavior Therapy and Experimental Psychiatry, 33(3-4), 143-158.

Nauta, M.H., Scholing, A., Emmelkamp, P.M.G., & Minderaa, R.B. (2003). Cognitive-behavioral therapy for children with anxiety disorders in a clinical setting: No additional effect of a cognitive parent training. Journal of the American Academy of Child & Adolescent Psychiatry, 42(11), 1270-1278.

Rapee, R.M., Abbott, M.J., & Lyneham, H.J. (2006). Bibliotherapy for children with anxiety disorders using written materials for parents: A randomized controlled trial. Journal of Consulting and Clinical Psychology, 74(3), 436-444.

Santucci, L.C., & Ehrenreich-May, J. (2013). A randomized controlled trial of the Child Anxiety Multi-Day Program (CAMP) for separation anxiety disorder. Child Psychiatry & Human Development, 44(3), 439-451.

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Shortt, A.L., Barrett, P.M., & Fox, T.L. (2001). Evaluating the FRIENDS program: A cognitive-behavioral group treatment for anxious children and their parents. Journal of Clinical Child Psychology, 30(4), 525-535.

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Spence, S.H., Holmes, J.M., March, S., & Lipp, O.V. (2006). The feasibility and outcome of clinic plus internet delivery of cognitive-behavior therapy for childhood anxiety. Journal of Consulting and Clinical Psychology, 74(3), 614-621.

Storch, E.A., Arnold, E.B., Lewin, A.B., Nadeau, J.M., Jones, A.M., De Nadai, A.S., . . . Murphy, T.K. (2013). The effect of cognitive-behavioral therapy versus treatment as usual for anxiety in children with autism spectrum disorders: A randomized, controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 52(2), 132-142.

Storch, E.A., Lewin, A.B., Collier, A.B., Arnold, E., De Nadai, A.S., Dane, B.F., . . . Murphy, T.K. (2015). A randomized controlled trial of cognitive‐behavioral therapy versus treatment as usual for adolescents with autism spectrum disorders and comorbid anxiety. Depression and Anxiety, 32(3), 174-181.

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