Accentuate the positive, eliminate the negative produces long-term gains

Lyricist Johnny Mercer may have stumbled onto a significant therapy when he cajoled his audience to “accentuate the positive, eliminate the negative” and “don’t mess with Mr. In-between.” The latest findings on the long-term effectiveness of cognitive behavioral therapy (CBT) suggest that it has positive effects for children up to 13 years after they first receive treatment.

CBT teaches individuals to reassess their negative thoughts and beliefs to try to instill a more positive set of judgments. There are some additional benefits to individual CBT over group-based approaches, but overall the findings suggest that practitioners working with children can be flexible about which treatment approach to adopt and remain confident about the chances of success.

The research, due to be published in a forthcoming edition of the Journal of Child Psychology and Psychiatry, involved young people that originally participated in randomized experiments investigating the effectiveness of CBT (for children with anxiety and phobic disorders) over a decade ago. CBT itself is described in more detail elsewhere on Prevention Action (See: The value of looking on the brighter side [1]).

At the time of those original experiments, all of the children had a diagnosed anxiety disorder. A common behavior adopted by clinically anxious children (and adults) is the avoidance of situations that make them fearful. Avoidance can become extreme enough to interfere with day-to-day life. The CBT prescribed to participants of these trials relied on the principles of exposure therapy. This meant exposing participants to anxiety producing situations so that the therapist could teach them how to cope.

Some participants received the treatment on an individual basis (ICBT); others attended group sessions with four to eight other children (GCBT). Both formats were standardized to ensure treatment integrity. They consisted of 10 to 12 sessions delivered by trained therapists. Wendy Silverman, a psychologist at Florida International University’s Child Anxiety and Phobia Program (CAPP), designed the program evaluation.
The experiments demonstrated significant short-term reductions in symptoms of anxiety—both reported by parents and the individuals themselves—compared to control group children who did not receive CBT.

A decade later, Silverman, with the help of a new team of researchers, tracked down many of the original participants to investigate whether the treatment gains observed all those years ago had been sustained. In all, 67 (out of 106) young people agreed to participate in the new assessment. They were now between 16 and 26 years old, having received CBT initially between 8 and 13 years earlier.

The results were more than reassuring. The reduction in symptoms of anxiety (the target of the intervention) reported by Silverman in 1999 was sustained over the long term. Not only that, but CBT also had positive effects on other associated disorders such as depression and substance abuse. This was especially true for participants who had received individual treatment. But outcomes were also good for those who attended group sessions.

Silverman and her colleagues write, “Our findings contribute to the literature by providing additional evidence that the majority of anxious youths who received CBT in childhood report an adaptive transition into young adulthood with respect to important mental health and social/occupational outcomes”. In other words, CBT can change lives for the better.

When left untreated, anxiety disorders can lead to increased mental illness and a variety of social and developmental outcomes. These outcomes include teen pregnancy, early marriage, dropping out of high school and delays or avoidance of further education. But for the participants of this study, such outcomes were rare. There were no high school dropouts and almost none of the young people were married or had children. At least half of them had some college education and a quarter had an undergraduate degree.

This is not the first time that the effectiveness of CBT has been proven. Robust evidence has been provided from at least 25 randomized controlled trials. They show that CBT has substantial short-term positive impacts. This is one of the first studies to demonstrate that those outcomes can last. Silverman and her colleagues write, "Our study is the first to report the long-term effects of GCBT for prevalent childhood anxiety disorders along primary and secondary outcomes of interest.”

This is a promising study but more work is needed. There are ethical complications to withholding treatments from participants over extended periods of time. No long-term follow-up study, therefore, has been able to compare the effects for those who received CBT to those who did not. This means that there is still a chance, albeit a slim one, that these sustained positive outcomes resulted from a kind of spontaneous recovery that occurred as the children matured into adults.

The demand for effective treatments has never been greater. In another paper to be published in the same forthcoming edition of The Journal of Child Psychology and Psychiatry, British researchers report a substantial increase in adolescent emotional problems over recent decades. CBT, hopefully, will be put to work to fight this rising tide, and, as Johnny Mercer would put it, “Spread joy up to the maximum.”

References
Saavedra L, Silverman W, Morgan-Lopez A and Kurtines, W (2010) Cognitive behavioral treatment for childhood anxiety disorders: long term effects on anxiety and secondary disorders in young children, Journal of Child Psychology and Psychiatry, Forthcoming.

Also see
Silverman W, Kurtines W, Ginsbury G, Weems C, Rabian B, Serafini L (1999) Contingency management, Self-Control, and Education Support in the Treatment of Childhood Phobic Disorders: A Randomized Clinical Trial, Journal of Consulting and Clinical Psychology, 67, 5, 675-687.

Silverman W, Kurtines W, Ginsburg G, Weems C, Lumpkin P, Carmichael D (1999) Treating Anxiety Disorders in Children With Group Cognitive-Behavioral Therapy: A Randomized Clinical Trial, Journal of Consulting and Clinical Psychology, 67, 6, 995-1003.

Collishaw S, Maughan B, Natarajan L, Pickles A (2010) Trends in adolescent emotional problems in England: a comparison of two national cohorts twenty years apart, Journal of Child Psychology and Psychiatry, Forthcoming.