CBT Improves Brain Functioning in Children with Anxiety

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anxious child

Researchers at the National Institutes of Health found overactivation in numerous brain regions, including the frontal and parietal lobes, as well as the amygdala, in unmedicated children with anxiety disorders. They also demonstrated that cognitive behavioral therapy (CBT) improved clinical symptoms and brain function.

The findings shed light on the brain mechanisms that underpin the immediate effects of cognitive behavioral therapy in treating one of the most common mental diseases. The study was led by researchers from the National Institute of Mental Health (NIMH).

“We know that CBT is effective. These findings help us understand how CBT works, a critical first step in improving clinical outcomes,”

said senior author Melissa Brotman, Ph.D., Chief of the Neuroscience and Novel Therapeutics Unit in the NIMH Intramural Research Program.

The findings could, in time, be used to enhance treatment outcomes by targeting brain circuits linked to clinical improvement. This is particularly important for the subset of children who did not significantly improve after short-term CBT.

Anxiety Elevated Brain Activity

The trial comprised 69 unmedicated children with an anxiety problem who received 12 weeks of CBT using an established methodology. The current gold standard for treating anxiety problems in children is cognitive behavioral therapy (CBT), which involves modifying dysfunctional ideas and behaviors through gradual exposure to anxiety-provoking situations.

The researchers used clinician-rated measures to examine the change in children’s anxiety symptoms and clinical functioning from pre- to post-treatment. They also used task-based fMRI to look at whole-brain changes before and after treatment and compare those to brain activity in 62 similarly aged children without anxiety.

Children with anxiety had higher levels of activity in several brain regions, including cortical areas in the frontal and parietal lobes, which are crucial for cognitive and regulatory processes like attention and emotion regulation. The researchers also noticed increased activity in deeper limbic areas such as the amygdala, which is responsible for creating intense emotions like worry and terror.

Cognitive Control Network Efficiency

Following three months of CBT treatment, children with anxiety showed a clinically significant decrease in anxiety symptoms and improved functioning. Increased activation seen before treatment in many frontal and parietal brain regions also improved after CBT, declining to levels equal to or lower than those of non-anxious children.

According to the researchers, the decreased activation in these brain areas could indicate more efficient engagement of cognitive control networks following CBT. However, eight brain regions, including the right amygdala, continued to show higher activity in anxious compared to non-anxious children after treatment.

This persistent pattern of increased activity implies that some brain regions, notably limbic areas that govern reactions to anxiety-provoking stimuli, may be less susceptible to the acute effects of CBT. Changing activity in these regions may necessitate a longer course of CBT, different types of treatment, or direct targeting of subcortical brain areas.

“Understanding the brain circuitry underpinning feelings of severe anxiety and determining which circuits normalize and which do not as anxiety symptoms improve with CBT is critical for advancing treatment and making it more effective for all children,”

said first author Simone Haller, Ph.D.

Chronic and Common

In this study, all anxious children underwent CBT. For comparison, the researchers monitored brain activity in a different sample of 87 kids who were at high risk of anxiety according to their newborn temperament (for example, strong sensitivity to unfamiliar stimuli).

Because these children were not diagnosed with an anxiety disorder, they had not received CBT treatment. Their brain scans were taken at 10 and 13 years.

Higher brain activity in teenagers at temperamental risk for anxiety was associated with increasing anxiety symptoms over time, and it resembled the brain activity seen in children diagnosed with an anxiety disorder prior to treatment. This provides preliminary evidence that CBT drove the brain changes in anxious children, and that they may serve as a dependable neural marker of anxiety treatment.

Anxiety disorders are frequent in children and can cause severe distress in both social and academic settings. They are also persistent, with a strong correlation to adulthood, when they become more difficult to manage. Despite the success of CBT, many children still have anxiety symptoms following treatment.

Enhancing the therapy to treat anxiety more effectively during childhood can have short- and long-term benefits and prevent more serious problems later in life.

“The next step for this research is to understand which children are most likely to respond. Are there factors we can assess before treatment begins to make the most informed decisions about who should get which treatment and when? Answering these questions would further translate our research findings into clinical practice,”

said Brotman.

Reference:
  1. S. P. Haller, et al. Normalization of fronto-parietal activation by cognitive-behavioral therapy in unmedicated pediatric patients with anxiety disorders. American Journal of Psychiatry (2024). DOI: 10.1176/appi.ajp.20220449