Abstract
Anxiety in children is a considerable bother since it is associated with the development of severe complications if untreated. Acceptance and commitment therapy (ACT) is one of the methods for treating the condition. ACT focuses on six primary points to develop psychological flexibility: acceptance, diffusion, contact with the present moment, self-as-context, values, and committed action. Its therapeutic stance and concepts seem appropriate for treating the condition.
Even though there is a considerable body of research that supports ACT as an intervention for anxious youth, the number of recent systematic reviews and meta-analyses is insufficient. However, since ACT fall under the umbrella of cognitive-behavioral therapy (CBT), the matter may be complemented by the abundance of evidence supporting CBT. In conclusion, ACT should be considered a viable method for treating anxiety in children and adolescents.
Introduction and Background
Every child has fears that may emerge and disappear without affecting their development. However, sometimes those worries may and interfere with everyday activities, preventing children from living a normal life. Such conditions are anxiety disorders, which include generalized anxiety disorder (GAD), panic disorder, separation anxiety disorder, and social phobia. According to Beesdo, Knappe, and Pine (2009), childhood and adolescence is the most dangerous developmental stage to acquire the symptoms of anxiety. The term refers to the reaction of the brain to stimuli that a person actively attempts to avoid (Beesdo et al., 2009).
However, the brain responses are usually adaptive since they facilitate the avoidance of danger. Pathological anxiety is associated with “persisting or extensive degrees of anxiety and avoidance associated with subjective distress or impairment” (Beesdo et al., 2009, p. 484). Even though there are many types of anxiety disorders, most of them share crucial features such as behavioral disturbance, extensive anxiety, physiological anxiety symptoms. The condition is common for children of certain ages and usually goes away without implications; however, some cases require interventions to avoid the development of complications.
There are various methods of treating anxiety in children, including cognitive-behavioral therapy (CBT) and acceptance and commitment therapy (ACT). CBT is an effective method of addressing the problem if compared with no treatment (James, James, Cowdrey, Soler, & Choke, 2015). Lynch, Laws, and McKenna (2010) mention that the method is recommended in 250 UK dedicated therapy centers to treat anxiety and depression. At the same time, James et al. (2015) state that CBT is no more effective than other active therapies. ACT is a cognitive therapy that aims at reducing unnecessary suffering and building the life that patients value (Batten, 2011).
ACT exercises pragmatic principles with a commitment to empirical support, which is vital for evidence-based practice (EBP). Studies have shown that ACT is an adequate substitution for traditional CBT therapeutic methods in certain areas (Hancock et al., 2016). The present paper offers an overview of ACT’s conceptual framework and therapeutic stance and provides empirical evidence confirming that it is a viable intervention to address anxiety in children.
ACT: Overview of Principles
Conceptual Framework
Some techniques used by ACT may be familiar to therapists; however, contextual behavioral theory and relational frame theory make the approach unique. The focus of ACT is pragmatic since it aims at helping a person move to valued outcomes. Much of what is seen as psychopathology from other perspectives ACT conceptualizes as resulting from experiential avoidance. Even though the framework has been around for almost forty years, it may be regarded new since the practitioners have become familiar with the treatment model only in the early 2000s (Batten, 2011). Since that time, the approach has become a subject of multiple studies.
ACT has six primary areas of focus: acceptance, diffusion, contact with the present moment, self-as-context, values, and committed action. Acceptance means making space in mind for painful feelings and sensations to learn to live with them. Diffusion refers to detaching from harmful feelings and contemplate them from a third-person perspective to adequately react to them. Contact with the present moment is described as being consciously aware of what is happening around all the time. Appreciation of self-as-context refers to the understanding that there is another ego that contemplates the thoughts and ideas going through the mind.
Minding values is realizing the ultimate goal of life. Lastly, committed action means operating in accordance with the values even if it may be difficult or unpleasant. While some of the principles are used in other approaches, ACT is the only therapy that unites all the six concepts together (Hayes, Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). All of the points added together develop psychological flexibility and the ability to resist the urges of experiential avoidance.
Therapeutic Stance
All the approaches in psychotherapy underline the importance of therapeutic relationships between the therapist and the client. However, most of the time, it is unclear what kind of qualities or behaviors of a therapist lead to beneficial relationships (Batten, 2011). The ACT model gives specific instructions about the therapeutic stance since the development of connection is considered the basis for the therapy. ACT proposes that a therapist is not an expert who has all the answers. Instead, he or she becomes a fellow human being representing non-judgmental acceptance of the client. Although distinct styles may vary among the therapists, relationships with the patient are characterized by openness, acceptance, respect, caring, and warmth. At the same time, appropriate boundaries are in place to guarantee the supremacy of the client’s needs.
Excessive Control
The ACT model insists that excessive control over feelings, emotions, and speech has played a part in the development and maintenance of the client’s problems. The purpose of a therapist is to help his patient understand that the issue is not that the client tried hard enough to control his behavior. The issue lies in the notion that “purposeful control of thoughts and feelings is a problematic strategy for effective living” (Batten, 2011, p. 18). Instead of trying to change the behavior, it is more beneficial to alter the motifs for behavior, which is to understand what matters and act accordingly. Excessive control over one’s behavior without appropriate motivation may lead to the development of discordance and disturbance of one’s mind.
ACT and CBT
CBT is a therapeutic approach that relies on the notion that thoughts and feelings are fundamental for shaping up people’s behavior. The core principle of CBT is to appreciate the automatic negative thoughts, assess, and control those (Arch & Craske, 2008). According to Lynch et al. (2010), the method has been widely adopted by therapists around the globe. While its efficacy for severe disorders remains a matter of discussion, CBT is an effective approach for treating comparatively mild psychiatric conditions (Lynch et al., 2010).
ACT is considered a “third-wave” intervention that falls under the CBT umbrella. According to Hayes and Hofmann (2017), the wave’s methods underlined the importance of mindfulness, emotions, acceptance, relationship, values, goals, and meta‐cognition. Even though there are some distinctive features of ACT, its core principles are coherent with traditional CBT methods.
On the surface, ACT and traditional CBT are quite different since CBT focuses on controlling one’s thoughts, while ACT insists that extensive control may be harmful. However, the approaches have many similarities if subjected to a thorough analysis. First, even though CBT supports cognitive restructuring and ACT promotes cognitive diffusions, both approaches aim at fighting experiential avoidance. Second, CBT’s control of though is impossible without acceptance of negative at least for a short period. Third, the mediators of change between the two methods are quite similar, according to Arch and Craske (2008).
Lastly, recent research shows that there is little difference in outcomes between the uses of two approaches, especially when speaking about treating anxiety in children. For instance, the results of a recent randomized control trial by Hancock et al. (2016) show that both methods produce similar outcomes when used for treating anxious youth. The fact that CBT and ACT are similar in its core leads to the understanding that evidence supporting CBT for treating anxiety in children can be used to promote ACT as a viable option to address the problem.
Treating Anxiety in Children
General Considerations
Since anxiety is closely related to avoidance and unwillingness, both CBT, in general, and ACT, in particular, seem to be suitable for treating the condition. The reason for the assumption is that both methods have experiential avoidance in its core (Batten, 2011). Therapists using ACT and CBT encourage their clients to find space for the bad feelings and thoughts instead of pretending that they do not exist. At the same time, ACT seems to be more appropriate for treating anxiety since one of its focuses is on being continuously connected with the present. Most of the time, worries are future-focused, and present-moment awareness seems to be an appropriate way to address the problem (Batten, 2011). In short, on the conceptual level, ACT is a viable option for treating anxiety.
The method is also beneficial for treating adolescence due to its therapeutic stance. Children may resist the acceptance of new ideas if they come from experts and authorities. Most of the time, teenagers are more willing to receive advice from their peers. Since therapists practicing ACT try to become friends with children instead of pretending to have all the answers, adolescents may be more responsive to the therapy. However, even though the considerations mentioned above may seem convincing for choosing ACT to treat children with anxiety, empirical evidence is needed to prove the effectiveness of the method.
Empirical Support for CBT
Before turning to the effectiveness of CBT in children with anxiety, it is beneficial to discuss empirical evidence supporting the notion that it is a distinctive method of psychotherapy. A study by Malik, Beutler, Alimohamed, Gallagher-Thompson, and Thompson (2003) compared CBT with non-cognitive therapies to understand if the cognitive approach is distinguishable. The results showed that cognitive therapies are more directive, less emotional, and more behavioral-focused if compared to non-cognitive methods (Malik et al., 2003). The findings are coherent with the previous research conducted by Goldfried, Raue, and Castonguay (1998), which explored the differences between CBT and psychodynamic-interpersonal therapy.
In their qualitative study, Goldfried et al. (1998) concluded that CBT is a distinguishable approach to treating anxiety, obsession, or both. The therapists practicing CBT were more likely to contrast the client’s functioning with that of others, stimulate experience between sessions, encourage new acquaintances, and work in the future timeframe. Taking into consideration the evidence summarized above, CBT can be considered a distinguishable approach to treating psychiatric disorders.
In recent years, CBT has been widely adopted by therapists to treat a variety of disorders, including anxiety in children. Lynch et al. (2010) mention that the method was recommended to be introduced in 250 medical centers to treat depression and anxiety. Indeed, a recent systematic review conducted by James et al. (2015) confirms that CBT-based interventions are associated with better patient outcomes if compared to the waiting list.
At the same time, the research found no significant differences in outcomes between patients treated as usual and those treated using CBT. The results may be trusted since the review included forty‐one studies consisting of 1806 participants. However, since the sample included only children and adolescents with mild to moderate severity of anxiety, it is unclear if CBT can be utilized to treat severe disorders.
While all the empirical evidence reviewed for the present confirms that CBT is an effective method for treating anxious youth, the findings concerning what format is best for interventions are inconsistent. The systematic review by James et al. (2015) found no statistically significant differences in outcomes between the individual, group, and family/parental formats. However, a randomized controlled trial by Maric, van Steensel, and Bögels (2018) shows that family involvement seems a valuable addition to treating anxiety in children. The researchers concluded that children high on attention-deficit and hyperactivity disorder (ADHD) symptoms profit from family CBT more than from individual CBT in the long term.
At the same time, the results of meta-analyses conducted by Reynolds, Wilson, Austin, and Hooper (2012) demonstrate that even though CBT is recommended method for treating anxiety disorders in youth, the researchers found that parental involvement benefits only younger children. The matter may be connected to the fact that older children and adolescents are more capable of engaging in psychotherapy in general. In short, the empirical evidence supports the use of CBT for treating anxious youth; however, it is inconclusive about the importance of family involvement in the therapy.
Empirical Support for ACT
Even though there are certain similarities between the methods used by traditional CBT and mechanisms utilized by ACT, presenting evidence supporting CBT for treating anxiety disorders in children is not enough to prove the effectiveness of ACT for the same issues. As a front matter, it is worth mentioning that both traditional CBT and ACT are valid for treating anxious youth. Moreover, according to Hancock et al. (2016), there are no statistically relevant differences in outcomes between the uses of the approaches. ACT produces better outcomes in quality of life three months after the therapy (Hancock et al., 2016).
These results are consistent with the findings of a recent, concise review conducted by Landy, Schneider, and Arch (2015), which explored the differences in outcomes between CBT and ACT. While ACT outperformed CBT in cases with a higher level of behavioral avoidance and comorbid mood disorders, CBT was associated with better outcomes in cases with a higher level of experiential avoidance and anxiety sensitivity (Landy et al., 2015). However, both methods are associated with considerable improvements in children’s conditions.
Even though ACT is a relatively recent approach to treating anxiety disorders, there is a significant body of evidence supporting its use. A systematic review conducted by Swain, Hancock, Hainsworth, and Bowman (2013) revealed 38 studies that explore the matter using scientifically relevant instruments. While the sample under analysis is characterized by the low study number and methodological inadequacies of some research, Swain et al. (2013) provided preliminary support for the use of ACT in patients with anxiety.
The approach was found to be beneficial for both clinical and non-clinical patients without favoring any particular format of delivery. For example, Roemer, Orsillo, and Salters-Pedneault (2008) evaluated acceptance-based behavioral therapy for treating GAD and depressive symptoms. Even though the effect size of the intervention was large, the evidence may not be considered reliable. The primary reason for the matter is the small sample size and limited applicability. In brief, while the body of evidence to support the efficiency of ACT in treating anxiety is substantial, additional research is needed to prove its efficacy in children.
Further Considerations
The amount of evidence supporting the use of ACT to treat anxiety is growing due to the increasing popularity of the method. A search conducted in Google Scholar, Cochrane Database, and Medline generated thousands of matches even when it was limited to the publication year 2018 and 2019. For instance, Herbert et al. (2018) found positive correlations between the utilization of ACT and outcomes in patients with a social anxiety disorder. Wynne et al. (2019) explored if therapy can be used to reduce psychological stress and anxiety in patients with inflammatory bowel diseases. Even though most of the recent research is high-quality scientific knowledge, no recent systematic reviews or meta-analyses were found to support the intervention.
The lack of secondary evidence concerning the utilization of ACT to treat anxious youth may be complemented by considering the systematic reviews for CBT. The works by James et al. (2015) and Maric et al. (2018) previously reviewed in the present paper are explicit examples of such evidence. Conceptual applicability of ACT for the condition discussed above can also be considered viable support for therapists to utilize the intervention. In summary, while the search found little secnodary evidence to support the approach, ACT may be considered an empirically supported intervention for children with anxiety
Conclusion
ACT is a third-wave cognitive-behavioral approach that underlined thoughts, feelings, and sensations as the target of change rather than a direct change of their form. On the conceptual level, the method seems to be applicable for treating children and adolescents with anxiety disorders. Even though there are some differences in the approaches of ACT and traditional CBT, both methods rely on similar mechanisms. A vast number of primary and secondary evidence supports the use of CBT for anxious youth. At the same time, empirical evidence promoting the utilization of ACT for the same condition is limited. The central issue is the absence of recent systematic reviews and meta-analyses of the matter. However, an analysis of ACT’s principles and a thorough review of the evidence demonstrates that ACT is a promising intervention for children with anxiety.
References
Arch, J. J., & Craske, M. G. (2008). Acceptance and commitment therapy, and cognitive behavioral therapy for anxiety disorders: Different treatments, similar mechanisms? Clinical Psychology: Science and Practice, 15(4), 263–279. Web.
Batten, S. (2011). Essentials of acceptance and commitment therapy. Los Angeles, CA: SAGE.
Beesdo, K., Knappe, S., & Pine, D. S. (2009). Anxiety and anxiety disorders in children and adolescents: Developmental issues and implications for DSM-V. Psychiatric Clinics of North America, 32(3), 483–524. Web.
Goldfried, M, Raue, P., & Castonguay, L. (1998). The therapeutic focus in significant sessions of master therapists: A comparison of cognitive-behavioral and psychodynamic-interpersonal interventions. Journal of Consulting and Clinical Psychology, 66, 803-810.
Hancock, K., Swain, J., Hainsworth, C., Dixon, A., Koo, S., & Munro, K. (2016). Acceptance and commitment therapy versus cognitive behavior therapy for children with anxiety: Outcomes of a randomized controlled trial. Journal of Clinical Child & Adolescent Psychology, 47(2), 296-311. Web.
Hayes, S., & Hofmann, S. (2017). The third wave of cognitive behavioral therapy and the rise of process-based care. World Psychiatry, 16(3), 245-246. Web.
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and commitment therapy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cognitive therapy. Behavior Therapy, 44(2), 180–198. Web.
Herbert, J. D., Forman, E. M., Kaye, J. L., Gershkovich, M., Goetter, E., Yuen, E. K.,… Berkowitz, S. (2018). Randomized controlled trial of acceptance and commitment therapy versus traditional cognitive behavior therapy for social anxiety disorder: Symptomatic and behavioral outcomes. Journal of Contextual Behavioral Science, 9, 88-96.
James, A., James, G., Cowdrey, F., Soler, A., & Choke, A. (2015). Cognitive behavioural therapy for anxiety disorders in children and adolescents. Cochrane Database of Systematic Reviews. Web.
Landy, L. N., Schneider, R. L., & Arch, J. J. (2015). Acceptance and commitment therapy for the treatment of anxiety disorders: a concise review. Current Opinion in Psychology, 2, 70–74. Web.
Lynch, D., Laws, K. R., & McKenna, P. J. (2010). Cognitive behavioural therapy for major psychiatric disorder: Does it really work? A meta-analytical review of well-controlled trials. Psychological Medicine, 40(1), 9-24. Web.
Malik, M. L., Beutler, L. E., Alimohamed, S., Gallagher-Thompson, D., & Thompson, L. (2003). Are all cognitive therapies alike? A comparison of cognitive and noncognitive therapy process and implications for the application of empirically supported treatments. Journal of Consulting and Clinical Psychology, 71, 150-158.
Maric, M., van Steensel, F. J., & Bögels, S. M. (2018). Parental involvement in CBT for anxiety-disordered youth revisited: Family CBT outperforms child CBT in the long term for children with comorbid ADHD symptoms. Journal of Attention Disorders, 22(5), 506-514.
Reynolds, S., Wilson, C., Austin, J., & Hooper, L. (2012). Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review. Clinical Psychology Review, 32(4), 251–262. Web.
Roemer, L., Orsillo, S.M., & Salters-Pedneault, K. (2008) Efficacy of an acceptance-based behaviour therapy for generalized anxiety disorder: Evaluation in a randomized controlled trial. Journal of Consulting and Clinical Psychology, 76, 1083–1089.
Swain, J., Hancock, K., Hainsworth, C., & Bowman, J. (2013). Acceptance and commitment therapy in the treatment of anxiety: A systematic review. Clinical Psychology Review, 33(8), 965–978. Web.
Wynne, B., McHugh, L., Gao, W., Keegan, D., Byrne, K., Rowan, C.,… Dooley, B. (2019). Acceptance and commitment therapy reduces psychological stress in patients with inflammatory bowel diseases. Gastroenterology, 156(4), 935-945.