Cognitive Behavioral Therapy Alters Brain Activity in Children With Anxiety

“We know that CBT is effective. “These findings help us understand how CBT works, a critical first step in improving clinical outcomes,” said lead author Melissa Brotman, Ph.D., chief of the Neuroscience and Novel Therapeutics Unit of the NIMH Intramural Research Program. .

Sixty-nine unmedicated children diagnosed with an anxiety disorder underwent 12 weeks of CBT following an established protocol. CBT, which involves changing dysfunctional thoughts and behaviors through gradual exposure to anxiety-provoking stimuli, is the current gold standard for the treatment of anxiety disorders in children.

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

Children with anxiety showed increased activity in many brain regions, including cortical areas of the frontal and parietal lobes, which are important for cognitive and regulatory functions, such as attention and emotion regulation. The researchers also observed elevated activity in deeper limbic areas like the amygdala, which are essential for generating strong emotions such as anxiety and fear.

After three months of CBT treatment, children with anxiety showed a clinically significant decrease in anxiety symptoms and improved functioning. The increased activation observed before treatment in many frontal and parietal brain regions also improved after CBT, decreasing to levels equal to or lower than those of non-anxious children. According to the researchers, reduced activation in these brain areas may reflect more efficient engagement of cognitive control networks after CBT.

However, eight brain regions, including the right amygdala, continued to show greater activity in anxious children compared to non-anxious children after treatment. This persistent pattern of enhanced activation suggests that some brain regions, particularly limbic areas that modulate responses to anxiety-provoking stimuli, may be less responsive to the acute effects of CBT. Changing activity in these regions may require longer duration CBT, additional forms of treatment, or directly targeting subcortical areas of the brain.

“Understanding the brain circuits that underpin feelings of severe anxiety and determining which circuits normalize and which do not when anxiety symptoms improve with CBT is critical to advancing treatment and making it more effective for all children,” said the first. author Simone Haller, Ph.D. , Director of Research and Analysis of the NIMH Neuroscience and New Therapeutics Unit.

In this study, all children with anxiety received CBT. For comparison, the researchers also measured brain activity in a separate sample of 87 young people who were at high risk for anxiety due to their childhood temperament (for example, who showed high sensitivity to new situations). Because these children were not diagnosed with an anxiety disorder, they had not received CBT treatment. Brain scans were taken at ages 10 and 13.

In adolescents at temperamental risk for anxiety, greater brain activity was related to an increase in anxiety symptoms over time and was consistent with brain activity observed in children diagnosed with an anxiety disorder before treatment. This provides preliminary evidence that brain changes in children with anxiety were driven by CBT and may offer a reliable neural marker for anxiety treatment.

Anxiety disorders are common in children and can cause significant distress in social and academic situations. They are also chronic and have a strong link until adulthood, when they become more difficult to treat. Despite the effectiveness of CBT, many children continue to show symptoms of anxiety after treatment. Improving therapy to treat anxiety more effectively during childhood can have short- and long-term benefits and prevent more serious problems later in life.

This study provides evidence, in a large group of unmedicated youth with anxiety disorders, of altered brain circuits underlying the treatment effects of CBT. Over time, the findings could be used to improve treatment outcomes by targeting brain circuits related to clinical improvement. This is particularly important for the subset of children who did not improve significantly after short-term CBT.

“The next step of this research is to understand which children are most likely to respond. Are there factors we can evaluate before starting treatment to make more informed decisions about who should receive what treatment and when? Answering these questions would further translate our research findings into clinical practice,” Brotman said.

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