Anxiety is one of the most common mental health problems in childhood and adolescence with prevalence rates ranging from 6 to 20% [1]. The anxiety disorders include agoraphobia, panic disorder, specific phobia, separation anxiety, social anxiety (including selective mutism), and generalized anxiety disorder. These disorders are frequently unrecognized and untreated in childhood [2, 3]. Anxiety disorders are common in children with PNES, but there is very little data to indicate how commonly they occur. In a recent multi-center study, 83.6% of children with PNES also met criteria for an anxiety disorder [4].

Major depressive disorder (MDD) is also a frequent mental health problem especially in adolescence [3]. It is estimated that 2% of children and 4–8% adolescents have experienced an MDD with males and females having similar rates in childhood and females having higher rates in adolescence [5, 6]. Studies have demonstrated that approximately 5–10% of children and adolescents experience subsyndromal symptoms of MDD [6]. Rates of MDD in PNES are not known, but the recent study by Plioplys et al. [4] also reported that 43.6% of the 8–18-year-old PNES sample had depressive disorders. Similar to the general child and adolescent population, older age and female gender increased the risk of having both depression and PNES [4].

In many children and adolescents, anxiety disorders and depression occur before the onset of PNES and often remain after the NES symptoms are treated [7, 8]. As a result, it is important to recognize anxiety and depression as commonly occurring problems in children and adolescents with PNES.

Among the different types of psychotherapeutic or psychosocial interventions, exposure-based CBT has the most empirical support for treating children and adolescents with anxiety disorders. But, it is of utmost importance that you identify if and when is the most appropriate time to address these PNES comorbid conditions with CBT. This will depend on the child’s response to the interventions to reduce PNES episodes, level of resistance, learning style, and rapport with you. It may be appropriate to try to incorporate CBT elements only after the child clearly understands and accepts the relationship among negative emotions, stress, and NES symptoms. As mentioned in the tips to treating PNES in Fig. 5.​1 of Chap. 5, children with PNES, particularly those with learning difficulties, are often resistant to what might appear to them as “homework.” Therefore, it is imperative that you introduce CBT at a much slower pace than would be typically utilized in a 10–12-week anxiety or depression CBT intervention protocol. If the child demonstrates nonverbal or verbal cues of discomfort or resistance, back off until you feel the child will benefit from CBT. Evidence-based protocols can be helpful to you, but you will need to carefully modify the timeline, order, and manner in which you introduce the CBT skills (see Appendix M for CBT resources).

In CBT, the clinician or therapist helps to teach the child adaptive coping skills and introduces practice opportunities (exposures) to develop coping techniques or skills to overcome the anxiety symptoms or situations that increase stress and impaired functioning. There is compelling evidence that children with anxiety disorders have a better treatment responses compared to adolescents. There appear to be neurodevelopmental changes in the brain that facilitate learning in childhood and disrupt the acquisition of new learning in adolescents [9]. There is also evidence that children with anxiety disorder have even better outcomes if a multimodal approach is utilized, and CBT is introduced in combination with a selective serotonin reuptake inhibitor (SSRI). Combined CBT and sertraline, an SSRI, has the highest response rates (80.7%), whereas CBT alone produced response rates (59.7%) similar to those of medication alone (54.9%) [10].

CBT is also recommended for depressive disorders in children and adolescents although its efficacy is not as strong as has been demonstrated in anxiety disorders [6]. Therefore, in children and adolescents with severe depression, antidepressants are indicated as soon as possible [6]. Psychotherapy can be introduced at the same time as medications are started or at some point afterwards. In adolescents, the response rate for combined CBT and SSRI treatment was 67% compared to 38.6% for usual care [11]. In children with depression, however, the evidence for CBT is less compelling as few clinical trials have been conducted in this age group (See review in [11]).

This section briefly describes the essential elements or key factors that have been deemed to be the most important when treating anxiety disorders in children and adolescents. It also explains how CBT works and what CBT components work better than others.

Eisen and Silverman [12] reported that cognitive restructuring and relaxation training produced similar reductions in anxiety. Silverman et al. [13] also found that skills training and contingency training reduced anxiety symptoms. More recently, Nakamura et al. [14] found that exposure tasks were important for achieving treatment gains. Peris et al. [15] recently attempted to determine the essential components of CBT in the treatment of anxiety disorders using data from a large-scale treatment trial (Child/Adolescent Anxiety Multimodal Study; [10]). The authors hypothesized that relaxation training, cognitive restructuring, and exposure would be imperative to reach treatment goals. Two techniques clearly contributed to treatment outcomes, and these included exposure and cognitive restructuring. These techniques reduced symptoms of anxiety and were linked to improved functioning. Relaxation training did not appear to significantly contribute to the reduction in symptoms of anxiety or change the course of treatment.