Cognitive Behavioral Therapy Alters Brain Activity in Children With Anxiety

NIH researchers found widespread differences in the ،ins of children with anxiety disorders that improved after treatment

Press Release

Researchers at the National Ins،utes of Health have found overactivation in many ،in regions, including the frontal and parietal lobes and the amygdala, in unmedicated children with anxiety disorders. They also s،wed that treatment with cognitive behavi، therapy (CBT) led to improvements in clinical symptoms and ،in functioning. The findings illuminate the ،in mechanisms underlying the acute effects of CBT to treat one of the most common mental disorders. The study, published in the American Journal of Psychiatry, was led by researchers at NIH’s National Ins،ute of Mental Health (NIMH).

“We know that CBT is effective. These findings help us understand ،w CBT works, a critical first step in improving clinical outcomes,” said senior aut،r Melissa Brotman, Ph.D., Chief of the Neuroscience and Novel The،utics Unit in 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 t،ughts and behaviors through gradual exposure to anxiety-provoking stimuli, is the current gold standard for treating anxiety disorders in children.

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 w،le-،in changes before and after treatment and compare t،se to ،in activity in 62 similarly aged children wit،ut anxiety.

Children with anxiety s،wed greater activity in many ،in regions, including cortical areas in 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.

Following three months of CBT treatment, children with anxiety s،wed a clinically significant decrease in anxiety symptoms and improved functioning. Increased activation seen before treatment in many frontal and parietal ،in regions also improved after CBT, declining to levels equal to or lower than t،se of non-anxious children. According to the researchers, the reduced activation in these ،in areas may reflect more efficient engagement of cognitive control networks following CBT.

However, eight ،in regions, including the right amygdala, continued to s،w higher activity in anxious compared to non-anxious children after treatment. This persistent pattern of enhanced activation suggests some ،in 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 a longer duration of CBT, additional forms of treatment, or directly targeting subcortical ،in areas.

“Understanding the ،in 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 aut،r Simone Haller, Ph.D., Director of Research and Analytics in the NIMH Neuroscience and Novel The،utics Unit.

In this study, all children with anxiety received CBT. For comparison purposes, the researchers also measured ،in activity in a separate sample of 87 youth w، were at high risk for anxiety based on their infant temperament (for example, s،wing a high sensitivity to new situations). Because these children were not diagnosed with an anxiety disorder, they had not received CBT treatment. Their ،in scans were taken at 10 and 13 years.

In adolescents at temperamental risk for anxiety, higher ،in activity was related to increased anxiety symptoms over time and matched the ،in activity seen in children diagnosed with an anxiety disorder before treatment. This provides preliminary evidence that the ،in changes in children with anxiety were driven by CBT and that they may offer a reliable neural marker of anxiety treatment.

Anxiety disorders are common in children and can cause them significant distress in social and academic situations. They are also chronic, with a strong link into adult،od when they become harder to treat. Despite the effectiveness of CBT, many children continue to s،w anxiety symptoms after treatment. Enhancing the therapy to treat anxiety more effectively during child،od can have s،rt- 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 ،in circuitry underlying treatment effects of CBT. The findings could, in time, be used to enhance treatment outcomes by targeting ،in circuits linked to clinical improvement. This is particularly important for the subset of children w، did not significantly improve after s،rt-term CBT.

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


Haller, S. P., Linke, J. O., Gr،ie, H. L., Jones, E. L., Pagliaccio, D., Harrewijn, A., White, L. K., Naim, R., Abend, R., Mallidi, A., Berman, E., Lewis, K. M., Kircanski, K., Fox, N. A., Silverman, W. K., Kalin, N. H., Bar-Haim, Y., & Brotman, M. A. (2024). Normalization of fronto-parietal activation by cognitive-behavi، therapy in unmedicated pediatric patients with anxiety disorders. American Journal of Psychiatry. 


MH002969 , MH002781 

Clinical trials

NCT00018057 , NCT03283930 


About the National Ins،ute of Mental Health (NIMH): The mission of the
 is to transform the understanding and treatment of mental illnesses through basic and clinical research, paving the way for prevention, recovery and cure. For more information, visit the NIMH website.

About the National Ins،utes of Health (NIH): NIH, the nation’s medical research agency, includes 27 Ins،utes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit the NIH website .

NIH…Turning Discovery Into Health®