Featured Article| Volume 19, ISSUE 4, 104583, April 2023

Addressing Anxiety in Primary Care With Cognitive Behavioral Therapy


      • Anxiety disorders, including generalized anxiety disorder, are often undertreated in pediatrics.
      • There is a need for improved screening and treatment for pediatric patients with anxiety.
      • Addressing anxiety in primary care is cost-effective and ideal for patients.
      • Cognitive behavioral therapy is a validated intervention for nurse practitioners to use.


      Anxiety disorders are prevalent among children and adolescents, and they are often overlooked, undiagnosed, and undertreated. Screening for and addressing anxiety disorders in the primary care setting are ideal for both patients and providers because they can lead to improved care and patient outcomes. Cognitive behavior therapy, which helps patients identify and alter irrational thoughts, use coping skills, and manage somatic complaints, is an ideal intervention because it is easy to train providers in this therapy, and it is effective in decreasing anxiety symptoms.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The Journal for Nurse Practitioners
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • de Lijster J.M.
        • Dieleman G.C.
        • Utens E.M.W.J.
        • et al.
        Social and academic functioning in adolescents with anxiety disorders: a systematic review.
        J Affect Disord. 2018; 230: 108-117
        • Centers for Disease Control
        Anxiety and depression in children: get the facts.
        • National Institute of Mental Health
        Any anxiety disorder among children.
        • Salloum A.
        • Johnco C.
        • Lewin A.B.
        • McBride N.M.
        • Storch E.A.
        Barriers to access and participation in community mental health treatment for anxious children.
        J Affect Disord. 2016; 196: 54-61
        • Malone P.
        43.3 Barriers to mental health care for ethnically diverse youth and their families.
        J Am Acad Child Adolesc Psychiatry. 2019; 58 (S61-S61)
        • Melnyk B.M.
        Reducing healthcare costs for mental health hospitalizations with the evidence-based COPE program for child and adolescent depression and anxiety: a cost analysis.
        J Pediatr Health Care. 2020; 34: 117-121
        • Wang C.W.
        • Chan C.L.
        • Ho R.T.
        Prevalence and trajectory of psychopathology among child and adolescent survivors of disasters: a systematic review of epidemiological studies across 1987-2011.
        Soc Psychiatry Psychiatr Epidemiol. 2013; 48: 1697-1720
        • Meade J.
        Mental health effects of the COVID-19 pandemic on children and adolescents: a review of the current research.
        Pediatr Clin North Am. 2021; 68: 945-959
        • Centers for Disease Control
        Morbidity and mortality weekly report (MMWR): mental health-related emergency department visits among children aged <18 years during the COVID-19 pandemic.
        • Skokauskas N.
        • Fung D.
        • Flaherty L.T.
        • et al.
        Shaping the future of child and adolescent psychiatry.
        Child Adolesc Psychiatry Ment Health. 2019; 13 (19-19)
        • Biel M.G.
        • Anthony B.J.
        • Mlynarski L.
        • Godoy L.
        • Beers L.S.
        Collaborative training efforts with pediatric providers in addressing mental health problems in primary care.
        Acad Psychiatry. 2017; 41: 610-616
        • Nursing process
        Pediatric nurse practitioner salary by state.
      1. NAPNAP position statement on the integration of mental health care in pediatric primary care settings.
        J Pediatr Health Care. 2013; 27: A15-A16
        • Villabø M.A.
        • Narayanan M.
        • Compton S.N.
        • Kendall P.C.
        • Neumer S.-P.
        Cognitive-behavioral therapy for youth anxiety: an effectiveness evaluation in community practice.
        J Consult Clin Psychol. 2018; 86: 751-764
        • Velting O.N.
        • Setzer N.J.
        • Albano A.M.
        Update on and advances in assessment and cognitive-behavioral treatment of anxiety disorders in children and adolescents.
        Prof Psychol Res Pr. 2004; 35: 42-54
        • Kemper A.R.
        • Letostak T.B.
        • Hostutler C.A.
        • Stephenson K.G.
        • Butter E.M.
        Screening for anxiety in pediatric primary care: a systematic review.
        Pediatrics. 2021; 148e2021052633
        • Lowe P.A.
        A Closer Look at the psychometric properties of the Revised Children’s Manifest Anxiety Scale–Second Edition among U.S. elementary and secondary school students.
        J Psychoeduc Assess. 2014; 32: 495-508
        • von Gontard A.
        • Moritz A.-M.
        • Thome-Granz S.
        • Equit M.
        Abdominal pain symptoms are associated with anxiety and depression in young children.
        Acta Paediatr. 2015; 104: 1156-1163
        • Allison V.L.
        • Nativio D.G.
        • Mitchell A.M.
        • Ren D.
        • Yuhasz J.
        Identifying symptoms of depression and anxiety in students in the school setting.
        J Sch Nurs. 2014; 30: 165-172
        • Ramsawh H.J.
        • Chavira D.A.
        • Kanegaye J.T.
        • Ancoli-Israel S.
        • Madati P.J.
        • Stein M.B.
        Screening for adolescent anxiety disorders in a pediatric emergency department.
        Pediatr Emerg Care. 2012; 28: 1041-1047
        • Evans L.
        • Haeberlein K.
        • Chang A.
        • Handal P.
        Convergent validity and preliminary cut-off scores for the anxiety and depression subscales of the DASS-21 in US adolescents.
        Child Psychiatry Hum Dev. 2021; 52: 579-585
        • Arnold P.
        • Banerjee S.P.
        • Bhandari R.
        • et al.
        Childhood anxiety disorders and developmental issues in anxiety.
        Curr Psychiatry Rep. 2003; 5: 252-265
        • Maaks D.L.G.
        • Starr N.B.
        • Brady M.
        • Gaylord N.M.
        • Driessnack M.
        • Duderstadt K.G.
        Burns' Pediatric Primary Care.
        7th ed. Elsevier, 2020
        • Shannon R.A.
        • Bergren M.D.
        • Matthews A.
        Frequent visitors: somatization in school-age children and implications for school nurses.
        J Sch Nurs. 2010; 26: 169-182
        • Öst L.-G.
        • Ollendick T.H.
        Brief, intensive and concentrated cognitive behavioral treatments for anxiety disorders in children: a systematic review and meta-analysis.
        Behav Res Ther. 2017; 97: 134-145
        • Bennett K.
        • Manassis K.
        • Duda S.
        • et al.
        Treating child and adolescent anxiety effectively: overview of systematic reviews.
        Clin Psychol Rev. 2016; 50: 80-94
        • Wang Z.
        • Whiteside S.P.H.
        • Sim L.
        • et al.
        Comparative effectiveness and safety of cognitive behavioral therapy and pharmacotherapy for childhood anxiety disorders: a systematic review and meta-analysis.
        JAMA Pediatr. 2017; 171: 1049-1056
        • James A.C.
        • Reardon T.
        • Soler A.
        • James G.
        • Creswell C.
        Cognitive behavioural therapy for anxiety disorders in children and adolescents.
        Cochrane Database Syst Rev. 2020; 11: CD013162
        • Hoying J.
        • Melnyk B.M.
        • Arcoleo K.
        Effects of the COPE cognitive behavioral skills building TEEN program on the healthy lifestyle behaviors and mental health of appalachian early adolescents.
        J Pediatr Health Care. 2016; 30: 65-72
        • Duhoux A.
        • Dufour É.
        • Sasseville M.
        • Laroche D.
        • Contandriopoulos D.
        Rethinking primary care delivery models: can integrated primary care teams improve care experience?.
        Int J Integr Care. 2022; 22 (8-8)
        • Asarnow J.R.
        • Rozenman M.
        • Wiblin J.
        • Zeltzer L.
        Integrated medical-behavioral care compared with usual primary care for child and adolescent behavioral health: a meta-analysis.
        JAMA Pediatr. 2015; 169: 929-937
        • Cummings A.D.
        • Van Horne B.
        • Correa N.
        • Schwarzwald H.
        • Chapman S.
        Can pediatric primary care practices afford integrated behavioral health? A comparison of 5 pediatric practices.
        Clin Pediatr (Phila). 2022; 61: 850-858
        • Melnyk B.M.
        • Gennaro S.
        • Szalacha L.A.
        • et al.
        Randomized controlled trial of the COPE-P intervention to improve mental health, healthy lifestyle behaviors, birth and post-natal outcomes of minority pregnant women: study protocol with implications.
        Contemp Clin Trials. 2020; 98106090
        • Mignogna J.
        • Hundt N.E.
        • Kauth M.R.
        • et al.
        Implementing brief cognitive behavioral therapy in primary care: a pilot study.
        Transl Behav Med. 2014; 4: 175-183
        • Wang C.
        • Pan R.
        • Wan X.
        • et al.
        Immediate psychological responses and associated factors during the initial stage of the 2019 coronavirus disease (COVID-19) epidemic among the general population in China.
        Int J Environ Res Public Health. 2020; 17: 1729
        • Moor S.
        • Williman J.
        • Drummond S.
        • et al.
        ‘E’ therapy in the community: Examination of the uptake and effectiveness of BRAVE (a self-help computer programme for anxiety in children and adolescents) in primary care.
        Internet Interv. 2019; 18100249-100249


      Elizabeth Coleman, MSN, CPNP-PC, is a nursing instructor, Marti Rice, PhD, RN, is a professor and Tedra S. Smith, DNP, CPNP-PC, is an associate professor at the University of Alabama at Birmingham School of Nursing in Birmingham, AL. Ms. Coleman can be contacted at [email protected]