Psychoeducation

Usually didactic in nature, information is provided about the nature of anxiety and emotions in general, features of the specific anxiety disorder being targeted in treatment, and the critical function of exposure therapy as part of the treatment program. This initial phase of treatment is not intended to be an active intervention but provides the rationale for CBT and may include attention to the role of behavioral avoidance and the recognition of anxious emotional states, including somatic cues of distress. For some forms of CBT, understanding when to implement anxiety management skills requires recognition of an anxious emotional state. Thus, the psychoeducation portion of treatment serves as the foundation for other components introduced later in treatment.

Coping Skill Training

After providing psychoeducation, many CBT protocols address coping skill development. Across many protocols, skill development includes a focus on managing the somatic symptoms through the use of relaxation training and/or problem-solving skills. For example, the C.A.T. program, an adolescent version of the Coping Cat protocol (Kendall, Choudhury, Hudson, & Webb, 2002), teaches adolescents how to engage in relaxation techniques (deep breathing, progressive muscle relaxation, use of relaxation aids) and identify the presence of somatic cues that indicate the need to implement coping responses (O’Neil, Brodman, Cohen, Edmunds, & Kendall, 2012). After acquiring relaxation skills, the C.A.T. protocol moves to training problem-solving skills. First, these problem-solving skills are practiced with nonstressful situations. Later, the skills are applied to more stressful situations. Problem-solving skills teach a method to deal with anxiety-provoking situations rather than feeling helpless about them. An adolescent dealing with test anxiety, for example, can learn to engage in positive study habits to prepare for tests rather than allowing worry about tests to result in avoidance of thoughts about and lack of preparation for tests. The development of problem-solving skills therefore can lead adolescents from behavioral avoidance to active engagement in problematic situations.

Cognitive Restructuring

Another common component of CBT for adolescents with anxiety disorders is the use of cognitive restructuring. Although the central importance of cognition and cognitive restructuring in the etiology and treatment of anxiety disorders in children and adolescents remains an open question (Beidel & Turner, 2007), research has been relatively consistent concerning the association between maladaptive cognitive processes and anxiety in children and adolescents. One study suggests that certain types of cognitive processes may play a casual role in the development and maintenance of posttraumatic stress disorder (Meiser-Stedman, Dalgleish, Glucksman, Yule, & Smith, 2009). Other data suggest that specific cognitive coping skills may be associated with problematic anxiety (Garnefski, Legerstee, Kraaij, Van den Kommer, & Teerds, 2002), and these coping skills may differentiate anxiety-disordered and nonanxious adolescents (Legerstee, Garnefski, Verhulst, & Utens, 2011), suggesting a role for cognitive processes in the maintenance of the disorder but not necessarily its onset. For a review of the role of cognitions in the development and maintenance of anxiety in children and adolescence, see Muris and Field (2008). Regardless of its hypothesized role in etiology, cognitive restructuring is a significant component of many CBT protocols, and its general principles are discussed here.

The general goals of cognitive restructuring are the identification of thoughts that may serve to produce or perpetuate anxiety and the use of techniques to challenge these thoughts. Therapists help identify inaccurate and negative thought patterns. For example, an adolescent with social anxiety disorder may identify a number of cognitive distortions, such as: overestimating the amount of attention directed at him/her, misinterpreting the outcome of social encounters as more negative than they actually are, and foreclosing on the belief that he/she will ever be socially competent. After identifying these thoughts, techniques are used to develop more realistic and accurate assessments of situations and alter self-talk to be more positive and proactive. These techniques include but are not limited to Socratic questioning, behavioral experiments, evidence examination, and cognitive rehearsal (Basco, Glickman, Weatherford, & Ryser, 2000; Kendall, Chu, Pimentel, & Choudhury, 2000). To continue the example, the adolescent might be asked to engage in social situations to observe how much attention is really focused on him/her and provide examples of positive and negative outcomes. The adolescent may be asked to reflect on what went right in the situations or recall times when he/she displayed adequate social skills, such as situations with family members when anxiety may have been minimal. Although many cognitive restructuring techniques exist, the results of their use should be more flexible, positive, and objective beliefs about anxiety-provoking situations.

Exposure

Although there are variations among CBT protocols, one common and essential feature is the inclusion of exposure to effect reduction of anxiety and associated symptoms (Kazdin & Weisz, 1998; Kendall et al., 2005). Exposure involves having adolescents face their fear directly. Exposure typically is done in a graduated fashion in which less feared situations are attempted before more challenging ones. Although the specific exposure instructions vary by protocol, typically the individual is asked to remain in contact with the feared situation or object until a specific length of time has passed or until habituation occurs (i.e., a reduction or elimination of anxiety in the situation). When situations cannot be reproduced in the clinic environment, imaginal exposure can be used. In imaginal exposure, the adolescent is asked to imagine feared stimuli using mental sensory cues to produce an accurate and realistic depiction of the feared stimuli. Depending on the availability, reproducibility, and actual threat value of the feared stimuli, treatment can make use of either or both types of exposure, imaginal and/or in vivo (actual live exposure to stimuli), although in-vivo exposure may produce more favorable results (Ultee, Griffioen, & Schellekens, 1982).

Regardless of the type of exposure, the procedure for carrying out exposure exercises is generally the same and consists of developing a list of anxiety-provoking situations, rating identified situations according to amount of anxiety elicited, and exposing the adolescent to these situations according to a graded hierarchy (Kendall et al., 2005). First, the adolescent, parent(s), teacher, or other parties knowledgeable about the adolescent are consulted about situations that typically provoke anxiety. Identification of these situations can be obtained through self-report scales, interviews, diaries, and/or behavioral observations. It may be particularly useful to gain information about situations that pose the most impairment, so these situations can be addressed specifically in treatment. It is useful to construct a list of situations with varying levels of distress to facilitate treatment and provide a graduated experience of exposure to increasing levels of distress in treatment sessions. Once a working list of situations is developed, the adolescent provides ratings using a Subjective Units of Distress Scale (SUDS) (Wolpe, 1969). Although the exact numerical anchors used for the SUDS ratings are somewhat arbitrary, some recommend making use of smaller numbers (e.g., 0–8 scale) and additional visual aids (e.g., fear thermometer) to help keep ratings simple and clear for children and adolescents (Kendall et al., 2005). Once situations have been assigned an associated SUDS level, the SUDS ratings are used to determine which situations will be addressed first in treatment. In some protocols, adolescents are encouraged to use their coping skills while engaged in the exposure task. In other cases, distraction is considered counterproductive. To date, there are no data regarding which of these strategies is more effective.

Relapse Prevention

The last element of many CBT protocols is consolidation of skills and experiences introduced in treatment and increasing the independent implementation of these strategies by the adolescent. Sessions become less frequent (e.g., move from weekly to biweekly sessions) in this phase of treatment. Before complete termination, booster sessions may occur at longer intervals (e.g., monthly sessions). Empirical studies are needed to determine whether these extra sessions increase effectiveness of treatment (Compton et al., 2004), but, nonetheless, many protocols formally outline their inclusion.

In addition to transdiagnostic CBT protocols, other empirically supported treatments are designed to address specific anxiety disorders. These specific interventions often include some of the same elements contained in more generic CBT interventions, but these elements are tailored to the unique symptom characteristics of specific anxiety disorders. To reduce redundancy, only the unique aspects of these interventions are described next.

Social Anxiety Disorder

Even though developers of many transdiagnostic CBT protocols have indicated that these general treatments are appropriate for adolescents with social anxiety disorders, there is evidence that socially phobic children do not respond as well to these treatments as children with other anxiety disorders (Crawley, Beidas, Benjamin, Martin, & Kendall, 2008). Fortunately, specific treatments for child and adolescent social anxiety disorder have been relatively well researched. A number of studies have provided evidence for the effectiveness of these social phobia–specific treatments in the short and long term (Albano, Marten, Holt, Heimberg, & Barlow, 1995; Beidel et al., 2007; Beidel, Turner, & Morris, 2000; García-López et al., 2006; Spence, Donovan, & Brechman-Toussant, 2000).

Although most of the elements common to CBT for other anxiety disorders are part of the interventions developed for social anxiety disorder, several protocols include additional treatment elements. For instance, most of these specific protocols focus on the development of social skills, sometimes substituting this element for skills to manage somatic symptoms of anxiety. For example, Social Effectiveness Therapy for Children and Adolescents (SET-C) (Beidel et al., 2003) devotes 12 sessions to teaching and practicing social skills (e.g., conversational skills, establishing and maintaining friendships, appropriate assertiveness). Many of these treatments also are delivered in a group format (e.g., Group Cognitive Behavioral Treatment for Adolescents [GCBT-A]) (Albano, Marten, & Holt, 1991), and some incorporate nonanxious peers to practice social skill development (Beidel et al., 2000; Olivares & García-López, 1998). The group format may provide additional exposure opportunities, given the interpersonal nature of social phobia. The setting of treatment also has been adapted in some treatments to include implementation in schools (e.g., Skills for Academic and Social Success [SASS]) (Masia, Klein, Storch, & Corda, 2001). One of the advantages of implementing treatment in school is the environment may be the primary setting in which adolescents experience social distress. Even when social skills training is included as an element of the treatment package, the emphasis of these protocols remains on exposure, and some treatments omit explicit focus on cognitive elements entirely in favor of behavioral techniques (e.g., SET-C).

Panic Disorder and Agoraphobia

Treatments specifically designed for adolescents with PD have received little attention until relatively recently. Work by Mattis and colleagues (Mattis et al., 2001; Mattis & Pincus, 2004; Pincus, Ehrenreich, Whitton, Mattis, & Barlow, 2010) has provided evidence for the efficacy of panic control treatment (PCT) adapted for use with adolescents. Similar to other forms of CBT, PCT includes psychoeducation, skills training, cognitive restructuring, exposure, and relapse prevention; however, the focus of the elements is specific to symptoms of PD and agoraphobic avoidance (see Hoffman & Mattis, 2000, for an overview of PCT session by session). One unique aspect of PCT compared with generic CBT for adolescents with anxiety disorders is the inclusion of breathing retraining to counteract the hyperventilatory response associated with PD. Adolescents are taught to breathe deeply from the diaphragm to counteract escalating physical symptoms associated with hyperventilation during a panic attack. Another unique aspect of PCT is the focus on interoceptive cues in exposure. Physiological sensations are induced during exposure to help adolescents habituate to these feared sensations. For example, an adolescent who fears feeling dizzy may be asked to spin in a chair during a session to induce feelings of dizziness and repeat this activity to habituate to the sensation of dizziness. When present, agoraphobic avoidance is also addressed with exposure. The cognitive restructuring component of PCT focuses on the probability overestimation of feared events and the belief in the catastrophic consequences of the feared event (e.g., I’m going to faint in the mall, and I’ll hit my head and die).

Generalized Anxiety Disorder

Although most transdiagnostic treatments for adolescent anxiety were developed to treat a cluster of anxiety disorders including GAD, some have begun to develop treatments specifically tailored for GAD (e.g., Léger, Ladouceur, Dugas, & Freeston, 2003; Payne, Bolton, & Perrin, 2001). Adaptations to CBT for GAD generally have not deviated from transdiagnostic CBT but rather focus on individual elements of CBT most related to the GAD clinical syndrome. For instance, these treatments tend to emphasize remediating problematic worry and develop better tolerance to uncertainty in cognitive restructuring and exposure. Specifically, cognitive restructuring focuses on evaluating beliefs about worry, including the usefulness of worry. Treatment also may focus on the development of tolerance to uncertainty by engaging in situations with uncertain outcomes and exposing adolescents to threatening mental images, especially images related to worry content. Problem-solving skills typically are part of GAD-specific treatment and include understanding the difference between solvable and unsolvable problems. Adolescents also are taught to redirect their focus on elements of threat in problematic situations and to identify benefits that can be obtained from problematic situations, such as preparing them for similar situations in the future.

The length of treatment and resources involved in implementing treatment protocols vary considerably. Reviews of CBT protocols for anxiety disorders list ranges of 6 to 24 sessions, with most treatments outlining 10 to 15 sessions (Ishikawa, Okajima, Matsuoka, & Sakano, 2007; Silverman et al., 2008). These reviews also point out that treatment sessions may be delivered in a group format or individually and may or may not incorporate parents and/or other family members.