Cognitive Behavioral Therapy (CBT), deemed a “well-established” intervention for the treatment of child and adolescent anxiety (Hollon & Beck, 2013), typically addresses anxiety using a two-pronged approach. In the first half of treatment, children and adolescents (referred to throughout as youth) are taught a series of coping skills to “fight the worry monster.” For example, during cognitive restructuring sessions, youth learn to identify their anxious self-talk (e.g., “If I am separated from my mother, something bad will happen to me”), gather evidence for and against these thoughts, and generate an alternative, more realistic coping thought (e.g., “I have been separated from my mother many times before, and nothing bad has ever happened to me”). Other coping skills typically discussed include progressive muscle relaxation, problem solving, and deep breathing exercises.
Youth then put these coping skills into practice in a series of exposure tasks, or “challenges.” To identify challenges, the youth and therapist collaboratively generate a graduated list of feared situations, or “fear ladder,” that best target core fears. For example, to create a fear ladder that addresses separation concerns, the clinician might ask “what would make separating from your mother a little easier for you? A little harder?” Answers to these questions are then used to generate an ordered list of challenges to be completed throughout treatment. Importantly, challenges are completed both in session with the clinician and at home, often with caregiver involvement.
Research has shown that exposure is critical in the treatment of youth anxiety (Bouchard, Mendlowitz, Coles, & Franklin, 2004; Kendall et al., 2005; Peris et al., 2015), although exposure use in community clinics remains low (Whiteside, Deacon, Benito, & Stewart, 2016). Several theories have been proposed to explain exposure efficacy, including the habituation and inhibitory learning models (for a review see Vinograd & Craske, in press). Both models have somewhat contradictory implications for clinical practice (e.g., the importance of expectancy violations are considered more integral to exposure efficacy in the inhibitory learning model), but each model emphasizes the importance of full engagement with the feared stimuli during exposures. Thus, clinicians should be sure to monitor avoidance and accommodating behaviors, or behaviors that serve to decrease youth anxiety in the short-term but maintain anxiety in the long-term by facilitating avoidance.
The reduction of caregiver accommodation is often emphasized. However, clinicians can also inadvertently engage in accommodating behaviors within session. For example, clinicians may not think to decrease subtle methods of distraction during exposure (e.g., not looking at a feared stimuli during a challenge) or allow the youth to decrease the intensity of an exposure unnecessarily. These kinds of clinician accommodating behaviors may seem necessary to preserve the alliance, but research shows that youth ratings of alliance remain stable during this phase of treatment (Kendall et al., 2009).
In general, the cognitive behavioral approach to treatment outlined above achieves response rates of about 60% across randomized controlled trials (Kendall, 2012), which is encouraging. However, future work is needed to better tailor treatment towards the individual. For example, few consistent predictors (variables associated with response across treatment modalities) or moderators (variables that specify which treatments work for whom) of treatment response have been identified and further research in this area is warranted. Findings from such studies can then be leveraged to develop treatments that target variables associated with non-response (e.g., comorbid disorders, family dysfunction), moving the field toward the ultimate goal of person-centered intervention.
Further work is also needed to increase long-term efficacy of youth anxiety treatment. In one of the largest longitudinal examinations of anxious youth, only 21.7% of participating individuals who were randomized into one of four treatment arms [either CBT (Coping Cat), medication, CBT and medication, or pill placebo followed by treatment of their choice] did not meet diagnostic criteria for an anxiety disorder at some point throughout four years of naturalistic follow-up (Ginsburg et al., 2018). Given the prevalence (Costello, Mustillo, Erkanli, Keeler, & Angold, 2003; Merikangas et al., 2010), impairment (Langley, Bergman, McCracken, & Piacentini, 2004), and negative sequalae (Swan & Kendall, 2016; Woodward & Fergusson, 2001) associated with anxiety in youth, best practices for maintaining treatment gains warrants additional examination so that long-term efficacy of CBT can be further enhanced.
Lesley Norris is a fourth-year doctoral student in the clinical psychology program at Temple University working with Dr. Philip Kendall. Lesley’s research interests center around the development of individualized interventions for anxious youth, with a focus on identifying baseline predictors and moderators of response and non-response to treatment. Clinically, Lesley is interested in the use of exposure-based treatments, including cognitive behavioral therapy for anxious youth and prolonged exposure therapy for those who have dealt with trauma.
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