1. Chapter 8: Anxiety Disorders in Adolescents Michael A. Mallott Deborah C. Beidel

2. Overview Adolescence: physical, social, psychological changes Prevalence of anxiety disorders: 12–20% (Costello et al., 2005) Median age of onset appears to fall in early adolescence In adolescents, prevalence is highest for: Specific phobia (19.3%) Social phobia (9.1%) Separation anxiety disorder (7.6%) Post-traumatic stress disorder (5.0%) Agoraphobia (2.4%) Panic disorder (2.3%) General anxiety disorder (GAD) (2.2%)

3. Evidence-Based Approaches Cognitive behavioral therapy (CBT) recognized as treatment of choice for adolescents with anxiety disorders Implementation of CBT interventions is often transdiagnostic Allows for implementation across the broad spectrum of anxiety disorders CBT protocols follow similar formats: psychoeducation, skills training (somatic management and problem solving), cognitive restructuring, exposure, and relapse prevention (Veltin et al., 2004)

4. Psychoeducation First part of treatment Didactic in nature Provides rationale for CBT Psychoeducation portion of treatment serves as foundation for other components introduced later in treatment

5. Coping Skills Training Typically after psychoeducation Focuses on managing somatic symptoms through use of relaxation training and/or problem solving skills E.g., C.A.T. project—adolescent version of the Coping Cat protocol Teaches adolescents how to engage in relaxation techniques (e.g., deep breathing) and identify the presence of somatic cues that indicate the need to implement coping responses

6. Cognitive Restructuring Cognitive processes may play a causal role in the development and maintenance of post-traumatic stress disorder Specific cognitive coping skills may be associated with problematic anxiety May differentiate anxiety-disordered and nonanxious adolescents General goal: identification of thoughts that may serve to produce or perpetuate anxiety and use of techniques to challenge these thoughts Therapists help identify inaccurate and negative thought patterns

7. Exposure Essential feature of treatment for anxiety reduction Graduated: less feared situations are attempted before more challenging ones Typically, 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., reduction or elimination of anxiety in the situation) If situation cannot be re-created in the clinic, can conduct imaginal exposure Imagine feared stimuli using mental sensory cues to produce an accurate and realistic depiction of the feared stimuli

8. Exposure Procedure Develop list of anxiety-provoking situations Through self-report scales, interviews, diaries, and/or behavioral observations Rate identified situations according to amount of anxiety elicited Rate using a Subjective Units of Distress Scale (SUDS); use smaller numbers (e.g., 0–8 scale) and visual aids (e.g., fear thermometer) SUDS ratings are used to determine which situations will be addressed first in treatment (e.g., situations with smaller SUDS numbers will be addressed first) Exposing the adolescent to these situations according to a graded hierarchy

9. Relapse Prevention Last element of many CBT protocols Consolidation of skills and experiences Increases independent implementation of strategies by the adolescent Sessions become less frequent (e.g., weekly to biweekly) “Booster” sessions may occur

10. CBT for Social Anxiety Socially phobic children do not respond as well to transdiagnostic CBT protocols as children with other anxiety disorders (Crawley et al., 2008) Often focus on the development of social skills Example: Social Effectiveness Therapy for Children and Adolescents (SET-C) 12 sessions Focus on teaching and practicing social skills (e.g., conversational skills, establishing and maintaining friendships, appropriate assertiveness) Many delivered in group format Some include nonanxious peers (e.g., Beidel et al., 2000)

11. CBT: Panic Disorder and Agoraphobia Panic control treatment (e.g., Mattis et al., 2001) Includes: psychoeducation, skills training, cognitive restructuring, exposure, relapse prevention Focus of elements: specific to symptoms of panic disorder and agoraphobic avoidance Unique aspects of PCT: 1) Includes breathing retraining to counteract the hyperventilatory response associated with panic disorder 2) Focuses on interoceptive cues in exposure

12. CBT: Generalized Anxiety Disorder Most transdiagnostic treatments for adolescent anxiety were developed to treat a cluster of anxiety disorders including GAD, and some have begun to be tailored for GAD (e.g., Payne et al., 2001) Tailored treatments focus on individual elements of CBT most related to GAD clinical syndrome E.g., emphasize remediating problematic worry and develop better tolerance to uncertainty in cognitive restructuring and exposure Length of treatment and resources involved in implementing treatment protocols varies 6–24 sessions most treatments 10-15 sessions

13. Parental Involvement Mixed findings for adolescents Some studies report that parental involvement in treatment may lead to better outcomes, but these better outcomes may be limited to younger children (Barrett et al., 1996) Four relevant characteristics of parental anxiety: 1) Parental overinvolvement/overcontrol 2) Parental assumptions/beliefs 3) Modeling/reinforcement of anxiety behavior 4) Family conflict/dysfunction

14. Adaptations and Modifications Developmental issues Wide range of physical, cognitive, emotional maturation found even among same-aged adolescents (Oetzel & Scherer, 2003) Treatment delivery Using group format may reduce the cost and burden of treatment vs. typical individual treatment Computer-based delivery Preliminary evidence for effective delivery of anxiety treatments (e.g., BRAVE transdiagnostic anxiety treatment; March et al., 2009) Potential for technology to augment or replace typical delivery of CBT

15. Measuring Treatment Effects Use of multiple informants provides the most robust outcome data (De Los Reyes et al., 2011) ADIS: commonly used semistructured interview that assess the presence of anxiety, mood, and externalizing disorders MASC: self-report measure that assesses overall anxiety and subscale scores for physical symptoms of anxiety, social anxiety, harm avoidance, and separation/panic CBCL: self-, parent-, and teacher-report available on multiple symptom scales

16. Disorder-Specific Measures SPAI-C: self-report to measure somatic, cognitive, and behavioral symptoms associated with social phobia SAS-A: self-report measure for total social anxiety, fear of negative evaluation, social avoidance, distress specific to new situations, and generalized social avoidance and distress CASI: self-report of anxiety sensitivity (related to panic disorder) PSWQ-C: self-report measure of worry in children and adolescents; used to assess GAD

17. Clinical Case Example: Tyler 14 years old Diagnosis: Social Anxiety Disorder Presentation: anxiety elicited by being evaluated (e.g., speaking to boys his own age)

18. Clinical Case Example: Treatment Social Effectiveness Therapy for Children (SET-C) Two sessions per week Social skills training: social environment awareness, conversational skills, interpersonal skills enhancement 24 sessions Outcome: developed friendships, reduction in parent- and self-reported social anxiety