According to Wagner (
2003), developmentally appropriate treatments for adolescents are those which “…take into account the unique developmental issues and problems characteristic of adolescence (e.g., ascendancy of the peer group, identity formation issues, propensity toward limit testing)” (Wagner
2003, p. 1349). In relation to CBT specifically, Grave and Blissett (
2004) noted that a developmental perspective needs to be incorporated into cognitive behavioral models and treatment design, as well as the delivery of CBT. In sum, a developmentally appropriate CBT for adolescents will account for the young person’s developmental context, their needs, and their capacities.
In discussions in the literature about treatment with adolescents, numerous suggestions have been made about how to take developmental factors into account when working with this group (e.g., Bedrosian
1981; Kendall and Williams
1986; Miller
1993; Wilkes et al.
1994). These suggestions are diverse and sometimes divergent, referring to just one or two developmental factors, as opposed to a broad spectrum of factors, or referring to specific protocols rather than making recommendations relevant to the design and delivery of CBT more generally. Few of the suggestions are specific to the treatment of anxiety in adolescents, and fewer still are empirically based. The lack of (empirically based) knowledge about how to account for developmental factors in the treatment of adolescent anxiety may be attributable in part to the ‘developmental level uniformity myth’ (Kendall
1984), which assumes that young people are a homogenous group. As a result, differences in the biological, social-emotional, psychosocial, and cognitive development of young people are overlooked. According to Holmbeck et al. (
2006), a ‘one size fits all’ approach is often used in the design and delivery of treatment. Given the heterogeneity which characterizes the adolescent period, the assumption that ‘one size fits all’ may have particularly negative consequences for treatment outcomes.
Fortunately, researchers and clinicians have begun to pay greater attention to developmental factors when designing, delivering, and evaluating CBT for adolescents. In the most recent of Holmbeck et al.’s (
2006) reviews of the application of CBT with adolescents, it was reported that 70% of the 29 empirical articles appearing between 1999 and 2004 mentioned developmental issues in treatment design and evaluation, an increase from 26% between 1990 and 1998. For the current review, a search of (English-language) empirical articles and treatment manuals was done for the period from 1990 to the present, using various combinations of the terms ‘adolescence’, ‘cognitive behavioral therapy,’ and ‘anxiety’. The results of this search are presented in Table
1, which provides a descriptive overview of a number of CBTs for anxiety in adolescence which explicitly emphasized developmental factors in treatment design and/or delivery.
Table 1
Examples of developmentally informed adaptations to CBT for anxious adolescents
Angelosante et al. ( 2009) | Treatment description and case study (n = 2) | 12–17 | Adolescent panic control treatment with in vivo exposures with (APE + fam) or without family involvement (APE) | Panic disorder and agoraphobia | Briefer and more intensive treatment to allow young people to more quickly return to developmentally important activities |
Included clinician-assisted in vivo exposures, to guide the adolescents in their execution rather than letting them do them unsupervised at home |
Parents/caregivers (in APE + fam) engaged as coaches |
Assessment of motivation pre-treatment and motivational enhancement techniques used in session |
Manual adapted to include developmentally appropriate and concrete examples, less technical language, and sentence structure was simplified |
Gradual transfer of responsibility and ownership of the treatment from clinician to the adolescent |
| Empirical study (n = 5) | 14–16 | Cool teens CD-ROM for anxiety disorders in adolescents (CBT) | Anxiety | Interactive multimedia presentation (text, audio, illustrations, cartoons, and live video) with examples and presentation relevant to adolescent clients |
Treatment delivered in a new media (computer-based treatment) suited to adolescents (allows for personal control and flexibility; reduces stigma of receiving treatment) |
Involvement of young people during content creation |
| Treatment description and case study (n = 2) | 13–17 | Online CBT for child and adolescent anxiety (BRAVE–ONLINE)—Teenage version | Anxiety | Interactive multimedia presentation (online, via internet) |
Visually appealing and interesting (bright, eye-catching graphics including real-life pictures) |
More complex text, examples, and stories, more advanced graphics, and interspersed with a greater number of interactive exercises (e.g., “quizzes”) than child version |
Aimed at a minimum reading level of age 12 |
Use of teenage characters as “models” for the use of coping strategies to overcome anxiety problems |
| Empirical study (Phase i, n = 8, Phase ii, n = 11) | 12 –18 | Cognitive behavioral and attachment-based family therapy | Anxiety | CBT components taught more quickly |
Cognitive therapeutic strategies emphasized |
Level of parent involvement in exposures negotiated as part of overall treatment focus of negotiating a balance of competency, autonomy, and attachment to parents |
| Empirical study (n = 79) | 7–18 | Dutch adaptation of the Coping Cat program (Kendall 1990) | Anxiety | Extra workbook pages added for adolescents (e.g., less childish; more in-depth explanation and application of cognitive techniques such as challenging thoughts) |
Ginsburg and Drake ( 2002) | Empirical study (n = 6) | 14–17 | School-based group CBT for African-American adolescents | Anxiety | Manual adapted to be developmentally appropriate and culturally sensitive |
Adolescent-relevant examples included |
Parents not included due to time constraints and scheduling conflicts |
| Treatment manual | 14–17 | The C.A.T Project (CBT) | Anxiety | Adolescent can choose their own name for the program (i.e., their own interpretation of the initials C.A.T.) |
More detailed psychoeducational material |
Reduced emphasis on affective education |
Cognitive therapeutic strategies emphasized |
Increased adolescent autonomy in the context of parental overprotection and control |
Scapillato and Manassis ( 2002) | Treatment description | 12 –15 | Group CBT | Anxiety | Group format |
Cohesion-building introductory group activities |
| Treatment manual | 12 –16 | Friends for youth (CBT) | Anxiety | Group format |
Features age-appropriate content, activities, and illustrations |
More room for group discussion rather than didactic interaction in treatment session |
Less attention to affective education |
Emphasis on self-esteem building and friendship skills |
More attention to challenging negative thinking |
Hoffman and Mattis ( 2000) | Case study (n = 2) | 13 | Panic control treatment (CBT-based) | Panic disorder | Clear, simplified language and verbal and visual examples used |
Lively examples of concepts incorporated |
New terms/analogies designed to help adolescents understand and recall concepts |
Parents involved in some sessions as ‘coaches’ |
Focus on active, experiential aspects of treatment over technical psychoeducational information |
| Treatment description | 13–17 | Cognitive-behavioral group treatment for adolescents | Social phobia | Group format |
Protocol was a downward extension of the adult version of the treatment |
| Empirical study (n = 5) | | | | Fears and anxieties are evaluated within a developmental context |
Presentation of case formulation to increase motivation and normalize problems |
Parent involvement in four sessions (psychoeducation, how to support child) |
Inclusion of behavioral social skills training |
More modeling, role playing, and behavior shaping in the first four sessions, with a shift toward active participation later |
Use of workbooks and handouts |
Focus on typical feared situations for adolescents (‘snack time practice’) |
| Empirical study (multiple baseline design; n = 4) | 13–17 | CBT | Panic disorder with agoraphobia | Parent involvement in exposure practice |
Conducting Assessment of CBT-Relevant (Cognitive) Capacities
In the literature on clinical child and adolescent psychology, the inclusion of developmentally appropriate measures to assess pre- and post-treatment functioning is often stressed (e.g., Eyberg et al.
1998). In addition to developmentally appropriate outcome measures, Hudson et al. (
2002) and Shirk (
1999) recommended that clinicians and researchers should attempt to assess a range of developmental factors prior to starting CBT with an anxious adolescent client. While age is a frequently used developmental marker for both clinicians and researchers, specific indicators of development may be more informative and meaningful, given young people of the same age may vary greatly in developmental status. Including such measures could allow for an exploration of the way in which developmental factors influence engagement in treatment, and in turn treatment outcomes (D’Amico et al.
2005; Wagner
2003). There are many readily available pen-and-paper measures for a wide variety of developmental factors (e.g., the Pubertal Developmental Scale; Petersen et al.
1988; the Adolescent Autonomy Questionnaire; Noom et al.
2001).
The assessment of CBT-relevant cognitive capacities is also particularly useful prior to starting CBT. Clinicians will often ‘estimate’ a client’s CBT-relevant cognitive capacities on the basis of a client’s chronological age, their physical appearance, or their IQ, and then use this estimate to adjust the delivery of cognitive therapeutic techniques to the perceived capacities of the client. However, the young person’s level of physical or intellectual development may not necessarily predict development in CBT-relevant cognitive capacities (Kendall and Williams
1986; Kinney
1991). Hence, such estimations can lead to inaccurate predictions about the extent of a young person’s ability to engage in cognitive therapeutic techniques (Weisz and Hawley
2002; Weisz and Weiss
1989; Wilkes and Belsher
1994). As noted by Holmbeck et al. (
2006), however, there is currently “…no straightforward user-friendly method of assessing level of cognitive development across different cognitive sub-domains” (p. 448). These authors proffered a number of suggestions for the assessment of cognitive capacities in adolescents. The clinician might make use of measures such as the similarities subtest of the WISC-IV (Wechsler
2003) in order to tap into abstract reasoning. The Selman’s Interpersonal Understanding Interview (Selman and Lavin
1979) might be used to measure social perspective taking. A more recent development is the Self-Reflection and Insight Scale for Youth (Sauter et al.
2009). This psychometrically sound and developmentally appropriate self-report measure provides another means of exploring a young person’s proficiency in cognitive capacities deemed relevant to CBT; namely self-reflection and insight.
A possible limitation inherent to such measures is that they tap into cognitive capacities which may only be distally related to the engagement of the young person in CBT, rather than assessing skills directly applicable to CBT (G.N. Holmbeck, personal communication, April 26, 2006). Holmbeck et al. (
2006) suggested that the clinician also conduct informal assessment of cognitive capacities during their sessions with the young person. Several examples of the ‘informal’ assessment of cognitive capacities are found in the literature. To ascertain a young client’s ability to access automatic thoughts, the clinician can ask the client in the assessment phase or early in treatment to recall and describe a recent, difficult situation they have experienced, and “what went through your mind when…?”. If this proves too difficult for the young person, the clinician can ask about what thoughts and feelings the client is currently having, or ask the client “what would someone else think in the situation?” (Stallard
2002b). Visual aids such as thought bubbles or cognitive cartoons can also be applied to informally assess cognitive capacities relevant to CBT (Kendall
2000; McAdam
1986; Stallard
2009). A number of interactive tasks designed to tap into the cognitive capacities relevant to CBT have been evaluated with young children, and these may also be suitable for use with less mature and/or less verbal adolescents (Doherr et al.
2005; Quakley et al.
2004; Reynolds et al.
2006). Anxious adolescents may have particular difficulties in describing their feelings and thoughts, due to both fears of negative evaluation and performance-related anxiety (Hudson et al.
2002). Therefore, the use of more formal means of assessing cognitive capacities (i.e., structured tasks or questionnaires) could be used if the clinician thinks the client’s anxiety levels may interfere with what is yielded during informal assessment.
Enhancing Motivation and Engagement in Treatment
The capacity to learn and to use the skills included in a CBT program is fundamental to engagement in CBT, but capacity is certainly not the only determinant of engagement. Engagement in CBT, as described by Shirk and Karver (
2006), involves developing a therapeutic alliance; being open to applying strategies aimed at achieving changes to thoughts, feelings, and behaviors; and being actively involved in treatment during and between sessions. According to Willner (
2006), a client’s willingness or motivation to engage in treatment and to remain engaged in treatment may be just as important to treatment success as is having the capacity to use treatment skills. Weisz and Hawley (
2002) proposed that low motivation for treatment may negatively influence the development of the therapeutic alliance between the adolescent client and the clinician, which in turn may reduce engagement in treatment and have a detrimental effect on treatment success.
An adolescent’s motivation for treatment and for engagement in treatment can be influenced to some extent by developmental factors (Holmbeck et al.
2006). The social context impacts upon the life of the adolescent, and this is true with respect to participation in treatment. It is often others in the adolescent’s context (e.g., parents or school staff) who make decisions about the adolescent getting help. When adolescents are referred for treatment by other parties they may not experience their ‘problem’ as one needing treatment (McAdam
1986; Rubenstein
2003; Weisz and Hawley
2002). Young people with anxiety may be afraid to give up inappropriate coping strategies (e.g., avoidance), play down or deny the negative consequences of their anxieties, and be reluctant to engage in treatment (Stallard
2009). Adolescent ‘egocentrism’ and a reduced capacity for self-reflection are other developmental factors that can make it difficult for some young people to accept their difficulties (Bedrosian
1981). According to Stallard (
2002b), the adolescent’s desire to function autonomously can lead to frustration regarding their inability to ‘solve their own problems’ which can lead to resistance, detachment or disengagement from treatment. As noted above, impairment in the therapeutic alliance can then affect the adoption and generalization of adaptive coping skills.
The adolescent client’s motivation for treatment warrants early and continued attention. In the early phase of treatment, the clinician can assess motivation via self-report measures (Weisz and Hawley
2002). Schmidt (
2005) recommended incorporating an informal in-session investigation of motivation during CBT with young people. Strategies to assess and stimulate motivation recommended by Schmidt include: (i) using a visual analogue scale to measure the willingness to change; (ii) providing extra psychoeducation; (iii) boosting the client’s confidence in their ability to change; (iv) questioning around discrepancies between values and current behaviors; and (v) orienting the client to their own personal goals. With respect to this last point, Stallard (
2002b) also noted that working together with the young person to set goals can increase motivation for engagement in treatment, as can encouraging the young person to offer input for the agenda for each session. Explaining clearly to the adolescent ‘what is in it for them’ in terms of the potential costs and benefits of treatment, and even proposing a time-limited agreement in which to evaluate the benefits of the sessions may help to engage even the most resistant young person in CBT (Angelosante et al.
2009; Bedrosian
1981; Oetzel and Scherer
2003; Wilson and Sysko
2006). Clinical experience suggests that using ‘adolescent-relevant’ means of communication before and between sessions (e.g., an email to invite the young person to attend the first session) can enhance their motivation for treatment. Many of the foregoing points are reflective of Motivational Interviewing techniques which have been recommended for increasing the engagement of anxious clients (Stallard
2009) and adolescent clients (Wilson and Sysko
2006).
CBT is in itself already oriented toward enhancing client motivation for change and engagement in treatment. An essential characteristic of CBT is the “collaborative empiricist stance” of the CBT clinician (McAdam
1986, p. 6), and this stance is regarded as a necessary ingredient for successfully building a therapeutic alliance (Friedberg and Gorman
2007; Kingery et al.
2006). Because adolescents differ in the degree to which they are able to co-operate with the clinician as an ‘equal partner’, the clinician would ideally modify their approach accordingly. Adolescents with a greater ability to self-reflect and to control their impulses can be encouraged to collaborate more with the clinician (e.g., increased involvement in, and control over, the treatment planning process; Chronis et al.
2006; Forehand and Wierson
1993). Less mature adolescents may benefit from the clinician’s use of a more directive approach (e.g., setting the agenda and determining the session content; Friedberg and Gorman
2007; Friedberg and McClure
2002).
Oetzel and Scherer (
2003) argued that a judicious use of empathy and positive regard is an essential tool to motivate adolescents for treatment. The clinician can help adolescent clients to ‘save face’ and to boost their self-esteem by empathically responding to their problems and paying attention to areas of the young person’s life which are going well. By so doing, the clinician works with and not against the ‘egocentrism’ which often characterizes an adolescent’s view of themselves and their position in the world (Stallard
2002b). However, too much empathy can seem less than genuine. Because adolescents seem to be able to detect insincerity and ‘fakeness’ from a mile away, they may respond better to “disciplined, benevolent frankness” (Edgette
1999, p. 40). The extent to which adolescent clients may be intrigued or else confused by such ‘frankness’ will vary, and the use of this motivational strategy needs to be carefully tailored to the individual client (Edgette
1999; Oetzel and Scherer
2003).
Clinical experience suggests a number of strategies that may help to motivate and engage young people in CBT for anxiety. Due to their strivings for autonomy, allowing adolescent clients to have input into the nature of exposure tasks to be conducted in-session and between-sessions, can enhance their co-operation with treatment plans (Kendall et al.
2005; Ollendick
1995). For example, Heyne and Rollings (
2002) recommended giving adolescents with anxiety-based school refusal more input into the decision-making about the type of exposure to be engaged in (i.e., graded school return vis-à-vis immediate full-time return). While having a say in the type of exposure tasks may be useful to motivate some young people, Angelosante et al. (
2009) suggested that adolescents may also value increased clinician guidance of exposure tasks, to give them an extra ‘push’ to confront anxiety-provoking stimuli. The authors also recommend reminding the anxious adolescents of the potential positive effects of treatment to reduce resistance to engaging in exposure.
Heyne and Rollings (
2002) also noted that it can be particularly challenging to engage anxious adolescent school refusers in treatment. They used an acronym (i.e., HARD GOING) to encapsulate behaviors and attitudes which the clinician can employ to increase the likelihood that an adolescent client will be engaged in treatment. These include: honoring the client’s perspectives; active listening; relating to the young person in an understanding and tolerant manner; demystifying the young person’s experiences of the intervention process; (attending to broader) goals of the young person (the fostering of positive); opinions about the young person (informed); interpretations of a young person’s behavior in treatment; negotiating with the young person about the process of treatment; and going about engaging the young person in treatment in a cautious and realistic manner.
Tailoring Treatment Language, Materials, Activities, and the Tempo of Treatment Delivery
It is often noted that many of the CBTs applied with adolescents have been downward extensions of treatment protocols designed for adults or upward extensions of protocols designed for children (D’Amico et al.
2005; Eyberg et al.
1998; Holmbeck et al.
2006; Weisz and Hawley
2002). Characteristics of these adult and child protocols—including language, materials, activities, and tempo of treatment delivery—do not automatically ‘fit’ the developmental needs of the adolescent age group. Adult protocols can be too ‘taxing’ for the adolescent, and as noted by Southam-Gerow et al. (
2001), the exercises and assignments associated with child protocols may be experienced by older youth as “somewhat childish” (p. 432). For treatment to be “real and relevant” for the young person (Friedberg and Gorman
2007, p. 188), developmental tailoring would ideally occur with respect to language, materials, activities, and the tempo of treatment delivery. This tailoring can facilitate the adolescent client’s engagement in treatment, which in turn increases the likelihood that the knowledge and skills addressed in sessions are understood and applied.
The question of language use in treatment has been discussed by many authors, including authors concerned with tailoring CBT for anxious adolescents (e.g., Siqueland et al.
2005). Complex therapeutic concepts can be made less adult-oriented and more ‘adolescent-friendly’ by employing the client’s own vocabulary; using clear, simplified language; and by giving specific, task-orientated instructions (Ginsburg and Drake
2002; Kingery et al.
2006; Wilson and Sysko
2006). At the same time, adolescent ‘slang’ and idiom must be used carefully, as they may come across as unnatural or fake (Friedberg and McClure
2002). Likewise, simplification in the form of concrete examples and basic terms may appear condescending for some mature adolescents (Oetzel and Scherer
2003; Werner-Wilson
2001). These mature adolescents may profit more from a detailed rationale for why the therapeutic techniques are useful (Braswell and Kendall
2001; Ollendick et al.
2001; Zarb
1992). A further language-based consideration arises out of the tendency for adolescents to think in ‘black-and-white’ terms (e.g., “good” versus “bad”; “right” versus “wrong”) (Wilkes et al.
1994). Stallard (
2002b) suggested that the clinician use terms which imply dimensionality (e.g., “better” and “worse”) rather than dichotomy, in order to neutralize such typical adolescent thinking. When delivering cognitive therapeutic interventions, the clinician may speak of “less anxiety-producing thoughts” and “more anxiety-producing thoughts.”
Metaphors and mnemonic aids are other language-based strategies which can help young people to learn and remember the steps of certain therapeutic techniques (Kendall et al.
2002). Well known examples are the ‘FEAR’ and ‘FRIENDS’ acronyms representing the key steps for managing anxiety in respectively the Coping Cat (Kendall
2000) and Friends for Youth (Barrett, Lowry-Webster, and Turner
2000) CBT programs. Friedberg and McClure (
2002) suggested the use of a ‘caterpillar’ (unhelpful) thoughts and ‘butterfly’ (helpful) thoughts metaphor for younger children. More adolescent-appropriate metaphors also exist. Automatic thoughts can be positioned as ‘pop-ups’, or ‘spam’ in your computer, and dealing with negative thoughts a process of “building a better firewall” (Stallard
2009, p. 160). A mnemonic like
WWW.Problem-solved.com may be particularly relevant for adolescents, representing the steps of problem solving (What is the problem?; What are the options for solving the problem?; Which will I choose?; Is the Problem Solved?).
The extent to which therapeutic activities are verbally based or non-verbally based can be adapted to match individual differences in adolescent clients. For example, increases in social perspective taking skills and fears of negative evaluation may lead some adolescents to feel embarrassed about talking about their anxieties (Hudson et al.
2002; Stallard
2009). Some adolescents may therefore feel uncomfortable with face-to-face dialogues and with ‘why’ questions during treatment (Bedrosian
1981). For these young people, the suggestions made by Bailey (
2001) and Bedrosian (
1981) seem fitting. That is, it may be useful to reduce the number of didactic explanations and the amount of ‘deep and meaningful time’ to avoid awkward silences, choosing instead to engage the adolescent in informal but therapeutically relevant conversation during therapeutic activities. Other adolescents will be highly ‘talkative’ and their verbosity can have the potential to interfere with engagement in specific CBT-related activities. In these cases, the clinician can structure client ventilation through the application of interviewing skills such as summarizing, minimal encouragers, and reflections (Edgette
1999,
2002; McAdam
1986).
Treatment which is not solely verbally based, but which involves materials providing pictorial representations of treatment-related tasks, may help to engage children and adolescents in treatment and allow them to more effectively apply therapeutic tasks (Grave and Blissett
2004). Visually oriented materials which can be used when delivering CBT with adolescents include: (i) handouts, for example, presenting somatic anxiety symptoms (e.g., Stallard
2002b); (ii) a flip-over or a whiteboard; (iii) visual analogue scales for rating the strength of emotions or thoughts (e.g., Chorpita
2007); (iv) pictures/drawings to identify self-talk (e.g., thought bubbles; Kendall
2000); and (v) diagrams when challenging maladaptive thoughts (e.g., responsibility and tolerance pies, the awfulizing scale; Friedberg and McClure
2002). However, the clinician must ensure that these materials are matched to the developmental level of the young person; adolescents in particular may find some materials patronizing or juvenile (Stallard
2009).
Just as visually oriented materials can enhance engagement in treatment, so too can the use of enactive procedures. Activities involving real-life demonstrations, such as games, role plays, or visualization exercises can stimulate active participation in the therapeutic process (Hoffman and Mattis
2000; Siqueland et al.
2005). An activity like ‘thought football’ (Friedberg and McClure
2002), used to detect automatic thoughts, may be particularly appropriate for adolescents due to its interactive and playful approach. The clinician asks the young person to throw balls of paper into a hoop, and the young person must say what they think and feel about every attempt they have made. When combined with guided questioning by the clinician, this activity can help the young person to more quickly become aware of their inner dialogue. For example, the client can be asked to observe what happens to their thoughts and feelings when the clinician increases the pressure on the young person by making negative predictions (e.g., “you’ll miss it for sure”). Stallard (
2009) suggested that drawing, writing poetry, or composing songs may also be therapeutic activities which may by useful in allowing adolescents to describe their thoughts and feelings. Role plays, in which the client and clinician apply therapeutic techniques, can be especially helpful in preparing the client for challenging situations in ‘real life’. In the case of social anxiety, adolescents can engage in in-session role plays to practice activities they find anxiety-provoking, such as initiating conversations, asking someone out on a date, or giving a talk (Albano et al.
1995). However, the young person’s level of abstract reasoning may limit their ability to participate in role plays (Holmbeck et al.
2000). In these cases, the clinician may choose to firstly work with cartoon sequences which tell a story, prior to engaging the young person in short and structured role plays.
Two recent developments focused on CBT for anxious adolescents incorporate developmentally sensitive recommendations for treatment materials and activities. Cunningham et al. (
2009) described the development of the Cool Teens program, CD-ROM-based CBT for anxious adolescents. This interactive media allows the adolescent to choose the order and tempo with which they cover the treatment modules. The high degree of personal control was regarded as particularly suited to adolescent clients in view of their strivings for independence. Further, the graphics (cartoons and animations), sound effects, and live video content were developed in consultation with adolescents to ensure that the materials would be relevant to the target age group. Another recent CBT for anxious young people is the BRAVE-ONLINE program developed by Spence et al. (
2008). This program has a separate adolescent version for 13–17 year olds. Relative to the child version, the adolescent version includes more complex psychoeducational information, more advanced graphics, and more interactive activities such as quizzes.
Other developmentally oriented recommendations are found in the literature focused upon exposure, a major component of CBT for anxiety. Kendall et al. (
2005) and Kingery et al. (
2006) suggested that the clinician make developmentally informed decisions about: (i) the type of exposure tasks to focus upon (e.g., considering situations more likely to be avoided in adolescence, such as eating in the school canteen); (ii) the complexity of information provided in the rationale for engaging in exposure tasks (e.g., less mature young people may benefit from a clear and concise explanation of how exposure ‘works’. Other young people may benefit from a detailed and theoretical explanation of the mechanisms of the technique, such that they understand how they themselves can be responsible for dealing with their distress); and (iii) the type of monitoring that the young person can carry out by themselves (e.g., less mature young people may require a simplified scale to indicate the intensity of anxious symptoms). Siqueland et al. (
2005) also suggested that anxious adolescents may be encouraged to engage in more between-session exposure tasks relative to anxious children (Siqueland et al.
2005). The question of parental involvement in exposure tasks with adolescents is addressed in
“Involving Parents in Treatment”.
Finally, consideration needs to be given to the tempo at which the CBT program is delivered with adolescent clients. According to Bailey (
2001) and Bedrosian (
1981), a reduced concentration span, combined with the cognitively demanding nature of self-disclosure and self-reflection, signal the value of conducting shorter CBT sessions with children and with adolescents. Session agendas are a common element of CBT, and these agendas are important for the optimization of treatment time. The process of developing a session agenda with an adolescent needs to account for the range of developmental issues already mentioned (e.g., the extent of participation in setting up the agenda in line with the adolescent’s level of autonomy development; attention to important adolescent tasks and transitions in terms of agenda points) (McAdam
1986). An example in which clinicians have adjusted the tempo of a CBT program for anxious adolescents can be found in Siqueland et al.’s (
2005) attachment-based family CBT. It was suggested that the primary skills addressed in the adolescent sessions (i.e., recognizing anxious symptoms; identifying anxious cognition; developing a plan to cope with the situation; and evaluating and reinforcing one’s performance) can be taught more quickly to adolescents relative to children (i.e., in three to four sessions as opposed to the eight sessions specified in a related CBT manual for anxious children).
Involving Parents in Treatment
Parents play a significant role in the life and ‘developmental trajectory’ of their adolescent child. By the same token, parent and family factors may be associated with the development or maintenance of anxiety disorders. (For a more detailed discussion of the role of parent and family factors in the etiology of child anxiety, see Bögels and Brechman-Toussaint
2006 and Ginsburg and Schlossberg
2002). Understandably, it is argued that it is fruitful, and sometimes even necessary to involve parents in interventions for anxious adolescents (Bögels and Siqueland
2006; Ginsburg and Schlossberg
2002; Kendall and Holmbeck
1991).
Current conceptualizations of parent involvement in child and adolescent CBT can help to determine just what kind of role parents might have in the treatment of adolescent anxiety. A commonly cited conceptualization views the parent role as one of ‘consultant’ and ‘facilitator’, ‘collaborator’ and ‘co-clinician’, or ‘co-client’ (e.g., Barmish and Kendall
2005; Kendall
2000; Stallard
2009). When parents are involved as ‘consultants’ they do not actively participate in treatment per se, but they receive psychoeducation about the treatment principles and strategies applied by the clinician and help the clinician by providing information about the young person (Stallard
2009). This information is used to shape the course of treatment with the young person. Parents can also be responsible for getting the young person to treatment sessions (Kingery et al.
2006). As ‘collaborators’, parents can assist their child with the application of therapeutic skills outside of the clinical setting, conforming to the ‘transfer of control’ model (i.e., transfer of knowledge and skills from the clinician to the parents, and then from the parents to the young person; Silverman and Kurtines
1996). For example, the parents can coach their child through the exposure task by preventing evasion of the task, and by prompting and rewarding them upon successful completion. They can also play a key role in monitoring treatment gains (Barmish and Kendall
2005; Suveg et al.
2006b). Parents can also be involved in CBT as ‘co-clients’. The clinician works with the parents to enhance their use of behavior management strategies aimed at modifying their child’s problematic behaviors or their own behaviors which may be involved in the maintenance of the child’s anxiety (Chronis et al.
2006; Hudson et al.
2002; Martin and Thienemann
2005; Suveg et al.
2006b). In addition, parental cognitions which impede the effective use of behavior management strategies can be explored and challenged (Heyne and Rollings
2002; Joyce
1994; Suveg et al.
2006b). Problematic thoughts and beliefs may relate to the developmental appropriateness of the child’s behaviors, the perceived coping capacities of the child, and the ways in which parents should respond to a child’s anxiety symptoms (Kingery et al.
2006; Nauta et al.
2003; Suveg et al.
2006b).
Current parenting behaviors need to be considered when making decisions about the nature of parent involvement in treatment for adolescents. ‘Over-involved’ or intrusive parents may have the tendency to ‘rescue’ their children from anxiety-provoking situations, which can result in the young person having fewer opportunities to deal with challenges in an autonomous manner (Suveg et al.
2006b; Wells and Albano
2005; Wood et al.
2003). It may therefore be desirable to engage these parents as ‘co-clients’ so they can learn skills to address these behaviors which may be involved in the maintenance of their child’s anxiety. ‘Under-involved’ parents may believe that their teenage child is ‘old enough and wise enough to solve their own problems’ (Wells and Albano
2005). These beliefs may prevent parents giving the young person the supportive and firm guidance that they may need when they are unable to ‘face their fears’ by themselves. If the beliefs and behaviors of under-involved parents prove to be rigid, the clinician can shift clinical attention to increasing the young person’s coping repertoire and exploring the social network for other sources of support for the young person (Wells and Albano
2005). In either case, extremes of parental under- or over-involvement are not conducive to treatment success, and a balance between the two is seen to be the most desirable (Suveg et al.
2006b).
Developmental factors also warrant close attention when determining whether and how to involve parents in CBTs for young people’s problems (Albano and Kendall
2002; Barrett
2000; Kendall and Choudhury
2003; Stallard
2009). The large individual differences across the adolescent period and amongst adolescents of the same age are likely to influence what is optimal with respect to parent involvement. Less mature adolescents are more likely to have a stronger emotional orientation to and connection with their parents; these young people may have significant problems in managing their own anxieties if their parents are under-involved (Forehand and Wierson
1993; Martin and Thienemann
2005). According to Wolpert et al. (
2005), parental prompting and monitoring of the child’s use of cognitive-behavioral skills (i.e., parent as ‘collaborator’) is suitable for “younger children”, and especially those with anxiety-related difficulties (p. 113). More mature adolescents are likely to identify more strongly with peers and to attempt to increase their autonomy from parents; these young people may rebel and resist offers of help if parents are (over-)involved (Kingery et al.
2006). The limited parent involvement associated with the ‘consultative’ role can be particularly relevant for this group (Stallard
2009). Indeed, adolescents may value highly the time spent alone with the clinician and become suspicious or resentful if the clinician meets regularly with their parents (Kingery et al.
2006). As noted by Wolpert et al. (
2005), the limited involvement of parents has the potential advantage of empowering the young person. Wolpert and colleagues suggested that minimal parent involvement (i.e., parent as ‘consultant’) is best suited to “older children, who are highly motivated” (p. 112). Developmental factors may also influence decisions about
which parent to involve: Bögels and Siqueland (
2006) suggest that as fathers may be particularly important role models for adolescents, involving them in treatment may be essential in successfully combating adolescent anxiety.
In cases where parents of anxious adolescents have the tendency to be over-involved or under-involved, a number of recommendations may also be relevant. Wells and Albano (
2005) recommended that the clinician working with over-involved parents recognize the parents’ concerns, while simultaneously using psychoeducation to emphasize the developmental tasks of adolescence (e.g., autonomy development) and the implications for parenting (i.e., encouraging the young person in independent problem solving rather than solving the problem themselves). In working with under-involved parents, the clinician can use psychoeducation to emphasize the fact that parents can play an important role in helping adolescents to ‘face their fears’. For example, although the young person may seem ‘all grown up’ in terms of independence from their parents, they are still developing, and they need the guidance of parents to help them in this process (Hudson et al.
2002). In addition, young people who are anxious may sometimes act ‘younger’ than their chronological age (e.g., failing to see the consequences of their behavior; displaying ‘immature’ behavior such as crying or running away), due to their desire to avoid anxiety-provoking situations or stimuli.
In the treatment of adolescent anxiety, it is particularly important to consider the question of parent involvement with respect to exposure-based tasks. In an earlier study, Barlow and Seidner (
1983) recommended that parents be involved in exposure practice in a CBT for adolescent agoraphobia. The authors reported that the adolescent participants seemed to be less able than adult clients to challenge their irrational cognitions related to the panic complaints (i.e., fears of dying). During exposure tasks, the adolescents turned to their parents for ‘help’ with dealing with the anxiety symptoms. How parents react to such requests from their children during exposure practices can range from ‘directive’ responses (e.g., physically guiding the execution of exposure practices between sessions), to ‘supportive’ and autonomy-granting responses (e.g., transporting the client to the exposure setting). Indeed, Siqueland et al. (
2005) developed and evaluated a treatment in which the parents of anxious adolescents were helped to achieve a balance between ‘directive’ parenting and the granting of developmentally appropriate autonomy. In the treatment, parents were engaged in discussions about their role in dealing with their teenage child’s anxiety, and about the most appropriate type and level of involvement that the parents might have in their child’s exposure practice. In addition, as co-clients, parents were helped to identify and reexamine beliefs about anxiety (i.e., as threatening, and something to be avoided) and beliefs about the role of parents with anxious children (e.g., to protect their adolescent child and themselves from anxiety-provoking experiences).
In a similar vein, a CBT program for anxiety-based school refusal in adolescence (Heyne et al.
2008) aims to help the parents of adolescent school refusers achieve a developmentally appropriate balance between ‘directive’ parenting and ‘supportive’ autonomy-granting. Depending on the case formulation, and in particular the role that parenting may play in the maintenance of the school refusal, parents are helped to employ a more supportive, autonomy-granting role or, as required, a more ‘directive’, authoritative role. In the autonomy-granting role, parents issue gentle prompts for appropriate behavior (e.g., successive steps toward school return) and reinforce such behavior in a developmentally appropriate way. At the same time, the adolescent is provided with opportunities to ‘show that he/she can try to face the fear’ without the direct involvement of parents. In the more authoritative role, parents are helped to employ a firmer approach should this be required. In particular, they learn skills with which to extinguish inappropriate behavior (e.g., arguments with parents about school return), and are helped to assume responsibility for determining the timing and process of their adolescent child’s return to regular school attendance.
Involving Peers in Treatment
During adolescence, the peer group becomes increasingly influential in the life of the young person. Adolescents often seek the company of friends rather than parents, and it becomes more and more important for the young person to have skills to be able to ‘fit in’ (Geldard and Geldard
2004; Holmbeck et al.
2006). Given the sense of social isolation that many anxious young people experience, opportunities for involvement with peers can be especially important (Scapillato and Manassis
2002; Kearney
2005). Peers can significantly influence and impact on adolescent attitudes and behavior, and interventions that include peer involvement may have increased efficacy (Jelalian et al.
2006). In addition, feedback from peers can be more reinforcing than that from adults (Forehand and Wierson
1993) and it can be very useful to have source of constructive support in the treatment program for the young person aside from the parents and the clinician. To identify suitable peers (e.g., siblings, classmates, friends), the clinician can ask the young person to nominate a suitable ‘peer assistant’, or query parents or teachers. Well-functioning friends, classmates or siblings can be included in treatment sessions to provide an opportunity for life-like situations in which young clients can practice the skills learned in treatment while still under the supervision of the clinician (La Greca and Prinstein
1999). Peers could also be involved in between-session ‘real-life exposures’ to avoided social situations (e.g., walking to school together; spending time together in the lunch break).
Though the use of peers can be a powerful tool in the enhancement of social competencies, the clinician is advised to consider the level of the young person’s social competency before involving a peer in treatment. For example, to maximize the success of a practice opportunity, Chorpita (
2007) recommended that an anxious child or adolescent should have a basic level of competency before engaging in role playing with peers. For some young people, involving peers may be the last thing they would want, due to their desire to ‘fit in’ and the embarrassment and shame associated with being ‘in therapy’. It is therefore important to involve adolescent clients in the decision-making around the (non)involvement of their peers.
Another way in which the clinician may capitalize on the influential role of the peer group during adolescence is to deliver of CBT in group format rather than in individual format. The results of a number of treatment outcomes studies with anxious children and adolescents indicate that group treatment is as efficacious as individual treatment (e.g., Liber et al.
2008). Group CBT with adolescents permits normalization of experienced difficulties and opportunities for positive social interaction (Scapillato and Manassis
2002). In the case of social anxiety, group members may participate in each other’s exposures (Albano and Barlow
1996). Albano (
1995) even argued that, given the nature of social anxiety disorder, individual treatment for socially anxious adolescents would be “counterintuitive and counterproductive” (pp. 276–277).