Chapter 8: Anxiety Disorders in Adolescents

Michael A. Mallott

Deborah C. Beidel

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%)

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)

Psychoeducation

First part of treatmentDidactic in natureProvides rationale for CBTPsychoeducation portion of treatment serves as

foundation for other components introduced later in treatment

Coping Skills Training

Typically after psychoeducation

Focuses on managing somatic symptoms through use of relaxation training and/or problem solving skillsE.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

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 anxietyMay 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 thoughtsTherapists help identify inaccurate and negative thought

patterns

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 exposureImagine feared stimuli using mental sensory cues to produce an

accurate and realistic depiction of the feared stimuli

Exposure Procedure

Develop list of anxiety-provoking situationsThrough self-report scales, interviews, diaries, and/or behavioral

observations

Rate identified situations according to amount of anxiety elicitedRate 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

Relapse Prevention

Last element of many CBT protocolsConsolidation of skills and experiencesIncreases independent implementation of

strategies by the adolescent Sessions become less frequent (e.g., weekly to

biweekly)“Booster” sessions may occur

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 formatSome include nonanxious peers (e.g., Beidel et al., 2000)

CBT: Panic Disorder and Agoraphobia

Panic control treatment (e.g., Mattis et al., 2001)Includes: psychoeducation, skills training, cognitive

restructuring, exposure, relapse preventionFocus 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 disorder2) Focuses on interoceptive cues in exposure

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 syndromeE.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 varies6–24 sessions most treatments 10-15 sessions

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/overcontrol2) Parental assumptions/beliefs3) Modeling/reinforcement of anxiety behavior4) Family conflict/dysfunction

Adaptations and Modifications

Developmental issuesWide range of physical, cognitive, emotional maturation

found even among same-aged adolescents (Oetzel & Scherer, 2003)

Treatment deliveryUsing group format may reduce the cost and burden of

treatment vs. typical individual treatmentComputer-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

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

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

Clinical Case Example: Tyler

14 years oldDiagnosis: Social Anxiety DisorderPresentation: anxiety elicited by being evaluated

(e.g., speaking to boys his own age)

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 sessionsOutcome: developed friendships, reduction in

parent- and self-reported social anxiety