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Clin Child Fam Psychol Rev (2009) 12:310–335 DOI 10.

1007/s10567-009-0058-z

Cognitive Behavior Therapy for Anxious Adolescents: Developmental Influences on Treatment Design and Delivery
Floor M. Sauter Æ David Heyne Æ P. Michiel Westenberg

Published online: 1 July 2009 Ó The Author(s) 2009. This article is published with open access at Springerlink.com

Abstract Anxiety disorders in adolescence are common and disruptive, pointing to a need for effective treatments for this age group. Cognitive behavior therapy (CBT) is one of the most popular interventions for adolescent anxiety, and there is empirical support for its application. However, a significant proportion of adolescent clients continue to report anxiety symptoms post-treatment. This paper underscores the need to attend to the unique developmental characteristics of the adolescent period when designing and delivering treatment, in an effort to enhance treatment effectiveness. Informed by the literature from developmental psychology, developmental psychopathology, and clinical child and adolescent psychology, we review the ‘why’ and the ‘how’ of developmentally appropriate CBT for anxious adolescents. ‘Why’ it is important to consider developmental factors in designing and delivering CBT for anxious adolescents is addressed by examining the age-related findings of treatment outcome studies and exploring the influence of developmental factors, including cognitive capacities, on engagement in CBT. ‘How’ clinicians can developmentally tailor CBT for anxious adolescents in six key domains of treatment design and delivery is illustrated with suggestions drawn from both clinically and research-oriented literature. Finally, recommendations are made for research into developmentally appropriate CBT for anxious adolescents. Keywords Cognitive behavior therapy Á Adolescence Á Anxiety Á Development
F. M. Sauter (&) Á D. Heyne Á P. Michiel Westenberg Unit Developmental and Educational Psychology, Leiden University Institute for Psychology, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands e-mail: fsauter@fsw.leidenuniv.nl

Introduction Anxiety is one of the most common disorders among young people (Roberts et al. 2009), and higher rates of anxiety disorders have been reported in adolescence relative to childhood. For example, Newman et al. (1996) found an age-related increase in the prevalence of anxiety disorders in a birth cohort, increasing from 7.5% at 11 years of age to 20.3% at 21 years of age. Similarly, Essau Conradt and Petermann (2000) reported that rates of anxiety disorders increased with age, from 14.7% at 12–13 years, to 22.0% at 16–17 years of age. Although separation anxiety disorder is less prevalent in adolescence relative to childhood (Cohen et al. 1993), other anxiety disorders such as generalized anxiety disorder (Rapee 1991) and social anxiety disorder (Westenberg et al. 2007) are more prevalent in adolescence. The presentation of anxiety in adolescence can be complex, chronic, and severe. Adolescents may be diagnosed with several concurrent anxiety disorders, as well as depression, conduct disorder, and alcohol abuse (Clark et al. 1994; Ollendick et al. 2008). Essau (2008) reported that the most common pattern of comorbidity in both community (n = 185) and clinical (n = 69) samples of adolescents aged 12–17 years was that of depression and anxiety, with comorbidity rates of 31.4 and 47.0% in the community and clinical samples, respectively. There is considerable evidence for the continuity of anxiety disorders into late adolescence and even adulthood (Costello et al. 2003; Kim-Cohen et al. 2003; Kovacs and Devlin 1998). The maladaptive coping mechanisms of anxious young people may become more entrenched over time (Hudson et al. 2002), which may intensify anxious symptoms with age. If left untreated, young people with problematic levels of anxiety often endure short- and long-term

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difficulties in their personal, family, school, and social functioning (Essau et al. 2000; Keller et al. 1992). The adolescent period is a developmental phase defined by transition. Many intrapersonal (e.g., cognitive development), interpersonal (e.g., seeking autonomy from parents), and contextual changes occur simultaneously in family, school, and other contexts; and biological, socialemotional, psychosocial, and cognitive development takes place (Holmbeck et al. 2006; Roeser et al. 1998). Developmental factors such as these are regarded as being important to the development, maintenance, and presentation of anxiety disorders in adolescence (Clark et al. 1994; Gosch et al. 2006). For example, the peak in incidence of social anxiety in adolescence coincides with normal increases in fears of negative evaluation and social embarrassment (Ollendick and Hirshfeld-Becker 2002). At the same time, growing independence may facilitate avoidance behaviors (Rao et al. 2007). These developmental transitions may also impact on a client’s willingness and ability to engage in CBT. Interventions for anxious adolescents can therefore be enhanced by taking into account the unique developmental characteristics of the adolescent period. Several reviews and reports of treatment outcome research allude to the importance of considering development in intervention with young people in general (e.g., Chronis et al. 2006; Kearney and Albano 2000; Kendall et al. 2005; Kendall and Williams 1986; Kinney 1991; Weisz and Hawley 2002) and with anxious young people in particular (Gosch et al. 2006; Kingery et al. 2006; Silverman et al. 2008). Indeed, examples of ‘developmentally appropriate’ treatments for anxious adolescents are beginning to emerge. These are interventions which seek to take into account the young person’s biological, social-emotional, psychosocial, and cognitive development (e.g., Kendall et al. 2002; Siqueland et al. 2005). To date, however, there has been no comprehensive review of the impact that developmental issues may have upon the way in which CBT for adolescent anxiety is designed and delivered. The purpose of the present review is to advance the use of developmentally appropriate CBT for anxious adolescents. We begin by presenting three main arguments for ‘why’ it is important to do so. Subsequently, drawing on clinical and research literature from developmental psychology, developmental psychopathology, and clinical child and adolescent psychology, we review and expand upon suggestions for ‘how’ CBT can be developmentally tailored for anxious adolescents. The review describes developmentally appropriate practice in relation to treatment with young people, developmentally appropriate practice in relation to CBT with young people, and, where possible, developmentally appropriate practice in relation

to CBT with anxious adolescents. In the absence of suggestions from the literature, adaptations relevant to CBT for adolescents with anxiety disorders will be proposed. To conclude, we provide suggestions for future research into developmentally appropriate CBT for anxious adolescents.

‘Why’ Consider Developmental Factors when Designing and Delivering CBT for Anxious Adolescents? Age and Developmental Level May Moderate Treatment Outcome Cognitive behavior therapy (CBT)1 is a widely implemented and evaluated intervention used to treat anxiety disorders. It is an amalgam of behaviorally and cognitively based strategies derived from behavioral and cognitive theories (Sanders and Wills 2005). In CBT, behaviorally based strategies involve the conceptualization of anxious symptoms in terms of conditioned responses to stimuli, with corresponding interventions emphasizing the blocking and extinction of avoidance behavior through exposure. Cognitive therapeutic techniques include self-monitoring of thoughts, feelings, and behavior and cognitive restructuring, aimed at modifying anxiety-related thought content and processes to produce changes in anxiety symptoms (Kendall 2000). Several meta-analyses support the effectiveness of cognitive and behavioral treatments for adult anxiety disorders (Deacon and Abramowitz 2004; Norton and Price 2007) and several recent reviews conclude that there is increasing evidence for the short- and long-term efficacy of CBT for anxiety-related difficulties in childhood and adolescence (Cartwright-Hatton et al. 2004; James et al. 2005; Ollendick and King 1998; Silverman et al. 2008). On average, 60–80% of children and adolescents treated with CBT no longer meet the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for their primary anxiety disorder at post-treatment (Ginsburg and Kingery 2007). As noted by Ginsburg and Kingery (2007), while CBT provides relief of symptoms for many young people, it is clearly not a panacea. A significant proportion of young people treated with cognitive behavioral protocols continue to report clinical and statistical levels of anxiety symptoms post-treatment. In their review of 10 clinical trials examining the efficacy of CBT for anxiety in young
1

Hereafter, the term ‘CBT’ will be used to refer to those interventions which comprise both cognitive and behavioral strategies for change, while the term ‘cognitive therapeutic techniques’ will be used when making specific reference to interventions aimed at cognitive change.

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312 Clin Child Fam Psychol Rev (2009) 12:310–335 people. many adolescents refrain from seeking professional help (Raviv et al. Researchers may combine young people of different ages into single categories (e. As Cartwright-Hatton et al. Zachrisson et al. nature. reducing the reliability and validity of statistical analyses used to examine age effects on treatment outcome. The lack of treatment outcome studies specifically focusing on anxious adolescents is one of the most significant obstacles to drawing conclusions about factors moderating the efficacy of CBT for this particular age group. and length of the transitions experienced by young people vary (Holmbeck et al. Fourthly. and specifically anxiety disorders. An even more important factor impeding our understanding of the efficacy of CBT for anxious adolescents is their under-representation in treatment outcome studies (Cunningham et al. Shirk 1999) and most anxiety treatment outcome studies focus on youth between 7 and 14 years of age (Barrett 2000). 1999. 2006). Firstly.. James et al. the extent to which a young person is engaged in the therapeutic process may influence treatment success 123 . whether older or younger age is likely to be associated with enhanced outcomes is unclear (Hudson et al. younger participants (7–12 years) attained significantly better outcomes than their older counterparts across both conditions (13–18 years.85 years (Compton et al. (2004) revealed that anxiety diagnoses were still present after treatment in more than a third of participants. Large individual differences in developmental pathways and developmental capacities are characteristic of adolescence (Oetzel and Scherer 2003). but these same processes can impact upon the way in which young people engage with the treatment process. Shirk 1999). Within the entire adolescent period.g. In turn. and CBT for anxious youth specifically (e. Yet again other studies report no age effects (e. Cartwright-Hatton et al. 2009. Cobham et al. parents. However. such as the severity and duration of psychopathology. ‘8–13 year olds’ vs. Cobham et al. the type of treatment may influence the outcomes.. 1998) while individual treatment seems to be more helpful for adolescents (e. There are more published treatment outcome studies with children than with adolescents (Roberts et al. However. The lack of clear and consistent age-related patterns in treatment response may be due to a range of factors. 430).. Bodden et al. In another study comparing individual and family-based CBT for anxious youth. rather than applying theoretically driven age-related distinctions (Kendall and Williams 1986.g. 1991). many studies report outcomes in terms of ‘treatment completers’. 2006). In a study examining predictors of CBT outcome for clinically anxious young people. ‘14 years and older’) or compare age categories derived from the sample mean or median. calling into question the applicability of the review findings for adolescents with anxiety. Secondly. 2007.g. 1998). Creswell and Cartwright-Hatton (2007) noted that most treatment outcome studies on CBT for anxious youth are underpowered. Studies and metaanalyses investigating psychotherapy for internalizing disorders in young people (e. (2001) found that older age was associated with poorer outcome posttreatment. which limits the extent to which more sophisticated agerelated moderation analyses can be conducted (Silverman et al. (2004) aptly concluded.g. the number. 1998). when ‘age’ is investigated in treatment outcome studies. 2008).. 2004). 2003. or others. A recent review of 21 studies evaluating the efficacy of CBT for anxious youth found that the average age of the participants was 9. Weisz and Hawley 2002). unlike adolescents displaying externalizing problems. Thirdly. In fact. As such. inasmuch as younger children seem to benefit from CBT with parent or family involvement (e.. Durlak et al.g. Accordingly. ‘‘There is clearly room for considerable improvement in the understanding and treatment of anxiety in this age group’’ (p. 2007). contrary to a priori expectations. Southam-Gerow et al. Barrett et al. 2008).g. Age is one variable which has been suggested to be associated with CBT outcomes. is very high amongst adolescents. have indicated that poorer response to intervention was associated with younger age. Anxious adolescents in particular may ‘slip through the cracks’ as they often do not present an immediate problem to school staff. Stallard 2002a). While the prevalence of mental health problems. there are some indications that adolescents may do less well. as well as amongst adolescents of the same chronological age. chronological age is regarded as a proxy for these developmental processes and an imperfect index of developmental level (Shirk 1999). Other studies investigating the outcomes of anxiety treatment in young people have found that adolescents fare less well than children. 2005. rather than developmental processes (Daleiden et al. recruiting adolescents for clinical trials can be very challenging (May et al. 2002). Kendall et al. which may artificially elevate reported rates of symptom alleviation (Albano and Kendall 2002). Developmental Factors May Influence Engagement in CBT The developmental processes inherent to adolescence make the teenage years a ‘window of opportunity’ to alter negative developmental trajectories (Cicchetti and Rogosch 2002). relationships currently found between age and treatment response may in fact reflect factors which are merely associated with age.. commencement. 2002). researchers use small samples with broad age ranges. and these findings may reflect the influence of developmental factors on engagement in CBT (Hudson et al. 2008).

2009). research into cognitive development has focused upon a selection of cognitive constructs (e. Given the overlap between CBTs for anxiety and depression (Weersing et al. and better developed emotion regulation may allow young people to more quickly adopt adaptive coping strategies learned in CBT (Bailey 2001. it is reasonable to expect that anxious adolescents who have more advanced coping repertoires would also have greater benefit from engagement in CBT. Engagement in Cognitive Therapy Calls for Consideration of CBT-Relevant Cognitive Capacities A major emphasis in the clinical and research literature on CBT with young people is the need to consider the development of cognitive capacities of the young person when designing and delivering treatment (Friedberg and Gorman 2007. Oetzel and Scherer 2003). (2006) and Kendall and Williams (1986) remind us to be mindful of the asynchronicity between physical development and other areas of adolescent development.g. parents. Holmbeck et al. impairing both the therapeutic alliance and the adoption and generalization of skills outside of treatment. in particular emotion recognition and regulation skills. Typically.e. or emotional capacities of same-age peers. given their awareness of multiple perspectives.g. Rohde et al. and the environment. This is held to be important because the exploration of personal issues may reactivate anxieties regarding the process of identity formation. The authors suggested that treatment outcome may be associated with the augmentation or activation of good baseline coping skills. strivings for autonomy can lead to resistance. given their tendency to view behavior in terms of external causes. Kingery et al. anxious self-talk) (Weisz and Hawley 2002). that young people who are in the foreclosure phase (i. the level of a young person’s emotional development. Marcia (1994) suggested..g.Clin Child Fam Psychol Rev (2009) 12:310–335 313 (Chu and Kendall 2004). For the purposes of this review.. Recognizing and differentiating emotions is essential for understanding and applying the cognitive model. the development of CBT-relevant cognitive capacities may have particularly large implications for the engagement of adolescents in treatment. CBT-relevant cognitive capacities are taken to include intellectual and executive functioning. as well as broader psychological constructs such as theory of mind and self-reflection (Grave and Blissett 2004). organizes.. 2006. 2008). 2006. The behavior of adolescents with anxiety disorders may be particularly challenging for those associated with the treatment process—clinicians. It is conceivable that high levels of anxiety in combination with these strivings for autonomy may lead some adolescents to resist accepting support when having to confront feared stimuli and may even contribute to ambivalence toward engaging in treatment and an evasion of exposure tasks. Holmbeck et al. parents often report that they cannot ‘‘pick them up and carry them to the car’’ as they might do with younger children. Stallard 2002b). With particular reference to young people’s engagement in CBT. Adolescents who have achieved the self-aware stage. and the need to tailor treatment content and delivery to the adolescent’s abilities. and school staff—due to a complex interaction between anxiety-motivated avoidance on the one hand and defiance fueled by strivings for autonomy on the other hand (Garland 2001). Suveg et al. For example. to the relative exclusion of other cognitive constructs (e. 2004). for example. Additionally. verbal. Social-emotional development may also impact upon an adolescent’s engagement in CBT. During treatment. and thus the augmentation of treatment outcome (Friedberg and Gorman 2007. can have a considerable impact on CBT participation. self-monitoring). information processing skills). for example. 2002). or ego development. developmental factors can influence the young person’s engagement in the therapeutic process in general as well as their engagement in specific therapeutic tasks (e. contingency management) is most suitable for young people below the conformist ego stage. and acts on their experiences of the self. Swensen (1980) suggested that behaviorally based treatment (e. Physically mature adolescents. detachment. also may have implications for the engagement of adolescents in particular therapeutic techniques (Kroger 2004. In addition.. Suveg et al. 123 . Stallard 2002a. or disengagement (Rubenstein 2003. clinical experience suggests that the physical development of the adolescent may have practical consequences for engagement in treatment: if they are reluctant to come to treatment sessions. others. the developing need for autonomy can make it difficult for some young people to acknowledge the need for treatment and to accept ‘help’ (Edgette 1999. who are highly occupied with adopting the values of figures they identify with) may benefit from a slower tempo in treatment sessions. The phase of identity development of the client may also influence their engagement in treatment. may not necessarily have acquired the cognitive.g. The way a client interprets. Westenberg et al.. In short. 2006). Given the important role of cognitive therapeutic techniques in CBT. (2006) found that depressed adolescents (aged 13–17 years) treated with CBT who had good coping skills had a faster recovery time than those who had less adequate coping skills. may benefit from cognitive therapeutic techniques such as the questioning of irrational beliefs (Swensen 1980). Kendall and Williams (1986) suggested that strategies such as self-monitoring may help to further a young person’s knowledge of themselves in the service of their identify development. and not their appearance.

Metacognitive skills such as psychological mindedness and self-reflection may allow young people to identify and discriminate their own thoughts. These results provide some preliminary evidence to support the notion that certain cognitive capacities are important for successful engagement in cognitive therapeutic techniques.g. In addition.314 Clin Child Fam Psychol Rev (2009) 12:310–335 There are many cognitive capacities implicated in the CBT approach to treatment. to think in a more organized manner. For example.g. Weisz and Hawley 2002. 2005. Reynolds et al.. 2006.. they may use less sophisticated cognitive coping strategies for handling the situations (Kingery et al. Ollendick et al. Weisz and Weersing 1999). there is very little in the way of scientific evidence to guide our thinking about which cognitive capacities warrant attention when designing and delivering CBT with young people. let alone with anxious adolescents.. and to objectively identify causal relations between them (McAdam 1986.g. Even if a young person has developed these skills. However.g. and behaviors (Blakemore and Choudhury 2006.g. given that young people participating in CBT are often asked to consider and anticipate the effects of their behavior on others (Kinney 1991). 2004. 2006a). and only during the formal operational period (from 11 or 12 years of age. The study found a relationship between a number of CBT-related cognitive capacities (e. Stallard 2009). even though adolescence is the period in which many of the cognitive capacities relevant to CBT are acquired. Further. the threshold of these changes is not absolute. as noted by Grave and Blissett (2004). there remains little consensus in the clinical and research literature regarding the age at which young people acquire the ‘minimum’ level of cognitive skills needed to participate in CBT. Unfortunately. Indeed. Schrodt and Fitzgerald 1987). Awareness of a young person’s metacognitive and social perspective-taking skills. Metacognitive and socialperspective taking skills are most frequently mentioned (e. Others have argued that CBT may be more appropriate for young people aged 11 years and older (e. adolescents develop an introspective thinking style which allows them to contemplate their thoughts. 2004. Despite the identification of these developmental patterns. The cognitive development which takes place during the adolescent period may result in an increased ‘receptiveness’ for cognitive therapeutic techniques in CBT (Oetzel and Scherer 2003. such as abstract reasoning and metacognitive skills (Blakemore and Choudhury 2006. they may still be relatively ‘inexperienced’ in applying them (Werner-Wilson 2001). 2006). 2001. Suveg et al. Steinberg 2005). Oetzel and Scherer 2003. feelings and behaviors. feelings. One potential lead is found in the work of Safran et al. 1991). Oetzel and Scherer 2003. Schrodt and Fitzgerald 1987). together with the other nominated capacities. relative to children. Kingery et al. Holmbeck et al.. hypothetical and deductive thinking (e. while younger children more commonly confused emotions with anxious cognition (self-talk) (Alfano et al. Social perspective-taking is also positioned as a useful skill for engagement in CBT. and future thinking (e.g. 2006). Harrington et al. adolescents who have a greater capacity to consider multidimensional constructs.. Steinberg 2005). because children are less cognitively advanced (Oetzel and Scherer 2003. when adolescents are in challenging or emotionally demanding situations. 123 . it is unhelpful to conclude that all adolescents are able to successfully engage in all cognitive therapeutic techniques. (1993) with adults participating in cognitive therapy. Some researchers claim that even very young children are able to engage in ‘basic’ CBT techniques (e. Durlak et al. and greater awareness and regulation of their own mental states (Keating 1990. enhanced organizational strategies. The pace of cognitive development varies considerably from one individual to the next (Everall et al. 2006. Grave and Blissett 2004. 2006. through to adulthood) do metacognitive skills mature. Indeed. consequential. Continuing neural and brain development during adolescence means that adolescents acquire and refine the cognitive capacities commonly regarded as essential to engagement in CBT. the ability to access automatic thoughts) and a range of outcome measures. 1998.. Holmbeck et al.. Shirk 1988).g. allowing the young person to reason hypo-deductively and think symbolically. Piagetian theory (Piaget 2001) states that it is only when children reach the concrete operational period (7–12 years of age) that they are able to begin to reason abstractly. Quakley et al. some adolescents will never acquire the highest levels of reflective thought and formal operational thinking (Werner-Wilson 2001). Weisz and Hawley 2002). Quakley et al. Indeed. may help guide clinicians in their decisionmaking about the use of cognitive therapeutic techniques held to require these capacities. 2006. From information processing research we know that adolescents develop greater processing capacity (e. Reynolds et al. memory). The use of such skills may be context-dependent. Other cognitive capacities mentioned in relation to delivering CBT with young people include abstract. and logical and causal reasoning (e. and to consider the perspectives of others may be better able to understand the purpose of treatment and to effectively engage in treatment. In addition to an increase in abstract thinking capacities. 2006).g. results of a recent empirical study with a population of socially phobic children and adolescents indicated that it was only adolescents who reported the presence of negative ‘selfthoughts’. Oetzel and Scherer 2003). Shirk 2001). Grave and Blissett 2004.. impairments in metacognitive skills may limit a young person’s ability to understand and participate in CBT.

such that the cognitive capacities of anxious adolescents may differ considerably from those of non-anxious same-aged peers (Oetzel and Scherer 2003)... their needs. a developmentally appropriate CBT for adolescents will account for the young person’s developmental context. as opposed to a broad spectrum of factors. According to Holmbeck et al. ‘cognitive behavioral therapy. using various combinations of the terms ‘adolescence’. In sum. Kendall and Williams 1986. In addition to developmentally appropriate outcome measures. the inclusion of developmentally appropriate measures to assess pre. Clinicians will often ‘estimate’ a client’s CBT-relevant cognitive capacities on the basis of a client’s chronological age. propensity toward limit testing)’’ (Wagner 2003.g.. a ‘one size fits all’ approach is often used in the design and delivery of treatment. book chapters) containing descriptions of developmentally appropriate practice in relation to treatment with young people. ascendancy of the peer group. their physical appearance. the Adolescent Autonomy Questionnaire.. and their capacities. and in turn treatment outcomes (D’Amico et al.. 1994). and evaluating CBT for adolescents. Few of the suggestions are specific to the treatment of anxiety in adolescents. numerous suggestions have been made about how to take developmental factors into account when working with this group (e. Wagner 2003).. As a result. Noom et al. The assessment of CBT-relevant cognitive capacities is also particularly useful prior to starting CBT. Eyberg et al. differences in the biological. ‘How’ Can Clinicians Developmentally Tailor CBT for Anxious Adolescents? According to Wagner (2003). Petersen et al. 2001). it was reported that 70% of the 29 empirical articles appearing between 1999 and 2004 mentioned developmental issues in treatment design and evaluation. given young people of the same age may vary greatly in developmental status. psychosocial. While age is a frequently used developmental marker for both clinicians and researchers. and fewer still are empirically based. This section on ‘how’ to conduct developmentally appropriate CBT with anxious adolescents is based on a review of the materials presented in Table 1.and post-treatment functioning is often stressed (e. Hudson et al.g. specific indicators of development may be more informative and meaningful. identity formation issues.g. as well as the delivery of CBT. These suggestions are diverse and sometimes divergent. the assumption that ‘one size fits all’ may have particularly negative consequences for treatment outcomes. developmentally appropriate treatments for adolescents are those which ‘‘…take into account the unique developmental issues and problems characteristic of adolescence (e. social-emotional. and. Wilkes et al.g. In relation to CBT specifically. 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. 1998).g. and cognitive development of young people are overlooked. or referring to specific protocols rather than making recommendations relevant to the design and delivery of CBT more generally. There are many readily available pen-and-paper measures for a wide variety of developmental factors (e. Six key domains of developmentally appropriate treatment design and delivery were consequently identified. 1988. Given the heterogeneity which characterizes the adolescent period. referring to just one or two developmental factors. Including such measures could allow for an exploration of the way in which developmental factors influence engagement in treatment. The results of this search are presented in Table 1. an increase from 26% between 1990 and 1998. where possible. which assumes that young people are a homogenous group. Conducting Assessment of CBT-Relevant (Cognitive) Capacities In the literature on clinical child and adolescent psychology. Miller 1993. together with a review of other materials (e. substance abuse) may delay or disrupt certain developmental processes. Bedrosian 1981.g. a search of (English-language) empirical articles and treatment manuals was done for the period from 1990 to the present. 2005.’ and ‘anxiety’. In discussions in the literature about treatment with adolescents. In the most recent of Holmbeck et al.Clin Child Fam Psychol Rev (2009) 12:310–335 315 concurrent psychopathology (e. and then use this estimate 123 . developmentally appropriate practice in relation to CBT with young people. and are discussed below. developmentally appropriate practice in relation to CBT with anxious adolescents.’s (2006) reviews of the application of CBT with adolescents. Grave and Blissett (2004) noted that a developmental perspective needs to be incorporated into cognitive behavioral models and treatment design. (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. 1349). researchers and clinicians have begun to pay greater attention to developmental factors when designing. Fortunately. p. or their IQ. (2006). the Pubertal Developmental Scale. delivering. For the current review. 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).

(2009) Treatment description and case study (n = 2) Cunningham et al. (2005) Empirical study (Phase i. and sentence structure was simplified Gradual transfer of responsibility and ownership of the treatment from clinician to the adolescent Cool teens CD-ROM for anxiety disorders in adolescents (CBT) Anxiety Interactive multimedia presentation (text. ‘‘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 12 –18 Cognitive behavioral and attachmentbased 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. 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. 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. (2003) Empirical study (n = 79) . via internet) Visually appealing and interesting (bright.g. examples.. more in-depth explanation and application of cognitive techniques such as challenging thoughts) 123 Author/Year Type of publication Angelosante et al. Phase ii. eye-catching graphics including real-life pictures) More complex text. more advanced graphics. and stories. (2009) Empirical study (n = 5) 14–16 Spence et al. reduces stigma of receiving treatment) Involvement of young people during content creation 13–17 Online CBT for child and adolescent Anxiety anxiety (BRAVE–ONLINE)—Teenage version Interactive multimedia presentation (online. (2008) Treatment description and case study (n = 2) Siqueland et al. and interspersed with a greater number of interactive exercises (e. less technical language. and attachment to parents 7–18 Dutch adaptation of the Coping Cat program (Kendall 1990) Anxiety Extra workbook pages added for adolescents (e. illustrations. less childish. n = 8. cartoons. audio.316 Table 1 Examples of developmentally informed adaptations to CBT for anxious adolescents Age (years) 12–17 Adolescent panic control treatment with Panic disorder and in vivo exposures with (APE ? fam) or agoraphobia without family involvement (APE) Treatment Intervention focus Developmentally informed adaptations Briefer and more intensive treatment to allow young people to more quickly return to developmentally important activities Included clinician-assisted in vivo exposures. autonomy.g. n = 11) Clin Child Fam Psychol Rev (2009) 12:310–335 Nauta et al..

(2000) Treatment manual Hoffman and Mattis Case study (n = 2) (2000) Albano (1995) Treatment description 317 123 . (2002) Treatment manual Scapillato and Manassis (2002) Treatment description Barrett et al.A. 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.T. activities.Table 1 continued Age (years) School-based group CBT for AfricanAmerican adolescents Adolescent-relevant examples included Parents not included due to time constraints and scheduling conflicts 14–17 The C. experiential aspects of treatment over technical psychoeducational information 13–17 Cognitive-behavioral group treatment for Social phobia adolescents Group format Protocol was a downward extension of the adult version of the treatment Anxiety Manual adapted to be developmentally appropriate and culturally sensitive Treatment Intervention focus Developmentally informed adaptations Author/Year Type of publication Ginsburg and Drake Empirical study (n = 6) 14–17 (2002) Clin Child Fam Psychol Rev (2009) 12:310–335 Kendall et al.e..) More detailed psychoeducational material Reduced emphasis on affective education Cognitive therapeutic strategies emphasized Increased adolescent autonomy in the context of parental overprotection and control 12 –15 12 –16 Friends for youth (CBT) Anxiety Group CBT Anxiety Group format Cohesion-building introductory group activities Group format Features age-appropriate content. their own interpretation of the initials C. 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 13 Panic control treatment (CBT-based) Panic disorder Clear.A.T Project (CBT) Anxiety Adolescent can choose their own name for the program (i.

A number of interactive tasks designed to tap into the cognitive capacities relevant to CBT have been evaluated with young children. 448). 2009). Holmbeck. A more recent development is the SelfReflection and Insight Scale for Youth (Sauter et al. (2006) suggested that the clinician also conduct informal assessment of cognitive capacities during their sessions with the young person. These authors proffered a number of suggestions for the assessment of cognitive capacities in adolescents. the young person’s level of physical or intellectual development may not necessarily predict development in CBT-relevant cognitive capacities (Kendall and Williams 1986. Hence. 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. and behavior shaping in the first four sessions. However. n = 4) Type of publication 13–17 CBT Panic disorder with agoraphobia Intervention focus Parent involvement in exposure practice Developmentally informed adaptations . Several examples of the ‘informal’ assessment of cognitive capacities are found in the literature. Stallard 2009). The Selman’s Interpersonal Understanding Interview (Selman and Lavin 1979) might be used to measure social perspective taking. McAdam 1986. the clinician can ask about what thoughts and feelings the client is currently having. April 26. how to support child) Inclusion of behavioral social skills training Focus on typical feared situations for adolescents (‘snack time practice’) Fears and anxieties are evaluated within a developmental context Clin Child Fam Psychol Rev (2009) 12:310–335 to adjust the delivery of cognitive therapeutic techniques to the perceived capacities of the client. Wilkes and Belsher 1994).N. rather than assessing skills directly applicable to CBT (G. 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. Holmbeck et al. 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. If this proves too difficult for the young person. To ascertain a young client’s ability to access automatic thoughts. personal communication. As noted by Holmbeck et al. Quakley et al. there is currently ‘‘…no straightforward user-friendly method of assessing level of cognitive development across different cognitive sub-domains’’ (p. 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. (1995) Empirical study (n = 5) Table 1 continued 123 Ollendick (1995) Author/Year Empirical study (multiple baseline design. or ask the client ‘‘what would someone else think in the situation?’’ (Stallard 2002b). and these may also be suitable for use with less mature and/or less verbal adolescents (Doherr et al. Anxious adolescents may have particular Use of workbooks and handouts Treatment Age (years) Albano et al. Weisz and Weiss 1989. 2006). 2004. namely self-reflection and insight. 2005. and ‘‘what went through your mind when…?’’. role playing. Reynolds et al.318 Presentation of case formulation to increase motivation and normalize problems More modeling. difficult situation they have experienced. Kinney 1991). however. 2006). Visual aids such as thought bubbles or cognitive cartoons can also be applied to informally assess cognitive capacities relevant to CBT (Kendall 2000. with a shift toward active participation later Parent involvement in four sessions (psychoeducation. (2006). the clinician can ask the client in the assessment phase or early in treatment to recall and describe a recent.

Therefore. According to this hypothesis.. elements of cognitive models of depression can be combined with models of anxiety in order to best represent the problems experienced by the young person and provide links to suitable treatment strategies. Ginsburg and Schlossberg 2002. When working with anxious adolescents. Dummett 2006). and decision making associated with the application of ` -vis cognitive techniques. The clinician can use a case formulation based on such a model when working with socially anxious adolescents in order to determine the value of certain therapeutic techniques to deal with maintaining factors (e. the impact that developmental factors have upon three facets of planning a CBT program is reviewed: the development of the cognitive behavioral case formulation. Rapee 1997) and the broader social context of the young person (Dummett 2006). thereby stimulating feelings of mastery and self-efficacy. and negatively biased pre. 2002. and dosage of treatment components or ‘modules’. (2003) suggested that children with a history of parental intrusiveness may experience new situations as anxiety-provoking due to their beliefs about their own inability to deal with challenges. (2003). certain cognitive content and cognitive processes may be specific to particular disorders (Beck and Perkins 2001). Recently. timing. These models are mostly drawn from research with anxious adults (Alfano et al. Chorpita and Barlow (1998) similarly viewed parental control as an important factor which may contribute to the onset and maintenance of anxiety symptoms in children and adolescence. resulting in low self-efficacy and a lack of mastery experiences in the young person. based on a cognitive behavioral model of psychopathology. task concentration training to manage self¨ gels 2006). behavioral vis-a Preparing a Cognitive Behavioral Case Formulation The cognitive behavioral case formulation summarizes accumulating information about the onset and maintenance of the young person’s presenting problems. such models may be less helpful in the preparation of the cognitive behavioral case formulation because it is commonly observed that anxious and depressive symptoms co-occur in young people (e.e. the authors concluded that the model can be used in the development of cognitive behavioral case formulations for socially anxious adolescents. O’Connor and Creswell 2005). (2003) reported that a previously developed adult model of the cognitive processes involved in worry (Dugas et al. Therefore.g. Models which have been developed in accordance with the ‘cognitive specificity hypothesis’ of anxiety and depression may be more helpful. whereby parents take over tasks which children or adolescents are able to perform independently. 2006. escalating conflicts with parents associated with autonomy development) which are associated with the development and maintenance of the psychopathology (Drinkwater 2005. due to both fears of negative evaluation and performance-related anxiety (Hudson et al. (2008) tested the applicability of this model with a group of socially anxious adolescents aged 11–14 years.. This information is then used to inform decision making about treatment. Currently. cognitive behavioral case formulations are developed in accordance with cognitive behavioral models of anxiety.. In particular. school transition. Laugesen et al. According to Wood et al.and post-event processing differentiated high and low socially anxious adolescents.. One of the well-known models is the Clark and Wells (1995) model of social anxiety. 2008).g. Schniering and Rapee 2004). an important factor in anxiety in children and adolescents is parental intrusiveness. increased self-focused attention. Hodson et al. 1998) could also effectively be applied to adolescents.g. A developmentally appropriate cognitive behavioral case formulation is one which elucidates the role of developmental factors and processes (e. 2002). On the basis of these findings. For example. Some models of the development and maintenance of anxiety in young people pay special attention to family and parental factors (Ballash et al. to understand symptoms and thus to guide treatment planning. 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. Studies into other cognifocused attention. It was found that the key cognitive elements of the model predicted levels of social anxiety. They suggested that such familial characteristics can increase the 123 . the study revealed that negative interpretations of social stimuli. autonomy-granting parents encourage their children to engage in new situations or tasks by themselves. Planning Treatment In the following sections. Bo tive models of anxious symptoms indicate that such models may also be relevant to adolescent clients. Wood et al.Clin Child Fam Psychol Rev (2009) 12:310–335 319 difficulties in describing their feelings and thoughts. In contrast. for example. When working with anxious children and adolescents. Cartwright-Hatton 2006. decision making around the selection. most models of anxiety only focus on a particular type of anxiety disorder and fail to include other comorbid problems such as depression (Ollendick et al. when developing cognitive behavioral case formulations for anxious adolescents with comorbid depression. and should be used to guide treatment of adolescent worry. the use of more formal means of assessing cognitive capacities (i.

the clinician can adjust the type of therapeutic techniques to be delivered. Chorpita and Daleiden 2004. based on the individual client’s case formulation (p.. Lewinsohn et al. (2007). For example. in order to more fully understand their potential influence on the adolescent’s current anxiety-related behaviors. Ferdinand et al. or ‘‘tools in a toolbox’’. and which may be applied to a greater or lesser extent with one client relative to another client (Kendall et al. cognitions. and cognitive development are important factors to consider when making decisions about the selection and dosing of the various components. 2008). individually tailored. They reviewed available treatments for many child and adolescent disorders and identified a number of ‘common elements’. Sequencing. ought to be considered when preparing cognitive behavioral case formulations. social-emotional. frequency and duration). the clinician may initially only discuss emotions and automatic thoughts in reaction to situations with the young person. This sense of control may be especially motivating for adolescents.. cognitive restructuring. With less mature clients. Depending on the developmental capacities of the young person. For example. and a module comprising cognitive restructuring. Similarly. goalsetting.. the clinician can ‘construct’ the cognitive behavioral case formulation and share (parts of) it with the young person to help them to better understand their difficulties. oppositional behavior). an optional model on ‘activity scheduling’ was incorporated in the CBT program because of the high levels of comorbidity between anxiety and depression. rather. Chorpita and colleagues (e. and share hypotheses about more abstract cognitive constructs such as core beliefs when it is judged that the young person is ‘ready’ (Drinkwater 2005). Involving the young person in the process of constructing a cognitive behavioral case formulation can promote a sense of control over the way in which their treatment progresses and the means used to achieve their own goals for treatment. 2008). in particular in relation to the developmental task of autonomy development. Using a modularized approach to CBT. these cognitions may become activated by negative life events and external stressors. In later development. For example. Weisz and Hawley 2002). the clinician’s use of cognitive therapeutic techniques will have the intended positive effect of stimulating the young person to deal with 123 .g.320 Clin Child Fam Psychol Rev (2009) 12:310–335 risk of a child developing cognitions relating to a low sense of control. Chorpita et al.g.e. the extent to which a module is addressed during treatment (i. the clinician may choose not to explicitly share the formulation with the young person.g. For some young people. In the case of anxious adolescent clients. 2005. and empirically supported packages made up of a number of ‘modules’ which are based on elements of pre-existing manuals. given their strivings for autonomy (Drinkwater 2005). 2007. Weisz and Hawley (2002) recommend the ‘modularization’ of treatment as a way of planning treatment such that it best meets the individual needs of adolescent clients. Selecting. a ‘modularized’ treatment protocol can be conceptualized as a collection of therapeutic techniques which can be selected and applied as modules. psychosocial.. cognitive therapy) together with ‘optional’ modules selected on the basis of the cognitive behavioral case formulation (Heyne et al. resulting in the experience of anxiety. and Dosing Treatment Components It is widely understood that CBT is not a unitary treatment. a module comprising exposure. 1993). Individual differences in biological. Chorpita et al. current and past parenting behaviors. according to the qualities and vulnerabilities of the client in question. and the high levels of depression in adolescence (Essau 2008.. Tailoring the Selection and Delivery of Behavioral and Cognitive Therapeutic Techniques It is often suggested that adolescents are well-suited to participation in CBT because of their growing cognitive capacities (e. psychoeducation.) which may or may not be employed with a specific client. it consists of various components (represented by different techniques such as systematic desensitization. or when the client does not believe in or understand the cognitive model.g. the extent of collaboration in the construction and presentation of the cognitive behavioral case formulation can vary. Forehand and Wierson 1993. 2005). our modularized CBT for anxietybased school refusal in adolescence contains a number of standard or ‘core’ modules (e. This approach to planning treatment is presented in a recently published treatment manual for anxiety disorders in children and adolescents (Chorpita 2007). 35). 2005) are leaders in the field of modularized CBT for young people. the most frequently occurring discrete clinical techniques used as part of a larger intervention plan (Chorpita et al. adolescent clients with both anxiety and depression can be offered a treatment module comprising activity scheduling. Alternatively. the clinician can use these profiles to create developmentally appropriate. The treatment manual includes modules for the young person and parents which are aimed at tackling the anxiety symptoms. etc. According to the authors. According to Chorpita et al. as well as the sequence in which the various modules are introduced. as well as other comorbid problems when present (e. They then developed evidencebased ‘profiles’ which ‘matched’ these common element components to certain child and adolescent psychopathology. and emotions.

Kingery et al. In the same way that behaviorally based techniques are especially suited to younger anxious children (i. presentation. it is a question of the relative emphasis to be placed on behavioral techniques and cognitive therapeutic techniques. (2006) similarly proposed that different ‘levels’ or versions of cognitive therapeutic techniques should be available within a CBT program. The ‘more complex’ cognitive therapeutic techniques regarded as most beneficial for adolescents with a higher level of cognitive development include identifying different levels of cognition (i. As noted by DiGiuseppe (1981). Less cognitively demanding strategies can be applied with less cognitively mature adolescents. alternative factors need to be considered. between-condition differences were observed on some measures. 2005. 2004. self-monitoring (Harrington 2005). behaviorally based activities and ‘real-life’ practice opportunities (D’Amico et al. For other young people. 61).g.. Stallard 2009). By ‘‘learning through doing’’. reinforcement and extinction) and more cognitively focused self-control procedures (e. Various authors have provided frameworks and suggestions as to which cognitive therapy techniques are more or less ‘complex’. Other ‘less complex’ cognitive therapeutic techniques seen to be suited to less cognitively advanced adolescents may include selfinstructional training (Friedberg and Gorman 2007. 160). self-evaluation) for anxious children and adolescents aged 6–16 years. Socratic questioning 123 . Ollendick et al.e. such as when the clinician provides information about the course. The selection of techniques rests upon an understanding of the variability in how complex and cognitively demanding the various techniques are. the clinician can include more concrete. Holmbeck et al. This manual contains several modules which represent cognitive therapeutic techniques of differing complexity. According to Willner (2006). selected according to the cognitive capacities of the young person. Henggeler et al. Bouchard et al.. Unfortunately. Zarb 1992). A second consideration concerning the tailoring of CBT delivery applies to the selection and delivery of the cognitive therapeutic techniques. In the absence of empirically informed guidelines for decision making about the use of ` -vis behavioral techniques or cognitive techniques vis-a their combination. (1999) argued that the internal processes which trigger psychopathology in less cognitively advanced young people may play less of a role in the continuation of the symptoms relative to socialization factors and environmental triggers. Rather. and the use of coping statements (DiGiuseppe 1981. Numerous authors have suggested that when an adolescent client seems to have difficulty engaging in cognitive therapeutic techniques. An additional factor influencing the extent to which behavioral techniques and cognitive techniques are employed is the clinician’s formulation of the presenting problems. the cognitive therapeutic technique ‘cognitive replay’ (for identifying automatic thoughts) can be used with young people of all ages.e. the young person’s cognitions may be indirectly challenged (Stallard 2009. cognitive techniques may be confusing or cause frustration (Werner-Wilson 2001). 2006. the authors suggested that either of these approaches can be effective in treating anxiety in young people. exposure. The strategies were organized according to their suitability for different ages and suggestions were made for adapting the techniques to increase their applicability for older or younger youth. In such cases. the targeting of cognitions may be less relevant. automatic thoughts as well as cognitive errors and unhelpful thinking styles. 1998. Stallard 2009. 2001). p. and modeling. similar to that of younger children) may also profit from a greater emphasis on behavioral techniques. Silverman et al. A recent example of a treatment containing different levels of cognitive therapeutic techniques is Chorpita’s (2007) CBT for anxious youth. Friedberg and McClure 2002. Stallard 2009. while interventions requiring higher level cognitive capacities may be more relevant to adolescents who have attained greater proficiency in CBT-relevant cognitive capacities. although less mature young people will need ‘‘more structure and feedback’’ (p. Merrell (2001) developed an index of intervention strategies (including cognitive therapeutic techniques) for depression and anxiety in young people. We propose a nuanced perspective which takes account both the extent to which behavioral and cognitive techniques are differentially emphasized. the question of how important it is for young people to be engaged in behavioral techniques versus cognitive techniques has received very little empirical attention (Stallard 2009). According to Merrell (2001).. Ultimately. and the selection and delivery of specific cognitive therapeutic techniques. Werner-Wilson 2001).. Psychoeducation can also be a simple technique for correcting certain maladaptive or distorted beliefs. the ‘downwardarrow technique’ (Merrell 2001). xix). and prevalence of a disorder (Willner 2006). ‘‘…therapy techniques may best be viewed along a continuum of procedures that can be used with [young people] of different cognitive ability’’ (p.g.. anxious adolescents with lower cognitive capacity (i. (1999) investigated the relative efficacy of behaviorally based contingency management (e. However. Both treatments were equally effective in reducing parent and child-reported anxious symptoms at post-treatment and up to 12-month follow-up. Zarb 1992).e. relaxation training. it is not simply a question of ‘whether or not’ to employ cognitive therapeutic techniques. Daleiden et al.Clin Child Fam Psychol Rev (2009) 12:310–335 321 emotional and behavioral difficulties. in favor of the cognitively oriented selfcontrol treatment.

we might regard the priming of cognitive capacities as a type of ‘scaffolding’ for cognitive therapy. the clinician may quickly socialize the young person into the cognitive therapy model in order to prepare them for earlier engagement in cognitive therapy techniques (Siqueland et al. For some young people. the adolescent’s desire to function autonomously can lead to frustration regarding their inability to ‘solve their own problems’ which can lead to resistance.g. Given that many adolescents have a greater capacity for thinking about the future. as described by Shirk and Karver (2006). Grave and Blissett 2004) and adults with intellectual disabilities (e. 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). Such priming has been described in reference to younger children (e. In addition to the decision to employ specific cognitive techniques. As noted by several authors (DiGiuseppe 1981. Some adolescent clients with more sophisticated reasoning abilities may even experience the ‘less complex’ cognitive therapy techniques as irrelevant and unhelpful. and more time on complex and refined discrediting strategies (Kingery et al.. 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. very early on in CBT a young person might be provided with opportunities to practice the self-monitoring of thoughts in order to improve their receptiveness to cognitive interventions employed later on. may be particularly pertinent for this group. such adolescents may regard the use of coping self-statements as less useful if these statements are not derived in the context of cognitive restructuring. Shirk 1998).. involves developing a therapeutic alliance. 2000). and being actively involved in treatment during and between sessions.g. impairment in the therapeutic alliance can then affect the adoption and generalization of adaptive coping skills. feelings. When delivering CBT with anxious children and adolescents. The clinician works to enhance emerging CBT-relevant cognitive capacities prior to formally commencing cognitive therapeutic interventions. As noted above. According to Willner (2006). and behaviors. the clinician can assess motivation via selfreport measures (Weisz and Hawley 2002). formal examination of underlying beliefs and assumptions (Harrington 2005.g. which in turn may reduce engagement in treatment and have a detrimental effect on treatment success. Dagnan et al. 2005). It is often others in the adolescent’s context (e. An adolescent’s motivation for treatment and for engagement in treatment can be influenced to some extent by developmental factors (Holmbeck et al. Some adolescents may benefit from earlier or greater attention to the cognitive therapy techniques in CBT. Rubenstein 2003. 2005). Further. According to Stallard (2002b). Young people with anxiety may be afraid to give up inappropriate coping strategies (e. the cognitive demands associated with acquiring new knowledge and skills may impede the acquisition and use of cognitive therapeutic techniques (Werner-Wilson 2001). In this way. the young person may be helped to develop skills in monitoring and recording predicted anxiety levels (Bouchard et al. decisions can be made about the manner in which the techniques are delivered. Engagement in CBT.322 Clin Child Fam Psychol Rev (2009) 12:310–335 (Siqueland et al. avoidance). Manassis et al. For example. 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. The social context impacts upon the life of the adolescent. Friedberg and Gorman 2007. play down or deny the negative consequences of their anxieties. Weisz and Hawley 2002). but capacity is certainly not the only determinant of engagement. In the early phase of treatment. parents or school staff) who make decisions about the adolescent getting help.. Kearney 2005). as well as decatastrophization and logical analysis (DiGiuseppe 1981. the clinician might spend less time helping the young person learn techniques for identifying unhelpful thinking. Zarb 1992). when the young person is able to identify and articulate their thoughts and feelings with minimal clinician guidance.. and it is likely to be most helpful when the skill being trained is in the client’s ‘zone of proximal development’ (Vygotsky 1978). The clinician can consider the extent to which an adolescent client will need extra guidance (e. 2004). 2006.g. 123 . Suggestions have been made about ‘priming’ CBT-relevant cognitive capacities in young people prior to engaging them in cognitive-behavioral interventions (Holmbeck et al. 2006). Schmidt (2005) recommended incorporating an informal in-session investigation of motivation during CBT with young people. The adolescent client’s motivation for treatment warrants early and continued attention. 2004). in the form of concrete instructions) and practice (Oathamshaw and Haddock 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. the suggestion by Bouchard et al. Willner 2006). For example. and this is true with respect to participation in treatment. When adolescents are referred for treatment by other parties they may not experience their ‘problem’ as one needing treatment (McAdam 1986. being open to applying strategies aimed at achieving changes to thoughts. 2006). detachment or disengagement from treatment.g..

(attending to broader) goals of the young person (the fostering of positive). Forehand and Wierson 1993). 2006). graded school return vis-a While having a say in the type of exposure tasks may be useful to motivate some young people. Oetzel and Scherer 2003). An essential characteristic of CBT is the ‘‘collaborative empiricist stance’’ of the CBT clinician (McAdam 1986. (ii) providing extra psychoeducation. Chronis et al.. Oetzel and Scherer 2003. Friedberg and Gorman 2007. 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. and the use of this motivational strategy needs to be carefully tailored to the individual client (Edgette 1999. p. Wilson and Sysko 2006).g. Heyne and Rollings (2002) recommended giving adolescents with anxiety-based school refusal more input into the decisionmaking about the type of exposure to be engaged in (i. (2009) suggested that adolescents may also value increased clinician guidance of exposure tasks. Angelosante et al. negotiating with the young person about the process of treatment. 2005. Due to their strivings for autonomy. 2009. Adolescents with a greater ability to self-reflect and to control their impulses can be encouraged to collaborate more with the clinician (e. opinions about the young person (informed). ` -vis immediate full-time return). (iii) boosting the client’s confidence in their ability to change. the clinician would ideally modify their approach accordingly.. Explaining clearly to the adolescent ‘what is in it for them’ in terms of the potential costs and benefits of treatment.Clin Child Fam Psychol Rev (2009) 12:310–335 323 Strategies to assess and stimulate motivation recommended by Schmidt include: (i) using a visual analogue scale to measure the willingness to change. the treatment planning process. With respect to this last point.e. These include: honoring the client’s perspectives. 123 . an email to invite the young person to attend the first session) can enhance their motivation for treatment. Because adolescents seem to be able to detect insincerity and ‘fakeness’ from a mile away. 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). and this stance is regarded as a necessary ingredient for successfully building a therapeutic alliance (Friedberg and Gorman 2007. they may respond better to ‘‘disciplined. Less mature adolescents may benefit from the clinician’s use of a more directive approach (e. For example. Ollendick 1995). Clinical experience suggests that using ‘adolescent-relevant’ means of communication before and between sessions (e. 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. and going about engaging the young person in treatment in a cautious and realistic manner. Friedberg and McClure 2002). p. too much empathy can seem less than genuine. 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. Activities. can enhance their co-operation with treatment plans (Kendall et al. Stallard (2002b) also noted that working together with the young person to set goals can increase motivation for engagement in treatment. 2006. Clinical experience suggests a number of strategies that may help to motivate and engage young people in CBT for anxiety. active listening.g. CBT is in itself already oriented toward enhancing client motivation for change and engagement in treatment. However. benevolent frankness’’ (Edgette 1999. as can encouraging the young person to offer input for the agenda for each session. 6). 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). allowing adolescent clients to have input into the nature of exposure tasks to be conducted in-session and between-sessions. 2005. The extent to which adolescent clients may be intrigued or else confused by such ‘frankness’ will vary. to give them an extra ‘push’ to confront anxiety-provoking stimuli. They used an acronym (i. and (v) orienting the client to their own personal goals. 40). (iv) questioning around discrepancies between values and current behaviors. Materials. Because adolescents differ in the degree to which they are able to co-operate with the clinician as an ‘equal partner’. increased involvement in. relating to the young person in an understanding and tolerant manner. By so doing. setting the agenda and determining the session content. Tailoring Treatment Language. Bedrosian 1981.. 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.. demystifying the young person’s experiences of the intervention process. Oetzel and Scherer (2003) argued that a judicious use of empathy and positive regard is an essential tool to motivate adolescents for treatment. Kingery et al. and control over.e.g. 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. interpretations of a young person’s behavior in treatment.

‘‘good’’ versus ‘‘bad’’. Chorpita 2007). When delivering cognitive therapeutic interventions. 1994). 2005). Characteristics of these adult and child protocols—including language. Complex therapeutic concepts can be made less adult-oriented and more ‘adolescent-friendly’ by employing the client’s own vocabulary. the clinician can structure client ventilation through the application of interviewing skills such as summarizing. This tailoring can facilitate the adolescent client’s engagement in treatment. simplified language. developmental tailoring would ideally occur with respect to language. and by giving specific. Holmbeck et al. the clinician must ensure that these materials are matched to the developmental level of the young person. 2006.. 2001. using clear. Ollendick et al. and as noted by Southam-Gerow et al. and reflections (Edgette 1999. which in turn increases the likelihood that the knowledge and skills addressed in sessions are understood and applied. in order to neutralize such typical adolescent thinking. 1998. (ii) a flip-over or a whiteboard. adolescents in particular may find some materials patronizing or juvenile (Stallard 2009). (iv) pictures/drawings to identify self-talk (e. Wilson and Sysko 2006). Kingery et al. and (v) diagrams when challenging maladaptive thoughts (e. Stallard 2009). minimal encouragers. the suggestions made by Bailey (2001) and Bedrosian (1981) seem fitting. (2001). In these cases. However. presenting somatic anxiety symptoms (e. For these young people. Treatment which is not solely verbally based. choosing instead to engage the adolescent in informal but therapeutically relevant conversation during therapeutic activities. thought bubbles. 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. including authors concerned with tailoring CBT for anxious adolescents (e.. Stallard 2002b).g. At the same time. adolescent ‘slang’ and idiom must be used carefully.g.g. For treatment to be ‘‘real and relevant’’ for the young person (Friedberg and Gorman 2007. Kendall 2000). materials. Stallard (2002b) suggested that the clinician use terms which imply dimensionality (e. Friedberg and McClure 2002).324 Clin Child Fam Psychol Rev (2009) 12:310–335 Eyberg et al. 123 .g. the clinician may speak of ‘‘less anxiety-producing thoughts’’ and ‘‘more anxiety-producing thoughts. Likewise. but which involves materials providing pictorial representations of treatment-related tasks. For example. Siqueland et al. 432). may help to engage children and adolescents in treatment and allow them to more effectively apply therapeutic tasks (Grave and Blissett 2004). Friedberg and McClure (2002) suggested the use of a ‘caterpillar’ (unhelpful) thoughts and ‘butterfly’ (helpful) thoughts metaphor for younger children. p.g. The question of language use in treatment has been discussed by many authors. The extent to which therapeutic activities are verbally based or non-verbally based can be adapted to match individual differences in adolescent clients. More adolescent-appropriate metaphors also exist. and the tempo of treatment delivery. materials.. and dealing with negative thoughts a process of ‘‘building a better firewall’’ (Stallard 2009.Problem-solved. Zarb 1992). A further language-based consideration arises out of the tendency for adolescents to think in ‘black-and-white’ terms (e. task-orientated instructions (Ginsburg and Drake 2002. Adult protocols can be too ‘taxing’ for the adolescent. Some adolescents may therefore feel uncomfortable with face-to-face dialogues and with ‘why’ questions during treatment (Bedrosian 1981). 2006. ‘‘right’’ versus ‘‘wrong’’) (Wilkes et al. as they may come across as unnatural or fake (Friedberg and McClure 2002). for example. 2002. the exercises and assignments associated with child protocols may be experienced by older youth as ‘‘somewhat childish’’ (p. responsibility and tolerance pies. Weisz and Hawley 2002). LowryWebster. 2002.g. activities. and Turner 2000) CBT programs. 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.. representing the steps of problem solving (What is the problem?. and tempo of treatment delivery—do not automatically ‘fit’ the developmental needs of the adolescent age group.’’ 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).g. ‘‘better’’ and ‘‘worse’’) rather than dichotomy. Other adolescents will be highly ‘talkative’ and their verbosity can have the potential to interfere with engagement in specific CBT-related activities. Is the Problem Solved?). the awfulizing scale. activities. (iii) visual analogue scales for rating the strength of emotions or thoughts (e. These mature adolescents may profit more from a detailed rationale for why the therapeutic techniques are useful (Braswell and Kendall 2001. or ‘spam’ in your computer. Werner-Wilson 2001). 160).com may be particularly relevant for adolescents. Visually oriented materials which can be used when delivering CBT with adolescents include: (i) handouts. What are the options for solving the problem?. 188). Automatic thoughts can be positioned as ‘pop-ups’. p. That is. simplification in the form of concrete examples and basic terms may appear condescending for some mature adolescents (Oetzel and Scherer 2003.. Which will I choose?. McAdam 1986).. it may be useful to reduce the number of didactic explanations and the amount of ‘deep and meaningful time’ to avoid awkward silences. A mnemonic like WWW.

and (iii) the type of monitoring that the young person can carry out by themselves (e. According to Bailey (2001) and Bedrosian (1981). Two recent developments focused on CBT for anxious adolescents incorporate developmentally sensitive recommendations for treatment materials and activities. and live video content were developed in consultation with adolescents to ensure that the materials would be relevant to the target age group. (2006) suggested that the clinician make developmentally informed decisions about: (i) the type of exposure tasks to focus upon (e. CD-ROM-based CBT for anxious adolescents. 2005). Further. When combined with guided questioning by the clinician. the adolescent version includes more complex psychoeducational information. and more interactive activities such as quizzes. Finally. asking someone out on a date. For example. less mature young people may benefit from a clear and concise explanation of how exposure ‘works’. the young person’s level of abstract reasoning may limit their ability to participate in role plays (Holmbeck et al. more advanced graphics. Other young people may benefit from a detailed and theoretical explanation of the mechanisms of the technique. 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. used to detect automatic thoughts. The process of developing a session agenda with an adolescent needs to account for the range of developmental issues already mentioned (e. (2008). or composing songs may also be therapeutic activities which may by useful in allowing adolescents to describe their thoughts and feelings. the extent of participation in setting up the agenda in line with the adolescent’s level of autonomy development. Other developmentally oriented recommendations are found in the literature focused upon exposure.g. 1995). and the young person must say what they think and feel about every attempt they have made. consideration needs to be given to the tempo at which the CBT program is delivered with adolescent clients. 2005)..g. 2000). The high degree of personal control was regarded as particularly suited to adolescent clients in view of their strivings for independence. sound effects. and these agendas are important for the optimization of treatment time. such as games. writing poetry. less mature young people may require a simplified scale to indicate the intensity of anxious symptoms). identifying anxious cognition. (2005) also suggested that anxious adolescents may be encouraged to engage in more betweensession exposure tasks relative to anxious children (Siqueland et al. Siqueland et al. Siqueland et al. such as initiating conversations. in which the client and clinician apply therapeutic techniques.e... such as eating in the school canteen). The question of parental involvement in exposure tasks with adolescents is addressed in ‘‘Involving Parents in Treatment’’. An activity like ‘thought football’ (Friedberg and McClure 2002). (2009) described the development of the Cool Teens program. the clinician may choose to firstly work with cartoon sequences which tell a story. In these cases. Session agendas are a common element of CBT. (2005) and Kingery et al. 123 .g. can be especially helpful in preparing the client for challenging situations in ‘real life’. An example in which clinicians have adjusted the tempo of a CBT program for anxious adolescents can be found in Siqueland et al. such that they understand how they themselves can be responsible for dealing with their distress). or visualization exercises can stimulate active participation in the therapeutic process (Hoffman and Mattis 2000. a major component of CBT for anxiety. ‘‘you’ll miss it for sure’’). (ii) the complexity of information provided in the rationale for engaging in exposure tasks (e. prior to engaging the young person in short and structured role plays. Relative to the child version. so too can the use of enactive procedures. It was suggested that the primary skills addressed in the adolescent sessions (i. role plays. considering situations more likely to be avoided in adolescence. Role plays. adolescents can engage in in-session role plays to practice activities they find anxietyprovoking.g. However. recognizing anxious symptoms.g.Clin Child Fam Psychol Rev (2009) 12:310–335 325 Just as visually oriented materials can enhance engagement in treatment.’s (2005) attachment-based family CBT. signal the value of conducting shorter CBT sessions with children and with adolescents. a reduced concentration span. Activities involving real-life demonstrations.. In the case of social anxiety. Stallard (2009) suggested that drawing. Kendall et al.. this activity can help the young person to more quickly become aware of their inner dialogue. or giving a talk (Albano et al.e. Another recent CBT for anxious young people is the BRAVE-ONLINE program developed by Spence et al. This program has a separate adolescent version for 13–17 year olds. Cunningham et al.. attention to important adolescent tasks and transitions in terms of agenda points) (McAdam 1986). combined with the cognitively demanding nature of self-disclosure and self-reflection. the graphics (cartoons and animations). may be particularly appropriate for adolescents due to its interactive and playful approach. This interactive media allows the adolescent to choose the order and tempo with which they cover the treatment modules.. developing a plan to cope with the situation. The clinician asks the young person to throw balls of paper into a hoop. in three to four sessions as opposed to the eight sessions specified in a related CBT manual for anxious children). and evaluating and reinforcing one’s performance) can be taught more quickly to adolescents relative to children (i.

e. 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. In either case. Kendall 2000.. and by prompting and rewarding them upon successful completion. Barrett 2000.e. and especially those with anxiety-related difficulties (p. 2006b). 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. parents can assist their child with the application of therapeutic skills outside of the clinical setting. the parents can coach their child through the exposure task by preventing evasion of the task. 2002. 2006. Barmish and Kendall 2005. and sometimes even necessary to involve parents in interven¨ gels and Siqueland 2006. Kendall and Holmbeck 1991). In addition. 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. Wells and Albano 2005. Understandably. these young people may have significant problems in managing their own anxieties if their parents are under-involved (Forehand and Wierson 1993. They can also play a key role in monitoring treatment gains (Barmish and Kendall 2005.or over-involvement are not conducive to treatment success. 2006b). 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. 2006b). A commonly cited conceptualization views the parent role as one of ‘consultant’ and ‘facilitator’. adolescents may value highly the time spent alone with the clinician and become suspicious or resentful if the 123 . Stallard 2009).. Parents can also be responsible for getting the young person to treatment sessions (Kingery et al. Indeed. ‘Over-involved’ or intrusive parents may have the tendency to ‘rescue’ their children from anxiety-provoking situations. and the ways in which parents should respond to a child’s anxiety symptoms (Kingery et al. it is argued that it is fruitful. This information is used to shape the course of treatment with the young person. see Bo Brechman-Toussaint 2006 and Ginsburg and Schlossberg 2002). 2003). 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. Stallard 2009). (For a more detailed discussion of the role of parent and family ¨ gels and factors in the etiology of child anxiety. According to Wolpert et al. Suveg et al. (2005). ‘collaborator’ and ‘co-clinician’. For example. extremes of parental under. 2006b). The limited parent involvement associated with the ‘consultative’ role can be particularly relevant for this group (Stallard 2009). Hudson et al. the perceived coping capacities of the child. parent as ‘collaborator’) is suitable for ‘‘younger children’’. Parents can also be involved in CBT as ‘co-clients’.g. Suveg et al. tions for anxious adolescents (Bo Ginsburg and Schlossberg 2002. Suveg et al. Problematic thoughts and beliefs may relate to the developmental appropriateness of the child’s behaviors. 2006). 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. and a balance between the two is seen to be the most desirable (Suveg et al. Wood et al. Kendall and Choudhury 2003. ‘Under-involved’ parents may believe that their teenage child is ‘old enough and wise enough to solve their own problems’ (Wells and Albano 2005). transfer of knowledge and skills from the clinician to the parents. parental prompting and monitoring of the child’s use of cognitive-behavioral skills (i. As ‘collaborators’. Martin and Thienemann 2005. these young people may rebel and resist offers of help if parents are (over-)involved (Kingery et al. Martin and Thienemann 2005). or ‘co-client’ (e. 2006b). 2003. Joyce 1994. If the beliefs and behaviors of under-involved parents prove to be rigid. More mature adolescents are likely to identify more strongly with peers and to attempt to increase their autonomy from parents. which can result in the young person having fewer opportunities to deal with challenges in an autonomous manner (Suveg et al. 2006).. 113). and then from the parents to the young person. By the same token. When parents are involved as ‘consultants’ they do not actively participate in treatment per se. conforming to the ‘transfer of control’ model (i. parent and family factors may be associated with the development or maintenance of anxiety disorders. 2006. 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). parental cognitions which impede the effective use of behavior management strategies can be explored and challenged (Heyne and Rollings 2002. 2006b.326 Clin Child Fam Psychol Rev (2009) 12:310–335 Involving Parents in Treatment Parents play a significant role in the life and ‘developmental trajectory’ of their adolescent child. Silverman and Kurtines 1996). 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). Nauta et al. Less mature adolescents are more likely to have a stronger emotional orientation to and connection with their parents. Suveg et al. Current parenting behaviors need to be considered when making decisions about the nature of parent involvement in treatment for adolescents.

and in particular the role that parenting may play in the maintenance of the school refusal.e.g. 2006). 2006). the peer group becomes increasingly influential in the life of the young person.. and they need the guidance of parents to help them in this process (Hudson et al. In the treatment of adolescent anxiety. Kearney 2005). the clinician can use psychoeducation to emphasize the fact that parents can play an important role in helping adolescents to ‘face their fears’. How parents react to such requests from their children during exposure practices can range from ‘directive’ responses (e. During exposure tasks. 2002).g. transporting the client to the exposure setting). To identify 123 . 2006). Given the sense of social isolation that many anxious young people experience. Involving Peers in Treatment During adolescence. In a similar vein. For example. In addition.. In particular. as co-clients. a more ‘directive’. it is particularly important to consider the question of parent involvement with respect to exposure-based tasks. the adolescents turned to their parents for ‘help’ with dealing with the anxiety symptoms.g. although the young person may seem ‘all grown up’ in terms of independence from their parents. and interventions that include peer involvement may have increased efficacy (Jelalian et al. 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. due to their desire to avoid anxiety-provoking situations or stimuli. parents are helped to employ a more supportive.g. At the same time. the limited involvement of parents has the potential advantage of empowering the young person. arguments with parents about school return). parents issue gentle prompts for appropriate behavior (e. In the treatment. autonomy-granting role or. authoritative role.e. to protect their adolescent child and themselves from anxiety-provoking experiences). they are still developing. Holmbeck et al. and it becomes more and more important for the young person to have skills to be able to ‘fit in’ (Geldard and Geldard 2004.. Depending on the case formulation. Developmental factors may also influence decisions about which parent to involve: ¨ gels and Siqueland (2006) suggest that as fathers may be Bo particularly important role models for adolescents. they learn skills with which to extinguish inappropriate behavior (e.e.. parents were helped to identify and reexamine beliefs about anxiety (i.. In working with under-involved parents.Clin Child Fam Psychol Rev (2009) 12:310–335 327 clinician meets regularly with their parents (Kingery et al.. and something to be avoided) and beliefs about the role of parents with anxious children (e. displaying ‘immature’ behavior such as crying or running away). as required.g. 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 more authoritative role. involving them in treatment may be essential in successfully combating adolescent anxiety. and are helped to assume responsibility for determining the timing and process of their adolescent child’s return to regular school attendance. Wells and Albano (2005) recommended that the clinician working with over-involved parents recognize the parents’ concerns.. a number of recommendations may also be relevant.g. the adolescent is provided with opportunities to ‘show that he/she can try to face the fear’ without the direct involvement of parents. 2008) aims to help the parents of adolescent school refusers achieve a developmentally appropriate balance between ‘directive’ parenting and ‘supportive’ autonomy-granting. physically guiding the execution of exposure practices between sessions). 112). opportunities for involvement with peers can be especially important (Scapillato and Manassis 2002.e. Peers can significantly influence and impact on adolescent attitudes and behavior. who are highly motivated’’ (p.. In addition. (2005). Adolescents often seek the company of friends rather than parents. parents are helped to employ a firmer approach should this be required.. young people who are anxious may sometimes act ‘younger’ than their chronological age (e. a CBT program for anxiety-based school refusal in adolescence (Heyne et al. In an earlier study. successive steps toward school return) and reinforce such behavior in a developmentally appropriate way. to ‘supportive’ and autonomy-granting responses (e. In the autonomy-granting role. As noted by Wolpert et al. In cases where parents of anxious adolescents have the tendency to be over-involved or under-involved. as threatening. encouraging the young person in independent problem solving rather than solving the problem themselves). failing to see the consequences of their behavior. while simultaneously using psychoeducation to emphasize the developmental tasks of adolescence (e.g. Wolpert and colleagues suggested that minimal parent involvement (i. 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. Indeed. fears of dying). autonomy development) and the implications for parenting (i.. parents were engaged in discussions about their role in dealing with their teenage child’s anxiety. parent as ‘consultant’) is best suited to ‘‘older children. In addition. and about the most appropriate type and level of involvement that the parents might have in their child’s exposure practice..

due to their desire to ‘fit in’ and the embarrassment and shame associated with being ‘in therapy’. Empirically supported models can then be used to inform further developments in adolescent-focused CBT protocols. Wood et al.g.328 Clin Child Fam Psychol Rev (2009) 12:310–335 suitable peers (e. 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). researchers frequently use age in analyses aimed at predicting treatment response. (2002) argued that more meaningful prediction analyses would make use of ‘‘measures specific to the important developmental forces’’ (p. Developmentally appropriate clinical trials will also modify clinical diagnostics and assessment (e. Albano (1995) even argued that.g. individual treatment for socially anxious adolescents would be ‘‘counterintuitive and counterproductive’’ (pp. Peers could also be involved in between-session ‘real-life exposures’ to avoided social situations (e. Chorpita (2007) recommended that an anxious child or adolescent should have a basic level of competency before engaging in role playing with peers. it is important to explore the influence of developmental factors on the outcomes of developmentally appropriate CBTs for adolescents. It is therefore important to involve adolescent clients in the decisionmaking around the (non)involvement of their peers.. Though the use of peers can be a powerful tool in the enhancement of social competencies. and others in the community can be educated about the ‘signs’ of anxiety (e.. alongside age..g. Liber et al. the relationship between autonomy strivings and avoidance behavior). The next generation of empirical studies into the etiology of child and adolescent anxiety is underway.. at least one other indicator of developmental status be included in 123 . Parents.g.. involving peers may be the last thing they would want. The first of these issues is a need to continue to develop and test cognitivebehavioral models of adolescent anxiety. researchers will be able to learn more about the merits of designing and delivering developmentally appropriate treatment. and the comorbidity common to adolescent anxiety (e. or query parents or teachers.g.g. avoiding school) and encouraged to refer adolescents showing such signs. the clinician can ask the young person to nominate a suitable ‘peer assistant’. classmates. including developmentally appropriate measures to assess pre. cooccurring depressive symptoms). As noted. barriers to adolescents’ involvement in treatment outcome research need to be reduced. It is for this reason that Hudson et al.g.and post-treatment functioning). For example. A second research implication concerns the systematic evaluation of developmentally appropriate CBT for anxious adolescents. There are some exceptions (e. Well-functioning friends. Group CBT with adolescents permits normalization of experienced difficulties and opportunities for positive social interaction (Scapillato and Manassis 2002). Thirdly. Future Research Directions Future research into developmentally appropriate CBT for anxious adolescents would ideally focus on three key research issues emerging from both the ‘why’ and the ‘how’ sections of the current review. given the nature of social anxiety disorder. 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. and the relevance of these models for anxious adolescents is still to be determined. 2003). siblings. and provide clinicians with training and supervision around the six key domains described in ‘‘How Can Clinicians Developmentally Tailor CBT for Anxious Adolescents?’’ in this review. but these models are yet to be systematically tested in the practice of CBT for anxious adolescents.g.g. the clinician is advised to consider the level of the young person’s social competency before involving a peer in treatment.. and such studies will ideally account for developmental factors (e. 837). Clinicians involved in such clinical trials can use ‘adolescent-appropriate’ means. Young people of the same chronological age may vary greatly in developmental status. walking to school together. make use of developmentally appropriate treatment manuals (e. 2008).. For some young people. school staff.g. 276–277). avoiding class presentations. In the case of social anxiety. modular treatments). account for developmental factors in determining treatment delivery mode (e. friends).. 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.. group versus individual CBT). For example.. Wagner (2003) recommended that. avoiding social contact with peers. group members may participate in each other’s exposures (Albano and Barlow 1996).. such as regular e-mail contact during treatment to increase the likely uptake of treatment by adolescent clients and to reduce drop-out.g. contextual factors (e. to maximize the success of a practice opportunity. Until now there have been very few models of anxiety which emphasize developmental psychopathological concepts when delineating anxiety in younger age groups. Researchers need to employ a developmental ‘frame of mind’ when planning clinical trials with this population. the role of parental factors in the maintenance of the problem). By monitoring the extent and quality of the clinicians’ adherence to the six domains. spending time together in the lunch break).

in which way these capacities can best be measured. the clinician should consider when it is best to involve parents in treatment in a more ‘supportive’. (b) how to conduct CBT with young people at different levels of development. Thus. Development in CBT-relevant cognitive capacities may influence the extent to which a young person extracts meaning from. That is to say. In short. It is particularly important to assess CBTrelevant cognitive capacities with respect to their impact on treatment outcome. standardized assessment tools and procedures are likely to increase the validity and reliability of estimates of the capacity to engage in cognitive therapeutic interventions. the suggestions described in the current paper are an important response to the calls in the clinical and research literature for developmentally appropriate treatment. future studies are needed to elucidate exactly which cognitive capacities are relevant to adolescents’ successful participation in the cognitive therapeutic strategies encompassed in CBT. The following key points are considered to be especially relevant to working with adolescents. autonomy development. reluctance to collaborate with the therapist and carry out the therapeutic tasks. and how valid the currently available tasks or questionnaires are. several key points deserve to be highlighted. Peers may be able to play a supportive role in treatment. in terms of both their developmental capacities and the tendency to avoid anxiety-provoking situations or stimuli. and at worst. and (c) how to conduct CBT with anxious adolescents. given the increasing influence of the peer group during the adolescent period. However. This ‘developmentally appropriate balance’ can be applied to all of the six key domains as described above. Suggestions associated with six domains of treatment design and delivery may serve as a guide for clinicians 123 . 1998. A key clinical implication emerging from the review is that clinicians designing and delivering CBT keep in mind what anxious adolescents ‘want to do by themself’ and ‘what they are able to do by themself’. Our review of the literature suggested six key domains relevant to ‘how’ treatment can be designed or delivered in a developmentally appropriate way. contextual factors. it is important that the cognitive-behavioral models take into account adolescent developmental tasks and transitions. authoritative role in order to best stimulate the young person’s participation in therapeutic tasks. and applies cognitive therapeutic strategies. It might even be that the refinement of cognitive capacities due to engagement in cognitive therapeutic strategies mediates therapeutic gains (Holmbeck et al. the clinician can differentially emphasize the extent to which behavioral and cognitive techniques are selected and delivered to best match the capacities of the adolescent client. we addressed the question of ‘how’ clinicians can best account for adolescent development. development in cognitive capacities could be examined as both a mediator and a moderator of treatment outcome (Eyberg et al. Variables representative of these developmental forces include pubertal changes. In terms of the implications for designing and delivering treatment with young people at different levels of development. Increased attention needs to be paid to the formal or informal assessment of CBT-relevant cognitive capacities. Further. social-emotional. as well as the tempo of treatment delivery according to the developmental level of the young person is essential when engaging both children and adolescents in treatment. 2006). The interaction between adolescent strivings for autonomy on the one hand.and inter-individual differences in the development of CBT-relevant cognitive capacities. and changes in parenting behaviors (D’Amico et al.Clin Child Fam Psychol Rev (2009) 12:310–335 329 developmentally appropriate research and practice. 2005). In addition. in exposure tasks. and activities. Each domain encompasses numerous clinical implications. Attention to motivation for treatment is indispensable when working with adolescent clients in particular. A developmentally appropriate balance between ‘supportive’ and ‘directive’ treatment delivery may best facilitate adolescents’ engagement in treatment. Hudson et al. can lead to ambivalence toward the therapeutic process. In particular. Tailoring treatment language. and in particular. and anxiety-motivated avoidance on the other. When developing case formulations and determining targets for treatment. Having considered the question of ‘why’ it is important to use developmentally appropriate CBT. due to large intra. given the influence that strivings for autonomy may have on engagement in the therapeutic process and on the therapeutic alliance. psychosocial. Conclusion The purpose of this paper is to advance the use of developmentally appropriate CBT for anxious adolescents. and cognitive development. and common comorbid disorders. and the implications vary in terms of their specificity to the topic: (a) how to conduct treatment with young people at different levels of development. 2002). While the clinical judgments of some well-trained and highly experienced clinicians may be valid. changes in peer interactions. materials. in view of the ‘transfer of control’ approach. the flexibility that comes with modularized treatments may help the clinician respond to individual differences arising from biological. it is prudent to retain a dimensional rather than a categorical perspective on the selection and delivery of the cognitive and behavioral therapeutic techniques contained in CBT. autonomy-granting role or a more ‘directive’. The clinical implications for designing and delivering CBT with young people at different levels of development are quite plentiful.

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