(p. 251) Prevention of Anxiety Disorders
(p. 252) Theoretical and Conceptual Models of Prevention and Change
3. Anxiety disorders are associated with significant comorbidity that often extends into adulthood (Costello & Angold, 1995).
4. The economic burden of anxiety disorders in the United States is enormous.
Prevention efforts should aim to reduce risk factors and foster protective ones associated with the etiology and maintenance of these syndromes. Some risk and protective factors cannot be modified (e.g., familial history, biomarkers), and thus the interventions need to target variables that mediate the relationship between risk factors and disorder. Timing is also important to consider because certain risk and protective factors may be more likely to exert their influence during certain developmental periods than during others. For example, behavioral inhibition may especially heighten risk for anxiety disorders as adolescents transition from middle to high school, when increased social independence is the norm (see Chapter 9 and below). Consequently, the development of effective prevention of anxiety disorders requires the following:
1. Comprehensive knowledge of the risk and protective factors as well as their complex interrelations during different periods in development
2. Advances in methods to detect the presence of these factors
3. Interventions that increase protective factors, reduce risk factors, or both
4. A societal investment in the importance of doing so
The goal of such programs is to reduce the enormous individual and societal burdens imposed by anxiety disorders.
Recognition of the relationship between investment in prevention science and reducing healthcare costs and burdens is not specific to psychiatry and psychology by any means. Referring to medicine more broadly, Yach and Calitz (2014) suggested that “low levels of investment in prevention research and development represent a missed opportunity to further scientific knowledge and improve population health,” and that “investing in prevention should be a strategic national priority to improve the lagging population health of the United States compared with peer countries.” As we review what is known thus far about the prevention of anxiety disorders, it is important to consider the state of our knowledge through the lens of lagging commitment to prevention in the United States in particular. The review here highlights that what we do not know continues to far outweigh what we do know, which makes it difficult to mount prevention efforts that will reduce the costs and burdens of anxiety disorders.
In our review of intervention studies aimed at the prevention of anxiety disorders in children and adolescents, we continue to follow the system advocated initially by the Institute of Medicine’s Committee on Prevention of Mental Disorders (Mrazek & Haggerty, 1994; Munoz, Mrazek, & Haggerty, 1996) and subsequently adopted by prevention experts (e.g., Craske & Zucker, 2001; Donovan & Spence, 2000; Fisak et al., 2011). This system classifies prevention programs as follows:
1.Indicated prevention programs, which target at-risk individuals who already have symptoms, a biomarker, or both, but do not meet full diagnostic criteria for a disorder
2.Selective prevention programs, which target individuals presumed to be at high (p. 253) risk for the development of a disorder (e.g., witnesses of violence)
3.Universal prevention programs, in which entire populations are targeted regardless of risk factors (e.g., third-graders)
Before considering the intervention studies themselves, it is important to consider briefly what is known about risk and protective factors at the individual, familial, and societal level, because it is knowledge of these factors and their interrelations that should inform the development of intervention strategies. Unfortunately, knowledge of such factors remains limited, and perhaps the paucity of prevention studies in anxiety disorders across the board is a direct result of this limited knowledge. It is also clear that societal factors influence the feasibility of conducting prevention studies with the information that we already have, since investigators from Australia in particular have managed to conduct the lion’s share of anxiety disorders prevention research over the past two decades, despite acknowledged gaps regarding the link between risk and protective factors with intervention strategies. This may be an issue of national priorities and how research funds are allocated nation by nation.
What remains of particular concern is the absence of evidence about protective factors that are specific to anxiety disorders. That is, although the youth resilience literature has generally underscored the importance of factors such as high IQ, self-esteem, social support, and positive coping in serving to protect young people from the development of psychopathology in general, there is a paucity of literature regarding whether any protective factor(s) may serve to protect against anxiety disorders in particular. Development of effective prevention programs will continue to be hampered until evidence-based knowledge has accumulated in this area; significant progress has not been made in the last decade in addressing these concerns sufficiently. It is also the case that only recently did investigators of risk factors begin to examine the complex interplay of these factors and examine their unique and shared contribution to predicting anxiety symptoms down the road—there may not actually be a single risk factor that captures the majority of the variance, but perhaps looking at these factors in concert may help us better understand how they exert their influence on the development of anxiety disorders.
Individual Risk and Protective Factors
Individual Psychological Characteristics
Elevated but Subsyndromal Anxiety Symptoms
Many children exhibit symptoms of anxiety at some point, and two questions are of particular interest here:
1. Do children with elevated but subsyndromal levels of anxiety show greater-than-normal levels of impaired functioning at home, at school, or with peers?
2. Does subsyndromal anxiety predict later psychiatric disorder, whether an anxiety disorder or some other diagnosis?
To answer both questions it is necessary to control for comorbidity with other symptoms and disorders; that is, impaired functioning or future anxiety disorder must be linked directly to the anxiety symptoms, not to other symptoms or disorders that may co-occur (e.g., depression with generalized anxiety disorder [GAD]).
To address the question of whether adolescents with elevated but subsyndromal levels of anxiety show greater-than-normal levels of impaired functioning at home, at school, or with peers, it is helpful to consider data from the Great Smoky Mountains Study of youth aged 9 to 16 (Copeland, Angold, Shanahan, & Costello, 2014; Copeland, Shanahan, Costello, & Angold, 2009; Costello, Mustillo, Erkanli, Keeler, & Angold, 2004). In this study, in which 1,420 children and adolescents and their parents were interviewed annually, children and adolescents with an anxiety disorder, but no other psychiatric diagnoses, were twice as likely to exhibit impairment relative to those with no disorder. Even among youths with no diagnoses, those with symptoms of anxiety were twice as (p. 254) likely to have impaired functioning compared to those with no symptoms. This was true of both prepubertal and postpubertal youngsters. Thus, in this population-based sample, subsyndromal anxiety symptoms were associated with youths’ impaired ability to function well at home, at school, and with peers. Findings at follow-up that spanned up to two decades indicated that more than one in five participants met the criteria for an anxiety disorder by early adulthood, and that these disorders were associated with adverse functioning in at least one domain by that time. Prior history of symptoms was associated with the development of a disorder later on, but having a disorder at time one was more strongly associated with having a disorder at the last follow-up.
Among children and adolescents without a history of anxiety disorders, those who developed one disorder in any given year of the study had three times as many subsyndromal anxiety symptoms in the year before they developed a disorder compared to those who did not develop an anxiety disorder (2.0 vs. 0.7 symptoms). Almost half of the youths who developed a new anxiety disorder the following year had at least two clinically significant symptoms the previous year, compared with one in five youths who would not develop a disorder. This finding suggests that it should be possible to identify high-risk children and adolescents for prevention programs with a high degree of accuracy, although the interview measures used in this particular study to do so are costly since they require highly trained interviewers, close supervision, and expensive quality assurance methods to do properly.
Although research findings are consistent in showing that children and adolescents with anxiety exhibit alterations in autonomic reactivity, Sweeny and Pine (2004) have noted limits in studies that have relied on cardiovascular measures as indices of autonomic activity. Cardiovascular measures are regulated by a wide variety of neural structures and thus provide relatively indirect information about the state of brain systems that might be implicated in anxiety disorders. In addition, abnormalities in cardiovascular control appear to occur in other conditions, and thus are not specific to anxiety disorders. The context in which cardiovascular measures are obtained can also influence reactivity, thereby raising a concern about whether such findings are actually epiphenomena (Sweeny & Pine, 2004). A Dutch prospective cohort study with 965 nonselected adolescent participants indicated that, rather than elevated autonomic reactivity per se, reduced autonomic flexibility in the form of limited heart rate variability predicted self-reported anxiety levels in girls 2 years later (Greaves-Lord et al., 2010); this small yet significant effect suggests that limited heart rate variability should be considered within a larger group of risk factors for the development of anxiety.
Respiratory indices, in contrast, are relatively free of the limits that affect cardiovascular measures (Sweeny & Pine, 2004). These include minute ventilation (the amount of air breathed every minute), tidal volume (size of each breath), and respiratory rate. Guided by Klein’s (1993) suffocation false alarm theory of panic, most studies involving these measures have concerned patients with panic disorder, other anxiety disorders, and healthy controls who inhale air enriched with carbon dioxide.
Although most studies show that patients with panic disorder experience panic attacks and exhibit changes in respiratory measures more often than do patients with other anxiety disorders or healthy subjects (e.g., Papp et al., 1993; Papp, Martinez, Klein, Coplan, & Gorman, 1995), the data are not uniformly consistent (Rapee, Brown, Antony, & Barlow, 1992; Woods & Charney, 1998).
Pine, Cohen, Gurley, Brook, and Ma (1998) extended this work to young people (ages 7–17; mixed sample of anxiety disorders), but separate analyses were not conducted for the preadolescent versus adolescent subsamples. Pine et al.’s findings with these youths paralleled those with adults. However, considerably more research is needed before firm conclusions can be drawn about the relationships between adolescents’ (p. 255) autonomic reactivity and the development of subsequent anxiety disorders per se.
A detailed review of the temperamental vulnerability for behavioral inhibition appeared earlier. Two independent laboratories have shown that children who were highly reactive to novel stimuli as infants were more likely than others to display extreme shyness, timidity, and restraint to unfamiliar people, situations, and objects when they were 2, 4, 7, and 11 years of age, and biological differences were found that implicated the amygdala (Fox, Henderson, Rabin, Caikins, & Schmidt, 2001; Kagan, 2002). Labs using less painstaking methods of measuring behavioral inhibition (e.g., parent report measures) have also found an association between behavioral inhibition and the subsequent development of anxiety disorders (e.g., Gar, Hudson, & Rapee, 2005; Hirshfeld-Becker et al., 2008). Notably, although these children appear to be at a threefold to fourfold increased risk for development of an anxiety disorder compared to those without elevated behavioral inhibition, most actually do not go on to develop one; this raises again the issue of the potential and yet clearly understudied role of protective factors in vulnerable children.
Chronis-Tuscano et al. (2009) conducted a prospective longitudinal study of 126 boys and girls enrolled at 4 months of age and repeatedly assessed for behavioral inhibition until age 7. The investigators conducted semistructured interviews with the subjects, then aged between 14 and 17 years. The results revealed that children who had repeatedly scored high on maternal ratings of behavioral inhibition across multiple assessment points during their first 7 years were 3.8 times more likely to meet lifetime criteria for social anxiety disorder by the time of the adolescent interview assessment than were other children. However, repeated ratings of behavioral inhibition did not predict a heightened risk for other anxiety disorders, nor did it predict current social anxiety disorder, thus implying that many behaviorally inhibited children lose the diagnosis before leaving adolescence.
All in all, it appears that behavioral inhibition is not an especially strong predictor of later anxiety disorder in and of itself. This finding points to the importance of identifying protective factors that limit the rate of later anxiety disorders in otherwise vulnerable individuals. It also indicates the potential advantage of studying multiple risk factors together and examining their separate and shared contributions to predicting anxiety later on, such as has been done with behavioral inhibition and attachment style (e.g., Muris et al., 2011; Shamir-Essakow et al., 2005).
There are individual difference variables linked to anxiety and its disorders in children and adolescents. In Chapter 9, we mentioned information-processing biases and anxiety sensitivity. In this section, we discuss coping skills and perceived control. Individuals’ coping skills—methods they use to manage negative or aversive situations—can be (1) problem-focused, (2) avoidant, or (3) emotion-focused. Problem-focused coping directly addresses or minimizes the effect of the problem. Avoidant coping denotes the avoiding the problem or escaping from it. Emotion-focused coping concerns attempts to attenuate the distress caused by the problem. Research suggests that problem-focused methods, such as actively seeking information, positive self-talk, diversion of attention, relaxation, and thought stopping reduce anxiety and emotional distress in 8- to 18-year-olds (Brown, O’Keefe, Sanders, & Baker, 1986). Generally, children’s and adolescents’ use of problem-focused coping predicts positive psychological adjustment more than does use of emotion-focused coping. Interestingly, adolescents’ use of avoidant coping is associated with high levels of depression in adolescence (Ebata & Moos, 1991). There has been little systematic research on the association between specific types of coping strategies and the development and maintenance of anxiety disorders in adolescence. There also has (p. 256) been little systematic research on which specific coping skills should be taught to adolescents across diverse anxiety-provoking situations. Research in this area is clearly of importance given that training in coping skills remains a feature of cognitive-behavioral treatments (see Chapter 10).
Perceived control is another important individual difference variable. Specifically, Barlow (2001) has suggested that children who experience uncontrollable events early in life may develop a propensity to perceive or process events as not being under their control, which for some youngsters may serve as a risk for the development of anxiety and its disorders. Chorpita, Brown, and Barlow (1998) found that perceived control may serve as a mediator of family environment among youths with anxiety disorders. Clearly, further research on the role of perceived control as a protective and risk factor in anxiety disorders is needed, especially regarding its specificity for anxiety.
As discussed in greater detail in Chapter 9, genetic factors influence the risk for anxiety disorders and, taken together, the epidemiologic and genetic data imply distinct biological profiles for the varied anxiety disorders, many implicating neurochemical processes. A meta-analysis found only a modest genetic contribution to four anxiety categories, and no evidence for a significant effect of shared environment (Hettema, Neale, & Kendler, 2001). When the individual studies themselves are reviewed, however, inconsistencies emerge with respect to the degree to which genetics were implicated in transmission of anxiety disorders; rates appear to vary as a function of the site of the laboratory, as well as the informant supplying the relevant information. There is evidence for genetic contributions to personality traits, such as neuroticism, introversion (Eaves, Eysenck, & Martin, 1989), shyness (Daniels & Plomin, 1985), and behavioral inhibition (DiLalla, Kagan, & Reznick, 1994; Kagan, 1994), each of which may increase risk for the subsequent development of anxiety disorder. There is some recent evidence from a large twin study indicating that separation anxiety disorder and adult-onset panic attacks share a common genetic diathesis not shared with childhood anxiety disorder (Roberson-Nay et al., 2012), which implies specificity of effects only between certain phenotypes. At the same time, it is also evident that even with early-onset obsessive-compulsive disorder (OCD), which is thought to be more closely associated with family history of OCD, the majority of families do not actually have a positive family history of OCD (e.g., Chabane et al., 2005), which means that factors other than genetics contribute to the likelihood of developing full-blown OCD. In general, many studies of the genetics of anxiety disorders involving children and adolescents have substantive methodological limitations, so there remains a great deal to discover in this area.
The presence of a genetic influence for anxiety disorders does not imply that the course of illness is immutable. From the perspective of prevention, it may be that studying other risk factors in youth at genetic risk for anxiety disorders may prove especially fruitful and may suggest roads to interventions that reduce the genetic risk, perhaps by improving our understanding of some of the nonbiological mediators by which that risk may be transmitted (e.g., modeling of fearful behavior, parenting styles).
All four of the attachment styles in children according to the classification by Ainsworth, Blehar, Waters, and Wall, (1978) and Main and Solomon (1990)—secure, insecure-avoidant, insecure-ambivalent, and insecure-disorganized—have been found to be represented in children with anxiety disorders. However, the highest risks for developing an anxiety disorder are associated with disorganized attachment, which is associated with unresolved trauma or loss, and ambivalent attachment (Cassidy, 1995; (p. 257) Manassis, Bradley, Goldberg, Hood, & Swinson, 1994; Warren, Huston, Egeland, & Sroufe, 1997). The specificity of an association between disorganized attachment in terms of its link with a specific type of anxiety disorder, such as separation anxiety disorder, has not been established.
Lutz and Hock (1995) examined whether adult mental representations of attachment relationships and memories of childhood experiences with parents contributed to a mother’s anxiety about separation from her own infant. Mothers with insecure attachment representations, when asked to remember details of their own childhood, reported more negative recollections of early parental caregiving, particularly rejection and discouragement of independence. Cassidy (1995) found that adolescents and adults with GAD reported more caregiver unresponsiveness, role reversal/enmeshment, and feelings of anger/vulnerability toward their mothers than controls. Systematic and formal assessments of the adolescent and adult attachment styles were not conducted in this sample, however. The biggest problem with this entire line of research, however, is that anxious people’s current clinical state may influence their retrospective recall of attachment as they search for viable explanations for why they suffer from these symptoms. Accordingly, prospective and even cross-sectional studies allow for a less biased view of these interrelationships and their potential contribution to the development of anxiety disorders.
Manassis et al. (1994) examined adult attachment and mother–child attachment in 20 mother–child dyads (children ages 18–59 months) in which the mothers had anxiety disorders. The mothers all had insecure adult attachments, and 80% also had insecure attachments with their children. Among the insecurely attached children, three of 16 met diagnostic criteria for anxiety disorders; none of the secure children did. Two had separation anxiety disorder (one with disorganized attachment, one with avoidant attachment) and one had avoidant disorder (with disorganized attachment). Insecure children also had higher internalizing scores on the Child Behavior Checklist (Achenbach & Edelbrock, 1984) than secure children. When the dyads who had been classified as disorganized and mothers who had been classified as unresolved were assigned their “best” alternate category, and combined with the remaining three attachment categories, a higher-than-expected rate of ambivalent/resistant attachment and a lower-than-expected rate of secure attachment were found.
Warren et al. (1997) studied 172 adolescents aged 17.5 years who had participated in assessments of mother–child attachment at 12 months of age. Of these 172 adolescents, 26 (15%) met diagnostic criteria for anxiety disorders. More of the adolescents with anxiety disorders were classified as anxious/resistant in infancy than the adolescents without anxiety disorders. More adolescents diagnosed with other disorders (not anxiety) were, as infants, classified as avoidant. Furthermore, being classified as anxious/resistant attachment doubled the risk of subsequently developing an anxiety disorder, and better predicted adolescent anxiety disorders than either maternal anxiety or child temperament. The interaction between anxious/resistant attachment and one aspect of temperament (slow habituation to stimuli) further increased the risk of a subsequent anxiety disorder. However, secure, insecure-avoidant, and insecure-resistant attachment were all represented among the adolescents with anxiety disorders (data on the insecure-disorganized classification were unavailable).
Linkages also have been found between attachment and subclinical levels of anxiety. Female undergraduates who were insecurely attached were perceived by their friends as being more anxious than their counterparts who were securely attached (Barnas, Pollina, & Cummings 1991). Crowell, O’Connor, Wollmers, and Sprafkin (1991) found that children with behavioral disturbances whose mothers were classified as secure on the Adult Attachment Interview rated themselves as less (p. 258) anxious and depressed than children with behavioral disturbances whose mothers were insecure-dismissing. Cassidy and Berlin (1994) reported increased fearfulness across several studies of insecure-ambivalent/resistant children.
Belsky and Rovine (1987) have suggested a potential linkage between attachment and anxiety when attachment is placed on a spectrum from the style associated with the most overt distress (ambivalent/resistant) to that associated with the least overt distress (avoidant). Secures are in the middle of the spectrum, with some exhibiting relatively high distress and some exhibiting relatively low distress (Belsky & Rovine, 1987). Consistent with Belsky and Rovine (1987), 2.5-year-old children who were either insecure-ambivalent/resistant or secure with relatively high distress showed higher indices of fear and separation distress than children in the other attachment classifications (Stevenson-Hinde & Shouldice, 1990).
A large study (644 adolescents) conducted in the Netherlands (Muris et al., 2002) examined behavioral inhibition, attachment, parental rearing behavior, and self-reported anxiety symptoms, and identified small to moderate correlations among these risk factors but also a modest but significant positive relationship between each of these variables and child anxiety scores, though little was found in the way of interactive effects. The absence of parent- or observer-reported data on adolescents’ anxiety levels is a weakness of the study, especially since the overall levels of anxiety reported were not particularly high.
Costa, Weems, and Pina (2009) examined the predictive value of attachment beliefs and parenting behaviors in a sample of 74 youth exposed to Hurricane Katrina. The advantage of this study was the fact that the investigators had assessments of attachment, anxiety symptoms, and parenting behaviors prior to the storm. Upon reassessment after the storm, it was found that youths’ perceptions of trust and communication with their mothers as well as acceptance and firm control moderated the association between youths’ pre- and post-Katrina anxiety: those with higher levels of anxiety and lower perceptions of trust, communication, or acceptance as well as higher perceptions of firm control before the hurricane were most likely to show increases in anxiety afterward. These data point to several potential intervention points, such as focusing on improving the parent–child relationship and the child’s perception of that relationship, in the context of trauma exposure.
In summary, attachment, in particular insecure attachment, has been linked with both clinical and subclinical anxiety in children of different age ranges. The link may be stronger when the child also has a temperamental vulnerability to anxiety, though the evidence there is not as clear. Limitations of this research include the paucity of prospective studies, the varying definitions of “anxiety” (e.g., anxiety symptoms, anxiety disorders) used across studies, and small sample sizes.
The research conducted on “parenting” has primarily focused on parental rearing styles, with the latter conceptualized along two orthogonal dimensions: warmth versus hostility, and control versus autonomy (Boer, 1998; Cassidy, 1995; Dadds, Barrett, Rapee, & Ryan, 1996; Festa & Ginsburg, 2011; Lutz & Hock, 1995; Manassis et al., 1994; Rapee 1997; Siqueland, Kendall, & Steinberg, 1996; Warren et al., 1997).
In a meta-analysis of five studies, with a total of 463 patients in the experimental groups, Gerlsma, Emmelkamp, and Arrindell (1990) found that adults with phobias reported a parental rearing style characterized by less affection and more control. Studies of adults meeting diagnostic criteria for panic disorder or social phobia/avoidant personality disorder have demonstrated a similar recollection of childrearing patterns, in that these adults view their parents, and their relationship with them, as low in affection and overcontrolling (Rapee, 1997). Parental overcontrol was also found to be predictive of social anxiety symptoms in a recent study examining the predictive (p. 259) value of parental and social factors (Festa & Ginsburg, 2011).
Empirical research has documented an influence of parental rearing styles on the development of anxiety (see Rapee, 1997, for review). Interestingly, adults with insecure-preoccupied attachments frequently report parental rejection and control (Main & Goldwyn, 1991), suggesting that parenting style may be related to adult attachment status. Here again, the possibility of biased recall cannot be discounted as a source of variance in any retrospective examination of parenting styles in anxious adults or youth.
Prospective Reports and Behavioral Observations
In an early study, Zabin and Melamed (1980), using a self-report measure of parental rearing patterns, found parental reported use of positive reinforcement, modeling, and persuasion was associated with lower levels of child anxiety when the child had to undergo a fearful medical procedure; parental use of punishment, physical force, and reinforcement of dependency was associated with higher levels during the procedure. Siqueland et al. (1996) found that parents of children with anxiety disorders were rated by observers as less granting of psychological autonomy than were the parents of “normal” controls. In addition, children with anxiety disorders rated their mothers and fathers as less accepting and less granting of psychological autonomy than control children rated their parents. The potential for a bidirectional relationship with respect to child anxiety and parental granting of psychological autonomy renders the meaning of these findings unclear, however, especially as they may relate to potential points of intervention. Parental anxiety in and of itself does seem to play a role in the development and maintenance of anxiety in children (e.g., Bögels & Phares, 2008; Kendall et al., 2009), although here again the way in which this risk is transmitted has yet to be clarified and is likely complex. What did emerge from Kendall et al.’s clinical trial, as discussed in Chapter 10, is that the presence of parental anxiety disorders was a moderator of outcome, such that if both parents had an anxiety disorder, then the child’s outcomes were substantially better in the condition that involved cognitive-behavioral therapy (CBT) including a strong family component, than in the one that was delivered individually. This implicates, but does not isolate, a potential effect of modeling for both anxious behavior and for approach behavior once the family has been familiarized with the CBT model.
Direct observations of parent–child interactions have provided further evidence of family processes that may be specific to families of children with anxiety disorders, and these processes may serve to either bring out and/or maintain these disorders in children (e.g., Chorpita, Albano, & Barlow, 1996; Dadds et al., 1996 see Ginsburg, Silverman, & Kurtines, 1995). For example, Dadds et al. (1996) studied specific sequences of communication exchanged between parents and children (ages 7–14) in a discussion of ambiguous hypothetical situations. Parents of children with anxiety disorders (n = 66) were less likely to grant and reward autonomy of thought and action than controls (n = 18). Dadds et al. also found that these parents fostered cautiousness and avoidance taking a social risk by modeling caution, providing information about risk, expressing doubt about the child’s competency, and rewarding the child for avoidance by expressing agreement and nurturance when the child decides he or she would not join in with the other children. Dadds et al. referred to this finding as the FEAR effect (Family Enhancement of Avoidant and Aggressive Responses).
Hudson and Rapee (2002) studied 57 children and adolescents (37 children with anxiety disorders and 20 non-clinic-referred children; ages 7–16 years) and found that mothers and fathers were overly involved not only with their child with an anxiety disorder but also with the child’s sibling (without an anxiety disorder). The authors concluded that because parents’ overinvolvement does not occur exclusively in youths with anxiety disorders, it probably is not simply a response to difficulties with anxiety and coping that they have observed with the diagnosed youth. It also suggests that parental (p. 260) overinvolvement does not in and of itself cause anxiety disorders.
Anxious parents could increase the risk of anxiety disorders in their offspring by doing the following:
1. Having difficulty modeling appropriate coping strategies
2. Reacting to their children’s fears negatively because they represent an aspect of themselves they would rather deny
3. Becoming overly concerned about their children’s anxiety, resulting in overprotection and thus reducing opportunities for desensitization.
The latter two reactions are consistent with dismissive and preoccupied adult attachment types, respectively. Anxious parents who are securely attached, on the other hand, may be able to empathize with their children’s fears, which may then be perceived as supportive. Thus, the transmission of parental anxiety may depend on the interaction between attachment and parental psychopathology (Radke-Yarrow, DeMulder, & Belmont, 1995).
Peers, School, and Community
The ecology of adolescent development and culture includes an expanded network of peer, school, and community affiliations. The transition to middle school and high school constitutes a period of high developmental risk, in which there is an increased incidence of school truancy, failure and dropout, engagement in high-risk sexual and self-injurious behaviors, smoking and drug use, initiation into gangs, and contact with the juvenile justice system. It is also a time period of increased exposure to interpersonal violence. For example, among high school students who dated, 21% of females and 10% of males experienced physical and/or sexual violence (Vagi et al., 2015). This prevalence rate has remained unchanged in the last decade (Black et al., 2011) despite increased efforts to publicize this problem as an important public health issue. With respect to traumatic experiences more broadly speaking, the majority of 6,483 adolescents (61.8%) who participated in the National Comorbidity Survey Replication Adolescent Supplement study (McLaughlin et al., 2013) reported a potentially traumatic experience, with 4.7% already meeting full criteria for DSM-IV posttraumatic stress disorder (PTSD). In the sections below, particular high-risk activities engaged in by adolescents and their associated risk with the development of anxiety and anxiety disorders are discussed.
Initiation into cigarette smoking in adolescence is recognized as a major public health problem. Approximately 3,200 adolescents start smoking each day (U.S. Department of Health and Human Services, 2012, 2014), resulting in about 23% of high-school seniors smoking or using other tobacco products daily. Smoking prevention and early treatment are important components of universal and selective public health prevention strategies, especially given that the American Health Association estimates that addiction to tobacco during adolescence accounts for 80% of adult smokers. As Upadhyaya et al. (2002) discuss, there is continuing interest in the interaction between the onset of adolescent psychiatric conditions and smoking behavior, including experimental smoking and cessation difficulty. Among the disorders studied, Johnson, Cohen, Pine, Kline, Kasen, and Book (2000) report that heavy cigarette smoking (defined as over 20 cigarettes per day) is associated with higher rates of agoraphobia and anxiety and panic disorders in adolescents. Zvolensky and Bernstein (2005) have identified a more specific link between cigarette smoking and the onset of panic-spectrum psychopathology in particular. Other studies have reported an even stronger association of adolescent smoking with attention-deficit/hyperactivity disorder (Johnson et. al., 2000) and major depressive disorder (Dierker et al., 2001). Most of these studies note the importance of the relationship between peer smoking influences and individual psychiatric vulnerabilities. The general conclusion is two-pronged: (p. 261)
1. Smoking prevention and cessation programs need to incorporate screening for adolescent psychiatric disorders, including anxiety disorders.
2. Attention to adolescent anxiety and comorbid disorders need to include strategies to address risks of tobacco addiction.
Adolescence is a developmental period in which experimentation with alcohol and drugs is common. It also a time of risk for early onset of alcohol and substance abuse/dependence. Nelson and Wittchen (1998) found that among youth and young adults, the peak incidence of alcohol disorders occurred at 16 or 17 years of age. Alcohol and drug use problems in adolescence represent a strong predictive factor for adult alcohol and drug dependence (Swadi, 1999). Studies of substance abuse and alcohol motivation in adolescents suggest a multifactorial explanatory framework. Among the many factors, Comeau, Stuart, and Loba (2001) found that high anxiety sensitivity predicts conformity motives for alcohol and marijuana use, while anxiety traits are associated with coping motives for alcohol and cigarette use. Zucker et al. (2002) reported that among young adults with panic disorder, up to one in five patients had an onset related to an adolescent experience with a psychoactive drug. In a review of studies of adolescent use of the recreational drug Ecstasy, Montoya et al. (2002) found a strong association between repeated drug use and anxiety disturbances, with potential neurobiological consequences that are of concern within this critical developmental stage.
Initiation and use of alcohol and drugs among adolescents is also related to life stresses, including traumatic events (Wills, Vaccaro, & McNammar, 1992). In one study, substance-abusing adolescents were found to be five times more likely to have a history of trauma and concurrent PTSD compared to a community sample (Deykin & Buka, 1997). In a large study of adolescents enrolled in four drug treatment programs, a high positive correlation was found between severity of posttraumatic stress symptoms and higher levels of substance use and HIV risk behavior (Stevens, Murphy, & McNight, 2003). Further support for the link between trauma and substance abuse was found in a large study of cannabis dependence and abuse, wherein PTSD diagnosis was directly associated with both the presence of a cannabis use disorder and with peer deviance which, in turn, exposes adolescents to more potentially traumatic experiences (Cornelius et al., 2010).
As with cigarette addiction, prevention strategies in regard to adolescent substance abuse need to include early intervention for anxiety-vulnerable and traumatized youth and, at the same time, recognize that prevention or early intervention for adolescent substance abuse may also constitute an anxiety disorder prevention strategy.
Gang Affiliation and Other Criminal Behavior
Gang affiliation is a serious cultural problem in adolescence. There are an estimated 33,000 gangs, with over 1.4 million members, active across the United States (U.S. Department of Justice, 2011). There is a complexity to youth involvement in gangs. Many studies have examined the confluence of risk factors that predict gang membership, including neighborhood, family, school, peer group, and individual variables (Hill, Levermore, Twaite, & Jones, 1996). There is an emerging literature about the extent of trauma and loss exposure associated with gang membership and delinquent behavior more generally (Wood, Foy, Layne, Pynoos, & James, 2002). Despite high rates of trauma exposure prior to gang membership, commonly youth report their worst traumatic experiences are gang -related and the source of current PTSD symptoms (Wood et al., 2002). Ages 11 to 13 are primary years for solicitation and inculcation into gang affiliation and activities, contributing to years of increased trauma and loss exposure during adolescence. Consequently, intervention programs to prevent youth from becoming involved in gangs should be considered an adjunct prevention strategy for adolescent PTSD.
(p. 262) Attention has turned to the high prevalence of adolescent psychiatric disorder present among juvenile justice detainees. Studies that have assessed PTSD in this setting have found it to be among the highest rates found (Wasserman, McReynolds, Lucal, Fisher, & Santos, 2002). Interestingly, separation anxiety disorder among adolescents (an age range where it is less expected) is surprisingly high among African-American and Hispanic/Latino detained youth (Teplin, Abram, McClelland, Dulkan, & Mericle, 2002). Further, among incarcerated boys with callous-unemotional traits, the rates of negative life events and PTSD were significantly elevated (Sharf et al., 2014). Such effects are also found in female adolescent criminal offenders: a review of the literature revealed high rates of trauma exposure, PTSD, and substance abuse disorders (Foy et al., 2012). The juvenile justice contact thus provides a key opportunity for mental health intervention that can play a significant role in an overall public mental health approach to adolescent anxiety disorders and delinquency prevention programs. Notably, there is evidence from a randomized controlled trial that providing substance abuse and mental health treatment in prison settings significantly reduces recidivism 1 year after release in adult male offenders (Sacks et al., 2012). This offers encouragement to researchers to develop prevention programs centered around treatment of mental health problems in adjudicated teens, which may reduce the risk of re-offending.
Adolescence and Trauma Exposure
Adolescence represents a development transition in the maturation of self-efficacy in the face of danger. There is increasing reliance on the peer group for appraisal of danger and estimation of needed protective actions along with greater engagement of the peer group in dangerous and protective behavior. Developmental epidemiology suggests that adolescence carries a high risk of exposure to a spectrum of traumatic situations, subsequent PTSD, comorbid psychopathology, and age-related impairments. Included among the salient types of exposure are adolescent physical and sexual abuse (Kaplan et al., 1998; Pelcovitz et al., 2000); interpersonal and community violence (Kilpatrick et al., 1997; Wolfe et al., 2001); serious accidental injury, especially traffic accidents (de Vries et al., 1999); traumatic losses, including those by homicide, suicide, and fatal automobile accidents (Minino, 2010); and life-threatening medical illness accompanied by life-endangering medical procedures (e.g., kidney and liver transplant; Shemesh et al., 2000; Meeske et al., 2001).
There also has been a lack of societal recognition that adolescence is the age range with the highest rates of criminal victimization (Menard, 2002). For example, adolescents are two times more likely than adults to be victims of serious violent crime and three times more likely to be victims of simple assault (Sickmund, Snyder, & Poe-Yamagata, 1997; Snyder, 1998). A national survey of adolescents found 23% reported having been both a victim of assault and a witness to violence, and over 20% met the lifetime criteria for PTSD (Kilpatrick et al., 1997). Boys are more likely to experience criminal assault, and girls are more likely to experience dating violence and rape. Despite a lower rate of filing criminal complaints, adolescence is the period in which, by self-report, sexual assault occurs most, with a rate during ages 13 to 17 years of 14.8% among girls and 3.7% among boys (Kilpatrick et al., 2003). In addition to general rates of exposure to war and disasters, international studies indicate that adolescents in these situations often are engaged in resistance and rescue efforts, and can become victims of torture (Nader et al., 1989; Pynoos et al., 2001). Bouwer and Stein (1997) reported that a significant subpopulation of adults with panic disorder had a history of traumatic suffocation experience, including political torture by suffocation in adolescence. Fear and symptom profiles included respiratory phenomena and nocturnal panic. Studies among adolescents indicate that there may be multiple forms of exposure, with comorbid admixtures of PTSD, depression, and separation anxiety disorder (Pelcovitz et al., 2000; Warner & Weist, 1996). Finally, adolescent trauma exposures often are superimposed (p. 263) on prior trauma histories and untreated chronic posttraumatic stress symptoms.
Considerable evidence indicates that traumatized adolescents are at increased risk for a spectrum of adverse psychosocial difficulties and functional impairments. These include reduced academic achievement; aggressive, delinquent, or high-risk sexual behaviors; substance abuse and dependence (Cavaiola & Schiff, 1988; Farrell & Bruce, 1997; Kilpatrick, Acierno, Saundres, Resnick & Best, 2000; Saigh, Mroueh, & Bremner, 1997; Saltzman, Pynoos, Layne, Steinberg & Aisenberg, 2001); and nonadherence to prescribed posttransplant medical treatment (Shemesh et al., 2000). Further, trauma in adolescence has been linked with long-term developmental disturbances, including disrupted moral development, missed developmental opportunities, delayed preparation for professional and family life, and disruptions in close relationships (Goenjian et al., 1999; Layne, Pynoos, & Cardenas, 2000; Malinkosky-Rummell & Hansen, 1993; Pynoos, Steinberg, & Piacentini, 1999). Ongoing reactive behavior to trauma reminders in adolescence carries the bimodal risk of reckless behavior or extreme avoidant behavior that can derail an adolescent’s life. Programs to help reduce adolescents’ risk of exposure to trauma would thereby seem to play an important role in preserving adolescent development.
The adult literature is replete with studies that suggest the possible beneficial effects of social support following exposure to traumatic events, but less is known about its role in mitigating anxiety disorder symptoms outside the context of trauma, and even less about the influence of social support in adolescent anxiety disorders. Studies of veterans from the Vietnam, Gulf, and Lebanon wars have found that veterans’ perceptions of poor social support are associated with worse PTSD symptoms; the relationship remains when veterans report retrospectively about the support they received immediately after their return from duty (Barrett & Mizes, 1988; Fontana, Schwartz, & Rosenheck, 1997; Foy, Resnick, Sipprelle, & Carroll, 1987; Solomon et al., 1988; Stretch, 1985; Sutker et al., 1995a, 1995b) and even when controlling for level of combat exposure, another robust predictor of PTSD symptoms among veterans (Boscarino, 1995; King et al., 1998). Among civilian victims of violence, poor social support also has been linked to PTSD symptoms in victims of violent nonsexual assault (Bisson & Shepherd, 1995), domestic violence (Astin et al., 1993; Kemp et al., 1995), and rape (Resick, 1993; Steketee & Foa, 1987; Zoellner et al., 1999). Moreover, Fontana and Rosenheck (1998) found that good postdischarge social support was strongly predictive of less PTSD in female veterans who were victims of sexual harassment, rape, or attempted rape. Social support is also associated with recovery among victims of “noninterpersonal” traumas, such as natural disasters (e.g., Madakasira & O’Brien (1987), motor vehicle accidents (Buckley et al., 1996), and chronic, life-threatening illness, including patients treated for breast cancer (Andrykowski & Cordova, 1998), African-American women with HIV/AIDS (Myers & Durvasula, 1999), and survivors of childhood leukemia and their mothers and fathers (Kazak et al., 1997).
There are a number of shortcomings to the extant adult literature on social support in the wake of trauma. First, although a large body of research supports the conclusion that social support is associated with decreased PTSD symptomology (e.g., Greene et al. 2006; Keane et al., 1985), most of these studies have relied on retrospective reports (some as many as 30 years after the fact) of social support. Second, the studies typically have aggregated and equally weighted the influence of friends, coworkers, and neighbors with that of immediate family, which may obscure the more influential effects for the latter (Griffith, 1985). Third, and perhaps most importantly for the purpose of considering prevention efforts, no studies have attempted to delineate the mechanism responsible for the apparent positive impact of social support on posttrauma recovery. Pennebaker and Seagal (1999) suggest that painful events that have not been structured in a narrative format may contribute to the continued (p. 264) experience of negative feelings and are more likely to remain in consciousness as unwanted thoughts (Wegner, 1989). Foa and Riggs (1993) suggest that trauma disclosure within naturally occurring social support systems provides three potential benefits:
1. Disclosure allows the trauma survivor to confront frightening memories in a relatively safe environment, allowing habituation of fear reactions much as is accomplished in exposure-based treatment of PTSD (Foa et al., 1991, 1997; Keane et al., 1989; Richards et al., 1994).
2. Given the observation that traumatic memories often are often disjointed and confused, disclosure, particularly repeated disclosure, provides the survivor with an opportunity to create a more coherent memory.
3. Disclosure is thought to provide an opportunity for the survivor to evaluate potentially mistaken cognitions regarding the impact on himself or herself (e.g., “I am incompetent or worthless”) or the world (e.g., “the world is unpredictably dangerous”).
Herman (1992) suggests disclosure may also serve to “reconnect” the trauma survivor to others within the social arena. That is, the act of disclosing the trauma to another person may provide an opportunity for the survivor to redevelop a sense of trust and attachment to others. Thus, disclosing the trauma to a supportive person may function in multiple ways to facilitate recovery.
There also is evidence that social support may mitigate the impact of negative life events in children and adolescents whose parents are divorcing (Cowen et al., 1990) and in those who have been exposed to community violence (Berman, Kurtines, Silverman, & Serafini, 1996; Hill, Levermore, Twaite, & Jones, 1996; White, Bruce, Farrell, & Kliewer, 1998) and hurricanes (e.g., La Greca, Silverman, Vernberg, & Prinstein, 1996; Vernberg, La Greca, Silverman, & Prinstein, 1996). For example, White, Bruce, Farrell, and Kliewer (1998) found a strong negative relation between anxiety level and family social support in a longitudinal study investigating the effects of family social support on anxiety in 11- to 14-year-olds exposed to community violence. In children exposed to the devastation of Hurricane Andrew in south Florida, higher anxiety, less social support, more intervening life events, and greater use of poor emotion coping strategies each predicted chronic distress at follow-up (LaGreca et al., 2010, 2013), which again underscores the importance of social support as a potential protective factor. Perhaps acceptance into a supportive social network attenuates the effects of the putative anxiety disorder risk factors described earlier. Thus, social support serves as one possible explanation for why so many children and adolescents elevated on these risk factors (e.g., behavioral inhibition, parental anxiety disorders) do not go on to develop full-blown disorders (e.g., Derivois et al., 2014; Festa & Ginsburg, 2011). The importance of the adolescent’s peer group suggests that social support may be particularly relevant during this period. (See Table 11.1 for a summary of putative risk factors.)
Table 11.1 Who May Be at Risk?
Elevated but Subsyndromal Anxiety Symptoms
Increased risk of developing full-blown disorder in next two years if elevated symptoms are already present
Behavioral Inhibition (Temperament)
Tendency to avoid novel stimuli and experiences; excessive shyness in response to new people
Tendency to interpret physiological sensations of anxiety as threatening and of themselves
Avoidant coping style, low perceived control
Insecure attachment, possibly interacting w/ behaviorally inhibited temperament
Parental tendency to suggest avoidant problem-solving strategies; overinvolvement & overprotection in response to child’s fears; poor modeling of coping responses
Peer, School, & Community Factors
Association with panic disorder in particular
Alcohol & Other Drug Use
Elevates other risk factors (e.g., motor vehicle accidents), may also elevate risk in and of itself
Gang Affiliation/Criminal Behavior
Exposure to traumatic events, commission of interpersonal violence
Experiencing a Criterion A trauma increases the risk for PTSD and other anxiety symptoms, perhaps especially in those who are already vulnerable or in response to certain traumas regardless (e.g., sexual assault)
Poor Social Support
Associated with more symptoms and poorer outcomes in adults, possibly a mediating factor
Early Detection and Screening
The success of prevention intervention programs for anxiety disorders in adolescents depends a great deal on having early detection and screening strategies in place at key access points where youths might be identified. The types of early detection and screening strategies are likely to vary with the type of preventive intervention program being implemented (universal, selective, indicated). In this section, key access points are identified and specific types of screens that might be administered, depending on the type of preventive intervention strategy, are summarized.
Before proceeding with this discussion, a general point is first worth noting. Namely, for the majority of access points or settings where early detection and screening strategies might be conducted, some type of rating scale is recommended for initial use. Because of their objective scoring procedure, rating scales minimize (p. 265) the role of clinical inference and interpretation. As a result, there is no need to use highly trained staff for administration and scoring. In addition, most rating scales contain questions that would be of clear concern to non–mental health professionals, such as school board institutional review board members, because the scales contain items that are face valid. Finally, a wide range of rating scales are available for administration to various informants, including children and adolescents, as well as parents, teachers, and clinicians. Consequently, information can be obtained from either a single source (e.g., adolescent only) or multiple sources (e.g., adolescent, parent) depending on available resources. If resources are limited, the consensus in the field is that information from youths themselves should be obtained for screening/assessing for internalizing problems, including anxiety (Loeber, Green, & Lahey, 1990).
Despite the advantages of using rating scales for early detection and screening, two caveats are worth noting. First, although the measures that are mentioned in this section all possess adequate psychometric properties in terms of reliability and validity, their actual utility for screening purposes awaits further empirical evaluation. For example, data on the measures’ sensitivity (the percentage of individuals who receive the diagnosis who were positively identified by the rating scale; true positives) and (p. 266) specificity (the percentage of individuals who do not receive the diagnosis and who are not identified by the rating scale as anxious; true negatives) (Vecchio, 1996) are scarce when it comes to child and adolescent samples, particularly nonwhite samples. Second, currently available rating scales are likely to select more false positives than true positives (Costello & Angold, 1988). That is, youths identified as anxious at an initial screen are likely not to be anxious or depressed at the second stage of an investigation. Consequently, a useful/cost-efficient approach for early detection and screening for indicated intervention programs would employ a multistage sampling design (e.g., Ialongo, Edelsohn, Werthamer-Larsson, Crockett, & Kellam, 1993; Kendall, Cantwell & Kazdin, 1989; Roberts, Lewinsohn, & Seeley, 1991). At the first stage, a rating scale would be administered to informants to identify youths who score 1 or 2 standard deviations from the sample mean or who deviate from normative data. These identified cases would then undergo more precise and comprehensive assessments (e.g., structured diagnostic interviews) at the second or third stage of the research.
Potential Access Points for Early Detection and Screening
The school setting is an obvious access point for early detection and screening of anxiety and its disorders because this is where the children and adolescents are! If a preventive interventionist were interested in developing and implementing an indicated prevention program, there are several rating scales that could be administered to target high-risk children and adolescents who may demonstrate minimal but detectable symptoms of anxiety and/or anxiety disorders. In general, most of the research studies that have used rating scales for screening anxiety symptoms/disorders have largely used preadolescent samples of children (e.g., McDermott et al., 2013). There is a paucity of work in which the study’s samples involved adolescents specifically.
For anxiety symptoms, the most widely used child and adolescent self-rating scale measure is the Revised Children’s Manifest Anxiety Scale (RCMAS; Reynolds & Richmond, 1978), which was used as an initial screen in the Queensland Early Intervention and Prevention of Anxiety Project (Dadds, Holland, Laurens, Mullins, Barrett, & Spence, 1999; Dadds, Spence, Holland, Barrett, & Laurens, 1997), described below. The RCMAS is a 37-item scale: 28 items are summed to yield a Total Anxiety score and the other nine items are summed to yield a Lie score. Youths respond either Yes or No to all 37 items. Factor analytic studies also have provided support for the RCMAS’s three-factor subscale structure (Physiological, Worry/Oversensitivity, and Concentration) as well as the Lie scale (e.g., Paget & Reynolds, 1984; Reynolds & Richmond, 1979; Scholwinski & Reynolds, 1985). Positive scale convergence between the RCMAS and other widely used child self-rating scales of anxiety and related constructs (trait anxiety, fear, depression) in community samples have been found as well (e.g., Muris, Merckelbach, Ollendick, King, & Bogie, 2002). A 15-item version of this scale has since been developed, and it performed well psychometrically (Ebesutani et al., 2012); this may increase the likelihood of use as a mass screening tool.
For anxiety symptoms linked more directly to DSM-IV anxiety disorders, the Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Connor, 1997), the Screen for Child Anxiety Related Emotional Disorders (Birmaher, Khetarpal, Brent, Cully, Balach, Kaufman, et al., 1997), and the Spence Children’s Anxiety Scale may be useful. The MASC, for example, is a 45-item scale that yields a Total Anxiety Disorder Index and four main factor scores: Social Anxiety (with performance anxiety and humiliation as subfactors), Physical Symptoms, (with tension-restlessness and somatic-autonomic arousal as subfactors), Harm/Avoidance (with perfectionism and anxious coping as subfactors), and Separation/Panic. In addition, six items yield an Inconsistency Index to identify careless or contradictory responses. Youths may (p. 267) be identified based on either specific subscale scores on these measures or the total score.
For social anxiety, the Social Anxiety Scale for Children—Revised (La Greca & Stone, 1993) and the adolescent version (La Greca & Lopez, 1998) as well as the Social Phobia and Anxiety Inventory for Children (Beidel, Turner, & Morris, 1995) have been found to be helpful in identifying highly social anxious children (Epkins, 2002; Morris & Masia, 1998), though variations in the two measures’ classification correspondence indicated variation with sample, age, and sex. In light of this variation, coupled with the fact that both Epkins (2002) and Morris and Masia (1998) did not sample adolescents (Epkins’s sample was 8–12 years; Morris and Masia’s was 9–12 years), additional research on the utility of these measures for screening among adolescents is needed. A study that examined several screening measures for social anxiety in pediatric primary care found that a single item from the Screen for Child Related Anxiety Disorders (SCARED), which was “my child is shy,” was moderately accurate for detecting generalized social phobia in primary care (Bailey et al., 2006). Moreover, research on all of these scales’ utility in the context of prevention remains lacking.
The Childhood Anxiety Sensitivity Index (CASI; Silverman, Fleisig, Rabian, & Peterson, 1991) has been used in a number of studies and appears useful as a screen for adolescents who may be at risk for displaying panic attacks and panic disorder (Hayward, Killen, Wilson, & Hammer, 1997; Weems, Hayward, Killen, & Taylor, 2002). The CASI consists of 18 items that assess the extent to which children and adolescents believe the experience of anxiety will result in negative consequences. Sample items include: “It scares me when I feel like I am going to throw up” and “It scares me when my heart beats fast.” Youths respond to each item using a 3-point scale: none (1), some (2), or a lot (3). The CASI yields a total score by summing the ratings across all items. CASI scores can range from 18 to 54, with higher scores reflecting higher levels of anxiety sensitivity.
In addition, evidence indicates that a large proportion of children and adolescents who display school refusal behavior are likely suffering from some type of anxiety disorder, particularly separation anxiety disorder in young children and social anxiety, panic, or GAD in older children and adolescents (Kearney & Silverman, 1997). This renders it critical that school counselors and psychologists be informed and educated about the nature of school refusal behavior so that they can help detect such cases and refer them for appropriate therapeutic, rather than disciplinary, action.
If a preventive interventionist were interested in developing and implementing a selective prevention program in a school setting, specific groups or individuals considered to be at risk for developing anxiety and its disorders need to be identified. At the preschool level, Rapee (2002) used a mother-completed rating scale of child’s temperament, followed by a laboratory observation of behavioral inhibition, as a screen for selecting youngsters in the Macquarie University Preschool Intervention Program (described subsequently).
In light of the high rates of traumatic exposure among young people, particularly adolescents, youths who have been exposed to traumatic events are another group that should be considered for early detection and screening in the school setting, focusing particularly on posttraumatic stress and anxiety reactions. Successful efforts in such screening, using most frequently the Reaction Index (Frederick, Pynoos, & Nader, 1992), have appeared in the area of community violence (e.g., adolescent sample: Berman, Kurtines, Silverman, & Serafini, 1996), natural disasters (e.g., child sample; La Greca, Silverman, Vernberg, & Prinstein, 1996; Vernberg, La Greca, Silverman, & Prinstein, 1996); and sniper shootings (e.g., child sample; Pynoos, Frederick, Nader, & Arroyo, 1987). March et al. (1997) and Foa et al. (2001) have developed and conducted psychometric evaluation of the Child and Adolescent Trama Survey (CATS) and the Child PTSD Symptom Scale (CPSS), respectively; both have been found to be psychometrically sound.
The CPSS, for example, assesses traumatic stress symptoms in children and adolescents, 8 to 18 years of age. CPSS items assess all 17 (p. 268) DSM-IV symptom criteria for PTSD and yield a Total Severity Score (17 items) and three empirically derived factor scale scores representing DSM-IV clusters B (Re-experiencing), C (Avoidance), and D (Arousal). The CPSS also includes a seven-item impairment rating scale to assess functioning in such domains as family, peers, and school. Evidence has indicated moderate to excellent internal consistency, retest reliability, and concurrent validity as well as excellent sensitivity and specificity (Foa, Johnson, Feeny, & Treadwell, 2001; Gillihan, Aderka, Conklin, Capaldi, & Foa 2013). In a South African sample, Suliman et al. (2005) found that the CATS can be used effectively as a screening tool for PTSD in school settings provided that appropriate cutoff scores are used. Together, these PTSD scales have the potential for use in early detection and screening of youths at high risk in developing posttraumatic stress and anxiety reactions due to their exposure to traumatic events, though further evaluative research regarding their utility for such purposes is needed. In addition, given that many adolescent-onset problems, such as cigarette smoking, frequently co-occur with anxiety and its disorders, as noted earlier, screening for anxiety using one of the anxiety symptoms scales may be worthwhile to include whenever beginning to work with adolescents on such problems.
Finally, Beidel and colleagues (Beidel & Turner, 1988; Beidel, Turner, & Trager, 1994) conducted a series of studies showing that the Test Anxiety Scale for Children (Saranson, Davidson, Lighthall, & Waite, 1958) could serve as a useful screen in identifying children who may show detectable symptoms of anxiety disorders, including social anxiety disorder, specific phobia, and GAD. Clearly, given that “high stakes” testing (e.g., SATs, ACTs) becomes more of a stressor with adolescence, the potential utility of test anxiety as a marker, and the Test Anxiety Scale as a screen among adolescent samples, deserves scrutiny.
There are multiple access points for early detection and screening in healthcare settings, particularly in pediatrics, obstetrics-gynecology, and psychiatry. The pediatric setting, for example, is the natural site for early detection and screening of young children with pediatric onset of either OCD or a tic disorder following an abrupt onset of symptoms after a group A hemolytic streptococcal infection (PANDAS). Indeed, for a large proportion of families, the pediatrician’s office is the “first gate” they enter when their child or adolescent begins to show disturbances associated with anxiety and its disorders, such as somatic complaints and panic attack symptoms. A recent study provided preliminary supportive evidence for use of another disorder-specific screening tool in primary care, the Autonomic Nervous System Questionnaire, which is a relatively short adolescent panic disorder screening instrument (Queen, Ehrenreich-May, & Hershorin, 2012). Similarly, Achiam-Montal, Tibi, and Lipsitz (2103) found that 20% of adolescents presenting with noncardiac chest pain screened positive for panic disorder in general outpatient medical settings. In general, it would thus seem to be critical for primary care physicians to have understanding of and knowledge about anxiety disorders so they could inquire about the presence/absence of key symptoms of the various disorders and refer the patient as necessary to a mental health professional for further evaluation based on the results of these initial queries.
Given the preponderance of female cases of anxiety disorders relative to male cases, particularly from adolescence and beyond, obstetrics-gynecology settings represent yet another potentially useful and critically important access point for early detection and screening. Studies have demonstrated that pubertal maturation in adolescent girls, particularly early onset, may constitute a risk factor for developing anxiety symptoms and disorders (e.g., Caspi & Moffit, 1991; Graber, Brooks-Gunn, Paikoff, & Warren, 1994), particularly panic attacks (Hayward, Killen, Kraemer, Blair-Greiner, Strachowski, & Cunning, 1997). Such findings suggest the potential utility of educating OB/GYNs about the risks of anxiety problems in their young adolescent patients. The manner in which such young patients may become overly (p. 269) sensitive to the physical changes that occur during the menstrual cycle (i.e., high anxiety sensitivity) might be carefully considered and even assessed using the CASI (Silverman et al., 1991). Relatedly, research findings, albeit sparse, suggest that hormonal fluctuations during the female reproductive cycle may serve to either exacerbate or reduce anxiety symptoms/disorders. For example, among some women, the postpartum period may be a risk for the onset and exacerbation of anxiety symptoms/disorders (March & Yonkers, 2001). Also among some women, pregnancy may be a period in which panic disorder improves (Shear & Oommen, 1995). In light of such findings, it seems critical for OB/GYNs to carefully consider their female patients’ emotional states during regularly scheduled appointments. Adult anxiety rating scales, such as the Hamilton Scales, may be worth administering as a potential screen for the presence of anxiety symptoms in these patients.
Finally, psychiatry departments housed in medical settings, in community mental health settings, or in private practice represent yet another important, though again largely untapped, access point by which to conduct early detection and screening. In light of the strong evidence for familial transmission of anxiety disorders, adult patients who present with anxiety disorders, depressive disorders, or both (Weissman, 1988) should be carefully queried about the functioning of their children and adolescents. For such purposes, parent rating scales such as the Child Behavior Checklist (CBCL; Achenbach, 1991) and the Connors Rating Scales (Conners, 1997) could be administered. Although parents with anxiety problems are likely to endorse high levels of internalizing problems in their offspring using the CBCL (e.g., Silverman, Cerny, Nelles, & Burke, 1988), some of which might be due to the parent’s own pathology, as noted earlier, this initial step is a screen. Further follow-up would then be conducted with the children themselves using structured interview schedules, such as the Anxiety Disorders Interview Schedule for Children: DSM-IV (Silverman & Albano, 1996). This interview schedule is the one most widely used in the child and adolescent anxiety disorders area and includes a child and a parent version.
The development of interventions designed to prevent anxiety disorders in adolescents has been hampered by insufficient and sometimes inconsistent information about the longitudinal course of disorders, the efficacy of procedures designed to reduce modifiable risk factors (e.g., anxiety sensitivity), the poorly understood influence of protective factors, and the possible additive if not multiplicative effects of multiple risk factors. Further, immersion in adolescent culture represents a time of increased risk for a variety of negative life experiences, and as such adolescents are at increased risk for the development of at least certain anxiety disorders during this time, such as PTSD and panic disorder. On the whole, the research literature remains underdeveloped, and addressing critical gaps will be important in developing adolescent-specific prevention programs.
The FRIENDS program, developed by Australian researchers led by Paula Barrett and colleagues and described below, has been evaluated extensively and is associated with the strongest effect sizes in the field. The FRIENDS acronym stands for Feeling worried; Relax and feel good; Inner thoughts; Explore plans of action; Nice work, reward yourself; Don’t forget to practice; and Stay cool. The program is cognitive-behavioral in orientation, can be delivered by teachers or psychologists, is conducted weekly for 10 weeks, and includes two booster sessions. The program has been used across the full spectrum from childhood to adolescence, but a clear effect for age has yet to emerge (Teubert & Pinquart, 2012); perhaps as a result of this, no adolescent-specific version of the FRIENDS program has been developed as yet. The FRIENDS program has been used in both selective and universal prevention studies. Developed and tested initially in Australia, the FRIENDS program has now been translated and adapted for use in other nations as well.
(p. 270) Types of Intervention
Our review of the extant intervention literature follows the organizational structure recommended by the Institute of Medicine’s Committee on Prevention of Mental Disorders: (1) indicated, (2) selective, and (3) universal prevention programs. Notably, some prevention intervention programs have been developed to target general psychopathology risk factors (e.g., children whose parents recently divorced; Pedro-Carroll & Cowen, 1985). However, because the link between these broader risk factors and the development of anxiety disorders is even more tenuous than the link between anxiety disorders and the specific anxiety disorder risk factors described above, we continue to limit our discussion to studies that focused specifically on prevention of anxiety symptoms and anxiety disorders. A comprehensive review of these broad risk factor studies is available elsewhere (Hudson, Flannery-Schroeder, & Kendall, 2004; Neil & Christensen, 2009).
Indicated Prevention Programs
These programs are most similar to the treatments for fully syndromal individuals with which the field is most familiar, in that patients are already experiencing anxiety symptoms that place them at higher risk for the development of the full-blown syndrome. Although prevention work with adults is relatively uncommon given that most who develop significant problems with anxiety or full-blown anxiety disorders do so during childhood or adolescence, traumatic experiences during adulthood can greatly increase the risk for PTSD across the developmental spectrum. Several indicated prevention studies from the adult trauma literature are relevant to discuss briefly here. Foa et al. (1995) conducted the first PTSD prevention study. Women who were recent victims of sexual and nonsexual assault and who met symptom criteria for PTSD except for the duration criteria (3 months posttrauma), received either a brief CBT program consisting of four weekly 1.5-hour sessions or four weekly assessments of their PTSD-related symptoms. At 2 months after the intervention assessment the CBT group had a recovery rate of 70% for PTSD versus 10% in the assessment control group. Using five sessions of Foa et al.’s prevention program (adding one additional session), Bryant, Harvey, Sackville, Dang, and Basten (1998) compared it to supportive counseling in male and female victims of motor vehicle and industrial accidents who met formal diagnostic criteria for acute stress disorder. At posttreatment, only 8% of CBT participants met the criteria for PTSD, compared to 83% of the supportive counseling patients. Although rates of PTSD increased over the course of a 6-month follow-up, CBT remained superior (17% PTSD incidence) to supportive counseling (67% PTSD incidence). In a subsequent study, Bryant, Sackville, Dangh, Moulds, and Guthrie (1999) modified the brief CBT by limiting it to psychoeducation and exposure, eliminating anxiety management (e.g., relaxation training) and cognitive restructuring, and compared this modified protocol to the full protocol and to supportive counseling. At posttreatment, 20% of participants in the full treatment program and 14% of participants in the brief CBT group met the criteria for PTSD, in comparison to 56% of participants receiving supportive counseling. At 6 months, the incidence of PTSD was 23%, 15%, and 67% for the full treatment program, exposure, and supportive counseling respectively.
Another group presumably at risk for the development of an anxiety disorder are individuals who present to emergency rooms with panic attack symptoms. Swinson et al. (1992) conducted an intervention study with such adults, 40% of whom met full symptom criteria for panic disorder, thus rendering this study an indicated prevention/treatment hybrid. Nevertheless, at 6-months follow-up, participants randomized to a 1-hour exposure-based condition were improved on panic and anxiety measures whereas those assigned to a 1-hour reassurance control intervention were no better than at baseline. Subgroup analyses examining outcome for those with full syndromal panic disorder and those who were subthreshold were not reported, however. Gardenschwartz and (p. 271) Craske (2001) also targeted the prevention of panic disorder, but recruited college students who had experienced a panic attack within the last year, evidenced elevated anxiety sensitivity, and did not meet the DSM criteria for panic disorder. Participants were randomly assigned to either a waitlist or a day-long CBT workshop that included psychoeducation about agoraphobia and panic, behavioral and cognitive strategies, and interoceptive exposure. At 6-months follow-up, 14% of the waitlist group had gone on to develop fully syndromal panic disorder, compared with only 2% of the workshop participants; significant effects also were seen on other relevant indices (e.g., panic attack frequency × intensity index). As the authors noted, a longer follow-up period may not have yielded a similar outcome.
The number of randomized indicated prevention studies remains few. LaFreniere and Capuano (1997) examined the effects of a program directed at mothers of preschool children (N = 43) already exhibiting anxious/withdrawn behavior, comparing it to no treatment. The intervention lasted for 6 months and consisted of four phases: (1) assessment; (2) educating the parents about their child’s developmental needs; (3) determining specific objectives for the family; and (4) implementing the intervention during 11 home visits with child-directed interaction, modification of behavior problems, training in parenting skills, and enhancing the effectiveness of social support systems. Given the age of the children, outcome variables included teacher ratings in social competence within the preschool setting and cooperation and enthusiasm during a problem-solving task rather than symptoms of a specific anxiety disorder. Results indicated that maternal stress was reduced and anxious-withdrawn behavior of the child was significantly lower at posttreatment in both conditions, although the social competence of children whose mothers received the intervention was greater prior to intervention than children whose mothers received no treatment. The relatively brief follow-up period and the lack of information about anxiety disorder symptoms limit the utility of the findings. Nevertheless, the study offered some preliminary findings about the potential benefit of such programs for behaviorally inhibited young children.
Chemtob et al. (2002) conducted a school-based, randomized study for youth in grades two through six with elevated PTSD symptoms (but not necessarily full-blown PTSD) 2 years after Hurricane Iniki and found that children assigned to a brief (4-week) CBT-oriented treatment program fared better both immediately posttreatment and at 1-year follow-up than those assigned to a waitlist comparison group. This study followed the recommendations of experts described above in first conducting a large-scale screening of potentially affected youth followed by identifying and then treating those found to have elevated symptoms of the disorder of relevance.
The Queensland Early Intervention and Prevention of Anxiety Project constitutes the most comprehensive effort made thus far in evaluating the efficacy of an indicated prevention program for children and adolescents (Dadds et al., 1997, 1999). As in the Swinson et al. (1992) adult panic disorder prevention study described above, Dadds et al.’s study can be better characterized as a hybrid indicated prevention/early intervention study because 55% of the selected children met diagnostic criteria for at least one anxiety disorder. A total of 1,786 children (ages 7–14 years) were screened for anxiety problems using teacher nominations and children’s self-ratings. After initial diagnostic interviews, 128 children were selected and randomly assigned to either a 10-week school-based psychosocial intervention based on Kendall’s Coping Cat protocol (1990) or to a monitoring group. The intervention was conducted over 10 weekly 1- to 2-hour sessions at each intervention school. Group sizes ranged from five to 12 children. Parental sessions were conducted at the intervention schools in weeks 3, 6, and 9. Anxiety disorder diagnostic status was assessed at posttreatment, 6-month, 12-month, and 24-month follow-up and yielded interesting results: the CBT and control groups differed significantly with respect to anxiety disorder diagnostic status at 6 months (27% vs. 57%) and at 24 months (20% vs. 39%) but not (p. 272) at 12 months (37% vs. 42%). Notably, treatment benefits were most evident for those children who initially had moderate to severe clinician ratings of severity, with approximately 50% of these children retaining a clinical diagnosis at the 2-year-follow-up, if they did not receive the intervention. For those children who initially showed symptoms of anxiety but did not have a clinically significant anxiety disorder, there was minimal difference between the preventive intervention and the monitoring-only condition at 24-months follow-up, with 11% in the intervention group showing an anxiety disorder and 16% in the monitoring condition. In other words, children with subclinical anxiety problems did not appear to be at a high risk of developing a more severe anxiety disorder if left untreated; they benefited only minimally from the intervention.
In an effort to test an indicated early prevention program in a school setting, Hunt et al. (2009) cluster randomized 260 high school freshmen from Australia with elevated self-reported anxiety symptoms to take part in the 10-week FRIENDS program led by school staff or a monitoring-only condition. Notably, although there was some evidence of improvement over time for the sample on the whole, there were no differences between the groups in terms of self-reported anxiety, depression, or anxiety diagnosis at the 2-year and 4-year follow-up points. Hunt et al. point to the methodological difference of using school personnel to deliver the FRIENDS program rather than CBT experts, as was done in the Queensland Early Intervention and Prevention Project (Dadds et al., 1997) upon which this was based. They also note that while close supervision by experts might have overcome this problem, such a procedure would have countered the aim of testing the FRIENDS program in routine school-based practice.
Selective Prevention Programs
Selective prevention intervention programs are delivered to individuals or groups who are considered to be high on risk factors for anxiety disorders but are not evidencing significant anxiety disorder symptoms yet. To date, most selective prevention intervention programs have targeted individuals or groups exposed to stressful life events such as parental divorce (e.g., Alpert-Gillis, Pedro-Carroll, & Cowen, 1989; Hightower & Braden, 1991; Hodges, 1991; Short, 1998; Zubernis, Cassidy, Gillham, Reivich, & Jaycox, 1999); transition between primary and secondary school, which can be associated with a number of psychological difficulties (e.g., peer relationships, school refusal behavior, substance use) (Felner & Adan, 1988); medical and dental procedures (Peterson & Shigetomi, 1981); and having a chronically ill sibling (e.g., Bendor, 1990). Although the findings from these studies generally yield positive effects, their direct relevance to preventing anxiety disorders in adolescents is unclear.
In a program designed specifically for anxiety disorder prevention, Rapee et al. (2005, 2010, 2013) launched the Macquarie University Preschool Intervention Program. Young children (ages 3.5–4.5 years) were recruited mainly via questionnaires distributed to preschools. Inclusion in the study was based on mother-completed ratings on the Australian version of the Childhood Temperament Scale (Sanson, Pedlow, Cann, Prior, & Oberklaid, 1996), followed by laboratory evaluation confirming behavioral inhibition. One hundred forty-six behaviorally inhibited children were randomly assigned to either an intervention or a monitoring condition. The intervention was conducted with parents only and focused on education about the nature of withdrawal and anxiety, parental anxiety management strategies, information about the importance of modeling competence and promoting independence, development of exposure hierarchies for the children and practice of graded exposure, as well as discussion of future development. The intervention was conducted in groups of six families and lasted for six sessions. Results at 12 months revealed that mothers in the intervention condition had self-ratings that indicated significantly greater decreases in their child’s inhibited temperament as well as in the number of child anxiety diagnoses compared to mothers in the control condition. However, (p. 273) laboratory observations at that same point indicated that children in both groups had reduced behavioral inhibition with no significant differences between the two groups. Rapee (2013) more recently reported long-term follow-up on this same cohort (approximately age 15) and found that girls whose parents had received intervention had fewer internalizing disorders and lower maternally reported anxiety symptoms and self-reported functional interference than those whose parents did not; no such lasting effects were evident for boys. The findings are encouraging with respect to the potential utility of selective interventions that can be delivered at relatively low cost. Rapee et al. also argue that young childhood may be the most appropriate time to conduct intervention trials aimed at prevention given what is known about the developmental trajectory of these symptoms and disorders.
Cooley-Strickland et al. (2011) tested a modified version of the FRIENDS program with U.S. urban children exposed to community violence. Ninety-three children ages 7 to 12 were randomized to the FRIENDS program (13 biweekly 60-minute sessions) or to a waitlist control; the active intervention was delivered by trained school personnel supervised by a licensed psychologist. Results indicated reductions in both groups’ total exposure to community violence and overall anxiety (RCMAS scores) from baseline to postintervention assessment, but no group-by-time interaction. The absence of a long-term follow-up may have obscured any delayed effects for the intervention, and even participants in the control condition reported that they liked being “members of the FRIENDS Team,” which might have influenced the changes observed in that group from pretreatment to posttreatment.
Ginsburg (2009) examined the efficacy of a cognitive-behavioral prevention program in a sample of offspring of adults with anxiety disorders; notably, children were excluded from the sample if they already had an anxiety disorder themselves. The Child Anxiety Prevention Study (CAPS) protocol involved parents and the identified youth and comprised six to eight weekly 60-minute sessions followed by three monthly booster sessions; the CAPS intervention was compared to a waitlist control. Forty families were randomized (20 per cell), and there were no between-group differences in dropout rate. Unlike the FRIENDS program, the CAPS intervention was based on Ginsburg and Silverman’s transfer of control model (Ginsburg, Silverman, & Kurtines, 1995; Silverman & Kurtines, 1996), which strongly emphasizes the importance of using parents in the delivery of treatment. Findings indicated that 30% of children in the waitlist condition had developed an anxiety disorder at the 1-year follow-up assessment, compared to none of the children randomized to CAPS. Moreover, anxiety symptoms as measured on the SCARED were significantly reduced at the 1-year follow-up in the CAPS children but not in those assigned to waitlist. Sample size limits strong conclusions and the use of a waitlist control leaves open the possibility that nonspecific treatment effects accounted for the results, yet these data provide an encouraging route for potential next steps in selective prevention research.
Universal Prevention Programs
In a large-scale examination of the FRIENDS program as a universal prevention intervention, Lowry-Webster et al. (2001) randomly assigned 594 children (10–13 years) within different schools to receive either the FRIENDS program or assessment only. The intervention was implemented by trained classroom teachers, and three separate sessions for parents also were conducted. Pretreatment to posttreatment intervention changes were examined universally and for children who scored above the clinical cutoff for anxiety at pretest. Children in the FRIENDS intervention condition reported fewer anxiety symptoms regardless of their risk status relative to the comparison condition. The 12-month follow-up data indicated that prevention effects were maintained for those who participated in the FRIENDS intervention. Notably, those who were already in the clinically anxious range on the Spence Children’s Anxiety Scale fared better in the FRIENDS program than the waitlist condition, as was found (p. 274) by Dadds et al. (1997). This suggests again that the FRIENDS program may be a useful intervention for children who are already experiencing significant problems with anxiety.
Lock and Barrett (2003) conducted another large trial (N = 733) that is of particular relevance here since they examined effects of the FRIENDS program in younger (sixth-graders) and older (ninth-graders) children; their schools were randomized to receive either FRIENDS or a standard curriculum, which served as a control. Results indicated overall reductions in anxiety over time, but also a group-by-time interaction at 6- and 12-month follow-up indicating greater reductions in the FRIENDS group than in the comparison condition. The children in the younger age range fared better than those in the older group, which may suggest that the optimal time for anxiety prevention efforts is before rather than during adolescence. In a longer-term follow-up study examining this same sample, Barrett et al. (2006) found significantly fewer high-risk students at the 36-month follow-up in the FRIENDS condition than in the control group. Gender effects indicating that girls had a larger reduction of anxiety at 12- and 24-month follow-ups were no longer evident at the 36-month follow-up, which may mean that either more booster sessions or more intensive forms of intervention are needed to help girls maintain their gains from universal prevention programs.
Stallard et al. (2008) also adopted a universal prevention approach when they tested the FRIENDS program in British schools in an open trial designed to examine its transportability beyond the centers in which it was developed. As was the case in several prevention intervention programs discussed above, school personnel (trained school nurses) conducted the FRIENDS intervention rather than clinical psychologists from outside the school system. One hundred six youth ages 9 and 10 participated in the FRIENDS program, 63 of whom were available at 12-month follow-up. Improvements in total self-reported anxiety (Spence Children’s Anxiety Scale) and self-esteem were evident at the follow-up assessment, as were improvements in panic, separation anxiety, and OCD subscales of the Spence scale. Despite the limitations inherent in any open trial, findings support the implementation of the FRIENDS Program with non–mental health professionals, which has important implications for service delivery and, perhaps more importantly, sustainability. Such findings are not consistent across the literature, however, which raises questions about the ideal training protocol, optimal school-based personnel to run the FRIENDS program, provision of ongoing supervision, and cost-effectiveness of using school personnel to implement the program rather than hiring outside experts to do so.
Farrell and Barrett (2007), who each played critical roles in the development and evaluation of the FRIENDS program, describe the following advantages of a universal prevention approach when it comes specifically to anxiety:
1. It eliminates the need for multiple-gate, presumably expensive screening procedures.
2. It allows for a broader reach for symptoms that may be virtually ubiquitous at least at lower levels of severity.
3. It reduces stigma by not targeting specific youth for participation.
4. It increases peer support by exposing all to the problems associated with anxiety.
5. It promotes a healthy learning environment for all.
In initial evaluations of its effects, children who received the intervention had lower self-rated anxiety levels than did controls at posttreatment; moreover, no statistical differences were found between the FRIENDS program delivered by either teachers or psychologists (Barrett & Turner, 2001), and this intervention when tested by its developers.
What Are the Active Ingredients?
The prevention intervention studies conducted thus far have not shed sufficient light on the mechanisms involved in producing the observed effects, since most of the designs used have compared active treatment packages to (p. 275) repeated assessment only (e.g., waitlist, standard curriculum). The superiority of the CBT packages examined thus far could therefore be attributable to a wide variety of nonspecific factors, such as treatment credibility and therapist contact. Dismantling studies typically follow the establishment of efficacy (e.g., Schmidt et al., 2000), and thus the field may still be a long time from discovering the impact of specific treatment interventions and their underlying mechanisms. Dismantling studies of this sort also requires interest in psychological rather than biological mechanisms of change, which may well be at issue at present in the United States with respect to the priorities of federal agencies that fund clinical research.
What Outcomes Are Targeted?
As noted above, in the studies conducted to date, the outcomes targeted have primarily focused on anxiety symptoms and disorders. As also noted, it might be worthwhile for future research to move beyond symptoms and diagnosis and pay increased attention to whether functional impairment has improved. For example, are there improvements in the adolescent’s grades or in his or her peer relationships? These are the outcomes that would seem to matter most and should be seriously considered in the design and evaluation of future prevention studies. As of yet there has not been a significant movement toward emphasizing these functional outcomes.
In addition, the potential of “positive psychology” has yet to be seriously considered in the context of preventing anxiety disorders in adolescents and targeting outcomes. Positive psychology is devoted to creating a science of human strengths that act as buffers against mental illness, including anxiety (Seligman, 2002). Dick-Niederhauser and Silverman (2003) have adapted positive psychology principles and have suggested their utility in serving as outcome targets for anxiety prevention studies. Thus, potential outcome targets might include instilling hope and the active pursuit of goals in young people, which in turn have been linked to the development of courage. Courage in turn has been linked with increased optimistic cognitive processing, a sense of self-efficacy, and skillful coping. Although measures exist to assess some positive psychological concepts, further instrument development and evaluation will be needed for positive psychology principles to be fully implemented and studied in the context of anxiety prevention research. Research on resilience (e.g., Zeller et al., 2015) and grit (e.g., Duckworth et al., 2007), psychological constructs that may well overlap, could potentially serve as points of emphasis in prevention intervention research as society aims to reduce the effects of anxious psychopathology on youth.
Conceptual, Methodological, and Practical Issues
Methodological and conceptual issues vary across types of prevention programs. That is, the methodological concerns that arise in universal prevention (targeting the broad population of adolescents) are different from those in selected/indicated prevention intervention trials. The former require more streamlined assessments to increase participation and compliance (thus ensuring sample representativeness) and reduce cost (thus ensuring feasibility). Accordingly, a major issue in universal prevention program research involves identifying the best ways to encourage adolescents to participate in a study that addresses a problem that they probably do not have. Universal prevention programs are especially likely to be conducted with involvement from school administrators, and thus capitalizing on the schools’ past successes in encouraging student participation will be important. As noted earlier, a brief survey conducted via a website might capture the interest of teens in particular, and thus computer technologies may prove essential in this kind of work. The costs of universal programs ultimately require a serious political commitment on the level of state or federal government, which exists in Australia in particular. For the selective/indicated programs, the primary methodological concern is how to encourage participation while at the same time protecting student confidentiality—this is all (p. 276) the more a concern in an era characterized by concerns about Health Insurance Portability and Accountability Act (HIPAA) violations. This may be especially important if the intervention itself is conducted at school and during school hours, when absence from regular classes might be conspicuous and thus negative social costs both real and imagined may impact participation. Moreover, if the intervention is conducted in groups, confidentiality among group members needs to be considered. Students who have been identified for intervention participation because of having experienced a trauma or for being excessively shy might be reluctant to share their experiences if they do not have assurance that what is discussed in session will not be discussed outside with nonmembers. Providing sufficient time to foster group cohesion to alleviate this concern would therefore be important in any selective/indicated prevention effort that involves discussion of personal material in a group setting.
Another issue that warrants consideration is when to intervene. As discussed above in relation to trauma exposure, immediate intervention provided to all individuals exposed to the trauma has not been found especially helpful with adults and thus should probably be avoided when conducting interventions with youth who have been exposed to a traumatic event such as shootings at the school.
Yet another issue is the match between the type of intervention and the developmental stage of the individuals being targeted. Perhaps group interventions can be particularly successful in adolescence when the value of the peer group is quite powerful and, if properly harnessed, may enhance the efficacy of the intervention. On the other hand, interventions in the managed-care context must take into account the limited amount of time available in a given medical visit to discuss seemingly peripheral issues such as anxiety symptoms; accordingly, the development of brochures, self-help programs, or interventions that can be delivered by support staff should be considered.
Prevention research by its nature requires longitudinal follow-up, and thus one major issue is how best to retain participation in the study, and how to guard against attrition over time. Here again informed consent from the student/family and active collaboration with the school will be helpful, but it is important to keep in mind that the most valuable assessment points for prevention programs take place years after the intervention is delivered. Thus, it is imperative to fund studies in a manner that will ensure the collection of data well into the future; inadequate participation in follow-up for these kinds of studies imperils the entire enterprise, as detection of sampling bias (e.g., better follow-up with less impaired participants or vice versa) threatens to compromise conclusions that could be drawn about the efficacy of intervention. Treatment studies have had to address this problem and have requested that the family provide the names of family and friends who will know how to contact them in the future if they move, social security numbers, and other such information to facilitate participation in long-term follow-ups (see Marchand et al., 2011).
A final issue that affects all prevention programs involves the ongoing assessment of risk, and responsibility for risk. Those at risk for anxiety also may be at increased risk for other psychiatric comorbidity, and thus procedures must be enacted within prevention intervention programs to manage clinical emergencies. Moreover, the role of the parent in these programs must be considered: if the child or adolescent is found to be at increased risk for anxiety disorders upon screening and is then eligible to participate in the program, how much or how little the parent should be involved or have access to the information discussed in assessment and/or treatment needs to be specified up front, as it will certainly impact both entry and active participation.
Problem of Sustainability (Boosters, Ongoing Programs, Training)
The prevention studies that have included follow-up have generally suggested maintenance of the intervention effects in those trials that found positive initial benefits, but here again these studies have typically focused on young (p. 277) or very young children and thus cannot inform the field about retention of benefits into and through adolescence and adulthood. A related question is whether booster sessions are needed to retain the gains from prevention programs, since the fairly predictable stressful life events that face young children growing into adolescence might compromise long-term maintenance. For example, studies discussed earlier suggest that young children with elevated but subclinical anxiety levels may benefit most from prevention programs; transition from middle school to high school may threaten these gains, and thus it may be reasonable to reinstitute the intervention during this transition. It is unknown whether this is the case, but the relation between loss of gains and stressful life events constitutes an especially important area for future study.
Problem of Contagion
There is no evidence of such undesirable effects from the studies of group treatment of youth that have been conducted thus far (e.g., Kendall, Flannery-Schroeder, Panichelli-Mindel, & Southam-Gerow, 1997), but the possibility for such effects remains. Although it is possible that discussion of anxiety themes may activate new fears in those who are already vulnerable, especially if the interventions involve group discussions, there is no evidence of such undesirable effects from group treatment studies (e.g., Kendall et al., 1997; Silverman, Kurtines, Ginsburg, Weems, Lumpkin, & Carmichael, 1999), including in groups in which the patients involved were very heterogeneous with respect to age (i.e., child and adolescent patients) as well as primary anxiety diagnosis (e.g., OCD, specific phobia) and other clinical features (e.g., presence/absence of school refusal behavior; Lumpkin, Silverman, Weems, Markham, & Kurtines, 2000). However, the example of Critical Incident Stress Debriefing (CISD) suggests that the long-term recovery of certain adults who have experienced a trauma and have attended group meetings may be impeded by participating, and possibly the mechanism by which this effect is realized involves exposure to other participants’ narratives of the traumatic event (e.g., Mayou et al., 2001). Provided that secondary gains (e.g., missing trigonometry class) for attending prevention intervention sessions are minimized, there is little reason for concern that students without anxious symptoms or risk factors would feign such problems.
Age-Appropriate Interventions (Developmental Approach)
The prevention intervention programs that have been evaluated thus far in research (e.g., Lowry-Webster et al., 2001) were designed for children rather than for adolescents; when these programs have been applied specifically with adolescents, an attenuation of benefit relative to that observed with younger children has been observed (e.g., Barrett et al., 2006). Accordingly, adaptations to accommodate the developmental needs of adolescents should be made, with specific attention to possible age-related increases in physiological functioning, emotional vulnerability, social and peer pressures, and comorbid conditions, as well as any other changes that these youngsters may be experiencing. In particular, prevention programs must consider the importance of the peer group within the intervention program itself, but also with an eye toward the social implications of participating in the program among nonparticipating students, especially if the program is either a selective or indicated one. Insufficient attention to these factors may reduce the number of teens willing to enter the program altogether, and can limit active participation within the program itself if a group format is implemented. One way to address this potentially important concern is to incorporate program graduates, who may serve as role models for new participants, as a way to alleviate concerns that program participants may not be perceived as “cool” among the larger student population. Another way to make participation more palatable is to present information about adult role models who have struggled with anxiety and have openly discussed their (p. 278) difficulties, such as actresses Emma Stone and Lena Dunham, who have openly acknowledged having been treated for anxiety-related difficulties in the past. However this is accomplished within a protocol, the culture of adolescence and the importance of the peer group must be taken into consideration when developing appropriate interventions for teens.
A Note of Caution from Adult Early Intervention Research
Longitudinal studies of trauma survivors (e.g., Mayou, Ehlers, & Bryant, 2002; Riggs et al., 1995; Rothbaum et al., 1992; Silver, Holman, McIntosh, Poulin, & Gil-Rivas, 2002) indicate that most individuals experience elevated levels of PTSD symptoms shortly after the traumatic event. In addition, elevated levels of depression and general anxiety often accompany PTSD symptoms. However, epidemiological studies indicate that for most trauma survivors these symptoms decline significantly over time without any professional intervention (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995). That said, a significant minority of trauma survivors continues to experience high levels of posttrauma distress that, without professional treatment, may persist for months or years (Kessler et al., 2005).
As discussed above, it is now well established that various forms of CBT are effective in reducing PTSD symptom severity as well as associated anxiety and depression (e.g., Nayak, Powers, & Foa, 2011). Although there are effective treatments for individuals who have chronic PTSD, many sufferers either do not seek treatment for their trauma-related symptoms or do not have access to treatment. As a consequence, individuals’ suffering and their inability to function can be prolonged. They also are vulnerable to associated comorbidity such as substance abuse (McLean & Foa, 2014). Such considerations have prompted trauma therapists to develop brief interventions applied shortly after the traumatic event in order to facilitate recovery and thereby prevent the development of chronic PTSD.
Two approaches to facilitating recovery following a traumatic event have been researched. Abbreviated CBT packages such as those developed by Foa et al. (1995) and adopted by Bryant and colleagues (e.g. Bryant, Sackville, Dang, Moulds, & Guthrie, 1999; Bryant, Moulds, Guthrie, & Nixon, 2005; Bryant et al., 2008) have been found to be efficacious in accelerating recovery and reducing the likelihood of chronic PTSD. The other approach involves psychological debriefing. Debriefing programs typically last only one session and are applied shortly after a traumatic event (frequently within 48–72 hours). In this session (which can be conducted in groups or individually), participants are encouraged to describe the traumatic event, including their thoughts, impressions, and emotional reactions. The session also includes normalization of the trauma survivors’ reactions and planning for coping with the trauma and its sequelae. Results of randomized controlled trials for debriefing are somewhat mixed, but a set of recommendations from early intervention experts (Bisson et al., 2009, p. 101) may provide some guidance as to how best to proceed:
1. Pragmatic psychological support and psychoeducation about common reactions should be provided in the immediate wake of trauma.
2. No formal intervention should be mandated for all exposed to trauma.
3. Culturally and developmentally sensitive interventions should be provided that are related to the local formulation of problems and ways of coping.
4. Lack of distress and/or rapid recovery may not necessarily be desirable.
5. The absence of strong evidence supporting early interventions necessitates careful monitoring of outcomes in individual patients provided with these treatments.
As noted earlier, unlike universal prevention programs, selective and indicated prevention programs specifically select participants based (p. 279) on elevations of anxious symptoms or on putative anxiety disorder risk factors. In the school context where most prevention interventions are likely to take place, the latter program types require identification of a subgroup of participants from among the broader population, who will be either encouraged or required to participate. The potential negative implications of this strategy have already been considered in the academic context with respect to educational issues, and have led to the gradual reduction of labeling for academic tracking systems (e.g., honors, regents, and basic classes) and to increased mainstreaming of special education students. Similar problems may be encountered in identifying already anxious or anxiety-vulnerable students for special attention or services. As discussed above, adolescence is a stage in life when similarity with the relevant peer group is valued, and intervention efforts that do not deal sensitively with this issue may be poorly attended or, worse yet, yield unintended negative consequences. Little has been written about this issue in the context of anxiety prevention programs implemented thus far, but methods to prevent such unintended consequences should be carefully considered.
Postintervention Follow-Up and Dissemination
The studies conducted thus far have involved acute treatment and, at least in some studies, follow-up assessment only. It is unknown how to encourage ongoing use of skills learned in the prevention programs, nor is it known how best to encourage participation in follow-up assessments. Because the primary dependent variable of interest in prevention programs must be measured years later than the intervention was conducted, it is imperative to develop methods that encourage cooperation with long-term follow-up. Given that most prevention interventions will likely be conducted in the school context, active collaboration with the school administration will be critical to promote collection of these data. Families also may be able to facilitate participation, and thus direct contact with families may be advisable. However, this raises issues with respect to confidentiality and the need to discuss up front with the young participant what will and will not be shared with parents and/or guardians.
The preliminary success of the FRIENDS program in the hands of teachers and school nurses in some but not all trials bodes well for transportability of this program to treatment providers other than mental health professionals with expertise in CBT. Clearly, the implementation of CBT-oriented prevention programs cannot realistically be limited to PhD-level psychologists, and a multidisciplinary approach may be the best way to proceed. This raises interesting questions about how best to disseminate CBT prevention programs and how much expert supervision will be needed in the short and long run to optimize treatment delivery; these questions touch on the cost-effectiveness of prevention programs. A similar line of research needs to be pursued in adolescent anxiety disorder prevention in particular, since the broad application of such interventions appears to be dependent on successful training of school personnel to implement these programs in the school context.
Impediments to Prevention
The first set of impediments to developing successful prevention intervention is the lack of knowledge about the complex interrelations among the various risk and protective factors for the development of anxiety disorders. Much is known about some specific factors but little is known about how they interact, which leaves the field bereft of a strong theoretical foundation upon which to build prevention programs. This may be why prevention research has continued to languish relative to treatment and now more basic neurobiological research on psychiatric disorders: the factors associated with etiology may not be same as those associated with maintenance, and thus comprehensive knowledge about the latter will allow for the development of treatment interventions even in the relative absence of the former.
Practical considerations have stunted the development of prevention programs as well. (p. 280) Prevention efforts are costly, as they necessarily involve collection of data from large samples over a long period of time. Large samples are needed because of the relatively low base rates of anxiety disorder in the population of interest, and because there is insufficient information about who will actually go on to develop an anxiety disorder. Consequently, it is important to conduct broad screens to obtain sufficient numbers of vulnerable children and adolescents for inclusion in indicated and selected prevention studies. For example, most behaviorally inhibited infants do not develop an anxiety disorder later in life, and thus a large sample of inhibited children would be needed to detect the efficacy of a prevention program targeting behavioral inhibition. Further, because the relevant outcome is the future development of anxiety disorders and perhaps of subsequent comorbid conditions (e.g., depression, substance abuse), prevention studies require data collection for years after the intervention to determine its ultimate impact. The need to conduct longitudinal follow-ups of these large numbers for long periods of time renders the study of prevention programs impractical, especially when the primary funding sources for anxiety disorders research (e.g., National Institute of Mental Health) typically have favored shorter studies with more tangible impact, and now appear to be much more strongly emphasizing biological research above intervention science. Thus, new sources of funding must be identified to generate knowledge that will inform the development of anxiety disorder prevention programs. Given the potential of anxiety disorders to derail adolescent development and thereby result in a substantial personal and economic impact, this should be a major priority for a society that alleges to leave no child behind.