Trends, advances and directions in cognitive-behavioral therapy for adolescent anxiety

Adolescence is a time of dramatic change in physical, behavioral, emotional, cognitive and social domains, and the context in which one matures plays a crucial role. The early 2020s provided a unique context for adolescent development, filled with unprecedented events across multiple levels of life. These contextual forces potentially impacted what we know from previously studied developmental trajectories during adolescence.

Here we briefly highlight recent research on adolescent anxiety associated with social media use and the COVID-19 pandemic, and focus on the latest trends and advances in cognitive-behavioral therapy (CBT) for treating anxiety in youth. We emphasize the importance of behavioral exposure tasks and the necessity of “flexibility within fidelity”¹ in manual-based CBT interventions. Lastly, we identify future research directions for evaluating the development, maintenance and treatment of anxiety in adolescents.

Rates of anxiety among youth – as well as depression, suicidality, and other mental health conditions – have increased in recent years. Specifically, anxiety symptoms increased during the COVID-19 pandemic, with 20% of surveyed youth experiencing these symptoms, compared to 11% before the pandemic². Further, across all socioeconomic levels, about 70% of adolescents reported believing that anxiety and depression are major problems among people of their age in their community³. Widening disparities in anxiety prevalence have been noted among girls relative to boys, and among sexual minority youth compared to heterosexual ones^{2, 4}.

Adolescents currently face stressors that may contribute to increases in anxiety. The COVID-19 pandemic took a toll on youth psychological well-being, including disrupted milestones, loss of peer interactions, and social isolation². Adolescents are heavy consumers of digital technology and social media: this has the potential to provide benefits to youth through opportunities to strengthen social relationships. However, social media may also lead to an increase in anxiety symptoms. In a longitudinal study of adolescents aged 12-15, those spending more than three hours per day on social media were prospectively more likely to experience internalizing problems (i.e., anxiety and depression⁵). It is not a stretch to see the double-edged features of heavy adolescent social media use.

Recent research continues to bolster the large body of existing evidence demonstrating the efficacy⁶ and effectiveness⁷ of CBT in treating adolescent anxiety, with the latest studies parsing treatment effects according to intervention modality and emphasis on key components (e.g., psychoeducation, cognitive restructuring, exposure tasks). When comparing CBT modalities to waitlist controls based on anxiety remission at post-treatment, significant benefits for individual, group, family, and remote-based CBT were observed. Individual, family, and remote-based CBT interventions also demonstrated superior remission outcomes relative to attention controls.

Although based on a limited number of comparative efficacy studies, the various treatment modalities did not show differential benefit (e.g., individual-based CBT did not evidence significant benefit compared to other CBT modalities). Albeit comparisons were bound by similar constraints, combined treatment with individual-based CBT and selective serotonin reuptake inhibitors (SSRIs) demonstrated greater effectiveness than either isolated treatment approach⁸.

Among the core components of CBT interventions, behavioral experiments (i.e., exposure tasks) are the most impactful. Reinforcing prior research examining treatment outcome associations based on exposure task completion (e.g., amount of in-session exposure tasks), recent CBT interventions have evaluated the effectiveness of treatments that emphasize exposures specifically. Youth anxiety outcomes were examined following randomization to one of two treatments focusing on different core CBT components: an exposure-focused CBT (EF-CBT) characterized by a lack of relaxation components and quicker initiation of exposure tasks, and a relaxation-based treatment⁹. Not only was EF-CBT effective in treating youth anxiety disorders, but it demonstrated greater effectiveness relative to the relaxation-based treatment. Results indicated that EF-CBT yielded “faster and more pronounced” reductions in youth anxiety. Participants randomized to EF-CBT were more likely to complete therapy relative to those receiving the relaxation-based treatment⁹.

Advancements in CBT for adolescents highlight the necessity of flexibly implementing manual-based CBT to increase its use and accessibility. Flexibility personalizes treatment based on youth interests (e.g., sports, computers, arts) and needs (e.g., comorbid diagnoses, level of cognitive development). Potential environments for administering CBT also require flexibility: they can include schools, community mental health centers, telehealth and computed-based platforms, and at-home efforts.

Key features of empirically supported treatments remain required, but features can vary based on needs for pragmatic and feasible implementation. Increased provision of CBT mediated by digital devices (brought about by the COVID-19 pandemic) highlighted flexible adjustment strategies and opportunities relative to standard in-person treatment. For example, using facetime or laptop cameras, exposure tasks can occur in an adolescent's real-world environment and be conducted with therapist support¹. Telehealth platforms make CBT interventions more accessible across geographic regions, enabling youth to both engage in exposures with peers and connect with others with similar mental health concerns.

The future is likely to witness an increasing focus on comparisons of in-person vs. telehealth administrations of treatment for adolescent anxiety. In the same vein, apps for adolescents to use when mastering their anxiety will not only be more prevalent, but will also need proper evaluation. We do not see artificial intelligence replacing a CBT service provider, but we do see telehealth having an increasing presence and impact.

Symptom reduction has been and remains an important goal for mental health service providers. However, we know that there is more to improvement than symptom reduction. Future studies will benefit from examinations of increased self-efficacy and idiographic gains in mastering personal anxiety-producing situations. Treatments for adolescents that address their need for reassurance and/or improve their social interactions will likely augment current approaches.

One can also be hopeful for computer-directed strategies to advance personalizing treatment. Currently, service providers “wing it” as they adapt their work to fit their patients. With machine learning, we can identify features of anxious youth who will respond to the various components of treatment. In other words, the findings from machine learning applied to large, homogenized data sets can inform providers of adaptations that, for the characteristics of a specific client, will likely be optimally effective.

Thus, CBT is now well established as a first-line treatment for adolescent anxiety, but efforts to personalize and augment this empirically supported therapy are likely to spread in the future and impact significantly clinical practice.