8
Theoretical Foundations of CBT for Anxious and Depressed Youth

Sarah J. Perini and Ronald M. Rapee

Introduction

A therapist wishing to implement cognitive behavior therapy with depressed and anxious youth should be familiar with the theories that underpin the treatment protocols (Sburlati, Schniering, Lyneham, and Rapee, 2011). The present chapter will introduce the factors that, according to research and theory, play a role in the maintenance of these disorders; and this will lead to separate integrated models for anxiety and for depression in youth. The similarities between the two models will be highlighted by way of a conclusion.

The Cognitive Behavioral Theoretical Framework

Cognitive behavior therapy is a structured, present-focused and time-limited psychotherapy that emphasizes the role of cognitions and behaviors in the development and maintenance of psychological difficulties. It is based on the cognitive model, which highlights the interaction between a person’s cognitive processes, his/her emotional experience and his/her behavioral response. While cognitive behavior therapy was originally developed for the treatment of adults, numerous controlled-outcome studies have demonstrated its effectiveness for children and adolescents with affective and anxiety disorders (Cartwright-Hatton, Roberts, Chitsabesan, Fothergill and Harrington 2004; Harrington, Whittaker, Shoebridge, and Campbell 1998).

Maintaining Factors in Childhood and Adolescent Depression

Family factors

Attachment theory

Attachment theorists propose that an individual’s earliest relationships are crucially linked to their emotional experiences later in life. Bowlby (1980) argues that a child’s bonds to his/her primary caregivers form the basis of his/her internal working model (IWM) of attachment figures and, on that basis, of the child’s complementary model of him-/herself – that is, of his/her own self. A child who has experienced consistent sensitive and responsive caregiving is likely to become securely attached and will consequently develop an expectation that important others are available, accessible, and supportive of their needs. The child’s complementary view of his/her self will be as someone valuable, lovable, and worthy of consistent support. Conversely, a child who has experienced caregiving that is inconsistent and largely determined by the caregiver’s own needs is likely to develop an anxious attachment, whereby they feel they have little control over the others’ responsiveness and become preoccupied with the attachment figures’ availability. Bowlby (1980) postulates that anxiously attached children are likely to doubt their own efficacy and worth and are therefore particularly vulnerable to depression. This vulnerability is especially acute when they are faced with the loss of a close relationship, no matter whether through illness, death, or some other form of separation.

Parenting style

The role of caregivers, particularly in infancy but also in later childhood, is seen as crucial to the development of a child’s sense of self (Bowlby 1980) or schemas (Beck 1967), and theories of youth depression consistently identify the important role of a child’s earliest relationships. There is extensive evidence linking parental factors to depressed youth, including the vastly higher rates of depression among children of depressed parents (Weissman, Warner, Wickramaratne, Moreau, and Olfson, 1997) and a well-established relationship between parenting style and child depression. In particular, parenting that is characterized by high levels of psychological control (overprotectiveness, guilt induction, shaming, intrusiveness) combined with low warmth has, in several studies, been linked to child depression (Alloy, Abramson, Smith, Gibb, and Neeren 2006; McLeod, Weisz, and Wood 2007; Rapee 1997). Parents of depressed children have been observed to be more critical (McCarty, Lau, Valeri, and Weisz 2004); so, unsurprisingly, depressed youth have been found to have less supportive and more conflicted relationships with their parents (Sheeber and Sorensen 1998; Sheeber, Davis, Leve, Hops, and Tildesley 2007). Additionally, parental marital conflict has been strongly associated with child depression, although it must be noted that this association applies to child psychopathology in general, not just to depression (Cummings 1994). Readers interested in the family factors relating to youth depression are referred to the comprehensive review by Restifo and Bögels (2009).

Cognitive factors

Cognitive theories of depression posit that some individuals have particular ways of thinking and processing information, which leave them vulnerable to becoming depressed when they encounter particular external stressors. Essentially, cognitive theories identify two factors – cognitive vulnerability and stress – which interact to produce a third factor – depression. Each of these three factors exists on a continuum (Abramson, Metalsky, and Alloy 1989). The more extreme the stress, the less cognitive vulnerability will be necessary to trigger the onset of depressive symptoms. Conversely, the more cognitively vulnerable an individual is, the less severe a stressor need be for depressive symptoms to emerge. Finally, the severity of the depressive symptoms themselves will depend on the severity of both these causal factors, in addition to the content of the thought processes that follow the stressful event. Content that is situation-specific is posited to lead to less severe depression than content that is generalized.

Beck’s cognitive theory

Beck’s cognitive theory centers on the construct of schemas (Beck 1983), which are defined as stored bodies of knowledge that affect the encoding, comprehension, and retrieval of information. According to Beck, some individuals have depressogenic schemas, which encompass a range of dysfunctional attitudes relating to themes of loss, failure, inadequacy, and worthlessness. Beck postulates that such schemas lie dormant until the individual encounters a negative life event, at which point they are activated and trigger a pattern of negatively biased, self-referencing information processing. The individual makes errors in thinking (such as overgeneralization) that lead to negative cognitive patterns about three areas: the world, the self, and the future. Beck refers to this as the negative cognitive triad and argues that, once the triad develops, depressive symptoms inevitably ensue.

Hopelessness theory

Hopelessness theory (Abramson et al. 1989) is a revision of the reformulated helplessness theory of depression (Abramson, Seligman, and Teasdale, 1978). Like Beck’s theory, hopelessness theory proposes that some individuals exhibit a depressogenic cognitive style that leaves them vulnerable to depression when a negative event occurs. However, hopelessness theory identifies a specific subtype of depression, called hopelessness depression. Hopelessness is defined as having the expectation that negative events will occur, that positive events will not occur, and that one is powerless to change this situation. The theory identifies the inferential styles that make one vulnerable to becoming hopeless. These are tendencies (1) to attribute negative events to global and stable causes; (2) to perceive negative events as having many disastrous consequences; and (3) to view the self as flawed and deficient following negative events. According to hopelessness theory, each of these inferential styles increases the chances of the occurrence of hopelessness. Hopelessness then leads to hopelessness depression.

Cognitive factors in children and adolescents

There is evidence that depressed youth exhibit a negative distortion in self-perception (Asarnow and Bates 1988; Hammen 1988; Kendall, Stark, and Adam 1990); but there have been some questions raised about the utility of cognitive theories when applied to child and adolescent populations. For example, Cole and Turner (1993) have argued that depression at younger ages results most directly from encountering negative life events and from subsequent environmental feedback rather than from the interaction of negative attributional style with stress. In a review of the literature regarding cognitive theories of depression in children and adolescents, Lakdawalla, Hankin, and Mermelstein (2007) concluded that the magnitude of effect for the cognitive vulnerability–stress interaction is in the small range in child populations and moderately larger in adolescent populations. More recently, however, evidence suggests that cognitive vulnerability theories may emerge as being more applicable to child populations when researchers statistically control for cognitive development (Weitlauf and Cole 2012).

Behavioral factors

Interpersonal skills

Interpersonal theories of depression emphasize the role of social relationships in the maintenance of depression. Theorists such as Coyne (1976) and Joiner (2002) argue that depressed individuals unintentionally generate interpersonal stress and conflict. Depressed individuals may generate this conflict both by selecting unsuitable relationships and by behaving in ways that cause relational difficulties. Interpersonal conflicts then serve to prolong or intensify depressive symptoms and result in the future recurrence of depression.

Rudolph, Flynn, and Abaied (2008), present an interpersonal model of youth depression that integrates traditional interpersonal theories with a developmental psychology perspective. They propose that early family disruption – such as insecure attachment or parental depression – interferes with the development of social competencies, resulting in social–behavioral deficits. Examples of such deficits are excessive reassurance seeking, social disengagement, social helplessness, aggression, and ineffective interpersonal problem solving. These social–behavioral deficits lead to relationship disturbances and cause youth to select maladaptive relationships, which add to the ongoing difficulties that may already exist within their family. Rudolph and colleagues (2008) argue that such relationship disturbances create a vulnerability to depression, and that this vulnerability is especially marked in youth whose personalities and sociocognitive styles make them particularly reactive to interpersonal stress. As youth move into adolescence, they are faced with a number of challenges such as the changes of puberty, the emergence of romantic relationships, and the growing complexity of peer relationships. Any interpersonal vulnerability to depression is therefore amplified at this time; this is particularly true of girls, who are more likely to rely on relationships as a source of self-definition. Depressive symptoms then interfere with young people’s interpersonal functioning and long-term social development, increasing their chances of further depressive episodes.

In a longitudinal study of young adolescents over two years, Flynn and Rudolph (2011) found that avoidance and denial in response to stress predicted subsequent self-generated interpersonal stress, and that this type of stress predicted, in turn, depression. There is also evidence that particular interpersonal behaviors are predictive of subsequent stress and conflict within child and adolescent relationships. These maladaptive behaviors include excessive reassurance seeking about one’s worth (Prinstein, Borelli, Cheah, Simon, and Aikins 2005; Shih, Abela, and Starrs, 2009), being unassertive or overly dependent on others (Shih and Eberhart, 2008), and negative feedback seeking (Borelli and Prinstein 2006).

Rumination

Response styles theory (Nolen-Hoeksema 1991) proposes that the way an individual responds to his/her own depressive symptoms impacts the severity and duration of these symptoms. In particular, Nolen-Hoeksema (1991) identifies rumination (as opposed to distraction or problem solving) as a response style that intensifies the depressive experience. It is argued that ruminative coping worsens depression in three ways. First, rumination impacts negatively on cognitions and information processing, as it increases the recall of negative events and reduces the individual’s perception of control. Second, rumination reduces the likelihood that the individual will engage in helpful, mood enhancing behaviors; and, finally, rumination impairs problem-solving abilities. Nolen-Hoeksema and Girgus (1994) have argued that response styles theory may help to explain why, although depression is equally common among boys and girls before puberty, adolescent females develop depression at a far higher rate than adolescent males. Women are known to ruminate more than men, and this sex difference has been replicated in adolescent populations (Rose and Rudolph 2006).

Environmental factors

Stressors

The role of stressors is another key feature that overlaps across models of youth depression. It is commonly argued that depressive symptoms arise when a child’s or an adolescent’s underlying vulnerabilities interact with one or more stressful events. The ecological transactional model discussed below notes that stressors may arise from the family, from the community, and from the broader culture. Additionally, this model draws attention to the role of developmental adaptation and to the cumulative consequences of developmental challenges that are not adequately resolved. An especially important developmental period for girls appears to be adolescence, when rates of depression rise dramatically (Wade, Cairney, and Pevalin 2002). This may be, at least in part, due to greater exposure to total stress, particularly interpersonal episodic stress, for adolescent girls (Shih, 2006).

A community study of over 400 seventh graders by Ge, Conger, Lorenz, and Simons (1994) demonstrates the role of stress in youth depression within a family context. Stressful events experienced by the students’ parents were found to be related to parental depressed mood. This low mood was found to impact parenting practices negatively, which in turn placed the children of these parents at increased risk of developing depressive symptoms. This relationship between stress and parenting also featured in a meta-analytic study by Grant and colleagues (2003), which found that negative parenting mediates the relationship between a particular stressor – poverty – and psychological symptoms in children and adolescents.

Transactional/developmental theories

Cicchetti and Toth (1998) have argued for the importance of a developmental psychopathology conceptualization of childhood depression. Their ecological transactional model identifies a range of psychological, social, and biological factors, each of which influence a child’s capacity to meet new developmental challenges. It is argued that, when children are able to positively adapt to a developmental challenge, this leads to competence and better preparedness for the next developmental demand. Conversely, inadequate resolution of a stage-salient developmental challenge is likely to compromise the resolution of future developmental tasks. Cicchetti and Toth (1998) postulate that the occurrence of childhood depression depends not only on the presence or absence of specific vulnerability or protective factors, but also on the interplay between these factors and current and previous levels of developmental adaptation, as well as on the developmental period during which risk factors are experienced. In addition to this transactional complexity, they argue that risk and protective factors exist not only within the individual child, but also within his/her family (microsystem), the community in which the family lives (exosystem), and the broader culture of which the community is part (macrosystem).

Other models that emphasize the complex transactional nature of youth depression include those outlined by Restifo and Bögels (2009) and Shortt and Spence (2006). Some of the numerous risk factors identified by transactional models are genetic factors; parental psychopathology; low socioeconomic status; parental death, divorce, or separation; child maltreatment; parenting style; marital discord; low perceived academic confidence; poor adjustment to school; low availability of treatment services; rapid cultural changes and erosion of traditional cultural practices. Central to these models is the notion that none of these single risk factors will result in a depressive outcome, but rather that they interact with one another across all stages of the child’s development.

An Integrated Model of Youth Depression

Across all the models of depression there are common factors that consistently implicate the impact of early experiences and of the subsequent sense of self on the way children process information and behave. Cognitive theories emphasize the impact of early experiences on cognitive style, whereas interpersonal theories emphasize their impact on relational and social skills. These are not independent: a child’s perception of him-/herself and others will impact on his/her social behavior, and conversely a child’s social relationships will impact on his/her beliefs and attributions. Attachment, cognitive, and interpersonal theories all stress the transactional nature of their specific components. Depressive symptoms are noted to be both a cause and a consequence of difficult relationships and negative thinking styles.

An integrated model of child and adolescent depression is shown in Figure 8.1. Caregiver characteristics such as parental insensitivity, absence, or inconsistency interact with the child’s own characteristics, for instance their genetic makeup and temperament. This interaction leads to an insecure attachment relationship, which manifests in the child’s negative schemas about themselves, others, and the world. These negative schemas impact on the way in which the child processes information, interacts with others, and behaves in response to periods of low mood. The child’s negative cognitive style and socio-behavioral deficits result in relationship difficulties with peers, with family members, and, in adolescence, with romantic relationships. These relationship difficulties may also be a result of conflicts within the family and of poor modeling of interpersonal skills from caregivers. Additionally, the child’s or adolescent’s negative cognitions and socio-behavioral deficits result in compromised performance at school – academically, behaviorally and in his/her general engagement with school life. Difficulties at school and in relationships reinforce the child’s negative beliefs about him-/herself and others and exacerbate socio-behavioral deficits, perpetuating a vicious cycle of depressive thoughts, interactions, and behaviors. All of this occurs against a background of dynamic stressors and developmental challenges, which may interact with existing vulnerabilities to trigger depressive symptoms.

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Figure 8.1 An integrated model of child and adolescent depression.

Clinical Implications

First, treatment should consider the family of the child or adolescent, with a view to increasing parental warmth, reducing parental criticism and psychological control, and generally improving the parent–child relationship where possible. Cognitive restructuring interventions may be used to target depressive cognitive distortions, although clinicians must keep in mind the cognitive development of their young client when doing this work. Behavioral interventions should be utilized to promote healthy and effective responses to stress and to reduce unhelpful and avoidant coping strategies that the depressed child or adolescent may use. Skills for dealing with relationships and conflict may be particularly useful for adolescent girls, who experience greater exposure to interpersonal stress. Finally, clinicians working with this population should remain alert to ongoing developmental challenges faced by their growing client and to the impact of stressors on the young person and his/her family.

Maintaining Factors in Child and Adolescent Anxiety

Several models have been proposed describing key factors and their interactions that lead to the development of anxiety disorders (Chorpita and Barlow 1998; Hudson and Rapee 2004; Manassis and Bradley 1994). Few of these models tend to differentiate between anxiety disorders; and they typically refer to anxiety disorders in childhood generically. As for theories of depression, most theories of anxiety tend to refer to relatively similar constructs, although the emphasis has varied between models.

Internal factors

Avoidant coping style

At a behavioral level, the core feature of anxiety is avoidance. A fundamentally avoidant style of dealing with the world seems to be characteristic of anxiety and marks temperamental styles that have been shown to precede anxiety disorders. Extensive evidence has shown that fearful or inhibited styles of temperament displayed very early in a child’s life dramatically increase the likelihood that they will later develop anxiety disorders (Chronis-Tuscano et al. 2009; Hudson and Dodd 2012; Schwartz, Snidman, and Kagan 1999). Interestingly, there appears to be some specificity, and it seems that interpersonal withdrawal early in life tends to predict only social anxiety later on (Hirshfeld-Becker et al. 2007). It is likely that physical fearfulness early in life would be a better predictor of nonsocial anxiety disorders, but the evidence for this is less extensive.

Emotional lability

In landmark research, Kagan and Snidman (1991) showed that infants who were more emotional and physically aroused at 3 months of age were more likely to become inhibited children by the age of 2. Consequently, high levels of physiological arousal and difficulties with emotion regulation are fundamental characteristics of anxiety across the lifespan and are likely to reflect core maintaining processes.

Among the poor emotional regulation strategies shown by anxious individuals are cognitive processes and content that play a key role in anxious reactivity. In the adult field there is extensive research of the hypothesis that a cognitive style that pays excessive attention to threat and interprets ambiguous cues as threatening is associated with anxiety disorders, and is even causally linked to them (MacLeod and Mathews, 1988). It now appears that the same types of relationships are also evident among young people with anxiety disorders (Hadwin, Garner, and Perez-Olivas 2006). Anxious children are characterized by the allocation of excessive attention to threat, biases toward interpreting ambiguous material in a threat-consistent manner, and high levels of automatic thoughts related to social and physical threat (Britton, Lissek, Grillon, Norcross, and Pine 2011; Muris and Field 2008; Schniering and Rapee 2004). These processes help to maintain a sense of present threat for the anxious young person, and it is this sense of current danger that directly increases the experience of anxiousness.

Family and environmental factors

Role of the family

In contrast to the situation encountered in depression, in anxiety there is very little empirical evidence supporting a key role for broader family factors in its genesis or maintenance (Rapee 2012). However, a wealth of evidence supports the importance of the parent–child relationship. In several models this has been discussed in terms of both attachment (Chorpita and Barlow 1998; Manassis and Bradley 1994) and parenting (Chorpita and Barlow 1998; Hudson and Rapee 2004; Rapee 2001), the empirical evidence being particularly focused on the parenting factors of overprotection and criticism. Parental overprotection is likely to increase anxiety by teaching the child that the world is a dangerous place and that he or she has little control (Rapee 1997; Drake and Ginsburg 2012). Similarly, a critical parent can reinforce the message that the child is not capable of coping or of controlling potential risks in the world. Several reviews have described the evidence that supports these parenting factors and their association with childhood anxiety (Bögels and Brechman-Toussaint 2006; McLeod et al. 2007; Rapee 1997). Naturally, there is less evidence to indicate whether these parenting styles precede anxiety. However, at least some research with both younger children and teenagers has shown that overprotective parenting at one time can predict increases in anxiety at a later time (Edwards, Rapee, and Kennedy 2010; Hudson and Dodd 2012).

In addition to the parent–child relationship, parental psychopathology has also been implicated as a factor important to the development and maintenance of anxiety. There is little question that anxious children are more likely to have anxious parents, and a large part of this relationship is clearly genetic (Gregory and Eley 2007). However, it is also likely that anxious parents will be more overprotective of their child and will model more avoidant coping styles (see below).

Conditioning and learning

Probably the most fundamental theory in psychology is the proposal that phobic fear and avoidance have their origins in conditioning. Over the years, the theory that clinical phobias could develop through conditioning experiences has been variously criticized and resurrected (e.g., Menzies and Clarke 1995; Rachman 1977; Seligman 1971). Perhaps surprisingly, then, few recent models of the development of anxiety disorders have included a strong focus on conditioning (notwithstanding some notable exceptions; e.g., Bouton, Mineka, and Barlow 2001).

In a paper considering the role of conditioning in the development of children’s anxieties, Field (2006) pointed to recent developments in the understanding of conditioning and argued that this better understanding could help explain some of the apparent anomalies in the application of the theory to clinical phenomena. For example, Field pointed out that a variety of experiences that involve a feared cue and occur before an aversive association – experiences such as prior irrelevant associations or prior non-aversive exposures – can affect the strength, duration, and nature of the learned association. Perhaps most importantly, he reviewed current conceptualizations of conditioning that view this phenomenon as a form of acquiring information about stimuli and their predictive relationships, and in this way utilize the same mechanisms as in learning through observation or verbal information. Thus a very wide variety of experiences early in life may produce associations between a set of stimuli and aversive outcomes. In addition to learning from specific negative experiences, learning via ongoing environmental influences (like parents or peers) is highly likely and has received some evidence. For example, several studies have shown that very young children can learn about novel fears by observing their mothers acting in a fearful or avoidant manner (de Rosnay, Cooper, Tsigaras, and Murray 2006; Gerull and Rapee 2002). Similarly, a series of studies by Field and his colleagues has shown that children can learn to become fearful of previously unknown stimuli following the verbal delivery of threatening information about the stimulus (Muris and Field 2010). As noted above, these displays (fearful reactions or verbalizations) are more likely to come from parents who are themselves anxious.

It should be noted that, regardless of views about the role of conditioning in the onset of anxiety disorders, there is little doubt that principles of conditioning are extremely relevant to some of the key methods of anxiety reduction, exposure, and cognitive restructuring. Therapists therefore need a good understanding of current conceptualizations of conditioning and extinction (Craske et al. 2008; Lovibond 2004) in order to better understand the principles behind their own techniques. In particular, understanding that extinction involves learning new information about a stimulus and its predicted relationships can help a great deal in applying exposure in complex cases.

Life events

Although the relationship between negative life events and anxiety disorders is not as strong as it is in several other disorders, including depression, it is clear that anxious children do experience a greater number of negative events in their lives than do nonclinical controls (Allen and Rapee 2009; Goodyer and Altham 1991). Interestingly, this difference appears to be primarily produced by a greater number of so-called “dependent” life events – in other words, life events that could potentially be a product of the child’s own actions (Allen and Rapee 2009). This would suggest that negative life events are more likely to be a result of having an anxiety disorder, although they, in turn, may be responsible for the maintenance of that disorder. Nonetheless, at least some evidence suggests that a slightly higher proportion of independent life events (events that could not be caused by the child) immediately precede the onset of anxiety disorders, which suggests that negative life events might also trigger anxiety disorders among vulnerable youth (Allen, Rapee, and Sandberg 2008). Several specific events have also been associated with anxiety disorders (although generally less strongly than in other disorders). For example, both sexual and physical abuse appear to increase the risk of anxiety disorders (Hudson and Rapee 2009), as do teasing and peer victimization (Hudson and Rapee 2009). Socially anxious children appear to display poorer interaction skills (Spence, Donovan, and Brechman-Toussaint 1999), and they are commonly excluded or ignored by peers (Hudson and Rapee 2009).

An Integrated Model of Anxiety in Young People

Extensive research has pointed to aspects of cognitions and behavior as both initiating and maintaining factors in anxiety among young people. Several overlapping factors are highlighted by the various models of child anxiety and by the accompanying evidence. These common factors are largely summarized in a model of the development of generalized anxiety disorder proposed by Rapee (2001) and later modified by Hudson and Rapee (2004). Although the models were said to be focused on generalized anxiety, the authors argued that the described factors were relevant to all anxiety disorders.

In brief, the model draws on the evidence that shows that one of the strongest predictors of later anxiety disorder is early temperamental vulnerability (inhibition, withdrawal). This temperamental style is partly a result of inherited characteristics. The temperamental style is composed of several factors; foremost among them is a basic avoidant style of dealing with perceived threat. However, a general emotionality (including heightened arousal and information-processing biases) is also likely to be important. The model further emphasizes the importance of specific styles of parenting, especially a tendency for parents to support the child’s avoidant coping (overprotection). However, it is clearly argued that this process is a reciprocal one, where the child’s distress elicits parental protection that, in turn, strengthens the avoidance. The parent’s own anxiety is also a key in the theory, naturally influencing genetic factors, but also moderating the parent support of avoidance as well as modeling anxious responding (as argued by conditioning theories). Finally, the influence of negative environmental experiences is described: these experiences influence the onset of anxiety disorder through their interaction with the child’s temperament. A new development that has become apparent from more recent empirical evidence and was not clear when the model was originally proposed is the likely influence of the child’s temperament in eliciting negative life events. In other words, the process is reciprocal: a withdrawn and inhibited child is more likely to experience negative life events (e.g., being bullied) and these life events interact with the vulnerability to increase the experience of anxiety. Finally, the concept of disorder also depends on a degree of life interference, and this construct is in turn influenced by several additional factors. In light of this more recent evidence, a slightly revised model is shown in Figure 8.2.

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Figure 8.2 A model of the development of anxiety disorders in children. Adapted from Rapee (2001) and Hudson and Rapee (2004).

Clinical Implications

The model shown in Figure 8.2 suggests a number of clear predictions for potentially relevant intervention strategies. Most directly, the avoidant style of coping needs to be directly addressed by teaching the child to approach rather than avoid feared cues (exposure). The emotional arousal that characterizes the underlying temperament also needs to be addressed through arousal reduction strategies. Several such strategies exist, including cognitive restructuring, relaxation, or attention-focusing techniques (such as mindfulness), and all have been shown to be of value in the management of anxiety. A fundamental difference between anxiety in young people and anxiety in adults, which has been highlighted by most models, is the presence of an overprotective or overly controlling parenting style. Thus the model suggests that teaching the parents methods to reduce their own protectiveness, and also to reduce the modeling of anxious or avoidant coping, should help to cut the cycle and to improve the longer-term maintenance of anxiety reduction. A component of the anxious parenting style is the parent’s own anxiety, and the model therefore predicts that helping the parent to manage his/her own anxiety should increase the efficacy of the treatment for the child’s anxiety. Somewhat surprisingly, evidence for this component has met with relatively little success (Cobham, Dadds, and Spence 1998; Hudson et al. 2013), but this may reflect practical difficulties of implementing parent anxiety management rather than its lack of value, in case it could be achieved. Finally, the model suggests that directly reducing the impact of negative life events should further reduce anxiousness and help to maintain gains. This might be achieved by teaching a variety of social, problem-solving, or coping skills designed to help the child better deal with real-world stressors.

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