Journal of Cognitive Psychotherapy: An International Quarterly Volume 20, Number 3 • 2006

They're Not Just "Little Adults": Developmental Considerations for Implementing Cognitive-Behavioral Therapy With Anxious Youth Julie Newman Kingery, PhD Johns Hopkins University School of Medicine Baltimore, MD

Tami L. Roblek, PhD University of California Los Angeles

Cynthia Suveg, PhD Temple University Philadelphia, PA

Rachel L. Grover, PhD Loyola College Baltimore, MD

Joel T. Sherrill, PhD National Institute of Mental Health Bethesda, MD

R. Lindsey Bergman, PhD University of California Los Angeles

Developmental factors direct optimal implementations of cognitive-behavioral therapy (GBT) protocols with children and adolescents. Although chronological age can approximate level of development, youthful clients benefit v^rhen clinicians carefully assess each child's cognitive, social, and emotional skills and adjust manualized treatments accordingly. Using several components of manualized GBT for anxiety in youth (i.e., affective education, cognitive restructuring, exposure tasks) as a framework, this article reviews empirical literature and provides practical suggestions for modifying these aspects of treatment to fit a child's level of development. Important issues such as engaging youth in treatment, and involving school personnel and parents in this process are also discussed. This article concludes with a call for

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future research that will inform the implementation of manualized treatments based on developmental factors. Keywords: development; cognitive-behavioral therapy; anxiety; youth

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here are several components that cognitive-behavioral therapy (CBT) treatments for adults and CBT programs for children have in common (e.g., setting an agenda, homework that allows for application of skills in "real life" settings, treatment as a collaborative and goal-oriented process). However, given the significant developmental differences between children and adults, it is crucial that CBT treatments are tailored to address the unique developmental needs of children and adolescents (Barrett, 2000; Piacentini & Bergman, 2001). In the realm of anxiety treatment, several empirically supported cognitive-behavioral protocols have been developed specifically for children and adolescents (e.g., Barrett, Dadds, & Rapee, 1996; Kendall, 2000; Silverman et al., 1999b). Nevertheless, simply using one of these child-based manuals is not enough. Manuals must be applied flexibly and creatively, with clinicians taking developmental principles and the particular needs of each case into consideration (Kendall & Choudhury, 2003; Kendall, Chu, Gifford, Hayes, & Nauta, 1998). Although chronological age provides a general framework for a child's expected abilities, it is important for clinicians to understand a particular child's level of cognitive, social, and emotional development, as these skills can greatly impact his or her ability to effectively participate in, and ultimately benefit from treatment. When implementing manualized CBT for anxious youth, clinicians must be knowledgeable, creative, and flexible—from implementing creative strategies for engaging youth in treatment and modifying various components of CBT to fit a child's developmental level, to involving family members and school personnel in the treatment process. Using several components of CBT for anxiety as a framework, we provide empirical grounding and practical suggestions for incorporating the unique developmental needs of children and adolescents into treatment sessions.

ENGAGING CHILDREN AND ADOLESCENTS IN TREATMENT Children and adolescents rarely seek treatment on their own (Piacentini & Bergman, 2001). More commonly, parents involve youth in treatment for symptoms that they view as problematic. Youth are often unsure of what to expect and may be reluctant to participate in therapy. Particularly at the beginning of treatment, clinicians face the challenge of developing creative and developmentally appropriate ways to engage youth in treatment. Friedberg and McClure (2002) suggest that therapists encourage collaboration and choose active, fun tasks that are developmentally sensitive and appealing to youngsters. Treatment components can be introduced using creative presentations, workbooks, stories, props, colorful drawings, and hands-on activities. Youth's interests and preferred activities can be incorporated into each session. For example, if a child or adolescent plays a sport or musical instrument, then examples used during the session can focus on these topics. Using a specific anxiety treatment manual as an example (i.e., Kendall's Coping Cat), creative ways to engage youth in treatment will be described in the following paragraphs (Kendall & Hedtke, 2006; Kendall, Kane, Howard, & Siqueland, 1990). During the affective component of treatment when youth are taught to recognize different emotions and somatic cues for anxiety, younger children may enjoy tracing their entire body on a large piece of paper and identifying areas related to somatic cues for anxiety, cutting out magazine pictures of various facial expressions for a collage, or reading children's books that discuss different emotions (Friedberg & McClure, 2002; Kendall et al., 1992). Alternatively,

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adolescents may enjoy making a collage with pictures from a teen magazine. When teaching relaxation skills, therapists can ask youth of any age to choose the location for an imagery exercise (e.g., beach, woods, other favorite relaxing place) and invite them to contribute to the imagery "story." Active tasks useful during the self-talk component include using puppets or small dolls to demonstrate coping statements (with younger children), writing information on a dry-erase board with markers, or completing role-play exercises during which the child and therapist verbalize their thoughts. Several additional factors should be considered when working with older children and adolescents, who can be particularly difficult to engage in treatment. Although also important with younger children, it is helpful for therapists to adopt a collaborative posture with adolescents to build rapport and trust. Overall, the adolescent should see the therapist as someone who provides suggestions and strategies and helps to tailor the best coping approach rather than as an authority figure that has all of the answers (Kendall et al., 1992). Similarly, therapists can invite adolescents to contribute to the session agenda, and examples from adolescents' own life (e.g., favorite activity, music) can be used in treatment. For example, in working with a 14-yearold girl with social phobia who had an interest in dance, the therapist asked her to imagine helpful or coping thoughts that her favorite dancer might use. The example of dance was also used to teach problem solving (e.g., possible actions she can take if she misses an important rehearsal) and to design exposure exercises (e.g., performing dances in front of others, inviting friends to attend a dance performance). Incorporating activities, friends, and interests makes skills learned in therapy more meaningful and generalizable to older children and adolescents. The adolescent version of Kendall's Coping Cat program (i.e.. The C.A.T. Project; Kendall, Choudhury, Hudson, & Webb, 2002) is one particular manualized treatment that takes the unique developmental needs of adolescents (ages 14 to 17) into consideration. For example, teens are given the opportunity to choose a name for the program by deciding what the letters "C.A.T." stand for (e.g., "Changing Anxious Thinking," "Coping with Anxiety for Teens"). In comparison to the Coping Cat program (Kendall & Hedtke, 2006) for younger children (ages 8 to 13), The C.A.T. Project includes more detailed psychoeducational information about the causes of anxiety, less of an emphasis on affective education and more time spent on cognitive skills, a discussion of specific "thinking traps" (i.e., cognitive distortions), use of a point system for rewards rather than stickers, and an increased focus on encouraging adolescent autonomy. The therapist manual for the C.A.T. Project also provides specific suggestions for establishing rapport and engaging adolescents in the treatment program. Another strategy related to engaging youth of all ages in treatment involves identifying rewards that take a child's individual preferences and developmental level into consideration. A reward list that is created in collaboration with the child or adolescent will ensure that the rewards are valuable to the particular child and will enhance motivation to comply with treatment (e.g., attending sessions, completing homework). Tangible rewards that have been used with younger children include Matchbox cars, comics or books, candy, additional time to watch television or play a video game, movie tickets or rental, school supplies, or other small prizes. Social rewards can include choosing a favorite activity or restaurant, special one-on-one time with a parent (e.g., baking, playing a game, reading favorite book), playing a game v«th the therapist, or inviting a friend over to play. In addition to the tangible rewards used with younger children, older children and adolescents often enjoy video and board games, gift certificates for clothing stores or for a manicure, makeup, magazines/books, CDs or DVDs, disposable cameras, additional computer or phone time, or staying up later. Social rewards for adolescents can include inviting a friend over, staying out later with friends, playing a favorite sport with the therapist, attending a special activity with family or fi^iends (e.g., amusement park, sporting event), or individual time to complete a special activity with a parent.

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AFFECTIVE EDUCATION COMPONENT OF TREATMENT In addition to the ongoing process of engaging youth in treatment, CBT treatment programs for anxiety typically include several skill-based components with improvement in treatment outcomes (see Suveg, Kendall, Comer, & Robin, in press). For example, at the outset of Kendall's Coping Cat program (Kendall & Hedtke, 2006; Kendall et al., 1990), youth learn to identify a wide range of emotions through facial expressions, tone of voice, and body language. After mastering this skill, they are taught to recognize their own somatic cues of anxiety (e.g., heart pounding, palms sweating, stomachache, shortness of breath). Prior to introducing affective education, regardless of a child's chronological age, it is important for therapists to assess the child's level of emotional development. Indeed, both the theoretical and empirical literatures provide support for the importance of considering a child's level of emotional development when conducting treatment for anxious children (see Southam-Gerow & Kendall, 2002, for a review). Two related areas of emotional development are particularly relevant to assess when conducting CBT with anxious youth: emotion understanding and emotion regulation. Emotion understanding includes skills in identifying, labeling, and understanding the causes/consequences of emotional experiences. Denham (1998) suggests that throughout the preschool period, children's level of emotional understanding increases dramatically; by the end of the preschool period, they are able to understand various aspects of both their own and others' emotional experiences. As children mature and their cognitive abilities also develop, they are able to consider multiple cues (e.g., both facial and situational) to better understand an emotional experience (Hoffiier & Badzinski, 1989; Saarni, 1999). The development of emotion regulation (i.e., the ability to manage emotional experiences in response to the demands of the environmental context) is tied to a child's skill in emotion understanding in that a child who does not understand an emotional experience is likely not going to be able to regulate the experience in adaptive ways. By mid-childhood, typically developing children possess a bank of diverse emotion regulation strategies, and as they mature into adolescence, this repertoire continues to grow (Saarni, 1999). Adolescents are better able to consider multiple factors when deciding on an appropriate emotion regulation strategy and to make use of complex, cognitively focused emotion regulation strategies than are children. Overall, it is important to consider that emotional development does not occur in a vacuum— emotion skills are related to each other and closely intertwined with youth's level of cognitive and social development (see Saarni, 1999, for a more detailed discussion of this topic). Research examining emotion-related skills in anxious children finds deficits in both emotion understanding and emotion regulation abilities, making it even more crucial for therapists to consider these factors when conducting treatment. For example, Suveg and Zeman (2004) found that children with anxiety disorders experience their emotions more intensely and perceive themselves as less able to successfully manage emotionally provocative situations than their nonclinical counterparts. Other research has likewise found that children with anxiety disorders exhibit deficits in skills related to emotion understanding (e.g., Southam-Gerow & Kendall, 2000). The results of these studies suggest that attending to the child's level of emotional understanding and ability to regulate emotions may be associated with improvement in treatment outcomes. Therapists should begin by assessing youth's understanding of various emotions. For children and adolescents who have difficulty understanding emotional experiences, more time may need to be spent on affective education. The therapist should begin by identifying the particular area of deficit given that "emotion understanding" encompasses several skills (e.g., identifying emotional states, understanding the cause of an emotion). Regardless of the particular emotion deficit, the therapy materials for treatment programs such as Kendall's Coping Cat

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offer therapists several different ideas for emotion education. The particular strategy that a therapist decides to use should be guided in part by age-appropriateness and the child or adolescent's level of comfort with discussing emotional experiences. If a child is not accustomed to discussing emotions and is very uncomfortable doing so, it may be less intimidating to identify emotions while creating a collage with magazine pictures. It may also be easier for youth to talk about another person's emotions (e.g., friend, family member, favorite television character) prior to discussing their own feelings. Alternatively, some children prefer taking a more active approach. For example, one 9-year-old female with separation anxiety asked the therapist to guess various emotions that she "acted out" in a charades-type game. Given that treatment outcome is dependent upon the child's willingness to discuss emotional experiences, it is crucial that the therapist follow the child's lead and not proceed too quickly if a child seems uncomfortable or has a skills deficit in this area. As noted previously, therapists can assess the particular emotion-related difficulty in order to best meet the needs of the individual child. In cases where the child experiences many emotions very intensely, the high state of emotional arousal may interfere with the child's ability to apply the cognitive techniques of therapy. For example, one 15-year-old boy with generalized anxiety disorder experienced such intense levels of anxiety when he heard a strange noise at night that he was unable to apply the cognitive skills that he had learned in therapy. In cases such as this one, therapists may want to spend additional time on deep breathing and relaxation exercises before the child is ready to move on to the cognitive components of therapy. More time may also need to be spent assisting the child in how to differentiate levels of emotional arousal (i.e., low, medium, or high level of anxiety in response to a particular situation). The ability to differentiate levels of emotional arousal is crucial because children are required to reflect on their level of emotional arousal when completing exposure tasks. Overall, a careful assessment of each child's level of emotional development will help the therapist determine particular ways in which the affective education component of CBT treatment programs for anxiety may need to be modified. COGNITIVE RESTRUCTURING COMPONENT OF TREATMENT Another core component of CBT for anxiety in children and adolescents is the modification of maladaptive thoughts. In adults, anxiety-enhancing thoughts are identified, challenged, questioned, and examined for confirming and disconfirming evidence. Focusing on maladaptive cognitions of children and adolescents of varying cognitive skill levels can represent a challenge for the therapist. Although CBT programs such as Kendall's Coping Cat are developmentally appropriate for children as young as 7 years of age, modifications to the cognitive component of treatment need to be made for children that fall within the lower end of this age range. A brief description of normative cognitive abilities in childhood and adolescence and developmentally appropriate treatment manual adaptations are discussed in this section. Piaget (1972) described middle childhood (ranging from approximately 7 to 12 years of age) as characterized by rapid developments in logic and perspective-taking skMls. Children in the 7 to 12 age group begin to reason deductively, thus greatly increasing their problem-solving skUls. However, logical thinking in middle childhood remains somewhat concrete and is often dependent on observable events. This stage of development is also marked by a decrease in egocentrism, allowing children to farther understand that others may have different thoughts and feelings than their own. From an information-processing perspective, metacognitive skills or the abilities to monitor and evaluate one's own thinking strategies emerge during middle childhood, and youth become more skilled in identifying information needed to solve problems (Siegler, 1998). In contrast to younger children, adolescents gradually begin to think more like adults. Piaget (1972) theorized that logical and moral reasoning develops during adolescence. Strong beliefs

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thought to represent the onset of organized theories also emerge in adolescence along with an increased ability to understand the perspective of others. In addition, the adolescent becomes more self-aware, leading to an increase in self-reflection and self-monitoring (Keating, 1990). Information-processing skills also improve in adolescence allowing for increased speed of processing, gains in attention, and enhanced memory (Keating, 1990). The advancement of cognitive abilities during the adolescent period enables teens to solve abstract problems and be more aware of their own mental processes (Keating, 1990). Despite the emergence of more sophisticated problem-solving and metacognitive skills in middle childhood, therapists may need to adapt the cognitive restructuring component of treatment to accommodate developmentally appropriate cognitive limitations. For example, as metacognitive awareness is relatively new during middle childhood, therapists may need to engage in more teaching about thoughts with younger children. Moreover, it may be helpful to use more concrete tools when identifying thoughts such as cartoons with thought bubbles or incomplete sentences (e.g.. When I have to go to school, I feel and I worry that ). One 7-year-old child who had difficulty identifying his own thoughts responded well when the therapist drew a stick figure with a blank thought bubble on a dry erase board. This technique provided a more concrete visual aid and made it easier for the child to articulate what he referred to as "what's in my thinking bubble" for a given situation. A list of simplified cognitive distortions or "thinking traps," such as "only thinking about bad things" or "telling the future," may also be helpful. Regarding the process of challenging maladaptive thoughts, some children in this age group may be able to collect "clues" to support or refute a thought, whereas other children may need to be given simple coping self-statements (e.g., "I can do it," or "Calm down"). If the child is cognitively young or has difficulty grasping the idea of "coping thoughts," the therapist may need to place less emphasis on this component of treatment and more focus on another component (e.g., relaxation skills, exposure tasks). Due to the cognitive advances during the teen years, the cognitive component of treatment with this age group can be relatively sophisticated. One option with adolescents is to introduce the concept and explain the importance of thoughts earlier in treatment. Identification of anxiety-provoking thoughts may be easier than with younger children due to the adolescent's more advanced metacognitive skills. Similarly, education regarding thinking errors and how to challenge maladaptive thoughts can be more complex in nature. For instance, a therapist may help the adolescent to weigh the pros and cons of several perspectives in the process of challenging an automatic thought. In contrast to the advanced cognitive skills that may make working with a teen easier for a therapist, the teen years present some unique challenges. For example, adolescents often have more complex worries than younger children. While a younger child may worry about meeting a peer because of a vague sense of "something bad might happen," an adolescent may fear that he or she may "say something embarrassing and then the whole school will know." More elaborate fears require the therapist to present more detailed skills for challenging and replacing anxiety-provoking thoughts. Also, some maladaptive thoughts, such as "everyone will notice my mistake," may be more difficult to challenge during the teen years due to the normative development of the imaginary audience (i.e., belief that everyone is watching or is aware of this adolescent). Notably, teens who are reluctant to share their thoughts with the therapist may talk more openly by guessing the thoughts of "others" (e.g., peers, person they admire) in preparation for discussing their own thoughts. EXPOSURE TASKS Although the affective and cognitive aspects of treatment are key components of manualized CBT for anxious youth, perhaps the most essential ingredient of such programs is the exposure tasks (Hudson & Kendall, 2002). During the initial stages of treatment, the therapist and child

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(with input from parents) work together to create a hierarchy of feared situations. In the Coping Cat program, once youth have developed skills for coping with anxiety they begin facing their fears by gradually working their way up the anxiety^ hierarchy. Given that the task of completing exposure exercises integrates various skills learned during treatment, therapists need to consider several different aspects of a child's development when planning exposure tasks. This section will provide recommendations for completing exposures with younger children and with adolescents. Although therapists can use chronological age as an approximation of level of development, each youth's emotional, cognitive, and social abilities should be assessed so that therapists can adapt exposure exercises accordingly. According to Kendall, Robin, Hedtke, and Suveg (2005), therapists need to be mindful of a child's developmental level when providing a rationale for completing the exposure tasks. Younger children may understand a more basic explanation (e.g., "When we don't face our fears, our anxiety grows. The only way to shrink that anxiety is to use our coping skills and face our fears."). Therapists can draw a large circle and then a smaller circle on a dry erase board as a visual aid for this explanation. With adolescents, therapists may be able to provide a more sophisticated explanation, using words such as "hierarchy" and "habituation." This more detailed discussion may make a teen feel more mature and respected, which may increase rapport and compliance with treatment (Kendall et al., 2005). Regardless of age, all youth can benefit from being reminded that similar to other situations they have faced that seemed scary at first (e.g., learning to ride a bike, the first day of a new school year, other new experiences), facing fears will become easier with practice. It is essential for therapists to be aware of what tasks are developmentally appropriate for children of different ages, as these often guide the creation of the fear hierarchy. For example, younger children may focus on inviting friends to play or attending sleepovers, whereas adolescents may face situations related to applying for jobs, inviting peers on social outings, and going on dates. However, the choice of initial exposure tasks is often more closely based on a child's anxiety severity and developmental abilities rather than his or her chronological age. Adolescents with a longstanding history of severe anxiety may begin with tasks ordinarily expected of younger children, and may require extra support from the therapist (e.g., standing next to the teen when he or she is placing a food order). For example, a socially anxious 16year-old female who had avoided ordering food in restaurants, attending sleepovers, asking for directions, and calling friends for many years, began by facing these situations before she was able to practice more developmentally appropriate tasks such as asking a friend to attend a movie or interviewing for a summer job. Similarly, a 15-year-old adolescent with generalized worries and separation anxiety began by working on sleeping in his own room and staying at home alone, tasks that would ordinarily be mastered much earlier in development. In terms of providing support for completing exposure tasks outside of the session, with younger children the therapist may rely more heavily on parents to schedule exposures and help the child carry out these exercises (e.g., by arranging to eat dinner at a restaurant so the child can order food, planning to stop somewhere so that the child can ask for directions). Younger children may also need extra support within sessions (e.g., cue cards, additional role-play practice with the therapist before completing an in vivo exposure). Adolescents, who spend less time with their parents and more time with peers, may need to take more responsibility for completing out-of-session exposure practice. If an adolescent feels comfortable sharing information about his or her anxiety treatment with a peer, the peer can serve as a "coach," reminding the teen to practice his or her new skills in relevant situations (e.g., introducing self, starting a conversation). Several other developmental considerations come into focus when completing exposure exercises. In terms of cognitive abilities, younger children's orientation toward the present may influence their ability to tolerate the momentary anxiety associated with exposure exercises.

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Older children and adolescents are typically more capable of understanding the "larger picture"—that momentary anxiety will subside and individual exposure practice is contributing to overall progress with treatment. Prior to completing exposures in social situations, it is helpful for the therapist to assess the child's level of social development or skills (e.g., does the child or adolescent have the skills necessary to complete the task of entering a group and introducing himself to others?). If a child demonstrates through an in-session role-play exercise that he or she lacks tbe skills necessary to complete an exposure task, then the therapist will need to teach these skills before the exposure exercise can be attempted. As mentioned previously, a child's level of emotional development (e.g., emotion identification, emotion regulation) must also be assessed in relationship to completing exposure exercises. For example, children with greater skills in this area will be better able to provide clinicians witb reliable ratings of the intensity of their anxiety during the exposure exercises (Kendall et al., 2005). In summary, integrating youth's level of cognitive, emotional, and social development will allow for an individualized approach to the planning and completion of exposure tasks.

DEVELOPMENTAL CONSIDERATIONS AND FAMILY INVOLVEMENT In addition to working individually with anxious children and adolescents to teach them the core skills mentioned previously, therapists often involve families and schools in the treatment process because it is within these contexts tbat children spend the majority of their time. As Friedberg and McClure (2002) state, involving family members and school personnel is crucial to treatment success because tbese environments "can either reinforce or extinguish adaptive coping skills" (p. 8). With respect to family involvement, parents have been incorporated in treatment sessions in a number of outcome studies focused on anxiety in general (e.g., Silverman et al., 1999a) and in studies focused on the treatment of specific disorders including school refusal (e.g.. King et al., 1998) and obsessive-compulsive disorder (e.g., Piacentini, Bergman, Jacobs, McCracken, & Kretcbman, 2002). Some treatments for cbild anxiety have even included interventions focused on reducing parents' own anxiety (Barrett et al., 1996). Some studies tbat bave included families in treatment find beneficial effects, although whether family-based treatments are superior to individual approaches remains to be evaluated (see Barmish & Kendall, 2005). The companion article by Suveg et al. describes a family-based approach to CBT witb anxious youtb; in keeping witb tbe theme of tbe current article, the section tbat follows addresses the topic of family involvement as it relates more specifically to developmental considerations. Generally, as children approach adolescence and then adulthood, they become more autonomous and the involvement of others in treatment may decrease. Tbe youth's developmental status, as it relates to family involvement in treatment, should be carefully taken into account when (a) defining agreed upon, age-appropriate treatment goals and (b) determining an appropriate role and level of involvement for parents in sessions and in between-session exercises. Parents' expectations regarding the kinds of situations that their cbild should realistically be expected to tolerate as well as tbeir beliefs about situations that pose realistic threat should be carefully assessed at the beginning of treatment. Flawed impressions regarding developmentally appropriate tasks tbat result in expecting "too little" from their children could promote the child's avoidance of anxiety-producing situations. For example, a parent of an 11-year-old witb social phobia believed tbat the child was not old enough to order her own food in a restaurant and tberefore did not encourage the girl to do so. Alternately, excessively bigb parental expectations might leave tbe cbild feeling incompetent or demoralized when tbey are incapable of fulfilling tbese inflated expectations. In families wbere parents' expectations initially do not seem developmentally appropriate, it migbt be necessary to further assess wbetber tbere are mitigating contextual circumstances (e.g., reluctance to allow tbe child to visit a neigbborbood friend because they live in a high crime area). In some cases, it

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might be necessary to provide corrective, normative information about what constitutes ageappropriate behavior. Incorporating parents' expectations regarding age-appropriate bebavior into mutually agreed upon tberapeutic goals is likely to foster tbe therapeutic alliance, enhance tbe family's adberence to the treatment plan, and consequently facilitate good outcomes. Given tbe demonstrated bigb rate of familial aggregation for anxiety (e.g., Beidel & Turner, 1997), it is not surprising tbat anxious children frequently bave anxious parents. It is not uncommon for a parent of an anxious cbild to overestimate tbe dangers associated witb certain activities. Left unchecked, parental bias about danger migbt promote tbe child's anxious interpretations of events. In some cases, it might even be necessary to challenge the parents' beliefs about whetber certain situations pose undue tbreat, or to more or less explicitly acknowledge that the exposure exercises serve tbe dual purpose of confronting the child's as well as tbe parents' fears. A cbild's developmental stage also impacts the nature and amount of parent involvement in sessions and between sessions. As mentioned previously, younger children generally tend to require more parental involvement tban older ones. For a young child, parental involvement can range from assistance witb tbe execution of exposure exercises to "coacbing" regarding coping skills learned in treatment. In contrast, older children migbt merely require parental reminders or transportation to exposure settings. Anotber area wbere parent involvement tends to differ with tbe cbild's age relates to parental involvement in the session with tbe tberapist. For younger cbildren, parental involvement in session is beneficial if parents are expected to be knowledgeable about and able to reinforce the principles learned in session. For older cbildren (i.e., adolescents), time alone v«th tbe therapist can be vital for establisbing rapport with tbe therapist and promoting self-efficacy through an active, autonomous role in their treatment experience. In fact, private meetings witb parents (witbout child present) sbould be avoided or approacbed witb caution wben treating adolescents, due to tbe tendency for such meetings to cause youngsters to feel tbat tbey are being treated too mucb like a child, or even cause them to feel "talked about," which could in turn interfere witb tbeir general sense of trust or comfort witb tbe tberapist. DEVELOPMENTAL CONSIDERATIONS AND SCHOOL INVOLVEMENT Symptoms and impairment associated witb anxiety disorders, including but not limited to tbose associated with school refusal, are often manifested in tbe scbool setting. In fact, researcbers are beginning to explore the feasibility and effectiveness of school-based delivery of CBT for anxiety disorders, including a group intervention for higb scbool students with social phobia (Masia, Klein, Storcb, & Corda, 2001). However, even for cases in wbich treatment is not school-based, tberapeutic targets and corresponding between-session exercises often involve some aspect of the scbool setting (e.g., situations in tbe classroom, excbanges with teachers, playground interactions witb peers). Tbe degree of school personnel involvement can vary, and sometimes it might be limited to securing teacbers' agreement to allow for variation in normal routine for the affected cbild (e.g., allowing a cbild witb separation anxiety to initially spend minimal time in tbe classroom witb parent outside and gradually increasing the difficulty of tbe separation situation). Sometimes scbool personnel may be more directly involved witb exposure assignments. For example, young cbildren witb severe social anxiety may have difficulty speaking with or asking questions of tbe teacber. In cases like this, the teacher may become involved in actual exposure assignments in wbicb tbe cbild interacts witb tbe teacher in situations of varying difficulty (e.g., alone after scbool, in front of one otber cbild, during unstructured class time). Witb regard to scbool involvement in treatment, tbe pattern is similar to that of parental involvement in treatment, sucb tbat involvement tends to decrease as cbildren get older. Again,

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this general pattern is at least in part related to the general nature of childhood development, with increasing autonomy with age, but it may be related to other factors as well. For one, at a logistical level, involving school personnel is more feasible in the younger grades (i.e., elementary school) when children typically have a single teacher rather than several different teachers. Involving even a single teacher in treatment in an ongoing and meaningful way can be a challenge. Doing so with multiple teachers (who have multiple classes of students) at the middle or high school level is not generally a realistic goal. Depending on the nature of the child's difficulty, it might be necessary for the therapist to observe the child in various settings (e.g., at lunchtime, on the playground, in one or more classrooms, in the hall between classes) and consult with a teacher, a principal, or even with multiple school personnel. Regularly scheduled extracurricular activities (e.g., gymnastics, other sports, art class) can also serve as a structured setting for addressing anxiety, particularly for anxiety in peer situations. As such, it may be prudent to involve coaches or teachers in these settings in the treatment plan as well. SUMMARY AND CONCLUSIONS Manualized CBT for anxiety is applied flexibly with modifications based upon each youth's unique developmental abilities. Although chronological age can be used as a guide, clinicians are best informed by a detailed understanding of a particular child's level of cognitive, social, and emotional development. This article reviewed empirical literature and provided practical suggestions from implementing creative strategies for engaging youth in treatment, modifying various aspects of CBT (e.g., affective education, cognitive restructuring, exposure exercises) to fit a child's developmental abilities, and involving family members and school personnel treatment. Future research that systematically evaluates developmental variables as mediators and moderators of treatment outcome will provide empirically based information as to how manualized treatments can best be adapted to suit a particular child's developmental needs and abilities. NOTE The views expressed in this article represent those of the authors and are not intended to represent the NIMH, NIH, or DHHS.

REFERENCES Barmish, A. J., & Kendall, P. C. (2005). Should parents be co-clients in cognitive-behavioral therapy for anxious youth? Journal of Clinical Child and Adolescent Psychology, 34, 569-581. Barrett, P. M. (2000). Treatment of childhood anxiety: Developmental aspects. Clinical Psychology Review, 20, 479-494. Barrett, P. M., Dadds, M. R., & Rapee, R. M. (1996). Family treatment of childhood anxiety: A controlled trial. Journal of Consulting and Clinical Psychology, 64, 333-342. Beidel, D., & Turner, S. (1997). At risk for anxiety: I. Psychopathology in the offspring of anxious parents. Journal of the American Academy of Child and Adolescent Psychiatry, 36, 918-924. Denham, S. A. (1998). Emotional development in young children. New York: Guilford. Friedberg, R. D., & McClure, J. M. (2002). Clinical practice of cognitive therapy with children and adolescents: The nuts and bolts. New York: Guilford. Hoffner, G., & Badzinski, D. M. (1989). Children's integration of facial and situational cues to emotion. Child Development, 60, 411-422. Hudson, J. L., & Kendall, P. G. (2002). Showing you can do it: Homework in therapy for children and adolescents with anxiety disorders. Psychotherapy in Practice, 58, 325-534.

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