As mentioned earlier, anxiety is not always pathological; however, it is commonly accepted across cultures that it becomes maladaptive when it is persistent, severe, and frequent, gives rise to avoidance behaviors and interferes with functioning. In children and adolescents, the differentiation between normal and pathological anxiety is a particularly difficult task, as they tend to manifest many anxiety-like symptoms as a part of normal development.

Table 10.1 illustrates some of the normative anxiety in childhood and adolescence along with the corresponding anxiety disorders that the adolescent may develop (Beesdo et al. 2009; Muris et al. 1998).

Most commonly seen anxiety symptoms in adolescents, which can be highly debilitating are manifested in form of social anxiety and examination anxiety. Social anxiety can be typically seen in form of having less friends, difficulty in classroom activities participation, and avoidance of social interaction (e.g., initiating conversations). It is further associated with loneliness, dysphoria, and long-term functional impairment. Examination anxiety is seen in form of moderate to severe anxiety before tests/exams or in any situation where the adolescent would be evaluated. This can lead to decreased performance and poor self-esteem. Thus, it is important for the clinician to carefully assess for the presence of these syndromes and plan management accordingly.

Usually presentation of anxiety symptoms in adolescence is complex and chronic. By late adolescence or early adulthood, decrease is seen in cases meeting the criteria for one anxiety disorder in favor of development of multiple anxiety disorders (Ollendick et al. 2008). It seems that the “load” of anxiety tends to contribute to the development of secondary complications. It has been consistently shown that anxious children are 8–29 times at risk of developing additional depression (Ford et al. 2003). Besides depression, alcohol and substance use and externalizing disorders, such as ADHD and conduct disorders are the most commonly co-occurring disorders (Bittner et al. 2007; Kendall et al. 2004; Ollendick et al. 2008).

Given these findings, it is important to work on the adolescent’s coping skills and family’s behavior early on to facilitate healthy development and possibly halt the transition to full-blown anxiety disorders. Thus, this chapter would highlight the role of cognitive behavior therapy or CBT with adolescents with anxiety symptoms as well as the need for involving their parents in the treatment process.

Various cognitive as well as behavioral factors are implicated in the development and maintenance of anxiety symptoms in adolescents. Therefore, it goes without saying that changes in approach/avoidance behaviors and cognitions are considered to be crucial for treatment change (Rapee et al. 2000), and therefore, CBT appears to be the obvious choice for management of anxiety symptoms.

The primary goals of CBT in adolescents with anxiety symptoms are to change the maladaptive learnings and thought patterns. It also involves skill-building in the session (use of role-plays and games, etc.) with an emphasis on generalizing these skills outside the sessions. As part of skill-building segments or as homework assignment, the adolescent is encouraged to practice the learnt skills in actual anxiety-provoking situations. The rationale behind exposure is that it helps the teenager in developing a sense of self-competence, which he/she also learns to acknowledge and appreciate. Additionally, an important component is involvement of parents or significant others who are not only made more sensitive to adolescent’s condition, but also learn newer skills to reinforce positive coping behaviors (Rapee et al. 2009).

To facilitate the process of learning and skill-building, the therapist needs to play the role of a “collaborative coach” who generates treatment goals with the adolescent and his/her family and tailors the intervention to match the person’s interest and ability. It has been seen that in most cases, 12–16 weeks of active treatment sessions are required, followed by spaced out “booster sessions” (Seligman and Ollendick 2011).

Given the fact the anxiety can present as a normative developmental behavior in adolescents, its assessment and differentiating between normal, subclinical and pathological anxiety states becomes challenging as well as important.

Therefore, a thorough assessment is of utmost importance before embarking on the course of successful cognitive behavior therapy. The first and foremost step in assessment is a complete diagnostic evaluation, and efforts should be made to determine whether the presenting symptoms are clinically significant. Given the high rate of comorbidity, precautions should be taken to determine their presence and deciding which symptoms would form the primary target for interventions. Avoidance patterns, environment’s reaction (for example, parents) to avoidance behaviors, and cognitive patterns of appraisals should be elicited in details so as to develop an individual case formulation. Information should be sought from as many sources as possible to have a full understanding of the person’s symptoms and their context.

Assessment includes both interviews and rating scales. However, behavioral and cognitive assessment forms a crucial element in reaching an individualized formulation and tailoring of treatment to meet the needs, age, and ability of the individuals. See Appendix I for more details on assessment.

Case Vignette 1: Juhi, a 16-year-old girl studying in class IX was bought for therapy by her parents. The main complaints were difficulty in talking to new people, feeling insecure, and feeling anxious in social situation. She had been experiencing these symptoms since a long time, but these had worsened in the past few months. Rapport was established, and diagnostic schedules were administered. Though she did not meet full criteria for social anxiety disorder, she was highly distressed by her symptoms. It was also seen that the primary caregiver who was the mother also exhibited anxiety symptoms during traveling alone in public transport, at high places and while undertaking long journeys. She would also be extra worried if Juhi was even 20–30 min late while coming from school or party.

Skill-based CBT packages for management of anxiety symptoms in adolescents typically include psycho-education, affect recognition, cognitive restructuring, relaxation, and exposure. Additional areas may include assertiveness, social skill training, and problem-solving strategies. Most of these packages also include a parent component (Kendall and Hedtke 2006). Figure 10.3 delineates the various techniques to be used while intervening with anxious adolescents.