Anxiety disorders are common in youth with a prevalence rate of 10% to 20%. It is associated with difficulties in academic achievement, social and peer relations and future emotional health. It is a risk factor for comorbidity and comorbidity is also very common.

Anxiety consists of a behavioural (1), physiological (2) and cognitive component (3). Anxiety is part of normal development (i.e. it cautions one against danger) and can bolster performance (e.g. tests). However, too much anxiety can quickly become distressing. Youth with anxiety view the world as dangerous (1), experience physical complaints (2) and avoid certain situations (3). Avoidance reinforces feelings of anxiety and avoidance behaviours.

Coping Cat is a treatment for anxiety disorders for children from the age of 7 to 13. This treatment targets all aspects of anxiety (i.e. tripartite model). It includes psychoeducation (1), somatic management skills (2), cognitive restructuring (3), gradual exposure to feared situations (4) and relapse prevention plans (5). Affective awareness is increased during the early stages of treatment and corrective information about anxiety is provided (e.g. normalization of feelings of anxiety). Somatic management techniques are introduced as adaptive responses. Cognitive restructuring focuses on challenging maladaptive thoughts and shifting to coping-focused thinking. The C.A.T. project is a treatment for anxiety disorders for adolescents. CBT may also be useful.

The goal of the Coping Cat treatment is to teach youth to recognize signs of anxiety and implement strategies to better cope with the distress rather than completely eliminate anxiety. There is typically an individual meeting with the child for several weeks and two meetings with the parents. Coping Cat mainly focuses on practicing the application of anxiety management strategies in real, anxiety-provoking situations.

In the first half of the treatment, children are being taught a four-step FEAR plan to organize the psychoeducational content into problem-solving steps:

1. Feeling frightened?
   Children ask themselves whether they feel frightened in this step to help them identify the physical symptoms associated with anxious arousal. This is a cue to address the anxiety (e.g. relaxation). They are being taught coping mechanisms, such as relaxation or deep breathing.
2. Expecting bad things to happen?
   Children ask themselves whether they expect bad things to happen. Expectations are first identified and then challenged to reduce faulty beliefs. The therapist helps with identification and changing the beliefs and then new beliefs are being established using coping self-talk. The therapist may use balloons as youth typically do not tell what they are thinking. Thoughts are first identified for neutral or ambiguous situations and alter for anxiety-provoking situations from low to high anxiety-provoking situations. Modelling and role play helps youth develop and practice these skills. The emphasis is on identifying and reducing negative self-talk.
3. Attitudes and actions that might help
   Children are being taught that it is useful to take action that will help change an anxious situation or a reaction to it. The child is taught to

Multisystemic therapy refers to a treatment for adolescents with severe antisocial behaviour and includes their families. It is appropriate and cost-effective for youth referred to by the juvenile justice system with serious and chronic patterns of offending and at high-risk of out-of-home placement due to the relative intensity of the treatment. Teenagers with conduct disturbances and substance abuse problems can also be included.

MST aims to address multiple risk factors associated with juvenile offending and bases itself on Bronfenbrenner’s model. Therefore, MST tries to target risk actors at multiple levels (e.g. individual; family; peer; school). MST also needs to address difficulties between the systems (e.g. caregiver interaction with teachers and peers). The factors that create barriers to the effective functioning of proximal systems must be addressed. MST thus tries to understand behaviour within its naturally occurring context. The intervention is delivered in ecologically valid environments (e.g. home; school) and whenever possible, delivered by key ecology members (e.g. teachers; caregivers).

The caregivers are seen as the main conduits of change. Interventions focus on empowering them with the resources and skills they need to be more effective. The therapist guides the caregiver efforts to successful outcomes. The main goals are improving parenting and decreasing youth association with deviant peers. The therapist works with the family and uses family strengths to overcome barriers to caregiver effectiveness. The therapist helps the caregiver design and implement interventions aimed at decreasing youth antisocial behaviour when the caregiver effectiveness increases. It is important to try and surround the adolescent with a context that supports prosocial behaviour, effectively replacing the context that contributes to antisocial behaviour.

The MST clinicians should be available 24/7 to make sure the sessions can occur at times convenient for the families. This allows the therapist to react quickly to crises (e.g. caregiver  needs evening support for drug relapse). The duration of the intervention is 3 to 5 months but is intensive.

MST does not follow a rigid manual and is based on nine principles. The interventions are designed to promote generalization and long-term maintenance. All aspects of MST must be strengths-based and the ecological strengths need to be used as mechanisms of change. The therapist thus needs to identify strengths and use these.

At the beginning of treatment, referral behaviour and other problem behaviours to be targeted are specified from the perspectives of stakeholders (e.g. caregivers). At this point, ecological strengths are also identified and perspectives on why problem behaviour keeps occurring is assessed. The desired goals are synthesized into overarching goals of the treatment. The ecological factors that appear to be driving the problem are organized into a coherent conceptual framework (i.e. fit). The therapist then outlines intermediary goals that need to be achieved to achieve the overarching goals. Based on this, specific intervention strategies are designed. The advances and barriers of treatment effectiveness are then measured and this is used to re-evaluate whether the ecological factors that drive the problem behaviour

Trauma-focused cognitive behavioural therapy (TF-CBT) addressed problems specifically associated with traumatic events that children experience or witness (e.g. PTSD). TF-CBT targets PTSD symptoms and outcomes associated with trauma. A PTSD diagnosis is not required.

PTSD includes negative cognitions about oneself, others or the world and negative affective states. There may be dysregulation in affective, behavioural, cognitive and physiological areas of functioning. TF-CBT targets reregulation in each of these areas with the goal of optimizing children’s adaptive functioning after trauma.

The main goal of TF-CBT is to help children overcome traumatic avoidance (1), shame (2), sadness (3), fear (4) and other trauma-specific emotional and behavioural difficulties (5). TF-CBT is not a first line treatment but can help children after they have stabilized.

TF-CBT includes cognitive-behavioural, attachment, family, humanistic, and psychodynamic therapy principles. The overall level s of adjustment in all areas (e.g. physiological; emotional) impact each other and influence overall well-being. TF-CBT thus attempts to reduce the impact of trauma across these areas and this is believed to lead to overall improvements.

There are several pathways to PTSD after trauma:

1. Classical conditioning
   This holds that a learned association during the trauma leads to avoidance and this exacerbates the problem.
2. Emotional processing theory
   This holds that posttraumatic symptoms reflect the development of a problematic fear structure comprising many stimuli, responses and meaning representations. When this is triggered, there are maladaptive reactions.

These theories state that exposure is essential. The social-cognitive theory focuses on the impact of trauma on pre-existing or developing beliefs about one’s self, others and the world. It states that trauma-related feelings and thoughts should be reviewed to process the experience fully and correct dysfunctional beliefs and emotional reactions.

The family environment and the therapeutic relationship is also essential. TF-CBT may reduce parental distress and enhances parents’ support for their children.

Goals of TF-CBT include:

• Mastering skills to manage stress and improve affective, behavioural and cognitive  regulation early in treatment.
• Inclusion of parents or other caretaking adults in treatment whenever feasible.
• Mastering trauma reminders and traumatic avoidance.
• Making meaning and contextualizing traumatic experiences through affective and cognitive processing (i.e. moving beyond victimization).
• Enhance safety and optimizing future development.

TF-CBT focuses on children between the ages of 3 and 18. The treatment is adapted depending on the developmental stage of a child and parents receive TF-CBT in parallel individual or joint child-parent sessions.

TF-CBT consists of several components named PRACTICE:

• Psychoeducation
  This provides information to children and parents about the nature of traumatic experiences and common reactions to trauma (i.e. normalize experience and reactions). Psychoeducation occurs throughout treatment. Euphemisms are avoided.
• Parenting skills
  This provides parents with training to target the child’s symptoms and practice what the children are learning in treatment. Additionally, parents’ emotional responses to the child’s trauma are also addressed.

Difficulties in social communication in ASD may result in disruptive behaviours (e.g. aggression). This is a significant source of stress to families.

Researchers have attempted to identify pivotal responses. The idea is that when certain core areas are targeted, widespread changes in numerous other untargeted behaviours would occur, leading to fluid and integrated behavioural gains.

Motivation to respond to social and environmental stimuli is essential for typical development. However, children with ASD may fail to understand the interconnection between their behaviour and the consequences from their environment as a result of repeated failures and non-contingent assistance and reinforcement from adults as a result of their social communication problems. This will, eventually, lead to an overreliance on adult support (i.e. learned helplessness).

Pivotal response training (PRT) focuses on decreasing the presence of learned helplessness by enhancing the relationship between children’s responses and reinforcement. This can help children to become motivated to respond, which leads to a positive feedback loop where more learning opportunities are provided. This, in turn, generates the social-environmental conditions for the development of more complex behaviours which are necessary for social, communicative and cognitive competence. PRT makes use of operant conditioning format of ABA but focuses more on increasing and maintaining the intrinsic motivational qualities within the ABA interaction. It uses the motivational strategies child choice (1), task variation (2), interspersal of maintenance tasks (3), reinforcement of response attempts (4) and the use of natural and direct reinforcement (5).

Children respond better to PRT when they begin before the age of 3. Fewer children respond with increasing age.

Self-initiation is common in typically developing children and serves multiple functions (e.g. information seeking). The form of self-initiation differs (e.g. joint attention; elaborate questions) but is inherently social in nature. Self-initiation occurs infrequently or is absent in children with ASD. Children who are taught to use self-initiations have more favourable outcomes. This means that motivating children to self-initiate can result in learning that increases autonomy as children become less reliant on adult-delivered learning opportunities. Motivating children to self-initiate provides them with tools that result in self-learning.

Children with ASD are often unmotivated to socialize but are motivated to engage with the non-social aspects of their immediate environment. The salient characteristics of non-social interests may be identified and embedded within a reciprocal social activity. This can enhance motivation to socialize, which, in turn, can lead to improvements in other areas of functioning. Incorporating restricted interests in mutually-reinforcing social activities (i.e. for the child with ASD and the typically developing peer) can lead to intrinsic motivation for social play.

The goal of PRT is to provide comprehensive intervention in key areas that increase independence and self-education throughout the day with rapid, widespread improvement of ASD. The teaching of pivotal areas is coordinated throughout the children’s day with parents, teachers and other service providers. Treatment is provided in a natural and inclusive setting to maximize the likelihood of typical

Some structured, manual-guided treatments may show reduced effects when they are implemented in more clinically representative contexts and compared to usual practice in those contexts. This may be because treatments tend to be developed away from the clinical practice. There are several potential mismatches between evidence-based practice and real-world clinical care:

1. Clinicians in practice settings typically carry diagnostically diverse caseloads but most evidence-based practices on one problem or a homogeneous cluster.
2. Clinically referred youth typically present with comorbidity.
3. Treatment may need to shift during treatment while evidence-based practice often does not take this into account.
4. Everyday clinical care often has an unpredictable course contrary to the design of evidence-based practices which are standardized.

The deployment-focused model of treatment development and testing includes a series of steps aimed at building and testing interventions with the clients and clinicians and within real-world contexts. It is also tested whether interventions improve on current practice in those contexts. Making evidence-based practice work well in practice mainly involves making the treatments fit variations in individual and family characteristics.

Personalized mental health interventions include strategies for selecting treatments, deciding whether and how to combine them, determining what problem to target first and with what techniques and using information about individual client characteristics and ongoing treatment response to inform clinical decision making. In other words, treatment should be personalized.

There are several methods of identifying an individual’s optimal treatment:

1. Meta-analyses comparing treatments for specific client characteristics
   This includes a meta-analysis which compares different treatments based on specific characteristics of the patient. This can help guide selection.
2. Individualized metrics (e.g. probability of treatment benefit)
   This quantifies the benefit each client is expected to receive from alternative interventions. This can facilitate consideration of multiple characteristics in selecting interventions for individuals.
3. Data-mining decision trees
   This includes treatment selection which accounts for multiple characteristics but is informed by decision trees based on detecting and interpreting patterns in data (i.e. data mining).

Further personalization after selecting a treatment may occur through monitoring client progress and using the resulting data to adjust interventions. This can be done in several ways:

1. Measurement feedback systems (MFSs)
   This is a tool which is used to obtain feedback about client progress and to guide treatment decisions. Contents include outcome and process measures taken at multiple times during the course of treatment (e.g. outcome questionnaires).
2. Personalized treatment goals
   This can be assessed and tracked by MFSs. Identifying the problems a client finds most important can allow for further personalization of treatment.
3. Sequential, multiple assignment, randomized trials (SMARTs)
   This can inform the construction of decision rules by dividing the treatment regimen into two or more stages. Participants are first randomized to a particular treatment and treatment response is assessed. Participants are then assigned to one of several next-stage treatments, based in part on their response on the first