There are three learning paths to fear:

1. Modelling (i.e. modelling and positive reward)
   This holds that fear develops as a result of imitation and stories (i.e. imitation).
2. Classical conditioning (i.e. systematic desensitization)
   This holds that fear develops through associative learning.
3. Operant conditioning (i.e. exposure)
   This holds that fear develops through gratification and reward.

There are three intervention techniques for anxiety:

• Cognitive-behavioural therapy
• Modelling
• Exposure

The information processing theory holds that attention, interpretation and memory biases will lead to problematic cognitions. This means that an ambiguous situation (e.g. “seeing children laugh”) could be interpreted negatively (e.g. “they are laughing at me”) and this could lead to a memory bias (e.g. “I only remember people laughing at me when I wore this t-shirt”).

All treatment protocols for anxiety treatment starts psychotherapy. Next, the child is prepared for exposure by doing cognitive therapy or relaxation technique. Afterwards, there is conduct of modelling and exposure.

Cognitive-behavioural therapy is the most evidence-based prevention and treatment method for anxiety disorders. The recovery rate for anxiety disorders after using CBT is approximately 60%.

There are several principles (i.e. steps) of cognitive therapy for anxiety:

• Cognitive restructuring (e.g. going from anxious thoughts to more healthy, neutral thoughts).
• Recognize the situation-thought-feeling and registering this.
• Differentiation between feelings (e.g. fear thermometer).
• Detecting negative thoughts.
• Challenging negative thoughts.
• Formulate helping thoughts (e.g. “I can do it”).
• Learn to apply thoughts in the form of self-talk when confronting fear objects.

The goal of CBT is cognitive restructuring. Children also receive homework in CBT. The situation-thought feeling (the five G’s) is used to give insight for the client and is a tool for the therapist regarding treatment course:

1. Event
2. Thought
3. Feeling
4. Behaviour
5. Consequence

The client has to identify all and elaborate on them. Detecting the negative thoughts can be done by using questionnaires or by using cartoons. People often find it difficult to formulate helping thoughts. Therapists can help them by provide the client with this or help them formulate it (e.g. give examples).

The presence of social anxiety disorder at pre-treatment leads to slower rate of change and poorer diagnostic outcomes when using CBT. This may be as group settings are more aversive for them. They may also show behavioural inhibition from infancy, making them more resistant to change. The therapeutic relationship may also be more problematic due to their SAD. Exposure may have opposite effects as social situations are more ambiguous and more difficult to interpret. This makes it difficult to see whether one’s initial interpretation was false.

Children with SAD may thus need a longer treatment programme and a more tailored programme that helps them disconfirm their negative social expectations (e.g. equip children with social skills prior to exposure). One way in which this can be achieved is using modular treatment. This allows the therapist to spend more time on problematic areas in the child with SAD. A relatively short modular CBT seems to be effective for 50% of the youth with SAD and for 80% at a 10-week follow-up. However, this result may be due to the inclusion of mindfulness as this may help with treating SAD.

Rational exposure refers to gradually exposing children to anxiety-provoking situation to diminish anxiety. The inhibitory learning hypothesis states that the patient learns that exposure does not lead to the dreaded consequence but is harmless. It is important to emphasize to children that the fear does not have to disappear completely but it will no longer hinder them in confronting these situations. There are several principles of exposure therapy:

1. Determine what the child is afraid of.
2. Determine what the desired behaviour is.
3. Create a fear hierarchy.
4. Confront child step by step with the frightening stimulus.
5. Give positive reinforcement to the child before undergoing the procedure.
6. Give positive feedback to the child about the exercise, rewarding every step even if it does not work.
7. Continue until a confrontation with the stimulus is no longer a problem for the child.

Modelling can be used to facilitate exposure. The idea behind modelling is that children learn by observing the model. The model should model step-by-step the desired behaviour and make sure there are no adverse effects (e.g. getting bit by the dog). The model shows behavioural alternatives. While doing this, it is important to motivate the child to join the model and give positive rewards for showing the desired behaviour.

There are three types of modelling:

1. Live modelling
   This refers to the client observing the model.
2. Symbolic modelling
   This refers to videos or other representations of models.
3. Participant modelling
   This refers to pairing the client with a model to deal with the dreaded situation.

Coping Cat is an efficacious treatment for anxiety disorders for children from the age of 7 to 13. It targets all aspects of anxiety and includes psychoeducation (1), somatic management skills (2), cognitive restructuring (3), gradual exposure to feared situations (4) and relapse prevention plans (5). The goal of the treatment is to teach youth to recognize signs of anxiety and implement strategies to better cope with the distress rather than completely eliminate anxiety.

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

1. Feeling frightened
   In this step, children ask themselves whether they are frightened to help identify physical symptoms associated with anxious arousal.
2. Expecting bad things to happen?
   In this step, children ask themselves whether they expect bad things to happen to help identify expectations. These expectations are then challenged to reduce faulty beliefs and negative self-talk.
3. Attitudes and actions that might help
   In this step, children are taught that it is useful to take action that will change an anxious situation or a reaction to it. The child learns that it is important to not rely on initial reactions.
4. Results and rewards
   In this step, approach behaviour is rewarded and anxious behaviour is reduced through shaping and positive rewards. Every effort (e.g. attempts) is rewarded. Rewards can be self-administered and this requires self-monitoring.

The second half of the treatment is devoted to the application of the FEAR plan within exposure to increasingly anxiety-provoking situations. Parental involvement is important in this treatment. The therapist meets the parent individually for two sessions and parents are told how they can foster positive outcomes and parent techniques are discussed. A parent-based Coping Cat treatment may be more effective when a parent also has an anxiety disorder.

The Coping Cat treatment is driven by techniques and not by session-per-session topics making it very flexible. Other versions of the Coping Cat treatment have mixed results (e.g. group-based is not successful for self-report of anxiety; emotion-based coping cat seems efficacious). Demographic variables (1), symptom severity (2), comorbidity (3), parental involvement (4), parental psychopathology (5), family factors (6) and in-session variables (7) may influence treatment outcome.

Comorbid ADHD may lead to less maintenance of results and other comorbid non-anxiety disorders may lead to less improvement. Youth engagement (1), youth involvement (2) and therapeutic alliance (3) is associated with better outcomes. The effect of parental psychopathology may depend on the child’s developmental stage.

There are several characteristics of efficacy studies:

• It tests whether a treatment works in an ideal setting.
• It uses a very selective inclusion criteria.
• It carefully monitors patient adherence.
• It uses specially trained clinicians for the treatment of interest.
• It limits the risk of confounding interventions (e.g. in the case of comorbidity).

There are several characteristics of effectiveness studies:

• It tests whether a treatment works in the real world.
• It does not use a very selective inclusion criteria.
• It does not carefully and monitor and enforce patient adherence.
• It uses clinicians which are representative of ‘normal’ clinicians.
• It uses a more real-world setting and does not control for confounding factors (e.g. comorbidity).

Personalized intervention for mental health problems includes reliable assessment of clinically relevant individual characteristics and treatments tailored for individuals who share those characteristics to optimize treatment gains. The assessment of individual characteristics can be before treatment (e.g. diagnostics; case conceptualizations) or during treatment (e.g. continuous assessment of client response).

Tailoring treatments to individual clients with anxiety can be done with knowledge of treatment predictors and moderators. For example, youth with anxiety disorders and ADHD need parental involvement. Youth with social anxiety disorder experience less benefit less from the standard CBT protocol.

Modularized treatments include self-contained modules. The modules can be compulsory (e.g. psychoeducation) and optional (e.g. parent involvement). The decision regarding modules can be made in three ways:

• Using the primary diagnosis.
• Using extensive case conceptualization (e.g. pre-treatment client; family characteristics).
• Use clinical decision making and regular assessment.

Using therapist feedback seems to not have an effect on treatment effectiveness when using modular treatment.

Treatments may be more efficacious than effective because of four reasons:

• Clinicians in practice settings have diagnostically diverse caseloads while this is not the case in an efficacy study.
• Clinicians in practice settings have to deal with comorbidity.
• Clinicians in practice settings may need to shift treatment.
• Everyday clinical practice has an unpredictable course.

Making evidence-based practice work well in practice mainly involves making the treatments fit variations in individual and family characteristics. Identifying an individual’s optimal treatment can be done by using meta-analyses (1), individualized metrics (2) or data-mining decision trees (3). Further personalization after selecting a treatment may occur through monitoring client progress and using the data to adjust interventions. This can be done using measurement feedback systems (1), personalized treatment goals (2) and sequential, multiple assignment, randomized trials (3).