Current Psychiatry Reports (2018) 20:25

https://doi.org/10.1007/s11920-018-0888-9

CHILD AND ADOLESCENT DISORDERS (TD BENTON, SECTION EDITOR)

Launching Anxious Young Adults: A Specialized Cognitive-Behavioral

Intervention for Transitional Aged Youth
Lauren J. Hoffman 1 & John D. Guerry 2 & Anne Marie Albano 3

# Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract
Purpose of Review There has been growing clinical and research attention to the unique developmental stage of emerging
adulthood. This stage is a time of significant change and growth for all individuals, as it includes identity exploration, emotional,
behavioral, and financial independence from caregivers, and completion of educational or vocational requirements.
Recent Findings Anxiety disorders are the most common mental health diagnoses among emerging adults, and indi-
viduals suffering from these disorders often experience compounding functional impairments across health, financial,
and social domains. While evidence-based treatments exist for both child/adolescent anxiety disorders and adult
anxiety disorders, no specialized assessment or treatment methods have been established for the unique period of
emerging adulthood.
Summary Our review examines literature pertinent to anxiety disorders in emerging adulthood and describes a novel, specialized
intervention to address the unique challenges faced by anxious emerging adults. The Launching Emerging Adults Program
(LEAP) is a developmentally informed cognitive-behavioral treatment model that aims to simultaneously reduce anxiety symp-
toms and promote independence. We conclude with a discussion of lessons learned and future directions.

Keywords Emerging adulthood . Anxiety disorders . Cognitive-behavioral therapy . Developmental transitions . Young
adulthood . Parenting

Introduction financial independence from parents, management of per-

Emerging adulthood, spanning the ages of approximately
18 to 25 years, represents a critical period of development
[1, 2••]. To be successful in transitioning from adoles-
cence to adulthood, individuals must be engaged in the
simultaneous achievement of several developmental mile-
stones, including growth of self-identity, emotional and
This article is part of the Topical Collection on Child and Adolescent
Disorders
* Lauren J. Hoffman
Lauren.Hoffman@nyspi.columbia.edu
1
Columbia University Clinic for Anxiety and Related Disorders,
Columbia University Medical Center, New York, NY, USA
2
Children’s Hospital of Philadelphia and Perelman School of
Medicine at the University of Pennsylvania, Philadelphia, PA, USA
3
Columbia University Clinic for Anxiety and Related Disorders,
Columbia University Medical Center and New York State Psychiatric
Institute, New York, NY, USA
sonal self-care, completion of educational requirements,
and establishment of long-term relationships. These un-
dertakings are daunting and often present challenges even
for typically developing adolescents and emerging adults.
For many, however, significant disruptions can occur dur-
ing this key period of maturation that can have long-
lasting implications for an individual’s economic security,
health, and well-being.
Navigating this developmental period is particularly difficult,
of course, for youth who struggle with psychiatric disorders.
Undeniably, the tasks that are central to successful transition to
young adulthood often depend on the very abilities that are im-
paired (e.g., emotion regulation abilities, social skills) [3], leading
emerging adults with a history of psychiatric disorders to expe-
rience impairment in health, financial, and interpersonal domains
[4]. The highest rates of mental illness are found during emerging
adulthood, and nearly two-thirds of the burden of disability
among young adults in the USA is associated with mental health
or substance use difficulties [5]. Compounding this risk are dis-
tortions in the provision of care; while nearly one-fifth of
25 Page 2 of 8
emerging adults aged 18–25 years suffered from a mental illness
in the past year, approximately two-thirds of those individuals
did not receive any mental health treatment [6].
As reviewed below, anxiety disorders, in particular, are
highly prevalent during emerging adulthood. Unfortunately,
the coincidence of clinical levels of anxiety during emerging
adulthood leads many individuals to suffer—or continue to
suffer—significant functional impairments. These can render
the transition to adulthood difficult, prevent it from occurring
in a timely manner, or even at all. In such cases, the risk of
academic failure and social withdrawal increases, dependence
on parents continues and deepens, and distress and disability
often takes hold for the long term.
The primary aim of this review is to provide a brief,
topical description of the problem of anxiety disorders dur-
ing emerging adulthood. This will include a review of recent
prevalence data and review of treatment-outcome research
to highlight the pressing need to develop, implement, and
evaluate developmentally tailored treatment programs to
improve outcomes for these vulnerable individuals.
Finally, we will outline the emergence of such a specialized
intervention, which has been designed to address the unique
challenges faced by anxious emerging adults, the
Launching Emerging Adults Program (LEAP).
Prevalence of Anxiety Disorders
Among Emerging Adults
As a class, anxiety disorders represent the most common
mental health diagnoses among children and adolescents
[7] and recent data suggests that this pattern holds during
emerging adulthood [8, 9•, 10]. Auerbach and colleagues
[8] analyzed survey data from 5750 college-age (i.e., 18–
22-year-old) participants from 21 countries. Participating
individuals were either actively enrolled in college, had
attended some college but discontinued, graduated from
secondary school but never attended college, or never
completed secondary school. Findings indicated that anx-
iety disorders were by far the most prevalent class of
disorders across all groups of emerging adults, with the
reported 12-month prevalence rates ranging from 11.7 to
14.7% [8]. A higher 12-month prevalence rate of 26.1%
for any DSM-IV anxiety disorder was found for 26-year-
old participants of the Dunedin Multidisciplinary Health
and Development Study, a longitudinal investigation of
the health and behavior of a complete birth cohort in
Dunedin, New Zealand [10]. Kessler and colleagues [9•]
found a remarkably similar estimate using US sample data
from the National Comorbidity Survey Replication.
Investigators expanded the age range to 18–29 years old
and reported a 12-month prevalence estimate of 22.3% for
any DSM-IV anxiety diagnosis. Specific rates were
Curr Psychiatry Rep (2018) 20:25
reported as follows: 10.3% specific phobia, 9.1% social
phobia, 4% separation anxiety disorder, 2.8% panic disor-
der, 2% generalized anxiety disorder, and 1.5% obsessive-
compulsive disorder [9•].
Beyond the simple preponderance of anxiety among psy-
chiatric difficulties in emerging adults, prevalence studies
have traced important developmental patterns of these disor-
ders. In their review of longitudinal and cross-sectional epide-
miological research, Costello and colleagues [11] found that
the overall prevalence of anxiety disorders increased from
childhood to adolescence and again from adolescence to
young adulthood. Indeed, recent prevalence data has
highlighted the transition from adolescence to young adult-
hood as a key period for understanding the developmental
course of anxiety. For example, the Great Smoky Mountain
Study (GSMS), a population-based prospective, longitudinal
study, repeatedly assessed 1420 participants between the ages
of 9 and 26 years from 11 rural counties in western North
Carolina [12]. Investigators found that while there was signif-
icant variability in the rates of specific subtypes of anxiety, the
overall prevalence curve of anxiety disorders across develop-
ment was U-shaped; there was a sharp attenuation during
middle childhood followed by increasing levels of these dis-
orders from early adolescence to young adulthood.
Most saliently, data from the GSMS indicated that the devel-
opmental period associated with the most dramatic increases in
the rates of anxiety disorders was the transition to early adult-
hood [4]. Investigators qualified, “the emerging anxiety land-
scape of young adulthood involves disorders without specific,
circumscribed fear (like specific phobia) and little evidence of
attenuation with time,” [4, p. 30] citing the particularly increased
rates of generalized anxiety, panic, and agoraphobia during
emerging adulthood [4]. Evidence also suggests that, in most
cases, anxiety disorders during emerging adulthood do not de-
velop de novo but rather are manifestations of chronic childhood
disorders. For example, follow-back analyses from the Dunedin
Multidisciplinary Health and Development Study revealed that
approximately 85% of 26-year-old individuals diagnosed with
an anxiety disorder in the past year met criteria for a prior diag-
nosis, with 54.5, 22.1, and 8.3% receiving their first diagnosis
between the ages of 11–15, 18, and 21 years, respectively [10].
Taken together, these data indicated that anxiety disorders are
common among young adults in the general population and,
while many of these disorders peak during the transition from
adolescence to young adulthood, anxiety during emerging adult-
hood can most often be seen as extensions of juvenile disorders.
Psychosocial Treatment for Anxiety Disorders
in Youth
Over two dozen randomized clinical trials have supported the
efficacy of cognitive-behavioral therapy (CBT) for anxiety
Curr Psychiatry Rep (2018) 20:25
disorders in children and adolescents. Moreover, CBT is consid-
ered the first-line psychological treatment for youth anxiety dis-
orders by the American Academy of Child and Adolescent
Psychiatry [13]. Similarly, according to criteria set by the
Division of Clinical Psychology of the American Psychological
Association, CBT is currently the only psychosocial intervention
to earn the designation of “well-established” [14].
The central pillar of this evidence base was established
by the Child-Adolescent Anxiety Multimodal Study
(CAMS) [15•]. Designed as a multisite national collabora-
tive project and ultimately including 488 youth ages 7–
17 years, CAMS is the largest randomized clinical trial
for anxiety treatment to date. Child and adolescent partici-
pants with a principal diagnosis of generalized anxiety dis-
order, social anxiety disorder, or separation anxiety disor-
der were randomly assigned to a 12-week treatment of
CBT, medication (sertraline), their combination, or pill pla-
cebo. Results posttreatment indicated that the combined
treatment was associated with greater response (80.7%)
than both CBT alone (59.7%) and medication alone
(54.9%). The monotherapies were found to be statistically
equivalent and all three active treatments were superior to
placebo (23.7%) [15•]. Notably, the short-term outcomes
for CBT in youth anxiety disorders are among the most
favorable for mental health problems in youth [16].
However, more recent research has qualified the durabil-
ity of these treatment effects. The Child/Adolescent Anxiety
Multimodal Extended Long-term Study (CAMELS) [17••],
a naturalistic follow-up to the original CAMS project, eval-
uated 288 youths (ages 11–26 years; 59.0% of the original
CAMS sample) a mean of 6 years after randomization
[17••]. Examining outcomes across the CAMELS sample
at follow-up, investigators found that only 46.5% were in
“remission,” as defined by the absence of any study entry
anxiety disorder based on semi-structured diagnostic inter-
view. Although the original assigned CAMS treatment con-
dition was not associated with remission status, anxiety se-
verity scores, or global functioning at follow-up, specific
remission rates in each active treatment were reported as
48.8% for combined treatment, 51.9% for medication, and
45.8% for CBT. More encouragingly, relative to youth who
showed minimal or no initial response to the 12-week treat-
ment, those who had shown meaningful clinical improve-
ment at posttreatment were more likely to be in remission,
had less severe anxiety symptoms, and had better overall
functioning approximately 6 years after randomization.
Nonetheless, study investigators stressed that relapse oc-
curred in almost half (48%) of acute treatment responders,
highlighting both the chronic nature of anxiety for a major-
ity of youth and the need for more intensive or ongoing
treatments [17••].
These findings are somewhat sobering, particularly
when considering the prospects of successfully extending
Page 3 of 7 25
our existing treatments for anxious children and adoles-
cents to emerging adults. Indeed, there is some evidence
from the original CAMS sample to suggest treatment
effects are moderated by age, such that adolescents
(12–17 years old) were less likely than children (7–
11 years old) to achieve remission posttreatment [18]. It
has been speculated that many factors may contribute to
possible attenuated effects of CBT with older youth, in-
cluding the accumulated years of disability from avoidant
coping, other maladaptive compensatory strategies, and
entrenched distorted cognitions [16].
In short, despite the established efficacy of CBT for
anxious children and adolescents, research is needed to
determine how to optimize treatment for the sizable
proportion of youth who do not respond to “the gold
standard” treatment and go on to develop increasing
impairment during the critical years of emerging adult-
hood. Further, little is known regarding the utility of
these interventions for specifically addressing anxiety
among emerging adults, let alone for remediating func-
tional impairment and for improving the life course of
these individuals as they move through development.
Indeed, to date, there is an absence of evidence-based
clinical services designed to address the unique chal-
lenges faced by emerging adults. Given that research
suggests that the implementation of an individually tai-
lored, developmentally sensitive approach to CBT pre-
dicts better outcomes for anxious children and adoles-
cents [19], it seems reasonable to assume an imperative
to develop parallel adaptations of CBT for anxiety for
emerging adults.
A CBT Model: Targeting Anxiety
and Developmental Transitions
Our model, the LEAP, conceptualizes anxiety disorders
from a developmental perspective to provide specialized
care to emerging adults and their families. LEAP inte-
grates empirically supported CBT for anxiety (e.g., self-
monitoring, psychoeducation, cognitive restructuring, ex-
posure) with developmentally informed interventions de-
signed to simultaneously reduce or develop tolerance for
anxiety symptoms and promote age-related independent
functioning. LEAP targets individual factors that main-
tain anxiety (e.g., cognitive distortions, avoidance), as
well as delays or deficits in life skills (e.g., problem-
solving, self-soothing, social skills) that stall develop-
ment. In addition, we hypothesize that anxiety and
stalled development are at least partially maintained by
well-intentioned parental behaviors that inadvertently al-
low the emerging adult to avoid challenging activities.
Hence, parent factors of overprotection and overcontrol
25 Page 4 of 8
are also targeted in treatment [20–22]. The interaction
of individual skills deficits and parental factors work
synergistically as young adults struggle with meeting
normative developmental tasks and transitioning to the
next life stage. In LEAP, individual sessions target skill-
building for the emerging adult, family sessions focus
on identifying and critically evaluating parent-emerging
adult interactions that prevent the emerging adult from
taking on age-appropriate responsibilities, and group-
based exposures allow the emerging adult to engage in
anxiety-provoking situations while gaining social sup-
port from peers.
The treatment model, presented in four phases, is
intended to be flexible and tailored for each emerging
adult patient and family. A session-by-session guide is
offered below, though clinicians are encouraged to per-
sonalize goals and interventions according to the patient’s
level of clinical distress, impairment, and functioning.
For instance, more intensive treatment that regularly in-
volves parents may be recommended for lower function-
ing patients who live at home and are not engaged in
academic or work-related pursuits. Alternatively, for
higher functioning patients who live independently and
attend school or work fulltime, once weekly treatment
with infrequent or no family involvement may be indicat-
ed. Thus, within each phase presented below, more or
fewer sessions may be necessary to meet the needs of
the particular emerging adult and his or her family.
Phase I: Psychoeducation—Understanding Anxiety,
Development, and CBT (Patients and Parents
Together)
Session 1: Introduction to Anxiety and Developmental
Transitions This first session focuses on psychoeducation to
anxiety and CBT. The interrelated nature of thoughts, feelings,
and behaviors is discussed and examples of both patient and
parent reactions to anxiety triggers are discussed in terms of
the three-component model. Therapists emphasize the role of
avoidance and well-intended parental involvement as mecha-
nisms for maintaining anxiety in the patient. Self-monitoring
is also taught. While patients are trained to use a daily diary
card to track reactions to anxiety-provoking situations using
the three-component model, parents are also provided with a
structure for monitoring the patient’s response to anxiety-
provoking situations. This session ends with discussion of
realistic, age-appropriate goals. Patients and parents are asked
to identify short-term (e.g., 1 week, 1 month, 3 months) and
long-term goals for the patient and the family.
Session 2: Examine Patterns of Anxiety and Avoidance
Session 2 begins with a discussion of the patient’s re-
cent experiences with anxiety to build the patient’s
Curr Psychiatry Rep (2018) 20:25
ability to identify triggers and discuss typical emotional
and behavioral responses to anxiety. The reinforcing cy-
cle of avoidance is highlighted. Special attention is giv-
en to the ways in which patient-parent interactions have
been shaped over time by the patient’s anxiety and
urges to avoid. Using the goals set in the previous ses-
sion, the therapist also leads a discussion of the ways in
which anxiety currently interferes with goal attainment
and self-sufficiency. Finally, an anxiety hierarchy is de-
veloped that includes situations that trigger excessive
anxiety and behavioral avoidance. Table 1 presents a
sample fear and avoidance hierarchy for an emerging
adult with social anxiety disorder. It should be noted
that similar hierarchies can be completed for concerns
related to generalized anxiety disorder, separation anxi-
ety disorder, panic disorder, agoraphobia, and obsessive-
compulsive disorder.
Sessions 3 and 4: Developmental Origins and Maintaining
Factors of Anxiety These sessions begin by discussing bio-
logical and environmental factors that elevate risk for or
exacerbate expression of anxiety. A major focus is on
explaining the reciprocal relationship between heightened
child anxiety and the emergence of parental overprotec-
tion and overinvolvement. Examples of these interaction
patterns are discussed, particularly as they relate to paren-
tal assistance in age- and stage-related tasks. For example,
take an anxious teenager who is unable to ask his teacher
for help on an upcoming project. Despite encouraging him
to email the teacher with his question, the teen remains
irritable, anxious, and avoidant. At the same time, parents
experience frustration with and/or concern for the teen, as
well as worry about his grade in the class. In the short-
term, a parent emailing the teacher for the teen reduces
anxiety in the teen, decreases family tension around the
issue, and may help him earn a good grade on the project.
However, if the parent assumes similar responsibilities for
the teen over and over again, in the long term, the teen
misses out on crucial opportunities to build self-advocacy
skills and develop confidence that he can handle anxiety-
provoking situations. Overtime, this parent-child interac-
tion cycle leads to persistent anxiety symptoms, skill def-
icits, and stalled development.
These sessions are used to elucidate the specific ways
in which parents have assumed responsibility for the pa-
tient in well-intended efforts to protect him or her from
excessive anxiety, failure, or missed opportunities.
Importantly, therapists reframe any parent interpretations
of assigning blame or responsibility (e.g., “I caused my
child to be this way”) as a natural expression of parenting
a child with anxiety (i.e., “Parents are meant to protect,
reassure, and comfort.”). These discussions are also used
for the therapist to identify deficits in social skills and/or
Curr Psychiatry Rep (2018) 20:25
Table 1 Sample fear and
avoidance hierarchy for emerging Situation
adult with social anxiety disorder
Messaging someone on a dating app
Interviewing for a summer job or internship
Asking a professor for an extension
Going to an Improv class
Initiating plans with peers
Attending a party where I don’t know many people
Sending back food at a restaurant or café
Stating my opinion about a controversial or hot topic
that is different from others’
Posting an unfiltered photo of myself on social media
Calling in sick to work
Eating dinner alone out in public
Talking to my doctor on the phone
problem-solving abilities that may also maintain patient
anxiety and functional impairment.
Another major goal is to identify the patient’s current func-
tioning in specific developmental domains. This is particularly
important as emerging adulthood is a time of great develop-
mental heterogeneity [1]. Indeed, patients of the same age may
struggle with different developmental tasks. For example, one
23-year-old might live and work independently but call home
several times daily for emotional support. Another 23-year-
old might live at home and rely on parents for tasks of daily
living (e.g., laundry, meals) but require little support manag-
ing emotions. Similarly, heterogeneity is present even within
individuals, as independence in one domain does not neces-
sarily correspond to independence in another. Thus, assess-
ment of current developmental functioning is crucial. To this
end, a developmental milestone assessment is completed col-
laboratively, as patients and parents work together to identify
the patient’s functioning in domains such as emotional regu-
lation, personal self-care, money management, and behavioral
independence. This assessment is via the “Launching
Emerging Adult Functioning Scale” a measure that is in de-
velopment by our group [23]. Ultimately, through remediation
of skill deficits and graded exposure, there will be a transfer of
responsibility for various tasks from the parent to the patient.
Using the developmental milestone assessment as a guide, a
developmental hierarchy is completed that includes ratings for
each task regarding the degree of emotional challenge and
current level of independence. This hierarchy will inform the
goals and pace of treatment. See Table 2 for sample develop-
mental hierarchy items.
At this point, the burden of responsibility for treatment and
the focus of attention is shifted solely to the patient. Parents
will be invited back for further sessions as needed, but as a
step toward shaping patient responsibility and parent “letting
go,” patients are now responsible for setting, keeping, and
attending their own appointments.
Page 5 of 7 25
Fear (0–10) Avoidance (0–10)
9 9
8 9
8 8
8 6
7 7
6 7
6 5
5 6
5 5
5 4
4 2
3 3
Phase II: Individual Skills Training in Cognitive
Restructuring and Social Problem-Solving Skills
Sessions 5 and 6: Cognitive Restructuring Skills Training
Using empirically supported CBT techniques, therapists teach
patients to identify, evaluate, and challenge thoughts and be-
liefs that maintain anxiety and difficulty mastering age-related
roles and tasks. Socratic questioning is used to help patients
identify more helpful disputes for automatic thoughts and neg-
ative schema. Therapists are encouraged to use role plays and
in vivo behavioral experiments to engage patients in activities
that provide evidence to refute their negative predictions.
Relevant homework assignments are used to help patients
develop and generalize a self-coaching style.
Sessions 7–9: Social Problem-Solving and Behavioral Skills
Training Failure to develop social and behavioral skills furthers
dependence on others, interferes with effective role transitions,
Table 2 Sample items for developmental hierarchy
Uses an alarm clock to wake up on own at reasonable hour
Self-soothes independently
Manages appointments independently (e.g., doctor, dentist, therapist)
Prepares simple meals and snacks
Does laundry independently
Manages own grooming (e.g., haircuts, showering) and dressing
(e.g., shopping for clothing)
Stays within a budget
Initiates social activities
Travels within community independently
Manages medications independently (takes as prescribed; calls in
for and picks up refills on time)
Registers for classes and communicates with professors/advisors on own
Resolves conflicts with peers independently
Visits a college without parents and stays overnight in the dorm
25 Page 6 of 8
and maintains anxious avoidance. Thus, these sessions focus
on teaching patients concrete tools to manage difficult emo-
tions and situations, with an emphasis on strategies to remedi-
ate the particular skill deficits identified during the assessment
and early treatment sessions. In addition to cognitive
restructuring skills, many emerging adults benefit from asser-
tiveness and social skills training, as well as learning skills for
general affect regulation, relaxation, and self-soothing.
Problem-solving skills are also taught and applied to a range
of situations encountered in daily life, including prioritizing
multiple/competing demands (e.g., time with friends and
homework completion) and negotiating with and/or seeking
support from superiors (e.g., professors, bosses). Adaptive life
skills are also addressed, as patients build skills for managing
schedules, sending emails, making healthy food choices, and
traveling independently throughout their neighborhood. In
general, these sessions are intended to reduce reliance on
others by helping patients build proactive, coping-focused, in-
dependent solutions to daily issues and challenges.
Session 10: Increasing Independent Functioning and Transfer
of Responsibilities (Conjoint Session) Patients and parents at-
tend session 10 together. This session focuses on transferring
responsibility to the patient by collaboratively reviewing
skills learned in previous sessions and addressing ongoing
patterns of parental overprotection and overinvolvement.
Therapists return to the developmental hierarchy developed
in phase I and work to uncover ongoing interaction patterns
or skills deficits that currently hinder the patient’s indepen-
dent functioning. Communication skills training and family
problem-solving strategies are taught to facilitate this process
[24]. Role plays and behavioral experiments are used to help
patients progress through the developmental hierarchy, while
parents are provided with a model of a healthy, positive
coaching style.
Phase III: Integrated Therapeutic Groups
Social Anxiety Exposure Groups Exposure therapy is cur-
rently considered the most effective treatment for anxiety
disorders, [25–27]. Its inclusion is particularly crucial for
the treatment of social anxiety disorder, one of the most
prominent anxiety disorders affecting emerging adults
[9•]. Our model includes group exposure sessions (i.e.,
cycles of 10 sessions) that are offered at the beginner,
intermediate, and advanced level. Group assignments are
made based on the patient’s previous experience with
CBT and/or exposure, his or her degree of anxious dis-
tress, and his or her current anxiety-related disability.
Patients may repeat any level of group as often as neces-
sary, ultimately working up toward the advanced group,
which focuses on high-level and in vivo exposures within
real-world settings (e.g., putting in applications for a job).
Curr Psychiatry Rep (2018) 20:25
In general, these groups follow the exposure procedures
outlined in Cognitive-Behavioral Group Treatment-
Adolescents (CBGT-A) [28] and include exposure exercises
designed to reduce escape or avoidance of challenging so-
cial situations. As the patient learns to stay in anxiety-
provoking social situations, he or she learns that anxiety
will naturally dissipate or can be tolerated as he or she re-
mains in the situation. In addition, repeated exposure allows
the patient to gather evidence to refute his or her automatic
thoughts, while building coping templates for similar situa-
tions that may arise in the future. Further, group-based ex-
posure exercises allow patients to test out new skills, build
mastery of previously challenging situations, practice pro-
active problem-solving, and receive and give feedback to
their peers. Exposure situations are designed collaborative-
ly between therapist and patient and include role plays, vir-
tual reality scenarios, and in vivo practice in community-
based settings (e.g., ordering coffee at Starbucks, texting a
friend to hang out). Concurrently, items from the develop-
mental task hierarchy are assigned and ultimately imbedded
in these exposures. Homework tasks are assigned weekly to
promote generalization. In addition to exposure, we have
found the peer support these groups facilitate to be invalu-
able to emerging adults in our program.
Role Functioning “Adulting” Groups Our program offers an-
other type of group for emerging adults who are lower func-
tioning insofar as they reside at home with parents, struggle to
engage in tasks of daily living on their own, and/or are mini-
mally engaged in work or academic pursuits. The “Adulting”
group is offered as a short-term intensive program that meets for
90 min each, several mornings per week for two or three con-
secutive weeks. The group intends to help these patients “kick
start” their day by getting out of the house and setting and
executing daily goals. Patients are taught healthy eating and
sleeping habits, organizational and time management skills,
and strategies for independently reaching daily goals (e.g., trav-
eling alone, responding to emails, doing laundry, cooking sim-
ple meals). These skills are then practiced during developmen-
tal task exposures, with the goal of increasing competence and
confidence in managing adult responsibilities. Patients may re-
peat this group as often as necessary. Of note, these groups do
not replace day treatment or intensive outpatient treatment pro-
grams that are often necessary for emerging adults with more
intense levels of distress and disability.
Phase IV: Solidifying Gains and Relapse Prevention
Follow-Up Family Session: Consolidating Independent
Functioning and Acceptance of Role Responsibilities A final
conjoint patient-parent session is scheduled toward the end of
treatment. Prior to this session, patients work individually
with their therapists to accept responsibility for preparing for
Curr Psychiatry Rep (2018) 20:25
and leading the session. Patients are coached to define issues
to be presented in the session and to use family problem-
solving strategies to work through differing opinions. By put-
ting the patient in control of the agenda and progress of the
session, the patient practices accepting responsibility, while
the parents gain experience with allowing a transfer of control
to occur. Parents also gain an opportunity to learn that mis-
takes may occur, but they are tolerable and facilitate learning
and growth in the patient.
A major goal of this session is to work through the final
stages of transitioning role responsibilities from the parent to
the patient. Developmental hierarchies are revisited as new
goals are set. Behavioral contracts are used to specify goals
for role transitions and clearly define responsibilities of each
family member. Goals often discussed during this phase in-
clude looking for a part-time summer job, scheduling college
interviews, and working with an apartment locator service.
With the therapist modeling confidence in the patient, the
patient works with his or her family to operationally define
time limits for completing specific goals, as well to problem-
solve a plan should the task not be completed. Ultimately, as
parents practice letting go of control and patients increasingly
accept responsibility, parents begin to view their son or daugh-
ter as a responsible, capable emerging adult and patients con-
tinue to build self-efficacy and confidence.
Final Group and Individual Sessions (Roughly Sessions 20–
22): Final Exposures, Relapse Prevention, and Termination
These sessions focus on promoting continued anxiety man-
agement and acceptance of role responsibilities. As patients
will continue to be confronted with anxiety-provoking situa-
tions and developmental challenges after therapy ends, a ma-
jor emphasis is placed on reviewing skills and concepts
learned throughout treatment to prevent the patient from
returning to avoidant and dependent coping patterns.
Patients work with their therapist to review progress on initial
goals and identify short- and long-term goals for the future. In
discussing upcoming developmental transitions, patients and
therapists discuss methods for ongoing exposure to increas-
ingly complex and challenging situations (e.g., traveling out
of the state alone, confronting a college roommate about sub-
stance use, completing job applications). Thoughts and feel-
ings associated with termination of therapy are processed.
Patients and therapists also discuss when and how to access
support posttreatment, including reaching out to family for
help and/or obtaining additional professional support.
Conclusion
While adolescence has long been known as the period of
“storm and stress” [29], young adulthood has been neglected
despite being the period where major mental health disorders
Page 7 of 7 25
including psychoses and substance abuse emerge and result in
serious and long standing disability and cost to the individual,
family, and society. Advances in both the pharmacologic and
psychotherapeutic treatments of anxiety in youth offer prom-
ise but also have led to questions about what pathology and
risk factors remain untapped when applying youth-focused
treatments via traditional therapy models. Bolstered by key
findings in neuroscience [30, 31], we hypothesize that our
focus on contextual factors (family environment and parent-
ing; peer interactions; typical age-appropriate settings from
dorm rooms to parties) being made salient and ecologically
valid in therapy is critical for improving functioning as well as
syndrome relief and for long-term recovery from anxiety. Our
Launching Emerging Adult Program, in contrast to typical
one-on-one or group therapies, directly addresses the youth’s
functional status and the context within which they live while
providing skill-building and exposure to treat the anxiety and
related conditions. Ongoing development and testing of the
LEAP model as well as innovative uses of virtual reality en-
vironments to enhance contextual cues is in process.
Compliance with Ethical Standards
Conflict of Interest Lauren J. Hoffman and John D. Guerry declare no
conflict of interest.
Anne Marie Albano is the Principal Investigator for the Child/
Adolescent Anxiety Multimodal Study (CAMELS) (NIMH) cited in this
manuscript.
Human and Animal Rights and Informed Consent This article does not
contain any studies with human or animal subjects performed by any of
the authors.
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