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. Author manuscript; available in PMC: 2024 Sep 18.
Published in final edited form as: Cognit Ther Res. 2023 Jul 4;47(5):841–850. doi: 10.1007/s10608-023-10408-2

Anxiety sensitivity and experiential avoidance: Relations with anxiety severity and treatment outcomes in anxious youth

Kyler R Lehrbach 1, Margaret E Crane 1, Thomas M Olino 1, Philip C Kendall 1
PMCID: PMC11410366  NIHMSID: NIHMS1981780  PMID: 39296328

Abstract

Purpose:

Anxiety sensitivity (AS) and experiential avoidance (EA) are associated with anxiety in both adults and youths. This study examined the separate contributions of AS and EA in predicting (a) anxiety (symptom severity) and (b) differential treatment outcomes in anxious youth receiving cognitive behavioral therapy (CBT).

Methods:

Participants (N = 89; age 10–17 years; 37% male; 78% white) met diagnostic criteria for an anxiety disorder and received CBT (Coping Cat). AS and EA were child-report measures collected at baseline. The outcome variables were anxiety symptom severity (Multidimensional Anxiety Scale for Children; child- and parent-reported) and Independent Evaluator-rated anxiety severity (Child Global Impression-Severity) collected at baseline and posttreatment. Multilevel models (MLM) examined independent and relative contributions of AS and EA to the outcome variables as a secondary analysis.

Results:

Both AS and EA were associated with levels of anxiety symptom severity at pretreatment and at posttreatment, varying by reporter. Neither AS nor EA predicted differential treatment outcomes: youth at varying levels had comparably favorable outcomes.

Conclusions:

Findings suggest similarity in AS and EA, and that both constructs may be adequately and equally addressed in CBT. Future research could consider examining change in AS and EA and anxiety across treatment in diverse populations.

Keywords: Anxious youth, CBT, anxiety sensitivity, experiential avoidance, treatment predictors

Anxiety disorders affect more than 15% of youths (Merikangas et al., 2010), and are linked to impairment in academic, occupational, family, social, and legal functioning (Swan & Kendall, 2016). Cognitive-behavioral therapy (CBT) has proven to be effective in the treatment of the majority of anxious youth, yet as many as 40% of those receiving treatment are still diagnosed as clinically anxious upon finishing treatment (Higa-McMillan et al., 2016; James et al., 2013). Existing research continues to work toward identifying which treatments are successful for whom and under what conditions, but thus far, few consistent moderators of CBT treatment efficacy for anxious youth have been identified (Norris & Kendall, 2021). One relevant construct may be anxiety sensitivity (AS), or the “fear of anxiety,” which is the belief that unwanted feelings of anxiety will result in a variety of negative experiences including illness, embarrassment, or additional anxiety (Reiss et al., 1986; Reiss & McNally, 1985). Also problematic is experiential avoidance (EA), or the reluctance to remain in contact with unpleasant internal experiences (e.g., thoughts, feelings, memories) and the tendency to avoid such experiences and contexts in which they may arise (Hayes et al., 1996).

Previous research has investigated other relevant processes for anxiety treatment in youth, including intolerance of uncertainty and parental accommodation (Kendall et al., 2020), but AS and EA have yet to be examined in this capacity for anxious youth. Within the cognitive-behavioral model of anxiety, AS is likely to impact individuals’ thoughts, leading them to interpret sensations of anxiety as being dangerous or intolerable; EA impacts a person’s behaviors, leading them to avoid anxiety provoking stimuli. The impact of AS and EA on the treatment of anxiety in youth merits attention, as there are potential clinical implications for maximizing treatment outcomes.

A person with high levels of AS may interpret anxious thoughts or sensations as threat-related, which induces a fear or anxious reaction (Silverman et al., 1991). Unlike trait anxiety, which is a general tendency to respond fearfully to a stressor, AS is described as responding fearfully to anxiety symptoms (McNally, 1989). Interestingly, AS appears to maintain trait-like stability when untreated (as implicated in Farris et al., 2015; Taylor et al., 2007). It has been theorized that AS develops from experiencing anxiety directly, witnessing others experiencing anxiety, or learning information regarding adverse consequences of anxiety (Chorpita & Lilienfeld, 1999; Knapp et al., 2013). AS is relevant in the treatment of anxiety as it can be considered a potentiating factor, meaning that individuals with higher levels of AS are more likely to use maladaptive emotional regulation strategies in an effort to avoid negative emotional states (Otto et al., 2019; Otto & Smits, 2018).

Research has found that children with higher AS were more likely to engage in avoidance (Lebowitz et al., 2015), with avoidance leading to an increase in anxiety impairment (Swan & Kendall, 2016). One study found that the relationship between family accommodation and anxiety severity was moderated by AS in anxious youth (Schleider et al., 2018). Other research supports an association between reductions in AS and reductions in anxiety and other internalizing disorders in adult populations (Otto et al., 1995; Schmidt et al., 2014, 2017). AS has also been identified as a mediator of anxiety and depression treatment outcomes in adults (Arch et al., 2012; Otto et al., 1995; Sauer-Zavala et al., 2012; Smits et al., 2004). CBT in particular reduces anxiety sensitivity and subsequent anxiety in adults (Smits et al., 2008), though this relationship in children remains less clear.

EA, or the avoidance of emotional experiences associated with anxiety (Kashdan et al., 2006; Suveg et al., 2007), can contribute to a subsequent increase in the emotional reaction to the experience (Campbell-Sills et al., 2006). EA can include the strategies of suppression, rumination, and avoidance of situations that invoke anxiety, all of which are significantly associated with heightened anxiety (Aldao et al., 2010). According to the acceptance and commitment therapy (ACT) model, EA causes a person to fail to take action consistent with their values and goals, which in turn leads to regret, disappointment, and feelings of worthlessness (Kashdan et al., 2006). Strategies within CBT (e.g. cognitive restructuring and exposure tasks) have been shown to decrease EA by enhancing exposure to what has been previously suppressed (Arch & Craske, 2008; Hofmann & Asmundson, 2008), and EA is even an explicit target in some CBT approaches (Barlow et al., 2018).

The relative impact of AS and EA on anxiety symptoms has been examined in adults, with mixed results on which variable accounts for more variance or has a stronger association (e.g., Bardeen et al., 2014; Kelly & Forsyth, 2009; Wheaton et al., 2010). Some studies show AS accounts for more variance than EA related to health anxiety (Wheaton et al., 2010), panic symptoms (Berman et al., 2010; Kelly & Forsyth, 2009), and panic/agoraphobia (Kämpfe et al., 2012). This pattern of results may not be surprising considering the overlap in measurement between AS and anxiety relating to concerns of bodily sensations, such as panic disorder and health anxiety. Conversely, other studies suggest that EA accounts for more variance in the relationship between AS, EA, and anxiety symptoms related to social anxiety (Panayiotou et al., 2014), general anxiety (Bardeen et al., 2014), perceived stress (Bardeen et al., 2013), and behavior inhibition system sensitivity (Pickett et al., 2012). When exploring the literature on the differences between the relative impact of AS and EA on anxiety, it is important to note that the evidence lies in studies with adults, as research is lacking on anxious youths’ experiences with different levels of anxiety sensitivity and experiential avoidance.

When examining treatment outcomes, research suggests that EA is associated with higher levels of AS and symptoms of psychopathology, particularly eating disorder symptoms in adolescents and adult women receiving eating disorder treatment (Espel-Huynh et al., 2019), and higher levels of depression symptom severity in college students who received a brief intervention (Stein et al., 2020). A previous study investigated EA as a mechanism of change in anxious adults receiving CBT (Eustis et al., 2020), but the relationship between pretreatment levels of EA or AS and the treatment for anxious youth receiving CBT has not yet been examined. In youth, only one study has examined the relationship between AS and EA in a non-clinical sample of 10–12-year-old children, finding that EA had accounted for more variance than AS with regards to children’s anxiety and social anxiety symptoms (Epkins et al., 2016). This research, coupled with the explicit or implicit targeting of EA in CBT treatment, suggests that it may have a stronger relationship with youth anxiety than AS.

Taken together, it appears that AS and EA are overlapping, but somewhat distinct constructs that may impact treatment outcomes. Although AS and EA are both related to the emotional disturbances of anxiety, the theoretical difference of the dysfunctional beliefs associated with AS (i.e., fear of bodily sensations) (Taylor, 1999) and the process of reflecting on an undesirable internal experience (Hayes et al., 1996) arguably maintain a distinction between the constructs. If AS or EA are identified as relevant factors in the treatment of anxious youth, there are clinical implications that may lead to improved treatment response, affording the opportunity for individualized treatment to address AS and EA, expanding beyond the existing literature that shows their relevance for understanding the presence of anxiety.

The present study examined the independent and relative contributions of AS and EA in their (a) associations with overall levels of anxiety and (b) differential outcomes in anxious youth receiving CBT. AS and EA were used as independent variables. We hypothesized that both AS and EA will predict differential overall anxiety and differential outcomes, with EA showing a stronger association, relative to AS, in the relationship between AS, EA, and anxiety.

Methods

Participants

Participants were 89 youth aged 10 to 17 years (M = 13.8 years, SD = 2.14) who received treatment for youth anxiety at a specialty anxiety research clinic. Participants identified as 78.66% white and 37.08% male, with further demographics identified in Table 1. Youth met DSM-5 diagnostic criteria for a primary anxiety disorder based on a structured diagnostic interview (the ADIS-C/P-5; Albano & Silverman, 2015). A breakdown of primary anxiety diagnoses and comorbidity are identified in Table 1. Inclusion criteria included having a primary diagnosis of an anxiety disorder, and exclusion criteria included not being fluent in English, having active suicidal thoughts or active psychosis, and receiving other psychological treatment for youth anxiety.

Table 1.

Summary Statistics

Pretreatment Posttreatment
Variable M SD M SD
Experiential Avoidance (AFQ-Y) 24.63 14.58 - -
Anxiety Sensitivity (CASI) 31.37 8.02 - -
Anxiety Severity (CGI-S) 4.39 0.51 3.51 1.00
Anxiety Severity (MASC-C) 58.70 18.45 42.67 22.13
Anxiety Severity (MASC-P) 57.80 15.85 44.73 18.45
Gender N % - -
Male 33 37.08 - -
Female 55 61.80 - -
Non-binary 1 1 - -
Race N % - -
Race: White 70 78.66 - -
Race: Asian 4 4.49 - -
Race: Black 3 3.37 - -
Race: Multiracial 8 8.99 - -
Race: not listed 2 2.25 - -
Ethnicity N % - -
Hispanic or Latinx 2 2.25 - -
Diagnosis N % - -
Primary generalized anxiety disorder 34 38.20 - -
Primary social anxiety disorder 26 29.21 - -
Primary separation anxiety disorder 5 5.62 - -
Primary panic disorder 2 2.25 - -
Primary specific phobia 1 2.25 - -
Co-primary social anxiety disorder & generalized anxiety disorder 18 20.22 - -
Co-primary social anxiety disorder & specific phobia 2 2.25 - -
Co-primary generalized anxiety disorder & panic disorder 1 1.12 - -
Comorbidities N % - -
Comorbidity: Major Depressive Disorder (current) 11 12.36 - -
Comorbidity: Major Depressive Disorder (past) 9 10.11 - -
Comorbidity: Persistent Depressive Disorder 5 5.62 - -
Comorbidity: Obsessive Compulsive Disorder 11 12.36 - -
Comorbidity: Post Traumatic Stress Disorder 1 1.12 - -
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Note. AFQ-Y = The Acceptance and Fusion Questionnaire for Youth; CASI = The Childhood Anxiety Sensitivity Index; CGI-S = Clinical Global Impression, Severity; MASC-C/P = Multidimensional Anxiety Scale for Children–Child and Parent Versions.

Measures

Anxiety Disorders Interview Schedule for Children Child/Parent Interviews (ADIS-C/P).

The ADIS-C/P (Silverman & Albano, 1996) was used to diagnose anxiety disorders. The ADIS C/P is a semi-structured diagnostic interview that produces a clinical severity rating (CSR) between 0 (no impairment) and 8 (severe impairment) based on presence of symptoms and the severity of impairment. A CSR ≥ 4 on either the parent or child ADIS indicated a diagnosis. The ADIS-C/P has been shown to have concurrent validity, inter-rater reliability (k = .92), and test-retest reliability (r between .80 and .92) (Lyneham et al., 2007; Silverman et al., 2001; Wood et al., 2002) (Wood et al., 2002; Lyneham et al., 2007; Silverman et al., 2001). The inter-rater reliability of primary anxiety disorders amongst assessors was (ICC = .82–.94) based on a subset of interviews (n = 20).

Anxiety sensitivity (AS).

The Childhood Anxiety Sensitivity Index (CASI; Silverman et al., 1991) is an 18-item self-report measure adapted from the ASI (Reiss et al., 1986) for youths aged 6–17 years (Weems et al., 1998). Youths rated each item based on the frequency that they experienced each symptom on a 3-point Likert-type scale ranging from 1 (none of the time) to 3 (a lot of the time). Total scores range from 18 to 54, with higher scores indicating higher levels of AS. Silverman et al. (1991) reported Cronbach’s alpha of .87 and a test-retest reliability correlation of .79 in a sample of emotionally disturbed youth. In the present sample, Cronbach’s alpha was .89.

Experiential avoidance (EA).

The Acceptance and Fusion Questionnaire for Youth (AFQ-Y; Greco et al., 2008) is a 17-item self-report measure of EA. The AFQ-Y was adapted from the AAQ (Hayes et al., 2004) for youths aged 10–17 years. Youths rated each item on a 5-point Likert-type scale ranging from 0 (no true at all) to 4 (very true). Total scores range from 0 to 68, with higher scores indicating higher levels of EA. Internal reliability has been demonstrated with a Cronbach’s alpha of .89 and .90 (Greco et al., 2008; Venta et al., 2012). Convergent validity has been supported as the AFQ-Y was correlated in the expected direction with measures of anxiety symptoms and functioning (Greco et al., 2008). In the present sample, Cronbach’s alpha was .91.

Anxiety symptom severity.

Multidimensional Anxiety Scale for Children–Child and Parent Versions (MASC-C/P; March et al., 1997) is a 39-item youth self-report and parent-report measure of youth’s anxiety symptoms over the past two weeks. Examples of items on the MASC-C/P include “I worry about other people laughing at me” and “I get shaky and jittery.” Youths and their parents completed separate questionnaires where they rated symptom frequency over the past two weeks on a 4-point Likert-type scale ranging from 0 (never) to 3 (often). The MASC-C/P produces a total score ranging from 0 to 117, with higher scores indicating higher levels of anxiety. In a sample of youth being treated for anxiety, Cronbach’s alpha was between .87 and .89 for parent and child versions of the MASC (Wei et al., 2014). In the present sample, Cronbach’s alpha was between .87 and .95 for parent and child version of the MASC. Coefficients for test-retest reliability at 3 weeks and 3 months were between .79 and .93 (March et al., 1997). The MASC-C/P correlated with other measures of youth anxiety, supporting its convergent validity (Baldwin & Dadds, 2007; Wei et al., 2014), and has also been shown to predict diagnoses based on structured interviews (Villabø et al., 2012).

The Clinical Global Impression Scale – Severity (CGI-S; Guy, 1976) is a clinician-rated single item measure of anxiety severity. An independent evaluator (IE) who completed the structured interview (ADIS-5, Albano & Silverman, 2015) rates the youth’s anxiety (per their anxiety diagnosis) from 1 to 7, where a lower score indicates less severe anxiety (i.e., not ill at all) and a higher score indicates more severe anxiety (i.e., extremely ill). The CGI-S was correlated .3 and .4 with the child and parent versions of the MASC in the present sample (Pearson’s r).

Procedure

All study procedures were approved by the Temple University Institutional Review Board. The sample was recruited from a sample of youth participating in an ongoing research clinic. Only participants between the ages of 10 and 17 were included for the present analysis as the AFQ-Y is not psychometrically validated for the younger sample. To determine eligibility, families completed a phone screen and subsequent assessment of anxiety symptoms. The assessment included the diagnostic assessment (the ADIS-C/P-5; Albano & Silverman, 2015) administered separately to caregiver and youth by two reliable diagnosticians. Diagnosticians were deemed to be reliable after receiving ADIS training and providing agreeing diagnoses on three out of four consecutive ADIS assessments. Youth also completed the CASI, AFQ-Y, and MASC-C, and their caregivers completed the MASC-P.

Youths received cognitive-behavioral therapy (CBT; Coping Cat protocol) for those ages 10–12 (Kendall & Hedtke, 2006) and the C.A.T. Project protocol for those ages 13–17 (Kendall, 2002; Kendall et al., 2002). Treatment was provided by graduate student therapists, who received specialized training in providing CBT for youth anxiety and weekly supervision by a licensed psychologist. Treatment was 16 weekly sessions included psychoeducation, coping skill development, and exposures. Therapists regularly communicated with caregivers and met with them for two parent sessions over the course of the treatment. Youth completed homework after each session related to either coping skill development tasks or exposure tasks. Following treatment, youths and caregivers completed the ADIS-C/P and the MASC-C/P, and the IE completed the CGI-S. All youth completed the full treatment. Listwise deletion was used to remove two participants who did not complete posttreatment measures. There was no significant difference between the baseline scores of AS and EA for those who did and did not complete posttreatment measures.

Secondary analyses included pretreatment measures of anxiety sensitivity (AS; CASI) and experiential avoidance (EA; AFQ-Y) and pretreatment and posttreatment measures of anxiety symptom severity (MASC-C/P; CGI-S). Multilevel models examined (1) change in anxiety from pre to posttreatment with time being modeled as a fixed effect and (2) whether each variable (AFQ-Y and CASI) predicted change in anxiety symptoms across treatment. Thus, models included the predictor variables of AS (CASI) and EA (AFQ-Y), as well as the interaction between each predictor and time, to examine pre to posttreatment change in child, parent, and independent evaluator-reported anxiety severity. In initial models, predictors were examined in separate models. We also examined a model that included both AS and EA, as well as both of their interactions, predicting the different anxiety outcome measures in separate models. To examine prediction of pretreatment anxiety, time was centered such that pretreatment was when time was 0. Likewise, to examine prediction of posttreatment anxiety, time was centered such that posttreatment was when time was 0. After no significant interactions were found, AS and EA were standardized to directly compare impact on outcome to see if one was significantly making a bigger difference than the other. Effect sizes were represented by correlations reported between the predictor variables and outcome measures.

Results

Descriptives and means are in Table 1. Correlations are in Table 2. Study results are summarized in Table 3.

Table 2.

Bivariate Correlations

AFQ-Y CASI CGI-S MASC-C MASC-P CGI-S (Post) MASC-C (Post) MASC-P (Post)
AFQ-Y 1.00 - - - - - - -
CASI 0.71*** 1.00 - - - - - -
CGI-S 0.39*** 0.40*** 1.00 - - - - -
MASC-C 0.65*** 0.63*** 0.35*** 1.00 - - - -
MASC-P 0.16 0.24* 0.08 0.39*** 1.00 - - -
CGI-S (Post) 0.10 0.07 0.23* 0.16 0.27* 1.00 - -
MASC-C (Post) 0.36*** 0.42*** 0.29** 0.56*** 0.19 0.45*** 1.00 -
MASC-P (Post) 0.11 0.23* 0.07 0.31** 0.48*** 0.44*** 0.44*** 1.00
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Note.

*

= p < .05

**

= p < .01

***

= p < .001

AFQ-Y = The Acceptance and Fusion Questionnaire for Youth; CASI = The Childhood Anxiety Sensitivity Index; CGI-S = Clinical Global Impression, Severity; MASC-C/P = Multidimensional Anxiety Scale for Children–Child and Parent Versions.

Table 3.

Multilevel modeling of AS, EA, and anxiety

MASC-C MASC-P CGI-S
Model Separate Models Joint Model Separate Models Joint Model Separate Models Joint Model
unstandardized unstandardized standardized unstandardized unstandardized standardized unstandardized unstandardized standardized
Time −16.02 (2.05) *** −13.07 (1.87) *** −.89 (.11) ***
AFQ-Y .68 (.11) *** .35 (.15) * 5.09 (2.2) * .16 (.10) −.07 (0.15) −1.10 (2.17) .01 (.00) * .01 (.01) .11 (.09)
CASI 1.31 (.19) *** .85 (.27) ** 6.80 (2.2) ** .50 (.19) * .60 (.27) * 4.80 (2.17) * .02 (.00) * .01 (.01) .06 (.09)
Time * AFQ-Y −.32 (.20) −.12 (.18) .00 (.00)
Time * CASI .13 (.36) .21 (.33) .00 (.00)
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Note. Statistics above list b with SE in parathesis

*

= p < .05

**

= p < .01

***

= p < .001

Separate models tested each predictor separately; the AFQ and CASI models controlled for time. In the joint model, the AFQ, CASI, and time were all regressed on each outcome variable.

The Effect of Time on Anxiety

MLM examined the association between time (treatment) and anxiety outcomes, finding that there were significant treatment effects for lower child-reported anxiety symptoms (MASC-C; b = −16.02, p < .001), lower parent-reported anxiety symptoms (MASC-P; b = −13.07; p <.001), and lower IE-rated anxiety severity (CGI-S; b = −.89; p <.001). At posttreatment, 23% of youth no longer met criteria for any anxiety disorder.

The Effect of Time and EA on Anxiety

MLM examined the association between EA (controlling for time) and anxiety outcomes. There was a significant main effect of EA for child-reported anxiety symptoms (MASC-C; b = .68, p < .001, r = 0.56) and IE-rated anxiety severity (CGI-S; b = .01, p = .02, r = 0.24), such that higher EA was associated with higher levels of anxiety, but not for parent-reported anxiety symptoms (MASC-P; r = 0.16).

The Effect of Time and AS on Anxiety

MLM examined the association between AS (controlling for time) and anxiety outcomes. There was a significant main effect of AS for child-reported anxiety symptoms (MASC-C; b = 1.31, p < .001, r = 0.58), parent-reported anxiety symptoms (MASC-P; b = .50; p = .01, r = 0.27), and IE-rated anxiety severity (CGI-S; b = .02; p = .04, r = 0.22), such that higher AS was associated with higher levels of anxiety.

The Effect of Time, AS, and EA on Anxiety

MLM next examined the association between both AS and EA and anxiety outcomes, controlling for the other predictor in the same model, respectively. When controlling for AS, there was a significant main effect of EA for child-reported anxiety symptoms (MASC-C; b = .35, p = .02, r = 0.25), such that higher EA was associated with higher levels of anxiety. However, there was no significant main effect of EA for parent-reported anxiety symptoms (MASC-P; r = 0.05) or IE-rated anxiety severity (CGI-S; r = 0.12). When controlling for EA, there was a significant main effect of AS for child-reported anxiety symptoms (MASC-C; b = .85, p = .002, r = 0.32) and of AS for parent-reported anxiety symptoms (MASC-P; b = .60; p = .03, r = 0.23), such that higher AS was associated with higher levels of anxiety. However, there was no significant main effect of AS for IE-rated anxiety severity (CGI-S; r = 0.07).

The Effect of AS*Time and EA*Time on Anxiety

MLM examined the association between the interactions of AS and treatment and EA and treatment for anxiety outcomes, controlling for the other predictor interaction in the same model, respectively. When controlling for AS, there were no significant main effects of EA for child-reported anxiety symptoms (MASC-C; r = 0.56), parent-reported anxiety symptoms (MASC-P; r = 0.16), or IE-rated anxiety severity (CGI-S; r = 0.24). When controlling for EA, there were no significant main effects of AS for child-reported anxiety symptoms (MASC-C; r = 0.58), parent-reported anxiety symptoms (MASC-P; r = 0.27), or IE-rated anxiety severity (CGI-S; r = 0.22).

The Effect of Time, standardized AS, and standardized EA on Anxiety

We standardized AS and EA to examine the association between both AS and EA and anxiety outcomes, controlling for the other predictor in the same model, respectively. This standardization did not impact main effects, meaning that the only outcome variable with significant main effects with both predictor variables was child-reported anxiety symptoms (MASC-C). Standardization allowed us to compare t values between both AS (t = 3.18) and EA (t = 2.36) to determine if one predictor was significantly more associated with the outcome variable than the other. The difference between both t values is 0.82, meaning there was not a significant difference between the main effect of AS on child-reported anxiety symptoms and the main effect of EA on child-reported anxiety symptoms. Directly comparing the coefficients using a linear hypothesis test also showed the difference between the coefficients was not significant.

Discussion

Are AS and EA associated with anxiety symptoms, and do they predict treatment outcomes? Even after controlling for the other predictor, there were associations between higher levels of AS and EA and anxiety symptoms, varying by reporter of anxiety outcomes. When standardizing predictors to directly compare association with outcome variables, there was no significant difference between the impact of AS and EA. Higher pretreatment levels of AS and EA did not significantly predict differential treatment outcomes in anxious youth receiving CBT. In other words, youth with more AS and EA have more anxiety but do not improve at rates differently than youth with less AS and EA.

After controlling for the other predictor (respectively), AS and EA were significantly associated with child-reported anxiety severity. However, AS, but not EA, was significantly associated with parent-reported anxiety severity, and neither AS nor EA were significantly associated with IE-reported anxiety severity. In understanding why differences between child, parent, and independent evaluator reported outcome measures may have occurred, it is important to note that both AS and EA are child-reported measures. Further, the measure of EA (AFQ-Y) asks and relates to the internal experience of the youth (Greco et al., 2008), whereas the measure of AS (CASI) asks and relates to more physical symptoms of anxiety, which may be more outwardly expressed or visible to a parent (Silverman et al., 1991). This distinction might help explain why AS, and not EA, predicted parent-reported anxiety symptoms, despite their statistical overlap. Research also suggests that child and parent reports, while valid for the reporter, do not always agree (De Los Reyes & Kazdin, 2005), which is exemplified in correlations found in the present study between child- and parent-reported anxiety symptoms (r = .50), although this correlation is higher than typically reported (a 2015 meta-analysis suggests that r = .28 is typical; (De Los Reyes et al., 2015)).

The present study did not find a significant difference between AS and EA on outcome variables. This finding is consistent with research on anxious adults, where there are mixed results with regards to whether AS or EA has a stronger association with anxiety (e.g., Bardeen et al., 2014; Berman et al., 2010; Kelly & Forsyth, 2009). AS and EA have theoretical distinctions (i.e., fear of physical sensations of anxiety for AS and the urge to avoid internal discomfort for EA), but it is worth noting that AS and EA were highly correlated (r = 0.7) in the present study. Similarly, research on adults suggests that AS and EA may be overlapping constructs (Kämpfe et al., 2012; Pickett et al., 2012). Research should investigate whether measuring both AS and EA can improve personalized treatment recommendations, or whether it is more parsimonious to consider AS and EA to be roughly the same construct.

The lack of significant association of AS and EA with differential treatment outcomes may suggest that therapists already address both AS and EA within CBT. Within the theoretical framework of the cognitive behavioral model of anxiety, these results might suggest that CBT may reduce both an individual’s negative interpretation of anxiety symptoms (AS), as well as their tendency to avoid internal experiences of anxiety (EA; Beck, 2011). EA conceptually originated in ACT, but research supports the overlap of these similar treatment modalities (Kocovski et al., 2015). If this is true, clinical implications of these results suggest that therapists following a CBT protocol using exposures, such as Coping Cat in the present study, may be addressing concerns that could arise from heightened levels of AS or EA (Higa-McMillan et al., 2016). Future research including posttreatment levels of AS and EA, as well as changes in AS, EA, and anxiety symptoms during treatment, are needed to elucidate this possibility. More expansive research in other samples and with other variables may rule out other potential explanations of the results, such as the possibility that levels of AS and EA are particularly low in this sample or that other predictors not assessed in this study are more influential than AS or EA.

Findings should be interpreted considering limitations. The anxious youth receiving treatment were 78% Caucasian, which limits generalizability. Research is inconclusive as to whether there are racial differences (perhaps due to cultural factors associated with race) related to noticing and reporting physical symptoms of anxiety. One study concluded that black undergraduate students noticed more physiological symptoms of anxiety (Gordon et al., 2015), while a different study found that black girls reported less physical symptoms of worry than white girls in a high school population (Latzman et al., 2011). Thus, it is possible that when using a construct that relies on reporting of physical symptoms of anxiety such as AS, there may be cultural differences in the focus and relevance of physical symptoms. Racial differences should be taken into consideration regarding the measures used for AS and EA. An additional limitation is that this study’s remission rate (absence of an anxiety disorder posttreatment) is lower than that of other comparable treatment studies (Ginsburg et al., 2011). Results should be taken considering this limitation, and future research should examine AS and EA as predictors in other and larger populations.

Another limitation to consider may be the generalizability of these outcomes in community settings and populations, as the current sample was comprised of those in treatment at a specialized anxiety clinic. Future research in community samples is warranted to determine if rates of anxiety sensitivity and experiential avoidance are similar, as well as their potential role in (or lack thereof) treatment outcomes. Another limitation of the present study may be the breakdown of anxiety disorder subtype. As shown in Table 1, the majority of participants in the study received primary diagnoses of generalized anxiety disorder (38%), social anxiety disorder (29%), or a combination of generalized anxiety disorder and social anxiety disorder (20%). It is possible that AS and EA may differentiability impact certain anxiety disorders (e.g., panic disorder).

This study examined the impact of AS and EA on anxiety outcomes in anxious youth who received CBT (i.e., Coping Cat). Findings indicate that although higher levels of both AS and EA were associated with higher levels of anxiety, treatment outcomes did not differ. Thus, AS and EA did not impact treatment outcomes, perhaps because CBT addresses both constructs. This study provides evidence suggesting that AS and EA may not be distinct constructs. Additional research examining the benefit of measuring AS and EA in personalized treatment is warranted.

Footnotes

Conflict of Interest: PCK receives royalties from the sales of published materials related to the treatment of youth, and his spouse operates and receives income from the publisher. Manuscript preparation was supported by National Institute of Mental Health grants awarded to MEC (F31MH123038).

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