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. Author manuscript; available in PMC: 2022 Feb 1.
Published in final edited form as: J Child Fam Stud. 2021 Jan 11;30(2):493–501. doi: 10.1007/s10826-020-01872-5

Beyond 16 Sessions: Extending Manualized Treatment of Anxious Youth

Elana R Kagan 1, Hannah E Frank 1, Mark J Knepley 1, Philip C Kendall 1
PMCID: PMC8317605  NIHMSID: NIHMS1661965  PMID: 34335000

Abstract

Cognitive behavioral therapy (CBT) is well established as an efficacious treatment for anxious youth, yet a number of youth remain symptomatic after the 10–16 sessions of treatment stipulated by most CBT treatment manuals. While a significant minority do not respond, no study has examined the frequency and impact of additional therapy sessions. This study examined youth receiving outpatient therapy at an anxiety clinic who were offered the option to continue treatment after completing 16 sessions of manual-based CBT. Fifty-nine percent of participants chose to continue treatment, with an average of approximately 20 total sessions across participants. Therapist ratings demonstrated a significant overall improvement between session 16 and the final session. No pre-treatment measure of symptom severity differed between those who extended treatment and those who ended at session 16. Parent-rated anxiety differed between groups at session 16, as did the length of time between the pre-treatment assessment and week 16 assessments. Findings indicate that extending treatment is not uncommon, is typically limited to several additional sessions, and is associated with an increase in treatment gains. Current results suggest that two factors at session 16, parental perceptions of anxiety and time to complete 16 sessions, are influential and may be central to the decision to continue treatment past this point. Clinical implications and future directions are discussed.

Keywords: anxiety, children, adolescents, treatment outcome, cognitive behavioral therapy

Anxiety disorders are common among children and adolescents (Merikangas et al., 2009), with studies indicating that anxiety disorders affect between 3–24% of youth (Ford et al., 2003; Kroes et al., 2001) and approximately 30% of adolescents (Merikangas et al., 2010). In addition to interfering symptoms, anxiety is associated with many functional impairments, such as diminished life satisfaction and poor academic performance (Swan & Kendall, 2016). Youth with anxiety disorders are at greater risk for alcohol abuse in adolescence (Schuckit & Hesselbrock, 1994), and those who do not receive treatment have an increased risk of atypical psychosocial development, further mental health problems, and substance abuse later in life (Connolly et al., 2007; Essau et al., 2000; Kim-Cohen et al., 2003; Puleo et al., 2011; Wolk et al., 2015). Thus, there is great public health need for maximizing the impact of treatments targeting anxiety in youth.

Cognitive behavioral therapy (CBT) has been established as an empirically-supported treatment for youth with anxiety disorders (Higa-McMillan et al., 2016; Hollon & Beck, 2013; Silverman et al., 2008) with a response rate of approximately 60% (Kendall et al., 2008; Walkup et al., 2008). Empirically-supported manualized CBT protocols for the treatment of anxiety disorders in youth typically stipulate 10 to 16 weekly therapy sessions (e.g. Barrett, 2005; Barrett et al., 1991; Kendall & Hedtke, 2006; Rapee & Wignall, 2002), with the expectation that this dose of CBT is sufficient to maximize treatment gains. However, approximately one third of anxious youth participating in such treatments do not demonstrate meaningful improvement after the typical range of sessions defined by CBT manuals, with approximately half retaining some form of symptomology (Compton et al., 2004). Additionally, a recent meta-analysis (James et al., 2015) found that approximately 40% of youth receiving 12- to 16-session protocols of CBT for the treatment of anxiety disorders did not achieve remission, indicating the need for enhanced efficacy.

Research has not yet examined the effects of an increased dose of CBT. Most treatment outcome research has been conducted in the context of formal randomized clinical trials, in which treatment ends after the number of sessions specified in the manual (i.e., typically 10–16 sessions). Protocols sometimes include “booster sessions,” to be used when a youth may benefit from additional sessions to apply skills learned in treatment to novel or potentially difficult situations (Seligman & Ollendick, 2011; Sun et al., 2018). The goal of booster sessions, however, is the maintenance of treatment gains and prevention of relapse (Beck, 2011) rather than the continuation of symptom reduction. In addition, booster sessions are intended to be conducted several weeks or months after the initial treatment protocol has ended, and not as a continuation of therapy (Rapee, 2000; Warner et al., 2007). Ongoing sessions intended to extend, rather than maintain, the work of a manualized treatment protocol have received little attention in the literature.

Relatively few studies have examined the dose-response relationship in psychological therapy more broadly, with dose defined as number of sessions of therapy and response defined as whether a particular outcome, such as whether treatment response (e.g., anxiety scores falling below a cut point on a given measure) and remission of symptoms has occurred. A meta-analysis of 156 studies examining the dose-response relationship in psychological therapy found that 100 studies indicated a positive relationship, 50 studies found no statistically significant relationship, and six studies indicated a negative relationship between therapy duration and outcome (Orlinsky et al., 1994). Questions remain, however, regarding the number of therapy sessions needed to optimize positive treatment outcomes.

Studies have explored the impact of additional cognitive therapy (CT) sessions on both adults and youth with depression. In a study examining adults with depression, responders to acute phase cognitive therapy were randomized to receive continuation-phase cognitive therapy (10 sessions over eight months) or no additional therapy, with the goal of reducing relapse and recurrence. Results demonstrated that 10 additional sessions of cognitive therapy reduced relapse rates significantly more than the control condition, suggesting that a larger dose of therapy may help in maintaining gains made during the acute phase (Jarrett et al., 2001). However, a review of studies examining recurrence and relapse in depressed youth indicated a lack of consensus and clarity regarding the most effective treatment for preventing both after the completion of acute phase therapy (Cox et al., 2012), suggesting that further research is needed. Such questions have not been examined with anxious youth.

This study was a naturalistic examination of the clinical characteristics of anxious youth and their families who chose to extend therapy beyond the 16 sessions indicated in the Coping Cat manual (Kendall & Hedtke, 2006). We examined pre-treatment predictors and characteristics of extended treatment, such as rationale, content, and number of additional sessions. Consistent with the response rates found in treatment outcome studies for anxious youth (Kendall et al, 2008; Walkup et al., 2008), we hypothesized that, when offered an option to continue beyond 16 sessions, approximately 40–50% of clients would choose to do so. Beyond these hypotheses, exploratory analyses were conducted to examine the characteristics of youth seeking to continue treatment, as well as the impact of the additional sessions. To our knowledge, this is the first study to examine the clinical characteristics of anxious youth and their families choosing to continue manualized CBT beyond the number of sessions stipulated by the manual, their reasons for doing so, and the potential benefits of extended treatment.

Methods

Participants

Participants (N = 41) included anxious youth aged 7–17 seeking treatment at a university clinic where therapy services were provided for a fee on a sliding-scale. All participants met DSM-5 diagnostic criteria for a principal anxiety disorder (see Table 1 for primary diagnosis) and many had comorbid secondary diagnoses. Participants included 23 males and 18 females ages 7 to 17 years (M=11.59, SD=3.01). Eighty percent of participants were Caucasian, 10% were African American, and 10% were self-identified as “other” or mixed race. To be included in the present study, participants had to complete 16 sessions of manualized CBT for anxiety. Participants were considered to have extended treatment (“extenders;” n=24) if, after completing the 16-session treatment program, they elected to continue treatment for at least one additional session. Participants were considered not to have extended treatment (“non-extenders;” n=17) if they chose to end therapy after the standard 16 sessions. Of note, 20 additional youth received services during this time period and ended treatment before completing the full 16 sessions. As this study examined the choice to extend treatment following a full course of CBT, these families were not eligible for the current study.

Table 1:

Differences Between Extenders and Non-Extenders (N = 41)

Factor (Instrument) Non-Extenders (n=17) Extenders (n=24) t or X2value Cohen’s d
Mean (SD) or n (% of Non-Extenders) Mean (SD or n (% of Extenders)
Pre-treatment factors
 Primary diag. (ADIS) 8.19
  Generalized anxiety disorder 8 (47.1%) 10 (41.7%)
  Social anxiety disorder 4 (23.5%) 9 (37.5%)
  Separation anxiety disorder 0 (0.0%) 2 (8.3%)
  Specific Phobia 5 (29.4%) 2 (8.3%)
  Anxiety state, unspecified 0 (0.0%) 1 (4.2%)
 Severity of primary dx. (ADIS) 5.17 (0.64) 5.3 (0.63) −0.58 0.20
 Number of anxiety dx. (ADIS) 2.41 (1.12) 2.25 (0.74) −0.56 0.17
 Number of clinical dx. (ADIS) 3.24 (1.39) 2.96 (1.04) 0.73 0.23
 Overall anxiety (MASC; parent) 50.75 (14.42) 52.79 (14.26) −0.44 0.14
 Overall anxiety (MASC; child) 54.11 (19.50) 54.13 (17.91) −0.00 0.00
Session 16 assessment factors
 Primary diagnosis severity (ADIS) 3.75 (1.18) 4.14 (1.08) −1.05 0.34
 Remitted primary dx (ADIS) 8 (47.5%) 10 (41.7%) 0.12
 Number of anxiety dx (ADIS) 0.94 (1.09) 1.08 (1.13) −0.40 0.13
 Number of clinical dx (ADIS) 1.47 (1.46) 1.42 (1.28) 0.13 0.03
 Overall anxiety (MASC; parent) 32.50 (16.36) 45.32 (19.09) −2.17* 0.72
 Overall anxiety (MASC; child) 35.82 (21.53) 38.45 (22.18) −0.38 0.12
 Weeks from pre-tx to session 16 21.47 (3.94) 19.10 (3.01) 2.19* 0.68
Last Session Factors
 Overall severity (CGI-S) 3.13 (0.92) 3.13 (1.03) −0.03 0.00
 Overall improvement (CGI-I) 2.33 (0.82) 1.88 (0.74) 1.81 0.58
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Note: ADIS = Anxiety Diagnostic Interview Schedule; CGI-I – Clinical Global Impressions – Improvement; CGI-S = Clinical Global Impressions – Severity; clinician = clinician diagnostician; dx = diagnosis, MASC=Multidimensional anxiety scale for children; tx = treatment

*

p <0.05

Procedure

Families completed a pre-treatment evaluation during which two diagnosticians conducted a semi-structured interview for anxiety disorders with both the parent and child separately, and parents completed questionnaires reporting on child anxiety. Following the completion of the manualized treatment at session 16, families again completed the diagnostic interview and questionnaires. In addition, diagnosticians rated overall client improvement. The child and parent assessments were conducted simultaneously by two different diagnosticians. Overall, 26.8% (n=11) of clients received treatment from a therapist who, as a diagnostician, administered either the parent or child semi-structured interview for the client’s first assessment. Assessments occurring after session 16 were always conducted by a diagnostician who was not the client’s therapist.

Following the post-session 16 assessment, all families were given the option to continue or end treatment. The decision to continue treatment was made by the parents, often in consultation with their child’s therapist. There was no standardized procedure for this decision; therapists assisted parents in collaboratively developing a plan that felt best for their family. To aid parents in making the decision, therapists provided information from the post-session 16 assessment as well as their own clinical impressions regarding the child’s response to treatment and the potential utility of additional sessions. When families elected to continue treatment, they were offered open-ended access to treatment, without needing to commit to a specific number of additional sessions. Throughout these additional sessions, a similar decision-making process was utilized to reassess the need for further sessions, and to determine when to end services.

The final assessment time point was after participants terminated treatment, at which point therapists rated both client overall symptom severity and improvement. For youth who chose to not to extend the intervention, the last session was session 16, meaning that the session 16 assessment was also their final assessment time point. For those who chose to extend treatment past session 16, the final assessment occurred after at least two months had passed without any further therapeutic intervention. All procedures were conducted with the approval of the university’s Institutional Review Board.

Therapy

As part of the therapy protocol used to treat anxious youth in our clinic, participants received 16 weekly 60-minute sessions of manualized individual CBT. Generally, youth ages 7–13 received Coping Cat (Kendall & Hedtke, 2006), and youth ages 14–17 received the C.A.T. Project (Kendall, et al., 2002). Several studies have demonstrated the efficacy (for a meta-analysis, see Lenz, 2015) and effectiveness (Villabø et al., 2018) of Coping Cat. For additional details about the Coping Cat intervention, see Beidas et al., 2010; Norris & Kendall, 2020; and Podell et al., 2010. Coping Cat and C.A.T. Project have comparable content, with slight age-relevant variations in language and illustrations. The discretion of the therapist allowed for flexible choice of the manual used depending on the youth’s level of cognitive development. For both Coping Cat and C.A.T. Project, the first half of treatment emphasized psychoeducation, including recognizing somatic reactions and anxious cognitions in anxiety-provoking situations, as well as learning strategies to cope with these reactions (i.e., relaxation; coping self-talk). The second half of treatment focused on behavioral exposure tasks, evaluating performance, and self-reinforcement. Treatment used behavioral training strategies such as modeling, imaginal and in vivo exposure, role-play, and contingent reinforcement. Weekly homework tasks were assigned to facilitate out-of-session practice of skills and exposures, and parents were engaged as collaborators and consultants to the youth’s treatment. Therapists were advanced graduate students in clinical psychology under the supervision of a doctoral-level psychologist. Clinic staff have previously been found to be 95% adherent with session goals when administering these specific manualized treatments.

Measures

Anxiety Disorders Interview Schedule for DSM-5 – Child and Parent Versions (ADIS-5-C/P; Albano & Silverman, 2016).

The ADIS-5-C/P are semi-structured clinical interviews that assess for the presence of child anxiety disorders, as well as other forms of child psychopathology. Diagnoses were derived from interviews with youth and parents separately by clinical psychology doctoral student-diagnosticians, who were supervised by a licensed clinical psychologist. Diagnosticians who had been trained to reliability (>.90) on the ADIS-5-C/P provided clinical severity ratings (CSRs) using a zero to eight point scale, with higher ratings indicating more severe impairment (i.e., a rating of zero indicating no impairment, a rating of four indicating a clinically significant level of impairment, and a rating of eight indicating an extreme level of impairment). CSRs of four or greater indicate a DSM-5 clinical-level diagnosis. As the child and parent were interviewed separately, two separate sets of CSRs were initially derived. A set of composite CSRs were then established by integrating the CSRs derived from both the youth and parent assessments (Albano & Silverman, 2016), with principal diagnosis determined by the disorder with the highest CSR in the composite. The ADIS has been shown to be sensitive to treatment (e.g., Kendall et al., 1997; Silverman et al., 1999) and has demonstrated strong concurrent validity (Wood et al., 2002) as well as test-retest reliability (r =.76; Silverman, et al., 2001). The ADIS was administered at the pre-treatment and session-16 assessments.

Clinical Global Impression – Severity and Improvement (CGI-S/I; Guy, 1976).

The CGI-S and CGI-I scales consist of single items rated on a 7-point Likert scale. CGI-Severity ratings measure the overall interference due to anxiety on the youth’s functioning. Scores range from one (no illness) to seven (extreme impairment). The CGI-Improvement rating reflects the change in anxiety symptoms since the pre-treatment assessment. Scores range from one (very much improved) to seven (very much worse), with positive treatment response indicated by a score of one or two. Diagnosticians gave CGI-S ratings at the pre-treatment assessment, and both CGI-S and CGI-I ratings at the session 16 assessment. Therapists also gave CGI-I and CGI-S ratings at the last therapy session. Both CGI scales have been significantly associated with symptom severity and changes in clinician-rated and self-reported symptoms in adults (Zaider et al., 2003).

Multidimensional Anxiety Scale for Children (MASC; March et al., 1997).

The MASC is a self-report, 39-item questionnaire that uses a four-point Likert rating scale to assess youth anxiety symptoms. The current study included the parent and child version of the MASC (MASC-P; MASC-C), which was completed by a parent or primary caregiver at the pre- and session 16 assessment. The MASC has demonstrated internal consistency (March et al., 1997; March et al., 1999) and acceptable convergent and discriminant validity (March et al., 1997; March & Albano, 1998). Retest reliability for the MASC is .79 in clinical samples (March et al., 1997).

Termination Questionnaire (TQ).

The Termination Questionnaire is a six-item therapist questionnaire created for the purposes of the current study. For those who chose to extend treatment, the TQ enquires about reasons for extending beyond 16 therapy sessions, as well as content, number, and frequency of additional sessions. For both extenders and non-extenders, the TQ assesses the reason for ending treatment.

Results

T-tests and chi-square tests examined potential differences between extenders and non-extenders in client characteristics at pre-treatment, session 16, and the final assessment. Descriptive statistics were conducted on characteristics of extended treatment, including rationale, content, and frequency of additional sessions.

Decision to Continue Treatment

Out of 41 participants, 24 (58.5%) chose to continue treatment past 16 sessions, while 17 (41.5%) chose to terminate treatment after 16 sessions. Of those who chose to remain in treatment, 83.3% (n=20) indicated that ongoing anxiety was among their reasons for doing so. Additional reasons included addressing other problems, such as mood or behavior (n=10; 41.7%), as well as providing ongoing support to the family for issues that were largely addressed during the initial 16 sessions (n=11; 45.8%; see Table 2).

Table 2:

Characteristics of Extended Treatment (N = 24)

n (% of extenders)
Reason for Continuing*
 Anxiety not fully addressed 20 (83.3%)
 Addressing comorbid conditions 10 (41.7%)
 Booster sessions to support maintenance 11 (45.8%)
Content of Additional Sessions*
 Additional exposures 19 (79.2%)
 Less structured skills and support 17 (70.8%)
 Parenting skills 6 (25.0%)
 Treatment of comorbid condition 4 (16.7%)
Frequency of Additional Sessions
 Weekly; ongoing 8 (33.3%)
 Weekly; decreasing frequency 3 (12.5%)
 Biweekly 3 (12.5%)
 Monthly or as needed 10 (41.7%)
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*

Therapist could select multiple responses

T-tests examined pre-treatment and session 16 characteristics that may have related to the decision to continue treatment (i.e., differences between extenders and non-extenders). No significant group differences were found on any pre-treatment measure, including number of pre-treatment diagnoses, diagnostician-rated severitys(CSR), or overall anxiety as rated by the parent and child (all p>0.05). Similarly, a chi-square test comparing primary diagnosis between groups was not significant (p>0.05). However, at session 16, a significant difference was found between groups for parent-rated youth anxiety on the MASC, such that those who chose to continue treatment had higher anxiety, t(36) = −2.17, p = 0.04. A significant difference was found for the number of weeks to complete 16 sessions, such that those who chose to continue treatment had progressed more quickly through the first 16 sessions, t(39) = 2.19, p = 0.03. Additional analyses (t-tests and chi square tests) found no significant session 16 differences between groups on primary diagnosis, number of diagnoses, diagnostician-rated severity, remission, or overall anxiety as rated by the child (all p>0.05; shown in Table 1). Rates of extending treatment also did not differ by responder status on the CGI-I, with 58.6% (n=17) of responders extending treatment and 58.3% (n=7) of non-responders extending treatment (p>0.05).

Frequency, Number and Content of Additional Sessions

After 16 sessions, there was increased flexibility regarding the frequency and content of additional sessions. Among youth who chose to extend treatment, 45.8% of participants (n=11) chose to continue with weekly sessions, although a quarter of these clients decreased to less frequent sessions over time (n=3). Biweekly sessions were continued with 12.5% (n=3) of participants, and 41.7% (n=10) dropped down to sessions that were either scheduled monthly or as needed. Additional sessions largely focused on anxiety, with 79.2% (n=19) of extenders completing additional exposure tasks, and 70.8% (n=17) also incorporating less structured support and review of skills. Of note, therapists indicated that 70.8% (n=17) of youth who chose to extend treatment had more than one type of therapeutic intervention in additional sessions (see Table 2.) Among extenders, the number of additional sessions ranged from 1 to 17, with a mean of 5.88 (SD =4.59). Across all participants, there was a mean of 19.44 sessions (SD=4.55).

Decision to End Treatment

Regardless of the number of sessions a youth completed, treatment was most commonly ended because the parents or therapist believed the child was no longer in need of services. Overall, 48.8% (n=20) of participants ended treatment because the therapist and family agreed that the child no longer needed additional services, while 14.6% (n=6) ended because the family felt the child no longer needed additional services, though the therapist felt otherwise. An additional 22.0% (n=9) ended treatment because the family was not able to make an additional commitment to therapy (e.g. busy schedule, moving away). Finally, 9.8% of participants (n=4) were referred elsewhere for additional services because an anxiety specialty clinic was no longer determined to be the most appropriate venue for treatment, while 4.9% (n=2) ended treatment because the therapist lost contact with the family (See Table 3). A chi-square test comparing extenders to non-extenders did not find a significant difference between groups regarding the primary reason for ending therapy (p>.05).

Table 3:

Reasons for Ending Treatment (N = 41)

n (% of overall sample)
Child is no longer in need of services 20 (48.8%)
Family believes child is no longer in need of services; clinician disagrees 6 (14.6%)
Family cannot continue to attend (e.g. moved, busy schedule) 9 (22.0%)
Lost contact with family 2 (4.9%)
Different services needed 4 (9.8%)
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Impact of Additional Sessions

T-tests examined the differences between extenders and non-extenders on the therapist-rated CGI-S and CGI-I completed at the final assessment and did not find any significant difference (p>.05). However, a within subjects t-test demonstrated that youth who chose to extend treatment experienced a significant gain on the CGI-I from session 16 to the final assessment, t(23) = 3.49, p<0.01. Also, none of the treatment extenders were rated as “very much improved” (a CGI-I of 1) at session 16, but 29.2% of the extenders (n=7) were rated as such at the final assessment. With regard to overall anxiety severity, there was no significant difference between post-session 16 CGI-S scores and final assessment CGI-S scores.

Discussion

This study was a naturalistic examination of youth receiving outpatient therapy for anxiety who had the option to continue treatment after 16 sessions of manualized CBT. Approximately half chose to continue treatment, with an average of approximately 20 sessions across all participants. This suggests that 16 sessions of CBT may not be optimal for all treatment-seeking anxious youth, although many are ready to end treatment after only several additional sessions. Importantly, youth benefited therapeutically from the additional sessions. Taken together, the results of the present study offer a hopeful picture for flexible clinical applications of manualized programs; for families that elect to continue treatment beyond the initial number of sessions indicated by a manualized CBT protocol, a small number of additional sessions may be clinically beneficial.

The results indicate that, even after 16 sessions of CBT for anxiety, remaining anxiety is a motivating factor for and focus of additional sessions. Among families who chose to extend treatment, 83.3% indicated that ongoing anxiety was one of their reasons for continuing. Similarly, 79.2% of extenders completed additional exposure sessions and 70.8% received less structured skills and support around anxiety. It is worth noting that the present sample was from an anxiety specialty clinic where all clients were determined to need anxiety-specific treatment (i.e., anxiety was the primary presenting problem at baseline). In addition, participants had chosen to complete the full 16 sessions of manualized treatment and did not end treatment or transfer to another clinic, further selecting for those families who wished to focus on their child’s anxiety. Of note, approximately one third of families seeking services in this time frame dropped out of treatment before completing all 16 sessions and were ineligible for the current study. Thus, the participants examined may not represent a typical community-based sample. However, findings highlight that, even among those who are able to complete the recommended dose of CBT for anxiety, additional sessions may be desired.

There is great clinical utility in being able to identify which families are most likely to extend treatment, particularly at the outset of services, as families often inquire about how long a youth’s treatment is likely to last. However, none of the pre-treatment factors that were examined were found to differ significantly between the two groups. The current analyses included type, number, and severity of anxiety diagnoses and the lack of significant findings may indicate that pre-treatment symptom severity is not the best predictor of who will choose to extend treatment beyond 16 sessions. This would suggest that other therapy-specific factors, such as engagement in therapy, parental involvement, therapeutic alliance, and motivation may be relevant in determining which clients find that extended intervention is needed. Psychosocial factors such as finances, geographic distance from the clinic, parental support structure, and outside interventions (e.g., medication use) may also influence a family’s decision to extend treatment. Alternatively, mean scores on measures of anxiety severity tended to be higher in the group who continued treatment. This suggests that the lack of findings could also be a result of underpowered analyses and should be examined with a larger sample.

Of the several factors that we examined at session 16, only two significantly differed between extenders and non-extenders. The first was youth anxiety as rated by parents on the MASC. This finding is not surprising given that parents have input on extending treatment and their endorsement of more severe anxiety likely contributes to the perceived need for more treatment. In contrast, type, severity, and number of diagnoses as rated by diagnosticians did not differ significantly between groups, nor did diagnostician rating of overall improvement since the beginning of treatment. Given that semi-structured diagnostic interviews are generally considered the gold standard to assess youth anxiety levels, this finding is intriguing and suggests that parents’ perception of their child’s anxiety may be the primary factor in the decision to continue treatment. Future studies should examine parental attitudes and beliefs about anxiety, parental self-efficacy regarding anxiety management, and family functioning as possible predictors of treatment utilization. Additional studies could examine parent-, youth-, and therapist-perceptions of youth anxiety severity and overall functioning after 16 sessions and compare which of these may be primarily responsible for the decision to continue. Clarifying how different families make this decision, as well as the implications for treatment outcomes, will assist in developing guidelines on how clinicians can best advise families on whether to extend or end treatment.

The second significant difference between groups was the length of time between the pre-treatment and session 16 assessments. Findings indicated that families that took longer to complete 16 sessions were more likely to end treatment after 16 sessions. It is likely that this measurement is a proxy for another factor, such as engagement in treatment. Treatment engagement itself may be influenced by a number of other factors, including motivation, parents’ perception of their child’s anxiety, or psychosocial barriers to accessing treatment. For example, those families that find it more difficult to attend weekly sessions (e.g., due to travel time to the clinic or competing demands in the family schedule) may be more likely to end treatment after 16 sessions. Similar factors may have influenced those families that chose to end treatment prior to completing the full 16 sessions of the manual. Future studies should examine these treatment engagement factors in a sample that includes participants who end treatment across various timepoints.

These findings have important clinical implications. First, therapists can feel confident in allowing families to extend past the number of sessions stipulated by manualized CBT protocols, as findings indicate that even several additional sessions may be beneficial. Findings suggest that interest in additional sessions should be anticipated, rather than viewed as a deviation from protocol, as the majority of families completed several additional sessions to target persistent symptoms of anxiety. Unfortunately, results of this study are not able to help guide clinicians in predicting whether specific youth will want or benefit from additional treatment. Additional research is needed, both naturalistic and experimental, to further our understanding of the factors influencing both the decision to extend treatment and the therapeutic value of this extension. Mixed method approaches will be informative in exploring parent, child, and therapist perspectives on this decision. In the meantime, therapists are advised to work closely with primary caregivers as well as youth to better understand their rationale and perspectives related to extending or ending treatment. As findings suggest parental perception of youth anxiety, not clinician ratings, are more highly asociated with the decision to continue treatment, it is important that therapists work to ensure that the family and therapist share an understanding of the child’s current functioning and agree on goals of additional treatment.

In spite of its strengths, the study has several limitations. First, we considered all youth who continued treatment as one group, although the number of additional sessions varied from one to seventeen. It is possible that some findings might differ if the number of extended sessions was examined continuously rather than dichotomously in a larger sample. Additionally, given the small sample and exploratory nature of this study, we chose not to correct for multiple comparisons. Future research should aim to replicate these findings in a more targeted study. The ratio of therapists to participants also limited our ability to consider therapist factors, and future studies should explore the impact of the individual therapist on the decision to extend. Another consideration is that the diagnostician measures used in this study (e.g., ADIS, CGI) have a restricted range of responses that is typically even more restricted in clinical populations. Therefore, it is possible that the lack of significant findings based on diagnostician ratings is due to a restricted range on those measures of symptom severity. Further work examining these questions with diagnostician-rated instruments allowing for a wider range of clinical responses, such as the Pediatric Anxiety Rating Scale (PARS; Walkup et al., 2001), is warranted. Finally, it is important to note that this was intended to be a naturalistic study examining the frequency and impact of additional sessions among youth receiving CBT for anxiety. As a result, the findings do not represent a random comparison between two treatment conditions, but rather provide a description of outcomes occurring in a naturalistic outpatient setting. Accordingly, there are threats to internal validity, as our ability to examine differences between extenders and non-extenders is confounded by families’ self-selection into each group. Therapists in this study also served the dual role of delivering treatment and advising families regarding potential continuation of therapy. Future studies should seek to examine the impact of additional sessions among youth who have been randomly assigned to receive additional sessions. Such a study should also examine differences between the two groups at a follow-up periods after treatment, to examine the impact of additional time on youth who chose to end rather than extend treatment.

Conclusions

This study is the first to explore the frequency and characteristics of treatment extension among youth receiving manualized CBT for anxiety. Findings indicate that treatment extension is frequent, most commonly consists of several additional sessions that continue to target anxiety, and is successful in increasing treatment gains. Current results suggest that the decision to continue treatment beyond session 16 is associated with parent-rating of the child’s anxiety, as well as the length of time between the pre-treatment and week 16 assessments. Future studies should aim to explore these and additional factors in a larger sample.

Acknowledgments

Funding: Hannah Frank was supported by the National Institute of Health [grant number F31MH112211]. Other authors did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

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