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date: 15 October 2019

Transdiagnostic Mechanisms and Treatment for Children and Adolescents: An Emerging Field

Abstract and Keywords

Transdiagnostic approaches promise robust conceptualizations of pathology and efficient and generalizable treatments by providing researchers with a novel way to integrate basic science, treatment research, and developmental psychopathology. It has inspired innovations in treatment development by distilling the most powerful treatment components from our library of evidence-based treatments. Transdiagnostic approaches have proved especially appealing in the youth domain given high rates of comorbidity and rapid developmental change. The chapter begins with an introduction to transdiagnostic conceptual definitions and history, then reviews state of the art cognitive, behavioral, and social research that explains mechanisms in the onset or maintenance of pathology using a transdiagnostic lens. It concludes with a review of the early efforts of transdiagnostic researchers to develop interventions to address multiple disorders simultaneously in children and adolescents. In all, the chapter provides a comprehensive introduction to the foundation and future directions of this emerging field.

Keywords: Transdiagnostic, child and adolescent, transdiagnostic mechanisms, transdiagnostic treatment, trandiagnostic approaches

In the past decade, since the first mentions of “transdiagnostic” treatment conceptualizations and unifying theories of pathology, interest in transdiagnostic approaches has skyrocketed. A quick Web of Science search using “transdiagnostic” or “unified protocol” terms reveals more than 400 publications from 2003 to 2014, with over 100 articles published in 2014 alone. What accounts for this interest? What topics encapsulate the transdiagnostic domain?

This chapter introduces the reader to an overview of definitions, conceptualization, and research on transdiagnostic approaches. It summarizes research on cognitive, behavioral, and social mechanisms that account for commonalities across disorders, and reviews state-of-the-art behavioral treatments that adopt a transdiagnostic lens. Children and adolescents will serve as the focus of this review, as these developmental stages lend themselves well to a transdiagnostic focus. We will highlight the unique advantages that such an approach brings to understanding and treating the most common behavioral problems in youth.

Three pieces of work signaled the emergence of modern transdiagnostic thinking. In 2003, Fairburn and colleagues (Fairburn, Cooper, & Shafran, 2003) made the case for a broader, “transdiagnostic,” theory to improve the efficacy of behavioral therapy in treating eating disorders by reconsidering how a client’s over-evaluation of eating, shape, and weight was formulated. Their model suggested that four mechanisms (clinical perfectionism, core low self-esteem, mood intolerance, interpersonal difficulties) played substantial roles in maintaining an individual’s eating pathology. These mechanisms helped explain frequently observed clinical complexities across bulimia nervosa, anorexia nervosa, and atypical eating disorders, such as high levels of comorbidity, temporal shifting between diagnostic states over time, and entrenched behavioral patterns. They then developed a transdiagnostic intervention that targeted the core common processes in a single, efficient package.

At the same time, Barlow and colleagues (Barlow, Allen, & Choate, 2004), were detailing their case for a “unified protocol” that was suitable for addressing concerns across a wide spectrum of emotional disorders. Noting the commonalities in etiology and latent structure across disorders, they proposed a distilled set of psychological procedures to provide an efficient and robust treatment approach. The resulting unified protocol focused on altering antecedent cognitive reappraisals, preventing emotional avoidance, and facilitating action tendencies that were independent from dysregulated moods. Particularly amongst anxiety and depressive disorders, the overlap of symptoms and phenomenology, high comorbidity, temporal relatedness across disorders, and the nonspecificity of treatment response all called for an approach that emphasized commonalities across disorders, rather than differences. The impetus for the unified protocol was rooted equally in a growing understanding of basic research and an interest in facilitating the dissemination of evidence-based practice. After several decades of furious treatment development in psychology, hundreds of treatment protocols had been produced, most with varying degrees of overlapping components. Distilling the numerous volumes of efficacious interventions into the most robust components would surely make evidence-based interventions more accessible for clients and easier to administer for local practitioners.

Finally, in 2004, Harvey and colleagues (Harvey, Watkins, Mansell, & Shafran, 2004) released a comprehensive volume that investigated the roles of key cognitive and behavioral processes in explaining the onset and maintenance of the entire scope of adult psychological disorders. The review included separate conclusions on the transdiagnostic roles of attention, memory, reasoning, thought, and behavior. The group also offered several theories to explain how common processes could lead to distinct disorders, a critical lynchpin for transdiagnostic models (Harvey, 2013). The “current concerns” model attributes different presentations of pathology to differing current goals of individuals. The “balance of common processes” model proposed that all universal processes operate on a continuum, and unique expressions of pathology are due to the relative activeness and strength of each process. It was acknowledged that distinct processes, laid on top of common processes, were also likely to play a role.

From these foundational works, one notes three distinct features of transdiagnostic frameworks: first, mechanistic and treatment research focus on identifying both the commonality and the distinctiveness of distinct disorders, represented by classification systems such as the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5; American Psychiatric Association [APA], 2013); second, basic processes (bio-psycho-socio-behavioral mechanisms) serve as the key unit of analysis for comparing and contrasting disorders; and third, treatment conceptualizations and strategies targeting these core mechanisms have the potential to produce more robust and efficient interventions. Numerous investigators have followed and reflected on the historical importance (Taylor & Clark, 2009), conceptual basis (Mansell, Harvey, Watkins, & Shafran, 2009), methodology (Mansell et al., 2009; Nolen-Hoeksema & Watkins, 2011), and treatment (McEvoy, Nathan, & Norton, 2009; McHugh, Murray, & Barlow, 2009) of transdiagnostic work in psychology.

Transdiagnostic Formulations in Youth

The first explicit description of a transdiagnostic intervention for youth was Ehrenreich and colleagues’ (Ehrenreich, Buzzella, & Barlow, 2007) extension of Barlow et al.’s (2004) unified protocol. Since then, the field has seen rapid expansion in the conceptual underpinnings, methodology, and treatment of transdiagnostic approaches as they apply to children and adolescents (Chu, 2012; Dozois, Seeds, & Collins, 2009; Ehrenreich-May & Chu, 2013a; Fraire & Ollendick, 2013; Nolen-Hoeksema & Watkins, 2011). The excitement is well-founded. Several factors make transdiagnostic approaches especially relevant for understanding emotional and behavioral problems in youth (Harvey, 2013). First, the fact that half of all lifetime disorders start by the age of 14 (Kessler et al., 2008) suggests that any approach that improves early prevention and intervention is welcome. Second, the high rates of comorbidity (the co-occurrence of two or more disorders) seen in adult populations are even higher in children and adolescents, where both within-class (e.g., multiple anxiety diagnoses) and across-class comorbidity (e.g., diagnosis of anxiety and conduct disorder) make comorbidity the rule rather than the exception (Angold, Costello, & Erkanli, 1999; Garber & Weersing, 2010).

Third, the field has become increasingly aware of the importance of dimensional conceptualizations of distress and multiple-domain outcomes (e.g., functional impairment, symptoms). This is true for adults, too, where the most recent edition of the DSM tried to incorporate dimensional descriptions into each disorder class, recognizing that most symptoms occur on a continuum and that multiple forms of impairment (e.g., occupational, interpersonal, somatic/health, quality of life) are critical for evaluating well-being (APA, 2013). Dimensional models may be even more relevant for youth, because great overlap in symptoms exists across youth disorders, and rapid development leads to some transitory symptoms across developmental stages. In addition, multiple informants (e.g., youth, parent, teacher, doctor, coach) add complexity to any diagnostic picture, which may be best accommodated by dimensional and multi-domain models.

Fourth, a transdiagnostic approach may help explain developmental phenomena such as divergent trajectories and “multifinality” (the case where a single risk factor leads to the subsequent expression of different disorders) (Nolen-Hoeksema & Watkins, 2011). As one example, longitudinal evidence suggests that many, but not all, teens and young adults who develop depression first displayed evidence of anxiety disorders earlier in life. Which teens and adults will ultimately develop depression, which will retain their anxiety disorders, and which will show remission from anxiety? Transdiagnostic research encourages the simultaneous evaluation of multiple processes (risk factors, mediators, moderators) with multiple disorders. This approach permits a unique understanding of the relative impact of the multiple processes involved in the development of symptoms, and how they may result in unifying and distinctive outcomes for different individuals.

Defining Transdiagnostic Research and Treatment

At its heart, transdiagnostic research encompasses any research that explicitly aims to elucidate the common processes that link, or differentiate among, multiple disorders (Ehrenreich-May & Chu, 2013b; Mansell et al., 2009). Such mechanisms research can aim to explain the differences between two or more problem sets, but problem sets can be defined as diagnoses, disorder classes (anxiety vs. mood disorders), or behavioral/emotional/interpersonal clusters (e.g., internalizing vs. externalizing symptoms). Transdiagnostic treatments aim to treat multiple disorders or problem sets using a common set of techniques or interventions. However, it is important to note that the defining feature of transdiagnostic interventions is that they target an identified set of core underlying processes (Ehrenreich-May & Chu, 2013b). This distinguishes them from therapeutic eclecticism, wherein therapists select interventions from a wide array of therapeutic strategies, based predominantly on pragmatic reasons, in an ad hoc fashion. Implicit to these definitions is the expectation that studying multiple processes across multiple disorders adds some explanatory power beyond what could be achieved simply by studying those same processes within a single disorder. Likewise, it is assumed that targeting core unifying processes gives an intervention greater efficacy, robustness, or efficiency (Ehrenreich-May & Chu, 2013b).

Does this approach reflect a revolution in science or a mere evolution of progress? We have made the case that, as applied to youth, transdiagnostic research and treatment appears to be a natural extension of the “best practices,” developmentally sensitive research that child and adolescent researchers have been advocating for a long time (Chu & Ehrenreich-May, 2013). Whereas many adult researchers have considered it a “revolutionary” movement to study multiple disorders at once, cross-diagnostic research has been commonplace in youth for years. Substantial comorbidity and rapid developmental transitions in this population dictate this flexible approach. As such, transdiagnostic research provides a unifying frame that joins the empirical study of basic science, developmental psychopathology, and treatment research (Chu & Ehrenreich-May, 2013).

Nevertheless, transdiagnostic research offers a unique and valuable extension to these prior approaches. To be transdiagnostic, we would expect that (1) any candidate mechanism will provide explanatory power in understanding the onset, development, or maintenance of target condition A and target condition B; but also that (2) the candidate mechanism will provide some kind of unique explanatory power in target conditions A and B that could not be attained through the study of A and B alone (Ehrenreich-May & Chu, 2013b). Inherent in this definition is the “sovereignty” of each disorder (or problem set or disorder class) as each is studied in relation to others. Transdiagnostic approaches do not claim to endorse a complete conversion in paradigm from a study of discrete categories to a fully dimensional model (e.g., Achenbach, 2005). The term transdiagnostic presumes there is value in maintaining the central classification of diagnoses. After all, individual anxiety disorders still have more in common with each other than they do with behavioral conduct or schizophrenic disorders. Thus a transdiagnostic framework encourages the understanding of the processes that illuminate both similar and disparate disorders, while retaining the knowledge we have gained from the science of diagnosis.

The above criteria only provide a conceptual starting point. We recognize the methodological and statistical challenges in achieving such clarity; the methods may not currently exist to satisfy these criteria completely. From an aspirational perspective, then, transdiagnostic science aims to identify the smallest number of key mechanisms that hold the most explanatory power in understanding psychological disorders. There are many steps to take to achieve this. Others have warned that transdiagnostic research must prove its unique value over current approaches (Ollendick, Fraire, & Spence, 2013). Transdiagnostic interventions must show greater efficacy (superior outcomes), robustness (superior generalizability or durability of effects), uniqueness (helping a different set of clients than do traditional evidence-based treatments), or efficiency (simplicity in training or client absorption of lessons). Transdiagnostic treatments must also distinguish themselves from “kitchen sink” eclectic approaches and must retain their mechanistic focus to enhance their scientific rigor (Chu & Ehrenreich-May, 2013).

The current literature does not live up to these lofty expectations. The explicit, intentional study of transdiagnostic mechanisms and unified treatments is in its nascent stages. Yet impressive progress has been made. The remainder of this chapter reviews research that was completed within an explicit transdiagnostic framework or that has transdiagnostic implications by virtue of its study of basic mechanisms across disorders. The next part of this chapter reviews the available basic research, and the final part compares and contrasts state-of-the-art transdiagnostic treatment approaches.

Transdiagnostic Mechanisms

An understanding of potential common mechanisms is necessary to building therapies that serve transdiagnostic functions. Research on basic processes has already begun, with a number of groups focusing their efforts on increasing their understanding of potential underlying mechanisms of both internalizing and externalizing disorders (Ehrenreich-May & Chu, 2013a). Mechanisms with growing support as transdiagnostic processes include coping styles, cognitive biases, behavioral avoidance, rumination, and peer relations. Although the majority of the reviewed research has not been conducted within an explicit transdiagnostic framework, each study addresses important questions of comorbidity across diagnoses and problem sets. Other studies address divergent trajectories amongst youth who demonstrate risk factors thought to be transdiagnostic.

Stress and Coping

An individual’s response to stress events has been one process proposed to explain the expression of pathology across disorder or problem types. “Stress” refers to acute events or chronic conditions that present a threat to a youth’s physical or mental health (Grant, Compas, Stuhlmacher, Thurm, & McMahon, 2003). Findings from over 50 prospective longitudinal studies have shown that stress is related to increased internalizing and externalizing of symptoms over time (Grant, Compas, Thurm, McMahon, & Gipson, 2004). Some research links specific stressors with specific disorders, such as the development of post-traumatic stress disorder (PTSD) following sexual abuse (McMahon, Grant, Compas, Thurm, & Ey, 2003). Other studies suggest that there is not a clear link between the type of negative event and the resulting disorder. For example, specific instances of parental loss or divorce, childhood maltreatment, parental pathology, and life-threatening medical illness in childhood are associated with higher rates of all types of pathology later in life. Another study found that 50–80% of individuals who have been exposed to stressors related to parental depression, such as low parental warmth and lack of structure, will meet criteria for a psychiatric disorder by the time they reach young adulthood (England & Sim, 2009). Chronic stressors, such as poverty and economic disadvantage and its impact on parenting, have been found to be associated with both internalizing and externalizing symptoms (Grant et al., 2003). It appears to be the case that stressful life events affect youth regulatory capacity, and it is possible that comorbidity occurs due to dysregulation that underlies multiple disorders, or that stress impacts multiple regulation processes underlying independent but co-occurring disorders (Compas, Watson, Reising, & Dunbar, 2013).

To explore these possibilities, research has examined multiple regulatory processes as they relate to different disorders. In particular, studies have explored the role of different coping strategies in the relationship between stress and symptomology. Primary control coping strategies include skills such as problem solving, emotional expression, and emotion modulation; secondary control coping strategies include acceptance, cognitive reappraisal, positive thinking, and distraction; disengagement coping strategies include avoidance, denial, and wishful thinking. In a study of 364 adolescents exposed to economic hardship, in which stress related to perceived economic strain and family conflict was associated with aggression, anxiety, and depression, it was found that youth with higher levels of stress in their lives were less likely to employ the primary and secondary coping strategies that were related to fewer overall problems (Wadsworth & Compas, 2002). A second study, with 164 adolescents and their families, found that poverty-related stress was significantly associated with both internalizing and externalizing symptoms, but that active coping strategies served as buffers against higher symptomology (Wadsworth & Santiago, 2008). Together, research suggests that common forms of stress can trigger a diverse range of symptomatic reactions in youth, and that dysregulation amongst several common coping strategies may determine who manifests distress and who may not.

Numerous studies have also explored the impact on youth of stress related to parental depression. Results across studies have demonstrated that secondary coping strategies, such as cognitive reappraisal and acceptance, have served as buffers between stress and externalizing and internalizing symptoms (Fear et al., 2009; Jaser et al., 2005, 2007, 2008, 2011; Langrock, Compas, Keller, Merchant, & Copeland, 2002). It is less clear whether primary or disengagement strategies have the power of acting as a buffer between stress and symptomology across disorders. Subsequently, Compas and colleagues (2010) have sought to understand how these common regulatory processes mediate change in treatment. In one study, Compas et al. (2010) implemented a preventative, family-based, cognitive-behavioral intervention in a group format for youth and depressed parents, which focused on teaching youth how to cope with parental depression by using secondary coping strategies. Changes in the use of secondary coping strategies between baseline and six-month follow-up were found to mediate the effect between treatment and depression, mixed anxiety and depression, and externalizing symptoms at 12-month follow-up (Compas et al., 2010). This suggests that secondary coping strategies play an important regulating role in the expression of a diverse range of symptoms.

The stress literature indicates two interesting directions for future transdiagnostic research. A traditional route would be to identify which internal regulatory processes mediate the impact of stress and various stressors on the individual’s functioning and development. A second route could be to explore which types of stressors serve unique or common roles across disorders and problem sets. Using a diathesis-stress model, in which a combination of stressors and pre-diposed vulnerabilities contribute to the development of symptoms, like this, we find novel avenues for transdiagnostic research in both components of the model.

Attention Processes

Another process hypothesized to serve mechanistic roles across disorders is cognitive attention. Attention dysfunction refers to an imbalance in the processes (alerting, orienting, and executive attention) (Berger & Posner, 2000) that allow us to take in relevant information while excluding other information (Hiatt-Racer & Dishion, 2012). Evidence for attention dysfunction as a transdiagnostic factor has shown that attention skills can moderate anxiety traits (Derryberry & Reed, 2002) and can act as a protective factor for the effect of negative emotionality on externalizing problems in children (Eisenberg, 2002). One longitudinal study demonstrated that strong executive attention helped protect youth from the development and maintenance of antisocial behaviors (Dishion & Connell, 2006; Gardner, Dishion & Connell, 2008). The study found that executive attention also moderated the effects of deviant peers, one of the strongest environmental predictors of the development of antisocial behaviors in youth (Dishion et al., 2004; Elliot, Huizinga, & Ageton, 1982; Patterson, 1993). Fraire and Ollendick (2013) conducted a literature review examining attentional control as a mechanism underlying the co-occurrence of anxiety symptoms and oppositional defiant disorder (ODD). The researchers proposed that, from a theoretical standpoint, children with comorbid anxiety and oppositionality might have deficits in their ability to shift attention; focusing on stimulus-driven attention and perceived threatening situations, which increase the likelihood of engaging in oppositional behaviors (Fraire & Ollendick, 2013). Their review found that there is empirical evidence to support information-processing biases as a transdiagnostic process underlying anxiety and ODD. Current cognitive-behavioral therapy (CBT) treatments target this process through training with vignettes and problem-solving strategies to help youth understand threatening and non-threatening situations and consequences and appropriate solutions (Fraire & Ollendick, 2013). Additional studies have demonstrated that executive attention moderates the relationship between psychosocial stress and increased risk for depression (Dishion & Connell, 2006).

Hiatt-Racer and Dishion (2012) drew on the treatment literature to develop a transdiagnostic intervention focusing on disordered attention. Empirical support has been found for attention-training having broad treatment outcomes, including improvements in attention (Rueda, Rothbart, McCandliss, Saccomanno, & Posner, 2005), intelligence (Stevens, Fanning, Coch, Sanders, & Neville, 2008), and academic performance (Rabiner, Murray, Skinner, & Malone, 2010), and an overall improvement in functioning and psychological health in youth (Hiatt-Racer & Dishion, 2012). Research has already demonstrated the effectiveness of broad-based attention training with cognitive behavioral interventions; however, more research is needed to assess the acceptability and feasibility of targeted attention-training programs, such as “Captain’s Log,” developed by BrainTrain, and attention bias modification (ABM), as primary interventions (Hiatt-Racer & Dishion, 2012). Captain’s Log is a computerized program that uses a series of games to train important attention skills, and it has various levels of difficulty to target a range of ages in youth (Hiatt-Racer & Dishion, 2012). The one published RCT as of this writing provided support for the efficacy of Captain’s Log as a treatment for attention difficulties, as a larger percentage of the children receiving the intervention demonstrated improvement on inattentiveness ratings compared to the children in the control condition (Rabiner et al., 2010). Attention bias modification (ABM) is a computerized dot-probe task, which has been used to target anxiety in youth and adults (Amir, Weber, Beard, Bomyea, & Taylor, 2008; Bar-Haim, 2010; Eldar, Ricon, & Bar-Haim, 2008). Studies on anxious and non-anxious children demonstrated that young children (7 and older) are able to follow the attention-training program and that the techniques were clinically beneficial (Amir et al., 2008; Eldar et al., 2008). Similar support has been found for attention-training programs across a diverse range of clinical populations (Hiatt-Racer & Dishion, 2012). Further development is needed, including standardization of both assessment and treatment approaches, but interventions that focus on basic mechanisms like attention have promise in benefitting diverse clinical populations.

Thus, research from both experimental and treatment literatures has provided preliminary support for the role of attention processes, particularly information-processing biases, in maintaining diverse forms of youth disorders, including anxiety and disruptive-behavior disorders. Computer-based programs designed specifically to modify attention processes have been applied primarily to anxious youth. Future research will want to develop such protocols across multiple problem areas.

Cognitive and Behavioral Avoidance

Avoidance refers to situations in which an individual does not enter, or prematurely leaves, a fear-evoking or distressing situation. Avoidant behavior is defined by the negative reinforcement the behavior receives by escaping a stressor, even as the escape forecloses further opportunities for positive reinforcement (Ferster, 1973; Jacobson, Martell, & Dimidjian, 2001). Avoidance can occur in either behavioral (e.g., fleeing, procrastination) or cognitive (e.g., worry, distraction) forms. In observational studies, youth participating in community and clinical studies have demonstrated that disengagement coping strategies, such as cognitive and behavioral avoidance and denial, are correlated with increased impairment across disorders, including internalizing and externalizing symptoms (Compas et al., 2001; Chu & Harrison, 2007) and anxiety, depression, and somatic complaints (Compas et al., 2006). In one study, youth with anxiety were more likely to interpret ambiguous situations as threatening and respond with avoidance strategies than were non-clinical or oppositional youth (Barrett, Rapee, Dadds, & Ryan, 1996). Another study prompted adolescents to generate strategies that would help them accomplish goals, and found that youth with both depression or mixed anxiety and depression reported higher use of avoidant plans than non-anxious/non-depressed youth (Dickson & MacLeod, 2004). Longitudinal studies looking at elementary school students found that withdrawal and social isolation increased their depression over time, and that increasing levels of withdrawal were related to higher levels of friendlessness, interpersonal instability, and peer exclusion (Gazelle & Ladd, 2003; Oh et al., 2008).

In the treatment literature, Whiteside, Gryczkowski, Ale, Brown-Jacobsen, and McCarthy (2013) asked parents and children to report youth’s level of avoidance prior to beginning exposure-based cognitive behavioral therapy, and found that parental report of youth avoidance was associated with parental report of youth impairment after controlling for anxiety symptoms, as was youth-reported avoidance with youth-reported impairment. Moreover, parental reports of behavioral avoidance predicted changes in anxiety symptoms over time, providing further support that avoidance (at least as perceived by parents and youth) plays a key role in the maintenance of anxiety disorders. Chu and Harrison (2007) conducted a meta-analysis of clinical trials for anxious and depressed youth who had utilized behavioral avoidance tasks. Results demonstrated that CBT for anxiety disorders, which teaches active, rather than avoidant, coping skills, produced reliable changes across behavioral outcomes (Effect Size [ES] = 1.02). This was not documented in depression trials, but this may be partly related to lesser representation of avoidance measures in depression trials and the fact that most measurement relied on ratings of pleasant activities and social skills, rather than observed avoidant behavior. Still, numerous treatment studies have demonstrated that reduced pleasant and increased unpleasant activities (two potential proxies for avoidance) are linked to youth mood (Wierzbicki & Sayler, 1991).

Rumination, which some have described as cognitive avoidance (Jacobson, Martell, & Dimidjian, 2001), is an important transdiagnostic risk factor underlying the development and co-occurrence of multiple internalizing and externalizing problems in children and adolescents (McLaughlin & Nolen-Hoeksema, 2011, 2012). Specifically, rumination has been found to predict depression (Hilt et al., 2008; Nolen-Hoeksema & Hilt, 2009; Rood et al., 2009), anxiety (Verstraeten, Bijttebier, Vasey, & Raes, 2011), eating pathology (Nolen-Hoeksema, Larson, & Grayson, 1999; Nolen-Hoeksema, Stice, Wade, & Bohon 2007), binge drinking (Nolen-Hoeksema et al., 2007), and self-injurious behaviors (Hilt, Cha, & Nolen-Hoeksema, 2008; Hoff & Muehlenkamp, 2009) in youth. In addition, theorists have argued that rumination plays a role in the transition from internalizing disorders strongly associated with rumination, such as anxiety and depression, to the development of aggressive behaviors in youth (Caprara, 1986). This can be explained by the failure model, which hypothesizes that aggressive and aversive behaviors lead to increased conflict and failures in social and academic domains, heightening the risk for anxiety and depression (Capaldi, 1992).

Longitudinal and experimental studies have demonstrated that failure experiences predict increases in rumination (McLaughlin et al., 2009; Michl et al., 2013), and rumination predicts increases in anxiety and depression over time in youth (Nolen-Hoeksema & Watkins, 2011; Verstraeten et al., 2011). In order to expand and examine the relationship between rumination and the transition from internalizing disorders to aggressive behaviors, McLaughlin, Aldao, Wisco, and Hilt (2014) conducted a longitudinal meditational analysis to assess their prediction that rumination would mediate the reciprocal relationship between internalizing problems and aggressive behavior. Results showed that rumination explained the co-occurrence of internalizing problems and aggressive behavior over time, and this relationship was found to be gender-specific to adolescent males (McLaughlin et al., 2014). The results of this study support the transdiagnostic role of rumination across internalizing and externalizing problems in youth, and that important factors (e.g., gender) may moderate the impact of the process on pathology expression (McLaughlin et al., 2014).

Social Relations

The extent to which youth are rejected or accepted by their peers is another important underlying factor in the development and maintenance of multiple psychological disorders. Compared to popular youth, rejected youth are more likely to display interpersonal, emotional, and academic difficulties, in addition to internalizing problems such as anxiety (La Greca & Landoll, 2011; La Greca & Lopez, 1998; La Greca & Stone, 1993) and depression (La Greca & Harrison, 2005). Much like other environmental stressors, interpersonal difficulties such as peer victimization and peer rejection may contribute to anxiety, distress, or depression, which then in turn may worsen the existing problems by inhibiting socialization experiences (Coie et al., 1990) or result in less desirable companions and increased social exclusion (Blöte & Westenberg, 2007). While differences become less distinct among adolescents, young girls tend to face more relational victimization, and young boys endure more overt peer victimization (Crick & Bigbee, 1998; De Los Reyes & Prinstein, 2004; La Greca & Harrison, 2005; Siegel et al., 2009). Relational peer victimization appears to be particularly associated with social anxiety among the adolescents who experience it (La Greca & Harrison, 2005; Siegel et al., 2009; Storch et al., 2003). Community studies support this finding, with peer-rejected youth having substantial interpersonal and emotional difficulties (Coie et al., 1990) and greater social anxiety (La Greca & Lopez, 1998; La Greca & Stone, 1993) and depressive symptoms than their peers (Prinstein & Aikins, 2004). In a clinical sample, Strauss, Frame, and Forehand (1987) found that youth with anxiety disorders were less well-liked than non-anxious youth.

Similar trends are seen with depressed youth, who tend to have higher rates of interpersonal difficulties, are more frequently rejected by peers, and are less popular than non-depressed youth (Little & Garber, 1995). Support has also been found for the role of social relations as a maintaining mechanism in externalizing disorders, with higher rates of peer rejection in early childhood predicting conduct problems in elementary school (Miller-Johnson et al., 2002), and both ODD and conduct disorder showing links to peer victimization (Kokkinos & Panayiotou, 2004) and rejection (Frick, 2006). Accordingly, it may be important for clinics to screen incoming youth for interpersonal difficulties, in addition to looking for areas of social support or competence to help counteract anxiety or depressive symptoms. Treatment that can help youth find ways to improve peer reputation, enhance positive skills, and reduce annoying or interfering behaviors may prove beneficial in decreasing impairment caused by the severity of youth anxiety and depression (La Greca & Lai, 2013).

Child and Adolescent Transdiagnostic Treatments

What treatments have taken a transdiagnostic approach? We limited our review to interventions designed to address simultaneous anxiety and depression, since the majority of early efforts have been made here. Furthermore, several approaches have been used to address comorbidity, including employing single-target treatments with flexibility and modular-based therapies (Chu, Merson, Zandberg, & Areizaga, 2011; McHugh, Murray & Barlow, 2009). Evidence exists to show that single-target and modular approaches can have an impact on comorbid conditions in anxious and depressed youth (Kendall, Brady, & Verduin, 2001; Weisz et al., 2012). Indeed, many youth protocols were intentionally designed to be multi-target interventions before transdiagnostic conceptualizations existed (e.g., Kendall et al., 1998). However, here we will focus on explicitly transdiagnostic approaches.

The first youth transdiagnostic treatment, developed by Ehrenreich, Goldstein, Wright, and Barlow (2009), evolved as a downward extension of the adult Unified Protocol for the Treatment of Emotional Disorders (Barlow et al., 2004). Since its initial clinical description (Barlow et al., 2004), the UP-Adolescent (UP-A) has undergone multiple revisions adjusting the format, and treatment modules and strategies to adapt to diverse age groups, service settings, and target problems. The original iteration (Ehrenreich et al., 2009) focused on three core components: (1) altering antecedent cognitive appraisals, (2) preventing emotional avoidance, and (3) encouraging actions that are inconsistent with disordered emotional states. It differed from the adult version by incorporating developmentally appropriate language and examples, increasing activity within sessions, and emphasizing adolescent collaboration and parental involvement.

Subsequent revisions to UP-A resulted in an updated protocol called UP-Youth (UP-Y), which divided the three core components into five mandatory modules: (1) psychoeducation about emotions and pain, (2) awareness of emotions and pain, (3) flexibility in thinking, (4) modifying emotion-driven behaviors through exposures, and (5) treatment review and relapse preventions.

The optional components are: (1) building and keeping motivation, (2) keeping safe (targeted at adolescents with suicidal ideation or intent), and (3) parenting the emotional adolescent. As a result, the unified protocols provide a comprehensive toolbox of skills that are designed to target several critical universal processes: antecedent cognitive appraisals, emotional avoidance, and behavioral avoidance.

Subsequent adaptations of the Unified Protocol include foci on treating co-occurring pain (Allen, Tsao, Seidman, Ehrenreich-May, & Zeltzer, 2012) and substance abuse (Suarez et al., 2006), and school settings (Ehrenreich-May & Bilek, 2012). Pilot studies of each version demonstrated decreased symptom severity, with results across one open trial and one RCT representing a total sample of 55 showing that both anxiety and depressive symptoms decreased at similar rates during treatment and led to significant reductions in clinical severity ratings at post-treatment. Ratings of anxiety continued to decrease between post-treatment and follow-up, while depression ratings appeared to plateau at post-treatment (Queen, Barlow, & Ehrenreich-May, 2014).

Chu, Colognori, Weissman, and Bannon (2009) developed group behavioral activation therapy (GBAT) as a transdiagnostic treatment targeting behavioral avoidance as a common mechanism for anxious and depressed youth. Avoidance maintains depressive and anxiety symptoms by reducing short-term distress, but it fails to produce positive change, and often creates additional problems in the process (Jacobson et al., 2001). Behavioral activation (BA) works to reduce depressive symptoms by increasing activities with natural reinforcers, while encouraging anxious individuals to learn to tolerate and cope with temporary distress brought on by fear-inducing stimuli. The program, titled Group Behavioral Activation Therapy (GBAT) SKILLS, adapts an adult BA protocol (Addis & Martell, 2004; Martell et al., 2001) for use with middle-school youth and incorporates exposure exercises for anxiety-related problems. Chu et al. (2011) adapted GBAT to create individual behavioral activation therapy (IBAT), a transdiagnostic approach that uses the same principles and skills to target physical escape or resistance, avoidance of emotional states, and low frustration-tolerance. Across one open trial and one RCT (Chu et al., 2009; Chu et al., 2016), representing a total sample of 40 participants, GBAT resulted in reduced impairment from pre-treatment to post-treatment. Early research found that IBAT was beneficial because it simplified necessary skills and allowed clinicians and participants to focus on one underlying principle. IBAT increased generalizability by allowing clinicians and youth to utilize only one manual and one set of problem-solving tools for both depression and anxiety symptoms.

Weersing, Gonzalez, Campo, and Lucas (2008) contributed to the transdiagnostic CBT treatments for pediatric anxiety and depression disorders with the development of integrated brief behavioral therapy (IBBT) for children and adolescents between the ages of 7 and 17 presenting with an internalizing disorder in a primary-care setting. Treatment involves “graded engagement,” which is composed of exposure and behavioral activation, to target avoidance. Through this central technique of active engagement, Weersing and colleagues proposed that anxious and depressed youth would naturally reduce their avoidance of fear-provoking or difficult situations. Following a promising pilot study with 54 participants, IBBT was expanded into a “Transdiagnostic Internalizing Toolbox” for the treatment of anxiety, depression, and somatic complaints in pediatric primary care, with two protocols: brief behavioral therapy (BBT) for pediatric anxiety and depression (previously referred to as IBBT), and brief behavioral therapy (BBT) for anxiety and pediatric abdominal pain (Weersing, Rozenman, Maher-Bridge, & Campo, 2012). Like IBBT, the core component of BBT is BA, but the expansion specifically aims to teach youth how to endure pain for longer periods of time through engagement in pleasant activities and the use of positive self-statements. BBT also expands parental involvement from weekly check-ins to a dedicated parent session that teaches contingency-management skills. Case studies using BBT suggest that the treatment leads to a reduction in symptoms across the cluster of disorders.

Kendall, Stark, Martinsen, O’Neil, and Arora (2013) developed the program titled, EMOTION: “Coping Kids” Managing Anxiety and Depression (EMOTION), as an early-identification, transdiagnostic preventative program for children exhibiting anxiety and/or depression symptoms in schools. EMOTION was designed as a 20-session group intervention to be delivered by school psychologists (Martinsen, Kendall, Stark, & Neumer, 2014). The program utilizes core therapeutic techniques of single-target treatments for anxiety and depression in order to target the common mechanisms: avoidance and maladaptive thinking patterns. EMOTION addresses psychoeducation, problem solving, cognitive restructuring, behavioral activation, and graded exposures through kid-friendly and hands-on activities. A pilot study was conducted with fifth-graders at a rural school in Norway to assess the feasibility and acceptability of the program (Ehrenreich-May & Chu, 2013a; Martinsen et al., 2014). The researchers reported high satisfaction ratings from both the participants and the deliverers of the EMOTION intervention. The initial findings indicate that EMOTION has the potential to be an effective school-based prevention program for children with anxiety and depressive symptoms.

Comparison of Treatments

Many similarities are apparent amongst current transdiagnostic interventions for anxiety and depression (Table 1). UP-Y and Emotion Detectives (Ehrenreich et al., 2009; Ehrenreich-May & Bilek, 2012) are outpatient treatments that target internalizing disorders, with the former geared towards adolescents, and the latter formatted for 7–12-year-olds. Other UP versions target anxiety and depression and chronic pain (Unified Protocol for the Treatment of Emotions in Youth with Pain [UP-YP]; Allen, Tsao, Seidman, Ehrenreich-May, & Zeltzer, 2012), which depart from the other UP protocols through increased emphasis on emotional reactions to physical discomfort and pain. GBAT and IBAT (Chu et al., 2009, 2011) were developed to treat anxiety and depression, with IBAT being delivered as a youth outpatient treatment, and GBAT being conducted in schools with seventh and eighth graders. GBAT was also designed to ultimately be implemented by school professionals (e.g., counselors, teachers) rather than specialized mental health professionals. Similar to the GBAT, the EMOTION program (Martinsen et al., 2014) was developed as a preventative intervention for youth (ages 8–13) who experience symptoms of anxiety and/or depression in school. Though the large number of required clinicians may present barriers for some school districts, school-based group psychotherapy could help facilitate access to youth as more students may elect to attend services when located in a familiar setting. BBT (Weersing et al., 2008, 2012) has two protocols, one focusing on anxiety and depression, and the other on anxiety and pain. Both were developed for youth ages 7–17 in primary care settings, with the intention that mental health workers, such as nurse practitioners or social workers, could deliver treatment. This increases ease of dissemination, but does present the need for additional training prior to, and supervision during, treatment delivery.

Table 1 Content Comparison Across Treatment Approaches (Number of sessions where a strategy is represented)

UP-Y

Emotion Detectives

GBAT

IBAT

BBT for Anx/Dep

BBT for Anx/Pain

EMOTION

Setting

Outpatient

Outpatient

School-Based

Outpatient

Primary Care Facilities

Primary Care Facilities

School-Based

Intended Client

Ages 7–12 Internalizing Disorders

Ages 7–12 Internalizing Disorders

Ages 11–16 Anxiety, Depression, Anger

Ages 11–16 Anxiety, Depression, Anger

Ages 7–17 Anxiety and Depression

Ages 7–17 Anxiety and Chronic Pain

Ages 8–13 Anxiety and Depression

Total Number of Sessions

8–21

15

10

14

8–12

6

20

Strategy

Psychoeducation: About nature of anx/dep, distress, treatment approach

2–3

1–4

1

1

1

1

  • 2

  • 2

Awareness of Emotion: Generalized emotion exposures, mindful awareness of emotions

1–3

Affective Education: Specific education about physical response to anxiety/depression

1

1

1

Relaxation Training

1

1

1

Cognitive Restructuring: Identifying and challenging negative thinking

2–3

1

10

Problem Solving

2–3

2

1

1

4

Self-Evaluation/Rewards: Contingency management (building and applying reward plan)

1

1

In Vivo Exposures

2–5

6

4

4

1

1

10

Presenting a Positive Self: Practice in self-presentation skills

9

Behavioral Activation (Tracking): Tracking and identifying link between events and mood

1–4

2

2

2

Functional Analysis: Identifying idiographic distress loops (TRAP: Trigger, Response, Avoidance Pattern)

3

3

Behavioral Activation (Pleasant Activities): Either assigning rewarding activities or conducting idiographic problem solving after functional analysis (TRAC: Trigger, Response, Alternative Coping)

6

3

3

3–7

10

Social Skills Building: Building talents for self-confidence/competence

Support Seeking: Seeking help from friends and family

1

Anti-Perseveration: Teaching youth to break from depressive perseveration/rumination

  • Parent Training

  • School Collaboration

1

  • 8

  • 20

Relapse Prevention

1

1

1

1

1

Greater differences are seen across formatting, treatment setting, and intended clients. Formatting for each manual is unique. Emotion Detectives (Bilek & Ehrenreich-May, 2012) consists of 15 90-minute youth and parent group meetings that teach a specified set of skills to all members. UP-Y (Ehrenreich et al., 2009) ranges from 8–21 individual sessions with five mandatory modules and three optional modules, and can be administered in both individual and group settings. The EMOTION prevention program (Martinsen et al., 2014) has a 20-session group format with a structured sequence of sessions and eight parent meetings. GBAT (Chu et al., 2009) uses a 10-week group format with a structured sequence of sessions, but treatment does not include separate parent meetings. IBAT (Chu et al., 2011) is individual treatment lasting 14 weeks and follows the same structure as GBAT. BBT for anxiety and depression lasts 8–12 weeks (Weersing et al., 2008), while BBT for anxiety and pain lasts only six sessions but includes substantial planning for out-of-session practice (Weersing et al., 2012). Both BBT treatments include parent participation and parenting skills training (Weersing et al., 2008, 2012). BBT is the shortest treatment, therefore decreasing time demands on clinicians and potentially proving more cost-effective than other treatments.

Each protocol format presents its own benefits and challenges. UP-Y allows for flexibility to individualize the pace and focus of treatment for each client regardless of symptoms stemming from anxiety, depression, pain, or otherwise. However, this also requires relatively substantial clinical judgement to choose which modules to employ and forces clinicians and clients to become well versed in multiple strategies and skills. The therapist’s manual does provide a recommended range of number of sessions to be spent on each module, giving therapists guidance in tailoring treatment. Emotion Detectives, the EMOTION program, GBAT, and IBAT utilize uniform delivery plans that simplify treatment by decreasing the number of modules that must be learned. Additionally, GBAT and IBAT increase generalizability by emphasizing one core strategy (anti-avoidant problem solving) for both depression and anxiety symptoms. Like GBAT, BBT simplifies concepts and manuals by focusing exclusively on avoidance, and follows a specified format regardless of the presenting disorder. While these approaches streamline the treatment focus, they may forfeit nuanced vocabulary and skills common to more comprehensive single-disorder treatments.

In terms of strategies taught, many similarities are evident (Table 1). Most manuals incorporate some form of psychoeducation and problem-solving lessons, rewards, and all include in vivo exposures or behavioral activation. However, there are substantial differences in the extent to which these strategies are employed. For example, in vivo exposures are implemented in anywhere from one (BBT) to ten sessions (EMOTION). The dose of each strategy seems tied to the overall length of the treatment, as longer interventions permit greater “dose” across all sessions. Some of the protocols also permit flexibility in the number of sessions (e.g., GBAT, UP-Y) so intervention dose can vary even within one protocol. There are some notable differences in strategy content. While all protocols include exposure exercises, not all include lessons on affective education, emotion awareness, relaxation, or cognitive restructuring. The choice of which strategies to include follows each protocol’s explicit theories of change.

Accordingly, the most significant difference among protocols lies in the explicitly targeted mechanism. The Unified Protocol treatments theorize that symptoms are maintained through high negative affect, with UP-Y emphasizing avoidance of emotional states. This focus stems from the theory that the high overlap and comorbidity between anxiety and depression result from general underlying neuroticism that is expressing itself differently in different people (Andrews, 1990, 1996; Tyler, 1989). Research on latent structures of internalizing disorders provides evidence for pathways leading from negative affect to both anxiety and depression among a youth population (Brown, Chorpita, & Barlow, 1998). Studies on emotion regulation provide further support for this concept, and suggest that treatments targeting dysregulation may be effective for multiple disorders (Ehrenreich et al., 2009). UP-Y does this by specifically emphasizing emotional awareness through modules that introduce youth to a broad range of both positive and negative emotional experiences. Treatment teaches mindful acknowledgement of these states and helps youth modify negative thoughts and increase their control of their emotions (Ehrenreich, Buzzella, & Barlow, 2007). As demonstrated in Table 1, UP-Y allots a greater number of sessions than either GBAT or BBT to increasing emotional awareness. Additionally, a primary goal of treatment is to teach kids how to examine and challenge negative thoughts that are related to their emotions. UP-Y also includes time for youth to be exposed to distressing situations and practice utilizing their emotional awareness, cognitive reappraisal skills, and ability to tolerate distress (Seager, Rowley, & Ehrenreich-May, 2014).

Conversely, GBAT and BBT assert that avoidance, rather than cognitive misappraisal, is the primary maintenance mechanism of anxiety and depression. Avoidance allows individuals to escape from immediate distress, but denies them the opportunity to learn how to tolerate and cope with negative feelings, situations, or behaviors (Chu et al., 2009). GBAT helps youth identify where they are “stuck” through self-assessment and monitoring. Treatment encourages them to approach distressing scenarios and increase their activity level by identifying meaningful goals and problem-solving typical avoidance patterns. Exposures and behavioral activation provide the opportunity to practice problem-solving skills and approach behavior.

BBT follows a similar structure on a condensed timeline, which caters to its proposed treatment setting of primary care facilities. The relaxation session may be particularly relevant for kids with chronic pain who experience a great many physiological symptoms. Time is spent teaching problem solving, and then practicing distress-tolerance through exposures. A greater emphasis is placed on out-of-session exposures in an attempt to decrease their time spent in the treatment facility and increase generalizability in the child’s day-to-day life. The protocol for depression includes additional sessions on behavioral activation in order to help promote natural reinforcers that can counteract the immediate relief that avoidance provides (Weersing et al., 2012). Reviewing session-allotment to strategies, each protocol is structured around its proposed mechanism, with UP-Y spending a great deal of time on emotional awareness and cognitive reappraisal, and GBAT and BBT treatment sessions focusing almost exclusively on identifying and altering behavioral avoidance.

The preventative EMOTION intervention takes a traditional CBT approach in addressing avoidance and maladaptive thinking patterns. It incorporates core components and strategies of empirically supported treatments for anxiety and depression. EMOTION is the longest and most intensive treatment reviewed in this section because it includes a large majority of the session material covered in the other treatments, such as psychoeducation, teaching and applying skills, and parent sessions (Martinsen et al., 2014). The authors believe that by focusing on these two main mechanisms, EMOTION can address the majority of concerns faced by anxious and depressed youth.

Related Interventions

Although not developed as specifically transdiagnostic treatments, there are several other interventions that serve transdiagnostic functions. For example, Manassis, Wilansky-Traynor, Farzan, Kleiman, Parker, and Sanford (2010) developed “The Feelings Club,” a school-based intervention to target children with anxious and/or depressive symptoms. This intervention was not specifically labeled “transdiagnostic,” yet it integrates a modular approach that targets the co-occurrence of anxious and depressive symptoms. The Feelings Club uses cognitive restructuring as a primary strategy. To help focus each youth’s experience, each group member was encouraged to select a feeling to focus on for the duration of treatment. Manassis and colleagues (2010) conducted a control comparison to an activity club that mirrored the Feelings Club activities but lacked the emotion content. Results from the study demonstrated anxious and depressive symptom reduction in both groups, but the treatment and control conditions did not significantly differ as a function of time.

Weisz et al. (2012) developed a modular protocol designed to treat anxiety, depression, and conduct problems in one intervention. The MATCH protocol (Chorpita & Weisz, 2005) is not uniquely transdiagnostic, but its flexible format enables it to target multiple problem areas within a single protocol. However, because it does not profess to focus on explicit unifying mechanisms, it might best be viewed as a delivery system that delivers eclectic treatment strategies based on the empirical evidence for treating specific problems. RCTs have demonstrated that youth receiving MATCH as compared to usual-care treatment reported significantly fewer diagnoses and produced significant improvement (Chorpita et al., 2013; Weisz et al., 2012).

Just as Fairburn et al.’s (2003) intervention for eating disorders served as a bellwether in the adult transdiagnostic field, progress has also been made in this domain for youth. Loeb et al. (2012) describes a family-based therapy (FBT) founded on the Maudsley approach that empowers parents to address disordered eating patterns in the child. FBT explicitly targets the common mechanisms of secrecy, fear, blame, and a belief that the adolescent has control over his/her symptoms. Empirical evidence supports the transdiagnostic conceptualization of FBT for adolescents with eating disorders (Loeb et al., 2012; Le Grange & Loeb, 2013). Results from RCTs on FBT for Anorexia Nervosa (AN) demonstrated that the treatment was superior to supportive psychotherapy, as adolescents reached weight restoration and experienced long-term health improvements (Le Grange & Lock, 2009; Lock et al., 2005; Lock, 2010). FBT has also been adapted to target the overlap between AN and anxiety symptoms, via exposure-based family therapy (FBT-E; Hildebrandt et al., 2014). Results from an open case series provide preliminary support for the application of FBT-E to target eating pathology and co-occurring anxiety symptoms (Hildebrandt et al., 2014). While studies on FBT for Bulimia Nervosa (BN) and Eating Disorder- Not Otherwise Specified (EDNOS) produced mixed results, the data from the available research on FBT indicate that the treatment is applicable across the age of onset, the diagnostic groups, and for both genders (Le Grange et al., 2007; Schmidt et al., 2007). In order to illustrate the application of FBT as a transdiagnostic treatment, Loeb and colleagues (2012) presented a case study of a 13-year-old female with a six-month history of an eating disorder. The results of the case study demonstrated that transdiagnostic FBT successfully targeted the mechanisms maintaining the eating disorder, as the participant experienced psychological relief and medical improvement. Future research is needed to evaluate the theoretical mechanisms underlying eating disorders and to assess the efficacy of FBT as a transdiagnostic approach in a treatment-effectiveness study (Loeb et al., 2012).

Conclusion

This chapter reviews the role that a transdiagnostic framework can play in creating a unifying frame that joins the empirical study of basic science, developmental psychopathology, and treatment research. In our review of basic mechanisms, we present initial evidence that the study of multiple disorders within the same research agenda can illuminate novel relationships within and across each domain of inquiry. Studying several disorders at once promises to accelerate the generation, dissemination, and translation of findings across multiple lines of inquiry. The potential for these benefits will come, in large part, from borrowing the methodologies encouraged in developmental psychopathology. These include multidimensional foci (e.g., diagnosis, symptom, basic mechanisms), openness to continuous and discrete entities, multi-method and multi-reporter assessment, and the explicit investigation of convergent and divergent trajectories over varying periods of time.

Our review of the treatment literature indicates that explicitly transdiagnostic interventions are early in their development. Case studies and uncontrolled trials have comprised the majority of evidence to support their feasibility, acceptability, and efficacy. However, this nascent literature already indicates some promising directions, not the least of which is the diversity of mechanisms hypothesized to serve as primary unifying processes. The simultaneous efforts of each investigative group will help provide convergent information about which universal processes hold the most explanatory power and which treatment interventions have the most promise in targeting these processes across multiple disorders. In all, the field is poised to make important gains as transdiagnostic models and treatments continue to establish themselves.

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