Adolescence is a time of dramatic change in physical, behavioral, emotional, cognitive and social domains, and the context in which one matures plays a crucial role. The early 2020s provided a unique context for adolescent development, filled with unprecedented events across multiple levels of life. These contextual forces potentially impacted what we know from previously studied developmental trajectories during adolescence.

Here we briefly highlight recent research on adolescent anxiety associated with social media use and the COVID-19 pandemic, and focus on the latest trends and advances in cognitive-behavioral therapy (CBT) for treating anxiety in youth. We emphasize the importance of behavioral exposure tasks and the necessity of “flexibility within fidelity”¹ in manual-based CBT interventions. Lastly, we identify future research directions for evaluating the development, maintenance and treatment of anxiety in adolescents.

Rates of anxiety among youth – as well as depression, suicidality, and other mental health conditions – have increased in recent years. Specifically, anxiety symptoms increased during the COVID-19 pandemic, with 20% of surveyed youth experiencing these symptoms, compared to 11% before the pandemic². Further, across all socioeconomic levels, about 70% of adolescents reported believing that anxiety and depression are major problems among people of their age in their community³. Widening disparities in anxiety prevalence have been noted among girls relative to boys, and among sexual minority youth compared to heterosexual ones^{2, 4}.

Adolescents currently face stressors that may contribute to increases in anxiety. The COVID-19 pandemic took a toll on youth psychological well-being, including disrupted milestones, loss of peer interactions, and social isolation². Adolescents are heavy consumers of digital technology and social media: this has the potential to provide benefits to youth through opportunities to strengthen social relationships. However, social media may also lead to an increase in anxiety symptoms. In a longitudinal study of adolescents aged 12-15, those spending more than three hours per day on social media were prospectively more likely to experience internalizing problems (i.e., anxiety and depression⁵). It is not a stretch to see the double-edged features of heavy adolescent social media use.

Recent research continues to bolster the large body of existing evidence demonstrating the efficacy⁶ and effectiveness⁷ of CBT in treating adolescent anxiety, with the latest studies parsing treatment effects according to intervention modality and emphasis on key components (e.g., psychoeducation, cognitive restructuring, exposure tasks). When comparing CBT modalities to waitlist controls based on anxiety remission at post-treatment, significant benefits for individual, group, family, and remote-based CBT were observed. Individual, family, and remote-based CBT interventions also demonstrated superior remission outcomes relative to attention controls.

Although based on a limited number of comparative efficacy studies, the various treatment modalities did not show differential benefit (e.g., individual-based CBT did not evidence significant benefit compared to other CBT modalities). Albeit comparisons were bound by similar constraints, combined treatment with individual-based CBT and selective serotonin reuptake inhibitors (SSRIs) demonstrated greater effectiveness than either isolated treatment approach⁸.

Among the core components of CBT interventions, behavioral experiments (i.e., exposure tasks) are the most impactful. Reinforcing prior research examining treatment outcome associations based on exposure task completion (e.g., amount of in-session exposure tasks), recent CBT interventions have evaluated the effectiveness of treatments that emphasize exposures specifically. Youth anxiety outcomes were examined following randomization to one of two treatments focusing on different core CBT components: an exposure-focused CBT (EF-CBT) characterized by a lack of relaxation components and quicker initiation of exposure tasks, and a relaxation-based treatment⁹. Not only was EF-CBT effective in treating youth anxiety disorders, but it demonstrated greater effectiveness relative to the relaxation-based treatment. Results indicated that EF-CBT yielded “faster and more pronounced” reductions in youth anxiety. Participants randomized to EF-CBT were more likely to complete therapy relative to those receiving the relaxation-based treatment⁹.

Advancements in CBT for adolescents highlight the necessity of flexibly implementing manual-based CBT to increase its use and accessibility. Flexibility personalizes treatment based on youth interests (e.g., sports, computers, arts) and needs (e.g., comorbid diagnoses, level of cognitive development). Potential environments for administering CBT also require flexibility: they can include schools, community mental health centers, telehealth and computed-based platforms, and at-home efforts.

Key features of empirically supported treatments remain required, but features can vary based on needs for pragmatic and feasible implementation. Increased provision of CBT mediated by digital devices (brought about by the COVID-19 pandemic) highlighted flexible adjustment strategies and opportunities relative to standard in-person treatment. For example, using facetime or laptop cameras, exposure tasks can occur in an adolescent's real-world environment and be conducted with therapist support¹. Telehealth platforms make CBT interventions more accessible across geographic regions, enabling youth to both engage in exposures with peers and connect with others with similar mental health concerns.

The future is likely to witness an increasing focus on comparisons of in-person vs. telehealth administrations of treatment for adolescent anxiety. In the same vein, apps for adolescents to use when mastering their anxiety will not only be more prevalent, but will also need proper evaluation. We do not see artificial intelligence replacing a CBT service provider, but we do see telehealth having an increasing presence and impact.

Symptom reduction has been and remains an important goal for mental health service providers. However, we know that there is more to improvement than symptom reduction. Future studies will benefit from examinations of increased self-efficacy and idiographic gains in mastering personal anxiety-producing situations. Treatments for adolescents that address their need for reassurance and/or improve their social interactions will likely augment current approaches.

One can also be hopeful for computer-directed strategies to advance personalizing treatment. Currently, service providers “wing it” as they adapt their work to fit their patients. With machine learning, we can identify features of anxious youth who will respond to the various components of treatment. In other words, the findings from machine learning applied to large, homogenized data sets can inform providers of adaptations that, for the characteristics of a specific client, will likely be optimally effective.

Thus, CBT is now well established as a first-line treatment for adolescent anxiety, but efforts to personalize and augment this empirically supported therapy are likely to spread in the future and impact significantly clinical practice.

青春期是身体、行为、情感、认知和社会领域发生巨大变化的时期，一个人成熟的环境起着至关重要的作用。 2020 年代初为青少年发展提供了独特的背景，在生活的多个层面上充满了前所未有的事件。这些背景力量可能会影响我们从之前研究的青春期发育轨迹中了解到的信息。

在这里，我们简要介绍了与社交媒体使用和 COVID-19 大流行相关的青少年焦虑的最新研究，并重点关注治疗青少年焦虑的认知行为疗法 (CBT) 的最新趋势和进展。我们强调行为暴露任务的重要性以及基于手动的 CBT 干预中“保真度内的灵活性” ¹的必要性。最后，我们确定了评估青少年焦虑的发展、维持和治疗的未来研究方向。

近年来，青少年的焦虑症、抑郁症、自杀倾向和其他心理健康问题的发生率有所上升。具体而言，在 COVID-19 大流行期间，焦虑症状有所增加，接受调查的青少年中有 20% 出现这些症状，而大流行之前这一比例为 11% ² 。此外，在所有社会经济层面，约 70% 的青少年表示认为焦虑和抑郁是其所在社区同龄人的主要问题³ 。人们注意到，女孩与男孩之间以及性少数青少年与异性恋青少年之间的焦虑患病率差异不断扩大^{2, 4} 。

青少年目前面临的压力可能会导致焦虑增加。 COVID-19 大流行对青少年的心理健康造成了损害，包括里程碑被打乱、同伴互动丧失和社会孤立² 。青少年是数字技术和社交媒体的大量消费者：这有可能通过加强社会关系的机会为青少年带来好处。然而，社交媒体也可能导致焦虑症状增加。在一项针对 12-15 岁青少年的纵向研究中，那些每天在社交媒体上花费超过三个小时的青少年预计更有可能经历内化问题（即焦虑和抑郁⁵ ）。不难看出青少年大量使用社交媒体的双刃剑特征。

最近的研究继续支持大量现有证据，证明 CBT 在治疗青少年焦虑方面的功效⁶和有效性⁷ ，最新研究根据干预方式解析治疗效果，并强调关键组成部分（例如心理教育、认知重建、暴露）任务）。当将 CBT 模式与基于治疗后焦虑缓解的候补对照进行比较时，观察到个人、团体、家庭和远程 CBT 的显着益处。个人、家庭和远程 CBT 干预也表现出相对于注意力控制更好的缓解结果。

尽管基于数量有限的比较疗效研究，但各种治疗方式并未显示出不同的益处（例如，与其他 CBT 方式相比，基于个体的 CBT 并未显示出显着的益处）。尽管比较受到类似的限制，但基于个体的 CBT 和选择性血清素再摄取抑制剂 (SSRI) 的联合治疗比任何一种单独的治疗方法都表现出更好的效果⁸ 。

在 CBT 干预的核心组成部分中，行为实验（即暴露任务）是最有影响力的。最近的 CBT 干预措施加强了先前基于暴露任务完成情况（例如，会话中暴露任务的数量）检查治疗结果关联的研究，评估了专门强调暴露的治疗的有效性。在随机分配两种侧重于不同核心 CBT 组成部分的治疗方法之一后，对青少年焦虑结果进行了检查：一种以暴露为中心的 CBT (EF-CBT)，其特点是缺乏放松成分和更快地启动暴露任务，以及一种基于放松的治疗⁹ 。 EF-CBT 不仅可以有效治疗青少年焦虑症，而且相对于基于放松的治疗也显示出更好的效果。结果表明，EF-CBT 可以“更快、更明显”地减少青少年的焦虑。相对于接受基于放松的治疗的参与者，随机接受 EF-CBT 的参与者更有可能完成治疗⁹ 。

青少年 CBT 的进步凸显了灵活实施基于手册的 CBT 以增加其使用和可及性的必要性。灵活性根据青少年的兴趣（例如运动、计算机、艺术）和需求（例如共病诊断、认知发展水平）进行个性化治疗。实施 CBT 的潜在环境也需要灵活性：它们可以包括学校、社区心理健康中心、远程医疗和基于计算的平台以及家庭工作。

经验支持的治疗方法的关键特征仍然是必需的，但特征可以根据务实和可行的实施的需要而变化。由数字设备介导的 CBT 提供的增加（由 COVID-19 大流行带来）凸显了相对于标准面对面治疗的灵活调整策略和机会。例如，使用面对面或笔记本电脑摄像头，暴露任务可以在青少年的现实环境中进行，并在治疗师的支持下进行¹ 。远程医疗平台使认知行为治疗干预措施在各个地理区域变得更容易获得，使年轻人能够与同龄人接触，并与有类似心理健康问题的其他人建立联系。

未来可能会越来越多地关注青少年焦虑治疗的面对面与远程医疗管理的比较。同样，供青少年在控制焦虑时使用的应用程序不仅会更加流行，而且还需要适当的评估。我们不认为人工智能会取代 CBT 服务提供商，但我们确实看到远程医疗的存在和影响力越来越大。

减轻症状一直是并且仍然是心理健康服务提供者的一个重要目标。然而，我们知道改善的不仅仅是减轻症状。未来的研究将受益于对自我效能的提高和在控制个人焦虑产生情况方面的具体收益的检查。针对青少年的治疗，满足他们的安慰需求和/或改善他们的社交互动，可能会增强目前的方法。

人们还可以对计算机指导的策略来推进个性化治疗抱有希望。目前，服务提供商在调整工作以适应患者时“即兴发挥”。通过机器学习，我们可以识别焦虑青少年的特征，他们会对治疗的各个组成部分做出反应。换句话说，应用于大型同质化数据集的机器学习的结果可以告知提供商针对特定客户的特征进行的调整可能会最有效。

因此，CBT 目前已成为青少年焦虑症的一线治疗方法，但个性化和增强这种经验支持疗法的努力可能会在未来得到推广，并对临床实践产生重大影响。