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Cited by 197Anxiety, Depression, Psychometrics, Treatment, Cognitive ProcessesChild and Adolescent Psychosocial and Emotional DevelopmentPersonality Disorders and Psychopathology

Development of a Unified Protocol for the Treatment of Emotional Disorders in Youth

Open access
Ehrenreich, Jill T., Goldstein, Clark R., Wright, Lauren R., Barlow, David H.·2009·Child & Family Behavior Therapy
DOI 10.1080/07317100802701228PMC PMC2712286
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Abstract

This paper reviews the development and initial trial of a treatment for adolescents that targets negative emotionality and associated psychological difficulties, particularly anxiety and depressive disorders, as a more singular entity by utilizing an approach rooted in both emotion science and theory. The rationale for such an approach is based upon the perceived need for novel treatment approaches that target commonalities in emotional disorder symptom presentation and their intervention. Utilizing the Unified Protocol for the Treatment of Emotional Disorders originally developed for adults (Barlow, Allen & Choate, 2004), we conducted a multiple-baseline design study of a slightly modified version of this protocol with three adolescents presenting an array of anxiety and depression symptoms. Adolescent participants in this preliminary investigation evidenced symptom reductions across disorders at post-treatment, with greater improvements noted at a six-month follow-up. Based on these findings and research regarding the association between emotion science and developmental psychopathology, we detail a more extensive set of modifications to the protocol, undertaken in preparation for a subsequent open-trial investigation of the revised treatment.

Integrity signals

Registry

Crossref · 10.1080/07317100802701228

Cites

39 of 39 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 35 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Parents reported feeling positive about being included in treatment.

    “Parents reported that they personally felt good about being included in treatment.”
    Quote in the paperNot a substantial claim
  • Findingown data

    All participants said emotion exposure exercises were the most helpful treatment part.

    “All participants reported that they found emotion exposure exercises to be the most helpful part of treatment.”
    Quote in the paperNot a substantial claim
  • Findingown data

    At post-assessment, each of Participant 3's diagnoses decreased by one CSR point.

    “At post-assessment, Participant 3's diagnoses reportedly each dropped one CSR.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: CSR ratings validly measure clinical interference or severity.
  • Findingown data

    Participant 2's difficulty starting the job application process was a major reason his post-treatment CSR was 4, still clinically interfering.

    “His difficulty initiating the job application process was a major factor in assigning the CSR at an improved but still clinically interfering level of a four.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: CSR ratings validly measure clinical interference or severity.
  • Findingown data

    When the adult protocol was used with the first pilot participant, a 12-year-old girl with Separation Anxiety Disorder, minor changes to treatment language and added parent-understanding strategies were needed to maintain basic treatment compliance.

    “However, in using the adult protocol with an initial pilot participant, a 12-year-old female with Separation Anxiety Disorder, it became clear that small modifications to treatment language and the incorporation of strategies to facilitate parent understanding of the strategies utilized would be necessary to ensure basic compliance with treatment procedures.”
    Quote in the paperSubstantial claim
  • Classified as probably not a substantial claim. 18
  • May combine two claims. 19

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participant 2 did not complete some assigned job-related exposures in the final treatment sessions.

    “during the final sessions of treatment he declined to follow through on some assigned exposures related to obtaining a new job.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    All three adolescents showed symptom reductions at post-treatment, with larger gains at six months, including full depression remission in the one participant with depression.

    “All three adolescents in this multiple-baseline design study evidenced reductions in emotional disorder symptoms at post-treatment, with much greater improvements noted across all participants at six-months following treatment, including the complete remission of depression symptoms in the one participant presenting with such.”
    Quote in the paperSubstantial claim
    • Rests on an assumption: The ADIS-IV-C/P accurately and reliably diagnoses emotional disorders in adolescents.
    • Rests on an assumption: CSR ratings validly measure clinical interference or severity.

  • May combine two claims.

    Findingown data

    Participant 1 received a post-treatment CSR of 2 for Anxiety Disorder Not Otherwise Specified, which fell to 0 at six-month follow-up.

    “A diagnosis of Anxiety Disorder Not Otherwise Specified, CSR was assigned at two at post-assessment and zero (i.e., in full remission) at six-month follow-up.”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: The ADIS-IV-C/P accurately and reliably diagnoses emotional disorders in adolescents.
    • Rests on an assumption: CSR ratings validly measure clinical interference or severity.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    One month after finishing the protocol, Participant 2 applied for jobs with four employers.

    “One month after Participant 2 finished the treatment protocol, he applied for jobs with four different employers.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participant 2 typically showed only basic understanding of session concepts despite repeated discussion and practice.

    “he usually demonstrated only a rudimentary understanding of concepts introduced in session despite repeated discussion and repetition to refine his knowledge and skill base.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Most participants thought treatment length was appropriate, but one parent suggested a few more sessions.

    “Most felt like the treatment was the appropriate length, although one parent suggested that the treatment be a few sessions longer.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Starting with the week-three acceptance and tolerance session, Participant 3 reported a subjective drop in anxiety and depression that continued through cognitive reappraisal.

    “beginning with the acceptance and tolerance session in the third week of treatment, Participant 3 reported a subjective decrease in her anxiety and depression that lasted through the cognitive reappraisal portion of the treatment.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    All participants and parents reported favorable views of treatment and said they would recommend it to friends or friends' children.

    “All participants and their parents reported favorable impressions of the treatment and indicated that they would recommend the treatment for friends or for friends' children.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Participant 3's exposures seemed to produce moderate habituation and were associated with a moderate anxiety decrease on her daily self-report.

    “These exposures seemed to result in moderate habituation to the emotions they evoked and correlated with a moderate decrease in anxiety given her report on a daily self-report measure of anxiety and depression.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    In the preliminary trial, adolescents showed reduced symptoms across disorders after treatment, and these improvements were larger at the six-month follow-up.

    “Adolescent participants in this preliminary investigation evidenced symptom reductions across disorders at post-treatment, with greater improvements noted at a six-month follow-up.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participant 3 repeatedly reported very high anxiety and depression, often with moderately severe suicidal ideation.

    “Participant 3 recurrently reported experiencing very high levels of anxiety and depression, often with concurrent moderately severe suicidal ideation.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Participant 2's six-month follow-up CSR was 2, below the clinical cutoff of 4.

    “Based on his six-month follow-up, Participant 2's CSR was assigned at a two (below the clinical cutoff of four).”
    Quote in the paperNot a substantial claim
    • Rests on an assumption: CSR ratings validly measure clinical interference or severity.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participant 1 self-reported a small reduction in anxiety.

    “Participant 1 verbally reported a modest decrease in anxiety.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participant 1 identified emotional exposures as the most helpful treatment component.

    “He indicated that he found emotional exposures to be the most helpful part of treatment.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Findingown data

    Participant 2 completed several exposures in the second half of treatment, including volunteering to ask questions in class and asking a young woman on a date.

    “Though Participant 2 successfully participated in a number of exposures during the second half of treatment (e.g. volunteering to ask questions in class, asking a young lady out on a date)”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingown data

    Participant 1 reported reduced anxiety sensitivity to physical sensations after interoceptive exposure practice during and after session six, despite little change in the intensity of those sensations.

    “he reportedly experienced a decrease in anxiety sensitivity to physiological sensations after practicing the interoceptive exposures during and after the sixth session.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Findingown data

    Several generalized emotion exposure triggers used early in the pilot (a music CD and photographs) either did not evoke relevant emotions or had an unclear purpose for adolescents.

    “several of the generalized emotion exposure triggers originally used during early sessions (an emotionally-evocative music CD and photographs) either failed to evoke relevant emotions in session or served an unclear purpose to adolescents in the pilot study.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Findingnone given

    Anecdotally, Participant 3, who initially had the greatest emotional dysregulation and diagnostic complexity, appeared to make the greatest treatment gains.

    “from an anecdotal perspective, the adolescent who seemed to make the greatest treatment gains was Participant 3, the teen who initially presented with the greatest degree of emotional dysregulation and diagnostic complexity.”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductnone given

    Supervisors and a doctoral-level clinician team verified the accuracy of diagnoses made after the ADIS-IV-C/P.

    “Diagnoses made by the clinician following administration of the ADIS-IV-C/P were reviewed by supervisors and a team of doctoral-level clinicians for accuracy.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Anxiety and depressive disorders share common etiological and latent structure features.

    “The commonalities in etiology and latent structure between emotional disorders justify condensing various protocols for anxiety and depression into a single treatment (Barlow, Allen, & Choate, 2004).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Barlow, Allen, & Choate, 2004

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Sufficient training for each of these protocols is limited and, when it exists, can consume clinicians' time, energy, and money.

    “Adequate training for each of these protocols is scarce and when available may tax clinicians' time, energy, and financial resources (Allen, Ehrenreich, & Barlow, 2005).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Allen, Ehrenreich, & Barlow, 2005

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Anxiety may be a risk factor for later depressive disorders, and these conditions tend to develop in sequence.

    “Brown and Barlow (2002) found evidence that these disorders generally develop sequentially, with anxiety possibly acting as a risk factor for future depressive disorders.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Brown and Barlow (2002)

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Adolescents and parents were randomly allocated to one of three baseline durations.

    “parent(s) and adolescents were offered participation in the current investigation and randomly assigned to one of three designated baseline lengths.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    The adult Unified Protocol targets anxiety and unipolar mood symptoms through three components: modifying antecedent cognitive appraisals, reducing and preventing avoidance of dysregulated emotions, and encouraging actions inconsistent with disordered emotional states.

    “Barlow, Allen, and Choate's (2003)Unified Protocol for the Treatment of Emotional Disorders was initially developed for adults to target anxiety and unipolar mood disorder symptoms by providing an intervention associated with three basic treatment components: 1) targeting antecedent cognitive appraisals, 2) reducing and preventing avoidance of dysregulated emotions, and 3) encouraging actions that”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Barlow, Allen, and Choate's (2003)

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductreasoning

    The baseline phase lasted two to eight weeks, and participants were reassessed afterward to control for changes over time.

    “Participants had between a two and eight week baseline phase before beginning treatment and were reassessed after this waiting period in order to control for major changes that might occur as a function of time.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Premisecitation

    Among depressed youth, comorbid anxiety occurs in 25% to 50% of community samples and up to 70% of clinical samples.

    “Rates of children and adolescents with depression who have comorbid anxiety disorders range from 25% to 50% in community samples (Angold, Costello, & Erkanli, 1999) and up to 70% in clinical samples (Birmaher et al., 1996).”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Angold, Costello, & Erkanli, 1999

      Not checked in the free run.

    • cites Birmaher et al., 1996

      Not checked in the free run.

  • May combine two claims.

    Premisecitation

    Maladaptive emotion regulation strategies can worsen unwanted emotions and contribute to the onset or persistence of anxiety and mood disorders.

    “Specifically, maladaptive emotion regulation strategies may serve to exacerbate unwanted emotions rather than to reduce them, aiding in the development or maintenance of anxiety and mood disorders.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Campbell-Sills & Barlow, 2006

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Premisecitation

    A growing body of research connects emotion-related processes to psychological difficulties, with implications for future youth intervention and prevention studies.

    “A developing body of research is beginning to link emotion-related processes to psychological difficulties – developments that clearly hold implications for future intervention and prevention studies in youth (Southam-Gerow & Kendall, 2002).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Southam-Gerow & Kendall, 2002

      Not checked in the free run.

  • May combine two claims.

    Study design and conductcitation

    The ADIS-IV-C/P is a reliable and valid semi-structured interview for diagnosing DSM-IV anxiety, mood, and externalizing disorders in children and adolescents.

    “The ADIS-IV-C/P is a reliable and valid semi-structured interview designed to facilitate the diagnosis of all DSM-IV anxiety disorders, mood disorders, and externalizing disorders of childhood and adolescence, and also provides screening questions for selected other disorders (e.g., psychotic disorders, eating disorders, and somatization disorders; Silverman, 2001; Albano, Marten, Holt, Heimberg,”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites Silverman, 2001

      Not checked in the free run.

    • cites Albano, Marten, Holt, Heimberg, & Barlow, 1995

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductown data

    An independent evaluator unaware of treatment course assessed participants after 13 sessions and about six months later.

    “Participants received a post-treatment assessment from an independent evaluator blind to treatment course after 13 sessions of treatment and approximately six months after the 13th session occurred.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Most Axis I disorders and all Axis II personality disorders involve emotion dysregulation or maladaptive emotion regulation strategies.

    “In fact, some studies show that most of the Axis I clinical disorders and all of the Axis II personality disorders involve dysregulation of emotion or maladaptive emotion regulation strategies (Gross & Levenson, 1997).”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Gross & Levenson, 1997

      Not checked in the free run.

  • Classified as probably not a substantial claim.

    Study design and conductreasoning

    The possibility that the small sample improved through normative maturation rather than the intervention cannot be ruled out.

    “However, the possibility that this small sample improved as a result of normative maturation and independent of the intervention cannot be completely ruled out at this stage and should be further investigated.”
    Quote in the paperSubstantial claim
32 of 32

  • The paper relies on this without support.

    Before this study, no known attempts had been made to create a unified treatment for emotional disorders in children or adolescents.

    “However, prior to the current investigation, no known attempts had been made to develop a unified approach for emotional disorders occurring in childhood or adolescence.”

  • The paper relies on this without support.

    Only recently have researchers begun to study emotion understanding and emotion regulation strategies in treating youth emotional disorders.

    “However, only recently have researchers examined the application of emotion understanding and emotion regulation strategies in the treatment of emotional disorders in youth.”

  • The paper relies on this without support.

    The ADIS-IV-C/P accurately and reliably diagnoses emotional disorders in adolescents.

    “the interviewer conducted the ADIS-IV-C/P first with the adolescent, then the parent.”

  • The paper relies on this without support.

    CSR ratings validly measure clinical interference or severity.

    “Table 2 summarizes changes in CSR across diagnoses for each of the three adolescent participants.”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Of the several transdiagnostic techniques available for adolescent ID, three appear most salient for addressing factors that also predispose SU among adolescents: emotion acceptance, emotional exposure, and behavioral activation.

    “Of the several transdiagnostic techniques available for adolescent ID, 3 appear most salient for addressing factors that also predispose SU among adolescents: emotion acceptance, which targets emotional regulation and distress tolerance and also enhances inhibitory learning during exposure [60,61,64,68]; emotional exposure, a primary driver of positive effects for adolescent anxiety [69]; and”

    From Family Support Protocol for Adolescent Internalizing Disorders: Protocol for a Pre-Post Quantitative Treatment Development Study (2024) · cites this paper as [61]

    In “A Unified Protocol for Adolescents > Results” (page unavailable), Participant 1 described emotional exposures as the most helpful part of treatment, and his anxiety ratings fell during sessions that emphasized exposure. The paper also describes exposures as useful for Participant 3, but this three-participant study does not establish emotional exposure as the primary driver of positive effects for adolescent anxiety generally. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • Transdiagnostic interventions have proven efficacious for adolescents with IDs in multiple baseline, open, and randomized trials, producing improvements in depression, anxiety, and emotion dysregulation symptoms.

    “Transdiagnostic interventions have proven efficacious for adolescents with IDs in multiple baseline, open, and randomized trials [60-63], producing improvements in depression, anxiety, and emotion dysregulation symptoms [60,61,64].”

    From Family Support Protocol for Adolescent Internalizing Disorders: Protocol for a Pre-Post Quantitative Treatment Development Study (2024) · cites this paper as [61]

    The Discussion reports symptom reductions in three adolescents with emotional disorders in a multiple-baseline study, including remission of depression symptoms in one participant. It describes the findings as preliminary, not as proven efficacy. The paper does not establish outcomes for adolescents with IDs or improvements in emotion dysregulation symptoms; its Abstract says an open trial was planned, and it reports no randomized treatment trial. (LLM, conf=0.89)

    Experimental — accuracy not yet measured

  • Emotional acceptance skills help reduce anxiety sensitivity.

    “In emotional acceptance, adolescents develop skills for noticing and accepting their emotions, including unpleasant and strong emotions [60,61,64,68], which help reduce anxiety sensitivity.”

    From Family Support Protocol for Adolescent Internalizing Disorders: Protocol for a Pre-Post Quantitative Treatment Development Study (2024) · cites this paper as [61]

    The adolescent protocol describes emotion-awareness and acceptance-oriented skills. In the Results (page unavailable), however, Participant 1 reported decreased anxiety sensitivity after practicing interoceptive exposures, not as a demonstrated effect of acceptance skills. The source therefore supports the skills component but not the claimed link between those skills and reduced anxiety sensitivity. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

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Related

Authors
Ehrenreich, J. T., Goldstein, C. R., Wright, L. R., & Barlow, D. H.
Affiliations
Boston University (US)
Corresponding author
Ehrenreich, Jill T.
ORCID
Venue
Child & Family Behavior Therapy
Publisher
Informa UK Limited
Published
2009-02-27
Volume
31
Issue
1
Pages
20-37
ISSN
  • 0731-7107 (ISSN-L)
  • 1545-228X
DOI
10.1080/07317100802701228
PMC
PMC2712286
OpenAlex
W2060778578
Cited by
197
References
40
Citations by year
2026: 8 · 2025: 15 · 2024: 10 · 2023: 15 · 2022: 11 · 2021: 5 · 2020: 19 · 2019: 12 · 2018: 7 · 2017: 13 · 2016: 10 · 2015: 13 · 2014: 15 · 2013: 10 · 2012: 11
FWCI
14.79
Type
journal article
Language
en
Open access
Locations
  • Child & Family Behavior Therapy (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
National Institute of Mental Health (K23MH073946)
Topics
  • Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
  • Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
  • Social Sciences › Psychology › Clinical Psychology › Personality Disorders and Psychopathology
Keywords
adolescents, negative affectivity, anxiety disorders, depressive disorders, psychology of emotion, developmental psychopathology, treatment protocol development, multiple baseline design, symptom relief, follow-up outcomes

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