Anxiety in Emerging Adulthood: A Developmentally Informed Treatment Model

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22 Anxiety in Emerging Adulthood: A Developmentally Informed Treatment Model Amy Kranzler, R. Meredith Elkins and Anne Marie Albano Department of Psychiatry, Columbia University Irving Medical Center, New York, NY, United States O U T L I N E Typical Development During Emerging Adulthood 500

Clinical Considerations: Integrating Parents Into Treatment

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Impact of Anxiety on Development During Emerging Adulthood

When Emerging Adults Need More

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“Adulting” Group Treatment

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Limitations in Existing Treatments for Emerging Adults

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Clinical Considerations

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Launching Emerging Adults Program Functional Assessment Program Structure

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Conclusions

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References

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Anxiety disorders constitute a widespread and significant concern for emerging adults. Large-scale longitudinal studies have demonstrated that the most prominent increases in rates of anxiety disorders occur during the transition into young adulthood (Copeland, Angold, Shanahan, & Costello, 2014). In particular, generalized anxiety disorder, panic disorder, and agoraphobia increase dramatically during this time period, and do not appear to attenuate over time. This is alarming given the impact of anxiety disorder symptoms on overall functioning and personal well-being. It is well established that that the presence of an earlier anxiety disorder impacts subsequent young adult functioning in health,

Pediatric Anxiety Disorders DOI: https://doi.org/10.1016/B978-0-12-813004-9.00022-0

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financial, and interpersonal domains (e.g., Comer et al., 2011; Copeland et al., 2014; Pine, Cohen, Gurley, Brook, & Ma, 1998; Roza, Hofstra, van der Ende, & Verhulst, 2003). Furthermore, anxiety disorders during this time period can cause significant impairment and disability, with the global burden of disease attributable to anxiety disorders peaking in adolescence and young adulthood (Whiteford et al., 2013). Yet despite the prevalence and impact of anxiety and the importance of clinical intervention during this time, young adults are among the least likely to access treatment. According to a large-scale nationally representative survey conducted prior to the passing of the Affordable Care Act (ACA), there is a precipitous decline in service utilization at age 18 19, just as serious mental health issues begin to emerge (Pottick, Bilder, Vander Stoep, Warner, & Alvarez, 2008). This finding is also consistent with results from the preACA National Comorbidity Study Replication, in which emerging adults ages 18 24 were significantly less likely to receive mental health treatment than older adults (Kessler et al., 2005). Those that do access mental health treatment are more likely to be referred by the criminal justice system than by family, friends, or social services (Pottick et al., 2008), suggesting that impairments in functioning have already begun to occur. Furthermore, even once they do access services, emerging adults are also more likely to prematurely drop out of mental health treatment (Wang, 2007), suggesting that existing services may not be adequately meeting their needs.

TYPICAL DEVELOPMENT DURING EMERGING ADULTHOOD In order to understand the way anxiety manifests during emerging adulthood, it is critical first to understand the challenges of typical development during this life stage. Over the last half century, the transition into adulthood has become a longer, more complex, and ambiguous process and emerging adulthood has been recognized as a new and important developmental stage (Arnett, 2000), distinct from both adolescence and young adulthood. The emergence of this developmental stage has been impacted by cultural and societal changes that have delayed the process of fully assuming adult responsibilities, and it is important to note that there are both commonalities as well as differences in the way this stage is experienced across cultures and social classes (Arnett, 2016; Hendry & Kloep, 2007). Furthermore, there are distinct biological developments that occur during this time, as individuals develop in cognitive, emotional, and behavioral domains (Arnett & Taber, 1994). Significant brain development that begins in adolescence (e.g., reorganization of regulatory systems, improvement in ability to evaluate risk and reward) continues during emerging adulthood, during which time there is ongoing growth in areas of the frontal lobes that are associated with processing, inhibition, and decision-making (see Casey & Jones, 2010; Labouvie-Vief, 2006; Steinberg, 2005). Functionally, there are several domains within which typically developing emerging adults are expected to demonstrate progress. In the financial domain, emerging adults are working towards being able to pay their own rent and manage their budget independently. In the domain of self-care, emerging adults should be showering or bathing themselves regularly, waking themselves up on time, taking their own medications, preparing their own food, and scheduling and attending their own doctor appointments, all without

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prompting from parents or significant others. In the domain of interpersonal relationships, emerging adults should be developing and maintaining friendships and romantic relationships, initiating spending time with peers, and communicating effectively with peers and authority figures (e.g., teachers, bosses). In the domain of self-identity, milestones include being able to identify and articulate personal values, recognizing one’s own limits, and engaging in behaviors that are consistent with one’s own values. In the domains of school and work, milestones include registering for classes, attending classes and completing assignments, looking for work, getting to work on time, and dressing appropriately for work and/or academic settings. In the domain of emotional independence, milestones include being able to soothe and relax oneself or seek support appropriately when experiencing difficult emotions, and identifying and expressing one’s own emotions. As evidenced, typical development during this time involves a progression towards independence and acceptance of personal responsibility across a wide array of different domains, often requiring a range of different skills and new learning experiences. Unlike other developmental phases in which specific tasks (e.g., walking, talking) are typically attained at certain ages, emerging adulthood is “defined by its heterogeneity” (Arnett, 2000, p. 477). Even within a group of nonanxious emerging adults there tends to be significant spread in the pace at which individuals achieve these different goals. For example, one 22-year-old may be living independently, working and supporting herself financially, while calling her mother multiple times daily for emotional support (having obtained independence in financial and residential but not emotional domains). In contrast, another 22-year-old may be completing schooling while living with her parents and relying on them fully for financial support, but having developed her own unique identity and requiring little emotional support. In this way, normative development during this time period can be highly domain specific, and growth towards independence in some domains may not necessarily translate into independence across other domains. Furthermore, even for a given individual growth within these domains is not always linear. For example, an emerging adult might move out of his parents’ home, but return home and require additional residential and financial support while pursuing higher levels of education (Cohen, Kasen, Chen, Hartmark, & Gordon, 2003). It is critical that clinicians understand that many emerging adults develop independence in some of these domains while they may continue to struggle in others, and many require ongoing financial and logistical support as they work towards autonomy and independence (Arnett, 2000; Scharf, Mayseless, & Kivenson-Baron, 2004; Schoeni & Ross, 2005). Thus, even for emerging adults without anxiety disorders, this can be a time period full of stress and tension as they work towards these myriad behavioral indicators of independence and navigate the unchartered path towards adulthood. Indeed, Arnett’s (2000) description of this developmental period suggests that it is one characterized as a time of identity exploration, instability, possibilities, self-focusing, and feeling in-between. Building on Arnett’s conceptualization, Tanner (2006) describes the developmental tasks of emerging adulthood as a process of “recentering,” which involves transferring responsibility for one’s own self-care from one’s parents and moving towards becoming responsible for oneself. She writes that, “recentering constitutes a shift in power, agency, responsibility, and dependence between emerging adults and their social contexts. . .” (p. 27). In Tanner’s conceptualization, this process is inherently relational, as the parent child

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relationship must transform in order to allow emerging adults to engage in this process of becoming adults. In this sense, successful navigation of this time period requires change and an ability to tolerate uncertainty on the part of both the emerging adult as well as his/her parents or caregivers.

IMPACT OF ANXIETY ON DEVELOPMENT DURING EMERGING ADULTHOOD When anxiety disorder symptoms emerge or escalate during this time period, they can impair an individual’s ability to effectively develop independence. Instead of engaging in the developmentally appropriate process of gradually transferring responsibility from their parents, emerging adults with anxiety often become “stuck,” feeling unprepared or unwilling to work towards these milestones. This phenomenon has colloquially been referred to under the term “failure to launch,” as well as “incompletely launched young adults” (Schnaiberg & Goldenberg, 1989), or “adult entitled dependence” (Lebowitz, Dolberger, Nortov, & Omer, 2012). Though anxiety across the life span is associated with avoidance behaviors, this avoidance can be particularly detrimental during emerging adulthood, as successful navigation of this developmental period is dependent on approaching anxietyprovoking tasks such as enrolling in college, advocating for one’s self with professors and superiors, applying for and starting a first job, or developing new friendships and romantic relationships. Each of these tasks requires a willingness to tolerate uncertainty, risk failure, and continue forward despite normative fear, which are precisely the situations that pose greatest difficulty for individuals with anxiety disorders. Table 22.1 provides sample developmental tasks that are often challenging for emerging adults with anxiety disorders. TABLE 22.1 Situations and Activities that Present a Challenge for Emerging Adults Domain

Task or Responsibility

Self-care Preparing and eating daily meals Doing one’s own laundry Keeping current on health and sex information Finances Managing a bank account Paying bills on time Relationships Making new friendships Maintaining friendships Engaging with parents on an adult level (Continued)

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TABLE 22.1

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(Continued)

Domain

Task or Responsibility

Work and School Seeking work independently Negotiating with superiors Registering for classes or duties on time Managing a schedule (daily and long-term plans) Seeking help when it is necessary Independent Tasks Buying and caring for own clothes Filling and picking up own prescriptions Being punctual and reliable Asserting oneself to have one’s needs met Maintaining awareness of current events Recreation Attending parties and social gatherings Involvement in clubs and/or sports Altruism Partaking in community service Extending oneself to help family and friends Religious/Political Views Choosing to practice or not practice a religion independently Voting in political elections Living Situation Seeking independence Living independently from family Emotional Independence Owning and accepting personal responsibility Self-correcting Managing difficult emotions effectively Expressing one’s own thoughts and ideas clearly Recognizing when asking for help is needed

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Unfortunately, anxiety and subsequent avoidance can be particularly pernicious during emerging adulthood. Because changes happen so rapidly during this time, anxious emerging adults who take a leave of absence from college or postpone enrolling in college or seeking employment may experience decreased self-esteem and self-efficacy, often reporting feeling “too far behind” their peers to catch up. Because it can seem as though their peers are developing rapidly as they form new relationships and embrace challenges in academic and professional settings, anxious emerging adults often express a sense of hopelessness when they first begin treatment and an important early treatment goal often consists of instilling hope about their capabilities to work towards these seemingly overwhelming milestones. Some emerging adults may have been experiencing subclinical or manageable anxiety symptoms prior to this developmental stage, but the ambiguity and uncertainty inherent in this time period as they graduate high school and often leave home may further elicit and exacerbate their anxiety. In addition, some emerging adults struggle during this transition as they have become accustomed to parental accommodations. The role of parental accommodation in the development and maintenance of youth anxiety disorders is well established (e.g., Aschenbrand & Kendall, 2012; Lebowitz, Scharfstein, & Jones, 2014; Lebowitz, et al., 2013; Thompson-Hollands, Kerns, Pincus, & Comer, 2014). Many wellmeaning parents of anxious adolescents intervene to minimize anxiety-provoking situations that their adolescents must face, such as speaking to teachers on their behalf, helping them with homework (or even completing homework for their anxious adolescents) and scheduling their social activities. However, these parental accommodations inadvertently allow the adolescent to develop a habit of avoiding anxiety-provoking activities. Furthermore, these accommodations prevent individuals from developing the skills they need to accomplish tasks independently and limit their opportunities to cultivate a developmentally appropriate sense of self-efficacy. When this pattern of accommodation has been pervasive, it can be difficult for emerging adults to feel prepared to engage in the process of “recentering” (Tanner, 2006), or gradually taking on more responsibility and agency in their lives. Furthermore, parents may recognize that their young adult children have not developed the skills they need and therefore have their own difficulty reducing their involvement, worried that their children will fail if they do. The following case illustrations, drawn from patients within our clinic, exemplify some of the ways in which anxiety disorders can present during this developmental period: “Ethan” is a 20-year-old male who presented at intake with significant social anxiety and depressive symptoms. Although he reported that he had “always” experienced social fears and discomfort, his close relationships with a small group of childhood friends had mitigated the interference of much of his social anxiety throughout his childhood and adolescence. When he began his freshman year of college, the necessity of forming new friendships, coupled with the demands of the new academic environment, contributed to overwhelming anxiety. He became increasingly socially isolated during his first semester, spending most of his time in his dorm room to avoid social situations, classes, and interactions with professors. His grades suffered significantly, and he developed comorbid depressive symptoms, ultimately prompting him to take a leave from college during his second semester. At the time of intake, Ethan was unemployed and living at home with his parents. He had little interpersonal interaction, as his childhood friends were away at their respective colleges. Although he expressed his desire to return to his four-year university, at the time of intake he noted that his social anxiety, social isolation, depressive symptoms, and low motivation led him to feel “stuck.” He was enrolled in one course at a local community college, where his attendance

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and work completion was inconsistent. Moreover, his personal hygiene and self-care had deteriorated significantly. He spent much of his day sleeping or playing videogames, and he was showering and changing his clothes infrequently. “Sam” was a 19-year-old young man who presented to our clinic after dropping out of college in the middle of his second semester. Sam had been anxious since he was a child, and was prone to intense outbursts that sometimes included physical aggression when he was forced to tolerate anxiety-provoking situations. Though he was quite bright, Sam was particularly anxious about completing homework and as a result, to avoid outbursts at home, his mother often intervened to request that teachers allow him to miss assignments. Ultimately, Sam was transferred to a high school program that did not require the completion of any homework assignments. While this accommodation decreased his anxiety in the short term and allowed him to graduate from high school, Sam was completely unprepared when he arrived at college, lacking the skills to tolerate his anxiety, complete his work, or speak with his professors himself about his difficulties. When Sam presented for treatment he was living with his parents, and expressed belief that he lacked the “strength” to complete school or hold a job, citing as evidence that fact that, “In my whole life I’ve never actually done anything hard.”

LIMITATIONS IN EXISTING TREATMENTS FOR EMERGING ADULTS It is critical that interventions targeting anxiety in emerging adulthood be designed with an understanding of the developmental context within which the disorder is situated. We have discussed the way the unique challenges and uncertainties of emerging adulthood can exacerbate anxiety, as well as the way the presence of anxiety disorders during this time can impede normative development and progression towards independence during this time. However, despite the importance of this approach, few evidence-based treatments for anxiety have been adapted to specifically address the developmental context of emerging adulthood. Existing evidence-based treatments for anxiety disorders are typically developed for adults and then adapted for children. As part of this adaptation, treatments are often simplified, incorporating terminology that is more comprehensible for children, including more interactive approaches, and including parents in the treatment process mainly to deliver positive reinforcement and encourage brave behavior. However, these approaches are often inappropriate for emerging adults, for whom the language and activities are often too childish and who often prefer that their parents not participate regularly in sessions. In contrast, adult treatment models often fail to include strategies for engaging unmotivated or ambivalent emerging adults and do not include any suggestions for parent involvement. We therefore suggest that there are several ways that anxiety disorder treatments should be adapted for emerging adults. Firstly, treatments should carefully and thoughtfully define the role of parents in treatment. Legally, emerging adults are above the age of 18 and have the right to control medical decisions surrounding consent for treatment and release of their medical records. However, treatment is often paid for by and/or arranged by their parents, raising challenges in terms of confidentiality, structure of treatment, and ownership and motivation for change within the emerging adult. We therefore posit that when working with emerging adults, clinicians must adopt a flexible treatment structure

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that involves parents while simultaneously empowering emerging adults to take ownership over their own treatment. Below we discuss the way our treatment model addresses this and also confidentiality. Second, an understanding of the many developmental milestones typically attained during this stage highlights the importance of including functional assessments throughout the treatment of emerging adults, in order to clarify the specific situations and circumstances in which patients are not meeting appropriate developmental milestones, and to understand the factors maintaining each area of interference. For example, while many emerging adults in our clinic report difficulties contacting authority figures, such as professors, administrators, or bosses, the factors maintaining this difficulty are varied. One patient may delay emailing a professor primarily due to fears of negative evaluation by the recipient, while another may feel unprepared to draft such an email because her parents have always intervened on her behalf with teachers, preventing the acquisition of this skill. Thorough understanding of the antecedents and consequences of problem behavior is therefore necessary to design the appropriate intervention for a given young adult. For these reasons, functional assessment is a critical component of treatment when working with emerging adults. We emphasize further that functional assessments should be ongoing throughout treatment and domain specific to best understand the unique ways that anxiety may be interfering with healthy development for a given patient. Third, as discussed above, one of the central tasks of emerging adulthood involves developing one’s own identity and emerging adults may be just beginning this process of considering their own values and how they may differ from those of their parents. In particular, for emerging adults with anxiety disorders decisions can be overwhelming and frightening and they may depend on parents and others to make their decisions. Other emerging adults with anxiety may have difficulty identifying what truly matters to them as they have become accustomed to making decisions under the central guiding principle of what will enable them to avoid anxiety and other difficult emotions. Empowering emerging adults to identify their own values is therefore critical in both promoting healthy development and increasing motivation for engaging in treatment for anxiety. In addition, by encouraging emerging adults to express and share their values with their parents, this approach helps shift the family system by encouraging parents to begin to support their child’s independence and autonomy.

LAUNCHING EMERGING ADULTS PROGRAM The Launching Emerging Adults Program (LEAP; see Albano & Hoffman, 2017; Hoffman, Guerry, & Albano, 2018) was developed to address these developmental considerations and support emerging adults with anxiety disorders in their transition to adulthood. This model integrates components of empirically supported, cognitive-behavioral treatment (CBT) for anxiety (e.g., psychoeducation, cognitive-restructuring, exposure) with developmentally informed interventions in order to best meet the needs of emerging adults with anxiety and related disorders.

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Functional Assessment At the core of this model is an emphasis on functional assessment of appropriate developmental milestones. As part of their initial assessment, emerging adults and their parents complete the Launching Emerging Adult Functioning Scale (LEAF; Albano et al., unpublished. Note: psychometric evaluation in progress), complimentary questionnaires designed to assess the young adult’s independence across the range of domains discussed above (e.g., self-care, financial independence, emotional independence, interpersonal relationships, self-identity, school/work). The LEAF is then used as a tool to discuss the young adult’s goals for further development in each of these domains and the way anxiety has impeded this progress. Parents or caretakers are included in these early discussions, which include a focus on the ways that they have assumed responsibilities for the patient in these domains and how these parental accommodations may be gradually reduced. By assessing independent functioning along with anxiety symptoms at baseline, clinicians communicate the importance of focusing on developmental milestones throughout treatment. Furthermore, this baseline assessment provides a point of comparison, enabling clinicians to highlight areas of change over the course of treatment, which might otherwise be minimized or overlooked. This functional assessment is also used to create a developmental hierarchy, which guides treatment. This hierarchy is somewhat similar to a fear and avoidance hierarchy (FAH) typically used in cognitive-behavioral treatment for anxiety, in which the patient and clinician identify relevant anxiety provoking situations and circumstances, which are then are ranked from least anxiety-provoking to most anxiety-provoking. Subsequent treatment targets each item on the FAH via imaginal and/or in vivo exposure, beginning with lower-level items and progressing to higher-level items as the patient gains mastery and confidence. Within the LEAP model, a developmental hierarchy is distinguished from a FAH insofar as it is focused specifically on tasks that need to be accomplished in order to achieve specific developmental milestones. For example, taking responsibility for one’s own healthcare might be divided into discrete tasks such as making a list of necessary appointments for the next 6 months, gathering personal and insurance information, maintaining a calendar of appointments, and calling doctors’ offices to make appointments. Each task is rated from 0 to 100 in terms of how emotionally challenging it is, as well as 0 100 in terms of the patient’s current degree of independence in completing the task, and the clinician and patient collaborate on addressing barriers to successful completion of each task, considering emotional as well as practical limitations. For example, when Sam first presented to our clinic he completed the LEAF. His responses demonstrated that he struggled across several different domains of independent functioning. In particular, Sam identified difficulty in domains of school and self-care. Sam’s individual clinician used this questionnaire to facilitate a discussion with Sam and his parents about the way Sam’s anxiety had historically made it difficult for him to complete his schoolwork or talk to teachers when he needed assistance. Sam’s mother expressed frustration about having to intervene on Sam’s behalf with his teachers and professors when he did not complete his work, as well as her belief that she had to intervene as he was incapable of doing so himself. The family agreed that before returning to the university Sam should demonstrate improved skills and independence in this domain.

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As such, a developmental hierarchy was created to identify treatment goals that would help Sam achieve increased independence in the school domain. Tasks on his developmental hierarchy included being able to choose and register for courses at a nearby community college, setting and waking up to alarms in order to get to class on time, breaking down overwhelming assignments into smaller, more manageable tasks, completing work on time, and emailing professors when he had questions or difficulties with course work. Furthermore, Sam’s responses on the LEAF indicated that his functioning in the domain of interpersonal relationships represented a relative strength. Despite his anxiety and intermittent mood symptoms, Sam and his parents agreed that he demonstrated good ability to initiate spending time with friends and a comfort in developing new friendships. This was highlighted as a strength of Sam’s, which he was able to take pride in. In this way, the functional assessment can be used as a tool to identify treatment goals and monitor progress towards these goals as well as to highlight strengths and increase a sense of self-efficacy.

Program Structure In order to best meet the needs of anxious emerging adults and their caretakers, the LEAP program has developed a structure that involves parents or caretakers (hereafter referred to as parents for the sake of brevity) while simultaneously empowering emerging adults to take ownership over their own treatment. In order to achieve this balance, individual treatment is designed to include both individual and conjoint “transition” sessions, which are intended to help families transfer responsibility to emerging adult patients. Below we provide a brief outline of a model individual treatment structure. We discuss this model of treatment with the young adult and parents during the intake, and work on obtaining agreements for discussing together the specific aspects of functioning and behaviors related to the family’s interactions, values, and environment, while preserving confidentiality for the patient. Often, a different therapist works with the family during the transition sessions, so that confidentiality can be maintained for the young adult, and that they have the opportunity to develop a therapeutic alliance and relationship with the primary therapist. Following initial assessment, early sessions are conjoint in nature and include a focus on psychoeducation about the biopsychosocial model of anxiety and CBT and the role of avoidance and parental accommodations in maintaining anxiety. By providing psychoeducation in a conjoint format, clinicians ensure that the emerging adult and their parents have a shared understanding of the treatment rationale and the process of change, which is critical in fostering cooperation and communication throughout the process of gradually transferring responsibility for developmentally appropriate tasks to the emerging adult. In addition, early sessions also assess areas of conflict between patients and their parents and increase understanding about how anxiety has shaped the patient parent relationship. As part of this work, both parents and emerging adults are encouraged to openly express their fears and frustrations about their current relationship and patterns of interaction. Emerging adults and their parents are often surprised to find that they share similar frustrations about the status quo and shared goals begin to emerge. At this point, the

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individual clinician utilizes the functional assessment to help the patient and his/her parents create a developmental hierarchy, and identify short and long-term goals that are developmentally informed. In the second phase of treatment, consisting of 4 5 sessions, the clinician works individually with the emerging adult. The function of these sessions is to address skills deficits, which have developed over time as a result of pervasive avoidance and parental accommodations. Such skills deficits may be practical (e.g., requiring discussion of and instruction in self-care tasks, financial matters, interpersonal communication, household duties), or emotional (e.g., developing coping skills for managing negative emotions, relaxation training, cognitive restructuring, problem-solving, etc.). These sessions are followed by a conjoint transition session with both the emerging adult and his/her parents, during which time new skills are reviewed. Parents are included in this session in order to continue to facilitate the process of “recentering,” and new skills are highlighted in order to increase parental confidence in their ability to transfer responsibility to the patient. As with other evidence-based treatments, patients are expected to complete “homework assignments” between sessions to strengthen their understanding of session material and facilitate skills generalization. Typical homework assignments during this phase may include completing cognitive restructuring worksheets, monitoring emotional experiences and implementing coping skills, or fulfilling behavioral plans to engage in developmentally appropriate tasks. In the third phase of treatment, emerging adults participate in gradual exposures, which are designed to help them progress towards developmental goals. These sessions are focused on empowering the emerging adult, who collaborates with the clinician in defining and developing exposures that are in line with their individual goals and values. For example, emerging adults may complete exposures related to emailing professors, initiating spending time with peers, purchasing self-care items, scheduling doctor appointments, or applying for jobs. Such exposure practices provide patients an opportunity to apply new skills discussed in earlier sessions, practice confronting their fears and tolerating uncertainty, and develop self-efficacy in their ability to complete tasks independently. Exposures can be completed in session with the therapist, and are also assigned as homework between sessions. Most often, we conduct these sessions in group format, where 5 7 emerging adults work together in simulated exposures (role playing of challenging situations), in our unique virtual reality environments for college-age youth, and also in vivo exposures in community, real-life settings (e.g., asking for job applications; conducting surveys on the street). This phase of treatment is conducted primarily with a focus on the emerging adult, to communicate that they are the primary agents of change. However, this work may at times require coordination with parents, often achieved during flexibly scheduled transition sessions or focused communication with the parents as needed. For example, for patients living at home and completing self-care exposures such as laundry, or scheduling a dentist visit, clinicians should communicate with parents to ensure that they do not complete these tasks on behalf of the patient. Parents are also encouraged to positively reinforce emerging adults when they observe progress in these domains. In the fourth and final phase of treatment, individual sessions with the emerging adult focus on final exposures, relapse prevention, and termination. Initial goals are reviewed, a new functional assessment is administered, and progress across multiple domains is

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identified and highlighted. This process helps facilitate self-efficacy by emphasizing both relative areas of strength as well as highlighting the patient’s ability to make progress in domains that were initially most challenging. Skills are reviewed and a plan is made to empower the emerging adult to continue implementing their own exposures and tolerating anxiety that emerges as they work towards continued goals. The final session is conjoint in nature. The emerging adult is encouraged to lead the conversation with his/her parents in which progress is highlighted and an ongoing plan to continue transferring responsibility is discussed. In this way, the therapist models confidence in the emerging adult and the parent has an in vivo experience of the transfer of responsibility as the emerging adult is guided to take the lead in planning for next steps. Importantly, the LEAP program is not intended to be implemented rigidly but rather to provide a flexible model that can be adapted to meet the needs of each emerging adult and their family. To this effect, there is no prespecified number of sessions or length of treatment, as the duration and frequency of sessions varies depending on the presenting concern of each patient and their parents. Some emerging adults and their parents may benefit from additional transition sessions and others may experience a developmentally appropriate desire for independence and may therefore resent parental involvement. When deciding how to integrate parents within this model, clinicians must take into account several considerations including degree of depressive pathology, hopelessness, and functional impairment in the emerging adult, degree of parental-patient conflict, degree of patient dependence, parental psychopathology and availability to attend sessions regularly, and degree of family dysfunction and stress (e.g., financial, marital, health). Our groups are usually compiled when a sufficient number of young adults is available (5 7) and agree to engage in 10 sessions of the group exposure work. Groups are classified as beginner (new to CBT exposure work), intermediate (increasingly complex or more challenging exposures), or advanced (high-level, mostly community-based in vivo exposures).

CLINICAL CONSIDERATIONS: INTEGRATING PARENTS INTO TREATMENT Though parental involvement is often critical when working with anxious emerging adults, it can also present unique challenges. One frequent challenge that we experience in our clinic is addressing parental anxiety about letting their young adult struggle or experience distress. Parents often have beliefs that “this situation is too important to fail” or “she doesn’t have the skills to handle this.” This latter belief is sometimes based in reality, but also functions as a self-fulfilling prophecy, leading to greater parental accommodations and fewer opportunities for skill development. As such, it is often beneficial to help parents develop the cognitive restructuring skills to identify and challenge their own catastrophic cognitions about what might happen if their child does struggle. For example, Sam was often anxious before his individual sessions and would call his mother from the parking lot before coming in to session, insisting that she join him. Sam’s mother would leave work and rush down to the clinic to ensure that he did make it on time for his session, and then would express frustration and anger that she had to leave work again.

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The clinician therefore met individually with Sam’s mother for part of the session and helped her identify her own catastrophic belief that if Sam didn’t attend that session “his anxiety would spiral out of control” and he would become even more “stuck.” After validating her anxiety and sense of urgency about Sam’s engagement in treatment, the clinician helped Sam’s mother recognize that Sam did possess the skills to calm himself down when he was feeling anxious, and reviewed recent situations in which he had demonstrated this ability. In addition, they discussed the realistic repercussions of missing one session and emphasized that it would be necessary for Sam’s mother to tolerate her own anxiety as well as Sam’s in order to transfer responsibility for attending therapy sessions to Sam. A second challenge when working with parents is that parents often express a sense of frustration at what can sometimes be a slow process of change, stating beliefs such as, “he should be able to apply for a job on his own and support himself already” or “she’s an adult, she shouldn’t need me to participate in his treatment.” These beliefs are often valid and constitute developmentally appropriate expectations from their child, and at the same they can interfere with treatment by invalidating the patient’s progress and increasing hopelessness. Still other times parents became polarized, with one parent struggling to reduce accommodations and the other parent angrily demanding a more rapid pace of change. Using the developmental hierarchy, it is critical to help parents understand the importance of scaffolding, assisting patients to continue to make gradual but sustainable progress through skills training and exposures. The developmental hierarchy can be used as a tool to show parents the roadmap for change, demonstrating that patients must work to achieve developmental milestones and also that such work typically consists of many gradual steps.

WHEN EMERGING ADULTS NEED MORE While the above treatment structure is effective for many anxious emerging adults, within our clinic we found that for some patients meeting once or even twice weekly with their individual therapist was inadequate to provide timely check-ins on progress towards meeting goals identified in sessions. If goals remained unmet due to the interference of mood or anxiety symptoms, or for logistical reasons, allowing several days to elapse between sessions impeded helpful problem solving. As a result, for the particularly “stuck” emerging adults, weekly individual meetings often did not generate the necessary momentum to implement and maintain behavior change. In addition, many of the emerging adults with whom we worked were not attending school and were unemployed. They often spent the majority of their time isolated in their homes with limited opportunities for behavioral activation, social engagement, or personal accountability. These emerging adults were often particularly hopeless about their ability to overcome their anxiety and make progress towards developmental milestones. For example, although Ethan was participating in twice-weekly individual sessions with his clinician, in addition to family meetings with his parents every-other week, his progress was quite slow. He often failed to complete agreed-upon exposure or behavioral assignments between appointments, and was unable to problem-solve barriers towards meeting these goals until his next session, thereby slowing his momentum. In addition,

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aside from attending therapy appointments and his one class, Ethan was not engaged in other activities during the week. He therefore continued to spend much of his day sleeping, and with very limited social engagement. This lack of behavioral activation was notable in contributing to continued depressive symptoms, which further compounded his ability to complete therapeutic tasks due to low energy and motivation. Although he lived at home with his parents, high conflict within their relationship negated the possibility that they could help hold Ethan accountable for behavioral change. To address the limitations of weekly treatment and provide a more intensive outpatient treatment option for particularly “stuck” patients like Ethan, we developed an intensive group treatment for emerging adults. The remainder of this paper describes the goals and format of this treatment program, as well as clinical considerations impacting the implementation of the program.

“ADULTING” GROUP TREATMENT Our “Adulting” group for emerging adults was developed as an extension of treatment provided according to the LEAP model, modified for delivery in an intensive group format. The term “adulting” was drawn from the colloquial expression used to describe responsible behaviors related to self-care, occupational, and interpersonal areas of life exemplified by high-functioning adults. The goals of the Adulting group treatment are to identify specific deficits in skills needed for each patient to transition into independent adulthood and to target these deficits through a combination of pragmatic instruction and evidence-based treatment strategies to address the impact of mental health on meeting these goals. Treatment is distinguished from individual and transition sessions as part of the LEAP model described above by the intensive format of treatment, the group structure and emphasis on peer support, and the focus on identifying and executing daily behavioral goals. Although emerging adulthood can be used to describe a broad age range, starting from late adolescence and spanning through the 20s (e.g., Arnett, 2000), and the LEAP model can be applied to young adults ages 16 through 26, the Adulting group is intended to serve young adults ages 18 through 26. This age restriction was applied to encourage group cohesiveness by optimizing the likelihood that group members will share similar experiences. To this effect, group members are also required have completed high school or its equivalent, given the unique challenges inherent in achieving developmental milestones post-high school (e.g., securing employment, enrolling in postsecondary education, having legal classification as an adult, etc.). Group members are also required to have their own primary individual therapist with whom they meet regularly. In addition, the group is most appropriate for individuals with anxiety and/or depressive disorders as part of their diagnostic profile, given the treatment’s emphasis on exposure practices and behavioral activation. Individuals with severe mental illness (i.e., schizophrenia or psychotic disorder), active suicidal ideation or intent, high-risk behaviors (i.e., nonsuicidal self-injury), or conduct disorder are not appropriate for the Adulting group. Although young adults with autism spectrum disorders are not excluded from participation, in our experience the group is most beneficial for those individuals who are higher functioning and who carry comorbid anxiety and/or depressive disorder diagnoses.

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Given their difficulties meeting the developmental milestones of this period, patients for whom the Adulting group is most appropriate typically are not involved in regular academic or occupational pursuits. As such, they often struggle to find regularly scheduled activities in which they can engage, and the resulting isolation and inactivity further compounds their mental health concerns. The intensive format of the Adulting group was therefore designed to provide much needed structure for this population. Within our clinic, this group treatment is delivered three times per week for 4 weeks, totaling 12 sessions running 90 minutes each. However, the duration and frequency of sessions could be adapted to maximize feasibility within a given clinic, or to meet the needs of a given group cohort. For example, the group could run 5 days a week for 2 weeks during intersemester or spring breaks. We have found that it is beneficial to discuss each patient’s schedule with them prior to beginning an Adulting group to be aware of potential conflicts that might interfere with their full participation, and to tailor the group schedule accordingly. Importantly, Adulting group sessions are held in the mid-morning, beginning between 10:00 or 11:00am. This time is not so early as to preclude the attendance of young adults who often go to bed and wake up later than typical adults, but also ensures that attendance inherently involves practicing skills involved in setting and sticking to an alarm regardless of mood and fatigue. Additionally, this timing also ensures that patients will have the remainder of the day following the session to engage in meaningful activities, which are often identified during sessions. As discussed above, emerging adults demonstrate relative strengths and weaknesses across the multiple domains necessary for optimal functioning as an adult (e.g., interpersonal relationships, self-care, work and school, independent tasks, etc.). Amongst group members, there are likely to be domains in which several group members endorse challenges, as well as domains that are less relevant for a given cohort. As such, the Adulting group treatment is designed to be modular in approach, rather than following a predetermined session order. This format allows for the unique presenting concerns of each patient within the group to be targeted in treatment. The first session of treatment therefore focuses on clarifying the presenting concerns of group members to create a “roadmap” for group treatment. Following a brief introduction to the group, each participant completes the LEAF questionnaire described above to provide an assessment of current challenges that can be addressed in treatment. Domains in which multiple group members identify deficits are prioritized earlier in treatment. For example, within the domain of work and school, Ethan and several other group members endorsed struggles with managing a daily schedule as well as completing tasks and assignments on time. He and other group members noted additional shared challenges within the self-care domain, including difficulties preparing their own meals and maintaining a healthy, balanced diet, particularly while trying to stick to a budget. Thus, early sessions in treatment were tailored to address the shared priorities and goals of the group, with more individualized deficits targeted during later sessions once momentum towards behavior change was more firmly established. In addition to completing a functional assessment and identifying shared challenges, early group sessions also include identifying each participant’s unique values to build motivation to establish and meet value-driven goals. Participants are asked to identify the values that are most important to them. Discussion centers on why these values

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are important to participants, to what extent they are presently living according to those values, to what extent anxiety prevents them from living according to those values, and what changes they can make to bring them closer to living in line with their values. Throughout the group, patients are encouraged to connect the daily goals they set to the values they identified, and to recall their personal values in the face of lagging motivation. Values shared amongst group members are particularly emphasized. During Ethan’s group, he and several other group members identified common values of autonomy and dependability. One group member highlighted a value of comfort, which she defined as “having everything I need provided for me without having any stress.” This led to a rich discussion of the ways in which values of comfort and pleasure may conflict with autonomy and dependability, particularly for anxious emerging adults. In particular, group members discussed how they often deferred to comfort in allowing their parents to do things for them, which eroded their autonomy. In contrast, another group member shared that a major contributor to comfort for him was “to get people off of my back,” noting that frequent conflict with his parents around his stalled development was prompting him to seek greater autonomy; thus for him, taking steps towards both comfort and autonomy could be achieved by taking similar steps towards meeting developmental milestones. Once the collective values and skills deficits of the group members have been established, treatment proceeds in a modular fashion. Modules are comprised of evidence-based treatment strategies adapted for the group and their presenting concerns. Modules include goal setting, self-care, time management, sleep hygiene, behavioral activation, interpersonal skills, exposure practice, emotion regulation/coping skills, healthy eating, and budgeting, among others. Within each of these modules, group leaders incorporate psychoeducation, goal setting, skill building, problem solving, cognitive restructuring, and in vivo exposure to challenging developmental tasks. Group leaders determine which module to deliver on a given day based on the presenting concerns of the group, and as often as possible empower group members to help choose session content they feel will be most helpful. Following a discussion of progress towards meeting daily goals (see below), group leaders present didactic information relevant to the module of the day, and engage participants in a discussion of how to apply the skill. The remainder of the session is dedicated either to applying the skill in the service of meeting individualized therapeutic goals, or to completing insession exposure practices. For example, within the course of one Adulting group, members identified common struggles with healthy eating and independent purchase of food items for preparation. A self-care module specifically targeting eating habits was subsequently introduced, with a focus on both the practical aspects of independently planning and purchasing food items, as well as psychoeducation regarding the relationship between mood, behavioral activity, and eating choices. The remainder of the session was dedicated to practicing establishing a reasonable budget for grocery shopping and going to a local supermarket as a group to purchase healthy items within the established budget. As another example, during the course of Ethan’s treatment, group members identified shared difficulties in following through with school responsibilities, including choosing classes for which to register as well as emailing school administrators, professors, and advisors. To target these concerns,

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a session was dedicated to addressing logistic challenges related to school. The session began by providing practical instruction in constructing a clear and respectful email to school personnel, as well as problem solving around registering for classes. Barriers to completing these tasks were also discussed, and group members were assisted in cognitive restructuring around anxious thoughts as necessary. Group members were encouraged to share their input and experiences and to provide suggestions to assist their peers during this discussion. Ethan provided valuable recommendations to peers about how to narrow down a few potential courses from an overwhelmingly broad course catalog, while other group members provided suggestions to him about constructing an email to his dean. Each participant then identified a personally relevant and manageable insession exposure task to complete during the remainder of the group, such as creating an account necessary to register for classes, drafting an email, or researching to whom an inquiry about returning to school should be addressed. In this manner, each module incorporates skills training, evidence-based treatment interventions, and exposure practices to build upon those skills in the service of meeting broader developmental milestones. Participants establish a personalized daily goal prior to the end of all sessions. These goals are written on a board to encourage visibility and accountability. Group leaders subsequently engage each participant in a brief discussion of potential barriers to achieving the daily goal, as well as identifying “backup plans” should the goal prove too logistically or emotionally challenging. At the beginning of each session, group coleaders write each participant’s goal from the previous session up on the board. Upon their arrival, participants are asked to come up to the board and check off whether or not they achieved their goal. In this manner, an atmosphere of supportive accountability is established, whereby group members’ attendance and fulfillment of daily goals is prioritized for the benefit of each individual member, as well as the group collectively. This emphasis on daily goal setting and accountability is the foundation of the Adulting group. As discussed above, for many emerging adults, their anxiety has led them to avoid transferring responsibility from their parents, and it can be extremely difficult and disheartening to begin the difficult process of assuming responsibility in their lives. By breaking down goals into small, manageable sizes, leveraging the group structure to increase both accountability and support for each group member, and meeting regularly so that barriers can be quickly problemsolved, this group structure is uniquely suited to help emerging adults begin to achieve developmental milestones. Throughout the course of treatment, group members are encouraged to support and validate their peers through sharing their values as well as the barriers they face in meeting their goals, providing invaluable peer support to one another as they progress through treatment. The impact of mental health concerns on meeting developmental milestones and fulfilling responsibilities is revisited continually throughout treatment. This process also provides a unique opportunity to address hopelessness, as patients realize that they are not alone in their struggle with the transition to adulthood. Furthermore, because patients struggle in different domains, it provides them an opportunity to experience being the expert in one domain (e.g., one group member can offer advice about registering for courses or applying for a job while another might feel more comfortable providing advice in the domain of interpersonal relationships).

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CLINICAL CONSIDERATIONS There are a number of clinical issues that are important to consider when delivering the Adulting group. First, as with individual treatment according to the LEAP model, the role of parents in treatment warrants comment. Emerging adults for whom the Adulting group is most appropriate are likely to live with parents, to rely on them to manage their schedule, transportation, and even self-care needs, and are likely to be highly dependent on their parents for emotional and financial support. More often than not, parents of group participants are providing payment for treatment. However, as previously discussed, as participants are over 18 and therefore legally adults, their parents are not privileged to details of their participation in treatment, which may create significant conflicts of interest as treatment progresses. The role of parents is therefore particularly delicate when, for example, a young adult does not arrive for group, is highly disengaged, or is consistently failing to follow through with daily goals. Even if participants have provided written permission for group leaders to contact their parents, it is important to consider how involving the patient’s parents will impact therapeutic goals of increasing independence and personal accountability. Whenever possible, we recommend discussing the role of parents with each participant and their caregivers prior to the start of group to develop an individualized plan for parental involvement. For example, in the case of nonattendance, an agreement could be reached that group leaders will attempt to contact the patient twice before reaching out to the patient’s parents. In this manner, therapeutic goals of decreasing avoidance of uncomfortable interpersonal situations may be met, as the patient has greater opportunity and incentive to address his nonattendance with the clinician directly. As another example, to meet broader goals of increasing personal responsibility, an agreement could be reached that the patient will be billed directly for missed sessions (as opposed to charging his parents), but that his parents need not be contacted in the case of nonattendance. As with all considerations regarding the involvement of parents in treatment, direct and clear communication between group leaders, the patient, and his or her parents is essential to optimize the benefit of group treatment. Participants’ motivation to participate in group treatment is an important clinical issue. As with other CBT approaches, the Adulting group is an active treatment, which requires not only session attendance, but also independent practice of treatment elements between sessions (e.g., exposures, meeting daily goals). Thus, participation requires a degree of motivation and commitment from group members, and it is important to assess each patient’s motivation to participate in group prior to their enrollment. Of course, it is not uncommon for participants to express hesitation about group treatment due to social anxiety, disinclination to commit to a regular appointment, or fear of failure, among other reasons. Moreover, motivation and engagement may wax and wane over the course of treatment. However, we find that at least a basic motivation to participate, desire for change, and willingness to commit to attendance is necessary for patients to derive benefit from the treatment, and for the group to function constructively as a whole. In contrast, we find that participants who are compelled to attend only due to parental insistence are less likely to benefit from group, as they are more likely to attend inconsistently or to neglect independent practice. This often erodes group cohesion and breeds resentment, as

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more engaged participants express frustration that their peers or not as committed to the therapeutic effort. Additionally, disengaged participants may model ineffective behaviors for other group members, which may deter individual and group progress. Group leaders should directly address the pros and cons of participation during the first session of treatment, validating the concerns of participants while also empowering them to work towards meaningful progress. Moreover, they should integrate motivational strategies throughout treatment, recalling each participant’s individual values and goals to strengthen motivation. Finally, it is important to consider the most appropriate level of care for each participant prior to enrolling in the Adulting group. As previously mentioned, this treatment is designed for those emerging adults for whom once or twice weekly treatment with their individual therapist is insufficient to make meaningful progress. It is not uncommon in these cases for clinicians and caregivers to consider whether a higher level of care is necessary, such as day treatment or residential treatment programs. Regrettably, there are many barriers towards accessing these programs. For emerging adults over the age of 18, participation in higher levels of care requires their voluntary registration. However, many of these emerging adults are highly resistant to self-enrolling in these programs. Even when emerging adults are willing to participate in a higher level of care, there is a serious paucity of residential programs for young adults (Pepper, Kirshner, & Ryglewicz, 2000), existing programs often have long wait lists, and the high costs of these programs may be prohibitive for many families. The Adulting group may therefore provide a desirable alternative for emerging adults for whom once or twice weekly treatment is inadequate. This approach serves as a middle ground to meeting either once weekly for a 50-minute session, or daily for several hours at a time. In this manner, group treatment provides additional structure and support for emerging adults while still permitting them to continue in their normal routines, which may facilitate generalization of treatment skills. Similarly, while the cost of participating in group treatment is certainly higher than for weekly individual sessions, costs are substantially less than those required to enroll in day treatment or residential programs. Moreover, emerging adults for whom higher levels of care are being considered, and for whom such an approach is undesirable, may be motivated to fully participate in the Adulting group treatment to demonstrate that they are capable of making meaningful change outside of a more comprehensive treatment program. Taken together, although the Adulting group is not a substitute for higher levels of care where clinically indicated, this intensive approach offers an attractive alternative for emerging adults who require additional structure to kick-start their stalled transition to adulthood.

CONCLUSIONS Emerging adulthood is now acknowledged as a distinct developmental period replete with its own triumphs and challenges. A growing number of emerging adults regrettably struggle to meet the developmental milestones necessary to transition to healthy adulthood, and anxiety disorders often compound these difficulties. Fortunately, treatments for this population are beginning to emerge. The Launching Emerging Adults Program (LEAP) targets anxiety disorders in emerging adults as they transition into independent

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living, offering a multimodal approach to addressing anxiety during this key developmental stage. Informed by an advanced understanding of the unique developmental factors impacting treatment for this population, this approach offers hope for emerging adults struggling with anxiety disorders.

References Albano, A. M., & Hoffman, L. (2017). Treatment of social anxiety disorder. In P. C. Kendall (Ed.), Handbook of cognitive behavioral therapy for child and adolescent disorders. (pp. 15 49). New York: Guilford Press. Albano, A. M., Poznanski, B., Hambrick, J., et al. The Launching Emerging Adults Functioning Scale (LEAF) [unpublished]. Columbia University Clinic for Anxiety and Related Disorders; New York, NY. Arnett, J. J. (2000). Emerging adulthood: A theory of development from the late teens through the twenties. American Psychologist, 55(5), 469. Arnett, J. J. (2016). Does emerging adulthood theory apply across social classes? National data on a persistent question. Emerging Adulthood, 4(4), 227 235. Arnett, J. J., & Taber, S. (1994). Adolescence terminable and interminable: When does adolescence end? Journal of Youth and Adolescence, 23(5), 517 537. Aschenbrand, S. G., & Kendall, P. C. (2012). The effect of perceived child anxiety status on parental latency to intervene with anxious and non-anxious youth. Journal of Consulting and Clinical Psychology, 80(2), 232. Casey, B. J., & Jones, R. M. (2010). Neurobiology of the adolescent brain and behavior: implications for substance use disorders. Journal of the American Academy of Child & Adolescent Psychiatry, 49(12), 1189 1201. Cohen, P., Kasen, S., Chen, H., Hartmark, C., & Gordon, K. (2003). Variations in patterns of developmental transmissions in the emerging adulthood period. Developmental Psychology, 39(4), 657. Comer, J. S., Blanco, C., Hasin, D. S., Liu, S., Frant, B. F., Turner, J. B., & Olfson, M. (2011). Health-related quality of life across the anxiety disorders: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Journal of Clinical Psychiatry, 72(1), 43 50. Available from https://doi.org/10.4088/ JCP.09m05094blu. Copeland, W. E., Angold, A., Shanahan, L., & Costello, E. J. (2014). Longitudinal patterns of anxiety from childhood to adulthood: The Great Smoky Mountains Study. Journal of the American Academy of Child & Adolescent Psychiatry, 53(1), 21 33. Hendry, L. B., & Kloep, M. (2007). Conceptualizing emerging adulthood: Inspecting the emperor’s new clothes? Child Development Perspectives, 1(2), 74 79. Hoffman, L., Guerry, J., & Albano, A.M. (2018). Anxiety disorders: transitional age youth. Current psychiatry reports: child and adolescent disorders (pp. 20 25). Philadelphia: Springer. Kessler, R. C., Demler, O., Frank, R. G., Olfson, M., Pincus, H. A., Walters, E. E., . . . Zaslavsky, A. M. (2005). Prevalence and treatment of mental disorders, 1990 to 2003. New England Journal of Medicine, 352(24), 2515 2523. Labouvie-Vief, G. (2006). Emerging Structures of Adult Thought. American Psychological Association. Lebowitz, E., Dolberger, D., Nortov, E., & Omer, H. (2012). Parent training in nonviolent resistance for adult entitled dependence. Family Process, 51(1), 90 106. Lebowitz, E. R., Scharfstein, L. A., & Jones, J. (2014). Comparing family accommodation in obsessive-compulsive disorder, anxiety disorders, and non-anxious children. Depression and Anxiety, 31(12), 1018 1025. Lebowitz, E. R., Woolston, J., Bar-Haim, Y., Calvocoressi, L., Dauser, C., Warnick, E., . . . Leckman, J. F. (2013). Family accommodation in pediatric anxiety disorders. Depression and Anxiety, 30(1), 47 54. Pepper, B., Kirshner, M. C., & Ryglewicz, H. (2000). The young adult chronic patient: Overview of a population. Psychiatric Services, 51(8), 989 995. Pine, D. S., Cohen, P., Gurley, D., Brook, J., & Ma, Y. (1998). The risk for early-adulthood anxiety and depressive disorders in adolescents with anxiety and depressive disorders. Archives of General Psychiatry, 55(1), 56 64. Available from https://doi.org/10.1001/archpsyc.55.1.56. Pottick, K. J., Bilder, S., Vander Stoep, A., Warner, L. A., & Alvarez, M. F. (2008). US patterns of mental health service utilization for transition-age youth and young adults. The Journal of Behavioral Health Services & Research, 35(4), 373 389.

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REFERENCES

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Roza, S. J., Hofstra, M. B., van der Ende, J., & Verhulst, F. C. (2003). Stable prediction of mood and anxiety disorders based on behavioral and emotional problems in childhood: a 14-year follow-up during childhood, adolescence, and young adulthood. American Journal of Psychiatry, 160(12), 2116 2121. Available from https://doi. org/10.1176/appi.ajp.160.12.2116. Scharf, M., Mayseless, O., & Kivenson-Baron, I. (2004). Adolescents’ attachment representations and developmental tasks in emerging adulthood. Developmental Psychology, 40(3), 430. Schnaiberg, A., & Goldenberg, S. (1989). From empty nest to crowded nest: The dynamics of incompletelylaunched young adults. Social Problems, 36(3), 251 269. Schoeni, R. F., & Ross, K. E. (2005). Material assistance from families during the transition to adulthood. University of Chicago Press. Steinberg, L. (2005). Cognitive and affective development in adolescence. Trends in Cognitive Sciences, 9(2), 69 74. Tanner, J. L. (2006). Recentering during emerging adulthood: A critical turning point in life span human development. In J. J. Arnett, & J. L. Tanner (Eds.), Emerging adults in America: Coming of age in the 21st century (pp. 21 55). Washington, DC: APA Books. Thompson-Hollands, J., Kerns, C. E., Pincus, D. B., & Comer, J. S. (2014). Parental accommodation of child anxiety and related symptoms: Range, impact, and correlates. Journal of Anxiety Disorders, 28(8), 765 773. Whiteford, Harvey A., et al. (2013). Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010. The Lancet, 382. Wang, J. (2007). Mental health treatment dropout and its correlates in a general population sample. Medical Care, 45(3), 224 229.

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