As noted above, the small number of intervention studies that have been conducted thus far have focused primarily on the reduction of anxious symptoms as measured by self-report (e.g., Lowry-Webster et al., 2001), although some studies examined whether patients met diagnostic status for an anxiety disorder at both post-intervention and, perhaps more importantly, at follow-up (e.g., Dadds et al., 1997). Both symptoms and diagnostic status are relevant, although the latter is less sensitive because participants can lose the diagnosis at a particular assessment point yet still remain elevated symptomatically and thus presumably also remain at risk for increased symptoms down the road. No studies have examined anxious symptoms and diagnostic status longitudinally through adolescence and into early adulthood. Such studies would yield data that truly test the success of prevention interventions. Yet another kind of successful outcome for universal intervention programs would be destigmatization of anxiety as a character flaw or weakness. Clearly, most youth who participate in universal prevention programs are at low risk for the development of anxiety disorders, yet informing this majority of the nature and impact of anxiety may help reduce problems that often face anxious youth in the social context, such as ostracism, teasing, and peer rejection.

The few prevention intervention studies that have been conducted thus far have not shed light on the mechanisms involved because most of the designs used have compared active treatment packages to repeated assessment only. The superiority of the CBT packages examined thus far could therefore be attributable to a wide variety of nonspecific factors, such as treatment credibility and therapist contact. Dismantling studies typically follow the establishment of ef

ficacy (e.g., Schmidt et al., 2000), and thus the field may be a long time from discovering the impact of specific treatment interventions and their underlying mechanisms.

As noted above, in the small number of studies conducted to date, the outcomes targeted have focused primarily on anxiety symptoms and disorders. It might be worthwhile for future research to move beyond symptoms and diagnosis and pay increased attention to whether functional impairment has improvement. For example, are there improvements in the adolescent's grades or in his or her peer relationships? These are the outcomes that would seem to matter most and should be seriously considered in the design and evaluation of future prevention studies.

In addition, the potential of “positive psychology” has yet to be seriously considered in the context of preventing anxiety disorders in adolescents and targeting outcomes. Positive psychology is devoted to creating a science of human strengths that act as buffers against mental illness, including anxiety (Seligman, 2002). Dick-Niederhauser and Silverman (2003) have adapted positive psychology principles and have suggested their utility in serving as outcome targets for anxiety prevention studies. Thus, potential outcome targets might include the instilling of hope and the active pursuit of goals in young people, which in turn have been linked to the development of courage. Courage in turn has been linked with increased optimistic cognitive processing, a sense of self-efficacy, and skillful coping. Although measures exist to assess some positive psychological concepts, further instrument development and evaluation is needed for positive psychology principles to be fully implemented and studied in the context of anxiety prevention research.

Longitudinal studies of trauma survivors (e.g., Riggs, Rothbaum, & Foa, 1995; Rothbaum et al., 1992) indicate that most individuals experience elevated levels of PTSD symptoms shortly after the traumatic event. In addition, elevated levels of depression and general anxiety often accompany PTSD symptoms. For most trauma survivors, however, these symptoms decline significantly over the ensuing 3 months without any professional intervention. That said, a significant minority of trauma survivors continues to experience high levels of posttrauma distress that, without professional treatment, may persist for months or years (Kessler, Sonnega, Bromet, Hughes, & Nelson, 1995).

As discussed above, it is now well established that various forms of CBT are effective in reducing PTSD symptom severity as well as associated anxiety and depression (e.g., Foa et al., 1999). While there are effective treatments for individuals suffering from chronic PTSD, many sufferers either do not seek treatment for their trauma-related symptoms or do not have access to treatment. As a consequence, individuals' suffering and their inability to function can be prolonged. They are also vulnerable to associated comorbidity such as substance abuse. Such considerations have prompted trauma therapists to develop brief interventions applied shortly after the traumatic event to facilitate recovery and thereby prevent the development of chronic PTSD. Two approaches to facilitating recovery following a traumatic event have been researched. Abbreviated CBT packages such as those developed by Foa et al. (1995) and adopted by Bryant and colleagues (1998, 1999) have been found to be efficacious in accelerating recovery and reducing the likelihood of chronic PTSD. The other approach involves psychological debriefing (PD). Such programs typically comprise one session and are applied shortly after a traumatic event (frequently within 48–72 hr). In this session (which can be conducted in groups or individually), participants are encouraged to describe the traumatic event, including their thoughts, impressions, and emotional reactions. The ses sion also includes normalization of the trauma survivors' reactions and planning for coping with the trauma and its sequelae. Results of RCTs for PD are somewhat mixed, but an important pattern is emerging. In general, participants in PD studies subjectively find the intervention to be helpful (i.e., high consumer satisfaction), yet objective measures of specific posttrauma symptoms typically yield no differences between those receiving PD and those who do not. Thus, the improvement typically observed following PD is better attributed to natural recovery, rather than to an active ingredient of the intervention (e.g., Bisson, 2003; Rose, Brewin, Andrews, & Kirk, 1999). Moreover, a few studies have found PD actually interfered with natural recovery (e.g., Mayou et al., 2000). The results of PD studies highlight the need for caution in using one-session interventions conducted shortly after traumatic events involving children and adolescents.

As noted earlier, unlike universal prevention programs, selective and indicated prevention programs specifically select participants on the basis of elevations of anxious symptoms or putative anxiety disorder risk factors. In the school context, where most prevention interventions are likely to take place, the latter program types require identification of a subgroup of participants from among the broader population who will be either encouraged or required to participate. The potential negative implications of this strategy have already been considered in the academic context with respect to educational issues, and have led to the gradual reduction of labeling for academic tracking systems (e.g., honors, regents, and basic classes) and to increased mainstreaming of special education students. Similar problems may be encountered in identifying already anxious or anxiety-vulnerable students for special attention or services. As discussed above, adolescence is a stage in life when similarity with the relevant peer group is valued, and intervention efforts that do not deal sensitively with this issue may be poorly attended or, worse yet, yield unintended negative consequences. Little has been written about this issue in the context of